As The Medical Home Turns: The Final Installment

Final Installment on As the Medical Home Turns:

Yes, students, today is the last installment in PookieMD’s dissertion on the ‘Medical Home’.  At our last session, we were midway through reviewing the “10 Simple Rules for the 21st Century Health Care System,” rules to guide the redesign of the health care system.  These guidelines were put out by the National Committee for Quality Assurance.  Why are we torturing ourselves with this tedium?  Because this may the  measuring stick by which CMS (Center for Medicare and Medicaid Services) will use to reimburse our practices.  And that means, of course, insurance companies will follow suit.  Following are rules 7-10 with my pithy commentary:

 

“7. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice and patient satisfaction.
8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.
9. Continuous decrease in waste. The health system should not waste resources or patient time.
10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.”

Item 7: “The need for transparency.” To me this sounds very similar to ‘rule 4’, free flow of information.  The salient feature is that the health care ‘system’ should make information available to patients about health plans, hospitals…etc.  Who will be responsible for each aspect–are physicians to review a patent’s health plan with them, and review each hospital the patient may go to?  This is an incredibly broad assertion of what needs to happen, but with no clear plan of who exactly needs to provide this information.  Part two, which references the “system’s performance”, appears to be directly related to measuring safety (think the never/ever no pay rules, for example), and also appears that your practice will be measured on evidence based practices and patient satisfaction.  We already discussed evidence based practices, which I consider the basis of modern Western medicine. However, the patient satisfaction issue is murkier.  What exactly IS patient satisfaction?  Would I get higher scores if I didn’t collect copays, gave out lots of oxycontin and ordered any test the patient saw on TV?  Clear criteria need to be established,  e.g. are patients seen with in 15 minutes of their appointment?  Are appointments accessible on a daily basis?  I’m not buying the criteria of “Rate PookieMD on a scale of 1 to 10–where one is the worst physician you ever saw, and 10, PookieMD is better than Marcus Welby, House and Hawkeye Pierce combined.”

Item 8: “Anticipation of needs.”  Yes, indeedy, I certainly try to anticipate my patient’s needs.  More importantly I try to anticipate outcomes.  If I do x, y will happen. But, I also try to have a plan in case z happens.  I can’t anticipate a patient’s every need, but I can use the best of my knowledge and resources to try to move the patient toward health.  Anticipation of needs smacks of wand waving, rather than reality.  Anticipation of outcomes is medical science, and an attainable goal. 

Item 9: “Continuous decrease in waste.”  Sounds good to me.  I hope that includes not wasting MY time filling out endless forms and jumping through hoops to make the ‘Medical Home’ a reality.  It is interesting that the Rules state the health care system should not waste resources or patient time, but makes no mention of physician time.  I’m all for decreasing waste, and hope that much more in depth thought goes into developing the operations and processes of the ‘Medical Home’, so it is not a gigantic bureaucratic wasteland.

Item 10: ” Cooperation among clinicians.”  Please do not patronize me.  Cooperation is a kindergarden skill, and doesn’t belong on this is on the list.  The physicians I know and work with are dedicated and caring, and certainly cooperative.  We don’t always agree on management, which is HEALTHY, and we certainly can be snappy when fatigued, but I think this is rule is over kill.  Shall we form a circle and sing Cum By Yah?

So my final take on the “Medical Home” is that it is a bunch of ‘rules’ that primary care  practices are trying to do already.  (Or as close as they can get with the limited resources they have.)  What it woefully neglects is how systems should be put in place to make health care, health information technology, and a much needed emphasis on PATIENT CENTERED care a reality.

Back to the drawing board.  This time, make sure you invite the physicians in the trenches that actually do the work–the family practice physicians,  the internists and the pediatricians, to guide the guidelines.

Wand Waving Part 2: Common Sense is Uncommon

Let’s jump right  into the second part of PookieMD’s dissertation on the Medical Home.   As you recall, I was reviewing the 10 rules of the medical home, as set forth by the National Committee for Quality Assurance.  The next three concepts are NOT new, and are, you guessed it, common sense.  (Why is common sense so uncommon?)

4.  Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge.
5.  Evidence-based decision making. Patients should receive care based on the best available scientific knowledge.
6.  Safety as a system property. Patients should be safe from injury caused by the care system.

Let’s tack number 4 next: “Shared knowledge and free flow of information…”  I think this is a thinly veiled reference to an EMR.  I am completely for nationwide use of an EMR, but am dismayed at the piecemeal, haphazard free for all that has ensued.  The EMR needs to be accessible to health care professionals across all spectrums of care.  Therefore, the myriad of programs out there are not going to create a system of good access for providers and patients.  It has been proposed that there be a nation wide EMR for all health care providers to use.  I am hesitant in advocating this, as many tout the VA’s system as the model.  I am loathe to advocate anything the VA uses, as I would summarize my experience with all things VA using two words: “profoundly inefficient.”  However, a nation wide, user friendly EMR  would probably be the best option.  BUT,  it has been estimated that it will cost $36,000 per physician to implement an EMR.  Where’s the money coming from?  I don’t see a huge surplus (!) coming any time soon into our Nation’s budget.

5. “Evidence-based decision making.”  No argument here.  I believe this is the very foundation of modern medicine in the West. 

6.  “Safety as a system property.”  It scares me that this is a rule.  Didn’t we take an oath to “do no harm?”  It also scares me that the folks at my favorite institution, the CMS (Center for Medicare and Medicaid Services), have bungled their way in to making rules to keep the patients safe from bed sores, c diff and catheter infections through the “Never/Ever No Pay” rules.  (See post below.) 

So what’s so new and exciting about the Medical Home?  No much so far, just more costs to the physician, a slick new name and a lot of press.  I’ll tackle the next ‘rules’ the next post.

For more info on EMRs, visit Dr. Kevin Pho’s informative post at http://blogs.usatoday.com/oped/2008/10/why-doctors-sti.html.  For more on the technical aspects, see Dr. Josh Schwimmer at http://www.healthline.com/blogs/medical_devices/2008/10/problem-with-emrs-in-united-states.html

Cheers!  Don’t let your hands cramp writing those SOAP notes!

What if Starbucks billed like ICD-10?

Ah, yes, ICD-10 is coming!  Yes, the new coding system with 10 times more codes than the previous is slated to go live in 2011.  Much of the world now uses ICD-10 because it has more codes, as apparently, we are running out of codes.  You, my beloved provider, will be shouldering the burden of the cost to implement the system.   A few reasons why this has made my normally smiling face curdle with disgust:

 

1.  There are TEN times more codes– all codes will be 7 digits, and then, yes, oh yes! You can add a modifier.  Simple, huh? 

“We are just now beginning to learn the increased costs on physician practices associated with moving to the ICD-10 code set – and they are staggering,” said William F. Jessee, MD, FACMPE, Medical Group Management Association president and CEO.

2.   It ain’t cheap.  Implementing the new coding system is estimated to cost $83,290 for a THREE physician office.  (See http://www.aapc.com/news/index.php/2008/10/icd-10-cm-coalition-press-release/).  At an average reimbursement of $50 per patient visit, that’s an extra 555 visits per year, per physician.  If a physician works 5 days/week, 48 weeks per year, this makes an extra 2.3 patient visits PER DAY!  If patients already feel rushed during their visits, think of it now!  And you know what, there’s not a dang thing the physician can do about it!  (Well, I guess concierge medicine might look more attractive…)

 

3.   You will wait even longer to get paid.  CMS (Center for Medicare and Medicaid Services), which is the government agency behind this change, notes: “…putting in the new system could initially boost by 10% the percentage of claims insurers return to doctors because of coding errors.“   (See http://blogs.wsj.com/health/2008/11/11/look-out-docs-here-comes-icd-10/)

 

4.   It’s another blow to primary care.  Many primary care offices are solo practitioners, or small groups (three or less.)  These are the groups least able to shoulder the cost of another complex government regulation. 

 

5.   You won’t have time to implement it.  You will need to learn the new codes, educate your staff, update your super bills and then change over your billing software to accommodate these new codes.   Most importantly, you will need to do some major cash flow planning.  (Yup, adding in an extra 65,000 codes takes time and money!)  This will be tough to do given the time frame the CMS is proposing.  Even the insurers want more time.  (Who’d a thunk it—me agreeing with medical insurance companies!)

 

6.   Get ready to buy more computers.  If your practice wants to be efficient, you will need computers in each exam room to quickly file the charges.  This is on top of the mandate that medical practies move to an EMR.  (Who’s going to fund THAT?) (See: http://www.ama-assn.org/amednews/2008/09/08/gvsa0908.htm).

 

7.   Beef up your documentation.  You want to get paid?  Prepare to be exacting!  The reason for a medical chart has changed—it used to be so that we could develop a working diagnosis and plan, based on history and exam to treat a patient.  You poor dinosaur! A chart is a way to get paid! 

 

8.   It will drive up the cost of health care.  The cost of soft ware, computers, training, IT support and the like will first be passed to physicians, and then eventually to patients.  There is no such thing as a free lunch!

 

9.    Patient care will suffer.  As physicians, we are ever more focused on computers, documentation, crossing Ts and dotting I’s.  Who will focus on patients when we are focused on coding?

 

10.   We will lose more primary care physicians.  Small practices, in rural/underserved areas can not afford the implementation involved in transitioning to ICD-10.  Implementing  ICD-10 will be a nail in the coffin of areas that desperately need primary care physicians the most.

 

I was thinking about opening a coffee shop.  I could code and bill for beverages as follows: a small cappuccino would be a 99212(01), a medium 99213(02), and a large a 99214(03), and jumbo would be a 99215(04).  I could add modifiers to denote skim, 2% or whole milk.  Shots of flavoring would require modifiers as well. So, a medium, skinny cappuccino with a shot of hazelnut would be a 99213(02)-7-13  (taking into account the ‘skinny’ or -7 and the hazelnut -13.)  I would of course charge you, the customer, more for my nifty billing system.   I also could bill based on how LONG it takes to make the beverage.  I don’t know why Starbucks doesn’t do this.  It seems so efficient.

The Medicare No Pay, Never Ever List

The Centers for Medicare and Medicaid Services announced 10 hospital acquired conditions for which it will not reimburse.  The no pay rule has been in effect since October 1.  So, with out further ado: (drum roll):

“Stage III, IV pressure ulcers

Fall or trauma resulting in serious injury

Vascular catheter-associated infection

Catheter-associated urinary tract infection

Foreign object retained after surgery

Certain surgical site infections

Air embolism

Blood incompatibility

Certain manifestations of poor blood sugar control

Certain deep vein thromboses or pulmonary embolisms.”  (List from AMedNews.com Aug 25, 2008).

CMS began to implement the no pay rule October 1, 2008.  Physicians will still be reimbursed for their services, but hospitals will not be reimbursed for their portion of the care.   Now, I don’t know about you, but I agree  some of the events are absolutely “never-ever” events  (retained surgical object, blood incompatibility), but some of the other conditions are out right ridiculous.

My colleagues and I have come up with some ideas on how to respond to this latest demonstration of government “efficiency.”  We have proposed “buttocks rounds”, where the wound RN examines every patient’s behind and charts presence/absence of pressure ulcers.  We thought it especially important to do this on those 35 year old youngsters we are obligated to admit for chest pain.  We also thought that perhaps we could have a “fanny cam” to take pictures, so our documentation would be impeccable.  We advocated noting that all patients had decubs at admission, but the hospital administration shot this one down.

Our next suggestion was that every patient, no matter what, should have an admission urine analysis, to document presence/absence of infection.  There could be a little check-in kiosk where the patient signs in, hands in a credit card for the hefty co-pay, and pees in a cup.  The patients could even dip their own urine, and record it on their check in information to speed the process up and decrease labor costs.  Additionally, we thought surveillance ua’s would be helpful in all patients with urinary catheters, probably daily.  Got to nip that e. coli in the bud!  We also considered putting a mandatory quinolone on every order set for patients with catheters, but became concerned when we realized c. diff may soon be added to the no pay list.  It may be worth a try for now, though!  Too bad about the cost of all those extra ua’s.

As to falls, I have little to offer on prevention of the noscomial hip fracture.  Our hospital uses bed alarms (frequently it requres a doctor’s order, though), and of course we can always get a sitter.  (However, all the hospitals where I work discourage sitters secondary to cost.)  Occasionally we try to get family members to stay with the sun downing patient,  but they rarely do.  Now that Granny is in someone else’s care, they will give some sage advice, like “Don’t use ativan, or haldol, or ambien or seroquel, because Granny gets really nuts with those.  And don’t restrain her either.  Bye.”  They then hurry to the car for their first meal out in months.  Who could blame them? 

CMS is planning on expanding the no pay list to ambulatory settings, nursing homes and home health agencies in 2009. 

I am always in favor of intelligent uses of government regulation, but someone missed the boat.  What do you say we make some fanny cam rounds at CMS?