Don’t Write Off E-prescribing

I may appear to be somewhat of a troglodyte, but I actually have  committed myself to learning to love technology.  I am the proud owner of a smart phone, have mastered my email, and actually use two different EMRs.  So, you see, this qualified me as an expert on EMRs and e-prescribing (wipe that smirk off your face!)

It was with interest that I read “Effect of Electronic Prescribing With Formulary decision Support On Medication Use and Cost” in the December 8/22 2008 issu3e of Archives Of Internal Medicineby Michael Fischer, MD, MS et al.  The authors describe a study in which physicians using e-prescribing with formulary decision support were compared with physicians using traditional paper prescriptions with respect to prescribing tier 1 medications.  When prescribing electronically, the physicians were more likely to choose the lower cost generic tier 1 medication.  There was a 3.3% increase in tier 1 prescribing, with a decrease in tier 2 and 3 prescriptions.  Fischer et al estimate that this would result in an $845,000 savings per 100,000 patients, based on the assumption that each patient filled one prescription per month.

I love saving money, but what was the cost of saving money?  According to the authors, “government estimates of approximate first year costs were $3000 per prescriber.”  In the study, Blue Cross Blue Shield supplied the software to the physicians, along with a free wireless device, access to a secure Web portal, licensing and wireless carrier.  So, the cost was not borne by the participating physicians.

I think as a first step toward an EMR, e-prescribing makes sense.  I do not think that every insurance company should provide physicians with it’s wireless device.  Can you imagine, five different devices for five different insurance companies?!

So what is to be done?  The federal government must mandate one SINGLE e-prescription system that we all should use, and insurance companies should bear the cost, based on percentage of patients enrolled in each plan.  Why should health insurance plans pay?  Because they are the ones that will enjoy the savings!  I think this would be an effective way to usher in the beginnings of an EMR.  Mr. Obama and Mr. Daschle, are you listening?

As physicians, we must look for ways that we can use e-prescribing efficiently and effectively.  We must commit to learning all the bells and whistles, and using it to our advantage.  So, stop hiding behind your prescription pad, and make way for what is inevitable.  Get out there and lobby for what should be done, rather than whining when we get handed the bill for something that will most benefit the health insurance industry!

Link Fest: Updates on group visits, RVUs, Medicare and the ‘Physician Shortage’

I’ve been storing up some links and today seemed to be a good time to have at ’em!  They range from the scary (Health Policy and Market) to the fun (the Efficient MD’s slide show.)

Read The Country Doc Report for another take on the group visit.  Country Doc relates how his practice does a group diabetic visit.  He uses smaller group sizes, and describes the three phases of the visit. 

For  an RVU Review, and exactly WHAT the RUC is, and how it effects you, visit Health Care Renewal blog. Boy, did I learn a lot about how we as physicians get paid (or not, as the case may be!)

To increase your understanding of the complexities of Medicare, Medicare Advantage, and Medicare Gap, see Insure Blog.  You may want to have this posted at  your front desk as patients come in with their “red white and blue” cards.

Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.

I love ways to improve my efficiency, and enjoyed the  fun, short  The Efficient MD’s  slide show.  I love his blog, and wish he would post more often!

For a chilly take on the role of physicians in the future, visit The Health Policy and Market blog.  According to the blog, we have plenty of doctors, and a “federal physician workforce policy” should be in place.  Just what I want, the federal government interfering even more into the business of health care! 

Establish a federal physician workforce policythat achieves the goals of organized care. TDI research has shown that the U.S. does not need more physicians; we have enough to care for America’s needs well into the future.

Let me know YOUR favority business of health care posts and I’ll put ’em up!

The Common Sense Declaration: How to Fix Health Care

I am on a reading frenzy, and finally got to the October 17, 2008 issue of Medical Economics.  There was an excellent article by Elizabeth A. Pector, MD, on fixing health care.  I will highlight some key points, but encourage all of you to see the entire article (pages 29-33.)  (www.memag.com)

“Establish equal rights for doctors.”  Dr. Pector advocates appropriate reimbursement, taming the paper tiger, and reigning in “etitlementiasisis” by patients.  Bravo!

“Improve access to doctors.”  She again targets physician reimbursement, but my only question is “how”?  Increasing physician reimbursement will be a tough sell in today’s economic times.  Sadly, I don’t see a way off the office visit treadmill that is the bane of primary care existence.

“Stop the blame game.”  Our society has turned into expert finger pointers.  Bad things just happen.  People die.  Sometimes, physicians make mistakes.  We need to have mutual respect between patients and physicians, rather than mutual antagonism.  And hey, tort reform wouldn’t be so bad either!

“Establish workable technology standards.”  Amen.  “We need to establish workable standards for PHR and EHR systems, including mutually compatible communications platforms.  Also, cash strapped doctors need help to fund changes…”  Technology is here to stay, but we need a coherent direction for all of health care, such that physicians and patients can access records through out the spectrum of medical institutions (clinics, offices, hospitals, nursing homes, etc.) 

“Stop punishing doctors and hospitals.”  See my previous rant on the medicare never ever no pay list.  The no pay list will continue to grow as Medicare pokes its fingers into patient management.  The no pay rules range from common sense to absurd, but there seems to be no one reigning in the free wheeling CMS.

“Take responsibility.”  Americans need to pony up and take responsibility for their choices, rather than shifting the responsibility elsewhere.  This will take giant social change, from throwing out the television and X-box to eating meals that don’t come in a “super size.”  Are we up for the challenge?

“Refocus the health insurance industry.”  Pector notes that physicians should be paid for what they do, with out the “gamesmanship” so common today when dealing with health insurance companies.  Additionally, she notes that insurance companies could actually (don’t faint!) assist in helping patients follow through on life style changes and medical compliance.

I think Dr. Pector is my twin sister of a different mother! Keep fighting the good fight, Dr. Pector!

Wave the Wand: The Medical Home Mandate

I am intrigued with the idea of the “medical home”. 

When hearing about the concept, my first thought was, isn’t this what we are trying to do already? 

My second thought was–and just how are we going to pay for all this?

Below is ” Crossing the Quality Chasm: 10 Simple Rules for the 21st Century Health Care System,” from the National Committee for Quality Assurance.  I will go through these ‘rules’, and the lengthy explanation from the PDF PCMH_Overview_Apr1{[1}pdf.  This will take a couple of posts, so don’t glaze over on me.  And yes, there is a homework assignment at the end!

“Crossing the Quality Chasm put forth “10 Simple Rules for the 21st Century Health Care System” to guide the redesign of the health care system. These rules underlie PPC (Physician Practice Connection) and describe a system different from most health care today.
1.  Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits.
2.  Customization based on patient needs and values. The system of care should meet the most common types of needs, but have the capability to respond to individual patient choices and preferences.
3.  The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them.
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.
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.”

 

PookieMD’s cross examination/rebuttal on items 1-3:

“Care is based on continuous healing relationships.”  This the very basis of primary care, and always has been.  The remaining docs that are weathering this storm and staying in primary care stay in it for the relationships!  They are certainly NOT in it for the abundance of pay! 

“Patients should receive care whenever they need it…”  Wait a minute!  Who is GOING to provide this care? At what cost?  Who is going to revise the entire insurance/medicare/medicaid system to accommodate this?   You can’t just start mandating that physicians start changing their practices WITH OUT PROVIDING THE TOOLS  TO DO IT!  (Monetary and otherwise.)  Please, please, please do  not set bench marks with out putting deep thought, strong policy and appropriate funding behind it.

“Customization based on patient needs and values.”  As physicians, we try desperately to accommodate patients’ needs and values.     I doubt that ANY physician is trying to force something on a patient that is NOT consistent with the patients’ needs and values.  I think that what is neglected here is the fact that PATIENTS MUST HAVE A PERSONAL RESPONSIBILITY IN MAINTAINING OR REGAINING HEALTH.  Many times a patent’s needs can NOT be met–it just isn’t possible with out a magic wand.  The patient must have as much stake as the treating physician in the wellness process.  Many patients do NOT recognize that their behavior contributes directly to their illness, and desire to just lay back passively and have the physician wave the magic wand.  (For an incredible case in which a patient demanded wand waving, read about a Rheumatologist who was sued and had to pay $400,000 because he didn’t provide an interpreter for a deaf patient.   Visit http://www.pointoflaw.com/archives/2008/10/doctor-held-lia.php.)

“The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them.”  I love it when patients have an opinion.  I also know that I need the TIME to review information and decision making with patients and families.  This is woefully covered in the ‘counseling codes’, and is frustrating for both patient and physician to do in a limited time frame.

All right, enough for today.  Your homework is to read the rules, and see how they apply to YOUR practice.  Then,  think of HOW you will implement them, and what resources you will need.  I’ll go through the rest, and try to dig up some real numbers on the cost.  I’m not dumping the concept, I’m just applying the light of  reality.

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.

Black Tuesday For Primary Care: Why Physicians Would Rather Do Anything Else

I have been in practice for 15 years, and most of my colleagues hate primary care.  (Remember, I come from a cohort of internists, the ones that should be the defenders primary care!)  In my rovings as the ExtraMD I still do some primary care, to keep me honest, and to remind me how hard primary care is.  Here are 9 reasons why most of my doc pals don’t do primary care:

1. The pay stinks. Consider this, my fellow refugees from primary care,: the average primary care physician in the U.S. earned $183,332 in 2007. A nurse anesthetist makes about $160,000 per year. (Think about the differences in school and training, as well as life style.)

2. Coding is really fun. Just to perk you all up, starting October 11, 2010, there will be a brand spanking new ICD, the ICD-10! According to Medical Economics October 3, 2008 (page 17) ICD-10 will have about “10 times the number of codes as ICD-9″.

3. You are a hamster on a wheel. The average physician spends just over 50% of their office time with patients, with 25% of their day taken up by answering calls and writing refills and reports.

4. You are a shrink. Here’s what it’s like in the trenches: “Even conscientious physicians …face many obstacles in delivering mental health services to their elderly patients who are depressed and suicidal.” (J Am Geriatr Soc. 2007;55(12):1903-191. And it’s not just the elderly that are depressed, “reliable estimates suggest that symptoms consistent with depression are present in nearly 70% of patients who visit primary care providers.” (The Journal of the American Board of Family Practice18:79-86 (2005). Hmmm, how much time can a physician spend with a depressed patient and get paid for it? Yes, you can code for counseling, but gosh, a colonoscopy sure pays better!

5. Insurance companies make life miserable. A typical primary are office has several staff members devoted to teasing out the tangled web we call health insurance. How much overhead does this add?

6. It’s not good mind candy any more. One of my favorite things about medicine is the diagnostic puzzle. Those days are limited to viewing episodes of “House.” Rather, we are mangers of chronic diseases, trying to find joy in motivating patients to change. (We are not well trained to motivate behavior change, but should be!)

7. You got an MD, rather than an MBA. Primary care medicine requires understanding the intricacies of practice financial management, insurance companies, marketing, HR, and ambassadorial level negotiating skills. Last time I checked, this wasn’t included in the standard medical school curriculum.

8. The environment is hostile. Patients have been fed a steady diet that physicians are uncaring sharks. We spend a fair amount of time dealing with patient anger, and more time yet dealing with re-education. Patients do have real grounds for complaints about waiting times, rushed physicians and lack of continuity of care, but this just adds to why physicians hate primary care.

9. A lot of stuff is unfixable. We’ve come a long way, baby, but we can’t fix everything. As a physician I want to make it all better, and patients certainly want it too! But I can’t, and boy is it frustrating.

So, keeping with my philosophy that if I complain about something, I should have ways to make it better, my next post will be on practice level AND global ways to make primary care better.   (I will have to do a lot of thinking on this, so send me some comments to get me started!!!)

Entering the Lions Den: Negotiating With Health Plans

Fighting with insurers isn’t something I anticipated doing when I was in my “save the world through medicine” phase (?haze?) during medical school, but none the less, here we are!  I came across an interesting article in Modern Medicine titled: “You Can Negotiate With Health Plans,” by Robert Lowes,