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!

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Medical Practice as a Socially Responsible Business

I have searched for a way to describe my view of medicine as a business.  I finally realized that the practice of medicine should be classified as a socially responsible business.   “Who cares?”, you say.  Well, I say we all should care.  We went into medicine to help people.  However, as I am fond of saying, we can’t help people if we don’t keep the doors open.  We need to have a way to do both.

So how to reconcile the two visions?  We have the altruistic Norman Rockwell picture of the benevolent physician examining a young girl’s doll directly opposing today’s appointment packed, hyper regulated, law suit filled world.  I propose we view our practices as socially responsible businesses.  So what does this mean?

  1. Owners of socially responsible businesses realize that making money is important.  Practices need to stay in business, pay their employees a competitive wage and make a decent living for the physician owners.
  2. Owners of socially responsible businesses realize that as a practice grows, non-financial benefits grow.  You CAN see patients who can’t afford to pay, or can only afford to pay a little if your medical practice/business is financially fit.
  3. Owners of socially responsible businesses realize that non-financial benefits have financial costs.  The socially responsible business may have to absorb higher costs and accept smaller profits.  NOTE: I didn’t say run the business as a charity!  By definition a business is NOT a charity!
  4. The socially responsible businesses/medical practice has at it’s core a mission to provide quality health care AND stay in business.  The two are NOT mutually exclusive, but must intertwine and co-exist.  One must feed the other.
  5. Government intervention and big business are not appropriate business models for socially responsible medical practice/businesses.  Physician owners must start from the ground up and build a profitable, socially responsible business model that DOES NOT involve government intervention.  Additionally, the typical frenzied profit taking by big businesses is not an appropriate model either.
  6. The socially responsible business/medical practice must seek efficiencies where ever possible.  Creativity is a core value of the socially responsible medical practice/business.
  7. The socially responsible business/medical practice avoids “short termism” and “poor governance and regulation, misaligned compensation and incentive systems, lack of transparency, … poor leadership and a dysfunctional business culture.”  (Quote from Al Gore, http://www.careerjournal.com/article/SB122584367114799137.html)  This means that the physician owner is in the medical business for the long haul, and has a clear vision as to where the socially responsible medical business/practice should go.  It means the physician must learn HOW businesses operate, and how to manage the practice in a long term sustainable fashion.
  8. The socially responsible business/medical practice behaves as if people and place matter, because they do.
  9. The socially responsible business/medical practice believes that time is money.  Therefore, it doesn’t waste the time of patients or physicians.
  10. The socially responsible business/medical practice embraces technology, but realizes that government mandates to REQUIRE technology will drive the socially responsible medical practice/business OUT of business.

For more resources and thoughts on the socially resonsible business of medicine, see www.bcorporation.net  View the declaration of independence on “b corporations” at:  http://www.bcorporation.net/index.cfm/fuseaction/content.page/nodeID/9e7f627c-487b-41f1-975b-5adfeceffbb4/  See also Ode Magazine, December 2008, pages 21-25.)  This issue is not yet available on line, but website is www.odemagazine.com.  I have no alliance with the B Corporation.net, or Ode Magazine.

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!

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!

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.