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When Fraud Isn’t Fraudulent: RAC And The Spanish Inquisition

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Dr. Rob Lamberts does an admirable job explaining why physicians are worried about the Recovery Audit Contractor (RAC) approach to identifying Medicare fraud. Complying with Medicare coding and billing rules is so difficult that physicians regularly resort to undercharging for their services, just to avoid the perception of fraudulent practices. Any medical practice that bills more than average is potentially subject to RAC audit, and the auditors themselves are paid a commission for finding “fraud.” In many cases, the “fraud” amounts to insufficient documentation of appropriate and necessary work performed by the physician.

Dr. Rob writes:

The complexity of E/M coding makes it almost 100% likely that any given physician will have billing not consistent with documentation.  Those who chronically undercoded (if they are still in business) are at less risk than those who coded properly.  Every patient encounter requires that physicians go through an incredibly complex set of requirements to be paid, and physicians like myself have improved our coding level through the use of an EMR.  This doesn’t necessarily imply we are over-documenting, it simply allows us to do the incredibly arduous task of complying with the rules necessary to be paid appropriately.

Have I ever willingly committed fraud?  No.

Am I confident that I have complied with the nightmarish paperwork necessary to appropriately bill all of my visits?  No way.

Am I scared?  You bet.  The RAC will find anything wrong with my coding that they can – they are paid more if they do.

Dr. James Hubbard writes:

It would be fine if they were truly looking for fraud and abuse, but they look for some technicality or just a different interpretation. Forget about any recourse. A few years ago, I was asked to pay Medicaid back $5000. I protested they were completely wrong with their interpretation of their findings. The auditors said I had to pay it, but could argue for a refund by sending forms and proof to the “review committee”. I did that and received a reply that the $5000 was too small for the review committee to take up. I stopped taking Medicaid.

Sounds like the Spanish Inquisition, doesn’t it?

***

For more excellent analysis of the subject, I strongly recommend Dr. Rich Fogoros’ recent book: Fixing American Healthcare.

The “Dark Horse” Of HHS: Place Your Bets

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Merrill Goozner has been speculating about who will be nominated as the new Secretary of HHS. He reviewed his most likely candidates (David Cutler or David Blumenthal), and threw in a “dark horse” potential nominee: Ken Thorpe (whom I’ve interviewed several times on this blog and spent time with during Obama’s inauguration ceremony).

Tommy Thompson told me that the nominee is likely to be a current or former democratic governor (such as Kathleen Sebelius or Howard Dean).

But I’ve been pondering the “long shot” question and think that Goozner may have missed a more obvious choice – someone who works with Ken Thorpe at the Partnership to Fight Chronic Disease: former Surgeon General Dr. Richard Carmona.

Here are the 10 reasons why Richard Carmona would be a smart choice for Secretary of HHS (in random order):

1.    He was confirmed by the senate as Surgeon General in 2002 and lived under their scrutiny during his term of service, meaning he has no hidden secrets, tax or nanny problems likely to embarrass Obama and could be confirmed rapidly – perhaps in under a week.
2.    He has forged extensive good relationships with both parties over the course of his tenure as Surgeon General and is known internationally.
3.    He has been the CEO of a large, public health system (including hospitals, Medicare and Medicaid clinics, nursing homes, and emergency medical systems in Arizona).
4.    He has been a paramedic, nurse, and physician and understands the healthcare system from the inside out.
5.    He has a track record of leadership in prevention, preparedness, health disparities, health literacy, global health and health diplomacy. He has worked on both sides of the aisle, including assisting Senator Kennedy with issues of disability and socio-economic determinants of health.
6.    He is Hispanic, which adds additional diversity to the Obama leadership team.
7.    He has experience managing local, state and federal health programs, including significant experience in immigration and border health issues.
8.    He demonstrated competency and leadership as manager of the US Public Health Service of over 6000 uniformed public health officers both nationally and internationally.
9.    He has extensive military experience, and is a combat-decorated Vietnam veteran. He maintains a strong relationship with military surgeons general and the department of defense.
10.    The fact that he is a political independent might actually provide a middle ground for parties with differing agendas in health reform.

Is point number 10 a deal breaker? It may be, but Obama could look farther and do much worse. And while the clock is ticking and credibility is paramount (as Maggie Mahar wrote, “Reform needs to be overseen by someone who is perceived as being above suspicion—purer than Caesar’s wife”) I think the Obama/Biden team needs to take a closer look at Dr. Carmona. He’s actually the most experienced, low risk candidate under discussion – and could truly hit the ground running at HHS. And wouldn’t it be nice to have a physician who is also a health policy expert with advanced managerial experience at the head of the healthcare reform table?

Parents need to know about vaccine safety

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By Stacy Beller Stryer, M.D.

After my blog last week discussing the recent increase in Haemophilus influenzae B (Hib) cases in Minnesota, I received a comment from “Indian Cowboy,” who is a blogger and fourth year medical student. While Indian Cowboy admits that he isn’t completely against vaccines, he does question their safety and says that, “if my (future) patients were to ask me specifically, scientifically, what the risks of vaccines are, I would be forced to shrug my shoulders and say I actually have no idea.” He suggests that pediatricians, in general, are not open and honest with their patients about any side-effects associated with vaccines. Furthermore, Indian Cowboy comments that he is a member of the “current generation of medical students,” where evidence-based medicine is important. Does this mean that we old-timers (yes, I am an ancient 45 years old), don’t practice medicine based on results of quality studies and proof of what actually works?

 

That is far from the truth. My colleagues and I practice medicine based on what has been proven to work and not just what we learned on a whim. We continue to read reputable journal articles and other medical literature, often discussing treatment changes based on new research. And I do not know any pediatrician who makes a blanket statement that vaccines are 100% safe. Personally, I spend a fair bit of time talking to parents who question vaccine safety. I tell them that anybody can have a reaction to a vaccine, just like anybody can react to an antibiotic, food, or something in the environment. I also discuss more common side effects of vaccines, such as fever, redness, and irritation at the injection site. In addition, I mention that there are very rare, more serious side effects associated with some vaccines, such as seizures and encephalitis. I am certainly not the only honest pediatrician in the United States. In fact, reputable organizations such as the Centers for Disease Control (CDC), which are major advocates for vaccines, clearly state on their website that no vaccine is 100% safe or effective.

 

Just as importantly, and an absolute necessity is discussing that the risk of becoming seriously ill or dying secondary to a vaccine is much lower than the risk of developing a serious illness or dying if a child becomes ill with one of the infections for which they could have been vaccinated. Parents must be aware of the benefits of receiving these vaccines. And they should know that vaccines are one of the greatest medical discoveries of the 20th century and have increased life expectancy and quality of life significantly.

 

Back to Indian Cowboy – he also comments that we really don’t know much about vaccine safety because studies only last days or, at most, a couple of weeks. This is also far from the truth. Before a vaccine is licensed, the Federal Drug Administration (FDA) requires testing. Once the vaccine is being used, the CDC and FDA look for any problems and investigate them through the Vaccine Adverse Event Reporting System. It’s true that this system depends on pediatricians and parents to report side effects. This was recognized as a problem, so in 1986 a National Childhood Vaccine Injury Act was developed which, among other things, required experts to intensively review any possible adverse effects of vaccines. In 1990 the Vaccine Safety Datalink project was developed, where researchers gained access to the medical records of over 5.5 million people to evaluate for common and rare side effects associated with vaccines. All of these different safety methods have led to changes in vaccines to make them safer. In 2000, children began to receive the inactive polio instead of the live polio vaccine due to the rare risk of developing polio from the oral vaccine. More recently, the pertussis vaccine was changed from a whole cell to an acellular one because of the increased risk of rare neurological side effects.

 

I could continue, but the bottom line is that immunizations have been tested extensively for safety and continue to be monitored by reputable, quality organizations. There is an abundance of information available on safety for every vaccine. It is true that we cannot assure parents that their child will not develop a severe allergic reaction or a rare side effect to a vaccine. And we cannot say that we are 100% sure that vaccines do not affect the brain or the immune system, such as we cannot assure them that they will not get into an accident when they step into a car or that they will not be hit by a car when they cross a street. But we can reassure them that the chances of such an event are rare and that the benefit of receiving the vaccine far outweighs the risk of not receiving it.

 

I certainly hope that the one case of epiglottitis and pertussis that Indian Cowboy saw last year makes him realize not only how serious these infections can be in infants and children, but also that he only saw one case of each whereas, without immunizations, he would have seen many more and, most likely, a few deaths.

 

Philadelphia College of Pharmacy and Science Is Planning To Honor Quackery

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David Kroll, Ph.D. and I share more than an appreciation for bibs and crab legs (pictured at left during our recent “academic” rendezvous) – we are pro-science bloggers who want to understand the evidence for (or against) health treatment options, both in the natural product world and beyond. At our recent meet up at The Palm we discussed homeopathy – a bizarre pseudoscientific approach to medicine often confused with herbalism. Homeopaths believe that “like cures like” (for example, since an onion causes your eyes to water and nose to run, then it’s a good cure for a cold) and that homeopathic remedies become more potent the more dilute they are. So if you want a really strong medicine, you need to mix it with so much water that not even a molecule of it is left in the treatment elixir. Of course, homeopathy may have a placebo effect among its believers – but there is no scientific mechanism whereby tinctures of water (with or without a molecule of onion or other choice ingredient like arsenic) can have an effect beyond placebo.

David graduated with his B.S. in toxicology from one of the most prestigious schools in the country, the Philadelphia College of Pharmacy and Science (PCP&S). In the early 1900s PCP&S graduates were critical players in combating snake oil hucksters and establishing chemical standards, safety, and efficacy guidelines for therapeutic agents. So it was with utter amazement that he received recent news that PCP&S was planning to award an Honorary Doctorate of Science to a major leader in homeopathy – on Founders’ Day, no less.

“Our founders would be rolling in their graves,” David told me. And he wrote a letter of complaint to the University president which you can read here. This is a choice excerpt:

Awarding Mr. Borneman an Honorary Doctor of Science is an affront to every scientist who has ever earned a degree from the University and, I would suspect, all current faculty members who are engaged in scientific investigation. Homeopathy is a fraudulent representation of pharmacy and the pharmaceutical sciences that continues to exist in the United States due solely to  political, not scientific, reasons. Indeed, homeopathic remedies are defined as drugs in the Federal Food, Drug, and Cosmetic Act [21 U.S.C. 321] Section 201(g)(1) as a result of the 1938 actions of U.S. Senator Royal Copeland (D-NY), a noted homeopath of his time. But scientifically, homeopathic remedies are nothing more than highly-purified water misrepresented as medicine based upon an archaic practice that is diametrically opposed to all pharmacological principles.

Honoring people who actively promote pseudoscience is wrong in many ways as David points out. I would also add that doing so confuses the public. If academic institutions committed to scientific integrity lend their names to cranks, then it makes it more difficult for the average person to distinguish quackery from science. I have the utmost sympathy for the patients out there who are trying to figure out fact from fiction in medicine. That is why I have a “trusted sources” tab on my blog – please click on them for guidance regarding health information you can trust.

As for PCP&S, if they value their academic principles (as no doubt many within the organization do) the president should rescind his offer to honor Mr. Borneman’s “entrepreneurial spirit” on founder’s day (February 19th, 2009). Finding a way to sell water to people as cures for their diseases is certainly entrepreneurial – but I see nothing honorable about it. I hope that President Gerbino sees the light before founder’s day.

The Value Of “The Oath”

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By Steve Simmons, M.D.

When I graduated from the University of Tennessee’s Medical School sixteen years ago, my last act as a student was to take the Oath of Hippocrates with my classmates and 98% of the other medical students graduating in the United States that year.  This oath still resonates within me today and connects me to all physicians reaching back over 2,500 years to the time of Hippocrates.

Implicit in an oath is the understanding that the profession chosen will require more sacrifice than the average vocation, that the occupation’s rewards should be more than a paycheck, and that a paycheck would impart less value than the enrichment gained from nobly serving others.  The high standard which society holds physicians to is still accurately described by the Hippocratic Oath. Regardless of what changes seep into our profession from outside influences, doctors will always be held to the ideals written in the Hippocratic Oath.

When I was a young medical student, the hope that becoming a physician would bring value and meaning to my life was more rewarding than thoughts of job security or financial stability.  This helped propel me and my classmates through many long nights of study.  One sentiment oft-heard in my medical school, and I suspect many medical schools today, was that no one would put up with ‘this’ just for money–usually stated prior to a re-doubling of the effort to get past a particularly challenging task.  Painful physical effort often was required, such as waking at 3AM to make hospital rounds,  or spending 24-hour long shifts stealing naps and bathroom breaks, sometimes even working over 100 hours a week during demanding rotations.  Steven Miles, a physician bioethicist, wrote, “At some level, physicians recognize that a personal revelation of moral commitments is necessary to the practice of medicine.”

I would proffer that few students would endure the sacrifices necessary to graduate without understanding this point.

In Paul Starr’s 1982 book, The Social Transformation of American Medicine, he stated that in the future the goal of the health industry would not be better health, but rather the rate of return on investments. This unfortunately has come to pass.  Arguably, medicine now is controlled by CEOs and other executives in the health industry — individuals who are not expected to take an oath.  Physicians, remaining loyal to the Oath, are an unwitting weak and junior partner in today’s health care industry.  Worse, doctors are now employees, often seen as interchangeable parts with one doctor considered no different than another. Third party providers in the health care industry fail to place any value on the personal interactions between doctor and patient.  It may be better that the CEOs of health insurance companies are not required to take an oath, since many are on record, admitting loyalty to the share-holder alone with profits their first consideration.

Before the Great Depression, only 24% of the U.S. medical school graduates were given the Oath at graduation.  Does this suggest they were less ethical? I don’t think so.  I believe the increased use of the Oath demonstrates a growing awareness on the part of our educators that business has taken a controlling interest in the practice of medicine and that their graduates should be reminded that society still expects them to deliver on the noble promises of the past.  Hippocrates’ Oath helped pry medicine away from superstition and the controlling interests of Greece’s priesthood in the fifth century B.C. Hippocrates plotted a course towards science using inductive reasoning while his Oath anchored his fledgling art on moral truths unassailable even today.  I suspect he would see little difference between those profiting within the priesthood of his day and those monopolizing healthcare today.   He would find familiarity in those putting forth their difficult-to-decode rules of reimbursement, recognizing these rules as intentionally confusing, pejorative, and detrimental to patients and physicians alike while profiting those few in control. 

How would Hippocrates advise today’s students and physicians when shown how monetary realities have finally subsumed us all?  He might remind us that money was not our motivation in pursuing this career and show us how a return to the reverence for our art, embodied by the Oath, could become a modern conveyance to the ideals of the past.  By regaining our reverence for what motivated and guided us through medical school and residency we should find ample courage to do whatever is necessary.  Much is needed to wrest control of today’s broken healthcare system from those making huge profits…. and an oath can remind us why it is important. 

Until next time, I remain yours in primary care,

Steve Simmons, MD

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