March 1st, 2007 by Dr. Val Jones in Medblogger Shout Outs
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Dr. Rob, the author of “Musings of a Distractible Mind,” is really good at explaining difficult concepts. If you haven’t read his description of healthcare’s coding system, you should take a peek. It explains why documenting care is so complicated, how doctors try to “game the system” and what happens to them if they do.
Here’s a small excerpt:
“You see, what you get paid for an office visit is not based on what you do at that visit, it is based on what you document. The more you can document, the higher you can bill… There are several responses to this situation by physicians:
· Undercode to avoid the accusation of fraud
· Use EMR to document more and bill at a more appropriate level
· Code at the higher level without documenting higher and risk audit, jail, etc.
· Stop accepting insurance and just accept cash up front based on your own criteria
· Do other things besides office visits – such as surgical procedures, labs, x-rays, or other procedures that pay much better than the office visit. The pay for EKG with interpretation is nearly as high as that of the decision making that the physician makes that may save the life of the patient.”
So next time your doctor is delayed in seeing you… she’s probably trying to document all the right check boxes and codes for the last patient she treated!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 26th, 2007 by Dr. Val Jones in Expert Interviews
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I had the chance to speak with Jim Herndon recently about how the current healthcare climate is affecting orthopedic surgeons. He said that there are 3 things that worry orthopods:
- Decreasing Medicare reimbursement. In 1990, reimbursement for a total hip procedure was $2,200. In 2007, the reimbursement is $1,190. Medicare is planning to further cut reimbursement 30% in the next 4-5 years.
- Increasing malpractice insurance costs. Premiums are steadily increasing. In Boston, the average malpractice insurance is about $50,000/year. In Philadelphia, the cost is $150,000. And if you’re an orthopedic surgeon specializing in spinal surgery, malpractice insurance premiums can start at $250,000/year.
- Pay for performance. No one really knows how this will be applied specifically to surgeons (other than the obvious infection rates), but fears are mounting regarding how to show the best possible performance in one’s practice.
Let’s say that a typical surgeon in Philadelphia pays 33% in overhead (the hospital facilities, staff, etc.). Let’s say that he is also taxed 33% on his income. That means that he’d have to perform 382 hip replacements per year, just to pay his malpractice insurance. That’s almost 2 surgeries/day, 5 days a week, 11 months/year.
So what are surgeons doing? They are reducing overhead by setting up outpatient surgery centers (Dr. Herndon estimates that 60% of orthopedic surgery can be performed in an outpatient setting), they are increasing the volume of surgeries they perform, they are buying radiology facilities where they send their patients for XRays, MRIs etc. (Dr. Herndon explains that Stark Laws don’t prohibit this, so long as the physician takes on the risk of the facility – i.e. that he can potentially make or lose money), and they are financing physical therapy practices that supply therapy to their patients.
Orthopedic surgeons in private practice have become very business savvy in order to survive in this climate. But somehow I feel saddened by all this – the business of medicine is a grim reality that can create a wedge between the physician-patient relationship. A patient is left to wonder about the motivations behind tests and therapies – and perhaps even behind recommendations for the surgery itself.
I guess the second opinion has become more important than ever before?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 17th, 2007 by Dr. Val Jones in Health Policy, Opinion
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Within the past few years the Centers for Medicare and Medicaid Services (CMS) chose to enforce a rule (casually known as the “75% rule”) that resulted in denial of services to many heart, lung, and cancer patients requiring rehabilitation therapies.
CMS was looking for a way to cut costs in rehabilitation facilities, and decided to create a rule whereby these facilities would lose their approval status if they admitted too many patients with certain conditions. The CMS arbitrarily decided that 75% of all patients admitted to inpatient rehabilitation facilities had to have one of 13 diagnoses, or else the rehab facility would not qualify for Medicare reimbursement. Many important diagnoses were not included in those 13, including cancer, heart and lung disease, and many types of orthopedic injuries.
What does this mean? It means that getting admitted to a rehabilitation facility is no longer based on need, but on diagnosis code. Because of the financial pressure exerted by CMS (Medicare is the primary payer for most facilities) these rehab centers cannot afford to be delisted. So they turn away patients in need, for patients who have the “right” diagnosis.
What has this rule done?
- Limited clinical decision making by doctors – a physician is no longer able to recommend patients for acute inpatient rehabilitation purely based on their need for it.
- Decreased choice for consumers – people recovering from heart attacks, cancer or COPD (to name a few) will generally not be offered the opportunity to be rehabilitated in an acute, inpatient setting.
- Reduced quality of care – rehabilitation facilities specializing in oncology or cardiopulmonary rehab will need to divest themselves of aggregated expertise. Since these centers would no longer qualify for Medicare funding, they can’t afford to remain centers of excellence in these fields of medicine. Instead, they will need to turn their attention to the 13 diagnoses that qualify for inpatient rehabilitation.
- Puts lives in danger – patients who are not admitted to acute rehab will be forced to recover in nursing homes (also known as “sub acute facilities”) that do not have the level of expertise to take care of them safely.
The 75% rule is one example of the kinds of decisions that a government sponsored universal healthcare system will make. When one payer (government or non-government) develops a monopoly, their decisions can single-handedly limit consumer choice, prevent physicians from exercising clinical judgment, and decrease quality and safety of care. What will Americans say when the decision to fund organ transplants for people over 65, for example, is denied across the board?
When medicine is no longer applied in a personalized (case by case) manner, and population-wide rules are in effect, we will face ethical dilemmas far surpassing those we already have. A system that serves the needs of many still fails the needs of some – and when we lose the flexibility to “bend the rules” for the exceptions we will lose the best of what American medicine has to offer.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 14th, 2007 by Dr. Val Jones in Medblogger Shout Outs, Opinion
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In my last blog post, I unwittingly evoked vehemence on the part of those pro/con a single payer model for healthcare. And so in this post I’d like to offer some more food for thought (while attempting to dodge the high velocity tomatoes):
First of all, Dr. Reece summarizes things nicely, suggesting that this debate is not entirely resolvable:
Incompatible Mindsets
• If your mindset is that government’s moral duty is to redistribute resources to protect the health of all, and that health is directly related to the extent of health system coverage, you think and receive information in a certain way. You generally attribute superior health statistics of other nations to universal coverage, even if these other nations have more homogeneous, smaller populations, and different cultures.
• If your mindset is that private markets provide the best care for most of the people most of the time, provide better access to high technologies, give more health care choices to citizens, distribute resources more efficiently and that the health of the people is more related to cultural behaviors and a nation’s heterogeneous population, you receive information in completely different way.
The Unending Argument
The power and efficiency of government vis-à-vis the power and efficiency of markets is a never-ending argument – an argument unlikely to change mindsets. To progressives, it’s a moral argument: to conservatives, it’s an exercise in reality. You can marshal persuasive arguments on both sides, without convincing either side who is right.
An economics blogger explains why extending Medicare benefits to all would not succeed:
The dirty little secret behind Medicare is that it works only because it does not cover every American. Part of the reason for this is that Medicare’s payment structure is designed to pay doctors and hospitals in such a way as to limit total spending, rather than to ensure they can break even. Clearly, they have to do better than break even to stay in business, and the people running Medicare know that. Medicare depends on the fact that there are lots of non-Medicare patients out there who (through their private insurance) can pay enough to keep the doctors and hospitals in business. This is called “cost shifting.”
Whether pro/con single payer system, I think that we nearly all can agree on one thing: price transparency is morally right. It’s hard to fix a system if you don’t really know where the money is coming from or going to. I think it would be nice to have people on both sides of the debate work together for that common goal first. Would you agree?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
