February 12th, 2009 by Dr. Val Jones in Expert Interviews, Health Policy
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I attended my very first Medicare Policy Summit conference today – and it was truly riveting (wonk alert). I took copious notes and will do my best to summarize some key points in a series of blog posts. This first post is devoted to the presentation by AMA President, Dr. Nancy Nielsen.
Dr. Nielsen began her lecture with an amusing story. She said, “congressional hearings are pure theatre” and described what she’d experienced three months ago at a meeting with Pete Stark. The conversation went something like this:
Stark: I’m sick of rich doctors driving up in their Porsches saying ‘I’m pulling out of Medicare.’
Nielsen: [Thinking to herself: First witness please?] I drive a GEO jeep.
Then Dr. Nielsen looked out at the Medicare Policy Summit audience and asked, “are there any doctors here?” I raised my hand enthusiastically at the back of the room. Then she responded, “Oh thank God. Well, you know we’re in the lion’s den…”
[Parenthetically, I didn’t see anyone else raise their hand – which is the subject for another conversation.]
What Is The AMA’s Current Agenda?
1. To expand coverage for the uninsured
2. To reform the physician payment system
3. To improve the quality and safety of healthcare
4. To improve public health
What Is The Bee In Nielsen’s Bonnet?
Nielsen explained that the sustainable growth rate is unsustainable. She stated:
“We can’t go through the annual death dance with congress over this. There is another 21% across-the-board cut in Medicare reimbursement scheduled for January 2010. And this cut will affect a group of small business owners (aka physicians) whose reimbursement has not increased since 2001 while their costs have increased 20%.”
What Does Nielsen Propose We Do?
1. Reform the system so that it reimburses for care coordination and prevention
2. Craft solutions based around patients’ needs
3. Rebase the SGR
4. Bundle services to increase value and reduce costs
5. Invest in disease prevention and wellness
6. Use comparative effectiveness to inform clinical decision-making (but NOT as a basis for coverage decisions)
7. Bring physicians into the policy decision-making process
Closing High-Five to Nurses
Dr. Nielsen closed with an amusing anecdote about inauguration day. Apparently she was standing in the sidelines of the parade route where Biden got out of his limo to greet the crowd. He gave a big hug to some nurses standing next to her and said, “I love nurses. They’re so much better than doctors.” Dr. Nielsen then had the opportunity to introduce herself to Biden and he responded, “Doctors saved my life, but nurses gave me the will to live.”
February 12th, 2009 by Dr. Val Jones in Humor, True Stories
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I volunteer at Walter Reed Army Medical Center (WRAMC) a half-day per week. I’m inspired by the soldiers in the occupational and physical therapy center, and am continually amazed by their abilities. The other day I watched a soldier with an artificial leg climb a rock wall better than I ever could, and marveled at a man who had both legs amputated above the knee – he was ambulating almost without a limp, and with the help of a straight cane alone.
As I watched these wounded warriors learning how to maximize their functional abilities – I overheard a staff member explain the reason why the Walter Reed hospital building is closing in 2011.
Apparently WRAMC is built on land owned by the District of Columbia. In an effort to subsidize the over-budget subway system, the city purposefully disallowed sufficient parking spaces to be built on the WRAMC site. The idea was to force staff to take the subway to WRAMC. The closest subway is a 20 minute walk from the hospital.
In addition to the limited parking, DC imposes a height restriction on all buildings in the district – they cannot be taller than the Washington monument. Therefore as Walter Reed grew and expanded, they could not add any floors to the hospital, but had to construct additional buildings on campus.
And so, in about three years time, Walter Reed will shut down, moving their remaining staff to the Navy hospital in Bethesda, Maryland where there is plenty of parking and no building height restrictions.
I’m not sure what the total cost of moving the army hospital to the navy center will be, but I’m guessing in the hundreds of millions. How much did the staff complaints about not wanting to walk to work play into all of this? I don’t know, but I’ve seen them drive in as early as 5:30 am to get one of the few parking spots. This attitude is consistent with Americans’ general unwillingness to adopt an active lifestyle, and it’s costing us all so much more than we realize.
It’s possible that laziness dealt the final blow to Walter Reed: a facility created to get people active again after war injuries.
How Ironic.
February 11th, 2009 by Dr. Val Jones in Primary Care Wednesdays
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By Steve Simmons, M.D.
Last week, my partner wrote about a game played between doctors and insurance companies. After reading his post, I recalled the time I first learned that modern medicine was something altogether different than what I had expected. I began my career as a primary care physician in 1996. Fresh out of residency, I was optimistic, naïve, and unaware that a very real game was being played. As time passed, I became a player in this game, but slowly realized that something of value was lost by my patients trying to translate their insurance coverage into health care. Likewise, the struggle to interpret the healthcare system for my patients caused me the same frustration that has led many doctors to leave primary care today.
Early in my practice I was eager to begin my career, relieved that my training was over. However, my training in the game had just begun. To my consternation, insurance company demands soon usurped the time I spent on everyday clinical problems. Often, I’d find my office stacked deep with charts waiting for my review and approval, a consequence of an insurance company changing a drug formulary involving dozens of patients. It seemed a day couldn’t pass without administrative staff requiring an explanation for a treatment I had already recommended so they could arrange pre-authorization.
Insurance coding was not taught in medical school or residency, yet it’s the primary language used to communicate with insurance companies. I needed to learn this ‘skill’ on the fly, using a code book to translate each medical diagnosis into a five digit number, with an additional number serving as a cipher to explain the type of work I had done for a patient. This code book does not contain some diagnoses and many of its diagnostic codes inaccurately describe medical conditions, causing inevitable mistakes that led to non-payment.
In Money-Driven Medicine, Maggie Mahar describes the 1990s as the time of HMOs, when reimbursement became paradoxical. Then, an HMO gave a primary care physician $10 a month per patient, regardless of what we did or did not do for that patient. If we saw our patient in the office we kept the co-pay, but nothing else was reimbursed. If we admitted a patient to the hospital, we received $0, resulting in lost office time, lost opportunities to see other patients, and lost revenue.
Some wonder why primary care physicians don’t go to the hospital anymore. Here’s why: They can’t afford to leave the office. They must stay put and move people through their office, which resembles an assembly line, if they want to stay financially afloat. When I observed that the only way to earn money caring for someone in an HMO was to never see them, my partner looked at an older colleague, smiled, and said, “He finally got it.”
Navigating nonsensical limits and rules became infuriating. One young man, brought to me by his tearful father, was hearing voices. Soon into my exam I realized he suffered from a mental illness. His plan stipulated the patient only could initiate mental health benefits, not a family member. However, the voice was telling him not to call; yet he agreed to see a psychiatrist if someone else would call. I spent well over an hour pre-authorizing his mental health benefit.
Examples include physical illnesses too. I diagnosed a cancer in a woman whose HMO offered only one specialist; someone I would not have consulted. With no choice, I referred her. Days later, she returned in tears stating that she would never see someone who knew less about her problem than she did. I agreed and spent the rest of the afternoon wrangling with her insurer to get a different specialist approved.
When I moved to the Washington DC area, I left primary care. For ten years I worked in urgent care, earning a steady paycheck while avoiding overhead expenses. I could go home without being followed by the constant frustration of trying to untangle impossible knots. Yet, I missed the opportunity to build relationships with my patients and was not using the skills I had developed. When given the chance to work in primary care again without the endless hassles, I seized it. Today, I am gratified to have returned to my calling. It is more rewarding to practice medicine outside of the current insurance model and I remain thankful to my partner at doctokr Family Medicine for the opportunity to do so.
Today, much is lost between patients and doctors. If physicians and patients could connect without so many distractions, primary care would, again, resemble a calling more than a job and the primary care shortage would not be reaching a crisis point. Too much time and effort is spent on a game controlled by endless rules and regulations; time that could be focused on the patient — who should be the true focus, after all.
Until next week, I remain yours in primary care,
Steve Simmons, MD
February 10th, 2009 by Dr. Val Jones in Celebrity Interviews
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Dr. Val & Mort Kondracke
I had the recent honor and privilege of having dinner with Mort Kondracke and his gracious wife Marguerite. Mort’s TV show, The Beltway Boys, offers entertaining and insightful political commentary each weekend.
Mort and I share a common medical interest: Parkinson’s Disease. Mort wrote an excellent book about his late wife’s battle with Parkinson’s. It’s called Saving Millie: Love, Politics, and Parkinson’s Disease. My experience working with patients with the disease has led me to become a supporter of the Parkinson’s Action Network (PAN). I look forward to seeing Mort at future PAN events, and I hope that the recent increase in funding to NIH will help to advance research in Parkinson’s Disease so that we may one day find a cure.
Also at the dinner: PAN CEO Amy Comstock Rick, Robin and Brian Strongin, and my husband Steve. Mort shared some personal perspectives on the famous political figures he’s interviewed over the years – and we compared notes on what they’re really like. Of course I won’t reveal the unsavory stories, but what I can say is that we both agreed that Bob Schieffer is one of the nicest people on earth. Go Bob!
February 10th, 2009 by Dr. Val Jones in Health Policy, Medblogger Shout Outs, Opinion
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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?
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For more excellent analysis of the subject, I strongly recommend Dr. Rich Fogoros’ recent book: Fixing American Healthcare.
