Health Care Health Care Reform

Thirty Dollars…Really?

I am riled up—almost to the point of being inflamed.

I hate it when doctors get dragged through the mud. It’s a matter of pride. Doctors are my team.

The latest kerfuffle centers on how much we should charge for return patient visits. The difference here is between moderate and moderately high visits–or about 30$.

From the Center for Public Integrity

When the Center for Public Integrity is investigating your profession, it’s unlikely to be good news. And it wasn’t. This time however, the usual baddies (back surgeons, cardiologists and other high-paid specialties) were not the culprits. Rather it was the worker bees of Medicine—office-based doctors.

In an exhaustive review of Medicare billing databases over the past decade, CPI found that doctors have gradually billed at a higher complexity for return patients. The Cracking the Codes investigation is exhaustive but can be boiled down to just this: a flip-flopping of Level 3 (of 5) codes for Level 4. The lowest codes and highest code did not change much. Again, the delta here is about 30$.

There’s a lot been said on this matter already. My take is that it should serve to remind us of the big picture of what’s wrong with US healthcare.

Start with the givens:

  • US healthcare costs too much.
  • We consume too much of it.
  • We overemphasize medicines, tests, procedures and surgery.
  • We undervalue cognitive tasks.

It’s well known that the US healthcare model favors doing. Procedure-related specialties like mine are compensated much more favorably than non-interventional fields. My thumb injury this summer illustrates this point: After having hand-surgery, I sat out of procedures for 6 weeks. This didn’t mean I missed work; I still came into the office and saw patients. As wonks say, I evaluated and managed patients. As I found out when looking at my productivity-based paystub recently, E & M work pays less than procedures—substantially less. And it was much harder work seeing patients all day. I know; this is not news.

Neither is this idea: That one way to reduce over-consumption of expensive health care is to emphasize office-based doctoring. The dreamy notion holds that doctors could take the time to learn about their patients, educate about healthy lifestyles, thoroughly explain treatment alternatives—including less-expensive stuff like giving a disease a tincture of time to abate naturally. Atrial fibrillation is a good example: I can (almost) do an AF ablation in the same time it takes to really explain all aspects of AF care to a new patient. One hour in the office with an AF patient pays about ten-fold less than that amount of time in the EP lab burning the atria. Truthfully, sometimes I question which hour is more valuable.

My wife’s work as a hospice and palliative care doctor offers another example of misplaced incentives. The human suffering relieved by hospice doctors is staggering. We will all die, and those not blessed to pass peacefully benefit immensely from skilled and compassionate end-of-life care. But again, in the time it takes my wife to see a new patient, address their goals of care, implement a treatment plan and give counsel to a grieving family I could implant two ICDs—and make more than ten-fold more.

It’s not right.

If we do one thing to change our healthcare system for the better, it would be to truly and wholly incentivize cognitive, non-procedure-based doctoring. We need the smartest doctors on the front lines of healthcare. We need them wanting to be in the office helping people to not need so much care.

That’s why I hate that the implications of “Cracking the Codes.” It suggests malfeasance on the part of doctors who do E & M work. Nothing could be further from the truth. As a lot, these are hard-working people doing important work. And even if you posited an over coding of level 4 visits, the impact is peanuts compared to the widespread over-use of really expensive care. Doubters can follow me for a tour of an ICU or emergency room—or even a cath lab.

Doctors that evaluate and manage patients in the office aren’t the problem. The problem is that we don’t have enough of them—because we don’t value their work. My friend and colleague, Dr Wes Fisher suggests that we compensate by time spent rather than boxes checked. That’s a good start.

Another would be to do the obvious:

Pay more for listening, guidance, wisdom and compassion and less for scans, procedures and surgery.


7 replies on “Thirty Dollars…Really?”

All of the problems you point out are real. The incentives are out of whack. Docs are frustrated and trying to cover expenses. Some feel like they’re doing everything they can just to keep their heads above water.

As a patient, Doctors are my team too. I love the guys and gals that take care of our family. I think mine are better than average and I want their paycheck to show that so they can focus on me and my family instead of office overhead.

None of that is justification for upcoding. Upcoding is cheating. It’s lying. It destroys trust. That’s no small thing for a Doctor.

Upcoding is like grade inflation in the academic world. At first, those doing it seem better off. The students seem smarter, or the office bills are being paid. Before long, lots of people are doing it and they’re not as well off as they thought.

It becomes normal and expectations (or reimbursements) adjust to the new normal. Now every student has only A’s and B’s, and every office is billing for more expensive services. Colleges have realized this and discount the inflated grades at admission. Payers have realized the game and adjusted reimbursements to make their total payouts the same.

Now, the only people being hurt are those who are still playing it straight. The teacher who didn’t lower his standards is standing alone in the wilderness. The provider who wouldn’t fudge the codes.

The system isn’t fair. What else can one guy do to stay afloat against a non-sensical and bureaucratic payment system? No one listens when he explains that he can’t stay in business at current reimbursement rates.

But fudging, adjusting, rounding up a bit……………….cheating?

Speaking of incentives – is this really the behavior we want to reward?

And there’s that issue of trust. Sold at what price?

I am on Medicare Advantage plan and I can see what the code is billed to my insurance co online.

My former PCP (changed for insurance) is my age (66 at the time) seemed to be to be under billing for the amount of time spent with me. I ask him how many years of medical school did it take to learn the ICD codes. He said that the would never have gone to med school if he knew that he had to deal with all of those codes.

I noticed that after I questioned it after a year he started billing some at the higher codes.

I agree with you completely, Dr. Mandrola. With the proper knowledge, there is so much people could do for themselves to get (and stay) healthy. Even though I’ve had an ablation and a mitral valve repair before that, I’ve always felt my primary care physicians were my first (and best) lines of defense. We need to nurture many more of them and people need to take responsibility for their own health, not abuse themselves for a lifetime and expect the specialists to save their lives.

My understanding is that the upcoming is the result of computer-generated coding. The truth is that most PCPs probably chronically undercode. They deserve the extra $30.

My own PCP has told me many times that he would be happy to give up fee for service in exchange for a fixed salary to look after a roster of patients. He feels he would be a far more effective doctor if he didn’t have to deal with the minutiae of health care billing.

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