I Couldn’t Say it Better: Medicare vs. Doctors

Http://Insureblog.Blogspot.Com/2012/01/Medicare-Vs-Doctors.Html    

Tuesday, January 17, 2012

Medicare vs. Doctors

Suppose you were self employed and the government decided not only which services they would pay you for, but how much you could accept and not a penny more as full payment for services rendered. How would you like that?

Believe it or not, that is exactly how Medicare treats doctors.

They provide them with a list of roughly 7500 different services that are reimbursable and then hand them a price list as well.

The doctor does not get to decide which services are best for the patient, nor are they allowed to set a price for their time. If a doctor CHOOSES to provide additional services not on the list because it would be of benefit to the patient they do so at their own expense.

Is there any chance that Medicare can get all those prices right? Not likely.

What happens when Medicare gets them wrong? One result: doctors will face perverse incentives to provide care that is costlier and less appropriate than the care they should be providing. Another result: the skill set of our nation’s doctors will become misallocated, as medical students and practicing doctors respond to the fact that Medicare is overpaying for some skills and underpaying for others.

The problem in medicine is not merely that all the prices are wrong. A lot of very important things doctors can do for patients are not even on the list of tasks that Medicare pays for. Some readers will remember our Health Alert on Dr. Jeffrey Brennan in Camden, New Jersey. He is saving millions of dollars for Medicare and Medicaid by essentially performing social work services to reduce spending on the most costly patients. Because “social work” is not on Medicare’s list of 7,500 tasks, Brennan gets nothing in return for all the money he is saving the taxpayers.

We have also seen that there are other omissions — including telephone and e-mail consultations and teaching patients how to manage their own care.

Welcome to Medicare. We trust you will enjoy the ride.

In addition, Medicare has strict rules about how tasks can be combined. For example, “special needs” patients typically have five or more comorbidities — a fancy way of saying that a lot of things are going wrong at once. These patients are costing Medicare about $60,000 a year and they consume a large share of Medicare’s entire budget. Ideally, when one of these patients sees a doctor, the doctor will deal with all five problems sequentially. That would economize on the patient’s time and ensure that the treatment regime for each malady is integrated and consistent with all the others.

Under Medicare’s payment system, however, a specialist can only bill Medicare the full fee for treating one of the five conditions during a single visit. If she treats the other four, she can only bill half price for those services. It’s even worse for primary care physicians. They cannot bill anything for treating the additional four conditions.

Who comes up with these rules?

Oh yeah, the government. That explains it.

Around the Web – Medicare Patients Readmission Rates Unacceptably High

Doctors have noticed these trends for years.  Because of insurance company pressures, we are sending patients home earlier and sicker.  There is pressure not to keep a patient in the hospital very long.  Are they being sent home before they are completely recovered?  Possibly.  Do you rest better in your own bed without someone coming in to take your temperature and blood pressure at 2 AM?  Definitely!

Medicare is now keeping track of how often patients who are discharged from a hospital are readmitted, and how soon this happens.  They have figured out that this costs them a lot of money.  Within 30 days, one in five people are back in the hospital (20%).  Within 90 days, one in three patients are back (34%).  This is costing Medicare over $17 billion per year.

Some patients develop infections.  Some patients have bleeding.   Something happens to an incision.  Something absolutely unrelated to the original problem will happen.  (Since when is a broken leg related to pneumonia for example?)  There are readmissions for medication problems.  People end up in the ER, and back in the hospital. 

Patients are leaving without really understanding what they are supposed to do when they go home.  Medications may have been changed while they are in the hospital.  They are unclear about which medications they are supposed to take when they get home.  Here are suggestions about what you as a patient (or caregiver to the patient who is coming home) should know and do:

1.     Know your diagnosis and any procedures that you had.

2.     Know when you should have a follow up appointment, and who it should be with (surgeon, family doctor, physical therapy, etc.)

3.     Schedule your follow up appointments ASAP.

4.     Make sure your regular doctor gets copies of any and all paperwork from the hospital.  If the hospital doesn’t send them, call your doctor’s office to let them know you were in the hospital so they can tell you how to arrange for records to be sent.

5.     Make sure you know what medications you are supposed to be taking when you go home.  Are you supposed to resume any of your previous medications?  Are any of the medications you are given different names for the same medications you take at home?  DO NOT LEAVE THE HOSPITAL UNTIL YOU KNOW THIS!!!!!

6.     Find out what you should expect that is normal.  Bruising?  Aches?  Swelling?

7.     Find out what you should look out for that is not normal.  Fever?  Redness?  Pain getting worse?  Shortness of breath?   

8.     What are you allowed to do?  What are you not allowed to do?  Lifting?  Showering?  Childcare?  Do you need someone with you?

9.     Who should you call if there is a problem day or night?

10.                        If you have dressings, stitches, a cast, drains or other surgical “stuff”, ask for directions on care and cleaning.  Ask about when things should come out. 

11.                        If there are test results that you are waiting for, ask how you are supposed to find out the results.

12.                        Before you sign any papers, make sure you understand everything.  Ask someone to explain it until you are sure you know what you are supposed to do.  Don’t let anyone rush you through this process.

13.                         If you have questions or problems after you go home, call the hospital where you were or the emergency number you were given.  We like to “head off” problems before they get big.  Sometimes a simple office visit will avoid a hospital stay. 

14.                         Bring a copy of all your papers to your follow-up appointment.

Hopefully these tips will keep you from having to go back to the hospital.  As doctors, once we send you home, we want to see you well and in our clinics or offices, not back in the hospital.  We hate those hospital gowns as much as you do!

http://www.washingtonpost.com/national/health-science/medicare-may-penalize-hospitals-that-readmit-too-many-patients/2011/10/18/gIQAAMTopO_story.html

“Uncompensated” Medical Care - Charity

Back in the old days, doctors used to do a certain amount of what they called “charity care”.  They would care for people who were truly poor.  They knew that they were not going to get paid in cash.

Sometimes a church, a school or some other organization would raise money to help pay some of the costs of that care.  People paid what they could.  They paid in chickens or pigs or apple pies.  If you couldn’t pay with money, you might come by and mow the doctor’s lawn or do some other work that needed to be done. 

Martha who kept the doc’s books would kind of figure out when your bill was paid.  Everyone (except possibly the IRS) was happy.

Sometime after WWII, employers started offering “health insurance” instead of increasing employee’s wages.  Doctors didn’t mind, because they got paid what they charged in real money. 

Then Washington decided that the government needed to get into the insurance business.  Medicare and Medicaid were born.  The government decided that it was not going to pay the whole bill.  Instead they would pay what they wanted to pay. 

More and more people qualified for these programs.  As the cost of the programs went up, what the government paid went down.  Doctors at first made up for this by working harder, and by charging other patients more. 

Insurance companies decided they didn’t want to pay the whole bill either.  They started to demand the same discounts as Medicare.  Doctors worked harder.   Patients got less time for each visit.  Our hours got longer.  Your waits got longer. 

Medicare and insurance companies developed more rules and regulations like prior authorizations, formularies, preferred providers and ICD and CPT codes.  Did that sound like a bunch of garbage to you?  Until I started “doctoring” it did to me, too.  They didn’t teach you all that stuff in medical school when I went, either.

Doctors had to hire people just to do the billing and “chase down the payments”.  Then they weren’t payments, they became “reimbursements”.  “Patients” became “Insureds” and office visits and surgeries became “claims” and “procedures”.  Insurance companies started “bundling” all your care.  Surgeons get paid the same no matter how many times they see you in the three months around your surgery.  OB doctors get paid the same for the entire pregnancy and 6 weeks afterwards.  It doesn’t matter how many times they see you in the office or the hospital.  The only thing that increases the fee is a cesarean section.  Some insurance companies won’t pay extra for that. 

There isn’t enough room here to discuss what happened when the lawyers got their fingers in the mixture.  Besides, my doctor wants me to watch my blood pressure.  Let’s just say that a lot more testing goes on these days to keep from being sued.  It costs lots of money and doesn’t add much to the answers we get.  Lots of paperwork ensues. 

Patients – pay attention here – that’s you! – are now so far removed from what things cost that they don’t care about what tests are done.  They want the CT scan or the MRI.  They want all the blood work, all the nuclear medicine testing, and all the consultants.  The insurance is paying for it after all.

Not really.  If you have private insurance, your premium goes up if you keep getting tests.  If you have “public insurance” the taxpayers pay for it.  Either way, it’s busting our system. 

Ask people who don’t have any insurance.  I have lots of them in my practice.  You see, I don’t take insurance any more.  I have gone from 4 employees to 1.  We will give you the papers to submit your insurance, but we won’t fight it for you.  That saves us hours on the phone.  I don’t participate in Medicare and Medicaid.  I don’t have to take those huge discounts.  So I get paid for my time. 

I get to spend more time with my patients.  My overhead is a whole lot less.  So I don’t have to charge for all those people that used to work here.  We have time to help figure out where the least expensive place for an MRI is and help our patients find other doctors to help them.  I also found a lab that gives discounts for cash.  We also decide what tests we really need, not what insurance will pay for. 

This is what I went into medicine for. 

Here’s another blog with another version of this:

http://roadtohellth.com/2011/11/why-does-the-cost-of-healthcare-keep-going-up/

Health Insurance 101-5 “Adjustments”

When an insurance company uses the word “adjustment”, they mean the discount they have “negotiated” (dictated) with your “provider” (doctor, pharmacy, hospital, nursing home…..).  This is the amount of the charge that they are not going to pay.  If the “provider” is “participating”, they cannot collect this money from you.  If they do not participate, they can collect this money from you. 

Generally speaking, the doctor had nothing to say about how much the discount was.  If the group is large enough, or if they are the only group in town, they can cut down the discount a bit.  If the insurance company is powerful enough (think Medicare), this is not possible.

Electronic Medical Record Rant 2

Meaningful Use

Last week my EMR got updated.  I’m finally almost making peace with software, so they have to change it.  They tell me that they are getting rid of some bugs and updating so I can meet “meaningful use criteria”. 

The gobment has criteria that they want every chart to cover in order to meet their criteria for “meaningful use” of the EMR.  So far I have discovered some of them.

1.     They want me to ask every one of my patients if she smokes, how much, and for how long.  I’m not sure what that has to do with a yeast infection, but…..

2.     Every patient is to have a height and weight, so we can determine a BMI.  This stands for body mass index.  The gobment wants to know if you are fat.

3.     They have not fixed the ranges for height.  A woman under 5’ or over 5’10” is out of range for the EMR.

4.     I must give a certain number of my patients written educational materials and document this.  If I don’t meet their %, I don’t get Medicare incentive money.  Since I don’t participate with Medicare, I don’t care about this.

5.     I must give a certain percentage of my patients written instructions and document this.  Same issue as #4.

There is no place for

1.     Did you explain to the patient what is wrong with them?

2.     Did you answer all the patient’s questions?

3.     I have a GYN practice.  Every patient is female.  One statistic I really need is when a woman had her last period.  There is NO place for this.  My pediatrics, family practice and several other specialty friends say that this is important to them, also. 

They did build in some sort of medication sheet that will follow which medications are prescribed by date.  This is encouraging.  Now, if I could only figure out how to get the sheet that I have been keeping since 1995 loaded into the computer…. (Oh, computer geeks, where are you?)

Meaningful use is hard to do when you are an old fart.