1) Some doctors are strongly motivated to perform procedures for monetary gain.The dangling carrot of a large (relatively speaking) financial incentive motivates medical decision making for some physicians.
2) As the WSJ just reported, defensive medicine plays an enormous (much bigger than any can every truly quantitative) role in health care costs. Can anyone say low probability chest pain? Imagine for a moment that I got a fever in the middle of the night. Now imagine I was admitted to the hospital to r/o bacteremia. Now replace fever with chest pain, and bacteremia with MI and you will see how silly it is to admit ever friggen chest pain that walks in the door. That's defensive medicine for you. Miss one (put any condition here) and you become a dart board for legal missiles.
3) Statistical reporting of mortality data by the Medicare National Bank, and the desire to look good on paper drives local surgeons in my community to refer cases with higher expected mortality or complications to academic meccas of the world. Cases the surgeon I spoke with felt could very well be handled at our hospital. Unintended consequences of health care reform and of payment scales and data reporting.
The purpose of any player in an established system is to manipulate it to ones own advantage.
Now, substitute the word player for doctor, hospital, patient or insurance company. Add that to your list of certainties in life.
As an aside,
I found out last week that there are Congressmen who believe a medical home is the same as a home visit by a physician. And we wonder why Washington is in gridlock. Nobody knows anything except what they get paid to know.
Regarding you aside, most politicians are blithering idiots.
ReplyDeleteThe only bigger blithering idiots are the blithering idiots who vote for these blithering idiots.
Begs the question what role greed plays in the system. Specialists' for high margin procedures, patients' for lottery lawsuits, generalists' to see quick and easy cases and refer anything that might slow the day and politicians who.....
ReplyDeleteShould reform centre on preventing the ability to maniputlate the system for extraordinary payouts? Would this not redistribute resources (read turn the tide so people want to become GP's again) and minimize defensive medicine (read tort reform).
Wouldn't the data collection remain the same in the market system?
ReplyDeletejust out of curiosity, the specialists you talked to admitted they personally were doing procedures for money or they thought they saw their competing colleagues doing so?
ReplyDeletei remember the surveys of physicians being influenced by pharma reps-queried physicians believed that (something like) 90% of physicians were affected by pharma pitches. yet < 25% said they themselves were affected.
laugh. i am impressed if your colleagues fessed up to being personally so moivated to doing inappropriate procedures. (would that decrease your referrals to them?) not saying it doesn't occur, but impossible to know how much without carefully reviewing each case.
We're all guilty of performing procedures for monetary gain, even yourself. You've said that you are an expert in coding charts and take pride in knowing exactly what documentation is necessary to bill for a certain level of care.
ReplyDeleteIf you know that insurance will reimburse a level 5 charge for a given diagnosis and you could actually make the diagnosis and provide appropriate treatment by only checking enough of the checkboxes to justify a level 4 charge for a given visit, then if you ever document more than is actually required you are as guilty as the rest of us.
In the ER, the difference between a level 99284 and a level 99285 is simply including the family or social history (which I never NEED to do to make my diagnosis and provide the proper treatment) so I consider myself "guilty" too.
If the government (and thus the insurance companies) continue to fix our prices, then we'll find a way to game the system to obtain the reimbursement that we think we deserve. I don't personally have an ethical problem with it, but let's call it what it is.
anon0836: glad you asked. We're talking about partners in the same group. And in fact even a hint of personal motivation from the doc I talked to. It is very clear to me that money is not the only, but is certainly a powerful motivation for practice style. I have discussed procedural medicine billing in my previous entry entitled "Red Headed Step Child". You can search for it in my blog from the side bar at the top of the page.
ReplyDeletescalpel. As I stated on the blog entry:
ReplyDelete"The purpose of any player in an established system is to manipulate it to ones own advantage.
Now, substitute the word player for doctor, hospital, patient or insurance company. Add that to your list of certainties in life."
When you say I am guilty. I am guilty of knowing what to document and how much to document. I am guilty of knowing the rules that E&M has established in order for me to get paid without being accused of fraud. So, yes, I'm guilty of coding correctly. Do I think a 95 year old needs a family history. Heck no. Does Medicare say I need a family history to get paid? Yes. So I must document the family history of a 95 year old to get paid. Other wise a level 3 admission automatically becomes a level 1 admission.
It is ridiculous and silly, but those are the rules of engagement.
In just about every patient that is sick enough to get admitted to the hospital, it is my duty as an internist to provide them with comprehensive care. That means a full history. A full physical. If a patient does not need either, I do not bill for it and I do not do the work for it.
I have a strong problem with the unnecessary proceduralizing of a patient just to get paid. And I have a strong problem with it because I imagine myself as that patient. So I guess I'm selfish like that.
nickel. Yes, and it does happen.
ReplyDeleteIs it not the duty of a Cardiologist (for example) to provide thorough care as well? An argument could be made that many echocardiograms or stress MIBIs are unnecessary (in fact, you almost made such an argument indirectly, and I would agree with you).
ReplyDeleteBut I don't see the difference between charging more for including unnecessary historical data (like a family history on a 95 year old) to increase one's charges and doing an extra ECHO. Both involve doing semi-unnecessary things in order to get paid, because that is what the government has decided that we must do if we want to maximize your charges.
You already admitted that you don't think a 95 year old needs a family history, but you do it anyway "to get paid." What you meant was, to get paid MORE. Or to get paid closer to what you think your evaluation is really worth. You'd still get paid if you didn't include it, just not as much as you would otherwise.
You can rationalize it if you wish, but I think it's the same thing as what the proceduralists do.
scalpel. I don't have a problem with using procedures to evaluate a patient. I have a problem with unnecessary procedures under the guize of patient evaluation, for the sole purpose of making money.
ReplyDeleteYou are correct. I would get paid for a level one admit if I spend 1 hour and did a complete history and physical, minus the family history. You are also correct that I would get paid a level 3 history and physical if I added the family history.
You argue that I'm no better because a family history is an unnecessary part and I am doing it to get paid. Well, if you look at it like that, then yes, you could say that just about every patient that gets admitted to the hospital, about 90% or more would have irrelevent family histories. One could argue that 90% of admissions should only qualify for a level 1 admission because the family history is unnecessary. If you believe that I overbill 90% of my admission because I do an unnecessary family history, so be it. I can live with that accusation.
If you can't see the difference between documenting a family history to get paid, and doing an echo to get paid, maybe some others readers can shed their views. I see a clear and distinct difference.
Linked!
ReplyDeleteAs a patient, I would like to know just how much the question "do you smoke?" actually costs me, especially if I've been asked it numerous times and the answer is always NO. If I'm paying a percentage (or full) cost of the exam, it certainly seems as frivolous as admitting me to the hospital for a 5-day IV steroid infusion to treat an MS flair when it could more easily be done as an outpatient.
ReplyDeleteIf the family/social history has absolutely no bearing on the diagnosis and treatment protocol, in the same manner that being admitted for infusions which can be completed in under 2 hours daily may not be necessary, then I do believe they are equally inappropriate.
Why is everyone trashing family/social hx? For social hx, asking about alcohol use would be relevant for most patient encounters. If asked in an intelligent manner, family history can also be helpful in many cases, though I admit it is less helpful for older patients. In my own sleep medicine practice, I find asking about family hx of sleep disorders very helpful, even if the patient's diagnosis is obvious and I have the polysomnogram results in front of me. If I am telling a patient that their polysomngram showed osa and I know that they have a close family member on cpap for osa, that allows me to tailor my explanation, and my discussion with that patient would be different than for someone with no familiarity with cpap. I have no ethical problem with documenting fam/soc hx to improve my billing.
ReplyDeletei agree with scalpel. you are documenting unnecessary bits of information to achieve what you think the appropriate level of reimbursement should be, rather than using the bare minimum to safely care for the patient. of course, alternately you could bill by time and not need the sf hx so i guess that's not completely true.
ReplyDeleteit still sounds to me like the answer was "no i don't personally do procedures for money (subjective hints aside), but i think i know people who do, maybe even people in my own group."
what are you going to do with this information? don't you have a responsibility to out them, if you believe inappropriate procedures are being done? you could retire on the fees from being the whistleblower.
Unnecessary coding to get paid is the same category of crime as unnecessary procedures to get paid... just like stealing a candy bar is in the same category as stealing a car.
ReplyDeleteHowever, I personally think it is probably important to take the magnitude into account. Stealing the plasma costs the victim so much more than stealing the candy bar.
Likewise, ordering an ekg is probably a crime of greater magnitude than sneaky coding.
Note that invasive/risky procedures improperly ordered are even a step worse than ordering an ekg.
These are all technically the same crime, but some are worse than others.
Morality may be a whole different issue... should the government have a right to set prices for your service? Then again, you signed up for this game!
Unnecessary coding to get paid is the same category of crime as unnecessary procedures to get paid... just like stealing a candy bar is in the same category as stealing a car.
ReplyDeleteHowever, I personally think it is probably important to take the magnitude into account. Stealing the plasma costs the victim so much more than stealing the candy bar.
Likewise, ordering an ekg is probably a crime of greater magnitude than sneaky coding.
Note that invasive/risky procedures improperly ordered are even a step worse than ordering an ekg.
These are all technically the same crime, but some are worse than others.
Morality may be a whole different issue... should the government have a right to set prices for your service? Then again, you signed up for this game!
As a retired pathologist and therefore pretty peripheral to this issue, I just have 2 observations:
ReplyDeletea. Obviously I no longer take patient histories, but in medical school I was taught that the family/social history, as well as review of systems, physical exam, etc. was an integral part of examination of the patient. Somehow a lot of these things have fallen by the wayside, unnoticed by even we docs. Are they really that irrelevant? I think not.
b. Gaming the system also extends to my specialty, in which immunoperoxidase stains are reimbursed at a much higher rate than routine 'special stains.' Did my group order unnecessary immunoperoxidase stains to raise the bill? Yes we did, although it was unspoken and not so blatant as to make any member speak up. One is gradually corrupted by rationalizing that we are just "following the rules", and "everybody does it." After watching Wall St., there should be a lesson there......
The public is woefully over-educated about certain conditions and not educated about others.
ReplyDeleteWe've been taught to go to the ER immediately to rule out the 1% case if we encounter any of the following problems:
Chest pain
Trouble breathing
Sudden severe headache
Numbness/tingling
Stiff neck plus headache
Etc.
All those "public service" announcements about early warning signs of this and that have just made us afraid without telling us the hundreds of other things (or non-things) that could be wrong. They also delude us into believing that these things can be caught far earlier than possible.
I don't think any of the people who flee to the hospital at the first sign of chest pain will be able to tell you what bacteremia is. They'd probably be brought in when they were obviously very ill, rather than being brought in just in case they might be very ill in the future.
That's the whole problem, really. We believe doctors can catch things early, before they present their full constellation of symptoms and detectable lab results. But doctors generally can't. The tests and the diagnostic criteria have limits.
But your patients don't realize this. They think medical science is incredibly advanced -- you can do a head to toe MRI and detect everything that is wrong with them before it ever becomes a problem... right?
The debate that we are having about this post could be resolved if health care acted more like a free market instead of having all of the stakeholders beholden to the third party payer who makes the rules - but that isn't likely to happen soon. What is considered necessary and unneccesary is always in the eyes of the beholder because this decision is often a dialogue between patient and doctor with ulterior motives by both parties. However, since we must covertly ration care the rules are set by the third party and we as physicians act in our own self interest as long as it doesn't harm the patient - that is human nature. I don't beleive that any specialist does procedures knowing trying to increase harm to their patients. Rather they see the actions as adding benefit with acceptable risk (colonoscopy rules out colon cancer - small risk of perforation). The difference between additional procedures and additional history is the risk of harm to the patient. Little harm from asking questions - potential significant harm from procedures.
ReplyDeleteI'm sure no one cares about what a college student has to say, but THIS is one of the reasons I fear joining the field of medicine.
ReplyDeleteI just don't want to be put in those situations where my ethics and the ethics of my profession are challenged... every friggin day.
What a load of crap =o.
I would agree with what Dr. Rack said above. Don't think I share the same level of cynacism about FMHx and SocHx. The patient is often telling you what they are worried about when they tell the Family history, which is as important to concluding the visit successfully as making the "right" diagnosis.
ReplyDeleteThe young patient who brings up CAD in a bunch of second degree elderly relatives is telling you "I'm worried about coronary disease." You are going to be able to do a much more effective job reassuring him about a normal workup if you acknowledge that concern and put it into appropriate perspective.
To anonymous commenter just above me- here's a free message from the clue bag. EVERY profession has ethical challenges. To be a human being is to be challenged to live a more examined life every single minute of the day.
You don't think contractors, mechanics, lawyers, accountants and hourly wage workers are sometimes (or daily) tempted to game the system? Exaggerate bils? Lie? Pad billable hours? Take something home from work? Steal business before moving to a new office? Punch out later than the work was actually done?
I think it's a sign of health that we have a discussion like the above and are calling each other and our profession to accountability.
And to HH: If you stop putting those portions of the history down on your H and Ps and your billing charges dropped a level or two consistently, would you be able to stay in business? I don't think anyone expects you to go out of business to satisfy your existential guilt.
Interesting discussion - Echo Doc
And "unneccessary echos" . . .
ReplyDeleteWTH??!??!?
Is there such a thing?
ok - kidding. Echo Doc