Policy changes Policy.

While roaming on Sermo today I cam across a post titled "Medicare only allows one body part". This came from a doc who referred a patient to physical therapy for low back pain and a shoulder injury. The physical therapist indicated that Medicare would only pay for "one body part" at a time. Which lead the doc to suggest that their patient has more than one body part. While this may seem funny, it is but a long string of unintended consequences for patients, hospitals and doctors alike as instituted by the Medicare National Bank. Just look at the unintended consequences of health care reform.   How does this relate to hospitalist medicine? I see it every day, mostly on the gastroenterology front. Dr Wes described how the games CMS plays with payment is affecting his bottom line in electrophysiology. If you do more than one procedure on the same calendar day, you get paid less and less for each additional procedure.

In response to the Sermo post, a gastroenterologist explained something I have known for a long time. When two endoscopic procedures are done on the same day, such as EGD and colonoscopy, the physician gets 100% of the going rate for the higher paying procedure, but only 50% of the going rate for the second procedure. The classic patient example in my practice is the unexplained abdominal pain or nausea or diarrhea. The full work up often includes both of these exams. The 2006 Legislative Annual Report for the American Gastroenterological Association lays it all out:

AGA continues to press for relief from Medicare’s multiple procedure discount policy as it applies to unrelated endoscopic procedures. The policy, implemented in January 1992, reimburses unrelated surgical procedures performed on the same patient on the same day at 100 percent of the fee schedule for the highest-valued procedure and 50 percent of the fee schedule for the next procedure.

It is not a mystery to my why my patients often get a colonoscopy and an EGD on two different calendar days, often delaying discharge by 24 hours. It is not a mystery to my why they must spend an extra day in a hospital to get a second dose of sedation for a secondary procedure. While they're waiting, they get another E&M charge from me ($60 or more). They get another E&M charge from the gastroenterologist ($60 or more). They get another day in the hospital to get sick (priceless). They take up a bed for another Medicare paying client.

I will let the Medicare policy speak for itself. Unintended consequences are everywhere. This is but one more example.

By trying to save a buck on the front end, they have created an incentive to charge hundreds more on the back end, increase patient risk for complications, medication errors and contracting infections will siting in a building full of sick people. You can't legislate the market out of the market. This is the basis of the failed sustainable growth rate policies of our government, compounded by the politics of the RUC. Throwing a socialistic price fixing government mafia program onto participants that operate in a capitalistic cost structure is a recipe for the ongoing disaster known as American health care economics.

As long as we bury our heads and pretend that the delivery of medical care is not a business, we will continue to operate in a legislative cesspool of backwards policies, false economies, poker room politics, distrust and discontent by patients and doctors alike. Like it or not, the delivery of medical care is a two trillion dollar business. A business. The longer we fail to accept that, the longer the dysfunctional government policies will destroy the patient-physician relationship and bankrupt our nation.

If you want the government to take over all of healthcare, so be it. That means everything. That means hospitals, doctors, nurses, drug makers, device manufacturers. That means IT. That means software. That means billing and collecting. That means research. Everything. Everything must be socialized. That means unsustainable tax policies that will bury our nation in anti global competition. The current policy of financing private enterprise with socialist policies is giving us exactly what we pay for. Don't expect anything to change until the market is allowed to operate. How many other 2 trillion dollar businesses do you know where a client can go to jail or lose their professional license for accepting a meal from a vendor trying to operate in the business world called America. The whole system is simply ludicrous. It's ludicrous because my patients stand idle as a natural consequence of the system we operate in.