A – Maze – Ing!
Dr. Bob has posted Part V of his series: Medical Coding: Compliance Penalties. We’ve been through three mazes, waltzed with a gorilla … and now find ourselves cornered by a Rottweiler.
Dr. Bob gives a few examples to round out the picture:
In another case, in February of 1999, 37 armed, flak-jacketed agents carried out a Medicare raid on East Tennessee Woods Memorial Hospital, a 72-bed hospital in Eastern Tennessee. The invading army of armed federal agents stomped into the hospital, trampling through sterile areas, forced employees into a small room and held them. In another case, at Dr. Danny Westmoreland’s office in West Virginia, three armed federal agents invaded and held everyone at gunpoint, including the physician, his wife, patients, and children.
“Welcome to health care in the new millenium.”
Man! Am I glad I went into Medical Informatics (Health Information Technology) instead of Health Information Management …
Doctor Bob over on The Doctor is In is giving us lessons on how those poor MD type Dudes and Dudettes make out their bills. This is not easy reading … and it’s not for the faint hearted! This is “bust your brains” sort of nasty!
As much I hate the idea, I understand more and more why so many docs are going for hospitalist careers … getting a paycheck sure beats dealing with Government regulations and Insurance claims!
Those of you who are brave and daring … sit in on Doctor Bob’s class:
April 5th, 2006 at 7:35 am
What does one do in the Health technology field?
April 5th, 2006 at 2:07 pm
Moof, My brain HURTS just reading that stuff. :)
April 5th, 2006 at 6:47 pm
Amie … the Health Information Technology field is a Medical Informatics profession. There are 5 distinct fields within the major – Clinical Informatics, Bioinformatics, Public Health Informatics, Organizational Informatics, and Social Informatics. Each one of those deals with something different. I believe that I will probably end up dealing with will either be transcribing electronic medical records, or working on building EMR Software and databases. At least – those are my areas of interest. Thank you for asking! :o)
Hey Pattie! Yah! I hear you on that! There are several parts of Dr. Bob’s posts that I had to read more than once. Doctors really don’t have time to be doctors anymore – when they have to deal with all of that silliness.
You’re not too far away … have you heard about they did in Massachusetts? Everyone has to be insured! I can see some serious drawbacks to that. What it looks like from my perspective is the poorest people will have to purchase the most inexpensive insurance … which, being what it is, won’t cover anything of importance; they’ll end up paying nearly full price for their medical treatments and meds, and for the insurance on top of it.
I have a feeling it won’t fly nearly as well as some people think it will.
April 7th, 2006 at 12:56 am
Salut, Moof:
As I said on a post on Maze I, the whole billing debacle takes advantage of the good intentions of doctors. Most doctors don’t want to deny their patients proper care, so they provide the care that is needed and just let the accountants sort it all out. The problem is, the insurance companies have most of the accountants and surprise! they judge in their own favor almost all the time. The insurance companies are in a nice position: they can make reimbursement a misery without any accountability, but if a doctor fails to provide appropriate care immediately he is held accountable morally and legally. HMOs are legally exempt from malpractice suits, even though they tell doctors what to do on a daily basis. I don’t think there is a bigger injustice in our healthcare system than that.
Some of the most mortifying experiences I have had as a doctor have been forcing patients into levels of care they do not want (usually a transfer to a nursing home) because the insurance deems that the patient no longer meets “criteria” for continued hospital stay. Yet there is no reason for the transfer at all except that it saves the insurance company a few dollars!
As to the universal health care in Mass, I wish them well. There is such a lack of will to fix what really ails healthcare in this country that I think every attempt and failure is a step ahead. The way things are now, I believe every possible option that falls short or real reform will have to be tried and crash and burn before the system is fixed. So bring it on! Let every state try, let every state fail. Once everyone has been let down, and our system is in ruin, THEN we will get real reform.
I am ready to lose, so we can ultimately win.
April 7th, 2006 at 6:49 am
Bonjour Docteur Hébert! Un grand merçi pour votre visite.
I agree with you on the Mass health care plan. I left a comment yesterday on Dr. Bob Centor’s blog which expresses what I think of it. When I checked into there last night, there were a few more comments, all along the same general lines. I haven’t heard a good thing about the new bill from a health care professional yet.
The more I hear from physicians about what a massive Gordian knot health care has become due to insurance companies and government regulations the more I worry about “tomorrow.”
You said:
I do see what you’re saying, I even agree with the sentiment … but from the position of someone with a chronic illness who would flounder financially without insurance, and be unable to acquire the medications that keep me going … the thought of the health care system failing makes me hear the “tolling of the bell.”
And I know that I would be only one in the vast number of individuals who would be sacrificed on the altar of health care renewal … after all, the renewal wouldn’t happen overnight.
I believe that there are ways to turn this around – but I feel that those ways call for something totally different than insurance companies and government involvement.
If you involve a large, powerful organization in the decision making behind anything – it’s going to most often end up being about their greed, even if at first it may have been more altruistic. If you involve the government, they will only serve to complicate matters to such an extent that doctors will have to become file clerks, transcriptionists, and lawyers – who spend 5 minutes with a patient, and then 25 minutes on the paperwork. Both insurance and the government will also magically become the medical experts who tell physicians how they will doctor … and even more disconcerting – how they will not doctor …
Dr. Hebert … tell me, please – that there’s another solution …
April 7th, 2006 at 3:01 pm
Moof, No More! I can’t take it! :)
Yes, I did hear about the mandatory insurance coverage plan in Mass. I caught Mitt Romney in an interview on NBC Nightly News the other night. Apparently, those not in compliance will suffer fines, which will be deducted from their income tax returns. I believe only those people making less that 10 K will receive free health care coverage, and the rest on a sliding scale. Should be interesting to see how this plays out!
April 7th, 2006 at 3:45 pm
You want another solution. Fine. But I am not wholeheartedly behind any of them.
Solution #1 Make the system cash only. This is a radical, but sometime alluring prospect. Doctors would deal in nothing but cash payments. Patients have to settle their reimbursements separately with insurance companies. The hope is that insurance companies, having to deal with their paying customers (patients) instead of with independent contractors (doctors) will do away with most of the paperwork because they will not be able to jerk around customers the way they do doctors. Expensive procedures like bypass surgery would have to dealt with differently. Perhaps patients would get an insurance credit card to pay up front. Then the balance would be settled between patient and insurance company after. At any rate, doctors and hospitals are left out of this silly reimbursement game.
Solution #2 Offer doctors bonuses for low tech diagnosis. I once knew a cardiologist who could estimate the results of an echocardiogram with 5% by physical exam. The problem is, an excellent cardiac exam can take 15 minutes to do, and doctors get nothing for doing it. Easier to check off a form and send the patient off for the test. Many tests could be avoided if doctors were trained in good examination techniques. If I had a patient with questionable neurological findings, I could send him to a skilled neurologist for a second physical exam ($200) instead of sending for an MRI ($2000). But quess what? A referral can be harder to get approval for than a diagnostic test! If doctors were trained to practice cheaper medicine, and if insurance companies actively rewarded such behavior, we could put a lid on this thing.
Solution #3 Front load the system. That is, reimburse primary care docs and psychiatrists more. (I know this is self-serving, PCP that I am.) But primary care is so much cheaper than specialist medicine. I once knew an ENT who argued that patients should not have to see primaries first before going to ENTs for ear infections. His argument: “The patient knows it’s his ear. He should be allowed to see an ear doctor!” THe problem is that this knucklehead charges $150 for a routine visit; I was changing $55. Specialists are expensive! PCPs deal with front line problems and can save the system a bundle, if they are used properly. I also think more money can be saved through nurse practitioners. Too much money is being spent on secondary, advanced care, and too little on preventative. This obsession with the high tech is killling us.
Solution #4 Pay patients to have routine health screens. Yes, that’s right I said PAY them. I just got a 10% cut in my homeowner’s insurance because I put an alarm in my house. Why not do the same for patients? Don’t smoke, and get one month a year free. This will also save money.
Solution #5 Restrict end of life care. This is a tough, tough one, but if we get a handle on it, we will save ghastly amounts of money. At least 40% of healthcare expenses occur in the last 1 year of life. If we eliminated most of that we would save billions without much change in mortality. This approach means not putting 80 year olds on dialysis, and not resuscitating as many chronically ill patients that come into the ER with respiratory arrest. Insurance companies should require patients to sign advance directives. There has to be an aggressive public education campaign to get people to understand that everyone has to die one day and sometime all we can do is put the Inevitable off for a few weeks, or hours. I have seen, literally, $1 million poured into patients I knew had no chance of living more than a few months. I understand families have a hard time letting go, but their psychological weakness is taking health insurance away from people who can actually be helped. A lot of the problem with health insurance in this country is that no one wants to give up anything. We are willing to trade away some of our civil rights so the government can protect us from terrorism, but we refuse to give up our right to a $20,000 treatment that only has a 40% chance of adding 6 months to our lives in exchange for cheaper blood pressure medication. This does not make sense.
Solution # 6 Make me king. I promise I’ll be nice, and I might even let GW Bush get away with nothing more than a severe beating for that Katrina thing.
April 7th, 2006 at 3:47 pm
I take one of my statements back. I am not wholeheartedly behind any of my propsals except #6. #6 will definitely work.
April 7th, 2006 at 4:12 pm
Hello Moof,
I couldn’t read the posts. My wife/billing manager wade through this stuff every single day. Forgive me for needing a break!
best,
Flea
April 7th, 2006 at 8:46 pm
Pattie – I know you’re down in the Carolina’s … I hope your hubby gets the employ he wants! Is he going for a practice of his own, or going in with a group?
Bob is, indeed, writing some really hard stuff … I have to read some of it over and over to get it to sink in and keep on track. I can’t imagine having to deal with this stuff …
I have a course coming up real quick for the ICD-9 codes … that’s one I’m not looking forward to …
Safe trip back up here!!! Let us know how you’re doing!
April 7th, 2006 at 8:57 pm
Dr. Hebert … thank you again – so much – for dropping in, and taking the time to outline that for us.
You have some ideas I hadn’t heard before, and which I find really interesting. Some of those just might work! (Especially #6! ;o)
The only one that I really have to respectfully disagree with you on is #5. I just can’t swallow that one. I understand that people cost more within a year of when they die, but just having an arbitrary cut off age, and “letting ‘em go” beyond that magic date … is too inhumane.
My Dad – who’s been gone for 19 years now – was 84 when he died. He was riding his motor cycle to work when he was 82 … and doing roof work for my lazy brother when he was 83. I know a fellow who’s over 90 who’s an active missionary in South Africa … and lives in a hut!
Not all shoes fit the same foot.
Perhaps being more honest with terminal patients – of whatever age, and not pulling out all of the stops for the added 6 more weeks of agony.
By the way … King Hebert? Hmmm … if we overthrow the government to make you king, will we have a chicken in every pot, and a free flu shot every year? ;o)
April 7th, 2006 at 9:00 pm
Dr. Flea! Thank you for visiting my humble abode!
Dear heart … I would forgive you for anything, if you had actually done something you needed to be forgiven for! It’s not like you would need the lessons anyway!
Now … let’s talk about this billing clerk you have … isn’t that a bit like indentured labor? Or maybe … wife abuse? *cough* ;o)
April 7th, 2006 at 11:13 pm
Oh, I would never say there are strict age rules regarding end of life decisions. But doctors and patients need to do a much better job of identifying patients that clearly will not benefit from further medical intervention.
Somebody needs to let the word out — medicine is not about “saving” lives, what ever that means. It is about preserving and enhancing quality of life. If the quality is not there, medicine needs to step aside, and allow God and nature to run its course.
April 8th, 2006 at 5:55 am
Moof,
Yes, I’m in N.C.
The big teaching hospital in Charlotte has been wooing my husband to come down here for well over a year. The incentives were so good, he couldn’t pass it up. His job would be working with a small group of about 5 surgeons. He would be responsible for starting up the hospital’s hepatobiliary department, and compliment their liver transplant program, already in place. The job is his, we just have to figure out if this place is the right fit for us. Of course, everyone has been so nice, it’s hard not to think it would be a good move. I’ll keep you posted!
April 8th, 2006 at 10:31 am
Dr. Hebert … I agree with that, as callous as it may sound on the surface, it’s really counter-productive to give people false hope, rather than helping them to cope with where they are in reality. I’ve watched this play itself out over and over with people who have late stage cancer. Hope – right up until the last procedures, carried out only a week or two before death. It’s not right to do that to the patient, and it is a strain on health care.
Now, here, I don’t know if we both explored this statement further if I would agree with you or not, but I have several problems with it as it’s stated here.
To my understanding, medicine does have a role in “saving lives.” Perhaps the difficulty is more semantics than ideology. Emergency and interventional medicine is intended, according to my understanding, to save lives.
Also – I’m assuming that when you say that the if the quality of life is not there, that medicine needs to step aside, that you’re referring to a medical situation that is beyond any hope of redemption.
By the way … have you seen the posts over on Maggie’s Farm? The Old Doc has posted some very cogent and interesting ideas ….
I will be gone until later tonight … perhaps quite late … but I will stop in to check the comments and do a quick blog run.
April 8th, 2006 at 10:33 am
Pattie … that sounds really nice. Have you made any decisions yet? If you do, how soon will you have to move?
My only regret, as I stated earlier, was not having gotten to meet you first … since you’re relatively close by now.
When are you coming back home?
Please – have a safe trip!
April 8th, 2006 at 1:58 pm
Seriously, Moofie,
I resisted the idea of Ms. Flea getting involved in the business at all. When we reached a crisis point a few years back, at which it appeared we needed to do some serious belt-tightening or go bust, we fired our billing company and my wife took over. It saved us $10,000 in the first year.
It’s backbreaking work for her. I hope and pray someday we’ll be able to hire someone to take over so she can go back to being a sane person again!
best,
Flea
April 8th, 2006 at 8:23 pm
Shalom Dr. Flea! I’m glad that you were able to get on top of the financial concerns … and I hear you about wanting to be able to hire someone to do take over … it’s got to be tough on both of you – with your profession eating away at your lives like that.
I hope that you get a lot of time together to make up for the craziness. These are the best years of your lives … and they tend to be the ones that slip by like quicksilver – hardly seen, barely tasted.
April 9th, 2006 at 6:57 am
Moof,
If we move, it would be after July 1st. There’s still time! :)