Monthly Archives: December 2013

The Next Government-Based Healthcare Debacle: Coding for Orca Bites?

Due to the ineptness of the Obamacare team and the debacle that has ensued, the botched rollout of the Affordable Care Act has dominated the political and medical headlines since October.  However, other healthcare changes are on the horizon (and have gone virtually unnoticed by the public) that have the potential to further disrupt our ability to treat patients.  In fact, the technical and time consuming aspects of these new government mandated changes for 2014 may result in even larger scale computer glitches than those seen with the infamous Obamacare website.  (if you can believe that).  This week in the New York Times, author Andrew Pollack describes a new government medical coding system that must be implemented in 2014.

For decades the Center for Medicare and Medicaid Services (CMS) has established billing codes for documentation and reimbursement purposes.  These codes are created by the World Health Organization (WHO) for the purposes of standardizing diagnoses in order to track diseases throughout the world–it allows for comparative study.  However, several governments (such as the US, France, Germany, Canada, and others) have long adopted these codes as a way to standardize billing for medical procedures.  These codes have long fallen short of specifically describing what is actually going on with the patient and have led to difficulties in accurately charging for medical services and procedures.  In brilliant fashion, there is now a new iteration of the coding system known as ICD-10 that will be mandated by the US government effective this fall.   Luckily, there are now codes for injuries that occur while skiing on waterskis that are on fire as well as codes for orca bites.  As you may imagine, these codes will certainly streamline my ability to treat my patients with these very very common ailments.

So why is it that our government and its agencies think that there administrators are well qualified to develop codes for medical diagnoses?  How is it that bizarre codes for humorous and extremely unlikely scenarios are being included and programmed into the system?  

If you ask CMS administrators, they will tell you that these new codes were adopted by the US government after careful consultation with coding experts, CMS administrators and physician advisors.  However, I am not exactly sure which physicians were involved in signing off on codes for “balloon accidents”, “spacecraft crash injuries” and “injuries associated with a prolonged stay in a weightless environment”.  The issue at hand is the fact that government is once again working to regulate situations and concepts that they do not understand.  Moreover, they mandate changes without adequate input from experts in the field in which they plan to regulate (such as physicians…)

What are the ramifications of ICD-10 and how might it affect healthcare delivery?

Certainly, if the healthcare.gov website is any indication, I would expect that the technology side of implementation of the new coding system is likely to be plagued with errors and inefficiencies.  Imagine developing software that will assist in billing and coding of numerous diagnoses for each patient–including “struck by a macaw” and “bitten by a sea lion” (yes, these actually exist).  ICD-10 will increase the number of available codes from 17K to more than 155K.  From a physician/provider standpoint, the coding process will likely bring efficiency and productivity to a slow crawl as the new codes are phased in.  In a survey conducted earlier last year, 90% of physicians expressed significant concern over the transition and nearly 75% anticipate a negative impact on their practice (both operationally and financially).  Practices and hospital systems will now require new employees (at a cost that ultimately will be passed on to the consumer) that are trained and expert in applying the new codes in order to keep up with government mandates.  Over the last year, physicians have been subjected to online courses and training in the new ICD-10 coding system–many leaving the classes more confused than when they began.

Ultimately, physicians will have to change the way in which they document office visits and procedures in order to ensure reimbursement.  Altogether, these changes are likely to make an overloaded system even more cumbersome.  As we have seen with Obamacare and other government related policy changes, more work is created, more inefficiencies are exposed—in the end, the patient will suffer.  Providers will become overwhelmed by even more government related paperwork and documentation requirements.  More time spent on coding Orca bites means less time in the exam room chatting with a patient.  My how medicine has changed….

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The Doctor Shortage of Tomorrow: Fact or Fiction?

This week in the New York Times, Drs Scott Gottlieb and Ezekiel Emanuel make the case in an Op Ed piece that there will NOT be a physician shortage as a result of the Affordable Care Act (ACA). Both have extensive experience in policy and have held respected positions in government.  Based on a projected need of nearly 90,000 more physicians by 2020, I have difficulty seeing how a shortage will not occur.  The Affordable Care Act has already demonstrated the ineptness of government to manage healthcare–the laughable website rollout, newly discovered “backend” issues with signups, inaccurate quotes and information and questionable security (and this is all since October).  Now, as the mandates loom, consumers are beginning to wonder where exactly they will be able to get care and who may be providing it…

How can there NOT be a physician shortage?

Using the Massachusetts healthcare plan as an example, Drs Gottlieb and Emmanuel argue that the shortage predictions are flawed.  However, Massachusetts is not at all representative of the entirely of the US–one cannot extrapolate the response in Massachusetts to the rural Midwest, or the Deep South or Sunny California.  Moreover, the provisions and funding of the legislation in Massachusetts are very different from those in the ACA.  (its like comparing apples to oranges).  They argue that the biggest driver of increased physician manpower needs is more related to an aging population rather than the impacts of Obamacare and the flood of new patients that are insured by either medicaid or the ACA Exchanges that are able to set reimbursement levels at new all time lows.  They state that the solution to shortage issues will come in the form of technology driven “remote medicine” and the use of non Physician extenders such as Advanced practice nurses and Physician assistants. Moreover, they go on to argue that the solution is NOT producing more doctors–rather it is getting those of us in current practice to become “more efficient”

Really?  We are already doing more every day with much much less than we have had in the past….

As doctors often do in clinical practice,  I respectfully disagree with their assessment.  Obamacare will soon flood the system with millions of newly insured patients.  As evidenced by the current climate in California, many physicians will choose NOT to participate in the exchanges due to very poor reimbursement rates.  Recent surveys in that state found that nearly 75% of doctors would not take the Exchange insurance or Medicaid due to the fact that the Exchange payments were far below the standard CMS Medicare rates.  Many practices are unable to maintain autonomy as payments continue to decrease–many are being integrated into hospital systems.  Overhead continues to increase in order to meet Federal requirements for electronic documentation and records as well as maintaining coding experts to keep up with the ever changing systems such as the newly minted ICD-10 to be implemented in 2014.   The concept of a completely free standing private practice will no longer exist within the next 3 years.  Whether in academic or private settings, all physician groups will be employees of health conglomerates.

What is ultimately going to drive the physician shortage and what are the potential solutions?

For starters…I certainly do not have all the answers….While I do agree that the aging population certainly presents a manpower challenge, I do not concede that this alone will be the driving force behind any potential physician shortage.  Medicine is becoming less attractive for young bright students considering a career in healthcare.  Training physicians is expensive–medical schools are pricey for potential students and post-graduate training (Internship, Residency and Fellowship) are costly for the academic centers where they learn.  Financially, students may no longer be able to incur the significant debt (in the hundreds of thousands of dollars) that continues to accrue when attending medical school when the job prospects promise declining financial rewards.  Once in practice, newly minted MDs will find that their hours are longer and the time that they spend with each patient will be more limited–increasing documentation requirements will result in more screen time and less time listening and bonding.

Physicians are essential to the delivery of care.  However, I also recognize the vital role that physician extenders play in healthcare today (and will in the future).  Nurse practitioners, Physician Assistants and Pharmacists are critical in ensuring that patient care is optimized.  These providers must work in concert with physicians–approaching the whole patient in a team care model will ultimately improve outcomes.  But, utilizing these allied health professionals in more independent and unsupervised roles as Drs Gottlieb and Emmanuel suggest is reckless.  Although well trained and expert in their scope of practice, these allied health professionals are not physicians–they have not completed the academic rigors of a four year medical school nor gained the experience of a 3-8 year Residency and Fellowship.  Replacing doctors with other provider types will NOT eliminate the need for physicians and will NOT forestall the expected physician shortage as we move into 2014 and beyond.  We must continue to work with physician extenders and other allied health professionals in order to meet the increasing demands of a busy medical practice–I do not advocate for the independent practice that is currently being considered in many states.

Remote medicine, telemedicine and remote monitoring are certainly complementary and extremely valuable in providing care.  In fact, as Drs Gottlieb and Emanuel suggest, these modalities may reduce the number of doctor visits and may play a major role in prevention.  While I am a real advocate for utilizing technology to engage patients and facilitate care, face to face interactions between doctor and patient must still be a part of the process.  We cannot rely on computers and other electronic devices in isolation–they can, however, enhance the delivery of care when carefully included in a comprehensive treatment plan.

Are We Simply Losing Our Way As Medicine Remains in crisis….

Ultimately, time will certainly determine the state of physician supply.  If we remain on our current course and continue to fund and implement (albeit haphazardly) the provisions of the Affordable Care Act, we will ultimately see the fallout of a significant physician shortage.  Long lines, significant wait times and scarcity of both newly trained primary care and specialty doctors will become reality.  Medicine in our country is at a crossroads. We must continue to advocate for our patients and protect our right to practice our noble profession in a way that provides the best possible outcomes for our patients today and in the future.

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Unsustainability: Obamacare, Medicaid Expansion and the Destruction of the “Art” of Medicine

During this last week of Thanksgiving, I began to reflect on the last year and the many good things that we have all been blessed with in healthcare.  I have the opportunity to serve patients and their families every single day.  I have the privilege of making a difference in the lives of others.  However, As I reflect, I am greatly troubled by what looms in the year ahead for physicians and their patients.

As Obamacare continues to roll out (or stumble and crawl out as the case may be), other programs such as medicaid are expanding as well.  In less than a month, already overwhelmed US healthcare systems are going to be flooded with new patients.  Experts argue that the medicaid expansion will allow for “timely access” for all new patients.  However, once again, the Obama administration has failed to look at one of the core problems with expansion–Who the heck is going to treat all of the new patients?  The current expansion of medicaid (in concert with the Obamacare mandate) is likely to result in long wait times for primary care office visits, limited subspecialist access to those with the worst insurance (medicaid) and ultimately poorer outcomes for patients.

Some experts predict a significant shortage of physicians (both primary care and specialists) as we race to meet the flood of newly insured patients.  During the design of the expansion of medicaid, no one with actual experience in caring for patients has seriously considered how the care they plan to provide will be delivered.  Traditionally, medicaid reimbursement rates are significantly lower and the payment process is filled with bureaucracy, paperwork and red tape.  As discussed in the Wall Street Journal this week, the medicaid expansion in California is underway.  Over 9 million people will enroll in the medicaid programs expanding all across the US very soon.  But many doctors will be unable to accept medicaid patients due to the low rates of payment included with the program–for example–in California where we have one of the largest medicaid populations in the US, only 57% of physicians will accept medicaid.  Many subspecialists will not–financially it is not feasible to pay increasing overhead costs, increasing malpractice premiums and receive reimbursement rates that are even well under traditional Medicare rates.  In fact, many physicians in California who have traditionally accepted medicaid patients will no longer be able to take on new ones.  In response, the government has issued “incentives” to persuade physicians to accept new medicaid patients.  These incentives include “higher” reimbursement rates for two years (then the rates revert back to the mean at that time)–what they do not tell you is that the increased rates are still below standard CMS medicare reimbursement.

How is this Changing the Landscape of Healthcare Delivery?

Clearly, we must provide care to all Americans. We must, however, do it in a way that makes good financial sense.  The practice of cutting rates for physicians and expecting them to continue to work 60+hour weeks, sacrifice family time and meet increasing demands of electronic documentation and higher patient loads is unsustainable.  As physicians, WE are part of a noble profession and we all care deeply for our patients.  Our passion is to help others battle disease.  We consider much of what we do to be SERVICE and the rewards for service to others are immeasurable.  However, physicians sacrifice a great deal of time to become expert in their respective specialities.  Some of us have endured as much as 10 years of post MD graduate training with low pay and long hours.  Many have mountains of school loans and debt to repay.

From a business perspective, many physicians are finding shelter under the cover of large healthcare systems and hospitals–both private and university based.  The private group or traditional private practice is becoming extinct.  Competition is beginning to dwindle in many markets as hospital systems gobble up other institutions and other groups that once competed for patients–essentially forming monopolies of healthcare delivery.  Add to the realignment of groups and hospitals the newly formed Exchanges that have limited choice and healthcare prices are no longer subject to free market competition.

What are the options?  Healthcare is a business, right?  Or is it simply another government program?

I certainly do not claim to have all the answers.  However, I do recognize that the course that the Obama administration has set upon is unsustainable.  We will soon be facing a crisis of physician shortages throughout the US.  Medicine, although a noble and honorable profession, is no longer an attractive option for many of our brightest young minds.  Of the physicians (like myself) that continue to practice and care for our patients with passion, burnout is common.   If we continue to limit reimbursement and increase workload physician burnout will continue to rise at levels much higher than in the past.

Maybe the answer is for the government to create a federally run health service.  In this model, the government selects prospective medical students and funds their medical training–pays for medical school and living expenses during internship, residency and fellowship training.  Once training is completed, the young physicians are then obligated to practice in a government owned hospital or clinic for a number of years (commensurate with the number of years that they benefited from government support).  The government would control their salary, their work hours and their practice location.  All patients who are signed up for medicaid are then assigned a clinic and a physician from which they will receive their care.  Those who choose not to participate in government clinics will most likely be a part of “boutique clinics” and concierge medicine.

Is this really what we want?  A single payer, socialist society?  

Free enterprise, entrepreneurship, and competition are what makes medicine in the US great.  We must carefully consider the impacts that the decisions currently being made in Washington concerning our healthcare may ultimately affect our freedom.  The time to get involved is now.  Let your voice be heard.  Advocate for your patients and your family.  Let’s get back to practicing the “art” of medicine and re-focus on what matters most–the care of the person suffering with illness….

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