The end of medicine as we know it ...

[PrincessFiona]

Re: The end of medicine as we know it ...

I guess the same way you mandate new pay structures. Without telling people you up rates for all high risk behaviors which increase costs ... Obesity, smoking and drinking come to mind.


Sent from my iPhone using Tapatalk

[PrincessFiona]

Re: The end of medicine as we know it ...

Add 4 wheeling, snow mobiling, bungee jumping ...


Sent from my iPhone using Tapatalk

[PrincessFiona]

Re: The end of medicine as we know it ...

PS. I want a million dollar house. I want to pay 100,000 for it. I think that is a fair price.

Also, how do we determine appropriate pay scales for plumbers. Ours will be earning more for a consult in our home now than Thomas.

Sent from my iPhone using Tapatalk

[DCJenn]

Why? because the first elected politician who says "smokers must pay more" or 'overweight people must either lose weight or pay more" or "perhaps having 8 embryos inserted at once is a bit much" or "passing out while overdosing on klonopin and and landing such that you cut off the circulation to your leg, thereby having to have your leg cut off is 100% on you, dummy [my parents best friends kid- yesterday]" will be labelled a Nazi or a Socialist.

Seriously, the reason why this 'reform' is so stupid is that actual health care has been removed from the process because Congress (Dems and Reps) are held hostage by the special interests.

No one is willing to pay the political cost for common sense.

It's sort of like making people pay airfare based on weight, just like their bags. Makes sense on paper but no one will ever do it.

Jenn

[Pollyanna]

Kris, I like the way you think!

Now that we are heading down the slippery slope...what about children that eat fast food, or that are not breast fed, or that don't wear a helmet while riding there bike, or...so how will the parents be held responsible for that?

[Pollyanna]

no one is willing to pay the political cost for common sense.

amen!

[PrincessFiona]

Re: The end of medicine as we know it ...

Great Scott. When did I start sounding like a republican? I really do support universal coverage of some sort. You know I was all about Hillary.

I can't support this reform or either versions of the HCR bill. Forget docs. Let's limit corporate buyouts of our elected officials and see if we can get reform that way.




Sent from my iPhone using Tapatalk

[PrincessFiona]

Re: The end of medicine as we know it ...

Kris, I like the way you think!

Now that we are heading down the slippery slope...what about children that eat fast food, or that are not breast fed, or that don't wear a helmet while riding there bike, or...so how will the parents be held responsible for that?

You are on to something. Maybe docs can start sueing patients for non-compliance if they get dinged for their a1c levels etc now that INS companies are linking reimbursement to how well your patients manage their chronic illnesses. LOL


Sent from my iPhone using Tapatalk

[Pollyanna]

You are on to something. Maybe docs can start sueing patients for non-compliance if they get dinged for their a1c levels etc now that INS companies are linking reimbursement to how well your patients manage their chronic illnesses. LOL


Sent from my iPhone using Tapatalk

Heehee!

[PrincessFiona]

For the doubters, here are some real live case examples:

1. Medicaid patient is 14 years old. Is referred to dh by ortho (who had the patient referred by an outlying FP) for a complicated case of osteo. DH examines patient, talks to dad and suggests (on a Thursday) that the child should have a line inserted same day and start aggressive tx the next. Dad refuses but agrees to outpatient treatment after the weekend because he wanted to take his son HUNTING! HUNTING! (Someone call CPS please!). Child falls from hunting thingy...breaks said leg and now require hospitalization. The issues are more complicated and said child was at risk for losing the leg. Hospitalization was extensive, surgery was required twice and treatment for infection is still uncertain.

Under the now changed fee schedule, because ortho saw this child, they could not bill a consult for the hospital admission. The hospitalist who admitted the child and did the H & P could not bill for the H & P because the FP had recently done one (the H & P is still required though) and Thomas can not bill a consult for his services which are now much more extensive than they would have been.

Who pays? You do. You and me.

Example 2. Medicare patient diagnosed with HIV 2 years ago. Poorly controlled on meds due to non-compliance. Initial consultation 2 years ago due to screwy bloodwork had been to heme-onc by generalist. This was appropriate because of a secondary issue, btw that is hematological. It was discovered that this pt. had hiv and he was referred to and has been followed by DH.

Pt shows up for a follow-up and is ill enough to require immediate hospitalization. He now has lymphoma (not uncommon in some of the HIV population) and oncology is called. Oncology can not bill a consult for this even though this is a new, completely unrelated problem than what was seen for 2 + years ago. Billing of H & P by anyone for admission is iffy. In order to bill any code that represents the complicated nature of the problems this patient now has, a physician would either have to outright lie or the patient would have to continue to decompensate.

Add to this that because the patient is being seen by a specialist that on the weekend when the internists do rounds...they will have trouble billing because a specialist has followed the case.

Things that make you go hmmmm.

[Sheherezade]

The one reason I was never for universal health care in this country was that I believe having it WILL give the government say in whether we smoke, drink, have dangerous sex lives, eat too much or drive too fast. After all, they are paying the bill for the extra care, so we need to listen up. I honestly don't believe that universal care leads to poor care. Starting Medicare was the start of the slippery slope, IMHO. Bad deal for we the people (taxpayers). Maybe we should have just done more to restructure the health care system then -- so that individuals could purchase insurance coverage privately that lasts after the age of 65.

The fact that our health insurance has always been seen as a benefit of employment has really screwed up the market. From what I've read, the system was created because employers (like GM) didn't want to give wage increases so the gave this new-fangled health care benefit instead. It caught on. Shame. It should be purchased by the individual when they are young and there should be policies available that prevent the insurers from kicking you out when you do become sick. Then, maybe the "life-time" risk/cost would actually be assessed and we could see what REAL insurance for each person would be. You could take in to account lifestyle all you wished.

Can't consults be billed as "new patient" on the initial contact and then as "existing patient" on all others? I've read that the RVUs for other components were adjusted up to compensate for this change and to keep the change "budget neutral" for hospitals. I've read it changes the consult fee by -20% for each visit based on the new category - but that some are concerned that consultants will just book more follow-up (existing patient coding) to make up for the shortfall and see a patient 3x instead of 2x while hospitalized.

[PrincessFiona]

Can't consults be billed as "new patient" on the initial contact and then as "existing patient" on all others? I've read that the RVUs for other components were adjusted up to compensate for this change and to keep the change "budget neutral" for hospitals. I've read it changes the consult fee by -20% for each visit based on the new category - but that some are concerned that consultants will just book more follow-up (existing patient coding) to make up for the shortfall and see a patient 3x instead of 2x while hospitalized.

No. If you have seen this patient within the last THREE years for ANY reason at all (and it is YOUR responsiblity as the doc to know this or be dinged by medicare) you may NOT. You may bill a level 3 ? hospital visit (worth significantly less money) if only certain criteria are met ...and only the first time. If you must continue to follow the patient in the hospital, you must bill even less for your service even if it takes you the same time UNLESS the patient decompensates in another area.

Certain billing was upped 6%. So you can bill 30% or so less for the consult, but 6% more for the lower level visit? That is still a net large loss. The hospital is of course paying you your RVUs (in our case) and so they get a cut and you get a cut. You earn less...they earn less.

If this was a wash, Angie and wouldn't affect money going out, they wouldn't have done it.

[Sheherezade]

I have yet to find a truly comprehensive article on this because it is all so specialty dependent. Maybe we should write one.

The idea that this was "slipped in the back door" bothered me thought because many of the articles I've read are from Nov and Dec before the change. Obviously, this wasn't in the news that much but it was known. Here's the time line presented from an article in Neurology Today.

The change caught physicians off-guard when the CMS first proposed it in July. Despite opposition from the AAN and many other medical associations, the CMS finalized its plan to stop paying for consultation codes when it published the 2010 physician fee schedule in late October.
At press time, private payers were still scratching their heads over the issue. Representatives of WellPoint, Cigna, Aetna, UnitedHealthcare, and some large regional health plans all told Neurology Today that they were studying the CMS decision and had not decided whether to follow its lead.
Even if private payers do decide to replace consultation codes, their contracts with physicians may prevent that move from being implemented until contracts are renewed.
“It is going to be complicated,” said AAN Associate Director of Medical Economics Amanda Becker.

No shit, Sherlock. I think the coders are not up to this yet --but there is hope that it will get sorted. The article goes on to address the inpatient two-doc situation:

Dr. Busis also foresees confusion related to concurrent care by two physicians for inpatients. The CMS said it will create a modifier that the admitting physician will use to identify himself or herself as the physician of record. However, if the admitting physician fails to use the modifier appropriately, consulting physicians may have trouble getting paid.

And this is the motivation I've seen echoed in most articles:

Changing ambulatory consultation codes to new patient visit codes would save Medicare more than $500 million a year. While that is a tiny fraction of Medicare's $59 billion annual tab, Dr. Shalowitz said higher pay rates for consultations devalues primary care.
“At a time when we want to encourage new physicians to consider primary care and support current practitioners, this differential sends a dissonant message,” he wrote. “Furthermore, as patients are increasingly responsible for out-of-pocket payments, it is difficult to explain to them why consultant physicians are paid so much more than their primary care physicians for the same or less time spent with them.”

From what I can tell, this is a bit of administrative law originating from CMS and is entirely separate from the health care bills. I'm not sure we can talk about them as the same thing.

[PrincessFiona]

“Furthermore, as patients are increasingly responsible for out-of-pocket payments, it is difficult to explain to them why consultant physicians are paid so much more than their primary care physicians for the same or less time spent with them.”

That really gets me! Try saying that you are paying for extra YEARS of training, experience and that physician taking extra time?

Seriously....I can't fix the plumbing in my sink. When we had a problem a few months ago, I was sad to let the $100 go for the 10 minutes the guy spent fiddling with my drain pipe...but thank goodness the dishwasher works again and we have had no more flooding.

That's bankroll ... This guy was well compensated for his expertise. Granted, I don't need my dishwasher to live, and I get the argument which is why I support health care as a human rights issue and not a privilege...BUT...you can't load docs up with debt, beat this shit out of them in training year after year, tax them until the cows come home, demand high malpractice and sue them when your farts stink ... and then take away the financial incentive.

I think I need some lexapro today! I just said fart on a public forum. LOL

[houseelf]

I honestly can not remove my rage from this discussion. (This is ironic since I was trained to write logically. ).

Seriously, my understanding that the peds specialties aren't affected by these underhanded billing codes PRESENTLY, but I stand in solidarity with my other physician families.

The sacrifice of medicine is huge. The sacrifice of additional training merits some sort of substantial reward.

I have nothing to add but my righteous indignation. I'll have to cool off before making a cohesive argument.

Kelly