Doctors who manage patients in the office aren’t the problem

I am riled up—almost to the point of being inflamed.

I hate it when doctors get dragged through the mud. It’s a matter of pride. Doctors are my team.

The latest kerfuffle centers on how much we should charge for return patient visits. The difference here is between moderate and moderately high visits–or about $30.

When the Center for Public Integrity is investigating your profession, it’s unlikely to be good news. And it wasn’t. This time however, the usual baddies (back surgeons, cardiologists and other high-paid specialties) were not the culprits. Rather it was the worker bees of Medicine—office-based doctors.

In an exhaustive review of Medicare billing databases over the past decade, CPI found that doctors have gradually billed at a higher complexity for return patients. The Cracking the Codes investigation is exhaustive but can be boiled down to just this: a flip-flopping of Level 3 (of 5) codes for Level 4. The lowest codes and highest code did not change much. Again, the delta here is about $30.

Doctors who manage patients in the office aren’t the problem

There’s a lot been said on this matter already. My take is that it should serve to remind us of the big picture of what’s wrong with US healthcare.

Start with the givens:

  • US healthcare costs too much.
  • We consume too much of it.
  • We overemphasize medicines, tests, procedures and surgery.
  • We undervalue cognitive tasks.

It’s well known that the US healthcare model favors doing. Procedure-related specialties like mine are compensated much more favorably than non-interventional fields. My thumb injury this summer illustrates this point: After having hand-surgery, I sat out of procedures for 6 weeks. This didn’t mean I missed work; I still came into the office and saw patients. As wonks say, I evaluated and managed patients. As I found out when looking at my productivity-based paystub recently, E&M work pays less than procedures—substantially less. And it was much harder work seeing patients all day. I know, this is not news.

Neither is this idea. That one way to reduce over-consumption of expensive health care is to emphasize office-based doctoring. The dreamy notion holds that doctors could take the time to learn about their patients, educate about healthy lifestyles, thoroughly explain treatment alternatives—including less-expensive stuff like giving a disease a tincture of time to abate naturally. Atrial fibrillation is a good example. I can (almost) do an AF ablation in the same time it takes to really explain all aspects of AF care to a new patient. One hour in the office with an AF patient pays about ten-fold less than that amount of time in the EP lab burning the atria. Truthfully, sometimes I question which hour is more valuable.

My wife’s work as a hospice and palliative care doctor offers another example of misplaced incentives. The human suffering relieved by hospice doctors is staggering. We will all die, and those not blessed to pass peacefully benefit immensely from skilled and compassionate end-of-life care. But again, in the time it takes my wife to see a new patient, address their goals of care, implement a treatment plan and give counsel to a grieving family I could implant two ICDs—and make more than ten-fold more.

It’s not right.

If we do one thing to change our healthcare system for the better, it would be to truly and wholly incentivize cognitive, non-procedure-based doctoring. We need the smartest doctors on the front lines of healthcare. We need them wanting to be in the office helping people to not need so much care.

That’s why I hate that the implications of “Cracking the Codes.” It suggests malfeasance on the part of doctors who do E&M work. Nothing could be further from the truth. As a lot, these are hard-working people doing important work. And even if you posited an over coding of level 4 visits, the impact is peanuts compared to the widespread over-use of really expensive care. Doubters can follow me for a tour of an ICU or emergency room—or even a cath lab.

Doctors who evaluate and manage patients in the office aren’t the problem. The problem is that we don’t have enough of them—because we don’t value their work. My friend and colleague, Dr Wes Fisher suggests that we compensate by time spent rather than boxes checked. That’s a good start.

Another would be to do the obvious.

Pay more for listening, guidance, wisdom and compassion and less for scans, procedures and surgery.

John Mandrola is a cardiologist who blogs at Dr John M.

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  • http://twitter.com/livewellthy Stewart Segal

    Well said! Unfortunately, the bean counters have placed a bounty on the heads of our colleagues, spending hundreds of thousands of dollars to recover the $30 difference you address above. Alternatively, their threats may well be intended to produce fear in primary care physicians inducing them to undercharge for services thereby saving Medicare and the insurers a small fortune. Whatever the intent, they are systematically killing primary care.
    The independent primary care physician is being forced to sell out to corporate America. An employed physician is much easier to control! The government and insurers continue to win at patients and doctors expense. What a pity!

  • http://www.thehappymd.com/ Dike Drummond MD

    While I agree wholeheartedly with what you have said here … you and I must admit that this is nothing different than what has been said about the insane state of reimbursement for medical services for decades.

    A bunch of primary care doctors like us harumphing about this – as we have been doing for a VERY long time … clearly does not make a difference in “The System”. Continued harumphing will have no different effect although the venting it allows will provide temporary relief from the anger and frustration.

    it is not right. It is real. It is not going to change without a nationwide general strike of primary care doctors and an organization that represents nearly 100% of us with the power to negotiate wholesale change in medical reimbursement. How likely is that to happen? (BTW, if you can think of any other scenario that has any chance of “changing the system” I would love to hear about it)

    If you are in primary care … the real question is what do you do to maintain your connection with meaning and purpose in your practice … despite the fact that you never have been and probably never will be paid appropriately? How do you keep yourself healthy in a system that has always made no sense?

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • http://twitter.com/KevinCuc Kevin Cuccaro

    Great post and too true. I had a similar reaction when I first read of the “sting.” Seriously, attacking the frontline and, arguably, most important physicians for promoting/maintaining healthcare (although what we have at this time is ‘sick’ care)?

    I am also in a procedure based specialty but am frustrated at the payment model and “quick fix” mentality of society.

    I think most of us realize that a true focus on preventive medicine/patient education &, frankly, accountability with lifestyle change are key to both improving health with the side effect of improving overall healthcare cost.

    This is not going to happen with the way our healthcare system works currently. It certainly isn’t going to improve by attacking office visits.

  • http://twitter.com/shihjay2 Michael Chen

    What Dike said, ” It is not going to change without a nationwide general strike of primary care doctors and an organization that represents nearly 100% of us with the power to negotiate wholesale change in medical reimbursement. How likely is that to happen? ”

    If I’m not mistaken, I think the fact that primary care physicians are truly angry for years (I think they are, some more vocally, but most are still silent and suffering) and patients, the environment is ripe and there would be support by our patients for a general strike of primary care.

    When I had to close my practice down due to the combination of reduced reimbursement (despite doing time-based billing for chronic care management in my solo micropractice), my patients were very supportive of my decision. I think most patients do value primary care and wish they could have more but are saddened to see the direction health care is heading. At the same time, they do not understand the payment inequalities for primary care. By holding a strike, this would serve as a wakeup call for patients and policy and lawmakers (hopefully). Although, ethically, physicians tend to shy away any kind of action that would impact our patients, even in the short-term, but if one was to think of the long game and long-term goals, we are not doing ourselves (primary care) and our patients a favor by continuing to be the punching bag for decades and more. Like the grape picker’s strike led by Cesar Chavez, a general strike by primary care physicians will bring our issues to the forefront. Timing it to the anticipated onslaught that is going to happen in 2014 with the ACA where patients will have greater access to care (which I believe is good) and only finding out that primary care is not “ready” to receive them (which I attribute to a lack of insight by our policy makers) will only highlight the plight of primary care physicians and the neglect in our field that has been going on for decades.

  • http://www.HealthcareMarketingCOE.com/ Simon Sikorski MD

    Look, doctors are not obligated to see patients that: don’t pay copays, refuse to be educated, refuse to follow treatment programs, show up late, complain, or come from referrals that are not qualified to benefit from treatment. All of HMCOE marketing clients receive training on how to prioritize patients and look at EMR data about physician referrals. Let me know if you’d like to receive a copy of our last report – Why are Doctors Struggling

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