Medicare patients: The government has just screwed you

My dear Medicare patients:

The government has just screwed you.  Did you know it?  Probably not, probably you have no idea about what the government is proposing to do.  But it is going to have profound effects on the quality of the care you are about to receive.  You are confused? You are surprised?  Let me explain.

The government is proposing to change the way it pays doctors for outpatients visits. According to Modern Healthcare, Medicare intends to pay physicians a flat rate for each visit.  That’s right, a healthy 65-year-old with a cold will lead to physician charges that are the same for a 95-year-old with congestive heart failure, emphysema, and out of control diabetes.

Accordingly, the complexity of the visit will no longer figure into the amount of reimbursement for the physicians.  What does this mean?  Physicians, fatigued and overwhelmed with patient care, will be much more likely to avoid sickly seniors.  It pays the same, why not select for the most healthy of the medicare population?

If you are old, sick, or have a complex medical problem, expect physicians to avoid you like the plague. Your care will cost us more, and lead to lower reimbursements.  For those of us in private practice, I expect that this will be the death knell.  You might as well sign up to a hospital based large medical group now, no one else will be able to afford to take care of you.

The reason why this is happening?  Apparently Medicare believes that physicians are overcoding.  The pound of fat for health care reform is going to be born by those who health care needs the most: primary care physicians.  It is the primary who handles the broadest, most complex, most multi-system problems.  These problems take time, deep thought, and advanced planning.  These were things that Medicare used to pay for.  Apparently no more.

This is a sentinel moment, a tipping point.

By the time I reach Medicare age, will there be any physicians left?

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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  • southerndoc1

    Calm down.

    The Modern Healthcare article you link to is incomprehensible. I THINK what they’re trying to say is that CMS will pay a standard facility fee for outpatient, non-ER visits, rather than a facility fee that increases as the level of E&M coding goes up.

    Of course this completely avoids the underlying issue that facility fees are the biggest scam going.

    • May Wright

      From that article: “The 1,200-page outpatient prospective payment system rule for 2014, posted the Wednesday afternoon before Thanksgiving…”

      How did we even get to this point?

      No wonder the direct-pay model is looking more and more attractive to primary care physicians.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Right. I think it’s only for hospital owned clinics, which means that many complex patients that regularly require more than a 99213 will be dumped on private practice and community health centers

        • southerndoc1

          “The old system encourages upcoding” link in the MH article indicates this applies to facility fees.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Here is the actual text:

            “Payment of Hospital Outpatient Visits: For CY 2014, we are finalizing our proposal to replace the current five levels of visit codes for each clinic visit with a new alphanumeric Level II HCPCS code representing a single level of payment for clinic visits. We are finalizing our proposal to assign the new alphanumeric Level II HCPCS to newly created APC 0634 with CY 2014 OPPS payment rates based on the total mean costs of Level 1 through Level 5 clinic visit codes obtained from CY 2012 OPPS claims data. For CY 2014, we are not finalizing our proposal to replace the current five levels of visit codes for each Type A ED, and Type B ED visits with two new alphanumeric Level II HCPCS codes representing a single level of payment for two types of ED visits,”

            If you feel like reading it, the link to both regs is here: https://www.federalregister.gov/public-inspection#special

        • Dr. Drake Ramoray

          ======================================
          I think it’s only for hospital owned clinics, which means that many complex patients that regularly require more than a 99213 will be dumped on private practice and community health centers
          ================================

          The same thing will happen with ACO’s and bundled payments.

          “Shaka, when the walls fell”

          http://en.memory-alpha.org/wiki/Tamarian_language

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Yep. “Job security” for little guys… :-)

          • Dr. Drake Ramoray

            “Temba, at rest……”

            I decline your gift from the big organizations (read dump) of the sickest patients as a small independent private practice physician who will be graded on how well this sick patient does that nobody else wants to take care of. I am happy to take care of sick patients but I have to think long and hard about it if I will be paid less to do so.

            “Kadir beneath Mo Moteh” – failure to communicate/understand

            “The beast at Tanagra” – the problem to be overcome

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I get it… :-) It’s one of my favorites, so I just couldn’t resist… Someone will have to die at Tanagra

          • Dr. Drake Ramoray

            I agree one of the best episodes and an excellent metaphor to talking to the “thought leaders.”

  • edpullenmd

    Physicians will be forced then to do less in each visit, see patients more often because we won’t be able to afford to spend enough time to do more than very focused visits. Agreed, this screws patients by increasing copays and travel/time expenses.

  • Anthony D

    While I disagree with the concept of the Government stealing from me,
    and every other American who actually has a job, every paycheck, and
    then misappropriates the money, I also disagree with calling Medicare an
    entitlement, and not calling Welfare an entitlement.

    That being said, IF the government plans to offer Medicare to folks who have paid into the rip off program for 40+ years, then the politicians should find a way to make it work correctly. Retirees who collect SS pay a little over $100 per month, and each of us pays 1.45%, and our employers pay 1.45%. I know, it is not enough to cover the liabilities, so why not increase the payroll tax portion by .5%, and the retiree portion by $25 per month.

    Better yet, why not establish something like an HSA, so that those using Medicare actually see how much the doctor is charging.

  • ninguem

    I could maybe possibly see a silver lining if it does away with the excessive documentation for billing 99214 and 99215.

    The key would be what that average visit is paid.

    • Dr. Drake Ramoray

      I respectfully disagree. There is no silver lining were this the case. Access will suffer and there will be a financial disincentive to see the sick. The same applies to capitation and ACO, the direction we appear to be heading.

      • southerndoc1

        I’m still confused by this, but if a set fee is paid for all visits, there is an enormous financial incentive to do the least possible at each visit (and do the minimal amount of documentation).

        • NPPCP

          That is exactly what I thought!! Paying a set fee actually encourages poor documentation and cattle calls.

        • Dr. Drake Ramoray

          Yes. But under a bundled payment ACO model they could move to a fee schedule where you get paid for say 6 mos of care and if you see the patient once or twice you get paid the same as if you see the patient six times. See surgeons who get paid for a procedure and then 30 days of after care regardless of what happens.

          This also doesn’t account for physicians collecting as many healthy patients as they can and booting the unhealthy ones. Once physicians accept outcomes as part of there reimbursement it just becomes a matter of tweaking the formula to put most of the pay on the “performance” side and take away any substantial payment for visits. The entire idea is designed to squeeze providers.

          Divesting physicians from fee for service is the death knell of medicine.

          • rbthe4th2

            Thank you for your explanation. While long, I appreciate the time and effort you put into it.

  • Dr. Drake Ramoray

    “Temba his arms wide”

    There is an old Star Trek the Next Generation espisode (STNG for those not as geeky as me) where the Enterprise meets a race that speaks in a peculiar language that is incomprehensible without understanding the cultural background of the species that speaks it (The Tamarians). Obviously understanding the cultural metaphors without understanding the language in the first place is the challenge.

    http://en.memory-alpha.org/wiki/Tamarian_language

    http://www.youtube.com/watch?v=ukMNfTnI5M8

    While I agree with southerndoc and the other posters that the changes cited in the original article pertain to facility fees (which shouldn’t exist in the first place), I am curious if Dr. Grumet can take the next step in his thinking (No not the obvious one that Medicare could impose what he actually thought is happening as there is little to keep them from doing so.)

    As I have been arguing tirelessly on this blog and in various other forms, accountable care organizations and bundled payments accomplish the same thing. See my response on this blog to the AMA.

    http://www.kevinmd.com/blog/2013/12/ama-repeal-flawed-medicare-payment-formula.html

    Bundling payments and accountable care organizations is jus another way of saying all patient’s are the same. Dr. Grumet objects to all visits being the same. The sick won’t be able to find a doctor! Well guess what. On a national level the same thing will happen if everything is pushed into an ACO or bundled payment scheme. Not all diabetics are the same, not even all uncontrolled diabetics. There are cultural, socioeconomic, educational, and obviously physiological differences in all patient’s with diabetes. I have lots of patient’s on U-500 an insulin that is 5x the strength of all other insulin and has unfortunate pharmacokinetics. Regardless once you get to 2-300 units of insulin it is typically an improvement. It is very tricky to use because there is 5x the insulin in the syringe than what it says in volumetric units (ie. 20 cc of U-500 = 100 units of insulin) and it has a non-physiologic and inconvenient duration of acion. This gives patient’s, other doctors, and even pharmacists fits.

    http://care.diabetesjournals.org/content/28/5/1240.full

    So how is bundling payments for uncontrolled diabetics making a young affluent healthy buisenessman who can’t remember to take his Metformin or check his blood sugars = to my high school factory working drop out on 3 shots a day of U-500 and multiple oral medications who struggles with math?

    Why don’t any of these thought leaders, especially Dr. Grumet as he saw the above plan so offensive, see that capitation is the same thing. All of you respond like I’m speaking an incomprehensible language.

    So Dr. Grumet. “Kiteo, his eyes open?”

  • tomsmith12345

    Doctors are overcoding. I am an MD and have always wondered how we are able to bill based on the number of medical problems a person has even if they are not addressed in the visit, but it seems everyone is doing it. As a patient, I saw my primary care doctor for an upper respiratory infection. I am young and have no medical problems. His office billed my insurance for a level 3 visit. As I pay 100% of everything until I reach my deductible, I pointed this out to his billers and they quickly adjusted it to a level I visit.

    • NPPCP

      Oops. Your post is very suspicious. You gave just a little too much away. No biller would ever downcode, I repeat Ever downcode a level 3 MD/NP visit to a level 1 visit. If you were really who you say you are, you would know this. Doing so would be fraud for reasons you would/should know.

      • southerndoc1

        A young, healthy doctor goes to see his primary care physician for a URI?

      • Michael Rack

        Agree with NPPCP. A level 3 return patient visit (99213) would be standard for an upper respiratory infection. Downcoding to a level 1 visit (99211)- the code for a seeing a nurse without seeing the doc- would be improper.

    • May Wright

      This blog is probably not a good place to try and BS anyone. There are a prodigious number of actual medical professionals here with finely-honed BS detectors, and they’re not known for suffering fools or prevaricators lightly. #Protip

    • ErnieG

      If you think a URI is a level 1 established, you don’t know how to code. Also I am pretty sure you are not a practicing physician
      Level one is nurse visit.

      Level 2 is 1 descriptor on H&P, and 1 system on PE. This is a level 2 note: CC: cough; History: cough; PE: Vitals; Plan- surveillance;

      Level 3 would be: CC: Cough, History: cough; PE: vitals, Pulm: CTA; plan- surveillance;

      Level 4: CC: cough; History: Cough for 3day, moderate, not associated with SOB, worse in the morning, non-productive ROS: no fevers, PE: Vitals, GEN: NAD, EYES: no discharge. PULM: CTA, HEENT: no exudate or erythema, COR: RRR EXT: no clubbing; PFSH: non-smoker PMH: healthy A/P URI, likely viral, use mucinex as expectorant; avoid irritants, if symptoms worsen or additional symptoms develop (fevers/chills, sore throat, shortness of breath, etc) pt is to call for evaluation. (although you probably should not code this as level 4 as medical decision making is pretty darn low)