Sunday, August 24, 2008

Reason for Consult: Old

You'd think our surgeons would get the hint. Particularly our uber-sub-sub-specialist surgeons. They bring a patient in for a routine gravy-train procedure, and on their ORDER SET... "Consult Hospitalists for Medical Management."

How can a consult be on standard order sets?

So when we find out it's from this particular group of surgeons, we have the nurses call the surgeon to make sure there really are medical issues for us to follow. Often... there are not.

Just so happens the other day this consult came during the day, and I saw the surgeon walking by.

"Do you really need us for this one?"

The response: "Yeah.... she's 75... ya know... not on any meds or anything but I think it would be a nice 0ne for ya guys... kinda frail."

Me, " ... uh... ok... I'll see what I can do."

What I really wanted to say was, "Really, asshole? Do you think Medicare is really going to pay for a consultation by me when the reason for the consult is 'frail'? I assume by 'frail' you mean 'old'. So does that mean there is an age threshold for consultation? Unless you're going to start sharing your revenues from your over-reimbursed procedures, you can manage 'old' all by yourself, big boy."

We clearly need to have a medical staff meeting. What a douche.

Wednesday, August 13, 2008


On my glorious drive out to the sticks, I had an epiphany...

What if in enlisting the general public to the cause of the primary care physician, one uses billboards to pique the interest of the average American?

I sure see enough religious propoganda out there... why not pool physician resources to buy up some billboard space?

Not that it's possible to explain something as complex as the death of primary care in the modern era in a space the size of a billboard.... but give little tidbits... and of course a website. The approach I think would be most effective would be counter-pointing the stump-phrases used by our politicians to woo voters: "We're for affordable all-you-can-eat healthcare!" That one is a hard one to counter-point on a billboard... but how about something like....

"Increasing medical school class sizes is just going to make more dermatologists."

"Universal healthcare is pointless if all the doctors only want to inject botox."

"What good are 100 heart doctors when all you need is your sore throat looked at?"

We just need to start somewhere... the ad campaign could even simply be titled: "Why Can't I Find a (Regular/Family) Doctor?"

Any thoughts?

Tuesday, August 12, 2008


Under a highly improbable set of circumstances, I briefly became the primary care physician for an elderly relative of a college friend. I tried to limit my exposure to the octogenarians given the breadth of my practice as a Med/Peds physician, but I was honored by the fact that friends thought highly enough of me to want me to take over her care.

Even though I loosely knew the patient from long-ago social contacts, the patient-physician relationship that budded was a comfortable one. Yes, she always tried to turn it into a social call when we truly had a few medical issues to discuss, but fortunately, she was wickedly healthy compared to her age-matched peers. She travelled. She read the paper. She exercised. It also helped that my hospital's productivity whip had not yet started to crack. I had a little time to burn with her at her Q6 month visits.

Then a tragedy hit the family far from home. This actually touched me emotionally as well -- this person was also a friend. Not surprisingly, some somatic complaints on the part of my patient began to manifest. Appropriate work-up was negative.

But almost simultaneous to the tragedy, I escaped primary care. My partner took over graciously. But the transition was not pleasant. Despite 2 visits very generous in time spent with the patient, she would call hours after her visit to complain to our office manager that the physician did not spend enough time with her. She felt rushed. She did not feel that her complaints were being addressed. This, despite the fact that my partner had a 2-page note from each of these "follow-up" visits. The office manager had to talk to her for an hour to calm the anger. The patient was "shocked" that there were "time constraints" on how long she was allowed to carry on her visits.

Obviously, grief plays into this. My departure from the office plays into this. But this is an otherwise rational woman who is pissed off that the current system doesn't allow her the time she feels she is due in her hour of need. She is in counselling, but she sees physician-patient time as a critical piece of that... a piece we're not letting her enjoy bite-by-bite over an hour.

I have mixed feelings about this. On one hand, I wish the healthcare system were such that a physician could spend more (even if not to the degree this woman wants) time providing lending an ear... having the hand-on-the-shoulder. On the other hand, our government and populace at large has made it clear they have no intention of paying for it.

I have a social ability to tell her to chill out... one that I don't with the average elderly patient. But she's not listening to me. I'm now just one of the cold mechanical voices of healthcare to her. And if this is how someone who's a hybrid social contact-patient is reacting to her primary care doctor... can you even imagine what the expectations of the average elderly patient are of their primary care provider? How can we ever win? These are the seeds of litigation.

She served to solidify my belief that for the forseeeable future, primary care is screwed.

Thursday, August 7, 2008

How To Save Primary Care

I was listening to talk radio today when one of the daily shows devoted a full hour to the challenges of rural medicine versus urban medicine. Their guest was a physician who had substantial experience practicing in an area of the United States far more rural than even I would ever have dared tread.

For nearly an hour I listened to him field questions about the unique challenges of being in a rural setting, the problem of access to healthcare, the need to expand medical school enrollment to fill this unmet need, and even universal healthcare. The elephant on the radio was just too great for me to bear, and so I did something fairly uncharacteristic and called in.

I made it known I was a young physician who had just recently escaped primary care (but did not elaborate -- I was time-crunched). I asked:

"Even if we doubled medical school enrollment and found a way to instantly insure 100% of Americans overnight, that doesn't solve the problem of who is going to be seeing these patients and staffing their 'medical home.' How will this ever be solved when medical students are tempted with subspecialist salaries that are 5-6 times what a primary doctor can make, often with better hours?"

Predictably, you could tell I'd struck a chord. He said that it was an excellent question, and that something that was going to have to happen would be a "very painful" reduction in subspecialist salaries. I resisted. I did not say another word. He neglected to mention CMS had attempted a modest shift in the RVU values to do just such a thing.

Sidenote: Many hospitals in our area (including mine) took cue and reduced their subspecialist salaries. But the primary care guys? Our RVU thresholds were compensatorily increased to completely negate the positive income effect that Medicare intended to happen. How they got away with it is truly beyond me. They literally pocketed the difference.

What it got me thinking about was this most recent prevention of the 10.6% cuts that nearly went through. (I'm of the mind that it would have been better for the cuts to go through, and truly watch the shit hit the fan, but oh well.) The biggest asset physicians had was the senior population. When patients stood behind physicians, the policymakers got off their asses.

It's awfully hard to convince the average American that someone making $170,000 a year deserves more (or at the very least, deserves to spend more time with less patients to make that amount of income). But that's precisely what primary care has to do. Unfortunately, I think the only way to get the general public to care about the relative-bottomfeeders in medicine is by focusing their attention to those being hand-fed olives plucked from the vine in the ivory tower.

I don't like the idea of "turning" on our overpaid proceduralist colleagues. But it has been physicians in those very fields sitting on the AMA and other policy-guiding groups who have protected their own turf at the expense of primary care. And it's time for it to stop.

Why is it for decades on end residents were allowed to work 40-hour "days" and 120-hour weeks? Because only after the public started getting wind of "medical errors" by "fatigued doctors" was pressure applied to put an end to it. If Joe Blow couldn't care less about medical errors, believe me, residents today would still be risking their lives on the post-call drive home from work.

Just because I escaped the cracks of the whips being applied to the backs of primary care doctors doesn't mean I care any less about the state of healthcare in our country. But if we truly expect anything to change, you have to get the public on your side. Just exactly how we do that... I haven't figured that one out yet.

And We Wonder Why Healthcare Costs Skyrocket...

It was one of those "Are you serious?" moments. My partners and I were required to carve out an hour and a half of our day (uncompensated, of course) to listen to a consulting firm that our hospital paid to come in to help "charge capture".

The situation we're facing is as follows:

The Medicare gods made up a term called the DRG (Diagnosis Related Group). The DRG is supposed to group diagnoses based on the severity of illness, and presumably the resources that patient will require. (Read: How much money do you get from the government to take care of this patient.) Depending on what diagnoses I document in my note, the DRG (i.e. cash-flow) changes. In premise, this sounds like a good idea. Sicker people are more expensive, right?

I truly am all for good documention. But for the purspose of conveying important information about the patient's condition and plan for their care to all parties of the healthcare team (doctors, nurses, physical therapists, etc.). I am not down with the shell-game.

But as most of you realize, "documentation" became less the basis for paying for the patient's care, and more and more the reason to deny payment for the patient's care.

So when the Centers for Medicare and Medicaid Services (CMS) decided to increase payment for the higher DRGs and lower the payment for the lower DRGs, hospital's got a fire lit under their asses. They scurried like cockroaches to figure out how to keep as much of this money as possible. How did they approach it?

They started paying consultants to tell us how to document "better". We now have a small army of people in white labcoats embroidered with "Documentation Specialist" circling our charts like vultures, fighting for chart-review time. We now get "suggestions" from them about how to make the patient sound sicker than they are. "Pardon me, doctor. 'Urosepsis' doesn't pay any better than 'UTI'. Do you think it would be appropriate to document 'sepsis with UTI'?"

Me, " Uh.... sure...."

How much money are hospitals shelling out in this effort to squeeze more pennies out of Medicare? CMS's efforts to lower what they're paying out makes the entire system more expensive by driving costs up across the board to claim the breadcrumbs. Healthcare systems grow into the income. It's not a simple proposal to ask them to trim the fat, when there isn't any fat in the system (expect, perhaps, proceduralists' salaries).

The part of my little "class" I found most incredulous was CMS's own admission that they expect that documentation will get better once they make these mandates. And so to compensate for the fact that people are expected to document better and therefore capture more money? They're going to lower payments.

When is our government going to realize that the promises they have made the American people are going to become interminably more expensive year-after-year unless they start telling people "No."? Their ONLY solution has been to simply give hospitals (and therefore the doctors that employ so many of us) less money, and that this will magically make costs contract.

It's beyond absurd. CMS seems to have realized they can't simply decree that they're going to pay 10% less for services that are being used more and are more expensive. So what are they going to have to realize they need to do?

Ah yes. The evil R word. RATION. It's going to have to happen. It's not a question of if. This WILL happen. The big question is, when Medicare refuses to pay for Procedure X, will hospitals be held liable for medical outcomes of not performing said procedure?

Oh what a tangled web we weave.

Monday, August 4, 2008

$100 Down the Drain

I'd argue that I received excellent training in residency. But in retrospect, my lack of exposure to the "Medicine Consult," proved quite the deficiency.

Prior to receiving my Hospitalist Hat, the only time I ever billed a consultation was in the outpatient setting for pre-op clearance. As a clinic slave, it was an unexpected little treat. I typically got 3.02-3.77 RVUs for relatively-brainless work, compared to the 1.42 RVUs for the 40-minute octogenarian diabetic time-suck. But as an inpatient guy (in a hospitalist program without the resources to do outpatient pre-ops), a "consult" to me now typically means:

1. A surgeon who doesn't want to fill out discharge paperwork (the 75-year old with controlled hypertension who has been on a sprinkle of HCTZ for 50 years, but is in for a ureteral stent).

2. A subspecialist (still listed on the ACPs website as Board Certified in Internal Medicine) who doesn't want to be bothered with things like diabetes when there are highly billable procedures to be done.

3. Either of the above who realizes that they suck at something I can do better.

In any event, it really doesn't bother me. Because it's better for the patient. And for a small portion of my day, I get to feel special. "Of course you can't take them to surgery silly. You'll kill them."

And even though it's (for the most part) easy work, it's the work no one else wants to do even if they have the know-how. For the most part, internists have been willing to play along. After all, it pays pretty well. Consider:


Now let's say the consult is full-on legit (new-onset CHF). My notes for such a scenario would typically qualify for an H&P III or a Consult III. At our $50/RVU, that equals $189.00 or $200.00. Not an enormous difference... but here's the rub.

This Medicare Coding class I just attended has informed me of a new change for 2008 that will start being enforced at some nebulous point between January 1, 2009 and Summer 2009. It's called Transfer of Care.

To illustrate the massive screw-job CMS has crafted for us, Dear Reader, consider the following scenario.

An otherwise healthy 56 year old is admitted with chest pain to the cardiology service on January 1st. Their initial troponin was 3, which is why they were not admitted to medicine. But their random glucose is 430, creatinine is 3 and their sodium is 118. Medicine is consulted.

The hospitalist dutifully comes to save the day, orders appropriate diagnostic work-up and initiates appropriate treatment. Now, I don't know about most of you, but we typically round on these patients daily. We manage the newly-diagnosed DM, the hypernatremia, and the acute renal failure. Perhaps we will involve other consultants. But we follow them to discharge and reconcile their new medication library. The patient goes home January 7th.

A lot of people out there bill something as follows (presuming appropriate complexity of care):

1/1/08: 99255 (initial inpatient consultation)
1/2/08: 99233 (subsequent inpatient care)
1/3/08: 99233 (subsequent inpatient care)
1/4/08: 99232 (subsequent inpatient care)
1/5/08: 99233 (subsequent inpatient care)
1/6/08: 99232 (subsequent inpatient care)
1/7/08: 99232 (subsequent inpatient care) -- keep in mind, we don't do the discharge here

But this would be fraud under the new rules. Because in Medicare's mind, if you are actively managing the medical conditions which you were consulted for, this is considered a Transfer of Care. And that means the highest level of care you can bill for your first note is? Are you ready? Can you wait for it?

99233 = 2.0 RVU = $100.00 (in my world)

That's right. I almost fell out of my chair. I wouldn't have believed it had my hospital not handsomely paid this consultant service to tell me this.

So instead of billing a 99255 (for $192.00), I get $100 for my 99233. Unless I squeak in prolonged services codes (which would be hard to justify in most cases), that is all Medicare tells us it's worth to start from scratch with a broken patient and fix them.

So how do you preserve the consultation code? You have to document the following:

1. That another provider has requested an advice, opinion, recommendation, suggestion, evaluation, direction or counsel concerning the patient problem or treatment options. (Caveat: the consultant is allowed to initiate treatment during the first consult.)
2. A report with the advice must be sent by the receiving provider to the requesting provider.
3. Make it clear that you are walking away from the patient.

The premise here (and it's not entirely without merit) is that the physicians requesting your opinion should be able to handle the diabetes, the hypertension, the pre-renal azotemia, as long as we give them a small refresher course in the form of a consult. They did, after all, go to medical school as well. Some of them are even Board Certified in Internal Medicine.

So what is this going to mean? I suspect there will be more snipping between internist and subspecialists. Now, these rules also apply to the subspecialist. But really... who cares about the difference between a daily note and a consult when you're performing your interventional cardiac cath? Or endoscopy? It's but a piss in the wind for those guys. But for some internists (thankfully not our hospitalist group), it's lifeblood. And suddenly the $100 dollars you lost by reclassification of your note as a "Transfer of Care" adds up.

I suspected that Medicare would focus some sniperfire on hospitalists before long. I just didn't think it was going to happen with such alacrity.