One way to improve medical care – pay for the right things

Medical payments systems for both physicians and patients are convoluted. Each time I physically see a patient in the office, I get paid to see the patient, not including charity care. If I see the patient in the AM, directly admit the patient, and then go to the hospital in the PM to check on the patient, Medicare and most insurance plans either deny both visits or pay for the lower of the two visits. Calling in medications, calling to see how patients are doing with their treatment plans, filling out disability/FMLA forms, taking care of mail order refills, preauthorizations for meds/radiology studies, and email are all free to patients. Most professionals, including accountants and lawyers, get paid for coordination of care without having to physically see the person each time. I’ve learned that in the end patients make it worthwhile and that you have to enjoy what you are doing caring for patients to survive in medicine.

On the flip side, would a family of an end stage 90 year parent really want the patient to be a full code/do everything possible to spend a hundred thousand dollars for the last week of life in the ICU in the hospital if the patient did not have a supplemental insurance or medicaid to cover copayments? For patients with IL Medicaid, why can they go to the ER for free for a sinus infectionbut have a $2 copayment for office visits for the same care? Insurance companies have increased copayments for ER visits up to $250 for 2009, and office visit copayments average $30 for 2009. What is the purpose of a copayment? Most likely it is to make the patient think twice about using the ER or office for care.

E&M visits, with their respective CPT codes, have average visit times associated with them. A level 3 established visit usually has a recommended time of 15 minutes. Patients and physicians may need slightly more or slightly less time. Once you have discussed the 1-3 items, then the patient and physician have used up the average billing time. Spending extra time to show the patient how to use a glucometer or to go over a low vitamin K diet is free time that I do to provide the best possible care to my patients.

The current system rewards physicians who see their patients frequently. One of my new patients was seen four times in 2 weeks by a group of primary care doctors, when two visits would have been sufficient for cellullitis. Each group member averages 70 visits/day and provides rapid care with a high dollar daily intake. What kind of care can patients get with minimal timed visits with minimal time for preventive medicine? Another difficulty is that Medicare and many private plans do not cover preventive annual physicals. Many private plans deny tetanus boosters, flu shots, and pneumonia vaccines. Patients get upset if they get a $30 bill for a flu shot, when they pay thousands to their insurance companies. Getting the flu is going to cause many missed days of work and productivity.

The entire payment system in medicine needs to be revised. Most private plans have limited fees that are at or below Medicare. The various private insurance companies simply duplicate the same services. Every company outside of plain Medicare requires preauthorizations for procedures/studies. The administrative time in primary care increases annually and continues to be done for free. I hire more people and spend more time on paperwork, while I watch my income related to cost of living decrease with increasing malpractice insurance and overhead. Medicine has business expenses, yet the caring business often is not reimbursed appropriately.