DB’s Medical Rants

Two other bloggers have written important entries about reimbursement. First, the Happy Hospitalist - In The Eyes of Medicare, You are a 99223. The Hospitalist goes to great length to explain coding and the notes it requires. If you are not confused or dizzy by the end of this rant, than you are a better person than me.

DrRich writes beautifully about the idiocy of our reimbursement system (driven by Medicare) - E&M Guidelines and Patient Care

When the E&M guidelines were first introduced, they were recognized immediately by doctors as a complete abomination. Indeed, the great hue and cry from angry physicians (and the arrival on the scene of a new Republican administration) caused the Secretary of HHS to appoint a special commission to review the E&M guidelines in 2001. The commission concluded that indeed, the E&M guidelines were entirely counterproductive to patient care, and in June, 2002 voted (20-1) to recommend abandoning them altogether.

But HHS declined to follow the recommendations of its own commission, instead leaving the E&M guidelines in force “temporarily,” and vaguely promising to revise them “soon” in order to make them less dangerous to patient care - knowing full well that the saurian lassitude of the bureaucracy would easily outlast the fleeting indignance of the medical community.

Accordingly, not only has HHS failed to take (or, alternately, succeeded in not taking) steps to revise the E&M guidelines, they also have vigorously pressed forward with audits and prosecutions for the federal crime of healthcare fraud, based on physicians’ inadequate compliance with them. And, as the bureaucrats must have predicted, there has not been any substantial noise from doctors about revising these guidelines for several years now.

So we have a byzantine system which no one understands. The system drives us to write notes for billing, not for patient care. For example, if a 90 year old woman with Alzheimer’s disease gets admitted from a nursing home for a decubitus ulcer, I am rewarded for recording her family history. As I often say at morning report, many patients have outlived their family history. Yet, if one logically omits the family history, you cannot bill as high.

Not only is the system byzantine, but the levels of reimbursement (as I have screamed about for the past week) is determined through a totally opaque process. This opaque process (the RUC) has taken an intellectually reasonable concept - RBRVS - and corrupts it to over pay procedures and underpay both office visits and hospital care.

This is the biggest problem in health care today. The reimbursement system drives decision making at the medical student level, the resident level, and the hospital level. Fixing the reimbursement mess would help decrease unnecessary procedures, imaging studies and decrease health care costs. If fixed properly, we would have more graduates choosing generalist professions. But who has the guts and clout to really address this issue.