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Free the Doctors (9/2/2009)

Posted in Health Care

I found the quote below at a US Government Health and Human Services website about Medicare payments. Believe me, I didn’t make this up.

This website is designed to provide information on services covered by the Medicare Physician Fee Schedule (MPFS). It provides more than 10,000 physician services, the associated relative value units, a fee schedule status indicator, and various payment policy indicators needed for payment adjustment (i.e., payment of assistant at surgery, team surgery, bilateral surgery, etc.). The Medicare physician fee schedule pricing amounts are adjusted to reflect the variation in practice costs from area to area. A geographic practice cost index (GPCI) has been established for every Medicare payment locality for each of the three components of a procedure’s relative value unit (i.e., the RVUs for work, practice expense, and malpractice). The GPCIs are applied in the calculation of a fee schedule payment amount by multiplying the RVU for each component times the GPCI for that component.” http://www.cms.hhs.gov/PFSLookup/

Who the heck has the ability to determine the relative values of 10,000 physician services? This must be what President Obama was referring to in his statement about treatment of sore throats when he said, “The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’” What a patronizing insult to the great bulk of doctors who are just trying to do the best thing for their patients regardless of the complicated reimbursement system! Probably a few have fallen into the trap of subconsciously playing the system to maximize their reimbursements. It’s hard to blame them. They are just doing what the government designed program encourages. If your boss says to you, “I’ll pay you more to do this than to do that,” are you going to do this or do that? It’s like playing Space Invaders or Dungeons and Dragons. Maximize your score. Get to the next level. The whole system is probably a product of the video game generation. Of course some have gone beyond subconscious game playing to outright fraud. It’s not hard to blame them.

The statement above about MPFS’s, GPCI’s, and RVU’s is exactly what is wrong with government involvement in health care administration and reimbursement. It may not be true for every government, but the Washington DC bureaucracy apparently cannot control itself and, as a result, creates systems that become tails wagging dogs. A whole new field called Medical Coding, including courses, certifications, and careers has built up around this system, and all the people and facilities and information technology involved in it are now part of our national health care cost.

We have, for example, the American Health Information Management Association, AHIMA for short, whose website puts forward this declaration:

Delivering quality healthcare depends on capturing accurate and timely medical data. Medical coding professionals fulfill this need as key players in the healthcare workplace.” That seems to me to be a self-serving statement of questionable verity! I would rather emphasize that quality healthcare depends on well-trained doctors with state-of-the-art technology, trained staffs, and time to do their jobs. Of course record keeping is necessary, but I don’t believe we need the degree of granularity provided by 10,000 classifications.

And further down the AHIMA page: “Currently, reimbursement of hospital and physician claims for Medicare patients depends entirely on the assignment of codes to describe diagnoses, services, and procedures provided.” Now we know why there will have to be some codes for “end of life counseling” if the doctors are to be reimbursed for time spent doing it. Find these statements and more at http://www.ahima.org/coding/.

If I need a lawyer, I pay him or her by the hour perhaps after payment of a retainer fee. Is our distrust of doctors so much greater than our distrust of lawyers that we have to pin them down to every single procedure they perform and then pay so much per procedure depending on the cost of living in the town they work in? Would it not make a lot more sense to pay them for their time and investment and free them to make the best possible decisions based on the symptoms, possible diagnoses, and available treatments? The President apparently would like to see a change because he spoke of payment for outcomes or results rather than activities. It’s an interesting idea, but I don’t believe that payment only for success is going to work. We will all eventually die. I would rather free the doctors completely from this onerous system and let them make the best use of their education while saving countless hours of red tape.

The talented guy who works on my 1994 8HP Mercury outboard motor charges $100 per hour for his labor. I trust him and would never think of asking him exactly how much time he spent changing the spark plug and how much installing the new fuel filter and how much changing the lube in the foot. (His personality is similar to that of Dr. Gregory House.) I wouldn’t take the motor to him if I didn’t trust him, and I certainly don’t want to go to a doctor I don’t trust. I think $500 per hour is probably a reasonable starting point for someone with a medical degree, several years of residency, investment in space and staff and equipment, and maybe a hundred thousand or so in education loans. IT and management consultants can easily charge $200 per hour. Even my wife’s masseuse gets paid by the hour. If massages were reimbursable by Medicare, there would be a several hundred-page schedule specifying so much per upper arm and so much per little finger, etc.

That Health and Human Services statement is ample justification for major reduction of government involvement in health care and major simplification of billing and reimbursement practices. Free the doctors!

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