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In my previous post I quote extensively from an article written about Atul Gaeande about primary care physicians (primarily family physicians) who are engaged in trying to reduce healthcare costs for patients who use an extremely large amount of health care. Dr Gawande quotes one of the family physicians, Jefferey Brenner,  as saying that he believes his patients are the same as anyone else. These unfortunate patients have found themselves as a consequence of chance, circumstance, and poor life choices in a situation where they require increasingly to access the health care system to obtain needed services. Dr Brenner sees his job like that of a mother. Someone who cares and is willing to say the same thing over again until the right thing happens.

I thought about this article again as I read an editorial written by Dr Mike McBrearty in the Scope Magazine (the publication of the Alabama Academy of Family Physicians). Unfortunately the editorial is not available online but can be obtained by contacting the Academy here. Dr McBrearty expresses a frustration common for Family Physicians and mothers, one of under-appreciation. Both groups find themselves performing the impossible, molding the behaviors of people who do not want to be molded.While mothers expect payment in non-monetary units (customarily kisses and hugs) physicians tend to expect more tangible rewards, While I have written some on physician reimbursement here some additional information might help illustrate the problem a little more clearly.

The rules for how physicians can submit bills are very convoluted. When Medicare was first established, physicians were able to submit a bill for services to all insurance companies and were paid based on a fee schedule. Typically, all of the physicians in a given community charged about the same thing and fess were set (believe it or not) by doctors who were new to town calling and asking the office staff of the others in town for their charges for certain types of visits. As health care costs rose, Medicare became the benchmark for payment. Private insurers tended to follow Medicare rules and benchmarked their payments for certain procedures on Medicare rates (percent Medicare). In the 1990s there was concern about rising costs in Medicare (sound familiar) and a new type of system was established. The office visit was defined more clearly. It included a history, a physical exam, some type of decision making, and an after visit care component.  This was contrasted with an activity such as a gall bladder removal which included some pre-operative history, the physical exam, the act of removing the gall bladder and closing the body, the care in the hospital after the gall bladder was removed, and the care at home for a period of time after the operation. Both of these activities were considered to be bundled into a global fee, with the schedule set by the insurance company. Physicians could not bill for each of the components that were included in these types of care separately and a language was devised to tell the insurance company what happened called CPT (Common Procedural Terminology) codes. The physician’s office told the insurance company what it expected in the way of payment  by submitting a diagnosis (using ICD-9 terminology) and a types of care provided (using the CPT code). The documentation had to be available to back up what the office said had happened. The fee for hospital care worked well because there was a hospital history, physical, and operative note to support the billing request. The fee for office care office  worked well when it reflected care for acute conditions (an ear infection, for example), the medication choice was simple (penicillin) and the after care was one phone call (I’m not better) with a fairly predictable outcome (then you need to come in). Doctors were expected to make money in the office based on volume (seeing lots of patients for little things).

Where did things go wrong? The amount of work that went into taking out a gall bladder got easier for the physician because hospitals hired people to help with some of the tasks (lab techs, nurses with special training) and the tools made care easier (laproscopic cameras). What used to be a three day event now takes 3 hours. In the office, the tasks became more complex (older patients with more problems, drugs not available on certain insurances, the need to arrange home health care, the need to write justifications for medical equipment) but no one stepped in to help out the doctors in the office by making care easier. In fact, the “enhancements” actually lead to more work for physicians in the office (electronic health records allow better access to information but reduce physician efficiency, drug formularies allow patients access to cheaper drugs but cost the physician time).What used to happen in the hospital over 3 days now happens in the office with the patient not present so the doctor can’t bill for it.  The CPT and ICD-9  language that physicians use to tell insurance companies what they have done does not include the detail needed to describe what really happens.For example,  I get no credit for working to get a patient to stop smoking. In fact, because they are going to be ill less frequently, I will get paid less.

We primary care physicians need to ask for payment to reflect our actual work. The “fee-for-service” model will not allow us to successfully accomplish this. Going back to the mother analogy if the mother only collects kisses when the knee scrape happens, the incentive is not to teach good bike riding habits but instead to teach poor habits and hope for a lot of banged up knees. Fortunately mothers tend to work towards long term outcomes. Some think Accountable Care Organizations will enable us to extract ourselves from this mess and work towards wellness with our patients. I await the new payment rules eagerly.