PookieMD's Blog: Where Physicians Learn About the Business of Medicine

According to MGMA, physicians’ number one concern right now is falling revenues.  Especially concerning is collecting copays. Copays are tricky–this is the part of the revenue that the physician is directly responsible for collecting.  Making it even more challenging is the fact that physicians didn’t go in to medicine to become business people, but rather to help and heal people. Some physicians find it abhorrent to even think about the business of medicine.

If you are one of those, I suggest you think about an important concept: you can’t practice medicine if you can’t keep the doors of the practice open.

If on the other hand, your practice is so well run that patients run in carrying cash for the copays and insist on leaving a tip at the front desk, read no further.

Here’s the deal: you must get paid for the work you do, you must meet the financial obligations of the practice, and you must take home some sort of paycheck to keep bread on the table, a roof over your head and clothes on your body.  Your dependents would probably appreciate this as well.  Health insurance and retirement funds are optional.

So what to do:

1. Set the expectation from the get go that a copay is  expected at the time of the visit.  Have a sign to this effect, and train your staff as to the importance of collecting the copay from the beginning.
2. The front desk should check the insurance card for the amount of the copay every time.  (I was at my ob/gyn office, and they tried to convince me to pay the “specialist” copay of $50.  Since when is a gyn visit for a pap smear a “specialist” visit?!)
3. The front desk person should ask, “how will you be paying the copay today?”  (Notice: not “will you be paying the copay today?”)
4. Take credit cards if your office can afford it.  Credit card companies take a 2.5 -3% of each transaction.  When your margins are really tight, this can be significant!
5. Ask for partial payment.   Getting even some of the copay and billing the rest is better than getting none at all.
6. Be diligent in following up on missed copays with billing.  Again, have the option of putting it on a credit card when you send out the bill.
7. Make sure you have a system for logging copays. 
8. Keep the goal in mind: doors open=practice medicine. 

Good luck out there!

What if physicians were reimbursed for talking about end of life decisions with patients? What if there was a code, say 99000-000.00 for the office based or bed side based talk with families and patients about end of life care? What if we could bill for one of the most important conversations we could ever have with patients?

Health care costs would fall and patient satisfaction would go up.  We could bring the patient and family to the office, have copies of medical power of attorney and “living will” paperwork available.  We could talk about where the patient is with their disease and life. We could take the time necessary to make plans to do what the patient wanted when the end of life neared, and stop doing the testing and treating that some patients (read many!) don’t want at the end of life.  Instead we could focus on what patients do want: dignity, friends and family, and freedom from pain.

So, maybe, there should be a place for the “99000-000.00″ visit in this climate of health care reform.  Think of the benefits for all, most importantly, the patient.

PS: in the meantime, consider handing out a copy of this article from MSN Money to patients.  Maybe it will convince them to move forward on their own to get an advanced directive.

The CMS put out a press release stating that it was considering restructuring how physicians get paid.  It proposed reducing payments to specialists when they see a patient, and raising the amount primary care physicians were reimbursed.

Sounds good on the surface.  However, I think the law of unintended consequences will come in to play.  Here’s the gig: if specialists are reimbursed less for patients visits, they will make fewer patient visits and do more procedures.  They are not stupid.  The money is in the procedure, not in the face to face contact with the patient!  What this will do is reinforce the fact the specialists do procedures.  They will have no reward to see and THINK about what is wrong with a patient–instead we will have more cardiac catheterizations and endoscopies.

How many times have you called a specialist because you need help diagnosing or managing a patient, and they tell you over the phone what tests to order, and then tell you they will see the patient before the endoscopy?

No, the CMS has it wrong.  We need to decrease the amount specialists are reimbursed for procedures.  We need to reward time spent with patients, not time spent with the endoscope.

By the way, you must click you way to Medical Marginalia and her take on specialists pay.  Especially poignant are the ending paragraphs where she describes how the hospital made a decision to shed primary care physicians to bring in a cardiologist.  Undoubtedly, the cardiologist will pay for himself/herself through more procedures.

(Apologies to specialists: I’m not picking on you, really! I think we need to get paid for taking care of patients, even if it doesn’t include a procedure!)

I have an opportunity to work for a new hospitalist group.  They have a different model–they pay by the patient.  This is a twist as usually hospitalists get paid by the shift.  The new hospitalist group wants to pay by the patient–$50 per patient, and $100 per admit.  This would include all comers, ICU/floor/”placement” patients etc.  I have been looking at taking on more work since my husband laid off, and decided to give this opportunity a thorough evaluation.

According to a cute little website, here is the break down on average reimbursement for various hospital and out patient visits.  Read it and weep.

Hospital H&P:

Level 1: 99221 (low complexity or time based between 30-49 minutes, anything less time and you can’t bill based on time) $66.50

Level 2: 99222 (medium complexity or 50-69  minutes)  $110.75

Level 3: 99223 (high complexity or 70+ minutes) $154.00

Rounding/subsequent visits:

Level 1:  99231  (low complexity or time based between 15  – 24 minutes , any less time and you can’t bill based on time) $32.00.

Level 2: 99232  (medium complexity or  25-34 minutes) $54.50.

Level 3: 99233 (high complexity or 35+  minutes) $77.60. 

Office visits  for established patients:

(I am using time based visits to give you an idea of how much the outpatient time is supposed to be, but we know that out patient billing is harder to do based on time.)

Level 2: 99212  (10-14 minutes) $37.00

Level 3: 99213  (15-25 minutes) $52.00.

Level 4: 99214 (25-39 minutes) $82.00

Level 5: 99215 (40+ minutes) $117.00.

My conclusion: I would get paid more if I did primary care, rather than taking on the stress of caring for acutely ill patients. In addition, I get to be available by pager until the 7:00 pm night doc comes in.  Would you do it?

 By the way, check out the website above.  It gives a quick look at what is required for each visit, and what the average  reimbursement is. I am going to bookmark it.

News flash: CMS proposes changes in payment to specialists, as well as primary care physicians.  See excerpts below from the press release!

“Based on current data, CMS is projecting a rate reduction of -21.5 percent for CY 2010. 

CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services.   Practitioners will use existing E/M service codes when providing these services instead.  Resulting savings would be redistributed to increase payments for the existing E/M services.  

CMS is proposing to increase the payment rates for the Initial Preventive Physical Exam (IPPE), also called the “Welcome to Medicare” visit to be more in line with payment rates for higher complexity services.  The IPPE benefit was mandated by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to pay for an initial assessment of key elements of a beneficiary’s health status within six months of the beneficiary’s enrollment in Medicare Part B.  Subsequently, Congress extended the time period for the IPPE benefit to within one year of the beneficiary’s enrollment in Part B.

In addition, CMS is proposing to refine how Medicare recognizes the cost of professional liability insurance in its payment system.  While these changes would have a modest impact, they will promote payment equity by redirecting the portion of Medicare’s payment for professional liability insurance to those physicians that have the highest malpractice costs.

 Taken together, refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6 and 8 percent (before taking into account the proposed update and other proposed changes to the fee schedule).”

Wow.  I foresee a big fight on our hands, but hopefully the “thinking” specialties will finally be rewarded as well as the “doing” specialties.  Stay tuned!

I have to admit that I am not fond of lawyers.  I have had a long and friendly relationship with the attorney that manages my business affairs, and have worshipped the ground my medical malpractice attorney walked on.  But none the less, I tend to view them as snakes–some are of the helpful garter type, but many are like rattlers–just a little shake of the tail and a quick bite, and you’re done for.

I may have to change my opinion.  I found a nice post from (gasp!) a lawyer on getting paid to think. Jim Clark’s blog, Fly Over Country, talks about the similarities between physicians and attorneys in getting paid to think.  Apparently, neither group gets paid to do just that.  In his post he states:

 ”For example, some of the most valuable time I devote to a client consists of nothing more than thinking about the case, perhaps while gazing out a window or taking a shower (I do some of my best work in the shower.)

Many clients similarly resist being charged for conferences with other lawyers.  They consider this wasteful.  That is stupid, because the second most valuable thing I can do for a client is sound out another lawyer on a thorny issue, particularly if the lawyer has experience on that issue.”

Bravo.  How frequently do we all wish for a moment to think deeper and broader about our patients, but can’t as we scurry to the next room?  How often to we eke out the time to call a specialist or run a case by another physician and gain new insight?  I think if we could take more time to think, we would order fewer tests and procedures and create a happier, healthier patient and a LESS expensive health care system.  Sounds like this could apply to the legal system as well.  Thanks, Jim for the post!

For fun, I decided to tackle each topic on areas of innovaction as listed in the  X prize criteria.  (See previous post on X prize.)  Today I will focus on behavior modification.  I think this is the key where the most impact can occur to make America healthier.  Health care reform must encompass reforming health habits!  We as physicians and care givers are NOT good at getting patients directed toward healthy habits.  Instead, we frequently focus on quick band aids (pills for blood pressure, diabetes, cholesterol, chronic pain.)  We are pill pushers, rather than health pushers.

Following is a global list on HOW I would encourage a national  change to healthy habits:

1. Make disease expensive and inconvenient.  Keep raising the taxes on cigarettes and ban tobacco products where ever we can! (PS: tobacco supporters, don’t even bother sending in your comments!  I’m a anti-tobacco radical!)
2. Subsidize healthy foods.
3. Have daily physical fitness required at all schools, for all grades, and mandate it at all government jobs.  Subsidize companies that have daily exercise sessions and reward based on participation.
4. Teach care givers, including physicians, how to encourage healthy change, and stunningly! pay health care providers to do this!
5. Make preventive health and such ‘health coaching’ part of medical school curriculum.
6. Make unhealthy patients pay more for care.  Suddenly, when you are paying for health care visits, medications, and therapies, you become inclined to change.
7. Health insurance must reward positive changes by lowering insurance rates and paying practitioners to keep patients healthy.
8. Encourage patient exploration into alternative modalities such as meditation, acupuncture, massage, yoga, etc.  (Yup, going out on a limb here!)

Tomorrow I will have a quick and dirty primer on how to get patients to change habits.  What are your ways to motivate patients to change long term?

See the December 29 post and enter your practice’s goals for 2009.  Include a plan by which your will achieve the goals.  The best plan wins a $15 gift card from Amazon.

I’ve been storing up some links and today seemed to be a good time to have at ‘em!  They range from the scary (Health Policy and Market) to the fun (the Efficient MD’s slide show.)

Read The Country Doc Report for another take on the group visit.  Country Doc relates how his practice does a group diabetic visit.  He uses smaller group sizes, and describes the three phases of the visit. 

For  an RVU Review, and exactly WHAT the RUC is, and how it effects you, visit Health Care Renewal blog. Boy, did I learn a lot about how we as physicians get paid (or not, as the case may be!)

To increase your understanding of the complexities of Medicare, Medicare Advantage, and Medicare Gap, see Insure Blog.  You may want to have this posted at  your front desk as patients come in with their “red white and blue” cards.

Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.

I love ways to improve my efficiency, and enjoyed the  fun, short  The Efficient MD’s  slide show.  I love his blog, and wish he would post more often!

For a chilly take on the role of physicians in the future, visit The Health Policy and Market blog.  According to the blog, we have plenty of doctors, and a “federal physician workforce policy” should be in place.  Just what I want, the federal government interfering even more into the business of health care! 

Establish a federal physician workforce policythat achieves the goals of organized care. TDI research has shown that the U.S. does not need more physicians; we have enough to care for America’s needs well into the future.

Let me know YOUR favority business of health care posts and I’ll put ‘em up!

America’s Health Insurance Plans (AHIP) has released a plan on how to reduce health care costs.  The platform is summarized below:

The new reform proposal would:

Ensure universal coverage by guaranteeing coverage for pre-existing conditions, fixing the health care safety net, giving tax credits to working families and enacting an individual coverage requirement;
Call on the nation to set a goal of reducing the growth in health care costs by 30 percent;
Enhance portability for people changing or in between jobs;
Provide more affordable health care options for small businesses; and
Increase value and improve quality.

An admirable statement indeed. But once again, one must look a little deeper. 

Reducing costs: AHIP points out “Respected studies have shown that patients do not consistently receive high-quality health care and receive care based on best practices only 55 percent of the time.”  Hmm, does  mean that we as physicians are giving ‘low qulaity’ care the other 45% of the time? Who is determining what is ‘high quality’ care?  They advocate using “evidence based standards.”  Aren’t we already doing this?  Furthermore, evidence based standards typically apply to ONE disease state, not the multiple chronic problems primary care physicians deal with.  C’mon give us something fresh!  Stop blaming the doctors for the problem.

AHIP also advocates “exploring” replacing medical liability with dispute resolution. No argument here!  Now who will reign in the powerful legal special interest groups that so effectively court congress?

The reform proposal also advocate controlling fraud.  Now really, how big of a problem is this?

AHIP also advocates pay for performance.  This is a little scary, given the current P4P mess.  I could see this as just another way to with hold payment to providers.  Based on my work as a hospitalist, I find it laughable when the 80 year old post op knee patient is expected to be discharged on day 3.  However, insurance companies don’t care to notice the hypoxia, anemia and confusion attendant with operating on the elderly. Instead, they leave a bright orange sticker on the chart demanding that I justify why the patient is still in the hospital.  Good thing I’m not currently paid for my performance in getting the total knee replacement patient out on time.  The heck with hypoxia!  Clearly I must be doing something wrong and my pay should reflect this!

They also advocate “streamlining” administrative costs.  Gosh, I’d love to streamline my claims, and not have to have extra office staff there to beg insurance companies to pay the bills, or jump through hoops for pre-authorization.  Insurance companies should begin immediately to streamline their administrative costs–they don’t need a government mandate or huge reform to do this–but, I suspect, this may take money from their own pockets.

AHIP states another priority: “Refocusing our health care system on keeping people healthy, intervening early, and providing coordinated care for chronic conditions.”  This is something the health insurance companies should be doing already!  It should not take a “crises” in health care for health care plans to make STAYING healthy a mandate.  They also advocate strongly for “patient centered homes”, a concept that I think is just repackaging of the current model, albeit more top heavy with “midlevel”  and ancillary providers.  

Information technology is embraced (how fashionable!) but no attempt is made as to explain WHO will pay for technology.  Why don’t we admit that the emperor has no clothes?!  There is no money to pay for an EMR and nationalized technology.  Putting it on the backs of primary care practices will drive more physicians out of primary care.  Perhaps insurance companies should pony up for this cost?

They also advocate that everyone should have insurance, regardless of condition.  AHIP also states there should be tax benefits to small businesses so they can offer health insurance, and “large markets should be strengthened.”  They even suggest that the government offer assistance to small businesses. They also advocate broadening SCHIP and medicaid eligibility, as well as offering tax credits to lower income families.    This completely ignores the fact that medicaid reimburses so poorly  that  physicians can’t afford to see medicaid patients!  AHIP also wants  ”community health centers” to receive “adequate” support.  Ah yes, another bail out in the making!

American Health Insurance Plans close with a mandate that the feds should provide a “framework” for reform, and that state governments should follow suit.  They also pledge to “cooperate” with the effort.  After reading the entire proprosal, I am left with just one question: what are the health insurance companies going to do?  Are they going to fly to Washington in their private jets to ask the government to pay for the uninsured?

 Visit the complete reform platform at:

http://www.americanhealthsolution.org/assets/Uploads/healthcarereformproposal.pdf