Archive for October, 2015
People go the the ER but often do not get admitted to the hospital. Why does this happen? Do they think the problem is an emergency or do they just not have access to other health care? The CDC presented the following data from 2011:
(note respondents could answer yes to multiple items)
The bottom line: people who go to the ER but do not get admitted do so because they think the problem is serious, but 80% also say they lack access to other providers.
Social factors often force the ER visit:
- No primary care provider has been established
- Primary care does not have enough walk-in capacity
- In rural communities once the few primary care offices close there is no other alternative
- Work hours force evening or night care for family members
- ER is closer than other options
- ER is more willing to see someone without insurance
- Patients seek continuity of care once they have been seen at the ER — they return.
A not uncommon scenario is when a single parent picks up a child from day care only to find they are sick but doctor’s offices are closed. And, the parent is expected back at work early in the morning.
- Encourage urgent care or “community ER” clinics. In many larger cities doctors or hospitals have opened urgent care clinics — they are not intended to provide continuity of care but just service when needed. In the UK such clinics are often staffed by nurse practitioners.
- Assign one provider in a primary care office to walk-in duty — thus increasing the capacity for unscheduled visits and allowing the other providers uninterrupted time to see scheduled patients.
- Locate some primary care clinics with extended hours next to the ER. The patients can see a primary care provider at a lower cost — but if the problem really is critical the ER is next door.
- Use the phone more. Also, use Skype since it is encrypted and should meet HIPPA guidelines. Cost would be lower for everyone if health care providers made better use of technology. Accountable care organizations (with less fee for service incentive) should find the lower cost aspect very attractive.
- Provide more mobile care. Some enterprising ambulance services provide service on location and don’t actually transport the patient to the ER. Unfortunately, the overhead cost is rather high — but the same can be said for the ER in general. It’s like the guy who comes to your driveway to replace a car windshield. Instead, you might get a laceration sutured in your kitchen! Or your child with a sore throat could be checked with a strep-screen.
Current Procedural Terminology codes (CPT codes) are what makes health care fee-for-service work. The codes function to increase profits for health care providers. Fee-for-service is widely cited as a root cause of high cost in the US health care system. The bottom line is: health care providers work to make money by performing CPT coded services whether the service is needed, whether quality is delivered, and whether a lower cost service would work just as well.
The American Medical Association (AMA) is dominated by surgeons and specialists who do procedures. When the AMA first published a book of CPT codes in 1966 insurance companies were happy to have some basis on which to pay claims. In 1983, for the same reason, Medicare adopted the codes. But, what originally seemed like a good idea, like Dr.Frankenstein’s monster, turned out badly.
The AMA followed simple economic principles and fractionated the health-care market with more and more codes until there are now thousands. Every little thing a health care provider can imagine is now a billable service. Fractionation of a market maximizes profit, and it really worked for doctors but not for patients, insurance companies or the government.
CPT codes in the US have driven fee-for-service to high levels, in fact, that was the purpose. Now, the question for US health care: how to get rid of fee-for-service and CPT codes as the gateway to payment? How to change the incentive system for the benefit of patients and the national budget?
An auto-assembly worker is not paid according to every little procedure — using a wrench (APT code Q70506), installing a radio (APT code F402305) or looking up an exhaust pipe (APT code C403843). No they don’t use Automobile Procedure Terminology, they get paid by the hour with some incentive pay for quantity and quality of the work. There is no reason health care providers should be paid in a different way.
CPT codes or something like them might have a place inside an organization to assess productivity or simply to know what health care providers are doing. The old saying “measure to manage” is indeed true. The mistake is to connect procedure codes directly to payment. Diagnosis, outcome, and patient satisfaction should have input into the payment equation as well.
The way to purchase health care is in the aggregate, like the price of a car, the whole enchilada, or the total amount of care a person might need for a year. The US needs a system of care whereby a patient, a business or a government can purchase health care BY THE YEAR. The incentive is turned around — a profit is present when the cost of care is lower.
Is there opposition to this idea? Of course. Health-care is a huge business. Reorganizing health care takes different forms in different countries. In the US the idea is the Accountable Care Organization (ACO). It’s an organization big enough to actually deliver all the care a person might need in a year and big enough to manage the financial risk. This is not a Mom and Pop operation, this is a huge business almost like an automobile manufacturer. We need this type of care, we need cost containment, we need industrial medicine! The US health care system is like a Dr. Seuss car when we really need a Ford.
DON’T GET AN ANNUAL EXAM. The data are clear — see the recent article in the New England Journal of Medicine and the op-ed in the New York Times — perhaps you missed this counter-intuitive health advice?
Mechanical devices need preventative maintenance. The aircraft mechanic in the illustration prevents engine failure by checking and replacing parts before they go bad. He knows the MTBF (mean time between failures) for the various engine components. You would think this is how the human body works but THAT’S NOT TRUE. You don’t take out an appendix like a spark plug just because they sometimes go bad — you fix it only when needed because surgery hurts and has complications.
One third of the US adult population get annual physical exams and primary care doctors spend 10% of office visits doing those exams. Sound research shows the annual physical is not needed and worse yet, may be harmful because of false positives (tests that say something is wrong but later are proven wrong). It’s the very essence of a false positive — an abnormal test in a healthy person! You know where that leads: “we need to do some additional tests or a biopsy” — just hope it’s not a brain biopsy.
The US healthcare system needs the wasted 10% of primary care time elsewhere. It’s totally crazy — doctors doing unnecessary annual exams that clog up the appointment calendar and make it hard for people with actual problems to get an appointment. And, a large number of people have health problems who don’t see health care providers when they should (but that’s another story)!
Doctors like to do annual physicals — it’s nice to visit with patients and not have to make any hard decisions. And, they make a lot of money doing the exams under the guise of “maintaining a relationship”. But, the exams are not needed.
A proactive patient would make health care appointments as needed for the following:
- Annual flu shot
- Tetanus vaccination every 10 years.
- Cholesterol test every 5 years
- For women over 40 a pap smear every 3 years and a mammogram every 2 years.
Do you really need to have a health care provider tell you the following things, or is this list enough?
- DO keep weight in normal range (BMI below 25)
- DO walk 30 minutes every day
- DO wear seat belts
- Don’t use drugs or alcohol
- Don’t smoke
- DO Check blood pressure every year (automated checks are just fine)
- DO see a health care provider if you have a health problem.
Keep in mind this discussion is about an exam for nothing in particular — just a “check-up” — which you don’t need. On the other hand, a patient needs visits with a health care provider to treat and monitor abnormal conditions. You need routine visits to adjust blood pressure medications, to treat diabetes, to treat acne and to evaluate arthritis.
The International Classification of Diseases version 10 is called ICD-10. Here is an example: S06.5X9A You can look this up on the CMS web site (ICD-10 Lookup) to find “Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter (that’s bleeding around the brain due to a blow to the head which the provider evaluated for the first time).
So, why is this important to you as a health care consumer? Because the bills sent to insurance companies use these codes — if the code is wrong then insurance will reject the claim. By looking up the code you will actually know the technical diagnosis made by your provider — something to add to your DIY medical record especially if it is a critical diagnosis in your situation.
The diagnosis codes are intended to force providers to be very specific about the conditions they treat. The people who connect diagnosis to outcome find the codes very valuable — which in turn helps consumers know how providers perform.
The codes are not always seen by the consumer — they are transmitted on insurance claim forms. In fact, insurance companies will refuse to tell you what diagnosis was used to bill services. But, the codes often find their way into the medical record — as they should.
The ICD-10 code tells the diagnosis. A companion code called Current Procedural Terminology (CPT code) tells what service was provided (like an office visit, or perhaps a brain surgery). ICD codes are in the public domain but the CPT codes are produced by the American Medical Association and are copyrighted.
From a purely economic standpoint the CPT codes serve primarily to fractionate the health care market to maximize profit for providers. It is helpful to know what service is provided but the CPT codes are blighted by meaningless detail. And, they are hard for the consumer to decode because of the proprietary nature of the codes. Many feel the CPT codes are part of the cause of high health care cost in the US. They should be scrapped and replaced with some international standard.
Customer service for most large businesses has gotten worse over the past few years according to American Service Index . Of course, cable companies and cell phone companies are the worst but medical related customer service is also at an all time low. This blog is not about phone calls to doctors and nurses but to insurance companies, retirement plans, ambulance companies, pharmacies etc.
You probably have your own horror stories (please add them in the comments). Here are a few from friends and family:
- The long term care insurance plan that repeatedly credited an account then send out a bill for the same amount.
- The ambulance company customer service that changed billing codes to anything they thought would get a claim paid but could not send any documentation for a Medicare appeal.
- The insurance company customer service that could not stop double billing for insurance coverage — “that’s a computer problem”.
- The laboratory customer service representatives that only know the amount of a bill but not the service that was performed — “we only do what is ordered” — they billed a urine culture but no urine sample was obtained.
One person had to call customer service over 20 times to get a medical billing problem resolved.
There are 2 major problems:
- customer service is outsourced — if the answers are not in the “computer” then you will get no help
- there is no follow-through. Meaning, customer service says they will send a message to some department that will respond in “7-10 days”. But, they never do and you have to call again.
So here are some suggestions for dealing with medical related customer service:
- Be prepared — have your customer number, billing number, a bill itself and other things you may need. Many medical bills will have billing codes (CPT codes and ICD10 codes — look them up online if you can). If your are calling for someone else (like a spouse or parent) — make sure that person can come to the phone. A cool way to make this easier is to use Skype to include multiple people in a call if they live elsewhere.
- Be friendly, not overly stern. Remember: you are dealing with a person, possibly one that has little control over the company, don’t make their day worse. You will get better results with honey than vinegar.
- Take notes as you talk. Absolutely record the name of the representative, the date and what they tell you to do. If possible get a phone number, fax number, email address and post office address if you need to communicate further.
Depending on the urgency or the dollar amount in question (like over $20) then send a letter to customer service summarizing your discussion and what still needs to be done.
- Is it worth your time: If the problem in question is minor consider dropping the issue — your time is worth something. If you have to call back because you did not get a call or letter that was promised or the instructions you followed were wrong then demand to talk to a supervisor from square one — not another front line customer service rep.
- Go to the next level: if the supervisor can not solve the problem or wants you to wait for a call-back or something to come in the mail tell them you need the phone number of the executive office or CEO in case the issue is not resolved since that is where you will call next. Again send a summary of your discussion to the supervisor.
- The executive team: If the problem is not resolved by the supervisor then call the executive office or CEO — you can almost always find the executive office phone number with a Google search for the business if needed. Again, send a summary letter of the conversation. Or if you can not get through send a certified letter with your concerns.
Pay the amount that is billed — but mark your checks “under dispute” if indeed there is a financial issue. In general, resorting to legal action is a waste of time and money for disputes less than about $1000 since most legal fees will exceed that amount.
Complaints to the Better Business Bureau, the State Licensing Board, the State Attorney General or the Insurance Commissioner often get their attention.
If you are going to go nuclear, first send the CEO a brief letter with your complaints, the harm that has been done and what you want them to do — say you are serious and do not plan to drop the issue (no threats!). Wait a while then send a second letter of what actions your are taking and do them – complaints to local or state officials or start legal action.
Medicare fraud is a serious matter, it should be reported as soon as it is identified.