Primary Care Reimbursement

Quote of the Day:
God looks at the clean hands, not the full ones.
--Publilius Syrus

A hot button topic for primary care doctors has been about the imbalance of  RVUs allotted for patient visits to a primary care doctor, and the lack of procedure codes. Unlike specialists who have a potpourri of procedures, codes, modifiers to up regulate their fees (all legal and proper), the PCPs are left with  few to chose from.

One fear that specialists verbalize is that the ‘Medicare pie’ is only so big, and CMS is not going to increase it, so that if PCP gets more specialists will get less.

This is a strategic move on the part of CMS and HHS. It has always been this way, and that is why specialists want to continue to control the RVU process. Divide and conquer weakens our voices.

 

My opinion is that specialists must support their PCP referral base. If we do not then

1. Your referral base will disappear if your PCPs get wind of  your opposition

2. It is foolhardy to enjoy the fruits of medicine no matter what specialty you are in, while other MDs are suffering from disparate incomes. Any health reform must equilibrate the work/reimbursement ratios.

3. PCPs now must have at least three years of postgraduate training, unlike years ago when one year of postgraduate training made one qualified to practice general medicine

In addition to that the AMA has the copyright to CPT coding, something that every physician uses everyday. In fact that is one reason why only 165,000 licensed MDs belong to the venerable AMA.

The AAFP has begun a campaign to change the system. An article in the Wall Street Journal by Anna Wilde Matthews elaborates,

“Primary-care physicians are pressing the agency that oversees Medicare to change a payment system they say places a higher value on work done by specialists.

The American Academy of Family Physicians has sent a letter demanding changes to a committee that plays a key role in Medicare's process for setting physician payments. The academy wants the panel to add more members representing primary-care groups, among other adjustments.

The academy also has set up a task force to propose new methods for calculating Medicare reimbursement for many of the services provided by primary-care doctors.”

In an article published in 2005 by the Dean’s Newsletter at Stanford School of Medicine, the issues about CPT codes and RVUs points out the added complexity of valuing CPT codes.

Stanford University uses a “Funds Flow Work Group” . If ACOs come to pass, this may be the model for distributing income allotted to physicians. No matter what it is going to be a very interesting and challenging time.

del.icio.us Tags: primary care,specialty care,cpt,rvu,Stanford,aafp,ama

Health Hangout Number 2

MARK YOUR CALENDAR----TODAY at  6 PM PDT    9PM EDT

The Second International Google+ Health Hangout Session will be held on Sept 7^th Wednesday at 6PM PDT 9PM EDT. You can find it by going to my stream at Gary Levin and look for the “I am hanging out “ Click on the “Join the Hangout tab”

For those of you who are not familiar with 'Hangouts” there is a video tutorial at:

Google + Video Tutorial Other information can be found at: www.google.com/+/ or just Google “The Google + Project “ .

You can also twitter me @glevin1. On the morning of the hangout I you will receive invites to all those in my “health hangout circle” and/or professional connections. If you follow my stream you will see a green “Join” tab. Clicking on it will bring you to the hangout. For those of you not on Google + I will send an email invite on Thursday AM at 9AM PDT and 12PM EDT.

Hangouts are limited to ten participants. If there are more than ten I will ask five in the hangout to leave every ten minutes to allow others to join. The Hangout will open 10 minutes before the listed times.

Google + has not been officially launched and is still considered in 'beta'.

Google + And Health Train Express

 

Readers may have noticed my posts here have trailed off a bit. Rest assured I am well and not burned out on blogging. I have been immersed in social media. I have always had a small presence on twitter and Facebook, however I have been seduced and carried away by a  new love…Google +. Google + has a particular feature that I think can and will revolutionize the way physicians can interact in groups of up to ten.

The big ‘G’ has finally  struck it big once again. After many fits of spurts and stops, including investments and acquisitions in many  other smaller enterprises (which seemed to go nowhere) in reality it was all foundational and a learning experience for Google.

The list for the intrepid Google is on this Infographic   

Google learned much from these “failed whales”. In reality the investment paid off big time, not in immediately on their books, however Google plus despite what naysayers opine is going to be big time. They gained knowledge in the areas of streaming video and conferencing.   Users will not abandon Facebook or Twitter because each of those serves other purposes. Although this market niche is dominated by FB and Twitter, there are other players such as Linkedin which play an important role especially for professionals in health and business.

My particular enthusiasm is regarding the role of Google + Hangouts. The potential for physician conferencing for education, consulting, and even patient group education by physicians or assistants is there. It is already to be used, if physicians can be brought to the table. Perhaps as physicians become more comfortable with EMR and HIT they will accept Google + Hangouts more readily. 

Physicians seem to like ancillary HIT, ie, that not involved in the direct physician-patient interaction. Health 2.0, mobile apps, and tablets have gained a strong foothold. The entrance of the tablet PC is making a significant impact in the clinical setting for physicians.

Health Train Express is establishing a weekly “Hangout” on Wednesday of each week.  An agenda will be published here on the blog each week on Monday preceding the video conference.  Each week will be focused on different interests. This coming Wednesday will be organizational and I will need some help in choosing topics ranging from HIE, Health 2.0, Mobile apps, EMR, Incentives, Algorithms in Diagnosis and Treatment, Social Media and many more. 

Hope to see you there on this coming September 7th 2011 at 6PM PDT and 9PM EDT.

del.icio.us Tags: google +,google hangout,Health 2.0,emr,hie,hit,physicians,tablet pc,social media

Health Hangout Post-mortem

Part I

The first hangout was shared by only a few of the best ‘hangers’. It was on short notice, however the time of the ‘H’ will better be placed in the evening after hours…Not many working stiffs (docs), not cadavers can take time to ‘hang’ right after lunch. Steve Eisenberg MD (oncology superior) from Poway Ca and I were ‘hanging’ when his nurse interrupted him for a phone call. He never quite made it back.

Be forewarned…hanging may interrupt and alter your office productivity. Also when leaving the room, mute your video and audio.  All the health care techs,, nurses and wannabees will come up to the screen to see who you are.

The next hangout will be in the evening, TBA.

So, if you  are a physician and want to ‘poo-poo’ social media, you do so at your own risk.

Here are some examples of what Social Media means to your patients.

Inventing Breakthroughs Day (800x450) from C3N Project on Vimeo.

Social Media Summit Scholarship Essay

MyIBD app for Crohn’s and Ulcerative Colitis

Social Media Summit Scholarship Essay - Jill Plevinsky

Social Media Summit Scholarship Essay – Corey Daniel King

Social Media Summit Scholarship Essay - Jim Pantelas

C3N - the Collaborative Chronic Care Network from Lybba on Vimeo.

When Patients Band Together

 

Tendon Surgery Facilitated by Social Media

 

The Top 10 Ways To Keep Social Media From Driving You Totally Nuts

 

Hanging out on the Health Train

August 31, 2011   

Google + Hangout today at 1PM PDT, 4PM EDT.

Good Morning. Today I am hosting the first Hangout on Google + for Health Professionals, Physicians, and Health Information Professionals. Date: August 31, 2011: Time: 1PM PDT, 4PM EDT. Place: Google Hangouts. Search for Gary Levin and Click on the Green “Join” tab. Invites will be sent out at 12:30 PM today. The Hangout room will open at 12:50, sign in early since there are only 9 spots in addition to mine. The Agenda will be organizational. the Hangout and topics to be discussed and a forward looking schedule for the next six months.

Some possible topics: EMR Incentives, EMR adoption, ROIs are there any ? Experiences of Early Adopters. Thoughts on Diagnostic and Treatment Algorithms. Use of tablet PCs.

 

Or look for the  Join This Hangout   tab on my profile page on the right by searching for  Gary Levin in the search box on the main stream page of Google +. Sign in early, check your mic and video.

 

del.icio.us Tags: Hangout,Google +,Health Train,EMR,HIT

Health Train Hangout +

    

I admit it. My interest in the blog has waned the past month, since I discovered G+. This is serious ! I have an addiction to G+, especially  ‘Hangouts”. I am finding many of my fellow Bloggers over there asking me to ‘Join the Hangout”.  I spent the past week building my circles. Constantly amazed at people who have 100,000 followers…I must be missing something. However the sillier the message, the more followers you will have. I will be back again in about a month or so. Do watch for my Hangouts, though. 

del.icio.us Tags: G+,Google Plus,Hangout,Sparks,Huddle,Circles

Health Train in a Hurricane

Having been through several earthquakes,hurricanes, floods I will take an earthquake any day !  I hope my east coast readers are all okay.

Katrina seemed to have taught emergency management many things.

1. Evacuate early

2. Be proactive…evacuate dependent elders, sick people

3. Encourage people to be prepared with emergency supplies, medications,,(keep them dry)

4.Have a personal plan for yourself and family

5. Let people know how to get ahold of you

6 Your life is more important that your property…that can be replaced, but not you.

7. Take news in small doses. Media tends to hype things.

8. Stay tuned to the weather channel.

9. Have an emergency radio, lantern, and food supply. When you shop don’t buy frozen or food requiring electricity. Chances are you won’;t have any.

10. When using cell phone use messaging..it saves bandwidth on the cell network. Keep you cell charging, and get an adapter for your car as well as a booster battery.

Follow me on twitter, G+ or Facebook

del.icio.us Tags: irene,hurricane,emergency plan,evacuate

Google Your Health Records

Another wake-up about privacy and security:

Huffington Post:

SAN FRANCISCO — Until recently, medical files belonging to nearly 300,000 Californians sat unsecured on the Internet for the entire world to see.

There were insurance forms, Social Security numbers and doctors' notes. Among the files were summaries that spelled out, in painstaking detail, a trucker's crushed fingers, a maintenance worker's broken ribs and one man's bout with sexual dysfunction.

At a time of mounting computer hacking threats, the incident offers an alarming glimpse at privacy risks as the nation moves steadily into an era in which every American's sensitive medical information will be digitized.

Electronic records can lower costs, cut bureaucracy and ultimately save lives. The government is offering bonuses to early adopters and threatening penalties and cuts in payments to medical providers who refuse to change.

But there are not-so-hidden costs with modernization.

"When things go wrong, they can really go wrong," says Beth Givens, director of the nonprofit Privacy Rights Clearinghouse, which tracks data breaches. "Even the most well-designed systems are not safe. ... This case is a good example of how the human element is the weakest link."

Southern California Medical-Legal Consultants, which represents doctors and hospitals seeking payment from patients receiving workers' compensation, put the records on a website that it believed only employees could use, owner Joel Hecht says.

The personal data was discovered by Aaron Titus, a researcher with Identity Finder who then alerted Hecht's firm and The Associated Press. He found it through Internet searches, a common tactic for finding private information posted on unsecured sites.

The data were "available to anyone in the world with half a brain and access to Google," Titus says.

Titus says Hecht's company failed to use two basic techniques that could have protected the data – requiring a password and instructing search engines not to index the pages. He called the breach "likely a case of felony stupidity."

The personal data was discovered by Aaron Titus, a researcher with Identity Finder who then alerted Hecht's firm and The Associated Press. He found it through Internet searches, a common tactic for finding private information posted on unsecured sites.

The data were "available to anyone in the world with half a brain and access to Google," Titus says.

In the wrong hands, health records can be used for blackmail and public humiliation. The information can also be used by insurance companies to inflate rates, or by employers to deny job applicants.

Usually when personal data are exposed, it's the result of a network break-in by a hacker or a theft of computer equipment. Sometimes, it can be a simple case of someone mishandling the information.

Leaks are more likely the more data are passed around within the health industry's increasingly interconnected networks.

Dozens of companies can be authorized to handle a single person's medical records. The further away from the health care provider the records get, the flimsier the enforcement mechanisms for ensuring the data are protected.

That's exactly what happened at Hecht's company. Hecht declined to go into further detail about how the information ended up online. He says many of the Social Security numbers and basic details about people's injuries were part of a database his firm compiled from information regularly sent by the state.

As instances of data mishandling become more commonplace, government officials may seek greater control over security policies of companies with access to health care records that aren't currently regulated.

Can electronic medical information be insulated from hackers? When there is a will, there is a way…Perhaps key identifiers should not include social security numbers. There are other identifiers available from computer algorithms which factor in date of birth, previous addresses,  which are already in use by credit card agencies.

While there are strict HIPAA protocols, it falls upon companies and entities far removed from the point of care delivery. Caveat emptor to the patients!

 

del.icio.us Tags: search engines,google,health records,hipaa,social security numbers,security breach,password,data mishandling

Information Overload

Barbara Duck in her blog “The Medical Quack” interviews Dr. Hamlaka, the outgoing CIO of the Harvard Medical School. He along with Sean Nolan have said, and why  It's time to take a break with a Health IT-Interview with Dr. Halamka and why he's stepping down as Harvard Medical CIO-there's too much on the plate tellilng ONC to ‘take a vacation’

 

PLEASE, TAKE A BREAK!
JUST STOP TALKING FOR AWHILE AND LET US IMPLEMENT STUFF.

My thought on this is “sure”. These federal employees are PAID to generate paperwork. Your tax dollars and mine are caught up in this process. Their ‘quarterly assessments” depend upon the volume of bureaucratic edits, they produce. If they stop their job is in jeopardy.  It is a self-propagating process at work in all areas of government unless Congress stops their funding.

According to Sean Nolan

“ I’ve spoken at some length about my enthusiasm for the current leadership at HHS and ONC. President Obama has both directly and indirectly engaged some really gifted individuals to help us address healthcare challenges through the use of information technology --- which is awesome. In particular, folks like Aneesh Chopra, Todd Park and Farzad Mostashari have brought the Internet to healthcare (or perhaps more accurately, healthcare to the Internet), and have convened some super-effective public/private groups to collaborate on specific issues with real success. I’ve had the good fortune to participate in a few of these, and it’s been some of the most rewarding work of my career.

Why stop now? I think the answer is increasingly clear. Between Meaningful Use Stage 1, the Direct Project and theHealth Data Initiative, government has kicked industry out of a funk it’s been in for the previous decade, and we’re seeing a ton of really exciting and positive innovation. But nobody, and certainly not ONC, knows at a detailed level how to turn that innovation into ubiquitous market reality. What we need now is a period of implementation, competition and iteration to figure out how to deliver on the promise.

What we need now is time for the system to work, partnerships to form, software to be upgraded in production systems, ideas to be tested, consumers to choose what to buy and what not to buy.

I’m not asking for the pace of innovation to slow down --- capitalism takes care of that just fine (even in healthcare, when the conditions are right). I’m asking for the government to slow down … recognize that ONC has found an incredible recipe to guide progress, but that it will only keep working if used strategically.”

Medical Quack interviews Dr. Hamlaka   

Rocketman

Sometimes I believe I should change the name of my blog to Health Rocket Express. Advances are proceeding at such a rapid rate that my Health Train cannot keep up with all the issues, social, technical, patient care, research, patient advocacy and more.  Far cry from my days as a very focused ophthalmologist. I find the new age just as exciting as it was when I took out my first cataract or corneal transplant surgery.

Technology changes in healthcare and medicine,as well as health information technology parallel advances in internet, video streaming, social media networks, wireless technology,

All of these technologies come at us simultaneously and compete for our attention. What to adopt? Will it be obsolete next year, and/or replaced by another advance? Rapid advances in imaging techniques with MRI, PET Scans, Minimally invasive surgery in cardiology, abdominal surgery, neurosurgery, orthopedic surgery.

Witness the transition and battle between Google Plus and Facebook.  A single social presence is not tenable at this point. Sermo has become a central focus for physician discussions. Some of it is purely social, but there is a great deal of clinical information exchange.

You may say, who needs it?  My answer is “Build it, and They will come” much like “Field of Dreams”, we are at the point where many of our dreams are here, now.

     

Social networking increases our power to communicate, not just in health issues, but politically as well. We can be heard..en masse. Most politicians now have a social media presence with a dedicated social media staff. It can’t get much more democratic that Twitter, Google Plus or Facebook. Aside from patient care and HIPAA restrictions there is so much to do with these platforms it is as revolutionary as the telephone or even the PC revolution which made it all possible. All of the aforementioned platforms have mobile applications on Android, iOS, and Windows 7 phones.

All of this innovation comes simultaneously with proposed massive changes in health care delivery. This has  created a stimulus for communications between providers, organizations, congress,  consultants, and pundits. We can certainly have our interests and opinions fairly presented, as organized medicine and even more important as individuals not aligned with political action committees and/or the influence and corrupting power of campaign donations.

I urge all of you to use the new media to express your opinions.

del.icio.us Tags: social media,facebook,twitter lists,google plus,google hangout,politics,rocketman

Color Me Confused

 

At one time there were only about 8 primary crayola crayons to chose from. Much like health insurance. However today we are faced with many more, not just in crayola colors, but the byzantine of flavors of health insurance coverage, with most having some blank spots somewhere or other.

The Image above is a ‘Radial’ design, however the same data can be presented in ‘Cartesian” format, below:

 

LINK to INTERACTICE COLOR WHEEL

This brought to  mind the charts and tables that appear in many medical journals and articles. Nothing can be more boring that trying to decipher what a chart or table lists.

The visual system does not organize tables into constructs for interpretation. Colors stimulate many more neurons, not just in the visual pathway but through interconnections that are sensory (ie, pain pathways which elicit photophobia in migraine attacks)  Some of these connections may also go to higher cortical centers in the parietal lobes, prefrontal cortex, limbic system and other centers connected with emotional reaction.  Consider the fact that blue elicits sadness, red-anger, and why do flashing strobe lights precipitate seizures in some people?  All food for thought. A bit off topic for health train express,

del.icio.us Tags: visual stimuli,crayola,crayons,tables,seizures,happiness,sadness,visual system,anger,neurons,color wheel

Emergency Department Charges

Akron General Patient Price Information Emergency Department

Demystifying, and Maybe Decreasing the Emergency Room Bill

Consumer Health Ratings: Typical Average Cost of Hospital ED Visit

Have you been to the emergency room lately?  Everyone tries to avoid ERs. For one thing they are meant for emergencies, and despite that fact there are many who use the ER in the evening on the weekends and holidays when their doctor is not available. This is especially true if you see a physician in a small group or a solo practitioner. Many sign out to the ER, and because ERs must examine all comers (by law) these patients add to the constant stream.  Some arrive at the ER from an accident, some have no physician at all.  Wait times are variable The frequency of true emergencies is very small. Triage is critical, and in some cases there is an urgent care center nearby that a patient can be referred to..  In our particular hospital there is a common reception area and a nurse practitioner or physician assistant screens a patient and refers them left to urgent care or right to the emergency department. Any chest pains are immediately shunted to the vital signs room to be hooked up to monitors, have blood drawn and have a detailed history taken.

The topic of my blog is not about triage and treatment in the emergency room but how ED visits are billed in general. This was brought to mind when I received a Medicare Summary Notice from 18 months prior to receiving the notice.  It speaks loudly about problems which simmer and simmer but never seem to be addressed.

The notice :

This is a typical Medicare Summary Notice which Beneficiaries receive in a month where their CMS has been billed:

1. Please notice the date of the notice: upper right corner: July 27, 2011. It arrived in my snail mail box on August 12, 2011.

2. Notice the Date of Service: 02/03/2010, the ED location was in a small town in Georgia. 

3. Notice the billing address is in Texas.

4, The providers were from an ED group (not the radiologist however).This is not uncommon because many EDs are staffed by companies that provide ED doctors for an entire region or part of one.

5.The total amounts billed to Medicare  were $ 755.00 and $ 180.00, while the Medicare approved amounts were: $ 114.14  and $ 42.10, and the CMS payments were: $ 91.31  and $ 33.68.  The remaining balance that I ‘might be billed’ was $ 22.83 and $ 8.42 .

Had I not had insurance, or Medicare I would have been billed the totals amounts of  $ 755.00 + $ 180.00.  The hospital might have given me a cash discount if I asked, however they would not volunteer that information.

The questions arise:

1. Why did it take 19 months for me to receive a summary notice? You will notice the claim was processed between July 12-15 2011. Was the bill sent in 16 mos late?  CMS usually pays an electronic claim within 14-21 days. Why did it take the providers 16 mos to submit their charges to CMS. Imagine if you will what their accounts receivable must look like.

2. Should I be euphoric that the bill was for $ 935.00 and I only would get billed: $ 31.25

3. No one can really construct a logical reason why the amount billed, the amount allowed and the amount paid are so disparate. It must be the law combined with an attempt to show immense billings as a measure of importance for that hospital in a chain.

Not many people plan to go to the ED, but there are some who do. Drug dependence is one area where patients make elective visits to the ED. There are not that many choices in picking an ED, so price comparisons don’t play a big role in selecting an emergency department.

I’ve been a physician for 40 years, and this was going on when I started practicing, so it is nothing new…

del.icio.us Tags: emergency room,billing,cms

Employee Benefit Package

 

How times change:

We can’t afford to pay for your health benefits.

del.icio.us Tags: health insurance,social media,facebook,employee benefits,cartoon