Healthcare Talent Transformation

Proposal for Simplifying the ICD-10 Codes - Who cares what monkey did it!

Jonena Relth, TBD Consulting

I was asked on the EMR/EHR Clinical Transformation group in LinkedIn how I would propose we simplify the ICD-10 Codes, so I thought I'd share my response here with my readers.

Off the top of my head:  (albeit this is a definitely the nutshell version)

1. Assemble a team of medical professionals, billing clerks, insurance executives and insurance clerks whose jobs are to be familiar with the current codes; the pros and cons of the current codes and the proposed new codes. 
2. Get buy-off from the "powers that be" for this group of people to represent their interests.
3. Compile Data: 
   Facilitate meetings with the group in (1) to Compile Data that will identify the:
   • Most-commonly used codes
   • Most-common coding errors and why they occur
   • Codes most accepted by ins companies
   • Codes most rejected by the ins. companies and the reasons behind the issues.
4. Get buy-off from the "powers that be" on the conclusions.
5. Simplify the Codes: The goal should be to eliminate as many code errors as possible. 
   Facilitate meetings with the group in (1) to:
   •   Determine how many codes a medical professional, billing clerk or an insurance clerk can truly remember and/or delineate from other codes. 
   •   Compare all the data and keep the codes that, when used, they closely-enough represent the problem/solution that would provide enough information for the provider or patient to be fairly reimbursed.
   •   Set-aside (to later consider eliminate) the codes that are confusing to providers and insurance companies.  If after training, the codes are still confusing - drop them from the list.
6. Get buy-off from the "powers that be" on the conclusions.
7. Get buy-off from a representative group of providers and insurance companies.
8. Implement the new codes to a beta group to work out the "kinks".
9. Make changes necessary and then implement the new codes throughout the medical establishment.

Whew...sounds daunting, and it is, but the one thing we need to remember is to keep the coding process simple and uncomplicated.  Once we add all the "ABC monkey kicked the patient" or "XYZ monkey kicked the patient," we're way too deep into the weeds.  No two people will get the nuances of the thousands of proposed codes, thus causing errors and allowing insurance companies an out for not paying for necessary services. 

For heaven sake, the monkey kicked the patient causing a laceration that required suturing by the provider.  If there are no complications, can't that be enough information for the insurance company to know how to pay the provider or patient?

Jonena

TBD Consulting has a proven track record for ensuring staff and physician adoption of EMR/EHR system implementations. Whether you need assistance to create a training department, help your existing training organization meet the communication needs of the ongoing changes, or simply need "extra hands" to meet your deadlines or ROI goals, please contact Jonena. She and her qualified staff are here to assist you with your organizational development, coaching and training initiatives.

Corporate Office 602-263-1961    Email Jonena today!

Health Wonk Review: Come Back, Leave the Light On

Another great edition of Health Wonk Review: Thanks to the Disease Management Care Blog for hosting.

Don't miss Jonena's addition to the HWR.  She laments about another waste in recent ‘healthcare improvements” by posing the question: Why are we allowing bureaucrats to make the administration of our healthcare reimbursement process to be so complicated that no one will get it straight? Read the entire post.

Integrative Medicine: Part 1

Dr. Stephen Schimpff, Medical Megatrends and the Future of Medicine

Can integrative medicine add value to standard western practices? Some would say absolutely not; others point to new scientific evidence that demonstrates the value of specific modalities in specific situations.  

Health care is complex, expensive and often depersonalizing. It shouldn’t be. At the University of Maryland Center for Integrative Medicine, the staff focuses on evaluating and involving complementary medicine into traditional western or “scientific” medicine. Founded in 1991 by Brian Berman, M.D., a family medicine trained physician, he had learned the certain alternative approaches could complement the usual diagnostic and therapeutic methods that he had been taught in his medical school education and training. He found that his patients’ experiences were enriched by treating the whole person rather than depending on a technology-focused practice. A grateful and forward looking patient offered him a grant to begin the Center with the proviso that it embrace and study evidence-based science along with education and collaborative patient care to create a comprehensive humanistic approach to patient care.  

Since its founding 20 years ago the Center has been awarded over $30 million in NIH grants and has been named as a center of excellence for research. From this work have come over 340 high quality peer-reviewed scientific articles published in the best medical journals. These have been in areas such as acupuncture, herbal remedies and mind-body therapies focusing on arthritis, pain depression, cancer, trauma and inflammation. The center employs a staff for clinical care that includes family medicine and other physician specialists along with licensed acupuncturists, massage therapists, nutritionists and many other disciplines. 

As just one research example, acupuncture was studied in a double blind fashion to determine if the addition of acupuncture to best standard treatment improved the lot of those with knee osteoarthritis. Those who got acupuncture, when compared to those that got sham acupuncture, has less pain, used fewer pain medications and had greater range of motion. 

At the “Health and Wellness Conference” a few weeks ago to celebrate the 20^th anniversary of the founding of Center, Delia Chiaramonte, MD described what an integrative approach to a medical dilemma might look like. She described a medical student who had suffered from severe headaches for many years that were limiting his quality of life and his effectiveness as a student. His physician had identified them as cluster headaches and had tried various standard medications without success. A frustrating situation. 

He was then evaluated differently using an integrative approach. It involved a lot of probing about his headaches, his lifestyle including diet and activity, his stresses and his school work. Like almost all medical students, he studied hard. He said he stayed up until about 3:00am, but in part this was because he couldn’t fall asleep any earlier. His diet included a lot of doughnuts and a lot of other high carbohydrate items plus about 12 cups of caffeinated coffee each day. He had no time for exercise. He sat - hunched over - in front of his computer for many hours each day, and his posture showed it.

His headaches fit the description of “cluster” headaches, often with a sense of an ice pick sticking into his right eye - near unbearable pain. The standard medical texts suggest use of ergotamine tartrate for cluster headaches and also note its potential side effects. There is no mention of other modalities or adjustments to lifestyle issues. But cluster headaches can be amplified by stress, worsened by sleep deprivation and the stabbing could well have been posture related. 

So instead of recommending medications, his integrative medicine “prescription” included the following: he was to see a nutritionist to devise a more healthy diet. He was to work with a personal trainer to establish an exercise program - one that could be done anywhere without impacting on his studies. He was to visit a chiropractor to release his sternocleidomastoid muscles and other neck muscles back to their normal length. In addition he was to have no caffeine after noon and he was to get to bed by 11:00pm each night.  

Given the pain and debility of his headaches, he was more than willing to give this prescription a try. It worked. The headaches disappeared, he felt generally better, he was no longer drowsy in class and he began to truly enjoy medical school.  And he was off all medications. 

This is the power of integrative medicine. It used a holistic approach and brought to bear many different disciplines including nutritional medicine, exercise physiology, stress management, chiropractic and family medicine. I wrote about this extensively in The Future of Medicine – Megatrends in Healthcare . 

Note: You can find the Center for Integrative Medicine on Facebook at http://on.fb.me/HWRPKp

Dr. Schimpff specializes in identifying medical megatrends and the future of medicine. He is the former CEO of the University of Maryland Medical Center, author of the three books, former senior investigator at the National Cancer Institute; former head of infectious diseases and director of the cancer center, Professor of Medicine and Public Policy at the University of Maryland, former chair Board of Governors of NIH Clinical Center, -- along with a life-long love of nature and a frequent visitor to Canaan Valley in West Virginia with his wife of 48 years.

 

Are we really using the "BEST" to Improve our Healthcare?

Jonena Relth, TBD Consulting

About 18 years ago, my company was working with an international organization that adopted an IT project management methodology so complicated and cumbersome that it required everyone who was impacted by the process to attend a "college-level" course to understand and implement it. Ultimately, the project was a serious money-maker for:

• The consulting company that sold their methodology that had to be seriously customized
• Training vendors who wrote the curriculum 
• Printers that copied tens of thousands of copies of the curriculum
• Shipping companies that delivered the materials all around the globeI 

I was not privy to the financials for the project, but our clients couldn't possibly have seen a positive ROI for the millions of dollars and thousands of man hours they spent customizing the methodology, marketing it internally to the masses and ultimately implementing and managing the process. The methodology was just too complicated to be sustainable. Being a bottom-line kinda gal, even back then, I asked our clients the same question that I would ask the Washington bureaucrats changing our healthcare system today,

"Why would you put a system in place to manage a process that is far more complicated that the process you're trying to manage?"

My client's answer was, "This methodology was developed by the one of the most respected IT consulting companies in the world and we want to align ourselves with the best.  If things don't go as well as we would like, we will be able to tell our CEO and Board that if XYZ Company's methodology didn't work, no one's would."   In other words, my clients thought they were protecting their jobs and their company by going with who was considered to be the best.

I need to be careful here, because that "best" consulting company's practices damaged so many of their customers' organizations that they finally sued their parent company and changed their name.  You know the drill - - New name, but same people...  Just because a company or government agency hosts a high-end golf tournament or outspends its competition to keep their name "top of mind" doesn't make them the best.   A "Best" designation should only be given to a company or agency that has a proven track record of consistently providing results that improve processes while improving the bottom line.   

So now I ask, are we making the same mistake with our healthcare system? Someone in Washington DC has determined who the "best" are to determine the future of our citizens' care delivery and how it will be managed.  What I see is that many of the "best people" aren't even medical professionals.  They are politicians who ultimately won't even be covered by the new government healthcare plan. They have their own health insurance plan.  I don't know if that resonates with you, but it speaks volumes to me.  Why would the citizens of the US agree to be covered by a healthcare system that our politicians say is good for us, but not for them?  After all, our politicians are paid by our tax dollars and work for us.  Shouldn't we decide which healthcare system we want and which healthcare system our civil servants should have?  And shouldn't we be allowed to help keep the system simple enough to administer that it will be sustainable in the future?

Just asking...  Jonena

ICD-10 Codes - There's got to be a BETTER Way!

Jonena Relth, TBD Consulting

Dr. Kerry Willis posted a great blog again last week, I'm Your Huckleberry, Mr. President.

I'd like to piggyback on his post about cost and labor savings suggestions with my own rant on ICD-10 codes.  READ AT YOUR OWN DISCRETION!

Question:  Why are we allowing bureaucrats to make the administration of our healthcare reimbursement process to be so complicated that no one will get it straight? 
Honestly, do we have to have MORE codes?

 We are kidding ourselves if we think by adding thousands of ICD-10 codes to the already 13,000, we will increase the instances of providers and patients getting paid timely by insurance companies.  Instead, I submit that by making the list so HUGE, we will only open up the floodgate for more mistakes, thus allowing insurance companies to delay and deny more claims.

**For those who are still in the dark: The ICD-10-CM revision includes more than 68,000 diagnostic codes, compared to 13,000 in ICD-9-CM.

As a Training Professional, I have to add:

• Training and HIT companies are now jumping on the bandwagon to teach the codes to the people who they believe won't be able to make sense of them otherwise.
• From a training and adult learning perspective, this is crazy. Why should the codes be so numerous and complicated that they require training for healthcare professionals and their staff to fill out forms correctly so patients and docs MIGHT can get paid for procedures?

I'm sure that the intent of making this massive change to the codes is to improve the accuracy of diagnosis coding so providers will bill more accurately and insurance companies will pay providers and insureds in a more timely fashion.  Seriously??  Did anyone ask a learning professional about how large a list is reasonable and at what point does the number of data points become impossible to follow?

I'm sure that insurance companies will be pleased with the ICD-10 codes because it will allow them to continue doing business as usual - - pay when and for what they choose to pay.  After all, the insurance companies don't really want to pay out, do they?  They would assert that it is not their problem if providers and insureds go broke waiting to get reimbursed for their medical care, even if the patients were covered by their policy.

Having increased the total codes by 55,000 is simply gov't. gone amuck. There has got to be a better way!

Jonena

TBD Consulting has a proven track record for ensuring staff and physician adoption of EMR/EHR system implementations. Whether you need assistance to create a training department, help your existing training organization meet the communication needs of the ongoing changes, or simply need "extra hands" to meet your deadlines or ROI goals, please contact Jonena. She and her qualified staff are here to assist you with your organizational development, coaching and training initiatives.

Corporate Office   602-263-1961 Email Jonena today!

Health Wonk Review: Spring Hath Sprung!

Spring hath sprung and so have many health wonky ideas!  Check out this week's edition of the Health Wonk Review hosted by InsureBlog.

Dr. Kerry Willis give a great opinion on hour physicians can be the President's "Huckleberry."  It is definitely worth the read. Check it out: I'm Your Huckleberry, Mr. President.

I'm Your Huckleberry, Mr. President

Kerry Willis, MD, www.aihinc.com

Dear Mr. President,

I love old westerns, and I’m a fan of some of the newer versions as well. One of my favorites is Tombstone and the one scene in particular where a bad guy is looking for a fight, Doc Holliday with his reply provides the answer to his questions. He is letting him know that Doc is the perfect guy to solve his problem. Well Mr. President, here’s a quick note to let you know that “I’m your huckleberry,” and I can help solve some of the problems in healthcare.

From a physician’s standpoint things have gotten very complicated. Most of us entered medicine because we felt we could make a difference in the lives of our patients. Mostly today, I have made a difference in the number of trees killed in the US as I have struggled through the mountain of paperwork that is required by our system. Sadly, I have failed in my attempts to slay the beast of bureaucratic entanglements and have spent far too much of my day signing forms and paperwork that will be repeated again in the future. One of my least favorite things to do is complete diabetic supplies forms. I work really hard to get my patients to take their blood sugar and adjust their regimen as needed. I fail to see any utility to these forms and wonder why they are all different. I’m pretty sure I could design one form that could be used by every doctor and would be glad to provide an electronic version to make signing easy. The standardization of many of the forms the government requires would make my life easier, and if we were really smart, the prescription and the form would be the same thing and wouldn’t that make life grand. You would think studies showing that 25% of a physicians' time is spent doing paperwork would mean something to someone. We could solve a large portion of the healthcare manpower shortage problem by eliminating uncompensated paperwork. I suspect being required to compensate physicians for much of the paperwork required by the government and insurance companies would solve much of the need for these forms.

Similarly much of my time is spent monitoring the business affairs of medicine in my office to be sure we have money to pay bills and meet payroll and such. Recent statistics  that I have seen reflect that as much as $30 is spent to collect the average office visit charge that runs around $75. This includes billing filing and electronic support and transmission charges and posting the charge to the proper account. It’s silly to think that this kind of administrative waste is acceptable. We seriously need to consider different models for primary care that don’t include filing claims.  A system where waste was eliminated would not involve spending a third of the cost of care on getting paid.  But as I said Mr. President, I’m your Huckleberry and I do have a solution. For every government program, let’s allow an option for patients to receive a voucher for their primary care needs and contract for their care with their doctor directly without any government involvement between the two. The patient could be allowed to use the voucher in a medical home setting where quality monitoring is part of the baseline arrangement and becoming an MBA to manage your business isn’t your primary concern.

There are many lessons to be learned from our current mess of a system that we have currently. One is its very complicated and two it doesn’t have to be that way. I fill out credentialing requests every year for the same companies and same agencies that are required to collect the same information required by our government. Perhaps our government should become part of the solution rather than causing the problem. Credentialing is becoming a huge problem. Why not require each state to develop and maintain a credentialing service for each physician in the state who is licensed to practice in that state? I could fill the forms out one time and the folks wanting that information could be allowed to query the state database for the needed assurances that I wasn’t a figment of the imagination. This would result in a uniform quality of credentialing and in fewer burdens on the individual practices. 

I hope Mr. President, that my thoughts have been helpful to you. I have some more ideas on cost savings that would increase the quality of care in medicine as do most of my colleges who don’t see the need of things required by the government just to make it happy and serve to delay care. I fervently believe that the best solutions will come from the ground level...from people working in the field every day. Most of us believe that we are your best “Huckleberry” and only wish we had a way of communicating our thoughts to you.

All the best,

Kerry A Willis MD

Dr. Willis is a practicing family physician in Beaufort, NC, where he founded East Carteret Family Medicine. He currently serves as Chairman and CEO of the largest and oldest self-sustaining physician-led network in NC, The Beacon Company, and Chief Operating Officer of Atlantic Integrated Health (AIH). A true believer in the need for healthcare reform, Dr. Willis believes that the best solutions will be community-based and provider-directed and are aimed at improving the affordability and accessibility of medical care by reforming the healthcare delivery. The need to consider new models that are patient-centered and eliminate many of the moving parts that cause waste are the driving goal for Dr. Willis and his organization. 

Lack of Care Coordination Leads to Patient Frustration and Poor Care

Dr. Stephen Schimpff, Medical Megatrends and the Future of Medicine

Medical images such as CT scans, MRI and pathology specimens are largely all digitized today so they can be transmitted to any location in an instant. This means that the most experienced physician at a distant institution can be called upon to review, say, a mammogram that has raised questions for the initial local reviewers or for a pathology specimen which is of an unusual type. It also means that when a patient goes for a specialty visit, his records could go simply and instantly and be available for the specialist(s.) This obviously will save time and improve patient care at limited increased cost. But it is largely not what happens today. Here is an example of what actually happens now. 

A gentleman, I will call him Otto, who lives in a remote area in northern Pennsylvania developed a chronic cough. He went to his primary care physician, who diagnosed bronchitis and gave him a prescription for an antibiotic. But the doctor was clearly concerned and told Otto to “come back in two weeks if the cough is not gone.” Two weeks later, the patient returned unchanged. He was sent to the closest hospital, about an hour away, for a CT scan of his lungs. The result was not good; it looked like lung cancer. To definitively confirm the diagnosis he was told to come back in four weeks [!] for a biopsy to be done by inserting a needle into his chest. Why four weeks? Because the specialist at that rural hospital only did these biopsies every other Friday and he was booked up until a month later. So Otto had to be “patient” and came back as scheduled. The biopsy, sent to another hospital a hundred miles away for review, confirmed lung cancer. Now he was referred to a surgical specialist in yet another distant city, an academic medical center. That took a few weeks to arrange and, when he met the doctor, he was told that to make a good plan for treatment it would be necessary to get a PET scan. “OK,” he said, and it was arranged for two weeks later – the PET center just down the hall being booked up until then. So he drove home and then back two weeks later. Once the scan was done, a call came from the surgeon’s office that his return appointment had to be postponed for a month since the surgeon would be out of town. His wife, protesting that that was too long to wait, arranged for a visit to be “fit in” in two weeks rather than four. 

By chance we happened to visit them that day and heard his story. I called my former University of Maryland Greenbaum Center colleagues and was told that he could be seen concurrently by a team of surgeon, radiation oncologist, medical oncologist and nurse practitioner in just three days time. But he would need to bring his medical record, his CT scan, the PET scan and the pathology report. So he had to call and then drive to each of the hospitals and pick up the materials. What he picked up were not pictures or films but CDs of his CT and PET scans and his pathology report; in other words they were already in digital format. Too bad these hospitals were not yet capable of just sending them via the Internet to the cancer center in the third city. This is supposed to be a story about the problems of getting information from one physician or hospital to another, but you will have also realized that it was about remarkably less than good care for him – waiting weeks to get the biopsy, more weeks to get the PET scan and then the absurdity of being told he could not be seen by the surgeon for another four weeks. What Otto needed was a well-coordinated, team-based approach to care, which he eventually got – but which he certainly should have gotten long before. This happens all too often in American medicine today.

This is the typical way most patients get treated for cancer (and most other chronic illnesses.) Go to one doctor and then once he or she is done with his/her recommendation, get shunted off to the next physician, and then the next, etc. The patient may be sent to another physician for a “second opinion” but never do the doctors actually sit down together and talk through the issues. When a team jointly discusses the patient’s situation, jointly listens to the patient’s (and family’s) needs and then jointly offers a plan, you can bet that the plan will be far superior – and there is not second guessing later. And as treatment progresses, the team can monitor progress and make course corrections as necessary. The multidisciplinary care coordination approach is not just better, it is far superior. If you develop a chronic illness and your doctor wants to refer you to a specialist, insist on a team-based approach.

Sharing information is a critical element of this approach. Today hospitals (and doctors) do not share medical information among themselves readily, such as when a patient is discharged from one hospital but then ends up in the emergency room of another hospital days or weeks later. Similarly, if a patient has a test at one hospital but then is referred to another for a procedure, it is nearly impossible, as we have seen in the story above, to electronically send that data from hospital to hospital. Instead, the patient usually has to act like “Federal Express” and pick up the information and hand deliver it to the other location, just like Otto. Not a good arrangement – it takes time and it only adds to the patent’s sense of anxiety when the systems should be working to reduce patient angst. Once the electronic medical record is available on a universal basis this difficulty should be abated. Meanwhile hospitals that determine how to share information now will find that they are benefiting patients and in the end benefiting their institution. They will be recognized as providing better care and be rewarded with patient referrals.

But this story raises the question as to why with the information in digital format and the Internet ubiquitous that records like Otto’s cannot readily be transmitted today?

Dr. Schimpff specializes in identifying medical megatrends and the future of medicine. He is the former CEO of the University of Maryland Medical Center, author of the three books, former senior investigator at the National Cancer Institute; former head of infectious diseases and director of the cancer center, Professor of Medicine and Public Policy at the University of Maryland, former chair Board of Governors of NIH Clinical Center, -- along with a life-long love of nature and a frequent visitor to Canaan Valley in West Virginia with his wife of 48 years.

Complex, Chronic Illnesses Last a Lifetime and Consume 70% of the Healthcare Dollar

We would like to introduce our newest guest blogger, Dr. Stephen Schimpff.  Dr. Schimpff specializes in identifying medical megatrends and the future of medicine. He is the former CEO of the University of Maryland Medical Center, author of the three books, former senior investigator at the National Cancer Institute; former head of infectious diseases and director of the cancer center, Professor of Medicine and Public Policy at the University of Maryland, former chair Board of Governors of NIH Clinical Center, -- along with a life-long love of nature and a frequent visitor to Canaan Valley in West Virginia with his wife of 48 years.

Medical care is organized to treat acute conditions but the need today is to prevent, diagnose and treat chronic illnesses. Unfortunately, we are sorely lacking in a good chronic care management system. this will be the first in a series of six posts on this issue.

Our medical care system has developed over decades and even centuries around diagnosing and treating acute illnesses such as pneumonia, a gall bladder attack or appendicitis. The internist gives an antibiotic for the pneumonia and the patient gets better. The surgeon cuts out the gall bladder or the appendix and the patient is cured. One patient; one doctor. But as the population ages, more and more individuals are developing what I will call complex, chronic diseases like heart failure, diabetes, chronic lung disease or cancer. These are diseases that once developed usually remain with the individual for life. These patients with chronic illnesses need a different approach to care. They need long term care, not episodic care. They need a multi-disciplinary, team-based approach where one physician serves as the orchestrator or quarterback and manages the myriad physician specialists and the other caregivers along with all of the tests and procedures to allow for a unified, coordinated care management approach. Not only are these diseases likely to last a lifetime, they are difficult to manage, have an adverse impact of both quality of life and mortality, and they are usually quite expensive to treat. Today 70% of our medical care expenditures go toward their treatment. As I will describe in detail later, it will take a new approach to organizing the care of these patients to both improve care and reduce the costs and this will require high quality health information technology.

However, it is valuable to first understand the implications of chronic disease. Most of us are just not aware that their incidence is rising - and rapidly. The Milken Institute (http://bit.ly/lGHFqP ) quantified some of these issues in a research report a few years ago. They evaluated cancer, diabetes [presumably type 2], hypertension, stroke, heart disease, pulmonary conditions and mental disorders. Here are some of the key findings:

• “More than 109 million Americans report having at least one of the seven diseases, for a total of 162 million cases.

• The total impact of these diseases on the economy is $1.3 trillion annually.

• Of this amount, lost productivity totals $1.1 trillion per year, while another $277 billion is spent annually on treatment.

• On our current path, in 2023 we project a 42 percent increase in cases of the seven chronic diseases.

• $4.2 trillion in treatment costs and lost economic output.

• Under a more optimistic scenario, assuming modest improvements in preventing and treating disease, we find that in 2023 we could avoid 40 million cases of chronic disease.

• We could reduce the economic impact of disease by 27 percent, or $1.1 trillion annually; we could increase the nation's GDP by $905 billion linked to productivity gains; we could also decrease treatment costs by $218 billion per year.

• Lower obesity rates alone could produce productivity gains of $254 billion and avoid $60 billion in treatment expenditures per year.”

To me the most telling and important finding is that “each has been linked to behavioral and/or environmental risk factors that broad-based prevention programs could address.” Restated, we as individuals need to take responsibility for our own health. Not every chronic illness is preventable, but most are. It is up to us to eat a nutritious diet in moderation, exercise our bodies, seek ways to reduce chronic stress and avoid tobacco. These four steps will make a huge difference in our health and our lives. Adding in dental hygiene, avoiding sexually transmitted diseases, using seat belts and not drinking and driving will further prevent many illnesses. Many do not appreciate either that following a more appropriate lifestyle will actually slow the normal aging process that ultimately leads to many of these chronic illnesses.

Meanwhile, when chronic illness does strike, it is imperative to have a single care provider take responsibility for care coordination. Someone to not only recommend tests, procedures, images and specialist visits but who will actively ensure that each provider is properly attuned to the patient’s needs and that all of the information is collected and aggregated in a meaningful manner. When this is done the quality of care rises markedly, many fewer adverse events occur, the patient is more satisfied and the costs of care are dramatically reduced. In most cases, a primary care physician is the appropriate one to coordinate care although sometimes a specialist is better equipped for this role (e.g., a very complex cancer treatment plan). To be effective, the PCP or specialist needs to have not only the willingness and interest but also the time available to actually do the care coordination – time that is not available for most PCPs today. This coupled with limited digitized health information leads to today’s inadequate care of many individuals with chronic illnesses. In future posts I will describe today’s problems with lack of care coordination and how it can be corrected.

I wonder what others think abut why the problem of chronic illnesses and the need for care coordination is just not well recognized?

Welcome to the New World Mr. President

Kerry Willis, MD, www.aihinc.com

One of my favorite movies involves a blue collar knight who becomes a jouster during medieval times who after unhorsing his arrogant aristocratic opponent went on to pronounce that he had been weighed and measured and found to be lacking. I believe that is the case with our healthcare system. The citizens of our country have weighed and measured and found that its costs are excessive and unsustainable as a portion of our national budget. They believe that better quality care can be obtained in a less complicated and more personal system than the one that has been fostered and patched and tweaked and served as a social experiment for every policy wonk who happened to be an advisor at the White House or who served as a healthcare staffer in Congress.  Given the current arguments in our country about healthcare, perhaps we should consider offering real reform to the public that will actually improve the system while benefiting doctors and patients as well as our government who, in large part, foots the bills. I realize that my view is from ground zero and not the typical flying at 40,000 feet view that is popular inside the beltway, but there may be some pearls to be gleamed in my words as I share my thoughts on what real healthcare reform would look like.

Healthcare costs at the macroeconomic level have become unsustainable and that is a foregone conclusion. What few people have the experience to know is that costs at the microeconomic [practice expense] level have become unsustainable as well. In my small, family practice office with three providers, we spent $17,000 alone in electronic expense associated with filing claims. I’m told that the actual costs of filing and collecting a claim average between $25-35 not counting appeals and refilling. Industry figures reflect that 10-20% of claim are rejected erroneously that should have been paid adding to the cost of getting paid even more. Our current model requires me to spend $30 on average to collect fees that average $75. I don’t think that kind of administrative cost is sustainable and indeed more and more physicians are leaving their practice to become employed by larger systems. The economics of that model are unsustainable as it depends on the government subsidizing “on campus” physicians at a higher rate than non employed physicians that is already threatening to be an excessive cost and has been targeted for elimination by MEDPAC. We need better models that are simpler and understandable that don’t choose winners and losers based on employment status.

Physicians are leaving the field or changing jobs at a rate never seen in the past. The pressures of running a practice are great enough from the medical standpoint. We have added to the difficulty by complicating the system to the point that one needs an MD MBA degree to survive and that seems wrong in so many ways. But as an example, The 5010 claims filing standards were recently implemented and my claims are being rejected because of the lack of the additional 4-digit zip code that is now required for no apparent good reason. If healthcare was about delivering packages instead of medical care, I could see the point but so far it evades me. The administrative costs of this implementation will likely be in the billions of dollars in costs that have little or no value. BTW, thanks for pushing the implementation of ICD 10 back two years along with its $2 billion implementation costs and endless hassle that will primarily benefit data mongers and little else. Most of our country is served by physicians in rural areas and mostly in practices of five or fewer physicians. Perhaps, it’s time to require that the implementation costs of the next policy wonks dream be revenue neutral at the microeconomic level as well as the national level.

I do have some ideas about the type of reforms that are needed. Let’s start with the repeal of the SGR formula. This problem has created such uncertainty  that physicians are unsure that they want to engage in any project. They are unable to predict if, what and when they will be paid and generally have been caught up in the gridlock that pervades our political system.  I understand their concern but I personally believe this to be one of the greatest entrepreneurial times in the history of medical care given the opportunities that are present with ACO and healthcare reform. The SGR idea is big government meddling with medicine in a manner that has never worked in any area it has been tried during our history. We don’t need to repeal it and replace it with another program that can’t work because it was designed from people flying at 40,000 feet to manage people at ground. Let it die the sudden death it deserves. Perhaps then tackling EMRs and ACOs and implementing the Patient Centered Medical Home Model will become projects that are possible rather than ones that are caught up in the uncertainty of the SGR Gap.  Practices can’t plan for the future when they don’t know if they will be in business in one year.

Given the background of my discussion above, let’s look at some real reforms that can be implemented easily.  One of the most common complaints I hear from doctors and patients is that they don’t understand Medicare and its maze of rules.  We have an annual deductible of around $175 before Medicare begins to pay for Part B services that primarily cover physician services. What we know about deductibles and primary care services is that they act as an impediment to patients seeking care for services. What we do in Medicare is threaten to fine doctors if they violate the rules that Medicare lacks a real time system to verify. We understand that minor conditions that could be effectively treated in an office setting are ignored and result in catastrophic costs as they get worse. We need a better system. Perhaps for Medicare, we should adopt the Federal Employees Insurance Model that eliminated deductibles for the outpatient office codes. Such a system could be weighted to allow simple and easily understood access to primary care and specialty services that would prevent patients from putting off conditions that could be treated easily when caught early. I would think that a program that allowed a $10 copay for primary care and a $30 copay for specialty services would promote appropriate care in the appropriate setting. There would be tremendous savings administratively for doctors, the Medicare system and for patients who would not need supplemental insurance to cover such services. The sustainability of such a system would be more likely than the confusing and overly costly system that is weighted towards spending revenue to capture revenue rather than provide and coordinate care.

Another reform that deserves attention is the promotion of the Patient Centered Medical Home concept. While the concept is relatively new, studies show that the model decreases costs and increases patient satisfaction with medical care. The PCMH builds in quality improvement and disease management as part of the concept. The problem is that we lack a model that values the services and compensates physicians properly for the changes that they must make in their practice style for it to work.  As I have pointed out, one of the biggest wastes in the system is the generation and collection of claims for primary care services. Spending huge amounts of money figuring out how to get paid and doing the billing to get paid doesn’t foretell of the sustainability of the small rural practices that most of our country depends upon. I do believe that there is no free lunch and primary care shouldn’t expect to get something for nothing. However, the PCMH model provides a vehicle for everyone’s goals to be accomplished. I would think that spending 10% of Medicare costs on primary care would be fair and reasonable if, in exchange, primary care doctors provided quality data and disease management data on a quarterly basis to the government. In exchange for a monthly fee of around $75 to $100 depending on the expense of practice already defined by the government along with a copay of $10 per visit, practices would complete all financial transactions with the patient at the time of the visit. Allowing resources to be focused on quality and patient care instead of claims expense would go a long way to fixing the problems that exist with our primary care system and improve access to those services. Eliminating claims costs for small procedures such as urinalysis and finger stick blood sugars as part of the global primary care fee would create savings for Medicare that would offset any costs of the new system.

Finally, we need to consider developing a voucher system for primary care services for all government services. If we examine the VA services we find that many Veterans are unable to access services because of expense involved in travel and lack of availability for those services. A fair voucher system could be developed to provide a fixed monthly fee to veteran to buy those services in their local community without the need for more bricks and mortar to be budgeted. Our Veterans could seek out and find the care they have earned tomorrow in a setting that promoted continuity of care with an established provider who would be available for urgent needs as well as their long term needs. A similar system would work for our active duty military families as well as our retirees from the military and promote better care in a better setting than the Emergency Department. Extending the model to Medicaid would be simple to administer and implement at the state level as well. Setting a fair fee for caring for these patients would shore up our primary care physicians and attract new physicians to the ranks of physicians as practicing in a small rural setting would become possible and plausible. Needless to say that implementing this model makes the savings desired by the Accountable Care Organization model possible rather than the pipe dream of policy wonks.

My character from my movie went on to observe that he had beat the odds and achieved his goal of becoming the best at what he did by introducing his opponent to the world where rising from modest means and becoming the champion of the people was possible and the elimination of the status quo was possible. Welcome to the New World Mr. President where achieving healthcare reform, improving quality and making it easier for everyone involved is possible. All we lack is the courage and leadership to make it happen.

Dr. Willis is a practicing family physician in Beaufort, NC, where he founded East Carteret Family Medicine. He currently serves as Chairman and CEO of the largest and oldest self-sustaining physician-led network in NC, The Beacon Company, and Chief Operating Officer of Atlantic Integrated Health (AIH). A true believer in the need for healthcare reform, Dr. Willis believes that the best solutions will be community-based and provider-directed and are aimed at improving the affordability and accessibility of medical care by reforming the healthcare delivery. The need to consider new models that are patient-centered and eliminate many of the moving parts that cause waste are the driving goal for Dr. Willis and his organization.