NEW FEE SCHEDULE UNLIKELY TO IMPROVE ACCESS

WCRI (WORKERS COMP RESEARCH INSTITUTE) SAYS THE NEW FEE SCHEDULE COULD IMPROVE ACCESS: Nonsense!


The WCRI said that the new fee schedule could change utilization patterns because it would increase pay to primary care providers. In the same breath WCRI admitted that "the institute does not expect that to be the case in California." The workcompcentral story by Greg Jones, 2014-02-21, stated that "a 2012 WCRI study  concluded that prices paid for office visits in California were 30% below the median of the 25 states that were reviewed, with only North Carolina and New York paying less."


By eliminating independent payment for reports under 99080 and by eliminating independent payment for review of boxes and crates of medical records under 99358, harm has been done that cannot be repaired by raising an office fee by $8. THAT is what was done in 2007 in California when office visits for CPT 99213 were raised from $45 to $53. The new codes under the RBRVS make similar smidgens of adjustment. THAT may be enough to fool WCRI, but it won't fool even the most junior accountant or office manager in any medical or surgical office.


The workcompcentral story by Greg Jones said that "there are some who think that California's payment rules prohibiting payment for record review ... will impede the ability of injured workers to receive treatment." It is then noted that "Medicare doesn't reimburse record review." That's because "The Centers for Medicare and Medicaid Services considers the cost of reviewing records to be bundled with the office visit payment." What utter and complete nonsense! Now that that miserly process has been shoved into Workers Comp, it is still somehow expected that after an hour or so with a patient another few or several hours will be devoted gratis to review of records. The treating doctor will be obliged to spend less time with the patient to allow time for review of records. In most cases, that adjustment will not suffice.


References


"New Fee Schedule Could Improve Access, WCRI Says," workcompcentral.com, 2014-02-21.


"CWCI and WCIRB: SB 863 lowered surgical center payments in California," Insurance Journal, 2014-02-26  (this article points out that facility fees were brought down by 26% and that procedure fees were brought down by 28%. An argument for the WCRI position is that if these centers are still in business despite across-the-board fee reductions then the fee reductions are viable despite the squawks of providers)

DISILLUSIONMENT INVADES MEDICAL PRACTICE

"The best decision I ever made was coming to the USA for advanced training. The worst mistake I ever made was deciding to stay."


So sayeth a respected physician, a department chairman in his specialty, whose name is being withheld since he didn't give us permission to use it. The point is that this doctor's doctor expected to spend his life caring for people, healing the sick, the force behind the profession for so many neophytes in medicine. They did not expect to become nursemaids to insurance companies or to the Affordable Care Act.  But that has become their fate because taking care of patients, actually comforting them, has taken second place to the requirements of paperwork without which neither doctor nor hospital can be paid. Today after  interviewing  a bevy of doctors who spent about an hour each on computerized hospital discharge orders (it used to take 10 minutes if you wrote legibly) it became clear how disillusioned they were.


In our previous column we described how the internists found a way to mega-wealth by opting out of clinical practice and opting into the rarified world of industrialized and corporate billing ($800,000 for the board chair according to that year's IRS 990 form). But here's the other side of that coin: according to Kathy Kristof's report in MONEYWATCH,  internists see one patient every 30 minutes, put in 54 hours per week, but waste 23 percent of their time doing paperwork for insurance companies. Take home pay is around $185,000 (about a half-million less than the board chair's 800 grand). The lesson is learned: income has shifted away from clinical medicine and patient care and towards control of capital just as in business.


The new motto is "profits before patients." Keep that in mind as your doctor rushes out the door from your clinical visit. You are important, yes, but the paper trail is crucial. That's where the money is. By the way, Kristof's article is entitled "$ 1 million mistake: Becoming a doctor."


References


$1 million mistake: Becoming a doctor, MONEYWATCH, by Kathy Kristof, 9/10/13 (my editorial comment-- insurance companies are increasingly forcing hospitals and their doctors to process patients as though they were produce, get 'em in,et 'em out, and bill 'em quickly)


Obamacare enrollees hit snags at doctor's offices, LOS ANGELES TIMES, by Chad Terhune, 2/04/14 ("people are having trouble finding doctors")


LifeForSale.com,  documentary movie, Evelyn Li, MD, Medical Consultant ("Life For Sale explores dangerous nooks and crannies of healthcare that until now have remained hidden from public view" -- RLW, Editor, www.politicsofhealthcare.com)

Late addition to post, 2/24/2014: "Doctors, insurers face off over pay," SAN JOSE MERCURY NEWS, by Tracy Seipel, 2/14/14,  ("... insurers are often caving in to the doctors ... medical costs are the largest component of a health insurance premium ..."  What this otherwise well researched story doesn't tell is that physicians' share of the health care policy premium is from 17 to 18% and that the insurers get the last word in the 'face off' when they use Utilization Review to deny specialty services, e.g., consultations, or refusing to cover physical therapy or to approve expensive diagnostic studies)




 

How Physicians Eat their Young

"Dear Colleague," begins the 5 February 2014 issue of the American College of Physicians newsletter just before it tells the recipient that "our records indicate that you earned your ABIM certification prior to 1990 and therefore hold a time-unlimited certificate." The newsletter then reminds internists in this category that they're sometimes  referred to as "grandfathered" because they don't have to recertify every ten years. Next comes the financially self-serving bombshell with the newsletter's announcements of the "ABIM Maintenance of Certification Changes" and the disclosure that "as of March 31, 2014, ABIM will begin reporting whether or not board-certified internists (including those with time-unlimited certification) are meeting 'Meeting MOC Requirements.' "


In other words, starting on 3/31/14 some internists will be more equal than others (see George Orwell's 1984).


The hammer falls on the next page where the newsletter tells its readers that "If you do not complete the ABIM MOC program requirements, you  will be reported as 'Certified, not Meeting MOC Requirements.' You will NOT be reported as "Not Certified" for failing to meet MOC requirements." Internists who don't measure up can count their lucky stars for ACP's largesse and also for the advice of its lawyers about what ACP needed to do to avoid individual and class action lawsuits.


This article from ACP does not disclose costs to prospective participants but it does mention that passing the MOC exam by 12/31/23 "is in addition to continuing to meeting the point requirements of the MOC program (including the two- and five-year milestones."


The first comment we've received by one of the board-certified internists with a time-unlimited certificate is this wry remark : "So ... they are going to allow those of us that do not have to recertify to continue to be listed as certified but will list us in a way that sounds LESS CERTIFIED than those that pay them (underlining added)."


We looked up some of the information that we think all physicians should be interested in, boarded or not, recertified or not. We relied on IRS Form 990, a public document few physicians ever see.


As of 2011, total assets of the American Board of Internal Medicine were $57,586,843. Internists should ask themselves why ABIM needs total assets of nearly $60 million. ABIM's Chairman of the Board's pay package was about $800,000 -- not bad, eh?  Recertification costs for an allergist were $2,700 while MOC costs for allergists were $2,850. Why shouldn't ACP want to get in on the action if there's a ready contingent eager to pay?


In fact, the door is open, not so much for complainants, but for competitors who can identify a possible need and a probable payer (the latter is the crucial element!). It's part of physicians' flight or fight response from the practice of medicine, unfortunately, with the focus on flight.


References


Journal  of American Physicians and Dentists, V. 16, #2, Summer, 2011, "Board Certification -- a Malignant Growth," Dubravic, Martin, MD


www.politicsofhealthcare.com, Saturday, 7/21/12, "Money and Medicine," Weinmann, Robert, MD


Journal of American Physicians and Dentists, V. 18, # 3, Fall, 2013, "Maintenance of Certification (MOC): the Elite Agenda for  Medicine," Christman, Kenneth, MD ("the elite medical establishment correctly foresaw that there was a huge treasure in the medical certification business")










 

INSIDER REPORT FOR WORKERS COMP CONSULTANT DOCTORS

REVIEW OF RECORDS UNDER CODE 99358 HAS BEEN DELETED
 
While this  report is aimed at doctors who are asked to do consultations for injured workers, its comments should be of interest to attorneys on both sides, insurance companies, adjusters, and injured workers. Most of the consultants who interview and examine  injured workers know by  now that Dr. Das, speaking for the administration at the workers comp hearing in Oakland earlier this month, told the audience that the doctors who do consultations should be "advocates" for their patients and should prepare their consultation reports free of charge. While well meaning, the remarks showed a lack of knowledge about how the system works. To begin with, consultations may also be requested by insurance companies, defense attorneys,  and adjusters, not just by injured workers, applicants, and their lawyers. Das' remarks would put the defense consultant in the position of  "advocating" for the insurance companies. In fact,, the consultant is supposed to provide an expert opinion as part of a search for truth. The consultant is  not supposed to "advocate" for anything but the truth as it is believed by the consultant.


As to the free-of-charge remark, Dr. Das didn't acknowledge that the transcription fee for these reports is often in excess of one hundred dollars. Providing such reports free-of-charge amounts to a subsidy for the insurance companies which works against injured workers' interests. More to the point, medical offices would find that shelling out a hundred bucks to provide "free" reports is the  straw that breaks the camel's back. The answer would be to stop doing consultations.  


Here's how the money part worked under the OMFS or Official Medical Fee Schedule with reference to consultations requiring review of records which would be billed under  Code 99358, now deleted as a billable code since January 1st.


99358  is, or was, the code number used to identify review of records, as in prolonged E & M services before and/or after patient care. Its standard reimbursement was $33.80 per unit. But the consultant would not be paid this amount because the insurance company would deduct $2.54 for what it called a "network" reduction, in other words, a payback to the MPN or Medical Provider Network which retained the consultant in the first place. Now that the code has been rescinded, the entire reimbursement to the consultant under 99358 has also been rescinded. Review of records may now enter a dark age of reduced enthusiasm. 


Readers should ask the workers comp division of the Department of Industrial Relations to provide transcripts of Dr. Das' remarks to determine whether or not her remarks were accurately presented in this column. Doctor Das is Medical Director of the California Division of Workers Compensation.

Injured Workers Lose Again

Ordinarily, California's  injured workers have issues to worry about other than how doctors do their billings. Not so anymore. Here's why: the change over from the Official Medical Fee Schedule (OMFS) to the RBRVS system has come with severe restrictions against injured workers and their doctors. Even though the OMFS paid near the lowest in the nation, insurance companies weren't satisfied. Here's an example: under the OMFS consulting doctors were allowed to bill for review of medical records. Such reviews often entail studying boxes filled to the brim with medical records. These cases are often complicated by divergent opinions from treating doctors, utilization review denials by doctors, many of whom are unlicensed in California, and by doctors who haven't reviewed the patient's complete medical file. Sometimes the shear complexity of injured workers' injuries is overwhelming, e.g,  as when multiple injuries occur, for instance, a fall from a ladder causing broken arms or legs,  neck or back injury, and a head injury.

Treating doctors and consultants often spend extended amounts of time on such cases. Hours just to review medical records is common and until adoption of the new billing codes was compensated under Code 99358. That code has now been eliminated. The next step for the doctor would be to file an independent report for which the code was 99080. That code has also been eliminated even though such reports quite commonly would be around 20 typed pages and would also have required lengthy preparation.

As a further slap in the face, the actual consultation codes, e.g., 99245, have also been eliminated and have been replaced by RBRVS codes based on Medicare that cost the insurance companies less despite a minimal increase in Medicare.  In a nutshell, consultation for and treatment of complicated injuries has become so prohibitive that primary treating doctors can often not get either. Recently, this writer had a case turned down by a teaching hospital: we were told outright that they don't accept workers' comp cases anymore (i.e., their reimbursement level was cut below the minimum standard the hospital felt it could live with).

A few years ago, when an attempt was being made to push SB 923 (Deleon)  through the legislature, Stuart Bussey, MD, JD, family practice specialist and President of the Union of American Physicians and Dentists, Local 206 of  the American Federation of State, County and Municipal Employees (AFSCME), AFL-CIO, testified that passage of the bill could tie his hands when specialty consultations were needed but were also unavailable. He said that this situation could leave him holding the malpractice bag. The bill crashed but some of its odious provisions were resurrected in SB 863 which is now the law and which mandates replacement of the OMFS by the RBRVS.

Here's the rub: the deletion of the 99358 code for review of medical  records means that many specialists will be unable to review cases as they should. The deletion of the 99080 code means that consultants, if and when they can be obtained,  will not be able to file comprehensive reports for  their patients. It means that Independent Medical Review (IMR) doctors may be much more likely to make decisions (75% of which deny care) without reviewing medical facts.

The billing code changes are a boon for insurance companies because it lowers their administrative expenses. It will also lower actual medical and surgical costs since absent these consultations and reports definitive medical and surgical steps will not be implemented. In chronic pain patients, for instance, it's likely to decrease physicians' treatment options. In this way chronic pain patients may end up on chronic opioids longer than would otherwise be necessary.  It's a chilling thought when this example is extended to other diagnoses requiring complicated orthopedic, neurosurgical, and psychiatric care.

As a result of SB 863, Independent Medical Review (IMR) Physicians will review the necessity of care after Utilization Review (UR) doctors have first had their shot. Readers of this column know that in an op-ed in the San Francisco Chronicle, 8/29/08, entitled "How to practice medicine without a license," it was pointed out that UR doctors don't have to be licensed in California (union leaders should be interested in knowing that AFSCME, at its International  Convention in Chicago in 2006, passed a resolution against this practice). 

Upshot: not only does the UR physician not have to interview or examine the injured worker, the UR doc does not even have to be licensed in California, the state in which he practices. Errors the non-California-licensed UR physician make cannot be evaluated by the California Medical Board. Alleged errors cannot be evaluated by the medical board of the state in which the UR physician is licensed, either, because the out-of-state board doesn't have jurisdiction in California.

All  of this largesse is now extended to the IMR physicians thanks to SB 863. The position of the insurance industry is now buttressed by the deletion of codes 99245, 99358, and 99080. Once again the injured worker takes it in the teeth. Nothing new in that, is there? It's just another injury to the already injured worker.

We recommend repeal of SB 863 and support for SB 626 (Beall) or similar legislation since Senator Beall pulled SB 626  in 2013.

 

Is misogyny (distrust of women) on the move in these three states?

Datelines California, Indiana, and Michigan, 12/26/13

The California Supreme Court refused to halt same sex marriages when it poured cold water on a legal challenge to ban  these marriages. Californians know the story: proposition 8 passed in 2008. Same sex marriages were supposed to be banned because that's what the citizens voted for. But in 2010 the ban was ruled unconstitutional. In June of 2013 the U.S. Supreme Court let the ruling stand -- the ban was gone, same sex marriages were on. Governor Brown ordered that county clerks could begin issuing marriage certificates. That's how that matter stands now.

It appears that antipathy to transgender issues has taken its place: As of 1 January 2014 transgender students will be allowed to use the locker rooms and washrooms that match up with the genders to which the students identify. One need not stretch the imagination to understand why issues of genitalia are confusing to parents and coaches alike. Opponents to the new law want to repeal it and have mounted an effort to get the issue on the November election ballot. It is in its own way a revisit of Proposition 8.

The argument that misogyny applies to California's effort to stop same sex marriages probably fails on the basis that the proposed legislation is equally unfair to all who apply, does as much harm to men as to women, excludes both sexes from participation in joint healthcare insurance, prevents both sexes from enjoying the tax benefits of marriage, and generally discriminates equally against both sexes. The currently proposed separate-by-sex restrooms and lockers equally inconveniences both sexes as well as transgender persons. So misogyny isn't an accurate label since the proposed legislation is equally unfair to both sexes as well as to transgender persons.

The Indiana legislature, meanwhile, is preparing to vote on HJR-6 which would amend the state's ban  on same sex marriage. Meanwhile, proponents of the ban on same sex marriage want to extend the ban to include anything similar to marriage, e.g., tax exemptions, shared health insurance, and civil unions. Indiana's proponents of banning same sex marriage go beyond California's Prop. 8.

This bill takes a serious swipe at same-sex anything. Not only does HJR-6 outlaw same sex marriage, it also takes an extra step by refusing to recognize legal alternatives to same-sex marriage, e.g., it would deprive same-sex couples of any status that could be deemed substantially similar to marriage such as civil unions and domestic partnerships.

The irony is that Indiana law already makes same-sex marriage illegal. If enacted HJR-6 would actually change the state constitution and tie the hands of future legislatures to prevent passage of legislation that would allow same-sex marriage.

One may reasonably argue that HJR-6 is mean-spirited but not that it is misogynous. It is equally unfair to everybody.

Not so In Michigan where a legislator recently spoke out against a push for what opponents are calling "rape insurance." The legislator disclosed more than a passing interest in the matter when she revealed in public that she'd been raped 20 years ago and that had the proposed "rape insurance" law been in effect at the time she could have faced untenable consequences.

Here's the scenario in brief along with our conclusion that the Michigan law is misogynous. The Michigan legislature just passed legislation banning health insurance plans from covering abortion unless it can be shown that the woman's life is in danger. The impact of this change in the law is that it means women and/or their employers will be obliged to buy separate insurance policies or "riders" to their insurance policies if rape or incest result in pregnancy. Opponents call this law "rape insurance" and argue that women who wouldn't want an abortion under any circumstances shouldn't pay for it since so doing enables abortions by others.

Although this law passed the Michigan legislature last year, it was vetoed by Governor Rick Snyder. If the law passes the legislature again this year, it becomes law without having to run the gubernatorial gauntlet a second time. In effect, under Michigan state law this move is a way to sneak one past the governor despite the popular will of the people (polls show widespread popular opposition).

This bill meets our definition of misogyny: it is directed against women. That is why State Representative David Knezek, State Senator Gretchen Whitmer, and others have called it "misogynistic." We also find it misogynistic.

We call your attention to an editorial entitled "The Most Misogynistic Law I've Ever Seen" by Sen. Whitmer, posted 12/23/13, published in Huff Post, 12/26/13. The opening line should knock your socks off even if you're not wearing any.

 

 

YOUR DOCTOR ISN'T IN THE PLAN ANYMORE. NEITHER IS YOUR PLAN.

"I'm sorry," tolls the receptionist in a bored voice, "but your doctor isn't in our plan anymore."

Senator Reid opts out: click on comments at end of this editorial re Reid's Obamacare snub

Item A concerns a doctor whose healthcare policy was abruptly canceled when her own physician announced he was quitting the health care plan, would no longer accept insurance, and would henceforth require monthly "concierge" style payment, plus a cash fee for office visits, and that she'd have to have separate insurance for hospitalization whether needed or not.  As for the healthcare plan he was leaving -- the plan would either be disbanded or taken over by doctors who could speak English.

Note: for the uninitiated, "concierge" style practices require advance payment arrangements such as monthly, quarterly, or annual payments plus fees applicable to the services patients use. Medications are not included. Insurance plans are not accepted.

Item B is about several doctors in various settings who have in common that they've sold their practices to corporate entities, foundations, exchanges, or other business groups. It works like this: the corporate entity buys the practice, then employs the doctor or somebody else to run it on a day-to-day basis. The corporate entity pays the staff, the rent, and the expenses. To recoup its money, and to make more money, the practice is required to double or triple its volume. To accomplish this task, the time spent with  each patient must be reduced, say, to a few minutes. That'll be the job of the staff who now no longer works directly for the doctor or the patient but who instead is responsible to the employer. In this plan, insurance is still accepted, in fact, is welcome. If the on-site managing doctor and his staff can't meet these goals, they'll be replaced.

Healthcare Plans that cover patients, doctors, and insurers vary widely. They may assign doctors to multiple plans and keep track of so-called "production," how many patients each doctor sees and how long the average visit takes. Doctors whose "production" numbers are profitable to  the company will have a higher rate of retention providing they don't rock the corporate boat in other ways (then they're called "disruptive" and get fired anyway).  What procedures and surgeries are allowed will be a corporate decision dependent on cost-benefit ratios, not patient need.

Healthcare Plans may be narrow and include a minimal number of specialists and no highly sub-specialized surgeons. It's your  personal out-of-pocket lookout if services not included in your medical provider network are sought.

Utilization Review (UR) is already used in California for injured workers who may be denied access to specialized care by a UR doctor who is not licensed in California and who has never seen the patient. The UR doctor's judgment may nonetheless overrule the California-licensed primary treating physician's judgment even though the primary physician has spent hours with the patient.

In this way, UR in California and the ACA throughout the USA are joined -- see our previous editorials on the Independent Payment Advisory Board (IPAB) which was originally rejected for Medicare under its previous name, the Independent Medicare Advisory Board (IMAB). Some pundits assert that the ACA under the guise of Obamacare is actually a nationwide watered down HMO and that to keep it that way it's necessary to eliminate as many hospitals and specialized centers as possible, and as many doctors as possible, while making the remaining doctors act like cattle herders trying to avert a stampede.

Stay tuned. These issues have long legs.

References

"How to practice medicine without a license," San Francisco Chronicle, 8/29/08