Dear Mr President, Medicare Stinks

Dear Mr President, Medicare Stinks

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Dear Mr. President:

The physicians and management in our office had a discussion this morning about the upcoming audits physicians are facing from CMS. I had to wait for my blood pressure to get out of dangerous range to write this letter. The frustration, fear, and powerlessness I felt made me really question whether it is worth continuing to see my Medicare patients.

I am a primary care physician and about 20% of my patients are covered by Medicare. As a whole, they are wonderful people, but difficult patients. The elderly are truly a delight to talk to, learn from, and care for; I consider it an honor to be their doctor. But the complexity of a person’s medical problems goes up exponentially as they near the end of their life. This means that I spend more time per patient for my Medicare population – which is OK if I can be paid for my extra time and effort.

But here is the message we physicians are being given:

Medicare auditors will be knocking at our doors, and if there are “problems” with our charting we will be told to send money back to CMS for our whole Medicare population. We are obligated to prove that we did not defraud Medicare to reclaim the money for the work we did. This is, obviously, consistent with the cornerstone of the American legal system, “A person is presumed guilty unless they can prove that they are innocent.”

The “problems” they are looking for are inconsistencies in the charting and the billing we do. These “inconsistencies” are not just egregious attempts at stealing money from Medicare, they are little things like this:

The failure to mention the EKG we ordered in the note (even if it is right there in the chart).

The appearance that we are using a “cookie-cutter template” to do our notes – i.e. if all of our physical exams, review of systems, or impressions look similar, then it will be assumed we are trying to defraud Medicare.

Forgetting to document a discussion of the patient about a diabetic eye exam.

Certain ICD-9 codes will be accepted by Medicare, but will be “flags” that we are possibly trying to cheat Medicare out of money. Diagnoses like Hypertension ICD-401.9 and Diabetes Type 2 ICD-250.00 will be flags. We need to be more specific in our coding to avoid immediate suspicion.

While my information may not be 100% accurate, the fear in the medical community is. We practice very good medicine in our practice and probably save money for the system (as studies have shown that a higher percentage of primary care in a community means lower cost – ask the Brits on this one). We use an EMR and are very tuned in to the quality of our care (NCQA recognized for our diabetes care). I strongly suspect that our quality of care and documentation are in the top 10%. Yet we are fearful that your government employees are going to use us as scape goats for the out-of-control costs of Medicare and put us out of business in the process.

We see what is being done to the hospitals with the “No Pay” diagnoses. That whole debacle is irrational and unfair, but the hospitals have no recourse. That makes us extremely pessimistic about our odds when facing the hit-men from CMS. If a hospital with its lawyers and other resources can be hung out to dry, what chance does a PCP have?

So at an increasing rate, we are discussing the option of dropping Medicare altogether. That really is an amazing thing, as we have always played by the rules and have seen our care for the elderly as a responsibility and civic duty we have. We have never considered our acceptance of Medicare as something that actually makes business sense – we just want to and like to care for the patients. But the increasing hostility we are seeing from the witch-hunters with their torches and angry mobs is making us really consider whether we can afford to stay on board.

The practice of medicine would be far simpler for us if we dropped Medicare and Medicaid – and probably more profitable. But I don’t want to. I love my patients and want to continue to have the honor of being their doctor. Please don’t convince me that it is not worth the effort. Please don’t hurt our elderly in such a way. Please don’t let the CMS cronies make it look like we physicians are the root of the problem. We may not be totally innocent; but most of us are doing the best we can in a system that is becoming increasingly hostile and incredibly burdensome.

On behalf of all scared physicians out there,

Dr. Rob

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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39 Comments on "Dear Mr President, Medicare Stinks"


Guest
Mar 16, 2010

So, if RACs are not a good idea, what would be your proposal for fighting the rampant Medicare fraud, that folks all over the spectrum are agreeing needs to be addressed?
Would do you think of Senator (Dr.) Coburn’s method of using “undercover patients”?

Guest
Mar 16, 2010

This is a rant. It is a very frustrated physician who is asked to jump through incredible hoops and still is on the hook at the end of the day if someone wanted to come after me. We pay by documentation, and that is a large part of the problem. “Rampant Medicare Fraud” is not because of doctors coding a 99214 instead of a 99213, it is a little more overt than that, yet the RAC brings the specter of slipping up and “being made an example of.”
I am not alone to think that the RAC’s will justify their existence by getting enough “rampant fraud” even if it is simply coding errors.
The point of this post was to explain how terrified this makes the rank and file of physicians. It is yet another argument in favor of docs dropping Medicare altogether. We are not raking it in from Medicare (not even close), yet we have to fear an audit, fines, and worse for not documenting properly. The documentation requirements are incomprehensibly complex.
It’s very depressing from my perspective (and I tend to be more optimistic than most physicians, believe it or not).

Guest
Mar 16, 2010

“Undercover patients” sounds like a witch hunt to me. I think EMR adoption will allow for better monitoring of docs’ behavior and reward better outcomes. I get the heebie-jeebies thinking about “undercover patients.” I feel like it’s setting a trap. It might not be – it may be a good idea – but I am not the only one with serious distrust.

Guest
archon41
Mar 16, 2010

If your “progressive” friends manage to revive the Public Option provision of HR 3200 through the “reconciliation / deeming” process, I don’t believe you will have the option of declining to treat the beneficiaries. On the bright side, you will be compensated, as I understand it, at Medicare rates + 5%.

Guest
MD as HELL
Mar 16, 2010

Doctors are being selected by profiles for further scrutiny. There is abuse in every Federal program. In a different light it is called “stimulus”. Finding abuse cannot be arbitrary and capricious.
My office did not take Medicare for the 1 plus days the senate failed to delay the fee cuts. If it becomes too dangerous to participate in caring for Medicare patients, we are done with it.
The RAC is very much like the Gestapo, Ja?

Guest
ExhaustedMD
Mar 16, 2010

Dr Lamberts:
Don’t wait for non providers to get what you have written, as most are expecting this pending health care deform to save the day. Yeah, on our backs.
If you are truly sending this letter to the current occupant in the White House, as I am not willing to address this man as President per his agenda, please consider either cc to me, as you can contact me at my email address to confirm my name, or if willing to allow cosignators, feel free to add my name. It is completely and totally on the mark.
Thank you for writing this, even if just for this blog site. Some colleagues not only agree with you, but feel it is time for the alleged powers to be in Washington to hear from us: add another yet stifling layer of control and supervision without true equal quality of management, and watch your health care system become that of a third world country. As handled by providers who are gutted and uninvested.
It has come to this point, Americans. You can hear it from invested and caring providers like Dr Lamberts, myself, and your own doctor, or, believe the lies from politicians.
2014 won’t come fast enough as is now!

Guest
Dennis
Mar 16, 2010

Ironically, these are some of the arguments behind true socialized medicine. If all physicians and other medical professionals were on salary and there were no insurance companies, then they wouldn’t have to worry about any billings: they would only have to focus on patient care. Of course, I’m sure they would find all this worse than what they desribe above. But it’s an invitation to think about how you would build a better health care system for everyone.

Guest
Mar 16, 2010

Let me point out that this is not a partisan problem. RAC’s were developed under the Republican administration. I don’t see either side as friendly.

Guest

Dr. Lamberts accurately relates the conversations that are occurring at provider office meetings today. Certainly fraud in Medicare has to be addressed, however once again it seems that the ‘low hanging fruit’ ie the providers, are the focus rather than the DME suppliers, home health agencies etc. We are easy targets because as a whole we have historically bent over and taken it on the backside with little fight.
The limitations and realities of RACs etc. are that indeed the system suggests a standard of ‘guilty until proven innocent’, the appeal process is heavily limited and weighted against the provider and in order to perform audits, consolidate EHR and paperwork and defend accusations, there will be substantial costs. In addition, cost-shifting will certainly be reigned-in with insurance reform, further widening the gap. Quite simply, it may not be economically feasible to continue to care for Medicare patients under this system.
There is no doubt that fraud must be addressed and the costs recouped if possible, but it is incumbent upon us to remove the targets from our backs, consolidate our voices and publicize our position.

Guest
Mar 16, 2010

Dr. Exhausted,
I asked you before and I will try asking you again, what is it that you find so offensive to physicians in the current bill?
As Dr. Lamberts mentioned RACs and Medicare audits are not new and the ludicrous “undercover patients” idea came from a conservative doctor, outraged by all the fraud in Medicare.
So is it this particular healthcare bill that is angering you, or is it just general unhappiness with the current President?

Guest
rbar
Mar 16, 2010

I work in nonsurgical specialty care and I am not sure what to think of all that.
There probably is rampant fraud, esp. in the device and therapy sector.
What I see from other providers based on their documentation seems usually alright … although there are some who write a handful of words re. history, and then there is some template filling in meds, vitals, ROS, exam, and then there is a very brief plan. I also saw a nonradiologist doing readings of self referred MRIs that seemed to be superficial and substandard, not even proofread. Depending on how these things are billed, these are services for a couple of hundred bucks (and in the thousands for the MRI). I could imagine that one can detect fraudulent work based on review of charts and billing. However, I believe that the big (fraud) bucks are rarely in primary care, but rather with tests, surgeries and devices. I hope they start looking there.

Guest
Mar 16, 2010

The problem with Medicare is that it’s Fee-For-Service. Always has been, and the reason for that is that it was what the AMA wanted when Medicare was introduced.
Fee for service is a crazy way to run health care. And I said exactly that in the VERY FIRST POST on THCB called “What’s wrong with Meidcare” http://www.thehealthcareblog.com/the_health_care_blog/2003/08/the_first_post_.html
So Rob–join a salaried practice, or agitate for single payer–but by definition FFS medicine is going to be bad news for you. And the only reason that the private guys arent as nasty is that they havent needed to be. But when they get squeezed (as is happeneing soon) it’s going to be like 1997 all over again.

Guest
Mar 16, 2010

I had no idea the effects of healthcare were frustrating so many general physician doctors.

Guest
ExhaustedMD
Mar 16, 2010

Go do a search on a Jeri Hassman, an MD who originally was charged with multiple counts of Medicare fraud, I think back in the mid to late 1990s, that was challenged voraciosly by the government, and then, from what I remember reading, whimsically dropped by the government. Unfortunately, her name comes up later regarding prescription fraud issues that I am not clear if legitimate or not, how convenient another government pursued matter (to clear them of prior transgressions?), but, I remember how they dragged her name through tons of mud without legitimate charges of Medicare fraud.
As to Ms GA’s repeated badgering of my position, what does this legislation do of good for doctors who went into medicine to treat people and maintain responsible and ethical independence to practice.
You people keep applying the rules of business to the practice of medicine! Medicine is NOT a business, and it fails now as it has foolishly, stupidly, and painfully allowed itself coerced into behaviors by forces it mistakenly thought it could not repel. I do not treat customers or clients, and anyone who argues those terms apply never took an oath of clinical care.
You know, the Lamberts on the internet really are making more mistakes than benefits by trying to reason with unreasonable people in a medium that thrives on quick fixes and unaccountability. You can call me hypocritical for using an alias, but, I am not going to be harassed further than I already have been by being honest and direct with others who do not engage on a level playing field.
Blog sites are more so soundboards these days than sites of facts and responsible discourse. You know what they say about opinions and anal sphincters, so I’ll leave you to finish the thought.
As to Dr Lamberts, we are screwed because you and I know that this legislation will just lead to more people on Medicare and Medicaid rolls, and you gotta love people who, at the end of the day, are just using lots of words to simply say, “you took a vow of poverty, so deal with it!”
I’d love to write what is the true and fair retort to this, but, I would be banished because being honest and direct with those who are inappropriate makes me the heavy, while they continue to get away with trying to force non-clinical judgment on those who are clinicians.
I do not know where you trained, but I had plenty of supervisors and mentors remind me through my training to watch out, everyone is a gd doctor until they screw up and run when the feces hits the fan.
Today is no different for what that advise entails!!!

Guest
Mar 16, 2010

Matthew: I respectfully disagree (respectfully since you are the boss around here). The problem is the definition of a unit of service being an office visit. We have a procedure based system which makes it tantamount to prove the procedure was done – hence the noose of documentation. All a procedure based payment system encourages is more procedures and more attention to documentation. If we instead focus on outcomes, it will make measurement of service rendered very different. I personally think that EMR is a necessary step before any cost control or any fundamental change to the payment system can happen. I am not talking about EMR as expensive gibberish generators; I am talking about EMR as a clinical database and a tool to inform better decisions. Is that P4P? Of a sort. But one that is informed by clinical, not claims data. It’s complex. I am writing a post on “why EMR is essential for reform.” I am sure it has been done before, but probably not by a private-practice PCP.