Oh, that clever Center for Public Integrity.  Look what they’ve gone and done now!  My, oh my.  According to the article, doctors are much of the the problem, billing “billions” of Medicare upcharges according to the center.

But what if the medical coding game itself is flawed?  Stop for a moment and imagine what it would look like if lawyers billed like doctors.  Suddenly, we see how bizarre the world of government billing codes and chart-completion mandates has become.

Not long ago I asked readers what my time is worth on a per-hour basis.  Collectively and independently, they settled on a number of about $500/hr (see the comments).  Now look for a moment at what Medicare pays, even at its highest level of billing for a physician’s time for evlauation and management of a medical problem: for 40 minutes of a physician’s time, it’s $140 (or $210/hr) before taxes.  Again, we see another disconnect as to how doctors are valued in our current system.

Doctors are working long hours to collect these fairly low fees from Medicare while jumping more hoops than ever to do so.  They have become pseudo-experts at the coding game, trying to get as much money for their extra efforts as legally possible.  But these fees paid by Medicare do not cover payments for time spent on phone calls, e-mails, and working insurance denials.   These services are still considered by our system as gratis. To partially counteract this coding problem, doctors realized (and the government insisted) that doctors use electronic medical records.

But when independent doctors set out to implement these records they quickly discovered that the expense and long-term maintenance costs of local office-based EMRs could not compete with more sophisticated systems already in use by their neighboring large health care systems.  Because of ever-increasing cost-of-living and overhead costs, not to mention the threats of large fee cuts, doctors have migrated to large health systems faster than ever.  With the fancier electronic record at those systems (streamlined for billing, collections, and marketing) fields required for higher billing codes (but not always material to the problem at hand) are completed in less time.  So are doctors really the problem?

It depends on who’s looking.  Since every medical test and order is tied to a doctor’s name, then of course it looks like doctors are the problem.  And yet it’s the government who has mandated the codes, the requirements for chart completion, and the electronic records to which our electronic signatures are attached.  But we should ignore these facts; in the eyes of the Center for Public Integrity, of course its the doctors’ and hospitals’ fault.

And what do you think the government’s response is to all of this?

Why, get get ten times the number of billing codes, of course!

So take a moment and imagine a world without codes might look like.  A world where doctors are paid for their level of expertise, time with patients, time with communication for those patients, and time their connected to the EMR to enter codes, document, e-mail, and care for patients.  No codes, just time-based billing at a level of commensurate with their skills.  If we can track billing codes, we can track doctors’ time.  Gosh, it’s sounding sane isn’t it?

If we really want out of this coding and billing conundrum, we should stop the coding schemes.  Pay doctors for what they are worth in today’s market.  Pay doctors for their time as well as their productivity.  Throw away the codes, the consultants, the code licensure fees, and the nonsense.  Compared to current administrators of these coding schemes, people might actually discover that doctors and hospitals are the path to salvation for excessive health care costs rather than the instigators of coding fraud.

Westby G. Fisher, MD, (aka Dr. Wes) is a board certified internist, cardiologist and cardiac electrophysiologist practicing at NorthShore University HealthSystem in Evanston, IL. He is also a Clinical Associate Professor of Medicine at the University of Chicago’s Pritzker School of Medicine. He blogs at Dr.Wes, where this post originally appeared.

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22 Responses for “Kill the Codes”

  1. sm2012 says:

    I went to a conference not too long ago and listened in on a session about ICD 10. The woman presenting was a leading person in the field and was discussing the complexity of linking ICD9 codes to ICD10. I asked why it was so hard to do if the US was the last country in the world to adopt ICD 10 – hadn’t the ICD9 to 10 links already been done by everyone else??

    Her answer – there are only a few 100 codes in ICD10. But the US – and the system of regulators and reviewers who went over the various codes – added many 1000’s of modifiers to create what will now be one of the most unwieldy assessment systems in existence! It was total insanity.

    Wes – you are completely right. I would love to see what would happen if lawyers or business consultants had to code like doctors do. And the idea that physicians are the problem to all things healthcare every time we bring up something that is running poorly is crazy making.

    We need another system – one that doesn’t allow for self serving test ordering, excessive charging, and the problems of defensive medicine, but that doesn’t focus on bureaucratic complexity and micromanagement as the solution.

  2. BobbyG says:

    Duly noted on my blog. What a mess.

  3. rbaer says:

    I actually do agree that the codes are a mess and that they should be greatly improved (i.e. simplified) or replaced.

    But I wonder about some statements:

    “they settled on a number of about $500/hr (see the comments).” – apart from the fact that this is not exactly what I recollect (but maybe I am wrong; but even if there was a link, I would be too tired to do beancounting) , we are getting in an area of ethical pay dilemma: is you time really worth 50x more then the time of the cleaning lady or security guard?
    - “A world where doctors are paid for their level of expertise, time with patients, time with communication “. Good codes would deliver exactly that. Medicare codes actually do allow for some time based billing (for counseling/coordination of care).
    -and the elephant in the room: Dr. Fisher who is – I am sure – a terrific electrophysiologist is so confident about his 4 figure/2 hrs income because he is greatly overpaid while doing ablations, and somewhat underpaid while doing cognitive medicine. The solution to that should not be that proceduralists are always paid as if they were doing procedures reimbursed per current medicare codes.

  4. DirkD says:

    interesting that Public Integrity didnt mention this in their report

    my sense is that many reporters have a fairly low level knowledge of the issues involved – these guys are supposedly experts of course, you’d think they’d bring a little more nuance to their report

    this speaks to the glaring pr problem that docs have managed to create for themselves over the years

  5. southern doc says:

    Note to self:

    Monday AM Cancel appointments. Call press agent stat. Fluff image.

  6. DirkD says:

    @southerndoc

    that would be the AMA’s job – not yours

    or whoever you guys collectively decide should be doing the representing

    you cannot seriously be arguing – after the passage of ObamaCare, that docs’ interests are being defended in Washington

    nah, you’re just grumpy and I don’t blame you …

  7. Jim says:

    Granted, the coding system is a mess. But, do you seriously think that you, and every other doctor in the US, should be paid $960K per year?

    I’m all for paying doctors for their time and productivity. But, how about we pay doctors for health as well? Left to their own devices, doctors and hospitals have been anything but the “path to salvation” for healthcare costs.

    The AMA owns the CPT coding system and is the primary source of the huge gulf between specialist compensation and primary care. “Physician, heal thyself”- then start tilting at the ICD-10 windmill.

    • BobbyG says:

      “P4P”?

      Let The Market Decide physician worth?

      Ron Paul got huge Primary debate cheers for insisting that people who failed to “plan well” should perhaps suffer their just fate curbside at the ER (this from a doctor, no less).

      I think competent docs should be well-compensated, but, this entire debate is hopelessly muddled.

  8. JimE says:

    Why shouldn’t the market decide physician worth? Why shouldn’t physicians compete in a transparent marketplace based on cost and quality? It isn’t the coding system that is maintaining the permanent obfuscation of what it costs to receive quality care- it is doctors and hospitals.

  9. Peter1 says:

    “But what if the medical coding game itself is flawed? Stop for a moment and imagine what it would look like if lawyers billed like doctors. ”

    Not sure of the point being made here? Do you assume lawyers bill honestly? Lawyers at least discuss price with the client and may work on contingency.

    “Not long ago I asked readers what my time is worth on a per-hour basis. Collectively and independently, they settled on a number of about $500/hr ”

    Would those readers be the ones covered by insurance and who don’t pay your fees? What do you think your heating contractor’s per hour time is worth? Would he charge more if he knew you wouldn’t shop price?

    “So take a moment and imagine a world without codes might look like. A world where doctors are paid for their level of expertise, time with patients, time with communication for those patients, and time their connected to the EMR to enter codes, document, e-mail, and care for patients.”

    That would be called salary – I’m all for it. Get rid of FFS.

    Doctor, you don’t think other people in this economy are working more for less?

  10. spike says:

    Peter nailed it.

    I said it on your last post, I’ll say it on this one.

    You’d be much more credible in your complaints if you were willing to go salaried and were willing to make the same amount as doctors around the rest of the world were making, namely 3x median national income instead of 5x median national income.

    Until then, you sound like a guy who doesn’t like having to work so hard so he can keep making payments on both his Porsches.

  11. spike says:

    I’m sure Dr. Wes means well, but this post is so misleading. $500 per hour was for a 3-hour max engagement to be a consultant on a medical malpractice case. $500 was chosen because it would be schedule S meaning lots of extra taxes. So in good faith the $140 after tax reimbursement should be compared more to $300 an hour for consulting. Then throw in the difference between a 40+ hour per week gig and a one-off consulting project. Why even bother talking about the $500/hour as if it is somehow comparable to your day job?

  12. rbaer says:

    Spike, I am really curious: why do you write about an old post as if you could remember every detail of said post?

    “$500 per hour was for a 3-hour max engagement to be a consultant on a medical malpractice case. $500 was chosen because it would be schedule S meaning lots of extra taxes. So in good faith the $140 after tax reimbursement should be compared more to $300 an hour for consulting. Then throw in the difference between a 40+ hour per week gig and a one-off consulting project.”

    Nothing of this sort (3 hour max, medicolegal etc.) was in the Dr. Wes original post, neither at his own blog nor at THCB.

  13. spike says:

    I was curious where the number came from, so I went back to his blog (through the link in his signature), went to the post cited here, found the link to the original blog post where the value of his time was settled: http://drwes.blogspot.com/2012/08/a-value-proposition-what-am-i-worth.html, and actually read through the comments.

    All of the comments that gave a number clearly stated their assumption that it was for a one-time consulting gig and recommended he double his actual expected wage to cover taxes and other overhead. The point of this article is to extrapolate that established value to his day job as a doctor, but the justification for $500/hour was that it was for a self-employed consultant and thus should be about double what he normally gets. So it’s disingenuous to take that number and use it for reference in a discussion about coding.

    The cool thing about the internet is that even if a post is really old, you can go and find it and read it and then remember the details of said post.

    • rbaer says:

      @spike
      “The point of this article is to extrapolate that established value to his day job as a doctor, but the justification for $500/hour was that it was for a self-employed consultant and thus should be about double what he normally gets. So it’s disingenuous to take that number and use it for reference in a discussion about coding.”

      Hhmmmh …. that sounds like you speak for Dr. Wes, and you end up defending his 2 posts vehemently. I wonder why you, spike, clearly a different individual than Dr. Wes, would do that and even make the effort to analyze and summarize the comments from the older post. In any case, your defense (“it’s disingenuous to take that number and use it for reference in a discussion about coding”) is very weak because this is exactly what Dr. Wes himself was doing in the above post, that post with the headline “Kill the codes”:

      “Not long ago I asked readers what my time is worth on a per-hour basis. Collectively and independently, they settled on a number of about $500/hr (see the comments).”

  14. spike says:

    So to be clear, I think Dr. Wes is being misleading by saying $500 an hour is a valid assessment of the worth of his time as a doctor.

    I am not defending him or his posts vehemently. If anything I’m attacking him for being misleading. I find Dr. Wes’s posts frustrating, honestly. He sounds very arrogant and entitled.

  15. Peter1 says:

    “All of the comments that gave a number clearly stated their assumption that it was for a one-time consulting gig and recommended he double his actual expected wage to cover taxes and other overhead.”

    Funny how wage stiffs get quoted an hourly rate, sans allowance for taxes. An individual’s tax is his rate, which differs to everyone else’s.

    What overhead, the one he already claims in his practice, or the one he gets for free from the hospital?

  16. Ruth says:

    Of course he is very arrogant. I’d like to speak to his patients.
    As mentioned above, salaries will reduce a lot of bullshit. Looks like Mayo got it right.
    FFS is a scourge.

    • Dr. Mike says:

      Mayo provides a service, and collects a fee. How is that not fee for service? Oh, you meant that the salaried doc is less likely to upcode. But are you sure? How many salaried docs do you know that are NOT paid productivity bonuses or who do not have to meet productivity targets? And what do you think those productivity numbers are based on? That’s right, those same codes.
      And by the way, when you go to Mayo, and you are in that initial consultation room and in walk the attendings from three different specialties accompanied by a crowd of their residents and medical students – who do you think it is that is paying for all the salaries represented in that room?
      No, the way out of this mess is not to simply salary the docs (not saying that isn’t a good idea) but to get rid of the cpt-based payment system.

  17. Dr. Mike says:

    When I worked full time in my solo family medicine practice I charged out over $550K per year (or $350K in AR after insurance “adjustments”) and took home about 150K. I figured out I was working about 50 hours a week (about 2500 hours per year) yielding an hourly rate of about $60/hr (with very limited benefits since self-employed). The midlevels (PA, NP) in my area make $78K (Primary Care) up to 110K (surgical mid-level) yielding hourly rates in the $40-$60/hr range (plus full benefits). Most specialists I know make in the $350-450K range and work about 60 hours a week or more, yielding an hourly rate in the $110-140/hr range. Even that doesn’t seem that unreasonable for me for someone who didn’t start work until about age 31 and likely has about $200K in debt.

    • spike says:

      Medical school is extemely over-priced too. Healthcare and education become more and more over-priced over time because there’s no way to increase productivity. i.e. college professors teach as many people today as they did 50 years ago. Doctors see rougly the same number of people today that they did 20 years go.

      The problem comes when people whose productivity is not increasing want salary increases above inflation.

      I 100% agree that doctors should be reimbursed for email and phone conversations, as that is the only way to increase a doctors productivity at this point, and thus the only way to provide legitimate salary increases that don’t wind up overtaxing the system.

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