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Category: Medical Practice

How to End Egregious Medical Bills (while minimizing the impact on the provider’s bottom line)

By HAYWARD ZWERLING, MD

I recently saw a patient who received a bill for an outpatient procedure for $333. The Medicare allowable reimbursement for the procedure was $180. I have seen other medical bills where the healthcare provider was charging patients more than 10 times the amount they expected to receive from Medicare or any insurance company.

Another one of my patients had an unexpected medical complication which necessitated a visit to an emergency room. He received a huge bill for the services provided. When I subsequently saw him in my office (for poorly controlled diabetes) he told me he could not attend future office visits because he had so many outstanding medical bills and he could not risk incurring any additional medical expenses. While I offered to see him at no cost, he declined, stating the financial risk was too high.

A patient is required to pay the entire medical bill if they have:

  • no insurance
  • poor quality insurance
  • a bureaucratic “referral problem”
  • an out-of-network provider, which means they have no contractural relationship with the healthcare provider/institution, as might result from an emergency room visit or an unexpected hospitalization.

Hospitals, physicians and other healthcare providers usually do not know what they are going to get paid for any given service as they contract with many insurance companies, each of which has a different contracted payment rate. Healthcare providers and institutions typically set their fee schedule at a multiple of what they expect to get paid from the most lucrative payer so as to ensure they capture all the potential revenue. In the process, they create an economically irrational fee schedule which is neither reflective of a competitive marketplace nor reflective of the actual cost of the services provided.

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Click and Exercise! Amazon, Netflix, Hulu—Are You Listening?

By DEBORAH A. COHEN

Physical inactivity is a mounting challenge for America. In reviewing the 2013-2015 American time use survey, we found that most Americans report spending their daily leisure time watching screens, and devote only a small fraction of leisure time—24 minutes for men and 14 minutes for women—to physical activity. A recent longitudinal examination of the National Health and Nutrition Examination Survey showed that sitting time increased by an hour a day between 2007 and 2016, with the largest increases among adolescents ages 12-19 and adults, 20 years and older. As mortality rates for heart disease have begun to climb, increases in sedentary behavior bodes poorly for future control of disease and health care costs.

The explosion in streaming apps and content is likely contributing to the increased sitting time. According to the Motion Picture Association of America, TV and movie views have more then doubled between 2014 and 2018. The availability of multiple series and the ability to binge watch can keep people glued to their couches for hours at a time. The immersive quality of the programming makes it increasingly difficult for viewers to pull themselves away from their screens. Yet, the technology could provide options to help viewers watch and still get regular physical activity.

Currently, after each episode, an option is available to allow the viewer to immediately call up the next episode. Why not consider adding a pop-up that can remind viewers that sitting more than 20-30 minutes at a time may not be good for health, and that it’s important to move around to avoid chronic diseases? A narrator could ask viewers to treat themselves to an activity break. Then the viewers could have the option to choose a short video that can guide them through a 10- minute exercise break. Or even a 5-minute break. Something is better than nothing.

There could be many options, from a just a simple stand up and stretch, like the 7th inning break at a baseball game, to vigorous workouts, like the 7-minute workout published by the American College of Sports Medicine or doing a Bhangra dance with a Bollywood film star. 

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Training the Modern Physician: A Call to Incorporate Finance and Law into Medical Education

By SAI BALA, JD

The United States medical education system is heralded as one among the top in the world for medical training. Given the strict standards of education, multiple licensing boards, and continuous oversight by governing bodies, getting a placement to train in the US is extremely competitive.  In 2017 alone, nearly 7000+ non-US citizens (commonly referred to as “foreign medical graduates”) applied to compete with 24,000+ US citizens for American residency spots to pursue specialty training. The reasons for this competitiveness are simple. The vast majority of medical institutions in the US boast a comprehensive curriculum that entails basic sciences, clinical principles, practical and hands-on didactics, and enriched exposure to the clinical aspects of patient care. This training produces astute clinicians that are capable of resolving the most complex diagnoses while providing comprehensive patient care.

However, it is high time to recognize that being a shrewd clinician is no longer a sufficient product for the demands of the healthcare market today. That is to say, the scope of medicine today for a physician has gone far beyond resolving complex medical problems, but demands a higher understanding of multidisciplinary skillsets, most important of which are finance and legal theory. In these aspects, the US medical education system direly underprepares physicians, and thus, requires a thorough reevaluation.

The art of medicine, as much as it was originally developed to be purely about the betterment of patient health, has become yet another siloed service industry. Simply put, patients are customers, and physicians are increasingly held accountable for the financial metrics and revenue their work produces. Compensation models are increasingly favoring productivity based payment methods, such as the relative value unit (RVU) system, and are moving away from the traditional, salaried physician. This has resulted in increased pressure on physicians to become more efficient with their workload and patient docket, while managing the often turbulent and contradictory interests of insurance, patients, and hospital administration.

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The Rise and Rise of Quantitative Cassandras

By SAURABH JHA, MD

Despite an area under the ROC curve of 1, Cassandra’s prophesies were never believed. She neither hedged nor relied on retrospective data – her predictions, such as the Trojan war, were prospectively validated. In medicine, a new type of Cassandra has emerged –  one who speaks in probabilistic tongue, forked unevenly between the probability of being right and the possibility of being wrong. One who, by conceding that she may be categorically wrong, is technically never wrong. We call these new Minervas “predictions.” The Owl of Minerva flies above its denominator.

Deep learning (DL) promises to transform the prediction industry from a stepping stone for academic promotion and tenure to something vaguely useful for clinicians at the patient’s bedside. Economists studying AI believe that AI is revolutionary, revolutionary like the steam engine and the internet, because it better predicts.

Recently published in Nature, a sophisticated DL algorithm was able to predict acute kidney injury (AKI), continuously, in hospitalized patients by extracting data from their electronic health records (EHRs). The algorithm interrogated nearly million EHRS of patients in Veteran Affairs hospitals. As intriguing as their methodology is, it’s less interesting than their results. For every correct prediction of AKI, there were two false positives. The false alarms would have made Cassandra blush, but they’re not bad for prognostic medicine. The DL- generated ROC curve stands head and shoulders above the diagonal representing randomness.

The researchers used a technique called “ablation analysis.” I have no idea how that works but it sounds clever. Let me make a humble prophesy of my own – if unleashed at the bedside the AKI-specific, DL-augmented Cassandra could unleash havoc of a scale one struggles to comprehend.

Leaving aside that the accuracy of algorithms trained retrospectively falls in the real world – as doctors know, there’s a difference between book knowledge and practical knowledge – the major problem is the effect availability of information has on decision making. Prediction is fundamentally information. Information changes us.

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Academic Medicine and the Peter Principle

By BEN WHITE, MD

Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.

The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”

In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.

The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).

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Primary Care Is at the Center of a Health Revolution

By KEVIN WANG, MD

If our urgent-care-as-healthcare culture isn’t killing us, it’s certainly wasting our time and resources. 

Consider these facts highlighted by Advanced Medical Reviews, based on various studies: 

  • U.S. physicians report that more than 20 percent of overall medical care is not needed.
  • The Congressional Budget Office recently estimated that up to 30 percent of the costs of medical care delivered in the U.S. pay for tests, procedures, doctor visits, hospital stays, and other services that may not actually improve patient health.
  • Unnecessary medical treatment impacts the healthcare industry through decreased physician productivity, increased cost of medical care, and additional work for front office staff and other healthcare professionals.

Most of today’s primary care is, in retail terms, a loss leader — a well-oiled doorway to the wildly expensive sick care system. For decades, practitioners have been forced into production factories, seeing as many patients, ordering as many tests, and sending as many referrals as possible to specialists. Patients, likewise, have avoided going in for regular visits for fear of the price tag attached, often waiting until they’re in such bad shape that urgent (and much more expensive) care is necessary.

The system as it stands isn’t delivering primary care in a way that serves patients, providers, employers, or insurers as well as it could. To improve health at individual and population levels, the system needs to be disrupted. Primary care needs to play a much larger role in healthcare, and it needs to be delivered in a way that doesn’t make patients feel isolated, neglected, or dismissed. 

Luckily, primary care is making a comeback — the kind that doesn’t just treat symptoms, but sees trust, engagement, and behavior change as a path to health.  

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Ordering Tests Without Using Words: Are ICD-10 and CPT Codes Bringing Precision or Dumbing Us Down?

By HANS DUVEFELT, MD

The chest CT report was a bit worrisome. Henry had “pleural based masses” that had grown since his previous scan, which had been ordered by another doctor for unrelated reasons. But as Henry’s PCP, it had become my job to follow up on an emergency room doctor’s incidental finding. The radiologist recommended a PET scan to see if there was increased metabolic activity, which would mean the spots were likely cancerous.

So the head of radiology says this is needed. But I am the treating physician, so I have to put the order in. In my clunky EMR I search for an appropriate diagnostic code in situations like this. This software (Greenway) is not like Google; if you don’t search for exactly what the bureaucratic term is, but use clinical terms instead, it doesn’t suggest alternatives (unrelated everyday example – what a doctor calls a laceration is “open wound” in insurance speak but the computer doesn’t know they’re the same thing).

So here I am, trying to find the appropriate ICD-10 code to buy Henry a PET scan. Why can’t I find the diagnosis code I used to get the recent CT order in when I placed it, months ago? I cruise down the list of diagnoses in his EMR “chart”. There, I find every diagnosis that was ever entered. They are not listed alphabetically or chronologically. The list appears totally random, although perhaps the list is organized alphanumerically by ICD-10, although they are not not displayed in my search box, but that wouldn’t do me any good anyway since I don’t have more than five ICD-10 codes memorized.

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Indigenous Medicine– From Illegal to Integral

Brooke Warren
Phuoc Le

By PHUOC LE, MD and BROOKE WARREN

In the 2020 Summer Olympics, we will undoubtedly see large, red circles down the arms and backs of many Olympians. These spots are a side-effect of cupping, a treatment originating from traditional Chinese medicine (TCM) to reduce pain. TCM is a globally used Complementary and Alternative Medicine (CAM), but it still battles its critics who think it is only a belief system, rather than a legitimate medical practice. Even so, the usage of TCM continues to grow. This led the National Institute of Health (NIH) to sponsor a meeting in 1997 to determine the efficacy of acupuncture, paving the way in CAM research. Today, there are now over 50 schools dedicated to teaching Chinese acupuncture in the US under the Accreditation Commission for Acupuncture & Oriental Medicine.

Image of Michael Phelps swimming in 2016 Rio Olympics after using TCM cupping. (Al Bello/Getty Images)

While TCM has seen immense growth and integration around the globe throughout the last twenty years, other forms of CAM continue to struggle for acceptance in the U.S. In this article we will focus on Native American/Indigenous traditional medical practices. Indigenous and non-Indigenous patients should not have to choose between traditional and allopathic medicine, but rather have them working harmoniously from prevention to diagnosis to treatment plan.

It was not until August of 1978 that federally recognized tribal members were officially able to openly practice their Indigenous traditional medicine (the knowledge and practices of Indigenous people that prevent or eliminate physical, mental and social diseases) when the American Indian Religious Freedom Act (AIRFA) was passed. Prior to 1978, the federal government’s Department of Interior could convict a medicine man to a minimum of 10 days in prison if he encouraged others to follow traditional practices.

It is difficult to comprehend that tribes throughout the U.S. were only given the ability to openly exercise their medicinal practices 41 years ago when the “healing traditions of indigenous Native Americans have been practiced on this continent for 12,000 years ago and possibly for more than 40,000 years.”[1]

Since the passage of AIRFA, many tribally run clinics and hospitals are finding ways to incorporate Indigenous traditional healing into their treatment plans, when requested by patients.

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We Can Stop America’s Surge in Opioid-Dependent Babies

By STUART H. SMITH

Imagine a massive public health crisis in the United States that affects tens of thousands of people. Now imagine that the government had a simple tool at its disposal that could prevent this kind of physical and psychological trauma. You might think that I’m writing about America’s deadly outbreak of gun violence, which has made headlines this summer from Dayton to El Paso.

But actually I’m talking about a different crisis that affects even more people – all of them children — and which could be sharply reduced with one simple step that lacks the bitter political animus of the gun debate. The issue at hand involves babies born to mothers who used opioids during pregnancy – babies who tend to develop a condition called Neonatal Abstinence Syndrome, or NAS.

Experts say that state and federal governments have grossly underestimated the number of NAS babies currently born in the United States, as the addiction crisis triggered by Big Pharma’s greed in pushing painkillers refuses to fade. They say an accurate accounting would find a minimum of 250,000 children — and possibly two or three times that every year born with NAS. These kids will face chronic symptoms such as trembling and seizures, gastrointestinal problems, and an inability to sleep. Their numbers are more than eight times higher than the last official estimate from the government.

For more than a year now, I’ve been working with a team of attorneyscalled the Opioid Justice Team who are fighting for any settlement of the massive court fight pitting more than 2,000 localities against Big Pharma to include a medical monitoring fund for the estimated hundreds of thousands of kids born with NAS syndrome. But our team has also been pushing for radical measures that would prevent many of these unfortunate cases.

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I Have a Strong Relationship with my Bank but I Almost Never Go There. How Could this Translate to Primary Care?

By HANS DUVEFELT, MD

Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch – and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.

Of course that’s not how banks operate. There are small ongoing charges (or margins off the interest they pay you) for keeping your money and for making it possible to do almost everything from your iPhone these days. Yes, there may be additional charges for things that can’t be done without the bank’s personalized assistance, but those things happen at your request, not by the bank’s insistence.

Compare that with primary care. The bulk of our income is “patient revenue”, what patients and their insurance companies pay us for services we provide “face to face”. We may also have grants if we are Federally Qualified Health Centers, mostly meant to cover sliding fee discounts and what we call “enabling services” – care coordination, loosely speaking.

Only a small fraction of our income comes from meeting quality or compliance “targets”, and those monies only come to us after we have reached those goals – they don’t help us create the needed infrastructure to get there.

Then look at how medical providers are scheduled and paid. We all have productivity targets, RVUs (Relative Value Units – number and complexity of visits combined) if our employer is paid that way and usually just straight visit counts in FQHCs (because all visits are reimbursed at the same rate there). Sometimes we have quality bonuses or incentives, which truthfully may be the combined result of both our own AND other staff members’ efforts.

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