Monday, August 18, 2008

The patients respond to "Fighting Chaos"...

Cindy posted an excellent response to Dr. Rob's blog post, "Fighting Chaos" . She gave me permission to post it here, too.

I have a rather unique perspective on this whole situation as I have had the opportunity to observe this issue from both sides….as a healthcare provider and a patient. I am a licensed physical therapist and have dealt with insurance, Medicare, medical necessity letters, depositions, documenting to the nth degree, paperwork , paperwork, paperwork, etc… Working in the healthcare arena is completely different than it was 20 years ago. And with the onset of HIPPA, it changed everything regarding the way a medical practice is run (i.e.: requiring a compliance officer, piles of documentation, etc…)

Insurance & Medicare reimbursement has slammed all healthcare providers. With the onset of the Balanced Budget Act, reimbursement for all Medicare patients was drastically reduced. And then, as you know, most insurance companies followed suit. Functioning within the Prospective Payment System as enforced by the HealthCare Finance Committee, we therapists were faced with learning a whole new way of approaching patient care. In physical therapy, patient are was based on their estimated Resource Utilization Group Score (RUGS) meaning it’s solely based on diagnosis. The time allowed to treat was based on this score. herefore, each patient had a different individualized program and we had very rigid requirements regarding the amount of time we spent with the patient based on these scores. For example, treating a patient with a Stage IV decubiti, we received higher reimbursement than a Stage II. A patient who required only gait training, would be allowed less reimbursement than someone who just had a total hip replacement. And with this RUGS system in place, I observed that the complicated patients were getting the care that they needed.

So how could this apply to a physician? The Healthcare Financing Committee is a powerful governing body and I don’t see any reason why they cannot utilize and enforce RUGS scores with physicians as well. In my honest opinion, I think all physicians should lobby to have the system changed. It would not be that difficult as it is already in place for therapies. Under PPS, a PT’s evaluation is service based, and then all treatments thereafter are time-based according to the patient’s RUGS score. Of course as a physician, during the discovery phase, you may not have a definitive dx; therefore the HCFC would have to develop a RUGS scoring system for the testing process in addition to the treatment. So, your initial evaluation of a patient is service based and therefore, you would get a flat fee. Once you submit the dx you want to test for, the patient’s RUGS score is determined on that dx and you are allowed a certain amount of time/reimbursement based on this. For example, a patient you suspect has diabetes vs. a patient you suspect has Cushing’s….the RUGS score will be much higher for the patient with possible Cushing’s as it is much more involved & requires multiple tests & treatments.

Yes, I too am a Cushing’s patient and I am thankful to doctors, like yourself, who continue to provide optimal care within the limitations of insurances & Medicare. But like you said, there are too many doctors who have given up the fight or just don’t care anymore and as a direct result, complicated patients are getting thrown to the wayside. (I myself, have had that happen, delaying my dx & treatment.) If the system changed, then I believe many doctors would change their way of practice. As they say “The squeaky wheel gets the grease”. For the sake of medicine as a whole and patients nationwide, I hope physicians start squeaking!!

Some of us were discussing this today, and Gina spoke up to say (and I quote with her permission):

Something I'd like to see more of is new docs to be able to serve 3-4 yrs in a area that is lacking PCP's in exchange for their student loans being taken care of. I have to believe that without having that burden of debt, some of these docs would not be in the situations they're in today.

That kind of opportunity is not given to any other type of grad/PhD level programs that I know of. I sure wish I could participate in this type of program because I would likely work in the non-profit sector vs. corporate America.

There is an innovative program that was started in Indpls by a couple of cardiovascular docs who wanted to go into private practice vs. being on a hospital staff. They made every mistake possible and eventually developed something called the "Care Group". This has now become a national network that provides doctors who are in a solo or small practice, the opportunity to have all kinds of services provided for them such as billing, insurance claims, etc. instead of hiring staff to do this for them.

The amount of the local docs overhead is drastically reduced and the services they receive for billing and insurance keeps them afloat because they've got experts taking care of that for them.It's rare to find a science/medicine person who's also got a good set of business skills....and even if they do, there's only so much time in the day!

I think this kind of doc-to-doc solution is just one of the many efforts needed to help make things better.

We are interested. We need to see a change. I believe the dialog in these blogs can make a difference.

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