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Comments on: American Medicine - Evil and Malevolent Coding (E/M) http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/ New Address is http://distractible.org Mon, 08 Sep 2008 12:50:38 +0000 http://wordpress.org/?v=2.2.2 By: Val Jones MD http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2280 Val Jones MD Fri, 02 Mar 2007 03:35:50 +0000 http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2280 The "medical home" is the AAFP's (and other primary care physicians) concept of centralizing care through an individual team leader (the PCP). What we've observed over the years is that patients are seen by a smorgaasbord of specialists, most of whom do not share information. This results in decreased quality of care due to repeat testing, duplicate prescriptions, and piecemeal diagnosis and treatment with only a superficial understanding of who the patient is and what he/she really needs. The argument is that if these patients had a medical home (a team lead who could help coordinate their care) they'd be much better off. I do believe that the AAFP is correct, but I am not convinced that returning to a "gate keeper model" is the right application of this idea. I believe that patients should have an Internet-based medical home, complete with coaches, disease management programs, physician email service, a PHR, and an insurance advocate system. Their primary care physician (and their specialists) should be invited to their home base to review their lab tests, vitals, and general self reported progress with disease management. The docs can give them some tips, and schedule in person meetings only as needed. (This is what Revolution Health is trying to create.) Consumers have to drive this - because then we docs will follow. I doubt that docs will initiate this eHealthHome. Now, the IMP concept is not so much about a medical home as it is about radically reducing overhead via IT, so that a physician can see fewer patients and still make a decent salary. Quality of care is enhanced by the luxurious 45 minute/patient H&Ps, and everyone enjoys the process so much more. Hope this helps to explain what I was getting at... Keep up the great work, Rob. TBTAM is right - you're an excellent explainer/writer! The “medical home” is the AAFP’s (and other primary care physicians) concept of centralizing care through an individual team leader (the PCP). What we’ve observed over the years is that patients are seen by a smorgaasbord of specialists, most of whom do not share information. This results in decreased quality of care due to repeat testing, duplicate prescriptions, and piecemeal diagnosis and treatment with only a superficial understanding of who the patient is and what he/she really needs. The argument is that if these patients had a medical home (a team lead who could help coordinate their care) they’d be much better off.

I do believe that the AAFP is correct, but I am not convinced that returning to a “gate keeper model” is the right application of this idea. I believe that patients should have an Internet-based medical home, complete with coaches, disease management programs, physician email service, a PHR, and an insurance advocate system. Their primary care physician (and their specialists) should be invited to their home base to review their lab tests, vitals, and general self reported progress with disease management. The docs can give them some tips, and schedule in person meetings only as needed. (This is what Revolution Health is trying to create.)

Consumers have to drive this - because then we docs will follow. I doubt that docs will initiate this eHealthHome.

Now, the IMP concept is not so much about a medical home as it is about radically reducing overhead via IT, so that a physician can see fewer patients and still make a decent salary. Quality of care is enhanced by the luxurious 45 minute/patient H&Ps, and everyone enjoys the process so much more.

Hope this helps to explain what I was getting at… Keep up the great work, Rob. TBTAM is right - you’re an excellent explainer/writer!

]]> By: Rob http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2270 Rob Thu, 01 Mar 2007 18:32:01 +0000 http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2270 You are all trying to butter me up. I am too much of a free-market guy to favor a one-payer system. I agree with Val that there may need to be a bigger "safety net" for those with no coverage (perhaps even for all inpatient care). It interests me that TBTAM does not get rid of Medicare. How many of these patients do you keep compared to the self-pay? It seems that most get rid of it first because of all of the rules that come along with accepting Medicare. We have been able to succeed in our practice despite accepting most insurances, but I am sure it is different than in NYC. In future posts, I will touch on the idea of the "medical home" as put forth by the AAFP, ACP, and AAP. This sounds similar to the IMP - is that true, Val? You are all trying to butter me up. I am too much of a free-market guy to favor a one-payer system. I agree with Val that there may need to be a bigger “safety net” for those with no coverage (perhaps even for all inpatient care). It interests me that TBTAM does not get rid of Medicare. How many of these patients do you keep compared to the self-pay? It seems that most get rid of it first because of all of the rules that come along with accepting Medicare. We have been able to succeed in our practice despite accepting most insurances, but I am sure it is different than in NYC.

In future posts, I will touch on the idea of the “medical home” as put forth by the AAFP, ACP, and AAP. This sounds similar to the IMP - is that true, Val?

]]> By: Val Jones MD http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2260 Val Jones MD Thu, 01 Mar 2007 04:05:01 +0000 http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2260 This is a great summary of our coding system! If I could provide you with the solution in a few paragraphs, I'd be a Nobel Laureate. There are many good people who propose very different solutions... but my personal opinion is that enhanced IT is the best way through. In theory, automating a lot of this coding process, as well as providing accessible price transparency, e-services (to keep folks out of the doctors offices when they don't need to be there), as well as a network of tools and services to help people prevent disease or manage their chronic problems would solve a lot of our problems. This is the approach that advocates of the new IMP (Ideal Micro Practice) primary care model advocate. Now, that still leaves the folks who are too ill, uneducated, or too poor to participate. They do need a safety net. Most say that a government sponsored system would be appropriate for them (and obviously that's what we have now in Medicare and Medicaid), though I worry about the sustainability of this system with higher volumes of aging boomers. IT does have a role to play here too, as many companies are competing to design automated/electronic home monitoring devices for the elderly so that if they're decompensating, we can catch them earlier on and send help so they don't end up in the ER. Again, if Medicare and Medicaid were fully IT enabled (with EMRs, automated coding and payments, ePatient services, etc.) it could save itself a lot of money. This is a great summary of our coding system! If I could provide you with the solution in a few paragraphs, I’d be a Nobel Laureate. There are many good people who propose very different solutions… but my personal opinion is that enhanced IT is the best way through. In theory, automating a lot of this coding process, as well as providing accessible price transparency, e-services (to keep folks out of the doctors offices when they don’t need to be there), as well as a network of tools and services to help people prevent disease or manage their chronic problems would solve a lot of our problems. This is the approach that advocates of the new IMP (Ideal Micro Practice) primary care model advocate.

Now, that still leaves the folks who are too ill, uneducated, or too poor to participate. They do need a safety net. Most say that a government sponsored system would be appropriate for them (and obviously that’s what we have now in Medicare and Medicaid), though I worry about the sustainability of this system with higher volumes of aging boomers. IT does have a role to play here too, as many companies are competing to design automated/electronic home monitoring devices for the elderly so that if they’re decompensating, we can catch them earlier on and send help so they don’t end up in the ER. Again, if Medicare and Medicaid were fully IT enabled (with EMRs, automated coding and payments, ePatient services, etc.) it could save itself a lot of money.

]]> By: TBTAM http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2257 TBTAM Thu, 01 Mar 2007 03:59:12 +0000 http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2257 Great post, this. I've taken a little bit of each approach in my practice - I've sropped all but one or two well-paying plans (but keep medicare because it's just wrong to drop it, even though so many of my colleagues are). This has allowed me to see a few less patients every day without a loss in income, and lets me spend the time I need to give good care. I use a lot of time based billing for things like Menopause management, PMS, depression, PCOS, sexual dyfunction, etc that require a lot of conversation. I bring these patients in at the end of the day so I won't be rushed, and keep track of the time. I use a click and point template rather than cut and paste in the EMR, so I can't overdocument by mistake. The only "gaming" of the system I do is when a ptient comes for what she calls a "routine" or "annual" check up, but then I find problems that require treatment. If I am not in her plan, I ask her which way she is more likely to get reimbursed for my visit- preventive or problem visit. Given I have done both, I could code either way, it's legit and works for the patients and for me. (I don't bother carving out the problem and preventive portions like I do in Medicare because most plan have no idea what to do with that kind of bill. ) Your posts are SO well-written, by the way. I really enjoy your blog. Great post, this.

I’ve taken a little bit of each approach in my practice - I’ve sropped all but one or two well-paying plans (but keep medicare because it’s just wrong to drop it, even though so many of my colleagues are). This has allowed me to see a few less patients every day without a loss in income, and lets me spend the time I need to give good care. I use a lot of time based billing for things like Menopause management, PMS, depression, PCOS, sexual dyfunction, etc that require a lot of conversation. I bring these patients in at the end of the day so I won’t be rushed, and keep track of the time. I use a click and point template rather than cut and paste in the EMR, so I can’t overdocument by mistake.

The only “gaming” of the system I do is when a ptient comes for what she calls a “routine” or “annual” check up, but then I find problems that require treatment. If I am not in her plan, I ask her which way she is more likely to get reimbursed for my visit- preventive or problem visit. Given I have done both, I could code either way, it’s legit and works for the patients and for me. (I don’t bother carving out the problem and preventive portions like I do in Medicare because most plan have no idea what to do with that kind of bill. )

Your posts are SO well-written, by the way. I really enjoy your blog.

]]> By: wolfbaby http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2255 wolfbaby Thu, 01 Mar 2007 02:56:04 +0000 http://distractiblemind.ambulatorycomputing.com/2007/02/28/american-medicine-evil-and-malevolent-coding-em/#comment-2255 Just think this is what I am going to school to learn.. *whew*. I do know that they say HIT is one of the bigest growing professions in the area. I also think alot of it depends on the Ins companies. HMO's are alot worse the PPO I do believe. I don't know the answer. I do know that I don't want the govt to be in charge of all ins cause then it would be worse then HMO as far as them telling us what we can and can not do for care. I have heard some real horror stories about people not being able to get test done etc through Medicare and such. I also know I hear alot of Docs saying how they are no longer taking Medicare so I doubt they would be liking the idea of Govt controled ins. I do know I always thought I had an amazing doc now I just think she is a saint;) Just think this is what I am going to school to learn.. *whew*. I do know that they say HIT is one of the bigest growing professions in the area. I also think alot of it depends on the Ins companies. HMO’s are alot worse the PPO I do believe. I don’t know the answer. I do know that I don’t want the govt to be in charge of all ins cause then it would be worse then HMO as far as them telling us what we can and can not do for care. I have heard some real horror stories about people not being able to get test done etc through Medicare and such. I also know I hear alot of Docs saying how they are no longer taking Medicare so I doubt they would be liking the idea of Govt controled ins.

I do know I always thought I had an amazing doc now I just think she is a saint;)

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