Patients and staff alike are asking “why”, “are you going through a mid life crisis?”, “why can’t you work in the system?”, “What are we going to do now?” The why is complicated for me to explain. I will try not lapsing into using medical language, acronyms, abbreviations. In general I can’t work in a system anymore that treats patients, my staff and providers of health care as it does. It is a broken system in need of change. As has happened in most areas of our lives, government, business practices, and the desire to control, are all working to tear the heart out of medicine. I’ll break it down into different areas in no particular order.
- Death by paperwork – Over the years both government and insurance companies have demanded more “documentation”. Some common themes, “if it isn’t written down, it wasn’t done”, if it isn’t documented right, then you are at risk of fraud:
- Coding: To simplify this for you, our notes become the visit on paper. What we do in a visit essentially has to be documented. So for every visit there is really two visits. If our clerical work is not good enough, and we pick a “management code” that doesn’t support our note, despite the code truly reflecting actual work or time spent, then that is an “coding error” and we can be audited and penalized with a large fine. The government uses contracted auditors to do this work and they get a large recovery percentage for their work. Recently the U.S. Department of Health and Human Services’ Office of the Inspector General reported a review of 2010 claims and shows that “Medicare inappropriately paid some $6.7 billion for incorrectly coded claims and those lacking proper documentation”. (This is far from the truth, we are highly underpaid, spend hours doing unpaid work doing government requirements. I’ll address this more in a later blog). They claim that “42% of Medicare claims are incorrectly coded” and came with a recommendation that Medicare “should educate physicians on billing and documentation”(backed up with fines). A recent presentation by the Washington State Medical Association recommended hiring our own certified coders and use an auditing group to do self audits so our claims would be coded correctly. This would add at least $50,000 or more to the yearly overhead costs. Documenting the visit has made us glorified secretaries. So once again the recommendation is to have someone write the note for us – called a “scribe” so we can “focus” on the patient. Scribes are not cheap, and they don’t do that good a job. (excellent doctors, like Dr. Park I mentioned in background, would be considered incompetent and fraudulent at the sparsity of his notes).
- Prior-authorizations: What you may not be aware of is that we have to get pre-approval from the government or your insurance for medications, referrals, and studies. This process isn’t cheap. Since 2007 medicare part D drugs that are restricted have gone from 18% to 36%, and those that need pre-approval have gone from 8% to 21% of all medications ordered. Now, I have one nurse spending 20+ hours a week dealing with medication pre-approvals. When reviewed nationally, physicians also spend 20 hours a week on prior authorization activities, which leads to a $83,000 annual average per physician cost (this is increased overhead costs) of interacting with insurance plans. We also have to get pre-approval for studies which add more paperwork. All of this is a money drain, time drain, and causes increased frustration. We are demanded to do things that exhaust our resources and there is no compensation for it.
- DME (durable medical equipment): We have to fill out forms for oxygen, CPAP for sleep apnea, splints, any medical equipment. We also have to make sure the note reflects the necessity of these products. We don’t get paid for this.
- Death by Overhead expense – Over the years insurance companies and the government have transferred the cost of managing and controlling these costs to our offices. In 1999 when I began working with my dad, we had 4 front office staff and 2 nurses. I think we added one more front office staff in my first few years, and that was for 3 of us. Now I have an inadequate number of staff with 8 full time front office staff and four nurses. I have to hire another person to help with the increase in prior authorizations and hire a certified coder and maybe even a “scribe” to help with the notes. Even that may not be adequate to cover the demands. We reviewed my father’s take home pay from 20 years ago, and a few of us make less today than he did 20 years ago and a few slightly more (this is actual dollar amounts, not adjusted to today’s dollars). If I have to add more staff, then we will all make significantly less than what was made 20 years ago. My overhead costs are increasing at such a rate, that the only way to compensate is to reduce the doctor’s salaries even further.
- Death by low reimbursement – What you may not be aware of is that there is significant variation on what insurance and government will pay for the exact same visit. If you go to a large doctors group, they can bargain with insurance companies and get anywhere from 40-60% higher rates, if you see a hospital physician’s group it will be at least 40% higher, and if you go to a Federal Health clinic it will be even higher yet. Being a small clinic, we get the bottom of the barrel in reimbursement. Insurance companies will not talk with us and have a take it or leave it attitude with us. We are not like any other business. We can’t charge what we want and collect it. In any other industry, what they charge you have to pay. In generalities, based upon my current overhead costs, Medicare pays just over the cost of overhead for regular visits, medicaid (state insurance) right now is the same, but unless congress acts, it will go back to previous levels of about $20 less than overhead (This means it costs me $20 out of my pocket just to see these patients). Regular insurance pays about $45 over overhead costs. If I have to add 3-4 more staff or hire a certified coder, there is no margin anymore and we will go under. Every year the costs of supplies rises as well. I can’t pay my staff the salaries or provide the benefits that the hospital does, so I have lost more than a few excellent staff to them. If I could get 40-50% more, as they do, then I could compete.
- Death by incoming coding – This one is more difficult to explain. We have ICD-9 codes, CPT codes, E/M codes,and HCPCS codes. Focusing on the ICD-9 codes, these are codes attached to particular diagnosis – like diabetes 250.00. There are 8,000 outpatient codes to choose from. In October 2015, this will become ICD-10 with about 70,000 out patient codes. Experts estimate the cost of implementing this change will cost small practices anywhere from $56,600 to $226,000 and on top of that an expectation of a $100,000 in payment disruption (slow payments for 3 months). Small practices can ill afford these additional costs of implementation, since we are working on such a tight margin to begin with. Now you have to understand none of these codes help me take care of you. It is all for data analytics, and reimbursement, not for my care of you.
- Death by non medical work – At least 40% of a doctors time is now filled with non medical work and non-reimbursed work (forcibly given for free). I don’t know the percentage, but most doctors spend a few hours a day after the office closes taking care of all the paperwork and charting that has to be done. Time taken away from the family, or other renewing activities.
- Death by caring – There have been so many stories from our patients of the excessive healthcare burden they are having to bear this past year especially. They now have to buy insurance that has a huge deductible that they couldn’t pay if they had to, ridiculous medication costs, lab costs, and studies costs (x-ray, MRI, CT scans, ultrasounds, etc.). Emergency room costs and hospital bills that are outrageous, (even I can’t understand the bills). It feels to me greed has overtaken the Business of medicine. It angers me that the business of medicine does this to hard working people. Private practice physician’s prices as I have mentioned are different, they have been kept low over the years and reflect a low cost system. If we had low overhead, I could easily manage with the payments we receive.
- Rebirth – Changing to the Direct patient care model gets rid of all of this in my office (see www.washingtonpark.md and also the direct care portion of this blog). I can breath again, can be excited again, can have a thriving practice and not controlled. To me it is freedom to be your doctor, spend my time thinking about your concerns, and helping you manage your ongoing medical issues, instead of spending my time in all the above mentioned time consuming work. I can provide low cost medications, low cost labs, reduced cost studies. I can focus on you – which is all I ever wanted to do. I started the Quick Medical Clinic 8 years ago as a cash only walk-in access clinic for people who couldn’t afford to access the healthcare system. We have seen over 5000 people through that clinic, and have received so many thank you’s – to them we have been a life saver. Gratitude like that is inspiring, motivating, and sacred.
NO this isn’t a midlife crisis, and no I can’t stay in the system, I am compelled to move a different direction. I’ll be staying in the current location and keeping as many of you who can or are willing to stay with me.