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Health care overbilling—symptom of a larger problem?
Posted: 24 September 2012 06:47 AM   [ Ignore ]
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I came across this article this morning:

http://www.nytimes.com/2012/09/22/business/medicare-billing-rises-at-hospitals-with-electronic-records.html?pagewanted=2&_r=0

It seems like medical overbilling (whether because of newly implemented electronic records and billing, or whatever) is symptomatic of a larger problem, that of reducing or eliminating the kind of competition, alternative ideas and treatments, etc., that the medical industry really needs in order to lower costs.

Thoughts?  Whether we like it or not, health care costs in the current system are going to go up no matter what.  Is there a better way, and if so, what is it?

Damon

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Posted: 24 September 2012 10:07 AM   [ Ignore ]   [ # 1 ]
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I can’t speak for all the details of this report but the tag line is just intentionally misleading or written by a writer who doesnt know the lay of the land.

EMR’s were forced on physicians over the past few years and will be going into the future. They are massively expensive and poorly designed in many respects. The implementation was badly run and some serious mistakes were made ( ie. EMR’s do not cross communicate for the most part and data entered into one system can not be ported to a new system if a doctor decides he doesn’t like the system he has and wants to change systems - incredibly dumb). Contrary to what is implied in the article the government subsidized but did not even come close to reimbursing physicians for the huge cost of purchasing and implementing EMR’s.

With that out of the way let me get to the root of the problem. Prior to EMR’s doctors spent most of their time seeing the patient and had to write the pertinent parts of the visit as quickly as possible so they could get on to the next patient. The more complicated the patient the less time you had left over to document things even though you really needed to write a longer note. As a result physicians routinely under billed for long visits because they didn’t have the time to create the documentation that would back up the need for a higher code.

Along comes the EMR and now some of the documentation can be automated. Previously I would do a complete exam but only document the pertinent negatives and positives. Now I can click one button that documents the entire exam in detail and just change the pertinent pos and negs. That allows us to now code more visits correctly. A visit that took 30 minutes and would previously be coded as a 99213 ( for which i might bet paid $45) can now be accurately and appropriately coded as a 99214 ( for which i may get paid $57). There is nothing evil or greedy about this in fact just the opposite. Physicians were cheating themselves out of legitimate charges before and now they are coding more accurately but the government doesn’t like this because they were getting away with paying for a lower level of service than the doctor was providing all these years.

I’m not saying there is no cheating going on by some doctors but the one benefit we saw to making this big investment was that we would finally be getting paid fairly and now the government is crying foul and trying to make us look like criminals. This was their idea not ours. Amazing how they can spin just about anything and the media just goes right along with it.

[ Edited: 24 September 2012 10:10 AM by macgyver ]
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Posted: 24 September 2012 10:29 AM   [ Ignore ]   [ # 2 ]
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Okay, this may indeed be true.  I’m certainly very far away from firsthand knowledge of medical billing, although a friend of mine’s wife is actually involved with that.

I was asking the question because I’m concerned in general with rising health care costs, and whether or not costs are rising due to correcting underbilling or what-have-you, costs are still rising.  Is there a better way to deal with health care in general, and if so, what is it?

Damon

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Posted: 24 September 2012 11:16 AM   [ Ignore ]   [ # 3 ]
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Well damon you and I have had discussions on this before. We don;t see eye to eye on the solutions. With all its faults I don’t see any way to correct the basic problems without some sort of centralized approach. I think any solution to the cost issue has to address these points.

1) Everyone needs to have access to preventive care - everyone has access now but only at the point of acute care for disease that has been untreated for years and reached critical stages. When people are critically ill the end up in the ER and we all pay the bill.

2) Coverage decisions have to be based on evidence - Unless we commit to evidence based medicine we will continue paying billions for tests and treatments that just don’t work (* see below)

3) Rationing ( or preferable called the wise use of limited funds) - We currently spend huge amounts of money treating diseases where the chance of long term benefit is very low and dont spend nearly enough on preventive services where the benefits are much greater and the cost comparatively smaller.

* The USPSTF is an agency set up to develop evidence based guidelines for screening procedures. They have made some recommendations lately based on very good evidence that have been very unpopular with the public.. recommending against PSA’s and against Mammograms in women under 50. Unfortunately our politicians don’t like good science if it upsets their constituents and are now trying to dismantle the USPSTF or staff it with people who are biased ( radiologists who disagree with the mammo recommendation and urologists who disagree with the PSA recommendation ). If this is any example of what we are up against the prospects of making any progress with the governement we have do not look good.

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Posted: 24 September 2012 12:18 PM   [ Ignore ]   [ # 4 ]
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Well, imho it’s important to be able to step back from the whole health care issue and try to look at it more objectively.  I would think that would be more difficult to do for those who are part of the existing system and therefore might have trouble seeing the forest for the trees.

To address your points, and add some of my own:

1) Everyone needs to have access to preventive care.  Yes, but what *kind* of preventive care?  And who decides what’s worthwhile?  One of the problems inherent in the current system is that the care available is generally what will maximize profits for the system as a whole.  So acute care is covered, whereas preventive care and lifestyle changes or improvements might not be.  To give a good example, is it more profitable to provide incentives for smokers to quit smoking, discount coverage for nicotine addiction products, etc., or to provide acute care for someone who develops lung cancer as a result of smoking?  How many insurance plans do you know of that actually *do* provide such pro-active incentives or coverage?

2) How should we handle so-called alternative therapies?  Unfortunately, it’s a truism that to a man with a hammer, everything looks like a nail.  To a conventional medical practitioner, the answer is often drugs or surgery.  What if more cost-effective (and more effective in general) treatment options might include acupunture, adjusting diet (like gluten-free foods for those suffering from Crohn’s Disease, for instance), and lower cost health plans which would require participation in exercise programs, weight-loss programs, etc., for those suffering from health issues related to lack of exercise or obesity?

3) We currently have dieticians, psychologists, in-home care specialists, etc.  What about whole-life counseling?  That is, a counselor who could interview a person and ask questions about their lifestyle, sanitary habits, sleep routine, workload, etc., and then make recommendations intended to improve general health?

Damon

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Posted: 24 September 2012 01:25 PM   [ Ignore ]   [ # 5 ]
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damoncasale - 24 September 2012 12:18 PM

2) How should we handle so-called alternative therapies?  Unfortunately, it’s a truism that to a man with a hammer, everything looks like a nail.  To a conventional medical practitioner, the answer is often drugs or surgery.  What if more cost-effective (and more effective in general) treatment options might include acupunture, adjusting diet (like gluten-free foods for those suffering from Crohn’s Disease, for instance), and lower cost health plans which would require participation in exercise programs, weight-loss programs, etc., for those suffering from health issues related to lack of exercise or obesity?

I agree with the convention that either something is medicine (it works), or it is not (it does not work better than a placebo). There is no such medicine in reality as ‘alternative.’ Also, to group acupuncture (as far as I understand, placebo effect only) with diet counselling (actually has effects if done properly) in the same category as ‘alternative medicine’ is an injustice.

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Posted: 24 September 2012 01:43 PM   [ Ignore ]   [ # 6 ]
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Imho, there are differences of opinion on whether acupunture “works”.  Perhaps part of the problem is that there isn’t a common consensus on what works and what doesn’t.

I have a friend who is a martial arts practitioner who utilizes the theory behind acupuncture in his techniques.  Basically, if you activate certain nerve groupings in the correct order, you can incapacitate a person with the right techniques.  From his experience in seeing it done to great effect, both on himself and on others, he’s gone from there to studying acupuncture and acupressure as an alternative method to dealing with things like migraines, chronic back pain, etc.  (His wife suffers from migraines every once in a while, hence his interest.)

Imho, it’s easy to criticize things like this, where rigorous scientific testing hasn’t been done and where it’s mostly out of one’s personal realm of experience, but which others claim to have positive health benefits.  Are there medical quacks out there who will promise miracle cures using alternative therapies?  Yes there are, and the same thing is true in many different areas of life (financial, relationship, etc.).  I acknowledge that going the alternative route does have its pitfalls.  But part of the problem I have with requiring a certain minimum level of health coverage is that it ignores the potentially beneficial effects of alternative therapies.  If one is required to be covered for conventional medicine that one by and large doesn’t need because of access to alternative therapies, then one is wasting funds that could be put to better use elsewhere, and the same can be said when it comes to possibly lowering health care costs for people at an aggregate level.

Damon

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Posted: 24 September 2012 01:45 PM   [ Ignore ]   [ # 7 ]
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You make some good points. I agree with some of them and some are already incorporated more or less in our system although its fragmented condition results in only partial implementation of some of these ideas.

1) As far as what kind of preventative care should be provided i refer you back to item 2 in my post above. It should be evidence based. All testing protocols, screening protocols and treatments should be evidence based where ever possible Where evidence doesnt exist studies should be ordered to clarify what works and what doesnt.

Some insurance companies do pay for preventive services ( smoking cessation consultations for example) but unfortunately they are the minority. This is one of the problems with a mulitpayor system. Investment in preventative care is a long term investment. People change insurance companies every few years. If Aetna pays me to spend time counseling a patient on a healthy life style Oxford may be the one that ultimately benefits from that investment when their insurance changes next year or 5 years from now. With a single payor system the system makes the investment and is there to reap the rewards.

Some insurance companies do actually penalize people with certain high risk behaviors. Our local hospital is one of the biggest employers in the entire region and they are self insured. All employees who submit to risk assessment get a discount on their insurance. That is the exception rather than the rule but again its an example of an entity willing to make the investment because they will reap the reward. Employees only have one option for insurance so the employer doesn’t have to worry that the rewards of their investment will end up in someone else’s pocket.

2) Alternative therapies?  - We need to put an end to this term. It is a false dichotomy. The assumption is that there are two types of medicine. One type that is traditional and one that is an :alternative”. In reality we need to look at this a different way. There are proven treatments that have been studied using randomized double blind placebo controlled studies and there are those that have not. Most of the treatments that are called alternative are unproven and most proven treatments are traditional but there is not a complete correlation. Some traditional treatments do not have good studies to back them up and some treatments that were alternative have good studies behind them ( at which point they are no longer alternative.

Using this definition covered treatments should only be those that have been proven to be effective with randomized double blinded controlled trials whenever possible.

3) It might be a very good idea to have dietitians or health coaches talk to people about Whole -life counseling but that intervention would have to subjected to the same sort of study as any other to see if it is effective and also to see if the cost justifies the benefits. For all its good intentions we may find that only a very small percentage of people listen to the recommendations and if that is the case the money might be better spent on other preventive services that are found to be more effective or not.

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Posted: 24 September 2012 02:08 PM   [ Ignore ]   [ # 8 ]
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damoncasale - 24 September 2012 01:43 PM

Imho, it’s easy to criticize things like this, where rigorous scientific testing hasn’t been done and where it’s mostly out of one’s personal realm of experience, but which others claim to have positive health benefits.

I went to Wikipedia (not as source material) to check out some of the citations at the bottom of the page. Here is one: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769056/

That is the British Medical Journal. From the conclusion:

A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear.

Scientific testing HAS been done for acupucture, and more than once.

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Posted: 24 September 2012 03:19 PM   [ Ignore ]   [ # 9 ]
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TromboneAndrew - 24 September 2012 02:08 PM
damoncasale - 24 September 2012 01:43 PM

Imho, it’s easy to criticize things like this, where rigorous scientific testing hasn’t been done and where it’s mostly out of one’s personal realm of experience, but which others claim to have positive health benefits.

I went to Wikipedia (not as source material) to check out some of the citations at the bottom of the page. Here is one: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769056/

That is the British Medical Journal. From the conclusion:

A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear.

Scientific testing HAS been done for acupucture, and more than once.

Even if it has, my martial arts friend has unscientifically observed exactly the opposite, and the martial arts techniques he learned are repeatable (a primary concern for scientific validity).  Precise activation of the appropriate nerve groupings is required, though.  Miss the nerve grouping and you get no effect.

He’s also visited a local practitioner of acupuncture and related to me his experiences there.  For him, his acupuncture treatment definitely had a very noticeable effect, and even if one attempts to label that a “placebo effect” then that raises the question of just how much mind can rule over matter.

If you want more details on what he’s done and what treatment he had, PM me privately.

Damon

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Posted: 24 September 2012 03:38 PM   [ Ignore ]   [ # 10 ]
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damoncasale - 24 September 2012 03:19 PM

Even if it has, my martial arts friend has unscientifically observed exactly the opposite, and the martial arts techniques he learned are repeatable (a primary concern for scientific validity).  Precise activation of the appropriate nerve groupings is required, though.  Miss the nerve grouping and you get no effect.

He’s also visited a local practitioner of acupuncture and related to me his experiences there.  For him, his acupuncture treatment definitely had a very noticeable effect, and even if one attempts to label that a “placebo effect” then that raises the question of just how much mind can rule over matter.

If you want more details on what he’s done and what treatment he had, PM me privately.

Damon

And that’s why the scientific method is required. Sometimes, even experts can observe seemingly inconsistent things happening. I have no doubt that your martial artist friend observes exactly what you say that he does. But that is not proof of acupuncture’s viability, nor is it disproof. For starters, here are some potential problems that your martial artists will have to overcome:

Martial arts techniques are not the same as acupuncture techniques. Acupuncutre involves sticking small needles in the skin. Martial arts involves applying pressure to or even striking those nerve clusters. One involves disturbing the skin -only- and the other actually transmits force to the inner nerves which can disrupt them directly. There’s no reason to expect similar results between the two disciplines.

Expectations can cause a tester to affect the outcome of a trial even if they don’t realize that they’re changing their behavior. I see this all the time in the chiropractic test of having someone hold out an arm and test their resistance to a downward force, delivered by the chiropractor. Anything from changes in force applied to changes in the direction of force can change the outcome, and it’s way too easy to alter that unconsciously.

Expectations can also affect the reaction of the ‘patient’. If someone expects pressure somewhere to hurt, they may feel pain, or at least react like they do, even if when they were ignorant no such reaction takes place. Expectations affect perception way too much to depend on subjects’ self-reperted experiences outside of a double-blind test. For a great example of this, check out Penn and Teller’s Bullshit! episode on bottled water, and how they are able to convince people that water, all delivered out of a garden hose, can seem to have many different tastes depending on what they were told about the water and how it was labelled on the bottle.

[ Edited: 24 September 2012 03:42 PM by TromboneAndrew ]
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Posted: 24 September 2012 05:02 PM   [ Ignore ]   [ # 11 ]
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TromboneAndrew - 24 September 2012 03:38 PM

Martial arts techniques are not the same as acupuncture techniques. Acupuncutre involves sticking small needles in the skin. Martial arts involves applying pressure to or even striking those nerve clusters. One involves disturbing the skin -only- and the other actually transmits force to the inner nerves which can disrupt them directly. There’s no reason to expect similar results between the two disciplines.

Which is why I’d mentioned both acupuncture and acupressure earlier.  smile

TromboneAndrew - 24 September 2012 03:38 PM

Expectations can cause a tester to affect the outcome of a trial even if they don’t realize that they’re changing their behavior. I see this all the time in the chiropractic test of having someone hold out an arm and test their resistance to a downward force, delivered by the chiropractor. Anything from changes in force applied to changes in the direction of force can change the outcome, and it’s way too easy to alter that unconsciously.

Yes it is, which is why I emphasized the repeatability of my friend’s experiences with martial arts techniques.  Although that doesn’t *directly* transfer over to acupuncture and acupressure, the theory behind all of those things is exactly the same.

Damon

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Posted: 24 September 2012 05:52 PM   [ Ignore ]   [ # 12 ]
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damon if we use your criteria then virtually every conceivable treatment would have to be covered. For every treatment, even those that are intentionally designed to be shams, there will be a group of people who claim to have improved. There will even be some among them who swear that every time they stop the treatment they get worse and every time they start it again they get better. Even if the pill has nothing in it but belly button lint. The placebo affect is quite powerful with some people. It has some characteristics in common with religious faith. But even if some people get better with placebo treatment the bottom line is that its a fraud. The only way for these treatments to continue to be effective is if we perpetuate the belief in this voodoo, but do we really want to do that? The level of scientific illiteracy is unacceptably high as it is without us promoting it further.

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Posted: 24 September 2012 06:14 PM   [ Ignore ]   [ # 13 ]
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macgyver - 24 September 2012 05:52 PM

damon if we use your criteria then virtually every conceivable treatment would have to be covered. For every treatment, even those that are intentionally designed to be shams, there will be a group of people who claim to have improved. There will even be some among them who swear that every time they stop the treatment they get worse and every time they start it again they get better. Even if the pill has nothing in it but belly button lint. The placebo affect is quite powerful with some people. It has some characteristics in common with religious faith. But even if some people get better with placebo treatment the bottom line is that its a fraud. The only way for these treatments to continue to be effective is if we perpetuate the belief in this voodoo, but do we really want to do that? The level of scientific illiteracy is unacceptably high as it is without us promoting it further.

Even though that’s true, I also look at the biases inherent in conventional medicine.  For instance, why do we use a cancer treatment—chemotherapy—which destroys the immune system of those it’s used on?  Chemo simply kills a person with cancer, more slowly and in a different way.  Surely the argument could be made that if there weren’t any bias, doctors would readily admit that in regards to the survival rate of people treated with Chemo compared with an “alternative” therapy, there would either be little if any difference, or the alternative therapy would win out?

What I’m trying to get to is, how do we as individuals move beyond the inherent biases and dysfunctions within the current system in order to more responsibly manage our own health care costs (and hopefully be in better health at the same time)?

Damon

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Posted: 24 September 2012 06:43 PM   [ Ignore ]   [ # 14 ]
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damoncasale - 24 September 2012 06:14 PM

Even though that’s true, I also look at the biases inherent in conventional medicine.  For instance, why do we use a cancer treatment—chemotherapy—which destroys the immune system of those it’s used on?  Chemo simply kills a person with cancer, more slowly and in a different way.  Surely the argument could be made that if there weren’t any bias, doctors would readily admit that in regards to the survival rate of people treated with Chemo compared with an “alternative” therapy, there would either be little if any difference, or the alternative therapy would win out?

What I’m trying to get to is, how do we as individuals move beyond the inherent biases and dysfunctions within the current system in order to more responsibly manage our own health care costs (and hopefully be in better health at the same time)?

Damon

Damon i realize your at a disadvantage here so I will be gentle but this statement is so far from the truth as to be down right offensive. It is a comment frequently repeated by those who are ignorant of the facts. It sounds good on the surface but when you learn the details you begin to understand how silly it is.

Chemotherapy is not one treatment but many different types of treatments that work through a variety of mechanisms. The idea behind all of these treatments is to destroy cancer cells and leave healthy cells alone. To do this you need to take advantage of the differences between cancer cells and our own cells. Because cancer cells ARE our own cells the differences are small but creative scientists and persistent doctors have found ways to exploit these small differences.

Initially the methods were crude. They relied on drugs that would kill cells when they were dividing. Since cancer cells divide faster than healthy cells they were more vulnerable to these drugs. It is more of a sledge hammer than a scalpel approach because some cells such as those in the gut also replicate rapidly but it is the best we had at the time and it allowed us to take a cancer like ALL ( a type of childhood leukemia) which killed almost 100% of it young victims in the 50’s and change it into a disease where 90% of its victims are cured today.

Today some chemotherapies use more sophisticated approaches that augment the immune system through the use of immune modulators or custom antibodies. Some newer ones use nanoparticles. The field is constantly evolving to develop newer and better treatments.

Cancer is not one disease but literally hundreds of different disease so many different kinds of therapies have been devised to try and treat these genetically varied diseases. Some of these therapies are more toxic to healthy tissues than others, but the idea is not to poison the patient. the goal is always to find the treatment that is most affective at killing the tumor while leaving healthy tissue alone. Its not an easy task. Its unbelievably complicated, but its far more likely to be successful when you understand the biology and apply it in a rational approach than if you just peel bark off a tree and feed it to someone hoping for some miracle cure.

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Posted: 24 September 2012 08:21 PM   [ Ignore ]   [ # 15 ]
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.......which is why ‘The war on cancer’ is so misleading. I is a very large umbrella of diseases with many causes, known and unknown, which progress in different ways, and have many different cures, some more successful than others. We are getting better and better at treating them. Cancers like ALL, typically a childhood leukemia, now has a 95% cure rate.  I used to work in a unit that treated cancers. When the cancer was diagnosed, it would be tested to discover the most effective treatment. Then the oncologists would formulate a specific ‘roadmap’ based on the test results.

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