More on Private Practice

Yesterday, I worked from 8:30 AM to 8:30 PM and basically crammed everything I could into the hours. I ate lunch in 10 minutes at my desk. And I still didn't get caught up. It's true that I'm learning a new electronic medical record that is quite complex and takes a lot of time to customize to my particular documentation. But I'm also having to learn an even more complex and arcane set of rules for documenting my activities for the purposes of billing. The currency of the medical realm is called a Weighted Relative Value Unit or RVU. Each procedure or visit is worth a certain number of RVUs. RVUs supposedly take into account the length of training and expertise, risk and so forth and were originally developed as a way to rationalize a payment system that had simply developed naturally over time. One of the key criticisms of the RVU system is that it rewards procedural specialties like surgical subspecialties, radiology or interventional cardiology. So-called cognitive specialties such as general internal medicine, pediatrics or psychiatry are reimbursed at a much lower rate. As a colleague of my once said, "The closer you are to the patient the less you get paid," and unfortunately it's true. This is why medical students are choosing procedural specialties over primary care and psychiatry.

At any rate, although I don't even know yet how much cash an RVU is worth, I have a two-page printout with the RVU value for each of about 40 different procedures that I might use. That is, I know the relative value of one thing over another. This is already driving my behavior, since I want to maximize my income. So now I carry around my RVU chart and am trying to memorize it. Note that a specific activity might be billed in one of several ways, so I'm going to choose the procedure code that nets the highest price. Each procedure has a complex formula involving a point system for various aspects of taking a history, examining the patient, interpreting labs and xrays, and the complexity of medical decision-making. So I'm learning to include certain things in my notes that have little import because the bureaucracy requires it. The hospital has many different coders who pore over notes and make sure that the documentation has the requisite elements to justify the procedure code. Each insurance company including government agencies have huge staffs who do nothing but make sure that documentation supports the procedure. Keep in mind that there is no reason to believe that any of this adds to patient care or improves outcome. In fact, it is not only a distraction and decreases actual patient care time, but it adds enormously to the cost of health care, all the while creating no added value.

When I was working directly for the patient, that is, through self-pay, I charged an hourly rate no matter what kind of activity I was engaged in, and as long as the patient was satisfied with the service. When patients called me, they called my cell phone, not a nurse or receptionist. I could treat more patients because I could do telephone care and secure messaging and texting and get paid for it. Now, I have to schedule a visit because nothing else gets paid for. This decreases my true productivity and inconveniences the patient unnecessarily, and also costs more because the patients often have to take off work to see me.

This system is one that rivals Alice in Wonderland. What it will take to change it is unclear to me. But I have to say I prefer both the salaried approach used by the VA and the self-pay system to this wierd, complex, arcane and burdensome system. No wonder the US spends 30 cents of every health care dollar on administration and meanwhile gets care that often falls short of even minimal expectations.

Private Practice is no Picnic

Since my return to Minnesota, I've been working  in a private practice health care organization in a highly managed care environment. I've worked previously in the Veteran's Health Organization (VA) and in a self-pay environment in Washington, DC, but not in this type of organization. It's been fun, invigorating, and challenging. And, it's giving me insight into some of the challenges facing American health care today.

One of the biggest concerns is that reinforcers of behavior are misdirected, guaranteed to induce behavior on the part of clinicians that result in net harm to patients. Here's an example: I tend to spend more time with patients and families, and I am penalized for that. There are other psychiatrists in the community that see patients for 5 mins or less for a medication check. I'm sorry, but I don't understand what can be really assessed in 5 mins. However, if I continue this way, she makes more money than I do. What message does this send? Do we expect doctors to be saints? I can tell you that idealism and professionalism go only so far. A new furnace, private school for the kids, and an occasional vacation for my wife and I are powerful competitors with idealism. 

What do we really want to reward in health care? How much would it take to meet everyone's needs, and if we can't do that how do we decide who gets what?

How do I resolve between my ideals (I've served poor people most of my career) and my personal needs (I have various debts to pay off, the house needs maintenance and we need a new car)?

At the same time, I feel that I am providing a service that people have not experienced before: true professional addiction medicine/psychiatry. Someone who can manage the complex patients, rather than just evaluating them for rehab. I've been surprised by the range and complexity of the patients I've encountered so far. My experience only increases my motivation to change the way we do business. We need to be providing truly professional science-based recommendations and treatment. And by and large, consumers do not have access to that. Rehab services are extremely imporant for those who cannot stabilize at home. In Minnesota, there are more programs than usual who are focused on providing evidence-based treatments such as Suboxone therapy for opioid dependence and pharmacotherapy for alcohol dependence. But what's difficult to access is professional treatment by physicians, the way diabetes, asthma, cancer, hypertension, and depression are treated. My goal is to create a system that will do just that.

Back in Minnesota: Opportunities and Barriers to Change

Blog entry 1-20-10

Well, it’s been over a month since I entered something in my blog. (I’m sure the millions of faithful readers have been wondering what happened.) Well, two things. The holidays. And re-entry. I’ve been negotiating re-entry into my family, my home in Minnesota, into the professional community of St. Paul-Minneapolis, and into a local health care organization (HCO) called Allina. Paul Goering, a psychiatrist and director of mental health services for Allina (a collection of hospitals and clinics in the metro area) was kind enough to not only give me a job on my return to the Twin Cities, but he also has recognized an opportunity to change the way we treat addiction. He has said repeatedly that “the way we treat addiction is not satisfactory” but that up to now there haven’t been any alternatives. Paul, besides being a really nice human being, is a skillful administrator who has made my return here much easier than it otherwise might have been. In addition, someone else I met this fall, Bobbi Cordano, is a human dynamo who serendipitously became the interim director for something called the Center for Clinical Innovation at Allina. The Center is still finding its way, but it’s devoted to supporting innovation in the delivery of services, particularly as they affect the broader community. She and I have also been talking about ALATYR, my initiative to change the way we treat addiction in America, and how we might work together to make it happen.

I have encountered other opportunities as well. The state of Minnesota Department of Human Services is interested in looking at ways to improve addiction treatment and I am in discussions with them about how to make it happen. Upon returning to Minnesota, I have been very impressed with how progressive the medical community is here, and how much the various health care organizations seem to be focused on improving care more than on making money (although they of course have to do that.) The fact that HCO’s in Minnesota have to be non-profit by state law may have something to do with this, but Minnesota also has a tradition of progressive politics and a communitarian focus. All in all, it appears there are many potential opportunities here to try out my ideas about a public health approach to substance use.

It’s also been interesting to practice in a private HCO in a highly managed care environment. Minnesota, Massachusetts, California and Seattle have led the nation in early penetration of managed care and at least in Minnesota virtually all health care is managed. (In contrast, in Washington, DC, it seems that very little of it is.) I had a small self-pay private practice in Washington before moving back here, but this is very different. And it’s giving me insight into some of the problems with our current system.

For one thing, the incentives are all wrong. I can only get paid for face-to-face time with patients, even though it would be more efficient and effective to work with a team of professionals such as nurses and therapists who provided various parts of care. Reimbursement for psychiatrists is greater for medication management alone rather than combined treatment with psychotherapy and medication management, which in my experience is more effective and is strongly preferred by many patients. A great deal of time (and money) is spent by multiple people to meet bureaucratic requirements of insurance companies and Medicare, while providing no benefit to patients whatsoever. There is no incentive to provide better outcomes, and in fact no measurement of outcomes. There is no incentive to provide better care or care based upon current evidence. Patients and families are left to their own devices to figure out where to get care, and who might be better at particular types of care, other than the annual “Best Doctors” issues of local magazines. In short, the current system with all its many interlocking components makes it extremely difficult to do the right thing. In my experience, it’s the system that determines the quality of care, not the individual provider. If we can’t line up the incentives more rationally, we are doomed. I must add, parenthetically, that the individual professionals at all levels seem to be devoted, careful clinicians and support staff who truly believe in what they do and want to provide the best care they can. The problem isn’t the people in the system- the problem is the system.

In the next few postings, I’ll share further experiences and insights as I care for patients and interact with the HCOs and government.