Wednesday, January 27, 2010

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.

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