Heartfelt with Dr Melissa Walton-ShirleyView all posts »
CMS to cut pay for second cardio test by 25%? Why in the world?Jul 15, 2012 08:38 EDT
I get it. Something's gotta give! Our sustainable growth rate (SGR) situation is, well, not sustainable. Henceforth, from January 2013, I will be called Peter Walton-Shirley, so there will be enough to go around to pay Paul. It's a shame, really. There is so much waste and graft in healthcare that it should not be necessary to rob me, my partner, or the 10 other employee families my colleague and I support in order to pay the "Pauls" of medicine. And don't get me wrong, I adore and revere the "Pauls" of medicine. I do not begrudge them one penny of increase in pay. They've been underpaid for far too long. My question is this: Why does their increase in pennies need to come from the pockets of us specialists—namely, cardiologists, who seem to have a bull's-eye on our reimbursement plans? What is the logic in reducing the technical fee for a different test performed on the same day, in the same office, by the same cardiologist? Does this mean our friends in other specialties will have to order a CBC on one day, a basic panel on the next, and a lipid profile next week? Applying the same logic to make this incredibly unintelligent misstep would certainly garner similar changes in other daily office habits, wouldn't it?
In January 2013, patients will get an even shorter end of the measuring stick they use to track the rising floodwater, such as the cost of pharmaceutical and insurance premiums. Patients, let me translate what this will mean to you: you get to come to our office for your initial visit, then you get to come back for your stress nuclear, then you get to come back again for your echo. If, for some reason, you don't have time to sit down with me on one of those days of testing to discuss your results, you will have to come back in for a fourth time to our office to accomplish what we could have done in two visits.
It would make sense to penalize us if the second procedure gave the same information. If we were "double-dipping" by doing two echos or two types of stress exams on the same day, I'd understand it, but a cardiac ultrasound is a completely different test from a nuclear stress assessment. (Do you get that, CMS? Do you understand that a cardiac ultrasound tells us things about stuff like valve leak, heart size, diastolic dysfunction, right ventricular pressure estimates, but nuclear stress tests tell us that artery blockage might be producing our patient's chest pain—just a quick primer for you.) For that matter, even a resting echo gives a completely different set of data points than a stress echo (but that might be a bit too complex for you to understand, and I don't have the space or time to explain it here). Does anyone at the CMS realize the inherent prejudice and undue burden they will place on rural or elderly cardiac patients who already cannot afford gas money to come see us once, much less three or four times, to get the same information? What about those who depend on working children, neighbors, or friends to transport them? Can you understand the impact of time off work on personal or corporate economies just from this ridiculous move alone?
Yes, I hear the voices echoing throughout the blogosphere: "But doctor, we have to start somewhere. We are all going to have to give a little! Why not start with you?" Let me answer definitively that, with the synapse of two tiny neurons in a nanosecond, I can find the CMS about a billion dollars per minute without having to plunder cardiology as a subspecialty and, admittedly, about a thousand other physicians could do the same, if they were just asked. For instance,
- At a doctor's office, Lupron injections for prostate cancer cost about $800 US. Across the street at the local hospital, I'm told they can garner a request for payment of up to $2400 per shot! CMS: don't pay a difference to anyone for this injection!
- One-way transport by helicopter to a tertiary-care center 90 minutes away costs $31 000. (Yep, I saw the bill and it was $3-1-0-0-0. Three zeros. I counted them.) Stop the madness!
- A very nice elderly patient is made to see his primary-care provider monthly to get his meds refilled for years; stable symptoms, no change in status. Cha-ching!
- A patient spends one night in hospital, has a CT for kidney stones, no surgery, and for a less-than-24-hour stay his bill came to a grand total of . . . drum roll please . . . $27 000 dollars! Come on!
Put your ear to the ground and you can hear the rumble of tons of good, unexpired pills falling into the bottoms of empty trash receptacles around the US. CMS: please fund the salary of a good pharmacist in every state to direct a pharmaceutical-sharing program. Deceased patients, patients who are intolerant, allergic, get better, get worse, just don't like their pills, or doctor shop and get a change in prescription every month chuck them by the thousands every second of the day. Our groundwater probably has enough beta blockers in it to grind every heart in 10 miles to 32 bpm if we drank it unprocessed. Tap this resource! And don't tell me you are worried about the potential contamination or tainting of those medications. I could probably stick every one of my neighbor's pills in my ear every single morning, ask him to swallow them, and they would work just fine. Disposing of those pills is like throwing away a $5 Starbuck's coupon. I'll bet no one at the CMS would ever throw away a Starbuck's coupon!
Ask one of our 50 states' CEOs of Anthem Blue Cross Blue Shield if you could meet on his yacht to discuss how he earned his annual salary of $4 million. Might start there, CMS, with examining the very definition of waste in medicine. Duh, "just saying."
Compare all of the above graft/waste/stupidity with the $350 a cardiologist gets reimbursed for a nuclear stress exam. "You've been overpaid for far too long," one of my noncardiologist colleagues used to tell me. Well, I'm not sure we ever were overpaid when you figure that for 20 years, my kids grew up with a mother who read cardiac ultrasounds until 9 pm every night. Consider the extra years spent in training before I could enter the work force and gladly said about 1000 times, "Yes, I rubber-stamp that plan for discharge or the plan to send that patient with heart disease to the OR" so the malpractice lawyer could draw and quarter me if something went wrong. Cardiologists should be paid well for those types of services. Our reimbursement has been whittled already to the point that we look like an old turned-oak cane with marbles enclosed in the shaft that my patient used to bring with him to his office visits. Enough already!
The folks at the CMS (provided there are any real human beings left at the CMS) should want an expedient workup. Do they think cardiologists are so stupid and wimpy that we will be deterred from ordering a stress exam and echocardiogram on someone who has risk factors and some type of chest discomfort who needs a diagnosis? Are there any real working practical common-sense–laden doctors at the CMS who have the capacity to understand this? Are there any real workaday cardiologists there with the testicular or ovarian fortitude to speak up? Anyone? Hello? Anyone up there?
There are so many ways to pay both Peter and Paul in the healthcare arena that it takes very little imagination or innovation to lay out a plan that can save time and money. The plan to reduce my technical fee because the procedures are performed on the same day for no other reason than to convenience to the patient is criminally irresponsible and detrimental to the goal of an expedient cardiac workup. To reduce my reimbursement by 25% so you can inconvenience the patient and grind our progress down to a halt is ridiculous. Why in the world, with so many other opportunities to reduce graft and waste in medicine, would you want to do it? Then, if you can't figure it out, move over and let someone else give it a try.