You beat me to it.

The plan to reduce my technical fee because the procedures are performed on the same day FOR NO OTHER REASON THAN CONVENIENCE TO THE PATIENT is criminally irresponsible and detrimental to the goal of an expedient cardiac work-up. 

 I couldn't agree more.

sb 

Thanks for reading Seth. I so much LOVE listening to your blogs and your guest appearances on our other blog (Harrington's was great!)

  Strangely, I feel I should pay someone for the hour I spent typing this piece. It was GREAT therapy!!!

Wish someone from the secret service would download it and place it on President Obama's night stand,...or better yet, slip it into Michelle's Recipe book! I bet she'd make him take notice!!! :)

Melissa

Dear Dr Walton-Shirley,

To begin with I must applaud you on your fine art of writing and expressing your thoughts in a manner which is refreshing. You have just echoed the thoughts of thousands from our clan. I sincerely hope that the "Doctors" at CMS do read your lines. I am sure they will not be able to read in between the lines because that would require a little more than an IQ of 50.

The figures you mentioned are ridiculous and we see these all the time. They will pay thousands of dollars for the same test done in the hospital but less than half for the test in the office. Private insurance companies are even worse.

We as Doctors should be billing like lawyers, for our time. My lawyer bills me to read emails and respond to them. That?s 5 minutes, which of course on his clock is 15. Yes, I got billed for that. As we grow higher in the ?sub?-specialty chain, we can no longer fathom how important our time is. All we really care is about our patient?s time, not ours. What about the time spent on the paperwork for disability claims, medical record sorting, requests for records from the lawyers, the 50 phone calls to return, review the labs, call back patients. That is time spent without return. Yes, we do it for our patients, but it is our time. After 12th grade, we spend on an average of 13-15 years to complete medical school, residency and fellowships. That?s time and now CMS does this. But we all know we will keep doing this because we love what we do and when one life is saved, we say its totally worth it.

The only way to end this never ending cycle is the get the neurosurgeons to do brain transplants on all these ?Doctors? making these decisions and policies which hopefully will impart the 6th sense in them, common sense. (But hold on??..Who is going to pay the neurosurgeon???Well, it might just be a part from our reimbursement ???and you know what, if it works, it may be worth it.)

BG

BG,

Thanks so much for your thoughtful commentary. I am constantly disappointed at the lack of communication with physicians in the trenches before policy changes are implemented.  Communication CommuniCATION COMMUNICATION is key to so much that could be better for our patients!!!

Melissa

Brilliant!

Well written, I agree completely.  I have for years now routinely accomplished the echo, stress test, and f/u o/v to discuss the results with patients all on the same day.  It is user-friendly for the patient and makes the most of their time, and communicates to them that we get that they have things to do.  But with CMS cutting the second procedure by 25%, we can't afford to do that (we are a small business, afterall).  A 25% cut in 1/2 of our procedure volume will mean the laying off of staff and reductions in salaries and benefits.  So we will instruct our staff to not schedule anymore than one procedure or OV per day.  And when patients complain, you can bet that I will not hesitate to tell them the truth:  that CMS decided the second procedure isn't worth as much if it's done on the same day; that CMS decided that patient's have nothing else to do other than come and go to the doctor's office; that CMS decided that good patient care is not in their best interest.   And I'll encourage my patients to call their congressional representative to complain about it.   In the history of stupid decisions, this one takes the cake. 

So very well stated I shared this with many.  

As an NP, I remember years ago having a new clinic/hospital designed by the CEO who had never stepped foot in a 'working' facility to see what the work flow really was...or to get input from the docs, techs, nurses, CNAs, radiologists, .....thus.... it was designed by an architect...Beautiful to look at.....poorly designed for actual patient care.

Now that I'm a Medicare recipient, I am amazed at what CMS is demanding.  

And spreading out the cardiac testing is just simply the most rediculous thing I've heard of for ages:  that means not only does it take more patient TIME (some really do work, too) but it requires the doc to open the chart (paper or electronic) and review the patient each and every time one of those tests comes in to see how it relates to all the other procedures being done and how it fits with the history and exam.

 Dumb and Dummer.  What else to say?

 

Lynn

PS love  Dr. Seth too!

Lynn, Russ, Gray,

thanks for reading, but I challenge you to pick up the phone today and voice your concerns to your political connections!  One of Kentucky's leading news outlets, The Courier Journal's front page revealed plans for a health exchange to enable shopping for the best insurance/medicaid coverage as a bit of a stall tactic before we sign onto the ACA. Our Governor is utilizing some of the 66 million they've been allotted to build that infrastructure. Wouldn't it be great if real physicians could actually utilize that 66 million to improve wellness and promote prevention instead of pouring it out like sand out of a bucket. I think our governor has our best interest at heart, but I know government and those who are making decisions like cutting the technical fee for a second test are likely the same type of  ill-equipped individuals who will be dispersing those funds.  If only a REAL physician could assist with the decision making when it comes to allocating funds, implementing changes in health care....what a glorious day that would be !!

thanks for posting!

Melissa

Well, this is not fair!!!!  I posted a rather long response here, and it didn't save here!  Shoot!  I'm not going to repeat it, my fingers are too sore!  I posted it on the 17th.

I'll just say that I think the whole thing needs to be scrapped.  Before the last election cycle, we had a huge thread on this forum where we all hammered out what to do for insurance reform.  We cussed and discussed this and disagreed (sometimes loudly) but in the end had things pretty well wrapped up.  I got permission from all the participants, copied it, and mailed it to both John McCain and Barak Obama.  Never got ONE word back--not even thank you for sending this.

If I could find that thread in the archives, I'd love to send it to the heads of both houses and say look here------if you would incorporate even SOME of these ideas, you'd save tons of money and not diminish access or services to anyone.  You know those gardens Mrs. Obama thinks she thought up????  Well, it was suggested in that blog!!!!  Along with education sources, resources, how to get rid of some waste, fraud and abuse, all kinds of things!!!!!

This law is very scary, and when it takes 1200+ pages that no one was allowed to even begin to read before it was passed, that makes it even more scary!

Thanks for listening to "the other side".  We need payment reform, not care reform.

Becky

 

You have to love a cardiologist that is not afraid to speak her mind!  Thank you!  They need to look at places like the Cleveland Clinic that now charges a 'facility fee' for testing and office visits.  I've had ETKTM (every test known to man) on the same day, but wait, they're a hospital!  My bill for an MRI included a office visit.  Silly me, I thought it was for the neurosurgeon visit immediately after the MRI.  He billed for an office visit too.  Their explanation, "It's a facility fee."  The billing department said, "If you walk in the door for anything, you pay a facility fee."  Hmm, this is a practice that is sure to spread.  I started my career as a cardiac sonographer and ended it as a clinical science specialist.  With less reimbursement, the trickle down results in a heavier workload.  Read the ASE blog.  Sonographers are complaining of short staff being required to perform 15 to 20 echos per day.  This is such a disservice to the patient, the physician and a blot on the healthcare community!  Please keep speaking out on our behalf.

 

you are totally correct and there are more seriouss examples of abuse by the system, such as not paying a consult or H&P done on the day of an interventional procedure (angioplasty/stent, etc). I would have to say that in part it is our fault since our organizations AMA, ACC, etc have not express a strong opposition to these decisions (hopefully they were not accomplices). 

Thank you so much for your blog.  Very well said.  In the end, the patients will suffer.  As a cardiology nurse for the past 16 years, and the last 14 in clinical research, I know all too well that patient safety will be jeopardized by these ridiculous requirements.

I share your frustration and most of your commentary. There also exists plenty of money to be saved by removing medical malpractice from our tort system and replacing it with a claims adjudication board of educated professionals with the goal of appropriate compensation for legitimate claims for health care costs and lost wages but an end to absurd awards for pain and suffering and use of some of the savings for retraining and education. In a generation or two we will then reap the benefits of a change in physician practice behavior through a reduction in the use of unnecessary tests and procedures. Let's not forget big Pharma. It's time to re direct some company profits. With responsible regulation we could tax profits and share some of the wealth generated around to globe to fund "no special interests" pure science clinical drug research and support a program to fund needed drug prescription costs for low income and no income families. Finally, let's debate regulation on management salaries for insurance company executives and the whole concept of for profit health insurance companies. If we want to have doctors and other educated health care professionals to be engaged and motivated and if we want to attract the best minds into clinical medicine then we will need to pay them fairly. 

Unfortunately, there does not appear to be anyone in politics listening or perhaps anyone with enough chutzpah in power to use common sense and do the right thing here. I fear we will all lose here as out system falls apart.

 

Well said all.  Circle the wagons and stand firm!

 

I am so sad about this situation.

And still no tort reform.....sigh......sigh.

The excesses of the system does not excuse the excesses of your discipline.  The typical pediatrician, family physician and general internist is NECESSARY for health maintenance.  Cardiologist aren't.  If the discipline disappeared tomorrow, it would only be a problem for the Bill Clinton's and Dick Cheney's of the world. 

 The reality is that most specialists should expect to get paid less to do more.  We are asking it of our teachers, police and firefighters.  There's nothing special about being a specialist physician that should exclude us from the secular realities.  You can try to respond by scheduling more frequent visits to increase revenue but the response from CMS will be to lower reimbursement even further. 

 If physicians were smart (many are not), we would mobilize against the waste and abuse that we ALL know is endemic in healthcare.  But I doubt it will happen.  Too many radiologists focused on counting their doubloons in the dark, too many dermatologists with 3-day workweeks and too many orthos with "cases" to squeeze in before jetting off to the Open.  We are our own worst enemies.  We participated in the creation of the chimera called the US health care system.  But when you ask physicians how to fix it, the typical response is . . . pay us more money and don't give us rules to follow.  That's how we got into trouble in the first place!

Melissa, quit your complaining. I have some words of wisdom for you from the President: Just because you were reading echos till 9 pm, "you didn't get there on your own ... you didn't build that" so you need to be nice and share. hahahaha!

Seriously though, I totally agree with your post. It's only gonna get worse as Medicare funds dwindle.

babydocmd,

Seriously? I have a newsflash for you: you and I (I'm an internist) are not NECESSARY for health maintenance. We will be replaced by nurses, computers and robots in the future. That is a fact. I know because I've been to the future. It doesn't take a genius to give vaccines, refer for a colonoscopy and increase amlodipine. Could we do a better job? Absolutely, but with finite funds (read: government takeover), compromises will need to be made. As PCP MDs fade away, the death rate will increase and less uncommon diagnoses will be made, but that's okay as long as everyone has insurance, right? And why so angry at the cardiologists? Actually, they are NECESSARY for health maintenance because if your patient dies of an MI, there is no patient to maintain. I guess then that sorta makes them not NECESSARY since you don't have to maintain dead patients. I'm confusing myself.

Finally, last I recall, the government created Medicare not doctors. And you know all MDs are not pediatricians, right? We and cardiologists take care of a lot of old people so not taking any Medicare patients in the old days would have killed a practice. It was the government that forced the hand of the MDs to play along.

In the end, it doesn't matter. For many reasons, the system will implode in about 25 years and we will go back to the days of patients giving doctors pigs and milk in exchage for medical care ... which would be awesome because I love bacon and sausage.

It is time for all practicing cardiologists to unite and realize neither the ACC nor the AMA currently represent us or our patients.  The ACC, the ultimate trojan horse,  and passive-aggressive enemy within, is a tool for academia control.  Wake up everyone and let's unite!  We need our own organization that truly represents practicing cardiologists and their patients. 

You said it all.

Thanks Melissa,

  I'm sick and tried of being the punching bag for all the disgruntled internists, fp's, peds....in my little part of the world, it's the primary care docs who are abusing the system. A substantial segment do nukes, echoes, stresses and everything else they can do in their office. And the reason for ordering the test is that BCBS or whoever will pay for it yearly, monthly, or whatever not any appropriateness criteria.  And somehow, it's us evil proceduralists who are to blame.

Guess what folks, it's us versus them not us versus us. The government and insurance companies want us fighting amongst ourselves. So as we stand apart, we are going to be divided and conquered. 

It just wants to make you scream!!  The folks I take care from WH and the Capitol just don't seem to get it some times.  As individuals they are warm and thoughtful, but when you get them together to decide health policy they degenerate into a bunch of teenagers on prom night - not much thinking, but lots of hormones.

I will be having lunch next week with President's physician - if ok with you I would love to share your blog post.  No one seems to be listening, but he can certainly slip it in front of the boss (or chief of staff).  I wish I could share some of the tales I hear from CMS staffers!!

KL

Everyone here makes great points but miss the elephant in the room. After 32 years of practice, doing cardiac intervention since 1982 starting with Andreas, I realize the Medical device, insurance and pharma industries and the American Hospital Association can outspend any group of physicians a thousand times over.  Insurers and CMS see the best way to save money is to either make patients more accountable for their health (will never happen) or to slowly strangle the ability to treat by those providers willing to treat.  As CMS reimbursement has already fallen below the cost of delivering care in a physicans office, and other third party payers are catching on, none of us will be able to stay in practice.  All but one of the 4 large cardiology groups in this city are employed by one of two publicly traded hospital systems.  Their patients not only have to pay a substantial facilities fee for every visit but also must pay a deductible for tests done in the "outpatient department" ( formerly known as the doctor's office) that is equal to or greater than the entire cost of the same test, done in the same facility by the same physician and tech prior to hospital-physician integration.  Speaking of the unintended consequences of squeezing private practice physicians, or maybe it wasn't unintended.  Get us all in the same barn, then threaten to burn it down if we don't agree to follow the edicts of the various specialty guidelines and appropriate use criteria.  The system would become and remain solvent if patients had more skin in the game, there was more transparency as to the true costs in the marketplace and efforts made to stop the rampant fraud and abuse from nursing homes, DME companies, Home healthcare agencies, Hospitals, imaging centers and yes even some physicians.  But if CMS reduced all physicians pay to zero, it would not keep Medicare solvent, except for the fact that we would all quit and no one would be hospitalized or otherwise treated.  The physician payment is such a small part of the CMS budget but we are the easiest, weakest and most vulnearable target.  Until our patients start speaking up for us we are a dying profession.  Forget about the AMA (they make a fortune from the government and insurers with their coding products) and our specialty societies are top heavy with academicians whose overhead is covered by the taxpayer or other institutional revenue.  Yes, we can (and will) all be replaced by computer algorithms, mid-level practioners and even bureaucrats.  The least costly patient is the one who dies in the first 24 hours of their illness.  Never thought I would see such wholesale destruction but we allowed this to happen. 

Dear Melissa, thank you for your blog. I whole heatedly agree your opinion. I am an interventional cardiologist and am a private practitioner. I am on call every third night and when I am on call, I need to be in 90 minutes away from inflating a balloon who is having a heart attack. That means I need to sacrifice many of the joys in life on these days, no restaurants, no movies, no dates, no swimming, no jogging, no wines, et cetera. And am I paid for this? Zero. If I am called in at 2 am to the hospital for acute MI, I can only charge for PCI, no consult fees because they are bundled to PCI, no special fees for coming in, "because that is your choice to become an interventional cardiologist", as some of my non-interventional colleagues say. When I am on call, hospital floor nurses constantly calls for questions, and I am always on my phone to answer them. How much am I paid for that? Zero. Many of my acute heart attack patients are indigenous people and they don't have insurance. How much am I going to be paid? Zero. Yes, I have professional satisfaction from saving life, but then, I cannot support my practice by zero payment. And now, am I going to be penalized by ordering more than one test at one office visit? It makes me feel aghast!many of my patients are elderly and they are dependent on their family for doctor's office visits. Many live by themselves. Many have pad and amputations of the limb. Many have home oxygen dependent. How can they afford to come to cardiologist's office many times? They have multiple comorbidities and if other specialities get into the same situation and get multiple visits for other sub specialities, then what will happen? Some of my patient who are not so sick are struggling to make their ends meet and working hard and they cannot take multiple days off to see me. Those changes make me sad and pessimistic about the future of the medicine in this country. I am still young and healthy, but when I get older and I myself become to be a patient, it would be a nightmare! 

At least it's good therapy.  My blogs are open for tweeting, facebooking, "like"ing, sharing and certainly the president. Feel free to share with anyone who will listen. Send to your local congressman. At least he/she will get an education on the topic if nothing else.

Melissa

I work in a rural community in Wisconsin.

All too often, people who make decisions, live in urban areas and assume that the rest of the world is just like what they see in their own community.

 

I get very upset with the HMO standard.  That is, the HMO is the insurance company, the health care provider and the hospital.  In my area of Wisconsin, we have HMOs in LaCrosse and Madison who advertise how good they are but then tell the physician that they must teach patients how to take better care of themselves.

 

I went to medical school to cure illness.  That is what I do best.  THe insurance company should be the one to teach people how to better take care of themselves, not the doctor in the clinic.

 

finally, I would like to see the single payer plan take effect and all of the HMOs, the mail order pharmacies eliminated, insurance companies closed.   Unfortunately, I do not believe that the federal government should be the single payer either. 

 

The government has a long history of being able to adequately regulate organizations, but it cannot control/regulate itself.  That is, we do not need a larger government.  

 

Finanlly, the physician who is no longer practicing medicine should not call him/her self a physician.  That person is a four letter worded bureaucrat.

 

Thanks,

 

Tom

Wow.  I can't imagine how frustrating it must be to have to think about how much you are getting reimbursed for each and every thing that you do!  I also work 60+ hour weeks, but rather than looking a patients as revenue I just do what I think is right, get paid a reasonable salary and share incentive rewards for providing higher quality care than my fee for service medicine counterparts.  

While I understand the good doctor's frustration with having reimbursement cut for a long-standing business practice that is good medicine, I have to ask:  Is there any efficiencey gained by having these tests done the same day?  One of the posters above said it herself in response to the issue:

 " that means not only does it take more patient TIME (some really do work, too) but it requires the doc to open the chart (paper or electronic) and review the patient each and every time one of those tests comes in to see how it relates to all the other procedures being done and how it fits with the history and exam. "

 To me, that sounds like doing it on the same day does in fact save time - and therefore money.  It would seem appropriate to receive a reduced level of reimbursement if it in fact saves money and therefore time.  In theory (and likely in practice), that time savings allows you to see more patients and bill for more services.  If that's not the kind of situation that calls for a discount, I don't know what is.

 Your other ideas for savings are great, but this is not an either/or proposition.  To become more efficient, we will have to do all of that and more to keep costs manageable.  And everyone's going to have to share in that pain.  I recently spoke to an employed pediatrician in a midwestern city that was making less than six figures and is under many of the same pressures as you are.  Do you want those savings to come out of their pay but not yours?

 Thanks for your thought provoking article

 Q 

Melissa - no question that there are multiple charges in medicine that are overpaid or underpaid - and the discrepancies between what hospitals get paid vs MDs reimbursemant - however, very few of us in primary care are shedding tears because of increasing our pay at the expense of the specialists - in 40 years of practice I have seen entirely too many expensive, lucrative tests done that are questionably beneficial.....PCIs, CTA,MRIs...etc.

In NW Pa. we have patients who drive 2-3 hours to see us, many times in bad weather. Family members or friends take off work to bring them so they lose pay and incur expences. If they can't get their studies done and see us on the same day it costs them alot or they may not get them at all. Maybe that's what CMS wants.

Q,

Asking us to test patients on separate days will NOT save medicare dollars. It will inconvenience the patient, cost more gas money, more time out from work for those transporting, but it will most definitely NOT save money.  

Art,

It would indeed be a noble thing to reduce my pay and then give it to some deserving underpaid primary care provider were it truly necessary. The truth is that you've been underpaid far too long but the same  system that has been underpaying you for light years supposedly has  morphed some intelligence from a sesspool of inefficiency and red tape? We are sitting on a gold mine of cash that is thrown out the door every single day as the patient is discharged without reconciling their home meds with their new meds, or following up the next day or two for CHF, or having nurse follow ups for compliance, or chasing the ever present detectable but non-diagnostic troponin I, or ordering the umpteenth echo on a patient who was just in a hospital across the street with an echo last week, or by NOT addressing diet in the office setting for BP control instead of adding a 12th medication to their regimen, or not discussing fluid restriction in those drowning in CHF, etc. etc. etc.  You see, there is really NO NEED to decrease anyone's salary when there are opportunities everywhere for improvement and cost savings. EVERYWHERE. 

If we just addressed the above issues alone, WE COULD ALL GET A RAISE!!!!!

 

Melissa

Melissa, It's great to see a great piece, written with the "gloves off" for a pleasant change. We have been played for the fools we are. I get a kick out of all the holier-than-thou docs who are so either egotistical or naive to believe that professional suicide is part and parcel of our benifescence. In the immortal words of Colonel Sherman T. Potter: Horsehockey! All the puppet masters you cite have taken advantage of our ethical and moral behavior for too long, and we MUST put it to and end before our profession....and the health of our patients....collapses completely. Your post should serve as warning to all docs whose ox has not yet been gored, or maybe just suffered only an abrasion. As an ObGyn, I can't tell you how for over 15 years I have railed against the arbitrary practices of bundling surgical procedures and progressive discounts for multiple procedures, begging primary care docs, other specialists (yes, many cardiologists too), ANYONE, to join my fight against all such heavy handed and unilateral reimbursement abuse. You could hear the crickets chirping! Your rant is appropriate righteous indignation, but reminds us all to heed the words of anti-Nazi theologian Martin Niemoller in his famous admonition "First they came for....". A contemporary version for us might read: First they came for the Surgeons But I did not speak out, because I was not a Surgeon. Then they came for the Radiologists but I did not speak out, because I was not a Radiologist Then they came for the Cardiologists But I did not speak out because I was not a Cardiologist Then they came for me And there was no one left to speak for me. Make no mistake about it. ALL of us are under siege and living in tyranny from many fronts. Now is the time for each and every doc to echo your outrage, before it's too late. Randy T

I think your post said it most eloquently Randy. Thanks for stepping out of your specialty circle to speak your mind in ours!

Melissa

Such a well written, no holes barred piece, Melissa! I most certainly agree with the arguments...Here is my take on it: I do not think that CMS has patient convinience in mind. I believe their goal is to make private practice of cardiology as intolerable as possible. Thus, this is one of their many attempts to infringe on practice of cardiology. The inevitable result will be continued shrinkage of the private practice , and, ultimately, a nearly socialized system of medicine where high costs will be contained by limiting procedure access. The high cost are definitely likely as the hospitals will "inherit" most of these patients/tests that are not performed due to the fee cuts, with many private practitioners simply giving those up, or unable to sustain their operations. The hospitals or facilities owned bythem will contain the cost by limiting access to testing. Get ready for a 3 motnhs wait to get a basic echo done!

I am actually a hospital-employed physician, and seeing the inefficiencies in the system, I am horrified at the prospects of compounding them even more...Yes, the going will be good for us for a whileuntil the hospitals realize how much money they are losing, and the next round of cuts will affect them as well. In a meantime, the rapid exodus of physicians from private practice will futher compound this situationa s these docs are joining the hospitals seeking shelter from the strom, so to speak.

The solution: punish our pateints by NOT taking Medicare?? These are hard-working folks who earned their livinghonestly, paid taxes. Are they now going to be confronted with the sutiation where no good doc wants to treat them? Ultimately, as crude as it sounds, it provides a great economic solution: no care=no health=early death=savings!! This is not my original thought-I read in New england Journal that no care option is economically the most advantageous!! In my mind, limiting access to care is the same as no care at all...

Two additional tidbits:

1.  Nope there are no cardiologists working for CMS and few of there physicians seem to have much clinical experience.

2.  All of these moves against in-office imaging are counter productive for taxpayers also.  They caused over 100,000 Cardiac SPECT procedures to move from physician offices to hospitals in 2011 alone.  That had to increase costs by more than $300million alone.

Sounds like whining to me! The abuses by cardiologists over time (witness Dr Midei in Maryland and the Elyria Ohio group, etc) have been so great and have accounted for such a huge cost to society (and harms to patients - excess radiaiton, etc.), I can absolutely see why this would happen. Should have happened sooner. I see that most of the comments are from your colleagues and are in agreement with you.  Some of your suggestions for money saving steps are fine. No one suggests cardiac SPECTs should be done pell mell without a firm indication. Government payer here we come!