Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Why micromanaging cardiology from the White House won't workDec 6, 2011 09:10 EST
Have mercy! After reading Shelley Wood's piece "Stents, ICDs inappropriate? Then, under new audit program, CMS won't pay," it's almost enough to make me want to become a Republican! For all of you folks at the Centers for Medicare & Medicaid Services (CMS), this is for you. Since there is a need to rein in graft in every workplace, audits are necessary to catch those crooks that are up to no good. Granted, I don't think there are nearly as many crooks in cardiology as there are philanderers or old men who like underage boys in politics (or coaching, it seems) but if there is even just one of us purposely ripping off Medicare or Medicaid, we need to be exposed, fined, and even sent to the pokey. I'm all for it. What I don't need is a "White House consult" every time I schedule a patient for a cath or a stress exam, and the tone of some of the language in this plan suggests there will be a ripple effect. Although we are just starting in a few states to look at certain procedures, this rapidly moving snowball will soon pick up other areas of cardiology and medicine. Whoever set their foot on it and started rolling it downhill must have never practiced medicine for any length of time in their lives. They are out of touch with the realities of the everyday practice of medicine. (I'll bet they wear a polyester leisure suit to work with a big wide belt, white shoes, and lapels down to their iliac crests.) Before you roll your eyes and assign these comments to the psychotic ravings of a madwoman, read on.
Cardiologists get it on both ends now. Blue Cross Blue Shield (BCBS), which pays just one of its state CEOs a salary of $4.6 million per year, tells me daily I can't get a stress exam on someone with risk factors because they aren't having chest pain. "But she's not going to be 60 years old for a few weeks," one BCBS physician told me, despite the fact that her ovaries had been missing in action for 25 years. Another day, I could not get a stress exam on an asymptomatic gentleman a year after he had a silent MI. He was still infarcting and recovered his LV function after a quick PCI. They wanted me to wait another year before I could get a follow–up stress exam because he wasn't "having typical symptoms" (duh). Now the CMS is telling me that the new trend in medical fashion will be "If you miss the diagnosis, you won't get paid for the workup." Will you also stop reimbursing normal head CTs after a loss of consciousness for an MVA? Will you embed FBI agents in every pathology department in the country to radio the White House that Ms Jones, with RUQ pain and a negative GB ultrasound, who had visited every ER in the district, had no gallstones? How about a negative colonoscopy for rectal bleeding? It is a sure bet that this political snowball will pick up a lot of testing and workup while rolling out of control downhill toward hell.
The opportunities to save money in all walks of medicine are as abundant as eggs on the White House lawn on Easter weekend. They are free. All you have to do is to bend over and pick them up. For the love of all things sacred in medicine, CMS--who in the world are you talking to? Do you ever ask anyone who is actively engaged in a full-time practice what they think will work to rein in cost? I've said it until I'm blue in the face. When you are looking at a budget and need to cut costs, the very first thing you do is examine the most expensive items on your expenditures, and I submit to you with absolute confidence that that is NOT CROOKED MEDICINE!
If you don't believe me, call Suze Orman, Dave Ramsey, even Donald Trump. They would open the books on medicine and point to congestive heart failure as the big-ticket item. Then they would ask, "What drives the cost of this item upward?" We as drones in the medical world would say, "Mr Trump, it's undetected and undertreated hypertension. It's rampant glucose intolerance that most overweight Americans have at this very moment who are being patted on the back and told it's just 'borderline diabetes.' Ms Orman, it's lack of exercise and improper diet. Mr Ramsey, it's greater than 50% medical noncompliance. It's America's love of smoking and the pathological paranoia that if you have to step outside to smoke, you'll wind up in a prison camp somewhere. It's the glaring omission of the need to map America and get every ST-elevation MI a primary PCI in a timely fashion and the need to make PCI stations as abundant as Wal-Marts. It's time to treat PCI without surgery on-site with the same respect as the need for intubation in respiratory arrest. It's time to emphasize the need for changes in the "healthcare reform plan," that diatribe that made War and Peace look like a comic strip, the one where trauma, family medicine, and obstetrics were mentioned, but NOT ONE TIME was the word "cardiology" uttered or the need to reduce heart-muscle damage by doing a better job at treating heart attacks. It's our convoluted thinking that you should be able to sue your doctor for a million dollars, your doctor who was trying to help you, had a good track record, and had a poor outcome, despite the fact that most Americans who bring those suits had never exercised regularly, ate right, or made much effort on their own to maintain good health. We have to stop the mentality that it's okay to drive 120 mph, but if you hit a tree and get a wound infection, you get a million dollars annually for life (or more correctly, your malpractice lawyer gets a million dollars to spend for life).
Furthermore, we cardiologists, who employ a substantial work force to fill out your forms and do your billing inquiries and kill trees and wreck carpal tunnels from all the necessary keystrokes, do not deserve to have our salaries reduced on a whim. Every year, it's a new threat of a 20% or 30% reimbursement cut when there is an opportunity to save billions by just having a conversation with the White House. Insist on driving real campaigns that target compliance, make all public buildings in the US smoke-free, and map America for timely primary PCI. Quit just talking about malpractice reform and DO it! Offer incentives for hypertension screening, dietary instruction, and access to and utilization of exercise facilities for every business in America. Do not engage in a pathetic witch hunt, but go ahead and lay a trap for the crooks that are few and far between in cardiology.
If you are running for public office, especially the highest level of office in our country—specifically I am addressing you, President Obama, and you, Mr Romney or Mr Gingrich—you owe it to us to sit down with a physician who is actively engaged in full-time private practice to understand the most important issues we face in our country. Instead of just being reactive, let's become proactive and at the same time react wisely and logically. Go ahead. Be bold. Focus on detection and prevention. Don't be afraid to drive up the immediate cost of healthcare by looking for renal-cell carcinoma or triple As or carotid disease. It will save in the long run by preventing two years' worth of chemo, radiation, and hospice care. Save billions of dollars in nursing-home stays for stroke. Drive the utilization of calcium scoring to detect asymptomatic coronary artery disease. Incentivize easy access to blood-pressure screening. Teach America how to check their pulses and screen for undetected afib. Make PE and health curricula in grades 1 through 12 just as important as math and science. After all, if we can't teach kids how to live longer, healthier, and more productive lives, we have taught them nothing of value.
A great first step, and about the only thing the CMS has done that makes any sense whatsoever, was to make a feeble attempt at obesity screening and counseling. Someone must have had a TIA up there to have actually tried to address a real issue. I applaud that, but it was a drop in the bucket. Politicians cannot micromanage what goes on in a cardiologist's office, but you can help us by laying the groundwork for success by just convening for a week on cardiovascular issues alone. If you don't know what to do, instead of just picking some crazy scheme, for the sake of the future of American cardiology, why not pick up the phone and ask someone who is actually practicing it? CMS, by putting all the drivers of our most expensive DRG under the political microscope in cooperation with the scientists who actually fight in the trenches of cardiovascular disease every day, you can be successful in putting American medicine on the right track. It is only through the utilization of this formula that we can successfully improve healthcare spending. Otherwise, you will fail, and so will we.