Government largesse: the shell game

The current (version 174.5) acting head of CMS, Andy Slavitt, was a former CEO of Ingenix, a division of UHC. They were indicted in New York for operating manipulated databases with fraudulent reimbursement schemes pertaining to repricing out of network claims. (Complicated, I know, just stay with me here for a minute).
This same Mr. Slavitt now heads the government agency responsible for Obamacare, Medicare, and Medicaid. Not sure how that job interview went, but here we are. After much spouting about the wonders of Health Tech, Health It, EHR, Meaningful Use, etc. a stunning about face came about last week. Meaningful Use has been a pure torture device for doctors and clinics, the EHRs are so cumbersome and difficult to access. I personally tried to access my own patient portal when seeing doctors and they're buggy, circa 1991 FORTRAN in look and feel. The website for any consumer goods merchant is far more interesting, easy to access and interactive. I wouldn't dare ask an octogenarian patient to go log on or do whatever it takes to qualify. It's just not right, and for what purpose? Where is this all data going? what is the bribery or kick back for? Perhaps to close the loop on Epic-->money to congress-->law enacted in their favor-->crumb thrown at doctor for shelling out $100K on EHR.

Read about it --

In light of comments last week from Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt on Meaningful Use as a component of the Medicare and CHIP Reauthorization Act  of  2015 (MACRA) and the Merit-Based Incentive Payment System (MIPS), Mr. Slavitt and Karen DeSalvo, MD—National Coordinator for Health IT—prepared a January 19th blog post that included the guiding principles of how the Meaningful Use Program will fit in with MACRA implementation.  

Mr. Slavitt and Dr. DeSalvo’s blog identified the following principles for the future of Meaningful Use, health IT, and physician value-based payment

1. Rewarding providers for the outcomes technology helps them achieve with their patients.
2. Allowing providers the flexibility to customize health IT to their individual practice needs. Technology must be user-centered and support physicians.
3. Leveling the technology playing field to promote innovation, including for start-ups and new entrants, by unlocking electronic health information through open APIs – technology tools that underpin many consumer applications. This way, new apps, analytic tools and plug-ins can be easily connected to so that data can be securely accessed and directed where and when it is needed in order to support patient care.
4. Prioritizing interoperability by implementing federally recognized, national interoperability standards and focusing on real-world uses of technology, like ensuring continuity of care during referrals or finding ways for patients to engage in their own care. They stated they will not tolerate business models that prevent or inhibit the data from flowing around the needs of the patient.

Mr. Slavitt and Dr. DeSalvo’s blog also emphasized several important points for the physician and hospital communities, including how current law requires that HHS continue to measure the meaningful use of Office of the National Coordinator (ONC) Certified Health IT under the existing set of standards. Although MACRA does provide an opportunity to adjust payment incentives associated with electronic health records (EHR) incentives in concert with the principles that they outlined, it does not eliminate the EHR Incentive Program, nor will it instantly eliminate all the tensions of the current system. CMS and ONC vowed to continue to listen and learn and make improvements to these programs based on what is happening in the field.

In addition, MACRA only addresses Medicare physician and clinician payment adjustments. The EHR Incentive Programs for Medicaid and Medicare hospitals have a different set of statutory requirements and are not directly impacted by MACRA. Mr. Slavitt and Dr. DeSalvo will continue to explore ways to align the principles they outlined for physicians with hospitals as well as the Medicaid program.

Moreover, their goal in communicating these principles at this point is to give all stakeholders time to plan for what’s next and to continue to give CMS and ONC input. They encourage the entire community to review the MACRA regulations this year; in the meantime, existing regulations—including meaningful use Stage 3—are still in effect.

The blog also discussed how Congress, in December 2015, provided HHS new authority to streamline the process for granting hardship exceptions under the Meaningful Use Program. This new paradigm will allow groups of health care providers to apply for a hardship exception instead of each doctor applying individually, which should make the process much simpler for physicians and their practice managers in the future. Mr. Slavitt and Dr. DeSalvo promised to release guidance on this new process soon. 

Lots of words, little tangible information. 

Never Mind the Bullous

Heard from a colleague across the country about an elderly patient with blisters covering her feet and unable to walk, unable to function. Many visits to doctors, ER's and no continuous care, no management. Finally went to a cash only practice where the doctor listened, examined, treated. This no longer happens at practices that serve everybody at all times. Unable to even get a follow up appointment! I'll bet that patient was asked many times by "staff" at the other ER's and derm practices whether she had her flu shot or wore her seatbelt, like good comrades they had they her fill out the customer care survey. Never mind the pemphigoid. ****** the Sex Pistols "Never Mind the Bullocks"!!!!!!******

This patient was seen once by an actual physician---all other visits were conducted by assistants and "providers" who can't possibly know how to diagnose such a thing; they patched her up with maybe a top. steroid and Cephalexin and turned her out. She got worse and developed complications. It's sad, and not uncommon. 

I've seen very similar things here, once for example, where a man was told he had condyloma on his penis, and for several visits at other practices the ARNP/PA performed cryo on it; the scab and ulcer never resolved so 2 months later he came to me, where I spotted grouped vesicles below the scab. Herpes simplex. He never saw a physician all the times he had been to other offices, and he had an HMO plan I do not participate with. He was very angry at the others, as he should have been. Another elderly woman with Medicare was given top. steroids FOR YEARS to apply to the scaly patch on her cheek. I biopsied it on the first day and it was SCC, she needed extensive Mohs and reconstruction. I accepted her Medicare too. But at the other places she rarely, if ever, saw a doctor. 

The system is set up for volume, graft, lying, and nonsensical care. Government mandates, insurance companies covered items, non-covered items, all changing on a monthly basis; Obamacare, Medicare HMO's, etc have destroyed medical care in the US. Our voices have been drowned out because we are in the trenches doing what we do best. We rely on our organizations, not entirely, but still, to communicate to the power elite what is happening in real time and what to do about it. They have all colluded in creating a monster, with flow charts, EMR, nonsense and irrelevant "quality care" mandates, and penalties. The AMA and AAD sells lots of books and CD's on how comply with the mandates. They rolled over and surrendered. So I have ended my membership with them. 

Another dermatologist friend was freaking out when her boss was making them do PQRS at the end of 2015. She spent hours on the phone calling up her patients and asking if they had their flu shot. Not to then admonish them nor administer it, simply a box had to be checked in the software and she felt she could only do this truthfully by calling them at home, and asking them. Think about that. A board certified dermatologist who can cure complex skin CANCERS and disease and diagnose from the doorway, was reduced to this. What a waste!!

The pie of decent doctors taking Medicare will disappear, and the only pie left will be the churning, take a number, inferior clinics--staffed by who knows who-- that will accept Medicare but not cure disease. Hence the two tier system we are talking about, it's here. We are in it.  

 

All I can do is periodically email congressman and women, I even called the White House one particularly maddening day and I screamed at the operator--and I tell my patients openly and honestly what's going on. They don't get it. They have very busy complicated lives, they just want "to go to the doctor and get this taken care of". They have no clue that it's not about them anymore. 

You better not be telling me what to do

Interesting and shameless recent patient interaction. He comes in once a year, maybe. The last visit was 18 months ago, because "I don't like paying the $35 copay".  This patient has a $0 cost (to him), Medicare Advantage plan with a company currently embroiled in a merger deal with another big five company.  I say, "well, I don't like working for free". He says his INSURANCE agent (who gets a commission for every policy sign-up) told him to "tell the doctor to send in the claim as a prevention visit and it would be covered 100%". I told him to go to his agent for his future medical care, and I was only half joking.

Where to begin?

Doctor comes from the latin word, docere, meaning "to teach". I teach prevention at every visit. As a dermatologist, it boils down to the basics that everyone hears all day--stay out of the sun, wear sunscreen, stay hydrated, moisturize. We're not talking about a 30 year old coming in for a check up and wants to know how to take care of herself. We're dealing with an 88 year old man with a history of dozens of basal cell skin cancers, squamous cell skin cancers, many Mohs surgeries, a chart rife with biopsy report after biopsy report.

I am an end of the line specialist for this patient, firmly in the realm of management and treatment for skin cancer. Referrals get made annually for him for Mohs surgery for those skin cancers that are too aggressive, irregular, located in tough spots such as the eyelids. Every visit for the past decade involves a diagnosis and a treatment. Preventative advice is freely given, and never followed. This is the same patient who told me 4 years ago he would sit in the Florida sun for 30 mins every day so he would get his vitaminD. This is on the same day I excise a basal cell skin cancer from his face. After telling myself to stay calm, I advise him that it's a bad idea to sit baking in the FL sun, with his Caucasian-white and terribly sun ravaged skin. Broken bones resulting from low levels of vitamin D can be prevented by taking a daily vitamin. There's no such remedy for skin cancer. The damage was done decades ago, when he was self professed sun worshipper, visiting FL from the northeast where he would come down and get sunburnt, then go home and show off his tan. ***eyeroll***

We are long past the point of submission of "prevention visits" for this patient. We are in the business of keeping him alive and well and not letting him succumb and suffer from readily treated skin cancers. We are also not in the business of following the exhortations from a salesman. Borderline fraudulent, the falsehood perpetrated by this agent feeds into the whole gestalt in our culture right now, "I need to get something for nothing". This isn't possible. If I don't collect the copay, I lose money, and on a grander scale, I may need to close my practice if I take a 15% fee cut across the board from all my patients with a copay. Then where would we be? No doctor, no help, increased morbidity and mortality in a community. All from an agent who thinks he can help us all "game the system" by getting something for nothing. I'm not going to justify my business costs, nor defend my ability to stay in business, by allowing a bottom feeding salesman piece of trash to tell a patient to tell me what to do, and how.

To add insult to the injury, medical records are often audited by this same company's "provider payment integrity department", and if the record doesn't fit congruently with the medical claim, recoupment of payment is initiated. No recourse, no contest. The money is garnished from future earnings or sent to a collections agency, and a blemish on your financial record forever. So you see, I'm on the hook after the payment is made to me, by the insurance company, for my integrity and honesty --or I sink like the Titanic.

This story hasn't ended. I am waiting for the call from his agent. I can't wait for it, actually, it's going to be soooo fun to deal with this one.