Sunday, November 09, 2008

Final Rule Hieroglyphics

Medicare offered its "Final Rule" for its 2009 Physician Fee Schedule for doctors recently. To see how this "Rule" applies to heart rhythm specialists is virtually impossible, thanks to the layers upon layers terms and specifications unique to only those who deal in such machinations. Here are a few such terms:
  • "CMS will continue using the “bottom-up” methodology to calculate Practice Expense RVUs."
  • "Practice Expense RVUs are calculated on the basis of a blend of RVUs"
  • "Harvard-valued codes"
  • "anti-markup rules"
  • "work GPCI floor"
  • And don't forget the "PE Database"
Is there any wonder that the guys who do the work are completely and utterly baffled by such a payment system? In every instance, the system obfuscates and confuses while supporting it's own network of highly-paid sycophants to decipher the hieroglyphics.

What an absolute and utter mess our system of physician payment has become. Even specialist societies, have to "continue to review the final rule and provide rate analysis of the impact on EP (electrophysiology) services in the weeks to come." (emphasis mine)

Most of us already know what the Robin Hoods of bureaucracy are going to do: steal from the rich (specialists) and give to the poor (generalists). After all, that's what "budget neutrality" is all about. But it's much easier to plug a number in to a computer formula than speak with people.

That's how people in the back boweries of government who don't deal directly with people work.



The Happy Hospitalist said...

Actually Dr.Wes, the codes that increased reimbursement, the cognitive care codes for outpatient and evaluation codes and consultation codes as well as inpatient admitting, consultation and follow up codes are codes used by all physicians that engage in thinking evaluation.

That includes specialists. Every doc that uses these codes gets a raise.

However, the payment model is irrational by any means measured.

Gary M. Levin said...

Didn't you mean back bowels of government...sounds much more apropos.

DrWes said...


I'm willing to bet that you are salaried by the hospital that employs you. As such, you are immune to the reality of what a 1.1% Medicare "raise" in payments means to the private practice, stand-alone practice charged with paying for their office overhead. Certainly, the current efforts are better than the threatened alternative (5.4% decrease). But E&M codes and their associated doctor payments, are far smaller than doctor procedural code payments. As such, they have become the prime target to fund the E&M code "raise" and are being cut substantially to offset the costs of paying for the increase in E&M codes that you are so "Happy" about. Specialists are seeing their incomes consistently shrivel year after year. Our current ecomonic woes exacerbate the problem. To suggest that doctors are getting a "raise" is flawed thinking: we are not even staying even when one factors in inflation. Also, to suggest that specialists' training and expertise involves any less of a "thinking evaluation" belittles specialists and serves to divide physicians as a collective force in the health care debate. Each of us (specialists and generalists alike) find ourselves pissing and moaning about each other's incomes, while third parties make consistently more than 1.1% profit annually on every health care dollar spent. Remember, doctors earn only 6% of every health care dollar. To suggest that real cost savings can be achieved by reducing or stabilizing doctors' incomes further is short-sighted as the intellectual capital that exists today exits the profession and is not replaced.

health train express -

I was trying to be more discrete, but I agree, "bowels" might be more appropriate.

The Happy Hospitalist said...

Hey Doc. Actually, I'm not employeed by a hospital. I am part of an independently owned private practice hospitalist group. And we are hardly immune to the skewed and flawed Medicare Economics.

The whole SGR/RVU system is inherently flawed, and I have maintained that fromt he beginning. IN the fixed pot of Medicare part B, for every winner, there is a loser. That's why hospitalist medicine if flourishing. They have left the constraints of the pot.

Gary M. Levin said...

Yes, all of the above is true Dr. Wes. If the readers will check out my healthtrain blog I have written an article on 'Peak Oil Medicine". Interesting analogy.
Our problem is that we preach to the choir. Our situation is illogical,and defies rational thinking. Our 'raises' are running far behind inflation, while the healthcare dollars go elsewhere.
My financial analysts and advisors say the meltdown is just beginning.
The next large ball of wax is healthcare. Not only will we see more uninsured, but a decrease in federal (ie medicare) and state programs.(medicaid)
The United States is bankrupt...far beyond what you can imagine. Money will flee the U.S. as well as people. We have not hit bottom and it will take at least ten years or more to recover. The rich will get richer (and not depending upon Obama's definition of rich. Even if you have a significant amount of money saved, and /or in the market it will be devalued. Our government that was supposed to buy "toxic assets" and defaulted mortgages, has instead bought shares in these failed financial institutions. It is so bad that JP Morgan has not even re-branded WAMU banks. They have a little white piece of paper on their doors, that WAMU is not part of JP Morgan....

So Dr Wes, and Happy, let's carry on and at least we can enjoy taking care of our patients.

Anonymous said...

Doc - could you talk about the census problems that hospitals are currently facing? Thanks CJ

Gary M. Levin said...


Not sure what region you live in.Census problems really depend upon where you live?

You cannot generalize.. Let me know and I'll get you the answers

Anonymous said...

I wonder if Happy's private hospitalist group receives a subsidy from the hospitals they service, effectively minimizing the financial impact? I also wonder what overhead the hospitalist groups have, which would also serve to minimize the effects on hospitalist groups.

Should all medical groups receive subsidies from the hospitals to help defray these expenses?

DrWes said...

anony 2:44 PM:

Your answer can be found in the comments here. It seems Happy's group is subsidized by the hospital to the tune of about $100,000 per physician per year.

The Happy Hospitalist said...

Hey doc. Just to clarify. the $100,000 figure is what the Society of Hospital Medicine published in their report in April of this year. The actual figure was about $93,000 per doc per year in hospital funding.

The contractual relationship that Happy's Hospitalist group has with Happy's Hospital is something that I am contractually obligated never to talk about.

So I won't.

Just clarifying...

DrWes said...

Thanks for the clarification and appreciate the info, Happy. Your model seems relatively unique - most hosptialist groups around here are employed by the hospital systems themselves.

Any non-compete clause in that contract you have (or would you have to shoot me if you told me)? I realize this might not be an issue if your hospital is the only game in town...

Anonymous said...

The point is Dr Wes that HH is an employee of private hospitalist group (unless he is a partner) and his group receives a subsidy from the hosptial. Hence in reality he doesn't directly deal with the issues that the rest of us do. Nothing wrong with it, he just doesn't presently have firsthand experience. I guess we can all become hospitalists once our big salary specialty practices go under.
PS: Before you give a snarky comment HH I was a hospitalist before fellowship back when you were in school.

The Happy Hospitalist said...

anon. I wish I could clarify more, but I can't. You'll just have to believe me when I say I think the whole system of RVU/SGR economics is an exercise in futility for the delivery of health care in our country. It has destroyed comprehensive care. And eventually, it will destroy the specialty societies as well.

It is not a viable program. The collapse of out patient comprehensive care is proof positive of that.

The thriving hospitalist movement is also proof of the failures of the fixed pot economics of Part B Medicare.

Gary M. Levin said...

No one in medicine seems to get the big picture. No one should be envious of others who have higher incomes, nor seem to have some advantage. First they came for them and them and , then they came for me...

Seems to me as physicians despite the challenges we should realize we are in a fairly unique group. Snipping and snarking at one group is not going to increase your income....That is what the payers and government want you to believe and they continue to divide and conquer.

No one specialty (except perhaps cash paying such as plastic surgery, or purely elective practices that do not deal with payors has an advantage in the long run....we are all going to be cut down to size...

Best hedge is to live simple, become a spartan, don't borrow money, get a green car, putup a windmill, and solarize your roof.

Obama is here!! Community organizer is another word for organizing the proletariat.... I am applying for a job at McDonalds if they are hiring. No shame there, and all the french fries you can eat.

I.m sure you remember Dr. Zhivago and the long cold winters...I never understood that movie until now....

Unknown said...

We would have lesser demand for specialist services if we took better care of ourselves and focused on prevention, as opposed to treating illness. Then the law of supply and demand would assist our efforts in allocating our healthcare dollars more efficiently.