Past Present and Future:
Wayne Gretzky famously stated: “I skate to where the puck is going to be, not where it has been”.
Read more at: https://www.brainyquote.com/quotes/quotes/w/waynegretz383282.html.
It has been a few months since I last blogged about health care and the practice of medicine. I have been feeling a lack of inertia regarding anything that might be “news” given the ongoing congressional “gridlock” regarding addressing Federal health dare policy.
The present failure to change the government’s stance seems to be a combination of “political paralysis” – our congress and even the president is fearful that any action will be associated with the inevitable market chaos- along with a dependency on the present Patient Protection and Affordable Care Act subsidies for those Republican governors who accepted the Federal carrot offered as a “bribe” to the states.
I am pleased to report that the proposed legislation is a step in the right direction. I propose ideally any tax deduction incentive should be available to all US taxpayers regardless of employment status or Medicare status. This “credit” should be across the board regardless of income as an incentive to take personal responsibility in the health care market. Such responsibility should be an individual choice which includes demanding transparency from the health care market. Individual choice increases our freedom to engage the market and that is always a good and better thing than centrally controlled economics.
I have been informing my patients and readers for a few years that the government’s policies and behaviors indicate that the Medicare program is insolvent. Any rational person should conclude that it is not reasonable to expect the system to provide us with anything that resembled the past Medicare program.
It is time for the ostrich to take its head from under its wing and survey the landscape. No American long term is willing to stand in queues and allow their freedom to seek services to be sacrificed to a niggardly, rationing health care system. Furthermore if anyone at the store was paying attention it is high time that our citizens/buyers demand a semblance of reality regarding hospital charges and name brand prescription medications. It appears that our federal policies have completely neglected to confront the “someone else is paying” robbery model presently in place. This is why I believe a rational person should conclude that asking the government to continue to try and control the health care market is just not a doable task.
The past 3 years has seen a surge in Direct Primary Care private practices. This is a result of physicians finally concluding that they can no longer nor will any longer tolerate the price fixing, work adding, fraud risk-taking model that Medicare has become. These doctors are preparing (I am now one of them) for the demise of the where the puck has been and are moving to where the puck is going.
Where has the puck been?
The puck has been on the ice of coded services. The Medicare Relative Value Unit system of payment was born out of the Omnibus Budget Reconciliation Act of 1993. It was here that the Republican Congress under President Bill Clinton decided to put a price on physician services using a formula whose concept was born out of the Marxist economic concept that goods are valued strictly by the cost of labor.
This RVU formula dictated the price that would be applied to physician services based upon the then time analysis for these services. It didn’t account for future time elements or other cost factors that couldn’t be predicted since no one knows the future. This legislation also made it illegal after 1997 for Medicare providers to accept payment over and above the RVU fixed price. It is this formula and price-fixing policy which is now making it impossible for physicians to comply with the ever rising bureaucratic demands of Medicare to prove a coded service was provided. Furthermore, the cost of documenting requirements, filing, coding and collecting the revenues paid has stripped the physician’s interest in remaining a provider for Medicare clients. The same follows for the insurance payers who are often paying BELOW Medicare’s fee schedule with even more “pre-authorization” requirements which means more staff and time overhead.
Using a coding model to document both what was provided as well as what the payment will be creates incentives to “optimize the higher paying codes” as well as optimize codable events. This means in order for your doctors to generate revenue they must provide a coded service and also require you have a face-to-face encounter in order to submit a bill for payment (by Medicare or your insurance provider). This necessarily results in more visits, more fragmented and limited “coded services per interaction” and what initially provides proper incentive for productivity soon becomes an incentive to provide unnecessary and higher paying coded services- “churning” if you will. It is any wonder that your insurance accepting providers now have you limited to 6 minute appointments? Also how can anyone be surprised it they are recommended higher paying services or even (if hospital employed) higher paying locations for those services. Hospitals under Medicare get much higher reimbursement for the same coded services provided in an office.
Where is the puck going?
Economics rewards efficiency. Given today’s internet and improved communications capabilities it is now possible for the health care system/doctors to leverage technology to enhance and increase your points of contact. It is also often more efficient for our personal lives and general economics to desire non office visit services. The system of coding doesn’t allow for these dynamics to play out. Membership payment for more comprehensive, personalized and modernized care now makes sense. Guess what? This idea freaks your traditional model out!!! If your doctor can monitor your vitals from home, send you customized newsletters and educational materials relevant to your personal health concerns as well as monitor and provide your health prevention services via computerized reports and queries wouldn’t this convenience and “on demand” method of care be preferable? Certainly you will need to be personally interviewed and examined depending upon your health issues but MUST you for all requests? Some of us doctors are actually interested in providing excellent, convenient and preferred services to patients. We are the ones that are taking the stand to offer these things BUT we understand trying to provide this kind of care in the present payment and coding constraints is not feasible.
What does all this mean- bottom line?
Independent doctors who hold their patient relationship as the highest goal will want to move to where the puck is going. This is better for the patient and it is better for all personas costs. Technology is already making coveted services (cardiac monitoring as an example) obsolete. Why wait for a doctor’s visit, pay for an expensive “coded” monitoring service when you can purchase a monitor or app and monitor for your i-phone allowing unlimited monitoring at the price of less than a consult? You still need your doctor and the health care system to deal with any pathology and this means you still have to pay for your doctors. Just not the traditional way.
It is time to question whether buying Medigap insurance is worth the 20% fictional payment assistance when your premiums routinely cost more than you consume year over year. It is less expensive to purchase your generic medications “cash” then it is to submit it through your insurance plan- why pay premiums for the privilege of paying more at the window?
There is going to be a strain and competition for your health care dollars- pay your providers who actually take care of you or pay an insurance company out of fear of the unrealistic price-gouging that you hear about on the news.
As one who sees the puck moving by, I challenge everyone to question the value of “full coverage insurance”. Hopefully we see legislation that allows for more freedom, less coercion regarding health care dollars and your personal money.
♦ Dr. Kordonowy offers memberships for all ages. He is uniquely offering blue-toothed dashboard monitoring services as part of his membership. Presently the dashboard service monitors the Withings line including weight scales, wrist activity monitor and blood pressure home monitor units. Fitbit units are also able to interface with the monitor dashboard. He has created a generic dispensing program for his patients which has in some cases saved patient thousands of dollars in medication expenses. The future is exciting indeed!