Medicare is changing the way it pays surgeons

Starting in 2017, Medicare will end global payments for operations. The current payment scheme combines preoperative, operative, and postoperative care into one fee. When the change occurs, each of those events will have to be billed separately—otherwise known as “unbundling.”

I missed this news when it first appeared late last year and thank one of my blog followers who calls himself Artiger for bringing it to my attention. An Advisory Board piece summarized the situation.

After analyzing a number of claims, Medicare came to the conclusion that it was paying for duplicate services. What a revelation! I could have told them that without a claims analysis.

For many years, certain surgical specialists have been delegating preoperative evaluations for “medical clearance” and postoperative management of everything but the incision to internists and hospitalists. Since the global fee was meant to include pre-and postop care, Medicare was indeed paying twice for the same service.

Representatives of the American College of Surgeons expressed concern that sicker patients would need more in-hospital postoperative visits thereby incurring more bills. [If they receive more care, maybe they should pay more.] They also worried that since postoperative care was covered under the global fee, patients might forgo office visits after surgery because of increased costs.

The unbundling of the global fee may have other unintended consequences. Since preoperative and postoperative care reimbursement will be separated from the fee for the operation itself, surgeons will be paid less for performing surgery.

Most surgeons would rather operate than make rounds and may look to perform more surgery to make up for the loss of income. This could end up costing Medicare more money.

With global payments, there is no incentive for a surgeon to keep a patient in the hospital longer than absolutely necessary. When the payment method changes, the exact opposite will exist. And surgeons who aren’t very busy might schedule more postoperative office visits to make up the difference caused by the reduction in the surgical fee.

This might all become moot anyway because Health and Human Services Secretary Sylvia Matthews Burwell has proposed that 30% of Medicare payments be converted to a non-fee-for-service model by the end of next year rising to 50% by the end of 2018.

According to a news@JAMA article, doctors may be given incentives to join Accountable Care Organizations. Quality indicators such as readmissions and infections currently applied to hospital fees might be imposed on doctors too. More bundled payments for acute care illnesses may be created. [This of course is the exact opposite of the plan to unbundle global surgery fees. Im getting confused].

One thing Im sure of is that none of this is making me regret that I retired.

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Medicare spends a lot of money unnecessarily

You may find this story hard to believe, but its true.

A 75-year-old non-smoking man with no serious medical problems and a relatively low-risk family history [father, a life-long smoker, died of a stroke at age 76] has been undergoing routine physical examinations by his primary care physician in Florida every 6 months for several years.

The visits include a full battery of laboratory studies, nearly all of which have been completely normal on every occasion.

The patient told me that he has been on a statin for about 20 years. At the time it was started, his total cholesterol level was 201 mg/dL. The genrally accepted upper limit of normal is 200 mg/dL.

After his last visit, the doctor told him to take his pill every other day because his most recent total cholesterol was 109 mg/dL.

Can hypocholesterolemia cause health problems? How low is too low? No one knows for sure, but cholesterol is a constituent of cell membranes and many hormones.

Ive blogged before about the overuse of medical care, particularly Pap smears, in Florida.

Why does Medicare pay for all these unnecessary tests and drugs? Medicare probably has no way of knowing that a statin was started and is being continued for no good reason. But what about the cost of the office visits and routine blood work every 6 months?

Its probably not much money per person, but of all the states, Florida has the greatest proportion of people who are at least 65 years old (17.3% in 2012).

The population of Florida in 2012 was 19.32 million so it has 3.28 million people over the age of 65. Theres potential for a lot of money to be wasted.

As one of its Choosing Wisely items, the Society of General Internal Medicine has recommended that routine general health exams not be done for asymptomatic adults.

A Cochrane Review of 14 studies comprising 182,880 patients came to the same conclusion and noted that important harmful outcomes of routine check-ups were often not studied or reported.

In June I wrote about the doctors who received seemingly excessive Medicare payments identified by various journalists and wondered why Medicare couldnt have discovered these obvious outliers on its own.

Routine check-ups every 6 months seem easy enough to identify and squelch. Why cant Medicare do something?

PS: For all you fans of rating doctors according to patient satisfaction scores, the patient in the above anecdote really likes his doctor and is worried that, because he is fed up with everything about the practice of medicine, he may retire.

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Medicine like air travel once was fun

A Wall Street Journal blog about a reunion of employees of American Airlines lamented the good old days of air travel. Heres an excerpt:

"They came together to celebrate the days when flight attendants in white gloves hustled to serve you, gate agents doled out upgrades and arranged seating so families could be together, and managers worked flights with the single mission of ensuring excellent customer service."

The employees told tales of the fun they had and the camaraderie they shared. The passengers had fun too.

One retiree said of todays airline employees, "They dont look like they are having any fun at all."

Certainly the same can be said of todays passengers.

Im usually not a fan of the airline-medicine analogy, but Im going to make an exception here.

Back in the day, those of us in medicine had fun too. Dont get me wrong. It wasnt at the expense of the patients.

We always approached our patients with a proper attitude of respect. But it was OK to enjoy those encounters and also the fellowship of colleagues. We helped each other out, and we did it with spirit and camaraderie.

Not anymore.

All we read about now is how doctors are burned out, stressed, depressed. We battle with electronic records, hospital administrators, clipboard carriers, third-party payers, the government and just about everyone else.

What happened to the fun? Its all about the money.

David Shaywitz in Forbes: "The view from the front lines suggests that hospitals and care delivery systems are obsessing like never before on doing whatever they possibly can to maximize their revenue. They are consumed, utterly consumed, by this objective."

He added: "Many (I’d say most) providers and provider groups feel that they are locked in a deadly battle with payors (and increasingly, other providers) for their livelihoods; many feel they are having to work harder and harder to bring in the same (or less) money then doctors a generation ago. Many feel that the profession has lost the autonomy and respect it used to enjoy, and that providers are now viewed as mechanized assembly line workers, held to strict quantitative “quality” metrics that rarely capture the complexity, or essence, of the patient experience."

I believe what Shaywitz said is true. Can anything be done or is it hopeless?

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The solo general surgeon is a dying breed What is next

This is a guest post by Dr. Paul A. Ruggieri, a general surgeon in Fall River, MA and author of a new book “The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry.”

A potential casualty of employment in a hospital system may be the ability to openly disagree with the organization. Will surgeons, as highly paid employees, be confident enough to speak up against hospital policies affecting patient care without worrying about corporate retaliation? Will employed surgeons be able to speak out against hospital cost-cutting measures that infringe on patient care without being labeled whistleblowers or troublemakers? Can they voice their displeasure without worrying about the security of their job? If you are branded “not a team player,” referrals may dry up. Or, you may suddenly be “asked” to take more emergency room call. You may also be asked to travel farther to see patients and generate surgical business in another town. You may be replaced. You could end up as a surgeon without a practice. If let go, you may discover that the clause in your contract prohibiting you from practicing within the area drives you out of town.

Will employed surgeons be able to openly highlight waste and fraud without fear of losing their jobs? As highly paid employees, surgeons risk much if they criticize the organization that employs them, even when the intent is improved patient care. Knowing the economic stakes of speaking against the corporate team, I suspect many may choose to be silent.

Now that more surgeons are giving up their independence and joining the ranks of the employed, will they have the ability to unionize? Historically, surgeons have been an extremely independent breed of physician, perhaps too independent for their own good. For whatever reasons—ego, stubbornness, a view of themselves as well above the average working stiff, money, competitive juices—surgeons have never been able to use their local muscle to influence hospital behavior. Instead of being able to unionize freely decades ago, surgeons may now be forced to in order to survive.

Will unionized surgeons be given collective bargaining rights when negotiating with their employers? Will surgeons be able to strike if they feel the hospital systems they work for are not negotiating salaries or working conditions in good faith? Can you see it now, a Teamster walking the picket line in solidarity with a white-coated surgeon over improving health benefits? Will there be appeal boards to contest unfair firings? As employees, will surgeons be able to negotiate for vacations, sick time, or family leave?

The writing is on the wall for all surgeons, including me. The era of the independent surgeon is drawing to a close. More and more patients will be cared for by surgeons whose economic and surgical lives are directly influenced by the corporate entities that employ them. What, if any, impact will this dramatic shift in the surgeon’s professional world have on the access and quality of surgery practiced in the future? It remains to be seen, but there is a reason the American Medical Association (AMA) specifically addressed this shift in 2012 with new guidelines for physicians selling their practices. Tellingly, the AMA stated that “patients should be told whenever a hospital provides financial incentives that encourage, discourage, or restrict referrals or treatment options.” The AMA statement continued: “Physicians should always make treatment and referral decisions based on the interests of their patients.” Isn’t this how physicians and surgeons already practice, and have for hundreds of years? Or is it?

As a patient, should you know who your surgeon works for before agreeing to an operation? If you’re interested in a dinosaur’s perspective, the answer is “Yes!”

What do you think about Dr. Ruggieris view of the future?

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