Tuesday, January 17, 2012

Coding: Hardening of Health Care Categories

Coding is the bane of the doctor class.


January 17, 2012 - Health reformers complain bitterly and condescendingly about inefficiencies and costliness of fee-for-service. FFS, they say, encourages doctors to do more – often one step, one test, one visit, one procedure at a time – to generate more income.

Why not, they go on, bundle fees for one episode of illness, one swath of services surrounding one hospital procedure, one illness with all of its ramifications?

What these critics overlook is this reality: the arcane, byzantine, sclerotic coding system covering 7500 tasks imposed by Medicare and private health care sycophantic payers compels doctors to behave the way they do.

The coding system pays doctors for one task per visit. The patient may have multiple problems, known is federal slang as “co-morbidities,” but doctors are only paid to code for one thing or one visit at a time. There is no code for telephone calls or emails, or other tasks or knowledge that be required to address myriad problems.

The coding system, in other words, traps doctors into charging a certain way. John Goodman, founder of the National Center of Policy Analysis, explains the trap this way in “How Doctors are Trapped” in a January 12, 2012 The Health Care Blog.

Every lawyer, every accountant, every architect, every engineer — indeed, every professional in every other field — is able to do something doctors cannot do. They can repackage and reprice their services. If demand changes or if they discover a way of meeting their clients’ needs more efficiently, they are free to offer a different bundle of services for a different price. Doctors, by contrast, are trapped.”

Goodman continues:

“In addition, Medicare has strict rules about how tasks can be combined. For example, “special needs” patients typically have five or more comorbidities — a fancy way of saying that a lot of things are going wrong at once. These patients are costing Medicare about $60,000 a year and they consume a large share of Medicare’s entire budget. Ideally, when one of these patients sees a doctor, the doctor will deal with all five problems sequentially. That would economize on the patient’s time and ensure that the treatment regime for each malady is integrated and consistent with all the others.”

Under Medicare’s payment system, however, a specialist can only bill Medicare the full fee for treating one of the five conditions during a single visit. If she treats the other four, she can only bill half price for those services. It’s even worse for primary care physicians. They cannot bill anything for treating the additional four conditions.”

“Since doctors don’t like to work for free or see their income cut in half, most have a one-visit-one-morbidity-treatment policy. Patients with five morbidities are asked to schedule additional visits for the remaining four problems with the same doctor or with other doctors. The type of medicine that would be best for the patient and that would probably save the taxpayers money in the long run is the type of medicine that is penalized under Medicare’s payment system".

FFS may be inefficient because of the coding system’s “one-task-at-a- time” mentality. The system permits no flexibility, no consolidation of services, no way of repricing services to fit the total task at hand – or the totality of time, effort, and knowledge that goes into addressing the clinical and social situation.

Tweet: The physician coding system pays doctors for one-task-at-a- time rather than the time, energy, and knowledge required for the total task.

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