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. I'm getting confused].

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

Medicare spends a lot of money unnecessarily

You may find this story hard to believe, but it's 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.

I've 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?

It's 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. There's 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 couldn't have discovered these obvious outliers on its own.

Routine check-ups every 6 months seem easy enough to identify and squelch. Why can't 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.

A different take on Medicare's release of doctor payment data

Journalists have had a good time with the Medicare data on payments to doctors. The most recent exposé is headlined "Taxpayers face big Medicare tab for unusual doctor billings" by the Wall Street Journal. Because of a paywall, most people did not have a chance to read the article.

It recounted several anecdotes about physicians who received huge amounts of money for procedures of dubious worth. I will summarize two of them.

In 2012, an internist in Los Angeles was paid close to $2.3 million for a procedure known as "enhanced external counterpulsation," or EECP, which is supposed to ameliorate angina in patients who are not surgical candidates.

Although not a cardiologist, he apparently used EECP on 615 patients. At the Cleveland Clinic, whose chairman of cardiology says the procedure should rarely be used, the procedure was performed on only 6 patients in a year—that's 6 patients total by a staff of 141 cardiologists.

A Florida dermatologist received $2.41 million from Medicare in 2012 for 15,610 radiation treatments for melanoma in 94 patients, an average of 166 treatments per patient. The usual number is 20 to 35 treatments. The doctor said he billed for each lesion separately and treated each one about 40 times.

A radiation oncologist who was interviewed questioned the appropriateness of the machine the dermatologist was using and said, "When a patient has several lesions, they commonly get treated simultaneously and are billed for as a single treatment, he said."

That is the way Medicare handles most multiple procedures. At best you might get away with billing a partial amount for an additional treatment.

Any physician who has spent time in the private practice of any medical specialty that involves the treatment of elderly patients can tell you that Medicare will nickel and dime you to death over a minor dispute about an evaluation and management code.

Medicare is also notorious for holding back money due to physicians who are just trying to make a living. A classic ploy is to request a copy of the dictated operative note for a simple procedure. This will add 4 to 6 weeks to the eventual cutting of a check.

They routinely perform unannounced on-site audits of doctors offices looking for discrepancies in documentation. I once experienced one myself and luckily was not cited or fined.

Here are some questions that I haven't seen any journalist ask.

Why does the Wall Street Journal have to point out such flagrant outliers? What does the Wall Street Journal know about detecting these practices that Medicare could not do for itself? How can Medicare continue to pay top dollar for questionable treatments and billing practices? Why doesn't Medicare do something simple like automatically reviewing any practice that receives more than say $500,000 in a single year?

Inquiring minds want to know.

What's your opinion?

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Why the No-Pay Policy for In-Hospital Infections Failed

I told you so.

Three months ago, I blogged about the Medicare (CMS) “never events” list, diagnoses that Medicare will no longer reimburse hospitals for. In Medicare’s eyes, these diagnoses are totally preventable, should never happen and will not be reimbursed. I pointed out that several were in fact not 100% preventable despite any institution’s best efforts, and the rates of many of these occurrences would not fall to zero.

Now the esteemed New England Journal of Medicine has published a paper which confirms what I wrote back in July. Its 13 authors compared rates of central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), two of the diagnoses on the “never events” list, with ventilator-associated pneumonia, a disease not on the list, as a control.

After reviewing data from 398 hospitals from before and after the establishment of the new Medicare rules, they found that quarterly rates of all three infections did not change and concluded that the “never events” policy was ineffective. The senior author of the study then tweeted “Our paper in NEJM - CMS non-payment policy didn't change infection rates. Do we need much stronger penalties?”

My answer to that question is “No.”

Penalizing hospitals did not work because we may have reached the lowest possible rates of infection already. Some infections will occur no matter what steps are taken. We are dealing with human patients and human care-givers. Perfection is not likely to happen.

Many people erroneously believe that all CLABSIs can be prevented with the implementation of strict sterile precautions when catheters are inserted. That has lowered infection rates but not to zero. Why not? In addition to the technique of insertion, CLABSIs can result from other factors. Solutions may become tainted. The integrity of the IV line itself may be violated during the administration of medications through the line. The dressing covering the line may loosen and allow bacteria to enter the puncture site. Patients may be immunosuppressed and unable to overcome even the slightest hint of contamination. Or maybe it’s just bad luck.

CAUTIs are also not totally preventable. Despite a major push to remove urinary catheters as soon as possible, some patients need them for days to weeks for many reasons. For example, there are patients who simply cannot urinate on their own due to old age, dementia, coma, paralysis, etc. Critically ill patients with marginal urine outputs need urinary catheters for monitoring. Patients who are incontinent of stool may contaminate their catheters despite the best nursing care.

No, much stronger penalties will not work.

How about if we simply decide what is an acceptable rate for these infections and aim for that?