Sunny with a chance of gloom
There is potential good news on the Medicare horizon as far as family physicians are concerned. However, the silver lining is attached to a big, black cloud that could rain on everyone's parade unless Congress intervenes by the end of the year.
On Friday, Oct. 30, the Centers for Medicare and Medicaid Services (CMS) put the final rule on the 2010 Medicare physician fee schedule on display for review and comment by all interested stakeholders. CMS plans to publish the final rule in the Federal Register on Nov. 25, 2009. CMS will accept comments until Dec. 29, 2009.
In the final rule, CMS finalized many of the proposals that it made in its proposed rule earlier this year. For those of you keeping score at home, that's good news for family physicians. In fact, in the final rule, CMS estimates that family physicians will experience a 4 percent increase in their Medicare allowed charges in 2010 as a result of the rule, all other things being equal. That is second only to ophthalmologists and optometrists, who are projected to reap a 5 percent increase, and much better than physicians in many other specialties, who are expected to see a decrease in their 2010 Medicare allowed charges as a result of the rule.
Of course, with Medicare, there's always a catch, and the final rule on the 2010 physician fee schedule is no exception. Under current law, the Medicare conversion factor, which translates Medicare's relative value units into payment allowances, is scheduled to decrease 21.2 percent on Jan. 1, 2010, which would more than wipe out the potential gains for family medicine noted above. That means Congress has until Dec. 31, 2009, to intervene, as it has the last several years, to avoid this cut. Forecasters inside the Beltway are optimistic, but as they say on Wall Street, past performance is no indication of future returns.
So, as we approach the new year, the outlook is sunny, but you might want to keep your umbrella handy, just in case.
Posted at 02:17PM Nov 05, 2009 by Kent Moore | Comments[0]
You might be a coding and payment geek if . . .
The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people. So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:
10. The first thing you associate with December is the arrival of the new CPT book.
9. You actually get excited when your new coding books arrive.
8. You wonder why the toy doctors bag you bought your kid doesn't include a claim form.
7. You worry your family physician is undercoding your visit.
6. You consider the Federal Register light reading.
5. You write to CMS more than to your own mom.
4. You actually understand Medicare's Sustainable Growth Rate formula.
3. You collect past issues of CPT Assistant on eBay.
2. When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.
And the number one sign that you might be a coding and payment geek:
1. You actually understood the humor in this blog post!
Posted at 01:10PM Oct 22, 2009 by Kent Moore | Comments[0]
Why?
I am trying to figure out why family physicians choose to contract with health plans.
My pondering of this question is prompted, in part, by an article, "What Does It Cost Physician Practices to Interact with Health Insurance Plans," which appeared as a web exclusive on May 14, 2009, in Health Affairs. According to the article, primary care practices spent $64,859 annually per physician – nearly one-third of the income plus benefits of the average primary care physician – on interactions with health plans. The article also notes that primary care physicians, especially those in small practices, spend larger amounts of time interacting with health plans than physicians in other specialties.
Why would a family physician voluntarily spend almost $65,000 per year for the opportunity to interact with commercial health plans? What do family physicians think they are getting for their money?
The article suggests that there are benefits to these interactions. For example, the authors point out, prior authorization and formulary requirements may reduce costs and improve the quality of care by reducing the inappropriate provision of services and promoting the use of appropriate procedures and medications. That may be, but somehow, I doubt that's why family physicians buy into the process. After all, $65,000 per year would go a long way toward the purchase of an EHR with decision support tools and electronic prescribing, which might also achieve the same results with less aggravation in the long run.
Some might suggest that family physicians don't "choose" to contract with health plans, that they have to do so for their practices to be viable. In this view, health plans are like some sort of health insurance Mafia that make family physicians "an offer they can't refuse" to ensure their practices stay open. Given the relative bargaining strength of family physicians and most health plans, this view is understandable.
The corollary to this answer is that if a family physician chooses not to contract with health plans, he or she won't have any patients, or at least not enough to sustain the practice. The premise here seems to be that patients do not value the services of family physicians beyond the co-payment most of them currently must pay for an office visit.
However, there are some problems with this answer and its corollary. One problem is that there are examples of family physicians who have successful cash-only practices, and I'm not talking about the kind of practices that only cater to the lifestyles of the rich and famous. Family Practice Management has highlighted some over the years; for example, see "2,500 Cash-Paying Patients and Growing" in the February 2006 issue.
Another problem is that it's not clear where else all of these patients would go if family physicians opted out of contracting with health plans. According to a one-pager produced by the Robert Graham Center, family physicians and general practitioners provided 24 percent of the average 838 million visits per year provided by all physicians in 2003. If my math is correct, the rest of the system would have to increase its capacity by one-third to cover all of those visits, if patients decided not to see family physicians because they didn't accept insurance. I find it hard to believe that is possible.
I understand that the counterpoint here is that contracting decisions are made at the individual practice level, not the level of the specialty as a whole. In other words, family physicians contract with health plans because they are afraid that if they don't, their patients will go to their colleagues who still do. I understand that counterpoint to mean that family physicians choose to contract with health plans because their colleagues do, from which one might conclude that if their colleagues jumped off a cliff, most family physicians would do the same.
A third problem with the "I-can't-afford-not-to" argument is that it runs contrary to what family medicine is saying and has evidence to support regarding the value of family physicians. Much of what is being discussed in the context of health care reform shows buy-in for the notion that there is value in primary care, and proposals on Capitol Hill would spend billions on primary care, including family medicine. Yet, interestingly, many family physicians seem convinced that patients won't pay more than $25 for their services.
The only remaining answer I can discern to the question of why family physicians contract with health plans is that they are making money on the deal. In short, it must be worth more than $65,000 per year to contract with health plans. I would find this answer more convincing if family medicine did not consistently rank near the bottom of earning lists by specialty. I would also find it more convincing if the percentage of U.S. medical student graduates choosing family medicine was higher or trending upward.
In the end, the more that I ponder the question of why family physicians contract with health plans, the less that I think I know the answer.
Posted at 09:28AM Sep 16, 2009 by Kent Moore | Comments[0]
