I had some fun last week with a true patient care experience from one of my family physician colleagues. While the content was unusual and humorous, the case raises questions about the greater issue of support for the work of family physicians, and the lack thereof by all the payers, both governmental and insurance companies. Here is the link if you’d like to review the details of the case: http://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-undefinable-work-of-a-family-physician-and-how-it-saves-society-a-fortune-part-i/
In this encounter, the patient wanted to talk about a number of concerns. Here I list the concerns and how the family physician responded.
- Depressive issues (but not really a diagnosis of clinical depression) – By taking the time to listen to the whole situation, the physician realized the depression was situational and was not adversely impacting the patient’s functionality. In other words, he had not lost his job because he stayed in bed crying all day. Brief guidance and counseling were provided, but no prescription was written. There are no good ICD-9 codes to tell an insurance company computer what the physician was really concluding in this case.
- Hypersexuality – The physician pretty much chose not to address this directly, though a recommendation was given at the end of the encounter. She did not prescribe formal counseling or Viagra. (Nor is there a good ICD-9 code for this issue.)
- Wheezing – The physician determined that the patient did not have asthma as he thought, but she concluded that his periodic wheezing was the result of smoking cocaine. She advised him to quit doing this. In the practice environment she works, other patient care options such as substance abuse rehabilitation and de-tox programs are not available. She did not prescribe any inhalers.
- Leg pain – She did not prescribe any treatment for his leg pain, especially a wheelchair, but advised him to take over-the-counter medications.
- Fear for his life – This was not a case of paranoia, as the physician found out when she took time to listen to the whole story. As we say in mental health sometimes, patients are not paranoid if someone is really out to get them. She prescribed no anxiety medications and recommended attitudinal and behavioral changes. (Same ICD-9 problem here too.)
Therefore, she addressed five distinct issues. The payers only pay for one or two issues per clinic visit in general, but the lack of payment is even more striking in this case. Here are the treatments she could have ordered that no insurance company computer would have caught as unreasonable (and I won’t even jack up the dollar amounts by assuming she wrote for branded drugs):
One year of a generic anti-depressant: $240
One year of Viagra: $2400
(and let’s assume he had sex only 1/3 of the days)
One year of albuterol and an inhaled steroid $840
One month of prescription naproxen $40
Plain wheelchair $150
One year of a generic anti-anxiety medication $150
(assume in addition to the anti-depressant)
Even if you assume that the Viagra charge is overkill because some insurance plans don’t cover its cost, the total is still well over $1,000.
How much did she get paid for this prudent care? The details are too convoluted and boring for me to thoroughly explain, but the reality is that she would only be allowed to code a 99213, which is a low complexity visit. The number of issues she addressed stops adding to the allowable-fee point system after the second issue. The fact that she did not order a bunch of tests nor write a prescription made her ineligible for the next higher code.
Yes, I’m telling you that the existing payment rules for primary care incentivize physicians to order more tests and write prescriptions.
This patient encounter was probably paid at a Medicare rate, which for Fort Worth is $69. If he had private insurance, it would be about $80. If he were on Medicaid, it would be about $40.
Therefore, society paid her about $70 to provide excellent care to this complex patient, and she saved society somewhere between $2,000-$4,000 by applying the culture and attitudes of family medicine to her decision making. She did this not because she got some sort of bonus or kickback for refusing to squander scarce healthcare resources, but just because in her judgment, her decisions represented the best care for her patient. The existing coding structure does not allow a physician to tell a computer all the things she did not do.
Better care at a lower cost. This case is a snapshot of how family physicians deliver the magic. Too bad the payers just don’t get it; nor Congress; nor the media; nor the regulators; nor the employers; etc., etc.
If you better understand now why so few American medical students choose to become family physicians, please spread the word. Our children’s futures depend on it.