Current billing process is a monopoly business controlled via RBRVS based CPT/ICD coding system and it is one of the root causes of excess costs and corruption. Government and Insurance Industry love this system since it provides them means to control the money.
Following paragraph is taken verbatum from wikipedia. Read it and think : Why should we allow such a corrupt system to control and distribute trillions of healthcare dollars?
"The
RBRVS system has been criticized on a number of
grounds:
Paying based on effort rather than effect skews incentives, leading to overuse of complicated procedures without consideration for outcomes.[3] Contrast with evidence-based medicine (EBM), which is based on outcomes.
According to this critique, RBRVS misaligns incentives: because the medical value to the patient of a service is not included in how much is paid for the service, there is no financial incentive to help the patient, nor to minimize costs. Rather, payment is partly based on difficulty of the service (the "physician work" component), and thus a profit-maximizing physician is incentivized to provide maximally complicated services, with no consideration for effectiveness.
One effect attributed to RBRVS is a lack of primary care physicians (PCPs) at the expense of specialists – because specialist services require more effort and specialized training, they are paid more highly, incentivizing physicians to specialize, leading to a lack of PCPs.
The regulatory committee (RUC) is largely privately run, an example of regulatory capture.[3]
The regulatory committee (RUC) is secretive, with the meetings being closed to the public and uninvited observers.[3][4]
The data is effectively copyrighted by the AMA, but its use is required by statue.
Although the RBRVS system is mandated by the
Centers
for Medicare and Medicaid Services (CMS)
and the data for it appears in the Federal
Register, the American
Medical Association (AMA) maintains that
their copyright of the CPT
allows them to charge a license fee to anyone
who wishes to associate RVU values with CPT
codes. The AMA receives approximately $70
million annually from these fees, making them
reluctant to allow the free distribution of
tools and data that might help physicians
calculate their fees accurately and fairly."
There is a lot of talk about over utilization of the health care and ‘too many’ procedures being done by the doctors. President claimed that 30% of the total cost is because of unnecessary procedures. There is some truth to this claim but we have not heard anybody (liberal or conservative) trying to explain why this is happening.
CPT stands for Current Procedural Terminology and as the name suggests it is designed to reward the procedures.
Next few paragraphs we attempt to explain the daily business in our current healthcare system: Out of thousands of CPT codes, let us analyze one of the most common code used in physicians’ offices: 99213. This is a payment code for an established patient visit. We dare challenge all the politicians and the general public if they have any idea what this means.
Example # 1
Let us compare two medical providers: The following scenarios are realistic examples that illustrate how absurd the CPT system is. A highly qualified physician Dr. Experience gets punished for making the right decision while inefficiency is rewarded by higher payment to PA Rookie.
Dr. Experience:
A renowned specialist physician with 8 years
of medical school plus 8 years of post-graduate
training, and 10 years of medical experience.
Physician Assistant
(PA) Mr. Rookie: A novice who has
just graduated with 2 years from a PA school,
and has no experience.
Now, let us say Mr. Universal is an established patient of Rookie clinic who comes to visit PA Rookie for complaint of chest pain. After a thorough evaluation, PA Rookie has no clue what is going on, but he still gets to charge 99213 according to Medicare rules and receives the same payment as Dr. Experience. Then, he orders several tests to find out what is wrong with the patient. The tests cost $3,000, and they all come back inconclusive, so finally, PA Rookie refers patient to Dr. Experience.
Let us say Mr. America is an established patient of Experience Clinic, who comes for a medical visit with Dr. Experience for chest pain. After spending 15 to 20 minutes with the patient and completing a thorough evaluation, Dr. Experience correctly diagnoses that chest pain is due to ‘gas and indigestion’ and prescribes appropriate treatment. Current Medicare rules allow him to charge CPT code 99213 to patient’s insurance. ($58.89)
http://www.wpsmedicare.com/part_b/fees/physician_fee_schedule/_files/2011-il-12.pdf
After few years in practice, Dr. Experience realizes that his overhead cost is out of control, and revenues from 99213 or similar services are falling short to maintain his practice. He discusses with his office manager what needs to be done and he decides to check around what his colleagues are doing. Dr. Experience realizes what the answer is and decides to change his practice accordingly. Next time when the patient presents with a similar problem, Dr.Experience spends only 3 minutes with the patient and as a specialist he schedules several procedures for the patient. After performing the procedures, he is able to use several more CPT codes in addition to 99213 and his revenues increase by 3 times. The additional hospital cost of the procedures is about $15,000.
Example # 2
This is another example of the CPT system:
Dr. Experience: Board Certified Specialist with 10 years of experience in practice.
PA Rookie (Physician Assistant): Recently graduated from PA school (not a medical school) one year ago.
A patient visits Dr.Experience for a follow-up blood pressure treatment. Dr. Experience performs a detail examination and gives his recommendations. ‘By the way Dr.Experience, I have a hang toenail that has been bothering me for a few days’ the patient says. Dr.Experience inspects the nail and correctly decides that the nail will come off in a few days without any surgical intervention, so he assures the patient and gives him instructions on how to take care of it.
A similar patient comes for a follow-up to Rookie Clinic for blood pressure treatment and also mentions a hang toenail. PA Rookie is a kind and caring provider and performs a detail exam for which Medicare allows a visit charge 99213. However, PA Rookie in not sure about the diagnosis and what the treatment plan should be. He decides to orders an X-ray of the foot and, then, determines that the nail needs to be removed. He then performs a mini surgery for the toenail excision.
What are the outcomes in the above scenarios? Same? Different? Or who knows? Do you think the patient ‘Mr. America’ knows? Can you imagine this happening in any other private business? This is like mendating that a burger at a burger joint, a steak at a fine steakhouse, or a meal at a nice French restaurant all cost the same.
This is today’s system. No accountability, no quality control, unnecessary overhead cost and over utilization. This is what goes on every hour, every day across the country, and therefore we are spending more than $2 trillion in healthcare while countries like Japan spend only one-third of what we spend per capita in healthcare.
The CPT system adds tremendous bureaucratic burden and extra cost on hospitals and doctor’s offices and forces them to find creative ways to generate revenues. Abolishing this system will reduce overhead cost from the entire healthcare industry by more than 10-15 %. The payments should be based on Doctor’s level of training, experience and efficiency and patient satisfaction, and not for the procedures and diagnostic tests. Thus, physicians will have to do fewer procedures to maintain their income, and less procedures means hundreds of billions of savings.
Joe
Joe was moderately successful in his career, but as he got older he was increasingly hampered by incredible headaches He finally came across a doctor who solved his problem. "The good news is I can cure your headaches... The bad news is that it will require castration. You have a very rare condition, which causes your testicles to press up against the base of your spine. The pressure creates one hell of a headache. The only way to relieve the pressure is to remove the testicles." Joe was shocked and depressed. He wondered if he had anything to live for. He couldn't concentrate long enough to answer, but decided he had no choice but to go under the knife. When he left the hospital, his mind was clear, but he felt like he was missing an important part of himself. As he walked down the street, he realized that he felt like a different person. He could make a new beginning and live a new life. He walked past a men's clothing store and thought, "That's what I need: a new suit." He entered the shop and told the salesman, "I'd like a new suit." The salesman eyed him briefly and said, "Let's see... size 44 long." Joe laughed, "That's right, how you knew?" "It's my job." Joe tried on the suit. It fit perfectly. As Joe admired himself in the mirror, the salesman asked, "How about a new shirt?" Joe thought for a moment and then said, "Sure..."
The salesman eyed Joe and said, "Let's see... 34 sleeve and... 16 and a half neck" Joe was surprised, "That's right, how did you know?" "It's my job." Joe tried on the shirt, and it fit perfectly. As Joe adjusted the collar in the mirror, the salesman asked, "How about new shoes?" Joe was on a roll and said, "Sure..." The salesman eyed Joe's feet and said, "Let's see... 9-1/2... E." Joe was astonished, "That's right, how you knew?" "It's my job." Joe tried on the shoes and they fit perfectly. Joe walked comfortably around the shop and the salesman asked, "How about a new hat?" Without hesitating, Joe said, "Sure..." The salesman eyed Joe's head and said, "Let's see... 7-5/8." Joe was incredulous, "That's right, how did you know?" "It's my job." The hat fit perfectly. Joe was feeling great, when the salesman asked, "How about some new underwear?" Joe thought for a second and said, "Sure..." The salesman stepped back, eyed Joe's waist and said, "Let's see... size 36."
Joe laughed, "No, I've worn size 34 since I was 18 years old."
The salesman shook his head, "You can't wear a size 34. It would press your testicles up against the base of your spine and give you one hell of a headache.
