| Today I'll talk about section 3003, addresses "improvements to the physician feedback system". Since I see only children in my practice, I've never gotten feedback from Medicare, only Alabama Medicaid and private insurers-- so I can't tell you what Medicare's feedback looks like now. I would imagine it is similar. The Secretary of HHS is supposed to develop "episode groupers" that combine "separate but clinically related items and services into an episode of care for an individual." Then physicians will be compared, both individually and in group practices, according to the resources they use (i.e, how much it costs for them to see a patient for an episode). Very vaguely, this section says the secretary might include quality information if it is appropriate. This information will be made public. And once again, the strange stipulation that there will be no possibility of administrative or judicial review of these measures. Since the "episode groupers" haven't been published yet, I'm not completely sure what they will look like. Maybe something like this-- a patient comes to see me with headaches. I do a certain amount on the office history and exam (which falls into a certain category of billing). For a typical child with recurrent headaches-- more common than you would think--I would need to do a fairly extensive history and physical. Remember, almost all diagnoses can be done correctly from a good H and P. I'd need to know all the details of what the headaches are like, when they happen and so on, which can take quite awhile to figure out if the family hasn't really been thinking about these things (me: "so how often does she have a headache?" Parent: "oh, every so often." Me: "is that something like once a week, once a month?" Parent: "well, it's every time she has a test in math". Me: "so, about how many math tests has she had this month?" and so on). It can go like that for every single question sometimes, but then I feel really victorious when I arrive at the answer! I need to know about the child's sleeping and eating patterns, caffeine intake, stress, family history, behavior changes, and many other things, and then I need to do a complete neurologic exam. |
If all those questions add up to sounding like one of the most common headache causes in children (usually either migraines or tension headaches), and if the exam is normal, then I don't need any other tests and in fact should NOT do them-- now my job is to educate the family on the diagnosis and what we can do about it. But let's say after doing all that, I find a red flag-- something like new, worsening headaches over just a few weeks with vomiting every morning, behavior changes, or an abnormal neurologic exam-- and I am worried the child could have a brain tumor. Fortunately that's rare-- I see kids with headaches every week, and in 14 years I've only had 3 with tumors. So even a red flag isn't likely to mean there is a tumor, just that I need to be sure. At that point I will need to order an MRI. If there's not a tumor, then we go back to managing the more common causes of headaches-- if there is a tumor, the child goes to neurosurgery and oncology. So I'm guessing the "episode grouper" would see either a level 4 or 5 office visit (level 5 is the most detailed) from me, plus or minus a prescription in the first instance, a level 5 visit plus an MRI with a possible prescription for the second, or a level 5 plus an MRI plus surgery/ hospital charges/ chemo/ radiation for the third. Personally, I wouldn't worry so much about trying to cut costs in the third case, just about doing everything possible to save the child. But when docs see kids with ordinary headaches, we can do a lot to help improve both care and costs. This might be an improvement over the current types of reports I get. Right now, my office visit charges and prescription costs are compared to my "peers" (and they don't tell me how they picked my peers). Also, for Medicaid, they count the number of ER visits my patients make. I'm happy to say I come out either even or ahead most of the time, but sometimes there are weird things in the reports. Since we are a medical school clinic, we tend to see patients with more complicated problems. We specifically get a lot of premature babies who have exhausted their private insurance benefits and wind up on Caid. When we get into the fall/winter, those babies may need to get a specific, extremely expensive medicine to help prevent severe infections with RSV (a virus everyone gets at least once a winter). We don't do that-- a local pulmonologist does it for us at his office. But the cost of that medicine actually gets attributed to me, and if I've had a lot of preemies lately, because I don't use a lot of other prescriptions that would average it out, it makes my generic and low-cost prescription ratios look bad. Recently, I got a report that had my prescription costs far worse than my peers-- have never had one like that before-- and I was puzzled until I looked at the details. The whole problem was a single prescription item that a specialist in Birmingham had given to a new patient in my practice-- he has a rare disease which can fortunately be treated, but it will be very very expensive. Trust me, he's worth it! But it doesn't make any sense for the insurer to give me bad marks on my costs due to only one such prescription. So maybe these new episode groupers will take that into account. A doctor who does longer, more detailed and maybe slightly more expensive office exam than a doctor who just says "oh, you have headaches? Let's do an MRI", because the first doc won't need to order as many expensive studies for a certain illness. It might take longer to do the counseling so that the family can help the child have fewer headaches, but the doctor who doesn't take time to do that will wind up doing more office visits and prescriptions later when the headaches have continued-- and then maybe will send the child to a neurologist to do management that she could have easily done herself. So then when I call the neurologist to refer a child for seizures, it takes me months to get him an appointment because of all those patients who didn't need to go to a specialist. Or when I want an MRI, it takes several days because of all the kids who shouldn't have had one but are scheduled anyway. If we used those resources more wisely, I think we'd have enough. See how seemingly small issues like that can wind up crashing the whole system? I don't know if using episode groupers will help change behaviors or not-- it will depend on how much detail we get. If I see that I am out of line but that it is appropriate because of the patient involved, that's fine. But if I see a discrepancy and can't figure out why I am suddenly a more expensive doc, then I won't know what to change. So I certainly hope HHS will seek input from docs on this. They sure haven't asked me! |
