AMA, DOJ, and managed care all on the same side?

That's right and they are all potentially aligned against doctors.

The lesson from the 1990's and again in the early 20th century was that politicians who were not competent to address health care reform in any functional way could come up with all sorts of off-the-wall-theories.  One of the most off-the-wall theories was that widespread health care fraud was a major cause of health care inflation.  It stands to reason if that is the case that is true, the perpetrators would be easy to find and put out of business.  To borrow typical language of the Executive branch it was a War on Healthcare Fraud.

To anyone who did not endure it, it is now a well kept secret.  The tactics of the government used in those days - entering clinics and doctors offices in an intimidating manner and taking out boxes and boxes of charts for review by special agents who were "coding experts" and then assigning some tremendous fine based on alleged "fraud" have been expunged from most places.  I sent two Freedom of Information Act requests to involved federal agencies and was told that information "did not exist" even after I provided the front page from one of the documents with the name of the agency.

It was quite a spectacle and it had doctors everywhere running scared.  After all, the interpretation of notes and linking them to billing documents was entirely subjective.  If a handful of notes was reviewed and bills were actually sent through the mail - racketeering charges via RICO statutes were possible and the fines would skyrocket to the point that nobody could ever pay them.  Federal prison was a possibility.  All for having a deficient note?

What followed was a carefully orchestrated set of maneuvers to render beleaguered physicians even weaker.  A decade of millions and millions of hours wasted on worthless documentation out of paranoia of a government audit.   Whose notes actually "fit" the government criteria?  The notes varied drastically from clinic to clinic and year to year in the same clinic.  And then a masterful stroke.  The government probably realized that their micromanagement of progress notes as leverage against physician productivity was probably undoable.  It would take far more agents than the budget would allow and they would no longer be able to demonstrate "cost effectiveness" in terms of recovered funds on the DOJ web site.

At that point they were able to turn this political device over to managed care companies who could selectively apply it anyway they wanted.  Some physicians noted that their documentation and coding scores by internal audit could be the best in the organization one year and the worst then next even though they had not changed any of their paperwork practices.  These audits to assure compliance with federal guidelines quickly became a mechanism for managed care organization (MCOs) to deny payment and "downcode" a practitioner's billing based on their review of chart notes.  Incredibly the MCO could deny payment for a block of billing submitted or pay much less than what was submitted.  Where else in our society can you decide to pay whatever you want for a service rendered?  That is the kind of power that the government gives MCOs.

Enter the new "partnership" to deal with health care fraud.  It is basically a coalition of the same players who have been using the health care fraud rhetoric for the past 20 years.  The DOJ, FBI, HHS OIG, large insurance companies and managed care corporations.  This quote says it all:

"The joint effort acknowledges the limitations of each health care insurer relying solely on its own data and fraud prevention techniques.  After a 2010 summit, 21 private payers and government agencies discovered that they were victims of the same scams.  As a result, the participants pledged to ban together against fraud."

The HHS Secretary chimed in:

"This partnership puts criminals on notice that we will find them and stop them before they steal health care dollars."

The newly elected psychiatrist-AMA president Jeremy Lazarus advises:

"Claims coding and documentation involve complicated clinical issues and the analysis of these claims requires the clinical lens of physician education and training."

Good luck with that Dr. Lazarus and heaven help any physician who gets caught under the managed care-federal government juggernaut.  And who protects physicians against those who are defrauding them by non payment or trivial payment for services rendered based on a totally subjective interpretation of a chart note?  Nobody I guess.  I guess we will continue to deny that is possible and a common occurrence.

This can only happen in a country where the government provides businesses with every possible bit of leverage against physicians and where most political theories about health care reform are pure fantasy.

George Dawson, MD, DFAPA

Charles Feigl.  New public-private partnership targets health fraud.  AMNews August 20, 2012.

The $40 Call

One of  the local HMOs has been heavily advertising their nurse practitioner diagnostic line. It caught my attention because the radio ad was focused on wood tick season, and it suggested the diagnosis and treatment of Lyme disease could be rapidly made over the phone and that it could require e-mailing in a picture of the rash or tick.

I used to teach a course in medical diagnostics and diagnostic reasoning and one of the examples I used in that course involved expert diagnosis of rashes from photographs.  An important part of medical diagnostics is pattern recognition. There is probably no better example than the diagnosis of rashes and it should not come as a surprise that experts in rashes or dermatologists do a much better than physicians who are not experts. That is true both in terms of making the actual diagnosis and in the total amount of time that it takes to arrive at that diagnosis.

When I heard about this new service to diagnose Lyme disease based on photographs I went to Medline to see if I could find anything written about it. Managed care organizations and HMOs frequently advertise the fact that they are evidence-based organizations. I really cannot find any studies done on using the Internet or telephone consultation for the diagnosis of rashes or Lyme disease.

I think that this new service has implications for how the business models are impacting the practice of medicine. With all the talk about transparency it would be useful for the public to know the false positive and false negative rates for this diagnostic service. That certainly would be consistent with the literature on the misdiagnosis of Lyme disease.

From a purely economic perspective, it is interesting that the cash charge for this service is on par with the most common cash charge for seeing a psychiatrist in person. As I have previously posted, there is a wide range for the psychiatric charge and it is conceivable that this telephone service generates considerably more cash than a psychiatrist does sitting in a clinic, seeing patients, and doing all of the associated administrative work.

The next logical step for this telephone service is to have patient's complete a number of rating scales and be treated for depression. Whether it is Lyme disease or depression the diagnosticians with the greatest pattern matching and pattern completion capabilities are taken out of the loop.

George Dawson, MD, DFAPA