Tuesday, June 10, 2008

Arrrrrggggghhhhh!



Below are three pages from the latest ACS (American College of Surgeons) Bulletin. I apologize for the quality, but it was a pdf file and I couldn't copy it directly; these are screen shots. For any readers who are surgeons, I also apologize for picking at a scab.





Assuming it's not really readable, let me explain. It's three pages of codes and explanations for how to bill for lymph node biopsy (SLN: sentinal lymph node biopsy) in various scenarios with or without various breast procedures. Let me also add: improper coding, as far as Medicare is concerned, is a felony. Fraud. Punishable by very heavy fines, and imprisonment. For nearly any other operation, there are similar rules, exceptions, combinations, suggestions, complications.

Now consider this: unless over-ridden by Congress, there are scheduled payment decreases in the pipeline for Medicare reimbursement, to the tune of about 16% in the next year. That's, of course, after lowering payments by about two-thirds since I first went into practice, and making it illegal (felonious, of course) to charge for the difference between one's "fees" (as if one's personal setting of a fee has any meaning) and Medicare payments.

Despite the inevitable comments that doctors are overpaid, ego-driven, profit-taking purulent pustules of putrefaction, isn't it logical to think that we're heading for trouble? Is it reasonable to think there's a point, for even the most selfless of people in any walk of life, at which the graphs of increasing hassles and of decreasing rewards (monetary and otherwise!) cross, and drive current workers out and turn away future ones?

Stir in and mix thoroughly: the projected shortfalls in the future number of surgeons required to fill the needs of the US.

Trouble. And that starts with T and that rhymes with R and stands for retirement.

21 comments:

Dr. John Baldwin said...

Before I "quit" (not retired) general and vascular surgery in Monterey, CA I had my CPA do a cost analysis. Conclusion: after all expenses, including office, staff, insurance (never sued 35 years), taxes, multiple licenses: for being an MD, for Rx, xrays, city, county and 401K for employees, their health insurance...I was clearing 18 cents on the dollar. As far as overpaid slugs, I note Barry Zito of the SF Giants has a seven year $128 million contract, which works out to $9,000 a pitch assuming a 20 game, 100 pitch/game season. Granted, he has talent I can't touch (even if his record this year is 1 won 9 lost) but we save LIVES for $200. Not any more...Ten years from now you will have to look long and hard for a good surgeon, but be sure not to get sick in anyplace even faintly resembling "rural".

rlbates said...

So Sid and JB, with the 16% cut and other increases in overhead costs what do you project the cleared on the dollar to be? If we haven't crossed to the negative, I'll be surprised.

Sid Schwab said...

ramona: based on the calculations my former clinic made, there were many codes for which the reimbursement was less than overhead, and that was a few years ago. It was for office codes, as opposed to procedures; but the trend has continued in all areas.

I should add that was in particular related to the Washington state equivalent of medicaid. But Medicare has dropped a lot since then, too.

The Happy Hospitalist said...

May I present to you Dr E&M. He can explain to you all about it.

Elaine said...

Not P for Pool, then!

Resident Anesthesiologist Guy (RAG) said...

I think that's one of the reasons newer surgeons are starting to move on the hospitalist movement. Personally it sounds like we've already breached the tipping point and it will continue to get harder for patients to see a surgeon - emergency, elective, or otherwise.

Buckeye Surgeon said...

Love the comment from dr baldwin. The ridiculous salaries for athletes makes it pretty hard to give a shit anymore if your favorite team wins or loses. It's just a travesty...

Ros said...

The solution is simple; give up medicine and go into government. The only remaining growth industry!

Bonewitz said...

Two things:
1. recent review BCBS, Aetna, United, Cigna Humana all pay within 10% of medicare for surgical codes.
2. Since Medicare's first cut in 1978, the consumers price index CPI has risen at least 3% a year; Medicare has cut at least 66% of our fees. All other insurances follow this Federal Subsidy. In a perfect world reinbursement rising with the CPI ,Medicare should be paying (1.03^30) or $243 dollars on $100 in 1978, where they are paying $34. So Medicare is paying 14% of what a logical businessman would assume.
Surgeons, all physicians are so hosed with this reimbursements.

Stalwart Hospitalist said...

T rhymes with R?

Sid Schwab said...

SH: Variation on "Trouble," from "The Music Man." Humor, or attempt at. In the form of absurdity. I thought medical types were supposed to be less literal than us surgeons.

Dr. John Baldwin said...

From American College of Surgeons June 08 Bulletin (same issue that had Sid's complicated three pages on how to bill for a lymph node!):
"Surgical practice in the near future will have all physicians as employees, with surgeons siloed into pre-op, intraoperative, and post op designations, the workday will be 8 hours in a 40 hour workweek, and continuity of care (as we know it now) will be extinct." Edward Copeland MD Prof Surgery, Univ Florida/Donald Trunkey, MD Prof Emeritus Univ Oregon.
I agree that this is the evolution, and in a nation with rapidly expanding and ageing populations in which US medical school graduates have not increased for 30 years, the future is "shift" docs mainly foreign trained, mostly in urban areas.
Just as we don't want to pick lettuce and a force came in to do it for us, being a glamorous doctor will pass into history and a force, probably less talented will take over.
Stay healthy and try to avoid the system. I apologize for bailing out before age 60, but frankly, I had done it all...the big University, a shooting war and a wonderful town practice..the only thing left for me was the "big mistake", otherwise known as wrong side, wrong person or wrong organ surgery. Thanks for listening...

Lynn Price said...

Can you imagine how poor docs will be with nationalized health care? The government will have the ability to pull a "Medicare" anytime they want. Bunch of hucksters.

peter said...

It's funny how the politicians constantly talk about improving "access" to healthcare, but no one seems to address the question of who'll be around to provide that access. It'd be interesting if at a debate someone actually asked about the reports predicting a physician shortage and asked what each candidate proposed to do about it. I'm no economics genius, but if a shortage of workers looms, I can't see how further cuts in pay are likely to improve the situation.

While not in a hospitalist situation yet, our practice has recently become (effectively) hospital employees. Our practice, while busy and leanly run, simply wasn't viable anymore. It seems not too long ago that we all were debating whether a solo practicioner was viable anymore. Now the question seems to be whether private practice of any kind is long for this world.

M said...

Thank you for your reply the other day, Sid.

"Once you lay your hands on a patient, that patient is yours."

These words came to me after I dealt with a head injury today. It was something of an epiphany.

dr. bean said...

"soul-destroying" is my moniker for this kind of administrative burden and the fear/intimidation that go with it.

And the psychological factor of being continually stiffed-I'd rather work for free half the time than get paid half what I'm worth all the time and told it's what I deserve. It's easy to feel resentful and lose sight of why I do this.
In a few years I'll pack it in and go work for Doctors Without Borders. You watch me.

Annie said...

The Senate Republicans beat back Medicare reimbursement restoration legislation, and on the same day, it's reported that over 60 BILLION in Medicare fraud occurs annually with only about 5% of claims audited, which if recovered, would pay for physician reimbursements 3x over.

And then I learned about Section 22 - the banality of evil courtesy of the OMB and how the agencies hide their funding needs to make them- er - functional.

Incredible, the government gutting that has gone on.

Sid Schwab said...

Yeah. In their quest to show government is the problem, a la Reagan, the Bushies have pretty much destroyed all accountability and competence. QED.

Health Train Express said...

Sid, I don't know where you find these allegorical pictures. The "meltdown" and slow strangulation of physicians is perfectly pictured here.

Medicine has become terrible. Even at that, just read some of the word gibberish that is published by the OMB in section 22 mentioned by a commentator above.

Yes there will be greater access, to CVS minute clinics (which by the way has one in my neighborhood. There are usually two PAs there and zero patients almost every time I walk by....
I give this about 24 months before the banks call in the loans and capital from CVS et al.

Then too I have been wrong about DRGs, HMOs, RVS codes, SGRs (they will never work...They didn't, but let's pretend they did....

Chris Bent said...

Hmmm, the worst part about posts like these is knowing I made the wrong choice doing research in breast cancer/mammography instead of plastic surgery :( Perhaps I really should have tried to be an engineer like my girlfriend, her current job and future prospects look brighter than mine everyday. Hell, no one tells her company what they can and cannot charge clients.

The 24 yr old MSIII.

Sid Schwab said...

Well, Chris, I feel bad when I read comments like yours, because we do need good people to choose medicine as a career, and I'm glad you did. Given the need for good doctors, it seems that the system will eventually be re-oriented in a way to find a balance. Let's hope so.