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According to a recent study summarized on Medscape.com,  about 50% of all patients don’t fill their prescriptions.  It is estimated that $100 billion dollars in unnecessary hospitalizations and $177 billion dollars total in direct and indirect health care costs are a result of people not taking their prescribed medications.  But why?  Why don’t people fill their prescriptions?

Some say it’s a lack of education – patients do not understand why they need the medicine so they don’t use it.  Or patients are prescribed medication that they have adverse reactions to and rather than discuss them with their doctor, they just quit taking it.  A lot of it could just be forgetfulness, especially if the doctor hands the patient a paper prescription that they have to deliver to the pharmacy and then wait for.  And of course there is the issue of cost – many people do not fill their prescriptions because they cannot afford them. 

Electronic prescriptions can help the problem but do not solve it – still about 22% of all e-prescriptions are never picked up.  Hopefully provisions in the health care reform act, such as the closing of the Medicare donut hole in prescription drug coverage, can assist people with the cost of their medications.  But I think it really comes down to education – doctors taking more time to describe to patients why the medication is important, even life saving, for them to take.  And for doctors to make sure they are prescribing medications that are indeed necessary.

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As more Americans become insured under the health care reform plan, the need for primary care doctors is going to become substantial.  This week in Washington there is a meeting going on to figure out how to deal with the increasing need for primary care doctors and the decreasing number of medical students going into primary care.  Leslie Kane, a blogger on Medscape.com, addresses two of the changes being currently discussed in her recent blog post.  They are:

1. Increase the 10% primary care bonus currently called for in the health care reform act – a 10% bonus is nice, but it is doubtful that it will be enough to draw students away from more lucrative specialities.  10% more for primary care doctors still cannot hold a candle to what some specialists make, and the hours are longer and the work more grueling in many cases.

2.  Pay much more money for more complex care – primary care doctors should focus on more difficult procedures and cases and get paid more for handling those while nurse practitioners and physicians assistants could deal with the more day-to-day situations that take up so much of a PCP’s time.

So what do you think of these suggestions?  Are they financially or professionally feasible?  How do you think patients would react to seeing their doctor only for more serious cases and dealing with a nurse practitioner the rest of the time?  We will have to wait and see what comes out of this current meeting and what changes might be in store for primary medicine.

A recent article in the New York Times discusses a very interesting topic at the heart of the debate over health care reform and controlling health care costs.  The article asks if the issues we are facing today with out of control health care costs aren’t really an issue of an inability to say no to unnecessary treatments on the part of the doctor and the patient?  Americans seem to have a “more care is better care” outlook and will accept recommendations for all kinds of unneeded and potentially dangerous treatments.  This try-anything approach has had some benefits for people but it has also had some major problems, including dangerous treatments like radiation and surgery being used or overused unnecessarily.

The main problem, the article argues, is that patients are often terribly uneducated about their treatment options.  Many just blindly do whatever their doctor tells them without asking questions or finding out about other options.  Frequently there are less expensive, less invasive options that may not cost as much (or be reimbursed as well) but would be most beneficial to the patient.   Firstly we need to know which treatments work and which do not in certain cases, or which have possible problems that outweigh the possible benefits, and then educate patients about all options. 

But at the heart of the problem is how doctors are paid, which causes them to recommend the more expensive and sometimes unnecessary treatments.  A change in reimbursement policies that award better care rather than more care is crucial.  The current reform takes some steps in that direction, but ultimately more change will be needed.  It seems that the answer for now lies in patients own decisions to limit their care to the most beneficial procedures and medications.  Who knows how many billions of dollars could be saved if people were able to make smart decisions about their own health care?

It’s an important question, considering that it is estimated that 3% of all health care spending, around$68 billion dollars, is lost due to intentional fraud and medical billing errors.  Stories abound of people who received exorbitant bills unexpectedly because someone had put in a wrong number here or an incorrect code there.  A whole new career called Medical Billing Advocacy has surfaced because the problems are so prevalent that many people need professional help to navigate the system and correct these problems on their behalf.    Many are wondering what impact the new health care reform bill will have on medical billing, and obviously there are those who are concerned that it will increase the volume of billing needed and, therefore, the number of mistakes.

Medical Billing Advocates of America says that 8 out of 10 hospital bills that its advocates review have errors.  Many argue that increased use of EHR required by the reform bill will help to decrease these errors by eliminating paper claims, but others say implementation is expensive and complicated and does not eliminate human error in entering data into the program.  Hospitals and physicians offices are not going to want to lose revenue, and so they will be seeing more patients and filing more claims and, probably, not increasing staff, making the chance for errors from overworked billers greater.

The best way to make sure your bills are correct is to be your own advocate.  Insist on knowing what the prices are for procedures up front, make sure everyone that you encounter during your treatment is in your insurance network, and demand detailed and itemized bills upon your release.    There will be a lot of bugs to work out as elements of the reform bill are instituted, and we can only hope that some kind of review system for billing errors will be part of the changes.  But until we see improvement industry wide (which may be a long time if ever), the best way for patients to protect themselves is to be informed, insistent, and persistent.

Sure, cheaper medications sound great.  Everyone would like to save a little money on their prescriptions.  But the promise of lower cost for medications in the health care reform bill may have implications a lot greater than a few extra dollars in our pockets.  Many of us still fill prescriptions even if they are expensive because we know we need them.  But for people on fixed or lower incomes, sometimes it becomes a choice between getting the meds and paying rent or buying food, and medication seems like the thing that can go.  But data shows that not taking medications faithfully, which about half of all Americans do, costs more than $100 billion dollars (the total cost of the reform bill) in avoidable hospitalizations and approx. 89,000 avoidable deaths each year.

In a new article on Medscape.com, they stress that “medication non-adherance is a treatable disorder.”  New laws that will close the Medicare “donut hole” in prescription drug coverage are just the beginning of the changes that are promised.  The implementation of EMR systems and the increased use of electronic prescriptions could help doctors better track who is filling their medications in a timely matter and who is not.  Then they can conduct follow-up appointments to determine why the patient is not taking the meds and what needs to be done.  Also, shifting doctor pay from a fee for service model to one where doctors are rewarded for patient outcomes will hopefully result in doctors taking more time to ensure their patients are compliant.  They need to have a real stake in their patient’s overall success, including the patient’s choices about medications, some argue.

So do you think this true?  Do you think these changes will help patient adherence, or is this an invasion of privacy and more work for already stressed out physicians?  How responsible should a doctor be for whether or not their patient takes their meds?  Is it any different from judging a teacher’s performance based on how a kid does on a standardized test?  Will it save money in the long run?

Now that the Health Care Reform bill has passed, it is time to stop debating it and start figuring out exactly how it is going to work and who will be affected by it.  As a professional billing and coding company, MD Alliance Billing is obviously concerned about what the upcoming changes will mean for the medical billing and coding business.  At the outset it would appear like the need for billing and coding professionals is going to increase because of the increased numbers of people who will be submitting claims to insurance as well as expanded Medicare and Medicaid coverage.  There may be new coding systems involved as coverage expands and new rules for pre-existing conditions come into effect.   Hopefully those who will be in charge of implementing these new guidelines will take into consideration exactly how this will affect the billing process.  Obviously there will be extensive training required for all current billing professionals to learn all the new rules.

All this change coinciding with the required EMR implementation for all physicians should make the next five years or so very interesting indeed.  The balance of the benefit of reduced paper returns with the learning curve of new software on top of new codes, new exceptions, and new billing processes may make billing and coding one of the most complicated professions in the medical field.  But if everything can get ironed out properly (and that’s a big “if”) this could be very good for medical billers, putting their services at high demand.

When we hear news like the premium rates in the state of Illinois going up as much as 60%, we think that there has to be a way to get health care costs under control.  The Obama administration is stressing that insurance premiums must be controlled, but the problem is that lowering premium prices will not put a dent in cost of health care because it doesn’t do anything to control what doctors and hospitals charge for their services. 

Controlling premiums without controlling what insurance companies are charged is like borrowing from Peter to pay Paul.  If the companies have less coming in in the way of premiums, they will have to reduce what they are able to pay out, meaning decreased coverage for their customers.  Reducing premiums sounds great, but it seems like it will really throw the whole thing out of balance for patients, doctors, and insurance companies alike.  I guess it all boils down to the problem of relying on for-profit insurance companies to provide healthcare for our country – we are the only industrialized nation that does.  In a system like that, if you take away from one area, the money has to be made up somewhere else.  And it still eventually comes out of our pockets.

On our other blog at Cloe Sill Bookkeeping and Tax Services we discussed the current jobs bill that is under review in Congress.  One of the measures on this bill is a delay in the reduction of Medicare reimbursements which was scheduled to happen this year on March 1.  The current bill would delayed the change to October 1.  This would be the second time the Congress has voted a delay – the first was the bill that passed in December that delayed the date from January 1 to March 1.

 The 21.2% reduction could be very financially difficult for many physicians, causing them to be unable to take any new Medicare patients or perhaps to have to drop the program all together.  The problem is the sustainable growth rate (SGR) formula that is key to Medicare reimbursements.  The formula triggers a pay cut when spending exceeds a target amount based on gross domestic product.  But each year since 2003 Congress has delayed the SGR changes, adding each year’s reduction on top of the previous, making it bigger and bigger.  Rather than reviewing the actual process and perhaps eliminating the SGR, these band aids are just making things worse. 

Some congressmen want to pass a multi-year pay freeze where Medicare reimbursements could not change for 5 years, but that is not part of this current bill.  And who knows what will part of the eventual health care reform bill that is passed, if there is one passed.  Why can’t we seem to be ahead of the problems for once?  As a physician, how would changes in Medicare reimbursements affect you?

Many of those interested in reforming our health care system have been looking to the Canadian system as an example of universal coverage.  However, a recent article on the Canadian Broadcasting Centre website highlights some of the problems that the Canadian system is facing that the US might be wise to make note of.

Canadians are facing a major doctor shortage, especially in the critical area of general and family practice.  The article states that 17% of Canadians, 4.1 million people, don’t have a family doctor.  And 51% of those who do said it take 3 to 4 weeks to get into see their doctor.  More medical students are going into specialty areas, and those that do go into family medicine are moving into the larger, metropolitan areas, leaving the rural areas underserved.  Or they are practicing out of the country altogether.

Could one reason for this shortage be the way the doctors are paid?  Is the universal medicare system causing doctors in Canada to go into specialty areas where they get paid more, or to practice in other countries where competition keeps prices higher?  Here in the US we already have a doctor shortage in some areas – would a universal system only make that worse for us?  Or is it simply that the doctors that are there need to reorganize the way they conduct business to fit in more patients?   If the US is truly interested in a universal system, the issues in Canada must be carefully studied and ways to avoid similar problems thought through.  Let’s not repeat the errors of our neighbors.

The words “I’m sorry” are not usually ones you want to hear from your doctor.  They can only mean one thing – an error was made that had adverse consequences for your or your loved one’s health.  But without the apology, the doctor seems cold and uncaring, denying responsibility, and the patient and family become more angry and resentful.  And that’s when lawsuits come into play.  So is a sincere apology from a doctor enough to curb the out of control medical lawsuits?  Can “I’m sorry” be tort reform?

President Obama and the Senate Finance Committee have long emphasized physician apology and offers of fair compensation outside the legal system as ways of reducing legal cases for medical malpractice.  There are proposals as part of the new health care reform bills that emphasize exactly that.  But is it really the answer? 

Many physicians are concerned that apologies, often given because the doctor feels sorry that an expected outcome was painful to the patient, can be used against the doctor as an admission of guilt in court.  Some states are trying to deal with concern and have passed apology laws that prevent the use of expressions of sympathy, regret, and condolence to be used against the doctor in litigation.  Some states even protect admissions of fault as well. 

It seems sad that there has to be laws to protect doctors so they can feel free to say “I’m sorry”.  It may cause them legal trouble, but it’s the right thing to do in all circumstances.  Overwhelming people say they want their physician to care about them and their families.  Perhaps the key to tort reform is the quality of the doctor-patient relationship – if the doctor can sincerely apologize and the patient forgive, imagine how many frivolous lawsuits we could avoid.