** Note: This post is part of a series of posts on my blog Musings of a Distractible Mind.

The Problem

In previous rants posts, I discussed the problems within the US healthcare system and some potential solutions. One thing that is not often discussed as being a major problem is the system by which medical billing occurs. Most non-medical people assume that the billing process is straightforward. Nothing could be further from the truth.

Code Confusion

There are several types of codes that doctors need to have for each visit:

It has been a long time.

I've been very busy doing a lot of things. My newest job is to serve on a task force by the National Governors Association regarding sharing of medical information across state lines.   Sounds exciting?  I think it means more to you than you think.

Yesterday was “one of those days.” We generally give our patients 15 minute visits and bank on the fact that some visits will be short and others will be longer. This rule works out the majority of the time, but occasionally the gods of medicine are angry at us and send patients who all need far more than 15 minutes to help their problems. That was yesterday.

Two of these “difficult patients” were back-to-back earlier in the day. They are both longstanding patients of mine with multiple medical problems. The main thing they both have in common from my perspective is that they both have gotten to the point that it seems I have nothing to offer them anymore.

Tap, tap, tap.

Silence.

Arms lifted high in a grand gesture.

Breaths held. Still silence.

With sudden force the arms fall and a grand sound fills the room. Arms sway from left to right, up and down. Sometimes they point, sometimes plea. Sometimes they move with small movements, sometimes large. With each movement there is a response: a change in tempo, pitch, or volume. The musicians breathe as a single unit, seemingly hypnotized by the flailing arms in front of them, each unable to move unless the hand permits.

I have now been a physician for 16 years. As a whole, the work has been as good as anything I could have chosen. My personality seems well-suited to the job, and I have had very few complaints. I have had a few bad experiences, however. One of the worst happened when I was in my third year of residency.

I was on call that night - covering the pediatric ICU at Riley Children’s Hospital. Since I am Med/Peds, I had a lot of experience caring for the critically ill. Medicine residents were given far more latitude to make independent decisions when on call. Also, we worked at the VA hospital and the county hospital in Indianapolis, where supervision was a lot less. So working in the pediatric ICU was always a step back in independence - having to call the fellow or attending for minor things. We had the reputation for being “loose cannons” in the ICU - although I think the attendings actually appreciated our knowledge.

In his latest post, Flea talks about the phenomenon of Retail-Based Clinics (RBC) that are reportedly sprouting up around the country. These clinics are located in retail stores, such as Wal-Mart and Walgreens(I don’t think it is limited to stores beginning with “Wal,” however), and are staffed by Nurse Practitioners. The promise is that for a fair price (in the $50 range), you can be seen quickly (within 20 minutes) and have your problem taken care of. This gives the added bonus for those stores that the patients will be walking around the store while they wait to be seen as well as being far more likely to use their pharmacy after the visit.

In a previous post, Steve Beller discusses causes of the high cost of healthcare.  All of his points are well-taken and on-target.

I think that there is a bigger cost factor that people don't mention: the rampant use of unproven procedures.  The New York Times recently reported about the effectiveness of coronary stents.  It begins:

“So, hon…what’ll it be today.”

“What are your specials today?”

“We just got a shipment of personal responsibility in. It’s really healthy (not one bit of trans-fat) and real satisfying. There are some folks here who religiously have this one. Oh yes, and it’s free of charge.”

“Sounds great. I’ll….”

“Hold on there, sugar! There is a catch to this one.”

“A catch?”

“Yeah. You have to eat all of it. If you don’t eat it all, then you have to pay $100, and it’s a big plate! Plus you have to keep coming back every week and get it again or we charge you another $100.”

Much has been said negatively about Wal-Mart - and much if it is deserved. They have driven out competition through aggressive marketing tactics, etc. They have pretty much put an end to the "mom and pop" store.

I also really hate that little smiley face that dances around and lowers prices.

The most recent thing they have done, however, could have real big positive effects. Effective last month, they are charging only $4 for a long list of generic prescriptions. Our local Wal-Mart has begun doing this and the response has been huge. Patients are all wanting these generic medications if possible. Other pharmacies (like Kroger) have matched these prices. Overall, the savings to patients will be great, making more drugs affordable for more people. I have done my best to try to use medications from that list when possible.

Those conspirators...err...people at CCHIT have approved of more EMRs.

The Certification Commission for Healthcare Information Technology approved 11
of the 17 ambulatory electronic health record products submitted in the latest
round of testing, Health IT Strategist reports. A total of 33
products now have received certification.

To be certified, ambulatory
EHR products must meet all of the more than 200 criteria for functionality,
security and interoperability. Vendors also must pay a $28,000 application fee.

The following new products received CCHIT certification: