I had the opportunity last week to participate in a day-long meeting sponsored by the Heart Rhythm Society. The goal was to help HRS develop recommendations for physicians and industry on providing patients access to information generated by wearable and implantable cardiac electronic devices. The organizers invited me to provide the viewpoint of an educated patient.
I can’t say how HRS will ultimately craft the guidance (and I am not involved in writing it), but the discussion was lively, and I came away with a number of impressions.
First, device manufacturers understand that they must move to afford patient access to the data their products are generating, but they are limited in how quickly they can do so by a number of factors, including the slow pace of technical iteration created by close regulatory oversight, the uncertainty of what data patients want and how to present it, and concerns about getting out ahead of electrophysiologists (their traditional customers) on this issue. Nevertheless, I was impressed that there seemed to be unanimity of opinion among the manufacturers that patients should have access to the same data that doctors see.
Continue reading Getting There
I am a terrible coder. I think I am a pretty good doctor, but when it comes to coding, the process of figuring out which billing code to pick to assign to a bill for an office visit, I am hopeless. No matter how many times I have had the rules explained to me, or how much feedback I have been given about specific visits, or which “pocket guide” to coding I have been handed over the years, I can’t seem to get it right. Even my errors are non-systematic. Sometimes I “over-code” (picking a visit level insufficiently supported by my note) and other times “under-code.” And the things I get wrong are all over the map – sometimes my history lacks some “elements,” sometimes my review of systems covers the wrong number of systems, sometimes my exam is shy an organ or two…you get the idea. It is very hard to get better if you keep doing different things wrong. Of course, this begs the question why doctors should be coding as well as doctoring, but that is an issue for another day.
For now, my deficiency explains why I was intrigued to learn that CMS recently proposed changing the rules governing the coding and reimbursement for physician office visits. Currently, we are bound to rules for so called “evaluation and management” (E&M) visits that date back to the mid-1990s. The rules align the 5 levels of visit intensity (each coded with a different billing, or CPT code) with required documentation. There are parallel sets of codes (and documentation requirements) for new patient visits and established patient visits. Did I mention that this guidance is 90 pages long? Each code carries a different level of reimbursement, and commercial insurers use the same codes (at different price points) to pay for care of their subscribers.
The new proposal pretty much scraps all of that. CMS is floating the idea of “collapsing” levels 2 through 5, and creating a single payment level for established patients and a single payment level for new patients, each of which is somewhere in-between what is currently paid for a simple (level 2) or complex (level 5) visit. The stated rationale is that physicians would be able to spend more time with patients and less time stressing over what to code (or typing clinically irrelevant stuff in the medical record to justify higher levels of billing). In the words of CMS, it will favor “patients over paperwork.” You can read all 1472 pages of the proposed changes to the Medicare physician fee schedule here.
Continue reading More Changes to Medicare
For each of the last several years, we have held a retreat for the leadership of our medical group. In the early years, we used the meeting to address basic questions about who we were and what we were trying to accomplish. In 2014 we established a series of priorities for our group, which we summarized in what we affectionately called “the flower”:
This road map served us well in the years since, but we decided it was time for a refresh, so at our most recent retreat we revisited our priorities, and came up with this:
Continue reading Strategic Priorities
I think that almost everyone would agree that making good choices requires access to good information. That may be especially true with regard to choices about one’s health, where the stakes are high, the issues are often complicated, and there is a lot of uncertainty. That is why I feel so strongly that promoting patient access to clinical data is the right thing to do, that it drives better care, and that patients will increasingly demand it.
Here is another, more personal, reason why I feel strongly about it.
Best wishes for a happy and healthy New Year.