Thursday, January 17, 2013

Pay Docs for Listening and Caring

Perhaps one of the more contentious issues in California's SB 863 reform bill, at least as far as medical providers are concerned, is the mandate that the medical fee schedule convert to the Medicare Resource Based Relative Value Scale (RVRBS) by Jan. 1, 2014.

California lags several other key states in adopting Medicare's schedule, and SB 863 authors and proponents see this as a significant method of controlling not only costs, but the variety of treatment options available to injured workers because reimbursement rates directly affect procedural motivations.

The California Division of Workers' Compensation (DWC) has said its general approach will be to adopt the Medicare ground rules, and only make changes to the payment ground rules “where appropriate in light of special needs of the workers’ compensation system.”

Public comment thus far has identified several areas where the special needs of workers' compensation require deviation from Medicare's system. DWC is taking public comments until Feb. 8 on possible changes to the ground rules that would be necessary to make RBRVS work as the basis for determining provider reimbursement in California.

For instance, according to Greg Krohm, former executive director of the International Association of Industrial Accident Boards and Commissions (IAIABC) and who remains a research consultant for IAIABC, when Texas adopted RBRVS in 2003, it also adopted a single conversion factor that paid all providers 125% of Medicare’s rates.

A 2007 study by Dr. Steven E. Levine and Dr. Ronald N. Kent found that the single conversion factor drove neurologists away from workers’ compensation. In 2002, 63% of neurologists were willing to treat workers’ compensation patients. By 2007, the number fell to just 9%.

I agree with Krohm, who said using multiple conversion factors for different specialty providers is one area where it is appropriate to deviate from Medicare’s rules that use only a single conversion factor. If the DWC is interested in maintaining physician participation in the system then it can not alienate potential medical vendors and thus risk medical access issues.

Deborah E. Kuehn, vice president of coding and reimbursement for U.S. HealthWorks, identified another area of concern and that is Medicare's discount when services are provided by physicians’ assistants and nurse practitioners. These providers are reimbursed at 85% of what would be paid to a physician who provided the same service.

Kuehn argues that until access issues to primary care physicians have stabilized it would be inappropriate to reduce fees to physicians’ assistants and nurse practitioners.

I agree with this analysis too. Physicians’ assistants and nurse practitioners perform more routine medical functions that don't require the expertise of a Medical Doctor and consequently help to keep the medical provider's costs low, and ergo, the overall cost of medical treatment lower than if these professionals were not available. 

If it is not profitable to employ physicians’ assistants and nurse practitioners then the routine care duties fall upon the M.D., and if there aren't enough M.D.s to provide such services access issues occur and the overall cost of a claim increases.

But the single most important recommendation in the public comments, in my opinion, is to provide for consulting with patients - the basic office visit. Medicare doesn't pay providers for consulting with patients.

In my opinion, much of the failure of the medical delivery system in workers' compensation, nay general health, is that medical doctors don't spend sufficient office visit time with the patients. Often medical patients just need someone to listen to them.

Workers' compensation is a volume medical business. Office visits with the professional are very time limited. The human and psychological components of medical treatment are virtually non-existent in work comp care.

Yet there are many studies suggesting that actual treatment costs and indemnity costs would be greatly reduced if injured workers felt their physicians were actually listening to their complaints.

It turns out that "bedside manner" is vitally important to the delivery of medical services.

Medical care is highly personal. Depersonalizing the delivery of care occurs when the professional lacks interest in the patient. This is communicated to the patient primarily by the allocation of time for each patient interaction. This allocation of time is directly affected by how and for what the professional is being paid.

If the professional is being paid to perform a particular procedure - surgery for instance - the professional is going to direct his or her services towards that reimbursement goal, even if the medical issue could be more appropriately dealt with by some other procedure that isn't reimbursed (i.e. the office visit with some good listening and counseling).

Bring back good medicine. Pay physicians for actually listening and caring for their patients rather than just performing some specific procedure. The system will benefit enormously when injured workers know that someone actually cares.

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