Medicare Micromanaging

The latest kerfuffle drawn from the double-ream of paper that is the new Congressional health care reform bill stems from the provision about allowing payment for a discussion of end-of-life care every five years. (What if the patient develops a new life-threatening condition four and a half years after the last discussion? Sorry, dude. You should have either thought of that four and a half years ago, or waited six more months to get sick.) Several other bloggers have already weighed in, mostly in an effort to debunk the deceptive misreading by right wingnuts claiming that the provision calls for euthanasia (which it of course does not).

The fact of the matter is that the provision is unnecessary, and is just another example of governmental attempts to micromanage medical care. This is an assertion I can actually prove.

In the first place, Medicare already pays for counseling. As long as more than half the face-to-face time of the visit consists of "counseling and/or care coordination," Medicare pays the visit based on the elapsed time of the encounter. Please note that there are no limitations on the topics discussed for the visit to qualify for payment. I can and do frequently bring elderly patients into the office and spend the entire visit discussing issues such as end of life care. I document and bill it accordingly, and no one blinks an eye. Nor should they; this is a completely legitimate medical encounter. It doesn't matter whether it happens once a year, once every two months or once every five years; whatever is appropriate for a particular patient is what I do.

That is why this new provision adds nothing of value to Medicare patients. On the surface it may sound like a good idea, but I have an example of something else that started out making sense that, once the government got ahold of it, perverted it completely out of any semblance of usefulness. I am speaking of the "Welcome to Medicare" physical.

It turns out that the way the original legislation was written, Medicare is legally forbidden to pay for preventive care. Various specific work-arounds have been legislated over the years to allow payment for specific items such as flu shots and pneumococcal vaccination, and a few years ago Congress decided to explicitly include a single preventive care service. Because this service was only eligible for payment during a patient's first six months (more recently extended to twelve months) on Medicare, it became known as the "Welcome to Medicare" physical.

"Wonderful!" I thought when I first heard about it. Finally, Medicare would pay for at least one preventive visit actually so labeled, as opposed to a more extended evaluation once a year that I usually do for my patients with multiple problems that I think of as a "physical" in my head, but never dare write down on paper. Ah, but then the devilish details came out.

Apparently Medicare didn't trust my version of what constitutes an appropriate preventive care visit. Instead, they promulgated detailed regulations about what the encounter had to include:

• Height
• Weight
• Blood pressure
• Visual acuity
• Electrocardiogram
• Depression screening
• Functional ability/safety screen
• Counseling and referral [note: NOT performance] of other preventive services, including:
  • vaccines
  • mammogram
  • pap and pelvic exams
  • prostate cancer screening
  • colorectal cancer screening
  • diabetes screening tests (and self-management training for patients who already have it)
  • medical nutritional therapy for diabetes or renal disease
  • cardiovascular screening blood tests (lipids)
    
  • bone mass measurements
  • glaucoma screening
  • abdominal aortic aneurysm screening sonogram

Note that these are minimums. I can do anything else I feel is appropriate for a preventive care visit above and beyond these things, though I don't get paid anything extra. The result is predictable: the "Medicare Initial Preventive Physical Examination Encounter" has become more trouble than it's worth. I tried it a few times. Basically, it turns into a generalized risk assessment for things like falls and depression, along with a most cursory exam. Frankly, once I'd finished covering all the "required" bullet points, there wasn't really any time left for my version of a physical (including an actual history, where one listens to the patient, as opposed to ticking off yes/no boxes to satisfy Medicare's documentation guidelines for the MIPPEE). It doesn't even pay all that well. Nowadays I'll do one if a patient requests it, but it's not something I'm pushing, as it doesn't add any value to the medical care I provide.

My fear is that CMS will promulgate a specific new code that must be used to bill these quinquennial visits for discussion of end-of-life issues, and that certain specific topics must be discussed (and documented) in order for the visit to be paid. And unless that particular code pays significantly more than a corresponding evaluation/management (regular office visit) code, I'm not going to bother. Oh, I'll continue to have discussions with my patients about end of life care and other issues on a regular basis, but all the sturm und drang about this provision will have been nothing but a giant waste of neurotransmitters and electrons.