Blog | Wednesday, April 4, 2012

Good things in medicine now include Medicare: shocking!

Sit down.

Reeve041476 by otisarchives4 via Flickr and a Creative Commons licenseReally, sit down. Trust me, please. You are going to be shocked with the news I am going to give you and I don't want any contusions, closed head injuries, street riots, or revolutions taking place in South American countries on my conscience.

Are you sitting? OK, here it goes:

Medicare got something right.

Pretty crazy, right? I am not sure if it was an accident, like the infinite monkeys typing on a keyboard producing the works of Shakespeare (they'd write all of the Harlequin romance novels too, by the way). They had to eventually do something right, something that really benefits people, makes my life better, and potentially cuts cost. The thing they got right? The Medicare preventive exam.

Up to a year ago, the only way I would ever get paid to see a Medicare patient was when they had a problem. If a person came in with the desire to keep from being sick, we would have to get a waiver signed and charge them full price. So at those visits we would fish for any problems to justify it as a disease-management visit or one for acute care. This meant that any prevention that I did perform on my Medicare patients had to be done on the side during problem-oriented visits. So the motivation to do prevention was dependent on the nature of the doc. If they are OCD, didn't care about getting home on time, or less concerned about getting paid, patients got better care. Otherwise it was hit or miss.

Plus, the chart itself was often neglected. Any time a doctor took to make the chart accurate was time away from other patients or time away from home. This sounds petty, but it takes a large effort to keep things updated, and with the low reimbursement of primary care, only those things that were grossly inaccurate got corrected in most patients' records. I was never given the time to make sure the records were accurate.

In January of 2011 this all changed (at least for Medicare patients). The Medicare Preventive Care Visit came into effect, paying well for keeping people well. The visit follows a specific structure (and arduous documentation, of course), and making the proper templates on our EMR and getting them to put out a suitable handout at the end of the visit took a lot of effort. But the effort paid off; my patients are very happy with these visits and I am able to do some things I have never had time for. The end result is this:

--The patients are given their problem, medication, and allergy lists prior to the visit and correct them for us.
--We can compile the names of other physicians they are visiting and make sure they are accurate.
--We do a functional assessment on people, identifying those at risk for falls or those in bad home environments.
--We screen for depression.
--I get to discuss advance directives with people (living will and health power of attorney). This is probably the biggest change, as I rarely had the chance to talk about this before (and felt very guilty about it). In the past year I have talked to hundreds of people about this, and have probably saved a whole lot of trouble down the line because of it.
--I check when their last screening tests (colonoscopy, mammogram, bone density) and get a copy of them when they aren't in my records (which is distressingly common). I order tests that are due and discuss with the patient when the next screening test is due.
--More of my patients are getting pneumonia shots (pneumovax), and many more are getting the option to get the shingles vaccine (Zostavax).
--In the end, the patient gets a handout (see below) that gives a road map of their care: what was done in the past and when, what was done today, and when things are due in the future. In short, the patient suddenly knows where they stand regarding their health, something that was not common prior to this.
--I am actually being paid well enough for these visits to motivate me to schedule them on as many patients as possible. Certainly, the improvement to the chart itself and to the overall care of the patient is also motivation, but it's nice to be paid for doing good from time to time.

There are (of course) some negatives, including:
--The document created in the chart is enormously wordy and not really useful on its own. Again, since we are paid for documentation, we get exactly that: lots and lots of words to justify our pay. This isn't too hard if you own a gibberish generator.
--Some of the local GYN groups are billing for a Medicare preventive visit (although I seriously doubt they are meeting the cumbersome documentation guidelines), so some of our patients' bills are not paid for. We do our best to filter patients who may be in this situation, but some still get through. I cringe at the thought of these GYN's charts being audited.
--Some patients try to get a disease management visit rolled into the preventive visits. They don't understand at first why I can't talk much about their diabetes on this visit, but when they get the finished product they are almost always satisfied.

Here is the first page of the handout given to the patient:

It's not bad. There are still some bugs being worked out, but it is very satisfying to have time to make sure the records are right and to have a significant percentage of my patients with up-to-date preventive care. This is very much like the GPS device I mentioned in an earlier post.

I am a little anxious about posting this, as it may encourage the government to double the number of monkeys on typewriters (i.e. bureaucrats) and so negate any good that comes of this. Anyhow, some of the monkeys are already busy running for president. But for now, I say something I rarely get to say:

Thank you, Medicare.

You may resume standing.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.