Thoughts of a Midwest Doctor

Surgeon General as a political pawn

2007-07-11T19:37:00.000-06:00

I hate to get political but...NPR had a story about the hearings where the Surgeon General testified on political pressure placed on the position. As a practicing physician trying to do the best for my patients and society, I was disguisted to hear what was said, and that a doctor let these things happen.

Imagine the Surgeon General being forbidden to appear at a Special Olympics event because it benefitted the Kennedy family. The White House should be ashamed!

EHR PHR and Patient Portals

2007-07-11T19:32:00.000-06:00

EHR PHR and Patient Portals

eClinicalWorks is working hard to stay on the cutting edge of electronic medical records with Instant Medical History. Of course execution is always a whole lot harder than announcing so we'll see how well they make it work.

I warned you about United Health Care!

2007-04-10T12:59:00.000-06:00

The WSJ today features an article about UHC's new policy of fining doctors $50 for repeatedly using the wrong lab. Others are talking about this tactic. If you read my previous post on UHC's delay in paying docs fairly for services, then you joined me in seeing this fining system as part of their business model.
Fortunately, our medical office building will soon have a Labcorp draw site. Of course nothing is easy; Aetna recently announced that their patients will soon be required to use only Quest for their blood tests. We have very few Aetna patients in our practice- for years they were the poorest payors so we never signed a contract. They do not have a big market share in the area so they need us more than we need them.

Can you sell an EMR without showing the product?

2007-02-27T19:08:00.000-06:00

Would you buy a car without test driving it? Last week our hospital EMR vendor Cerner did a "high level" presentation to the Executive Team on their office EMR product called PowerWorks. Now that the Stark laws have been relaxed, hospitals can help physician office buy EMR products and it was natural to ask Cerenr to be in the running. It was a presentation by "vice presidents" of Powerpoint slides showing the benefits of their product and the interconnectivity with the hospital information system. They showed in diagragmatic form how all the systems could talk to each other and tranfer data seamlessly, or so they promise, using their technology called Health-e. I was amazed by several things.

First, you would think that the Cerner office product would easily talk to the Cerner hospital product. Oh, no. We would need to purchase an interface for this to happen. In fact the interface would cost the same if we interfaced Cerner to Cerner or Cerner to any other office product.

Second, the saleman described all the wonderful benefits of Powerworks, and as an example he described a doctor in the Midwest that uses Cerner Powerworks and sees 70 patients a day and "just loves the system." I'm exhausted if my day has 25 patients and I wonder what I missed. If this doc is seeing 70 patients, it is not good medicine and I would not brag about an affiliation.

And finally they did this presentation without a single view of the product itself. I just don't get it- not even a short test drive. Sure the hospital CEO wouldn't know a good EMR from a bad one, but at least a quick demo...

The hospital is setting up a demo for some key physicians to look at both Powerworks and eClinicalWorks (as discussed in previous post). Hopefully Cerner will be wise enough to have the actual product to demonstrate. Then I can beat the pants off it with my demo of eCW!!!!

Some Doctors just don't get it

2007-02-03T18:27:00.000-06:00

I was called by one of my case managers to review a case at the hospital. The patient was a 97 year old who was admitted from a nursing home after a stroke. She was unresponsive, unable to communicate, unable to eat. The CT scan showed a large stroke and it was clear to all that she would not recover. The family elected hospice care and asked that she be returned to the nursing home. The physician was called by the nurse to discontinue the intravenous fluids and get the order for hospice. While he was willing to give the order for hospice, he refused to discontinue the IV fluids and in fact ordered more blood tests for the next morning, saying that she was dehydrated. When the family was informed of his orders, they called the doctor himself and he relented and cancelled the blood tests, but wanted the IV fluids for one more day.

The next day, he finally agreed to stop the IV and send her back to her "home" to spend her last days. But, just prior to discharge, the nurse checked the blood pressure and it was elevated. She called the doctor (big mistake) and he ordered nothing but said to hold the patient for one more day. The family was again distraught at the change in plans but agreed, feeling the doctor knew what he was doing.

So here was a 97 year old woman who just wanted to be allowed to die where she was comfortable- in her nurinsg home room, with her family. But this doctor insisted on treating "the way he always treats patients- his way." This clearly was not in the patient's best interest and cuased great consternation in the family. This doctor is one of the senior members of the medical staff but still practices like it was 1980, keeping patients in the hospital longer than necessary, ordering unneeded tests and just not keeping up with the changing art of medicine. He's not dangerous, but it's just not good medicine to not respect patient autonomy.

United Healthcare Screws physicians again...

2007-01-31T19:24:00.000-06:00

I got two notices from United Healthcare on the same day. The first one stated that I should find all UHC patients on a certain list of drugs and switch them to double strength pills that I have to teach them to cut in half so UHC can save money. The second notice told me that a promised adjustment to the way they pay for a visit where you are performing a "well patient" exam along with addressing an acute problem- in essence refusing to pay for the care provided for the illness. You can read this policy statement on page 7 here.

So, I came up with a modification to their Policy statement. Enjoy!

Half Tablet Program may be ignored due to
Preventive Medicine and Screening Policy Delay

Implementation of previously announced policy changes to be delayed.
UnitedHealthcare requests physicians disregard memo concerning cost-saving measures for patients and insurer.

In the May 2006 Network Bulletin, it was announced that UnitedHealthcare finally recognizes the value of the work physicians perform when addressing acute illnesses (CPT 99201-5 and 99212-5) that are discussed during a preventive Care Visit (99381-99397). Unfortunately, the stock option back-dating scandal has resulted in unexpected corporate costs and it is believed that by suspending implementation of this policy for a year, the stockholders of UnitedHealthcare will be able to maintain their investment value.

In an unfortunate coincidence, a plan to cut costs and increase stockholder value which involves more unreimbursed physician time and effort was rolled out at the same time. This new initiative involved asking physicians to contact every patient who was prescribed medications which Unitedhealthcare felt were safe to break in half and write new prescriptions for a double-strength pill and instruct the patient in the use of a pill cutter. Although many of these pills were not scored for half-dosing and no studies have been done to ensure that the medication is distributed evenly throughout the tablet, UnitedHealthcare felt the value added to the corporate bottom line exceeded the potential liability risk, which is shifted completely to the physician.Until the corporate coffers are replenished and we are able to put the new reimbursement policy into effect, UnitedHealthcare understands why physicians would not implement the Half Tablet program and we regret the unfortunate timing of the release of this new initiative. We would like to ensure our physicians that we are aware of the sky-rocketing costs of operating a medical practice and constantly seeking ways to make money that have less of an impact on their reimbursement, but we would rather take money away from a provider than raise rates charged to our policy holders or cut the salaries of our corporate executives.

UnitedHealthcare anticipates the implementation to occur in December, 2007 although the ongoing SEC investigation is nowhere near completion and we anticipate an extremely generous compensation package for our next CEO, so no guarantees can be made. Until that time, please disregard the Half Tablet initiative. We apologize for the inconvenience this delay in implementation of our policy modification may cause.

If you do not contract directly with UnitedHealthcare, and participate in our network through an arrangement in which we "Lease" a network from some other entity, (boy, do we make a ton of money off this arrangement), some of the information provided in this communication may not be applicable to you and/or impact you differently. It will though give you a taste of what providers have to deal with on a daily basis from insurance companies. If you have questions regarding any of the information or need to better understand its impact on you, try Google, We certainly are not going to take your phone calls. If you happen to actually speak to a human being in our office, chances are it is a temp we hired from that company that advertises relentlessly on morning radio and she knows nothing except how to transfer calls to unmanned phones.

Please do not reply to this email address, this mailbox is used for outbound email only and we are not able to respond to messages sent to this address. Questions or Comments? Keep them to yourselves.

We respect your right to privacy but unfortunately the contract you signed allows us to sell your name and personal information to whomever we choose. Next time read the contract before you sign it. You can call our opt-out number, but it will be answered by the temp referenced in paragraph one.

It doesn't get worse than Humana

2007-01-23T18:54:00.000-06:00

So first the radiology precertification process, now a mess with a "new" product. A patient made an appointment with me stating he had Humana HMO and had my name on his card. When he arrived, his card was labeled "National HMO." We had never signed an HMO contract and were never oriented by Humana about any HMO product. Assuming it was a hybrid, I referred him to a specialist for evaluation and testing was performed. We had no referral forms and never knew one existed so he went with a note of referral.

Three weeks later the specialist called looking for a referral. My receptionist took it upon herself to figure this out. She spent 30 minutes on the phone (timed) and talked to 4 people who transferred her four times to the wrong department. Finally she got the right department and they sent us a copy of the referral form. We filled it out and forwarded it to the specialist.

Next week, the patient gets admitted to a local hospital (without my knowledge or approval.) We again tried to get the proper person to talk to in order to authorize the hospital stay. Again transferred all over the country to wrong departments. Never got to the right person.

I called myself and after three different numbers and after multiple phone menus I got a human (although not very intelligent.) I explained the situation and asked to talk to provider relations. She transferred me to the Medicare Part D patient enrollment hot line.

Three hours later Humana called to notify me that my patient was admitted to the hospital. Knowing that I wanted to talk to them, my receptionist asked the person to hold for the doctor. I got on the phone immediately and asked for the information about the admission. She (her name was Shanelle) told me "I gave the information to your receptionist and it is now gone from the system and I cannot retrieve it." Exasaperated, I asked , "shouldn't the doctor himself have access to the information?" She then hung up on me without saying a word. I hope the Humana CEO reads this, tracks this girl down and fires her ass on the spot for hanging up on me!

That was the straw that broke the camel's back. We then called the patient's family and told them that Humana made a mistake and that we were not part of the Humana National HMO and to call them to get assigned a new doctor.

I wash my hands of this mess- let them send a lawyer after me for breach of contract. And people wonder why insurance companies frustrate doctors.

We've joined the electronic age of medical records!

2007-01-21T16:51:00.000-06:00

This week we installed and started training on our new EMR, eClinicalWorks. I first saw this company at Pri-Med in 2003 and loved their system. At the time it was a small company and the President did most of the the sales presentations himself. Now they have over 300 employees, and if it is a measure of success, the waiting time from contract signing to implementation is almost 3 months. They continually win best-in-class awards, including KLAS, for small offices.

The first week was crazy!! We had two excellent trainers but the technical aspects were more daunting than learning the system itself. Digiboards, VPN's, Remote Desktop, Scanner twains, domains, and on and on.

We bought the new Lenovo X60 tablets. They have performed great so far, although one had a screen that did not work with the digitizer pen, and one was almost a $2,500 doorstop when we temporarily (3 hours of me sweating and swearing) couldn't get past the fingerprint detector.

Our staff is doing great! Many are not computer literate but when they saw how an EMR will improve their work flow, they fell in love.

We "go live" this week so we'll see how that goes...

Call me a liar if you must...

2007-01-14T15:11:00.000-06:00

but I take back all the nice things I said about Blue Cross's pre-certification process for CT scans. Friday I got a call from one of the GI docs that he scoped a 51 year old patient and found a rectal cancer. He requested a CT scan to stage the disease. The patient has Blue Choice Select, an HMO-like Blue Cross product. This product is like pracicing medicine in 1997, not 2007. Paper referrral forms are needed for any service; the form requires my name, address, phone number, and ID number and the same for the specialist. No other insurance company in the area requires a paper referral, much less one that requires all the information they already have on file. So to get the CT, we call a numberer, go through a phone menu, and wait and wait on hold. Finally the clerk answers and insists on a date of service. Once again we explain we can't schedule without an authorization, but she insists on a date. So we pick a random date.

Now I remember why I get so upset when I hear those Blue Cross radio commercials with doctors describing how much they like Blue Cross. In an effrot to grab as much market share as they can, they create these bizarre hybrid plans with unique rules and forms.

So much Lung cancer

2007-01-10T20:40:00.000-06:00

Today I saw a 30 year old patient who drives a semi for an entertainment company that produces rock road tours. He is on the road 300 days a year. He was denied his medical card for his commercial drivers license due to high blood pressure and needed it controlled by the end of the month when his license expires. He then told me he smokes 4 packs of cigarettes a day. Yep, 4 packs. He tells me he gets them in bulk in the South where there is no tax "So it's not that expensive and I'm healthy." Boy, did he get an earful, along witha prescription for an antihypertensive.
I told him that in the last 2 months I have found three new lung cancers in smoking patients under 50. First one came in with a headache, convinced she had a brain tumor. I did a chest xray because she smoked. She had surgery and was found to have unexpected metastasis. Not good. Next one came in coughing blood. His was completely resected- lucky guy. The third one- little cough like a cold that would not go away. Lungs full of cancer- not long for this world.
Why do people continue to smoke when the dangers are so clear? I just don't get it...
I've had some luck with Chantix, a new medication for smoking cessation, in those that want to quit. Shouldn't everyone want to quit?

The authorization that started all this...

2007-01-07T14:03:00.000-06:00

was for an MRI for a patient who had 2 months of back pain. Physical therapy failed, medications didn't work. It was time to get an MRI. So I go to the web site for Humana's Radiology Precertification and have to fill in boxes with my full name, phone numbers, license number, the patient's complete information, including his cell phone number (why would they need that?). It even asks for the CPT code for the MRI. Since it is a mandatory field and I don't know the codes so I type "I don't know" and it accepts it. I press Submit and off it goes.

The last time I did one of these, I got a call back asking for the date the patient was going to have the MRI. What a STUPID question! They require a pre-authorization to allow us to schedule the test, but to get the pre-authorization they require the date of the test! Typical insurance company thinking! So we just make up a date. Their response to that, "You must call us if the date changes." No way are they getting that call!

So, we'll see what happens tomorrow when the representative calls with our authorization number. I'm not hopeful!

Contrast this with the procedure for Blue Cross PPO, contracted out to American Imaging Management. A wonderful system, instant authorization. Clearly designed with the busy provider in mind.

Physicians never like to be told what to do or how to do it, but most of us realize the necessity of systems like this to be sure test are medically necessary. But there is a right way and a wrong way to do it. Humana clearly doesn't understand that. Blue Cross does.

Welcome to my blog!

2007-01-06T17:24:00.000-06:00

Today I sat at my computer on a crazy Saturday trying to get authorization for a patient's MRI. The on-line system looked like it was written in 1995 with MS-DOS. Earlier in the day, while shaving, I was listening to the radio and an ad for a major insurer came on touting the hassle free care patients receive.

At that point I decided that I should publish the common hassles I face as a primary care doctor in the suburban Chicago area. I am also involved in our hospital's administration so I will provide perspectives on the world of hospital medicine and management.

As background, I am a general Internist with a special interest in HIV Medicine. I am also the Medical Director of Case Management and physician resource for Cerner, our health information system, at a local community hospital. I am the husband of a wonderful woman who works as my medical assistant in the office and I am also the father of three wonderful children.

I'll keep my name and location confidential so I do not violate any privacy laws and it will allow me to be more candid in my comments.