Confessions of a Pediatric Practice Consultant

For the record, I'm not in favor of a single-payer system.  But I'm also not a fan of much of the rhetoric that I hear against the concept.

In particular, I have always wondered why those advocating for the strength of choice aren't presently railing at the lack of payer choice for both physicians in patients in so many places.  I remember my first time confronting this when I was in Rochester talking to some practices about insurance negotiation and they asked, "What if the plan represents 75% of my business?"

How, on earth, is a plan covering 75% of the lives in a given metro area, or state, not an acute example of restraint of trade?

The AMA wonders too.  From a sadly eye-opening article:

One insurer held 70% or more of the health plan market share in 24 of 43 states measured, up from 18 in 42 states in the previous year's study. In 92% of the 313 markets in the report, one insurer held at least a 30% share. 

Read the rest of the article - crazy!  Look at the concentration in some of those markets, so often by the local BCBS plan.  60-100%!

If I were in charge of health care reform, this is where I'd start. 

A surreal moment - I am in Richmond, VA listening to Dr.Lander talk about coding during the Pediatric Alliance/VAAAP event while working on the blog.  And watching my laptopbattery drain quickly!

About a year ago, we did a quick run-down on the "non face-to-face"codes, more commonly known as "billing for phone calls." It was both encouraging and sad at the same time.  Time foran update.

Things are still sad - it's a small minority of PCC clients using thecodes (5%?).  However, the news is not all bad.

We have insurance payments, now, in 13 states - CA, MA, NJ, MD, PA,VT, MI, GA, OH, NY, IL, WA, and KY.  

We have some major growth in the non-physician phone codeusage (98966-98968).  

Below, I've split the results into two categories - how much was charged/paid when the code is paid and how much is charged/paid overall.  Note that there isn't a whole lot use of these codes when it's not being paid.  

Interesting, certainly, no?  

Back to the meeting! 

It started when Susanne Madden sent me this "nice" message from Horizon to help me warn our clients about games Horizon continues to play.  Bottom line: they expect to stop paying for -25 or -59 modified codes starting May 10, 2010.

Two minutes of email exchange led the helpful Dr. Stoller to send me this announcement from MSNJ.   Good work.

I would love to have been in the room when the folks at Horizon decided to break the rules of their settlement.  "I wonder if any of the docs will react?  Let's try this!"  

More importantly, though: there shouldn't need to be a class action lawsuit to keep these bozos from flouting the CPT rules.  This is bad medicine and it makes the doctors and patients pay the price.  Shame on you, Horizon.

Many thanks to Siousxe for sending me this awesome ICD-9 lookup tool that even works well with an iphone.  There are some other ICD-9 tools on-line and I'm such a nerd that I do it by hand, but this is well conceived and delivered.If only the AMA would actually help it's members by doing the same thing with CPT codes and RVU values.   

Check out my new favorite toy:

What's More Profitable: Demonstrating Meaningful Use or Managing Your Productivity?

The good folks over at SRSsoft, whose CEO Evan Steele is one of the few people in HIT telling the truth, pointed me to their Productivity Calculator tool.  I think this should be the first step anyone takes towards purchasing an EHR!

I entered in some rough pediatric numbers - 25 kids a day, 4 days a week, $500K revenue, 32 clinical hours...and learned that losing a minute of time per visit to work on the EHR will cost a pediatrician about $26,000 a year.

Enter your numbers.  Fascinating stuff.

Good work, SRSsoft. 

We had a knock-out AAP-endorsed practice management event in Miami two weeks ago.  I say "knock  out" because every single person who completed the survey at the end of the day gave us a perfect score in the following categories "Speakers's Knowledge of the Subject," "Preparation/Presentation," "Class Materials," and "How Would You Rate The Seminar Overall."  4 out of 4, every single box, every single person.

Some of you were there, so tell me if I missed your survey :-)  The only non-perfect score we received was for "Time Spent Covering Information" where one person gave us a 3, leading to an average of 3.96.  I agree - we should have gone longer! 

Of course, I enjoy the comments more than the numbers, as they tell me more about what needs work.  My favorite quote of all:

Absolutely incredible learning experience. You can't help but to increase profit after meeting.

I love that second sentence!

So, I write today to tell you that we'll be in Richmond, VA on Mar 5-6.  The wonderful folks at Pediatric Alliance (combo IPA and GPO) have put together a 2-day event.   You can read our piece about it, download their PDF, or sign up ASAP, as seating is limited.

I hope to see you there. 

After all, you "can't help but to increase profit after meeting." 

We continue to get daily calls and requests for information about the ARRA funding.  We were even told by a potential client that they went with a well-known (but little liked) vendor now in order to maximize their ARRA $$, even though the money itself may be a mirage and they don't even know what their state is going to do. 

Big sigh.

One thing we do know is that, for pediatricians, there is a "20% Medicaid" requirement on the Federal level.  Note that individual states may have additional requirements, we just don't know what they are, yet.   So, how many pediatricians actually qualify for the minimum known requirement so far?  

One-third.  1/3.  Not even, really - 31%!

That's right - only one-third of you private practice pediatricians appear to have 20% or more of your visits fall under the Medicaid category.  Sure, PCC's sample is likely to be biased (we don't have a massive RHC contingent), but I bet it's pretty close to reality. 

Here's how we figured this out.

According to CMS:

"Ps must annually meet patient volume thresholds, measured by a ratio where the numerator is the total number of Medicaid patient encounters (or, in the case of eligible professionals practicing predominately at FQHCs and RHCs, needy individual encounters) over any representative continuous 90-day period in the most recent calendar year and the denominator is all patient encounters over that same 90-day period.  For all EPs except pediatricians, the patient volume threshold is 30 percent; for pediatricians, it is 20 percent."

Each state is then responsible for certifying patient volume and distributing the money via Medicaid.  

Well, we counted up the total visits for each of our "full time" providers and counted the Medicaid visits.  Overall, 18% of the visits were Medicaid, which means that the "average" pediatrician doesn't qualify.  Still, Medicaid visits are not distributed evenly, so it turns out that 31% of PCC's providers reach ARRA's minimum standard for ARRA fundin.  It's possible that a few more might qualify during any given quarter (you don't need to have that volume for an entire year), but we have already learned that moving 5-10% of your visits from private pay to Medicaid for even a quarter eats up your funding pretty quickly.

I don't know what to think except that a lot of the SOAPM folks I know are not even close to the required Medicaid volume.

Thoughts?

A few years ago I passed a church as a wedding party pushed out onto the lawn at the end of the ceremony. My boys were in the back seat and the younger looked out the window and said out loud, "Dad, I don't want to have to get married."

I wasn't too surprised, really, because even then, at the age of4 or 5, he was full of funny exclamations. "Why not, buddy?"

"Because sometimes...sometimes, I just need a day off."

Well, I need a day off from "work" so I can get to the blog. Whenever you see a gap in my posts like I've had recently, it's because there's so much happening in the world of pediatrics that I don't have time to blog it all. Thus, I'm relegated to the shotgun post.

• PCC has another AAP endorsed pediatric coding and practice management event in Miami, FL at the end of January. I know a few of you are already signed up, but we still have room. For non-PCCers who have attended similar events, there are a few new classes. For PCCers who attend everything we do (you know who you are, Lynn Cramer), there's at least one AWESOME new class in here that will make the entire trip worth your while.

  We're about to announce an other event in Virginia any moment now.

• Many of you probably already read the HISTalk interview with Bill Zurhellen, but if you haven't, please do. Bill was the brave soul who stood up at the CCHIT committee meeting and said, "...if our work isn't about improving healthcare, then why are we here?" I don't know if he realizes - and is therefore thankful or spiteful - that I put the HISTalk folks in touch with him or not. I think the interview is excellent, though I am a little dissapointed that he toned it down!
• PCC's world has started to circle around the Meaningful Use drain, though we're doing our best to get caught in it as little as possible. I remember learning about the "Bread and Circus" back in junior high and I can't think of a better analogy. Nearly everyone we speak to these days wants to know if they're going to get their money. I've written about this issue for the AAP before. Pediatricians need to focus on REAL meaningful use, imo. If you want to read the 700+ pages related to the bill - in it's "Preliminary Final" form (what does that mean?), you can get the details here and here.
  You can also find some interesting summaries and helpful documents here and this summary by HISTalk is quite helpful.

How is this not a giant waste of money?

Over on PedSource, we just ran an in-depth piece about the effects of the recession and the Swine Flu on our clients from 2008 to 2009. 

The bottom line: it looks as though the average PCC client has similar overall revenue in 2009 vs. 2008, but it took a lot more visits to do it.  The reason?  Many of those summertime well visit slots were taken up with sick visits.  I'll show off the diagnosis impact of the swine flu, but it's impressive.

Anyway, enjoy the article.  There's a lot of subtle data in there.

I had grand plans to keep track of all the different payers and publicize/shame many of them, but by the time the data came in...it was too late.

Still, how have PCC clients fared with the new H1N1 administration code? 

Better than I would have guessed.

The bottom line is that PCC clients averaged $14.90 from insurance companies and $16.73 from patients when they billed for the H1N1.  That's actually higher than our clients average for the 90465 or 90471, at least when I looked at it last year. 

Of course, the variance is large, but not entirely the fault of the payers.  I might look at a state - like AZ - and see that 1/2 of our clients are using the Medicare Code (G9141) and getting paid a penny because they charged a penny...while their neighbors use the 90470 and charge $25 and get paid $20.  Same procedure, two very different billing methods.

However, there are clearly some super-lame payers out there. A payer in NY - let's call them United - might pay $25+ to one practice and then $7 to another in the same county.  

The clear "winner" for our clients is Tufts, available to folks in Massachusetts, often paying is excess of $40 per H1N1 admin.  Many of the payers in New England paid higher than the rest of the country, no question.  $25-35+.

Interesting stuff.