Let me address your points.
1. Yes, we are legally required to follow CPT rules. Witness the
many prosecutions for fraud when there has been deliberate over-
coding. There are also the thousands of medicaid and medicare audits
that nail doctors for improper coding. Insurers are under no such
obligation. They license the CPT codes from the AMA, but are under
no obligation to follow them. They are also under no obligation to
follow RBRVS methodology. They can choose to ignore codes they do
not like and underpay any code they feel like underpaying despite its
RVU value as established by HCFA. There is no level playing field.
2. You are already required by law to follow CPT and code properly
for the services provided under those guidelines. Payers are not so
obligated. Therefore any legislative mandate to force them to value
and pay codes according to CPT and RBRVS could only benefit physicians.
3. UHC is the largest payer in the US and dwarfs most of the
others. They have eaten up dozens of smaller plans, control the
company, Ingenix that is heavily involved in coding and other health
care ventures, they are the dominant player in many markets and form
an oligarchy of major payers in many markets such that their is
little real ability for physicians to not participate and still have
enough volume to stay in business.
4. Negotiation is an art and is highly dependent on regional needs
and distribution of physicians and payers, as well as the reputation
of the group involved. It is often, but not always dependent on
size. I personally feel that the small practices are going to face
increasing hurdles to economic viability and am a huge proponent of
"Getting Big" using various models. In fact that will be the subject
of my seminar at NCE2007 in San Francisco. While your statistics
suggest we have too many primary care doctors, I can tell you that in
my small part of the county alone, it is nearly impossible to find a
primary care internal medicine practice that is taking new patients
and that many of the practitioners are nearing retirement. As the
ACP has put forth in their position paper titled the Impending
Collapse of Primary Care, you docs are shunning primary care because
they cannot afford to go into this low paying, high stress, high
aggravation field given their level of indebtedness.
5. Most successful health care companies get that way by pricing
their product lower than others and being successful marketers,
rather than providers of quality care. We are the providers of
quality care and we have allowed ourselves to be controlled by the
payers because many of us look upon a realistic view of the business
of medicine as somehow "dirty" and beneath us. Unless we assert
ourselves in a big way, I guarantee you that we will never "share
equally" with insurance companies, especially those of us in primary
care. If you own an MRI or CT scanner perhaps, but not if you think
for a living.
I do agree with you that forming larger groups and negotiating on a
business like basis for the benefit of the group's shareholders is
the only way for us to acquire a larger slice of the medical pie from
the proceduralists and the institutions, and allow us to continue
caring for children in the way we "nice guys" would really like to do.
Capitalism, unfortunately, is not a warm and fuzzy thing. The
insurers know this and act accordingly. We are just now beginning to
learn this fact. Hopefully, we will learn fast enough to keep giving
our all to care for the kids. If you can't keep your doors open and
attract new pediatricians, then kids will have little or no access to
Herschel R. Lessin MD
Medical Director & Director of Clinical Research
The Children's Medical Group, PLLC
104 Fulton Avenue
Poughkeepsie, NY 12603
On Jan 31, 2007, at 10:26 PM, W. Adams wrote:
> --"If we ignore CPT coding we go to jail for fraud."
> Are you sure the law that says you are required to accept CPT codes?
> --"This requires a legislative remedy to be sure that both sides
> ARE REQUIRED to follow CPT rules."
> Then you want a law saying I have to follow CPT codes?
> --"...monopolistic companies like UHC"
> Is UHC a monopoly?
> --"My large pediatric group of more than 20 pediatricians has more
> than 30,000 patients."
> I've always thought you and your group were very cool, I read the
> stuff you write for the AAP.
> But New York State has 19,000 primary care physicians and 8000 more
> NP's and PA's in primary care. Dutchess County is ranked in the
> "least needed" as far as primary care ( http://
> ZIP_Code_PC_Needs_Analysis_7_06.pdf ) How could you hope to
> negotiate based on size. So how do you do it?
> Successful insurance companies get that way by offering health care
> quality and value, not by being monopolies. When doctors can offer
> health care value, quality, and efficiency (and my office doesn't
> seem very efficient) we will be able to share equally with
> insurance companies. It is probably necessary to form much larger
> groups to accomplish these efficiencies. However you do not join
> together in order to negotiate, that's antitrust.