WSJ has been running a series on Medicare entitled “Secrets of the System”.
The first article focused on medicare’s database and the problem with transparency and its lack of completeness. While we may know that somewhere in NY City there is a female family practice doc who pockets more than $2 Million in medicare, the journal doesn’t mention the physician by name but reports that the physician does a hands on treatment called “manipulative therapy” and likes to do a lot of EMG and nerve conduction studies along with sleep analysis-all of which have been identified by antifraud authorities as requiring special scrutiny. We don’t know whether a PT is doing any of the EMG stuff or for that matter if a hired PT is doing the “manipulative therapy”. Most of the article details the history of why it isn’t publicly available and how the database is used for detecting fraud and abuse mostly thru identification of outliers whereby certain fee for service procedures are heavily used when you would least expect them to be-like EMG for a family practice doc. The lack of completeness of the data really gets to the heart of the matter. Perhaps this family practice doc employs 10 physicians who simply re-assign the benefits to her thus making her income look artificially hi.
We have known for years that Medicare’s data lacks integrity at many levels. We don’t even know whether the approx $4 Billion in physical therapy outpatient payments goes to private practice PT’s or docs with PT’s (side note, if you run the numbers Medicare about 1/8th of all of medicare or $62.6 billion goest to providers with PT getting at best about 6% of that money inclusive of POPTS). The bigger problem of course is that using data mining for abuse detection when applying outliers might be reasonable, but one has to apply logic and policy to the bigger picture of medicare. We know based on published studies that physician’s have higher utilization when they own their own MRI, surgical center, and physical therapy clinic yet we don’t have government data that shows how overutilization contributes to the bigger problem of healthcare. We only know what we already know-there is fraud and abuse in the system and what is likely the larger problem-conflict of interest is not an outlier.
The second article really describes the way that the Relative Value Scale Update Committee (RUC) arrives at code valuations which in essence essentially determines how Medicare dollars are spent. While the article presents perhaps a critical view of the process, it also points out a very important issue-this is only relative to the physician piece of the medicare puzzle. Shouldn’t there be just criticism laid out over other areas of CMS including its administration, conflicting policies, and arbitrarily choosing to delay payments to name just a few? While RUC is not perfect it appears rational. The process has actually benefited PT quite a bit due to the gross re-adjustments in value of evaluations and one on one procedures versus several years ago. This is undoubtedly due to the influence of RUC at least embracing specialists through participation in the process including physical therapists. While there is likely horse trading between vested parties on this, over time there are ways to course correct. The article does point out the obvious, codes that pay more in a fee for service environment are used much greater-reimbursement does drive practice. If PT codes were not re-evaluated, I believe that every physician would be given an ultrasound and electric stim with their stethescope at graduation.
I am hopeful that WSJ will focus on other “secrets” of the system including the hi cost of regulatory compliance of medicare including coding, superimposed rules which make practice acts irrelevant, screwed up definition of quality called PQRI, excessive documentation requirements, antiquated plans of care, and additional billing technical compliance which does nothing but increase cost and delay payments. These hidden costs and not just the projected decreases in payments will be why many just will withdraw from seeing medicare patients and in large part the “secret sauce” that leaves a bad taste of medicare from a provider standpoint.
larry@physicaltherapist.com
