Things That Make Me Crazy

I sometimes think I live in a tight little fantasy bubble where I want life to make sense and be fair.  I want it to be an uncomplicated place where, when resources are limited, we assess the problems and direct the dollars to things we know will efficiently fix the problems.  I'd like us to use our public health  dollars to feed hungry people, to house those without some place warm to stay, to help those in need learn strategies and get jobs so they can help themselves, and to provide health care to those who are ill.  In cases where there are big-picture items that lead to devastating consequences and enormous costs to society, I'd like us to target the causes with early interventions that are known to be effective: so measures to prevent drug/alcohol/tobacco abuse, better and more available drug treatments, and more resources dedicated to early education so that everyone gets the skills they need to earn a living and grow up to be a taxpayer.  

Instead, through some mix of politics and medicine, there are these untested (or poorly tested) ideas out there that cost billions of dollars and money gets diverted away from being used for the direct good of the people.  Maybe I'm wrong-- I'm sure there are plenty of people who disagree with me and think that these changes are important and will make the world a better place -- so by all means, feel free to comment. tell me why I'm wrong, or do add to my list.  It's a little of 'one guy unsuccessfully tried to blow up a plane with his sneakers so millions take off their shoes for screening every day.'  The cost is phenomenal, but I do have to  admit that no planes have been blown up with shoe bombs since, and if my child was on a plane that didn't explode, then the cost to society was worth it, but it's not a very "public health" way of thinking.  But you have to wonder what we're giving up when we put a lot of time, money, or resources towards low-probability events or towards paperwork for the sake of paperwork.  In no particular order:

Dinah's List of Aggravating Diversions from Productivity in 2013

• CPT codes that force psychiatrists to differentiate "medical care" from psychotherapy with rate changes depending on whether the psychotherapy component takes 52 minutes or 53 minutes or the session, and creates 15 different options for coding a single psychotherapy session.
• 68,000 ICD-10 codes for the purpose of diagnosis/billing. Really?  ClinkShrink will be thrilled, code Y92146 is for getting hurt at a prison swimming pool.  Prisons have swimming pools?  And Y92253 is for being hurt at the opera, so Clink and Jesse can both rest assured that injuries they may incur can be coded. This helps us how?  And, no, US prisons don't have swimming pools, but why should that stop us from having codes?
  
• Legislation -- complete with the cost of databanks, means for reporting to such databanks, and the cost of enforcement -- to keep the poorly-defined 'mentally ill' from owning guns when there is no such effort to keep the family members or roommates of those people from owning guns, and there is no such effort to keep guns from those who are known to be dangerous if they are not mentally ill.  The laws in Maryland also include 'habitual drunkards,' -- but there is no provision to report those who goes to detox/rehab or have a second DWI/DUI from having a gun. 
• Continued support of the Second Amendment as interpreted rather widely, despite 40,000 gun deaths/ year, some of them innocent small children. "A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed."  I'm just not sure that the founding fathers foresaw a society of drug addiction, rampant suicide, and a country with a firearms death rate beyond any other country in the world.  There was slavery when the second amendment was written, and I don't think the amendment included slaves, so clearly the 'right of the people' did not mean all people, or include assault weapons that did not yet exist.  The second amendment has become an impenetrable devotion -- in Maryland's it's some state legislator's main forum -- as if it were a religious belief.  And people with mental illnesses have taken the blame for all inappropriate uses of guns.  See yesterdays Bloomberg Report for our President's pronouncement, and by all means, read the comments.   
•  Meaningful use -- a government/Medicare phenomena that creates a tremendous amount of work for physicians that does not seem to directly improve patient care (correct me if I'm wrong), and if it does, it doesn't improve patient care/outcomes in a way that warrants the time, and expense.  I don't really know what Meaningful Use is (such details never stop me from ranting), but I know the government will give me money if I'll convert to electronic records and use it in a particular way.  Otherwise, for every Medicare  patient I see, I must charge a lower fee if I don't use e-prescribing (which is not conclusively shown to improve patient outcomes) a certain percentage of the time, and that in 2013, to prevent an drop in my fees, I needed to put a PQRS code on one patient's insurance claim form.  I could not figure out what that meant, so I asked an APA assembly member who runs a hospital.  After two  separate half-hour phone conversations, one in-person meeting, and I have no idea how many hours of his time, he provided me a list of options which included things like "medications not reconciled, reason not given."  I opted to list on one patient's claim a code indicating he was not a tobacco user, and I'm told this was good enough to keep my fees from dropping 1.5% next year.  What's meaningful about this?
• CRISP/Government portals of patient records collected without patient knowledge/permission.  These may be very helpful for emergency care in crisis situation,  and perhaps they allow for data/outcome collection that will be used for outcomes research, but they cost a lot of money and after the NSA scandal, are we all comfortable with the government keeping our health records without our expressed permission?  Are we sure our health information won't bounce back at us in unwanted ways?
• Hospitals that spend HUNDREDS OF MILLIONS OF DOLLARS to replace existing, function, Electronic Medical Records when there are people sleeping on cardboard boxes outside their doors, and when such medical records increase the amount of time clinicians spend with computers and decrease the amount of time they spend with patients -- and don't necessarily decrease medical errors.  This feels wrong to me  on so many levels: there are shortages of physicians and we're diverting their attention to clicking through screens and checking off boxes that have nothing to do with the care of that particular patient, adding hours a day to physician workload, promoting physician burnout, and diverting funds to this project that could be used to pay for health care for human beings.
• Government-run health insurance exchange(ACA) websites that are basically unusuable and create too much frustration for the average person --especially the average person with medical or psychiatric issues-- to work efficiently.  One of my patients was blocked from signing up because he forgot his password, and the recovery question involved his pet's name, only he's never had a pet and was locked out of the system. 
• Hospital medical records that afford no privacy because thousands of people have access to them and patients can not opt out, other than to get care at another institution.  But if you want information about a patient from another institution, with the patient's permission, barriers are put in place to make this next to impossible.  I recently requested records from a local hospital ten minutes from my office, and two weeks later they sent me a form saying that the authorization my patient signed was not good enough, it had to be signed on their specific form.  How crazy is this?  Perhaps it's because that hospital's administrator was so busy looking up my PQRS codes that he wasn't updating their information release policies.
• That my state is proposing to spend money on programs to increase cultural awareness and competency on number of measures when people need food/housing/healthcare/job training.  I'm all for treating people respectfully, but maybe it would be cheaper to fire those who are demeaning to others rather than to set up training programs to make them 'culturally aware.' (Please forgive my cynicism, in a world where everyone is fed, housed, has healthcare, heat, education and jobs, I'm all in favor of programs to increase sensitivity to cultural issues).
• "That my state is proposing to add Assisted Outpatient Treatment (read: forced care) when we don't have enough information to know if this really works without other services in place.  We don't have  enough resources to care for people who want care, and this will entail forcing people to take medications that are known to have detrimental cardiovascular effects in some people,  distressing side effects in others, and may include forcing care on people when that care does not decrease their symptoms. If I thought the legislation was truly about getting care for the very sickest of people -- those 'dying in the streets with their rights on' -- I would be in favor, but I believe it's a "do something" measure to address spree shooters and has been tied to federal funding. 

Thank you for letting me rant.  That's what this was, and I appreciate it.  I feel much better now. 

They'll Come Knocking

Behind all the anxiety of new CPT codes-- because change is hard-- there is not just the angst of more paperwork, or the question of whether gathering specific data distracts from the work of caring for the individual patients.  We wonder whether the burden of new billing systems and more documenting for the sake of being able to code like "real doctors" will actually translate to higher reimbursements.   More than that, though, there is the fear, which lately does not go unspoken: the fear of doing it wrong and being accused of insurance fraud.  Our presenter at a CPT training seminar warned that down-coding is just as fraudulent as  up-coding, and my feeling is that we should accurately code the work we do within the confines of the very complex Evaluation and Management schedule, such that our services do get higher reimbursement --- it's difficult to follow but it's either about collecting the right number of bullet points in each category or it's about spending more than 50% of time counseling and coordinating care.  Funny, now psychiatrists have to talk more than they listen.   Yet everyone I've spoken to says they code low because they don't want to draw attention to their work and don't want to be accused of fraud.  I suggested that this is wrong when the doctor is paid a salary and so the hospital collects lower fees.  I also think it's wrong when the doctor is out-of-network and the patient's reimbursement, from their health insurance company with those very high premiums and very low reimbursement for expensive psychiatric services, depends on the code. 

 Some docs are just trying to ignore the upcoming changes, especially those in small private practices.  Insurance companies don't typically audit charts of solo practioners who are not in their networks.  It's likely rare that Medicare does either, unless perhaps something looks fishy?  So some say, "they won't bother me."  Others say, they're coding low to stay off the radar, and at least 2 docs I know are opting out of Medicare, because Medicare audits are scary with their $10,000 per claim fines.  (Am I right about this?)

Emailed to me today, with the actually title, "They'll Come Knocking":

Subscribe to Compliance Watch to Steel Against Investigations and Unnecessary Penalties 

Do you know the new definition of fraud? Are you up to snuff on changes to CPT codes? Big changes are on the horizon. Are you ready for how they will affect your day-to-day and business practices? To survive in our new healthcare environment, staying current on mandates and preparing adequately for investigations and audits is crucial.

Of course this company is selling their services and they are doing it through scare techniques, but still.  

Send a Message to Congress: Don't Cut Access to Healthcare for Medicare Patients

Medicare has been using a flawed formula to annually revise Medicare fees to all providers. The formula results in a larger and larger cut each year, which often gets temporarily "fixed" at the last minute. Due to the current dysfunctional Congress, the expectation is that it won't get fixed this time around, and so this year's cut -- 30%! -- will stay in place, resulting in many doctors, nurses, psychologists, social workers, and other providers to drop Medicare.

What we need is for them to repeal this flawed "Sustainable Growth Rate" (SGR) formula, and replace it with something that makes sense.

Please CLICK HERE to take a few minutes to let your elected representatives know what you think about this.

Thank you.

What Medicare Cuts May Mean For Patients Who See Psychiatrists

Over on Shrink Rap News, Roy wrote a post about proposed Medicare cuts.  He continued the conversation here on Shrink Rap.  

I want to expand on the discussion in what I hope will be easy-to-understand terms.  Why would anyone who is not a doctor even care what Medicare reimburses their docs?  Let me tell you why you might care.

Doctors all have one of four designated categories within the Medicare system:
1) The doc participates and accepts Medicare assignment.  The fee for the service is set by Medicare, the patient makes a co-pay and the doctor bills Medicare and gets the rest of the fee from Medicare.
2) The doctor is "non-participating" --which is a deceptive term, because non-participating docs are within the Medicare system.  The fee for the service is set by Medicare and is typically 5% less then the fee for participating docs, but the patient pays the Medicare fee in full to the doctor, the doctor files a claim with Medicare, and Medicare reimburses the patient for a portion of the fee. 
3) The doctor has formally opted-out.  In this case, the doctor charges the same fee that every other patient is charged, the patient pays the doctor in full.  No forms are filed to Medicare and the patient receives no reimbursement at all.  A doctor who opts in one setting is opted out in all settings, so one can't opt out in private practice and also work in a clinic where Medicare is accepted. 
4) The doctor never files anything with Medicare.  He can not see Medicare patients at all, ever, in any setting.  Perhaps he can see patients for free(?), but no money can change hands and no forms get filed.  This is not the usual.


The current proposal is for a 30% cut in provider fees for 2012.  Oh, we dance this dance every year.  But this year, the thinking is that it may stick.  As is stands now, the current Medicare fee for a non-participating provider in the area where we live, for a 50 minute psychotherapy session, with medication management, in a non-facility (meaning, for example, a private practice that is not hospital-based) is $120.96.  This fee is notably lower than going community rates, and because of this, many psychiatrists who practice psychotherapy have opted out: they can charge what they'd like and they don't have to deal with the hassles of filing any paperwork.  Oh, but it's not just psychiatrists, some internists have opted out of Medicare.  It means that when you hit 65, either you pay your doctor out-of-pocket, or you change doctors.


Currently, it's hard for patients to find psychiatrists who participate with Medicare, and those who do often limit new Medicare patients. A doctor can come highly recommended, and you may be a multi-millionaire, but that doesn't matter, because once a doctor is in Medicare as either participating or non-participating, the fee is set by Medicare and being rich doesn't buy you in, because all Medicare patients pay the same fee. 

If the fee drops so that an hour of work is reimbursed at $84.67, a 30% decrease, more psychiatrists will opt out.  From the doctor's point of view, they kind of win: if they can hold on to a big enough patient base, they can charge their usual (generally higher) fees and they don't have to hassle with claims.  From Medicare's perspective, they definitely win: patients are forced to get care outside the system and they reimburse nothing.  It's not like going out-of-network with your private insurance where they will still pay for services, perhaps at a lower rate or with a higher deductible, but they do compensate for a chunk of the care.  Those doctors who remain in the system are those who can make it work for them--- they see patients for Pharmacologic Management with a code that does not have a time requirement and cram as many patients in as fast as they can see them.  But as SteveMD has pointed out in his comment, when fees drop by 30%, even the workhorse psychiatrists who can go at an exhausting pace of 4-5 patients per hour will be making much less money to provide one-size-fits-all 10 minutes-with-a-shrink care. 


From the patient's point of view: they lose.  Suddenly their doctor doesn't accept Medicare.  They now get hit with a much higher fee and they get no insurance reimbursement.  This is why you should care.
------
On a lighter note, the photo above is a picture of Oreo, a very sweet Havenese poochie we befriended during our book signing at the Baltimore Book Festival today.  I put a photo of us up on our Facebook page.....one more illustration of Roy ragging on me.  Please do visit our FB page at Shrink Rap Book and by all means, "Like" us!

Medicare: Access to Mental Health Care in Danger

In many states, Medicare fees are at the bottom of the barrel, prompting physicians and other health care providers to stop accepting new patients or even to opt out of Medicare completely. A recent proposal from MedPAC (Medicare Payment Advisory Commission, which makes recommendations to Congress) would further reduce rates by up to 38% over the next 10 years.

I wrote an article yesterday in Clinical Psychiatry News explaining this critical danger to the health care safety net for seniors, baby boomers, and people on disability.

I think Medicare needs to reinvent its game by moving away from per-visit payments -- which reward volumes -- toward payments based on severity-adjusted episodes of care combined with quality and outcomes multipliers -- which rewards quality and efficiency.

By re-inventing the way Medicare pays all providers, not by quantity but by quality and efficiency, it has a chance to bend the cost curve without making it harder for beneficiaries to find a doctor who will accept Medicare. Medicare enrollees deserve to be treated better. If Congress messes this up, there will be hell to pay at the ballot box.

 --------------
         Dinah added a post explaining what this might mean for patients at : http://psychiatrist-blog.blogspot.com/2011/09/what-medicare-cuts-may-mean-for.html

Call Back Never

Okay, so I've been complaining about the hassles with Medicare since I changed my address. So this morning, Monday at 9:23 AM I decided to call the Highmark Medicare Enrollment Helpline. I went through the assorted menus --- with several stops at : Please visit the website. So finally I get to the juncture where I can press O to speak with a live person. Oh, but the message I get is: "We are currently experiencing high call volumes and can not take your call." They suggest I call back later, and specifically suggest that the best time to call is 8AM-9AM on Mondays. Next week, perhaps? Oy.

Medicare Oh Medicare

I've written before about the difficulties I'm having with Medicare because I simply wanted to change my address. Medicare has 221 downloadable forms, none of which are change-of-address forms. In order to do this, I needed to fill out a 27-page enrollment form. I did, but was rejected because I didn't also fill out a 5-page form giving Medicare access to deposit funds in my bank account. Oh, but I'm a non-participating provider--- Medicare pays the patient, not me. And, I work in a clinic where they bill Medicare for my work under my name, and I certainly don't want money that belongs to the clinic going to my bank account. There's no upside to them having this information, and much potential for hassles. I filed an appeal, and it was denied. This has been going on for months. I've stopped being aggravated, and I was pleased when one of my patients mentioned she'd gotten a reimbursement check, so who knows how long I will exist, and I may surrender and send them my bank information and hope for the best.

You can read about my prior rantings Here and Here.

So the day of my latest rejection by Medicare, Meg was kind enough to send a link to an article about a Medical Society President (a dermatologist) who opted out of Medicare. The Business Review writes:
Dr. Leah McCormack, who has a dermatology practice in Forest Hills, said in an open letter dated June 30 that “I can no longer bear the shackles of government and insurance company rules, the burdens of their regulations and the fear of their retributions for the paltry reward of their monetary compensation for my services.”

The article goes on:
“I have been in the solo private practice of dermatology for 25 years,” she wrote. “I have tried to practice with the total focus on my patients, but this has become impossible. My staff and I spend an exorbitant amount of time dealing with claim denials, insurance managers, pre-authorization managers and pharmacy benefit managers. There is so much health system managing that there is little time for health care.”

Read more: Medical Society president declares independence—from Medicare - The Business Review (Albany)

Thanks for the heads up, Buggy!

The Stressed Out Shrink Rapper

http://psychiatrist-blog.blogspot.com/2010/05/stressed-out-shrink-rapper.html

Yes, shrinks get stressed out, too. Can I tell you about it?

I hate paperwork, in case I never mentioned it. And I hate dumb things that are mandated by institutions and don't make sense. So I'm getting ready to go to APA this weekend ( see you there?) and I'm trying to tie things up. It's not going so well. Here's my list:

MEDICARE.
Remember I told you that I moved and tried to change my address with Medicare? Ah, 221 downloadable forms on the Medicare website, and not one of them is a change of address form. To change my address, I had to re-enroll. 27 pages. Then they wanted my office utility bills. But I don't have utility bills, they are included in my rent. I faxed my rent invoice--it has my address, and it says "office rent" on it. It's a very nice office. I figured I was done.
Two days ago, I got a letter from Medicare. I've been denied my application as a Doctor of Medicine. I can appeal. Why? I didn't send in three things: 1) Downloadable form 558 giving access to my bank account so they could pay me. Only I'm not an in-network doc. They don't pay me. Ever. 2) my participating agreement. I'm non par and wish to stay that way. 3) my utility bills as proof of address. Am I the only doctor who rents space with utilities included?
I called. Twice. If I won't give them my bank account numbers and routing information, I'm out. Which means I have to leave my clinic job where I've been for 12 years. I don't have to fill out a participating agreement. And they'll take another copy of my rent invoice. I have 30 days to appeal. From the date on the letter which came 2 days ago. The letter is dated in April (it's now May 20th). And I'm really not happy about giving them my bank account information---what happens when they pay me for patients I see at the clinic? I'm salaried there, I don't get paid by the patient, the clinic does. If I do nothing, I'm quickly opted out, and that's a good thing...unless you're my Medicare patient and you no longer can get reimbursement or you're the clinic that wants me there. Have other people had to give their bank account info to change their address? Never done this before. Time expended: who knows. Hours. If you're a non-par provider could you offer some words of wisdom here/?

Next problem:
Clinic says I need to be tested for TB along with all the other employees. So I get a ppd placed, no big deal. Only I work there one morning a week, and in the past, I've read it myself or had a dr. friend sign off on it, because it's a hassle to get to the hospital, park, and take off work for this. Now I'm told I can't read it myself or have another doctor read it, unless it's an internist, pediatrician, or pulmonologist. Okay, found a friend, still have to get the form faxed in. Time expended: 2 hours.

Next problem:
My cell phone blitzed last night. I called. They said I needed updates and they'd push them through. Whatever. The phone worked, I thanked them, and half an hour later, I was on my merry way. Only then the phone didn't work. And my kid's phone didn't work. I called back I held. I powered off, I powered on, I removed the sim cards, I read the numbers, I switched the sim cards, I powered on and off and ate the batteries and prayed for ducks to come. The phones aren't reading the sim cards. I need to get new ones. Okay. Hours. I got to work today. The phone works fine. I called AT&T. Can't be the sim card. Husband's phone works fine. Must be the degrading tower. What's a degrading tower? Does it crumble? Why does husband's phone work? Very strange, no explanation, but tonight, all the phones work. Time expended: 2.5 hours.

I suppose the last thing is the book. Time expended 4,237 hours. Our editor wants it in Mid May. I think that happened. It's almost there. We still need a little polish on the last few chapters and a table of contents and Suggested Reading . If you know a shrink book that's been helpful to you, please let us know in the comments===we'll try to stick it in.

Hanging on for: http://www.patobriens.com/patobriens/havefun/hrricane.asp

Thank you for humoring me tonight, please send a bill

I Don't Know What to Charge!

I got a letter today from a patient asking me to explain why I've billed him roughly $4.50 more than Medicare allows. He included a statement from...?Medicare or it's administrators saying that this lower amount is the Medicare-allowed amount and that if his doctor charged more, a refund is due.

Every year, in December, I try to figure out the Medicare fees. Mostly I call a shrink friend who is in the same jurisdiction who is also a non-participating Medicare provider, which is different then someone who "opts out." I have to charge the Medicare amount, but it's always this funny challenge to figure it out just how much that is. At one point, I couldn't even figure out where I practice---in Maryland there are two districts, 01 and 99, and my office appeared to be located in neither. So now I think I know where I am (no one else I asked was completely certain either). For the record, it's not easy to find the fees, they vary by district and by procedure and by whether you are a facility or non-facility, participating, or non-participating, and there is the limiting fee and caps, and it gets mailed to me as a CD that doesn't open, and it's not on a website that I can find and the psychiatric society doesn't always have any better luck, and some of my friends are "participating" and have different fees, and most have "opted out" and one just can't deal so he doesn't charge any Medicare patient any fee and he doesn't submit...easier to work for free.

Okay, so every year for the past couple of years, Medicare is cutting fees by 21% or 24%. But at some point, Congress changes their minds and undoes the cut, so I've taken to keeping my fees the same, with the idea that it will be easier to reimburse patients (or credit their accounts) then it will be to tell patients that I was wrong to drop my fees and they now owe me money. And every year, Congress votes, after a period of ranting and uncertainty, to undo the fee cut. This year, Congress seems to vote to delay the cut multiple times every few weeks. I called a friend, he got a similar letter from a patient. The tone of the letters imply that we are purposely overcharging or willfully committing Medicare fraud.

The executive director of our state medical society got pulled in. He sent out a newsletter from the Medicare folks. It states:

On April 15, 2010, President Obama signed into law
the “Continuing Extension Act of 2010.” This law
extends through May 31, 2010, the zero percent
update to the Medicare physician fee schedule
(MPFS) that was in effect for claims with dates of
service January 1, 2010 through March 31,
2010. The law is retroactive to April 1, 2010.
Consequently, effective immediately, claims with
dates of service April 1, 2010 and later, which were
being held by Medicare contractors, have been
released for processing and payment. Please keep in
mind that the statutory payment floors still apply and,
therefore, clean electronic claims cannot be paid
before 14 calendar days after the date they are
received by Medicare contractors (29 calendar days
for clean paper claims).

Given the uncertainty regarding MPFS claims with
dates of service June 1, 2010, and later, please
watch your listservs and your contractor‟s website for
more information.

So Medicare is saying there is no decrease, at least not for the next 2 weeks, at which point we can again try to figure out what to charge. But CMS is telling patients that the fees we are charging are illegally high. Whistle blowers and Medicare fraud publicity and fines, leave me wishing it was easy for everyone to simply know the correct fees.

Can Medicare Make ME Crazy?

I've moved. You know that. The new office is terrific, shabby chic walls and all.
So I'm working on the whole change-of-address thing. I've notified the post office, the bank, sent a zillion notices out. I've notified my malpractice insurance agent so many times that he called to tell me he changed my address weeks ago and I keep notifying him. I called the Controlled Dangerous Substance folks in my state. It costs $50 to notify them of a change of address. What gives with that. And the DEA...no forms, I tried emailing, I guess I'll send a real letter. The hospital gave me a local number, but it's out of service.
And Medicare: have I mentioned the 221 downloadable forms and how to change your address you have to fill out the 27 page enrollment form? I did? I guess I did.
Did I mention that I'm a non-participating Medicare provider? I don't want to 'enroll.' I finally tackled the form, figuring it would have a box at the end where I could check off that I'm not a participating provider....since I have not 'opted out' ...I'm actually participating by not participating. Try explaining this all to a distressed patient.

I surrender. Tomorrow, I'll try calling. I will no longer be blogging. I anticipate the next year of my life will be on hold.

If you have any answers, by all means....

Forwarding Address

I moved my office yesterday. As fate would have it, the final piece of mail I received at my old address was a notice from Medicare informing me that I needed to update them if there were any changes in my practice, for example, a change of address. It told me where to go (on the internet, that is).

Okay, so in case you're wondering, Medicare has 221 downloadable forms on their website.

If I understand the directions right (and do feel free to help me out here) CMS-8551 is the form for me:

Additional Information Physicians can apply for enrollment in the Medicare Program or make a change in their enrollment information using either: 1. Have a National Plan and Provider Enumeration System (NPPES) User ID and password to use Internet-based PECOS. • For security reasons, passwords should be changed periodically, at least once a year. • For information on how to change a password, go to the NPPES Application Help page and select the “Reset Password Page” on the NPPES Application Help page. 2. Go to PECOS to complete, review, and submit the electronic enrollment application via PECOS. 3. Print, sign, and date the two-page Certification Statement and mail it with all supporting paper documentation to the Medicare contractor within seven days of the electronic submission. NOTE: A Medicare contractor will not process an Internet enrollment application without the signed and dated two-page Certification Statement and the required supporting documentation. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed two-page Certification Statement that is associated with the Internet submission. Physicians who are enrolled in the Medicare Program, but have not submitted the CMS-855I since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS-855I) as an initial application when reporting a change for the first time. If a physician has any questions about reporting a change, the physician should contact his or her designated Medicare contractor in advance of submitting the CMS-855I.
(Note, I deleted the Medicare web addresses from the body of the text I copied)

Okay, so 221 downloadable forms, and the form for change of address is the CMS-8551. No prob, I'm on it. PECOS. What are PECOS? I know what pesos are, but PECOS? So form CMS-8551, downloaded for my change of address is 27 pages long. What would it take to get Medicare to have 222 downloadable forms, with the 222nd form being a one-page change of address form.

Because I Said So....

I recently linked to an article on the Well Blog about a child with Asperger's Syndrome in NYC. The boy's parents were at odds with their housing co-op about the boy's need for an emotional support dog in the no-pets-allowed complex.

Roy said that's what docs get to do: determine medical necessity.
Commenters on our blog and the Well blog were mixed, and I really don't have enough facts to feel comfortable commenting on the situation.

It did get me thinking about the concept of Medical Necessity and before I start rambling, let me say that I didn't see the term "medical necessity" on anything associated with the kid and dog case. What I read simply said that doctors thought a dog would help the boy, that the co-op agreed to let him have a small dog with many stipulations attached, and the feds, specifically HUD, took on the cause and felt the co-op discriminated against the family. You can read Here.
Medical Necessity is a funny concept, one I'm not always 100% comfortable with. I think the issue here is that when we as physicians deem something Medically Necessary, it implies some imposition, usually financial, but in the case of the service dog--furry-- on someone else. Usually we use the term to mean that it's something someone's health insurance should pay for that they don't (or may not want to) pay for. If there's not a cost (financial or otherwise), then one can leave it at "My doctor said to do ...." and there's not a reason to deem it "medically necessary." That's a term that goes in writing and means someone, somewhere will find it inconvenient.

I don't usually declare that things are Medically Necessary from a psychiatric viewpoint, except for specific medications-- sometimes Name Brands (as opposed to generics) and then because the patient has tried the generic and found that either they don't work as well or they cause side effects. The other Medically Necessary things I recommend are sessions (ie, treatment is medically necessary) or Hospitalization...ah, the joys of managed care. Sometimes I tell people to stay home from work, especially if I feel their behavior during an episode of illness puts them in jeopardy, and I'll write a note saying they need time off, or that they were at a doctors' appointment, but this usually doesn't require a statement of medical necessity, per se, it falls under sick leave. My stationery doesn't even say I'm a shrink, and unless I'm specifically asked, I don't volunteer that in "doctor's excuse" notes.

In the case of the dog and the kid, the term "medically necessary" wasn't used-- it was simply said that the dog might be helpful to the boy. What about another occupant who might require a animal-free environment? How do we determine whose rights trump whose? Maybe this is a bad example, because one can envision that one condo owner could live with a dog in such a way that the other people in the condo aren't disturbed by it and the presentation by the press left the reader feeling that the complex owners are unsympathetic child and dog hating meanies who were being unnecessarily arbitrary. I got curious and did a little googling-- it seems the dog would be going through a training process with the boy. The other issue was concern by the building about the area around the entrance to doctors' offices in the building.

So this is my concern with extending the definition of what is a disabilty and what we should do as a society to accommodate the needs of the disabled: if the issues get too diffuse, then ultimately the laws to protect the disabled hurt them. Don't want any autistic kids here because then we'll have to allow their dogs. Okay, maybe that's silly, but the issue isn't just what one group needs, it's also the fear of being sued because of the perception of injustice, or the fear of having to accomodate. The issue of medical necessity feeds into this unless we hold to a fairly strict notion of what is medically necessary, and as doctors.

If you want to read more about the kid with the battle for the dog:
Try this or this.

And just to be clear, this is a rambling post. Most often, 'medical necessity' is a term that has to do with Medicare reimbursement...somehow I've gone off about service dogs and co-ops and broader implications to society.

The Beginning of the Middle of the End of Medicare

The Beginning of the End of Medicare was when Congress passed the rules which require physician fees to follow a Sustainable Growth Rate or SGR,  followed by the Medicare Modernization Act or MMA, which added the prescription drug plan but prevents Medicare from negotiating lower rates from Big Pharma.  The problem with the SGR is that its calculation is fatally flawed, requiring increasing annual reductions in physician payments.  Congress recently overrode Bush's veto of their bill to nullify this year's planned SGR reduction of 10% in provider payments.  There is another 40% reduction planned over the next several years.  Since all other costs go up annually, it is a no-brainer that annual reductions in Medicare fees will eventually result in providers ending their participation in the medicare program.

We are now at the Middle of the End.  Medicare now has this bounty hunter system using "recovery audit contractors", where auditors look for "overpayments" and errors.  There has been criticism, though, about inconsistent methods and a lack of oversight of the auditors.

But for physicians who come under the gaze of the contractors, the costs to the practice can be far more than the Medicare money at stake.

Marilou Terpenning, MD, a hematologist-oncologist in Santa Monica, Calif., had to respond to several rounds of medical record requests from PRG Schultz for claims involving alleged overpayment for chemotherapy. Some of the cited overpayments were as little as $13 or so per claim, but the cost to the practice of retrieving the corresponding record and forwarding the information could be 10 times that amount, she said.

I suspect that this is part of Medicare's death by a thousand cuts.  The hassle factor for dealing with Medicare will exponentially increase to the point that few participating providers will be left standing.

(It was raining all morning, so I decided to write a relevant post :-)

Landmark Medicare Bill Passes Senate; Removes Federal Discrimination Against Mentally Ill

Yesterday, the US Senate passed, by a 69-30 vote, a bill that would finally remove the anachronistic and discriminatory "brain tax" from Medicare.  Elderly and disabled on Medicare have had to pay a 50% copay for outpatient treatment for mental illness since Medicare started in 1965.  Any other type of illness requires only a 20% copay.

But mainstream media is largely ignoring this historic success in the fight against this discrimination.

This blatantly discriminatory and stigmatizing financial penalty against America's seniors has long resulted in undertreatment of mental health problems, often leading to even higher costs for other somatic conditions due to self-neglect.  Finally... a Medicare parity bill that passed both House and Senate!

I did a search on Google News for "medicare bill +mental|psychiatric" and "medicare bill -mental|psychiatric" to determine the number of articles in the past month on the Medicare bill which either did or did not mention the words "mental" or "psychiatric."

6,466 Articles . . . . . DO NOT mention the bill's mental health provisions

   408 Articles . . . . . DO mention the bill's mental health provisions

Please write to these article's authors and tell them to get a clue.  And let Bush know that you don't want him to veto the bill (McCain has already said he would have voted against it).  

This is much bigger news than the annual passage of a bill to block cuts in Medicare physician (and all other providers, BTW, incl. social workers, psychologists, etc) fees.

H.R.1663 - Stark's Medicare Mental Health Modernization Act

There are several bills before Congress that would help to end insurance discrimination against people with mental health problems. In addition to HR1663, there is also SB558, HR1367, and HR1424.

Here is Pete Stark's speech introducing his HR1663 [pdf], the Medicare Mental Health Modernization Act (my emphasis added):

SPEECH OF HON. FORTNEY PETE STARK OF CALIFORNIA IN THE HOUSE OF REPRESENTATIVES FRIDAY, MARCH 23, 2007

Mr. STARK. Madam Speaker, I rise today with my colleagues JIM RAMSTAD of Minnesota and PATRICK KENNEDY from Rhode Island to introduce the Medicare Mental Health Modernization Act, a bill to provide mental health parity in Medicare. I have introduced a version of this bill in every Congress since 1994. Perhaps this time we can actually enact it.

Medicare's mental health benefit is fashioned on treatments provided in 1965, but mental health care has changed dramatically over the last 42 years. Medicare limits inpatient coverage at psychiatric hospitals to 190 days over an individual's lifetime. In addition, beneficiaries are charged a discriminatory 50 percent coinsurance for outpatient psychotherapy services, compared to 20 percent for physical health services.

The Medicare Mental Health Modernization Act eliminates this blatant mental health discrimination under Medicare and modernizes the Medicare mental health benefit to meet today's standards of care.

This bill is long overdue. One in five members of our senior population displays mental difficulties that are not part of the normal aging process. In primary care settings, more than a third of senior citizens demonstrate symptoms of depression and impaired social functioning. Yet only one out of every three mentally ill seniors receives the mental health services he/she needs. Older adults also have one of the highest rates of suicide of any segment of our population. In addition, mental illness is the single largest diagnostic category for Medicare beneficiaries who qualify as disabled.

There is a critical need for effective and accessible mental health care for our Medicare population. Recent research has found a direct relationship between treating depression in older adults and improved physical functioning associated with independent living. Unfortunately, the current structure of Medicare mental health benefits is inadequate and presents multiple barriers to access of essential treatment. This bill addresses these problems.

The Medicare Mental Health Modernization Act is a straightforward bill that improves Medicare's mental health benefits as follows:

It reduces the discriminatory co-payment for outpatient mental health services from 50 percent to the 20 percent level charged for most other Part B medical services.

It eliminates the arbitrary 190-day lifetime cap on inpatient services in psychiatric hospitals.

It improves beneficiary access to mental health services by including within Medicare a number of community-based residential and intensive outpatient mental health services that characterize today's state-of-the-art clinical practices.

It further improves access to needed mental health services by addressing the shortage of qualified mental health professionals serving older and disabled Americans in rural and other medically underserved areas by allowing state licensed marriage and family therapists and mental health counselors to provide Medicare-covered services.

Similarly, it corrects a legislative oversight that will facilitate the provision of mental health services by clinical social workers within skilled nursing facilities.

It requires the Secretary of Health and Human Services to conduct a study to examine whether the Medicare criteria to cover therapeutic services to beneficiaries with Alzheimer's and related cognitive disorders discriminates by being too restrictive.

In April 2002, President Bush identified unfair treatment limitations placed on mental health benefits as a major barrier to mental health care and urged Congress to enact legislation that would provide full parity in the health insurance coverage of mental and physical illnesses. We've made important strides forward for the under-65 population. Twenty-six states have enacted full mental health parity. The Federal Employees Health Benefits Plan (FEHBP) was improved in 2001 to assure that all federal employees and members of Congress are provided parity for mental health and substance abuse treatment. This month, Representatives KENNEDY and RAMSTAD introduced H.R. 1424 , the Paul Wellstone Mental Health and Addiction Equity Act, to provide full parity for mental health and substance abuse in the private insurance market nationwide.

I'm proud to join them in support of this legislation, which was introduced with 256 cosponsors--well more than the 218 majority needed to pass the House of Representatives.

While some in the business community are concerned about increased costs associated with providing these benefits, a recent study of the FEHBP mental health coverage concluded that implementation of parity benefits led to negligible cost increases. In fact, some businesses are now embracing parity because they recognize the increased productivity from workers over the long run and how improving access to mental health services has the potential to avoid other additional costly care.

I am similarly sure that modernizing the Medicare mental health benefit will reduce unnecessary spending. Medicare mental health expenses have historically been heavily skewed toward more expensive inpatient services, with 56 percent of the total going to inpatient care and only 30 percent toward outpatient services in 2001. This relationship is in contrast to national trends showing a reversal in inpatient and outpatient spending over the past decade. In the last 10 years, inpatient spending declined from 40 percent to 24 percent, while outpatient spending increased from 36 percent to 50 percent of all mental health spending. In addition, improving beneficiary access to timely mental health care could well yield savings by minimizing the need for other services.

Science has demonstrated that mental illness and substance abuse are manifestations of biological diseases. It is long past time for
us to take action with regard to Medicare's inadequate mental health benefits and structure. Over the years, Congress has updated Medicare's benefits for treatment of physical illnesses as the practice of medicine has changed. The mental health field has undergone many advances over the past several decades. Effective research-validated interventions have been developed for many mental conditions that affect stricken beneficiaries. Most mental conditions no longer require long-term hospitalizations, and can be effectively treated in less restrictive community settings. This bill recognizes these advances in clinical treatment practices and adjusts Medicare's mental health coverage to account for them.

The Medicare Mental Health Modernization Act removes discriminatory features from the Medicare mental health benefits while facilitating access to up-to-date and affordable mental health services for our senior citizens and people with disabilities. I urge my colleagues to join Mr. RAMSTAD, Mr. KENNEDY, and myself in support of this important legislation and to work with us to improve mental health coverage for everyone.

Medicare Mental Health Copayment Equity Act of 2007

Here is the letter that the Medicare Mental Health Equity Coalition (MMHEC) sent to Senators John Kerry (D-Mass.) and Olympia Snowe (R-Maine), thanking them for re-introducing this bill, which would end the discriminatory policy of charging copays for outpatient mental health care which are 250% that of copays for non-mental health care. It takes six years to transition under the plan, but it is better than nothing. It is simply amazing that this type of discrimination has remained for as long as it has.

The undersigned organizations of the Medicare Mental Health Equity Coalition, representing patients, health professionals, health care systems and family members, applaud your introduction of the Medicare Mental Health Copayment Equity Act of 2007 (S.1715). Your legislation will eliminate the unfair provision in federal law imposing a 50 percent coinsurance rate for outpatient mental health services under Medicare instead of the usual 20 percent coinsurance for outpatient services. Our coalition supports enactment of legislation like this that will bring payments for mental health care in line with those required for all other Medicare Part B services.

The Medicare program was established to guarantee health care coverage for all older adults and people with disabilities. However, the 50 percent coinsurance for mental health services has proven to be a harmful barrier preventing many Medicare beneficiaries from accessing services they need. Since its enactment in 1965, we have learned that mental health disorders are highly prevalent in the elderly and disabled populations covered by the Medicare program. A landmark report by the Surgeon General on mental illness in 1999 found that 20 percent of the population aged 55 and older experience mental disorders that are not part of what should be considered as normal aging. In addition, a 2006 report by George Washington University found that 59 percent of Medicare beneficiaries with disabilities have a mental illness and 37 percent have a severe mental illness. Tragically, only about half of those experiencing a mental illness receive mental health treatment, due in large part to antiquated and discriminatory health coverage provisions, such as the 50 percent coinsurance rate under Medicare.

There is simply no reason for maintaining a discriminatory barrier to mental health care for America’s seniors and individuals with disabilities, particularly since these populations present a high incidence of mental health concerns.

We greatly appreciate your leadership in addressing this fundamentally unfair Medicare policy for the 44 million Americans that depend on this program.

MMHEC member organizations include the American Association of Geriatric Psychiatry, the American College of Physicians, the American Psychiatric Association, the American Psychological Association, the Association for Behavioral Health and Wellness, the Center for Medicare Advocacy, Inc., the Medicare Rights Center, Mental Health America, the National Alliance on Mental Illness, the National Association of Social Workers, the National Committee to Preserve Social Security and Medicare, the National Council for Community Behavioral Healthcare, Psychologists for Long Term Care, Inc., and the Suicide Prevention Action Network USA.

Please write each of your senators, asking them to co-sponsor this bipartisan bill to end this antiquated, discriminatory policy against people who require mental health treatment.

My Three Shrinks Podcast 20: Mother Talkshoe

[19] . . . [20] . . . [21] . . . [All]

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We had to do something a little different this week. We three shrinks were all busy ... Mother's Day weekend, yard work, Longwood Gardens, and luaus kept us too busy to get together to do a podcast. I insisted that we find a way to do it online, so I FINALLY convinced Dinah that even she could do it ;-)

Ten o'clock last night, it all came together, and we were able to do a podcast, thanks to Talkshoe. (If you haven't checked out Talkshoe, do it. It lets you podcast by phone!) As luck would have it, a storm came through and turned the transformer down the street into a Fourth of July celebration. Despite being without power, we still managed to get it done. Is that dedication, or what?

So, here ya go. It is a little rough, as we weren't sure what we were doing (what else is new?), and recording it via cell phone caused occasional lags and silent periods... hmm, just like psychotherapy.

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May 13, 2007: #20 Mother Talkshoe

Topics include:

• Happy Mother's Day!
• Turkewicz law blog a hit with Clinkshrink. Her recommendations? Malpractice Primer and Economics.
  
• Q&A: Zoe Brain asks "Is there a Standard of Care for GIDNOS in the case where the patient is intersexed? And does the degree of intersex affect the therapeutic regime, and if so, how? I'm familiar with the WPATH (Formerly HBIGDA) v6 SOC for GID. But once a diagnosis of GIDNOS is established, the SOC does not appear to apply."
  Answer: Huh? (We did the best we could.) Also, see Farmer v. Brennan.
  
• APA says people with Medicare Part D having trouble getting their psychiatric medications. Also, discussion of the "donut hole."
  
• Medical Truth in Advertising bill: Is your "doctor" really a doctor?
• Ethical conundrums: trains and Tarasoffs and guns (oh my!). Also, Maryland's problematic law requiring reporting of childhood abuse, even if you are now 90 or you don't know who the perpetrator is. And, what do you do with a dead astronaut on the way to Mars?
• If Dinah had Lost It in Space, she Wishes she would have a Crystal Ball.
  
• A shrink like me?
  

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Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Clin Psyc News notes: May 2006

• Ritalin patch: I expect to see this a lot in nursing homes. I've seen methylphenidate make a huge positive impact on older depressed folks, and a patch form of administration makes it easier. But, it's another one of those dang off-label issues that's flaring up lately.
  
  
• 4.6% Medicare cuts next year: Will this ever get fixed? Locally, I hear of folks having a hard time finding psychiatrists who will even take Medicare. It used to be one of the easiest to participate with... no multipage treatment plans, etc. But practice costs increase every year, and we cannot make up the difference by seeing more pts (although I hear there have been some "creative" docs who have learned how to squeeze 50 90807s in a 24-hour day... no, thanks).
  
  
• Top 10 Psychiatrist Diagnoses: Something is wrong with this picture. The #1 dx is 296.2 (single episode major depr). I would expect recurrent episode major dep to be #1. And all of "Anxiety states" is only #3? I don't think so. The data come from Verispan's survey of 162 psychiatrists. GIGO.
  
  
• Don't flush your fluoxetine: Says to advise your pts on how to dispose of old pills, but does not say what to tell them. I used to tell them to flush them, but now I say to either return to pharmacy. It seems that flushing has led to high drug levels in the water supply.
  
  
• Prazosin reduces PTSD nightmares: This is new to me. Alpha-1 antagonists apparently reduce sleep problems and nightmares in PTSD. [PubMed]
  
  
• Vivitrol: I saw an ad for this recently approved i.m. form of naltrexone (it was going to be named Vivitrex, but I guess this was too close to some other name). Even if there is some efficacy data, this drug will go nowhere. Why? $695 per injection! Are folks gonna pay $22/day to be sober? It's cheaper to stay drunk! Cephalon blew it. I can only imagine that the market they are going after is the court-ordered treatment market. If they hit that one, they will have a blockbuster on their hands, because it is worth $22/day to stay out of jail. (The number of ad-blogs for this drug are incredible.)