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BLOG: Who is driving the boat?
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As an avid boater, this is a sad time of the year at the Jersey shore. Boats must be pulled out of the water and winterized for storage. It was a great summer; however, with lots of adventures to reflect upon over the long, cold winter.
When you ride in a boat, much of your comfort depends on how the captain drives the boat. Trimming the outdrive correctly allows for a smooth, level ride. In the Intercostal Waterway, navigating over the wake of an oncoming boat can be a slight rock or a drenching slam depending on the skill of the driver.
In the current phase of health care reform, I often wonder, “Who is driving the boat?” In what is becoming a daily occurrence, I find myself on the phone arguing with a pharmacy benefit functionary who is saying that the drug that I have prescribe for a patient cannot be used because it is not on the patient’s formulary. In the recent past, this was often just a request to use a generic form of the same drug. Once this became accepted practice, the cost-driven pharmacy benefit managers have become more aggressive with a demand to switch to a different drug in the same class, and one available in generic form.
Of late, and particularly for patients with ocular surface disease, we are required to choose from a completely different class of drug and often use one that is ineffective and has previously failed to meet the clinical need. In some cases, especially for my glaucoma patients with severe nerve damage and field loss, I have taken the time to write a report to defend the use of my choice of drug only to have my request denied with no explanation.
This problem is not limited to pharmacy benefits. In providing medical care, the correct match of procedure codes and diagnosis codes are essential for payment. As the financial knot of health care cost has tightened, each managed care plan has developed creative ways to deny claims. “Oh, don't worry,” the customer service department will tell your patient, “that service is covered; your doctor is just not billing it correctly.” For the most part, this is a correct statement, and if you juke around with different coding combinations, you can get paid. It is just that each payer has a unique combination of procedure and diagnostic codes that unlock the payment. But why do we need all this drama in health care? Who is driving the boat?
Another disconnect in the evolving world of health care administration is the unique challenges of the new ICD-10 codes. Although this rolled out with relative ease last year, this month marks a new challenge with the mandatory change of more than 500 new and revised codes to better define diabetic retinopathy, glaucoma and other eye disorders. These codes allow you to differentiate disease states between each eye. Your patient may now have 10 or more ICD-10 codes to carefully describe their exact clinical condition.
But, wait: once you carefully define it, you can only use four codes per procedure or the entire claim will auto reject and you will not be paid. And remember, each procedure code has to have an exact match of diagnosis code or the claim will also reject. All this work to define the status of the patient in codes and then we cannot submit them. Who is driving the boat?
On Jan. 1, 2017, we will enter yet the next phase of the health care reform payment system. This is the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). You may recall that I recommended that eye doctors in each region get organized to take advantage of the alternate payment models, but this has not happened for most optometrists. As such, most of us will be learning to deal with the Merit-based Incentive Payment System (MIPS). This will require the exchange of protected health information with secure electronic transfer and the uploading and downloading of Consolidated-Clinical Document Architecture (C-CDA) in your Electronic Health Record (EHR).
Have you tried this? It is a cumbersome multi-step process that requires a lot of careful doctor time and, if done incorrectly, will create a messy chart or perhaps crash your EHR and make that medical record inaccessible. Clearly this process was not designed by doctors, is not being implemented by doctors and will be more of an impediment to the very care that it is trying to reform. Again, I ask, who is driving the boat?
Although I am confident that this will all get worked out in the long run, we need more doctors to get involved with the process and work through the issues. Doctors will need to be more “tech savvy” to understand how this system evolved and how to make it better.
My hope for the future is that when a patient gets onboard for medical care, we have a doctor driving the boat.