Friday, July 11, 2014

Health Care for the Poor: The Sequel

In a previous post, I described how the American health care system is morphing into a system designed to service impoverished populations, and concluded that the transition “will take time, thoughtful planning, lots of innovation and a carefully cultivated disdain for human life”. However, a new blog post from Dr. Peter Ubel makes me think that it may not take that much time after all. It seems that Dr. Ubel has been “writing a bit lately on the need for health care providers to talk with their patients about health care costs”, and it seems that some have pointed out that this sounds very much like rationing of care for poorer citizens.

In a Forbes article explaining why this type of criticism is “misguided”, Dr. Ubel is pointing out that individual patients may have different preferences and it is entirely possible that a “patient who pays 20% of the cost of a $100,000 chemotherapy treatment might decide that the potential benefits of the chemotherapy are outweighed by the $20,000 in out-of-pocket expenses they will incur”.  If the empowered patient has $0 in his wallet, division by zero would indicate that the potential benefits of life-extending or even life-saving treatment would be outweighed by a factor of infinity.

Having settled the rationing argument, Dr. Ubel is proceeding to suggest an innovation that should help “providers” bring costs into treatment decisions, not necessarily for everybody, but just for “those who are financially distressed by the cost of medical care”. Since most “providers” don’t know much about costs of treatment, the “financially distressed” will be directed to “walk down the hall and talk to one of the billing experts in the clinic”, because “meeting with this kind of a financial expert will help patients gain a fuller sense of the costs and benefits of their health care alternatives”.

I am not sure how the “billing expert” turns into a “financial expert” in the span of one short paragraph, or how one gains a fuller sense of treatment benefits after a conversation with a coder in the back office, not to mention the technical problems in clinics where the “financial expert” positions were outsourced to India through this or that cloud-based EMR company. Presumably to address these difficulties, Dr. Ubel proceeds to list all sorts of philanthropic Internet startup companies that will help patients figure out costs of care, largely out of the goodness of their hearts. Consistent with his other articles, Dr. Ubel is advising physicians to not “resist this inevitable trend”, but rather “embrace the opportunity to help their patients better understand the full ramifications of their healthcare alternatives”.

Since unlike Dr. Ubel, I don’t find it “relatively straightforward to imagine a shift in our clinical paradigm, where physicians alter the flow of patients in their clinic” to send poor people to the back, I would like to suggest a different solution which should require no imagination at all. Let’s make poverty a disease, most likely one of those “lifestyle” diseases. Instead of just V codes, let’s give it a few regular ICD-9 codes and plenty of ICD-10, and let’s add a special CPT code for ancillary “financial expert” services that can be billed incident to a physician visit for patients diagnosed with Poverty and proper manifestation codes of commercial insurance or no insurance (which is basically the same thing when you have Poverty). Note that publicly insured individuals can only be afflicted with unspecified Poverty, and do not have out of pocket manifestations, so their claims will fail medical necessity checks and will be denied.

If you think about it, Poverty fits very well in the documentation templates of any EMR. For the HPI section, Poverty can be acute or chronic and it can have date of onset and duration. It certainly has severity levels, and it can be better with some things and worse with others. Poverty has well known co-morbidities and you can even reasonably document previous treatments. Both the Family and Medical Histories can accommodate Poverty in relatives and previous bouts of Poverty in the patient. We will need to formally add an organ, or system, to both ROS and Exam sections, and the canned Normal findings could be something like “wallet plump to palpation, credit scores clear with no discharges and no late payments”.  

Poverty with commercial insurance or no insurance manifestations, is of course a secondary ICD code which cannot be billed on its own (you are a doctor, not an accountant), so before you can document your assessment and plan for the primary diagnosis, you will need to send the patient for a “financial expert” session, either in the back of your office, or at an outside facility, just like an x-ray or a cardiology consult. After the patient has been carefully made to understand that the benefits of $100,000 chemotherapy are outweighed by the lack $20,000 in her pocket and the unavailability of assets, loans or other debt instruments, you can complete your assessment and add orders for affordable hospice medications to her plan. This can be done remotely through secure email to save the patient the inconvenience of one more visit, and the care plan can then be shared with the rest of her care team via health information exchange facilities.

After five long years of political bickering, the solution to our health care problems now emerging from all our legislation, regulations, court battles and billions of dollars to "support transformation", seems to be one which requires doctors to take poor people to the back room, one by one, and educate them on the fiscal subtleties barring them from access to proper medical care. Why try to fight this brave new system? Why resist this inevitable trend, when you can embrace the opportunity?

And there is indeed great opportunity here. First, reimbursement rates for Poverty consultations are bound to be fabulous, and the prospects of “shared savings” are almost boundless. Second, the old coder in the back office may be a poor match for “financially distressed” people, and there is no denying that medical knowledge should help things along, and an MD could be the most effective consultant. So perhaps MDs with MBA degrees will finally be provided with a proper venue to exercise their craft, and perhaps a new specialty will rise to the forefront of value-based health care. May I suggest Paupertology (: the branch of medicine that deals with ability to pay disorders of the poor)?

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