Wednesday, October 22, 2008

EMR donations: Who is paying the money, where is it from?

Commercial labs, including my own, are now offering six-figure "donations" of EMR (Electronic Medical Record) software, maintenance, and training to clinicians. While this is not illegal, it does bring to bear the possiblity of conflict of interest.

Just where is the money coming from ??? From patients and insurance companies of course. And unneccessary medical testing (triple immunohistochemical stains, working up multiple prostate cores when only working up the most severe is required, routine UroVysion FISH analysis on non-smokers with microhematuria) provides the excess revenue which can be skimmed off the bottom line to support these donations.

Clinicians should know that accepting EMR docations could incentivze laboratories to run unnecessary tests ultimately paid for by their patients co-pay and deductibles. Labs that do not have to make a profit for external investors have less of an incentive to overutilize lab resources.

Wednesday, March 12, 2008

Excessive Medical Testing hits NY Times

NY Times

March 11, 2008
Many Doctors, Many Tests, No Rhyme or Reason

I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his monthlong stay he was seen by a hematologist, an endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a nutritionist, a general surgeon, a thoracic surgeon and a pain specialist.

He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work-up chronic anemia).

Despite this wearying schedule, he maintained an upbeat manner, walking the corridors daily with assistance to chat with nurses and physician assistants. When he was discharged, follow-up visits were scheduled for him with seven specialists.

This man’s case, in which expert consultations sprouted with little rhyme, reason or coordination, reinforced a lesson I have learned many times since entering practice: In our health care system, where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur.
Though accurate data is lacking, the overuse of services in health care probably cost hundreds of billions of dollars last year, out of the more than $2 trillion that Americans spent on health.

Are we getting our money’s worth? Not according to the usual measures of public health. The United States ranks 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place, according to the Commonwealth Fund, a health-care research group, among major industrialized countries in health-care quality, access and efficiency.

And in the United States, regions that spend the most on health care appear to have higher mortality rates than regions that spend the least, perhaps because of increased hospitalization rates that result in more life-threatening errors and infections. It has been estimated that if the entire country spent the same as the lowest spending regions, the Medicare program alone could save about $40 billion a year.

Overutilization is driven by many factors — “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.
The most important factor, however, may be the perverse financial incentives of our current system.

Doctors are usually reimbursed for whatever they bill. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. If you cut the amount of air you take in per breath, the only way to maintain ventilation is to breathe faster.
Overconsultation and overtesting have now become facts of the medical profession. The culture in practice is to grab patients and generate volume. “Medicine has become like everything else,” a doctor told me recently. “Everything moves because of money.”

Consider medical imaging. According to a federal commission, from 1999 to 2004 the growth in the volume of imaging services per Medicare patient far outstripped the growth of all other physician services. In 2004, the cost of imaging services was close to $100 billion, or an average of roughly $350 per person in the United States.

Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.
“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was.

“I tried to practice ethical medicine, but it didn’t help. It didn’t pay, both
from a financial and a reputation standpoint.”

His nuclear imaging camera was in an adjoining “procedure” room. He broke down the monthly costs for me: camera lease, $4,500; treadmill lease, $400; office space, $1,000; technician fee, $1,800; nurse fee, $1,000; and miscellaneous expenses of $200.

“Now say I get on average $850 per nuclear stress test,” he said. “Then I have to do at least 10 stress tests a month just to cover the costs, no profit going into my pocket.”
“So,” I said, “there’s pressure on you to do more than 10 stress tests a month, whether your patients need it or not.”

He shrugged and said, “That is what I have to do to break even.”
Last year, Congress approved steep reductions in Medicare payments for certain imaging services. Deeper cuts will almost certainly be forthcoming. This is good; unnecessary imaging is almost certainly taking place, leading to false-positive results, unnecessary invasive procedures, more complications and so on.

But the problem in medicine today is much larger than imaging. Doctors are doing too much testing and too many procedures, often for the sake of business. And patients, unfortunately, are paying the price.

“The hospital is a great place to be when you are sick,” a hospital executive told me recently. “But I don’t want my mother in here five minutes longer than she needs to be.”

Dr. Sandeep Jauhar is a cardiologist on Long Island and the author of the new memoir “Intern: A Doctor’s Initiation.”

Monday, February 11, 2008

A community pathologist asks "How can I survive?"

I am at a small community hospital and I feel like they do need a pathologist here. But my thought is that in order to support one, higher fees have to be charged. I do 3000 cases per year and take care of the lab. So I am diverse and busy but I am not a specialist. It makes the most sense to me that specialists like you should be reading all of my prostates and derm experts should be reading all my skins (etc). You are cheaper AND better at it. If I was a patient, that's what I would want. So how do I keep my job? The most efficient use of healthcare dollars would eliminate those of us at small places but we need to be here (I think). I am not trying to make a killing but I am trying to make a living. My hospital does do my billing but I have profit sharing and they listen to my input. The example of the 12 set biopsy is an extreme but I do know that ALL of my charges are high. So anyone without insurance is charged this. And insurance companies pay less. I didn't know that you were allowed to set up special fees for those who don't have insurance. I think we just wait for the patient to call and say they can't afford it, then we write some off.I just wonder if other small hospital pathologists have similar concerns about this.

Thursday, February 7, 2008

The $8000 Prostate biopsy evaluation.

Mouse writes:

I believe that the hospital I work for (as an employee)charges over $300 for both the technical and the pro fee that they bill on my behalf. We do not get many prostate biopsies. When I do get them in a set of's over $8000. Just for the H and E (I have not needed special stains). I really doubt any insurance is paying this but it makes me sick to know that some guy without insurance would get a bill for such an amount. Have you ever heard of such huge fees? What can I do to make it right?


Well, unless the patient does not have any insurance, he will not be paying the full $8000. If he has no insurance, and even if he does, then he can negotiate with the lab to pay less. He can advise his urologist to ask the lab about the excessive fees (My lab would charge a non-insured patient about $360 for this service). This might prevent other patients from being similarly ripped-off in the future. But the real question is this: What party do you want to "make it right" for ? Please clarify what type of insurance, if any, this patient has.

Have I heard of such huge fees? Unfortunately, yes.

J. Oppenheimer

Monday, February 4, 2008

Jane Pine Woods Esq. advises on Avoidance of Defamation

I ask any party who believes that this blog contains any defamatory statement(s) to notify me immediately so that they may be reviewed and if unsupported, removed at the earliest opportunity.

J Oppenheimer

Ms Wood today sent me the following communication.

Amen! I am hearing many of the same concerns from virtually all of my clients. Like you, they want to be competitive and obtain new business, but they also want to comply with legal and ethical guidelines. That's hard to do when some pathology providers don't play by the same rules.

I also suggest, as an aside, that you be careful using the names of other laboratories to avoid possible claims of defamation. Use of the phrase "I believe" or "It is my understanding that" can also be helpful.

See you in Denver.

Thanks, Jane

Jane Pine Wood, Esq.McDonald Hopkins LLC 956 Main Street Dennis, MA 02638direct 508.385.5227 fax 508.385.4355

Cytospins on Prostate Biopsies

Just thought I'd share an e-mail with you.

To: Jonathan Oppenheimer ; XXXXX
Sent: Fri Feb 01 14:35:59 2008
Subject: Another way to rip off the patients
I just wanted to let you both know some info that was passed along to me through XXXX this morning. We lost our biopsy business at XXXXX Urology in XXXXX, AZ.
We knew this was coming due to their merger with XXXXXXX, but this is the kicker.
The reason the group decided to go with XXXX Diagnostics on their prostate biopsies is because at XXXX after they extract the prostate core from the formalin vial, they do a cyto-spin on every formalin vial.
What way will they think of next to rip-off the poor patients?

Outrageous Examples of Pathologists Gone Bad

I received some slides for a second opinion today. Four immunostains (P63, -903, P504S, and CK 5,6) were performed on each of three prostate cores. That's a dozen IHC stains performed at a cost of over $1000. The letterhead of the report identifies the lab as based in the urology office. A hired pathologist reads cases in their office. Technical services (88305-TC and 88342-TC) are provided by the same laboratory which supplies the hired pathologist for the (88305-26 and 88342-TC) professional services.

Interesting thing is that the tumor is easily recognizable on the routine H&E slide. All the money and effort spent on the secial stains were unneccessary. BTW, I have heard that the Urology group has an investment in the Pathology Services Company that manages the laboratory.

It would be interesting to hear of other Pathologists-gone-bad examples as comments to this post.