"We Have Met the Enemy and He is Us"

These words have been repeated dozens of times since they were first uttered by Pogo the possum, Walt Kelly's beloved and brilliant cartoon character of the mid-twentieth century. Several leaders of the medical field apparently feel that the gist of these words just may be more than appropriate in the face of the pharmaceutical industry's current twin image problems -- danger-filled drugs offered at seemingly unfairly-high prices when sold in the United States -- that recently have caused so much anguish and even more finger-pointing. Feeling seems to be that there is more than enough blame to go around.

We are not trying to be flippant; just factual. Pogo's original words were targeted at America's lack of a cohesive conservation plan. But they certainly seem to apply to today's confused pharmaceutical policies. We've gathered some contradictory-appearing facts from a variety of published sources…

. Point. In the 1980s, most drugs were first made available to patients in Europe and Japan, simply because the FDA demanded maximum test time and precautions…which was often derided. In 1992 Congress directed the FDA to speed up the long and costly trials that were keeping potential "wonder drugs" from patients literally begging for them. At the time, there was one adverse drug reaction for every 16,300 prescriptions filled. After a decade of "speed up", that number is close to doubling… to one in 9,000 prescriptions filled. That leads to gigantic totals; over 350,000 bad reactions were reported to the FDA in 2003, which has currently led to a number of law suits.

Point. Currently 75% of new drugs are now consumer-launched in the United States. So rather than coming in a little later and presumably a lot safer, we are being referred by a number of medical ethicists as the test market to the industrialized world. Many in Congress who once demanded speed now complain we have become a nation of prescription drug "guinea pigs".

Point. The Europeans once depended on the veracity of the FDA "tracking records" to identify possible problems early as possible. But the FDA grew cautious, fearing that too-immediate reaction would also be seen as keeping needed drugs from sometimes-desperate patients. So that world-respected drug "tracking system" was reigned in; today the Europeans and Japan often identify, analyze and target potential product problems long before we do.

On a different track. Early in the 1990s the FDA broke a long-standing rule and permitted the pharmaceutical companies to advertise directly to consumers and the "Ask your doctor…" commercials were born in gigantic numbers. Volume naturally rose and with it "me-too" versions of most-popular products, often at the expense of or research into possible breakthrough drugs in other areas. The number of all-new drugs approved by the FDA has fallen from 53 in 1996 to 21 in 2003, though most companies report they are spending much more in product development.

And there is pricing, of course. Consumer costs stayed up largely because all these competitive products had patent protection that kept prices up. Most brushed aside the thought that their product might be only a little better and perhaps even less-safe-to-take than older and much less-expensive drugs which offered comparable results. Things got "pricey" and to save money people started to look across the border to Canada and beyond; this became the beginning of the current reimportation groundswell that is now meeting resistance on both sides of our northern border, while talks of reimporting from Great Britain, Ireland, even India and Israel have become standard fare in newspapers and on TV.

All of which brings us more or less up to date…making you wonder if Pogo may just have been right about many things.

CMS: Help Us Control Coding Confusion

Up and down. According to a recent CMS report, more than 10% of all medical payments in the 2004 fiscal year were improperly coded, which resulted in doctors and other healthcare providers requesting too much or too little payment.

The estimated overpayment requested was $20 billion, which Medicare is quick to reject, as they always have. But this year they also singled out about $1 billion in underpayment…and CMS has stated quite firmly they want to work with medical associations to create guidelines which will assure fair-payment-as-due to providers. Which is seen by many happy providers as one of the first times Medicare is genuinely interested in "giving" rather than "taking away".

CMS says that the largest number of provider bills requesting lower-than-legally due reimbursements were related to the interpretation of the Evaluation and Management code, which most providers, coders and government administrators agree is still too tied to judgment calls. The E&M codes have been used since 1992 for some of the most-common services doctors provide. These guidelines were updated in 1997. Many practitioners question whether they can ever be made to fit into tighter guidelines.

At least one party involved in this process referred to the fact that physicians have effectively been conditioned to under code Medicare, simply because they don't want the extra annoyance and paperwork that is the consequence of an initial billing rejection Overall, more than 10% of total Medicare payments were returned-to-provider for clarification in the past fiscal year. Below is the breakdown -- within the overall 10% rejection figure -- of the specific reasons why CMS found these requests for reimbursement either too-high or too-low.

(It is worth repeating, these figures are only fractions within the 10% of initial CMS rejections.)

Failure to provide sufficient documentation: 43.7%
Failure to respond to error review request: 29.7%
Prescribed medically unnecessary services: 17.2%
Incorrect code submitted: 7.7%
Miscellaneous: 1.6%
Marginal note…also within the overall 10% rejection figure, Medicare claims error rates were surprisingly high in a number of specialties in fiscal year 2004. In descending order they were: infectious disease: 23.7%…nephrology: 23.2%…cardiac surgery: 22.3%…pulmonary disease: 20.2%…radiation oncology: 18.2%…endocrinology 17.8%…interventional radiology: 17.3%…plastic/reconstructive surgery: 16.8%.

Pediatric medicine ran 17.7% with internal medicine a bit lower at 16.2%.

Prevention and Performance

Both private and public healthcare services are targeting on "prevention" in 2005, with suitable rewards - some counted in dollars, many counted in better health -- available to those who excel. The American Cancer Society, Diabetes Association and Heart Association have all strongly endorsed this new policy.

For example, since the beginning of the year, new Medicare enrollees have been eligible for a "welcome to Medicare" physical exam at a small fraction of cost. At the same time, all current and future Medicare recipients will be given free cardiovascular and diabetes screening on request. These are just some of the steps Congress approved and President Bush signed under terms of the Medicare Expansion Program at the end of 2003. Objective is to save or extend tens of thousands of lives…while saving billions of "wasted" dollars in cost-of-healthcare.

All this is being added to current Medicare preventive services such as vaccinations…plus breast, cervical, colorectal and prostate cancer screenings. A number of stop-smoking programs for recipients with smoking-related diseases are also covered.

Meanwhile…the word "performance" is also coming to the forefront in medical care delivery. Over the winter, Blue Cross and Blue Shield of Florida initiated a program that rewards doctors in their system with sizeable financial bonuses for superior performance that results in better patient care. BC/BS says these bonuses could means as much as an extra $12,000 a year to the highest scorers. Not to be outdone, UnitedHealthcare, Florida says it plans to introduce a similar program later in the year, this with top bonus in the $20,000 class. Aetna reportedly has a similar but smaller such project working in Jacksonville. Most programs were developed with the full imput and support of physician advisory groups.

The programs are based on new thinking by advocacy groups that claim it pays to try harder. Florida, especially south Florida, has been singled out because the easily-measurable Medicare healthcare records show that recipients in the cold of Minneapolis, for example, stay just as healthy for half the cost-of-care as those in South Florida.

The parameters and grading of all programs are reportedly being developed under the guidance of carefully-chosen groups of medical professionals.

Expanding Use of eICU

Current ratios of intensive care specialists (6,000) to patients admitted to ICUs each year (close to 5 million) is at a dangerous level in the United States and electronics is being used to breech the gap. An increasing number of hospitals and medical centers across the country are signing on to a system that enables these specialized doctors and nurses to electronically monitor a number of patients at a time and, if hands-on help is needed, immediately contact on-site nurses over an existing video conferencing hookup.

Oddly enough, practitioners of eICU relate their level of care to an air traffic controller keeping track of a number of planes taking off, landing, or just flying in proper air space.

The ICU specialists are not in the hospital, but at a central location that enables them to simultaneously closely-monitor patients in several ICU rooms at several hospitals at the same time. The off-site specialists sit before screens that give them an up-front visual of the patient…while also displaying the individual's diagnoses, vital signs, doctors' notes and hour-by-hour progress.

The first such system was put in place close to five years ago at Sentrara Healthcare. It has since been expanded to five of the system's hospitals in North Carolina and Virginia ...and has been credited with directly saving dozens of lives by being able to react immediately to the always-expected unexpected emergencies of ICU. The "on call" doctor doesn't have to be called; a highly-qualified doctor effectively is right there, 24/7.

Intensive care patients -- feeling much more alone and vulnerable that others in the hospital -- seem uniformly happy to accept this "eye" over their bed effectively monitoring their every move. While out in at least one state's rural areas, similar-type telemedicine thinking is be put to even more-general-purpose use…

Georgia to "Hook Up"

As a condition of permitting Blue Cross Blue Shield of Georgia to "go private" and become part of Anthem, the insurer has agreed to install a live-video hookup that will bring a "big city level" of medical advice and service to 36 rural hospitals. Estimated cost is $126 million. BC/BS will buy the transmission lines, video cameras and monitors …and will also cover maintenance costs for the first three years, plus salaries for necessary tech staffers at both the rural hospitals and the state's four teaching medical centers.

A telemedicine program initiated about ten yeas ago was never made fully operational simply because the state did not have sufficient available discretionary funds to service its entire area. The new network will begin to be put together in the next 12-18 months with initial location selections skewed towards rural areas farthest from top-level medical specialists.

This proposed system is being called the biggest such network in the United States. The addition of BC/BS Georgia, incidentally, will make Anthem America's largest healthcare insurer.

"Think Tank" Presentation

Last month we reported that Dr. David Brailer, HHS National Health Information Technology Coordinator was asking all who would listen for new and innovative ways to move our lagging industry into the technological future…and thereby help make healthcare more affordable. The first report and suggestions are now in.

A group of thirteen health and technology-related organizations have presented a 54-page document they refer to a "framework" that would move us firmly into the 21st century. It requests initial federal financing and leadership in developing basic technological standards…with the feds then effectively standing back and letting the experts lead the way within given parameters. The plan is supported by the American Health Information Management Association, the Healthcare Information and Management Systems Society and the Liberty Alliance Project.

The report suggests a step-by-step approach, feeling this is the best way to gain maximum support from all involved. At this stage, they are firmly against both a mandated centralized national healthcare database of patient records and "health ID cards", referring to these as elements which would effectively put massive emotional roadblocks in the path or any effort.

Novel idea put forward is to have the health network operate something similar - but not as open -- as internet-based "e-mail". Under strict controls, they feel this would assure a high level of record protection but still enable virtually-instant open communication at all provider and patient levels. The group projects that this will result in savings of $24 billion a year over our current paper-based technology.

This program, they conclude, would eliminate duplication of tests and speed medical reaction to patient complaints…but stressed that at this initial effort must concentrate first on affordability. Which makes it in reality a small -- but vital -- initial step in the long road ahead.

"Medical" Bracelets at Work

And they are put to work in a variety of ways these days. For example, two illustrations at opposite ends of the "scale"

…To treat a patient. According to a recent article in the British Medical Journal, it pays to wear a standard-length magnetic wrist bracelet if you have osteoarthritis in the hip or knee, the most-common joints that are affected by the often-debilitating disease. The 200 patients in the 12-week study reported measurably less pain than those in a control group that work a weaker or non-magnetic bracelet.

Though they called the results "clinically useful", the ever-cautious British researchers were not ready to give blanket acceptance to a conclusion they accepted but didn't quite understand. Hence the final caveat that they cannot discount a possible placebo effect had skewered the results.

...To make a statement. Many doctors in southern Illinois have adopted a garish lime-green rubbery bracelet they now wear all, day, every day, at work and at social engagements. The almost blindingly-colored bracelets are designed to attract attention to the words imprinted on them…"Keep doctors in Illinois". In other words, convince legislators to pass medical tort reform.

The originators of the idea point to just two counties in southern Illinois that have lost 160 doctors in the past two years; doctors who reportedly served thousands of patients but apparently moved on because they could not afford what they saw as unbearable increases in insurance premiums. Reportedly 200,000 of these wristbands -- now also worn by hospital workers, patients, pharmaceutical reps and even teenagers -- are currently in circulation. (Lime-green t-shirts with the same message are now being added to the program.)

Pharmacy Turnaround

Many of the neighborhood pharmacies that were gobbled up by the giant chains are getting a chance to gloat these days as the chains are in what seems like a losing battle against pharmacy benefit managers that are increasingly using prescriptions-by-mail as the latest "bulk buy" method to keep costs down.

Mail sales of the big three benefit manager firms were up 21% to 100% in the third quarter of last year. Looking at possible giant losses in volume, Walgreen's has created its own benefit management unit and CVS is streamlining the benefit management unit it recently bought from Eckerd. Rite Aid says it is "considering" development of its own benefit management unit.

It's all about pricing. Forcing those covered to order through the mail enables the benefit managers to go around the pharmacies and buy a particular drug one time and in bulk directly from the pharmaceutical company... rather than making many small -- and therefore more-costly -- purchases day by day, individual prescription by individual prescription. Bulk buying like this, of course, is the reason why every other industrialized country in the world is able to negotiate from strength and realize unit prices that are much lower than in the United States.

Patients in general are not too happy, railing against paperwork and waiting for the mail. Corporations on the other hand generally applaud the initiative, seeing it as a new way to cut some of the rising costs of employees' health care packages. The benefit management companies of course are happiest of all, getting the added volume and the increased profit that goes with it.

Meeting Penelope

About this time, Penelope the computer/robot is going to get her on-the-job test as a scrub nurse during an operation at New York-Presbyterian Hospital. If she passes this and increasingly-more-difficult tests before year's end, Penelope could quickly become a fixture at several hospitals across the country.

Reason for her debut, according to her inventors, is the increasing shortage of highly-qualified nurses in so many hospitals. The scrub nurse's job in any operation is to hand the surgeon the items he needs when he needs them.

Penelope is something very special to her inventor -- who calls "her" faithful, clever and resourceful. He is supported by a team that includes a biomedical engineer a software developer and a computer programmer. Development work has been financed by a $600,000 grant from the national Science Foundation. The robot has visual recognition and the ability to interpret and respond to voice commands.

Penelope's debut will nonetheless be made during a simple procedure…the removal of benign eye cyst. Her unit cost is projected at $150,000 per, quite-reasonable as medical technology goes today.

Medical Minutia

Dr. Benjamin Rush was a signer of the Declaration of Independence as well as one of the more influential physicians of his time. He was as known for his willingness to treat the poor as he was for his apparently-excellent medical abilities.

Dr. Rush established the first "free clinic" in the United States in 1786, four years after he had begun a concerted effort to convince his fellow physicians to accept goods and produce from patients too-poor to pay in the coin of the time.

Coding Tips

When coding replacement of cardiac pacemaker, coders frequently forget to code the removal.

A pacemaker is the pulse generator and one or two leads. Physicians, when documenting, may call the pulse generator the battery. Therefore, when replacing the battery, the generator is replaced. Two codes are necessary to code this procedure. When coding replacement of dual chamber pacemakers, code 33233 is for the removal of the pacemaker in addition to coding 33213 for insertion of dual chamber generators.

When coding replacement of dual chambers with two leads, codes 33208 and 33233 are needed.

Transcription Tips

Contractions are two words with missing letters denoted by apostrophes. It is preferred that they be avoided, except in direct quotations. Edit "can't" to "cannot," "I'd" to "I would," and "it's" to "it is" (note the possessive form is "its" which is NOT extended). In ALL cases, extend abbreviations that contain contractions: "OD'd" to "overdosed."

If a contraction is used, be sure to accurately place the apostrophe.

Auditing the News

Six New Jersey hospitals have been forced to close over the past two years, the most-recent ones in Passaic, Orange and Kearney. The New Jersey Hospital Association blames this retrenchment on the shortfall of too-low reimbursements and often-unreimbursed charity care, plus the rising costs of technology and labor. The also singled out the increasing numbers that are having procedures done in the state's 1,000 ambulatory surgery centers.

New Jersey currently has 83 acute care hospitals.

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Last updated May 2006