Michael S. Victoroff, MD

If a doc is compensated when he schedules a patient visit to convey the routine results of a lipid test, but not when he phones the patient, which behavior will he choose?

Michael S. Victoroff, MD

It's about time managed care organizations paid providers for non-face-to-face care. Failing to reimburse non-face-to-face care hurts medicine in at least two ways: It retards good practices from implementing creative delivery systems, and it induces in some practices a mischievous form of financial "churning" — a misbehavior I call "Shanghai appointments."

Once upon a time, I asked our staff to record over three months every "non-face-to-face" contact that we had in our family medicine practice. We used the sparse and inadequate codes in the CPT, coupled with the Medicare RBRVS to assign monetary values to everything we did. For items not listed in the CPT, we modified existing codes that were closest to the actual service rendered.

Below the waterline

Our goal was to find out how much of our practice went on below the waterline of direct office visits and procedures.

We identified three levels of clinician phone contacts; three levels of result reports and recall reminders; a couple of types of conversations with consultants; some different ways to deal with paper and electronic records; and so on. Since we did lots of correspondence via computer (drug interaction reports, recall reminders), we created categories for those things. And, we designated encounter types for e-mail, fax, and voice messages; media we used for tasks like hypertension management, prescription refills, and surveys. (This last was extremely useful for all those instruments that are so underused in primary care, like depression inventories, SF-36s, and ADHD screening.)

We didn't record activities unrelated to patient care, like CME, administrative duties, professional committees, teaching, office parties, and such. We just made note of things we would have charged for under a fair and equitable fee-for-service system, if one existed. (I am no great fan of fee-for-service as a method of physician compensation. I think it's a very problematic system for paying doctors, especially using the CPT/RBRVS in its flawed current form. But, that's an argument for another time.)

We noted what we'd done on special encounter forms laid out like the charge slips we used for "real" billing. Of course, we didn't bother submitting most of our non-face-to-face charges to third-party payers. After all, we didn't want anyone laughing at this serious research. Nor did we charge our "cash" patients (I think we had two) for things that no insurance company would cover. After three months, we calculated what the monetary value of this work would have been, if anyone had paid us for it.

The result won't surprise primary care office managers. Almost 30 percent of our labor was spent in non-face-to-face care, and — if we had actually been able to collect reimbursement at 100 percent of Medicare rates (whoopee!), our practice revenue would have increased by 25 percent. (We also noticed that a few payers did reimburse sporadically for charges that nobody else recognized.)

Most of our non-face-to-face care involved telephone, fax, and snail mail — the staples of informatics as it's practiced in today's backward, paper-driven system. This wasn't "telemedicine" in the high-tech sense, since most strict definitions of telemedicine exclude phone calls. But, broadly construed, that's what we were doing.

OK, so what's the lesson from this exercise?

For one thing, it allowed us to quantify a percentage of our patient care that was uncompensated — and uncompensable — under current reimbursement theories. You'd better believe that this awareness influences the way medicine is practiced — and malpracticed — in the U.S.

At the time of our study, about half of our patient care was prepaid. I love capitation in theory (let's call it "retainer-based compensation" now). But, I dispute the notion that typical cap/retainer rates already take non-face-to-face activities into account (although they easily could). This is because most cap contracts are calculated from historical fee-for-procedure experience that excludes exactly the services we're talking about. They're just not in there, for the most part. And, doctors are convinced these payments aren't recognized — even in the rare cases when they are.

This sets up a specific form of abuse, in some practices dependent on fee-for-procedure revenue: namely, snookering patients into the office who don't really need to be there. I think of these visits as Shanghai appointments, after the old nautical custom of kidnapping unwilling sailors to work on China-bound freighters.

One tremendous benefit of retainer-based medicine is that it lets practitioners provide non-face-to-face services without any resentment that they're working for free. In contrast, visit churning is one of the corrupting effects of the CPT/RBRVS. (I've also seen this abuse in capitated practices, but most doctors realize that it's not lucrative to churn appointments for a $10 copayment, unless your patients are desperate enough to accept five-minute visits.)

This offense really irks me. Partly, I admit, it's because I've seen visit-churning make a lot of money for some medical colleagues who aren't as sympathetic as me to patients' time. Shanghai appointments tend to occur to different degrees in different geographic regions, correlating somewhat with physician supply, but also with local usage. You hear horrible stories in some areas from patients whose doctors insisted on office visits for the most trivial administrative tasks, like reporting normal test results for stable conditions; or weekly "hypertension checks"; and — my personal nemesis — "follow-up of otitis media" in kids with no symptoms.

Principles violated

Cranking patients through the office who should be handled by a non-face-to-face method, just to collect a fee, violates the principle of the AMA Code of Medical Ethics that forbids charging for unnecessary treatment (Section 2.19 of the Code). Hauling people out of their life or job, stacking them in your waiting room and brushing past them for a quick encounter is the opposite of the "standard of care," even if it's standard operating procedure in some communities.

Those who routinely do this often claim that face-to-face treatment is some kind of medico-legal Eleventh Commandment. And, some practitioners who can't deliver non-face-to-face services safely and effectively dismiss non-face-to-face medicine as "substandard care." This bogus liability argument is intellectually dishonest. "You're taking a huge risk to practice medicine over the telephone. You really need to examine every patient, every time." Oh, please! I can tell the legal difference between reporting the results of a normal pap smear and diagnosing spinal cancer on the phone.

Recall that I'm not saying the contact is necessarily unnecessary. It just doesn't have to be done in person. So, I will repeat my proposition that we'd all be better off if typical insurance coverage reimbursed for non-face-to-face care.

True, the people accountable for costs on the payer side could argue that, if my figure of a 25-percent increase in primary care payments were accurate, current insurance premiums couldn't fund the activities I've described as non-face-to-face care, even if they were reasonable and necessary.

To them I reply that, if you increased the outpatient cost of primary care by 25 percent, you wouldn't really have such a shocking number, especially if you offset this with savings from improved primary care access. I would argue that this will bring savings from compliance, error reduction, patient satisfaction, and reduced emergency room visits, among other things.

But, more to the point, the cost argument is irrelevant. It is inescapable that insurance must cover next year's new drugs and procedures (assuming they're evidence-based and beneficial), no matter what this does to actuarial projections. Non-face-to-face care is standard of practice, and meets every test of "medical necessity." This would make coverage mandatory, in a rational universe.

A more serious problem is the justifiable fear of payers that opening the fraud gates to charges for non-face-to-face care would allow unethical practitioners to generate a large volume of superfluous claims. You would expect these to come most from those practices that currently churn appointments. When you're a cheat, you cheat whatever system you're in.

This concern is an important barrier to coverage, even with the promise of offsetting benefits that will accrue even from the Shanghai practices.

Auditing claims

The answer to this problem is statistical auditing of claims, to find frequency outliers. The IRS has been doing this for decades, with tax deductions. Asking practices that have eye-popping rates of non-face-to-face charges to document need and outcome is completely reasonable. Plus, claim review provides value for all sides, both for its sentinel effect, and the occasional possibility of identifying best practices.

Ethical misdemeanor

The message in this story for payers and employers is that the policy of not paying for non-face-to-face care tempts and rewards a specific ethical misdemeanor by physicians. It inconveniences patients, impairs health care delivery, and inhibits the development of communication systems. I'm not using the other-blaming extortion argument that goes, "I'll keep on cheating until you pay me more." But, I am convinced there is an opportunity here, to rethink our assumptions about the place of service in a way that could benefit everyone.

Paying for non-face-to-face care involves little risk, will encourage creativity among the better practices, can foreseeably improve disease management, and will make patients and providers happier. There's a chance it could reduce office visits — at least silly ones. I encourage forward-thinking health plans to experiment with payment for non-face-to-face care (it's been done, here and there), and report the effect they see on outcomes and patient satisfaction. I bet the crowd will follow.

Michael S. Victoroff, MD, is a family practitioner in Denver who has also been an HMO medical director.

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