Unveiling excessive medical billing and greed

Recent op-eds have questioned medical billing and doctors’ pay, as both seemed high. Medical “greed” has become more apparent in the past two decades and has been well highlighted by two of my Dartmouth MPH Professors, Elliot Fisher, MD and Thom Walsh, PhD, DPT. Dr. Fisher has documented that higher billings compound the U.S. health care crisis, including medical debt, and that particularly affects minority patients.

Walsh has shown that monopolies drive up costs. Where competition exists in a health care community, it benefits Medicare and Medicaid patients, which reimburse the lowest. Unfortunately, this then drives up the “need” (motivation?) to bill higher codes and get reimbursed more to offset practice losses.

As a podiatrist for over 30 years, I have also noticed a higher level of service billing, “unbundling,” and unnecessary procedures, all which usually produce higher income for providers and the medical entity they work for. Sometimes, the motivation is to cover the ever-rising costs, including overhead and equipment. Other times, it is pure greed. One can notice this by the shift in E&M codes (office billings) from the bell-shaped curve of the middle code of “level 3,” which should be billed the most frequently for most specialties, to levels 4 and 5 (the highest E&M code). This may be more likely when provider income is based on productivity (billings) as opposed to salaried positions.

I see articles on the Lapidus bunionectomy procedure showing the need for more implants to perform a successful procedure. The procedure traditionally was performed with two orthopedic screws (which are a few hundred dollars). Now, the procedure can be performed with two plates and eight screws, nine for an additional joint if fused (several thousands of dollars for this hardware), and the providers then change the code to a midfoot fusion. This almost doubles the reimbursement to the surgeon and the facility and substantially increases the RVUs for the procedure. In fact, some providers unbundle the code when they just perform the bunionectomy without fusing the additional joint. (Full disclosure: I have published that “better” results occur in my hands using one plate and three-four screws.) This unbundling is why, in recent years, I have seen coding experts explaining how to code the Lapidus procedure and outlining which code is correct when treating a bunion (CPT 28297, by the way), i.e., not fraud.

In the first month of my MPH coursework, we discussed the problems with practice and evidence-based medicine (EBM) in U.S. health care. I related the stats that show the percentage of U.S. doctors practicing EBM is about 18 percent. Therefore, it appears hard to practice that way. One of my classmates asked in the chat, “Why is it so hard for doctors to do that?” I explained that there are many reasons, including financial motivation and payment systems, why U.S. doctors may not practice EBM. Fisher and Walsh’s articles imply that the incentives should be aligned. The former and unfortunately deceased CEO of my present group used to say, “What is good for the patient should be good for the foundation and, therefore, good for the doctor.” If we move toward more EBM as they have in many other parts of the world, using the resources we have, we can improve U.S. health care with lower costs and better access to cost-effective treatments.

Amol Saxena is a podiatrist.

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