Pigs Gets Slaughtered

pigs_get_slaughteredThe recent gyrations of the stock market had me remembering an old expression about Wall Street investing: “Bulls make money, bears make money, but pigs get slaughtered.”

This expression is supposed to be a reminder that investing rewards patience and long term thinking, not impatience and greed.  So, what have I done over the past week with reference to the stock market?

401KNothing at all really, other than buying equities through my maximum 401k contributions this week and two weeks ago.  Why am I so cool, calm and collected about the stock market, you ask?

First of all, having been investing since the early 1980s, I have seen multiple ups and downs in the markets.  Not panicking and continuing to stay the course of periodic contributions whether the markets were high or low has treated me very well.  The economic principle of dollar cost averaging truly works, as it has over the last 4 decades.

Secondly, having a long range horizon also helps a great deal to help with the short term panics or crises.  If I know I will not need this money for at least the next 5 to 10 (if not more) years, I can stand pat and continue to watch and wait.

Bull-and-BearMy best advice is to stay with the plan that has already been worked out by the greatest financial minds. Use the power of dollar cost averaging, compounding, diversification of your portfolio, and long range focus.

Years from now, when someone asks you about the stock market turbulence of the summer of 2015, you will barely remember it.  Turn off the financial news and read a good summer thriller on the beach.

My Solution to the Primary Care Shortage

disappearing-primary-care-doctorI have been seeing a number of articles recently about the primary care physician shortage, or “crisis” depending on whom is writing the article and where it is being published.  If someone is just now recognizing that there is a PCP shortage, he or she must have been living with his or her head in the sand for the past 20 years, or is a modern version of Rip Van Winkle.

As a primary care representative on a number of statewide and local committees, I have discussed this issue several times in the past.  In doing so, I have felt like the living manifestation of the motto of my alma mater Dartmouth College, “Vox clamantis in deserto”: A voice crying in the wilderness.  Despite being the PCP of record in these venues, I truly felt that no one was listening to me.

At one point in time, I tried to make the other specialists and the hospital and insurance administrators aware that many of their programs actually made the existing PCP’s life and practice worse and less inviting to young doctors coming through the pipeline of medical school and residency.  The constant nickel-and-diming of prior authorizations for studies and medications drains the energy of the PCP.

electronic_medical_records_problemElectronic records, which were initially seen by others as a panacea, have frustrated providers and reduced their productivity & their ability to communicate with their patients.  Rather than making primary care medicine more attractive to the younger professional, most of the initiatives to improve medical care have been built on the backs of the primary care providers.  PCPs do most of the grunt work and share very little of the reward, if there is any.

In these committee meetings, you could hear a pin drop when I brought up the next topic: Money.  It is no surprise to anyone that most medical school graduates are carrying over $200,000 worth of loans into their residency and practice years.

If they are a married medical couple, and there are more of those lately, the loan portfolio load can reach over a half million dollars.  This weight affects decisions these doctors will make.

These are very smart people.  Despite what is said about doctors and their ability to handle money or not, this is actually relatively simple math.

Should I leave my internal medicine, family practice or pediatric residency and practice primary care in an office setting because there is a need, or should I extend my education by a few more years to become a specialist and make twice as much money for the rest of my life?  Hmmm . . . Let me think!

doctor_brokeAnother option that has become very popular for those who don’t want to do the extra time in fellowship is to become a hospitalist or ER doctor.  The salary is not double, but it is a lot higher than the office practice compensation.

Also, PCPs can practice in what they are well trained, which is hospital based medicine.  They also don’t have to deal with the hassles of modern medicine like call schedules, nursing home coverage, and paperwork, even in the age of EHRs.

A cardiologist at one meeting was lamenting about the fact that he and his family hadn’t seen their designated PCP in years in the office because that PCP is always assigned to the nurse practitioner.  I leaned across the table and asked him, “Are you serious about attracting more PCPs not only to Maine but to the profession and the country?”.

“Yes,” he replied with a resounding nod.

“Good,” I said, “I have an easy solution that would be very effective: Pay PCPs like cardiologists.”

doctors_meetingFor the most part, we are way over-doctored in cardiology compared to all primary care areas.  I know that many cardiologists go into that field because they love the study of the heart.

OK, I get that. But if you were to tell a med student or resident, “Hey, you can make the same money as a cardiologist if you choose primary care medicine and get a jump on paying off those loans”, it would turn some heads in the PCP direction.

If the primary care shortage is really a crisis, and I truly believe it is, action is needed and fast.  Each year more and more doctors are retiring from primary care and they are not being replaced.

They cannot all be replaced by the physician extenders of all the various stripes, no matter what hospital administrators think.  They must not only be paid better than they are now, they must be paid A LOT better.  Primary care medicine is becoming the choice of only the most altruistic of us.

I have seen the young doctors in our local Family Practice residency, who have espoused the principles of old fashioned family practice when they enter the program, become ER docs, hospitalists and administrators when the realities of economics and family life come crashing down on them.  I truly don’t blame them. I think that they are making a very rational decision.

lonely_dinosaurIt is just very uncomfortable to watch the area of medicine that I practiced for over three decades and loved become a relic.  Now, I know how the last dinosaurs felt.

Coding Is King

medical-codingIf I really want doctors I know to immediately go into a daze and start thinking about other things they need to do, I start to talk about medical coding.  However, as far as their compensation and pay are concerned, how they code is, and will continue to be, extremely important.

For the non-medical readers, I should briefly discuss what coding is.  Basically, everything a doctor does in terms of procedures, and even the office visit and what is discussed within the office visit itself, has a code.

health_insurance_moneyInsurance companies and the federal government in the form of Medicare and Medicaid use those codes to determine how much work was done.  Most importantly, they use the codes to calculate how much they should paid us doctors for that service.

Each code is associated with what is called a Relative Value Unit (RVU), which means how much work was done and how much it costs relative to other medical work.  Each insurance entity determines a conversion factor which is a unit of money that they will pay per RVU.  Conversion factor times RVU = amount of money paid for that code.

Whew! Writing that summary took a lot our of me, and that was just an overly simplified explanation!

wastepaper-bin Most doctors consider coding to be beneath them and not that important as it is something relegated to medical record and billing clerks.  This could not be further from the truth.

Bad or inaccurate coding can seriously their salaries whether they are in private practice or in a productivity based salary position.  In addition, if the coding is inaccurate, they the doctors are ultimately responsible to the insurance companies and more dangerously the government for those inaccuracies especially if it results in more money being dispensed than the documentation would allow.

doctor_with_clipboardIn this area, I have had several mantras. The first and most important is document, document, document.

It is no exaggeration to say that if you don’t document something in a medical setting, it is as if it did not happen both in legal and reimbursement senses especially.  Even if you think you have an iron trap memory, you cannot remember within the torrent of patients you see every day a particular conversation or procedure if it is not documented.  For example, if you talk about smoking cessation with that COPD patient because you do it every time you see that person, you need to document each time AND you need to code for it.

That leads into Mantra #2: Everything you do and document as a medical professional needs to be coded if there is a code for it.  In general, there is a code for all sorts of things, especially because the insurance companies and the feds want to follow such codes to see if you are doing them.

doctor_memoryTo follow the previous example, if you talk to your patient about stopping smoking but do not code for it even if you have documented it, they do not register you as performing that task.  Nowadays, that can affect reimbursement but also more importantly, going forward that lack of coding can affect your quality ratings, which will eventually affect reimbursement in the coming world of accountable care and value-based care.

Finally, despite what many think about doctors, most doctors undercode.  This means that they choose a code that under-reports what they did.

If this act reduces reimbursement, why do docs do this?  Frankly, one answer is laziness.

As noted previously, many docs do not think of coding as important and frequently pick a middle-of-the road “favorite” code.  One time I reviewed the documentation and coding of the doctors in my own group and found one doctor coded every visit the same.

He used the code 99213 which is the average evaluation and management code most primary care visits for EVERY visit.  When confronted, he had no defense other than convenience and that he did not want to think about how much more documentation he needed to justify the next higher code. Aargh!

I could go on at length about the irresponsibility and unprofessional nature of undercoding in a future blog post.  Suffice it to say, coding for a doctor is very important and should not be relegated to a secretarial function.

keep-coding-and-make-moneyIn fact, I think that many of the reasons that physicians have lost prestige, financial power and control within the medical infrastructure is that they have ignored important issues of documentation that they thought were beneath them.  For the sake of not only your credibility as a medical professional, but also as a medical professional desiring to attain more wealth in the long term, you should not do the same.

Coding is not beneath you.  It gets results, and it ultimately creates wealth.