Categories
Physician Finances

Retirement Planning In The Time Of COVID-19

I’m taking a break from rounding in the ICU this afternoon while waiting for 3 of my patients’ COVID-19 test results to come back. And I was trying to think of anything good that has come from the financial melt-down that has occurred over the past month. There is at least one small opportunity that the sudden drop in value of the stock market presents, namely, the opportunity to convert your traditional IRA into a Roth IRA with less negative tax implications.

Physicians are generally not able to contribute directly to a Roth IRA because they have too high of income. However, physicians (or anyone) can contribute to a traditional IRA with after-tax dollars. In a previous post, I outlined why I believe that traditional IRAs are an unwise investment option for most physicians. However, many physicians (and other people) have traditional IRAs that they have accumulated when rolling over a pension plan into an IRA. This often happens when changing employment and leaving one employer’s pension plan to join another plan.

I have been a long-standing proponent of annually contributing to a traditional IRA and then shortly thereafter, moving the money in that traditional IRA into a Roth IRA, a process called a Roth conversion. This is also called the “backdoor Roth”. In the past, the only mechanism for contributing to a Roth IRA was by people who have annual incomes less than $124,000 ($196,000 if filing jointly in 2020) contributing directly to the Roth with pre-tax dollars. However, several years ago, a law governing Roth contributions expired, allowing anyone (regardless of income) to “convert” a traditional IRA into a Roth IRA. This now allows a person making more than $124,000 to contribute to a traditional IRA with post-tax dollars then convert that traditional IRA into a Roth IRA.

The advantage of the Roth IRA is that it grows in value tax-free and then when you take the money out, you don’t have to pay any taxes on it. I believe that the Roth IRA is an important component of a diversified portfolio of retirement investments.

One consequence of converting a traditional IRA into a Roth IRA is that you have to pay regular income tax on increase in value of the traditional IRA at the time of conversion. So, if you originally contributed $2,000 to a traditional IRA and it increases in value to $3,000, then when you convert it to a Roth IRA, you have to pay regular income tax on the appreciation value of $1,000. Other than doing an annual “back door Roth” conversion, there are two times that it is smart to convert a traditional IRA into a Roth IRA: (1) when your income tax rate is low and (2) when the stock market crashes.

As I have stated in previous posts, my philosophy to retirement planning is to be able to have enough retirement savings that when you retire, you can withdraw enough out of your retirement funds to equal your current income. If you are successful with that, then you are not going to be in a lower tax bracket when you retire so option (1) for traditional IRA to Roth IRA conversions will not be possible. The COVID-19 outbreak and its effect on the world’s stock markets makes option (2) now very appealing.

When we changed our physician practice corporation in the early 2000’s, I rolled my former corporation’s pension plan into a traditional IRA. In 2009, the stock market dropped precipitously and I used that as an opportunity to convert about half of my traditional IRA into a Roth, thus minimizing the amount of income tax that I had to pay at the time of conversion. Over the next several years, the stock market regained all of its losses and then continued to grow in value so when I retire and take money out of my Roth IRA, I won’t have to pay any taxes on all of that increase in IRA value.

Over the past month, the stock market has fallen by about a third of its value. Consequently, most people’s traditional IRAs have fallen to their lowest value in many years. As a physician, I know that epidemics eventually pass and COVID-19 will eventually go the way of all other previous human epidemics. When that happens, the economy will get back into gear and the stock market will rise again. Therefore, this may be one of the best times in years to convert a traditional IRA into a Roth since you will pay considerably less in income tax on the conversion now than you would pay on withdrawals from the IRA in retirement.

One small silver lining an a sky otherwise full of dark gray COVID-19 clouds

March 21, 2020

Categories
Intensive Care Unit

The Management Of Respiratory Failure In COVID-19 Patients

Every hospital in the United States is bracing for a potential deluge of patents with COVID-19 infection and many of these patients will require admission to our country’s intensive care units. There are not enough critical care physicians to manage all of these patients so it may be necessary for doctors and nurses who do not normally manage critically ill patients to step in. Although we hope that the seemingly draconian measures our countries leaders are taking will “flatten the curve” of the prevalence of COVID-19 in the United States and minimize the demand on our hospitals, it remains possible that the critical care crisis that has occurred in Northern Italy will happen here.

The Ohio State University Medical Center is taking a multi-faceted approach to the COVID-19 outbreak and one of the tasks that I was assigned was to create a webcast that could be used by physicians around the world who need to know how to manage COVID-19 patients in the intensive care unit. Rather than repeat everything from that webcast in this post, I’m giving you a link to the 1-hour webcast by my colleague, Dr. Rachel Quaney and myself. I’m hoping that this presentation will give physicians, nurses, and respiratory therapists the tools that they will need to improve the survival of these patients who are in our ICUs. Click this link to access the webcast.

March 20, 2020

Categories
Epidemiology

Why Hospital Door Handles Should Be Made Of Copper

This morning, when walking in from my car to my office in the hospital, I had to open 6 doors and press 2 elevator buttons. With each door handle and elevator button, I was having contact with someone else’s fomites. Fomites are the small droplets that are formed when a person coughs or sneezes and are the primary way that respiratory viruses get transmitted. Bacteria, such as Staph aureus, are instead usually transmitted by skin contact with infected tissues, for example, by touching body secretions containing bacteria. In both situations, it is the hands that are the primary conveyance mechanism – whether they touch a person infected with Staph or whether a person with the flu blows their nose into a hand-held Kleenex. Anything that those hands touch can spread the viruses or bacteria in those fomites. Those door handles and elevator buttons that I touched this morning contain the fomites of hundreds of patients and hospital staff.

Certain materials are inherently more antimicrobial than others. Most hospital door handles are made of stainless steel or aluminum because steel and aluminum wipes off easily and because it’s shiny appearance looks clean. However, it turns out that steel and aluminum do not have antimicrobial properties so viruses and bacteria can survive on steel knobs, buttons, and handles for hours. Copper, on the other hand, has potent natural antimicrobial properties. This has been known for centuries – for example, copper water vessels were preferentially used in ancient times because water would be of better quality when transported in copper containers as opposed to containers made of other materials.

The medical literature about copper’s antimicrobial properties is extensive and it has been shown to inhibit/inactivate fungi (such as Aspergillus and Candida), viruses (such as influenza and polio), and bacteria (such as E coli, Clostridium difficile, and MRSA).

One of the problems with copper as a building material is that it tarnishes and then looks old and dirty. However, copper can be combined with other metals to form alloys such as brass (copper + zinc) and bronze (copper + tin) which are more commonly used for building fixtures. Although these alloys are better than steel with respect to their antimicrobial properties, then are not quite as effective as pure copper. For example, 99.9% of E. coli are killed within 120 minutes on copper surfaces but similar kill rates take up to 270 minutes on brass surfaces and 270 minutes on bronze surfaces. In contrast, E. coli can survive on stainless steel surfaces for weeks. The antimicrobial properties of copper are temperature dependent. At temperatures of 4 degrees C (40 degrees F), bacterial killing requires 1 hour longer than at 20 degrees C (70 degrees F).

As we renovate our hospitals in the future, we should look back to using copper and brass door handles, cabinetry fixtures, and buttons. Copper may not look as clean and sterile as stainless steel but looks can be deceiving. A $4 door handle may just have as big of an epidemiologic impact as a $20,000 ultraviolet room sterilizer…

March 10, 2020

 

Categories
Epidemiology

Why COVID-19 Mortality Is Higher In China Than The Rest Of The World

Initial reports from China in January 2020 was that the mortality rate of the novel coronavirus, COVID-19, was about 3%. Since then, the World Health Organization has been reporting daily mortality updates on its situation report website and the mortality rate has held at 3.4% in China. As of February 24, 2020, there have been 77,262 confirmed cases of COVID-19 in China with 2,595 deaths. However, outside of China, there have been 2,069 confirmed cases and only 23 deaths or 1.1%. So, why is the mortality rate of COVID-19 three times higher in China than anywhere else? When analyzing the outbreak, I believe that there is more than one reason.

Differences in hospital care

The United States gets a lot of criticism about poor overall national health compared to other economically advantaged countries. However, our nation’s poor health really relates to lifestyle issues (obesity, high numbers of suicide by gun, etc.) and outpatient healthcare (high percentage of uninsured citizens, poor access to primary care, high cost of medications, etc.). American inpatient hospital care is actually among the absolute best in the world. Similarly, Canadien and European nation hospitals provide great inpatient care to the sickest patients. On the other hand, many countries, such as China, lack the same ability to care for critically ill patients in their acute care hospitals and particularly in their intensive care units. The greatest danger of COVID-19 is respiratory failure and to successfully manage a large number of patients with respiratory failure, there has to be a well-trained population of critical care physicians, critical care nurses, and respiratory therapists. In addition, there has to be a sufficient supply of mechanical ventilators, monitoring equipment, and inpatient infection control practices in place. With SARS and Ebola outbreaks, the highest mortality rates were in those countries with the least ability to manage critically ill patients; in more economically advantaged countries, the mortality rates were much lower.

Virus detection rates

To accurately determine the mortality rate of a disease, you have to be able to identify every person who gets that disease. It is becoming clear that many patients with COVID-19 have milder forms of the disease and likely have gone undetected in China. In other countries, there have been efforts to track down and test any contacts of persons with confirmed cases of COVID-19 and as a consequence, milder cases are more likely to be detected in these other countries. When more of these milder cases are diagnosed, the ratio of deaths to confirmed cases falls resulting in a lower mortality rate. It is likely that there have been many more than 77,262 cases of COVID-19 in China and if that true number was known, then the mortality rate would likely be much less than the currently reported 3.4%.

Differences in the number of elderly and debilitated patients

In China, the outbreak of COVID-19 has struck large metropolitan areas, such as Wuhan (a city of 11 million people). Like influenza, the people who are most likely to die from COVID-19 infection are the elderly, the very young, and those people with chronic medical conditions. In cities such as Wuhan, there are large numbers of these vulnerable people living in close proximity to each other with the result that many elderly and debilitated persons become infected. Until this week, most of the cases outside of China have involved persons traveling from China. International travelers tend to be young and middle aged adults. Newborns, the very elderly, and those suffering from chronic disease tend to not do as much international travel. Those infected international travelers are therefore a select population of people who are best able to survive COVID-19 infection. This may be changing soon, with large numbers of domestically-acquired cases of COVID-19 being recently reported in South Korea and Japan.

Differences in quarantine practices

Here in the United States, the Centers for Disease Control has recommended a very high level of quarantine for patients with suspected COVID-19 infection including droplet, airborne, and contact isolation. This means gowns, gloves, negative airflow hospital rooms, and face shields. Many countries do not have the resources to provide this level of patient isolation. Indeed, persons suspected of having the infection are told to just stay home. In crowded, often multi-generational housing (such as exists in many Chinese communities), this quarantine practice can facilitate transmission to the vulnerable elderly, debilitated, and infants. In hospitals, sub-optimal isolation practices can facilitate transmission to other patients in that hospital and these patients with hospital-acquired COVID-19 are a select population of particularly vulnerable people who are more likely to die of the infection.

Lag-time differences

Death from COVID-19 does not occur instantly. There is first an incubation period of up to 14 days. Once a person develops symptoms, it takes several days to develop respiratory failure and die. The outbreak has been present in China for 2 months and so there has been sufficient time for those persons who get infected to develop symptoms and die of the infection. However, in other countries, patients with the infection have been identified and confirmed relatively early in their disease and in many cases, those people have not yet had time to develop respiratory failure and die.

Last year in the United States, an estimated 35 million Americans contracted influenza and 34,000 Americans died from influenza. That works out to about 1 death per every 1,000 people infected with influenza. The COVID-19 virus kills 34 out of every 1,000 people in China and about 11 out of every 1,000 people in countries other than China. If the outbreak spreads to the United States, based on these numbers we can expect COVID-19 to be about 10 to 11 times more lethal than influenza.

February 25, 2020

Categories
Electronic Medical Records Inpatient Practice

Are Verbal Orders A Patient Safety Concern?

Hospitals have a love-hate relationship with verbal orders. On the one hand, they can expedite care to the patient and can save physicians time. On the other hand, they can increase medical errors. Some groups believe strongly that the goal should be to have zero verbal orders whereas others believe that there should be no barriers to verbal orders. Electronic medical records have reduced the use of verbal orders in some situations but promoted the use of verbal orders in others.

The Joint Commission, the Leapfrog Group, the Institute of Medicine, and the Institute for Safe Medical Practice have all called for reducing or eliminating verbal orders. Nursing groups often see verbal orders as dangerous because of the risk that a verbal order error will place nurses in a position of liability. The Health Systems Management Society that determines best practices in hospital medical record keeping has set a goal that verbal orders should be < 10% of a hospital’s total inpatient orders and < 5% of a hospital’s total outpatient orders.  The literature is rife with anecdotes of the nurse who thought a doctor said to give a patient 10 mg of Viagra when the doctor actually said to give 10 mg of Allegra. The reality is that verbal orders can both improve patient safety and worsen patient safety.

Electronic medical records have reduced verbal orders

Much of the literature on verbal orders is from a pre-electronic medical record era. 15 years ago, most hospital orders were written in the patient’s paper chart that was kept in a nursing station. For a physician to place an order, that physician had to go to the nursing station hand write the order. If the doctor was out of the hospital or was on a different floor of the hospital, then entering an order was not possible and verbal orders proliferated. A bad phone connection, a doctor with a foreign accent, or a lot of background noise in the nursing station helped to foster mistakes. Although physicians had to eventually sign those orders, signing often didn’t happen until weeks after the patient was discharged when the patient’s chart was flagged by the medical record department as containing an unsigned order. Every physician who practiced in the 1990’s can remember weekly trips to the medical record department where each physician would have a stack of discharged patient charts requiring signatures.

Pharmacy orders were a particular problem. In the by-gone era of the physician’s prescription pad, a hand written prescription was given to patients at the time of an office visit or when being discharged from the hospital. But if that patient called in with an acute illness or needed a prescription refill, then the doctor had to call the pharmacy to give the pharmacist a verbal order for a medication. On nights that I was on-call, I would almost always have to phone in a verbal prescription to a pharmacy for a patient needing an antibiotic or an asthma inhaler; the options were either a hand-written prescription or a verbal order.

With the advent of electronic medical records, a physician no longer had to be physically in a specific nursing station to place an order. Doctors could now access the patient’s chart from a computer located anywhere and can even place orders from an app on their phone. I have not hand-written a prescription on a prescription pad in years. Even when I am on call, I find it easier and faster to send in a prescription by computer or by an app on my phone than to call a pharmacy (and be put on hold for several minutes). It is now easier than ever before to place an order electronically and this has reduced the need for verbal orders.

When verbal orders are a good thing

There are times when a physician simply cannot safely place an order in the electronic medical record. For example, the surgeon who is scrubbed in the middle of an operation cannot break scrub to place an order for the nurse to give the patient a fluid bolus. The family physician who is at a restaurant having dinner and gets a call from a patient with bronchitis cannot easily walk away from the restaurant, drive home, get on a computer to access the electronic medical record, and then send an electronic order for an antibiotic to the patient’s pharmacy. When a physician is driving to work in the morning is called from the ICU about a patient who is seizing, that patient needs to receive a dose of lorazepam immediately and not 15 minutes later when the doctor has access to a computer to place the order.

The reality is that most hospital locations have to use verbal orders some of the time in order to ensure timely care of patients. But there are some areas where a higher percentage of verbal orders (> 10% of the total) is more necessary than other areas:

  1. Operating rooms
  2. Intensive care units
  3. Cardiac catheterization labs
  4. Endoscopy labs
  5. Dialysis units
  6. Cardiac echo labs
  7. Emergency departments
  8. Radiology areas
  9. Patient emergencies anywhere in the hospital

When verbal orders are a bad thing

Although electronic medical records are ubiquitous today, most hospitals have only adopted them in the past 10 years. Consequently, there are many physicians who are still unfamiliar with the use of electronic medical records. Probably every hospital in the country has that doctor who still has not figured out how to place an order in the electronic medical record and gives all of his/her orders as verbal orders to a nurse. As younger, more computer literate physicians replace older, less computer literate physicians, this will be less of a problem in the future.

It can take time for a physician to enter orders in the computer and having someone else do it for you can improve your efficiency and allow you to spend more time actually talking to the patient. Consequently, many physicians like having a nurse that they can dictate orders to follow them around in the clinic or during hospital rounds, entering those orders into the computer as the doctor goes from one room to the next. This is an expensive use of a nurse and most physicians in small private group practices realize that it is financially untenable. However, hospitals have to court certain specialties, particularly surgical specialties, to keep them from moving their practice to another hospital in town. So, hospitals are often willing to provide an order scribe to the surgeon who brings a lot of high value surgical procedures to the hospital’s operating room. They know that they stand to make more from the surgeries than they will lose in the cost of the nurse to do order entry. The hospital can stand to ignore the hospitalist who says “Let me give verbal orders or I will leave” but cannot ignore the joint replacement surgeon or neurosurgeon who says the same thing.

There are situations when orders are generally not emergent and the risk of a medical error from an incorrect verbal order is just too great:

  1. Chemotherapy orders
  2. “Do not resuscitate” orders
  3. Orders for narcotics when the nurse/pharmacist cannot confirm that the person calling in the order is actually the doctor

Minimizing the risks of verbal orders

Given that the use of verbal orders is beneficial to patient care in certain situations and essential to patient care in others, complete elimination of verbal orders is neither practical nor possible. However, there are certain steps that the hospital can take to reduce the chances of verbal order errors:

  1. Use “read-back” of the order by the nurse or pharmacist so that the physician can confirm that what he/she actually said was what the nurse or pharmacist heard.
  2. Avoid using abbreviations. “QID” can sound too much like “QD” on the phone. Saying “K” for potassium can be confused for vitamin K.
  3. Beware of “sound alike” medications. It is easy to mistake “Tramadol” for “Toradol” or “clonidine” for “Klonopin”.
  4. Keep the noise down. A lot of people talking loudly in the nursing station makes it harder for the nurse taking a verbal order to hear that order correctly.
  5. Beware of accents. Regional American accents, foreign accents, and speech impediments can make it difficult for the nurse or pharmacist to understand the doctor accurately.
  6. If it doesn’t make sense, confirm it. If the ER physician tells a nurse to do a pregnancy test on the patient in bay 5 and the nurse walks in to find that the patient in bay 5 is a 70-year old named Joesph Smith, then it is best to double check with the doctor before asking for a urine sample.

Despite what some would have us believe, verbal orders are not inherently evil. However, they can create vulnerability from both a patient safety and medical-legal standpoint. Hospitals do need to regularly monitor for judicious use of verbal orders.

February 22, 2020

Categories
Medical Economics

United States Healthcare Expenditures

Every year, CMS publishes the National Health Expenditure (NHE) data; the most recent information was updated in December 2019 and reports data from 2018. The NHE gives important insight into how Americans spend their money on healthcare. For example, in 2018, health expenditures increased by 4.6% to an average of $11,172 per American. This represents a startling 17.7% of our gross domestic product. The growth in spending was not uniform, however – Medicare spending increased faster than any other source:

  • Medicare spending grew by 6.4%
  • Private health insurance spending grew by 5.8%
  • Medicaid spending grew by 3.0%
  • Out of pocket spending grew by 2.8%

To put that in context, in 2018, the U.S. annual inflation rate was 1.9%. The average household income rose 0.8% during this period. In other words, the average American’s health costs increased 6 times more than their annual income increased in 2018.

The report shows that although Medicare spending increased the fastest, total expenditures are still the greatest for private health insurance. Overall, the total national health expenditures were $3,649,400,000,000 (i.e., $3.6 trillion). Of that:

  • Private health insurance = $1,243 billion (34%)
  • Medicare = $750 billion (21%)
  • Medicaid = $597 billion (16%)
  • Out of pocket = $376 billion (10%)
  • Other Federal (CHIPs, Veteran’s Administration, Department of Defense) = $138 billion (4%)
  • Other governmental (Indian Health Service, worker’s compensation, etc.) = $370 billion (10%)
  • Investment = $174 billion (5%)

The NHE report also projects expenditures over the next 7 years at an annual increase of 5.5% per year. This will reach an estimated $6.0 trillion by 2027. As a percent of gross domestic product, health expenditures will rise to 19.4% by 2027. Currently, about 10% of the American population is uninsured and this is projected to remain the same through 2027 (although this percentage is subject to change based on changes in Federal healthcare legislation).

State-specific per capita health expenditures are available through 2014 (data will be updated with the upcoming 2020 U.S. Census). Six years ago, in 2014, the average personal health expense per person was $8,045. There was considerable variation by individual states with Alaska being most expensive ($11,060 per person) and Utah being the least expensive ($5,981 per person). However, states could be grouped into regions with the states within those regions having fairly similar costs. New England states were the most expensive and Rocky Mountain states wee the least expensive. The data can also be analyzed by healthcare costs as a percent of each state’s gross domestic product – Maine ranked the highest at 22.3% of GDP and Wyoming ranked the lowest at 9.3% of GDP in 2014.

Not surprisingly, as people age, their health costs go up. In 2014, the average personal health care spending per American child was $3,749, per working-age American was $7,153, and per American over age 65 years was $19,098. Even though the elderly only accounted for 15% of the U.S. population in 2014, they accounted for 34% of total health spending. For all age groups, per person spending for females was higher than for males with an overall average of $8,811 per female versus $7,272 per male.

The U.S. has an almost insatiable appetite for health care. However the NHE projections through 2027 show that there is a limit to what we can afford. It may be time for our country to put our health care appetite on a diet.

February 19, 2020

Categories
Epidemiology

The Novel Coronavirus 2019-nCoV

In December 2019, an outbreak of a new coronavirus began in Wuhan City, China. Within weeks, it had spread throughout China and to a number of other countries. This post will outline the history of the outbreak, what we have learned from other, previous coronavirus outbreaks, and what physicians and hospitals need to know about managing suspected patients in order to control the outbreak.

Coronaviruses are common upper respiratory viruses that generally cause fairly mild infections. They account for about 5-10% of common colds and cause typical cold-like symptoms such as fever, cough, and sore throat. Like other upper respiratory viruses, they are spread by aerosolized droplets and primarily occur in the winter months. The regular coronaviruses are detected with the standard respiratory viral PCR panels that most hospitals use. These panels detect other common viruses such as influenza, rhinovirus, parainfluenza virus, and others. Treatment is supportive and there are no effective vaccines or anti-viral antibiotics. As with all respiratory viral infections, patients admitted to the hospital should be placed on droplet isolation.

Sometimes, Coronaviruses Go Rogue

SARS.

From 2002 – 2004, an outbreak of a coronavirus resulted in SARS (Severe Acute Respiratory Syndrome). Overall, 8,098 people were known to become infected with 774 deaths, a 10% mortality rate. The natural host of the virus was the horseshoe bat and the outbreak was traced to a remote cave in Yunnan Province in China. From the bats in this cave, the SARS virus was spread to a masked palm civet, a cat-like wild animal in China that is often hunted for food. The civet was killed by a hunter and landed in a meat market in Guangdong, China in November 2002 where the virus then jumped to humans. Chinese health authorities were not forthcoming about the spreading Guangdong outbreak and did not report it to the World Health Organization (WHO) for several months, resulting in rapid spread of the infection due to a lack of public and healthcare worker awareness that it even existed. In February 2003, a businessman traveling from China became ill and was admitted to a hospital in Hanoi, Vietnam. An astute Italian physician working at the hospital, Dr. Carlo Urbani, recognized that the man’s infection was something different than regular influenza and notified the WHO. However, several healthcare workers at the hospital became infected; both the businessman and Dr. Urbani ultimately died of SARS. Meanwhile, a doctor from Guangdong unknowingly infected with SARS had traveled to Hong Kong where he stayed at the Metropole Hotel. He transmitted the virus to 16 international guests at the hotel who then traveled to Canada, Singapore, Viet Nam, and Taiwan, carrying the virus with them. On February 23, 2003, an elderly woman returning to Toronto from Hong Kong became ill with SARS and went to her local hospital. Canadien health authorities and healthcare workers did not have adequate infection control protocols in place and were unprepared for SARS and consequently within weeks, 257 people in Toronto were infected. In the United States, there were 27 cases and no deaths.

The incubation period for SARS ranged from 1-14 days but was usually 4-6 days. Like other coronaviruses, it was spread by droplets. With international efforts to stop the spread of the virus, the outbreak was contained and the last known case was in in January 2004. There are several lessons to be learned from SARS:

 

  1. Air travel permits rapid world-wide spread
  2. Don’t cover it up. By not being forthcoming about the emerging outbreak, Chinese authorities permitted the virus to quickly spread
  3. Rapid epidemiologic investigation is essential
  4. Countries must work together for epidemiological control
  5. Have a high clinical suspicion.
  6. Infection control works. Toronto did not have proper infection control practices in place, resulting in the Toronto outbreak
  7. Health personnel are at greatest risk

MERS.

From 2012 – 2015, another coronavirus caused the Middle East Respiratory Syndrome. Overall, 1,227 people became infected with an average mortality rate of 37%. The natural host was the dromedary camel and the virus made the jump to humans in Saudi Arabia. There were two main outbreaks of MERS, the first in Saudi Arabia in 2014 when 402 people became infected. The second outbreak occurred in 2015 when a businessman traveled from the Arabian Peninsula to South Korea, unknowingly infected with the MERS virus. Ultimately, 150 Koreans became infected and the main locations that these people acquired their infections were hospitals and clinics that were not prepared to institute proper isolation precautions and infection control practices. Ultimately, the South Korean outbreak alone cost $8.5 billion. The main symptoms of MERS were cough, shortness of breath, and fever. Chest x-rays showed patchy pneumonia or ARDS patterns. There are several sessions to be learned from MERS:

  1. A single missed infected person can cause a nationwide outbreak
  2. Hospitals and ERs can accelerate spread
  3. Doctors in community hospitals and clinics are the first line of defense
  4. New coronavirus strains can have a very high mortality rate
  5. Outbreaks are expensive

2019-nCoV

Wuhan City is the 7th largest city in China with a population of 11 million. To put that in context, New York City has a population of 8.6 million, Los Angeles 4 million, and Chicago 2.7 million. Wuhan is a traditional manufacturing hub and the political, economic, and commercial center of Central China. Its location on the Yangtze River as well as its location at the intersection of several rail lines and highways makes it one of China’s main transportation hubs. The main rail station sees up to 80,000 people per day and the airport serves 20 million passengers per year with direct flights to Tokyo, Paris, London, San Francisco, and Chicago among other international destinations. In December, 2019, a new coronavirus called the “novel coronavirus” or 2019-nCoV appeared in Wuhan City and is believed to have originated at a Wuhan market where wild and domesticated animal meats are sold.

As with the SARS outbreak, Chinese health authorities were slow to recognize and report the emerging infection. The result was that the virus rapidly spread through Wuhan City and from there, to other towns and cities in China. Within weeks, the virus had spread to many other countries throughout the world, including the United States. Like other coronaviruses, the presenting symptoms are fever, cough, and shortness of breath. The incubation period is 1-14 days. In some people, the infection is rather mild but in others, it can result in severe illness. The mortality rate is about 3%.

When should 2019-nCoV be suspected?

  1. Fever AND symptoms of lower respiratory infection AND either:
    • Travel from Wuhan City, China in the past 14 days
    • Close contact in the past 14 days with a person under investigation for 2019-nCoV
  2. Fever OR symptoms of lower respiratory infection AND:
    • Close contact in the past 14 days with a person with laboratory-confirmed 2019-nC0V

ALL of the following isolation procedures should be used in suspected cases in the emergency department and the hospital:

  1. Contact Isolation:
    • Gown
    • Gloves
    • Hand hygiene with soap and water (alcohol based hand sanitizer if soap & water not available)
  2. Droplet Isolation:
    • Mask
    • Face shield or goggles
  3. Airborne Isolation
    • Negative airflow room
    • N-95 mask or PAPR

What should you do if you have a  suspected case?

  1. Place patient in isolation immediately
    • In the ER or hospital: contact + droplet + airborne islation
    • In an office setting: put patients with a possible history in a private room with a closed door; give the patient, family members, and healthcare workers a regular mask until additional history is obtained to determine if the patient requires transfer to a hospital for full isolation and additional testing
  2. Obtain a full travel history
  3. Communicate with the hospital infection control personnel and the local health department to determine if the patient needs testing
  4. Currently, testing is only done at the CDC and requires prior permission from the CDC

When performing testing, ALL of the following should be submitted:

  1. Sputum or bronchoalveolar lavage or tracheal aspirate
  2. Serum
  3. Nasopharyngeal AND oropharyngeal swab/wash/aspirate

Importantly, the standard respiratory viral panel test used by most hospitals does NOT detect 2019-nCoV. Therefore, a positive coronavirus test on a respiratory viral PCR panel does NOT indicate 2019-nCoV and instead indicates one of the regular coronaviruses that typically cause a common cold.

All testing should be performed with the patient in proper isolation, including airborne precautions; testing should not be performed in regular emergency department rooms or clinic rooms that are not capable of negative airflow. There is no effective anti-viral for 2019-nCoV so treatment is primarily supportive. For those patients who develop respiratory failure and require mechanical ventilation, intubation should be performed in a negative airflow room with all isolation precautions and should be performed by the most experienced physician available (this is not a procedure for trainees). If a person believes that he/she might have 2019-nCoV, then they should call ahead to the emergency department so that their throughput can be expedited and avoid exposing other patients in the waiting area.

The mainstays of response to any epidemiologic threat are preparedness, surveillance, containment, and education. Even though 2019-nCoV is frightening, influenza remains a greater threat to Americans. The CDC estimates that last year, 35 million Americans became infected with influenza and 34,000 died. So, even if 2019-nCoV is not present in your community, always use standard infection precautions:

  • Maintain proper hand hygiene practices
  • Cover your cough
  • Stay home if you are sick
  • Get your Influenza vaccination
  • Use droplet isolation with any admitted patient with a suspected viral respiratory infection
The 2019-nCoV outbreak is a rapidly evolving situation so check the CDC website and the WHO website for updates.
February 1, 2020
Categories
Medical Economics Outpatient Practice

Prior Authorizations, Insurance Denials, and Physician Burnout

Insurance denials and insurance prior authorizations are the bane of existence for any physician who practices in an outpatient setting. The are at best an annoyance but last Friday, I had an experience that nearly made my head explode. At issue was the denial of a high resolution chest CT that I had ordered several months ago for a patient with interstitial lung disease who had deteriorating pulmonary function tests despite treatment. I wanted to determine if his interstitial lung disease was worsening to decide if his treatment needed to be changed or if he needed to be referred for a lung transplant. I entered the order into our electronic medical record with ICD-10 code J84.9 (interstitial lung disease) and typed into the “reason for the test” box that he had interstitial lung disease of uncertain cause with worsening pulmonary function tests. The patient’s insurance company contracts with a radiology test benefits management company (which I am going to call “Roadblock, Inc” so that the real company does not blacklist me) to review orders for radiology tests and then approve or deny the tests based on whether or not the tests meet evidence-based indications for that particular test. Last week, shortly before the CT was scheduled to be performed, I got an email from our office staff that the insurance company had called to tell us that Roadblock, Inc had denied the CT and then left a case reference number and the phone number at Roadblock, Inc for me to call. Here is a summary of my subsequent phone call to Roadblock, Inc:

  • 2:00 PM – I call Roadblock, Inc and am on hold for 2 minutes
  • 2:02 PM – A Roadblock, Inc customer service representative answers the call and takes down all of the information about the patient and the test that was ordered
  • 2:04 PM – She transfers me to the clinical review department. I am again placed on hold for 1 minute
  • 2:05 PM – A second customer service representative answers and again asks for the case number, patient’s name and birth date as well as my name and contact information. She informs me that the reason for denial is that the only approved indication for a high resolution chest CT is interstitial lung disease or worsening pulmonary function tests. She asks me if I would like to be transferred to the physician appeals department. I answer yes and am placed on hold for 2 minutes
  • 2:08 PM – a third customer service representative answers and I am again asked for the case number, patient name, and date of birth as well as my name and contact information. She asks me if the previous customer service representative told me why the CT was denied and I answered yes. 
  • 2:10 PM – I explained that the original order had the correct ICD-10 code for interstitial lung disease and additionally had the typed clinical information that the patient had interstitial lung disease with worsening pulmonary function tests. I pulled up the original date-and-time-stamped order from a few months earlier to confirm this and offered to fax it to her. The customer service representative stated that when the order was processed by Roadblock, Inc, that the indication for the test was not completed. I explained that the information that we sent to Roadblock, Inc included the correct ICD-10 code and the correct written indication for the test.
  • 2:13 PM – I then ask to schedule a “peer-to-peer” phone call with one of their physician reviewers. The customer service representative tells me that a peer-to-peer is not permitted for a test denial. The customer service representative acknowledged that the information that I had entered into the order and sent to Roadblock, Inc was the correct indication for a high resolution chest CT but that on the Evicor computer system, that information had not been documented and therefore the test had been denied.  
  • 2:16 PM – I asked for an appeal since the error was on the part of the Roadblock, Inc’s employee who had recorded the information that our office had sent to them. The customer service representative tells me that she is sorry but that appeals are not permitted. 
  • 2:18 PM – I tell her that I would send in a new order for the CT scan. She tells me that I am not permitted to re-order a CT when the original order is denied. She tells me that Roadblock, Inc’s policy is that I cannot order a new CT scan for a 2 month period after a denial. 
  • 2:20 PM – I ask to speak with her supervisor. She tells me that I can call the insurance company to see if they will make an exception to the denial. 
  • 2:21 PM – My head explodes and I tell the customer service representative that her company has failed this patient.

This is not a unique experience. Prior authorizations and denial appeals take up an enormous amount of physician and office staff time. A recent survey of 1,000 physicians by the American Medical Association found that 91% reported that the prior authorization process had a negative impact on patient care; 28% reported that prior authorization had resulted in delays of care that resulted in hospitalization, death, or disability; 86% reported that the prior authorization process placed a high or extremely high burden on their practice; and 88% reported that the prior authorization process has gotten worse in the past 5 years.

The Council for Affordable Quality Healthcare found that prior authorizations increased 27% between 2016 and 2019. Currently, the average physician has to do 34 prior authorizations per week and the total time cost to the physician and office staff is 14.9 hours per week devoted just to prior authorizations.

About 25 years ago, our pulmonary practice group held an all-day coding and billing session for all of the physicians. We hired a coding specialist from one of the major health insurance companies to come to teach us how to best document and code for the services we were billing with the thought that the best person to teach us about correct documentation and coding was a person from an insurance company coding department. She told us that the staff in her department were told to deny every 10th claim. If the physician appealed the denial, then they would simply approve the claim and move on. But the insurance company had found that most physicians do not bother to appeal claim denials and just write them off. By randomly denying claims, the insurance company was able to save an enormous amount of money.

Medication denials are a particular problem. Many drugs are members of a class of medications that are all relatively interchangeable for most patients. For example, statins used for high cholesterol, ACE inhibitors used for high blood pressure, and inhalers used for asthma. The insurance company will negotiate with the drug manufacturers to get the lowest price for one of the drugs in a class of medications. These drugs are then placed on the insurance company’s “formulary” of approved medications; if a patient is prescribed a drug that is not on the approved formulary, then the patient has to pay retail price for that drug out of pocket. I deal with dozens of different insurance formularies. Some insurance companies permit a computer interface with physicians’ electronic medical record so that physicians can tell right away if a medication that they are prescribing is on that insurance company’s formulary and then pick another drug from that same class if it isn’t. But many insurance companies do not permit an interface with the physician EMR. Although the physician can go to the internet and look up a formulary, most of these on-line formularies are not very user friendly and often require the physician to scroll through pages and pages of a PDF file to hunt for a drug that would be covered – this can take the physician 5-10 minutes to determine which drug is or is not covered. If a non-formulary drug is prescribed, the physician will usually get a letter in the mail that the prescribed drug is not on the insurance company’s formulary. The problem is that those letters do not tell the physician what drug in the same class is covered so the physician either has to spend time on the internet trying to determine what is covered or continue to randomly prescribe medications in that drug category until they hit on one that is covered. Furthermore, the insurance companies change their drug formularies every January and a drug that is covered one year will often not be covered the next year resulting in a flurry of denial letters being sent to physician offices all over the country every January.

Prior authorizations and denials are a great business model for insurance companies, radiology benefit management companies, and pharmacy benefit management companies. By creating a barrier to approving expensive tests such as CT scans and MRIs, they can reduce the number of these expensive tests that are actually done. By denying medications that are not on their insurance formulary, they can reduce the number of prescriptions that are filled.

The sad part of prior authorizations and denials is that most of the time, the physician can eventually successfully appeal the denial of a test or a prescribed medication, as long as the physician is persistent and dedicates the time necessary for the appeal. The net result is that these denials and prior authorizations create an enormous cost to physician practices with no real benefit to the patient. As a consequence, the American prior insurance authorization and denial system is a major contributor to the U.S. having the most expensive healthcare in the world but still lagging other countries in quality of healthcare.

A 2018 report from Harvard concluded “Physician burnout is a public health crisis that urgently demands action by health care institutions, governing bodies, and regulatory authorities. If left unaddressed, the worsening crisis threatens to undermine the very provision of care, as well as eroding the mental health of physicians across the country.” Some of the primary drivers of burnout is burdensome administrative requirements, excessive bureaucratic requirements, and consequences of electronic medical records. Insurance denials and prior authorizations fit squarely into these drivers of burnout.

Ironically, the payers that generally pose the least denials and prior authorizations are Medicare and Medicaid. I am generally a strong proponent of free market economic systems but in this case, the American health insurance free market has resulted in a broken system that is increasing healthcare costs to Americans and contributing to physician burnout.

January 25, 2020

Categories
Life In The Hospital

Hospital Power Outages

Perhaps no buildings are more dependent on electrical power than our hospitals. Almost everything that we do to heal and to cure ultimately depends on a reliable power supply and when that supply is interrupted, hospitals shift into disaster mode. I’ve been through several hospital power outages over the past 30 years, ranging from a few minutes to many hours; this is what I have learned.

Where does the hospital get its power?

Fortunately, there are multiple redundant power sources in hospitals, from the main power feed from the local electrical grid, to back up generators, to back up batteries on pieces of equipment. In an optimal situation, a hospital will have 2 independent feeds from different parts of the electrical grid so that if there is a regional power failure affecting one area, power can be drawn from the second feed to ensure a steady electrical stream.

Most hospitals will also have a back-up generator, often run off of diesel fuel, that can kick in within seconds of a loss of electricity from the regional power grid. However, the back-up generators can usually only supply a fraction of the normal power needs. This results in “emergency power” circuits in the hospital that are usually indicated by red electrical sockets (as opposed to the standard white sockets that are connected to the regular power grid).

Hospital electrical systems are unique

Despite the systems of back-up power, sometimes power can be lost. One of the reasons for this is that most hospitals are made of buildings of varying ages. We tend to add-on to existing buildings or build attached buildings as patient demand grows, rather than raze the old hospital building and then build an entirely new one. This leaves us with electrical components of varying ages and the hospital’s electrical system is only as good as its oldest components. Additionally, the amount of power a hospital consumes is enormous and so fuses can often weigh 200 pounds or more, making emergency repairs more difficult and time consuming.

So what do you do when the power goes out?

One of the first priorities is to activate the hospital’s disaster command center that is used to coordinate responses too disasters. Most hospitals will do 2 or more mock disaster drills each year to practice for disasters. The disaster that you get is usually not the one that you practiced for but by doing drills, you can ensure that your communication channels and key response personnel are in place and can adapt to the specific needs of each unique disaster.

Intensive Care Units. The first priority is to ensure that life support equipment has power. This includes mechanical ventilators in the ICUs, dialysis machines, and operating room equipment. Modern ventilators have back-up batteries but older ventilators may not work when the power goes out so hospital staff need to immediately go and check on mechanically ventilated patients. An ambu-bag should be brought to every room with a ventilator being used. If telemetry monitors no longer work, then a nurse or respiratory therapist should be assigned 1:1 for ICU patients. There should be a flashlight in every room. If a sustained power outage is anticipated, then moving patients to a different part of the hospital that can serve as a surrogate ICU may be required. Ideally, this should be location that has existing cardiac monitors and medical gases such as the surgical post-op recovery room, the endoscopy suite, and the cardiac cath lab recovery area. It can be very helpful to bring in additional nursing staff, respiratory therapists, and physicians. When we had a recent power outage involving our ICU, we moved patients to the surgical recovery area and brought in 2 extra critical care physicians. One physician was in charge of logistics and maintained a white board in the recovery area to list which patients were going to different recovery room bays, which ones had ventilators, which ones had chest tubes with pleurovacs (needing wall suction), etc. This physician triaged the order of patient movement, directing which patient should be moved first and grouped patients together for optimized nursing and respiratory care.

Operating Rooms. Operating rooms are unique. Usually, there will be sufficient power available on the emergency power (red power socket) system to complete a surgery but air handlers may be on regular power with the result that an operating room may quickly exceed approved temperature or humidity thresholds. Therefore, assessment of temperature and humidity controls of each operating room need to be assessed to determine if they are working and if not, then surgeries in those ORs may need to be canceled. Usually, a surgical procedure that has already been started can be completed before temperature and humidity thresholds are exceeded; however, if a very long surgery is underway and the air handler for that OR goes out, then it may become necessary to complete a portion of the surgery, close, and then bring the patient back for a staged procedure the following day. Although this can result in significant surgeon and patient dissatisfaction, it is better than risking a surgical infection if thresholds are exceeded. Be sure to check refrigerators and freezers in the OR area because supplies like frozen bone grafts require very specific low temperatures.

Nursing units. Most patients on regular medical/surgical floors are not connected to life support equipment as occurs in the ICUs. However, a sustained power outage can affect patient comfort. Having lots of bottled water and extra blankets is helpful. Patients’ medical conditions can change so if the elevator power is out, it may be necessary to use stair sleds to transport patients off of a floor. Most hospitals maintain a supply of stair sleds but staff often are not experienced in using them. It is a good idea to practice use of these sleds during disaster drills.

Elevators. Each elevator needs to be assessed to determine who is in them when power is lost. Elevators with patients being transported between floors should be prioritized for rescue. Elevators containing staff and visitors can be assigned a lower priority for rescue. Be sure to get a cell phone number for someone in each elevator to keep in your command center.

Emergency Department. If power loss is anticipated to continue, then the ER should be placed on “divert status” which directs emergency squads to take patients to other hospitals in the area. You do not want patients with myocardial infarction, stroke, or trauma coming to the ER if you are not able to assess or treat them.

Pharmacy. The first task for pharmacy is to ensure that patients can get needed medications. Many hospitals will use a Pyxis system to keep medications on individual nursing units. If the Pyxis machines lose power and cannot be opened, then medications will need to be brought up from the pharmacy. The second step for the pharmacy is to preserve medication inventory. Most medications have specific temperature thresholds. Medications in freezers or refrigerators may need to be moved to alternative locations. If air handlers to the pharmacy area are affected, then temperatures should be monitored to ensure that thresholds for shelf medications not exceeded. Arrangements may need to be made for medication compounding at another location.

Laboratory. The hospital lab is particularly vulnerable when there is power loss. There are reagents in freezers and in refrigerators that can have very specific temperature thresholds. These reagents can be very expensive so prioritizing moving these freezers and refrigerators to emergency power sockets or portable generators is necessary. When we had to do this, we found that having a lot of extension cords in our facilities department really paid off (you can never have too many extension cords in a power failure!). Refrigerated blood products in the blood banking areas also need immediate attention. The chemistry and hematology analyzers have fairly strict temperature and humidity thresholds – as long as these thresholds are not exceeded, then the analyzers simply lie dormant until power is restored but if thresholds are exceeded, then the analyzers may be down for days while reagents are replaced, controls are run, and analyzers are checked and serviced. We brought portable air chillers into our lab that ran off of emergency power to ensure proper ambient air temperature when we lost power. This is especially important in the lab where freezers and refrigerators running on emergency power can generate a lot of heat that can quickly warm up the lab area. Once power is restored, it may take several hours to get the lab analyzers back on-line. It is very useful to have a contingency plan for the lab with a courier system and an alternative lab that can run samples. Don’t forget about blood gas analyzers – these generally have a back up battery supply and can continue to run for a short time in the event of a power loss. Because these machines can generally also do hemoglobin and basic chemistry tests, they can be an important resource and should be prioritized to connect to emergency power or a portable generator.

Fire safety. If power loss results in the hospital’s fire alarm system being off line, then you should contact the fire marshal. In most communities, it is the fire marshal (and not the hospital’s administrative staff) who decides whether or not a building needs to be evacuated due to power loss. If the fire alarm system is not functioning, then a “fire spotter” will need to be assigned to each floor of the hospital. This is a hospital staff member who is equipped with a flashlight and a cellphone or other communication device whose sole job is to constantly patrol that floor for fire or smoke and can report directly to the command center.

Radiology. CT scanners and MRIs are particularly susceptible to power loss. When these systems go down, it can take 1-2 hours to bring them back on-line and even longer if one of their fuses blow at the time of the power outage. This may require bringing in management-level personnel who are experienced with rebooting these devices. Most hospitals utilize portable x-ray machines that can run off of batteries. This can at least allow for basic x-rays to be performed. Power loss may result in an inability to transmit the images to the hospital’s PACS system for review by a radiologist but at least there is usually a monitor on the portable devices that permits x-ray review by an on-site physician.

Cardiac catheterization laboratory. The cath lab has equipment, medications, and supplies that have specific thresholds and attention to temperature and humidity in these areas is necessary so that medications and equipment can be relocated if thresholds are reached. Additionally, the imaging equipment in a cath lab can take a long time to reboot. Bringing in your hospital’s clinical engineering personnel is essential for bringing cath lab equipment, radiology equipment, and other electronic equipment back on-line.

Inventory. All kinds of supplies in the hospital have specific temperature and humidity thresholds. A typical hospital will have about $1 million of supplies in the operating rooms alone. If temperature or humidity thresholds are approached, then it may be necessary to relocate these supplies to other locations to prevent losses.

Food services. Patients need to eat and if the power to the kitchen goes out, then alternative food sources need to be identified. There are portable kitchens in mobile trailers that can be brought on-site to do food preparation. It is a good idea to know who to call for portable kitchens as part of regular disaster planning so that one can be brought on-site quickly if needed. Food inventory in refrigerators and freezers requires attention and either needs to be relocated to meet temperature thresholds or need to be disposed of. Don’t forget about refrigerators in nursing units and procedure areas that contain snacks and drinks as these will also need to be disposed of if temperature thresholds are exceeded. If there is a sustained power outage, then hospital staff also need to eat, particularly all of those who are staying past their normal shifts to attend to patient care and safety. Bringing in pizza, bottled water, and snacks for nursing units can really help maintain morale. Calling in a couple of local retail food trucks can also help.

Central sterile supply. Sterilized surgical instruments will have specific thresholds and if sterilized packages get condensation in them, then they will need to be re-processed. Have a contingency location for surgical sets and case carts so that they can be maintained within thresholds.

Security. When power is lost to monitoring cameras and to public area lighting, there is increased demand on hospital security staff. It may take bringing in additional staff for patrolling parking areas at night and for patrolling hallways and waiting areas to ensure staff and visitor safety. Many access doors in hospitals will have electronic locks and badge readers. Be sure to send someone out to manually raise bars in gated parking lots to permit cars to enter and exit.

Electronic medical records. These often seem like the bane of physician existence but when they go off-line, it can paralyze patient care. Fortunately, most medical record systems get turned off for maintenance on a regular basis so hospitals have contingency plans for using paper charting for orders, progress notes, etc. It turns out that one of the hardest things to do when the electronic medical record goes down is to discharge patients, for example, from the emergency room.

Morgue. It is the last thing that anyone thinks about but don’t forget about the need to maintain low temperatures in the morgue if the air handlers are down. Options can include bringing in a portable refrigerated truck or identifying an alternative morgue location.

Equipment that you will need

Some of the items that I have found to be particularly useful to have during a power failure are extension cords, portable temperature/humidity monitors, and flashlights. Extension cords can allow you to re-route refrigerators, freezers, and essential electronic equipment to emergency power sockets or portable generators. Flashlights are useful everywhere. Portable temperature/humidity devices are a great way to tell if you are approaching thresholds in places like the operating rooms, pharmacy, lab areas, and central sterile supply. Ideally, bringing in infection control personnel and arming each of then with a hand-held temperature/humidity device allows for constant rounding and monitoring of these areas. It is also a good idea to document the temperature and humidity at regular intervals in each location so that once power is restored, it is easy to determine if thresholds were exceeded and for how long they were exceeded in order to determine what inventory needs to be disposed of. Hospitals will also maintain a stock of portable 2-way radios for communication. We use these but I have found that I use my cell phone primarily. If the power is out for more than a couple of hours, having cell phone chargers on had can be helpful.

Hopefully, your hospital will never have a power outage but every hospital needs to prepare and practice for how to respond in case power loss occurs.

January 18, 2020

Categories
Outpatient Practice Physician Finances

Should Doctors Bill For Phone Calls?

Beginning in January 2019, the Centers for Medicare and Medicaid Services (CMS) rolled out G2012 – a new CPT code for “Brief communication technology-based service (virtual check-in)”. This code can be used for patient phone calls as well as electronic medical record patient portal contacts initiated by a patient. For the first time, doctors can charge for patient phone calls – but should they?

The details behind G2012 are that the physician cannot have seen the patient for a regular billable encounter for 7 days prior to the phone/portal encounter or for 24 hours after the phone/portal encounter. The medical discussion should be between 5 – 10 minutes and has to be between the patient and the doctor/NP/PA and not the office staff. The patient has to give verbal consent acknowledging that the telephone/portal visit will be billed. The patient must have been seen by the physician or a physician in the physician’s group within the past 3 years. This CPT code is compensated at 0.41 RVUs ($14.78 for Medicare).

When Medicare released its plans to roll out G2012 a year ago, physicians all over the country breathed a sigh of relief and said “…finally!”. Every physician who is responsible for direct patient care in the outpatient setting knows the burden of patient phone calls. On a typical Monday, I have 15-20 phone messages in my electronic medical record “in basket”. On a Monday after a holiday weekend, that number can increase to 25-30 and it is not uncommon for me to spend 1-2 hours on those Mondays just returning phone calls. It has been estimated that the average primary care practice gets 21 calls per day for every 1,000 patients in the practice.

There are additional CPT codes that are designated for phone calls of various lengths of time for physicians (99441, 99442, and 99443) as well as for advanced practice providers such as NPs or PAs (98966, 98967, and 98968). However, Medicare does not currently reimburse these codes so they are generally not used unless a commercial insurance company recognizes them. Similarly, there is a CPT code for email responses to patients for physicians (99444) and advanced practice providers (98969) but these are also not currently reimbursed by Medicare.

Some phone calls are entirely legitimate, for example, a person who gets an asthma flare when traveling out of town and needs advice and a new inhaler. But some phone calls are simply because a patient does not want to come into the office or a patient wants to avoid an office visit co-pay. In these situations, the physician is providing free healthcare to the patient. And that equates to uncompensated physician time as well as malpractice vulnerability. There are pros and cons to billing for phone calls.

Pros

  1. It can reduce overall healthcare costs. The office overhead expense associated with a face-to-face office visit can be considerable. As opposed to a regular office visit, there is no need for registration staff, nursing staff, office space use, and checkout staff with a phone call.
  2. It allows more flexible use of the physician’s time. The doctor can return that call at a time when he/she has a few free minutes rather than committing the doctor to a fixed appointment time for an office visit.
  3. It is more convenient for the patient. Having a medical problem managed by a phone call can obviate the cost of travel to the doctor’s office and the time involved in getting to and from the doctor’s office. For the patient who is a student or who is working, it also obviates the need to take time away from classes or time off work to go to the doctor’s office.
  4. It improves doctor satisfaction. Physicians have provided free medical care over the phone ever since phones came into existence. Knowing that you are getting paid something (even if not very much) can eliminate that sense of being taken advantage of that you otherwise would have. From my perspective, this is one of the most important reasons to bill for patient phone calls.
  5. It can create a barrier for patients who abuse the system. Every physician who practices outpatient medicine has had the last minute cancelation by a patient who then calls the office an hour later asking if the doctor can call them back and manage by phone the medical problem that they were supposed to come in for. The physician still has to pay the overhead cost of that no-show on the schedule in terms of the nurse’s salary, office rent, the receptionist’s salary, and the the utility bills not to mention the physician’s own salary. Every physician also has the patient who sends lengthy messages via the EMR patient portal on a daily basis or calls multiple times a week. The awareness that the patient (or at least their insurance) will be billed for those calls can reduce abuse.
  6. It encourages use of email communications through patient portals. Phone calls create more overhead expense than emails. There is the time the office staff takes to answer and transcribe patient messages, the time it takes someone to answer the phone when the physician calls back, the time it takes for the patient to actually get on the phone, the time it takes the physician to document the call in the medical record, etc. An email communication eliminates much of that overhead cost of office staff and physician time. Furthermore, when the patient has the doctor on the phone (as opposed to an email message), it often results in additional medical questions that follow the comment: “Oh, and while I have you on the phone…” and this adds additional time as well as complexity of medical decision making. I can answer 3 patient emails in the time it takes me to return 1 patient phone call.

Cons

  1. The patient has a co-pay. Although the reality is that at $2.50, it is a bargain. Nevertheless, for patients used to getting free medical advice over the phone, the co-pay can be surprising.
  2. The patient has to give verbal permission/acknowledgement that the phone call will be billed. The easiest way to do this is to incorporate scripting into the nurse or office staff who initially answers the phone and starts the phone message.
  3. Phone calls do not pay much. The cost of your revenue cycle department to submit and collect the phone call bill may be nearly the $14.78 you will be paid by Medicare for the phone call.
  4. It is not usually covered by commercial insurance. Usually, it takes commercial insurance companies a year or two to catch up to new CPT codes introduced by Medicare. Currently, few insurance companies cover phone calls so the patient may be charged the full amount. This can result in patient dissatisfaction (although it can be a deterrent to patients who abuse phone availability).
  5. The phone call must be for analysis or decision making that requires the physician. In other words, you should not be billing for a patient phone call that is simply to request to reschedule an upcoming office visit. It is the physician’s time that must be > 5 minutes and not the nurse’s time or the office staff’s time.
  6. The phone call must be at least 5 minutes. It only takes 1-2 minutes to send in a prescription refill and so it would be difficult to justify billing for a phone call simply to request a refill. However, for a patient with a COPD exacerbation, by the time the doctor reviews the patient’s past history in the chart, takes an interval history over the phone, checks for allergies, reviews the current medication list for potential drug interactions, sends a prescription for an antibiotic and prednisone to the pharmacy, and then documents the telephone encounter, it almost always takes at least 5 minutes. Be sure that the time spent on the encounter is documented in the medical record. Because Medicare auditors can audit time stamps in the electronic medical record, the amount of time between the physician initially opening the telephone encounter in the EMR until the time the physician closes that encounter must be > 5 minutes.
  7. It creates a disincentive for the patient to come into the office. Although it is true that you can practice a lot of medicine over the phone or over the internet, sometimes a physical examination is essential, even if just to get an accurate set of vital signs. Moreover, it becomes more difficult to arrange a needed EKG, a pulmonary function test, a chest x=ray, or blood tests when you are managing a patient over the phone as opposed to the patient being in the office where those tests are readily available in the office. If patients believes that they can get just as good of medical care with a phone call as they can by a face-to-face office visit, then they may stop coming into the office. Not only can this have the potential to jeopardize high quality care, but since the reimbursement for telephone calls is so low compared to an office visit, physicians who do nothing but phone calls all day long will soon go out of business.

When used appropriately, billing for phone calls is a win-win-win. The patient wins by getting their medical problem addressed without having to take the time involved in going to the doctor’s office or the emergency room. The insurance company wins because that $14.78 phone call can often avoid a much more expensive trip to the ER or an urgent care facility. The doctor wins because she/he now gets paid at least something with the psychological benefit to the doctor being worth considerably more than the financial benefit.

December 1, 2019