The C in CPT stands for Current.

I think we knew all of that (except what the C stands for; thanks mcpath).
I was kinda hoping for some ideas on how to make things better. Oh well...

Thank you again for facilitating the debate, Dan! I'm certain that we'll see some lively discussion.

And, remember, the push for EMR adoption is based on this system, which I have pointed out in many posts, is a flawed model.

wanglib those of us that are relatively fresh out of training (5 years for me this month) a lot of this debate has been very informative. I have had to look up the sunbeam incident, read up on the girl in NY who died (allegedly house staff being fatigued played a role in her death) whose father's advocacy went on to the new ACGME work hour limitations (I forget her name) and now this post. So while most of us may have known the above, not all of us did.

Also, two serious posts from you in one day? You feeling ok? :)

Thank you Dan,and this emphasizes what I have mentioned several times here:The insurance industry's fraudulent use of the term "usual and customary fees",because they know by law(which they most likely lobbied for),that physicians can't prove them wrong.

Here's an old Sermo post a few months ago showing the inequities of the CPT codes. I contacted the Coding dept and spoke to a nice person who informed me that the only way to reinstate of add a code was to go to my professional organization, in my case the AAP and get a "certified" letter acknowleging the need. There was a whole stack of paper work involved and being overburdened, I just don't have the time.

CPT code for Sundays and Holidays
The AMA has deleted the CPT code 99054, Sundays and Holidays work. The new codes added were 99060-Called out of office during regular hours and 99053-work done between 10pm and 8am. I'm concerned about the deletion of the Sunday and Holiday code as this makes it difficult for arranging call schedules for our small local hospital. I'm a general pediatrician(we have no hospitalists, neonatologists, intensivists, etc) so the 3 of us left (all in individual solo practice) often find it difficult to cover during major holidays. There is no real incentive to cover Christmas. I'd rather spend time with my family. But with no peds coverage, we can't have OB deliveries and the ER would have to transfer simple admissions(the nearest tertiary center is 150 mile by air only). I'd like to see the 99054 reinstated. Even a small compensation for coming in for a C-section at 2 am on Thanksgiving will be helpful (I'm up to 70% medicaid now). And we have about 50 deliveries a month, 10-15 C-sections, 5 +complicated NSD. Am I too greedy? Should I write to the AMA? Am I wasting my time? Thanks in advance !

there you go.... $$$$$70M+++ .======== PERKS for the WHITE HOUSE,CONGRESS and AMA and the "boys" ball in the park!!!!

...Congratulations, Mr President for identifying specifically the root issues of our current health care system! GREED at the expense of social welfare USA!!!

I enjoin every doctor decry, lament to the rooftops the current desperate situation as emergent and if nothing will be done... we will be no different from the countless places, despondent colleagues that I have visited abroad because of simple neglect, abject disregard of patient welfare and physician wasted professional resources!!!

... as WE enjoin with you a FRESH organization, transformation, restoration of the sound practice of medicine, the young generations could uphold true medicine and be rewarded accordingly ...

primarily, prayerfully NOT with FINANCIAL GAIN but utmost quality (as the world watches) in the exercise of unadulterated health care system everyone can be proud of as the best doctors in the greatest country of this century!

Can we ever simplify the process, patients pay at visit and when discharged from hospital. They can get reimbursed by insurance as soon as they call insur. That will keep insur wary of dumping overhead costs and delaying the process since consumers will just quit on them if they hate the process unlike doctors who suck it up and jump through all the hoops.

Simply put, get rid of the old CPT codes. The new CPT code works for me: cash please!

Incidentally, let's get rid of the abominable and heinous E & M codes as well. That will make my day (my century!)

I dropped out of the AMA years ago due to their liberal politics and their big goverment attitude, so this CPT collusion doesn't surprise me one bit. I urge every physician to boycott the AMA as they DO NOT have our best interests at heart but rather the perpetuation of their bureaucracy. To hell with them all, they've become as selfish and morally bankrupt as congress, and that's just sad. And please stop sending me insurance offers, you bunch of losers.

The codes are fine. Just see your share of patients, and you'll make a living.

We allow Big Brother to control us. Coding is good for record keeping just like SKUs let a department store know what item moves off the shelf. They force us to use these codes so they can decide what to pay us. After the government finishes controlling the cost of healthcare by telling docs, hospitals, what we can make, are they going after Mobil, Hess, Exxon, Costco, Sams Club, and McDonalds? When does this control nonsense end? Are we Nationalizing all aspects of the US economy, or just the ones Washington can get away with? Which politicians sit on which boards, that have the ear of Congress? Look at the Warren Commission and see who sat on that panel and who ran Washington 20-30 years later!

The AMA, by creating and promoting CPT codes, the same CPT codes which have made our jobs so unpleasant and costly, have clearly shown their allegiance is NOT with physicians, but rather with themselves and insurance companies.

To put it more bluntly, the AMA has been working very hard at making our lives very difficult.

They should call themselves the American Insurance Association since that is who the benefit the most.

Jadedmd The case you are referring to is Libby Zion. Her death was attributed in part to house staff fatigue. Because of this incident New Yrok state passed work hour restriction that were long ignored until around 1999 or so when the ACGME got involved and put the 80 hour limit restrictions in place. At the time I was finisheing my last year and I can tell you the quality of care fell tremendously. I also knew a resident on Long Island that received a letter from the local prosecuter that if a patient died and it was found out that a resident was involved at the time of death was violating the work hour restriction then criminal charges could and would be pressed.


Now onto CPT. I think the codes work in a sense. They allow each physician to look at a code and know what procedure was done without writing out a load of wrods (as pointed out by another Sermo member in a different post). However basing my work on these codes is ridiculous especially the E&M portions. Worring about the number of bullet points I am writing down in the chart so that I can get the maximum paymnet makes the "Art of medicine" no longer an art or scientific process. It turns medicine into cookbooks. And as I remember some of my old professors and mentors telling me...."Diseases do not read text books!"

The AMA having the rights to liscense CPT codes and forcing us to us them is antitrust in that there is no alternative. This is called a "monopoly" and is against the law. It is the reason that companies like AT&T in the 80 was broken into smaller companies. When compettition is not allowed because of proprietary rights and people are forced to use the one and only "good" there is no free market. Maybe if we took it upon ourselves and sued the AMA for antitrust/monopolizaion of CPT we might get somewhere.

As far as insurance companies using CPT codes to manipulate their payments. Again this is antitrust because they use Medicare rates as the basis of what they decide to pay. This is collusion. Physicians are not allowed to discuss what they charge ofor a procedure because this could lead to price fixing yet the insuranceindustry does it everytime the negotiate a contract/price by basing their reimbursment not on the value of the service but on some random formula created by government beurocrats.

more later....

Thank you very much for this eye-opening posting. I'm a new grad scheduled to begin practice on August 1st, and did not know about the AMA "owning" CPT codes. Thanks a lot, residency program! Thanks for fueling my fire against the AMA!

The AMA has colluded with insurance companies and politicians to the detriment of those they are supposed to represent.
With respect to E&M codes, I spent a couple hours with one of our 60 corporate billing & coding gurus about a month ago before a shift. It was a refresher course for me since I'm one of the lowest E&M coders in my group and we are partly paid by RVU's. I informed her that I could care less about playing the verbage game in order to bill a higher E&M code since most of my patients in the ED are Medicaid or Self Pay. In addition, the government takes it all away in taxes so it really doesn't matter anymore. I'm currently in a position to work just a couple of shifts a month due to all this insanity. Just waiting for Barry and this retarded congress to force my hand.

Dan - you are out of line. You are using your position as the CEO of Sermo to become the defacto speaker for us all. The AMA may not represent all my views, but they certainly represent them more than you do. CPT is just a coding system. If you don't like them, propose an alternative. Proposing that we all go to cash practice is just silly. A few people can do it, but the whole country can't.

Sermo surveys are nice, but to make a press release based on one claiming that somehow you know the will of your population is ridiculous. You have the clicky-clicky opinions of a minority of the Sermo population, biased by the fact that those who have an axe to grind are far more likely to comment on your article that those who quietly disagree. Furthermore, even if I say that the AMA does not represent me, that doesn't mean that I think the AMA is terrible, or that I necessarily agree with your ideas.

I always thought you created Sermo to allow honest dialog between physicians. Now it feels like you did it in order to create a platform for yourself. Clearly you have the same right as us all to express your opinion, but do so as Daniel Palestrant,MD, not as "FOUNDER OF SERMO". And I hope to never again read a press release that claims to know what the great SERMO masses think. Such press releases are a disservice to us all.

This is the very reason that many physicians decided to go cash-only practice.
When the third parties are growing overpower, both patients and physicians are suffering.
The pie is only this big. The bigger the third parties grow, the smaller the physicians shares shrink. Or the pie has to grow so big to meet the bigger appetite of the third parties at the expense of patients and public dollars. The equation is this simple. CPT code system is a tool for the third parties. Lawyers utilize time as their currency, why cannot we? It is simple and transparent, you have a clock in each exam room, everyone sees it.

I understand the need for codes to some degree - what I call a partial mastectomy you call a lumpectomy and someone else calls a quadrantectomy. There needs to be some way of defining what we do, and codes are as good as anything.

I do think that the code system needs an overhaul. Any surgeon can tell you how when forced to use an "unlisted procedure" code that reimbursement can be prolonged, if not simply refused.

How RVU gets assigned to a CPT code is a whole different ball of wax, and even more difficult to understand/defend.

Talk is cheap. It is time for us to be heard. We need to write another letter to President Obama.

If anyone should create codes it should be physicians. I do not want to give this job to anyone else. But I can't believe a group of physicians created the current system. What were they smoking? I wonder if they had any outside influence in the matter that had other interests. For those of you without EHR, the whole process of finding the right CPT codes is what slows the system down so much. Half of the codes say "DO NOT USE," or they do not apply. Some are written in layman's terms and others in medical terms. Dont even get me started on the V codes!

E + M codes ARE CPT codes. Of all the CPT codes, the documentation requirements for the E+M codes are the most damanging (for honest docs), and drive the most unecessary time expenditure in a PCP's office (examining and charting to reach the barely-break-even level III). Vis the remark above, cardiologists swim in the warm sea of consult E + M codes and procedural codes. Now we have RAC among us, and it is the E + M codes they will be auditing in your office, mostly.

To me the great beauty of a cash practice is the ability to perform the necessary elements of the examination and nothing more, just what is needed to make a sensible clinical decision about the disease in question. In many of my patients the documentation would require a few information-packed narrative sentences, not the current double-sided chart form with check boxes all over it.

One small point but a fulcrum point: we need to use language correctly. Technically, any time a physician bills anyone (patient or third party) for a particular level of service rendered on a specific date, this is "fee for service". Alternatives to FfS are capitation and retainer medicine.

The growing trend is towards cash basis practice. We have been living with the third-party version of fee-for-service all this time.

This is my understanding of correct nomenclature; I am happy to stand corrected if anyone disagrees.

To all the PCPs out there (I'm not one but I love you guys and gals) - CASH BASIS PRACTICE. Break the chains. Screw the CPT book and the ICD-9/10 - have a bonfire of the AMA's vanities.

As I reread your post, I am once again offended.

"This posting is part of an ongoing series addressing critical issues facing physicians. As the community weighs in on the posting, Sermo will publicize the vote results and comments out through the mainstream press and the Sermo blog (www.sermo.com/blog)."

Its not like you are raising a topic and then asking the Sermo community to discuss it. You are making a very pointed editorial statement, and then asking people to fill out a survey based on it. You are not asking people to participate in discussion - you are hitting them over the head with your rhetoric and then waiting for their comments.

Its not that I disagree so much with what you have to say, but man the way you are using your position in Sermo is absolutely revolting to me right now.

In terms of paying for service having a middle person/insurance between a doctor a patient is a huge problem. On the hand, how can someone pay 100's of thousands of $
when become sick? The only way out is to have others to pay and this is what insurance is all about. But this creates a middle person/insurance and here we go again in circles. The fundamental problem is that by its nature medicine is so expensive no one can afford it. This only will get worse as population is increasing and aging. Medicine is not a good business for providers for that reason and will never be.

SMFleet... go and sharpen your stethoscope... your missing a lot of murmurs!!!!

...the CPT ramblings are NOT murmurs!!!!

The CPT system was designed by surgeons, because internists were "too busy" to participate. The surgeons do procedures, so the codes emphasize procedures. It's not the surgeons' fault, it's the fault of those specialties which could not be bothered to help (guide, correct) them.
We can junk the current system,and the AMA too. But I see nobody with a better replacement, and we would need it RIGHT NOW. I see no critic with any detailed proposals for better, just gripes about how bad things are. Are no tools better than mediocre tools? You can't replace something with nothing (unless you want chaos).
Open source codes? Just ask an EMR vendor if their software can update daily.

Dr.dp, i realy appreciate you, you are the source of our power which is knowledge.
But Dr.dp, this is time for action, not to mention,i want to see how should we act now or never.
please guiade us.

Dan, blaming the CPT codes for our being "screwed" is analgous to blaming the barbed wire for being locked in the gulag! (Now, it may be particularly galling that your brother-in-law manufactured the barbed wire, but that still doesn't make him responsible for your being locked up!)

We're "screwed" because we permit it. For now, at least, we don't have to participate in third party payment schemes. We don't have to "accept" Medicare (whether par or non-par). We don't have to contract with insurance companies. But the vast majority of us do on a completely voluntary basis. We agree to take what they decide to give us, when they decide to give it to us, on whatever terms they decide. Why?

Stop participating in third party payment schemes. Tell your patients what they will have to pay you for you to see them and care for them. Some of your patients will agree to your terms. Others will seek care elsewhere. When enough of us stop participating with third parties, one of two things will happen: the third party scheme will collapse or they will reform their payments and practices to lure you back.

Thanks for the thought Dan. So AMA 250,000 members with 70 million dollars in CPT code income makes about 25 dollars each member. Nice. My Cousin's husband works for the AMA and makes a nice living at it.
I looked up this issue and to my dismay it is true. I spent years in the AMA and didnt feel they got much right.
"Development and maintenance of these codes is overseen by editorial boards at the AMA, and the publications of all the software, books and manuals needed by those who use them brings an estimated $70 million in income to the AMA"
How about the ICD-10 deal. Another great idea foisted upon us by people who have little to do with what I do for a living.
Since we are all in a rant about the AMA how about the speciality societies and the need for Maintanance of Certificates? Another money maker that is now being threaten to be extended into my age group. I havent done enough? I worked 110 hours a week in training and did every other night ICU for 2 months a year! I do 200 hours of CME a year hello....I am President of my Allergy society I am in leadership in the hospital and from those positions alone I have done 4 weeks of training a year. Tell me that taking a test which is mainly written by academics with rare diseases as the "best" source for questions is going to protect patients or make me a better doctor? Where is evidence that MOC or EMR or CPT or ICD-10 leads to improved patient care. I would like to see the data please

dan speaks for me and i am happy that he is stepping up to the plate

I disagree with Dr Fogelson's post... someone needs to more forcefully advocate the plight of private physicians and the impending collapse of the American medical system... It certainly is NOT the AMA. I think what Dr, Palestrant is trying to do is to develop a consensus opinion from those of us in the trenches, and then present it to a national forum... IF someone else from Sermo wishes to be the speaker, it is fine with me... The questions is NOT the messenger, it is the message!!!

The worsening burdens of practicing medicine in the country have been well enumerated here, maybe we should all just call them the BPM's.. (burdens of practicing medicine) and leave it at that in future discussions..

The administration and congress have to date, publicly stated few concrete changes that they wish to implement.. so we are left in the wind, hanging so to speak.

While there is still time, we need to emphatically discuss quality of care, burdens of litigation, futility of care, fair reimbursement strategies, .. etc...

If we do not have a voice in this embryonic process now, we may end up with a Frankenstein worse then we have NOW.

Agree with nichfogelson completely.

On the CPT code issue, I think CPT codes suck, too,but once again, I'd love to see the alternative plan. And saying cash=CPT codes is not going to fly with anybody outside our profession, especially the vast majority of patients who can't afford cash, particularly with procedures or hospitalizations. We will look like the greediest self-serving creeps in the country if we say cash-only is THE solution. So again, I like the dump CPT rhetoric, but what can we replace it with besides cash-only that the other players will go for?

just called My insurance carrier to discuss how INSANE for them to deny MRI ordered by the Chief of Neurology .. they have such dumbed down workers in the blockaid you can not even explain this to them!.. and they will not let me, the "educated and helpful patient" even explain!! i guess TEDDY Kennedy did not get treated this way.. WHEN Obama and "PUBLIC Servants (?)" put themselves on Medicaire and their Kids on Medicaid and GET THEM TO WORK.. solutions will abound.. while they are in the glamour seat with no real problems.. for their own Federal and STate benefits.. We MUST speak out.. THANKS for attempts to get docs together to correct the insanity..

mhellermd, it will make more of an impact if we all drop the insurance and government programs together or at least in the same month. I was kind of thinking last December would have been good but since that didn't happen and this July didn't happen, maybe January of 2010?? It's a step of faith for most of us in surgical fields but the insurance companies are likely obligated to pay what we ask if we aren't a participant and they have agreed to pay on behalf of their members. Maybe we can reach agreement on that??? CPT are very frustrating and reimbursement is even more frustrating.

Cognate: I'd vote for rarmstrong!!

So, who do you think helps the AMA with the actual codes. Well, its YOU, generally through your specialty society. We all have representation into the CPT editorial process and WE USE that representation to make sure that we get codes that we can use.

If the AMA did not make money from non-dues income - how much do you think they would have to charge for dues? I'd guess more than $2000. They would have no members at that price.

Like it or not, the AMA really does represent you. If you don't like what they do, then come to the Organized Medical Staff Section and propose a resolution that will do what you DO LIKE.

Without the AMA there would have been no stopping the SGR mandated fee decreases over the past few years. We would all be making less than half of what we currently receive from Medicare.

Stop carping about the AMA and JOIN. If you don't like it change it from the inside.

nick you are wrong

Dan has created a platform that has mobilized more than 100,000 physicians in a very short time. Being the creator of this platform, his current and past work watching this unfold 24/7, dealing with the AMA, engaging Pharm, politicians and nearly every facet of medicine that affects us all, puts him the perfect position to become the central prossessing point for many of these critical discussions. I assume this posting, like the others, went out to all sermo members. The sampling of physicians that have been responding is amazing. Not suprising, but truly amazing. I see nothing wrong in releasing this info to the media and the public at large. The affect will encourage public debate, increase physician mobilization, and will only help the cause of all physicians. If you feel that his position in inappropriate, create a post on sermo stating your case and we'll vote on it.

I spoke to a patient the other day who had purchased "disaster insurance" only - but it wasn't from an insurance company. For his family of 6, he paid $250 per month for coverage beyond $1000 per month in claims. However, he did not pay his premiums to an insurance company - he sent it every month to another family in the program who had recently made a claim (along with a get well card). Every month, he got a new name and address to send the check to.

His last child was delivered pre-maturely and incurred around $90,000 in charges. He negotiated the charges directly with the hospital down to $50,000 and created a payment plan - $5,000 per month. He recieved 20 or so checks every month from other members in the plan and paid off the balance in 10 months.

Systems like this make sense to me - elegant and simple. CPT and ICD-9 codes and insurance reimbursement policies are neither.

American medial system has now been adopted in countries like India who are also using CPT to screw local people. Please see my post about unaffordable prices for poor people in developing countries due to emulation of American Healthcare models.
CPT and ICD should NEVER be used for billing purposes. ICD is good for statistical purposes but to use to for any other purpose its crazy.
AMA has taken on a role similar to that of mafia bosses who expect a cut with every transaction while they are constantly breaking knees and hurting vital organs of their unwitting customers.

There's nothing wrong with the codes per se. The problem is how much the insurer pays you per item. Why are you blaming the AMA for that?

Many physicians have become very rich using these very same codes. Bunch of bellyachers on Sermo

Servant--I would tell you what to do also, but I have no idea what "Pain Medicine" is. Why don't you get a real career?

As far as getting paid for the CPT code system, you would all have to understand the concept of "intellectual property." Not easy to comprehend for many Sermo folks.

Pain Medicine--are you the guys who kill celebrities?

In last week's posting, Sermo has put all 700+ comments, without names attached, out there for the public to view...both positive and negative. I am certain that the comments from this week will also be available next week as part of a public forum.

What is stated above, if you have been working as a physician in this system, is true. The problems that it creates are very real and have been a source of trouble for physicians for years.

An open debate that begins to discuss real changes and alternatives that could benefit both physicians and our patients is a needed and healthy discourse.

I'm interested to see how this unfolds.

Sermo is in a unique position to make a difference because of it's wide interactive audience.

I never cease to be amazed at how the STATE RUN MEDIA has even MISINFORMED DOCTORS!!
all FOUR forms of GOVERNMENT MEDICINE are in DISASTER.
Medicaire is the last to fail..
Medicaire RAN OUT OF MONEY in 1990 ... as PREDICTED in 1965 when it was set up at 1/5th the KNOWN cost for premium and copay to get it PASSED by Pres Johnson... Pres Johnson then intimidated the Head of the Insurance Commission and Insurance co to NOT TELL CONGRESS or HE WOULD RUN THEM OUT OF BUSINESS.. so behind the scenes the lie is constantly changed to UNPANIC the masses... they keep adding more years to Medicaire TIL it runs out of money BY DECREASING OR eliminating payment for DOCTOR services....

this is WHAT they have done for years in the VETERANS health care, Medicaid, and of course too the Indian Reservations who complained to Obama that they had NO DOCS, NO Facilities, and (?no surprise here) NO Services... am I shocked? NO the NORM FOR GOVERNMENT MEDICINE..

in reality when patients were partners with paying for Insurance and had REAL copays THEY controlled spending.. by not going in excessively .. this made them partners!! who actually listened and followed thru and valued care..

the Falsehood that Government Medicine or ONE payer is the Cure is SICK and shows the extent of depravity of Gov't officials who are suppporting it..

Dan-

Your split with the AMA couldn't have happened at a better time for the policy wonks.

<a href="http://drwes.blogspot.com/2009/07/are-doctors-sheeple.html">http://drwes.blogspot.com/2009/07/are-doctors-sheeple.html</a>

If you think CPT is bad, wait until ICD-10!

The reality: It's only going to get worse and the fractionation of the physician lobbying community further fractionates our voice on the Hill.

>The AMA having the rights to liscense CPT codes and forcing us to us them is antitrust in that there is no alternative. This is called a "monopoly" and is against the law.

WRONG.

It is intellectual property. In this country, rights to intellectual property are ensconced primarily in copyrights and patents. CPT codes most likely belong in the copyright category.

The AMA owns them. Period. It is a matter of law. You don't like 'em? Don't use 'em.

As much as I dislike CPT codes themselves, we cannot just breeze over the law here.


>Maybe if we took it upon ourselves and sued the AMA for antitrust/monopolizaion of CPT we might get somewhere.

You don't like the books on the shelves or the movies on the screen? Write your own. You have no rights to the work of others without compensation...just as they have no rights to your work without compensation.

before the codes were forced on us,, medicine actuallty worked for patients and doctors.. the ONLY REASON FOR CODES is so the "KINGS" of the world can BRAG about how they have (pick your favorite) increased or decreased such and such in their Kingdom.... Since most gov't officials are INCAPABLE of productivity, they LOVE To use others hard work to Glorify themselves and Increase their Bonuses and Benis.

We gave Free or Cheap care where needed,, and everyone felt great.!! NOW you have attorney generals as in NY state Accusing you of Medicaid Fraud when you only get paid 34 cents for services that COST YOU min $ 26 to provide.. The State and Fed LOVE TRAPPING DOCS and Fining them ,, for mistakes even for Underpayment

Did you know they want ot get rid of the E&M (CPT) codes for consults? as a specialist, that will have a huge impact on me. Consults pay more than than "new patients". And it's not like I'll stop sending info back to the referring MD, so it's not less work for me. What about internists who do pre-op evals on patients as requested by a surgeon? They just bill an out patient follow-up?

Good job pointing all the issues out --- gesharon
The re-certifications, CPT code etc have been rammed down our throat.
The whole system has been intertwined and rigged to benefit a few, mainly the insurance companies and then all our societies. If you don't recert you loose payments, and you wont get hospital privileges etc... got to go see a patient ... and have bills to pay !!

<<Lawyers utilize time as their currency, why cannot we? It is simple and transparent, you have a clock in each exam room, everyone sees it. >>

Cardiocare:

Lawyers, plumbers, accountants have the right to charge for their work; doctors are slaves, and everyone has a right to healthcare and doctor's services.

Simple, isn't it?

The AMA could have ended alot of the ABUSE of the insurance companies thru managed care IF The AMA supported MDS in taking ridiculous decisions of the managed care doctors to that doctor's state medical board for review. IF this had happened crazy insurance MDs decisions would have stopped in their tracts. WHERE was the AMA in this? I don't belong to the AMA and don't believe it actually is for its members.

dpalestrant - I appreciate your post. I believe your point is that we need to let go of the 3rd party payor system completely. No cpt, billing, denials, mandatory BS documentation requirements and just work with the patient. I really think this is the answer for primary care docs and people can use the insurance for catastrophe only(what a concept).

I am with you but I am concerned about implementation and it would be great to start a real honest discussion about how we do it.

thanks

nickfogelson,
I think you are ill informed. Dan did get his information by soliciting our comments. He did not come up with this data on his own and in speaking as a representative of our opinions he used the replies that we sent in. He didn't make this up.

Perhaps you belong to a large group of physicians and don't even know the ass-pain that looking up individual CPT-ICD9 codes is all about. For those of us in small practices, doing the foot work ourselves or paying salaries to have someone look up codes for us, generating billing forms and agonizing over nonpayment, it makes a huge difference.

In Primary Care, every item counts! We don't do thousand dollar procedures. We do office or hospital visits and each and every one of those visits whether paid or denied makes a difference in our take-home pay.

I can only hope that the stir created by Palestrant will catch on and generate a change in the stranglehold the insurance industry has on the practice of medicine as we know it.

whatever happened to the idea of my charging a fee that I feel is fair for my services, and patients actually paying it? It seems to work well for my auto mechanic, plumber, electrician, etc.... The system reminds me of a line from a movie, where a computer learns about futility. After trying all possible scenarios, the computer reaches the following conclusion: The only way to win is not to play the game.

I believe we should institute (or return to) the system my veterinarian uses when I take my dog in for her appointments: I am charged a fee (which I pay in full), then am given an itemized bill to submit to my insurance company (from which I am partially reimbursed). Fees should be listed up front, patients should pay immediately. If the patients had to deal with the insurance companies for reimbursement the outcry would be heard in Washington.

In addition to the above this cpt coding has helped another industry: those that publish the cpt code books, manufacture cdroms and offer coding seminars. The beauty of this is that they will continue to do well since there are continued updates of these codes. Hence there are many that greatly profit from the cpt coding system bar one: the physicians.

At the vets, unless you pay, you don't get your dog back.

Solution: Allow physicians to balance bill E&M codes? That is all that they are allowed to balance bill. why?

1) invites in market forces.
2) governs demand because of pt having some responsibility in paying
3) unlocks us from the government/insurance price fixing.
4) instant relief for primary care and favors time spent with the patient

I just thought the AMA was a bunch of OLD GUYS who didn't really represent me. I didn't realize how much power they have and what a poor job they have done in defending the doctors that they are supposed to represent. The info about where the AMA gets their money was new to me. Thanks Sermo for fighting for us, we need your help.

..."especially the vast majority of patients who can't afford cash, particularly with procedures or hospitalizations..."

... patients go to restaurants twice weekly and pay cash.... travel every year and pay cash for gas, food, hotels, entertainment, shopping new clothes etc..... including cash for tattooes! while $200/month for their cigarette expense!!!....

and did i hear.. the insurance FINALLY paid after three months of $50!!!!... while twice, thrice rejected because of improper coding, etc. etc. preauthorization papers...

did you ever ask your patients why they have insurance?
why they prefer to pay cash?
why most of them did not declare their annual income, cheated on their income tax returns and when asked if they are willing to pay cash!!!

hmmmmm... you must be a wealthy doc!!!, well i am not!!!

SMFleet.... thanks for wanting to know me...

I could teach you how to listen at anytime over a cup of coffee unless you are AMA cleansed/free!!!

Medical Physicians should be paid for their time, period. I have a few attorney friends who charge $500 per hour I probably charge 200-250/ hour if I'm lucky. And my overhead is much larger than there's. Lets think out of the box.

Suppose we have a "time card" and the patient punches in and punches out.
There are two parts to the card, one for the patient and one for the practice.
If insurance is involved they are billed for the physicians time rather than using a CPT code.
They could be billed by the patient (preferable) or by the doctor.

There are several advantages to this:

1. You are not a slave to documentation because there is no complex mapping to payment.
2. There is no waste of time figuring out what code to use.
3. There is no waste of time worrying about being "fraudulent".
4. The patient becomes the "watchdog" for fraud and insurance abuse because they know how much time was spent and they know what your hourly charge is (because you make it available)
5. The physicians contract is with the patient rather than the insurance company.
6. As physicians gain experience they can increase their hourly fee. As it is now a physician in practice six months makes the same revenue as a physician practicing 20 years. Why, because there's so much focus on the physical examination (which is hogwash) in determining CPT code. If you really do in examination it makes little difference how many years you've practice. I do a lot of counseling with patients and I guarantee anyone the patient gains much more from my 20- 30 minutes than a less experienced physician.


I'm sure there are other advantages, but I'm just throwing these out there for now.
I see nothing wrong with simplicity. Why is it that everything has to be crazily complex when that's not necessary.
I think the CPT coding was originally the bright idea of some statisticians and insurance managers who felt they could quantify everything in healthcare. For some reason the AMA went along with that, probably because there were financial incentives and possibly because they wanted the data themselves. Back then there was a lot of thinking about socialism (from a positive point of view) and the more the AMA and Uncle Sam knew the more control they could have over societal systems.

JMK

...was it a Cardiologist at bedside JackoWacko unable to listen to his murmur !!!

$150k/mo for an AMA cardiologist ... not bad!!!

"Focus on the things that unite us, ignore the things that divide us. Concentrate on large numbers."

The voting and comments confirm two things. There may not be a unanimous embrace of certain concepts, but about 90% voting on questions 2,3 and 4 shows most physicians have good olfactories. Unfortunately, some voters, and the one's with the Crayola computers prove you need not be bright to become a
physician.

uh-oh, it was a cardiologist!

Them that own and create the information RULE !!! You go Dan, Sermo movement will soon morph into a real sustainable, indispensible, invulnerable physician grass roots organizations.

Long live community based, open source decision making. We physicians have the power to control our own destiny if we want.

We only have fear we have is to fear our selves.

After my first private practice went broke due to the failure of BC/BS of TN to pay their bills, (yes, they were sued succesfully, pennies on the dollar in payment), I worked in Mental Health clinics for years, then decided to return to private practice without the insurance companies. Now I accept cash, checks, and credit cards, and my office will help patients bill for out-of-network payments, but I don't take any money from insurance companies. I've been in practice 3 years, and I'm not rich, but I'm not as broke as I was when BC/BS decided not to pay.
I do think there is a place for insurance in health care, but it shouldn't pay the doctors and hospitals, it should pay the client. If each person could freely choose their health insurance policy (not through their employer), and if the insurance companies had to compete with each other to get people to buy their policies, and if there were some controls on the fine print in those policies, we might actually achieve a free market economy in health care.

karasalle, your experience and what you are saying is so abundantly clear!

Almost all routine outpatient services should be paid in cash.

Insurance companies should market comprehensive, clear catastrophic policies nationwide, directly to consumers who can vote with their wallets who to buy from.

This is the only sensible way to reduce costs...one transaction at a time, with patient responsibility.

I hate the AMA, but, if you think it would be better if the government got its hands on this alone, you would be thinking how sorry you are that you let that happen. At least with committees like the RUUC, there is some input from actual doctors instead of theoreticians and bureaucrats.

Poor fpmdjk...mired in the past and wasting time actually TALKING to the patient! Join the 21st century mk. Get an EMR, pad your level of service with pish posh about complimenting the patient for use of smoke detectors, seat belts and high number sun block, hit enter, and watch as the screen spins like a slot machine, stopping at the big CPT payout...JACKPOT! Hire yourself a Hamburger Helper...OOPs that should be a Physician Extender, (I tried one from a late night infomercial and it didn't work for me) and soon your practice's new EMR juiced codes will have you and your Extender at the Lexis dealership. The sharpies are out there doing it while you waste time actually doctoring. Race you to the hospital in our horse and buggies?

It isn't just the coding but what is reimbursed for each code. For now, the insurers determine this not the AMA.

One of the more interesting contributions I've seen on this topic, from an adjacent post by tnkaiser ( Sermo Doc ). Always amazing what happens when physicians are able to have a place to compare notes:
_____________________________________________________________
A little vignette, with and example of how "organized medicine" screws the "members":

You may or may not know that I was the lead plaintiff (my instigation) on the Cigna suit. I started this suit, myself, with my own attorney, and we filed the first class-action against an insurer for changing CPT codes, downcoding, bundling, etc. - essentially not paying doctors for the care they provided.

As the suit became known, a group of well-connected law firms (including one, which, for example, was convicted of fraudulent behavior in other class actions and the firm dissolved), with the help of an astoundingly "friendly" (to these particular law firms, anyway) federal judge in Miami, inveigled themselves into the case. They brought, as their "plaintiffs", a set of "medical societies", including several state societies and the AMA.

Long story short - the physicians, who actually DID the work that the billings were unpaid for, got almost nothing in the settlement, the "medical societies", including the AMA, were given large sums for "education" and other nonsense. In short, the medical societies screwed their own members, DIRECTLY, out of money the members had coming to them. The lawyers, of course, made millions.

Upon learning that these societies had "joined" the suit, I knew exactly what they were doing. I objected to the final settlement for a very long time, because of the clear rape of their own members that the AMA was performing, and finally just gave up, quit the AMA, all state medical societies, and everything else except my specialty academies (AAOHNS). I warned the AMA committees, as well as the state medical society committees responsible, that their actions would result in a dramatic loss of membership when what they had done became common knowledge.

The AMA is comprised of career political hacks. Their actions in the CIGNA case were despicable. No one, NO ONE, should join the AMA. Pick the AAPS, pick SERMO, pick anything else, but DO NOT PAY DUES TO THESE PEOPLE.

Every physician, EVERY SINGLE ONE, should stop his/her AMA membership AT ONCE. The physicians who are the "administration" of the AMA should be ejected from their own specialty societies, and ignored by all other physicians.

Remember that the power in medicine resides in ONE PLACE. That is, the little "pigment-dispensing device" that you hold in your hand every day. No one can order a test but you. No one can write a prescription (except where that has been lost to other practitioners) but you. No hospital can operate without you. No insurance company can charge premiums without somebody to send the patients to.

It takes guts, but you are in charge. Always, all the time. Never forget this. Let's make sure that things like this become common knowledge among physicians.

I am cash only...my rates are comparable to monthly cable bill/cell phone bill or filling up the hummer, thus I am not expensive....I spend an hour with the patient...I don't have to deal with the insurance co...I love medicine.

LOL, great comment auburngal!.... The CPT discussion is VRY interesting and worthy of investigation, but is only a piece of this tangled web. As a FP now employed by a health insurance company, I wish everyone could sit in my chair for a day. The inefficiency, waste, greed in our system has truly made this insustainable, and I could point fingers at EVERY segment of the healthcare system. Any reliance on a government-run program is insane (what has our government run more efficiently than private industry, and how pray tell is this Congress so smart to figure out a solution to this dreck in a few short months?? We all hate Congress anyway). Until all parties can come to the table and play nice without finger-pointing and promotion of self-interest, no successful solution to this crisis will emerge.

Few patients can afford to pay their hospital bills with cash.

After 17 years the stuff in public domain! The question is why are we even using it.. Again the money trail leads to insurance companies , pharma and politicians. No doctor ever wanted CPT codes.

I have always found it abhorrent that the CPT manual is proprietary and not open to public scrutiny. Thank you for raising this issue very clearly and directly. I would very much like to see a national campaign developed to raise this issue with Congress so that the AMA is forced to open up CPT under threat of legislation.

I'd put tnkaiser and dan on the new sermopac

Is not AMA a non-profit ??

Nice to see all the comments and critiques; unfortunately I have spent too much time watching physicians lose control of the practice of medicine over the last forty years. In my early days I did my best to get docs to recognize what was happening but everyone was too busy caring for the sick and their own pocketbooks. Physicians have failed to provide a united effort; they have not spent the time needed to control the practice of medicine in the USA. Now physicians are chasing their tails and once again spending valuable time complaining and splintering their political efforts. Why does the AMA do what it does? I have been a long term critic of the AMA'; I have never joined the organization and never tried to change its tactics. How can I criticize folks when I have not done the work?

I quit private practice in 1980 when I saw the handwriting on the wall; I had worked hard through my local and state medical society to get docs to pay attention to the infringements of insurers and the government on medical practice. I found insufficient support from docs who were too busy "practicing medicine" and increasing the size of their pocketbooks. I spent 25 years in government service trying to work from within the system and still tried to get physicians to see that they need to pay attention to government control issues. I have watched inept government administrators pressure groups into making rules and statements as means of self defense. I would bet big money that CPT coding was probably the better of two evils and not the work of a group of physicians trying to make money off their peers.

Personally, I believe our profession missed the boat a long time ago; now is not the time to form another splinter group; it is time to work together like the "longshoremen". Congress and government officials respond to one thing - NUMBERS. Physicians need unite as one profesional organization, gather valid numbers and present their case to the right people (finding out who the right people is a major effort). By the way, physicians need to provide cash along with their time. They need to stop complaining and start working in a united effort; very importantly they should not leave their future up to others especially nonphysicians.

My reaction to Dan's CPT missive?...omg, I agree with Trent Lott!
("There have been many attempts to break the CPT monopoly, most notably by Senator Lott in August of 2001." )

Some background on the Trent Lott issue...

Sermo Doc

Suvarov

The difference between intellectual property like a book and CPT is that I am not forced to use a book in order to do what needs to be done for my patients. Because of the way the systems runs now I am forced to use this "intellectual property" to do what I need to do. This is the basis of the antitrust arguement. Let the AMA have the CPT codes, but do not force them upon physicians and insurarnce companies and others.

ssalan, I totally agree. Real change doesn't happen by us wishing it would happen- it takes effort and $$$. Doctors need to make an effort to go to their professional society meetings, communicate with legislators, and be a visible presence in their communities. This is what other groups do when they want to get things done.

As for prior comments, I am not sure about Sermo becoming the 'doctors' spokesperson' but I do agree that it needs to be known what the overall perceptions are about about the AMA and the direction that healthcare reform should go.

So in that respect, I agree with Sermo putting out a press release.

ssalan, I have done the work; I have worked from within, and so I shall criticize. (Actually, I did so in last week's thread.)

I agree with you, though, in that physicians need to unite NOW in terms of message, in terms of time, and in terms of cash--because those tend to be the terms that Congress understand best. I've been to the Hill to lobby for better Neurology research. Why not lobby for health care reform? Why not us? And why not now?

I guess I am another advocate for Sermopac!

Out of curiousity when did Dan Palestrant became the chairman of Non AMA association and became their voice. Why all of a sudden so bitter on AMA, when at some point of time AMA was the best friend???

I am not an AMA member but out of curiousity

I have created a model of reimbursement that eliminates CPT codes. I detail it here under the post "Medicare Reform Part 3: New Model for Reimbursement": Sermo Doc

But to summarize, it involves a base hourly rate determined by experience, board certification, years of training multiplied by a complexity factor (e.g. neonates and elderly are more complicated than 24 year-old with no medical problems). This refocuses doctors to getting reimbursed for spending time with patients who need it most, and in my plan I describe how to prevent abuse.

ragrawal....officially about 1 week ago...around the time of his first posting. Thank goodness.

I certainly won't disagree that the complexities of the present CPT coding system are mind-bending, but "Cash please, thanks" doesn't work for people who face bills for tens of thousands of dollars for medical care. The only way most people can afford health care is through the insurance pool, and whether it's CPT or some other coding system, payors need a description of what services were provided before they pay a bill.

To those who critiqued my previous comment -

I read and re-read it, and your comments, and stand by what I said. I don't disagree with Dr Palestrant's points, largely, but it still feels like someone else is trying to speak my mind for me. Each survey question is very biased, and could only have one result.

Example - "Do you think that it is right that the AMA makes more money from selling licensing for CPT codes than it does from membership dues?" - The wording of the question implies that it is not right, an that the answer should be no. To take questions like this and then publish a press release seems very non-scientific to me. We would laugh at a scientific paper that used this as its methods.

In our numbers, we have a great deal of power, and there is great potential to instrument change through this power. I think that Sermo clearly needs a leader that can help to coalesce the cacophony of voices into a clear message, and carry this to the public masses. Perhaps Dr Palestrant should be that leader - but first he must be elected by the masses. We are too big to be ruled by fiat.

I like where we are going with this, and even have a thought that 10 years from now Sermo could be the new "AMA". But we have to start democratically, not autocratically. We need to have an election to decide who will represent Sermo. DP would almost certainly win, just as the founding fathers of the United States were the first few presidents, and he would be a deserving first President!

We want to have a great organization here, and that means being democratic. If we are going to wield the power of our masses in the public forum, there must be a democratically elected spokeperson.

This is yet another example of the real problem in American medicine- insurance companies. They are trying to portray in the media that the problem is from doctors ordering too many tests, but the real problem lies in the collusion of the AMA and insurance companies. It is all one big industry, I will no longer renew my AMA membership. I wish all doctors could band together in one unified front and stop taking all insurances. Then we could show everyone who is really in charge.

Ahhh, but Nick, we just don't have ten years!

I truly believe there isn't a practicing physician in America who doesn't understand the problem of delivering, excellent health care. We talk, we form advisory committees, we send our letters to the local papers. President Obama holds a Health Care Summit & invites the CEOs of the Pharmaceutical Companies, the insurance Companies & the Union Leaders. The icing on the cake is the head of the AMA. Not one of theses participants represents the Primary Care Physicuian, in deed they represent the problem. The giants of the Medical Industry will fix Health Care in a manner similar to the presidents of Ford, GM & Chrysler fixed the auto industry.

Thousands of doctors in gleaming whirte coats, standing in front of the White House will impart an image far greater than NYTimes editorials. If we keep ringing the bell maybe President Obama will invite us to the table

Speaking of NYT articles, didn't see this posted so far but I think it sums up how docs feel about the current climate:

"The rising commercialism, driven in part by increasing expenses and decreasing reimbursement, has obvious consequences for the public: ballooning costs, fraying of the traditional doctor-patient relationship. What is not so obvious is the harmful effects on doctors themselves. We were trained to think like caregivers, not businesspeople. The constant intrusion of the marketplace is creating serious and deepening anxiety in the profession."


Sermo Doc

When are we going to stop talking about our frustration and start taking action? Are we going to continue to be, as the author eloquently pointed out, cars on top of a hill with the parking brake on? Are we going to continue to put all of our effort to keep that car there instead of figuring out how to move forward?

nick....I am starting to sense you moving over to the SERMO side and it has only taken about 24 hours.....I'm sensing you are starting to see the tremendous potential in an organization that was able to recruit so many people and disseminate so much info in such a short time. I was one of the very first sermo posters on this site and the evolution and sophistication has been unimaginable. The numbers of docs on this site are growing at a staggering rate. It is that momentum and that energy that is lacking in the AMA and it is why Sermo will become the New AMA. Even the AMA knows it...don't kid yourself. This is the spark that is lighting the fuse my friend. Jump on board and enjoy the ride. Now it's time to get all the colleges and specialty societies on board.

I agree,I think we should have our own "Million White Coat March" in Washington...and soon! or this socialist bureaucratic government the masses have elected will destroy the Best Medical care system in the world,notice I said Best,not Perfect.

I see that many here have cash only practice like me. I do it to be able to circumvent insurance and gov't control. My concern is that when the "health care reform" is passed, esp if the gov't becomes the only health care program available, and we are all forced to join or not get paid, it will be the end of private practice, esp the cash only version. I wonder how many share my concern.

Two points:
1. The ICD diagnoses codes were originally developed to help organize research, to get all papers about a given topic to the same place, even if the authors use a different title. The code was published as a 100 page paperback--great for filing articles but not specific. THIS WAS CO_OPTED by the AMA. Another digit or two was added to each code and now they think it's sufficient to describe all illnesses the human organism can develop!
2. A few office based docs in my area, in response to economics-both medicine specific and society in general-are going with the oldest payment plan available:
the old fashioned 'Pictures of the Presidents' plan. The gross charges are discounted significantly from the charge billed to insurance companies but patients pay 100% of the charge at the time of service-with no billing, coding or other back-loaded costs.

Dan, thanks for your comments. I agree. I just started a concierge practice. I won't practice on the hamster wheel any longer. However, you don't note in your article that the new CPT-10 scheme is NOT written by the AMA and they (the AMA) will no longer get $$ from it (and it will be a real issue for them). I believe, however, that the real reason the CPT codes were written were to better study medical problems and treatment by using codes to list Dx, and not so much for what the GOV"T plans to use it for today to crack down on our "inappropriate " treatment, or treatment out of the norms.

I'm all for demonstrating in DC, but even 100,000 physicians is not a lot of people. We need to educate our patients to advocate for sensible healthcare policy and get them to take a hard look at the feeling that healthcare is an entitlement (actually most of them seem to think of being healthy as an entitlement). Our patients represent nearly the entire US population! That's a lot of people. They need to understand that SOMEONE is paying for their healthcare, either through insurance premiums, taxes, or cash. There is no free healthcare and the level of ignorance is staggering. Yes, CPT is a pain and has been used unfairly to compensate physicians, but that's only a small part of the problem started when Congress decided to ignore the AMA and Edward Annis and created Medicare. And now Congress wants to raise taxes again on the productive segment of the population to fund public healthcare. We can also be sure that Congress will vote on this healthcare reform without having read the bill (just like they did on the cap and trade legislation).

I hope that everyone who has written in this thread and the the one before has written to or called their congressmen about the proposed legislation and is urging their patients to do likewise. If you haven't, quit whining, and do it.

The veterinarians and chiropractors did figure this out before the physicians. The only way to pay your own bills is to take cash up front and either courtesy bill for your patient, or let them bill.

You have no idea how bad it is to bill for osteopathy. I actually went to an osteopathic medical school to be an osteopath (surprise!!). We have a set of CPT codes for doing OMT based on number of areas treated (1-2, up to 9-10). So far so good, right? But it doesn't matter if I spend 15 min or 2 hrs on the treatment, the reimbursement is the same (assuming you get reimbursed). However, if I was a PT, I would get paid by the 15min increment. Not only would I get reimbursed for the full hour I spend with my patients, I would actually get paid more.
Here's the kicker: the insurance companies (esp BC/BS) change my correctly billed OMT codes to PT codes and then deny them based on a PT visit limit. Is this even legal??? Then they tell my patients that I billed it incorrectly. Arrgh.
So I am out of network for all but Medicare and Tricare. Those two are my own personal civic duty choices. My patients pay cash/cc/check at the time of service. I courtesy bill for them. They erractically are reimbursed by their insurance companies.
What has this done for my patients? They are totally engaged in how the system works, infuriated on my behalf that the codes are manipulated (no pun intended) by the insurance companies, and on the phone with their insurances to get their fully due reimbursements.
As stated above, in what other profession can you say "Yeah, I know your bill is $100, but I only think the service was worth $80, and I'm only responsible for a percentage of that".
Not until we opt out and everyone is engaged in this struggle will things change. Reimbursement should be a contract between patient and insured. Paying at time of service creates more transparency in fees and ability to choose where you want to spend your money.
My practice is tinier than micro, and I struggle to pay my bills daily, and have considered closing, but at least what I do today, I earn today, and I put in the bank today.

Loving the new series Dan.Keep it up.Thanks.

The AMA is not the problem. As ineffective as they may be viewed by member of this forum, they have tried very hard to stem the erosion of physician rights in medicine. Maybe if more docs joined, they wouldn't need to worry so much about making money on CPT codes, which I think would continue to be used no matter who controlls them (in that case, maybe better to have a physician group in charge). And believe me, the seventy million the AMA apparently makes on them is absolutely inconsequential compared to the other forces bankrupting Medicine!

So it's easy to say "NO" and point out what's wrong. It's another thing to do the work , get informed, and come up with a better plan.

Dump CPT codes?

Cash only?

Is that the plan? Will anyone outside this forum and in the doctor's dining room go for that?

Will the insurance plans and Medicare say "just charge whatever you like", with no documentation of what you did or what the patient had and they'll pay it? Really?

I think this one needs some more work. Again, the AMA may be the easiest target, but this is Dan's axe to grind, and badly diverts the attention away from where it should be- the insurance companies, the drug companies, a badly unrealistic public expectation of what the health care system should do for people, and the malignant idea that medicine can really be better practiced by mindless, micromanaged protocols than by individual practitioners doing what they have been trained to do.

The CPT codes are a huge subject. They are irrational, to say the least. For example, there are at least 55 CPT codes for excision of skin lesions and for layered repair after the excision, depending on their size and location. For removal of intra-nasal lesions, or tumors within the deep areas of the neck, there is one code each, size and corresponding difficulty, and time spent, all be damned. THAT makes a lot of sense, doesn't it? I often do specialized, legitimate, necesary surgical procedures that have NO CPT code, and as one other poster has mentioned, these are some of the most challenging procedures, and yet there is often NO PAY whatsoever from government agencies because there is NO CPT code! And if the government doesn't pay for it, the private insurance companies will not. Sure, you can spend the rest of your life trying to get one established through the "proper channels" of the AMA, but good luck with that as a lifetime project.

These are only some of the reasons for many physicians' lack of respect for the CPT system, if you can call it a system.

My tip for readers of this thread is that you do NOT have to buy an ICDA book every year. Free ICDA coding is readily available on the internet at Sermo Doc It is quick and reliable and FREE! It will save you $75 a year, since you almost certainly already have to have internet for other purposes. It will also deprive the AMA of that income, which is A-1 fine with me. I'll never forget that when Hillary Clinton was trying to take over American healthcare, the AMA President was standing beside her on national TV, declaring that he thought the AMA would be able to make it work! All the while claiming to represent American physicians! I will NEVER send money to those traitors!

jbluster,we have to start somewhere;we needed a nidus,if you will;the momentum is impressive.If nothing else,it has exposed a lot of wrong;misplaced priorities,poor governance,impotence,ineptitude,politics as usual and overall failure.Stay for the ride.

What many here are forgetting is that we became the "bad guys" when the suits got together at Jackson Hole and created the 1980's nightmare that became "managed care (costs)", because medical costs were too high for employers. Today medicine is a business... Insurers continue to exist because we citizens invest in their stock, and 85% of Americans are happy with their health coverage. Joe Six- pack will never feel sorry for you. One million MD's are less than 0.3% of the total population, and we don't have the political muscle, or will to fight together. Congress has successfully divided and conquered us since 1965.
The AMA is not the enemy, the AMA is us. 180 specialty organizations go to the House of Delegates twice a year, along with state reps based on AMA membership . If you disagree with policy, get involved and change it from inside. MD's who have sold their soul and gone to the dark side are the ones you should be chastising; like the ones reading retail clinic charts, and those working for ins. co's. Stop shooting into the circle.
Our patients depend on us to take care of them.

jbluster, I think that "mindless micromanaged protocols" are facilitated by the current method we use for coding and billing our services. I agree that these(especially template driven EMRs based on CPT coding) interfere with individual physicians doing what they have been trained to do. I prefer the word physician because that is what I worked so hard to become. The term practitioner devalues me.

We don't need a coding system in office practice if the patient pays at the point of service. It is their responsibility to pay for the services provided, which will become less expensive to provide if the third party bureaucracy is eliminated from the relationship.

Glad I joined Sermo, glad I did not join the AMA.

These emails from the 'founder of Sermo' have definitely caught my attention, but I, too, was wondering just who this Dan guy was -- where did he come from? I originally thought of Sermo as my medical Facebook -- social networking, education (love the cases)... and then, voila, there is an explosion of political activity.

I LIKE that (getting to educate and explore political and current hot-topics). But I completely agree with nickfogelson that we need to show more than biased questions showing what we as 'sermoans' (am I really one of 'those'?) believe.

I would appreciate more discussion prior to having issuance of press releases. I think that separate strings would foster further discussion that can then be pursued... and if a thoroughly vetted idea (an alternative to the AMA, CPT, cutting through just all of this administrative BS that is just bogging down the medicine that we love) -- then go for it. Just because I answered a survey question like 90% of others taking it... that doesn't mean that you all can 'speak for' me.

Thanks, Dan for bringing this out in the open. I have actually had to deal with ICD-10 codes because I had to work in an indigent clinic for a while, and these were needed for "proper reporting". They really are a nightmare - if you think that ICD-9 is bad, just wait! I wonder who will "own" them??

The public needs to be aware of what is really happening, but there have been so many distractors and "smoke screens" thrown up by the insurance companies, lawyers, the government and others that the public really has no idea what is happening. All they know is that medical care is about to change, but they don't really have an appreciation as to how it will affect them personally. They really think that it will just be a variation of the status quo, but really just don't realize that this will be the death of medicine as we know it now if what is coming down the pike really does take place in its present form. I just fear that people will realize too late what has happened AFTER it takes place and it will be too late.

Also, if we fight amongst ourselves, nothing will get resolved - this is something that all the "powers that be" have used to our detriment for years. Time to put aside our differences!

I will. I made the decision to get involved a couple of years ago by joining the CMA and AMA, after many years of sitting on the sidelines frustrated by all of the above. I became my hospital's OMSS representative and got elected to the CMA OMSS Board for California. I can tell you my preconceptions of AMA ineffectiveness and slothful, self-serving good old boy BS was way, way wrong. Attending the CMA AMA Meetings has been among the most inspiring and gratifying things I have done in years. I stepped up, said things at the mic, changed peoples minds, and introduced motions that became AMA policy, and I'm just starting. What's exciting is to see the consensus of a group molded by the inspired stand of even one member. We all agree Medicine is in desperate shape. and we cannot afford to let it go the way of Canada and Great Britain. We can and must do better. But complaining about it and doing something about it, including coming up with a plan based upon correct information and real vision, are far different things. I appreciate Dan's commitment to change, no matter what his personal stake in Sermo may be, I just think this anti-AMA thing is destructive, divisive, and ill-informed. And it's insulting to the many physicians I have met at these meetings who really are passionately and selflessly committed to fighting for physicians and a better system, hamstrung only by the utter unwillingness of their fellow physicians to do anything other than complain about how bad things are.

So I say to this forum, all of you, join ME at the AMA. What we could change with the passion and commitment of the doctors in this forum, and the many other members sitting on the sidelines convinced they can't make a difference. We CAN change things. It's waiting for us. Our patients are depending on us.

I think that everyone should be clear on the point that the International Classification of Diseases(ICD) is a publication of the World Health Organization(WHO) which is an arm of the United Nations.

Sermo Doc

This is separate from CPT. But the ICD-10 role out by CMS(who uses the system) is a complex nightmare.

One more thing. Nice poll, Dan! How about a few more answers to choose from? Like, "Do you think membership dues should be high enough in an organization so that it doesn't need to supplement it from outside sources, such as from drug and insurance companies?"

And no doubt you will proclaim the 4% of your members responses to this as "The Voice of 100,000 Physicians"!

Engagement leads to Empowerment which creates Efficacy with the outcome of Effective Execution. Go Dan !!

Focus on the things that unite us, ignore the things that divide us. Concentrate on large numbers.

Take a stand. Tie a knot.

louermd - I was never not on the SERMO side, just against misrepresentation by unelected spokespeople (No offense intended to DP). I've been on Sermo since the near beginning, and have been a regular contributor to my subspecialty section since.

But in the years I have been on, it has been clear to me that Sermo is still ruled by a minority of the population. In my field it is steeldoc, obgynflyer, flagyn4, and a few other up and comers. Do I think these few people speak for OB/GYNs across the country? Hell no. They are all good folks who, like me, have strong opinions and a desire to share them. But what about the 95% of folks out there who aren't so strongly opinionated about stuff. Or, believe it or not, the massive number of folks that have never used Sermo at all, and in some cases don't even use the internet. Can we really say that we represent them?

Another issue - I question the legitimacy of aggregating the opinions of anonymous masses. People will say all kinds of things when they think nobody knows who they are. Perhaps they say how they really feel, but sometimes I think people say things that are on the fringe of their own beliefs, that they would never say if they we held accountable for their statements. I understand the concern for anonymity when it comes to legal discoverability of posts. I would love to see a SERMO that was legally protected, where everyone could speak under real names without fear of their comments being held against them. That's something I would campaign for in government, and given the protection allowed to M and M conferences, would probably be attainable.

I think that we're missing half the story. CPT codes are a standardization of the services we provide, to the extent that they can be standardized. My beef is not so much with the code, it is with the insurers rules that say they will only pay for one service per day, and down code a second service, or worse yet, just ignore a modifier 25 for a separate service, or 59 separate procedure. Modifier 62 to split the fee for two surgeons is routinely ignored. Global exclusions and bundling are not defined by CPT, but rather by CMS. I don't buy a new book every year, so I'm not overfeeding the beast that way. Maybe I just don't understand the argument as it is presented. I think you are barking up the wrong tree.

We are now in a tree legged dysfunctional health care system each driven by seperate set of priorities. There is no doctor in the world that will make a 46 million bonus at the end of the year no matter how many lives he or she saves. Such is not the case for health insurance CEO's. Our helathcare system is predicated on the "denial of care" and not its provision.
Daniel in his mobilizing opening letter has presented some binary (direct patient and provider relationship) systems. As one of the original founders of Pricedoc.com I am pleased with the new evolutionary or perhaps revolutionary medical mindset because this is exactly what we are doing at Pricedoc.com. We went live in Seattle area two months ago and going to California shortly. Our providers offer their health services for direct cash payment devoid of billing and reinbursment paperwork. Those administrative savings are passed on to consumers through cash discounts. If we are sufficiently capitalized we plan on going national this fall.
We have had a great response in Seattle area although our early adopters have been dental, plastic, dermatology, walk in centers and bariatric surgery. We hope to attract a broader scope of medical services as more physicians choose to offer their services devoid of administrative burdens. On the consumer side forget not that there are 87 million people who are underinsured and likewise will benefit from your qualified services. For those docs who are national superstars the Pricedoc platform offers national exposure to consumers seeking their specific and unique services.
It is a market implementation of the very topics discussed in this blog.
So check out www.Pricedoc.com and see how this platform can work with your practice today or perhaps tomorrow.

That sounds good, but I'm afraid this "Kill the AMA" IS divisive, and will really alienate the many physicians that are involved with it who believe in it. Frankly, the frustrating part of this forum is that Dan has presented a very slanted view of things as fact, and used the pent up frustration of physicians for his own agenda. I resent that and feel used by it.

Should we really have the rule by opinion poll? I don't think so. I'll stick with a vote by members that have the chance to hear all sides and the time to check the information out for themselves. That's what we attempt to have in our national elections, and what I have experienced at the AMA and CMA meetings I have attended. Many times a hot button issue has been referred for further study, and when that further information was obtained, we didn't think it was such a great idea after all.

So again, if only this group would take this energy and passion TO the AMA, what things could be accomplished.

I have to say, I am disgusted and infuriated by the press release by Dan and Sermo. How dare you use an unscientific survey on this website (and if you have even done a true research study, ie one published in a well-respected peer-reviewed journal you would know to what I am referring) and your position as the CEO of Sermo to become the speaker for physicians. You are free to express your opinion, as yourself, but not for me as a member of Sermo, or for all members of Sermo. I thought this site was founded based on creating a place for communication and dialogue between physicians, not as a way for on individual to "rise to power" and promote himself and his views, using a crappy survey. If you are all about open communication, I would love to know why originally you partnered with the AMA (for 2 years) and then when it didn't work out, you turned to bashing the organization as if it is a personal vendetta.
I would love to hear more positive ways to improved the practice and business of medicine for physicians, such as your members, and less blame and finger pointing. You don't like CPT, fine. Tell us your proposal that will work better. I would love to hear any ideas anyone has to make things better- ideas that are constructive... All these press releases have done have made physicians as a group look bad!
I would love to see how many members you would represent if you start charging for membership to this site. I think that may be an interesting "study".

fmac65 illustrates another aspect of the CPT code that physicians detest: the lack of willingness by insurance and government agencies to follow it when it is to their self-interest not to do so. So here is a guide to how the game is going to be played, but the payors can ignore and/or revise any part of it whenever and however they choose. For example, Medi-Cal (California's medicaid program) routinely denies billing for the second ear when bilateral myringotomies and tubes are done, or for the second side of bilateral endoscopic sinus surgery, and only pays for destruction of one skin lesion even if 20 warts are frozen at one sitting. Downcoding has become routine. So then it becomes a game of overcoding on our part in anticipation of downcoding by the payors, and vice versa.

You forget the AMA's other source of income which is quite concerning. Most of us already know they collect our prescribing habits from Drug Store reporting. They then sell this info to the Pharmaceutical companies for huge amounts of money. You (meaning the reader of this missive) are worth thousands of $$$ to big Pharma --- each. Have you been compensated for your share of the AMA's profits. Hell no! What happens however if you get a pen from your friendly neighborhood drug rep? You both get fined, lose your jobs, could go to jail. What happens if your hospital, insurance company, mail order clearing house get paid off (I mean discounted) to put drug X on their shelf vs drug Y? Cash in pocket, untold profits. What if you speak for a company and get compensated for your time? Jail, Federal investigation, huge fines that end up who knows where? Why? Look to the gilded tower in downtown Chicago for the answers. All this was brought to you by the clan that Barack thinks represents the heart and soul of America's Medical Community. Now, who will admit to me you are a member and be proud of it?

mlazarus, unless I am blind or can't read, Dr. Palestrant is using Sermo as a vehicle for physicians to express their opinion about some very divisive and controversial subjects that are very hot topics. I don't think that he has claimed anywhere that this is a scientific survey of physicians. Rather this is an opinion poll and is reported as such. Just as if there was a survey of who do you believe represents you the best...the Democratic Party, the Republican Party or neither party and that opinion poll was reported to the media as the opinion of physician members of Sermo.

That this series of presentations and comments with associated questions is so emotional and has received such a flurry of activity is newsworthy on it's own.

The practice of medicine is a complex endeavour. I think many physicians who read this, especially those who have recently entered medicine as a career, will learn quite a bit from reading these posts and the varied comments that follow.

If this has a positive effect on the future of medical practice in the United States, by virtue of the open discussion of difficult issues, it will have been a success.

I personally hope that it is the beginning of a new awakening that is long overdue.

I confess to not reading all of the prior comments.

My take on CPT and ICD-9/ICD-10 codes is that these do not benefit doctors, just insurance companies ("the better to monitor you my dear" yet they somehow get it wrong- all my "care advisory letters" are WRONG about diagnoses, medications, lab frequency,etc) and the AMA for selling.

They SLOW practice down terribly and often time there are situations or diagnosis codes that don't easily fit. I hate having a diagnosis where all patients and doctors would recognize the diagnostic term, but it takes 5 minutes of searching through a coding book to come up with the "closest."

In the age of the internet. CPT and ICD-9/10 should not only be FREE but should be in at an easily searchable web database. Why are we pouring through books when a quick search of topic words should be able to easily get to the appropriate code.

As a complete aside, but a statement on where money is spent in medicine, I recently got an announcement that in my county in 2007, 212 million was spent on Medicaid... of which only 11-12% went to doctors.... where did the 88-89% go? not specifically broken down but it has to be administrative costs, hospitals, and pharmaceuticals. And they wonder why the doctors no longer want to participate in Medicaid.

Everyone likes to make money off of medicine and find a way to have the doctors (who are supposed to be the core of medicine) make less and have devised nice ways to prevent this (no union, no bargining powers, etc) and to have our representitive group (AMA) screw us like everyone else.

Nick you do know that millions of people vote for president in this country without anyone knowing who they are either.

Anonymity does not diminish legitimacy

just cause you stand up in the middle of the AMA delegate meeting does not mean your argument is any more valid than mine. And you were doing so well nick....come back my son/daughter. Those footprints you saw in the sand...that was when we were carrying you. (subtle Jesus reference...my bad)

steeldoc is the voice of OB? I thought he was the voice of the Steelers?

Jbluster....according to the initial survey....we are only going to run the risk of alienating 10%

That's like Iowa and Montana in the electoral college and maybe north dakota I didn't really do the math ok might have to toss in Hawaii, Alaska and Puerto Rico

These anti-AMA tirades will do nothing except give comfort to our enemies. Before trying to discredit an institution that's been around since before the Civil War, I think a lot of you should take pause and consider your words and actions. Sermo is not a national voice representing all physicians, and it never will be. If you want an AMA that reflects your interests and ideas, you have to join and mold it in your image. Sermo letters, ranting and raving, and delirious "calls to action" will only divide the medical community. A left leaning administration will eat this up. Why Dan has chosen now to air dirty laundry or discredit a national organization is a mystery to me and, I'm sure, to others. A house divided will fall.

SMFleet, there is no house. The cards have fallen, long ago. We may have some hope to pick up the pieces and rebuild. It has to start somewhere. Let's hear from the AMA. Where are their teeth, their spine for American physicians?

Like most aphorisms, "A house divided will fall" has exceptions, the most obvious being the American Revolution. Eternal vigilance is the price of liberty. Give me liberty or give me death.

For most of its history the AMA was too reactionary. It can only reflect what its members want and express at any given time.

There will be no revolution, btw. You will just discredit the AMA and indirectly all physicians. There must have been a house or some standing if the president chose to speak to the AMA. Sermo is a fun site but will not evolve into anything more than posturing and talk.

As a current delegate to the AMA HOD and active leader in organized medicine, I beleive the AMA should surrender its copyright on CPT codes to the government and stop assisting in their development. I beleive that the conflict of interest is too high. It is unacceptable for a body that represents physicians to profit off the regulation of physicians. Without the regulation of medical payment for physicians from central planners, their would be no need for CPT codes.

Physicians should set their own fees. Medicare can pay what it wants and the patient can bear the rest based on a private contract with their physician.

I know that the AMA leadership will say: "If we don't make money off of it- someone else will". That was also true of slavery. We abolished that.

David McKalip, M.D.

I am quite certain that the president's choice to speak at the AMA was a carefully crafted and orchestrated political maneuver, designed to prove in the media that he is appealing to America's physicians. I am also sure that his staff is well aware of the numbers that were elucidated in last week's posting. They are very smart and he is quite adept at what it takes to move his agenda forward.

I don't believe that they really understand what they are doing or have a true grasp of the depth of the issues. I think that his public option proposal is an attempt to rein in the private insurance companies with the threat of government competition. This has obviously not been thought through or well debated. With the artificially imposed congressional deadline this will be pushed through the congress with little thought or understanding on the part of our representatives and senators who have only a superficial understanding of complex health care issues, with the exception of a few MDs in the congress.

This forum has a chance to stand up for the physicians of America. My hope is that the AMA and others could be jarred from their long slumber.

McKalip, thank you!

It has already been suggested a number of times in this thread that we all just stop participating in insurance companies, I would add especially those that are traded on the big board and paying dividends to shareholders with money they obtain by denying payment to the only people in the system that are actually doing the work.

Opt out of them all as a group on the same day. That should get some attention.

As far as the CPT codes...it is a system that serves a purpose, the problem is that it has been coopted to anther purpose altogether. So let it stand for Cash Please, Thanks. The hospitals can still bill the insurance companies. But docs should contract only with the patient.

>jabmd1 Surgery, General

>The difference between intellectual property like a book and CPT is that I am not forced to use a book in order to do what needs to be done for my patients.

Careful, now. Your need has no bearing whatever on the property rights of others. Does a sick person have a right to your labor? Does a hungry person have a right to a farmer's crop? No.

So those CPT codes are, in fact, the intellectual property of the AMA. It doesn't matter how much you or anyone else needs them. Property is property.

You may be aware that copyrights and patents are not forever, and such knowledge eventually passes into the public domain. It is basically a trade...in exchange for sharing unique knowledge, govt grants what amounts to a temporary monopoly to profit from it.

Without such laws, every trade secret and technical advance would be jealously guarded, because if anyone else ever figured it out, they could just rip off the idea. If there were no intellectual property, there would be little incentive to invent or innovate.

>Because of the way the systems runs now I am forced to use this "intellectual property" to do what I need to do.

No you are not. You could go cash only.

Try having anything like these kinds of discussions at your local hospital department meeting or, better yet, at grand rounds and watch how quickly and subtly the talk is turned off. Even in the doctor's lounge, physicians who mention such things are not taken kindly to. At least Sermo voices a lot of pent up stuff we should have had the chance to talk about for years. Don't know how much it will influence the Washington machine, but it sure feels good.
By the way - I never joined the AMA due the abortion bullies running loose. Remember that issue? Doctors taking perfectly healthy human lives for profit, convenience and peer pressure?

It is good to see an airing of this issue, but the major problem still is decreasing autonomy of physicians. I have worked in public sector systems for all of my career and have avoided ever having to bill anybody. In the long run, the best system will be a mixed system. There are now a majority of physicians who are employed, rather than owners of practices. Large, single or multispecialty practices that can spread the administrative burden over many practitioners make more economic sense. Just as there were local general stores 50 years ago and now Walmart, Target, and other big box stores dominate, medicine will become more aggregated. I worry about single payor, as absolute power will corrupt. I advocate for mixed payment systems so Ted Kennedy can get what he wants and the poor person can at least access basic care. I do not want poor people getting the care Ted Kennedy gets. It would bankrupt the system. I can afford better cars, etc, than the waiter down the street. The whole idea of community standard frightens me. Guess what. Some people can afford better care than others. Or better restaurants. Life, liberty, and the pursuit of happiness. Everything else should be allowed to reach its own level. I really don't give a damn about CPT codes, because somebody else figures it out and pays me a salary. I am happy people go to cash only. I am happy people go into large groups or single private practice, or any other form. If the model you are in does not work economically for you, go into a different practice. MD training does not guarantee a certain level of income. I am a lousy businessman, so I chose to isolate myself from that aspect. What I fear is single payor. When the same cabal determines what you can do, what will be the payment, and what are the quality indicators, we are doomed.

Could I ask one question of all the people posting here who are proudly boasting that they are not, never were, and never will be AMA members?

What is your alternative suggestion on how to fix the myriad problems with CPT, ICD, reimbursement, the RUC, Medicare, RVU's, Medicaid, the costs of pharmaceuticals, and government "public plan" option, and all the other concerns raised in this series of posts?

Do you honestly think it would be as simple as every doctor in the US hanging out a sign tomorrow saying "Cash Please, Thanks"? What are you going to tell your patients when they show up to the office that day? "So sorry, I am doing this because it's what is best for you and the US healthcare system."

If you think the AMA is so feeble, and your plan is to cripple it further by asking everyone to resign their membership, can I ask how you plan to make the decision makers inside the Beltway craft a health care system to your liking?

AND, btw, I am appalled and horrified that 92% of respondents so far believe that govt should essentially STEAL the intellectual property of the AMA.

I don't care whether you like the AMA or not. Property is property.

You don't think govt should just take YOUR house or car, do you? Does anybody here have a patent or a copyright? Anybody here ever write a book or software?

Do you think govt should just take it or allow others to steal it without compensating you?

How can people believe govt should steal the property of its citizens and at the same time feel upset when others have a sense of entitlement to the labor or goods of others?


Come on people! We must have the rule of law. At the foundation of a free society are property rights, and that includes intellectual property, too.

CMS proposes a 21.5% paycut in Medicare payments starting Jan. 1, 2010 under the Medicare Physician Fee Schedule and to remove the sustainable growth rate formula. The pay-cut will effect 1 million physicians and non-physician practitioners. CMS is accepting comments until Aug 31 and the final rule will go into effect Nov. 1, 2009. CMS is also proposing to stop payments for consultation codes from specialists.

See Sermo Doc

See Sermo Doc

Nickfogelson is correct. Dan Sermo is angling to get your money out of your pocket to continue to finance his operations. Dan can call the AMA all the names he wants to but he should disclose his OBVIOUS conflict of interests.

Dave Redfern, MD

nickfogelson OBGYN Posted Jul 08, 2009 at 1:07 PM
Dan - you are out of line. You are using your position as the CEO of Sermo to become the defacto speaker for us all. The AMA may not represent all my views, but they certainly represent them more than you do. CPT is just a coding system. If you don't like them, propose an alternative. Proposing that we all go to cash practice is just silly. A few people can do it, but the whole country can't.

Sermo surveys are nice, but to make a press release based on one claiming that somehow you know the will of your population is ridiculous. You have the clicky-clicky opinions of a minority of the Sermo population, biased by the fact that those who have an axe to grind are far more likely to comment on your article that those who quietly disagree. Furthermore, even if I say that the AMA does not represent me, that doesn't mean that I think the AMA is terrible, or that I necessarily agree with your ideas.

I always thought you created Sermo to allow honest dialog between physicians. Now it feels like you did it in order to create a platform for yourself. Clearly you have the same right as us all to express your opinion, but do so as Daniel Palestrant,MD, not as "FOUNDER OF SERMO". And I hope to never again read a press release that claims to know what the great SERMO masses think. Such press releases are a disservice to us all.

I guess it looked a little different in 2007:

FOR IMMEDIATE RELEASE
AMA and Sermo Enter Into Partnership To Empower Physicians
Nation's largest physician organization teams with leading online physician community to hear and act on physicians' needs in a way never before possible

Cambridge, MA - May 30, 2007 - The American Medical Association (AMA) and Sermo today announced a collaborative agreement to empower physicians by making their collective voice heard in a way never before possible. By teaming with Sermo, the AMA will be able to address important professional and public health issues in a multi-phase, multi-year alliance aimed at improving medical practice, physician advocacy, and patient care.

"The Sermo community represents an innovative forum for physicians to share their voice with the AMA and discuss emerging issues on the front lines of medicine," said Cecil B. Wilson, M.D., chair of the AMA Board. "Engaging with Sermo's virtual community adds to the resources the AMA can call upon to rapidly assess and respond to the issues and concerns of physicians across the Unites States."

The AMA and Sermo have been working together to create initiatives that have a tangible value for physicians. "We're working with Sermo to learn how we can use cutting edge Web technology to better serve our physician members and help advance our strategic pillars of advocacy, communications and involvement," said Dr. Wilson.

The CPT system is just a dictionary if you will of commonly done things. Anyone can create such a system if they want. I suspect that if CPT didn't exist, then EVERY insurer would develop their own system and make us use theirs when billing them. For everyone who has ever billed anything that didn't have a code yet and had to experience the pain of that, imagine if there were NO uniform codes. EVERY bill would be like that.

Whether you get paid or not for a code is not the fault of the AMA or of CPT, it is on the payers to determine how to pay for each code. Yes, some more granularity can be helpful in some codes, but the more codes, the more complex the system is. There does have to be a balance. Is the solution to just take cash? Perhaps, but I can guarantee that at least for surgeons, few people could do this and get away with it, especially if they take any emergency call. In my neck of the woods, I doubt that anyone could assemble a patient panel big enough of cash-paying patients to keep us in business for a month based on the income level of those around me.

If you have a better system of describing what we do that you think should be adopted, by all means create it. If it works better, convince an insurer or some large group to use it. Charge lots and reap the benefits or give it away. As Suvarov says, property is property. It'd be yours to do what you wish with it. Then keep it updated for ALL specialties. Sound like fun?


As to the other issues here. To me, the press release seemed to imply that this was a properly done scientific sample. Here is some of the text of the press release.

"Sermo (http://www.sermo.com), the world's largest online physician's community, today released the results of a new survey indicating US physicians—at least a representative sample of the more than 100,000 who use Sermo—do not believe the AMA represents them and have no intention of being an AMA member. "

"The demographics of physician respondents is representative of the US physician population1 with respect to geographic distribution, specialties and age. All respondents are verified and credentialed, ensuring they have valid, active licenses to practice medicine in the United States. Physician respondents work in practices of all sizes in all major urban and remote rural locations across the Unites States. "

While not actually saying that it is representative, it does imply it. We all know as people who read a lot of journal articles, that the way this survey was done doesn't meet muster to claim that. Also, the constant claim of 100,000 physicians ring hollow, when you realize that many were paid to join, and many never contribute again based on my admitted unscientific sampling of random user IDs from the physician search tab. It be a better number if Sermo release the number that had logged in even once in the last year as a real number. Otherwise, it's just a cumulative number of people who have ever been paid to join (even the dead ones). That's something lots of internet companies do to inflate their numbers to look better to investors, but when reporting numbers for this purpose, you need to do better. (The AMA could then claim millions including all the dead ones). This is not to denigrate Sermo. I was a early participant and a reasonably regular contributor, and I value what Sermo can do. The ability to openly talk and debate is a worthwhile function.

Speaking of which, I still believe that the wholesale posting of these posts to the blog including the identifying information actually in the posts should be taken down at al least anonymized. Sermo Doc
People post here thinking that it is a community for licensed physicians. They do NOT expect that these posts, unfiltered will go out into the general internet space. Dr. Palestrant, you once called this cutting and pasting of threads a Terms of Service violation. If you are going to use your position to move threads out of Sermo as the voice of physicians, can any of us do this do? I'd ask that you consider taking that blog down and at least deleting the names that appear in the comment texts.

As an ER Doc, I am really tired of hearing docs whining about how we are victims of this system.
a) We don't have a system.
b) To the extent that it is a system, it is better at producing profits than health,
c) The income gap between primary care providers and specialists is disgusting, the former are disappearing, and, as a result, the care of our neighbors is getting increasingly fragmented and more expensive.
d) The income of the specialists (not all of them, but many) need to come down so we can narrow the gap in a zero sum manner. Aside from the issues of the cost of coding, which seems to be real for some of you, the reimbursement is based on RBRVS, which is the real culprit. It needs a revolutionary overhaul.

Instead of whining about our incomes, maybe we should raise our voices and share our insights about why it costs so much with our elected representatives, so they can figure out how we can find the savings necessary to cover everybody. I am more than a little concerned that we have become the mercenaries of the system. We are at least somewhat complicit in allowing this non-system to evolve. Maybe "mercenary" is too strong, but where's the evidence?

Dear Dr. Palestrant
I have to agree with surgonc that we shouldnt have our thoughts posted or used on the public forum. That would be a true violation. I have worked in leadership at my local hospital for over 10 years slowly slowly reaching the top. I will be the President of Staff in a couple years. I have worked from the inside to improve the hospital for all concerned. I am proud to have done it. It is a better place for all. I invite us all that care about medicine to do the same. Lots of good ideas and thoughts are posted here.
Go out and work at the local level to make it better for all. I have a MEC meeting tommorrow on my morning off and Performance improvement and Peer Review on my day off. This has been like this for years. Put up or shut up. Improve locally apply globally. I have spoken to the three physicians in congress I know in the last year. I just talked to my own congressman this last week. I send them money. It helps. How much have you all spent on donations to the couple of physicians in congress?

Someone please tell me I'm wrong in the following train of thought:
a 'intuitive EMR modules' are used to justify the high cost of EMR
b these modules will be required for CCHIT certification (medicare)
c we will be forced to supply (pay for) the processors that will use this expanding
coding system to our further detriment
d there will be many more doc's investigated for fraudulent billing when these
modules kick up their coding

HEY GESHARON, GO PAT YOURSELF ON THE BACK FOR ALL THE ALTRUISTIC THINGS YOU DO ON YOUR DAY OFF, INCLUDING"HAVING AN M.E.C. MEETING".ALL THIS HAS NOTHING TO DO WITH THE DAILY HARASSMENT OF WORKING PHYSICIANS BY THE INSURANCE INDUSTRY,THE GOVERNMENT AND MALPRACTICE LAWYERS. SO PAY ATTENTION TO WHAT DAN IS SAYING ABOUT THE REAL PROBLEMS FACED BY DOCTORS ACROSS THE NATION,AND STOP TELLING US WHAT A GOOD CITIZEN YOU ARE.

Ouch! Upper case! This reminds me of the old days of Compuserve using a TRS-80 from Radioshack.

So ANYWAY...things looked different in 2007. What exactly was the deal between the AMA and Sermo in 2007? How much dinero changed hands? Was there to be a renewal? Did someone back out? Did this explain DP's attack on the AMA, or was this all coincidence? Why was the AMA a great partner in 2007 but the incarnation of evil now...the biggest threat to American doctors?

If the problem is an AMA establishment at odds with its own members and even its own leadership, why not just expose this supposed evil and try to clean up the AMA's alleged dirty back rooms? Why lump the whole AMA into one basket?

Another day...hmmm!
I just wanted to add here that I agree with surgonc, that CPT(and the ICD system) are not the enemy, they are just a reference system that allows for a more coherent collection of data. My difficulty(especially with EMRs) is how these systems have been and are being used.

The behavior of the third party payers with regard to these systems has made the business life of many physicians much more difficult and added another layer of overhead. If we were to develop a truly intuitive EMR system that used CPT and ICD systems running in the background, but not in the exam room, I think that the outcry would be much less severe.

I also agree with suvarov's comments about the right of ownership of intellectual property. I think that it is helpful to have clear discussions like this one to help educate all of us. It helps us understand complex issues that we don't usually spend much time thinking about during our hectic daily schedules.

And lastly, I wanted to thank Dr. David McKalip for entering the discussion and for his comments. There is a major conflict of interest issue for the AMA regarding their ownership and marketing of the CPT coding system and materials. I would welcome some more transparency and clarity from the AMA on this subject.

Would it be possible for the AMA to retain ownership of their intellectual property and their rights to the profits from marketing these products as a separate spin off entity that remained apart from an organization that advocates for and represents physicians? I think that the cleanest answer to this is no. But, I think that an open discussion of the issue would be helpful and interesting.

Also, I think that the major source of angst among physicians is how the third party payers use the coding system and it's complexities against us, both from a financial standpoint and in their regulatory and "routing out fraud" activities. These things are at the core of physicians difficulties and one of the reasons for the disdain we feel for the CPT system.

I don't think that the CPT system is at fault, anymore than Webster's dictionary is at fault. The problems are with the way it is being used.

rarmstrong, well stated and I agree. Excellent !

ntavani... thank you!

thanks nakaiyd......, but a statement on where money is spent in medicine, I recently got an announcement that in my county in 2007, 212 million was spent on Medicaid... of which only 11-12% went to doctors....

"where did the 88-89% go? not specifically broken down but it has to be administrative costs, hospitals, and pharmaceuticals. And they wonder why the doctors no longer want to participate in Medicaid!!!

"In the age of the internet. CPT and ICD-9/10 should not only be FREE but should be in at an easily searchable web database. Why are we pouring through books when a quick search of topic words should be able to easily get to the appropriate code. "


...FREE... or used as a guideline and report your own diagnosis as best presented during the office visit!!!

Thanks, Dan, for spearheading this movement for change. I'm nearing the end of my medical practice in research (approx. 7 years hence) and don't deal with CPT codes, Medicare, etc. But I support my colleagues who do, and also being a patient at times, I hope this will reduce the interference in my docs' practices.

The problem, as I see it, was hit on the head: we as physicians have not taken a stand as a UNITED profession. As a child of the '60's, I would agree that perhaps a union, or some sort of massive, organized protest, would only help. As long as the outside parties have us as disorganized and afraid to take a stand, we will always be on the losing end.

Suvarov,

I am not arguing that the CPTs should not be allowed to be protected by the copyright laws. I am arguing that the problem is how they are used and how physicians (even cash only docs) are forced to use them. For a general surgeon going cash only is committing practice suicide. I could do this for all of my office based visits/procedures but when someone needs a colectomy or other major major procedure how are they going to be able to afford the costs when they cant even pay their share of the deductible?

For the cash based physician he/she is making the patient ask their insurance for reimbursement. For the patient to do that they need to have a bill from the doctor with the diagnosis and CPT/E&M code so that the insurance knows what was provided. Yes you could make the patient find the code themself, but imagine how hard it would be for them to find the right code when physicians have a difficult time.

The CPT system is not the root cause of the problem but it contributes to it. When physicians are forced to "hit bullet points" in order to be paid what is a somewhat adequate amount for the service they provide, we turn medicine (a science and an art) into a cookbook. Once that happens physicians are no longer needed, the recipe can be followed by any level practioner to a logical conclusion-results be damned. Think about the fact that this is already happening in many retail stores-their "minute clinics"

If medicine was that easy it would not entail 4 years of postgraduate schooling, and several more yearrs of residency training.

jabmd1, if a system of HSAs, government supported for those at the "poverty" level, personally supported by some(fully tax-deductible) and employer supported by those businesses that offered it, then ALL routine outpatient medicine could be transacted on a cash basis with a HSA debit card at the point of service. There would be no paperwork required and the patient would be spending "their" money.

Then, large medical expenses(like the colectomy that you mentioned) would be covered by catastrophic medical insurance. The insurance should be a straight forward understandable product, marketed to patients nationwide. It could be offered by employers, or not. I should also be fully tax deductible. Employers could offer it as a benefit(an incentive to get good employees), but should not be punished by the government if they don't. The policy language needs to be clear and understandable to both patients and their physicians. The contract, however, is between the patient and the insurance company.

The government's role would be to enforce the law against insurance fraud, to protect the consumer.

I think that this is an issue that will not be addressed, since the average member of the public has no idea or understanding of the problem. I'd rather see our collective efforts address tort reform or the disproportionate diversion of CMS funds away from the caregivers and to the beancounting clipboard carrying paperpushers. I think those are things the public can understand and that the legislature can address. I would really like to see a lot more people talking about the March in D.C. on October 1st, it seemed to stir some interest at first but has now died down. A grass-roots non-AMA demonstration of the frustration and desperation of U.S. physicians would go a long way towards getting the publics attention.

I would add my voice to all who advocate "No Support to the AMA" simply because the AMA has sold us for money and they do NOT represent the doctor's voice by any means. It's a case worse than "taxation without representation"; it's rather a severe case of black market sell-out. They have been doing that for many years and have their dictator-like permanent RUC committee to make decisions and sell them out as "doctor's voice"! It's time to marginate the AMA commensurate with its sad-of-a-case representation of the medical community!

i don't understaand how /why the AMA gets paid licencing fees. is the AMA the entity that created the CPT codes and so can charge for them? it that it?

It turns the "medical encounter" into a commodity.

I know that it (CPT) (and DRGs and OPPs) were set up in an effort to have a more uniform manner for insurance companies to assess "reasonable rates" of reimbursement.
(Note that "reimbursement" - as originally medical insurance was almost like a reinsurance for the patient - it "reimbursed" 80% of "reasonable and customary" fees (after the deductible.)

Clearly, it favored the procedural nature of medicine at the time - think it was in the 70s but I could easily be wrong. But, it has turned the Art and Practice of Medicine into a bean counter.

Should medicine and paying for it go back to that used by plumbers and electricians, or more like lawyers? I know we'd all like to be more like lawyers - paid for our time, renting our brain and hands, but clearly that isnt going to be the case. So what else?

In theory, I really agree with Michael Porter and Elizabeth Olmstead Teisberg about Value-Based system. (see Redefining Health Care: creating value-based competition on results or Porter's opinion piece in this week's NEJM - a very nice summary) The problems as outlines in the payment system
1) need first to collect data - relative costs/efforts to reach certain outcomes based upon initial conditions. (What I do like is that they/this system acknowledges that not all patients are created equal. Differences in education, socioeconomic, family unit, as well as genetic makeup can make a significant difference in outcomes. We need to better delineate those differences, but we are adverse to doing so because... well it implies we are not completely equal.)
2) implicit in this system is a "network" for each - it implies a team concept, but is vague enough to be unclear if this is just same a physician led team (educators, nutritionists,nurses, physical therapists/trainers,.....) or a team of physicians and their associated professionals.

The key is the initial step of data collection and comparison. Without that data one cannot even begin to pretend to be fair in payment "for a condition".

I also see a problem in that it covers more "treatment" but not the diagnosis process.

Fascinating posts, Dr. P. I agree with you.

The complexity of the issue and of the process is a huge part of the problem. Let's not make it more complex. It is this complexity that allows for hidden expenses to remain hidden and difficult to expose.

We need to design a system that is "elegantly simple". What I mean by this is that it is a system based on complex technology that has a very simple and intuitive user interface. Think of the iPhone for instance. It just works, for real. It is based on complex communication and internet technology, but you don't have to know that to use it. We need systems in medicine that do the same thing for our work flow and billing. We are trying to fit our old habits into the technology of a new century.

How has it been going?

rarmstrong-



what would you do with medical conditions that are not real emergencies but can potentially benefit from treatment-say venous insuffiency and varicose veins. SHould these be covered by "catastrophic insurance" or part of the HSA?

Prior to CPT coding, reimbursements were not complicated. The cost to collections and days in AR were a fraction of present stats. We warned of this present situation 35 yrs ago - few understood the future. When the business world took control of reimbursements they protected their margins and reduced the Providers. Now we see the Hospitals, Pharma, and Insurance third parties negotiating their positions with Orzsag in exchange for leaving the Providers to struggle. --That's business.

jabmd1, "catastrophic" would only need to be defined as those expenses that are above the yearly "limit" of an HSA...say $5000 to $8000 dollars. The other thing is that the HSA belongs to the patient. Even if the government supplies the money to a low income segment of the population, the HSA account is theirs, deposited in their local bank. But, once they use up the funds, they are gone.

This accomplishes the most important basic issue concerning cost control in health care spending. It puts the economic decision back in the hands of the consumer of services...the patient.

Changes in behavior would not occur overnight. But, when people begin to realize that they were depleting their own funds to purchase health care, they would begin to make market-based, more intelligent choices about spending.

It's the same way that you teach your child about spending their allowance. If you give them an open checkbook...they will spend it all and more. If you give them $100/month and refuse to give them more if they spend it all in the first week...they begin to understand the value of intelligent spending and planning.

This is basic, it is necessary and we are not being good stewards of America's money now.

As physicians, when we take a step back and try to figure out why we have had such a difficult (almost pathological) time coming together, it becomes clear that for the most part, there are no "simple" answers. There are no quick fixes. There are no magic bullets. And certainly there are no solutions that will not require us to make big changes. That being said, it is equally clear that we have missed some critical opportunities on a small number of issues that are so central, so defining, so obviously in the interest for ALL physicians, you start to wonder how any organization that is (ostensibly) acting in the interest of physicians could fail so miserably on these central topics.

For me, personally, this realization started almost two years ago. Within 72 hours of signing a binding legal agreement with Sermo, the business-side of the AMA decided that they "could not fulfill their obligations". Ironically, those obligations were not to Sermo (Sermo has never received a penny from the AMA). They were to you. The physicians that the AMA ostensibly represents. Although the AMA had agreed in writing to provide Sermo members access on-line to all AMA journals for free, they felt that they could not follow through on this, because the potential impact to their revenue, on further analysis, was too great.

Well, the announcements had been made, the public had been notified, so what choice did we have? Sermo decided to focus on the other key feature of the relationship, advocacy. Myself and my team logged well over 35 trips to Chicago to work with the AMA, providing them MILLIONS of dollars of market research and consulting only to come to the realization that they just didn't care. It was as simple as that. In meeting after meeting in wood paneled office after wood paneled office they'd role their eyes, call Sermo physicians "non-joiners" and argue again and again that they were "right" and the Sermo physicians were "delusional". When I sat through a meeting where the AMA had hired an independent survey of physicians for hundreds of thousands of dollars that showed the EXACT same thing......physicians didn't identify with the AMA, where did the conversation turn. The upcoming multimillion dollar "campaign for the uninsured" and the fact that it was projected that it would raise the AMA's brand among the general public. The more I asked the tough questions (how many members are actually paying members? Where does all the money for this art work come from? Why are these offices nicer than the Goldman Sachs Headquarters?) the more evasive people became. Nobody would give me straight answers.

The final straw for me was my interactions with the late Ron Davis. Ron was the AMA president at the time who, tragically past away suddenly from pancreatic cancer. Ron got it. He tried to interact with this community. He saw the trend playing out and he discussed with me what was REALLY happening with the AMA membership and what had become of the AMA. Then one night, he called me and said that the business-side of the AMA had forbid him from further interactions. As he put it, he had been "muzzled".
Sermo would go on to try working with the AMA for another year after that. But, from then on, I "got it". The AMA CANNOT be the voice of physicians. It is too fundamentally conflicted, both among physicians and within itself.

Mark my words, physicians will remain victims until they ditch the AMA. The AMA ditched them a long time ago. There have been so many missed opportunities, so many places to take a stand. We can argue the reasons why, but there is little argument that the AMA has failed. Anyone who thinks that the AMA should be blindly supported is perpetuating the same mistake that physicians have fallen into for the past 25 years. Clinging to the same strategy will bring the same outcome.

(cont'd)

My decision to focus on CPT codes is very calculated. The path to success will require physicians to do much more than "just" ditch the AMA. We will have to recognize that the AMA far from helping us has led to our downfall. CPT codes are the first of those things, but as you'll see in future posts, there are many, many more. Like the AMA, CPT codes started off innocently enough as a common procedural taxonomy. In time, however, they became subverted by parties who wanted money or power. Like the AMA itself, those parties saw that CPT codes could be subverted to achieve their own means. And like the AMA itself, this country's physicians went along like sheep. Hey if we don't have the AMA, we don't have anything.

Meanwhile, physician income has imploded. AMA revenue for licensing fees has exploded (greater than $110MM last year) and US physicians have abandoned the AMA in such droves that the only people who seem to want to talk with the AMA are the insurance companies and politicians because it allows them to advance their own interests. But don't worry.....where would we be with out the AMA? Who is being played the fool now?

People ask if I have an ax to grind, they wonder if Sermo has an agenda. They wonder what right I have to take these positions. Let me tell you. I do have an agenda. I do have an ax to grind. And I do have a position. I've looked at the problem from the inside and the outside. I know why physicians continue to get screwed. I know where the skeletons are and I know what is about to happen to our profession.

What right do I have? I have 3.5 million comments made on Sermo. I have hundreds upon hundreds of emails, messages, and letters. I have the support of tens of thousands of physicians. I have the best interests of our profession at heart. And more than anything. I have the truth and I have history. The AMA has failed on both those accounts by anybody's measure.

The first step in the path forward is recognizing that we have a problem. That is where we are now. The AMA is the enemy within and CPT codes are the shackles that bind us. Casting them off will not solve our problems but it is the necessary first step.
I think people here are making a very valid point about the need to stop the whining and move to action. The action at this point is very simple:

Focus on the things that unite us, ignore the things that divide us, concentrate on large numbers

Take a stand. Tie a knot.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.

And again, Dan, Thank you for this cogent explanation...I'm not surprised.

How do lawyers and accountants charge ? No CPT codes for them.

Dan,

Thank you for your post. This should clear up for many of our community the reasons behind the "sudden" change of heart. If the facts of your story are true, which they probably are then we ned to begin doing more then ranting on a limited forum. We need to take this to the public. I personally am willing to work from within the system to exact change but am also not so blinded that it may be better to work from outside the system to exact real changes.


Way to go and thank you.

The CPT coding system is a large part of the economic (and reward) problems for me in my traditional IM practice. The CPT codes do VERY little to reflect how much of my time and mental energy I put into any particular patient. It does nothing to account for the amount of time I spend reviewing loads of information when the patient is NOT in the office. Reviewing all that BS from third parties is stealing a lot of my fun in my work, and isn't reimburseable as other "professionals" are paid for their time--accts, attys, etc. I think it won't get better as long as we stay in the CPT coding as it presently stands. What I know TODAY is that I will quit if we get the 20% pay cut that is presently on the books for 2010. But, long term at today's reimbursement rates and the cost of doing business continuing to increase, my business plan is not sustainable for long anyway. I love my EMR; I really do take better and more efficient care of my patients. But, it has cost a lot of money, and I'll be that I will see none of the financial incentives that are on the books; I feel sure I won't qualify due to some coding BS that will arise. Besides, the incentives do nothing to cover the expense I have paid over the years for the EMR and maintenance. I just felt it was the right thing to do for my practice, and don't really regret it (except the cost). But, I'm getting tired of no rewards for doing the right thing always.

It is quite clear that a majority of physicians are outraged re The Healthcare System we now face and the approach that "outsiders" to the profession are taking to fix it. Although we as a providers may have different ideas on "the Fix" the reality is that none of our voices are being heard by those making policy decisions. Can't we utilize this forum of Sermo to at least allow our Congressman and the White House see the outpouring of ideas and personal and professional experiences from Physicians? Perhaps Dr Palestrant can provide a web feed or limited policy question access of all of these comments just so policy makers can be informed! The Physician community has been denied (on purpose) the ability to coalesce and Unionize and our professional societies are not getting the right word out!! The Mayo Clinics and Healthcare Think Tanks may be well meaning but they don't have a clue what physicians have to deal with on a day to day basis in the real world!

Dan's extensive comments shed some light on his dissatisfaction with the AMA. On the other hand, I have been around long enough to realize that there are often two, if not more, sides to a story. What might be helpful is for AMA leadership and Dan to have a special post on line to hash this out...a debate, perhaps. I wonder if they (the AMA) have a story to tell also. The post should be a series of comments from Dan and a series from the AMA, and later questions from the Sermo peanut gallery. It's 2009 for chrissakes! Can't we set this up?

CPT is certainly the best example of how the AMA has screwed us but as we all know there are others, including the response they gave to Obama a few weeks ago. Where are your spines people? I respect an individual who tells me to my face that they do not agree with my opinion, as opposed to an individual who bullshits in front of me and then behind my back tells others their true opinion (see Dan's post above about his dealings wiht the AMA). That is just what the AMA did. In addition, we cannot forget the numerous sell outs to pharma, and of course the insurance industry. However, in my opinion the AMA's biggest travisty is misrepresenting its membership and calling itself a voice for the American physician.

For those who have stated that Sermo does not have the political clout or experience to take on the American Political System, I wholeheartedly disagree. We have a higher membership then any physician group, or academy in the country. No one can argue strength in numbers. Furthermore, it is my opinion that a number of physicians do not realize that we are the house in this game of cards called healthcare reform. Without us there is no game. We need to start with a united front that we will not participate in any government helthcare program where we are not involved in a major way in the process, including tort reform and reimbursement.

Points that I would like to see would be:
1. an abolishment of the CPT system and a change to a system where the patient pays the doctor directly and then submits to their insurance directly. This would likely save 10-25% in total healthcare costs. If the patient does not want to submit it, let the physician charge the patient for their cost.

2. A staged implementation of healthcare reform starting with Universal catostrophic coverage as we do not have enough PCP's to treat all these newly insured patients (see Massachusettes for details). When the PCP shortage is corrected then we can consider full unverisal coverage.

3. A condition in the bill that would allow private insurance to exist. As we all know that every employer is going to drop private insurance if Ob's plan is passed. However, there should be caps on profits, executive salery and the elimination of interference by insurance i.e. prior authorization must go, as does pre existing conditions, and dropping the very sick.

4. A new medicare drug program, without the dougnut hole, with copays based on the individuals income and assests. A program that gives the federal government the power to negotiate prices similar to the VA.

That is just a start and as Dan has said we must unite and stick together on this. We also need to use the media to gain support and it would not be unreasonable to hire a public relations person if they do not alread exist. It also likely means that we may have to pay some for of dues to support the efforts, however given the AMA's performance this will be money well spent.

Finally, and to those who have posted in this blog and Dan's prior blog that Sermo has no chance for success at a national level. I heard similar comments when a group of us attempted to our fellow residents together in to protest low wages and long hours. That group went on to become CIR.

We need to print this thread or at least the post and put it on the docs corkboard and docs lounge in every hospital in America.....

just did it in ours

This was the response that Kevin MD recieved from the AMA about the Sermo relationship...

<The AMA has decided not to continue its business relationship with Sermo.

The AMA is always looking for effective ways to communicate with physicians. After an evaluation of the initial relationship with Sermo, we have decided that the value was not there to justify the investment of AMA members' dues dollars. We continue to explore ways to communicate more effectively with all physicians.>

My guess is that will be it. I can't see where they would feel that it's in their interest to say anything else.

How much clearer a message from the AMA do we need. They have droped the gaudlett and if there is any doubt in anybodys mind that the AMA will try everything in their power to bring down SERMO, you have to be a fool.

I may be a bit naive than most, but from my perspective and life experiences - THE TRUTH ALWAYS WINS OUT IN THE END!!!!

Keep the faith we are on the verge of moving physician leadership to a higer level of influence.

Strategy- Structure-Systems and Skills to Manage-Monitor-Measure the TIme- Talents and Tasks.

Focus on the things that unite us, ignore the things that divide us, concentrate on large numbers

Take a stand. Tie a knot.



Bob

Oh, jointdoc, bless your little heart and bones and muscles, too. I, like most of us, HATE the E/M codes, and CPT codes. It is so absurd, and I know I am paid less because most of my visits take a minimum of 20 minutes and I am too chicken to code the 14 and use the 13, even though all is documented.

And I scream at the thought of EHR. This will not solve anything. Who can afford it? We are two docs, old ones at that, but due to the vicissitudes of Medicare, in debt. How can we possbily borrow thousands of dollars more for those stupid EHRS?

Dan, thank you, thank you for this excellent post and superb summary of our trials and tribulations. I had no idea the AMA made all that money off our backs

McKalip, excellent, and thank you, tool Our executive secretary of the Dade County Medical Association (Miami, Florida) has been emailing us many of your excellent articles.

And I found out long ago that pharmaceutical reps could go to drug stores and find out what we were prescribing. After an initial screaming fit, I found there was some site on the AMA where we could opt out. Which, of course, we did.

Didn't realize that the AMA was behind this program. That they actually provided info to drug companiesl I thought it was just a service to the medical community helping us to opt out.

Dan, I agree with louermd. You ARE gathering a consensus here and this is an important point.
Carry on

And I definitely don't think government should steal the codes from the AMA.
they just should not exist.

There are rights to intellectual property. Or is Obama taking that away, too?

Mr President ...

Grateful forever for your vision to lift us up (our patients) at the blindful leadership of AMA, greedy pharmaceuticals, insurers, trial lawyers, and infamous Washington deities!).
The agony outcry of daily practice is beyond description and shared by thousand colleagues ... and by the end of the day, my staff and I exhale... WE HAVE SURVIVED another day of AMA sponsored onslaught!
Again, the situation has reached to its maximum of (in)tolerance, point of no return ... that the medical machinery of patience, compassion and wisdom has been prostituted and bottomed up!
Thus the gratitude... that the orphaned physicians need ASAP SERMO resuscitation!

With thousands behind you by Gods grace the outcry will be vindicated... we will rise up again and be the kind of healing practitioners God want us to be!

PS. Copies were made and distributed both to friends, patients and colleagues!!!

...rarmstrong... thank you

Dan, has sermo made an official response to the AMA reply posted by rarnstrong on KevinMD. This is end of an article just put on the internet 37 minutes ago:

We're not the ones throwing stones," an AMA spokesperson said. "This conflict has been promoted by Sermo."

Calls and emails to Sermo were not immediately returned.

YOU'RE THE MAN !!

The CPT system is based in part on the Cartesian notion that the more refined our understanding of the particle, the better our understanding of the whole.
I've not seen that the CPT system helps us understand health care. It seems to be a significant distraction in our daily lives. Too many of our conversations on line and in person with colleagues revolve around coding and getting paid.

We need to get back to the core values and ethics of our profession and step away from the ever-expanding games of coding and compliance. Too many of our colleagues spend valuable time going to "coding" classes, too much of our mental energies are spent figuring out if we can check a few more of the complex boxes that would allow us to bill more for the work we've done. Most EMR systems are organized around robust E&M coding.

We must stop being coding clerks and start being physicians again.

Let's discuss alternatives to this crushing administrative trivia game.

L Gordon Moore

Funny....suddenly, the thought of a patient glaring at me and yelling.

"I'm going to report you to the AMA!"

makes me chuckle....

I'll second that, Gordon!

Dan does it again. I am just looking through the CPT coding inlcuded with our new EMR. It is a mess and I can't dig my way out.
I luckily have a large cash population. It keeps the electric bill paid while I wait on the insurance checks.
Good to have you weighing in louermd-
Count me in Dan. I promise I will disagree when you stop making sense.

good message gmoore. "We must stop being coding clerks and start being physicians again."

Makes a good slogan

And thank you, Louer....I'm chuckling along with you

Dan, nice story: Sermo Wars with AMA:

Sermo Doc

Dr. Reece admonishment of Dan:

Thursday, July 9, 2009
In Defense of the AMA

I believe in civil discourse.

In my opinion, Daniel Palestrant, MD, founder and CEO of Sermo, crossed the line with the title of his message to Sermo's 100,000 members. The title was "Why Physicians Always Get Screwed, Thanks AMA."

I do not object to what Dr. Palestrant stands for. As a matter of fact, In my book, Obama, Doctors, and Health Reform, I devote two chapters to Palastrant and to Sermo's open letter to the American public. I agree with his observations and insights - that the deck is stacked against doctors, that there is a disequilibrium between the supply and demand of physicians, that the quest for "perfect information" is unrealistic, and that is shift to consumerism is underway.

I do not object to what Palestrant is saying in his latest attack of the AMA - that the complexity of AMA dominated CPT coding burdens doctors with excessive paperwork and overhead, raises administrative costs, allows payers to aggregate and lower physician fees, keeps the general public and physicians themselves from comparing fees, competing on the basis of fees and services.

I do not even object to his bringing to light the fact that the AMA receives $70 million annually in "licensing fees," thereby monopolizing the coding process.
What I object to is use of the word "screwed, " and the implication that the AMA is engaged in some sort of secret cabal to simultaneously "screw" the public and AMA members alike.

Like any other large organization, the AMA needs margins to function. As the nun CEO of a Catholic health system observed, "The margin, no mission." To say that the AMA is in collusion with Medicare and other payers to rip off the health care world seems to me to be verbal overkill. Palestrant is politizing and polarizing doctors, and I, for one, do not think this is a good idea. On the other hand, like Patrick Henry in the American Revolution, his words may have a useful function by moving the AMA to action.

Let's get real. Being the AMA -- satisfying members representing 190 different specialties; overcoming the image of being a physician union dedicated to protecting doctors incomes and opposing Medicare, a widely popular public program; serving as a quasi-regulator of academic medicine and the number of doctors and residency slots; having a visible presence as the most powerful lobby in Washington, D.C, for physicians interests; and meanwhile, securing for physicians a legitimate presence at the health reform negotiating table - isn't easy.

The public and CMS thinks of the AMA as representing doctors as a while. This has its good sides. For example, the AMA's new president, J.James Rohack, MD, of Texas, has immediate access to the pages of the America's national newspapers and other media. The AMA's publications, particularly JAMA and The American Medical News, are balanced and give valuable insight into what doctors are doing, thinking, and reacting. And the AMA's stance on health reform makessense

• Pluralism - Namely that we are a nation with multiple systems, public and private points of view.

• Freedom of choice - We ought to be free to choose among hospitals, doctors, and other caregivers, and among the various technologic options.

• Freedom of practice - Doctors ought be freedom to choose their mode of practice - solo, group, employment, concierge, cash only - even if that mode means not accepting patient in government programs such as Medicare and Medicaid.

• Universal access for patients - Universal access - being able to see a doctor when one pleases - in not the same as universal coverage - being covered by insurance whether one is able to find a doctor when one is sick. Universal coverage without universal access may be meaningless given the looming doctor shortage.

So let us not be too harsh or too uncivil towards the AMA. It may be too bureaucratic, too removed from its members on the ground, too slow to adjust to the new political realities . With a plunging membership and widespread physician discontent, the AMA cannot continue to function as it is. It is politically and financially vulnerable, and it needs to reassess its role. For now, however, it is our main representative in the public discourse on health reform.
Posted by Richard L. Reece, MD at 12:11 PM

It's odd that whenever I mention Sermo to anyone, staff, nurses, doctors, most have never heard of it. So for Sermo to be the new AMA, you still have a lot of work ahead.

SMFleet, it won't take long...people will be happy to know that you are a member of Sermo...it won't take long:-)

Dr. Wes writes-" the house of medicine is burning" in his column Tuesday, July 07, 2009 Are Doctors Sheeple? He suggest that maybe in the greater scheme of things it would be better for Dan and the AMA to kiss and make up.

Sermo Doc

It is clear that the AMA is affraid of Sermo and its potential or they would not have responded

Dan you need to challange Wes to a webcast debate.

"The AMA's publications, particularly JAMA and The American Medical News, are balanced and give valuable insight into what doctors are doing, thinking, and reacting"
this is the best BS I have ever read. JAMA is so influenced by pharma and is completely on the take. Google its prior editors comments.

A webcast debate will surely grab media attention and keep the sense of urgency alive. You got my vote Dan.

AMA reveals its true nature: you have the right to agree with the leadrship.

Do you all remember how Lundsberg was fired for exercising true editorial independence and published a study on teen sex that a hidebound AMA board of trustees disagreed with? Look at how JAMA routinely publishes article that fail its own peer review criteria now.

There will never be any public debate, so don't get your hopes up.

Wes is nobody, I thought you were referring to a debate with someone from AMA.

Why didn't anyone tell me about this foreign travel stuff?

    APPROVAL OF FOREIGN TRAVEL
The Board voted to approve foreign travel for the three AMA Presidents as follows:

Drs. Davis, Nielsen, and Plested to represent the AMA at the October 3 - 6, 2007, World Medical Association (WMA) meeting, Copenhagen, Denmark. The three Presidents serve as the AMA delegation to WMA. Travel expenses for the WMA meeting will be reimbursed by the AMA Office of International Medicine's budget.

The Board voted to approve foreign travel as follows:
(a)
October 13 - 14, 2008, Taipei, Taiwan - Dr. Nielsen will participate in a Taiwan Medical Association (TMA) symposium. The symposium will introduce Dr. Nielsen to TMA leadership and activities; TMA participation in regional professional medical groups; domestic health delivery systems; and current medical care issues. Accommodations will be reimbursed by TMA.
(b)
October 15 - 18, 2008, Seoul, Korea - Drs. Nielsen, Davis and Heyman will serve as the delegation to the World Medical Association (WMA), and will represent the AMA at the WMA Council Meeting. The President-Elect will not be attending this meeting. The Board Chair will attend in the President-Elect's absence. Travel expenses for the WMA meeting will be reimbursed by the AMA Office of International Medicine.

Maybe the money's from their books, not my dues.

I've said this before but I'll say it again

Docs need to go back to being docs, plain and simple.

If during the evaluation of a patient, you start making decisions based on non-medical issues such as cpt, icd, hippa, formularies, referalls, etc, the stop, take a deep breathe, and reevaluate. If I was a patient and a doc made decisions based on those factors instead of on what was medically needed, I would go elsewhere.

It will not be long before the public understands this. And when they do, the physician community better have a response. My response was in Jan 2008 when I dropped third parties and went cash. I have less patients, but also less overhead, more time, and a lot more respect and value from my patient's.

Go green and throw out your cpt and icd manuals!!!

I read Dr. Reece's comment.....

hmmmmm

sounds to me like we're over the target, esp when the prinicipal objection is the use of the word "screwed"

That's like objecting to porn because the dialogue is boring

The ICD 9 is just as bad. Just wait for ICD 10, an explosion by more than 10 fold. It is estimated that a 4 person practice will spend tens of thousand of dollars to enact this upgrade. Do we really need to know the difference between slow transit constipation and constipation not otherwise specified? More importantly does the clerk at the insurance company need to know this except to deny payment?

SMFleet I would not want Sermo to be the new AMA but what I WOULD like is an organization for doctors that actually listens to its constituents instead of existing to make money off of them. Ideally the subspecialty and political organizations already in existence should have enough members between them to make a substantial impact as a coalition. The only issue is geting them to agree on common issues and stop fighting over reimbursement for specialists vs PCPs and fight for proper reimbursment of ALL doctors.

I hope that these other organizations would learn from what has happened to the AMA and note the effects of pushing archaic political agendas and stop using strongarm tactics ('You NEED to be a member to get access to our products that are essential to practice'- or in ACOGs case to continue to be board certified).

SMFleet I don't want Sermo to be the next doctors' organization. I WOULD like to see an organization for doctors is receptive to the views of constitutents and not in existence merely to make money off of them.

It is too late in this debate to mobilize doctors for a new organization and we know how quickly the AMA reacts to change. There are enough specialty orgs and political orgs that together represent substantially more of practicing doctors than the AMA. At this point should form a coalition on common issues without the infighting about reimbursement of PCPs vs specialists but work for proper reimbursement of ALL doctors.

sly1977 I'm getting dizzy trying to figure out how those last two comments compare and contrast, like the cartoons that have something different you have to spot.

The specialist vs. generalist fight is a tough one. I actually see it both ways.

There is only one course to follow: Drop ALL insurance. Tell AMA and any state medical society which continues to negotiate the destruction of the medical profession to go to hell.

CPT and EM codes are tools used by insurers to hang MDs . Profiling me with NPs and PAs , telling me I bill too many levels 4s and 5s. It all must go .

MDs must be payed for ALL time spent on patients care. Call backs , weekend , night calls , calls to other MDs on patient's behalf , all forms , medical records completion , calls to insurance companies , surcharge for the cost of Med Mal Practice , and pre-auths . There must be a minimum level of payment that has nothing to do with the diagnosis, the "medical decision making , the bullets in the PE . It should not matter if a patient seeks advice on a hangnail or the symptom of chest pain . My office overhead is the same for both conditions .

The AMA is a crucial part of the problem...an organization that has jumped in bed with any enterprise that could parasitize us; we have been defenceless all along. I think the CPT codes are just one example. The Board certification process, the time & cost of taking prep courses on top of the cost of the exams, is another example of the parasitization that we have allowed to occur. (I think a system could be devised that is not only better & of greater integrity, but less costly & less time consuming...& dare I say, maybe even enjoyable. Then there are the politicians & the lawyerdom from which they spawn who are artfully self-serving, creating a Milton-Bradley game to their benefit. while putting on a pretense of being high-minded and out to defend people's rights....reaping the rewards of an ill-deserved lion's share while driving up the cost of doing business in all areas, and notably in the medical field
But, I think that WE remain the biggest part of the problem. WE have allowed this dysfunctional system to start, go on and continue,...because WE have been dysfunctional. We need to try to be a cohesive force and work together....I believe that if we genuinely champion our patient's interests, profits & reward will naturally follow.
We should shine a LOUD BRIGHT EMBARRASSING light on the issues where transparency is needed, ie., the Pharmaceutical companies, the Insurance companies, and the costs of the necessary practice of Defensive Medicine. We need to be less complicated (lawyers like to complicate matters), and be more WISE than intelligent.
And just one more thing.....there is NO party that is in our corner, not before, and not now.................and I guess that's all I've got to say. Ahhh, I feel better now.
Thank you, Dan, for your smarts & your courage. I'm definitely in your camp.
I

I get paid more for diabetes with neuropathy/retinopathy attached than just plain diabetes yet they may take the same time to see. I think cpt codes are useful documentation tools but they should not be what drives billing. The fact we have to have a dedicated person trained in cpt coding and billing just to send in our codes to insurance companies to get paid is the problem. When I collect $2 for every $10 I bill because of adjustments or current insruance contract rates plus overhead plus the fact it may take 90 days to get the money from the insurance company if all goes smoothly plus the free care thrown in, it adds up to poor business. As noted, a plumber, lawyer, cpa etc calculates the time involved and sends you a bill based on his time. There is no negotiation involved, you pay at time of service or when your case/taxes are done. Why does it have to be so complicated in the first place? Just like some plumbers may charge 100 per hour and another 90 per hour, why cant we just charge by time and for those procedures that are done whether surgical or otherwise, each has its own monetary arrangement so a lap chole costs X and should take X amount of time? Complications add time to the procedure therefore, attach this as a 'modifier' for billing purposes. Time is measurable. Letting some insurance company dictate what they think they should pay me based on what code I listed does not make much sense to me.

topdoc.... well stated, thanks

Many physicians have been happy to get $50 directly from the insurance company rather than wait for the patient to (never) send $100. There are physicians for whom no price is too low as long as some money comes in. They will cut any deal they can. This has also hurt the economics of the profession.
The answer might be the "cash" approach and insurance goes directly to the patient, but I think it's too late to put that genie back in the bottle. The problem is that doctors were also seduced by the insurance companies and the hope that a big company would be more apt to pay than an ungrateful patient who will pocket the insurance check and buy cigarettes, twinkies, and lottery tickets.

In the beginning, the insurance companies weren't so bad. In Ohio, BC/BS would have a special rep who would come out to the office and go over codes with you to maximize efficiency and payment. I recall that it a few cases she even told me I was charging too LITTLE.

The whole society has deteriorated in the past twenty years. Whether it was credit cards, housing, Wall St. speculation, or celebrity adulation, we became a society interested in rapid wealth with little respect for anything else. It is not surprising that the AMA, just another part of society, jockeyed to get its "share." The enemy is us, but not just physicians, the entire society. I was hoping the recent recession/depression would make people wake up to what was really important in life. Unfortunately, hard times sometimes just make people more bitter and competitive.

How very true Louermd...I love that analagy

OMG, I never knew....

As somewhat of an aside but along the same topic. Everyone of you should read Glenn Beck's "Common Sense". I am not saying that I agree with all that he has to say in the book, but it can shed some light on the issue at hand, how do we change a politcal environment that is dug in and ready for any attack that might be thrown at it.

This is not going to be an easy fight, it may take many years and much sacrifice, but in the end if what you believe is truely right and just, then you must stand up for it and make that sacrifice. Everyone will be much better off in the end.


To this end I make the following proposal.

As the AMA represents only a small portion of physicians based upon membership numbers, and as the majority ofmembers of the Sermo community have expressed a very strong opinion that they no longer want the AMA to speak for them, I propose that we set up an elective process within Sermo to establish a new group of physicians from all specialties to collect our ideas, come to a concensus of priorities to make it that each physician can practice medicine as he/she ses fit for the betterment of his/her patients and for the best interest of the physician. Much as the United States began with a simple document stating its ideals and purpose, I believe that physicians should do the same and establish a "Declaration of Healthcare". This should be in simple terms but strong convictions. It should be made available to all Americans so that they may understand the plight of American healthcare and the American Doctor.

All those in favor?

Going green as DoctorSH has put forth and had previously posted as a series, makes most sense- however, woe to us who practice in a rural area where most people do not have the $$.
In the meantime, we have to maximize coding abilities to maximize (actually just be realistic) with the payments.
I, for one, agree with the word screwed (though I take the word to actually imply pleasure....or is it just me?)

Sermo and the AMA should kiss and make up. Then you'd have 350,000 potential members. You might try for a new AMA, perhaps sermo-ized. You can't have Sermo as it is now represent you--you would need a separate structure, not a Dan profit machine but a separate, independent non-profit.

To: Dr. Daniel Reece,

i respecfully disagree with what you believe you are doing with the AMA. i wonder how many of you running that show actually practice medicine. and in particular primary care- by far, by exponential factors, the hardest hit currently the most important of all specialties in this country.

the AMA is as politico as the two major political parties in this country. it is a business entity that is manipulated by the most powerful of its constituents to and fro as they see fit. i mean, jesus, it is so centralized that a delegate of the AAFP who attended the Chicago meeting was quoted as saying that it was a GOOD IDEA to let subspecialists apply for the title of medical home!!!! all this because the subspecialists want a piece of the business pie. can someone explain to me how a cardiologist or allergist is going to provide comprehensive primary care for his patients? oh wait, that's right- a PA! so he can take the patients from a real internist. wait till patients start dropping like flies- in DKA at the cardiologists' offices the way they do at walk-in clinics all over the country nowadays.

explain to me the last two paragraphs at the bottom left of the front page of the lastest AMA medical newsletter? what are you people thinking. is anyone there capable of resisting being as starstruck as the typical american when obama shows up acting like he's god?

The benchmark 'standard of care' is an expectation these days. To be informed as to what that means, physicians must confer with one another individually and through conferences or other organized groups. How, why, and what it costs to provide this 'standard of care' has to be talked about. It seems that discussions among physicians about fee for certain services (CPT codes) is an important part of those discussions. How can that be considered an anti-trust violation? Why also is it an anti-trust violation for physicians to unionize?

nickfogelson, your point is well-taken. But, every movement and/or revolution ultimately begins with one person or a very small group. Is Sermo the beginning of a revolution? Possibly. It depends on whether or not it is sustained, grows, achieves publicity and with that, power. It also depends on the amount of outrage that exists within the profession and without. At this point, there is outrage, but it is minimal. But, it is increasing. I see nothing in the future that will serve to decrease the amount of outrage and dissatisfaction out there.

The primary obstacle to achieving change is the historical reluctance of physicians to act as a unified group. How much longer will this be the case? Answer that question and you can work miracles.

If it will make some of you folks happy, I DO NOT WANT TO DO PRIMARY CARE! NO "HOME", NO GENERAL MEDICINE, NO PAPS, NO IMMUNIZATIONS. NADA.

I remain a member of the AMA just to vote against the heinous policies. I feel that once in the AMA (like Congress) MDs park there and enjoy the perks while selling us downstream. Sometimes, compromise is not in order, i.e. patient care and quality.
Many of you may note that AMA delegates are often almost appointed in states by the board of directors of medical societies.
The AMA represents less than a majority of the US physicians. We are more guided by our specialty academies and other societies. Unfortunately, we are also poor financial contributors to the political lobby.

I feel that this letter incites a much needed debate. We have all expressed similar sentiment. Why can we not have a unified voice that actually speaks with authority and conviction regarding the MD position. We watch as the lesser trained personnel expand privileges without the training and experience. Maybe we need to let the public go to Walmart for care until we are recognized as the appropriate authority for life threatening decision making.

SMFleet, we really weren't too worried about that. I don't know ANY cardiologists who would like to do primary care. Primary care is difficult to do well, even for those of us who do it every day and are trained in it. No, making specialists into a "medical home" is a very bad idea. I think the government might like it, but that just proves my point.

The problem is that there are NOT enough primary care doctors. And, this is primarily a function of inadequate reimbursement. Unless this reimbursement problem is fixed, the situation will not improve. And indeed, specialists may be FORCED into primary care by the government. Put that in your pipe and smoke it!

My home is a dark, cold hole where I read echo's and stress tests. For fun, I do CME on my iPhone.

thanks for your insight, since we have no time to deal with this. I guess insurance companies want us to be busy and oblivious. Big question? I it legal to doctors to unionize? I have all kinds of answers. If we do, is it truth we can go to jail as well..?

Most physicians refuse to believe it, but actually an adequate capitation HMO contract may pay better - and certainly more predictably and with a lower overhead - than CPT billing based PPOs.

Strong work, Dan. I'm not sure if CPT codes are being completely ignored, however - as I just received this email from the CAP requesting I complete a survey about our CPT codes... See below: I'm sure a "re-evaluation" would be beneficial for us - ha ha.

Dear Colleague:
We need your help!
In response to a request from the Centers of Medicare and Medicaid Services (CMS) to the American Medical Association RBRVS Update Committee (RUC) to review the surgical pathology code family, the College of American Pathologists (CAP) is asking pathologists providing these services, to complete an important survey. The information being collected will be critical in aiding the CAP in formulating recommendations to the RUC, in determining if 88300-88314 codes are appropriately valued. These codes are under scrutiny by CMS for possible revaluation.
To structure an approach to review these important CPT codes, the CAP needs to determine how much time and work pathologists currently spend on various specimen types. Specifically, CAP is interested in the total time and work needed to evaluate each of the specimens presented in the survey, from the time of receipt of the specimen to completion (sign out) of the case.
In the survey, you will be asked to estimate your pre-, intra- and post-service times on cases provided. We are looking for quick "off the cuff" estimates, not actual time studies. Additionally, you will be asked to determine how much work (which includes time in conjunction with mental and physical effort) is required to complete the case study presented, compared to a reference specimen. The survey should not take more than 15 minutes to complete.
The CAP appreciates your willingness to participate.
Sincerely,
Chair, Economic Affairs Committee
College of American Pathologists

We need a real organization of physicians. The AMA has abdicated that role. I don't think the shrinking membership was because there wasn't a desire for organized representaion. Comments here have made it clear that there is a strong desire to organize.

Rather, it is clear that the AMA left physicians along the way and now represent a small contingent of doctors who probably continue to belong out of habit more than anything else.

Frankly, I have a very busy practice, a family, and educational goals that must be met. Finding time to participate in medical organizations is difficult at best. Volume requirements to pay overhead, etc. leave little time to focus on other endeavors. I would like an organization to advocate for the PHYSICIAN to keep us sane and in practice where we actually can help people. All the aggressive capitulation to others has resulted in a miserable lifestyle for us all.

CPT cpdes and RVUs went hand-in-hand. There was a divide and conquer strategy in play and it worked. They are using the same tactics again now (as recently promoted by Obama). To wit:

The central premise of the strategy is to convince primary care physicians that they are being under paid essentially because specialists are over paid. This is a false dichotomy and is intended to spark conflict among ourselves.

The fundamental premise is that there is only a certain amount of money to spend on healthcare. Therefore, if someone gets more, then someone else must get less.

First of all, what is the appropriate amount of money to spend on healthcare? I hear we are spending too much, so what is the right amount? Actually, no one really knows. There is no known finite limit on what should be spent on healthcare as far as I am aware of.

Primary care is important. PCPs should receive compensation that is appropriate for the very important work that they do. This compensation has nothing to do with what specialists are paid and should be a stand alone issue.

Let us not fall AGAIN into intramural squabbling about who gets what share of the pie. It does not serve any of our purposes.

mammo1

As a radiologist , I work in a discipline not typically known for using E&M codes, or consults. Yet as a breast imager,at least 2 hours of my workday are dedicated to issuing second opinions on outside studies because my referring physicians and patients do not always feel comfortable relying on the interpretations of mammograms, ultrasounds, biopsy recommendations, etc, issued by other offices in the area. Since I ,and not my primary care or surgical colleague ,am the one perfoming most of the breast biopsies leading to an initial diagnosis of cancer, I am the one spending 20-30 minutes, not counting nursing and secretarial time, in meeting with the patient and her family, informing them for the first time of a positive diagnosis, discussing the nature and extent of disease, giving a rundown of likely treatment options, setting up MRI appointments, genetics counseling appointments, and facilitating surgical and oncology appointments, and of course, providing lots of reassurances and sympathetic support. These patient interactions occur in real time, frequently within half an hour of a biopsy. I do not believe, and recent research has confimed this, that I should need to make a patient come back on another day to discuss these issues. However. as we know, the insurers are not friends to us or our patients. Many insurers, including Medicare, will not reimburse at all for a second opinion, even though there is publsihed data pointing to significant alterations in patient care with improved outcomes from such specialist consults, and virtually none reimburse for a well documented E&M (including pertinent clinical exam and history) if done immediately pursuant to "classic "radiology services. Because I strongly advocate improved access to care, I still accept all payors, but I would like to receive appropriate reimbursements for time spent that goes well beyond a standard mammogram interpretation, This unfunded mandate has led to many in my specialty refusing all insurances or dropping services entirely, but does nothing to improve quality of patient care or access to it.

smfleet and voyager-

cards groups and others already hire lots of pa's and np's to manage lipids and even DM2!!!! (they were all gung ho about the berkeley test till that fad fizzled out) and the more business minded of them are the ones lobbying to extend the med home model so they can adapt it and obtain increased reimbursements for the job their PA and NP's are doing. that is where my concern comes from. here in florida 50% of cards groups have PA's doing this... and even prescribing abx for uti's for god's sakes!

I have little sympathy for specialists complaining of cuts. For too long they have had a blank check in reimbursements. How many needless high cost tests are done due to self serving interests and not for any valid clinical ressons although one can always be manufactured using the proper coding system. Perhaps if the bad apples among the specialists had been better controlled by their specialilst orgainzations and peers we wouldn't be in this mess we are all facing today. Primary care gets less and less and I'm supposed to feel bad for my overpaid brethren??

I believe that there is enough money to go around for the adequate payment of all physicians. There is enough money for actual health care. What needs to be whittled back is administrative costs in the "system."

Fewer layers and more actual care.

We need billable hours: time compensation for phone calls, letters, medication adjustments, and other non-face-to-face time. I am in a specialty which mostly involves assessments and management of disabled children, adolescents and adults. The codes do not fit my practice--and when I code according to time, I am not reimbursed unless the patient sits in front of me. This is absurd. We need compensation like the lawyers: payment for our time instead of procedures alone. If I took off a wart in 1 minute, I would make more reimbursement than deciding on the entire destiny and treatment plan for a complex patient for an hour. Thanks, AMA.

The feds are moving quickly on healthcare reform legislation.

If Sermo is indeed a movement, it needs a strong laxative to get it moving quickly or we will end up with soiled undergarments.

We need a seat at the table, separate and distinct from the AMA, to truly represent the grass roots interests of physicians, both primary care and specialists. The govt will continue to try to divide and conquer. If they suceed we are forever screwed as a profession.

On another issue, how can the hospital industry allow a decrease of 100 Billion? over the next 10 years to fund more uninsured in the hospitals? If they get paid less and have to treat more, it does not make sense. Please someone enlighten me!!

Enlightenment: Sermo Doc

The title of the article this leads you to is: "Industry Lobby Spends $1.4 Million Per Day"

It cites "medical groups" in the line-up, but once you read for detail, that, of course, means the AMA. Yet another reason to distance ourselves.

This has been a very interesting discussion with the predominate attitude being," I am mad as hell and not going to take it anymore!" Conservatives think that the AMA is too liberal and liberals think that the AMA is too conservative. Specialists see the AMA as slanted toward primary care and vice-versa. I have been a member of the AMA House of Delegates, and the way policy is shaped is long and tedious. I would argue that any organization that tries to unite physicians will quickly have the same problems that the AMA has. The AMA has tried to re-invent itself for the last 15-20 years without much success. Unfortunately, it is the only organization with political clout that speaks for all types of physicians. I agree that the AMA should be not involoved with CPT codes, but then, who would decide how to set reimbursement rates if not a physician group? I hope that the AMA leaders are monitering this situation at Sermo, because it clearly indicates that there is great anxiety about the current political climate and a desperate need for a strong physician voice in the political arena.

It is very sad for me to see how our physicians are easily divided. It reminds me the time of HMO. A group of professionals who are well respected by public due to our devotion and commitment can not find the common ground to work together and be a leader who we are entitled to. If we keep this way, we will be controlled, pushed and forced to do the job only we can do in the way that we do not want. We have a choice but we seem to decide to give it up again. What is our common ground? Ask yourselves before you enter into the argument mode again. What are you willing to do to make it happen? Where are we now? Where do you want to HEAD?

After reading the comment about the cuts proposed for cardiologists:
Please remember that, if the story is correct, there will be a coresponding pay increase for primary care. Perhaps the problem is the paradigm: In my region echocardigrams are ordered so routinely and this may not really be necessary.
If it becomes harder to schedule an echo, we may think more before ordering one.
If we want better office care we may have to reimburse office work more and procedures less.

DP thanks for the enlightenment on CPT's.
But, how about seeing what we can do about ICD-9 (soon to be ICD 10) codes???
I see these as a bigger threat to doctors and our patients. Cataloguing all of our patients' diagnoses is right up there with monitoring how many eggs and donuts we eat each year. I would guess that <10% of the population know that the gov't and insurance companies have this data on them.
I have always been offended that I had to supply the insurer with an "acceptable reason" (the ICD9) and divulge private patient information to be paid for the CPT.

Younger physicians and "providers" do not remember that there was once a time when patient's actually had rights to privacy, even from the insurer. (That was when TV's didn't come with remotes) Now it is commonplace for the insurer, based on proprietary knowledge, to proactively contact doctors regarding how often their patients are filling their meds. May sound helpful to some, but is rather scary to me. Also, because the insurer does not have all the current visit notes (thank G-d) they make assumptions about care that is not accurate and are outdated. We then have to respond with more explanations. I just can't wait for the Healthcare Czar!!!!

My wife and I just met with our attorney where we discussed asset protection. Recommendation: Family Limited Partnership—sounds good for our needs—set-up cost $7,500. All just to protect us from other lawyers. Template forms printed by paralegals, modified to accommodate your assets, resulting in 3-5 hours of actual attorney work. $1,500+/hr.

I fight for table scraps from commercial insurers and Medicare. Where did I go wrong? Trying to help people.

I am amazed at the depth of feelings expressed here against the AMA. I agree with them, but I am surprized to find so many physicians with whom I agree.
The AMA makes more money from it's CPT and ICD9 coding it manages, which it reworks every few years to make money for itself. This generates far more revenue for the AMA than its dues, which are exorbitant.
I have often wondered why the whole system cannot be replaced by.... English? Our computers have advanced ot the point that it would be easy. The numbers were devised for a computer system that has long ago become outmoded and replaced. Why have numeric codes that just must be translated into English? Why not just establsh a unified English diagnostic lexicom?
Becuase, that could not be licensed, because that would not need expensive training courses, because it would not be controlled by the AMA.

The AMA believes in Socialized Medicine. The AMA believes the pharmaceutical companies have undueinfluence over practicng physicians. The AMA beleives in "Best Practice" standards as a method of reducing medical care costs.

I don't agree with the AMA, and haven't for a long time.

Dr. Jay Rissover

Did anyone stop to think just where those lobbyists are getting $1.4M per day from? The groups are the AHA, AMA, PhRMA and individual pharma companies, plus insurers.

I have difficulty believing that much money is coming from AMPAC, for example.

There is an urgent need for strong, bold, and vocal physician representation. I clearly sense that physicians of all creeds are becoming less apathetic and that the prospects for unity are now greater than ever.

I really like the idea of open-source CPT codes. In fact, using social media tools and leveraging the collective intelligence of physicians can make such an idea come to relatively quick reality. It's just going to take a little organization and leadership initially. The Linux operating system was developed as an open-source project and it's now the biggest competitor to Microsoft's OS.

We need to hold it together guys and gals. At the end of the day the public thinks we are over paid, maybe we are at some levels, the govt just wants us to become slaves, the lawyers want us to set more guidelines (read lawsuit mills) and our individual patients want more time and partnership with us. As a group we can do great things as bright as we are but very low level of participation at the level of goverment because we are too busy and not vested in our political leadership. Please keep our emotions in check and use Spock like logic. I like the idea that we get feedback directly from the AMA on some of these issues. I pay for my membership to the medical societies why not ask for a response?
oshechter get a life, personal attacks do nothing. I do my bit and try to help from the inside of medicine not just cry in my soup.

I think the AMA is a politized organization permeated by particular interests (the insurance companies). I don't feel represented by the AMA at all. We need to set a unified position before it's too late.

Daniel, your posts are beginning to border on the absurd. I am a cardiologist, it is CMS that is proposing the cuts to me. (assuming no health care reform), not the AMA. Why are you at war with the AMA? I also take offense that you claim to speak for "100,000" I , like many, signed up to this as a tool to communicate, never dreaming you would suddenly veer off on a tangent with a series of "plebiscite" votes as claiming some mandate to speak for all, as opposed to a real democratic discussion of issues as DOES happen in the AMA house of delegates. Your views are NOT representative of all people signed up, that is a delusion on your part, and for you to be claiming that to the press is the real lie here.
Fyi, I am for major health care reform, but battling each other like this will never accomplish that. Only the hard work of meeting with congressmen, carefully working out policy and discussing with a wide range of people in an open forum will do that.
I have my disagreements with the AMA, but I prefer an open discussion of ideas, not a blog and assumption of a self appointed messiah. Your blogs and pronouncements are now offensive and divisive, not at all what most of us signed up for, consider me out of this. I will battle for real health care reform , this blog is not that at all.
Mario Motta, MD

I salute Dan for raising the question(about the AMA and CPT codes) and creating 'transparency' about an organization whose roots are in the late 19th century. The partnership with Sermo offered a fine opportunity for the AMA to listen attentively and absorb what is being said by the grass roots of physicians in the U.S. Let's remember that the axe is not only Dan's to grind, but he issues the data that is extracted from SERMO's surveys. The AMA in true form has 'pissed away' this opportunity to really partner with SERMO, and they need us more than we need them. The real opportunity was to harness diverse ideas into one, not meld them into a useless, boiled down voice of an "AMA". Like most organizations, eventually the organization develops it's own inward looking culture...detached from it's members. Their reaction will not gain new members. The transparency of open networks, although diverse in opinion more realistically represents those of us who use 'new media'. The organizational model of medical politics has changed....

July 10, 2009
Dear Dr. Palestrant.:
1. It is better that the AMA designs the CPT than some ins co. or government agency.
2. Rather than your bashing the AMA and using inflammatory language, it would be much better to follow your own advice to join hands and focus on areas of agreement rather your differences with the AMA. The AMA has a lot to offer, esp given what Wash DC has in store for medicine and private practice . Sermo and the AMA together are much better than each separately.

United we stand, divided we fall, was never more real.

Dan,

"Focus on the things that unite us..." Whereas I have seen some comments in support of CPT (at least in theory if not practice), I have yet to see anyone post that malpractice is not a serious issue. If we all agree that lawyers contribute to the problem, then why are we not putting our focus in fighting the injustices done to patients and ourselves by these parasites of society?

"Ignore the things that divide us..." We ARE a house divided but this is a forum that can help galvanize us. Please use more of your talent and drive in harnessing all this energy here.

You've taken a stand. Great. Now how do we get the rest of us on board in a real and tangible way? I've contacted my elected reps, but once they are in office, they don't respond as well as when it's election time. Seems to me we have to get more grass roots. We have to involve our patients, without whom we have no jobs and who have at least as much to lose as we.
How about a consensus letter that we can give to patients to tell them what's at stake and how they can participate?
How about a consensus letter by and from us to our government reps?
What about SermoPAC?
How can *I* help besides talking to my colleagues and patients, and contacting my reps? (AMA has long since NOT been an option for me as well)

yet another true, depressing post. if i wasnt on call, it could be washed away by a nice cold beer.

Medical Physicians should be paid for their time. I have a few attorney friends who charge $500 per hour I probably charge 200-250/ hour if I'm lucky. And my overhead is much larger than there's. Lets think out of the box.

Suppose we have a "time card" and the patient punches in and punches out.
There are two parts to the card, one for the patient and one for the practice.
If insurance is involved they are billed for the physicians time rather than using a CPT code.
They could be billed by the patient (preferable) or by the doctor.

There are several advantages to this:

1. You are not a slave to documentation because there is no complex mapping to payment.
2. There is no waste of time figuring out what code to use.
3. There is no waste of time worrying about being "fraudulent".
4. The patient becomes the "watchdog" for fraud and insurance abuse because they know how much time was spent and they know what your hourly charge is (because you make it available)
5. The physicians contract is with the patient rather than the insurance company.
6. As physicians gain experience they can increase their hourly fee. As it is now a physician in practice six months makes the same revenue as a physician practicing 20 years. Why, because there's so much focus on the physical examination (which is hogwash) in determining CPT code. If you really do in examination it makes little difference how many years you've practice. I do a lot of counseling with patients and I guarantee anyone the patient gains much more from my 20- 30 minutes than a less experienced physician.


I'm sure there are other advantages, but I'm just throwing these out there for now.
I see nothing wrong with simplicity. Why is it that everything has to be crazily complex when that's not necessary.
I think the CPT coding was originally the bright idea of some statisticians and insurance managers who felt they could quantify everything in healthcare. For some reason the AMA went along with that, probably because there were financial incentives and possibly because they wanted the data themselves. Back then there was a lot of thinking about socialism (from a positive point of view) and the more the AMA and Uncle Sam knew the more control they could have over societal systems.

JMK

It is a shame that as a young physician my day is filled with disgust and frustration over the little value placed on my service to patients. I would like Barrack to know that everyday I fight to not let this effect my patient interactions, but it is. I will spend less and less time healing and more and more time figuring out what it is "they" want me to do to keep my life afloat and moving patients in and out on a conveyor belt. Is this what they want? The profession of physician is overwhelmingly honorable- do they understand this?

Mario Motta MD wrote...."i am a Cardiologist........";followed by purulent vomitus.This CARDIOLOGIST obviously lives in his own world where he is full of himself.PLEASE DO NOT COME ON THIS BOARD AND INSULT OUR DANIEL!! You did not have to come here;you were not solicited or even invited.Do you have a clue what it takes to do what this man has done with some help from his team?Do you know how many hours of flying,sleepless nights,time away from family geographically and emotionally,millions of dollars in debt,an eternity of trying to stay within the law,trying to justify within your self that it is all worth the cost if your suffering colleagues would just be heard for one milli-second?You probably think you are a big shot,living in Boston and perhaps heading up some medical society under the auspices of one association or another irreversibly attached to the coat-tail of the AMA.THIS IS OUT OF CHARACTER FOR ME,EVEN IN JEST,but you have really made me realize just how much Dr Palestrant's enormous sacrifices are taken for granted;especially by people like you.I do not know you,I do not ever wish to know you;WHO THE -----DO YOU THINK YOU ARE?TO YOU SIR,I YELL ON TOP OF MY VOICE:GO TO HADES,AND STAY THERE!!!!!!!!!!

I am truly sorry sermoans,colleagues,I lost my temper for the first time in 27 years.Forgive me but the aggro was totally provoked.If he had bothered to even read some of the commentary he would not have opened the window,exposing himself to my wrath......"I am a cardiologist....."Better just crawl into a fathomless hole after this one 'cos you will never live it down.Dr P can always fend for himself but I CHOSE TO DO THIS,for myself,in appreciation:-)

I'm not quite done.Cardiologist Motta,why don't you simply point and click?Remove yourself from this forum.If you were half a man,that's your only course of action.Dan,remember,actually OWNS sermo.FYI.

AMA
unethical
conflict of interest
should not represent doctors at all
sucking insurance money
no other business
would accept this model
doctors are just stupid
AMA aka mob
GETTING MONEY FROM BOTH SIDES
legal mafia
where are the federal investigators
ha

ak4700al,

Dr. Motta said nothing that should be at all offensive to you. You talk about sacrifice. You think Dan had to sacrifice to create a for-profit company. Maybe he did, but he doesn't even practice medicine - nor did he ever practice medicine. Do you have any idea what Dr. Motta has sacrificed in order to fight for YOU, to do everything he can to try to improve the practice of medicine for everybody else that is not willing to take the time away from their family. He has given countless hours to the cause for FREE. Time going to meeting after meeting. Time away from his practice causes him to give up income. He does not deserve to be spoken to like that. He was simply trying to get the point across that this anti-AMA sentiment is unwarranted. Are you against cardiologists in general? Are you against Bostonians? Are you against people that work hard? What is your issue?

ePediMA,how old are you?How long have you practiced the art?I will not insult you because you are ignorant,JUDGING FROM WHAT YOU JUST SAID.If you give your time and dedication to an organization that has demonstrated whorishness and impotence repeatedly,you do not deserve my sympathy or respect.On the other hand,someone that does not practice medicine or surgery specifically,for reasons most of us know about,yet,decides to get involved,virtually risking everything including a young family,having seen first hand and continuing to witness atrocities perpetrated upon his clan and keen by the SYSTEM with which your hero is involved,has earned my utmost respect.I shall not place you in the former category yet,a category of imbeciles.Your choice,you may decide to engage me,or not.I'll wait:-)

Old enough to understand that you are truly the ignorant one. Your comments to Dr. Motta show a lack of professionalism and a clear disrespect. Nobody should speak to a fellow human like that let alone another physician. For a physician to speak like you did is horrifying to me. How old are you? Regardless of your age, you are quite immature. I do not doubt that it takes courage to take the risk to start a business the way Dan did and I respect his entrepreneurial skills; however, how can Dan speak for us when he has no idea what we go through on a daily basis? At least Dr. Motta and Dr. Heyman and others who have repeatedly been insulted spend their days actually seeing patients as do I.

mmotta your logic is just not there. The AMA sold us out many years ago. It has multiple conflicts of interest and is making false claims of its physician membership. How do you advocate having such a corrupt organization represent us. Should we keep prescribing Oxycontin to the drug addict? (or perhaps something more appropro to your specialty. Propofol to the pop icon who can't sleep?) You sound like the typical academic physician who is so very far out of touch with the real practice of medicine and more importantly the business of medicine.

Here are the facts:

this site likely has three times as many PRACTICING PHYSICIANS as the AMA

the AMA is controlled by pharma and the insurance industry which supplies a good portion of its funding. Besides of course the sales the AMA gets from CPT codes.

CPT coding is a means for insurance companies and Medicare to deny care and their advent along with HMO's, which btw the AMA advocated its members to join, have ruined medicine.

there likely is a democratic discussion and then the AMA leaders do what the insurance companies and pharma tells them to.

you are delusional if you think that meeting with congressman is going to accomplish anything. They are going to do what pleases the highest paying lobbiest.

Healthcare reform without physicians leeding the way is not going work, it will only get worse. This is a real threat to our lives and overall well being. Besides your family what is the most important thing in your life? Your practice. Would you not fight if someone was trying to harm your family. Taking the typical whimpy physician stance (see AMA when Ob came to visit) is going to doom us. We need a united stance and a contingency plan in case we are left out which is the likely outcome at this time. Most of all we need an orginzation with the balls to stand up to the president and congress.

...."Are you against cardiologists in general?Are you against Bostonians?Are you against people that work hard?...."Since you asked those questions,I have one for you:How did you get into medical school?You must provide an answer;I doubt you really qualified!Some of us have ways of checking.Jokes over.I'm still waiting..........

OK everyone. Take a breath. Let's try to tone down the personal attacks on both sides.

Just as there are those who can't stand the idea that the AMA is perceived as speaking for all physicians when all physicians aren't members, one needs to emphathize with those who feel that Sermo's sudden turn doesn't speak for them. Sermo brought in people as a neutral forum. Some (Many?) people even joined when the linkage between the AMA and Sermo occurred. It's hard for those people to then not feel betrayed when Dr. Palestrant uses those member numbers as part of his "base" when speaking for his viewpoint. While I don't think anyone challenges his right to do whatever he wants to with his website, him saying he speaks for everyone who has ever registered on the website regardless of their current level of activity is certainly going to bother those that disagree with him. It's also not going to bother people that agree with him. So, imagine if the statement were reversed and Dr. Palestrant had come out in favor of Canadian style single payer, would you still be as enthused about the way he is using the site? How about if he came out for all physicians taking big pay cuts? [He isn't for any of those, but the point is, it's easier to approve of his actions when you approve of his message).

Let's also try to agree that the AMA is not composed of evil people who are trying to "screw" physicians. They are physicians, and people. 2200 people went to the House of Delegates, unpaid, taking time away from their practices because they cared enough to try to be involved. They are not infallible, and to the extent that they are trying, let's try to give each of them the benefit of the doubt that they are doing their best to improve health care as they see it. Call them wrong, call them misguided, but calling them individually unethical or some variation on that or implying that their sacrifice is worthless because they haven't accomplished what you want them to is unnecessary.

Telling people to leave Sermo because they don't agree with your point of view (or Dr. Palestrant's) goes against what I believe the potential power of Sermo is for, allowing opposing viewpoints to discuss issues, educate each other and come to consensus to move forward. It seems that people who have left are sometimes told that they are cowards, and those that do respond are told to go away. Good arguments get stronger with more testing and withstand that test in an arena, friendly or hostile.

I'm likely as guilty as the next person in not adhering to all of the above, but I have been trying and am rededicate my posts to providing good information, logical arguments, and yes, perhaps occasionally a little passion.

Can we please argue the issues and try to leave the personal insults of other Sermoans aside?

ak4700sl,

I am not going to have a discussion like this in a public forum. The rest of Sermo should not be subjected to listening to this. Any further discussion between us can be private.

ePediMA,you do sound like a M.A. If you can still justify any defence of POLITICS in medicine,you have joined the aforementioned category.Open your eyes,just for one nano second.Don't get caught up in methodology established by ineptitude and herd mentality.Review your stats,then say somthing of substance.How dare you.ewe lamb!!

Surgonc sir,with all due respect,if you feel the sentiments on sermo do not represent your experience,why are you here?I am being sincere.This is war,literally.You are with us or against us.What is there to negotiate?PHYSICIANS WHO STILL FEEL THINGS ARE FAIR MUST TELL THE REST OF US WHAT THEY DO TO GET BYE,regardless of speciality.The span of life is too short for some of us to continue on this path while less informed and 'worthy' people have it all.WTF?And some kid fresh out of residency,already brainwashed by the system that rapes us, opens his septic stoma.I'm here,bring it.

You are either a politician or a physician,you cannot be both.Review that statement.I stand by it,inexorably.

ePediMA,please do not send me ANY more private e-mails;I have nothing to hide.If you have anything to say,let all share.Such exaltation;what makes you think you can have a 'discussion' with me,starting the way you did?You speak of respect.Who raised you???

This is getting way over the top. Come on guys relax. If there is any role for Dr P it should be to ban people who are resorting to personal attacks. The idea that somebody should leave Sermo because they don't agree with "Sermo" is almost scary. We are a big diverse population. There is no "Sermo" opinion. If I am wrong, then this site is becoming a cult. I hope I am wrong.

I have not once accused an individual member of the AMA of ANYTHING.THE ORGANIZATION has misplaced priorities.During the Presidential address,why did the charade continue after he said NO to tort reform?Somebody,anybody give me a reasonable answer and I WILL SHUT UP,for good.

Maybe they wanted to show The President of The United States of America the respect commanded by his office.

Hey, Mario is from Salem. Calling him a Bostonian is like calling an Irishman English.

nickfogelson,everything in life has some kind of heirachy.You have practiced for less than 5 years,in academic OB/GYN.Forgive me but you are not in any position to even begin to understand anything.There, lies part of the problem.Candidly evaluate your experience with the system,the only system you know,obviously,since you were still in grade school when medicine........what's the point?Good luck.

My five years in practice in academic OB/GYN were not necessary for me to know that you are being a total ass.

SMFleet,I have followed your perspectives.Forgive me for rant.Deep within your heart,do you think there was any cause for some 'effect'?

nick,I said less than five.3 to be exact.You have only mastered abortions.Tell me it is not true.

Ah.. you edited your post after my comment - no fair!. I'm doing fine and enjoying my job taking care of my patients. There are all kinds of problems with the current system for sure, but they don't make me not like being a doctor.

I don't disagree with the goals of reform, but I am against the kind of hyperbole you are promoting, and the mispresentation of the Sermo population as some sort of mass consensus of physicians. We're too many too all agree. Can't we just have good dialog?

It seems like as a whole, the AMA isn't getting the job done for us. But as individuals, it is filled with a lot of good ethical people who put in a lot of time because they think they can do some good. So they don't get it all right. Neither does the President, but at least he tries.

Sorry about my last comment, but I just had to say it.

There is a lot of heat here, ak4700sl, and a lot of strong feelings. Although this is understandable, it is also true that behind the names you see here are real people. Mario, for example, is a hard working physician from Salem, who knows private practice inside out. He genuinely works hard to promote physicians' interests. He is not pompous or self-serving. To insult him is simply wrong. On the other hand, if you don't like the AMA and have strong feelings, that's OK.

Huh?. I'm board certified general OB/GYN and I do it all. I also have an interest and expertise in family planning that you are referring to, but it doesn't define me. Read my posts - lots of stuff outside of family planning.

Were I you,I WOULD FIRST LEARN;certification does not breed wisdom,common sense or sagacity.This is not an insult.You are probably just as old as my offspring.Nothing lost,just learn a bit more before you jump in.You are innocent in a corrupt society.

Good lord. We all have a lot to learn. You should read the Four Agreements. A good book.

I have no beef with you;I am a vegetarian:-)Have a good night.Aloha.

Mario insulted all of us,albeit indirectly.He works hard, yes.Dr Palestrant has been more relevant in my opinion.This has to come to a head.A lot of us are tired,have nothing to show after years of dedication.I was harsh,angry,perhaps loud but I chose to be.It came from the heart.I still think he shouldn't be here if he thinks the AMA'S WAYS WILL CHANGE ANYTHING.Here,we seek a new order:-)

it appears that people take for granted the service that physicians provide never taking into account how hard it is to become a good doctor. In the Cardiology aspect, Cardiologists and other specialist will have to find a way to defend themselves.
- Example: You want to cut down 40% in the pay of reading echos. Ok very simple... I would use a software to make me 40% faster, Read echos 60% quicker. It would be nice if just one day doctors decided to unite and only see 50% of the patients they needed to see in one week just to evaluate that outcome...

AK4700sl.
I've been on Sermo, nearly from its inception. I enjoy reading what others are thinking, and occasionally am pleased when I can help a fellow physician out with an opinion or insight as to their problems. A specific viewpoint didn't seem to be a particularly strong focus of the site, and everyone's opinions seemed welcome across the site (the occasional AMA attacking post aside). This only came to a head, when in the past few weeks, Dr. Palestrant felt it his prerogative to appear to change the focus of the site. It's his right to do so, but having spent some time with people who have worked within the AMA, and having done so off and on, felt that they were being unfairly maligned. Offline, I have spent as much time being frustrated as any of you, but having worked hard in trying to fix some of these problems, including flying to DC multiple times to meet with my congressional representatives' aides, I can personally vouch that effecting change isn't as easy as one would hope.

So why am I here? I'm here because I enjoy participating in Sermo, particularly on the clinical side and talking with other physicians across the US. I'm willing to accept a few slings and arrows as I've been on the Internet since 1991 and know well how easy it is to get carried away with your emotions on line.

Why am I still participating in this post? I have never said that the sermo discussion does not reflect my experience and frustration with the hassles of being in practice. What we have, at least in my discussions is a question of tactics and what the source of that frustation is, as well as what is the most productive avenue for proceeding currently. I have not disputed your experience (I don't think so anyway, hopefully; if so I apologize), nor your passion. While my experience in working with the AMA has been different, it is just that, my experience. I still believe, that an open exchange of our ideas and our experiences in any forum is worthwhile, and hope that by providing my thoughts, others will benefit from my experiences. I also still believe that all physicians should try to have a role in shaping the future of health care. If Sermo turns out to be an avenue, I will do my best to influence debate here, as I have done my best to influence my specialty society and the AMA. Of all the societies I participate in though, the AMA is the most democratically run. Sermo has an even greater capability to be so, but we have to be open to debate and to those that disagree, if we are to be strong when we decide on a course of action. That also involves, IMO, Dr. Palestrant not self-selecting himself as our spokesperson, and stating that he speaks for us all without a mechanism to ensure who that "all" is and what that "all" wants in a representative fashion in a way that we can properly discuss (allowing us to put in our own answers on his FtF posters would be a good start) what our preferred language would be.

And thus, I believe in healthy debate, trying to avoid insults whenever possible. This reflects the Sermo code of conduct Sermo Doc and I will stick to it as best as my human fallibilities allow me to.

Another problem over the years has been incrementalism. I mentioned how the procedure codes didn't seem so bad years ago, and BC/BS would even teach you how to use the codes more effectively and make more money in your office. Similarly, the joint commission probably wasn't so bad at first, just making sure there were no cockroaches running around in the OR. Before you know it, you're asking former Navy Seals in the cardiology clinic whether they feel "safe at home." Btw, the nurse or medical assistant forgets to ask whether the patient has been hospitalized since the last visit or has had chest pain, but "are you safe at home?" You have to sign your name 12 times and write four notes before you can press one button to do a simple cardioversion. There are little "pain posters" on the wall so patients can point to their level of pain. I believe the posters were produced by some drug company that makes pain pills.
In short, all these aggravations and demeaning things have built up gradually over the years. Now, it's time to step back and see what the problems are and work together to solve them. The last thing we should do is fight each other.

Our country is still wealthy enough that there is enough money to go around, to treat the sick, and make sure we can all make a living, generalist or specialist.

As far as the legal system is concerned, there must be protections for patients so that when a jackass doctor does stupid, injurious things there is some recourse to collect damages.
On the other hand, we all know how many exams and tests are done unnecessarily. We all know how many CT's of the head have to be done before you find one tumor causing headache. My suggestion is to fight fire with fire, to hire a huge staff of renegade tough ass lawyers who can expose the malpractice profession for what it really is, a tool of lawyers to make big money, and in so doing, bring medicine to its knees and bankrupt the economy.

surgonc,your points are well-taken and quite appreciated.Please review the comment by the Cardiologist that instigated this melee.If Dr Palestrant is 'delusional',what does that say about the entire physician population of sermo?Clearly we were dubbed psychotics.Simply stated,he said Dan has built castles in the air,but worse,we all moved in.I'm over it.People should not insult me or others and expect immunity.Claiming they did not 'mean it that way' is not valid,it is in print.Please review the original comment by Dr M.

As I've 'opined' in various other posts, the issues involved in this cause clearly have defied 'solutions through established channels'.Where are the alternatives?Nobody has even heard a whisper;not the government,not the corporate giants,not the citizens of this great country who overwhelmingly believe we are all rich and finacially secure.First,we need to at least be heard.Somehow.

ak4700sl--we all thought you might cool off overnight. Even with all this political storm, it's still a nice summer!

Again,I'm truly sorry I lost my temper.Please move on with more progressive thoughts.SMFleet,it is indeed,a lovely day.

I agree with NICKFOGELSON on the first page of posts on this thread. I think it's completely inappropriate for Dan to pretend to speak for all of us by writing biased surveys to justify his own rhetoric. True DISCUSSIONS are engendered by asking open-ended questions (perhaps Dan forgot this from his med school days??), not by typing sermons (sermons on sermo, ha!), biased questions begging for specific answers, and then asking for comments.

I do not find CPT codes offensive in and of themselves. Are there problems with their current use? Absolutely! Yes, we SHOULD be documenting thoroughly and properly to get paid--and EMR will definitely help with that, making documentation easier to justify higher level reimbursement. What's wrong with that? For example, if I had a 15 minute conversation with a teen about safer sex, STI/HIV prevention, routine STI/HIV screening, etc. you bet I'm going to (and should) document that. What I find offensive about CPTs is that PROCEDURE-based specialties reap HUGE gains from their use over THOUGHT-based specialties, which is precisely why procedure-based MDs make a heck of a lot of more money than thought-based MDs, generally speaking. THIS is what I find unfair. I could care less who "owns the rights" to CPTs codes. I care that given CPTs are reimbursed fairly, respecting that thought-based diagnoses and time should be paid just as well as, if not more than, procedure-requiring diagnoses and procedures themselves that may take less time. For example, compare a 2 minute mole excision by a dermatologist vs. a 30 minute well visit with preventative health counseling by a pediatrician. Which is reimbursed more and why? What else I find offensive is that certain insurance companies can choose to reimburse for given CPTs or not. Take for example "obesity". Many lump this in with preventive/well care and won't pay for "obesity" in and off itself--nevermind that you spent 15-30 minutes of documented time counseling the patient on specific dietary changes and exercise routine. How to get around this? Code for its comorbidities "acanthosis nigricans," " elevated blood pressure," "dyslipidemia", etc. and/or call it something else within reason, eg. "abnormal weight gain". So, in summary, are CPTs all that bad? No, I think they're necessary--regardless of who "owns" them. But do they need SIGNIFICANT revisions? Absolutely!

Finally, would a cash-only (Cash Please, Thanks) practice really work? Sure, if you work in an affluent area, and many here on Sermo have made it work for themselves. That's great! But consider the populations they're serving. For most of us, absolutely not--from a financial point of view of just having enough patients to stay afloat--let alone the discussion around access to health care and servicing patients' needs the best.

Finally, Dan, if you really want to build consensus, engender real discussion. Tie a knot, not a noose. Better yet, make a braid; work together. Knots are too fixed. Get off your high horse!

From the American College of Cardiology: "The Centers for Medicare & Medicaid Services [CMS] proposes cardiologist paycuts ranging from 10% to more than 40%." GPs, FPs, internists, and geritricians will see an increase in payments of around 6% to 8%. Cardiology consultation codes will be eliminated and paid as hospital or office visits (at 11% increase).

Echo payments (93306) will be cut by 42%, left heart cath by 24%, and EKGs by 21%. Any decrease in Medicare payments will soon be followed by third-party cutbacks at well.

So, all of you cardiologists posting above comments, should unite to fight the CMS proposals before they go into effect. Don't fight amongst yourselves here. The Obama federal healthcare program is about to screw all of you.

By and large, we cardiologists are well represented through the ACC and other societies such as SCCT, ASNC, ASE, etc. Also, most people (including legislators) are familiar with family members having heart attacks, etc., and hopefully have had decent experiences dealing with cardiologists.

General internal medicine and family practice are often less charismatic than the subspecialities. You folks HAVE to stress the importance of preventive medicine in reducing health care costs. You need better representation. The ACP, as I recall, seemed to have its head up its ass. They could never figure out a way to make internal medicine more compelling and desirable for medical school graduates.

"GPs, FPs, internists, and geritricians will see an increase in payments of around 6% to 8%."

GOOD! About time primary care and thought-based specialties got increases! Have you ever heard of a poor cardiologist, really?!?

Just to share this troubling report, though.....I think we pediatricians may see some troubling times ahead:

Sermo Doc

........... and of course, the other option is to opt out of medicare ........... change to low overhead model and enjoy free time with your kids

Primary care has been promised increases for over twenty years--I remember waiting for the increases in the 1980's, and it never happened. If they promise something, you're going to have to ride them hard to stick to their promises.

Assuming an increase of 6 to 8 percent comes to pass,is it really significant?15 years ago,i could pay my MAs and front office staff between $8 to$10/hour;now,they make $15/hr,after all those years of loyal servitude;they have families and have to deal with inflation.Rents,materials,premiums,everything,has gone up in cost but overall income has declined.If primary care payment is doubled,perhaps we can call it redress.I did not mention you have to work twice as hard to make the approximately 30% less income;you have to jump all the new hoops to comply with all the mandates.6-8% just does not seem fair.How do we reconcile 30% less income with 40% inflation in the cost of running an effective internal medicine practice?

I completely disagree with dipping into specialist income.They do not make enough either,perhaps not as blatantly as primary care.Where is our own bail-out?We probably contribute more taxes than a few of these industries that were bailed out with the peoples' money.

I'm not saying the actual figure of 6-8% is a lot at all. I'm merely applauding perhaps the recognition that primary care and thought-based specialties should be more highly valued than they currently are, relative to procedurists.

Glad to see the tone cool down and the focus returning. Ak4700sl it is a war and unfortunately physicians in general would rather fight among themselves than unite. Until this really changes many times what we progressives are doing seems helpless.

Sermo is a movement, soon I hope to move to a viable , sustainable, indispensable and invulnerable organization.

We physicians have too long allowed others to eat our lunch and at the same time have many times chosen to give our lunch away.

It is time to find the uncommon common ground and unite to revive our profession and protect our patients.

The war is on, who side are you on? Patients and Physicians vs. government and insurers.

Agree,latinomd.Sermo is a great vehicle;not only the best to date,but apparently the only one.Remember how Barrack won the election?Truth and transparency;he just now cannot control implementation.Darwinian principles remain the order of the day.

CPT even ruins it for the cash-only on concierge practices (which I am sadly not a part of either) in my area. They still have to create 1500 forms to give to the patients for reimbursment. They can't even get away wit giving them a superbill for the patient to turn in.

If every AMA member said to the AMA . " Do not allow the use of the CPT coding system (since the AMA owns the rights to it). " Basically pull it off the "shelves, computer systems, coding systems, ect. What would happen to the governments' and insurance companies' ability to perform their functions of payment for services? I bet the government would TAKE the CPT from the AMA " for the common good of the people". However, it would create quite a problem. Not that the AMA would actually listen to its members and stop the selling of the CPT.

I believe the third party payment system is incredibly inefficent. Leaving out all of the "middle men "from the point of your money leaving your hands as a patient to entering the hands of the provider of service is much more cost effective. Health insurance... to protect us financially from castatrophic events... has morphed into the third party payment system for all forms of "health care". The middle men are "always" going to take their cut so that they can stay in business (whether it is a private insurance company or the government). Price transparency and competition with cost and quality as factors for the quality of service (product) provided will be brought back to medicine if the system of care were transformed into one where patients are responsible for first dollar costs. However I do not believe we will be able to go back to a cash basis system. But one that eliminates the middle men will put the decisions back into the hands of the physicians and patients. We doctors would have to accept that the patients are going to ask us "how much is this going to cost?" and give a competitive and honest answer to stay in business. Oh for the days when my father-in-law got a chicken, pig, or a piece of furniture for payment for his service as a country doctor. Things were much simpler then.

What the govt giveths, it can taketh away. Do you really think 6-8% more for primary care will actually matrialize, and wthout strings attached? It will be a farce, just like the rest of the "reform" that is close to eing shoved down our throats, wiht very little if any input fromindividual practicing physicians, as opposed to large "physician organizations", that have their own interests in mind.

As for cash only, my area is a mix of upper, middle andlower income levels. My "retainer" portion of my practice has individuals from each strata. So your statement about cash only only working in affluent areas is more elitist propaganda.

If you truly want to help the lower income, bring costs down by owering the cost of doing business, and allow competition to develop. Having govt set prices stifles competition and keeps the lower income stuck there, instead of giving them a way up and out.

Do you think that Obama is going to put through a federal government legal program so that all American citizens can have access to legal services at reasonable rates? Hell no, he's an attorney. He'd rather screw doctors instead. He doesn't receive Medicare/Medicaid medical care services. So what does he care if our payments go down.

He's already a multimillionaire who wastes taxpayer money by traveling all over the world with his family.

I'm telling you that the medical profession is coming to a crossroad fight with the feds. Obama wants to push thru his healthcare program at OUR expense. It's time for us to organize to start saying no to CMS, Congress, and Obama. If we just keep arguing amongst ourselves, we'll be dead in the water this time. Obama is the toughest president we've had to deal with and he doesn't plan on losing.

We need Sermo to assist us reverse any CMS paycuts for next yr or you will get hit in the pocketbook for sure. And we need to start very soon in going after the CMS paycut proposals. Don't count on Congress this time to bail us out. Not with Obama in there...this guy doesn't quit and give in!

I agree that we need to stand up and be heard. Start by having a conversation with every single patient, every employee, every colleague, every member of the staff at your hospital. Host a talk at your medical staff meeting. Congress may try to push this through to a vote by the end of August. Call ALL of the 535 members of the House and Senate not just your representative from your state. If they say you don't live in their district, remind them that you pay federal taxes and that they are your employees. Our power is in speaking up and being heard and in the fact that we are still very respected members of society. Be respectful and offer solutions. It would be great if a large number of us would support a solution of our own. Face it, we are going to pay for whatever changes that are made in health care whether it is in lower reimbursement or volume (they can only decrease "costs" by fixing and lower prices or by rationing), or by increased taxes that we will pay. If you go down without even trying to be heard then you deserve what you get.

All the docs that treat those congressman and senators, Speak up!!
If they don't listen. Fire them as a patient.

CPT codes, like AMA membership are a voluntary matter. Doctors, smart enough to get into and through med school, are skilled enough to dump both of the above and operate successful fee-for-service practices.

The America Association of Physicians and Surgeons is our real advocate. Check 'em out: AAPSonline.org

The less hands controlling how money comes from payers to physicians the better. We are the end users in this corrupt system. RNP and PA are unable to do all the work, even though if they continue in their practice pursuits they are eating the lunch of primary care physicians( the volume easy work) and leaving the complex care and chronic care complex issues to physicians who will be getting paid less but expected to deliver higher care.

Organize, stay focused, use SERMO as a tool and maybe our best alternative currently, things will evolve and today's SERMO will not be tomorrow SERMO, Dan knows this , he is trying to show the community the light on this dark path, how to navigate this complex road.

We first must trust the truth and transparency. Then something that is harder needs to follow and that is trust one another that our collective will , values and shared goals will drive optimal change.

I always find it interesting when organizations tell you that the problems will be addressed in the "new and improved" version.Oh, by the way that it at the "low,low price of $ 399". I think that we are seeing the government's plan for universal coverage is slowly unfolding. First, we make those responsible pay for it. (I thought that indentured servitude had been abandoned.) Second, start with the greatest offenders, cardiologists-no more $100k pacemakers/defibs, caths, PCIs with stents,etc.;next in line, procedure-oriented MDs esp GI, Pulm and nephrology.The latter group needs to do all for "one low payment of".....The goverment attitude of doing more with less is at work.Again I find it quite disquieting that those in charge can in America restrict the income of a group of citizens and do it in the name of fredom and equality.

Another great organizing tool:

Sermo Doc

I don't mind CPT coding as much as I mind arbitrary rules like GLOBAL periods and refusals to pay for two codes in one day. This is complete BS. Even most in the medical profession are unaware that consults and surgeries cannot both be reimbursed within 48 hours of the initial presentation. This makes all emergency consults by surgeons FREE. For example, if I get called into the ER at 4 AM to see an appendix patient and take them to the OR that day, I get nothing for the consult. This irks me more than anything. I should be reimbursed MORE for coming to see the patient off-hours, rearranging my schedule, and doing the patient's surgery urgently.
Likewise, if at the end of a 5 case, exhausting day, I am changing my clothes to go home at 7 pm, and as always I get paged to the ER for an urgent surgical problem. Again, no pay for this at all. Show me ANY other profession that would put up with this crap. Meanwhile my dentist makes 2 grand for a crown.
Now our office has a rule that surgeries can only be scheduled 3 days after initial consult (non emergent cases.) We need to have the kahunas to flip the bird to insurance cos. and Obama. I'm preparing my debt schedule to run lean and mean and take more time off when the system gets worse.

OK, see the report from the Iowa Medical Society. We need to organize and become activists. Get the letter writing team together again and this time write something brief and to the point: We won't tolerate a paycut and will refuse to see Medicare/Medicaid patients. Write the letter to CMS, Congress, and Obama. It can be done within one week with no bickering done. You will not have another chance in a few months. The paycut for 2010 will be a done deal; Congress is NOT going to reverse this one like they have done during the past years.

See

Sermo Doc

dated July 10, 2009 and do an email subscription so that you can keep current on what's going on.

Wow, after a long week I cannot tell everyone how heartening it is to come back to this post. Seeing the discussion cool back down and people returning to the issues at hand might in fact be a Sermo first :) Perhaps this issue is that critical?

The series of FtF posts have already succeeding in their primary goal of opening critical discussions among physicians. As a group, we are starting to question things that just don't make sense (AMA membership is $800 and their 2008 income statement says they got $44MM from membership dues? Do the math). CPT codes are completely absent from the current debate, go figure? President Obama stands in front of the AMA congress and says we are going to radically overhaul our healthcare system and then states that tort reform is not on the table.....and the AMA president claps? Now is our moment to be asking the tough questions.

The first step to recovery is recognizing that we have a problem. It is a tough process, and frankly I don't think any of us relish it. The next few weeks we'll be seeing this effort shift into it's next phase. There is already a grassroots effort underway. Anyone who would like to participate in that effort, please email me and I'll put you in touch with the physicians leading the effort. Likewise, the weekly posts will gradually shift to community generated, nominated and voted. The beauty of this medium is that it creates the opportunity for profound transparency and democracy. You can bet we'll taking advantage of that.

Take a stand. Tie a knot.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.

The AAPS language sounds about right to me, but I don't think it will play in places like MA or NY. The link to their lawyer's speech in Texas is also very good.

Speaking of Texas, can someone summarize what happened there with the Texas Board of Medicine that some are alluding to? What were the issues? How was the Texas Board anti-physician, as the AAPS lawyer comments? Did the great state of Texas go cuckoo?

Dan, very good! Thank you!!!

As far as AMA dues, they definitely offer discounts to large groups (like Lahey). The students and retirees probably pay gor nicht mit gor nicht. So the $800 figure probably doesn't hold across the boards. Of course there's always the possibility they inflate the membership number.

Take a drink. Tie one on.

I also think they bundle dues sometimes with the state and local organizations. You can also get a multi-year discount. In short, who pays retail?

We made the Huffington Post:

Sermo Doc

The Dues this year for the AMA itself for a full practicing physician was $420. According to the website, the 1st 2 years of practice and military physicians got discounts. Residents pay 45/yr; Students pay 20/yr and part time semi-retired physicians (1-20hrs/week) pay $210. Sermo Doc
Not shown anymore is the (now discontinued?) lifetime membership option that they used to sell.

Many states are also ~400/yr so that's were the $800/yr comes in I think most people think of for dues, although you can join the AMA and not join your state society, I'd venture to guess that more people join their state and not the AMA than the other way around.

Arianna is another nut case.

DoctorSH, since when is Moorestown, NJ "a mix of upper, middle and lower income levels???" It's one of the wealthiest, most elite towns in South Jersey!!!! What do you consider "lower income?" $65,000/year??? Come on now. Aside from a small number of rent stabilized housing that Moorestown was forced to take by law, I'm not seeing too much suffering going on.

I sure hope ak4700sl Internal Medicine checks his lithium level before he gets back on here.

He has his own post now and is working on making a new AMA. All MD members would be connected by computer and could vote on resolutions. If the new AMA had 600,000 members, at $1000 a pop, it could accumulate 600,000,000 dollars. I selflessly offered myself up as treasurer if that will help the cause. Funds would be deposited in Peabody, MA, where they would be safe. I would arrange for doughnuts and coffee if there were any "live" meetings.

I read the Huffington post article and don't necessarily mind Dan reporting the survey results, but I'm very uncomfortable with seeing our actual posts listed, even without names. As Sermo citizens, I feel we should be afforded a little privacy so that we can enjoy the liberating experience of posting semi-anonymously. But having our words—often emotionally charged and sometimes quite raw—out for public inspection is very discomforting.

Dan, I hope you reconsider this strategy, because this disclosure may make many physicians wary of writing honest, thoughtful posts. Moreover, if we intend to formulate some type of strategy to combat insurer and government oppression, we don't need to show our hand too soon.

Also, some real names get into the comments, both one's own name and people mentioned. This is often a judgement call, but the audience intended is the Sermo members, not the whole internet. For example, if I mention the head of the Mass Medical Society, he is kind of a public figure at this point. But I'm not sure I want specific names going out to the whole internet. If the comments go out wholesale like this, I would reconsider Sermo membership.
Also, physicians may be honest with each other about money concerns, petty rivalries within the profession, specialist vs. generalist, who has the right to admit or refuse admission from the ER, etc. These are "family matters" meant for physicians, not to display dirty laundry to the whole world.

Also, humorous comments may not be understood by the internet at large. Comments we make about each other, practice, patients, etc. may not be politically correct but may allow us to let off steam. They are not meant for public reading.

I don't think Sermo should allow any of this to go out into the public without clearing all comments through the writers/speakers. Again, I may have to leave Sermo if this continues, and others should also reconsider their membership. This seems contrary to the originally intent of this site. Think I'll do a post of this now.

<Think I'll do a post of this now>

Good idea.

Agree with jbluster. It's getting a bit boring to read complainers over and over again. I want to hear from people who are actually trying to push their way through the organizational chaos of medical finance and come up with some real ideas for making a real difference, that doesn't make things any worse than the already are.

I am planning to go to my first State AMA meeting this October. How many of you have even done that? How many of you have not done that, yet claim that no one is doing anything for you?

Who among you would complain that nobody helped you get through medical school? Nobody else but you could take those tests or examine those patients on clerkships. You are all self-built private corporations. Stand up and be proud of that, remember your roots, and get motivated about organized medicine!

fpmdjk,why lithium?Such a basic element.What's wrong with valproate or lamotrigine:-)Everyone else moved on.Try and have a bit of fun;sometimes it alleviates the tedium.

Excuse me, I just read the entire transcript of the Obama speech (admittedly on the AMA website) and I could find no mention of any particular policy toward malpractice reform or tort reform, other than multiple references to saving money. Is there any location in this great Union that tort reform has made the overall cost of healthcare rise?

Can somebody clarify this for me?

If Organized Medicine declared that "we must have tort reform", and in reply Mr. Obama declared that he "must have consensus from all stakeholders to make a deal", I don't think that necessarily constitutes opposition. That's a pragmatic starting position for the top power broker in a very complex negotiation.

I ask the participants on this website to not make broad statements about a sitting President's antipathy for tort reform if it actually does not exist.

Certainly, he may have said something like that on the campaign tral to get the left wing into his camp. However, now that he is elected he seems much more pragmatic than the liberal intelligentsia might have wished. I think that's just fine with me and the House of Medicine. I think we can work with the man and actually get something useful accomplished.

SMFleet,I am not 'working on' anything;merely making suggestions.I leave the 'working' to the rest of you that have the ways and means:-)Im just one of the primary care serfs.

Think about the alternatives. Would we be better off if every insurance company required us to use a different and unique coding system? In fact CPT allows us to effectively understand each requirement for development and submission of a "clean claim."

Now, the fact that the system isn't free but is licensed by the greedy scumbags at AMA is an entirely different issue...

They Are about spruce up a cart being pulled by a dead horse. My wife have been in family practice 28 years. We recently got hit with a "audit" by Oxford. They are disputing $2218.36 on 62 claims from '02 to '07. Based on that dispute they are trying to extrapolate the claim to$109,000.00 based on their interpretation of CPT coding. We did our own audit and found that 90% of the disputed codes were for medical clearance physicals that they are trying to down code to simple office visits. We cannot move forward toward so called health care reform until we eliminate the cpt coding system altogether. Development of EMR to perpetuate a flawed system is lunacy. We have a three physician group and as of september 1st we intend to completely dismantle our practice and start all over as fee for service only. The practice model we are working now is simply not sutainable. AMA was never inour corner and never will be. I say shut it all down and start anew.

I am starting new practice and have signed up with BCBS and one local HMO (pays 120% of medicare) only.
All else pay cash.

I hope to build practice enough in 6-12 months that I can start chopping off these insurances as well..... hopefully before they go bankrupt or are shut down by the govt. Their contract does say that if they shut down, I hold no claim.

Working with insurance co is getting worse and worse ......... as they drown in their own sins (bad investments), they will pass the risk to us (recovering money in addition to routine tactics).

Go cash.
It may be tough, but it has its joys.-- at least you will get paid for what you do.

or go micro -- Gordon Moore model.

SMFleet, the Texas Medical Board has been cuckoo for some time. They are not so affectionately known as the Taliban Medical Board. Now, in all fairness to them, there have been some recent changes in a positive direction. The Medical Director who was both a lawyer and doctor, idiot and a$$hole, has been replaced. I don't know much about his successor, but ANYONE (including my pet terrier) would have been an improvement. The President of the TMB, a very dishonest Pain Specialist (who was also a huge problem) recently resigned in well-deserved disgrace, when it was determined that her husband had been anonymously filing complaints against physicians, some of whom were her "competitors"! Only in Texas!

Texas is sorely in need of physicians but the TMB has actually taken steps to prevent doctors from relocating to the Lone Star State. It is madness.

Does anyone have a problem with the fact that our posts were made public? Bueller?... Bueller?... Bueller?...

droelhaf-

Obama stated that he has no intention on placing a cap on malpractice awards. Here are his exact words.


"Now, I recognize that it will be hard to make some of these changes if doctors feel like they're constantly looking over their shoulders for fear of lawsuits. I recognize that. (Applause.) Don't get too excited yet. Now, I understand some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That's a real issue. (Applause.) Now, just hold on to your horses here, guys. (Laughter.) I want to be honest with you. I'm not advocating caps on malpractice awards -- (boos from some in audience) -- (laughter) -- which I personally believe can be unfair to people who've been wrongfully harmed.

But I do think we need to explore a range of ideas about how to put patient safety first; how to let doctors focus on practicing medicine; how to encourage broader use of evidence-based guidelines. I want to work with the AMA so we can scale back the excessive defensive medicine that reinforces our current system, and shift to a system where we are providing better care, simply -- rather than simply more treatment.

So this is going to be a priority for me. And I know, based on your responses, it's a priority for you. (Laughter.) And I look forward to working with you. And it's going to be difficult. But all this stuff is going to be difficult. All of it's going to be important."

This whole statement just shows how stupid Obama thinks doctors are. Sure. I am for reducing errors. But as a lawyer himself, he would know as better than most that most of these law suits have little merrit

Sandyfoot, the only folks who I think really might be upset would be those who used their real names. I wasn't one of them. To some extent it is probably a good thing. It appears that the Huffington Post people got the message that many, if not most physicians are dissatisfied, both with the current system and all the potential "solutions" being offered. I think that Liberals (in general) do not view physicians as the enemy, and tend to respect our opinions.

Well, anyway, it WAS the very first time that anything I have ever said has ever appeared on the HP. I would not be one of their favorite commentators.

And Littman, you are spot on. Obama thinks we are stupid, Of course, the feeling is mutual for some of us.

sharpdoc, I'm glad you cleared that up. As far as names go, I think that you should stand up for what you believe...proudly! I'm proud to disagree with the AMA and I'm proud to stand for being in favor of returning the practice of medicine to us...the professionals who know how to do it.

I agree with jbluster.
The 2 biggest problems right now are 1. Drug companies and insurance companies and administrators are stealing the biggest share of our medical payment dollars instead of the money going to those who take care of the patients. 2. many sick people cannot afford health care.
Going to all cash solves the first problem but makes the second one worse.
It is simply immoral for physicians to only be concerned with our own working conditions and income without addressing the needs of lower income people who cannot afford medical care.
The AMA is not the problem, CPTs are not the problem its our system that is the problem and unfortunately it looks like we need government to fix it as it is clear that what we have been doing so far isn't working. Physicians need a voice in planning the solution but that voice needs to be willing to recognize that our patients should be our biggest concern not our wallets.

gashrink, there is no question that the bureaucracy of health care has been siphoning off dollars that should be used for the patients at an increasing rate over the last 30 years. The health care administrators have figured this out...big time. And the AMA has been aware of this and has played along...big time!

This is the central issue, and the most difficult.

I am also sure that the majority of physicians would not turn away a patient who is truly in need of our help.

But, it is immoral to enslave any portion of our population by defining the service they provide as a right to be consumed at the government's(that's all of us by the way) expense. This is also a huge issue...not well understood, even here.

Once again, Dan, you show your true colors.

Why wouldn't I want PHYSICIANS in control of the CPT? I damn sure don't want Obama, one of his Czars, or some federal health "board" to be in charge of the CPT codes.

JBluster comments are very germaine. Dan, you should actually read them.

Dan--your action hurts us all in medicine---you don't like the AMA--Fine--but you do a disservice to those of us who are trying to make it a better organization.

Why don't you go to Wall Street and look for investment capital instead of hurling insults at the AMA?

Dave Redfern, MD
Rogersville, MO
A PROUD AMA member

CPT codes suck just as the whole system does. Doctors have been so devalued by the current syswtem that it is a wonder we can keep taking care of people like we do. The organization I work for contracts with the State of Texas to provide services. They will not pay me for some CPT codes even though I am trained to provide the service. It seems having a medical degree and post doctoral training doesn't matter because the people with no medical training are telling me what to do, which meds to use, whether I can use them or not etc.....

Anyone at all.

When you are treating an individual, do you think about cpt codes to use?

If so, why?

If not, why not?

IMHO, cpt codes do nothing for patients and cause doctors headaches. Why we continue to use them is difficult to understand. Ever heard the saying, "Just say No!"

No, I do not think about CPT codes when I am in the exam room. I do think about them when I dictate the note in my office after the exam. I identify the type of visit...consult, follow-up, etc. and my coding staff takes care of it from there. If you can have a documentation system that "codes in the background" and is not in your face as you are working, it is not obtrusive and doesn't bother me.

But, what happens with the coding after it leaves my office is another issue!

voyager, thank you for the TMA ifo.

DoctorSH: "Just say no" to CPT codes? They are irrelevant to practicing good medicine, but are the only way you'll get paid. Unless, of course, you "opt out" of insurance and Medicare contracts. If you will, I will...

Does anyone think reimbursement will be any better if there are no CPT codes?
What would happen if the AMA was not the coordinating organization.
Every insurance carrier could have their own set of codes...would that be better?
Insurance carriers will not pay you by the hour.
My patients cannot afford to pay for a pregancy out of pocket, or a major surgery, or sometimes even a pap smear. (yes I do charity care).
Many of the ideas suggested have been attempted by the AMA and lost.
You should be speaking to your congressional representatives-they make the laws that regulate and regulate enforcement of the laws that make it illegal for physicians to balance bill, legal for an insurance carrier to deny payment for a service provided (or even because they do not like the way you filled out a form), or even pay less than the cost to you to provide that service, acceptable to place your name on a lawsuit for a patient you never saw......

I think about CPT codes after I finish my patient visit-how can I best represent the work that I performed in their language (so I can be paid and continue to provide patient care)

Mary LaPlante, MD, FACOG

It's an interesting question that Dr. LaPlante poses. What would happen if we weren't using CPT codes as the currency for our professional services? Perhaps the insurers would each devise their own set of codes or a "system" to pay physicians. She is correct that this would not be a sustainable model. The question I can't help but ask myself is, what would take its place? Would the government come to the rescue of insurers or would the payers instead be forced into a marketplace where physicians negotiate for the value of our professional services based on OUR belief of OUR worth and without a standard currency that now allows the insurers an unfair advantage. They hold all the cards and know what each of us is being compensated while we have no idea what one another have negotiated independently. We're forbidden from sharing that information or risk breach of contract. This allows the payers to value our skills by the criteria that they see fit and play games to constantly make us jump through more hoops in order to properly "qualify" for compensation. Who would hold the stronger hand without CPT codes, them or us? Our patients, not by third parties, should judge our worth. Having said that, we physicians are good people who understand the need to care for those who are less fortunate. Allowed to operate in a free market and without fear of litigation, I bet that we could address this need far better then a government committee.

Adam Sharp, MD

Sandyfoot: While I still take traditional medicare, I opted out of ALL other third parties in January 2008.

Your turn now...

So long as there is a third party payor system, there will be a need to convert what we do into numbers that determine reimbursement. The old (really: the OLD) system was much simpler: I provide a service for a posted or pre-negotiated price which is bought for value-up-front. If the purchaser is dissatisfied, heshe can hire an attorney -- or a legbreaker. Unfortunately, there are flaws in this system... The reason we all accepted third party payment is because at the time it maximized payment/profit and ushered in a golden age of medicine for everyone. Now the third party is firmly in control and clearly uninterested in anything except profit. It has been freed of all accountability, all responsibility for outcomes and allowed to dictate to patients and providers every aspect of health care. The tail is wagging the dog. It is time for a change, and I don't see much hope in so-called "free market" forces. They aren't free and have no interest in me or my patients except as a source of revenue.

>Does anyone have a problem with the fact that our posts were made public?<

NO!

DoctorSH,

I'm fascinated to know the details: age of practice, location, area competition, fee schedule, impact on revenue, personal satisfaction, etc.

We have thought of opting out of commercial insurance for some time. I agree Medicare doesn't pay great, but has few hassles for us. Commercial insurers in our area (Florida) pay little more than Medicare rates with significantly more administrative headaches. Unfortunately, we are in an area saturated with other primary care physicians, and of course the fear is that there will be a mass exodus from the practice if we were to go cash only. As owners of our building (with rental space), we are not in a position to start a low-overhead micropractice.

I have to say I'm impressed with your decision, and think there are others willing to do the same. Our practice will certainly revisit this. I guess you just need to be brave.

I am so pleased to see that I am not alone. That it appears that the AMA and AAFP leaders are in bed with the administration not the members. When you decide a proposal is garbage, as well as the current system, ideas need to circulate on how to fix things. Going to fee for service sounds wonderful, but will be difficult for the masses to afford when it comes to hospitalization or surgery. I respectfully submit the concept of dissolution of employer based insurance. Each individual will need to choose their own insurance. Local brokers will develop that can help them with these choices--H.S.A, catastrophic, etc. Huge surges of people into individual policies will drive down policy prices. We, ALL physicians, will take cash for services rendered. The patient will take our bill to their local agents for reimbursement based on their plan. This is no different than what one does when they make a home or car claim. Insurance has to streamline things for the customer. We have become captive to the current system. CHANGE THE SYSTEM, CHANGE THE CUSTOMER, CHANGE THE PROCESS.
We will be able to lower overhead costs and discover higher reimbursement rates. The patients can "shop" for rates that fit their needs/budget. We will also then be able to say to Medicare/medicaid that they either pay us their maximum payment or their patients will not be seen. If their amount is not acceptable, we cannot be forced to see Medicare patients as we are a cash service business in all other terms. It becomes voluntary rather than forced. Medicaid/Medicare needs to be operated by a third party system. (Did I really say that?) Unfortunately, BC/BS biggest profit margin is thru their Medicare program. They run it more efficiently than the government. The Caveat here is that they need to pay better for the services and their margin needs to be reduced!
Finally, no change is passed unless meaningful tort reform is passed. PERIOD.
This is one suggested plan; any others? This keeps specialists and primary care together in this fight, not pitted against each other.

I started a cash-only, opted out of Medicare, micro practice from scratch 11/08. Patients get the concept and find value in this practice model.

I'm paid my fees at the time of service. All prices are transparent to the patients. They can use their insurance for covered labs, radiology, and consultants. It's their responsibility to know what is covered by insurance.

I practice medicine. I spend my time thinking about, reading about and researching my patients' conditions. I do not spend time knowing which insurance covers what or how much they "reimburse" for specific codes.

As a courtesy, I will submit a CMS 1500 on my patients' behalf so that they can be reimbursed directly from their insurance companies. If the insurance company says that they will only pay $66 for an establish medcial care H&P, fine. I've already been paid $120 by the patient who has walked out of my office satisfied with the medical care and personal attention. If s/he then gets back $66 from the insurance company...great. But I won't do that amount of work to be "reimbursed" by the patient's insurance a bit more than half my fee, two months later. I provide a service that my patients value and they pay me at time of service. (Checks, credit cards or cash).

In general, my fees are now about $60 per 15 minutes of time spent with patients. I charge more for procedures, drawing blood, injections etc. The price list is available to the patient. I charge for filling out forms not brought to an office visit.

I have never been a member of the AMA. I live in Paradise in a beach town / vacation destination on the Central Coast of CA. There are very wealthy (think Oprah) and also middle class, students and many low income people in this community. They all understand this model of care.

YMMV.

It seems to me that a lot of the AMA supporters are in OBGYN. Is there a natural affinity between OBGYN and the AMA for some reason? Just curious.

I just sent in my delayed AMPAC 100 bucks yesterday. I think the AMA needs our financial help, not attacks. I give a honeybee to the ACCPAC also.

Fleet,

I was also wondering this!

In a recent post Dr. Heyman (Ob-Gyn) from the AMA attacked steeldoc, another Ob-Gyn, with the following words when he criticized the AMA.

>Just what the world needs for compassion and understanding, an OBGYN (steeldoc) who combines sexism and cruelty with inability to spell. <

Maybe the AMA had some luck at some point with keeping midwives at bay?

They were also able to prove through genetic analysis that the Salem witches and midwives were one and the same.

July 15, 2009
Dr. Palestrant:
1. Working with the AMA is much more valuable than bashing it with harsh language.
2. It is better that the AMA makes the CPT codes than some ins co. or government body.
3. Your own credo is to emphasize the positive and work towards common major goals but you are not applying this here. Egos needs to be left aside. The AMA can be a big help.
4. Divorcing yourself from the AMA is a bad move. A house divided will not stand well. History has amply shown this dating back to Bibilical times.

agree 100% with audiodoc!

I also feel that if "we", the AMA, the physicians, own the CPT, the money should come back to "us."

If it's some cabal inside the AMA that steals the money and enjoys cigars and wine on the coast of France, this should be proven and exposed.

There is an organization for people who want to help advance the indepence of physicians; The Association of American Physicians and Surgeons (AAPS). I invite you to have a look, Sermo Doc

SMFleet:

Our country voted for change and we got Obama who is radically changing the direction of our country and has made the conservative parties a minority looking for a direction.

The AMA is similar in context, but they are being moved to the minority looking for a direction, while other movements, SERMO, AAPS, and others , both conservative and liberal are gaining strength.

So to say that we have to support the AMA, even if they do support our own views, just because they are the AMA, is ridiculous.

There still is individual choice and freedom in our country. For how long, remains to be seen, so all docs regardless of their views should get out of their offices and strongly and vocally support their issues. That is the only way that docs can become a part of the debate that effects change, instead of just waiting to get changed.

If you think that Sermo and AAPS are going to gain strength and accomplish what you're talking about, you are wrong IMHO. You need the AMA. You actually need your grandfather's AMA before it tried to be politically correct. But "to each his/her own."

The AAPS is too right wing for most of the country. They are based in Tucson. Don't think they'll appeal to most docs. You need the more middle of the road AMA in Chicago--they're your best bet whether y'all like it or not. Sermo is a money making tool which largely benefits one individual, and it seems to have gone to his head.

Since when is Chicago "middle of the road"? Isn't that where BO got started?

Sermo is a money making machine, a private company. WHoopee.

The AMA is not a money making machine? How is the AMA any different in sucking out doctors incomes than third party insurances and govt?

DoctorSH--if Dan and Sermo are your heroes, fine. It won't get you anywhere. When Dan closes Sermo in a few months or years, he'll be sitting on millions, and you'll be a government worker because you betrayed the AMA.

Tsk Tsk

I don't have problem with CPT codes per se, just the documentation guidelines for E&M, which screwed us, and that CPT codes are controlled by a cabal who demands FDA level of evidence of use before a code can be considered a billing code. For example, quantitative sensory testing...a standard test for 20 years...still doesn't have a billable code. Forcing MD to use unlisted procedure is just control.

We should have also straight time billing guidelines which are more reasonable thant he E&M. Current ones screw us for the time between 40 and 65 minutes on a return. Nobody at AMA asks the guys in the trenches what needs to be done.

The RVUs are also way out of whack.

Fleet,

>They were also able to prove through genetic analysis that the Salem witches and midwives were one and the same.<
This definitely explains why the OB-GYN cabal is more active in the AMA! :-)

SMFleet:

What is the AMA doing to stop the govt takeover of medicine. The House plan wants to outlaw all new individual insurance plans, effectively putting insurers out of business.

You can't fight city hall, and I do not trust the AMA not to kow-tow to OBama.

We need a new movement and if its Sermo, thats fine with me. If its AAPS, thats fine as well.
But we need a movement that holds physicians interests first and foremost, not the insurers or the govt. We should not be playing politics with our healthcare system, and that is what OBama is doing with the capitulation of the AMA.

went to million med march and tried to click on "more" but could not get to petition.
Maybe a site problem.
will try again tomorrow.
Thanks again, Dan. we need to be united

Yes, SM, she is a conniving little nut case. And I am close to people who know her.

Does anyone have a problem with the fact that our posts were made public?<
NO. I have no problem with this.

I try to talk to my patients and a lot of them dont seem to care...just wait.
So, whatever we can do to make this public.....I have no problem

DAN-what about contacting Lou Dodds? He would be very inteterested.
Sorry, I don't know him. But with the weight of Sermo behind you ...possibly?

I said it in the next post---our only salvation for ourselves and aor patients is to opt out. You may need to decrease your lifestyle at first, but you sure will increase your integrity.

I've been on many different sides about the 'right' solution, often in my frustration doing paperwork late at night or on weekends, promising myself that some day, going cash is the answer. Clearly the solution is not that simple and while i can convince myself that cash might be the answer for myself, I know this is not the answer for all of healthcare. Being married to a surgical subspecialist, it is impossilbe to imagine that he could ever go all cash especially when patients have choices. However we do have to take bold steps and risks as a community if we're to ever have a chance at surviving as a profession. Why is the idea of cash basis so controversial? Our psychiatrist colleagues have been doing this for decades? I don't think coding CPT's is the problem. The problem is doing unncessary things to justify the CPT's and in the end we all become business minded or revenue minded when we work rather than patient centric. My greatest dissapointment in medicine has been this fact, that i cannot make a living concentrating on the profession i was trained for but rather I have to spend time justifying and validating my $29's worth of allowable reimbursements. I don't think charging for time is the answer either. We all know that 5 minutes can be crucial to an MI and these 5 minutes are not equivalent in value to 5 minutes holding a hospice patient's hands. You be the judge which hold greater dollar value. We are certainly a society of insured. We insure our houses, cars and other things of value so medical care seems logical to have insurance for. However I believe the solution to healthcare starts with ownership. The patient must take ownership of their own health including the cost, not the provider. Compliance will increase and frivolous malpractice claims ( hopefully) will decrease, perhaps even (patient's own) preventative efforts will increase, all leading to save overall healthcare costs. I say put healthcare in the hands of the patient and make them responsible for payment, whether it be cash, check, credit or insurance. Doctors should not worry about payment, the patients should. We are to provide the service and should be paid at the time of service just like any other commerce transaction.

First step to cash is becoming NONPAR on Medicare and refusing (getting out now) of bad payor contracts. Taking this first step prepares you, and may be sufficient to continue being friendly to patients (charitable at times even), make ends meet, and keep in the black.

The AMA is behind the current house bill.

to me, as prospective new solo
first step was to find a way to survive without all insurance
I was able to figure out to start with BCBS, one local HMO and Medicare only
now recent shakes have scared me about Medicare

so far, I am doing ok on BCBS & local HMO plus some moonlighting..... and of course, COP
COP part is rising faster than I thought. I should be able to get out of BCBS soon.