Stanley Feld M.D., FACP, MACE Menu


If You Know What To Do Why Do The Opposite?

Stanley Feld MD,FACP,MACE

Mark McClellan declared that 90% of Medicare costs are spent on the complications of chronic diseases. The Institute of Medicine has published that evidence based medicine for chronic disease is only practiced 10% of the time.

Osteoporosis and Diabetes Mellitus are two of the chronic diseases of the 5 big chronic diseases that clinical Endocrinologists’ have exceptional expertise in. These two diseases absorb a large part of the Medicare dollars. Osteoporosis and its complications absorb 20 billion dollars per year in direct costs. Diabetes Mellitus and its complications absorb 120 billion dollars per year in direct costs.

Evidence based medicine has demonstrated that with effective diagnosis, treatment and patient adherence to treatment of these diseases, we can reduce the complication rate by at least 50%. If 90% of the dollars for these two diseases are spent on the complications of these diseases, then 50% of 90% is 45% savings to the healthcare system. If we could translate evidence based medicine to clinical practice, we would save of 9 billion dollars for osteoporosis and 54 billion dollars for diabetes mellitus.
The total savings of 60 billion dollars would go a long way to repairing the Financial difficulties of the healthcare system. It would also go a long way to improving the quality of care for chronic disease in this country.

The distortions in the DRG system that evolved over the last 23 years must be fixed. Medicare was going to do something about it.

However, Medicare backed off by the weight of a well organized hospital association’s and medical device manufactures’ lobbying effort. Medicare backed off quickly as a result of this political effort. Medical care should not be politically driven nor its fate be decided by the vested interests of secondary stakeholders.

The solution to the medical cost problem is creating Centers of Excellence and Focused Factories. Systems of Care have been developed decrease or eliminate the complications of chronic disease.
Medicare has to reduce prices of the DRGs because it simply can not afford to pay the rising prices created by the old DRG system. Medicare has to reformulate a new DRG system. The excessive DRG charges are the main source of the uncontrolled healthcare costs to treat the complications of chronic diseases.

Who is the next candidate for a cut in fees? The physicians are of course. We are the most unorganized and least effective political force. We are losing members in the AMA and local organizations at a rapid rate. Unfortunately, the AMA has lost its effectiveness. Physicians have walked out with their feet and their dues.

I mentioned the 5.1% per year reduction until 2010. There is also a proposed cut in the payment for Bone Mineral Density testing. The BMD is the gold standard in the early diagnosis of osteoporosis. A note from the American Association of Clinical Endocrinologist states;

Dear AACE Member:
AACE is partnering with the International Society for Clinical Densitometry (ISCD) in conducting an online survey to respond to the Centers for Medicare & Medicaid Services (CMS) recently proposed dramatic cuts in reimbursements for DXA (from the current ~$140 to ~$40 by 2010) and Vertebral Fracture Assessment (VFA) (from the current ~$40 to ~$25 by 2010). These cuts will be in addition to the already-enacted imaging cuts outlined in the Deficit Reduction Act of 2005.

“AACE needs your assistance to assure that the work required for the performance of quality central DXA and VFA is accurately presented to the CMS by August 21, 2006. Therefore, your participation in this online survey is critical to our response to CMS.

This survey must be electronically completed no later than Thursday, August 10.
However, only online surveys will be considered. Estimated time of completion for the online survey is 45 minutes”

I am sure many physicians would want to complete the survey. However, few have the time to devote 45 minutes in a day to complete the survey. The American Hospital Association and the Medical Device Manufacturers did not have to complete a survey for Medicare to back off. Why can’t Physicians do the same for the good of patient care?

If Medicare wants to increase the quality of care for chronic disease and decrease the complication rate, cutting the BMD fee is absolutely the wrong way to go about it. The proposed payment for bone density is lower than cost of service. It is counter-productive to the goal of developing centers of excellence for the diagnosis and treatment of osteoporosis.

From my experience, the present level of reimbursement is low for Bone Density testing. Medicare reducing the fee to $40 is not an incentive for Clinics to even think of doing Bone Densitometry and increasing their quality of care for a silent disease that only generates a chief complaint when the complications of the disease occur. The specialty seeing the most patients at risk for osteoporosis are Family Practitioners. Medicare should help develop centers of excellence for osteoporosis so the Family Physician can have incentive to diagnose and treat these patients before the complications of osteoporosis occur. Family Practitioners are struggling to survive. They are not going to create a Center of Excellence that loses money.

Another important question is how much Medicare is going to pay the hospital for a Bone Mineral Density. Remember Dr. David Westbrock’s knee story. Medicare paid the hospital 3 times the amount it pays for the same x-ray in a physician’s office.

Something is wrong with the administrative system, and the patches it applies simply make the healthcare system worse.

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