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President’s Letter

The Arms Race

By Scott L. Furney, MD

A few months ago, one of my patients brought me a and that the echo was the best test to guide our further testing and
bill from his recent surgery. Unbeknownst to me, treatment. There was long pause and it became clear to me those
he had undergone an outpatient knee arthroscopy words were not on the checklist. She started right back on the
for persistent knee pain. He is in his mid-40s and checklist and I asked to speak with their nurse or MD to bypass
this step. A few minutes later, the nurse approved the test without
had an injury to his meniscus in high school sports. An MRI further delay.

before surgery showed a chronic medial meniscal tear with early In reviewing our process for tests, I learned these orders
frequently get passed from my non-clinical staff to my nurse. My
degenerative changes. He was optimistic about getting back to nurse can take care of 90 percent of these “second level” reviews
with her peer nurse on the phone, which leaves me with the most
running as his preferred exercise, but was startled by his bill. As complex 10 percent that requires MD peer review. Those three
levels of review are the tip of an iceberg when compared to the
many of our patients do now, he has a high-deductible plan and infrastructure needed to “justify” medical care in the hospital
environment. We have hired a small army of people to support the
was responsible for much of the up-front cost of the procedure. billing of medical care in the United States. On average, the U.S.
has three to five times the administrative costs of the Canadian
Those three levels of The total bill was system. We feel these costs in the time it takes our clinical staff
review are the tip of an more than $30,000. He to get tests scheduled. The patients feel it when they pay their
described the procedure deductibles, which must include the costs for the staff on both sides
as uneventful and his stay of the administrative arms race.

iceberg when compared in the ambulatory surgery So, what do I tell my patient about the cost of care? Do I justify
center was measured in the costs as a necessary evil for working in a complex system? Do
I tell him his procedure, compared to physical therapy, is unlikely
to the infrastructure hours. The operation itself to provide a long-term benefit toward his goal of returning to
took less than an hour. running for exercise? Do I tell him, if he had seen me first, I would
have been unlikely to order the MRI or refer him for surgical
needed to “justify” His question should be evaluation without first exhausting other evidence-based and
apparent: How could a higher value services?
medical care in the
hospital environment. few hours of medical care I am impatient for change. In writing this, I carefully considered
We have hired a small cost so much? the solutions for this conundrum and came up with what will likely
be an unpopular conclusion: We either need a single payor system
A few days ago, I to reduce the “arms race” or move more rapidly to value-based
got a personal look at contracts where we (physicians and health care systems), and not
some of the waste in patients, take on the financial risk of providing good care. I am
not sure if officers of the Medical Society can be impeached, but I
army of people to the system as I tried to figured with just a few months left in the year, I would risk it.
order an echocardiogram
In humble service,
support the billing of on an elderly patient
with dyspnea and lower P.S. If you are interested in a graphic representation of the
“arms race,” Google images with the terms “growth physicians
medical care in the extremity edema. Using and administrators health care.”
those two ICD-10
United States.
codes, I sent the order
electronically to my

staff, expecting the test

to be scheduled and performed quickly. It was, after all, medically

indicated and relatively inexpensive. A few hours later, one of my

staff asked for my help in getting the pre-authorization completed.

She had been on the phone for 45 minutes and was not sure how to

get it approved. As she talked with the insurance company, I asked

her to put the call on speakerphone so I could quickly provide the

necessary information. What I heard was frankly disturbing.

“Does the patient have elevated troponin blood tests? Does the

patient have acute systolic heart failure? Does the patient have

…” The pronunciation and halting nature of the questions told me

the insurance representative was non-clinical. She was running a

checklist of words that would allow the test to pass their first level

review. My staff member is non-clinical as well, so it was a tough

conversation for them to have! I politely interrupted and told her

I was concerned about diastolic heart failure from hypertension

Mecklenburg Medicine • October 2018 | 5