Teladoc revisited...Ochsner related

Marketplace had a quick segment on telemdecine the other day. It specifically talked about rural medicine. Pre-pandimic is was 0.1% of visits/consults. Post-pandemic it has settled around 10%. I only see that number going up, especially with rural hospitals and doctor's offices closing and staffing shortages. marketplace link

Anecdotally, I'm a fan. I have to have twice yearly visits with my neurologist to get my migraine Rx re-upped. It's usually "you good?" Yeah, I'm good." "Okay, here's your script." It's so much better on my phone at my desk than having to dive across town for that bullshite.

I think you’re talking about two fairly unrelated portions and goals of the healthcare industry here. Welcome to the weeds:

Ochsner’s losses.
7-figure losses seem like a lot. They acquired an entire hospital system (Lafayette General, which had 5 or 6ish hospitals under its umbrella). Why would a company losing money acquire a bunch of things? Because reimbursement is changing very rapidly in medicine. You talk about MCR reimbursement falling, but that’s only half the truth. The other half is, to quote the Great Dr William Flanary, to figure out how to milk money out of the flesh-colored money bags known as patients (this is how every insurance company and hospital views the people that rely on its care). MCR is cutting rates to the small, independent guys. But they’re offering a secondary system- they assign dollars to diagnosis codes, and if you can spend less than they think you should spend, they’ll cut you a check for a big portion of the difference. It has absolutely zero to do with the actual care of the patients and everything to do with moving numbers around on paper so they can get more accurate numbers by getting doctors/healthcare systems to better summarize human lives into 7ish digit alphanumeric codes called ICD10. Why does this have nothing to do with patient care? Because there are over 15,000 codes with some significant overlap and “gray area,” and those who find the right gray areas are rewarded handsomely. I don’t get paid to tell them which bone in the hand is broken (there are over 200 codes to describe this), but I can get paid for hand pain. MCR thinks that “anxiety” is worth (not accurate numbers but accurate ratios) $1000/y but an “unspecified mood disorder” is worth $5000/y. Coronary artery disease without angina is worth $1500/y, but “disease of artery” is worth $7500. Back pain with sciatica from a disk pressing on the cord is worth $800/y, but you call that an unspecified spinal cord disease, and it’s up in the $5,000 range. Again, don’t quote me on the numbers. But drawing hairline distinctions between disease processes and paying a lot of money on the backend (in savings) is a certain way to make sure that systems like Ochsner who have the manpower to review chart and change codes will do so (they can’t actually change the code, but they can refuse to accept specific ones and basically force the doctor to choose the higher paying one. Or in other words, they can absolutely change the codes) and reap benefits. Practically no office is capable or willing to participate in these pools alone, so you join groups (Accountable Care Organizations) who review your savings rate and split the benefit with the docs, and they group doctors together so that outliers don’t cause drastic losses when your patients are sicker because you don’t have that many on this/that contract. Unfortunately, none of it really does anything positive for the patient unless you think that CMS will eventually use the data to increase funding for certain illnesses. In reality, the portion of savings will go down, they’ll readjust how much money each illness is worth until they have accurate numbers and then Medicare reimbursements will fall. But for now, they’re lucrative to groups with coders and a large number of lives under contract (Ochsner, et al).
Just like there are silly little codes that could apply to tack on back end reimbursements without improving the quality of care, there are loads of stupid little reimbursable things you can do to patients to get paid. One of them, which I refuse to participate in on a wide scale, is Remote Patient Monitoring. Convince a patient to send you 16 blood pressure readings a month, even if they’re stable on one blood pressure medication for the last 20 years, and Medicare throws you $50ish/m. Got 200 patients with hypertension? It scales nicely. Ochsner, back when I did residency interviews, was getting Apple Health integrated into their EHR. I’m fairly certain they can afford to give away compatible monitors for the data collection. There is a company I’ve spoken with that will give patients cellular-connected cuffs and call them weekly until they regularly submit 16 readings a month. Are there instances where getting a patient to do this would help me? Sure. About 10/m or so. Is it worth the hassle to collect the reimbursement on it for them? To me, it’s really not. Do some people feel justified handing it out to every patient who ever had a high BP in the office once, calling them diet-controlled hypertensives, and collecting 6-figures a year off of what basically amounts to non indicated monitoring? You bet your arse. But it’s one to me that feels like they’ll pull the “that’s fraud” on in some period of time, so I’m not jumping on. There are tons of times it’s useful. Setting up a system around it would probably not be worth it for how little I find it to actually be clinically useful, so I’ll continue to just do it for free because it just seems so damn unnecessary. So I’ll leave you with those examples, but let you know there are dozens more of “hot” things to get reimbursed for in ways that are always changing. Volume is what pays, and having a middle layer of non-clinicians to push the paper the right way is going to pay off for them extremely well.


Now, telemedicine.
What good is it? A ton. Someone in their off hours can get paid extra money to extract money from patients that were usually just treated with a phone call. It’s here to stay, and the reimbursement will probably stay decent. Heck, the insurance companies have even jumped on board (fun note- early in the pandemic I, a primary care provider, got an email or a letter from my office’s insurance company that suggested I should skirt my PCP office and do telehealth with them if I felt sick, and it would save them the copay they’d usually pay their PCP. I wrote an email expressing disappointment in the insurance company for undermining that established relationship and explained that it would make a lot more sense for someone to do a telehealth with their PCP, and if this was their new MO that next open enrollment, I’d probably reconsider who I got my insurance through. I actually got a phone call from an account manager, and they started allowing our patients to see us on telehealth without a copay. Again- I won’t complaint that they’re paying me, but to drive patients away from the point of healthcare that’s tied to lower mortality and lower costs just seemed…like something that would benefit the insurance company directly or a major oversight. Fortunately it just seemed to be a major oversight and it got corrected.

There’s a market of people out there, however, who will never really establish with a doctor who follows them chronically. They’ll bounce from urgent care to urgent care (or ER) when convenient and they feel they need something. Most of those places operate on patient satisfaction rather than solid principles of medicine, and they tend to cater to the patient who doesn’t mind paying cash. There will probably always be a decent market there, and the pandemic was the “can of worms” that is going to draw some significant portion of business away from Urgent Care to do that.