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Saturday, October 17, 2009

CPT: The mother of all financial evil in medicine

We have experienced a dramatic change in the culture within academic medicine with the marked changes in the relationship between industry and Universities. It has had some painful elements and perhaps has gone a bit overboard. However, the experience has awakened a consciousness regarding the underlying motivators of our actions, particularly relating to what we do to patients and why.

We are flawed human beings whose default mode is to look out for ourselves. The presence of industry influences for the most part gently molded and manipulated our behaviors, gently nudging us toward prescribing this drug or another, utilizing this test vs watchful waiting. I can say with a great degree of confidence that while industry influence may have pervasive effects throughout medicine, there are much more profound and undesirable influences which basically touch and strikingly influence virtually EVERY encounter.

I am talking about the CPT and how it controls what health care providers do. For those of you who do not know about the CPT, it stands for Current Procedural Terminology. It is a series of billing codes owned by the AMA which are required for billing essentially all encounters in medicine. Unless you are flying without any ties to third party payers, you are inextricably tied to use of the CPT.

The use of the CPT can be linked to two of the worst aspects of present day medicine. First, the practice of medicine has become heavily focused on money and revenues. In a recent article in the NEJM "Money and the Changing Culture of Medicine" by Hartzband and Groopman, they point to altered behavior in physicians who are involved in substantial sharing of financial data relating to their practices. The altered behavior included loss of empathy for their patients. The shared financial information they referred to was primarily the use of items such as P&L data for specific physicians.

They seem to have missed the most pervasive financial element which touches every encounter; the bill with its associated CPT code. Every physician (and extender) has basically every patient visit punctuated by an encounter with CPT. This serves as an immediate and consistent reminder that every service action has an external and arbitrarily assigned economic value, independent of any value received by the patient. The typical physician quickly learns what CPT codes are valuable, and what codes are to be avoided. Talk about immediate feedback loop! This is a B. F. Skinner dream. If this does not alter behavior I do not what what does.

The pernicious element of the CPT is not just the value assigned to any given code, but is the conceptual nature of what it values and what it does not value. The explicit message from CPT is you get paid for doing things recognized within CPT, for doing things to patients in your own little silo, and what is valued is only what you do and document when patients are in your presence. Doing things for patients when they are not in your presence is basically never linked to dropping a bill or a CPT code. In this case the lack of a CPT code is almost as reinforcing as its presence. The message is there is no code, no bill, and no pay.

One could potentially view this as a indictment of fee for service in general. However, the fee for service in and of itself is not the problem. Exchange of money for services or goods within an environment which allows for explicit and transparent pricing and a binary exchange system is the fundamental unit of exchange in free societies. This type of free exchange allows for wealth generating "win-win" transactions, the foundation for the remarkable economic transformation which has occurred over the past millennium.

The problem with CPT is it applies dysfunctional constraints in the form of an artificial set of allowable transactions associated with arbitrary and fixed values, unrelated to actual value received by patients. We then place CPT in a position to influence human behavior in a most fundamental way. Presto! It should be no surprise that it ends up altering our behavior in a way much more fundamental than drug rep donuts or big pharma pens. It is the most extreme case of the tail wagging the dog.

It should be no surprise that we have ended up with perverted incentives and fragmented health care. That is exactly what CPT rewards those involved to do.

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