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Sunday, May 16, 2010

The CPT and financially inspired savantism

From Wikipedia:
Savant syndrome, sometimes abbreviated as savantism, is not a recognized medical diagnosis, but researcher Darold Treffert describes it as a rare condition in which people with developmental disorders have one or more areas of expertise, ability, or brilliance that are in contrast with the individual's overall limitations. Treffert says the condition can be genetic, but can also be acquired.
What does this have to do with health care? Savantism is most commonly recognized as a developmental disorder but it has also been recognized that it can develop later in adult life. I would argue that the CPT based payment system has functioned as an evolutionary impetus to create a culture a medical savantism.

The CPT contains about 7000 billing codes and is basically divided into two basic types of codes. One type, which makes up the vast majority of  codes identifies a billable activity which tends to be technical and procedural, and is focused in time and space. These tend to be identified as higher margin activities and successful billing and collection for these activities is not dependent upon mastery of a broad knowledge base in medicine out side of the particular technical expertise.  These specific technical codes make up  about 99% of the CPT codes.

The second type of codes is an evaluation and management code. There are distinct codes for particular contexts whether that be inpatient or outpatient, new patient or follow up, consultations or non-consults. They all follow the same basic format and there essentially five levels of E&M services; easy, minimal difficulty, moderately difficult, very difficult, extremely difficult. The key point n all this is that management of the most difficult problems which is paid by an E&M code results in less financial renumeration than the payment received from many of the defined technical activities.

The most financially advantageous position to be in is to find a highly remunerative focused activity and become incapable of more modestly or poorly paying services. Everyone in medicine shares the E&M codes and this results in no one becoming their champions. The E&M services are at best a loss leader. From purely a financial perspective, why invest the time and effort to maintain competence in broad problem solving when strategic incompetence means being able to focus on what you do well  and what pays well.

What does medicine look like when there is a wholesale exodus from from trying to see the big picture and the biggest rewards are directed towards those who have pursued their focused technical expertise with savant like zeal? It looks like our present medical model.  Call it financially inspired savantism.

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