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Tuesday, August 14, 2012

Wants and needs and menus

What health care delivery shares with many other industries is it addresses human wants and needs and for the most part it delivers care directly to end users, the patients. To understand how to accomplish various health care related tasks better, perhaps we need to look at a most fundamental question? What does it take to address human wants and needs? In some contexts it is very simple to address this. A person drives up to a window at a fast food restaurant at lunch time and they are hungry.  They order a sandwich and a drink off of the menu. They want it hot, fast, and tasty. The rules of the game are that you need to order from the menu. You generally cannot order food from your car where there is no drive through (although you can call in using your cell phone).  You also cannot get food in a drive through laundry or drop off your laundry at the McDonald's drive through. Virtually everyone understands these rules unless you are Borat.

However, not all circumstances are so easily addressed. In particular, the health care industry does not provide such clear signals as the fast food industry as to where clients needs to go in order to get their needs and wants addressed.  Health care services are generally offered without menus. There are exceptions to this rule. The retail clinics post their menus and their prices. This does not stop patients from trying to order off the menu, looking for a convenient place to seek help for acute chest pain, acute fractures, or anaphylaxis. We try to inform people what is clearly off the menu. If I call my physician (of virtually any sort), the first thing I hear is the opening message of the phone tree. It tells me that if I have an acute and life threatening problem I should hang up the phone and call 911. That is simply not on the menu of services offered and that is made clear right up front. It is one of the only things made clear in terms of services offered or encouraged.

Once a patient has gotten past the filter directing them to 911, there are few clues as to where to go. Retail clinics have identified a list of twenty or so services which can be managed in a relatively rules based manner. They represent the fast food equivalent although the discounts offered are more in the realm of time than money. There are a host of services advertised aggressively in assorted media outlets where menus are well defined. These tend to be value added processes and also represent either non-insured procedures or ones where the margins are sufficiently high and competition exists to deliver. No long term commitment here. These are practices looking for people to do things to, drop a bill, and after the value is added (or not) be in search of new game. In the cash business, the price mechanism operates but in the insured realm price controls keep the prices from falling.

 There is a master menu of covered medical services but the public is not really aware of its presence. There are rarely defined prices linked. It is called the CPT (Current Procedural Terminology) code book. It is owned by the AMA which makes a handsome sum of money licensing these. At first it appears there are a dizzying number of codes, over 7500, corresponding to some medical service which gets charged. The numbers may seem large but let's compare restaurant menus to medical menus.

The CPT codes have changed only modestly over the past 30 years. There are new ones approved but the lion's share of codes in existence now were the same as when I trained long ago. Compare that to the food and restaurant business. Think of all of the cuisines which essentially unheard of in this country 30 years ago. The menus of the food business have exploded. We have new cuisines and expansion of old cuisines. In contrast, the menus of the health care field has stagnated. Everybody uses the same ones. The prices are set administratively.  We have access to new high profile drugs and high tech equipment but the ability of the industry to better address individual patient wants and needs has gone essentially nowhere.Review the process to get codes added or changed and you can see why.

How are requests for changes to CPT reviewed?
Specific procedures exist for addressing requests to revise CPT, such as adding or deleting a code, or modifying existing nomenclature.
Medical specialty societies, individual physicians, hospitals, third-party payers and other interested parties may submit applications for changes to CPT for consideration by the Editorial Panel.  The AMA’s CPT staff reviews all requests to revise CPT including applications for new and revised codes. If AMA staff determines that the Panel has already addressed the question, staff informs the requestor of the Panel's coding recommendation. However, if staff determines that the request presents a new issue or significant new information on an item that the Panel reviewed previously, the application is referred to members of the CPT Advisory Committee for evaluation and commentary. Applications that have not received any CPT Advisor support will be presented to the CPT Editorial Panel for discussion and possible decision unless withdrawn by the applicant.  Applicants will be notified if their applications have received no CPT Advisor support approximately 14 days prior to each meeting of the CPT Editorial Panel meeting.  Applicants have the ability to withdraw their applications up until the agenda item is called at the meeting—thereafter the CPT Editorial Panel has jurisdiction over the agenda item. 
The CPT Editorial Panel meets three times each year.  AMA staff prepares agenda materials for each CPT Editorial Panel meeting. Panel members receive agenda material at least 30 days in advance of each meeting, allowing them time to review the material, review CPT Advisor comments and confer with experts on each subject, as appropriate. The Panel addresses nearly 350 major topics a year, which typically involve more than 3,000 votes on individual items.
A multi-step process naturally means that deadlines are very important. The deadlines for submitting code change applications and for compilation of CPT Advisors’ comments are based on a schedule which allows at least three months of preparation and processing time before the issue is ready for review by the CPT Editorial Panel. The initial step, which includes AMA staff and CPT Advisor review, is completed when all appropriate CPT Advisors have been contacted and have responded, and all information requested of an applicant has been provided to AMA staff.
Following review and compilation of CPT Advisors’ comments, AMA staff prepares an agenda item that includes the application, compiled CPT Advisor comments and a ballot for decision by the CPT Editorial Panel. Once the Panel has taken an action and preliminarily approved the minutes of the meeting, AMA staff informs the applicant of the outcome.
The Panel actions on an agenda item can result in one of four outcomes:
  • addition of a new code or revision of existing nomenclature, in which case the change would appear in a forthcoming volume of CPT;
  • referral to a workgroup for further study;
  • postponement to a future meeting (to allow submittal of additional information in a new application); or
  • rejection of the item.
Applicants or other interested parties who wish to seek reconsideration of the Panel's decision should refer to theprocess described on the AMA/CPT website.
In Atlanta alone there are almost 400 restaurants listed on Open Table alone. That is a fraction of all the restaurants in this city. If each had only 20 items on their menu, that alone would match the entirety of the options in the entire CPT code book. Consider if each of these restaurants were limited in terms of their menu offerings to only what was approved in say we call it the CCO code book (Current Cullinary Offerings). Want to create a new pizza at Fellini's. You will need a new CCO code. After review by all of the cullinary experts and other stakeholders, we are forced to address the question as to whether the public really needs a new pizza variety? The experts say no. There are enough food choices to address public needs. Who cares about what they might want. That is not important. We we should probably cut back on choices since the public is getting too fat.

CPT is a menu which is not for patients, but for those providing the services. The reality is there are no readily accessible menus for patients because the options developed are not about what patients want. They focus on what the experts believe that patient need, a perception strongly influenced by the financial interests of those vested in the current system.  Patient choice and empowerment may sound good but they are not really on the table. Create an environment to reward patients who control their own resources and menus with prices will come quickly. So will new menu offerings.

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