Current billing process is a monopoly business controlled via CPT/ICD coding system and it is one of the root causes of excess costs and corruption. Government and Insurance Industry love this system since it provides them means to control the money.  We should demand an alternative method to determine the cost of physician's service and other medical services in a clear and transparent way instead of complicated mumbo-jumbo type CPT system that is being manipulated to generate excess charges. The most important feature we want is the patient should be allowed to actively engage and determine the cost of services he wants or receives, ultimately controlling his own bill which any consumer should do.

There is a lot of talk about over utilization of the health care and ‘too many’ procedures being done by the doctors. President claimed that 30% of the total cost is because of unnecessary procedures. There is some truth to this claim but we have not seen anybody (liberal or conservative) trying to explain why this is happening. CPT stands for Current Procedural Terminology and as the name suggests it is designed to reward the procedures. 

The following is an example of daily business in our current healthcare system: Out of thousands of CPT codes, let us analyze one of the most common code used in physicians’ offices: 99213. This is a payment code for an established patient visit. We dare challenge all the politicians and the general public if they have any idea what this means.

Let us compare Dr. Reagan who is a renowned physician with 8 years of medical school plus 8 years of post-graduate training, and 10 years of medical experience. Physician Assistant (PA) Mr. Carter, a novice who has just graduated with 2 years from a PA school, and has no experience.

Let us say Mr. America is an established patient of Reagan Clinic, who goes for medical visit with Dr. Reagan. After spending 15 to 20 minutes with the patient and completing a thorough evaluation, Dr. Reagan correctly diagnoses and fixes the problem. Current Medicare rules allow him to charge CPT code 99213 to patient’s insurance. ($58.89)

Now, let us say Mr. Universal is an established patient of Carter clinic who goes to visit PA Carter. After a thorough evaluation, PA Carter has no clue what is going on, but he still gets to charge 99213 according to Medicare rules and receives the same payment as Dr. Reagan. Then, he orders several tests to find out what is wrong with the patient. The tests cost $3,000, and they all come back inconclusive, so finally, PA Carter refers patient to Dr. Reagan.

After a while, Dr. Reagan realizes that his overhead cost is out of control, and revenues from 99213 or similar services are falling short to maintain his practice. He decides to look around and notices what his colleagues are doing and discusses with his office manager about changing his practice pattern. Next time he sees the patient with a similar problem, he spends only 3 minutes with the patient and as a specialist he schedules several procedures for the patient. After performing the procedures, he is able to use several more CPT codes in addition to 99213 and his revenues increase by 3 times. The additional hospital cost of the procedures is about $15,000.

What are the outcomes in the above scenarios? Same? Different? Or who knows? Do you think Mr. America knows? Can you imagine this happening in any other private business? For example, if we have to pay same price for a burger at the McDonald versus Steak at Ruth Chris how long do you think before one of the outfit or may be we all go bankrupt?

This is today’s system. No accountability, no quality control, unnecessary overhead cost and over utilization. This is what goes on every hour, every day across the country, and therefore we are spending more than $2 trillion in healthcare while countries like Japan spend only one-third of what we spend per capita in healthcare.

The CPT system adds tremendous bureaucratic burden on hospitals and doctor’s offices. Reforming this system will reduce overhead cost from the entire healthcare industry by more than 10-15 %. The payments should be based on Doctor’s level of training, experience and efficiency and patient satisfaction, and not for the procedures and diagnostic tests. Thus, physicians will have to do fewer procedures to maintain their income, and less procedures means hundreds of billions of savings.

Joe was moderately successful in his career, but as he got older he was increasingly hampered by incredible headaches He finally came across a doctor who solved his problem. "The good news is I can cure your headaches... The bad news is that it will require castration. You have a very rare condition, which causes your testicles to press up against the base of your spine. The pressure creates one hell of a headache. The only way to relieve the pressure is to remove the testicles." Joe was shocked and depressed. He wondered if he had anything to live for. He couldn't concentrate long enough to answer, but decided he had no choice but to go under the knife. When he left the hospital, his mind was clear, but he felt like he was missing an important part of himself. As he walked down the street, he realized that he felt like a different person. He could make a new beginning and live a new life. He walked past a men's clothing store and thought, "That's what I need: a new suit." He entered the shop and told the salesman, "I'd like a new suit." The salesman eyed him briefly and said, "Let's see... size 44 long." Joe laughed, "That's right, how did you know?" "It's my job." Joe tried on the suit. It fit perfectly. As Joe admired himself in the mirror, the salesman asked, "How about a new shirt?" Joe thought for a moment and then said, "Sure..."

The salesman eyed Joe and said, "Let's see... 34 sleeve and... 16 and a half neck" Joe was surprised, "That's right, how did you know?" "It's my job." Joe tried on the shirt, and it fit perfectly. As Joe adjusted the collar in the mirror, the salesman asked, "How about new shoes?" Joe was on a roll and said, "Sure..." The salesman eyed Joe's feet and said, "Let's see... 9-1/2... E." Joe was astonished, "That's right, how did you know?" "It's my job." Joe tried on the shoes and they fit perfectly. Joe walked comfortably around the shop and the salesman asked, "How about a new hat?" Without hesitating, Joe said, "Sure..." The salesman eyed Joe's head and said, "Let's see... 7-5/8." Joe was incredulous, "That's right, how did you know?" "It's my job." The hat fit perfectly. Joe was feeling great, when the salesman asked, "How about some new underwear?" Joe thought for a second and said, "Sure..." The salesman stepped back, eyed Joe's waist and said, "Let's see... size 36."

Joe laughed, "No, I've worn size 34 since I was 18 years old."

The salesman shook his head, "You can't wear a size 34. It would press your testicles up against the base of your spine and give you one hell of a headache.