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From the July-August ACP Observer, copyright © 2004 by the American College of Physicians.

In-office drug infusion

While I was pleased to see you recognize subspecialists other than oncologists who provide drugs in the office setting, the article downplayed the significance of physician-office infusion in other subspecialties. ("Medicare's new office-drug payment policy has oncologists concerned about access" in the April ACP Observer.)

I believe the statement by rheumatologist David G. Borenstein, FACP, that infusion represents only a small part of his practice and that his group will have to decide whether to provide in-office infusions in the future, is misleading. In-office infusion is a significant portion of our practice of eight rheumatologists and that of many other rheumatology practices nationwide.

Rheumatologists' ability to provide infusion drugs, specifically infliximab (Remicade), has revolutionized the treatment of rheumatoid arthritis. And in-office infusion of these drugs provides other significant advantages. For one, the office setting is controlled by physicians and preferred by patients. In addition, administering these drugs in a physician's office is dramatically more cost-effective than in hospital outpatient settings.

The increase in reimbursement for the infusion administration codes (CPT codes 90780 and 90781) for 2004 was a big victory for rheumatology. The fact remains, however, that oncologists are still reimbursed nearly twice as much for infusion administration codes (96410 and 96412) even when the complexity is similar or exactly the same.

I do not wish to engage the oncology community in conflict. I would simply like the reimbursement for infusion administration to be set according to the complexity of the drug, not the specialty of the physician. This is especially significant when you consider that there are nearly 20 complex biologics nearing approval to treat non-oncologic diseases.

It is in the best interest of all subspecialists, oncologists included, to preserve the 32% "transitional increase" that is currently in effect. This added percentage has made 2004 bearable and preserved access to care for our patients. Without this adjustment, overall reimbursement for a typical infusion will decrease by nearly 40%.

Matthew P. McGarvey
Albany, N.Y.

Editor's note: Mr. McGarvey is the practice administrator for the Center for Rheumatology LLP.

Access fees and primary care

The article on access fees in the April ACP Observer was well-balanced, but it neglected to mention several related issues. ("Access fees have physicians moving cautiously."

First, these fees are only "access" fees if charged to everyone. Charging an annual fee for those who wish to pay for an added bundle of services (such as e-mail responses, phone-in prescriptions, and copies of results mailed or faxed to patients) does not limit access to the practice or to basic health care. The idea of charging extra for extra services is certainly worthy of discussion and debate.

Second, primary care specialties need a way to prove the value of our services, much of which are innovative when compared to medical services provided 25 years ago. Insurance companies and patients are willing to pay for innovative procedures, therapy and technology—and primary care physicians need to find a way to convince them that our added services also fall into those categories.

Patients are willing, for example, to pay more than $1,000 a year for what is, in most cases, the very modest benefit of taking clopidogrel over aspirin. If health services research could show a quality of life, morbidity or mortality benefit of the added services we provide, patients might view paying an additional $50 to $350 a year as a bargain.

Without such an objectively demonstrated benefit, I'm afraid that primary care physicians will continue to suffer from what seems to be the mantra haunting nonproceduralists: The costs of extended evaluation and management services should be borne by physicians, while the costs of extended procedural and therapeutic services are passed along to others.

Robert A. Murden, FACP
Columbus, Ohio

Evaluating EMR software

The article on evaluating electronic medical records (EMR) software by Jerome H. Carter, FACP, said that if a vendor will not provide a fully functional demonstration copy, physicians should eliminate that company from consideration. ("Tips for evaluating electronic medical record software," April ACP Observer.)

I have been researching EMR software for my six-physician primary care group for the last year, and I've found that few companies offer a functional demonstration disk. This includes most of the major EMR vendors.

Physicians shopping for an EMR should evaluate all companies and not use such blanket disqualifications. You need to view the product in person or via a Web demo with adequate time to see all the features. You also need to conduct site visits and talk to current and prospective users through discussion groups.

The top product my group is evaluating has been viewed by my partners and my office manager once, and by me three times, and we have still not taken the plunge.

Ronald Hirsch, FACP
Elgin, Ill.

Dr. Carter responds:

It is not possible to get a feel for how a software program functions by watching someone else use it. The same is true of driving a car or any other complex activity.

Given the fact that every EMR product is designed with specific constraints—such as key functions, workflow patterns and user interface—the challenge for potential buyers is to see if they can live within those constraints. It takes many hours to become sufficiently familiar with a product to be able to judge how well its features, functions and interface match your needs and work habits. Canned demonstrations, in my experience, simply don't provide much useful information—or give you the familiarity you need to make that call. Site visits, while potentially useful, have many of the same limitations.

Finally, a fully functional demo is not a special piece of software, but an actual copy of the working product that is limited to protect the vendor. Vendors are protected by offering potential customers a copy of the product that works for a limited period (such as 30 or 60 days), allows only one registered user or is installed on a single workstation, not a server.

In any case, caveat emptor...

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