Automatic Follow-up Appointments: Issues in 2005

Editor's note: I urge ALL clinicians to read and review this article as soon as possible as it will potentially impact the management of every patient you see. I would like to personally express my gratitude to Dr. Fifer, for once again sharing timely and important information with audiologists and the entire healthcare community. ---Dr. Douglas L. Beck

As graduate students and young professionals, many of us were taught that quality of service depends in part on the thoroughness and intensity of follow-up services provided to our patients. Many of us have recommended something along the lines of ... "Return in one year for a follow-up audiogram to monitor hearing status."

Indeed, pediatric audiologists often recommend a follow-up hearing test at six months of age for newborns who passed the in-hospital newborn hearing screening test. Of course, adults also receive recommendation for annual audiograms following diagnosis of sensorineural hearing loss or to accompany hearing aid re-checks. Each time this happens the follow-up recommendation is offered in good conscience and with a sincere belief that the audiologist is providing high quality care.

Unfortunately, in reality, these follow-up recommendations (see above) run contrary to the rules, regulations, and guidelines set forth in the provision of health care services for all disciplines.

The prevailing rule for any medical visit focuses on the necessity of services, not the intensity of services. This is derived primarily from Medicare rules and regulations, and applies to Medicaid and many third party payers. The necessity for this guideline came about as a result of numerous studies throughout the 1980s relative to the cost of delivering health care services.

There is little disagreement that the quality of healthcare and the quality of health in this country have improved dramatically from 1940 to the present. But gains in health and well-being have come at an expensive and increasing price. In 1960, health care spending was 5.1% of the Gross Domestic Product (GDP). In 2003, health care spending commanded 15.3% of the GDP -- with no apparent signs of slowing (see "Effects of Health Care Spending on the U.S. Economy." aspe.hhs.gov/health/costgrowth

Increases in healthcare spending were particularly rapid in the 1970s and 1980s. Medicare spending rose from $3.2 billion in 1970 to $15.7 billion in 1985. Medicare spending for 2005 is estimated to be $54.2 billion. Increases in healthcare spending far outpaced inflation, salaries, cost of living, and every other expense (GAO Report: Medicare Physician payments - Information on Spending Trends and Targets. May 5, 2004. www.gao.gov/cgi-bin/getrpt?GAO-04-751T This ever-increasing "line item" of the annual congressional budget was never intended to be a substantial portion of the GDP and is being monitored closely.

In the early 1980s, congress asked, "How much does it cost to provide health care services?" No one knew the answer. To ascertain this information, Congress directed Health and Human Services (HHS) to contract with Harvard Medical School and the Harvard School of Business to conduct a survey of physicians and other health care professionals. Elements of the survey included time and scaled work intensity required on the part of the physician for each procedure, the cost of ancillary personnel assisting the physician, the use and cost of investment equipment (greater than $500), disposable supplies, and fixed overhead (administrative support personnel, rent, utilities, etc.). The outcome of that survey established the foundation for the Resource Based Relative Value Scale (RBRVS), which placed in rank order the relative value of each procedure, with regard to work intensity and related costs. No dollar amounts were applied to the formula, only the rank order of relative difficulty and related expenses were applied.

During this same period of time, HMOs began to establish a foothold with increasing enrollment and new patient visit rules. Health care networks began to flourish on the premise that physicians would be paid less for their services but the number of referrals would increase to make up for lost income. The combination of decreased payments, increased patient loads, and the RBRVS system produced several unintended consequences.

As Congress continued to struggle with containing health-care costs, it instituted numerous rules to control costs and reduce fraud. Among these rules was the "medical necessity" guideline. In essence, this guideline stated that a patient needed a reason to be seen and receive health care services and that the reason had to be based upon symptoms, whether real or perceived (42 U.S.C. 1395y Section 1862 (1)(A)).

In other words, there has to be a medically justifiable reason for the patient to be seen. Initial or return visit recommendations, based strictly on the preference of the audiologist, without medical justification, is no longer permissible.

Currently, it is not acceptable for an audiologist to tell a patient, "Let me see you back in six months for a re-check." Or, "Let's set up an appointment in a year to repeat the hearing test."

It is acceptable for an audiologist to say, "If you experience any change in symptoms, such as ringing in your ears or a change in hearing, let me see you back for a repeat evaluation to see what's happening." In similar manner, if the patient perceives a worsening of symptoms, a sudden or dramatic change in symptoms, or new symptoms which did not previously exist, justification would exist under the medical necessity guideline for a repeat evaluation.

However, the focus of this justification must be a change in the patient's condition -- not a standard follow-up recommendation on the part of the audiologist. For infants, this indicates that a "normal" newborn who passes the in-hospital hearing screening may have no justification for a return visit in six months to re-check hearing.

As implied above, the working assumption is that the change in symptoms resulting in a return visit will be "after-the-fact." That is, the patient will have noticed (subjectively) that something is different in the form of a new symptom or a change in status of an old symptom.

However, after a medical diagnosis has been made and confirmed, if a reasonable medical probability of status change exists (based on the confirmed diagnosis) this might trigger a situation in which ongoing monitoring might be justified.

For example, administration of ototoxic medications as part of an anti-cancer therapy regimen, or perhaps the diagnosis of a particular type of viral infection with associated delayed onset hearing loss. Either of these might trigger a scheduled follow-up appointment. In infants, diagnoses such as cytomegalovirus (CMV) or other genetic disorders could justify a follow-up regimen in anticipation of auditory changes during the pre-lingual period of development.

Any recommendation for follow-up without a prior change in symptoms, regardless of age, should be based on "reasonable medical probability" of a degradation of auditory function or a change in overall status associated with a related, confirmed medical diagnosis.

The medical necessity guidelines will require a change in mindset of a number of audiologists. Keep in mind that this change came about as a way to reduce the overall cost of health care in addition to preventing the patient from "needless" return appointments in the absence of medically justifiable reasons for follow-up. A secondary goal would be to improve patient compliance through assurance that every recommendation is fully justified, for the patient's well-being, and part of a program to provide excellent quality of care.

Robert C. Fifer, Ph.D. is currently the Director of Audiology and Speech-Language Pathology at the Mailman Center for Child Development, Department of Pediatrics, University of Miami School of Medicine. He is the President of the Florida Association of Speech-Language Pathologists and Audiologists, a member of ASHA's Health Care Economics Committee, and the ASHA representative to the American Medical Association's Relative Value Update Committee (RUC) Health Care Professions Advisory Committee (HCPAC) in addition to being ASHA's representative to the AMA's Practice Expense Review Committee. Additional responsibilities at the state level include serving as a consultant to Florida Medicaid for Hearing Services and to the Florida Department of Health's Children's Medical Services.