SAN FRANCISCO Infectious disease specialists at one institution provided over $93,000 worth of curbside consultations without reimbursement, Dr. Christopher J. Grace said at the annual meeting of the Infectious Diseases Society of America.
Members of the specialty "need to get a handle on this. We're giving away the farm," said Dr. Grace of the University of Vermont, Burlington.
A 1-year prospective study at Fletcher Allen Health Care, a 500-bed community and tertiary care center in Burlington, found that infectious disease specialists gave 1,001 curbside consultations, defined as advice or suggestions given to another physician without seeing the patient. Curbside consults took place in person or by telephone, letter, or e-mail.
Without the physicians or nurses who requested the curbside consultations knowing it, the infectious disease specialists assigned a CPT code to each event based on whether the patient in question was an inpatient or outpatient, whether the consultation dealt with initial care or subsequent care, and how complex the case was. They then gave a physician-work relative value unit, or RVU (used by the Centers for Medicare and Medicaid Services [CMS] to calculate reimbursements) to each curbside consultation based on the CPT code, and multiplied the aggregate RVUs by the 2005 CMS conversion factor of $37.89 per RVU to estimate costs.
In 98% of cases, curbside consultations focused on a specific patient, rather than on theoretical patients or general topics. Among consultations for patients, 34% were for inpatients and 66% were for outpatients. Events were coded as initial consultations in 96% of cases.
The main clinical topics of consultations focused on skin disease in 16% of cases, pulmonary disease in 8%, bone or joint infection in 8%, and bacteremia in 7%.
The curbside consultations accounted for 21% of all infectious disease consultations that year and were equally as complex as formal consultations, Dr. Grace said.
The curbside consultations generated a total of 2,462 RVUs, which would have meant $93,285 "if we were paid the standard Medicare reimbursement fee," he said.
Formal consultations in the same time period generated 9,409 RVUs worth $356,507. The number of RVUs per consultation was higher for curbside (2.46) than for formal consultations (1.22) because the former had a higher proportion of initial consultations.
Who asked for curbside consultations? Questions came about equally from the health center's staff and from community physicians with medical privileges at the center. More questions came from general internists than other specialists.
A physician in the audience urged Dr. Grace to share the results with colleagues in other specialties at his institution. "When you do, they'll be horrified that they're using you this way. It tends to bring your formal consults up," he said, based on his own experience.
Dr. Grace noted that some physicians requesting the curbside consultations practiced 20150 miles away, making formal consultations more difficult.
Hospitals, insurers, and others need to integrate curbside consultations into productivity measures and compensation measures, he said.
Many in the audience agreed. "We all should have done this 30 years ago, and we'd have more leverage with the payers," one physician said.
Another suggested refusing to do curbside consultations. "At some point we just need to draw the line. If you offend the people who are curbsiding you, you lose nothing," he suggested.
The definition of curbside consultation in the study excluded consultations for infection control, antibiotic restriction efforts, follow-up on formal consultations, education of students or residents, and curbside consultations that converted to formal consultations on the same day.