Category Archives: Health Economics

Two Games and Vulnerabilities with Generic Drugs

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For those of you who like online games, there are two that I recently discovered that are quick and fun. Currently, both games are free.

  • MapTap.gg Daily geography game. Each day, the game asks you to identify 5 locations on a realistic unmarked 3D globe. The closer your guess, the higher your score. Each day there are short vignettes and facts.
  • Anno-Game Daily history game. Each day, the game asks you to determine the year of 5 important historical events. The closer your guess, the higher your score.

K Schulman, AL Kellermann. NEJM 2026;394:1669-1672. Substandard Generic Drugs — Threats to Patient Safety and National Security

An excerpt:

Generic drugs account for more than 90% of prescriptions filled in the United States. The first paragraph on the home page of the Office of Generic Drugs at the Food and Drug Administration (FDA) asserts that “FDA-approved generic drugs have the same high quality, strength, purity and stability as brand-name drugs.” On the strength of this assurance, America’s doctors, pharmacists, and patients assume that every version of a generic drug is equally safe. But this proposition is now being seriously challenged...

Between 2009 and 2019, the availability of generic medicines saved U.S. patients $2.2 trillion, according to the FDA.

Over time, intense price competition drove most production of generic drugs and ingredients offshore to countries with low labor costs and lax regulatory controls. Once that shift occurred, relentless pressure to minimize costs led some manufacturers to compromise on quality. Rapid globalization also outstripped the FDA’s capacity to monitor manufacturers. In 2022, the Government Accountability Office reported that 61% of foreign plants had not been inspected by the FDA in the preceding 5 years.1

When FDA inspectors finally reach these plants, some find glaring problems…More than 60% of generic-drug shortages are attributable to quality concerns, according to the FDA…

A private-sector laboratory detected high levels of nitrosamines (known carcinogens) in drugs made by several FDA-approved manufacturers, prompting recalls of metformin, angiotensin-receptor blockers, angiotensin-converting–enzyme inhibitors, prazosin, and ranitidine. More recently, independent tests of generic methylphenidate found nitrosamine levels above the FDA’s safety threshold in 7 of 15 immediate-release products…2

Recently, a team of U.S. and South Korean researchers with access to FDA data determined that significantly more serious adverse event reports were linked to generic drugs manufactured in India than to equivalent drugs manufactured in the United States…4

In 2008, a total of 238 deaths in the United States were linked to adulterated Chinese heparin. When the FDA toughened its approach to quality assessment of foreign manufacturers, shortages of more than 200 medications followed. This crisis prompted the FDA to prioritize minimizing drug shortages over ensuring safety… 

There is a better way to assure the safety of generic drugs. In 1994, the European Medicines Agency (EMA), for example, established a proactive approach involving risk-based surveillance in addition to systematic planned and ad hoc testing of generic drugs both on the market and during routine inspections of manufacturers (in contrast, the FDA does not routinely test generic-drug products themselves, either on the market or during quality inspections of manufacturing plants). EMA testing relies on a network of official medicines control laboratories (OMCLs) that operate in accordance with International Organization for Standardization (ISO) accreditation standards for testing and calibration laboratories. At any point in a drug’s life cycle, an OMCL can pull samples for product testing...

The U.S. government should oversee an effort to rebuild America’s capacity to manufacture generic drugs, combining investment in private manufacturing with incentives for purchasing U.S.-made products under the Medicare and Medicaid programs. Currently, the United States is vulnerable to an embargo of essential drugs or the materials required to make them. A recent evaluation for the Department of Health and Human Services found that 87% of sites that make active pharmaceutical ingredients (APIs) and 63% of sites that produce finished dosage forms were located overseas…

My take (borrowed from the authors): Most generic drugs are safe, but a troubling minority are not…The United States already tests a wide range of consumer products. We should also test our generic drugs.

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Iguazu Falls

Cheaper Generic Ozempic (semaglutide) Is Coming Soon — But Not for Americans

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NBC News 5/13/26: Cheaper Generic Ozempic (semaglutide) Is Coming Soon — But Not for Americans

An excerpt:

Outside the U.S., approved generic versions of semaglutide are beginning to hit the market. India and Canada recently approved their first generic versions of Ozempic, and countries including China, Brazil and South Africa are expected to soon follow…The U.S., however, remains on a very different timeline.

Evergreening

The standard length of a drug patent in the U.S. is 20 years from the filing date. Novo Nordisk first applied for a U.S. patent on semaglutide in 2006. Due to patent extensions, approved generic versions of semaglutide aren’t expected in the U.S. until at least the end of 2031…

Drugmakers often file additional, secondary patents — a tactic known as evergreening — to extend their monopoly on their product and delay generics. The additional patents can include new doses, formulations or delivery devices…

Novo Nordisk has filed at least 49 semaglutide patents… 

Drugmakers’ use of the patent system has delayed cheaper competition and kept prices high for patients.

My take: This is a bad deal for U.S. There is no good reason why patients in the U.S. need to be paying 5-10 times as much for semaglutide as patients in Europe.

Related blog post: “Gaming” U.S. Patent System by Big Pharma

Kiawah Island, SC

High Health Care Costs: Plenty of Blame to Go Around

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Zack Cooper, NY Times, 5/4/26. This Is the Biggest Culprit for High Health Care Spending.

An excerpt:

Responding to the wrongdoing of insurers is imperative, but it won’t do much to address the unsustainable cost of health care. We are directing our anger at the part of the system that is most visible and frustrating (insurers’ restrictions on care) while ignoring the part of the health system that is most responsible for high costs and economic pain: hospital prices…

Hospitals in the United States earn $29,000 on average for a replacement covered by private insurance and $16,000 for one covered by Medicare. In Germany, the public system of nonprofit insurers, which covers 90 percent of the population, pays hospitals $9,400.

Hospital prices are the leading driver of the 320 percent increase in insurance premiums that Americans have experienced over the past 25 years. Since 2000, prices at hospitals have grown faster than prices in virtually any other sector of the economy. They have grown three times as fast as inflation and twice as fast as prescription drugs and doctor visits.

The reason hospital prices are so high: hospitals’ accumulation of market power, which brings them more bargaining heft when they negotiate prices with insurers. Since 2000, there have been more than 1,300 hospital mergers among the nation’s approximately 5,000 hospitals. When hospitals that were once competitors merge, prices go up, often by double-digit percentages, with no measurable improvement in patient outcomes. Even though we rely on competition to determine hospital prices, 21 percent of hospitals are effectively monopolies — they have no competitor within a 30-minute drive — and an additional 24 percent face only one competitor…

If hospital prices are such a key driver of rising costs, why aren’t elected officials doing more about them? Partly the answer is politics. Hospitals are the largest or second-largest employer in many counties in America, and a formidable lobbying force — spending more than $100 million annually in Washington, often more than health insurers spend, to protect their interests. Politicians who represent places with dominant hospital systems are not eager to pick a fight with these institutions. Moreover, when an insurer denies your claim, you know it immediately. When a hospital merges and its prices go up, the harms — slower overall economic growth and job losses outside the hospital sector — are real but diffuse…

Holding that tension between the immense good that hospitals do and the economic harm their market power creates is what it will take to address the rising cost of health care.

In reaction to this editorial, the American Hospital Association Blog responded on May 6, 2026: Setting the Record Straight: Three Ways the Hospital‑blame Narrative Gets it Wrong

“Let’s start with a basic point — the entire concept of hospital “prices” is flawed. Hospitals are largely price takers, not price setters. Government programs like Medicare and Medicaid set rates administratively. But Medicare reimbursement continues to lag behind inflation — covering just 83 cents for every dollar spent by hospitals in 2023 — resulting in over $100 billion in underpayments. Needless to say, government rates fall far short of covering hospitals’ actual costs. Likewise, commercial insurers aggressively negotiate payment terms with hospitals. In many cases, these are large, vertically-integrated companies that hold significant shares in their markets. With that kind of market power, commercial insurers do not simply accept the numbers that hospitals offer and then sign on the dotted line. Thus, the notion of hospital “prices” does not reflect how those purposed “prices” are set in the real world…But here’s the reality: Over the same time frame, commercial insurance premiums have increased more than hospital prices…premiums are primarily growing due to an increased need for services: People are sicker and they need more care.”

“The essay also … appears to excuse commercial insurers’ role in deciding to raise their own premiums because they are in the “business of making money…The essay argues that policymakers must be harder on hospitals.”

“The essay also fails to ask another important question: Why are hospitals forced to raise their “prices”?…In 2025, total hospital expenses grew 7.5%, more than twice the rate of growth in hospital prices. Costs increased in every major category — workforce, drugs, medical supplies, and more. Hospital expenses also increased because of increased patient complexity; growing uncompensated care; continued government underfunding; changes in the policy landscape; and the many commercial insurer tactics like prior authorization and improper denials that the essay observes.”

My take: There are lots of reasons for high healthcare costs. There are not simple fixes nor enough incentives to make changes.

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Perito Moreno Glacier, Argentina

Understanding the Business of Medicine and Downstream Consequences

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There are several insightful and concise articles that highlight the reasons for increased U.S. healthcare costs as well as challenges: corporitization of health care, private equity, and health-harming corporations.

A Mollica, AW Mathews. WSJ 4/6/26: Why the U.S. Spends So Much on Healthcare

An excerpt:

“Americans spend more on healthcare than anyone else in the world. Just insuring a family here costs nearly $27,000 a year, enough to buy a car. The main cause: Prices are far higher in the U.S. for the same medical products and services, from surgeries to drugs.

American patients have also been using more care recently, including costly hospital treatment and expensive new drugs for weight loss.”

  • Prescription drugs cost a lot more in the U.S.
  • Big hospitals can charge higher rates because of consolidation
  • The U.S. spends far more than other countries on administration
  • Labor costs are higher
  • Americans are using more healthcare

LP Casalino. N Engl J Med 2026;394:1249-1251. Physicians, Corporatization, and the Unmeasured Quality of Care

This article notes that historically, in economic experiments, physicians have acted more altruistically than members of the general population and this results in better outcomes for patients. However, “extreme size and corporate ownership are leading to the widgetization of care. It is difficult or impossible for a large organization, even one with well-intentioned leaders, to avoid treating its physicians and staff like interchangeable widgets whose behavior can be monitored and controlled to maximize profit….Physicians who feel like widgets are more likely to behave like widgets…there is evidence that corporatization is leading to higher prices, higher health care spending, and unchanged quality or poorer quality.”

R Yearby, M Alson. N Engl J Med 2026;394:937-940. Private Equity’s Transformation of American Medicine — Implications for Health Equity

An excerpt:

“Accumulating evidence presented in scholarly articles and government reports indicates that the proliferation of PE in health care has reduced access to care, increased costs, and compromised quality of care…PE firms often extract value using tactics that obscure a health care system’s profitability while maximizing financial returns for the firm and its investors. These tactics include sale–leaseback transactions, in which facilities are sold to entities affiliated with a firm and then leased back to the seller at inflated rates. Another strategy is dividend recapitalization, whereby fund managers take on additional debt to pay partners instead of putting money toward staff, critical maintenance, or supplies…

PE investors achieve cost savings by laying off workers, reducing salaries and the number of full-time employees, assigning services previously provided by physicians to other health care professionals, and cutting critical but low-profit services…

Cream skimming — selectively caring for healthier (i.e., lower-cost) patients — is another widely used PE practice. This tactic limits access to care for older and sicker patients, leaving them worse off after PE investment.2 Despite this behavior, hospital acquisitions by PE firms have been associated with increases in emergency department deaths and deaths after emergency surgeries.3,5“

Consortium of the Center to End Corporate Harm, University of California, San Francisco. N Engl J Med 2026;394:1231-1237. Corporate Vectors of Chronic Disease — Using Internal Industry Documents to Craft Counterstrategies

An excerpt:

“Health-harming corporations use common tactics to corrupt scientific data, including influencing research questions, attacking and discrediting independent science and scientists who do not support the industry’s position, suppressing scientific data on the health harms of their products, and sponsoring research that downplays those harms.27,28

For example, the primary U.S. manufacturers of perfluoroalkyl and polyfluoroalkyl substances (PFAS) — DuPont and 3M — used multiple tactics to downplay evidence of PFAS toxicity, including successfully suppressing for more than 20 years internal studies showing adverse effects of PFAS…

Corporations have various tactics for influencing the public’s beliefs about their products’ benefits and harms. These include sophisticated and pervasive advertising and marketing campaigns; use of public relations companies, front groups, and think tanks; and capture of consumer groups.

For example, opioid manufacturers deployed particularly insidious advertising strategies for marketing opioids to vulnerable populations, such as recruiting youth coaches and school nurses to encourage opioid use by children, developing unbranded initiatives encouraging adolescents to ask clinicians for pain medications, promoting “safe opioids” for untreated pain in women, and distorting policy discussions of unmet needs for pain medication…

Make America Healthy Again initiative highlights the roles of toxic chemicals and pesticides, ultraprocessed foods, and corporate influence on science in harming children’s health.47 But…the administration has appointed former lobbyists and scientists from the chemical and petroleum industries to lead EPA offices responsible for regulating air pollution, toxic chemicals, and pesticides48,49 — and plans to eliminate regulatory and other measures, which will lead to increased exposure to toxic chemicals and air pollutants, thereby increasing child health risks.50,51 

My take: Poorly-regulated capitalism is not good for patients. Insurers, private equity, hospitals, pharmaceutical companies and many providers may prioritize profits over care.

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Humor: MAHAspital

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This satire is particularly amusing for those who have watched “The Pitt.” Unfortunately, many of the health care policy changes under this administration will cause harm here and throughout the world for decades.

3/14/26 SNL: MAHAspital

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Reimbursement Reduction for Gastroenterology Practices

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JA Busam, ED Shah. Clin Gastroenterol Hepatol 2026; 24: 281-284. A Decade of Decreasing Reimbursement Strains Gastroenterology Practices and Threatens Their Independence

Background: “Over the past decade, a remarkable number of independent community gastroenterologists became part of larger groups, primarily due to financial concerns. Although the number of gastroenterologists increased between 2012 and 2020, the number of associated practices decreased by more than 650 (14%), with the number of physicians practicing in groups of less than 10 decreasing by nearly 1500 (35%).1 Simultaneously, the number of self-employed physicians decreased,2 while the number of hospital-employed and private equity affiliated physicians increased.3,4 Surveys of practices engaged in such consolidative behavior most often cite financial uncertainty given increased costs, decreased revenues, and continuing regulatory pressures, along with personal financial gains, as important motivations.5,6“

Methods: The authors examine how “Medicare reimbursement has affected independent, community practices over time, with a particular emphasis on hourly rates to account for any efficiencies in endoscopic procedure times over the past decade…[using] multiple datasets from the Centers for Medicare and Medicaid Services (CMS).”

Key finding:

  • “All major endoscopic procedures investigated brought in decreased associated professional revenue between 2014 and 2024 per unit billed. Most procedures saw a reduction between 30% and 40% in the amount of cash brought into the practice per procedure”
  • “Although independent practices faced tough decisions due to these trends, other health care stakeholders benefited. Concurrently, facility revenues, medical complexity,13 overall health expenditures,14 drug prices,15 and pharmacy benefit manager profits16 all increased, the latter by approximately 80%”

My take: This small study shows how “independent gastroenterology practice reimbursement decreased substantially since 2014 despite increasing patient complexity and capital flows into health care, threatening the viability of many community practices.” 

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Health Insurance Improves Survival and Outcomes in Patients with Liver Disease

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In a previous blog post in 2019, it was noted how the IRS proved that having health insurance saved lives (How The IRS Proved That Health Insurance Saves Lives); just receiving a letter recommending getting coverage reduce deaths by ~1 in 1600. Another study in 2014 (in Massachusetts) showed that for “every 830 additional people who got insurance under Massachusetts’ health reforms prevented roughly one death.” If this were extrapolated to broaden health care coverage to everyone in the U.S this could amount to preventing 20,000-45,000 deaths per year (A Leading Cause of Mortality in U.S…. and 45,000 Unnecessary Deaths Per Year).

A new study shows how important ACA expansion has been to improved liver outcomes:

TL Walker et al. Clinical Gastroenterology and Hepatology 2026; 24: 312 – 327. The Affordable Care Act Improves Access, Survival, and Racial Disparities of Patients With Liver Disease: A Systematic Review

This review identified twenty-seven studies that met inclusion criteria across 4 clinical categories: hepatitis C virus (n = 4), liver transplantation (n = 10), hepatocellular carcinoma (n = 9), and cirrhosis or CLD (n = 5).

Key findings:

  • Twenty-three out of 27 studies showed patients benefited from the ACA, which notably included improved liver-related mortality in Medicaid-expansion (ME) states.
  • “Difference-in-difference analyses showed liver transplantation listing increased by 1.8% to 6.0% in ME vs NME states; early-stage hepatocellular carcinoma (HCC) diagnosis increased by 5.4%, and cirrhosis-related mortality rose more slowly in ME states (0.5–1.0 per 100,000 vs 1.4–10.4 per 100,000).”

From Related summary: ACA expansion linked to better liver disease outcomes (GI & Hepatology News):

  • HCV studies showed improved access to direct-acting antiviral therapy in ME states. Expansion states consistently reported higher direct-acting antiviral prescription rates and Medicaid reimbursement levels compared with NME states.
  • HCC survival outcomes improved more consistently in ME than in NME states after ACA implementation (median overall survival, 7.3 months versus 4.5 months, respectively).
  • Of the five studies that examined chronic liver disease and cirrhosis, ME was associated with lower emergency department readmissions, shorter hospital stays, and reduced hospitalization costs.

My take: The study findings, while not surprising, quantifies some of the improvements in survival and outcomes for patients who gained access to health insurance.

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    Gastroenterology and the Rise of Private Equity Investments

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    TA Brenner et al. Clin Gastroenterol Hepatol 2026: 24: 7-9. Geodemographic Trends in Private Equity Acquisitions of US Gastroenterology Practices: An Analysis of Transactions From 2013 to 2023

    An excerpt:

    “The combination of high-volume procedures, strong ancillary revenue streams, and opportunities for outpatient consolidation has made gastroenterology a prime target for PE-backed investment. For many gastroenterologists, this trend is no longer theoretical—it is local, visible, and shaping the landscape of everyday practice.”

    “Between 2013 and 2023, PE firms acquired 114 outpatient gastroenterology practices, encompassing 1169 clinical sites nationwide…That includes 854 clinics, 266 endoscopy centers, and 49 infusion centers. Collectively, these sites employed approximately 2675 physicians and advanced practice providers. In total, around 14% of all gastroenterology clinical sites nationwide are now affiliated with PE-backed platforms.”

     (A) Trend in private equity acquisitions of gastroenterology practices (red)
    and gastroenterology clinical sites (blue) by year.

    “PE firms are less likely to invest in gastroenterology practices located in the poorest communities… Practices in zip codes with the lowest income levels were about 60% less likely to be acquired than those in wealthier areas (aRR, 0.37; 95% CI, 0.31–0.45; P < .001)…PE firms tend to prioritize markets with strong commercial payer mixes and higher rates of elective procedures, steering clear of areas with high Medicaid penetration or large numbers of uninsured patients.”

    Key Points:

    • “First, consolidation is accelerating…Even if you are not interested in selling, you may need to compete with PE-backed groups that have more capital, better tech infrastructure, and stronger payer contracts”
    • “Second, staying independent may become more difficult. As regional consolidation increases, remaining unaffiliated could put independent practices at a disadvantage. PE-backed platforms often negotiate better rates with commercial insurers and have the scale to invest in centralized billing, marketing, and compliance.”
    • “Third…If PE firms avoid lower-income or rural areas, gastroenterology access could become more uneven and more challenging to sustain in underserved regions.”
    • “Studies in other specialties suggest that practices owned by PE firms often face changes in staffing, autonomy, and productivity expectations. Physicians may experience higher pressure to perform more procedures, see more patients, or adopt system-wide workflows they did not design.”

    My take: PE acquisitions are affecting broad areas of healthcare. However, they do not seem to result in improvement in patient care or physician satisfaction.

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    Why Corporatization Occurs in Health Care -What Motivates Hospitals

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    S Lipstein. NEJM 2025; 393: 1249-1251. Insight into Corporate Governance — What Motivates Hospitals and Delivery Systems

    This commentary provides a useful perspective on how hospitals view consolidation of health care. This article is one of many on the topic of corporatization of health care in recent NEJM issues. The author pushes back on the notion that the motivation is purely financial. And, the author argues that a lot of the concerns with poor outcomes/life expectancy despite high expenditures in health care actually are related mainly to poverty level, gun-related mortality, and public social services expenditures.

    Here’s an excerpt:

    Critics of such large-scale combinations argue that when clinical assets are aggregated within contiguous geographic areas, there is market consolidation. And market consolidation leads to anticompetitive behaviors, resulting in higher prices without concomitant quality improvements, fewer small innovative providers left to disrupt the status quo, and depressed wages for health care workers.

    Delivery system leaders view asset aggregation in a different way — as a vehicle for efficient deployment of human, physical, and financial capital to achieve a health care mission. Upsizing by means of mergers and consolidation, hospitals and delivery systems realize benefits that come with economies of scale, spreading fixed operating costs…over a larger base of patient care revenue. Aggregating hospitals and physician practices within contiguous geographic areas enables systems to make large investments in facilities and technology that serve more people and avoid costly duplication….

    Large-scale aggregation of health care delivery enterprises helps level the playing field with large-scale payers…

    Often underappreciated is the importance for health systems of cultivating managerial bandwidth and subject-matter competencies unique to health care. As a health system grows, it gains the ability to compete on a national scale for top talent and expertise…

    Use of the term “corporatization” suggests that health care mega-providers are money-motivated, focused on goals that are all about the bottom line. But money motivation in health care is not unique to big corporations…

    In my experience, governing boards of delivery systems have four expectations of their executive leaders. Each expectation drives a financial motivation to generate the requisite revenues, operating margin, and investment capital.

    First, to take good care of people when they are sick or injured and to help people remain as healthy… the delivery sector must have the financial capacity to invest in workforce skill development and training, renewal and expansion of patient care infrastructure and technology, and business and enterprise management systems…

    Second, to operate in a financially responsible way, a delivery system needs to generate a positive operating margin, meaning revenues greater than expenses…

    Third, to position a health care enterprise for long-term sustainability, it requires the financial fortitude to withstand the vagaries of economic and political cycles that might jeopardize the future availability of services…

    And fourth, to stay true to a social or academic mission, many health care institutions make substantial financial commitments to their local communities and affiliated universities…

    Comparisons of life expectancy and health spending are unadjusted for important differences among countries, including household income and poverty levels, gun-related mortality, and public social services expenditures.2,3 Nobody benefits if we ascribe poor health outcomes to corporatization and ignore true determinants…

    Until we devise better solutions to improve the health of people whose economic disadvantages and behaviors reduce longevity, the United States will continue to lag.

    My take: This article explains how health care systems view consolidation. Overall, my view is that the costs associated with hospitals are too high and some of this could be curtailed without affecting outcomes (see: When Hospitals Look Like The Ritz (But Cost Even More)).

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    Mary Suhr: Coding Update 2025

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    Mary Suhr, a coding expert, provided our group with an excellent update on coding and the changes needed in documentation. I have taken some notes and shared some of her slides. There may be inadvertent omissions and mistakes in my notes.

    • In 2025, billing/coding relies entirely on medical decision-making OR time codes.  While documenting a comprehensive history and an exam are important for patient care and good practice, they are not important in billing/coding.
    • Medical decision-making (MDM) consists of three areas: diagnosis, review of data, and risks of treatment.  Data includes points for each lab reviewed/ordered and each radiology test.  If you order/review CBC/d, CRP, and CMP, this would be up to 3 points in this category.
    • With the changes in requirements in coding, the RVUs were increased for both outpatient and inpatient codes.  This reflects the increased difficulty in selecting some codes.  For example, the change in requirements, some 99214 codes several years ago will now qualify for 99213 codes.  It is much more difficult to use a 99215 code based on medical decision-making and the time spent is up to 40 minutes to use this code
    • Followup visits who are not doing well generally would NOT be a low level visit if documented appropriately
    Coding for F/u visits
    See slide below regarding split/shared services below.
    If APP spends the majority of the time, then the time codes can be billed by the APP
    or the MD can bill based on medical decision-making (but not time code).
    • Discontinuing a prescription medication can be counted as prescription drug management if documentation explains the potential benefits/risks of this
    • Newer codes that may be useful:
    • G2211 –>long-term longitudinal care code
    • 99451 –>interprofessional consultation (if patient consented). If an ED physician calls for consultation, documentation could allow for this code as long as the patient is not seen before or after within 7 days
    • 98016 –>audio (telephone) consult code for established patients. This could be used to check in to see if the patient needs an office visit
    • New ICD-10 codes for IBD with fistulas, BMI codes and eating disorders
    • If a patient is seen in ED and leaves ED, recommended to use ED codes, not office-based outpatient codes
    • For inpatients, HAL management is generally a high risk medication/treatment for coding-billing purposes
    • Document defensively.  Increasingly, insurance companies are trying to downcode visits.  Recommend resisting this and document why the initial codes were selected
    • Except for Medicaid, can use modifier 25 and bill if patient seen in clinic by one provider and in the hospital by another provider, if each was involved in patient care