Copyright Monopolies In The Middle Of Health Care Reform Debate As Well

from the all-about-the-monopoly-money dept

Thu, Jan 7th 2010 9:39am — Mike Masnick

An anonymous reader sent over yet another example of copyright being abused for monopolist reasons that have absolutely nothing to do with "promoting the progress," and actually represent a serious healthcare issue. I had no idea, but apparently the various "codes" used by doctors to classify every visit are actually covered by a copyright held by the American Medical Association, which refuses to allow any free or open distribution of the codes (known as Current Procedural Terminology (CPT)). That's because the AMA makes about $70 million per year "licensing" the codes.

I'm having serious trouble figuring out what about the codes could actually be covered by copyright, however. They're numbers corresponding to a particular medical service. As the post above notes, it's things like "90801 Psychiatric Diagnostic Interview." It's difficult to see what the creative component of such a listing is that would allow it to be granted any sort of copyright protection. A simple database of codes by itself shouldn't really qualify, should it? However, the real issue seems to be that Medicare and Medicaid have required the use of these codes, meaning that pretty much everyone needs to use them... and then has to pay up for them. While a court did find that this arrangement clearly involved the AMA misusing its copyright and noted that "the adverse effects of the licensing agreement are apparent," the AMA did some legal tap dancing to get around the issue and keep things effectively the same.

So why is this bad for pretty much everyone outside of the AMA? It makes it that much more difficult to comparison shop between doctor's services, since publishing such info can run afoul of the copyrights. One of the biggest problems in healthcare today is the fact that the true costs of pretty much everything are hidden from the consumer through a convoluted insurance system. The end result of any economic situation where the true costs are hidden from the buyers is that the market is woefully inefficient. But, so long as that inefficiency lets the AMA collect $70 million per year (double what the AMA makes from membership dues), it doesn't seem to care.

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Filed Under: codes, copyright, healthcare, monopolies
Companies: ama

42 Comments

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Nastybutler77 (profile), 7 Jan 2010 @ 9:48am

Oh, don't worry, I'm sure that the new Health Care package Congress is about to pass will fix everything...
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Dr. Anti-Mike, 7 Jan 2010 @ 10:05am

The AMA spends billions on...well...lobbying. Surely they deserve to see a return on their investment.
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senshikaze (profile), 7 Jan 2010 @ 10:12am

i work in healthcare, and have to say, CPT codes SUCK.
There are literally about a hundred for "bleeding out of left arm." I am not kidding.
I wasn't aware that the AMA had a copyright on them. I am not even sure how they would recieve money on this. our doctors have memorized the codes they need and we have a file on our EMR server that can translate CPT codes into things for the database, but we made that list from scratch with a dr telling us what it meant. Now, they may have had to buy the list of CPT codes in med school, but i don't think our business had to buy one directly.
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Richard (profile), 7 Jan 2010 @ 10:47am

National Health Service
Now if you had a National Health Service then the doctors would all be government employees and so the codes would be automatically in the public domain....
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nraddin, 7 Jan 2010 @ 10:56am

Why are you surprised?
The AMA has been screwing the American public for years. They are far more worried about the bottom line for doctors and big Pharma, than they are about your health or even nurses, CNAs and the like that they are suppose to rep. People think the AMA must be on their side, but they are are the side of making more money and that is it. They are for all practical purpouses the RIAA or MPAA of health. They screw you over for hte bottom line (Money) and only have the goal of making more money for themselves, if you get sick and die in the meantime that's ok.
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Hulser (profile), 7 Jan 2010 @ 11:04am

Re:
Now, they may have had to buy the list of CPT codes in med school, but i don't think our business had to buy one directly.

Shhhh! Shut up or you'll have AMA agents knocking at your boss's door asking for this year's licensing fees and all previous years' fees too! "So, we hear that you haven't been paying CPT code licensing fees, Dr. Senshikazesboss."

Oh, and even some docotors don't have to pay for the licensing directly, all of the American public had to pay for them indirectly.
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Anonymous Coward, 7 Jan 2010 @ 11:08am

Not so much National Health Service... rather a national health insurance.

Canada has national health insurance. The doctors are NOT government employees. Doctors run their business and pay their staff but instead of having a complex building system and fighting with insurance companies they just submit ONE bill to the government (IE: ONE insurance company) who then pays the doctor. The doctor then pays the staff, liability insurances, rent, etc.

The single source of insurance (payer) saves tons money in the billing process. The doctor puts a cast on you... they bill the government $800 for the services and materials rendered. The prices are largely fixed for every service so the doctors have to do volume and run an efficient business to make money. You do not like your doctor then you go see another one. In some provinces if you feel you need that non-critical MIR ASAP then you can fork the money out of your own pocket and get it done privately. Simple for billing and for the patient.

The issue of which insurance you have and if your married whose insurance come first, etc all go away. Everyone is covered as you pay taxes for cover your insurance premiums and since everyone MUST join the cost is really cheap. The bonus is that is not for profit... the government gets any profits via cost savings and YOUR taxes go down!

As the government is going to start running the show they can dictate new billing codes and really good description of each. If the hospital or government does not like then to bad they do not need to get paid. Money is a very power influencer... just ask any politician.
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Trails, 7 Jan 2010 @ 11:13am

Similar thing with ACR codes
There's also a set of diagnosti codes used in radiology to describe anatomy and pathology, known as ACR codes (American Colleage of Radiologists, I think).

They demand licensing as well, with similar merit.
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Hulser (profile), 7 Jan 2010 @ 11:15am

Unfunded mandates
However, the real issue seems to be that Medicare and Medicaid have required the use of these codes, meaning that pretty much everyone needs to use them... and then has to pay up for them.

There's a parallel in the financial industry. I can't remember the exact details, but I believe that there is a federal law in place that stipulates that certain kinds of companies must have a certain percentage of their assets in stocks of a certain rating. And who rates the stocks? Why, for-profit companies of course. So, in both situations you have the government requiring the use of (and payment to) non-government organizations in order to comply with government mandates. Maybe this makes sense in some cases, but I don't see how it does in either of these cases.
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Anonymous Coward, 7 Jan 2010 @ 11:41am

Re:
hmmm yet the Canadians all come to the US for medical service, seems they dont like the 6 month + time frames,
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ChurchHatesTucker (profile), 7 Jan 2010 @ 11:46am

NFPA Placard codes?
Tangental, but does anyone know if the NFPA codes (those four-diamond-shaped signs on trucks and railcars) are under some kind of copyright? I can't figure it out.

E.g., If I started making identical signs, am I liable?
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CastorTroy-Libertarian, 7 Jan 2010 @ 11:48am

Acutally the CPT codes are used by Billing Companies. And the people who pay the AMA is the Certified Coders that work for those companies (they pay to be certified and for their books, which change ever year). My Wife is one, and she is the first to point out the system is stupid.

She handles various E.R's from around our state, and if 1 person codes it and another looks at it, it will be wrong, why because the way they do the codes theres about 50 ways to answer every thing that needs to be coded.

The funny part is, my wifes mother did this same thing (handled private practice billing) and before Medicare and Medicad,they didnt have all the hassle as the Private Insurance companies wanted the least hastle to keep their customers and teh doctors happy and to keep their costs down.... as the Governement has pushed more and more into health care the costs for just dealing with it have spiraled into orbit. One office that i am friends with bets, that dealing with Insurance companies and Medicare and Communistaid (Medicad) have tripled his costs on providing basic services, much less anything else, and as a result pretty much had to drop all those patients with those plans. More hassle than it was worth.
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Yakko Warner, 7 Jan 2010 @ 12:05pm

I wonder how they're licensed
I once coded a web app for a medical insurance company that assisted members in estimating and comparing treatment costs, and it included filling out online forms (and printing out forms that you could take to different doctors) to identify different treatments, and all these forms had these CPT codes all over them. They even displayed two sets of codes -- one for the current and one for the previous year -- as, apparently, the codes change from year to year.

It now makes sense to me why these codes would change from year to year, so the AMA can require everyone buy the new codes.

I wonder if said insurance company had to license the codes for use in this web application first, before I ever started coding it.
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Anonymous Coward, 7 Jan 2010 @ 12:20pm

Re:
just like a bandaid will fix a bullet wound
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Anonymous Coward, 7 Jan 2010 @ 12:21pm

Re: Re:
Canadian nurses come to the states to work, too. Seems they get paid more.
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senshikaze (profile), 7 Jan 2010 @ 12:28pm

Re:
yea, i have been talking to my billing people and it seems that CPT codes are almost only for billing stuff. Still not sure if we pay AMA anything, though.
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senshikaze (profile), 7 Jan 2010 @ 12:30pm

Re: NFPA Placard codes?
completely off topic: but i just got your username's reference. just thought you might like to know.
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jjmsan (profile), 7 Jan 2010 @ 12:35pm

Re: Re:
It's only fair. We buy all their drugs.
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TW Burger (profile), 7 Jan 2010 @ 1:24pm

ADA Codes
The American Dental Association codes are available for anyone and are published many places on the web.

http://support.previser.com/documentation/UsingPreviser/Appendixes/ADACodeTable.htm

I suspect that dentists are not looking for any more reasons for people to dislike them.
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Sean T Henry (profile), 7 Jan 2010 @ 1:27pm

Re:
I would like to say that I am a Certified Professional Coder (CPC), you know one of the people who is trained in using CPT and ICD codes.

I hope that you are not serious about your doctor did not just tell you what to put in the EMR/EHR. The reason some of the codes change from year to year or are added and removed.

How does the AMA make money off the ICD and CPT codes? THEY SELL BOOKS. As a coder and/or billing specialist you need to get a copy of the new books each year, one for Procedure codes, one for Diagnosis codes, and usually one for HCPCS (medical supplies hospital codes ect.)

CPT codes do not suck unless you get a book from a crappy publisher. If you give almost any 3.0gpa high school grad who never really tried the 8hr CPC test after looking at the three books mentioned above. They will pass on the first try.

What needs to happen is get many coders, doctors and hospitals to create a class action lawsuit for extortion against the AMA. Then this might stop.
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Sean T Henry (profile), 7 Jan 2010 @ 1:28pm

Re: National Health Service
No the AMA is not a government entity and they own the codes.
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Sean T Henry (profile), 7 Jan 2010 @ 1:36pm

Doctor shopping
Having the CPT (procedure codes) available for free to every one will not allow someone to shop around for doctors any more than with out them. The reason is what you pay and what the doctors are paid is set by the insurance company you use.

The only way to "shop" for doctors is to call them up and ask about there self pay options and use the one with the best self pay discount. Usually it is based off the Medicare allowable and the patient has to pay a set sum upfront.
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Sean T Henry (profile), 7 Jan 2010 @ 1:41pm

Re: Re:
People do not pay the AMA its the doctors offices, insurance companies, hospitals, CPCs, and anyone else that bills for medical services.
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TW Burger (profile), 7 Jan 2010 @ 1:56pm

Re: 6 month + time frames
The waiting times in Canada are greatly exaggerated (usually by Republicans or Fox News).

True, there are problems and limits that need to be addressed in Canada's public health care. Canada's health care system has huge room for improvement but it does usually work. If I was living in the USA, treatments my family members needed would probably have forced me into bankruptcy several times over.
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PaulT (profile), 7 Jan 2010 @ 1:58pm

Re: Re:
Funny how the defenders of your broken system always love to mention this as though it's a majority of Canadians travelling, yet forget to mention that 6 million Americans each year travel abroad for their healthcare:

http://news.health.com/2009/04/08/traveling-treatment/

Newsflash: every country has people who prefer other systems and will travel abroad for healthcare if they can afford it. That in no way invalidates a system that doesn't leave people dying or bankrupted if they can't afford healthcare. Only one country in the civilised world doesn't take care of a majority of its citizens.
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Colin (profile), 7 Jan 2010 @ 2:00pm

I suppose that since the issue has been raised here, it won't be too long before wikileaks has the codes posted
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Richard Hussong (profile), 7 Jan 2010 @ 2:07pm

Re: Canadians
You don't actually believe that, do you? People south of the border may not realize this, but most Canadians are reasonably happy with the medical services they have received all their lives (as are most Americans, as it happens), although small majorities in both countries are dissatisfied with waiting times to see doctors.

Anyway, what does Canada's medical system have to do with the propriety of the AMA's enforcing copyright on CPT codes?
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The Real Zano, 7 Jan 2010 @ 3:22pm

Re:
"The bonus is that is not for profit... the government gets any profits via cost savings and YOUR taxes go down!"

This is a pretty naive view of things. I imagine they'd expand/create a program or two rather than lowering taxes.
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TW Burger (profile), 7 Jan 2010 @ 3:39pm

Canadian Health Insurance
Don't forget that Canada has private insurance too. Canadian public health insurance does not cover dental work (except some emergency), most prescriptions, eye glasses, most physiotherapy, most chiropractic, and many other things. My private coverage does cover these needs albeit with limits, deductibles, and surcharges.
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senshikaze (profile), 7 Jan 2010 @ 3:47pm

Re: Re:
from an it standpoint, you know one of those people who spent time learning non-medical skills, CPT codes do suck.

I may have been oversimplifying how we did it, but there is a file that translates CPT codes to something (i think for HL7 files or something, no my area of expertise) for our EMR. Our billing dept uses CPT codes more than our doctors do, though.
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TW Burger (profile), 7 Jan 2010 @ 3:51pm

RE: American Health Tourists
Good point, I had heard that India offers a very nice surgery and luxury recovery/vacation package for far less than American costs (80% less including airfare).

Also, if a Canadian becomes suddenly very ill or is injured in the US we are screwed if without a good travel health policy. If an American uses our system while visiting Canada immediate emergency services are mostly free.
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TW Burger (profile), 7 Jan 2010 @ 4:20pm

Re: Re: Re:
There is software that translates CPT codes into meaningful medical procedure descriptions. I do some work in health informatics and have built these systems. It is typical that the billing department would use them more than the doctors. CPT codes are really only for insurance billing and are part of the incredibly convoluted and inefficient (but incredibly profitable) system that has developed in the USA.

P.S. HL7 is a defacto universal standard information exchange protocol used in health information technology systems. It allows different systems to exchange patient information and keep patient data up to date between these systems.
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alternatives(), 7 Jan 2010 @ 5:14pm

Re: ADA Codes
interestingly Densits are one of the last groups least effected by the HMO movement....considered the 'most free' of the 'doctor' class.
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alternatives(), 7 Jan 2010 @ 5:17pm

Re: RE: American Health Tourists
India offers a very nice surgery and luxury recovery/vacation

And if you want a sex change - my understanding is other nation are far cheaper than the US of A.
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ChurchHatesTucker (profile), 7 Jan 2010 @ 6:35pm

Re: Re: NFPA Placard codes?
Yeah, worth noting. (He's a lazy bastard.)

Still would like to know if anyone has a copyright on the NFPA codes, though.

Anyone?
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senshikaze (profile), 8 Jan 2010 @ 10:38am

Re: Re: Re: Re:
HL7 files suck too. ;)

its like they said "let's make a format almost but not quite like xml. Then run it through a few idiot business-types then see how that works." yea.

I so wish they would dump HL7 for xml with a medical DTD.
Would make so much more sense.

but HL7 is better than the alternative: faxing medical documents. our VPN tunnels to the local hospitals are alot more secure than any fax or email could be.
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Dementia (profile), 8 Jan 2010 @ 12:49pm

Re:
Actually bleeding out of the left arm would not be a CPT code. Bleeding out of the left arm is a diagnosis, that would be and ICD-9 code. The treatment provided to determine the diagnosis and to remedy the condition is what would be a CPT code. Apparently the ICD-9 codes are public domain, unlike the CPT codes.
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Dementia (profile), 8 Jan 2010 @ 1:04pm

Re: Re: Re: NFPA Placard codes?
The diamonds you're talking about on trucks are not part the NFPA codes. They're designated by the US DOT for hazardous materials. That said,the NFPA codes are, apparently, covered under copyright by the National Fire Protection Association. According to the information on Wikipedia, and my own experience, anyone can access the info via the web, you just can't produce digital or hard copies.
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Idobek (profile), 12 Jan 2010 @ 3:05am

Re: National Health Service
Maybe, maybe not. In the UK they would most likely come under Crown Copyright.
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Mikhail Edoshin, 13 Jan 2010 @ 8:38am

Re: CPT codes
I worked with CPT codes for some time, so here's what I know about them. From the technical standpoint they're just unique unambiguous identifiers for most standard medical procedures. Such codes are apparently necessary in one or other form if you need to collect and analyze information coming from various sources. Assume you run a large insurance business and collect doctor bills from all over the country. You'd sure want to record them in machine-readable form at least to collect the statistics and, of course, to see what you're paying for. Without codes you're out of luck; but with codes for procedures, combined with codes for diagnoses (ICD-9) you can get rather deep analysis.

They don't cover all possible procedures, of course, so there's some generic codes. The yearly changes are normally rather minor; most codes stay same. They're very much billing-centered; there are, for example, separate codes for ‘first vessel’ and ‘each subsequent vessel’. (As far as I understand this is why doctors don't like them: they run contrary to their understanding of the medical subject.)

What's copyrighted are books that present all codes as a system and their electronic counterparts. If you make an electronic version, you'd have to pay royalties, but they're very modest. I don't remember exactly, but I think it was like $18 or $30 extra from each copy sold goes to AMA. WIth hefty price tags on most medical software this is literally nothing. (I remember a rather shitty system whose price tag was around $40,000, so go figure.) As far as I understand this is where all this ends. Doctors don't have to pay anything to AMA to be able to actually use codes, they can just go to a library, compile a cheat sheet for their own branch of medicine and use it for billing.

If I'm entitled to opinion, I'd say that with large insurance companies one or another coding system is a technical necessity. To keep and maintain a coherent set of codes does take some effort, so someone has to pay for it. I'm not an expert in copyright law, but I think the only thing that can be protected is the whole database. I don't think that copying an individual code from a book into a bill or to a price list is the kind of copy that is subject to the copyright law. But I'm not an expert; I myself would love to listen to a professional :)
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