Blog | Monday, September 23, 2013

Adventures in medicine, part 3

So, to pick up from previous posts, Dr. Ron wants to play for Simon Powell on “Doctor Idol,” and Chuck (“Chuck,” I mean) wants to play for the Mud hens. What’s wrong with that? Nothing, actually, aside from their total lack of athletic and musical talent. What’s wrong is the part of the stories preceding these winsome wishes of our dear compadres.

1. The Interaction

Both doctor and patient imagined a simple interaction between doctor and patient, as they are the only two humans physically in the exam room. Unfortunately, there are many others in the doctor’s office and exam room in a non-physical, but very real, sort of way.

The outer circle is comprised of the entities or tasks that are taking Dr. Ron’s mind out of the exam room. These include:

• Insurance companies, with their complex rules (more to follow on this) of payment and ever shrinking payments.• The government, with its growing involvement in the office in areas of measurement, regulations, and (above all else) bureaucracy. Ron feels their ever-growing presence in the office each day.
• The huge amount of paperwork generated by both of these entities (and others).
• The media, with its hype machine built to sell advertising, not truth.
• Denials of claims (and decreasing reimbursement), which lead to …
• The need for higher patient volume, putting Ron further behind and giving Chuck more time to enjoy his waiting room adventures.
• The Internet with its double-edged sword of information/misinformation, leading to patient confusion and decreased patient trust.
• Specialists, who Ron uses to help him manage problems on his patients, but who often don’t send him any information about those visits, do procedures that Ron doesn’t always agree with, and are paid 3 to 4 times more than him (mostly through contracts negotiated by physician groups led by specialists).
• Hospitals, who alternately treat Ron as royalty (to get his referrals and ancillary orders) or dog poo (because he doesn’t generate direct revenue for them like the specialists do).

Sitting in the exam room between Chuck and Dr. Ron are things which are immediately on Ron’s mind, distracting his attention away from Chuck and his back.

While the threat of malpractice is not high for Ron, as a primary care provider, he knows he’s always one exam room away from potential catastrophe. The presence of these distractions make it harder to give the focus needed to avoid missing something important.

Financial pressures, either running the business itself (like Ron does) or cowing to the demands of the hospital overlords (as many other docs do), put finances at the center of the universe in the exam room. Are all the possible charges being entered on each patient? Is he spending too much time with them and therefore decreasing his overall volume?

CPT/ICD codes, whch Ron sees as a trap, with its incredible complicatedness, always seeming to give payers an “out clause.” Patients try to convince him to leave off a diagnosis, while billers want him to include the second digit after the decimal on every one. Ron wonders how digits after decimals became such an important thing in his life.

E/M coding compliance – Like most doctors, Ron realizes two things. That he is paid for documentation, not care. Having a specific number of bullet points in the history, review of systems, exams, and documenting certain thought processes are the things auditors look for when evaluating the records. Ron is forced to either put in a huge amount of information to justify the visit, or to “down code,” charging less for the visit than he deserves to avoid documenting diarrhea. No matter how hard he tries, he is never 100% compliant with documentation requirements. This is the ticking time bomb PCP’s face, as they realize that non-compliance with the impossibly complex documentation rules, in the eyes of hungry auditors has another name: fraud. Ron prays that no auditor with an agenda looks at his charts, as he knows that any doctor could be used as a public whipping-boy.

HIPAA – While Ron likes the fact that HIPAA keeps prying relatives out of the chart, he worries that he will mistakenly talk to someone who is not authorized and get into trouble. More worrisome is the fear of electronic communication or patient records getting out of the office, giving authorities another chance to take him down in public for something he has little control of, let alone understanding of.

Quality measures, while seemingly a positive thing, to reward good doctors, Ron always feels that the real agenda is to go after the “bad” doctors. He’s worried that because he doesn’t get rid of complicated or non-compliant patients, he will be labeled as an “underperforming” doctor, and get on someone’s “doctors to avoid” list. He also thinks it will be used as a reason to lower his payment.

Meaningful Use seems like a classic “bait and switch,” where doctors are lured into using computers with money, only to use the information gathered on him with those computers to increase his chance of being labeled as an “underperforming” doctor, or making the job easier for auditors to hit him with the charge of “fraud.”

All of this surrounds Dr. Ron with a series of barriers that Chuck must unknowingly cross to do the seemingly simple task of telling the doctor what’s wrong. All Chuck knows is that his back hurts and that perhaps buying the Roomba wasn’t such a good idea. He just wants to make sure there’s nothing serious going on, and he wants to feel better.

We’ll address those issues in our next post …

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.