Blog | Monday, September 30, 2013

Adventures in medicine: part 4

In the last post we saw how complicated the visit is from Dr. Ron’s perspective, and how many things were working to pull him away from our hero, Chuck. So what about Chuck? What about his perspective? I ended the previous post with the statement: “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.”

In other words, Chuck is interested in two main things: quality of life and quantity of life.

What he wants to avoid is: death, disability, disfigurement and pain. Please note that I could have used “dysesthesia” to keep with the “D’s,” but chose to speak English (a talent which many doctors lack).

Now, when Dr. Ron listens to the story of a patient like Chuck, there are three main tasks he focuses on: 1) Ruling out serious problems (or assessing risk), treating symptoms and making a diagnosis.

He does this by listening to Chuck’s story (his symptoms), looking for objective findings (via physical exam, labs, or other tests), and looking over Chuck’s back-story (his past problems, symptoms, and risk factors).

From Chuck’s vantage point, as long as Ron has ruled out bad stuff and makes his back feel better, he doesn’t benefit from making a firm diagnosis. That’s what Chuck thinks he’s paying for (both from his wallet and from the precious moments of his life wasted in the waiting room). But here’s where things start to get complicated: Ron doesn’t actually get paid for the two things that Chuck wants the most (ruling out bad stuff and treating symptoms), instead he’s paid for:

1) Coming up with “diagnosis” (problem) codes to describe Chuck’s situation.

2) Coming up with “procedure” codes to describe what he did in the office.

3) Doing his medical record in a way that “justifies” his codes to insurers (in case he’s audited).

4) Paying a bunch of staff to make sure this information is submitted exactly right, as any mistakes could result in denial of payment.

Ron’s new fancy-schmancy computer record program is built to make sure all of the information needed to justify the charge is put in properly, and that the diagnosis codes and procedure codes are also properly entered so they can be electronically submitted to the insurance company. Ron likes the fact that it makes this easier, but it bothers him that so much of the note is just “packaging material” that obscures the most important part of the note to both doctor and patient: the plan.

To make matters worse, Ron has to find a code from the ICD-9 code list, which are specific codes that the insurers accept for treatment. This is sometimes hard, as the codes for common things (like weakness of the arms) are mysteriously missing, while codes for strange things (like being injured by a space ship) are on the list.

To “improve” this situation, the government is soon to introduce ICD-10, which will increase the number of codes by 500%, now including the important code for “burns incurred from flaming water skis” (it’s about time).

Ron’s EMR gets to these codes (relatively) easily because they are essential to be paid.

Additionally (and worrisome to Ron), the insurers are taking these diagnosis codes and problems on the list to measure the “quality” of Ron’s care. Ron worries about this because payment is increasingly being linked to quality measures, and the folks doing the measuring are the ones doing the paying, which means they would benefit from measuring low. Another negative of having problems accumulating on lists is the all-inclusive nature of the lists, which include:
• Chronic disease (like diabetes, hypertension)
• Past events (heart attacks, cancer)
• Symptoms (back pain, fatigue)
• Risk factors (family history of heart disease, cancer)
• Abnormal test results (high cholesterol, low sodium, abnormal chest x-ray)
• Exam findings (heart murmurs, skin lesions)
• Minor problems (allergies, baldness)
• Acute problems (Viral infections, sinus infections)

This makes these lists grow quite large, which is often made worse if the acute problems are don’t drop off of the list, which is often the case. Taking the time to clean up and organize records is something most doctor’s offices don’t have time to do.

What does this have to do with Chuck’s Roomba-assisted back injury? Nothing good. Unfortunately, it makes Ron focus on the least important thing: the diagnosis (remember, Chuck really just wants to rule out bad things and feel better). It rewards doctors for finding problems and doing procedures to fix those problems. It also rewards Ron for putting things into the chart that makes it jumbled and confusing. Since Ron’s pay is dependent on his documentation, he spends much of his time and energy putting information into the record, as Chuck sits and watches him type.

So, for the 10 minutes in the exam room together, the majority of time is spent inputting information and finding diagnosis codes. Ron feels bad about this, a feeling that tempts him to do what many doctors do: order X-rays, MRI scans, and prescribe medications for a simple back strain. But Ron knows that these do nothing useful for Chuck and just raise the cost. Ironically, Ron’s decision to do the right thing makes Chuck wonder about how good of a doctor Ron is, as he leaves with nothing to show for his time and inconvenience other than a sympathetic look, instruction to take ibuprofen, and a back exercise sheet. It seems like a waste of time and money.

Ron agrees with this assessment, wishing that he was rewarded for doing the right thing, not penalized. Both Ron and Chuck leave the visit frustrated. Chuck goes home to plot against his cat, while Ron moves on to the next patient, hoping for something a little more satisfying.

To be continued …

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.