I could say the cliche' things about it seeming like yesterday, yet like it has been forever since I worked anywhere else. I guess I just did…so there’s that. But more to the point is the reality that I actually survived. Many expressed confidence in me when I started doing this, while many others expressed supreme skepticism over whether or not this type of practice could actually work. To both of those groups of people I say: keep waiting to make your final judgment. The practice, while profitable and now growing steadily, is still not near to the point I need it to be. It’s heading in that direction, but there are no guarantees; I still could mess this thing up.
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For those still unaware (perhaps looking through catalogs for gigantic inflatables for president's day), ICD-10 is the 10th iteration of the coding taxonomy used for diagnosis in our lovely health care system. This system replaces ICD-9, which one would expect from a numerological standpoint (although the folks at Microsoft jumped from Windows 8 to Windows 10, so anything is possible). This change should be cause for great celebration, as ICD-9 was miserably inconsistent and idiosyncratic, having no codes describing weakness of the arms, while having several for being in a horse-drawn vehicle that was struck by a streetcar. Really.
Like my practice, membership medicine is still in its early phases. Like my practice, the future of membership medicine depends on a lot of things beyond our control. But the excitement I hear regularly from physicians, residents, medical students, patients, business owners, and even politicians about its potential is quite remarkable. Both of these conferences were full of something that I once thought no longer existed: doctors who were excited about medicine and cautiously optimistic about the future.
My previous two posts lamented the incredibly bad the documentation I get from a local hospital is. In truth, the documentation I get from everyone is terrible. Seldom does it tell me what I actually want to know, and if there is useful information it is buried in an avalanche of yada yada. The main reason for this is that documentation is driven by our ridiculous payment system, which requires us to follow arcane rules to generate notes that justify the obscure codes we submit for money from the payors. This is the reason for much of the gibberish. These rules, combined with computers' ability to quickly and efficiently generate drivel (see also The Entire Internet) are the hot house and Miracle Gro for meaningless words. Sprinkle the rules on a computerized medical record and stand back! Useless words and codes will spew out at you like milk from the mouth of an overfed baby.
Good news: my local hospital has the fanciest, newest, coolest computer system (costing major bucks, of course) and now is routinely sending me "transition of care" documents on my patients.
Bad news: they are horrible.
Seriously, we get several of these documents per day and often can't figure out what the document is about. On the bright side, sometimes after taking 10-20 minutes of looking through the 12-14 page document, we do actually gain some useful information.
Long-time reader, first time writer! I want to know why it is that my doctor makes me pay to get my own medical records. It seems like since they are my records, they should be free to me! Can you explain this to me?
- Lucy in Texas
Thanks, Lucy, for asking such an astute question that is near and dear to my heart.
There is, in fact, a simple answer as to why doctors don't want you to lay hands on their medical records, Lucy. It's the same reason you don't want your son's underwear after his first semester in college (known to have broken autoclaves): they stink.
Why do they stink? It's complicated. The best way to see this answer is to look into the past. Way back.
When I say we need more tech, I am not saying we need more computerization so we can produce a higher volume of medically irrelevant word garbage. I am not saying we need to gather more points of data that can measure physicians and "reward" them if they input data well enough. The tech I am referring to is like that I used regarding my father. I want technology that does two things: connects and organizes. I want to be able to coordinate care with specialists and to reach out to my patients. I want my patients to be able to reach me when they need my help. Technology can do this; it sure did for my dad.
Sit down. Really, sit down. Trust me, please. You are going to be shocked with the news I am going to give you and I don't want any contusions, closed head injuries, street riots, or revolutions taking place in South American countries on my conscience.
Are you sitting? OK, here it goes:
Medicare got something right.
Pretty crazy, right? I am not sure if it was an accident, like the infinite monkeys typing on a keyboard producing the works of Shakespeare (they'd write all of the Harlequin romance novels too, by the way). They had to eventually do something right, something that really benefits people, makes my life better, and potentially cuts cost. The thing they got right? The Medicare preventive exam.
Up to a year ago, the only way I would ever get paid to see a Medicare patient was when they had a problem. If a person came in with the desire to keep from being sick, we would have to get a waiver signed and charge them full price. So at those visits we would fish for any problems to justify it as a disease-management visit or one for acute care. This meant that any prevention that I did perform on my Medicare patients had to be done on the side during problem-oriented visits. So the motivation to do prevention was dependent on the nature of the doc; if they are OCD, didn't care about getting home on time, or less concerned about getting paid, patients got better care, otherwise it was hit or miss.
Plus, the chart itself was often neglected. Any time a doctor took to make the chart accurate was time away from other patients or time away from home. This sounds petty, but it takes a large effort to keep things updated, and with the low reimbursement of primary care, only those things that were grossly inaccurate got corrected in most patients' records. I was never given the time to make sure the records were accurate.
In January of 2011 this all changed (at least for Medicare patients). The Medicare Preventive Care Visit came into effect, paying well for keeping people well. The visit follows a specific structure (and arduous documentation, of course), and making the proper templates on our EMR and getting them to put out a suitable handout at the end of the visit took a lot of effort. But the effort paid off; my patients are very happy with these visits and I am able to do some things I have never had time for. The end result is this:
- The patients are given their problem, medication, and allergy lists prior to the visit and correct them for us.
- We can compile the names of other physicians they are visiting and make sure they are accurate.
- We do a functional assessment on people, identifying those at risk for falls or those in bad home environments.
- We screen for depression.
- I get to discuss advance directives with people (living will and health power of attorney). This is probably the biggest change, as I rarely had the chance to talk about this before (and felt very guilty about it). In the past year I have talked to hundreds of people about this, and have probably saved a whole lot of trouble down the line because of it.
- I check when their last screening tests (colonoscopy, mammogram, bone density) and get a copy of them when they aren't in my records (which is distressingly common). I order tests that are due and discuss with the patient when the next screening test is due.
- More of my patients are getting pneumonia shots (pneumovax), and many more are getting the option to get the shingles vaccine (Zostavax).
- In the end, the patient gets a handout (see below) that gives a road map of their care: what was done in the past and when, what was done today, and when things are due in the future. In short, the patient suddenly knows where they stand regarding their health, something that was not common prior to this.
- I am actually being paid well enough for these visits to motivate me to schedule them on as many patients as possible. Certainly, the improvement to the chart itself and to the overall care of the patient is also motivation, but it's nice to be paid for doing good from time to time.
There are (of course) some negatives, including:
- The document created in the chart is enormously wordy and not really useful on its own. Again, since we are paid for documentation, we get exactly that: lots and lots of words to justify our pay. This isn't too hard if you own a gibberish generator.
- Some of the local GYN groups are billing for a Medicare preventive visit (although I seriously doubt they are meeting the cumbersome documentation guidelines), so some of our patients' bills are not paid for. We do our best to filter patients who may be in this situation, but some still get through. I cringe at the thought of these GYN's charts being audited.
- Some patients try to get a disease management visit rolled into the preventive visits. They don't understand at first why I can't talk much about their diabetes on this visit, but when they get the finished product they are almost always satisfied.
Here is the 1st page of the handout given to the patient:
It's not bad. There are still some bugs being worked out, but it is very satisfying to have time to make sure the records are right and to have a significant percentage of my patients with up-to-date preventive care. This is very much like the GPS device I mentioned in an earlier post.
I am a little anxious about posting this, as it may encourage the government to double the number of monkeys on typewriters (i.e. bureaucrats) and so negate any good that comes of this. Anyhow, some of the monkeys are already busy running for president. But for now, I say something I rarely get to say:
Thank you, Medicare.
You may resume standing.
Since I am self-employed (as part of a partnership), the easy answer would be to say I work for myself. That is not, however, what was meant by the question (and it would make a dull blog post if it was); the intent of the question was this: for whose interest am I most working for? Who am I trying to please? Who is my boss?
My answer? I have many bosses:
- My patients
- The insurance companies
- My patients' employers
- Our business
- The government
So who really is my boss?
We all, in the end, work for Oprah. That's a given. I won't add any more to that as it is self-evident.
Being a primary care doctor, I would like to say that I work for my patients. I would like to say that the only thing that matters is the health and happiness of the people in my care; but that would not be true. I fight to keep this focus in my office, but sadly it's still not the reality I live. The reality I live is that of a planet being torn out of its orbit by larger, more powerful celestial bodies, all trying to make themselves the center of my universe.
Who is my boss?
They certainly write a big chunk of my paycheck, commanding an increasing amount of my time. I have contracts with insurance companies, agreeing to what they pay. I follow rules of insurance companies to get the patients the care they need and what the insurers dictate, (which are sometimes at odds). Insurance companies have more access to patient records than patients do, or at least they have easier access. Insurance companies can decide if they will pay me or not, while the patient doesn't have that option.
Clearly, the pull of the insurers' gravity is stronger than that of the patient. Clearly my patients are not my real boss.
But who writes the check for the insurance companies? Employers do. Employers dictate just how strict of rules the insurance companies will keep me under. When they choose an insurance plan for their employees, employers dictate how much I can charge at each visit, what services I offer will be covered, what payment structure I will receive (capitated, fee-for-service, or high-deductible). Much of what I can or cannot do is dependent on this decision.
If you asked employers, however, they would tell you that they are "at the mercy" of the insurance companies. Despite the fact that the employer is writing a check to the insurer, the relationship is hardly one of control on the part of the employer. As owner of a my own business I can attest to the one-sided nature of my relationship with my employees' insurance carrier.
Are my patients' employers my boss? No, it's not really close. Insurance carriers win that contest with ease.
So what about my business? Is my practice my boss? Since I am a part-owner of my business, it is not quite as clear as it would be for physicians employed by a practice or hospital. But the reality is the same in many ways. My practice decides what contracts we will accept or reject. It tells me if I am seeing enough patients, dictating how much time I am spending on each patient. The practice pays for the medical record system, tells me when I can have time off and, in extreme cases, could fire me. I certainly feel like a factory worker at times, punching in at the start of a long day with a conveyor belt of patients coming in so I can make money for "the man."
But who am I fooling? Our practice is also totally dependent on insurers, going to great lengths to make what I do come out in a format that will please insurers enough to pay us. Our practice could go broke should the government go through with its threatened cut to Medicare reimbursement. We are a service industry, totally at the mercy of our "customers," or "clients." Our business is but a pass-through vehicle for me to be paid by insurers and a front to let me see patients.
I work at my practice, but not for my practice. My practice is not my boss.
A significant percentage of my patients are either Medicare or Medicaid, so a large chunk of my paycheck comes from the government. Many of the contracts I get from private insurers are based on a percentage of Medicare's rates, so the government is a very powerful force in determining what I get paid. In addition, while I can opt out of any insurance plan if I don't like the rates, and have the option of negotiating a better rate, dropping out of government contracts is much, much harder. There is also no chance for negotiation; I either take what they offer or don't have their patients.
- The government set up our procedure-driven model of care that has so favored the specialist over primary care.
- They pay for enormous hospital bills but not (up until very recently) for me to prevent those enormous hospital bills.
- The government sets the rules for documentation - those rules that force me to put so much meaningless information into the record that I can't find the useful information I need.
- The government says that I can't send many kinds or e-prescriptions, even though doing so would be more secure and less prone to abuse.
- The government sets malpractice laws that favor the accuser and so makes my nurses quick to send people to the ER unnecessarily and makes me increase my test-ordering and documentation to avoid litigation.
- The government doesn't just tell me to get on electronic medical records (which I had already done), but gives me a large number of hoops I must jump through to prove that I am using them "meaningfully."
- The government promises to make those rules more invasive and onerous as time progresses.
- The government is supposed to regulate the insurance carriers, drug companies, and device manufacturers, many of whom are making huge profits during a time of economic crisis. They "regulate" the drug industry, letting companies gouge with generic drugs, set prices inordinately high, and advertise directly to patients information that tricks them into believing things that aren't proven or that are patently false.
- The government does nothing while more and more people outside the doctor-patient relationship plunge onto the system and plunder it for what they can get.
In short, the government stands watch while the health care system crashes and burns, the end result of which is that my patients are able to afford less and less care and I am too busy dealing with pleasing the system to give them the attention they deserve.
So who am I working for? The one for whom the system is designed, the patient, is not just competing for my attention but is on the periphery looking in while I deal with these other entities. The patient waits for an hour while I see extra patients and document profusely. The patient can't afford prescriptions I write because the cost of drugs is too high or the drugs are denied due to insurance formularies. The patient is afraid of me making a diagnosis for fear of losing their insurance. The patient pays more and gets less. I work harder and get less.
Who am I working for? Far too many people who are making it far too hard to do my job.
I wonder what care would look like if I actually did work for my patients? What would real care, not care that is torn apart by competing gravitational forces, be? What would the chart look like? How long would the visits last? How much would the visit cost, and how much would drugs cost?
What would care look like if the patient was really who I was working for?
I'll ask Oprah the next time I get a chance.
One of the main things driving me back to blogging is madness. While I can’t be sure that I am not overcome by madness, it is not my own of madness I am referring to. Well, no, I am mad, but not mad in the way that I hear Elvis whispering in my ear or think that the squirrels are evil robots put there by aliens to spy on us. The squirrel theory may be true (evidence does strongly support it), but it’s not that kind of madness I am talking about.
I am angry at the madness of our system.
I am angry when patients come to me after a two week hospitalization and I have no records or even an idea that they were hospitalized. I am angry when I have to rely on my patients to find out what happened at the specialist, the emergency room, or in the hospital. I am angry at all of the money that is being wasted on useless and sometimes harmful care and is done because nobody knows what is going on with patients. I am angry when my life is spent chasing around ever-changing drug formularies and drug “shortages.” I am angry when my patients have to wait for a three-hour visit with a specialist who I recommended, only to have their complaints ignored and their questions unanswered.
I am angry about the political game of chicken that is regularly played by congress with Medicare reimbursement. I am angry that it is far more lucrative to document than it is to care for patients. I am angry at all the time I spend more time every day dealing with rules and regulations I don't understand than I do deciding what's best for people's health. I am angry that electronic record systems pay more attention to "meaningful use" certification than they do to making their systems be useful in a meaningful way.
I am angry at doctors who prescribe narcotics like candy and then send me their patients when the DEA investigates. I am angry at patients who try to fool me into prescribing drugs they are not taking, but selling. I am angry that there are no psychiatrists available and so I am forced to perform amateur psychiatry on them in a 15-minute visit. I am angry that my patients assume their doctors know their medical history when they don't, and that doctors assume the patient knows their medical history when they don't.
If any other business operated like health care, it would go out of business and the people who ran the business would go to jail. I am serious. People are gouged by our system and are given terrible care in return. More and more I am seeing why people no longer trust the medical community and are turning to alternatives. If our system is treating them poorly, they find someone who will do otherwise. I can't blame them.
And guess what, folks; it's an election year! Prepare for more madness. Prepare for politicians who prey on the fear of the elderly by telling them the other party wants to kill them. Prepare for simplistic, head in the sand solutions to the problem that avoid the real problem because doing so would lose votes. Prepare for promises of bigger, better programs that will fix our bloated system. Prepare for complete madness transformed by political spin to look like rational policy.
Yes, there is a lot of madness to be had. Everyone can have their fill. The fire hose of madness is waiting to knock over whoever stands in its spray.
All of this makes me sad. I am sad because I sit in the room every day with people who are pummeled by this madness. I am sad because the madness hurts people I am trying to help. I am sad because I know of things I could do to decrease the madness for my patients, but would be rewarded with a decreased salary. I am sad because I have to choose between making a living for my family and giving the best care possible. I can't have both.
People need to know how dysfunctional our system is, not on a political or sociological level, but in the reality of the exam room. This madness is making the most committed doctors have second thoughts about their profession. I didn't go into medicine to learn to "play the game." We all deserve better than this.
Don't worry; I don't intend for this blog to be a whining rant. I wouldn't have come back to blogging just to complain about problems without giving hope. There is hope, but few people see it. Perhaps the biggest tragedy is that many if not most of our problems do have real solutions. I want to beat the drum of sanity. I want to bypass the spin and rhetoric, the editors and publishers with agendas, and tell you what I see here. At some point the little boy needs to speak up about the emperor's nakedness. There are others saying it, but the voice needs to be loud enough to be heard over the societal cacophony.
Maybe once we do that, we can get that squirrel problem under control.