Kumar Yogesh, MD

Welcome to Medical Economics' blog section

 which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with Kumar Yogesh, MD, a practicing independent physician in Dresden, Tennessee. 

The views expressed in these blogs are those of their respective contributors and do not represent the views of 

	When I began my career in medicine as a physician, patient satisfaction meant something for employers. If a physician had a reputation for bringing satisfaction to patients by practicing good medicine and treating people well, he or she was of interest to clinics and hospitals to hire.

How to express sympathy without receiving a malpractice lawsuit

	It seems to me that America’s healthcare system is deviating further each day from this simple idea as third parties are becoming progressively more involved in management of patient’s healthcare. The focus for medical directors and managers of clinics and hospitals has now become: How do we satisfy insurance companies and the government so we can get compensation for our physicians’ work?

	When this happens, guess who gets to decide what “patient satisfaction” means? No, not, the patient. No, not you, the doctor. No, not even the management at your clinic or hospital. Yes, the third parties. That is, the people who do not even spend one second of facetime with the patient, the doctor, the patient-doctor exam room or the facility!

 to update me on “my performance” according to the company’s Physician Quality Star Rewards program. I was befuddled as I continued to read Humana’s perception of my quality of care given to my patients based on their data. The program is supposed to promote “improvement in quality and to recognize primary care physician practices for demonstrating achievements for specific NCQA HEDIS measures.”

	The data illustrated my practice target performance in several areas, such as breast cancer screening, A1c diabetes control, high-risk medications in the elderly, and so on.

Top 11 gripes physicians have with patients

	First, from the perspective of a physician who diligently sees patients every day in a facility that is meant to provide healthcare to people, this data seemed to have been pulled from the sky. I have never had a visit from a Humana agent to collect any such data on patient quality of care or patient satisfaction. 

So where were they getting all of this information from?

Next: 'Let us denounce (this) with a single voice'

	If anyone came to my practice to perform a random quality check on the care I give to my patients or to interview my patients, I cannot imagine he or she would leave with much dissatisfaction from the data collected. However, the notices that came in the mail from Humana suggested otherwise.

	Second, as a pulmonary/sleep physician, most of my patients are referred to me by physicians who are already providing exceptional care to their patients in these areas. Why would Humana want me to interfere with other physicians’ work?

	I was perturbed and called their 800 number. I was greeted by a friendly gentleman. When I explained this situation to him, he understood that as a consulting doctor, I did not have to interfere in these areas and told me not to worry about it. Subsequently, I repeatedly asked him to remove this erroneous information from my record; however, he could not give me a satisfactory answer that this would happen.

	As a pulmonary physician, I thought my job was to learn about ARDS, IPF, COPD, etc., which I have a passion for. Suddenly, such outside parties are now forcing me to learn terms like NCQA and HEDIS, which causes unnecessary turmoil. I would think that all of our fellow physicians are experiencing similar issues in their practices as well. A great question is: Why have we, as physicians, allowed all of this to happen?

	Eventually, my suspicion is that the creation of such erroneous data by insurance companies, if not corrected, can lead to the accumulation of negative information against us, causing harm to our reputation and penalties against our compensation. Or maybe this is a sadistic way for third parties to kick us out of their plans.

	A distant analogy would be the current situation happening with NFL. Just like I want to mind my own business being a doctor (and not being bothered by issues like HIPAA and HEDIS), most avid NFL fans also want to be left alone watching the game on a quiet Sunday. Suddenly, the one refuge where fans could go to vent their frustrations and de-stress is being hijacked by political agendas, causing great turmoil, and seizing enjoyment from fans’ Sunday afternoon.

	I have a strong feeling that when we receive these letters from regulatory agencies and insurance companies, the well-being of my patients is the last thing on their mind. I think they always have ulterior motives as their bottom line. Similarly, the idiots creating havoc in the NFL probably care the least about the fans and the true spirit of the game.

	I appeal to my fellow physicians, let us denounce with a single voice such practices by third parties. Let’s demand that we just want to be doctors with control of the field we practice in. To hell with HIPAA, ICD-10, CPT, NCQA and the rest. 

Articles

I appeal to my fellow physicians, let us denounce with a single voice practices by third parties.

A call for physicians to denounce third parties once and for all

 which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with Kumar Yogesh, MD, a practicing independent physician in Dresden, Tennessee. 

, physicians were considered the pillar of the community and 

the role of primary care physician (PCP) was a respected position

. I'm guessing that during that time, we, the physicians, assumed the role of custodians of patients’ medical records.

 Top 11 gripes physicians have with patients

In today's world of electronic medical record systems

, we all have realized that tremendous unnecessary data is being generated to satisfy regulatory agencies and billing systems. Patients have taken it on themselves to see multiple physicians while marginalizing the concept of PCP. In such an environment, being custodian of these records is becoming increasingly cumbersome, useless and very expensive.

	I would like to propose a novel idea to our fellow physicians. It may sound unconventional in the beginning, however, if you ponder carefully, it is very doable. Tremendous amounts of time, energy and money can be saved and redundancies eliminated, resulting in much less stress for our staff and much less destruction with performance and duties of physicians. Let all physicians unite and demand to relinquish control of medical records and transfer this responsibility to the patient.

 It's about time PCPs say enough is enough

	Recently, I had quite a revealing experience during the acute illness of my father, who was in India, requiring an emergency visit for me to go there. He had acute urinary obstruction and acute renal failure. By the time I arrived, he had already received excellent care by a urologist and nephrologist with procedures such as cystoscopy and nephrostomy. He was home recovering and I was pleasantly surprised that he had all the detailed records, including ultrasound, CT films and physician notes in his possession.

Next: 'This entire process was in stark contrast with the chaotic environment we experience'

	Even the video of cystoscopy was present on a thumb drive. I did not have to call anyone to obtain the records. Apparently, this is a tradition there that patients are in charge of their own records. It is called "file" (what we call a chart in USA). He also had all his previous records covering the last several years in his "file.” This made it extremely easy for me to review and obtain knowledge of his condition.

	Subsequently, he suffered a heart attack while I was there. We took him to the hospital with his file. Things went smoothly, since physicians had all the information needed on hand. While in the hospital, he received a copy of every test done on the same day. Hospital physicians made daily visits, explained everything to the patient and family and his notes were short and concise.

	A consulting cardiologist gave proper explanations and entered brief, but precise, notes. Every day, a person visited the patient's room and asked for any grievances and complaints, which were all solved promptly. On day of discharge, a discharge note and instructions were given and entered into the file. During subsequent visits for different consultants, we carried the file and things went smoothly.

	Documents were reviewed from the file and new documents were entered. No faxing, no calling anyone, and it was a much more efficient and low-cost operation with much better patient care since all the needed information was readily available in the proper format.

	This entire process was in stark contrast with the chaotic environment we experience here in our clinics. Every time I'm looking in my office, someone is always making copies, spending endless amounts of time and wasting paper. When I get a pulmonary referral from other physicians, most patients arrive with hundreds of pages of documents which are impossible to review.

	Most of them are copy and pasted and repetitious. Every single day we get a barrage of requests for patients applying for disability and other various reasons, requiring my staff to make hundreds of copies. Every time my patient visits the emergency department or needs hospitalization, an average of 80 to 100 pages of records arrive with senseless information, and most of the time these records arrive after the patient has already left the office. My nurses are constantly sending records to the billing agency, insurance companies for prior authorizations and who knows where else.

Next: 'We, as physicians, demand a change with a single voice'

	Recently, we did an audit and it was shocking to learn that with our two-physician practice, we are utilizing more than 20,000 sheets of pages every month. I would encourage all readers to do the same and I guarantee you will be surprised.

	What a colossal waste of time and energy, and it creates a severe distraction for us and the question is, why have we accepted this responsibility? Time has come to change this practice.

	In today's world of Facebook, emails, Twitter, and so on, most Americans are used to electronic gadgets and, in fact, they love it. Americans are used to managing complex bank accounts, paying bills and handling many of their financial affairs electronically. It would be naïve to believe that they cannot handle the simple task of controlling their own medical records. I would venture to say that this may be far more efficient in terms of privacy and preventing data breaches.

	Let me propose this scenario: A patient walks into my clinic and I would be happy to provide him a laptop with an internet connection. The patient can log into his or her electronic record and grant a clinician access when he/she arrives. The physician can open up a blank page and enter the notes and at the end of the visit, save a copy to the patient’s file and send one copy to his/her system.

	In certain circumstances, the document can be left open for 48 hours or so for the clinician to complete the note. I have discussed this with a number of software engineers and have been told that this is achievable with today’s technology and would maintain the security of the record with tamperproof mechanisms. This would protect both patient and clinician much more efficiently without the harassment of HIPPA. 

	Suddenly, we can get rid of our electronic health records, copy machines and save a tremendous amount of staff time. Thousands of dollars would be saved along with thousands of trees, which would be a music to the environmentalist’s ears.

Five ways to reduce heathcare administrative costs

	No consulting office, emergency room or hospital will have to call us anymore, since they can obtain all this information from the patient. When we order our tests such as CT scan, MRI, or if we prescribe any medications, the controlling authorities can look into the patient record for their approval process. No need to bother us anymore for any prior authorization and let us be doctors focused with patient care. I can imagine my office being a lean, mean machine with 100% dedication toward patient care. Would this not be a dream?

	I certainly think that this is an achievable goal if we, as physicians, demand such change with a single voice.

During the good old days, physicians were considered the pillar of the community and the role of primary care physician (PCP) was a respected position. I'm guessing that during that time, we, the physicians, assumed the role of custodians of patients’ medical records. 

My proposal to change the American healthcare system for the better

 which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with Kumar Yogesh, MD, a practicing independent physician in Dresden, Tennessee. He is join in this blog by his daughter, Niti Yogesh, PA-S, a physician assistant student at Bethel University. 

The United States Congress failed once again

. Honestly, it does not break my heart because I'm very much doubtful that the new law would have made any difference anyway. Basically, what they were trying to do was an insurance reform (not a healthcare reform) which is a quagmire created by politicians themselves.

	America is the most powerful and free nation in the world. It is a fact that our doctors are the best in the world and our nurses are the most competent and caring group of professionals in the world. The

that every American receives is unmatched anywhere else in the world.

Is healthcare a collective right or individual privilege?

	Despite these facts, why is our healthcare system being mismanaged?

	1)    Involvement of the government and insurance companies.

	2)    Ourselves. Including the people and physicians.

	The three most important groups involved here who have the most to lose or the most to gain are:

			Patients: This group includes all 325 million of us in America. Democrats, Republicans, independents, moderates, Libertarians and all others.

			Doctors: Approximately 800,000 or more. Democrats, Republicans, independents, moderates, Libertarians and all others.

			Nurses: Approximately 2,500,000 or more. Democrats, Republicans, independents, moderates, Libertarians and all others.

'Willful neglect' of Obamacare is unsafe and unacceptable

	I have been told by senior physicians that in the early 1900s until the mid-1960s, doctors were very well-respected community members and medicine was truly a noble field. Since the mid-60s, with the inception of Medicare and the American Medical Association-created CPT system, things went downhill. Maybe we did allow ourselves to be commercialized and be controlled by the government and insurance companies rather than remaining true custodians of our patients.

Next: "We have failed by being so passive"

	Yes, we have failed by being so passive and allowing third parties to control this sensitive problem that touches our lives personally. Subsequently, 500 politicians in Washington and 5,000 insurance executives have taken control and put our nation on a path to bankruptcy. If we still expect the same people to fix the system, we may be committing a crime against our own profession.

	I think the answer should be coming from us, the physicians, and not from politicians.

Waiting on Congress to fix healthcare could be hazardous to physicians

	Whenever politicians get together and propose "comprehensive reforms,” whether it may be immigration, healthcare or any such topic, I immediately become suspicious. "Comprehensive " appears to be a buzzword in politics and usually it evolves into some type of "dirty scheme" with heavy regulations such as Obamacare, Meaningful Use, MACRA and so on. The only thing it does is create more regulatory burden for the common man and businesses while at the same time becoming very lucrative for lawyers.

	Let us start with a simple idea and just address the failing aspects of current healthcare system.

			Repeal and replace the CPT and RBRVS based current payment system. This system is a setup for corruption and inefficiency since it is not based on free-market principles.

	Instead, all of us practicing physicians, regardless of specialty, should demand simple visit, fee-based payments. Such payment should be rendered at the completion of the service. I would be happy to define my visit as a 10-minute face-to-face time with my patients. Current Medicare rate for 99213 payment should be sufficient for this visit. It would easily eliminate 10% of my overhead cost. Tests and procedures can be priced separately.

			Additional 10% of our overhead cost can be eliminated by transferring the ownership of medical records to the patient. Eliminate all current complex electronic health record (EHR) systems that are based on individual platforms and do not communicate with each other.

	EHRs are creating havoc since we're constantly copying and faxing papers all day. Each time the patient goes to the emergency room, another doctor or a hospital, we get hundreds of pages with useless information and nobody knows what to do with these papers. If patients carry their own medical record with a simple universal Word-based format, I would be happy to work into their system, record my office visit and copy it to myself for my records.

	All the medical information remains with the patient's device and is easily accessible by any medical person wherever the patient is. Such systems would be infinitely more secure and private and most likely make HIPPA irrelevant. For example, my email system is much more private and under my control than my own medical records in my own office.

	This can be just the starting point, and subsequently we can tackle the remaining issues. I wonder how many practicing physicians would agree with such concepts?

The United States Congress failed once again to come up with any meaningful changes in Obamacare

Author | Kumar Yogesh, MD

Articles

A call for physicians to denounce third parties once and for all

My proposal to change the American healthcare system for the better

Here’s the answer to fixing healthcare