Doctors share their thoughts on practicing medicine today Your voices Compiled by Jeff Forster, Editor
"Like most family doctors, I've spent years undercoding. Now that I'm learning to do it right, level 3 and 4 visits are going to be a lot more common, and should boost my productivity by 15 to 20 percent.
Medicare, meanwhile, is starting to get tough about services. I know when I need to do an ECG, but it's hard to find the right code to convince Medicare that when I put a patient on a particular medication I need to monitor his conducting system. I'm getting a lot of denial lettersat least one a week. My partners are, too. But we appeal every one, and so far we've won them all."
"No matter what name is given to itprofession, job, vocation, callingmedicine is a wonderfully rich field of endeavor. My bias is that nothing will ever change this. My own goal is to make headway in practicing evidence-based medicine that is scientific and substantive, and is also sensitive to the individual needs of individual people.
I've always loved the 'game plan' capsulized by Stephen Grellet (1773-1855): 'I expect to pass through this world but once. Any good thing, therefore, that I can do, or any kindness I can show to any fellow human being, let me do it now. Let me not defer nor neglect it, for I shall not pass this way again.' "
"My relationship with my father has been the biggest influence on how I live and think. Not having gone to college himself while six siblings were college graduates, he saw to it that all seven of his children got a college degree. He was proficient in three languages, read extensively, and discussed world affairs with us routinely. He taught me tolerance and acceptance of those who are socioeconomically lower and different in caste and religion. I carry that beacon."
"Japan gives new meaning to the phrase 'in your face.' It is one of the most densely populated countries in the world. Much of its extreme public politeness and elaborate manners, I suspect, evolved from having to live amiably in small homes and crowded public places.
Contemporary Japan is one of the most expensive places to visit. It makes Aspen look like K-Mart; I think of it as Aspen on steroids. Our room at the beautiful Park Hyatt in Tokyo was $390 a night, not including a 15 percent consumption and hotel tax. The sticker shock continued: $5 for an apple at the market, $9 for a cup of coffee at a luxury restaurant, $110 for a piece of fresh tuna, $150 per person for a meat entrée cooked at your table. I did come across one book that recommended staying at "love hotels," which are clean and cheap. We have now been to every continent; our two-week excursion through Japan was by far the most expensive. (The least expensive, for the record, was South America.)
But the trip itself was fascinating, and everything we hoped it would be. My wife Becky is a better gardener and potter, I a better World War II historian. Beautiful ceramics, fans, hand-painted parasols, gold-plated lacquerware, woodblock prints, and stunning photographs will continue to remind us of this fabulous trip. So will our Visa card balance."
"Managed care contracts are written in legal jargon precisely so they will be difficult to understand and will require legal advice before signing. However, many physicians just sign the contract and cry later. Every check for every reimbursement must be scrutinized, because insurers often don't even pay what they say they will pay.
I negotiated one contract to pay me 120 percent of the Medicare fee schedule. When I received the first check, I discovered that it was based on a Medicare fee schedule that was 2 years old. I would not accept the company's lame explanation, and they are now using a current fee schedule."
"Every day, in addition to running my practice in orthopedic surgery, I review three to 10 requests for preauthorization or reimbursement for a health plan. I pore through other doctors' charts, trying to determine if patients I have never seen are getting quality care. I am not an insurance company prostitute, and my motto is not 'Just say No.' I am simply a physician trying to do my small part to help my peers.
If it isn't written in the chart, it didn't happen. Our training programs drilled that thought into our heads. Documentation has always been essential for communication between professionals, but now it has become one of the strongest incentives to get paid for our work. I am here to tell you that you can get approval for almost anything you wantif your documentation is complete.
Twenty years ago, or even just 10, a patient and doctor could arrive at a treatment decision and have confidence that most third parties would pay the bill. Today, almost any procedure must be preauthorized, and even then, payment is not assured. Computerized auditing programs, all-pervasive, have made it very difficult for a physician to get paid unless the documentation is complete.
I regularly get requests for diagnostic studies or treatment without the basic requirements to meet a standard of care for orthopedic patients. Many times I've seen an MRI followed by a myelogram-CT followed by a discogram, with no intervening objective clinical findings that would justify either the expense or the invasive nature of the procedure. In today's extremely busy offices, physicians are using the tools of modern technology to make a diagnosis instead of talking to the patient and putting their hands on the patient. The intellectual powers that got us through medical school are being left behind in the pressure to see more patients in order to meet the overhead of an office stuffed with staff to deal with the insurance companies!
The request for a diagnostic arthroscopy, accompanied by one page of illegible scratches, is not going to be approved. The request for a total knee on a 49-year-old man, accompanied by one page of medical informationwith no X-rays, no CT, no follow-up, and no early historyis not going to be approved. In a back injury, further intervention requires documenting a reason in the medical recordsuch as the failure of routine conservative care, accompanied by increasing radicular pain, or some other change in an objective finding.
You wouldn't want your children to have surgery based on some of the charts I see.
I truly believe that most of us perform a complete history and physical. What we don't do very well is put it on paper. I don't believe that my colleagues perform surgery and other procedures just for the money. Sometimes, however, I can see how an uninformed lay reviewer might conclude that the doctor's house payment was due, or the tuition just went up at his daughter's college.
The rules have changednot necessarily for the better, but they have changed. We all know how to document our reasons for recommending a particular course of treatment, but we have allowed others to come in and pick the bones of our charts. Make sure the chart is complete when your staff forwards its preauthorization requests. Make sure the information is legible and that it says what you intended.
Automatic chart-writing programs are great and getting better. But you need to take responsibility for making the record concise and complete. Send copies of X-ray reports, CTs, other specialist consults, and anything else that reinforces your diagnosis and proposed treatment.
Most of the requests I see are probably indicated. Unfortunately, unless all the paperwork is complete, the job is not complete. Document what you want to do, and I'll bet your approval rate goes up."
Jeff Forster. Your voices. Medical Economics 2000;18:124.