"The Government is Clueless about Visits"

     This is the title of a May 2012 letter to the editor about the requirement for physicians to adopt software programs (with start-up costs including staff expenses for transitioning of $150,000) and coding for office visits.  It is so much expresses the feelings of doctors I know, that I feel compelled to reprint it.
     It's from Medical Economics, and was written by Douglas Morrell, MD, from Rushville, Indiana.  He resents being forced by the new EHR (electronic health records) mandate to use a computer (or accept big cuts in payment) (by the way, who lobbied congressmen for that?--it surely wasn't doctors) while having a conversation with a patient.

          I am going to have to be keying in so much "stuff" that typing is going 
          to take up more than half of the encounter time with my patients.
          The government is clueless about what actually goes on between a
          patient and doctor during an office visit.  If you take care of an acute
          medical problem and do the rest of the "stuff," it will take more than
          45 minutes, and every encounter will essentially be a 99215 level.  
          These bills will then be flagged and denied because of the number that
          will be completed during the day;  reimbursement will fall all the while.
          The entire program is just going to implode on itself because of the cost
          and complexity.
          I am a solo practitioner on my third server to run the upgraded software. 
          The software has lots of glitches in it, and I have to do charts manually
          when the system is down  I am pretty computer-savvy and have good
          good computer people, but this has been a nightmare.  I am going to be
          64 soon, and it may be time to just hang it up.  I enjoy the patients and
          am as medically competent as I have ever been, but running a practice 
          on crashing software is really making it tough.

     Here's what this is about.  As a solo family physician we are supposed to do a whole lot of things when we see a patient for anything.  There are no purely "acute" (meaning quick, in and out) visits in a family practice office if the doctor is doing what we're all supposed to be doing--important things that keep patients from getting bad diseases and costing the country and themselves money and years of productive life.  We can't add any more to our roster of requirements, and EHR's don't make sense for many of us.
     Today I saw a new patient who "just needed a refill" on her blood pressure medicine.  Never mind that the medicine was having an adverse effect on her heart, a finding that showed up when I put my stethoscope on her chest and listened carefully.
     So I did an EKG and asked a few more questions.  Turns out she had a long list of symptoms in places all over her body:  shortness of breath, moles on her legs and back, insomnia, swelling in her legs, heartburn, a 40-pound weight loss in six weeks, vertigo, ringing in her ears.  She had just moved from another part of the state and was trying to adjust and find a new church.  Her husband had left her, which was still painful after many years.
     Her physical exam revealed more problems.  There was a surgical scar indicating a past cancer.  Her nails had telltale signs of psoriasis.  Her hair was thin and she had no eyebrows--they were painted on.  A chest x-ray was abnormal.
     My job as a family doctor is to do labs to check cholesterol and other important indicators of disease, and to make sure she's had a colonoscopy, mammogram, pelvic exam, ophthalmology check--three referrals and another visit to see me.  She needed a biopsy of her skin lesions.  She hadn't had pneumonia or shingles vaccinations, and one wasn't covered by her insurance.  She didn't want a colonoscopy, which entailed a long discussion.  She seemed confused and overwhelmed, perhaps from loneliness and the move, but maybe an organic brain problem.  There was so much to think about, and then there was the patient, who wanted to talk about her medicine, side effects of other medicines, what she could and couldn't pay for, and she wasn't sure she could trust me!  She looked me up on google and read about the FBI investigation, but then saw some positive reports by patients, and decided to check me.
     Now, I'm supposed to organize all these symptoms and findings, order tests, refer her for recommended preventive exams, persuade her that they are necessary, avoid prescribing medicines that could cause side effects, make her feel better, stay within her budget, write all this in an office note that will surely be several pages long--and not bill a 99205 code, because Medicare will audit me and find that I couldn't have spent an hour with a patient who simply came in for a refill on blood pressure medicine.  I must have invented her problems, or spent more time than necessary.
     In addition, I have to make sure I code everything exactly right, despite the labyrinthine rules and ambiguity about the process--or that could be judged to be "fraud."  And there are dozens of codes required for this visit, with modifiers and special documentation guidelines.  And I should be instituting a new and (we all know) imperfect software system, as well as electronic prescriptions, and protect the patient's privacy, and make sure my staff doesn't violate any standards of care.  Yes, this is a high-complexity visit, but will I code it that way?  Almost no doctors do this--so we lose revenue in the hope of avoiding scrutiny.
     Oh, I forgot.  The patient is angry that she had to wait an hour to be seen, because, in fact, every patient is this complex, the the doctor takes time to listen and examine, and if all the guidelines ("other stuff") are followed for good patient care.  Every patient has many issues, and needs time, and questions the medicines, immunizations, cost, guidelines, tests, and recommendations doctors make.  And now these same patients have questions about my integrity.
     ARE YOU READY TO TAKE CARE OF 35 MILLION NEW PATIENTS?  a news headline shouts at me.  These are patients who haven't had medical care, people who are likely to be added to the rosters with the new Affordable Care Act.  Patients who haven't had medical care need a great deal of attention.  Family doctors are sued most often for "failure to make a timely diagnosis," but how can we do this, if we are attacked by insurance companies when we spend the time necessary to be thorough, and if we are attacked by patients and their lawyers when we don't?
     Good luck, America.  Physicians are dropping from the rosters like flies sickened by poison--it's everywhere.  If you don't take care of us, we can't take care of you.