Thursday, October 4, 2012

The Burden of Documentation

     I dread going to work each day.  This has not always been the case.  I watch the clock, as I did in the days before medical school when my tedious eight-hour job as a word-processing secretary was no match for the bustling ambitions of my spirit.
     "Do you dread coming to work, too?"  I asked Celeste, a nurse-practitioner who has been my sidekick for many years.
     "I don't dread the patients--I dread the writing," she answered.
     She nailed it.  She and I sit in our separate offices, night after night, long after our patients have disappeared with their good-heartedness and our deeply-considered advice.
     We sit there writing away.  I have two aching trigger-fingers as a result of all this useless writing.  Every now and then I inject cortisone into the metacarpal heads where the overworked tendons of these fingers get swollen and stuck in their sheaths, so that--like athletes who can't allow torn cartilage or sprained ankles get in the way of their performance--I can keep documenting information that no one in my office needs.
     Neither do the patients need all this writing.  Sometimes my office visits with them are conducted without even opening their charts.  I have memorized their medicines, and I am so caught up in the network of their symptoms, causative factors, medications, families and attitudes that the chart is an obstacle to diagnosis.  It interferes with the delicate act of intuition.
     We document--meaning, write down everything we say, do and think in every encounter with patients--insofar as such a thing is even possible--and then translate it all into codes, and "levels of visit" for insurance companies.  The problem is:  we don't know who we're writing for.
     Insurance companies employ "coding specialists" whose job it is to determine whether the company can get away with paying less than we billed, for the service we provided.  They pay less if our documentation falls short, and the way they make this determination is by counting "bullet points" in our notes.
     A Level IV visit, for example (which pays $68, on average) requires that an office note prove a provider addressed at least four active problems, and intervened with those problems;  also, that we analyzed symptoms in ten different categories;  and examined at least eight different areas of the body.  In addition, the "complexity of thought processes" referable to the visit has to be explained in detail, and if the coding specialist doesn't think it is "complex enough" the visit will be "downcoded"--meaning, the insurance company sends us a lower payment, or no payment, or even chalks the visit up as an example of "fraud."  Have you ever tried to explain, in rational language, your intuitive processes?
     Who is making decisions about whether our office notes meet the grade?  All the coding specialists I've interviewed and worked with fall short when it comes to understanding how doctors work and think, or how disease processes manifest, or even what the designated codes for all medical work mean.  Most of the applicants for billing positions in my office, over the past twelve years, have been big on confidence and short on know-how.  Therefore, I must assume that these are the very same people for whom I am writing my notes.  That means that my employees and I must dumb-down our notes, explaining in fifth-grade language, at times, what it is we are thinking, so that a coding specialist can't fail to accept that we did the work we billed out.
     Electronic records wouldn't make this easier.  More likely, with its templates and cues, it would get in the way of the creative thought process that is at the heart of good medical care.  I don't want a computer making pop-up suggestions about patients' conditions and probable diagnoses, and I don't want it tickling my decision about what level of coding is required.  The computer doesn't have a heart--it doesn't even have a brain--and it certainly doesn't have my brain, or understand my patients.
     Seeing patients is the joyful part of my days.  Entering into their worlds, sorting out their many symptoms, calculating the contribution of environmental and family dynamics, intuiting the psychological backdrop of their suffering--these are my element, and like any technician after decades of practice, I've gotten good at it.  My brain churns through raw data like a sorting machine in a huge factory, then I step back and make my bold hypotheses:  This is what's going on, and here's what you and I can do about it.
     Staying up late to write long treatises to invisible coding people at cold-blooded insurance companies whose only concern is profits, is making me and my colleagues sick.  We should be out gardening, or socializing with friends, or studying, or partaking in community activities, or taking excursions to places like the springs or the beach--activities that rejuvenate the brain for the next day's labors.
     What other industry requires this degree of validation in order to get payment for goods or services? Does the guy who put new tires on my car have to spell out why he chose one brand rather than the other, or describe in painstaking detail the process of taking off the old tires and putting on the new ones, or transcribe the conversation he had with me about the deal?  Does the hair stylist have to put into script her running dialogue with me to get paid for highlighting my hair?  Does the floor stripper have to document two pages of description to get the $600 he charged for laying new wax on the exam room floors?  Do any other service providers have to subject themselves to scrutiny by high-school graduates with a few weeks of coding training, whose marching orders are to find errors, or to capitalize on areas of ambiguity, which allow whoever pays to withhold payment--and even to claim that the specialists who provided expert services didn't do the job, or didn't do it well enough, on the basis of the written explication?
     The requirement to document every moment of an encounter with a patient, and the underlying assumption that doctors are "trying to get away with free money," or are "committing fraud, which has to be punished," or are "billing for more than they did," is killing the entire medical profession.  The constant refusals to pay, by insurance companies, and the byzantine appeals processes doctors must follow for objecting to non-payments, and the general atmosphere of mistrust, and withholding, and criminality in which we physicians must live and practice, is destroying our internal diagnostic apparatus, and even our capacity to care.
     If you hammer and attack, and whittle and scrape away at a profession long enough, you change the very nature of that profession.  Medicine isn't what it used to be, I hear people say.  Well, take doctors off the chopping block, stop futzing around with payment for legitimate services, quit calling us liars-- and basing that judgment on treatises we're required to write for every patient we see and every dollar we earn--documentation for which the grading system is arbitrary, punitive, determined by individual insurance companies, and constantly changing. 


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