Heartless Medicine: The Ethos of Calling Meets the Reality of Ruthless Commerce

Thirty years ago, most newly minted doctors, fresh out of their long dark marathon of medical school/internship/residency/fellowship hung out a shingle, hired a secretary, rented office space and opened practice as a shop owner, often with partners, often without.  Close to 90% of physicians did that.  Today, in the 21st century, new doctors want a W-2 form, a job, a salary and 90% work for a corporation, a large group and they are no longer independent shop owners: They are employees.

Physicians, like me, voted with their feet, away from the entrepreneurial mode of medical practice as the burdens of running a business beat them down. 

"Just let me practice medicine," we said."Put me on salary. You take care of the money."

Surgeons, who have always been different from physicians, have not been as eager to make that leap and while they often have contracts with corporations, they still run their own shops, and often many other shops--as partners in surgical centers, owners of buildings in which medical practices are located, but physicians, your internist, pediatrician, specialists in neurology, rheumatology, endocrinology, pulmonary have opted out of the business end--leave that to the folks with the MBA's.

Radiologists, pathologists, anesthesiologists for the past 50 years typically were not shop owners--they worked for big groups that had contracts with hospitals, or they were employed by hospitals or by universities. 

So there are many different cases, but the big numbers, most doctors and surely most of the doctors the average citizen sees have gone down a very different road. For many of them, they have found the "be careful what you wish for," thing kicking in.

Today, I spoke with an assistant Chief Medical Officer of a hospital system looking to hire me to take care of the hospitalized patients who are current running an average blood sugar of 300 during their stays in hospital. 
 "Well, who are these patients?" I asked. 
"Oh, you know old guys with pneumonia, post operative patients, broken arms in diabetics on insulin."
"So, how long are these patients actually staying in the hospital with their blood sugars of 300?"
"Average stay is 3 days."
"So," I asked, "What difference does it make to the patient to have a blood sugar of 300 for 3 days? You know I could make a lot of non diabetics get up that high by just admitting them to a hospital, or more surely, to an ICU. But 3 days later, they are home, past their crisis, eating normally, up and about again, taking their usual doses of insulin rather than the brew the hospitalists gave them and they are running sugars in the low 100's again."

"But our hospital's metrics are worse than comparable hospitals."
"So what? The patients have suffered no harm."
"Oh, of course, I know that! Everybody knows THAT. But we are paid by insurance companies based on quality assessment ratings of the hospitals and that's one of the big metrics."

Profit driven medicine, in a nutshell. Doesn't make the patient any better. Doesn't do anyone any good, but we have our metrics and we must meet them. And this hospital practices "patient centered medicine" it advertises. 

As if.

One of my younger colleagues asked me about a patient I had just seen for diabetes and found him to be in atrial fibrillation, phoned his cardiologist, and shipped him over the hospital.
"How did you know he was in AF?" 
"I listened to his heart."
"Why would you do that? He was in for diabetes."
"Well, I have them take off their shirts in case there's a melanoma lurking about. And I listen to everyone's heart, in case they are in AF, which is common. Had to borrow an EKG machine from oncology. We don't have one? Did you know that? No EKG machine in our clinic!"
"Yeah. Why would you want an EKG machine?"
"Well, sometimes listening is not enough to be sure they are in AF. Sending him across the street to the ER based on just listening? That's a lot of time and worry for the patient, if you're wrong."
"But then you have to interpret the EKG."
"Well, we all did internships. I think I can recognize AF when I see it. I bet you can too."
"Yet, but then you're responsible."

And so it went. 

This particular doctor is a wonderful endocrinologist. He taught me how to see thyroid glands with sonograms and he is a master at fine needle aspirations of thyroid nodules. Most endocrinologist produce unusable specimens from FNA's of thyroid nodules about 12% of the time. His rate was 1%. 

So he is very good.
But he quickly calculated that if he sees a new patient for a thyroid nodule (consultation $540) does a sonogram of the thyroid ($85) and uses that sonogram to biopsy the nodule ($350) that patient visit is $975 in billing. All that takes 60 minutes. If he sees two returning patients at 30 minutes each, he can bill $115, or total $330. 
So he makes sure his secretary makes the new patient/thyroid nodule a priority.

When I arrived at this clinic there were no gowns for patients to wear when they took off their shirts. Nobody every examined their hearts. 

The nurses were perturbed when I insisted all diabetic patients take off their shoes and socks so I could examine their feet. The patients complained about the cold floors. They had to get towels for the bare feet. Patients asked why they could not take off just one shoe.

"Well, fine," I told the nurses. "Just tell them to take off the shoe on the one foot they want to save."

Older doctors are retiring fast. 
Electronic medical records, being told what to do by thirty something managers reading spread sheets about "productivity." Elimination of anything which does not add to profit, insistence on efforts which are medically worthless but which enhance profits are just too much to bear.

If they are lucky, these old docs have salted away enough to retire. 

But, you know, it's not them we ought to worry about.

For Profit Medicine: Coding As the Window into Absurdity

If ever there were a case of the devil being in the details, the Medical Coding Industry has to be it.

 

This is such an arcane topic, where the monsters are buried beneath a dung heap of regulations so deep it is daunting just to consider trying to explain it to a distracted public, which has its own day to day problems, thank you very much.

But the Phantom has decided to try.

His colleagues, who face the vast theater of the absurd have warned him.
But the Phantom has said, sometimes it's fun tilting windmills.

The whole system of "Coding" offers a window to several important truths:

1/ Medical insurance is not the same thing as medical care.

2/ Medicare for all  would solve the problem of access to the doctor& the hospital but it would not solve the problem of what happens once the patient gets there.

3/ What we now have is a system where young women (mostly) who have been trained as "auditors" and clerks are employed to exert a level of control over medical practice which exceeds the effect that professors of medicine and surgery at university medical schools would envy. 

It's as if marketing department were editing the articles in the New York Times to be sure each paragraph generated the possibility for expanding the market of the newspaper. 

Or imagine if the cashier at your auto repair garage told the mechanics which repairs they can do, and how to do them, and you'll have some idea of what Coders now do in medicine.

4/ When private enterprise, which seeks to maximize profits, is given a set of rules by government, it can respond by undoing the intent of the government rules in a way which maximizes profit but destroys intent and which drives doctors to test the windows in their offices to see which can be opened wide enough to leap from.

 

To understand all this, if you are still interested: When you go to see your doctor now, he likely works for a corporation and this corporation will present a bill to your insurance company, which follows rules set by the biggest and most fearsome insurance company of all: Medicare.

Now Medicare gets lots of bad press, but the fact is, Medicare has been listening to doctors over the years and it even employs some doctors to rule on cases.

Your doctor will do whatever it is he thinks you need but then he has to go to his Electronic Medical Record (EMR), which is a software program built by geeks to streamline and maximize billing and, oh-by-the-way, it also allows for generation of a "medical record."

So let's say you are a diabetic and your doctor discovers a foot ulcer, and he might even treat this in the office. Not every ulcer needs to be "debrided" (cleaned) but this can be done in the office.

Now he has to enter a bill for this service, and he has two basic choices: He can bill using a very mysterious and almost incomprehensible "Evaluation and Management" system or he can simply bill by the amount of time he spent, as long as he has spent that time according to the rules Medicare has established. 

He cannot, for example, spend his time in his office reviewing his stock portfolio during the 30 minutes you have been clocked in on his schedule, then tip toe into your room for 5 minutes, say, "Hi," and charge you for a 30 minute visit.

There are rules:  His "time statement"  has to say, "I spent 30 minutes with this patient and GREATER THAN 50% of this time was spent in counseling and coordination of care."  And then he has to specify exactly what the counseling was.

Now that could take a long time, longer to document than it actually took to do, but that's where the magic of the EMR kicks in: He can drop down a "counseling and coordination of care" template which looks like this, with a box next to each which he can click and a check appears:

• Increase exercise
• Encourage weight loss
• Decrease Fat
• Diabetic Patient Counseling
• Smoking cessation
• Decrease alcohol
• Decrease Salt
• Increase Fiber
• Increase H20
• Conseled patient regarding Lab/Dx/ need for follow up
• Discussed medications, side effects & compliance.

Now, you might ask what "decrease fat" or "Increase Fiber" or "Increase H20" mean, but then we would have to assume we are talking about dietary advice and then we could spin off into a dark hole of a discussion about the scientific basis for dietary recommendations or lack of it, but if you are the doctor, you have been beaten down enough to simply check the boxes.

For those doctors who write a letter to the referring physician in which he details all of the advice and counseling there is a nasty surprise: The Coders do not know enough medicine to read these letters, which are often filled with technical doctor speak, and things which have to do with what actually happened in the office and why.

So nothing in the letter is "admissible." It's not part of the chart, the doctor is told. "Just click the boxes," the coder says. And sitting right next to the coder is a pert thirty something, an administrator who has an MBA degree and she is sitting there with her laptop, nodding sagely, and repeating, "Just click the boxes."

"So, just tell me what you want me to say," the doctor says to the coder. "Let's put it into the record, so you can understand it. Give me the words."

"Oh, no doctor, that would be 'cutting and pasting' and Medicare does not like pre formulated boilerplate."
"But is checking off  boxes is not preformulated? It's not boilerplate?"The doctor's face grows red, "Checking off those boxes is the essence of preformulated! The essence of boilerplate!"
"Now don't shoot the messenger, doctor.Don't take it personal."

The doctor composes himself. Don't shoot the messenger. Don't take it "personal."

The doctor takes a deep breath.

A sly smile plays across his face: "Suppose I have spent 21 of 40 minutes doing counseling face to face, but then, just as we are finishing, the discharge summary from the patient's recent hospitalization pops up and I take 10  MORE minutes to read it. Now I have spent 21 minutes counseling but 29 minutes doing other things, so I've spent less than 51% counseling? Can I still bill a 99214?"

"No, doctor,"  the coder sighs and casts a sidelong glance to the thirty something MBA administrator, who is already rolling her eyes, "You can only bill if GREATER than 50% of the time was spent counseling. And now you've spent more time, but LESS than 50% of your time counseling, so you have to downgrade the visit to a 99213!"

"But I've spent MORE time with the patient. I've done better care because I reviewed the hospitalization!"

"Sorry, doc. Don't shoot the messenger. You shouldn't have read that discharge summary. You just lost the company money." 

 

The doctor considers whether the window in his office will allow a body to exit it short of smashing through it. 

Later he recounts his experience with the coder to a colleague sighs. 

"Oh, you know what I discovered?" the colleague tells him,  "My partner always debrides the ulcer, whether it needs it or not."

"Why would he do that?"
"Because THEN he can bill a 99214--it's a procedure--and he doesn't need to get into counseling or any of that stuff."

So now the doctors, to keep the coders happy, are doing medical procedures dictated by the coding regs.

The inmates are now in charge of the asylum.