Let's get rid of worthless documentation

I just became aware of this article by Lucy Hornstein, MD on modifying the current documentation process and found it to be quite exciting because I have had very similar thoughts for some time:

I may be a fellow dinosaur, but I could not agree more.  The vast majority of documentation especially in the EMR is worthless largely because of the proliferation of stereotypical documentation to fit business and government requirements.  The businesses wanted to slow us down at least until they figured out that they could literally reimburse us for whatever they wanted irrespective of the billing code or note.  The politicians want all the bullet points because of the erroneous notion that coders can actually read a note and objectively  decide on the correct code (they can't) and therefore they can fight fraud. 

In the meantime, vast areas of hard drive space are occupied with worthless data because of these notes and the trees die anyway because requesting the information results in an EMR driven telephone book sized tome  with very little information (if any) on each page.

The only thing worse is the EMR driven initiative to rapidly assemble a massive note from existing data using smart text and a few key strokes.  I was on a committee once where we reviewed 10-16 page daily progress notes compiled in various fonts.  The majority of each note was already listed in the record.

I can recall working on a very busy neurosurgical service where we saw 30 patients a day (6-10 in the NICU) and did all the documentation in 2 - 3 hours before going to the OR.  All of the progress notes for the entire hospitalization generally fit on one page.

I have been thinking about Dr. Hornstein's approach for some time and have come to the same conclusion.  The current notes and coding system is basically driven by paranoia and not patient care.  Any EMR system worth its salt should be able to display all of the daily relevant data and provide a check box so there is documentation that the attending reviewed it all and signed off instead of the physician doubling as scribe and displaying it all (after a flurry of mouse clicks) in a massive note.  The actual note needs to reflect the fact that an intelligent life form visited the patient and there is a thoughtful analysis and plan. 


That doesn't happen by filling up templates in an electronic medical record.

George Dawson, MD, DFAPA

Mismanagement of Knowledge Workers

In a previous post,  I discussed Drucker's concept of “knowledge workers” and how that concept applied to psychiatrists and physicians. The basic concept is that knowledge workers know more than their managers about the service they provide, work quality is more characteristic than quantity, and they are generally considered to be an asset of corporations.  I pointed out that physician knowledge workers are currently being managed like production workers and referred to common mistakes made in managing physicians and psychiatrists. Today I will tell attempt to describe how some of that mismanagement occurs using examples that psychiatrists have discussed with me over the past several years.

Inpatient psychiatry has taken a severe hit over the past 20 years in terms of the quality of care. Many people have talked with me about the discharge of symptomatic patients occurring in the context of high volume and low quality. Depending on the organization, a psychiatrist may be expected to run an outpatient clinic in addition to a busy inpatient service or in some cases provide all the medical services to the inpatients with minimal outside consultation. Most hospital care is reimbursed poorly despite political suggestions to the contrary. Psychiatric DRGs are typically 20% less than medical surgical DRGs and they are not adjusted for complex care. Administrators generally "manage" psychiatrists in a way to make sure that inpatient beds are covered. That frequently means that psychiatrists who prefer practicing in an outpatient setting end up doing some inpatient care. An outpatient clinic may be canceled so that a psychiatrist is available to run an inpatient unit. There have been situations where inpatient beds or whole units have been shut down for lack of psychiatric coverage. The only explanation given is that there is a "shortage" of psychiatrists.

I had the pleasure of running into one of my residency mentors in an airport last May. I let him know that I was just finishing up 21 years of inpatient work and moving on to something else. He smiled and said: "Three months wasn't enough?".  I always liked his sense of humor but there is also a lot of reality in his remarks.

I don't mean to imply that it is any easier on the outpatient side. If you are a manager, what could be easier than having a unit of production that you could hold your employees to? It turns out there is something easier and that is being able to set the value of that unit of production. That is what RVU based productivity is all about. A standard managerial strategy these days is to have a meeting with an outpatient psychiatrist and show them how much they are "costing the clinic" based on their RVU production. Spending hours a day answering phone calls, doing prior authorizations, questions from other clinicians, curbside consultations, discussions with family members, and documenting everything doesn't count. I have had the experience calling a clinic at 7 PM and hearing keyboards clicking in the background. I have asked outpatient colleagues how they are able to produce outpatient documentation themselves and still get out of clinic on time. Now that I work in an outpatient setting myself, I know what they were telling me was accurate and that is the documentation gets deferred until later.

The mismanagement does not stop there. At some point in time medical schools decided that there were also going to start basing faculty salaries on clinical production. I suppose every medical school as a formula for converting teaching and research time into production units, but until I see those formulas my speculation is that any activity that does not result in billing leads to lower compensation. The days when physicians were hired as teachers and academicians seem to be gone.  Because of discriminatory reimbursement, departments of psychiatry will be disproportionately affected.

Within psychiatry there used to be an interest in organizational dynamics and how they impacted patient care. The dynamics in most organizations today are set up to promote the business. That has produced a focus on high volume-low quality or in some cases supporting the specialty with the highest reimbursement and procedure rates.   Associated dynamics are in place to select and shape an idealized corporate employee who will modify his or her practice according to the whims of the Corporation. It may be hard to believe but large medical corporations everywhere are trying to figure out how to recruit young physicians who believe in their models. Physicians who don't accept these ideas frequently find that the company is not very friendly to them. There are always various political mechanisms for ousting any dissidents and there is minimal tolerance for debate.  The dissent can be as mild as asking why consultants with less expertise than the physicians in the practice are being called in to critique them and come up with a plan.

When it comes to physician mismanagement there are few businesses that can equal the government. RVUs, the Medicare Physician Payment Schedule, pay for performance, and various failed political theories like fraud as the cause for healthcare inflation, and managed care amplifying all of the above and focusing all of that irrational management directly on physicians.  The result is obvious as enormous inefficiencies, job dissatisfaction, and demoralization. Governments partnering with businesses and placing business practices like utilization review and prior authorization in state statutes increases the burden exponentially. At the heart of this conflict is a physicians training to be a scientific critical thinker and function autonomously with the businesses interest of making a buck. Despite all the lip service to quality, business decisions are always made on a cost rather than quality basis.

It is often difficult to see any light through the blizzard of government and business propaganda that passes for the management of physicians and psychiatrists. Psychiatry has bore the brunt of mismanagement over the past 20 years and that has well been well documented in the Hay group study showing the disproportionate impact of managed care on our field. Inpatient bed capacity has dwindled and the beds that have not been shut down are managed for high-volume low quality work. Outpatient clinics including those run by and nonprofits are managed according to the same model.  Businesses and governments have provided the incentives for this type of practice.  The available consultants in the field only know an RVU based productivity model and nothing else. Rather than treating psychiatrists as knowledge worker assets, the available jobs frequently reduce us to micromanaged clerical workers utilizing about 10% of our knowledge.  It should be no surprise that the environment makes it seem like anyone can do the job.

One of my favorite quotes from Peter Drucker was: "More and more people in the workforce and mostly knowledge workers will have to manage themselves".   After all, only  the knowledge worker knows how to best complete the job.  Every psychiatrist that I know, knows how to get the job done and it is often at odds with what we are allowed to do. The best pathway to do this is to optimize the internal states of the knowledge workers and create environment where they manage themselves.  There are very few environments available where that can happen today for psychiatrists.

George Dawson, MD

"The land of 10,000 90862s"

The title of this post is an inside joke for psychiatrists.  90862 is the billing code associated with a psychiatric visit that is commonly referred to as the "med check."  It is an example of what can happen to a profession when government bureaucrats and businesses run amok in determining what they think you do or what you should be doing when you provide patient care.

I first became aware of the political importance of this system in the 1990s, when I had to attend mandatory billing and coding seminars at my place of employment.   In those seminars I learned that the politicians and insurance companies were so desperate to use this arbitrary system that they told us we could go to federal prison for a long time if we submitted a "fraudulent" billing document.  The "fraudulent" document they were talking about was any bill connected to the document of a patient encounter that did not have enough bullet points to qualify for that level of billing.

That is an important concept so let me say it another way.  After every patient encounter, the physician needs to document a note about what happened and indicate a level of billing for that encounter.  When I first started training the note could be as little as one or two lines.  For example, at one point in my training I covered an entire surgical service with a team of doctors.  We could round on 25-30 patients with very complicated problems and write all of the documentation in about 2 hours.  The documentation was "Pain is well controlled, surgical site looks good, vital signs are stable."  We did not have to bother with any billing documents because a hospital billing specialist came by and confirmed that we had seen the patient and submitted the bill.

Somewhere  in the 1990s, a government initiative changed all of that.  The government decided that they needed a way to control the global budget for physician salaries and they decided to develop a system of codes for patient encounters that they assign relative values to and then multiply that by a certain number to set reimbursement for that code.  The entire system rests on the assumption that somebody can look at the description of a patient encounter as written in a note and audit the associated billing document.  It turns out that when this assumption was tested several years later - it was determined to be false, but that did not deter the federal government or the health insurance industry (see reference).

The 90862 is probably the most abused billing code in the psychiatric profession.  The interpretation of what constitutes an encounter that qualifies for this code varies from practice to practice and between organizations.  Patient experience varies from literally talking to a psychiatrist for 5 minutes with the goal of getting a prescription refill to a much richer encounter that includes a discussion of other current problems, additional medical diagnostic discussions and psychological advice.  In some cases, acute medical problems requiring emergency care have been identified in these sessions.  There is no doubt that a considerable amount of gaming occurs on the part of some clinicians and most insurance companies and government payers.

The only gaming possible by the clinician occurs at two levels.  The first is total time spent with the patient.  The folklore is that these are all 15 minute encounters.  Some clinicians insist on seeing patients in half hour blocks and others see 3 - 4 people per hour.  The second is total documentation.  You can literally do a few lines or you can write several paragraphs and stay after work just to do the documentation.  A lot depends on whether you think you will be audited and somebody will be making an arbitrary decision about whether your note qualifies for the charge that you assign to it.

There are myriad ways that a managed care company can game the system.  First of all, they can assign any level of reimbursement to any billing code that they want.  I quoted a New York Times article in another post as saying that a psychiatrist could see three patients for medications and get reimbursed at $50 per session, but the actual reimbursement can be less than half of that.  That same managed care company can also take any bills submitted for patient encounters with higher reimbursement levels and say: "we are only paying you for a 90862 no matter what you do."  If you happen to be working in an institutional setting, a managed care company can negotiate a per diem rate with your employer and not pay the 90862 billing at all.

Stated another way, a psychiatrist can see a patient with complex medical and psychiatric problems and get reimbursed at a level that might lead to them break even - to getting no reimbursement at all depending on the insurance company and contracting arrangements.  Within organizations the relative values for these codes are the basic way that physicians are manipulated to see more patients.  It is referred to as their "productivity" even though producing work for little or no reimbursement is not really productive activity.  The physician managers can demand that they see more and more patients to compensate for the poor or nonexistent rate of reimbursement by managed care companies.

Another artifact of this system is that procedures like surgeries, endoscopies, and angioplasties are reimbursed at a higher rates than a doctor talking with you and discussing the diagnosis and treatment.  That lead to a movement to reimburse the cognitive or nonproceduralist specialties at higher rates.  But given the amount of government payer and insurance company leverage it is impossible to make that happen.

Is there a solution to this problem that in effect makes physicians work impossibly harder to earn a professional salary?  The solution is as easy as considering how I pay my attorney, accountant, mechanic, plumber, electrician, and chimney sweep.  I pay them all by the hour.  In some cases there is an agreed fixed amount, but it is generally many times more than what I would get reimbursed for the lowest 90862 reimbursement.

Getting back to the title of this post, when I looked at the lowest current reimbursement for a 90862 and calculated how many of those bills would need to be submitted to make a professional wage, it came out to about 10,000 patient encounters per year.  Working 50 weeks per year that would mean seeing 40 established patients per day.  The only clinic where I have ever observed those numbers had three nurses rooming the patients and doing all of the documentation before they were briefly seen by a psychiatrist.

As I contemplated all of this I had the thought: "I am living in the 'Land of 10,000 lakes' - maybe we should just change that to the 'Land of 10,000 90862s.' "

George Dawson, MD

King MS, Lipsky MS, Sharp L. Expert agreement in Current Procedural Terminology evaluation and management coding. Arch Intern Med. 2002 Feb 11;162(3):316-20.

90862 Redux? An Update.