Collegial Conversations

Responding to Jim Amos' post on what keeps us all going led me to recall some of my most valued conversations with colleagues and what happened to those conversations.  I began working at a major hospital in the Twin Cities sometime in the late 1980s.  These conversations happened sometime in the 1990's.  At our hospital there was a large cafeteria are in the corner of the building so that it it was bordered by windows to the exterior on the north and east sides.  One the far east side was a separate room about 1/8 as large as the entire space that was reserved for medical staff.  It was separated by a door from the main cafeteria, but the door was usually open unless there was more noise than usual in the main room.

At one point the GI specialists were all seated at one table.  I knew all of them from consultations they had done on my patients and one of them from medical school.  We had both been in the very first class (Biochemistry) together.  After a while we all routinely met there.  We were joined from time to time by several Renal Medicine, Endocrinology, and Infectious Disease specialists.  The occasional Cardiologist or Surgeon would drop by.  We talked about movies.  I recall one of the films we were discussing was Sylvester Stallone's Cliffhanger and that would have put that conversation sometime in 1993.  One of the discussants was an expert in hostas and he often talked about that botanical speciality.  We spent time talking about pancreatic cancer, imaging studies, narcissistic personality disorder, dementia, psychosis, and futile care and what could be done about it.  The conversations were lively.  Plenty of self deprecating specialty specific humor.  Most of the people there had a good sense of humor.  We discussed topics that were both serious and not serious in a calm and even manner.

I looked forward to those lunch meetings.  It was a chance to talk with colleagues in an open and relaxed manner.  Nobody was bleeding to death or unconscious.  There was no pressure to do a last minute consultation before everybody left the hospital.  More importantly there was none of the nonsense you might encounter let's say on the Internet.  There was no one upmanship.  No moral hypertrophy.  No discussion focused on the superiority of one speciality over another.  Reading the internet gossip, it might be hard to believe that doctors buy their own meals and don't spend every waking moment plotting about how they can use the newest heavily promoted drug.  In fact many of the conversations were focused on just the opposite.  I can recall reading a critique of heavily promoted acetylcholine esterase inhibitors for Alzheimer's disease (AD) with some primary care internists.  The asked me what I thought of these drugs especially the most recent billion dollar drug.  I have been involved in AD drug trials, the initial clinical application of tacrine and the subsequent approved drugs.  I thought that their effects were undetectable.  The internists agreed and one of them said: "Leave it up to the pharmaceutical companies to invent a rating scale that works for their drug but has no clinical meaning."  None of us wanted credit or acclaim for that commentary.  None of us claimed we were keeping Big Pharma honest.  We we just clinicians comparing notes and agreeing that a certain class of medications was not as effective as it was advertised to be.  In this group we had many of these conversations.

Things suddenly changed when the administrators decided to erect a new building along the east side of the existing hospital.  Suddenly the view and windows were completely gone.  Sitting in the doctors section was like sitting in a cave.  At about the same time, we were all told to report to coding seminars and warned that we could be charged with a violation of the RICO statutes if it was found that we were submitting "fraudulent" billing.  Fraudulent billing was basically either billing that somebody said was fraudulent (there was and is no objective criteria) or countersigning a resident's note and not doing enough documentation to actually prove that you had seen the patient.  Proof for the purpose of that seminar was basically doing identical documentation as the resident.  When I heard that I could end up in a federal penitentiary I took the new billing and coding guidelines seriously.  Over the next few years the documentation burden went through the roof.  That resulted in me no longer working with residents.  They were angry about the degree of documentation they saw me doing and thought it reflected on their work.  No matter how many times I said: "No this is me trying to stay out of federal prison" it did not assuage their anger.  I suppose it sounded incredible - even absurd.  But my billing, documentation and coding was actually reviewed based on those standards for years.  That was such an obstacle at one point I decided that it was easier to work by myself.  There was no time for teaching anyway due to the documentation requirements.

My colleagues were under similar constraints.  People just stopped showing up for lunch.  I would run into one or two in the hallway from time to time.  The administrators were also actively involved in moving my colleagues around.  Many did not like it and some of them left.  I had the feeling that if we were left to our own devices and kept things running the way they had been running for years, that we would still be meeting at noon and having the same discussions we had in 1993.  But there was no such luck.  The last time I saw one of my colleagues was about 5 years ago.  We met in the hallway of the same hospital.  We were both thinking about that Stallone movie.

A curious thing happened about 10 years later.  Some administrator had the brilliant idea that a "doctors' dining area" made sense.  They separated it completely from the cafeteria.  They made it more high end to attract the doctors back in the place.  I even met up with some of my previous colleagues there from GI and Renal Medicine.  The conversations still had the potential to be inspiring.  But something was gone forever.  There was no time for collegial conversation anymore.  Most of us were fairly isolated as a result of how the practice had changed.  It was forever transformed by corporate America.  Doctors no longer seemed like inspired people on a life long mission of patient care and education.  And we all knew this could disappear as easily as it materialized.

I had travelled up to northern Minnesota at one point and went down into an old iron ore mine.  There 2,300 feet below the surface was a lunch room.  It was inside a steel cage to protect the miners from cave ins.  I could imagine people working all day a mile below the surface, covered in iron ore dust, and eating lunch in that room.  For a minute I pictured myself as one of those miners.  Brutal unending work in the worst of all conditions.  At one point the tour guide shut off all the lights to demonstrate what it was like lit by carbide lamps on helmets.   We were in a large room about 100 x 100 feet with a 20 foot ceiling. The floor was visible in a dim arc about 5 feet in the distance and everywhere else it was pitch dark.  Miners actually worked like that before electricity and only a few of them had carbide lamps.  It was depressing.  Then we learned that before carbide lamps, the miners used candles.  Even more depressing.  I felt that medicine had taken a step in the direction of the old iron ore mine.

I enjoyed seeing my colleagues every day.  I enjoyed and learned from what they had to say.  If I needed to go to a hospital or clinic in the future I would want to go to one where there were collegial conversations every day.

But I suspect those places are few and far between.


George Dawson, MD, DFAPA

Supplementary 1:  The billing and coding seminar described here actually happened that way.  At the time the FBI was raiding practices and they made some of these decisions.  In internal reviews I went from the best documentation one year to the worst the next even when I had not changed a thing.  Eventually the FBI decided there were probably better thing to do than enforce a purely subjective standard against doctors who were hardly engaged in criminal or terrorist activities.  The out for most organizations was to have an internal compliance department to do the same reviews,  After about 10 years, documentation with residents returned to nearly what it used to be and I could resume teaching again.

AMA, DOJ, and managed care all on the same side?

That's right and they are all potentially aligned against doctors.

The lesson from the 1990's and again in the early 20th century was that politicians who were not competent to address health care reform in any functional way could come up with all sorts of off-the-wall-theories.  One of the most off-the-wall theories was that widespread health care fraud was a major cause of health care inflation.  It stands to reason if that is the case that is true, the perpetrators would be easy to find and put out of business.  To borrow typical language of the Executive branch it was a War on Healthcare Fraud.

To anyone who did not endure it, it is now a well kept secret.  The tactics of the government used in those days - entering clinics and doctors offices in an intimidating manner and taking out boxes and boxes of charts for review by special agents who were "coding experts" and then assigning some tremendous fine based on alleged "fraud" have been expunged from most places.  I sent two Freedom of Information Act requests to involved federal agencies and was told that information "did not exist" even after I provided the front page from one of the documents with the name of the agency.

It was quite a spectacle and it had doctors everywhere running scared.  After all, the interpretation of notes and linking them to billing documents was entirely subjective.  If a handful of notes was reviewed and bills were actually sent through the mail - racketeering charges via RICO statutes were possible and the fines would skyrocket to the point that nobody could ever pay them.  Federal prison was a possibility.  All for having a deficient note?

What followed was a carefully orchestrated set of maneuvers to render beleaguered physicians even weaker.  A decade of millions and millions of hours wasted on worthless documentation out of paranoia of a government audit.   Whose notes actually "fit" the government criteria?  The notes varied drastically from clinic to clinic and year to year in the same clinic.  And then a masterful stroke.  The government probably realized that their micromanagement of progress notes as leverage against physician productivity was probably undoable.  It would take far more agents than the budget would allow and they would no longer be able to demonstrate "cost effectiveness" in terms of recovered funds on the DOJ web site.

At that point they were able to turn this political device over to managed care companies who could selectively apply it anyway they wanted.  Some physicians noted that their documentation and coding scores by internal audit could be the best in the organization one year and the worst then next even though they had not changed any of their paperwork practices.  These audits to assure compliance with federal guidelines quickly became a mechanism for managed care organization (MCOs) to deny payment and "downcode" a practitioner's billing based on their review of chart notes.  Incredibly the MCO could deny payment for a block of billing submitted or pay much less than what was submitted.  Where else in our society can you decide to pay whatever you want for a service rendered?  That is the kind of power that the government gives MCOs.

Enter the new "partnership" to deal with health care fraud.  It is basically a coalition of the same players who have been using the health care fraud rhetoric for the past 20 years.  The DOJ, FBI, HHS OIG, large insurance companies and managed care corporations.  This quote says it all:

"The joint effort acknowledges the limitations of each health care insurer relying solely on its own data and fraud prevention techniques.  After a 2010 summit, 21 private payers and government agencies discovered that they were victims of the same scams.  As a result, the participants pledged to ban together against fraud."

The HHS Secretary chimed in:

"This partnership puts criminals on notice that we will find them and stop them before they steal health care dollars."

The newly elected psychiatrist-AMA president Jeremy Lazarus advises:

"Claims coding and documentation involve complicated clinical issues and the analysis of these claims requires the clinical lens of physician education and training."

Good luck with that Dr. Lazarus and heaven help any physician who gets caught under the managed care-federal government juggernaut.  And who protects physicians against those who are defrauding them by non payment or trivial payment for services rendered based on a totally subjective interpretation of a chart note?  Nobody I guess.  I guess we will continue to deny that is possible and a common occurrence.

This can only happen in a country where the government provides businesses with every possible bit of leverage against physicians and where most political theories about health care reform are pure fantasy.

George Dawson, MD, DFAPA

Charles Feigl.  New public-private partnership targets health fraud.  AMNews August 20, 2012.