A Doctor's Declaration of Independence

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clando
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A Doctor's Declaration of Independence

Post #1 by clando » May 1st, 2014, 2:30 pm

WSJ wrote:In my 23 years as a practicing physician, I've learned that the only thing that matters is the doctor-patient relationship. How we interact and treat our patients is the practice of medicine. I acknowledge that there is a problem with the rising cost of health care, but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it.

As a group, the nearly 880,000 licensed physicians in the U.S. are, for the most part, well-intentioned. We strive to do our best even while we sometimes contend with unrealistic expectations. The demands are great, and many of our families pay a huge price for our not being around. We do the things we do because it is right and our patients expect us to.

So when do we say damn the mandates and requirements from bureaucrats who are not in the healing profession? When do we stand up and say we are not going to take it any more?

The Centers for Medicare and Medicaid Services dictates that we must use an electronic health record (EHR) or be penalized with lower reimbursements in the future. There are "meaningful use" criteria whereby the Centers for Medicare and Medicaid Services tells us as physicians what we need to include in the electronic health record or we will not be subsidized the cost of converting to the electronic system and we will be penalized by lower reimbursements. Across the country, doctors waste precious time filling in unnecessary electronic-record fields just to satisfy a regulatory measure. I personally spend two hours a day dictating and documenting electronic health records just so I can be paid and not face a government audit. Is that the best use of time for a highly trained surgical specialist?

This is not a unique complaint. A study commissioned by the American Medical Association last year and conducted by the RAND Corp. found that "Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction."

In addition to the burden of mandated electronic-record entry, doctors also face board recertification in the various medical specialties that has become time-consuming, expensive, imposing and a convenient method for our specialty societies and boards to make money.

Meanwhile, our Medicare and Medicaid reimbursements have significantly declined, let alone kept up with inflation. In orthopedic surgery, for example, Medicare reimbursement for a total knee replacement decreased by about 68% between 1992 and 2010, based on the value of 1992 dollars. How can this be? Don't doctors have control over what they charge for their services? For the most part, no. Our medical documentation is pored over and insurers and government then determine the appropriate level of reimbursement.

I don't know about other physicians but I am tired—tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces. The legal profession would not. The labor unions would not. We as physicians continue to plod along and take care of our patients while those on the outside continue to intrude and interfere with the practice of medicine.

We could change the paradigm. We could as a group elect not to take any insurance, not to accept Medicare—many doctors are already taking these steps—and not to roll over time and time again. We have let nearly everyone trespass on the practice of medicine. Are we better for it? Has it improved quality? Do we have more of a voice at the table or less? Are we as physicians happier or more disgruntled then two years ago? Five years ago? Ten years ago?

At 58, I'll likely be retired in 10 years along with most physicians of my generation. Once we're gone, who will speak up for our profession and the individual physician in the trenches? The politicians? Our medical societies? Our hospital administrators? I think not. Now is the time for physicians to say enough is enough.

Dr. Craviotto is an orthopedic surgeon in Santa Barbara, Calif., and a fellow of the American Academy of Orthopedic Surgeons.

http://online.wsj.com/news/articles/SB1%20...%2075310.html

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clando
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Re: A Doctor's Declaration of Independence

Post #2 by clando » May 1st, 2014, 3:43 pm

Thought it was an interesting letter and complaints I often hear from physicians. The main problem is healthcare is changing, for better or worse, and some people including this physician aren't happy with change. Things have to change because the current system is simply not sustainable financially or quality wise.

but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it.

As a group, the nearly 880,000 licensed physicians in the U.S. are, for the most part, well-intentioned.

So when do we say damn the mandates and requirements from bureaucrats who are not in the healing profession? When do we stand up and say we are not going to take it any more?
Yes, Doctors have lost lots of "independence" in decision making. There are now standards of care, which dictate exactly how physicians should treat conditions. Lots of doctors dislike these standards of care because they think it infringes on their individual abilities. However standards of care came about because it was demonstrated that these individual treatment methodologies weren't working. The standards of care are the researched and validated best way to treat conditions. Doctors are also now required to perform medication reconciliation, which lots of doctors hate and consider an administrative waste of time. Why do we require medication reconciliation? Because we have over 98,000 deaths a year from medication errors in this country.

There are "meaningful use" criteria whereby the Centers for Medicare and Medicaid Services tells us as physicians what we need to include in the electronic health record or we will not be subsidized the cost of converting to the electronic system and we will be penalized by lower reimbursements. Across the country, doctors waste precious time filling in unnecessary electronic-record fields just to satisfy a regulatory measure.
Unnecessary electronic-record fields? Here are some of the meaningful use required fields: provide clinical summary for patient for each visit, drug-drug & drug-allergy interaction checks, up-to-date problem list with current and active diagnoses, active medication list, vital signs, smoking status, etc. These are all clinically relevant fields which this doctor portrays as unnecessary regulatory measures. Not to mention almost all of these fields can be filled out by a medical assistant or nurse, which requires little to no extra work by the physician outside of reviewing and signing off that they are correct.

This is not a unique complaint. A study commissioned by the American Medical Association last year and conducted by the RAND Corp. found that "Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction."
This I absolutely agree with. There is a lots of dissatisfaction amongst physicians with regards to EHR. Lots of them are not designed the most efficiently with regards to physician work flows, but the single biggest problem I encounter with EHR implementation is physicians being unable to type or adequately know how to use a computer.

I'm sure the business world had difficulties when they switched from paper to computers back in the late 70's early 80's. I don't think you would find anyone who would claim the business world is more "inefficient" with computers, which is exactly the claim this physician is making here.

In addition to the burden of mandated electronic-record entry, doctors also face board recertification in the various medical specialties that has become time-consuming, expensive, imposing and a convenient method for our specialty societies and boards to make money.
Something he might want to take up with his own profession as they regulate his licensing. I don't understand exactly why he is questioning the desire that a physician demonstrate competency in their specialty though.

Meanwhile, our Medicare and Medicaid reimbursements have significantly declined, let alone kept up with inflation. In orthopedic surgery, for example, Medicare reimbursement for a total knee replacement decreased by about 68% between 1992 and 2010, based on the value of 1992 dollars. How can this be? Don't doctors have control over what they charge for their services? For the most part, no.
A little ironic of a complaint considering Orthopaedic surgeons are one of the highest paid physicians.
The median expected salary is $410,919! And a whopping 20% make over $500,000 dollars. The majority of orthopedic doctors make $312,000 to $575,000.
http://mdsalaries.com/2011/09/27/orthopedic-surgery-salary/
While reimbursement levels have not gone up, total knee replacements have improved meaning that physicians can do them faster and for less costs. Do you really think orthopaedic salaries have dropped 68% for those that do knee replacements?

Our medical documentation is pored over and insurers and government then determine the appropriate level of reimbursement.
Well when you paying a physician and hospital $10,000's of dollars for a procedure, you tend to want documentation of what was exactly done. I'm not sure of many professions that get reimbursed for services they don't have to demonstrate that they did.

We have let nearly everyone trespass on the practice of medicine. Are we better for it? Has it improved quality?
Interestingly most of the things he complained about in this letter are things that were developed by physicians: standards of care, meaningful standards, board certification, etc.

At 58, I'll likely be retired in 10 years along with most physicians of my generation. Once we're gone, who will speak up for our profession and the individual physician in the trenches?
There are less and less "individual physicians" in the trenches. The model of a single physician practice is going away. It's just not a sustainable business model anymore. I won't make any judgements whether this is a good or bad thing, but it is something you see in lots of other industries. Box stores have replaced corner stores, chain pharmacies have replaced local pharmacies, large banks have replaced corner branches. Right or wrong, that is the movement we have seen in the past years and medicine has not been immune to the change.

I do feel bad for the physician because he is trying to hold on to an outdated business model that is no longer sustainable. He is fighting a battle that has already been predetermined and has simply not realized it yet. The world is going electronic and there are significantly more benefits to electronic medical records. The new physician grads have no problems with using EHR's and I think you will see the dissatisfaction decrease as the older physicians retire.

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optimusprime
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Re: A Doctor's Declaration of Independence

Post #3 by optimusprime » May 3rd, 2014, 6:13 am

Interestingly most of the things he complained about in this letter are things that were developed by physicians: standards of care, meaningful standards, board certification, etc.


Very true

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7rob7
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Re: A Doctor's Declaration of Independence

Post #4 by 7rob7 » May 4th, 2014, 8:32 am

My mother-in-law is seeing a new doctor tomorrow because her last one is giving up medicine and going into religion: he said he didn't go to medical school to be a clerk. He is the fourth she has seen over the past dozen years who has given up being a GP in order to either specialize or leave medicine entirely.

Am I wrong, or would single-payer reduce the paperwork and bullstuff enough that this wouldn't be a trend?
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clando
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Re: A Doctor's Declaration of Independence

Post #5 by clando » May 5th, 2014, 9:39 am

7rob7 wrote:Am I wrong, or would single-payer reduce the paperwork and bullstuff enough that this wouldn't be a trend?
A single-payer system would not reduce the "paperwork and bullstuff". What you have to understand is that the paperwork and bullstuff are the things physicians should have ALWAYS been doing. Physicians have always been required to provide diagnosis code (ICD-9), procedure codes (CPT), and a medical note justifying the previous two.

Paper charts were very time consuming to audit. It was logistically impossible to do any large scale audits of paper charts. Each physician or practice could organize their charts anyway they wanted, meaning they could put whatever (or leave whatever out) in their medical records with little to no feedback. EMR's have standardized charts as every chart is organized the exact same way (within that EMR system) and it is much easier to audit large number of charts. So it's not that physicians are being required to necessarily do more "paperwork and bullstuff," they are being held more accountable for doing the things they should have always been doing.

I don't foresee the amount of documentation ever really going down. If you want to get paid for a service you are always going to have to document what services you provide. Additionally with some of the low standards of quality we have in this country, there will be continued document requirements in attempts to improve those standards.

I do feel for these physicians as the profession has and is changing, and a large number of them are at points in their career that they aren't interested in changing. However that doesn't make these changes necessarily bad. If your mother-in-law's doctor doesn't want to document what they do, doesn't want to document allergies, medication reconciliation, etc they probably shouldn't be practicing medicine anyway.

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7rob7
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Re: A Doctor's Declaration of Independence

Post #6 by 7rob7 » May 5th, 2014, 12:23 pm

Ah. Once again my glibness alters my intended meaning.

I was talking about -- and I think my mother-in-law's doctors were frustrated by -- the time and paperwork involved in filing insurance documents, not medical records. That's what I thought single-payer would reduce, through consolidation.

Accurate medical records are critical in my mother-in-law's case, as she is on so many medications for so many various reasons that we have to be extremely careful when introducing a new drug or even adjusting dosages of the old ones. Whether or not that record-keeping is what keeps prompting her physicians to "abandon" (her word) her is something I do not know, and didn't mean to imply.

Thanks again for clarifying!
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clando
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Re: A Doctor's Declaration of Independence

Post #7 by clando » May 5th, 2014, 1:07 pm

7rob7 wrote:I was talking about -- and I think my mother-in-law's doctors were frustrated by -- the time and paperwork involved in filing insurance documents, not medical records. That's what I thought single-payer would reduce, through consolidation.
There aren't really any "insurance documents". The only insurance specific document I can think of would be authorizations, but those are rarely handled by physicians. When physicians complain about "paperwork" they are typically complaining about medical record documentation.

A single-payer system would reduce the "reimbursement complexity", but it probably wouldn't change much regarding the actual provision of care. A single-payer system would eliminate the need to have contracts with hundreds of insurances, and you wouldn't have to know what is approved/not approved for each of the insurers. However the provision of care, and billing of that care are pretty much the same for every insurer. My providers only fill out one encounter form (billing sheet), they don't have to fill out separate sheets for each insurer.

7rob7 wrote:Accurate medical records are critical in my mother-in-law's case, as she is on so many medications for so many various reasons that we have to be extremely careful when introducing a new drug or even adjusting dosages of the old ones. Whether or not that record-keeping is what keeps prompting her physicians to "abandon" (her word) her is something I do not know, and didn't mean to imply.
Medication Reconciliation wasn't a full requirement until 2011. It is still only a process requirement for Joint Commission Certified Organizations. This is a new change and one that almost all physicians resisted when implemented. Even now the medical assistants and front desk do the majority of the work with regards to updating and collecting the information for medication reconciliation.

7rob7 wrote:Thanks again for clarifying!
No I think you meant exactly what you were trying to say. I just don't think you are aware of the nuances in what is being portrayed as "paperwork".

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Bill Bryan
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Re: A Doctor's Declaration of Independence

Post #8 by Bill Bryan » May 5th, 2014, 7:27 pm

Got my first ever complete physical last week. They tested my blood, of course.

Everything good except super-duper-extra-super-duper high calcium levels. Huh? What did I eat that raised my calcium levels so high?

Oh, wait. Three days before the physical I had been in there complaining about stomach problems. For a couple days there I was eating (generic replacement for) Tums like candy. So I look at the ingredients on the antacid bottle:

Calcium carbonate.

They took a re-sample today. I'm expecting normalcy. :crazy:
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