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I'm a neurosurgeon and former Democrat. Healthcare policy turned me into a Republican. Longtime listener to the Ricochet flagship podcast. Now I just rant about how stupid our healthcare system is.
I looked up at the electronic chart the resident had loaded on our workroom monitor. Sure enough, the patient’s problem list included ICD-10 code V95.43XS: “Spacecraft collision injuring occupant, sequela.”
“He’s an astronaut?” I asked, hopefully.
“No, I don’t think so” the resident responded, “he appears homeless. And high.”
I was disappointed, my hopes that we had admitted a space traveler to our service overnight were dashed. Instead, the diagnosis was clearly a case of clerical error, a byproduct of a cumbersome and onerous diagnosis system forced upon healthcare providers.
For a hospital or physician to bill for services, the Center for Medicare and Medicaid Services (CMS) requires both a diagnosis and a procedure. These are both assigned alphanumeric codes: Diagnosis codes come from the International Statistical Classification of Diseases, 10th revision (ICD-10) codes, developed by the World Health Organization. Procedure codes come from Current Procedural Terminology (CPT) codes, developed by the American Medical Association.
Every time a physician writes a clinical note, performs a procedure, orders a test, or has any sort of patient encounter, the electronic medical record (EMR) asks for an ICD-10 code. Go to a primary care office, and the doctor will want to bill for every issue discussed that day, so multiple ICD-10 codes will be entered.
The ICD-10 coding system is so specific and complex that multiple different codes exist for similar problems. The primary care physician might simply put in M54.9 (back pain) but when they come see me, the neurosurgeon, I know to put in M48.061 and M54.16 (lumbar spinal stenosis without neurogenic claudication but with radiculopathy). I could probably add in M51.16 (displacement of lumbar intervertebral disc with radiculopathy) as well. Of course, I’m not going to go through the trouble of deleting the primary care doctor’s initial assessment. He had written notes associated with it. Now the patient’s problem list has four items listed for one issue.
He might be a new patient to our clinic, so I would like to add his diabetes to the problem list. I can’t just add E11.9 (diabetes), as that is far too generic for our EMR, so popup boxes appear after I select “diabetes.” What type of diabetes, how long has the patient been on insulin, what are their complications, how severe is their retinopathy and/or kidney disease? In all, there are 58 different boxes (I counted) to click through to get the “accurate” diabetes diagnosis. Of course, being a neurosurgeon, I have no clue about this patient’s diabetes complications or retinopathy. Information on differing insulin types left my brain long ago. So I click through as best I can. After a few frustrating seconds, I arrive at Z79.4. I’m sure his primary care provider will come up with a much more accurate and detailed ICD-10 code which will join my Z79.4 on the patient’s problem list. The same must be done for his hypertension, headaches, acid reflux… Eventually, I just give up. His problem list already takes up the entire page. I don’t envy those poor primary care doctors.
The complexity of the ICD-10 coding system clearly explains how our homeless gentleman received a NASA-related diagnosis. Some provider, likely rushed for time, was clicking through and simply chose the wrong code. An encounter with extraplanetary craft is not the only obscure condition enshrined with its own ICD-10 code. If one is trying to enter a bone marrow disorder, one might mistakenly click on W61.111XA (bitten by macaw). Perhaps a problem with fluid retention is mistaken for V91.07XD (burn due to water-skis on fire, subsequent encounter). Of course, if a physician is ever searching for a code to use, there’s always Z63:1 (problems in relationship with in-laws).
But, no, alas our poor homeless man just had Z59.0 (homeless single person) and F15.929 (methamphetamine intoxication, not to be confused with F15.10 [methamphetamine abuse] or F15.11 [methamphetamine use disorder, early remission]). I still haven’t had the pleasure of treating an astronaut.
I'm a neurosurgeon and former Democrat. Healthcare policy turned me into a Republican. Longtime listener to the Ricochet flagship podcast. Now I just rant about how stupid our healthcare system is.
“We had to downgrade half of your notes this month.” The coders sat opposite the table from me. The department chair sat to their left.
“You billed a level 5 clinic visit for Mr. Arancibia here,” they brought my clinic note up on the screen.
“Yes,” I replied, “I spent an hour discussing his brain tumor surgery with him and his family. It’s a very complex tumor and required at least that much face-to-face time. I figured it would be worth the highest level of billing.”
“But you didn’t document that you listened to the heart and lungs.”
“I didn’t document because I didn’t do it. I didn’t do it because whatever I heard wouldn’t make a lick of difference in my clinical plan. I’m a neurosurgeon. I haven’t used a stethoscope since medical school.”
“We can’t bill a level 5 unless you document that you listened to the heart and lungs. You have to perform a comprehensive physical exam for a level 5. We had to bill this visit as a level 2.” The coders looked disappointed.
The department chair shook his head, “A level 2 is only worth 0.93 RVU. A level 5 would have gotten us 3.17. And that’s just the professional fee. Look at this,” he gestured to a spreadsheet that the coders brought up on screen, “we could be nearly tripling your clinic billing if you just documented appropriately.”
Mentally, I weighed my options.
Would you like me to cut my discussion with the patient short so I can perform a comprehensive physical exam, even though that won’t change anything about the patient’s workup or treatment?
Would you like me to simply lie about my physical examination in the note?
Would you like me to see fewer patients so I can fit in more comprehensive exams and the appropriate documentation?
I knew the answer, though. No need to be snarky. It’s not the chairman’s fault that these rules exist.
It’s not even the coders’ fault. Their job is to take my clinical note and turn it into a billing code.
That’s the problem.
Traditionally, medical care is reimbursed as “fee for service.” Provide a service (clinic visit, inpatient consultation, surgery, etc) and receive a fee. What it has become, however, is “fee for documentation.”
The most common services physicians provide are within the broad category of “Evaluation and Management (E&M)” codes. E&M codes include all clinic visits, ER visits, and care for admitted patients. Essentially anything that isn’t a surgery or procedure. The codes are typically stratified into levels 1-5, based on the complexity of care. The differences in reimbursement are huge. However, the rules governing what can be billed in each tier are complex and murky at best.
They are complex and murky because they are determined by the government. This isn’t because of private insurance or the result of a fragmented system. This is top-down governmental regulation.
The Centers for Medicare and Medicaid Services (CMS) issues guidelines on what must be documented to bill for each level of E&M code, certain checkboxes that must be met. This all must be included in the clinical note. Thus, physician notes have gone from a means by which physicians could outline their clinical reasoning and communicate with one another to a means by which coders can assign billing codes.
Physicians and coders have decided that more information in the note means a higher likelihood of it passing a CMS audit. With electronic medical records’ ability to automatically import data, notes have ceased to have any clinical utility. Brief notes which should only occupy a few lines are now pages long, with every lab and radiology finding from the last year auto imported. Notes are copied and pasted from one visit to the next. The physicians who generate the most revenue off their clinic visits are those who ensure each note has the required CMS guidelines for a level 5 evaluation. Time writing notes is rewarded, not patient care.
Entire industries exist around these guidelines. There are classes physicians take to maximize billing. There are companies that contract out the coding and consulting firms that train unyielding doctors on how to become stenographers. There are lobbyists at CMS and within the American Medical Association who come up with the guidelines for each code, along with the codes themselves.
Ever wonder why doctors don’t reply to emails? There’s no code associated with that.
Instead of using clinical judgment, physician behavior revolves around the documentation “guidelines” assigned to each code. Patients experience this with those forms at the doctor’s office, asking about a lengthy list of obscure and unrelated symptoms. That’s because CMS decided that the top-level billing codes require a physician cover a 15-point “review of systems.” Since covering a review of 15 comprehensive bodily systems alone would eat up twice the allotted appointment time, physicians have patients fill out the form themselves. Of course, that review of systems was derived for a primary care practitioner, yet it is still mandated that every dermatologist, gastroenterologist, or orthopedist include it in documentation if they are to receive adequate compensation. The same goes for the physical examination requirements. Heart and lungs are a must, even if your specialty is bones or brains.
That’s why, as a neurosurgeon, I’m expected to use a stethoscope on every patient. I simply can’t bill for a top-level clinic visit otherwise. It doesn’t matter that I’m not trained to interpret heart sounds and am the last person who should be basing clinical decisions around the results of a stethoscope examination. CMS would rather I do that rather than spend time covering what, in my professional judgment, matters.
So here I am, documenting at all hours of the night, taking my work home. Here we are, as a profession, writing lengthy and useless notes to satisfy our coders. Those who claim the administrative burden will improve with Medicare-for-All have never read CMS billing guidelines.
I'm a neurosurgeon and former Democrat. Healthcare policy turned me into a Republican. Longtime listener to the Ricochet flagship podcast. Now I just rant about how stupid our healthcare system is.
All I could hear was mumbling behind the plexiglass shield and double masks.
“Yeah, I brought my own bags,” I repeated, nearly shouting as I showed the grocery store clerk my two cloth bags. I didn’t want him to mistakenly put in the mandatory 20 cent charge for using disposable bags. I knew my voice must sound equally muffled from the other side of the plexiglass.
The man intending to bag my groceries poked his head around so I could hear: “we need your basket.”
“I got this, I can bag them myself,” I replied, trying to be helpful to the clearly overwhelmed employees.
As if I was trying to board a plane with a loaded gun, the men jumped into action.
“NO SIR.”
“GIVE US YOUR BASKET!”
Stunned, I bent down under the counter, retrieved my basket, and handed it to them as they began lecturing me.
“You can’t bag your own groceries, sir, it’s a public health risk.”
I stifled an eye roll. I tried to show empathy, commiserate with these employees who probably deal with angry customers all day long.
“I’m sorry you have to deal with these rules. It must make things difficult for you guys,” I said.
They both look at me, indignantly I surmised (it’s difficult when you can only see someone’s eyes). “The groceries go back in your basket and you can put them in your bags OUTSIDE, where it is SAFE. We are doing this to protect YOU. You do KNOW why we have these rules, RIGHT?”
“In theory….” I stop myself. Because science now tells us that reusable grocery bags release clouds of COVID if someone dares insert their own broccoli? Because Gavin Newsom releases bonehead and contradictory dictates weekly? Because here, in the bluest of blue states, we follow the SCIENCE-BASED RULES?
I swallowed my frustration and watched as the bag man put all my groceries back in my basket. I wanted to talk back to the cashier who was lecturing me about public health. I wanted to tell him how I spend 80 hours a week at the county hospital, the place where the majority of hospitalized COVID patients are treated.
I wanted to ask him what happened to civility and common sense? We are all dealing with frustration over this virus, the rules surrounding the virus, the endless talk of the virus… That’s still no excuse for losing civility in the most mundane of human interactions. Instead of civility, we have embraced a nanny-state tattle tale mentality that would make Mao blush. The insanity over the virus and the RULES surrounding the virus have driven people mad. Twitter, Nextdoor, Reddit, and Facebook are all filled with our neighbors vilifying each other.
We can’t eat out, take our kids to playgrounds or get groceries without getting lectured about public health. How about instead of scolding one another, we all take a deep breath, exhale into our N95s and remind ourselves to be civil again?
These were just the thoughts running through my head as I was being scolded by the grocery store cashier for simply trying to bag my own groceries.
However, I couldn’t hear much more of what he had to say. Thank you, plexiglass.
I'm a neurosurgeon and former Democrat. Healthcare policy turned me into a Republican. Longtime listener to the Ricochet flagship podcast. Now I just rant about how stupid our healthcare system is.
After his car accident, he was rushed to his nearest trauma center. Unconscious, the trauma team inserted a breathing tube and resuscitated him. A CT scan of the brain revealed an epidural hematoma, life-threatening bleeding on the brain. Dr. Oliver, the local neurosurgeon, was called in and deftly removed the blood clot, preventing a catastrophic brain injury.
Brady underwent his recovery. Dr. Oliver rounded on him daily, carefully documenting his progress in his clinical notes.
“Dr. Oliver, we have to talk about your notes,” the administration would say to him. He would be called into a meeting where they highlighted how his documentation is sub-par. There were six members of the coding team, all present at the meeting. Two were MDs and four were RNs.
What was his offense? Not making Brady Harold look sicker in his notes.
“When you state his CT scan showed ‘swelling,’ we can’t risk-adjust for that. You need to use these terms approved by the coders,” the coding team would lecture him. “We need you to make the patient look as sick as possible.”
They would pester and hound Dr. Oliver, pointing out how his documentation didn’t make Brady look sick enough. They would send him angry emails, page him during surgery and call his cell phone after hours. Dr. Oliver would eventually relent and try his best to alter the documentation. It took him away from other patient care duties, but that was beside the point. After the administrators were done, they could paint the picture of Brady Harold, chronically ill patient who already had an unusually high risk of death. He never knew what a miracle he was.
So how did we get to this place? I, for one, blame baseball. Don’t get me wrong, I love the sport. It conjures up associations with warm summer days, hot dogs, and statistics. In fact, it’s the perfect statistical game. It’s zero-sum; for every offensive accomplishment, there is a corresponding defensive blight. Many kids’ understandings of statistics, probabilities, and averages comes from baseball. As the science of statistics has advanced, analysts have fine-tuned metrics that closely approximate the “true skill” of players. Batting average gave way to OPS which gave way to exit velocity and launch angle: better and better numbers to reflect the players’ skills.
If we care so much about a silly game to devote years of brainpower to its statistical analysis, surely, we could do the same with medicine. Physicians and hospitals should have their statistics published. A patient should know which doctor has the best “batting average,” right? This is where the analogy breaks down. Patient care is not a zero-sum game. There is no official scorer in medicine. There is not even consensus on the ideal outcomes.
Despite this, the government thought that incentivizing outcomes would improve patient care. The reasoning is easy to see. Instead of incentivizing more care, the government thought it would make more sense to incentivize better care. This is only necessary because there isn’t a functional free market in medicine. As Hayek eloquently stated, “Once the free working of the market is impeded beyond a certain degree, the [government] planner will be forced to extend his controls until they become all-comprehensive.”
Of course, that meant statistics must be derived. If the patient can’t determine value themselves, as is the case with a functioning market, the government must determine value. Therein lies the problem. It’s not as simple as baseball, where an objective scorekeeper can decide what is a hit or what is an error. Medicine is an infinitely complex system without defined “good” or “bad” outcomes. Instead of hits, outs, errors, and runs, what are the scorekeepers of medicine to measure?
“…as if only that which can be counted really counts.” – Jerry Z. Muller stated in The Tyranny of Metrics. Tracking statistics for physicians is not as simple as it seems. What statistics should be tracked? Comparing the survival rate between a trauma surgeon, oncologist, and pediatrician doesn’t seem appropriate. In fact, looking at the mortality rate of a pediatrician would yield very little information about the quality of said pediatrician. It’s very difficult to find reliable, objective measures of physician quality. Creating artificial metrics can have disastrous outcomes in any industry. Every centrally planned economy in history has faced this problem.
Of course, what really matters is the patient. The metrics should align with what the patients value. However, patient satisfaction scores, as measured by a number of quantifiable surveys, is highly subjective. In fact, it’s influenced by wait times, hospital décor, and cafeteria quality more than the ability of the physician. One study even showed that the patients with the highest satisfaction had the worst outcomes (along with costing the most). In some cases, notably drug-seeking patients or those wanting to self-harm, satisfying the patient’s wishes would be counter-productive to health. How does one judge value at the end of life? Some patients want to live as long as possible, while others just want to die a dignified death at home.
Early metric tracking in medicine seemed to be filled with promise. Just tracking the number of infected central lines (IVs inserted into the big veins near the heart) led to an improvement in practices and drops in the number of infections. The same principle was applied to urinary tract infections (UTI) after urinary catheters. Then hospitals realized they could game the system. A hospital-acquired UTI would count against the statistics, but not if the patient had one on arrival. All patients were suddenly tested for UTI when they enter the hospital, leading to a massive increase in testing costs in order to document UTI on arrival. Then, when a physician wanted to test for a UTI during the hospitalization, that test would be blocked by administration. You can’t find a UTI if you don’t look.
Gaming metrics reached its peak with the observed to expected complication ratio. Some hospitals have sicker patients at baseline than other hospitals. It wouldn’t be fair to penalize those hospitals with sicker patients. Thus, the metrics all must be risk-adjusted. Based on a risk-adjustment formula, hospitals would have an expected complication rate that would be compared to their observed complication rate. There’s a much bigger return on investment in making the expected complication rate as bad as possible rather than actually improving care. Just by having the coders round with the physicians, revenue on a single service was increased by 40%. This was without improving care in any way.
A whole industry has grown around this metric fixation. The US government has spent over $1.3 billion on developing quality metrics from 2008-2018. This money has gone to several private firms to devise these metrics and risk adjustment formulas. Five organizations alone were awarded nearly $900 million. On top of that, given the complexity of these metrics, consulting firms have sprung up. These firms will assist hospitals in coding and tracking metrics, improving the expected to observed ratio. This also partly explains the continued rise in administrative costs within US healthcare. More metrics require more administrators. People who say our system of multiple private insurers is what’s driving administrative growth have never dealt with Medicare.
These expenses are necessary from the hospital standpoint, as they can make or break the bottom line. In 2019, CMS adjusted $1.9 billion in Medicare part A payments. This program is revenue-neutral, so that $1.9 billion was simply shifted from the “worst” hospitals to the “best.” Losing out on these payments could mean closing hospitals. In some communities, it leaves populations with only one choice for healthcare (or employment if you’re an HC worker). Even worse, it leaves some communities without any healthcare.
Are these value-based payments worth it? If healthcare quality improves, one could argue it is worth the cost. The data is robust: it does not help. The hospitals treating the most vulnerable patients are hurt the most. It worsens disparities. This makes sense, as Medicaid patients tend to be sicker, cost more to treat, and reimburse less. This leaves these hospitals with less money to spend on consultants to help game the numbers. It can also detract from actual attempts to improve care. As coders get better and better in making patients look as sick as possible, stagnant care will actually appear to be improving. This “improvement” in care is just a byproduct of improvement in risk adjustment coding. It has even been shown that hospitals will engage in behaviors that increase mortality in order to meet statistical benchmarks.
Shared medical decision making is the core of the patient-physician relationship. The patient and physician should arise at a treatment plan after careful discussion. Each patient will have different goals and willingness to accept treatment recommendations. This is the core of healthcare. Fostering this relationship should be the goal of government intervention. The metric-industrial complex does the opposite. It inserts metric fixation into the patient-physician relationship. Physicians are forced to care about their stats, either consciously or by aggressive administrators.
I'm a neurosurgeon and former Democrat. Healthcare policy turned me into a Republican. Longtime listener to the Ricochet flagship podcast. Now I just rant about how stupid our healthcare system is.
The government seized all funding of health care and outlawed private insurance.
The first casualties were the independent practice physicians. They knew that the regulatory burden and billing complexitywere far worse than any busywork imposed by the private insurers. Unable to meet the demands of the regulatory burden with Medicare reimbursement, they were forced to sell their practices to the local health system conglomerate. Independent practices had previously competed against each other, getting in the way of standardization and algorithm-based medicine. Their collapse caused much rejoicing.
The direct primary care (DPC) physicians tried to hold out with cash-pay patients. Because of the up-front, transparent pricing, the government determined DPCs were risk-taking entities, classifying them as insurance practices. Eliminated with them were the cash-pay surgical centers, also entities that assume risk in treating patients. As examples of the “free market” and “profiteering” in healthcare, their collapse caused much rejoicing.
Free from competing for independent physicians and surgical centers, the large hospital conglomerates grew into powerful, rent-seeking monopsonies. Economies of scale were the only way to navigate the Medicare regulations. These conglomerates thrived by extracting as much money as possible from the rates set by the Centers for Medicare Services (CMS). Patients whose conditions corresponded with high-value Medicare codes were cherished. Medicare also continued to reimburse for risk-adjusted quality metrics. Patients’ risk-factors were up-coded to increase payment modifiers, making the coders the most powerful entities in the hospital. Patients with risk factors that did not fit the risk-adjusting scheme were turned away. The quality metrics improved while patients were harmed. The improving metrics were widely touted by the press. There was much rejoicing.
Consulting firms boomed, helping hospitalsgame the system. The CMS models are so convoluted that only private consultants can decipher them. These firms thrived with the hospital conglomerates, raking in record profits, gaming the system, and working with lobbyists to write the rules to the game. The consulting firms, lobbying firms, and CMS would routinely interchange employees, driving up their value. The IPOs buoyed the stock market. There was much rejoicing.
Increasing coding and metric-gaming led to increased busywork for physicians. Medicare’s use of prior authorizations continued to grow as well, being necessary to control ever-rising costs. Physicians were held responsible for all of this and the burnout crisis worsened. The hospital conglomerates hired advanced practice providers (APPs; consisting of nurse practitioners and physician assistants) to offload some of the busywork. Once the legal restrictions on physician supervision of APP work were completely abolished, hospitals began cutting back their physician workforce. The APPs were much better at following orders, upcoding, and gaming metrics. Nurses were even allowed to perform surgery. Patients who were told they could keep their doctors were given a nurse practitioner instead. Money was saved and there was much rejoicing.
Patients that had costly conditions and comorbidities that could not be adequately captured by the Medicare codes had to be offloaded. These patients might negatively affect the bottom line. The large hospital conglomerates gamed the system to offload these patients to the local public hospitals. These hospitals, previously a haven for the un- or under-insured, were accustomed to dealing with these “difficult” patients. They were not accustomed to gaming the metrics. They operated at a loss, cutting services to the bare minimum and relied on taxpayer funds to stay afloat. Self-assured that healthcare financing was guaranteed by the government, the public no longer acknowledged the two-tiered system existed. There was much rejoicing.
The large academic hospitals were shielded from much of this. The resident workforce was used to do the documentation, coding, and metric gaming. The attrition rate in residency rose, but with many of the physician jobs filled by APPs the doctor shortage wasn’t acutely felt. Meanwhile, the physician advocates of single-payer at academic institutions beefed up their CVs by publishing on the improving metrics. Residents silently did their thankless work while the academic physicians grew their CVs. Eventually, the best and brightest college students began to turn away from medicine, towards other careers. There was much rejoicing.
The disgruntled physicians of the former DPC, cash-pay surgical centers, and independent practices also found other work. Consulting, law and politics were popular choices. However, many found that they could practice their ideal medicine just outside the reach of the US. The Cayman Islands, Bahamas, Mexico, and other nations were happy to let American trained doctors open cash-pay hospitals on their soil. These hospitals embraced free-market medicine with lower costs and superb outcomes. The wealthy American elite joined the Canadians and Brits in traveling abroad for medical care, boosting the local economies. They agreed that American doctors did provide the best medical care. They just did it on foreign soil. There was much rejoicing.
Every time a new president entered office, half of America was horrified that the person was a tyrant. Occasionally they were correct. Given that all healthcare was funded through the federal government, the new president had control over the entire entity via executive action. The new president, through the HHS secretary, manipulated the Medicare reimbursement to specifically harm target populations. The power that comes with central control of the largest industry in the nation is outstanding. Subtle changes in funding were used to influence life and death. Levers were pulled, cronies made money and enemies had healthcare funding choked off. The would-be tyrant realized that controlling healthcare meant controlling America. There was no more rejoicing.
Brady Harold never knew what a miracle he was.