How the system incentivizes unethical physician behavior:
The doc comes in to see a patient (I witnessed this many times with one doc in particular in the CCU) at about 11pm. He or she writes a not after examining the patient. Then he/she waits around until 12:15am , and checks a new set of vital signs, cursorily reexamines the patient and writes another note dated the new day – gets credit for two days notes with only one visit.
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{ 11 comments }
One can not comprehensively deal with ethics without dealing with money. Since the FTC removed the ability to the medical societies to sanction physicians for overcharging, they rendered them moot except as lobbying organizatons–certainly not true professional societies.
The eventual result of the abuses is that the government will set prices–not just for their patients but for all. A few pigs will result in the loss of freedom for all and the last shreds of free market economics in healthcare. I do some insurance review work and see some shocking charges. My concern is for the poor sap who is out of network or uninsured who get stuck paying the absurd bill.
I dont see anything unethical about this. Where is the law that states the notes must be seperated by 8 hours or so? It is perfectly fine to “throw 2 notes on the chart” around 12am as far as I am concerned. Writing a note has little to do with patient care. Do you think the patients care what kind of notes we write? Or do you think the intubated, sedated ICB pt minds the close proximity of the 2 visits?
As long as you are on top of the labs / studies / available for questions or family concerns who cares what time the notes are written. He was technically and truthfully seen on both days.
Whos side are you on?
SP
In our area, the largest (non-profit, teaching) hospital is directly affiliated with a 300-member, for-profit physician association. The hospital justifies its tax breaks by heavily promoting its charity care programs, but many of the charges during a hospital stay — not just physician bills but also tests, lab work, radiology and such — are billed by the for-profit clinic, exclusive of any charity care. Medicine seems to find ways to get the $ it wants, one way or another. You can decide if it’s ethical or not.
“I dont see anything unethical about this. Where is the law that states . . . .”
You wouldn’t because you are clearly morally blind, indicating that by confusing “ethics” and law. The behavior cited is NOT illegal. The physician has a ethical obligation to allow the only consideration in the care provided to the patients whose care he has assumed to be the clinical needs of the patient–not financial. He can protect his own financial interest in selection of patients and in how he charges, but any impact on the actual services rendered is unethical however legal it may be. If there is no clinical reason to hang around until after midnight, then he is padding the bill with unnecessary services.
Non-profit status has to do primarily with taxation. It has nothing to do with the management, which has the same incentives as a for-profit institution, just without stock options. Financial incentives abound, whether via salary, bonus, or rich retirement pensions. The same people run non-profits who run for-profits.
To the first anonymous:
How can you justifiy two notes separated by 20 minutes? Unless the patient rapidly decompensated or some important new info came to light – this is just PURE laziness on the physician’s part – and greed.
To the several anonymous’s who think this double billing is justifiable…”government doesn’t pay enough, patients don’t know or care, hospital does for-profit not charity”…blah blah blah.
As I tell my 12 year old..there is a lot you can get away with in life because no one sees you…but you need to look yourself in the mirror each day and decide if you like what you see. End of story.
I gotta be honest here, the only time I worried about the clock would be as follows:
1: In residency to try to push the 23:30-23:55 note after midnight so I wouldn’t have to necessarily rewrite the whole note in the AM (besides a short interval note)
2: In practice, to try to make sure the note is done before midnight so at least I get paid for the followup note (which I would do no matter what as the patient would need re-evaluation).
Otherwise , what is being proposed here is slimy and unethical even if legal. Has our profession obligation fallen so far that we are wiling to pad the bill with an unnecessary f/u note? Is not re-evaluating the patient the next AM really best from a clinical standpoint? I think not. It may be legal but it’s not right.
Note writing is a bunch of crap.
You document to placate the insurers. It has little to nothing to do with patient care.
I do not see this as such an unethical act. If I am on top of what happens throughout the day…follow up labs later, available to nursing staff/ housestaff, pt/family, answer phone calls and do everything else.. whats the big deal if I wrote a note at 12:01am. The notes themselves do not take care of patients.
Relax with how unethical it is.. I can look at myself in the mirror just fine. If I wrote a note at 12:01.. shut off my beeper, didnt answer calls or questions and wasnt on top of anything else going on thats something else.. thats a poor physician. But documentation itself is a pain in the ass and cutting corners does not necessarily make it unethical.
So Dr. Simon, do never take vacations, never have anyone else cover for you, never get second opinions, never have patients go elsewhere for a second opinion, and plan to live forever?
Perhaps the problem is your attittude towards writing notes. If you write them only for insurers that is indeed all that they are good for.
As a medical student (and a consumer of insurance), I can say without question that it doesn’t take long to come to view insurance companies as the enemy. I don’t think writing two notes, one on either side of midnight, is ethical, but it is hard to work up much sympathy for the insurers. Obviously, they go to great lengths to delay payment or avoid paying claims altogether. I have yet to have a health insurer that hasn’t tried to worm its way out of paying some legitimate claim. They systematically violate the spirit of the insurer-insured agreement by appealling to some esoteric language buried in the fine print. Beyond that, what power do the insured have anyway? If you are lucky enough to have health insurance benefits through your employer, you still have to take what you get in the way of your coverage. My medical school doesn’t provide any health coverage for us, nor much in the way of in-house care beyond the student health clinic. The real problem with this kind of unethical physician behavior is that whatever extraneous billing the physician does will inevitably get passed along to the insured, not the insurer. Physicians make better livings than 99% of their patients, so their priority should be the patients’ best interests. Also, in response to SP 5:55, there are plenty of behaviors that are perfectly legal but that are not ethical. Just look at our government for copious examples. Why should the legality be the sole determinant of whether something is ethical?
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