The fine line between gaming the system and maximizing documentation

Does your doctor use a computer instead of a paper chart?

Chances are that she does. The rate of adoption of electronic medical records (EMRs) over the last three years has been very steep.

The main driver of this is a government subsidy from a part of the 2009 Stimulus Act (called the HITECH Act) that incentivizes doctors and hospitals to make the conversion to electronic record-keeping.

The push has been on for medical practices to “go electronic” for a long time. It’s about efficiency. Reliability. No more issues with doctors’ handwriting. A better reason: we should be able to share records electronically and analyze them collectively to discern ‘best practices.’

The New York Times ran a nice piece of investigative reporting, demonstrating that the transition to electronic record keeping has been anything but cost-effective.

Computers allow us to set scripts for our visits with you (whether in the hospital, the ER, the OR, or the regular office). Using the scripts, loaded with check boxes, we are able to check off many positives and negatives (e.g. the patient does have fatigue, or the patient does not have headaches, etc.).

Enumerating symptoms and signs in this way allows us to maximize the documentation trail we create. Of course, maximizing the documentation thereby allows us to maximize what we claim on bills of service to insurers like Medicare.

The Times reporters found that over a five year period, claims to Medicare increased by $1 billion. It wasn’t that more service was delivered. When they analyzed individual hospitals, they found huge increases in claims for roughly the same number of visits. As but one outlier example, Baptist Hospital in Nashville saw its ER billings increase eighty-two percent the year after installing an electronic medical record. There are many other examples, suggesting this is no coincidence.

Depending on your viewpoint, one of two phenomena are occurring:

  1. Hospitals and doctors are gaming the system to “upcode” every visit to a higher level, resulting in a higher bill OR
  2. Electronica has simply allowed us to more legitimately capture what it is we do and bill accordingly–known as charge capture

Of course, the answer is somewhere in the middle–some are no doubt gaming, others likely just doing things better and reaping the rewards. The article noted, however, that the Department of Health and Human Services discovered that a mere 1,700 doctors nationwide (out of nearly a half million doctors in practice, or 0.4% of physicians) contributed $100 million of the increased charges. That amounts to sixty thousand dollars per physician in increased year-over-year charges. Do you really think a full time doctor could increase her billing that much for roughly the same amount of work, even allowing for perhaps a small inflation in patient volume or number of office visits?

So, another esoteric post about how and why health care costs so much in the U.S., right? Does anyone really care?

Two days after the Times article, HHS Secretary Kathleen Sibelius and U.S. Attorney General Eric Holder co-signed a “strongly worded” letter to hospital associations across the country warning them to steer clear of fraud.

Wait. Does the government want us to implement these computer systems or not? Looks like we’ve hit some unintended consequences of what seemed like a reasonable policy goal.

John Schumann is an internal medicine physician who blogs at GlassHospital.  

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  • Larry Sheldon

    As a victim of the system–recent observations.

    As luck would have it I have been in one “clinic” (nee “office”) on the average of once or twice a week since UNMC went to “One Chart”.

    Every trip to any office, including one I was in the day before, requires 20 to 40 minutes of me looking at somebody’s butt while they work through the printed meds list that I take in EACH AND EVERY TIME. The list has the generic name of each drug, the Brand Name of it if it has one, the dosage, and when I take it (AM, PM, Night, As required).

    As the work through it, they ask me if I am taking it, when I last took it, …..

    My cardiologist for several years quit rather than spend the visit looking at the computer.

    Some time during a recent visit for drive-by cataract surgery, it appears that the Ophthalmology Resident renewed a prescription for a drug I know longer take at that dosage. I found out about it when the bottle of pills and billing summary arrived in the mail. (Seems unlikely that Ophthalmology would be dinking with my Synthroid script, doesn’t it?

  • JPedersenB

    One has to be very careful with this rush to electronic records. Check out Scot Silverstein at Heathcare Renewal to hear some of the horror stories! I also worry about confidentiality issues as it it sooo easy to forward records….

  • Ignacio Alvarez

    I still don’t understand how the bills can go up because of EMR. If we consider the fact that the EMR were suppose to drop the administration cost, taking exemple of the Baptist Hospital in Nashville, that means that they are making at least 100% profit with ER.

  • Deep Ramachandran

    Great article John. I have often written about my experiences with EHR both here and at my blog. I think another reason that billing levels have increased is the creation of a consulting industry that is meant to help physicians maximize billing and avoid audits. There was absolutely no training in billing when I was a resident, but the introduction of the EHR has brought this to the forefront, and newly trained physicians now know alot more about billing than i did when I came out of training.

    Many practices now live in constant fear of an audit, this has in turn caused them to be much more vigilant about documentation, the coincident introduction of the EHR has made it much easier for physicians to document better, and hence to increase their billing to insurance.

  • David Voran

    Underscores the fallacy of using detailed documentation as a source for billing. People will do what they get paid to do and all too often we document to the bill rather than documenting what we do. Eventually the fee-for-service payment scheme will crumble and we can go back to documenting what’s important clinically instead of what’s important to maximize reimbursement. The computer has enabled us to include practically the whole chart at a click that in the past would take a half-hour of writing or 15 minutes of dictation for which we’d be paying the transcriptionist.
    I’m looking for the day we don’t have to do any regurgitation of what’s already in the chart but just add our contribution and be evaluated on that as opposed to volume.

  • ljslossmd

    This is the inevitable outcome in systems with 1st dollar, 3rd-party payment. Physicians are not paid for rendering service to their patients, they are paid for submitting chits to the payment system. There is a powerful incentive to conform the encounter to yield maximum economic reward, to cram the record with code-supporting documentation and upcode to match; the actual service rendered to the patient is completely
    irrelevant and immaterial to the payment system, since the actual recipient of
    the service has no voice whatsoever (beyond a trivial copayment where
    applicable) in the financial transaction.
    It should be no surprise that institutions and large-scale business-model practices run on
    high-volume throughput and aggressive coding (especially when management compensation
    is linked to the bottom line). It should
    also be no surprise that practices run with a true service orientation, individual
    responsibility, longer visits and personal interactions are struggling
    financially. Honorable physicians and
    the populace at large are the losers in a game based on greed, unthinking and/or forced compliance with formulaic rules and regulations, and the default of a
    professional calling and its moral and ethical foundations to service of a
    system that is wasteful, self-serving, inhumane and destructive.

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