The insurance companies have discovered a new way to give me a headache.
About a month ago, a number of providers in our practice received an email with instructions about a new task to which we had been assigned.
Apparently, we were supposed to log on to some website, create an account, and fill out a SOAP note on about a dozen of our patients.
Wait, a SOAP note? Didn’t I write one of these already when I saw them in the office?
According to the team that is the liaison with the insurance company, we are supposed to complete these long, detailed forms to show that we are “taking good care” of our patients.
This information is being collected and, we discovered later, will be used in upcoming contract renegotiations, and our failure to do this could apparently cost our institution significant money when the final rate increase is calculated.
As expected, in what is normal behavior for busy clinicians, all of us essentially ignored the email for the first month. A follow-up was sent, which made us groan again, and our continued ignoring led to a follow-up email from our division chief informing us that these forms were “not elective.”
So yesterday afternoon, with some blocked-off administrative time, I sat down at my computer to dutifully complete their SOAP notes.
I printed out the instructions, went to their website, and was greeted with an announcement that said, essentially, that the SOAP note feature of their website (what I was there for) was disabled, and they apologized for the inconvenience.
Not a promising start.
I checked with one of my partners about this, and she told me that even though the site said that feature wasn’t working, one could override that notice by clicking on the button that said, “retrieve all patients.”
Once that button was clicked, all of the patients covered by their managed care organization insurance plan that were “attributed” to me were brought up on the screen.
Interestingly, while there were patients of mine on the list, a lot of the names were unfamiliar.
I shot a quick email back to the folks at the insurance company who sent me the list, saying that only a small fraction of the patients on their list were actually mine.
They sent me an email back and told me that, no, those patients were mine, and to fill out the forms on them.
I decided to investigate further. I looked into the medical records of all of the names on the list and discovered that several of the patients were followed by residents in our practice, some were patients who used to be seen in our practice, but had not been seen in years and some patients had never, in fact, been seen in our practice at all.
The team at the insurance company told me that their attribution system was absolutely correct, that this was “a live feed,” 100 percent accurate.
One patient on the list had the same last name as a former patient of mine, whom I have not seen in several years, and I suspect that this is his wife; I think that when they enrolled in the insurance plan long ago she must have picked me as her primary care provider, but never came in for care.
This whole issue of attribution is critically important as we move into an accountable care model, since we are going to be the ones responsible for care, and the costs of care, and if insurance companies are telling us that someone is under our care, well, they darn well better be.
The SOAP note itself, the data they wanted us to collect, did not seem to add much value or provide any new insights about the patients, and for the life of me I could not figure out how this might enhance the idea that we are taking good care of our patients. Or that we are providing more efficient and less expensive care for our patients, which is in the interest of the insurance companies.
The first section on the computerized data entry form was a list of every single item for which a claim been submitted to the insurance company for that patient over the past three years.
We were supposed to select those that were “active,” “resolved,” or for which we were treating the patient.
The next section required us to manually enter the ICD-9 codes for all of their medical conditions.
This information was combined by the computer, and then we were supposed to answer questions about what we had done on that encounter date related to these issues, whether they were stable, and whether a medical plan had been put in place for those problems.
There were questions about family history, a place to enter vital signs, a detailed review of systems and physical examination, and then a long series of questions about what we done at the visit, followed by an assessment and plan, and a validation box where we acknowledge that we are, in fact, treating this patient.
Unfortunately, as is typical for this sort of system, there were multiple times where, when you would click a box, another action would pop up that you had to address, and the system would refuse to allow you to move forward. Frustratingly, it would repeatedly say you must resolve this issue or state what you did about this issue, or change it to something else, to continue on.
Usually, it was easier just to scrap these questions, skip them, and get on with the process.
There was, we discovered, a “cheat sheet” — a bare-minimum way to complete the SOAP note that would minimize what we actually had to put in, but would still allow them to collect it as a finalized “complete” note and have it count.
This included clicking on the required allergies field, clicking that this was an outpatient visit, entering blood pressure and body mass index, clicking “Normal” for the complete physical examination, and then entering a plan for a single diagnosis.
That, essentially, would let this one count in the win column.
In addition to the whole complicated issue of attribution, and who really are our patients and are we really being assisted in providing them care, this sort of process raises a number of issues.
Bad data in, bad data out.
Surely, most of the information that the insurance company was looking for is already available in their database, or could easily be transferred from our electronic health record directly to them, without making the providers manually type it all in.
And even if I filled one of these out in excruciating detail, with every one of the patient’s medical conditions, ICD-9 codes, medications, allergies, family history, a detailed review of systems, all components of their physical examination, and my detailed assessment and plan, their lab results, imaging studies, and opinions of the consultants who take care of them, how would this help the insurance company, and why would my doing so make us get a better rate from the insurer to take care of our patients?
In order to provide efficient, evidence-based, high-quality, timely medical care to our patients in a patient-centered medical home model, with an overarching accountable care organization, we need to get the systems of collecting useful data in place before we get started.
Simply responding to these sorts of requests, doing lip-service to collecting health information on patients (when, in fact, many of them are not even “our patients”) seems to be putting the cart before the horse.
In the end, I was only able to complete 15.4 percent of the patients on the list that they provided to us. Despite their insistence that I must be involved in the care of these patients, or in the case of my residents that a bill is going out under my name, the vast majority of the patients that they requested me to complete these forms for had never been under my care, either personally or in a supervisory role.
If you never come to see me, I should not be responsible for the efficiency and completeness of your health care. Even if I want to be.
But if insurers help us build a system where we can see our patients, where we can provide evidence-based, patient-centered care, where we can provide efficient care, where our patients come first, then I’ll happily fill out all the forms they want.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.
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