Below the headlines, the bad news about medicine is that the paperwork burden just got larger for ordinary docs, who just want to practice medicine.

American Medical News story 1:

Medicare fraud penalties tougher under proposed bill.

U.S. Reps. Ileana Ros-Lehtinen (R, Fla.) and Ron Klein (D, Fla.) said the Medicare Fraud Enforcement and Prevention Act is “a tough new bipartisan bill” that will help crack down on Medicare fraud, protecting seniors and taxpayers alike….

so far so good. They are after clinics who are in poor neighborhoods and overbill and oversee ordinary folks to make a profit.

Of course, how often is “too many visits”? Ah, the beancounters will decide that…so Mrs. Smith, who always figures her blood pressure is cured after one month of pills, and stops them, won’t be able to come back for three or six months according to the beancounter, but Doc Smith and his nurse practitioner know that if they check Mrs. Smith every month, she’ll be reminded to keep taking her medicine…besides, she enjoys the visit, and if she didn’t come to the clinic, she might never be checked at all.

Of course, visiting nurses could do it too…but after x number of visits they didn’t get paid, so we’d have to re see her and change her diagnosis so she could qualify for another 3 or six months of nurse visits…

so that is why I shudder when I see this in the bill:

The act would double criminal penalties for false claims and violations of the anti-kickback statute from five years to 10 years, and increase fines from $25,000 to $50,000.

So marking her down as “congestive heart failure” when as long as she takes her blood pressure pills she doesn’t have, could be considered a “false claim”…the dirty little secret is that to “diagnose” high blood pressure or CHF, all you have to do is have the patient stop taking her pills and voila, a week later she is in the ER with a stroke or with a BP level of 200/110, or in acute pulmonary edema.

But never mind. The regulations don’t see these things.


headline number 2:

Patient safety, quality experts hope health reform delivers substantial improvements in care

the problem with this can be seen just under the headline

The health system overhaul will increase quality data reporting, and could help cut hospital readmissions and prevent nosocomial infections.

yup. Increase paperwork so docs are in a rush. Make them mark a piece of paper every time they wash their hands, for example.
The Health Care  bill was passed because it was being “sold” as a way to get medical insurance to the uninsured: but a lot of us opposed it because it was a way to takeover medicine and tell us how to practice medicine, increasing the paperwork burden to please the bureaucrats and to implement social policies that some of us who are pro life think are a way of killing those who lack policial correctness.

And voila, our fears are coming true:

Most of the attention given to the health reform law has focused on its sweeping changes to the insurance system. But the law also could dramatically change the way that care is delivered, according to experts on patient safety and quality.

For example, the overhaul uses pay bonuses and penalties to physicians and hospitals to incentivize the care coordination and safety interventions that can help prevent nosocomial infections and unnecessary hospital readmissions. It also requires an unprecedented level of public reporting on hospital and physician quality performance, and could hasten implementation of care improvement practices, experts said.

translation: A beancounter will decide if you are any good, depending on how well you fill out the paperwork.

Doesn’t matter if the thing has been done (dirty little secret is that paperwork can be faked). If you are a good doctor, but your priority is caring for the patient, and sometimes you forget to dot every i and cross every t required in the complicated form, you are a bad doctor.

and how will they “entice” physicians into going along with it?

They’ll cut your Medicaid billing if you don’t.

Reporting Initiative with bonuses of 1% next year, dropping to 0.5% through 2014. Starting in 2015, physicians face a 1.5% Medicare pay cut for not participating in PQRI, with a 2% penalty starting in 2016.

but the dirty little secret about Medicare and Medicaid is that they only pay two thirds of your billing.

So if you bill 100 dollars for a visit, you might be paid $60. Cutting that down to $56 or even $48 might actually result in more docs refusing to see Medicaid and Medicare patients.

Another problem is that it ignores patients.

I spent a lot of my time in poor areas, so the assumption that if a person is readmitted, it’s the doctor’s fault. Yet see above about Mrs. Smith.

So it will be hospitals with the least educated patients who will be affected by this part:

Studies have found that about 20% of Medicare patients are readmitted to the hospital within 30 days of discharge. Hospitals with high readmission rates will have their payments cut. The change will save Medicare $7 billion over 10 years, the Congressional Budget Office estimates.


The AMA warns that the practical result of this will be ER docs sending home patients instead of readmitting them. A few of these patients will die.

Another result will be fewer inner city hospitals, and fewer hospitals in poor rural areas.

So the end result is more paperwork for overworked docs, who already do reams of work that is “unseen” and unpaid for.

From the WashingtonPost:
A five-physician practice in Philadelphia caring for 8,440 people used its electronic medical records system to analyze the daily work of each practitioner. Each physician had an average of 18 patient visits per day, with the average patient coming to the office twice a year. The workweek was 50 to 60 hours.

In addition to the patient visits, each doctor got 24 phone calls a day. About three-quarters were fielded by the doctor, with the rest answered by someone else in the office.

A third of the calls concerned an acute medical problem and resulted in a prescription or an order for a test. The doctors also received an average of 17 e-mail messages a day, about half seeking explanations of test results.

Each physician processed 12 prescription refills a day (in addition to refills that were part of a patient’s visit). There were 20 lab reports and 11 diagnostic imaging reports (for tests such as X-rays, CAT scans and MRI studies) to review. There were 14 reports from consultants — usually other physicians, but also visiting nurses, physical therapists and other practitioners — to look at and respond to, as well.


Makes me tired just to read it, and happy someone has finally noticed all the important time spent in trivial things that are very important but not paid for….


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