The LATimes has an article about outsourcing medical transcription to Manila.

I have no problem with that. Waiting three days for the notes to get on the chart usually means you have to not only dictate everything but write it all out in longhand too, since you need the information right away..

But the part of the article that annoyed me was this part:

The woman needed an operation — fast. But before the surgeon could wheel her into the operating theater, he had to find out whether the patient’s insurance company would pay. That meant paperwork: An examination report had to be dictated, typed up and submitted to her insurer for approval.

THAT, my friend, is the problem.

I’ve had too many times I’ve had to fight bureaucrats on the phone to get “permission” to get my patients treated.

Sometimes the permission is straightforward (as in the discussed case). But sometimes you aren’t sure of the diagnosis, and sometimes–especially if you work in a rural hospital where a lot of the lab and X ray services are sent out– you can’t even start to guess what is wrong.

By the “books”, the patient doesn’t need transfer (and you can be sued for “patient dumping”) or the clerk insists they need more information, but can’t quite comprehend that the information they need won’t be available for three days, or the specialist’s second opinion means sending the patient 120 miles to see the nearest specialist.

If you are lucky, you get a nurse or physician who will approve the transfer on your say so. If you are unlucky, you will end up in a shouting match with a clerk or nurse trying to explain why you can’t treat a  someone in your twelve bed hospital where lab has to be called in at night and X ray is read by you, not a radiologist, and the CT scan you think she needs NOW only comes on alternative Thursdays.

But delaying emergency surgery for an “approval”?

Actually, what usually happens is that the surgeon goes ahead, and does it anyway. Once in awhile, he’ll lose the approval, but write off the bill.

The problem? As more and more physicians turn to HMO’s, there are fewer loopholes for such freedom.

In the past, private physicians could see indigent patients and write off the bill, or arrange a payment schedule. Often we changed the books: Mrs. X’s long complicated visit was not charged for, or we would see three kids with strep throats but only bill for one.

But then, we were warned that if we charged less to cash patients than we did to Medicaid, we could be accused of fraud.

So no more “Free” care. We just kept billing people with no money (which costs us a dollar a bill back then). After three or six months, we either sent them to collection or to the deadbeat file and wrote them off. All this was documented, of course, in case someone decided to see if we were not charging everyone equally.

Of course, it would have been a lot cheaper just to throw the bill in the office trash can nd get “paid” by a cake at Christmas time or some fresh fruit next season, but one couldn’t do that anymore (such things were “undeclared income”, and you’d be guilty of tax fraud).

But Medicaid was worse when it came to paying. Not only did they turn down paymen for a lot of the bills you sent them, but they only paid two thirds of the cost of the visit, and often the payment took months to arrive.

So if you saw a kid with a cold, they wouldn’t pay for a cold. You had to make up a diagnosis that the clerk would allow (acute rhinosinusitis with secondary bacterial infection). We kept finding new “acceptable” diagnoses for payment, because after all, the mom was there with the sick kid, and maybe all he needed was tylenol, but you still had to examine the kid and spend five minutes explaining why we don’t use antibiotics for colds.

And often, the visit included discussing mom’s stress caring for her elderly mother, or her oldest son who was caught smoking marijuana or other problems that never got into the chart. Yes, you could sign mom in as a patient, and bill (and probably not get paid for it) but you were busy, mom didn’t want to go through all that paperwork just to spend five minutes talking to a kindly adviser, and besides, she didn’t want you writing it down because she doesn’t want her sister in law in medical records to find out what you discussed.

What got me out of private practice was when my income was the same as the amount in my deadbeat file–and the same as my malpractice insurance bill–and the same as my clerical employees salary.

I figure that without the hassle of paperwork required by insurance and government programs, I could have done the same amount of work for one half the billing.

But HMO’s made things worse, because you only saw your own HMO patients. Where did the uninsured go? I never quite figured that one out.

PPO groups were a bit better. You got paid for your PPO patients but could see other patients on the side, and there was less paperwork. But again, you needed approval for specialized services.

Quick: Mrs. C, a chubby menopausal lady whose blood pressure is pretty high and who is under a lot of stress, is having chest pains. Is she having a panic attack or a heart attack? Should she just drive to the ER or will you approve an ambulance for her?

If you say yes and it’s nerves, you get a reprimand by the HMO/PPO. If you say no and she dies of hypertensive induced cardiac arrest (she was so stressed out that she forgot to take her pills and her blood pressure shot through the roof) you, not the one who wrote the regulations, are sued for a million dollars (not to mention of course that poor Mrs C is dead).

The Wall Street Journal had an article last week telling why physicians refused to see Medicare or Medicaid patients. The physician wrote that the time and money spent billing for these patients made treating such patients a money losing proposition.

But the bad news is not the article, but the comments about the article: from cliches like “doctors are greedy” to remarks hinting we should not treat “zombie” patients to complaints about the AMA regulating physicians.

But all of these people have it wrong.

What is driving good physicians out of medicine is only partly the increased time and effort we spend trying to get the paperwork right.

The real problem is that when we complain about this, we get a blank stare from the clerk/beancounter types who see everything as numbers to be placed into the correct box , or who place budgetary constraints above what we think our patients need.

Despite being lectured by one expert after another, I still resent having to spend time and energy learning complicated billing procedures, and then spending extra time and energy doing unnecessary documentation so that some clerk can pay me.

Want to solve the problem?

Years ago, I visited a Canadian friend.

He showed me his billing. One sheet of paper. Each line had the bill for one patient: patient name, number, diagnosis (in English), lab/xray charge, MD charge.

One paper for ten patients.

In contrast, at the time, we had to fill out a complicated form for each patient, that required details and numbers for each diagnosis and each “procedure” that what you did. Usually you carried a “cheat sheet” for the common ones, but often it meant pulling out a large book and searching for the correct number.

And if we got one number wrong, or didn’t fill out every line of the paper correctly, we wouldn’t get paid.

Most of us entered medicine to treat patients, and making us spend time and energy learning to please the regulators instead of spending it caring for people is not going to improve health care.

It’s not the “single payer” vs “socialized medicine” vs the present day system that is the real problem.

It’s the pervasive idea that it’s more important to get the paperwork correct than to treat the patient.


Nancy Reyes is a retired physician living in the rural Philippines. Her blog is Finest Kind Clinic and Fishmarket , but she writes on medical matters at HeyDoc Xanga Blog

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