Documentation Gone Awry

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I’m obsessed about finding ways to better deliver high-quality and affordable medical care.

And, yes, it obviously starts by eliminating the medical waste that’s preventing it. What’s on the chopping block for today?

Mandated medical documentation.

Follow me around for a single morning. It’s the most obvious waste you will recognize.

Ninety-five percent of it might as well be monkeys typing on a typewriter. No one providing care wants to read any of it. Because it’s not helpful.

There are lots of letters on the page. And, there are lots of pages.

Frequently, it’s an unsolvable puzzle. In fact, I challenge you to find much of anything that really matters inside a patient’s chart anymore.

I guarantee you the insurance companies don’t read any of it. I send them records all the time trying to get studies approved for my patients. They read absolutely none of it.

They just deny the test. Then, I have to call them. Wait on hold. Talk to a nursing supervisor. I just hung up the phone with one a few minutes ago. Do you know what she asked me?

“Doctor, can you tell me the reason you are ordering this test?”

Tell you?

I sent you two-dozen pages of notes. You are looking at them now. Why don’t you read what I send you?

I’ve got my theory on this one.

WE HAVE ALL JUST GIVEN UP.

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Open Letter Response to CMS on MACRA & MIPS

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My recent post appeared to catch the attention of Mr. Slavitt, Acting Administrator for the Centers for Medicare and Medicaid Services (CMS):

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My article recapped another day of insanity within our healthcare enterprise, and yes, taking a look, Mr. Slavitt, would be greatly appreciated.

Choosing to see, however, is my challenge for you—for as a friend reminded me, you seem to be very good at “feeling our pain.”

But, I must admit, thanks to you, I was contacted by a CMS official overseeing the startup of MACRA.

For those that don’t follow healthcare policy closely, MACRA is our government’s latest medical project. Another soon-to-be-implemented healthcare law with 962 pages of rules, including the most recent method devised to pay physicians, something known as the Merit-Based Incentive Payment System (MIPS).

CMS was seeking my perspective on MACRA and MIPS.

My written response to them—edited only somewhat for brevity—is shared below:

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Enterprise Gone Overboard

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My satellite clinic is about an hour away. I drive there with my nursing staff each month.

We load up ECG equipment, pacemaker programming machines, and a few other doctoring items in my truck.

I provide services to an area that has no permanent resident doing what I do.

Then, I return home.

Today is one of those days. I arrive back to my main office. It’s after 5pm and officially closed for the evening. I hurry to help my remaining staff return numerous phone calls to patients who had left messages while I was away. I hope to finish up at the office soon. Then, I intend to check on a patient at the hospital before making it home for dinner with my family.

I peer down at a piece of paper on my desk, given to me by one of my staff. It’s a printed email message. Sent by the Centers for Medicare and Medicaid Services (CMS).

The message is arguably from the most descriptive email address on the planet—and I’m not making this up—it’s from DONOTREPLY@CMS.GOV.

DONOTREPLY.

It’s rather fitting.

Because they definitely don’t want you to reply. That would be easy for me. Too efficient, perhaps. No, they don’t want a reply. They just want me to DO what they say.

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The Bullfight For Evidence

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It’s been a chatterbox kind-of-week for evidence-based medicine.

First, an article appeared in the New England Journal discussing its limitations. Then, a rebuttal came from an established bull in the China shop, and we were well on our way. Ultimately, all sides made a point.

Seemingly bored by the chatter, however, may have been Medical Progress herself. She has and will continue to move forward on her own terms—sometimes with and sometimes without randomized controlled trials.

There are not many novel ideas to discuss here. Evidence frequently has claimed to be guiding medicine. Sometimes it has originated from the experience of a single person or two. Sometimes pseudo-clarity has required the trials of ten-thousand. Only very recently has evidence even existed for some in hierarchical structure—”hard” or “soft” these people now say.

But, what does “hard” or “soft” evidence really mean anyway? And, who gets to define these terms?

The policy makers?

The New England Journal?

The bull? The baker? The candlestick maker?

Almost contrary to what the gnostics of evidence proclaim to be best, the majority of individual medical decisions are made using so-called “soft” evidence. And, no, this isn’t some atrocity.

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Getting What We Pay For

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I arrived with my family. I handed the usher our tickets.

We entered the auditorium. The stage was lit. We were directed to our seats.

We were there to watch an OPAS Junior production—a performing arts play for families and children.

The performance would soon be what we paid for, an enjoyable Sunday afternoon event with my wife and boys.

The actors and actresses did their job. They appealed to us, the audience. They danced, sung songs, provided humor, and so forth. They were there for us that day. And, we were there for them.

We paid for their performance. And, they gave us one.

*   *   *

A compelling strategy has consumed American healthcare. It’s known as pay-for-performance. It’s trying to replace our unknown fee-for-service model, because it seems more logical.

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Creating Our Own Hardships

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I enjoy documentaries. My wife says she enjoys watching them with me. The way I usually see it, they help her fall asleep.

But, not this one.

Not Poverty, Inc.

If you haven’t watched it, you should. We both enjoyed it.

It’s not one of these pick-a-political-side kind of shows. For the record, people across the political spectrum have endorsed it. The film has won like forty honors and twelve awards that I know absolutely nothing about. But, if you watch it, you’ll get the gist why.

We occasionally need disruptive thinking. Something to challenge our perception of reality. We actually need more of this when contemplating healthcare delivery, too. But, I’m not talking about that right now.

Poverty, Inc. is about poverty… and the humanitarian aid we use to fight it.

It’s also about government. And, business. And, how the collusion of these things isn’t solving poverty at all. Like I said, you should watch it. It provides you a fascinating perspective.

I won’t give it all away, but there are a few predominant themes that unfold in the film as you watch it.

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Solving Nothing

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American tax payers have spent billions funding our current healthcare computer systems.

“Cash for Clunkers,” he calls it.

“[The legislation] gave $30 billion,” says technology entrepreneur Jonathan Bush, “to buy the very pre-internet systems that all of the doctors and hospitals had already looked at and rejected.”

And, he’s right. We’re using clunkers. Paid for by the U.S.A.

The reason for this is simple. These government subsidized and heavily regulated software systems were never designed for the physician end-user. They were built to satisfy thousands and thousands of pages of federal regulations. And, they’ve essentially achieved two things: (1) to create privilege for some, and (2) to politicize everything for the rest of us.

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To be Great is to be Misunderstood

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In this post, I examine the firestorm surrounding Dr. Lisa Rosenbaum’s article, N-of-1 Policymaking — Tragedy, Trade-offs, and the Demise of Morcellation, which was published in the New England Journal of Medicine in March 2016. To appease the medical pious everywhere, I disclose that I have never met Dr. Rosenbaum in person. I do follow her on twitter @LisaRosenbaum17. I have no financial stake in power morcellation, a medical procedure that I will discuss below. And, yes, I dislike bullies. 

Mostly normal people leading normal lives don’t speak out very much.

They just sit there. They read stuff. They watch news stories.

They may very well be engaged with a topic. But, they will infrequently write reviews or give comments. That kind of stuff usually always comes from the extremes. And, as you know, the extremists either love you or they hate you.

Dr. Lisa Rosenbaum got the extremists juiced up earlier this month by writing an article about the tradeoffs and demise of a medical procedure known as power morcellation. If you’re a normal person that happens to run in my professional circle and have been following this saga, I suspect that you have moved on. That’s what normal people do with non-stories.

If, however, you are an extremist, you continue to write about it. That’s me.

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The War on Judgment

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wrote previously about the ongoing federal approval process for a medical device known as the WATCHMAN™, now available to treat certain patients at risk of stroke.

As expected (and really just because it’s how things get done around here) the Centers for Medicare and Medicaid Services (CMS) has compiled a 32,000 word decision memo related to how it intends to pay (if at all) for patients receiving this approved device. This memo is commonly referred to as a coverage determination.

A thoughtful piece was also written recently by Dr. John Mandrola on this very topic. He and I usually share many of the same goals, although admittedly, we differ from time to time on how best to obtain them.

Regardless, Dr. Mandrola’s piece is full of clarity and is very supportive of CMS’s intent to require an evidence-based formal “decision tool” to be used by the physician and the patient prior to implanting the WATCHMAN™.

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