Cutting and pasting in electronic health records as evidence of fraud and audits for Meaningful Use are hot topics in medical news these days. That prompted me to think about the move from volume to value in health care payment systems.
When I started as a resident, we documented so those who read our notes could understand what we did.
In my day as an administrator, I reviewed a lot of notes that included just a date, a diagnosis and an RX. A while after that, Medicare, and by default other insurers, began paying providers based on what they documented.
A bunch of people got together and decided that the note was the source to know what the physician had done, and, therefore, billing was to be based over what was in the note. Points were assigned for each element of the note, and the more elements, the more you got paid. Fairly simple, but people quickly realized that you can document a lot of unnecessary stuff (like an examination of a toe when the complaint was a sore throat) and possibly get more money for doing unnecessary stuff.
The next iteration of billing was then based on the complexity of the visit. If you did something “complicated” you got more than something simple, but they blended the two systems, and required documentation pertinent to the level of complication. So payment for an exam of a toe for a sore throat didn’t pay more, but if the patient with the sore throat was also diabetic and had heart disease, that was theoretically more complicated and required more complex thinking.
There were lots of coding seminars and articles where people tried to explain what complex decision-making was, but I mostly remained confused and tried guessing how complex I was thinking for that patient. Of course, you still had to document and if you failed to document to the level of the visit, you got dinged.
We assumed that you did actually do the things you wrote down. Outright fraud—or documenting something you didn’t actually do – is maybe the subject of another blog.
EHRs came in about this time, and they electronically made sure you could bill correctly, or even suggested that had you actually asked about five different systems in your Review of Systems, you might be able to tweak the visit code up a notch and make more money. Done in real time, it allowed you to ask and get paid for the system you forgot, or didn’t think really mattered to the complaints at hand, but, hey, it was a few more bucks for another question or two.
We became (again, excluding the fraudulent) good documenters of the care we delivered—at least from a billing point of view. I’ve never been a fast or clear writer, so having an EHR in the middle of my career allowed me to document better, more clearly, and bill better.
“If you didn’t write it down, you didn’t do it,” was certainly never true, as I didn’t generally document every word of my conversation with every patient. The challenge: It was terribly time-consuming. You either spend your time writing (or typing or clicking) or paying attention to the patient.
I tried mightily to do both, and still to this day explain to patients that it takes more time to write down or type in what I did than to do it. The documentation became a means to the wrong end—billing— instead of a means to share what you did for anyone who later read your note (and to protect you from malpractice, but that, too, is another blog).
This has been documented in time motion studies, but if they had asked, I could have told them that years ago. You can make a lot of money by doing a lot of stuff but never was there an incentive or payment for doing the right stuff.
Which brings us to today.
Won’t it be nice to be paid for how well you take care of patients, instead of how much you wrote down or did? I’d prefer to be paid on how well my patients turn out, and darn it, if they don’t turn out better, I want to know how I can improve my care. You know, I am pretty good at writing notes to get paid. Maybe it’s time to get paid for what really matters.