Doctors in Hot Water   1/96

by Del Meyer, MD

It makes us sad when we read about one of our members who makes the local press citing some allegation. On occasion we are privileged to read the transcript of charges. When they are without substance, it is a cause for concern and evaluation as to what went wrong. Even if nothing really went wrong, it still may be a cause for adverse action from licensing boards and facilities that give us privileges to practice. It is of minimal comfort to know that physicians outside of organized medicine have approximately twice the incidence of adverse actions.

The recent notice in the press that one of our SEDMS members was hauled into court and threatened with a jail sentence for doing what he thought was medically necessary is such an item. Although there may be factors other than those in the press and that were made known to us, he allegedly reviewed his patient's nursing home charts, including the nursing notes that were recorded over the previous 30 days since the last visit, and examined only those patients that he or the nurse felt had a new problem. This may actually be the standard of care despite what many of us think it should be.

The cause of the problem may have been twofold. When Medicare decided to pay less for the second and each additional patient seen after the first on any one day in the convalescent hospital, the extent of the evaluation decreased consistent with what was thought to be absolutely necessary. I remember some of discussions in the staff room at that time that the $8 for each additional patient would hardly pay for a chart review of the previous month's activity, much less for an exam. Some said they would only proceed to an exam if there were a compelling reason to do so. The compelling reason would be if either the review of the 30 days of nursing notes or the nurse felt there was medical problem that needed more evaluation.

Secondly, there were no billing problems with our CMA developed Relative Value Scale. These RVS numbers basically divided our evaluations into about 5 levels. Medicare and MediCal normally recognized only three numbers. Hence, we would refer to them as a "brief, routine, or extended examination, evaluation, and/or treatment." Whether the patient was seen in the office, home, hospital, nursing home, the numbers were easy to remember. They all ended with -40, -50, -70 depending on whether it was a "brief, routine, or extended" evaluation. The minimal (-30) and intermediate (-60) numbers caused more difficulty in explanatory discussions than they were worth and were seldom used.

The problem seems to have developed with the use of the new Resource Based RVS (RBRVS) numbers. The and/or has been replaced with and. We are in effect saying that we have done a problem focused, or expanded, or detailed history, and a problem focused, or expanded, or detailed exam, and medical decision making that is straightforward, moderately, or highly complex, (or in some cases two of the three items) and have spent 15, 25, or 35 minutes at the bedside and ... facility floor or unit. This allowed lay personnel to add up the presumed extent of our services allowing for adverse action when the standard of care was not breached. If the reimbursement is, e.g., $30, 40, or 50, respectively, and the overhead of our professional business is $100 to 125 an hour, how can we be expected to provide these services at a loss? And if we follow the RBRVS (now CPT codes) exactly, but no one witnesses it, or we don't spend an extra 10 or 15 minutes to fully document it, can we be guilty of a crime? Sometimes our documentation for a $50 evaluation exceeds that of a $5,000 surgical procedure. Is it ever enough?

It is my understanding that physicians were involved in this strange turn of events. Under the illusion of emphasizing cognitive skills so that primary care physicians could get paid more closely to the scale of surgeons, we are actually getting paid even less. In fact, Medicare approved an increase in surgeons fees of 12% and in primary care medical fees of only 7.9%, the exact opposite of what it was designed to do. The challenge is to figure out a way to keep us from doing this to ourselves.

I think most of us agree that a brief exam is essentially always necessary, even in the convalescent patient. We should not allow reimbursement considerations determine the extent and quality of care. But shouldn't we professionals be the ones that make that determination?

Tom Philp, medical writer for the BEE, headlines, "Fewer Doctors in Hot Water..." In 1988 hospitals reported 282 disciplinary cases. This year they reported 114... During the past two years we have run articles from surgeons and attorneys who have major Peer Review involvement indicating that probably over half of adverse actions have nothing to do with quality of care. Perhaps in part, because of this exposure in Sacramento Medicine, and the consequent dialogue, the QA actions that had nothing to do with QA have been lessened by the hospitals thus explaining this 60% reduction. The written word may be one of medicine's most powerful tools.

Mortimer Zuckerman, Editor-in-Chief of US News, in one of his weekly editorials, quotes a poet who was asked, "If your house was burning and you could save only one thing, what would you save?" The poet answered, "I would save the fire, for without the fire we are nothing." Perhaps a clumsy analogy. But let us use the fire of the written word. It has and will continue to make a difference. Any one of us may be the next person in "Hot Water."