A Country Doctor Writes:

My old strategy for getting insurance approvals for imaging tests doesn’t seem to be working anymore.

I used to put my thinking in my office notes so that a reviewer at one of the imaging management companies would clearly see my rationale for ordering that CT scan or MRI my patient needed.

Now I am getting more and more requests to initiate a “peer-to-peer” call instead. My heart sinks every time; each one is a sure time robber. Even with today’s talk about paying for value and quality, I still live in a world where my “opportunity cost” is $7 per minute. That is what I must generate every minute of my work day. A five minute call could mean one less patient visit for a skin rash or an ear infection or a patient call to communicate an important test result instead of sitting in a phone queue, listening to Barry Manilow tunes.

The other day, my “peer” was a nurse, a “near-peer” human filter, who listened to my story about why the abdominal and pelvic CT was necessary for my patient with abdominal pain, diarrhea and elevated liver function tests but otherwise unremarkable blood work, including hepatitis titers. She instantly gave me an authorization number. Afterward I asked, “don’t you read our office notes these days?”

“No, we stopped doing that. In this case we were told the patient had a lump.”

“I coded for the three symptoms.”

“But we need to know what you are looking for.”

“A rule out?”

“Yes.”

“But you can’t code for a diagnosis the patient doesn’t have, that’s insurance fraud.”

“Well, that’s what we need to know.”

“So I need to spell that out, if you don’t read my notes. You know, in many offices the one whose job it is to call you is a lay person.”

“And so is the person who answers the call at our end.”

And I thought my notes were still read by a medical person. I should have asked if they stopped reading the notes because they have gotten too long and cumbersome for them to read. I’m sure a radiologist who reviews imaging requests has an opportunity cost, or a must-save-the-company-per-minute cost, of a whole lot more than $7.

Note to self: Always add “R/O” after describing the symptoms.

Of course, in cases where there is no time for the Barry Manilow queue, it is a well known fact that the emergency room doesn’t have to worry about prior authorizations.

The other day, as I was wrapping up my visit with Mrs. Brown, she said:

“Harry is no better, he is coughing and spitting something wicked.”

Her husband, silent during the visit, was unshaven and looked a little tired.

“How long have you been sick?” I turned to him.

“Going on two weeks now. The cough medicine I got last week hasn’t helped.”

I opened his chart in the computer. He had been in six days earlier. A colleague had noted that his lungs were clear and diagnosed him with a viral illness.

“Let me listen to you”, I said.

He had scattered rhonchi and a few wheezes, and at the bottom of his right lung I heard faint crackles.

“You need an antibiotic”, I said, and made sure he didn’t have a fever and that he wasn’t too short of breath.

I created a “new telephone encounter”, documented my findings and e-prescribed an antibiotic for him.

“Be sure to come back if things don’t turn around quickly”, I said.

There’s no way I could charge him for a brief visit. And that’s got nothing to do with whether I wanted to increase my productivity numbers or our clinic revenue.

In this day and age, there is no such thing as a quick visit to make sure someone is okay or to avert clinical deterioration or disaster.

In order to meet all our quality requirements for being a patient centered medical home and all the other ways we are judged and measured, a visit note has to include, even if the patient was seen just one single day before, a complete medication reconciliation, updated past medical and surgical history, social history and specific questions about any other care the patient has received since last seen. In our EMR it would be impossible to get around all these clicks by building a note template that says nothing has changed since last time; the computer tracks the actual clicks we make in the EMR.

So in cases like Harry Brown’s, I have these choices: Treat him for free right then and there, make him come back some other time when we have time for all the extras, or send him to walk-in care in the big city.

My choice is clear, but I can’t help wondering if the people who created the requirements for overambitious repetitive inquiries into the past history of people we already know quite well really understood that instead of becoming more patient centered, we would start giving free care or turn away patients and thereby fragmenting their care.

“Stop Excessive Measurement.”

Those three little words were music to my ears. The fact that they were spoken by Don Berwick, creator of the Institute for Healthcare Improvement and former head of Medicare, made them even more significant.

I was in our state capital today for a regularly occurring conference by Maine Quality Counts. The theme was “Achieving Excellent Patient & Provider Experience”. There was a lot of talk about provider burnout. Dr. Berwick spoke of the central role of the provider-patient relationship and the failures of the current quality movement.

He told a touching vignette about his brother, who is a patient in a rehabilitation facility. All his brother wants right now is to go outside for a few minutes and experience spring, but the rehabilitation hospital is so focused on keeping their falls statistics down that they haven’t been able or willing to work with him to see how he can safely meet his goal.

Berwick more or less said that if you serve your patient well and keep his or her needs in sharp focus, quality will improve, waste will decrease and provider burnout will diminish. How refreshing.

His remarks were originally made at the IHI and published in JAMA a year ago today, during a time when I fell behind in my journal reading.

He describes three eras in medicine.

The first era was the autonomous physician, serving a calling and belonging to a self-regulating profession. Science exposed variation and inconsistencies in the healthcare of the first era, and a second era was born.

That second era, which we now live in, is the era of accountability, measurements and incentives.

The ideals of those two eras are incompatible, but they point the way to a possible third era, which he calls the moral era, where providers are subject to fewer measurements because organizations trust their commitment to their patients and to the principles of quality.

I need to hear things like that now and then.

Watch Don Berwick speak about the third era: