The very idea that a bad cold you have checked out in the emergency room translates into thousands of dollars in health care expenses–and 17 pages of medical records faxed to me–should tell you something’s wrong with the health care system.
I’ll explain how this happens, but first here are two of the most common health care complaints I hear:
- From doctors of all specialties: “All I do is sit in front of my computer, endlessly entering meaningless data. EMRs (electronic medical records) add hours to my day, sometimes killing my evenings too. I know it doesn’t contribute anything to anybody’s health—it’s just insurance-required paperwork so we’ll get paid.”
- From patients: “I came into the examining room and the doctor barely glanced up at me. She spent the entire time staring at her iPad, asking questions, pointing, clicking, and commenting on how slow the system was. Then she stood up, said she’d emailed a prescription to my pharmacy, and left.”
A brief history of medical record keeping (aka patient chart notes)
When I was in medical school, I was taught that if you worked alone as a primary care doc, you kept just enough notes to enable yourself to keep track of your patients over the years. The notes didn’t need to be complicated, and you usually wrote them in a sort of shorthand of your own creation.
If you joined a group of doctors, you had to write clearly enough so that other physicians could decipher your notes. Longer observations (such as surgical operative reports or hospital summaries) could be dictated to a secretarial pool located somewhere in the bowels of the hospital.
Up until the 1960s, a chart note for a person with a cold might read like this: 10/31/57 Sx URI (non-prod cough, sore throat) O: afeb. ENT/Lungs neg P: strep neg; symptomatic rx
To translate, patient presents with an upper respiratory infection, her physical exam is unrevealing, her strep test is negative, and the visit ended with self-care advice–probably aspirin, lozenges, and cough syrup.
In other words, two or three lines at most.
By the late 1960s, patients were getting more complex in ways that hadn’t existed a few years earlier. Now it was important to follow cholesterol levels, blood pressures, and tobacco use. In addition, medical groups were larger, there were more diagnostic tests and specialists, and, hovering in the background, malpractice attorneys. I remember late in my residence training being told to “do more tests and write down more data about each patient.”
When you hear the term “defensive medicine,” that’s it.
All this writing led to medical records filled with lengthy descriptive paragraphs, until in the late 1960s someone invented a patient chart system dubbed SOAP notes, still taught in medical school and still quite useful, even in the current transition to EMRs. Let’s break down the acronym…
- S The patient’s subjective emotional and physical complaints about a specific problem. “I have a terrible cold” is an S item. If you have two problems (“I also have a yeast infection”), that merits a second S note. If you have ten problems, each gets covered during your visit and in the SOAP notes.
- O The doctor’s objective findings from the physical exam, including comments about lab results and x rays pertinent to that problem.
- A The doc’s assessment (diagnosis) of your condition.
- P The doctor’s plan to deal with your condition.
SOAP issues are numbered, so that SOAP #1 is your cold, #2 your yeast infection, and so on.
Obviously, SOAP recording took a lot more handwriting, especially when I went into geriatrics, where every patient appeared to have at least ten problems and each visit seemed to add another. But most doctors today agree that the SOAP system remains useful for organizing the note-taking process. Really, as obsessive as SOAP notes appear on the surface, we do like them!
System changes lead to the 17-page emergency room fax
And now the situation has shifted again. Medical malpractice has become much less of a threat, but physician notes are longer than ever. Why?
Because now doctors write their notes for health insurance company chart auditors.
Here’s an important part: Physicians are reimbursed by insurance companies based on the complexity of their interaction with the patient. This doesn’t necessarily mean just the amount of time spent, but also how many issues need to be addressed, how detailed the examination is, and whether lab reviews are done or specialists must be notified, etc.
Medical reimbursement is such a complicated field you can actually get a college degree in it, and if you do it’s unlikely you’ll ever be unemployed in this lifetime.
So if you arrived at your doctor’s office today with a cold and your doc were practicing like we did in the late 1950s, she’d see you and then either collect cash or bill your insurer for a “simple visit,” for which she’ll be paid at a minimum rate. In a situation like this, if you ever wondered why you saw your doc (or her assistant) for only five minutes, it’s because she’s being paid for about five minutes of her time.
But…if you go to your primary care doctor’s office for a cold and also have high blood pressure, psoriasis, are overweight, smoke, take Prozac, etc., she’ll then write a SOAP note on each of these, bill your insurer for a significantly higher amount of money, and likely (and rightfully) collect it. Instead of being paid just for your cold, she’ll be paid for six more diagnoses.
However–and this is the big however–your insurance company may want to see evidence that she’s actually doing (as per her chart notes) all that she’s billing them for.
During your visit, your doctor is pecking out a lot of stuff on her computer for two main reasons. First, there’s always the very remote chance your chart could end up in a malpractice suit. And second, she’s preparing for a possible inspection (audit) by a representative of your health insurance company. Because there are a lot of insurance companies, there are a lot of auditors these days.
Auditing could (and did) occur regularly during pre-EMR days, but not to the extent that it’s being done now. The increase in insurance watchdog behavior has been brought on by the system itself—so much money is involved, and so many players are there to take their share, that the insurance companies are trying to reduce costs. Of course, as for-profit companies this translates to increasing corporate profits. Only the preternaturally naïve think that chart auditing has anything to do with improving health care quality.
The insurance company sends the physician a warning before an audit. “Please pull out charts on these ten patients,” and then one morning the auditor, often a nurse, shows up to look at those ten charts. If you’ve ever seen bank examiners at work, I think the two are pretty interchangeable. The only difference is there are just a couple of government agencies currently doing bank audits, but more than a dozen large insurers, along with Medicare and Medicaid, are regularly performing audits.
The goal of the auditor is straightforward. She’s looking for evidence that the doc might be charging the insurance company for more services than the chart notes indicate. If the auditor sees a trend, she’ll ask for more charts and, ultimately, the doctor will receive a certified letter requesting a refund for what the insurance company regards as “billed for but not provided.” Physicians call this a clawback. The insurance company isn’t actually saying the physician committed deliberate fraud, but the threat is implied if it doesn’t receive its refund check.
Curiously, both parties generally agree that all this is most often a misunderstanding of the incredibly complex US billing and coding regulations, but in the end the result of an audit is either neutral or in favor of the company. In the history of medical audits, no physician has ever heard, “Why, doctor, you’re doing such a good job with your patients, and spending so much time, that you’re really not charging us enough. We probably owe you thousands of dollars! Please let me send you a check as soon as I get back to the office.”
Back to the emergency room
The 17-page report on your emergency room visit is nothing more than a primary care office visit on steroids. EMR software systems can magically transmogrify what should be a fairly simple physician-patient encounter into an interaction as complex as a visit to Mayo Clinic. Emergency rooms are expensive to run, requiring a cash flow many multiples higher than a primary care office visit. What better way to boost revenues than an EMR system that produces a report that can both generate maximum dollars and satisfy every conceivable requirement in the auditor’s policy manual?
Obviously, the cost overruns with health care like this can be mind-boggling.
Even though the report on you that I receive is 17 pages long, do you honestly think that some poor soul sat down and wrote 17 pages about your cold? The secret’s in a software creation called a template. Maybe you work somewhere where you use templates, pressing CTRL + 1 or more additional keys to fill whatever you’re writing with lots of verbiage. Form letters are templates. Write to your Congressman about the environment and some clerk enters your name, hits two keys, and an entire personalized-looking response appears in your inbox.
EMRs provide doctors with templates for everything imaginable needed for a chart. You come in with a cold and the doc writes an entire SOAP note with a keystroke. If there’s too much detail or not enough, she can edit the template to suit her needs. The template system can also be personalized to offer diagnostic test suggestions (blood count, chest x ray) that may or may not be acted on. A newbie in an ER–say a medical student fearing malpractice or labeled sloppy by his senior resident–tends to follow all the template’s suggestions. If your x ray is mildly unusual (an old scar is seen, for example), this can result in the student measuring your blood’s oxygen level, ordering a CT scan of your chest, and/or referring you to a pulmonologist.
EMRs with their templates generate beaucoup bucks.
(Templates can also lead to careless mistakes. The doctor can hit the “Normal Female Exam” template for a 30-year-old man, and since EMRs cannot be altered, the poor man forever carries a record of having a normal pelvic exam.)
If you’re already in the hospital’s system when you visit the ER with your cold, all the previous medical problems in your records will immediately pop up in your ER notes. The ER doctor will comment on each of these, usually with a SOAP note. All your diagnoses (even those from years earlier) will appear on your emergency room discharge diagnosis sheet to maximize billing. Many templates add a paragraph on the side effects of each of the meds you’re taking (or ever took), contributing line after line to the 17 pages of your ER visit.
Finally, after you’ve been examined, tested, x-rayed, and indeed the docs says you have a bad cold, you’ll be given about five pages of self-care instruction, also part of the fax hurrying out of my machine. These often read as if written for illiterates, with simple words, stick figures, and the like. I suspect the hospital’s legal department reviews each page with a magnifying glass before approving.
On these instruction pages, you’ll learn to take an aspirin if you feel achy, blow your nose using a tissue, and dispose of the tissue properly. You’ll learn the most up-to-date coughing technique (into the crook of your arm) and, if you think you’re near death, to dial 911.
Why all this busy work?
Why, instead of talking directly to you and making actual eye contact, are the doctor’s fingers flying across his keyboard, inserting (and editing) template after template?
You’ve figured this out by now. Because with each diagnosis, the ER doc is allowed to add a billing code, which can then be submitted to your insurance company so the doc (or rather his hospital employer) will be paid more money. Actually, the doctor himself is usually a salaried employee, totally oblivious of the billing process he’s participating in.
In 1957, if you visited a family doctor with a cold the visit would set you back $10 cash, your prescription cough syrup maybe another $2. By the 1970s, the visit had increased to $45. And today, by generating paragraph after paragraph of meaningless filler into your medical records, a visit to your doctor’s office visit may run around $150.
But that 17-page ER visit, with all its template-recommended bloviating and review of all your records, comes to about $5000.
Just take an aspirin and blow your nose.
David Edelberg, MD
PS The immediate-care centers you see everywhere are actually much more efficient. They, too, will fax me details of your visit, usually two to three pages max. I have no idea how much they bill your insurer for a visit, but since the immediate-care industry is doing well, they must be making someone (namely the insurers) happy by charging lower fees than emergency rooms.