DOCTORS ' Lounge
SPEAK YOUR MIND If you would like to respond to an article in this issue , please submit an article or letter to the editor . Contributions may be sent to editor @ glms . org or may be submitted online at www . glms . org . The GLMS Editorial Board reserves the right to choose what will be published . Please note that the views expressed in Doctors ’ Lounge or any other article in this publication are not those of the Greater Louisville Medical Society or Louisville Medicine .
“
What
36 LOUISVILLE MEDICINE
If They Only Had A Brain
Mary G . Barry , MD Louisville Medicine Editor editor @ glms . org
was CMS thinking ?” was my first response to the proposed 2019 Medicare fee schedule changes . As initially reported , it read as though no matter how complex the presentation of the patient , no matter how old or frail or critical the patient , the office doctor would be paid the same . Things would not change for procedure fees . These fee schedules would apply to “ doctors who think ” as their primary service offered to the patient .
Of course , the doctor takes a legal risk which is not the same for all . The knowledge , experience and effort required for the chronically ill with a new and serious problem versus the young person with a cough are dramatically different . “ Got a sore throat ” would equate to “ I ’ ve had a 104 degree fever , and I don ’ t know what ’ s wrong .” Getting paid the same for both immediately strikes all diagnostic physicians as just nuts .
We must pull together miles of data , onscreen and in memory , ask all the right questions , then do a confirmatory / explanatory exam . We will sort all that out and make sense of it and make a differential diagnosis , and then together with the patient , make a plan of treatment and explain it . This requires negotiation . There are many social issues which affect both the problems and the solutions . We must take into consideration the weight of deductible spent versus probability of disease , versus the risk of skipping not just helpful , but essential tests . We must explain the treatment and its benefit and risk . The patient must consider caregiver coverage , lost wages , work and school schedules , transportation , etc . The patient must consider if giving up smoking , or paying out of pocket for PT , or taking up daily exercise is worth the trouble . We must discuss the individual barriers and anxieties the patient has surrounding all these issues . This is never cut and dried ; we have to think about it together .
A closer reading of the CMS proposal is minimally more reassuring . The premise is that reducing the complexity of required documentation will keep doctors practicing . Right now , we wade through screen after screen simply to meet the billing requirements so that the government and the commercial payers will pay us “ fairly ” for the work we have done . We are drowning under these documentation requirements . Older physicians have retired in droves and young internists are choosing only hospitalist care and specialties . In 20 years , there will be very few internists outside the hospital . To survive the billing requirements , we have templates that cover various clinical situations , for which we change the findings and details appropriate to that patient at that moment . I have built my templates to reflect what I actually do , but they require an awful lot of typing because I am not a computer and I refuse to sound like one . My templates are built so that if I had to justify my data at any point , I would know that what is documented , I have done . But to accomplish this and continue to see our patients properly , many of us who share my profession work on the computer for hours and hours every day outside of the office .
“ Properly ” means person – to- person care . The ER doctor has brief but intense relationships with patients ; those in my profession have years and years of sharing patients ’ medical lives , and each encounter is enriched by the one before . The fear of all doctors taking care of people for a long time