DOCTORS ' Lounge
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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