I am not...

I

am not

old enough

to have a

21 year old daughter today!

The OR Rorschach Test #8

For today's quiz, you need to be old enough to have read classic children's books, and young enough (at heart) to recognize a character:

OK, after searching high and low, I now realize that Curious George was never drawn with a tail, but c'mon ---

--- if you are as old as I am, you gotta think Curious George when you see a monkey shape! Besides, Cheeta never played the piano, and though the Barenaked Ladies sing about chimpanzees, there's not actually one playing an instrument in their video.

Any other ideas?

Snow White, RN and the Seven Surgeons

Once upon a time, there was a princess who lived on the hospital surgical ward named Snow White, RN. She was beautiful, cheerful, helpful, efficient, and a damn good nurse. She took great care of her patients, and expected the same level of care from her compatriots. Naturally, that meant that she ran afoul the wicked witch, AKA the Queen Nurse, RN, BSN, PhD, QRS, ABC, etc. Fearing her independence and strengths, the Queen refused to promote Snow White, RN, to management. Every day, she would peer into her Blackberry to ask "who is the ablest one of all who has filled in the most EBN matrix forms, completed the most forms on the EMR system, answered every question on the staff survey correctly, and doesn't ask "Who is that" on my semi-annual trips to the ward." Never seeing Snow White's name on the Blackberry, she was pleased; she did not need Snow White's heart in a jeweled box, because she was boxed in. (image source)

Snow White, RN was not pleased, and sought another position. The HR department, despite being warned by the Queen Nurse, had a moment of weakness and directed her to flee to the woods Operating Room. Lost and frightened, Snow White, RN was befriended by creatures who rarely ventured beyond the OR -- scrub techs, CNAs, anesthesia techs, PACU nurses and operating room RNs. The friendly staff showed her around, and she soon discovered a room deep in the woods OR. Finding seven scruffy chairs, crumbs on the floor, spilled soda, half-eaten pizza, a table with coffee stains resembling an ancient mozaic, and a TV permanently tuned to ESPN, she assumed the room was an adjunct of the frat house at the local university.

But it soon became apparent to Snow White, RN that the room was the surgeons' lounge, occupied daily by seven surgeons --- Doc, Grumpy, Happy, Sleepy, Bashful, Sneezy, and Dopey? Er, not exactly:

Dick Doc is the, well, you know...

Grumpy old Bastard is the general surgeon in his late 50s who has never seen an OR run more inefficiently, has never seen a room turnover in less than an hour, and looks like the barnacle encrusted crab that he is.

Hippie is the laid back surgeon who listens to Tales From Topographic Oceans during surgery. Thought he'd look like The Dude when he got to be 50, but looks a bit more like this dude instead.

Sleepy is the trauma surgeon who lives by the motto "Don't walk when you can ride the elevator, don't stand when you can sit down, don't sit down when you can lay down, and don't lay down when you can sleep." He enjoys a cozy relationship with the recliner in the surgeon's lounge; the anesthesiologists can tell him from the OB sleeping next to him by counting snorts per minute.

Brashful is the young general surgeon just out of training, full of piss, vinegar, and opinions. Sometimes wrong, but never in doubt.

Sleazy is the surgeon who is working -- hard -- on his third divorce; also known to the staff as "Dr. Winky" or "Dr. Pinchmeister." Never got the memo about sexual harassment in the workplace; thinks gold chains aren't just a fashion accessory, they are a lifestyle.

Mopey is the general surgeon who (according to him) just can't seem to catch a break. His cases never start on time, always run late, are always harder than everybody else's cases, and never seem to be elective. He'd hire Eeyeore as a personal life coach if he just got enough time off call....(deep sigh).

As for Prince Charming, Snow White, RN never found him in the surgeons' lounge. She wised up and met a nice cardiologist who swept her off her feet and took her away to live happily ever after.....working in his office with no night call, no medication reconciliation forms, no admission and discharge matrix forms, and no weekends!

Billing Fraud or Documentation Errors?

I'm not really sure where it came from. Perhaps it started during medical school, where I funded dates with SWIMBO by typing lecture notes ($30 a pop for the shared lecture note service). Maybe it came later, trying to understand a patient's prior hospitalization reading someone else's notes that were so cryptic Mr. Turing would have had difficulty sorting through them. Regardless, I am sort of compulsive about documentation of my interactions with patients --- histories are always dictated as soon as I see a patient, operative notes are dictated as soon as I have spoken with the patient's family, etc. Even if I check on a (sick) patient half a dozen times during the day, I always leave a brief note in the chart.

There are two reasons to be compulsive about medical record keeping: [1] to provide a clear trail of a patient's course of care, as well as the thought process that led to it; and [2] to protect myself in the possibility of a lawsuit --- the adage in medical malpractice cases is that "if it isn't documented, it didn't happen."

A third, and more troublesome to deal with, reason to be anal-compulsive about documentation is to be compliant with Medicare's billing regulations. The billing process involves a tangled mess of diagnostic (ICD9-CM) and treatment (CPT) codes that must align accurately to get the government (or insurance company) to cut you a check. Sounds simple --- you arrive in the office with uncomplicated gallstones (ICD code 574.10) and episodic right upper abdominal pain 789.01), I see you and schedule you for a laparoscopic cholecystectomy (CPT 47562). Assuming you are fairly healthy, most of the visit is taken up by discussing gallstone disease, treatment options, and the risks associated with surgery or observation. If you are not so healthy --- have heart disease, diabetes, a history of blood clots, etc. --- I gotta

think a bit more about how to care for you. Common sense would dictate that the healthier person with gallstones would be charged a lower level office visit than the sicker patient with the same problem, but getting paid for that service is not really common sense. In order to ensure that I get paid, I have to document a large amount of information; unfortunately, much of the documentation required is as useless to the patient's care as a wristwatch is to a pig.

Here is the 51 page document laying out the requirements for each "level" of evaluation and management charge. If it looks a bit silly and even contradictory in areas.....it is IMNSHO. It also forms the focus for a big chunk of electronic medical record systems, which can automate the process of documenting the large number of "negative" systems reviews and physical findings that patients have (which have nothing to do with their care or presenting problem), all required to make sure that your office note aligns with the bill for the patient's visit.

Because it is easier to measure, regulate, fold, spindle, and mutilate the documentation and billing part of medicine than actually measuring quality of care, there is a significant effort expended to prevent physicians from overbilling for patient care. From the OIG web site:

Because the Government invests so much trust in physicians on the front end, Congress provided powerful criminal, civil, and administrative enforcement tools for instances when unscrupulous providers abuse that trust. The Government has broad capabilities to audit claims and investigate providers when it has a reason to suspect fraud. Suspicion of fraud and abuse may be raised by irregular billing patterns or reports from others, including your staff, competitors, and patients. When you submit a claim for services performed for a Medicare or Medicaid beneficiary, you are filing a bill with the Federal Government and certifying that you have earned the payment requested and complied with the billing requirements. If you knew or should have known that the submitted claim was false, then the attempt to collect unearned money constitutes a violation. A common type of false claim is “upcoding,” which refers to using billing codes that reflect a more severe illness than actually existed or a more expensive treatment than was provided.

So, American physicians daily go through the exercise of trying to document properly --- not completely for patient care, but to make sure we can get paid for the care we deliver and to make sure that CMS can't come after us for improper billing. It's kind of like playing Jenga, but instead of pulling out blocks, each patient bill can be something that brings your whole practice down.

Of course, I have read about several instances where unscrupulous physicians have bilked the government out of substantial amounts of money; I like the idea that they are caught and prosecuted. But like most law abiding physicians, I am nervous about the idea that the government has created a system more Byzantine than the IRS with the potential to make any physician that is audited a criminal, because it is pretty dang difficult to document well enough to satisfy a government auditor who has never taken care of a patient.

Oh. One more thing. This process just got worse:

It has created a new interagency task force called HEAT (Health Care Fraud Prevention and Enforcement Action Team) under which health-care officials will collaborate with the FBI to go after Medicare fraud. In addition, it has expanded to several cities the Medicaid Fraud Strike Force that authorizes FBI and Drug Enforcement Agency agents to jointly analyze Medicare claims data in real time to detect and investigate irregularities by area doctors. More chillingly, however, the administration is defining Medicare fraud down to include “unnecessary” and “ineffective” care. And to root this out, it plans to make expanded use of private mercenaries—officially called Recovery Audit Contracts—who will be authorized to go to doctors’ offices and rummage through patients’ records, matching them with billing claims to uncover illicit charges. What’s more, Obamacare increases the fine for billing errors from $11,000 per item to $50,000 without the government even having to prove intent to defraud.

That doesn't give me warm and fuzzies about "single payer" health care delivery in this country.