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Can I Please Just Treat My Patients?

How sick are our patients?

In the old days, it used to be our job to figure this out.

That’s pretty much what a lot of doctoring and nursing and other care is all about.

In fact, that’s pretty much what the entire healthcare system was built around.

Who was sick, who needed an immediate medication, procedure, or surgery.

And who needed to make some dramatic lifestyle changes, some slow and steady progress, some small incremental steps towards positive healthy change.

One of my mentors once described the instinct that a good doctor has for telling who is sick and who is not as “smelling badness,” that gut feeling you have that this patient needs to be in the emergency room right away, that this patient needs to go to the MICU, that this patient needs an urgent evaluation, and which patients, although they still need to be taken care of, can be dealt with on a slower, more measured pathway.

But these days, it feels like the task of figuring out who is sick has been taken out of our hands, and left in the hands of bureaucrats, coders, and insurance companies.

Just recently on Twitter I saw a discussion about the utility of the Review of Systems, and how it feels like this was created and evolved to only be something that proves how sick or not sick a patient is, and how thorough we were in evaluating them.

In the old days, the narrative of medicine, the History of Present Illness, would contain pretty much everything you needed to know in terms of relevant positives and negatives, so that when we finished reading that section there was really no need for a whole other list of things that were noncontributory or not affected by the current situation.

Yes, it’s true, perhaps that patient has some dry skin, and some joint pains, and some depressed mood, but are those really relevant to their admission today for pneumonia?

Several people pointed out that the Review of Systems noted by trainees could be useful for those hearing about the cases, because often they knew more about what might be relevant and what might not be than those students and residents seeing the patient initially.

But overall, the Review of Systems has become something that the bean counters look at, how many organ systems we went through, and did we write it out correctly, not just “negative,” or “normal,” or “unrevealing.”

Someone has mandated that we click all those boxes and include all those things to make sure our note is fluffy enough, plumped out enough, to deserve getting paid for taking care of our patient.

Is this truly a reflection of how sick our patients are, and how much care we provide on that day?

I think not.

Under guidelines instituted through the ACA, a process has been developed whereby every year, on January 1, the Federal government apparently forgets about all the diagnoses a patient has.

It has become incumbent on us to tell them once again how sick our patients are, what diagnoses they carry, so that our high-risk coding can be used to support the risk modification codes that will allow us to be paid appropriately for the care these elderly and often quite sick patients need.

Why did we allow ourselves to let the government “forget” that a patient has an amputation, diabetes with ophthalmologic complications, polyneuropathy, metastatic cancer, end-stage renal disease?

It feels sort of insulting as a physician that we’re to now be told that we need to remember to remind the government that our patients have these debilitating chronic conditions that we have been managing.

I guess it’s possible that some of these things could be no longer be relevant, that one of our patient with stage IV chronic kidney disease underwent a transplant and now has essentially normal renal function; then the codes for this condition should no longer apply to them.

But wouldn’t the government know that the patient had had a transplant?

Many of these represent chronic conditions that are just not going to go away, and in fact many of them will only progress.

The fact that the burden has shifted to us to inform and report all of these things belittles the work we do, devalues the care we provide, and makes us just another cog in the administrative bureaucratic moneymaking thing that our healthcare system has become.

Certainly, if these are the rules, we have to figure out a way to do this, but it has become yet another exhausting part of trying to take care of our patients.

Years ago, when we billed for our office visits, we were trained to know that billing for something that you did not acutely manage today in the office was tantamount to fraud.

We were taught to bill for the signs and symptoms that the patient presented with, their medical complaints (cough, knee pain, chest pain), the diagnoses we made (viral upper respiratory infection, primary osteoarthritis of the left knee, unstable angina), the chronic medical conditions we managed today (their hypertension, their COPD, their depression), as well as those diseases that may have significantly interacted with today’s issues that made it more challenging to care for this particular patient (asthma in that patient with a URI, diabetes in the patient with cellulitis of their foot).

If we billed for an amputation or end stage renal disease when we weren’t taking care of those things today, we were gaming the system and stealing from the insurance companies.

We have to decide that even if all of these rules exist, that we need to have a fully fleshed out review of systems, a massive HPI, a problem-based assessment and plan, with every organ system documented as being examined, whether we are willing to allow this to persist as what we think is the best way to take care of our patients.

We all understand that without some degree of checks and balances, fraud can certainly occur, and that billing for patients who are seeing you for a small minor issue should not be the same as someone with seven chronic conditions, ten medications, and eight chief complaints.

But we as the ones doing all the hard work out here need to decide that enough is enough, that either this stuff needs to go onto someone else’s plate, to satisfy all these rules, or else we need to scrap the whole thing and go back to a system where I see a patient, I figure out what’s going on, I smell the badness, and then I decide how much to charge for the visit today.

The government may not trust me, and insurance companies may not trust me, but the system they’ve built to try and prevent the fraud that occurs around the edges has belittled what we do, reduced our patients to items we need to check off in the electronic medical record, and totally devalued the care we provide.

We can all smell the badness.