Monday, June 9, 2014

Medical form over Substance

The State of Nevada addressed issues with medical forms in its May 2014 Medical Unit Newsletter. They recently learned that "treating doctors are charging injured employees to complete workers' compensation forms." They acknowledge that fees for form completion are "common" in many "other types of insurance coverage," but caution this practice is "not acceptable with injured workers" under Nevada law. Doctors who charge for this in workers' compensation could face significant fines according to the newsletter. It is a reminder that doctors tend to see the paperwork as something additional to the care they provide to a patient.

Also recently, featured an article The Trouble Festering in Primary Care by Dr. Pelzman. He makes some interesting points about the paperwork challenges for primary care physicians. Dr. Pelzman notes that he receives calls from patients and he has to then create a referral to some other provider such as a dermatologist. He does not explain why he receives calls instead of sees the patients. He says that upon receipt of the calls, he "more often than not" needs to "select some benign (or made up) diagnosis ("dermatitis" or "Nevus, non-neoplastic") that will allow the patient to be seen since we most likely do not know why they are there, and allow the dermatologist to be reimbursed by the insurance company." the parentheticals are from the original. Ignore for a moment that he is making up a diagnosis. 

Dr. Pelzman complains that completion of the referral form is "work that no one should have to do. A ridiculous administrative burden has been created that prevents every one of us, no matter the level of our licensure, from being able to do the jobs in healthcare that we are desperately trying to do." I am wondering if the job is seeing and diagnosing patients? If it is, why not see the patient, make a diagnosis, then make a referral if same is necessary instead of just desired? 

He questions "who made up this stuff," and explains that no one in the doctor's office wants to complete these forms. He explains that this "stuff" should not be any part of the health of our patients, any part of the healthcare system of our country." He argues that people who enter into contracts (buy insurance) should not be troubled with meeting the terms of the contract (see primary care before specialist, see specialist on referral of primary care). His arguments seem to reject the primary care provider model relied upon by some insurance contracts. Of course there are a wide variety of options out there, including insurance contracts that patients can purchase that do not require such primary care "gatekeeping." Dr. Pelzman does not address whether doctors should be making up diagnoses or making referrals to specialists for patients and conditions which she/he has not evaluated as the primary care doctor. 

He concedes that some form of data collection is likely needed, to document that physicians are "optimizing the use of health information technology," to improve health and track diseases, and to keep costs under control (can we track the existence and prevalence of disease when primary care doctors make up diagnoses for patients they have not seen and report those maladies to insurance companies?). He laments the current process of administrative burdens "so onerous, so taxing, that we should not be surprised if no one in their right mind chooses to enter the healthcare field at the present time." He does not explain how his views on the legitimate goal of improving health or tracking disease is furthered by making up diagnoses, which are then likely tracked by the healthcare system.

He concludes that "if I never have to fill out another prior authorization form or threshold utilization override form, or transportation form, or any other form that adds nothing to the care of my patients, I'll be ecstatic beyond belief." 

The point that is missed is that America has become a vast bureaucracy. There are forms to fill out for anything we need or want in this worldAnd, yes, they are part of providing medical care under some contracts into which people enter. It would be much more efficient if a physician could tell a patient the name and dosage of medication and send them to the store where the patient would buy and appropriately use the medication. Why can't the patient buy an antibiotic without paying the doctor $100 for an office visit and prescription? Apparently we can get a referral to a specialist with a manufactured diagnosis by telephone, but we have to be seen to get a script for Amoxicillin? Society has found that allowing patients to make their own decisions about medication does not work, however, and we therefore require a form (prescription) for communication between doctor and pharmacist. 

The belief that other forms add nothing to the care of patients is short-sighted. Just like the script for medication, the referral form brings care through the primary medical practice, and medical professionals make decisions about the need for other professionals. Not all health plans (contracts) require this, but some do. No all loan agreements (contracts) require arbitration, but some do. When we make a contract, we accept the terms of that contract. 

The health plans (contracts) that require primary care as a gatekeeper look to that doctor to lead the health care team. They do so based on their training and education. They evaluate, examine, and diagnose. I mean actual diagnoses, not just what some other physician might "make up" as a response to a phone call. Just like the script is needed to obtain the medicine, the disability form is needed for the patient to be paid. Without that form, there is no cash and as a result perhaps no food, shelter, etc. Can anyone argue that patient care is not affected by the comfort and piece of mind that come from having a place to live and food to eat?

It has become rare for people to pay for their own medical care in America today. It occurs, but most have adopted the third-party payer (insurance, public or private) as their model. These third-parties (by contract) require documentation in order to provide payment. The documentation of diagnosis is part of that model. So is the primary care physician. Their role in that model includes completing documentation of their participation, which allows health insurers to participate in determinations of appropriateness of care and the reimbursement therefore. Should they be involved? That choice was made by the consumer who purchased that health insurance contract, with its benefits and its burdens. 

Is all the paperwork necessary? Perhaps not. Perhaps we should be able to trust patients to only buy and properly use medications that are efficacious. Perhaps we should abandon the pharmacy model. Why should a patient have to see a physician before obtaining medication? Is it because society has determined that this physician and their training is critical to protecting health in our society? Is there logic to such societal trust in people who find greater harm in the inconvenience of completing forms than they find in making up diagnoses? Physicians who forego examining their patients and make up opinions so that the patient can see a specialist? Would a doctor make up a diagnosis for me on one of those pesky prescription forms so that I can get what I want without the burden of coming to his office for an appointment? If I phone in, could I get a made up diagnosis and some Oxycontin?

I am sure I do not know all the tribulations of providing medical care in today's world. I know this though, there may well be valid reasons for requiring paperwork. The processes of obtaining care through someone else, based on a contract made with them, can be subject to a variety of requirements of that contract. Patient well being may very well be affected by those documents and forms, and completing them completely and promptly may very well benefit the patient. I also know that making up diagnoses for a form, to help a patient that has not been seen, is wrong. In fact, simply making up a diagnosis is wrong, for any reason. 

We need to strive to streamline. The effort in Florida with the DWC-25 is a good illustration of that kind of effort. A single form for use by the treating physician on every visit. A single form upon which all of the relevant information can be clearly stated and effectively communicated. Of course, the efficacy of this form is just as susceptible to made up diagnoses as any reporting mechanism would be. 

Perhaps if we lived in a world where honesty in fact was more prevalent, then the volume of bureaucracy and forms designed to document and verify could decrease? Maybe we should be able to expect such honesty in fact from the professionals in our society, be they doctors, lawyers, architects, accountants or otherwise? There is no form that will be effective when professionals intentionally provide false or made up information. 

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