The Death of Patient-Centered Health Care
It all began with government involvement. Not that Government involvement can’t be beneficial. It can be, and it should be, but it didn’t work out that way.
Before Medicare or other government programs, medical care was an uncomplicated agreement between physicians and their patients. Basic market forces controlled the cost of care. Physicians needed to charge only what patients could reasonably pay. Few drugs were available, and those drugs needed to be affordable in order to be sold. Of course, expensive and advanced technology was not yet available, so the cost of receiving medical care was much less than it is today.
Technology changed the situation. The cost of advanced treatment was often unaffordable for the average person. Insurance was the logical answer, and Medicare was initially a form of insurance. Unfortunately, when someone else is paying the bill, the usual market forces no longer apply.
You get what you pay for, it has been said. This is also true with medical care. And today, with insurance, what is paid for is determined by the government and by your insurance carrier. So, what do they pay for, and how is this determined? The answer is that they pay for CPT codes. This stands for Current Procedural Technology.
There are thousands of CPT codes, and each code signifies some sort of procedure or work. When applied to procedures such as a colonoscopy or hernia repair, the CPT is easy to define, and the degree of difficulty among the same procedures reasonably averages out over time. The problem comes when the CPT code is applied to patient encounters such as office visits. How can a CPT code distinguish different amounts of work that are delivered with office visits?
Before delving into that question, it’s important to understand that each CPT code is considered to represent a certain amount of work compared to other CPT codes. These comparative values are designated “relative value units” or RVUs. Compensation for a CPT is the RVU multiplied by a dollar amount that is subject to change based on politics and available funds.
So, the problem that has been created by this system of compensation relates primarily to the definition of patient encounter-based CPT units. How is this determined? For each type of encounter (office, home, hospital, initial visit, follow-up, etc.), there are 1-5 levels of visit, each with a different CPT. Consistent with many legal constructs, the level is entirely based on the chart documentation. And charting takes a lot of physician time. Furthermore, most of the required charting is irrelevant and has no association to any benefit for the patient. Today, the CPT is most often determined by a computer-generated record. More documented items result in more RVUs and higher compensation.
What’s wrong with that? Physicians are paid more if they add questionable diagnoses, order unnecessary tests, and prescribe unnecessary medications. Time spent listening to patients, explaining things to patients, and answering questions are given no value. The compensated activities detract from the physician’s ability to see enough patients to pay for their overhead and to generate a net income. In short, the physician is compensated for time spent generating a comprehensive record, regardless of the benefit to the patient, and the physician is not paid for useful time spent with the patient.
Moreover, computer generated charts add items that are fraudulent. It’s common to see, in a chart, a thorough physical exam described when the physician did no more than check the “normal” box on the computer screen after looking at the patient across the desk. One computer click automatically adds extensive language to the record. The documented complete exam allows a more lucrative CPT. Beyond that, physicians commonly use a copy-paste function on the computer to incorporate prior records into a current note. Not only does this technique allow the physician to claim a more comprehensive evaluation and more RVUs, but it also perpetuates the prior fraudulent exam and incorrect diagnoses.
An independent study, using actors as patients, evaluated secretly video-taped physician encounters and compared the encounters to the computer-generated record. A fraudulent discrepancy was identified in about 90% of records. From personal experience, I will attest that it is common to review a >10-page emergency room record that fails to communicate the patient’s problem and the treatment that was delivered. Yet the chart allows the maximum level for billing purposes. The computer-generated record is designed for billing, and that is the dominating value of those records.
It’s also relevant that almost all physicians beginning practice today are employed under a contract that compensates them almost entirely based on RVUs. It has been estimated that about 48% of the RVU compensation relates to work presumed to be done by the physician, and the remainder pays for practice overhead. Furthermore, whether the physician is employed by a hospital system or a physician group with facility ownership, the employer further benefits from the unnecessary tests that are encouraged. A physician who fails to generate the expected number of RVUs will be offered lower compensation or even terminated. Time spent listening and explaining detracts from the physician’s ability to meet expectations. And, financially, the worst thing that a physician can do is spend time explaining to a patient why a test or treatment is not needed.
Add to this situation aggressive direct-to consumer (DTC) marketing of medications and other treatments. Patients come to the office already convinced that they will benefit from new and expensive drug or that they need a special evaluation. Who has the time to explain the downside of this magical therapy or evaluation? It’s easier to prescribe the new treatment, even if it offers doubtful benefit to the patient. However, Pharma or the providing facility will profit. And the physician will get credit for the RVUs.
Medicare added the option of using “face-to-face” time with the patient as an alternative to the detailed documentation. This seems reasonable, except that record review, charting, and many of the other essential “non-face-to-face” tasks have been estimated to require much more time than the “face-to-face” encounter. Moreover, the compensation based on “face-to-face” time compensation is inadequate to cover the costs of running an office considering the number of employees that are needed to comply with government mandates.
In 2021, Medicare partially corrected this problem by basing “time” on all physician time spent on everything relating to the patient on the day of service. Regardless, RVUs generated by a seven-minute physician visit using a (mostly fraudulent) computer generated record is the only way for physicians to meet the RVU requirements of their employer and to generate enough revenue to pay for practice expenses.
For several years, Medicare has been attempting to define “quality” as a parameter to determine compensation. Medicare has adjusted compensation per RVU up or down depending on the physician’s participation in a “quality” program. This program required the physician to develop measures of quality and then report back their percentage of compliance. This was a complicated and burdensome process. Large groups were able to comply, largely with fabricated documentation built into their computer records. It was determined that the cost to small specialty groups greatly exceeded the increase in compensation. There was no reason to believe that patients benefit from this program. On the contrary, the required documentation detracts from time that could have been used for patient benefit.
Now comes Medicare Part C. Medicare Part C is a group of HMOs that contract with Medicare to “manage” patients and physicians. Essentially, they receive a certain amount of money for each Medicare patient, and they try to limit the services provided to those patients to generate maximum profits. They can limit their physician panels to exclude physicians who are more expensive; that is, order more tests or medications.
These Medicare HMOs generally require the physician to engage in a time-consuming precertification process before ordering tests or prescribing medications. These pre-certifications are basically harassment to make it too difficult to order important tests. My personal experience is that pre-certification usually requires about 30 minutes, mostly staff time but often 10-15 minutes of physician time. Minimally-trained insurance personnel ask a variety of questions with escalation to nursing staff and even more advanced staff, always asking the same questions until the test is invariably approved.
And Medicare HMOs are also rampant with fraud. Chart-mining companies have been hired by the HMOs to review records and add irrelevant diagnoses to create the appearance that the patients are more complicated than they actually are. This fraud goes hand-in-hand with the fraudulent computer-driven records that hospitals and physicians use for billing. These contracted “chart-mining” companies request that physicians release patient records to them, creating an additional expense for the medical offices.
So, where does all of this fiasco leave the patient? Certainly, the patient is not at the center of our healthcare model. With the historic healthcare model, the patient was at the center, and all other entities were tools for the benefit of the patients. Today, the patient has essentially become a tool of the industry that is needed to generate revenue for the primary players: Pharma, the hospital industry, the insurance industry, and a group of other industrial players.
Physicians, while still well-compensated, have become tools that are used by the medical industry to serve their profit motives. We have many well-intentioned physicians, but they’re swimming against the current. Other physicians have learned not to care. Our well-intentioned physicians have been demoralized. This has been called “burnout”, and burnout is bad for both physicians and patients.
So, what’s the solution? I have no idea. Whatever it is, I don’t think that it will happen. Other nations have developed superior systems. I’ve heard the statement: “you can’t get there from where we are”. We'll see if private enterprise is able to offer patients a better option.