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The Last Word – December 2019

By Hujefa Vora

I want to close out this year talking about change.  How much have your practices changed in the past year?  How much have your lives changed over the past year?  You’ll notice that I use the terms practice and life interchangeably.  Unbeknownst to our patients, our clients, our friends, and sometimes even our own families, these terms are equivalents.  One cannot achieve the title of physician without accepting this fact.  Our work defines us as human beings.  There is no other way to make an accounting of all the time we spend caring for others while neglecting our personal responsibilities.  This year, I missed my daughter’s first gymnastics meet because I had a patient attempting to code in the hospital.  Life changes.  Practices change.  When the government rolls out new regulations governing how we practice medicine, it changes not only our interactions with our patients and their insurance companies, but also the relationships we have nurtured over the years.

So how has my practice changed?  I recall a time just 10 years ago when I could easily see 20 patients a day in my office.  Comfortably.  I remember being able to do my documentation while I sat in front of the patient.  Prescriptions were sent off with a click or two of my mouse.  Follow ups were scheduled and the patient was satisfied. I started my practice 13 years ago with the exact same electronic medical records system that I am using today.  That has not changed, though there have been many updates to the system over the years.  What has changed quite dramatically now is how I use this system.  Practice with the same system for more than a decade, and users build a higher level of proficiency and efficiency.  It would make sense that I would be faster with the system, that my proficiency would make it easier to navigate the windows and the electronic maze of my patient’s chart.  Changes over the years in the rules behind coding and documentation have not made us more efficient though.  Let me give you my most cumbersome example of change in my practice pattern brought on by changes in rules and regulations brought about Medicare.  I am an internist by trade, but the vast majority of my patients are diabetics, so I fancy myself a closet endocrinologist most days.  When I first started practicing, I routinely ordered glycosylated hemoglobin (a1C) levels to gauge the degree of control my patients had over their diabetes.  My staff would order the test for the patient to have drawn at a local lab.  We would get the results back and I would call the patient a week later, provided the patient went to get their blood work in the first place.  Based on the results of that test and the discussion with the patient, I would call in any medication changes.  Then, we would follow up with the patient in a month or two and see if the medication adjustment worked by rechecking the levels.  This worked for a few years, until Medicare and the insurance companies decided that a1C levels would only be paid for if they were drawn three months apart.  Patients would get angry at me and my staff when they started getting bills for the a1Cs I was ordering.  We were forced to move away from this really good method of tracking diabetic

Patients would get angry at me and my staff when they started getting bills for the a1Cs I was ordering.

control.  I started bringing my diabetics into the office every three or four months.  My supply salesman introduced me to a machine that we could use in the office to check a1C levels. The catch here was that regulations dictated that because I was not

running a certified lab, the insurance companies would not always pay for the a1Cs we drew in the office.  Thus, only some of my patients got everything done at the point of care.  It was easily noticeable with my patients that those who had their a1Cs checked at the time of visit had better overall long-term outcomes in relation to their diabetic care.  Medicare eventually took notice of the importance of measuring glycosylated hemoglobin levels and started asking us to track these levels more routinely.  With the advent of Medicare’s quality initiatives several years ago, tracking a1C levels became a key quality indicator for diabetes control.  It is only recently that they started paying for this test if it was done in the office.  Reporting of quality metrics has been the ultimate gamechanger.  As every insurance company begins to incorporate the reporting of these quality metrics, the process has become even more cumbersome.  I decided that the easiest way to tackle this issue was to measure all a1Cs in-house.  If the insurance company would not pay, then my practice would eat the cost, not pass it along to the patient.  Every company we have worked with on this particular metric has a different way that they want these values reported to them.  Medicare has codes for the different ranges of the a1C that have to be coded into the note at the time of care, so whether or not they paid for the test became irrelevant.  A patient with no reported glycosylated hemoglobin level was just as bad as an uncontrolled diabetic in terms of the scoring of the quality of care being provided by the physician.  Ultimately, a lower quality score means a significant drop in revenue.  Most insurance companies would not allow us to simply document the level in the chart.  Medicare would not allow an a1C to be reported without proper documentation that the test was done in-house.  We are now required to document the value of the test, followed by phrases stating that the test was “drawn, collected, and performed in office, in-house, today <today’s date>, at <time>.”

My patient volume has not increased substantially, but the amount of time required to see each patient has made it impossible to continue to do this on my own.

Understand that Medicare has primary care physicians tracking over 30 different quality metrics for every patient we see.  Also understand that what Medicare does in terms of regulations trickles down to every commercial insurance plan eventually.  So how has my practice changed?  I am a five-star rated doctor for Medicare.  That means that because I am truly obsessive-compulsive about most of these details and metrics, my staff and I keep track of all of these metrics for all of our patients at all of their visits all of the time.  First and foremost, we do our best to provide the ultimate in good service and care to our patients.  Then, we spend the rest of our time buffing and polishing the patients’ charts so that we can stay in business and continue to serve our patients.  A typical visit of 10 minutes of face-to-face time with the patient requires about 20 minutes of documentation, insurance processing, and quality reporting.  A simple follow-up visit takes a minimum of 30 minutes.  A new patient may have taken 30 minutes when I first started my practice, but we typically give an hour of my time for these visits now.  And I had to hire a second nurse practitioner to keep up with the flow of patients.  My patient volume has not increased substantially, but the amount of time required to see each patient has made it impossible to continue to do this on my own.

And so, the practice of medicine continues to change.  Our lives continue to change.  I hate to be a pessimist, but not much of the change feels positive right now.  The optimist in me says the next year will be better.  I just hope that I don’t miss too many more gymnastics meets.  No one twirls quite so beautifully, or awkwardly, as my little girl.  That too will change.  My name is Hujefa Vora, and this is the Last Word.

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