The business of healthcare in the U.S. is doing just great, as indicated by the high and rising percentage of our gross domestic product it consumes annually, while the value of care delivered lags behind other developed countries and too often provides less than what patients require.5,6 Meanwhile, an increasing percentage of revenues earned from physicians’ work is being diverted to administrative expenses.
A Fundamental Change
The shift from value to volume has fundamentally changed the content and usefulness of medical records. High-value care back in the day involved reporting the critical positive and negative clinical information that supported our identifying the patient’s problems, creating management plans for each of them, prompting re-assessments at timely intervals and communicating this essential information to others. They supported an iterative process. The components of a comprehensive history and physical examination were performed only when necessary; other evaluations were focused according to the patient’s needs and the individual physician’s role.
In contrast, current high-volume record keeping involves reporting more work components in more detail to maximize reimbursement, independent of, even contrary to, its value in supporting high clinical performance and effective communication. Nowadays, a physician gets paid less for a focused evaluation, even if it takes longer and requires higher skill, unless lots of irrelevant information is added.
Immediately after new evaluation and management visit requirements were released in the 1980s, I attended an ACR Clinical Council meeting at which the discussion revolved around, “What makes a visit a Level 4 instead of a Level 3, and how can we make it a Level 5?” Game over!
The assessment of physician performance should be returned to structured peer review … rather than the current monitoring by administrators & payer clerks.
Different Specialties, Different Impacts
It is clear to everyone that physicians who evaluate and manage complex patients over long cycles of care are the big losers—primary physicians, geriatricians, infectious disease specialists, neurologists, endocrinologists, psychiatrists and rheumatologists, as Dr. Atul Gawande recently observed.7 Their work often requires review of voluminous prior records, detailed examinations, complex analysis and record keeping, and coordination of care across health systems over long time spans. What the Level 5 billing code pays cannot begin to cover the time and resources appropriately consumed by this work, no matter how much documentation the physician provides. The result, according to Gawande, is that these practices are starved for resources, and physicians are compelled to do work that others could perform better, and at a lower cost.
