American College of Physicians: Internal Medicine — Doctors for Adults ®

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President's Column

Restoring the joy of practice by attacking hassle factors

From the May 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

Internists live for the gratification that comes from patient care and the intellectual challenges of clinical medicine, education and research. Increasingly, however, we are besieged by unreasonable administrative hassles that are taking the joy out of practice.

I was recently reminded of both the gratification and frustration that clinical practice can bring. It was a typical Chicago winter day with gray skies, a temperature near zero and snow made particularly unpleasant by high wind. While the schools were open and the streets were clear, the pace was a little slower than normal, and I had a little extra time to spend with two patients I had been seeing for more than 20 years.

The first was a retired school teacher who suffers from advanced COPD and requires continuous oxygen therapy. Despite her condition, she has remained fiercely independent and continues to live at home.

During her visit that day, I had the pleasure of introducing her to Thomas L. Petty, MACP, a renowned expert on respiratory failure who was serving as a visiting professor and had stopped by my office to pay a visit. When I explained that Dr. Petty's work had helped revolutionize the use of therapies like oxygen, steroids and arterial blood gas determinations for her condition, she decided to give her opinion on the subject.

She told Dr. Petty that she refused to have any more blood gases drawn because they were painful, that steroids made her fat and unable to sleep and that the oxygen equipment was burdensome. She said all this with the grace, dignity and humor that had surely made her a formidable presence in the classroom. It was a conversation that I'm sure Dr. Petty will remember.

The second patient I saw that day was a 38-year-old man with cystic fibrosis awaiting a lung transplant whom I have treated since he was 15. The patient worked at a bank until two years ago; now he receives continuous oxygen therapy, inhaled antibiotics and chest physiotherapy four times daily. The treatments are administered twice daily by a professional therapist and twice by his wife, who works full time.

Despite this patient's condition, his attitude is superb. He has been on the waiting list for a lung transplant for two years, yet he remains positive and upbeat.

Because of the inclement weather that day, several patients canceled their appointments, giving me much more time than usual to work with these two remarkable individuals. We talked about topics such as their prognosis, end-of-life issues, managing pain and maintaining independence. While they were in the office, I spoke on the telephone with their family members, who worried that the patients spent too much time alone. Both were emphatic about not wanting to move.

Months of hassles

In the three months that have passed since I saw those patients, I have been hassled by their insurers on an almost weekly basis. The visits were audited and I was told that I had problems with both "downcoding" and "upcoding." I was also told that there was "insufficient documentation" to qualify the visits as "comprehensive," that my telephone conversations with the families need to be documented and billed "separately," that my documentation of their histories was "incomplete" (I wonder what they think I have been doing for 20 years) and that my treatment plan indicating "no change" was "unacceptable."

In addition, my COPD patient was told that she will no longer receive reimbursement for her oxygen and visiting nurses, which turned out to have been triggered by a mistake in the insurer's paperwork. My cystic fibrosis patient is continually hassled by his insurance company for virtually everything, despite the fact that he has not been hospitalized for 18 months. He previously averaged two to three admissions a year at an average cost of $50,000.

Most internists can relate to my experience with stories of their own. We resent the unreasonable administrative hassles that are rapidly becoming a daily part of our practice.

The College responds

The College understands these pressures and has responded by creating programs to reduce administrative hassles. Some involve strategies to decrease administrative burdens imposed by government and third parties. Others include making assistance available to improve internists' efficiency.

Here are some specific examples of those College programs:

Fraud and abuse. The College's Managed Care and Regulatory Affairs Department is preparing a guide to help members make sense of the government's much publicized, but highly confusing, fraud and abuse campaign. Despite the political hype, much of the substance of this campaign concerns the mundane nuts and bolts of correct coding and documentation. Our Washington staff will expand its set of practical tools to help members satisfy the government's documentation requirements and to avoid fraud and abuse trouble.

In a closely related project, the Washington staff also plans to develop materials to guide physicians' daily decision-making once new evaluation and management guidelines are issued later this year. The College will create charts that explain documentation and coding decisions that physicians must make.

Financial management. In addition, the Center for A Competitive Advantage (CCA) is working on a cost-accounting tool that even modest-sized practices can use to analyze their finances. Most physician offices never really know the precise cost of the services they provide. In a world of downward spiraling reimbursement and cutthroat managed care contracting, that position is becoming untenable. Combined with the Center's excellent benchmarking service and laboratory profitability software, this cost-accounting tool will give practices the financial management expertise they need to maintain economic viability.

Managed care. The CCA is planning two other projects that will address managed care pressures. First, to cope with an increasingly transitory patient base, the CCA will offer a new marketing publication to help members attract and retain satisfied patients. The new publication will complement the CCA's Patient Satisfaction Check Up product, which helps internists conduct patient satisfaction surveys.

Second, the CCA's long-term research and education project will help internists more efficiently manage their patient visits. That will help physicians cope with pressure from employers and payers to reduce the length of each encounter. Results from the project may also provide statistics to counter unrealistic length-of-visit standards that managed care and other organizations propose for purely business reasons.

I encourage members to contact the CCA (800-338-2746) for help with these and other administrative hassles. The gratification and intellectual challenge of internal medicine must not be lost.

I welcome your comments at waddingt@rsh.net.

--Whitney W. Addington, FACP

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