Dear Mr. President:
The physicians and management in our office had a discussion this morning about the upcoming audits physicians are facing from CMS. I had to wait for my blood pressure to get out of dangerous range to write this letter. The frustration, fear, and powerlessness I felt made me really question whether it is worth continuing to see my Medicare patients.
I am a primary care physician and about 20% of my patients are covered by Medicare. As a whole, they are wonderful people, but difficult patients. The elderly are truly a delight to talk to, learn from, and care for; I consider it an honor to be their doctor. But the complexity of a person’s medical problems goes up exponentially as they near the end of their life. This means that I spend more time per patient for my Medicare population – which is OK if I can be paid for my extra time and effort.
But here is the message we physicians are being given:
Medicare auditors will be knocking at our doors, and if there are “problems” with our charting we will be told to send money back to CMS for our whole Medicare population. We are obligated to prove that we did not defraud Medicare to reclaim the money for the work we did. This is, obviously, consistent with the cornerstone of the American legal system, “A person is presumed guilty unless they can prove that they are innocent.”
The “problems” they are looking for are inconsistencies in the charting and the billing we do. These “inconsistencies” are not just egregious attempts at stealing money from Medicare, they are little things like this:
The failure to mention the EKG we ordered in the note (even if it is right there in the chart).
The appearance that we are using a “cookie-cutter template” to do our notes – i.e. if all of our physical exams, review of systems, or impressions look similar, then it will be assumed we are trying to defraud Medicare.
Forgetting to document a discussion of the patient about a diabetic eye exam.
Certain ICD-9 codes will be accepted by Medicare, but will be “flags” that we are possibly trying to cheat Medicare out of money. Diagnoses like Hypertension ICD-401.9 and Diabetes Type 2 ICD-250.00 will be flags. We need to be more specific in our coding to avoid immediate suspicion.
While my information may not be 100% accurate, the fear in the medical community is. We practice very good medicine in our practice and probably save money for the system (as studies have shown that a higher percentage of primary care in a community means lower cost – ask the Brits on this one). We use an EMR and are very tuned in to the quality of our care (NCQA recognized for our diabetes care). I strongly suspect that our quality of care and documentation are in the top 10%. Yet we are fearful that your government employees are going to use us as scape goats for the out-of-control costs of Medicare and put us out of business in the process.
We see what is being done to the hospitals with the “No Pay” diagnoses. That whole debacle is irrational and unfair, but the hospitals have no recourse. That makes us extremely pessimistic about our odds when facing the hit-men from CMS. If a hospital with its lawyers and other resources can be hung out to dry, what chance does a PCP have?
So at an increasing rate, we are discussing the option of dropping Medicare altogether. That really is an amazing thing, as we have always played by the rules and have seen our care for the elderly as a responsibility and civic duty we have. We have never considered our acceptance of Medicare as something that actually makes business sense – we just want to and like to care for the patients. But the increasing hostility we are seeing from the witch-hunters with their torches and angry mobs is making us really consider whether we can afford to stay on board.
The practice of medicine would be far simpler for us if we dropped Medicare and Medicaid – and probably more profitable. But I don’t want to. I love my patients and want to continue to have the honor of being their doctor. Please don’t convince me that it is not worth the effort. Please don’t hurt our elderly in such a way. Please don’t let the CMS cronies make it look like we physicians are the root of the problem. We may not be totally innocent; but most of us are doing the best we can in a system that is becoming increasingly hostile and incredibly burdensome.
On behalf of all scared physicians out there,
ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.