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Most hospitals have slim margins, and budgets are set based on anticipated average patient reimbursement at Medicare rates. Some private insurers pay higher rates than Medicare, and the differential is often used to offset the cost of treating Medicaid patients. Medicaid reimburses at about half what Medicare pays, which is usually not enough to break even. Out of financial necessity, Medicaid patients are often given limited access to care and services. This is done in some subtle and some not-so-subtle ways. In a recent conversation with an orthopedist friend of mine, he confided in me candidly:
“Some of my colleagues in private practice can’t pay their office overhead if they treat Medicaid patients. So we see poor people with severely arthritic joints left in pain at home. In addition, with bundled payments, the surgeon gets a fixed amount for the patient’s operation and recovery. What incentive is there to send the patient to a rehab facility? It just takes money away from the surgeon. So the poor have to suffer with very long wait times to see someone who will operate on them, and then afterwards they’re on their own for recovery. Patients who go straight home are at higher risk of falling and may have much poorer outcomes. Surgeons get financial incentives for good outcomes, so it becomes a double disincentive to treat Medicaid patients. You don’t get enough for the operation, and you’re likely to get penalized for their poorer outcomes. Some surgeons I know wont touch a patient with Medicaid for any elective procedure. I have ethical problems with that – so I work at a non-profit hospital where we treat everyone. But I have to do higher volume to break even. I work 90 hours a week and barely see my family. I don’t know how much longer I can do it.”
It is common practice among nursing homes to have a limited number of “Medicaid beds.” The facility simply declines to admit more than 20% of patients with Medicaid. I hear case managers on the phone all day long, looking for a post-acute care facility who will accept a Medicaid patient. For the few non-profit facilities who don’t turn them away, deep financial costs are incurred as they struggle for survival.
The reality is that Medicaid rates are so low that having this insurance is not much better than none at all. As I’ve explained previously in the outpatient world (see an example of an insanely low Medicaid reimbursement for eye care), Medicaid is tantamount to charity care. The news that 21.3 million Americans might receive Medicaid coverage in the next decade should not be hailed as a leap forward. As I see it, that’s just a larger group of people with debilitating arthritis who can’t get hip and knee replacements and are left to suffer in pain at home.
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In a recent Forbes editorial, conservative commentator John Goodman argues that the Texas Medical Board is sending the state back to “the middle ages” because they are trying to limit the practice of medicine in the absence of a face-to-face, doctor-patient relationship. He believes that telemedicine should have an unfettered role in healthcare – diagnosis and treatment should be available to anyone who wishes to share their medical record with a physician via phone. This improves access, saves money, and is the way of the future, he argues.
He is right that it costs less to call a stranger and receive a prescription via phone than it does to be examined by a physician in an office setting. But he is wrong that this represents quality healthcare. As I wrote in my last blog post, much is learned during the physical exam that you simply cannot ascertain without an in-person encounter. Moreover, if you’ve never met the patient before, it is even more likely that you do not understand the full context of a patient’s complaint. Access to their medical records can be helpful, but only so much as the records are thorough and easy to navigate. As the saying goes: garbage in, garbage out. And with EMRs these days, auto-populated data and carry-forward errors may form the bulk of the “narrative.”
Telemedicine works beautifully as an extension of a previously established relationship. Expanding a physician’s ability to connect with his/her patients remotely, saves money and improves access. But bypassing the personal knowledge piece assures lower quality care.
I currently see patients in the hospital setting. I run a busy consult service in several hospital systems, and I have access to a large number of medical records, test results, and expert analyses for each patient I meet. Out of curiosity, I’ve been tracking how my treatment plans change before and after I meet the patient. I read as much as possible in the medical record prior to my encounter, and ask myself what I expect to find and what I plan to do. When medical students are with me, we discuss this together – so that our time with the patient is focused on filling in our knowledge gaps.
After years of pre and post meeting analysis, I would say that 25% of my encounters result in a major treatment plan change, and 33% result in small but significant changes. Nearly 100% result in record clarifications or tweaks to my orders. That means that in roughly 1 in 4 cases, the patient’s chief complaint or diagnosis wasn’t what I expected, based on the medical record and consult request that I received from my peers.
If my educated presumptions (in an ideal setting for minimizing error) are wrong 25% of the time, what does this mean for telemedicine? The patient may believe that they need a simple renewal of their dizziness medicine, for example, but in reality they may be having heart problems, internal bleeding, or a dangerous infection. Let’s say for the sake of argument that the patient is correct about their needs up to 75% of the time. Are we comfortable with a >25% error rate in healthcare practiced between strangers?
Goodman’s cynical view of the Texas Medical Board’s blocking of telemedicine businesses for the sake of preserving member income does not tell the whole story. I myself have no dog in this fight, but would side with Texas on this one – because patients’ lives matter. We must find ways to expand physician reach without eroding the personal relationship that makes diagnosis and treatment more customized and accurate. Texas is not returning healthcare “to the middle ages” but bringing it forward to the modern age of personalized medicine. Telemedicine is the right platform for connecting known parties, but if the two are strangers – it’s like using Facebook without access to friends and family. An unsatisfying, and occasionally dangerous, proposition.
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The digital revolution in healthcare has transformed most hospitals into EMR-dependent worksites, dotted with computer terminals that receive more attention than the patients themselves. I admit that my own yearning for the “good old days” was beginning to wane, as my memory of paper charting and a patient-focused culture was becoming a distant memory. That is, until I filled in for a physician at a rural hospital where digital mandates, like a bad zombie movie, had bitten their victim but his full conversion to undead status had not been completed. At this hospital in its “incubation period,” electronic records consisted of collated scans of hand-written notes, rather than auto-populated templates. I’m not necessarily recommending the return of the microfiche, but what I experienced in this environment surprised me.
1. Everyone read my notes. Because everything I wrote was relevant (not just a re-hash of data from another part of the medical record), reading became high-yield. Just as people have adapted to ignoring internet advertising (Does anyone even look at the right hand rails of web pages anymore?), EMR-users have become accustomed to skimming and ignoring notes because the “nuggets” of useful input are so sparse and difficult to find that no has time to do so. The entire team was more informed and up to date with my treatment plan because they could easily read what I was thinking.
2. I was able to draw diagrams again. Sometimes a picture is worth 1000 words – and when given a pen and paper, it is great to have the chance to quickly draw a wound site, or visually capture the anatomical concerns a patient may have, or even add an arrow, underline, or circle for emphasis. Thorough neuro exams are so much easier to document with stick figures and motor scores/reflexes added.
3. I could see at a glance if a consultant had stopped by to see a patient. It used to be customary for specialists to leave a note in the paper record immediately after examining a patient. If they didn’t have time to jot down a full consult, they would at least leave me their summary statement – with critical conclusions and next steps. It was a real time-saver to know when a consulting physician had evaluated a patient and get their key feedback if you missed them in person.
Nowadays consultants often see patients and order tests and medications in the EMR without speaking to the requesting attending physician. It may take days for their notes or dictation to show up in the electronic medical record, and depending on the complexity of the system, they may be nearly impossible to find. The result is redundant phone calling (asking the consultant’s admin, NP, PA etc. if they know if he’s seen the patient and what the plan is), and sometimes missed steps in the timely ordering of tests and procedures. At times I simply resort to asking the patient if Dr. So-And-So has stopped by, and if they know what he was planning to do. This doesn’t inspire confidence on the patient’s part, I can tell you.
4. I could order anything I wanted. EMR order entry systems force you to select from drop down menus that may not reflect your intentions. When you have a pen and paper – imagine this – you can very clearly and accurately capture what you’d like to order for the patient! There is no confusion about drug taper schedules, wound care instructions, weight bearing status, exercise precautions. It’s all as clear as free text. You can even explain why substitutes are not acceptable, thus heading off a follow up pharmacist call.
5. The patient became the focus. Since I didn’t need to spend all my time entering data into a computer system in real time, I was able to focus more carefully and clearly on the patients. My attention was not constantly being distracted by EMR alerts, unimportant drug interaction warnings, or forced entry of irrelevant information in order to complete a task. I felt more relaxed, I had more time to think, and I got more important work done.
In conclusion, it is obvious to me that we have a long way to go in making EMRs fit our natural pre-zombification hospital workflow. At the very least, we should be developing the following tools:
1. We need better ways to separate the signal from the noise. Even something as simple as a different font color for the new information that we doctors enter (in a given progress note) would help the eye latch on to what’s important. There should be a simple, visual way to distinguish between template and free text.
2. We need a pen feature that allows authors to signify emphasis. Wouldn’t it be nice if there could be an overlay that allowed us to circle words or add arrows or underlines? If the TV weather man can do this on his digital map, why can’t EMRs allow this layer? For example, physicians would like to circle lab values that are changing, and indicate the direction of change.
3. We need boxes where we can draw diagrams. A simple tablet function would be easy enough to enable. Sure it would be nice to have a stylus, but I’d settle for mouse or track pad entry. This is not a feature of most EMRs I’ve used, but could easily become one. Perhaps not everyone will want to use this feature, but for the artistic among us, it would be a god-send.
4. We need a Four-Square check in type feature so that physicians immediately know if their patient has been seen by the requested consultants. Their impressions should be quickly accessible (perhaps with a voice text to the ordering MD) while their formal consultation notes are grinding their way through the system days later.
5. We need to pare down the unnecessary EMR alerts, and off load data entry required to meet billing requirements to non-clinical staff. Physicians need to focus on their patient care, not spin their wheels figuring out coding subtleties and CMS documentation requirements that could be completed by others.
6. We need more flexibility in data order entry – so that treatment intentions are captured, not forced into an ill-fitting box. Currently, physicians are finding ways to free text their orders in bizarre “work arounds” just to get them on the record somewhere. This is a recipe for disaster, as lost orders are fairly commonplace when staff aren’t on the same page regarding where to look for free text orders. I feel badly for the nurses, since “note to nurse” seems to be the favored way to enter a complicated pharmacy order.
I am grateful that I got one last look at hospital care as it used to be – so that I can put my finger on why our new digital system is not working well. I just hope that my suggestions help to make processes better for all of us medical zombies in the new digital world.
More advice for EMR Vendors here.
Pluses and minuses of EMRs.
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Electronic medical record systems (EMRs) have become a part of the work flow for more than half of all physicians in the U.S. and incentives are in place to bring that number up to 100% as soon as possible. Some hail this as a giant leap forward for healthcare, and in theory that is true. Unfortunately, EMRs have not yet achieved their potential in practice – as I have discussed in my recent blog posts about “how an EMR gave my patient syphillis,” in the provocative “EMRs are ground zero for the deterioration of patient care,” and in my explanation of how hospital pharmacists are often the last layer of protection against medical errors of EPIC proportions.
Considering that an EMR costs the average physician up to $70,000 to implement, and hospital systems in the hundreds of millions – it’s not surprising that the main “benefit” driving their adoption is improved coding and billing for reimbursement capture. The efficiencies associated with access to digital patient medical records for all Americans is tantalizing to government agencies and for-profit insurance companies managing the bill for most healthcare. But will this collective data improve patient care and save lives, or is it mostly a financial gambit for medical middle men? At this point, it seems to be the latter.
There are, however, some true benefits of EMRs that I have experienced – and to be fair, I wanted to provide a personal list of pros and cons for us to consider. Overall however, it seems to me that EMRs are contributing to a depersonalization of medicine – and I grieve for the lost hours genuine human interaction with my patients and peers. Though the costs of EMR implementation may be recouped with aggressive billing tactics, what we’re losing is harder to define. As the old saying goes, “What good is it for someone to gain the whole world, yet forfeit their soul?”
|Pros Of EMR
||Cons Of EMR
|Solves illegible handwriting issue
||Obscures key information with redundancy
|Speeds process of order entry and fulfillment
||Difficult to recall errors in time to stop/change
|May reduce redundant testing as old results available
||Facilitates excessive testing due to ease of order entry
|Allows cut and paste for rapid note writing
||Encourages plagiarism in lieu of critical thinking
|Improves ease of coding and billing to increase reimbursement
||Allows easy upcoding and overcharging
|Reminds physicians of evidence-based guidelines at point of care
||Takes focus from patient to computer
|Improves data mining capabilities for research and quality improvement
||Facilitates data breaches and health information hacking
|Has potential to improve information portability and inter-operability
||Has potential to leak personal healthcare information to employers and insurers
|May reduce errors associated with human element
||May increase carry forward errors and computer-generated mistakes
|Automated reminders keep documentation complete
||May increase “alert fatigue,” causing providers to ignore errors/drug interactions
|Can be accessed from home
||Steep learning curve for optimal use
|Can view radiologic studies and receive test results in one place
||Very expensive investment: staff training, tech support, ongoing software updates, etc.
|More tests available at the click of a button
||Encourages reliance on tests rather than physical exam/history
|Makes medicine data-centric
||Takes time away from face-to-face encounters
|Improved coordination of care
||Decrease in verbal hand-offs, causing key information to be lost
|Accessibility of health data to patients
||Potential for increased legal liability for physicians
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A physician friend of mine posted a copy of her Medicaid reimbursement on Facebook. Take a look at the charges compared to the actual reimbursement. She is paid between $6.82 and $17.54 for an hour of her time (i.e. on average, she makes less than minimum wage when treating a patient on Medicaid).
The enthusiasm about expanding Medicaid coverage to the previously uninsured seems misplaced. Improved “access” to the healthcare system via Medicaid programs surely cannot result in lasting coverage. In-network physicians will continue to dwindle as their office overhead exceeds meager reimbursement levels.
In reality, treating Medicaid patients is charity work. The fact that any physicians accept Medicaid is a testament to their generosity of spirit and missionary mindset. Expanding their pro bono workloads is nothing to cheer about. The Affordable Care Act’s “signature accomplishment” is tragically flawed – because offering health insurance to people that physicians cannot afford to accept is not better than being uninsured.
After all, improved access to nothing… offers nothing. Inviting physicians to work for less than minimum wage so that politicians can crow about millions of uninsured Americans now having access to healthcare, is ridiculous. Medicaid expansion is widening the gap between the haves and the have-nots. The saddest part is that the have-nots just don’t realize it yet.