In medicine, hardly a week passes without the introduction of some new acronym, previously unspoken in the average practice, which then grows to prominence — take HIPAA, PECOS, CPT, ICD, etc. — the list goes on and on.
I believe that after 14 years of practice I’ve earned the right to introduce an acronym of my own: CRAPP. For the last several months, my partner and I have used this term to describe the volumes of denials, pre- and prior- authorizations (is there really a difference?), and faxes that seem to grow like weeds on the fertile planting grounds of our desks.
More specifically, in our office the acronym CRAPP stands for: Continuous Restrictive And Punitive Paperwork. To put it blithely, CRAPP could represent any document you wish someone had put on your partner’s desk instead of yours.
On a more emotional level, this acronym captures the visceral response I have whenever my attention is drawn away from my patients and redirected towards some nonsensical busywork — much like someone yelling at a golfer during their backswing.
One does not have to explain to you that a piece of paper in your hands is CRAPP; you know it when you see it. If an office worker scurries away apologetically after putting a piece of paper on your desk, it might be CRAPP. If your good mood evaporates and is replaced by a confused affect after reading the first two sentences in a never before seen type of document, it might be CRAPP. If a fax makes you revisit a clinical decision you have made over and over again, well by now you should get the point so I’ll leave the Jeff Foxworthy cadence aside.
Last Monday began with a document denying a brain MRI for a patient suffering for almost two years from headaches because I was not “in the system.” Setting aside the visual image of being drawn into someone’s system, I remembered that I had previously answered all their medical questions explaining the reasons my patient needed this MRI and my staff had faxed the entire medical record to them the preceding week. So, I answered all the personal questions confirming my qualifications and shared the collection of numbers unique to me (NPI, UPIN, Tax ID #, etc.) thus, finally, enabling my patient to have the MRI without paying for it himself.
As I walked this completed document to the office fax machine, my attention was drawn to the letterhead on the fax: “Medical Solutions.” In a moment of clarity, I conceived the second rule of CRAPP (the emotional loss of focus being my first rule). The second rule identifying a document as CRAPP: if the antonym of the company name accurately describes the process a document has set in motion it might be CRAPP. My thesaurus listed muddle as the antonym for solution and the second rule of CRAPP had passed its first test.
Which brings me to the heart of it all: We’ve all heard that “two’s company and three’s a crowd.” Well, the doctor-patient relationship is crowded with a third “partner” that is always present, whether you think of them or not. This invisible partner makes its presence known in innumerable ways, robbing busy doctors of an always rare daily resource: Time.
CRAPP steals time from our patients and takes away from the quality of the practice of medicine and in large part explains the growing shortage in primary care medicine doctors. I would like to tell you that it will get better with the new reform bill. However, I suspect Uncle Sam and the insurance industry will be spreading CRAPP much like Johnny Appleseed spread his famous seed.
Until next week, I remain yours in primary care,
Steve Simmons, M.D.