Letters to the Editor

Issues with time, then ICD-10

I read the column by Robert Centor, MD, MACP, “Excellent internal medicine takes time,” in the February ACP Internist. Dr. Centor's good intentions aside, for the last 20 years of my 35 years as an internist, I've heard the commentary about how spending quality time with our patients, our most valuable “tool” and in their view a real quality metric, continues to be ignored as a standard by insurers and Medicare. Unfortunately, these (I hate to say tired) statements from numerous physicians in leadership positions have resulted in no notable actions.

Dr. Centor posits that the current payment model impairs our ability to provide good care and reassures us that ACP will persevere to promote this issue. What is quite clear, however, is that the insurers and Medicare are not listening. Their strategy is valid: Continue to ignore us, as organized internal medicine has shown no inclination/action to fight back.

We must also acknowledge the astounding lack of support (actually, the complicity with the payers) of the large institutional health care providers who employ so many of us, and who, despite talk of payment reform and quality contracts, continue to worship at the altar of the almighty relative value unit and demand/threaten us to meet productivity targets (more visits and relative value units, less time with patients) to maintain our salaries.

If internal medicine's leadership is limited to complaining, we will never see positive change. I don't have a discrete answer or plan, but I suggest ACP leadership urgently devote time and resources to developing a proactive, action-based strategy to address this critical patient care issue that is the core of what we do.

Next, I, and I suspect other primary care internists, do not share Brian Outland's enthusiasm for ICD-10, which he discussed in the February column “ICD-10 changes looming amid a modern medical landscape.”

Prior to completing a tedious, redundant, and marginally relevant 9-hour, web-based ICD-10 training course mandated by my institution, I thought of ICD-10 as another uncompensated chore consuming valuable time better spent with patients. I was wrong. After the course, several troubling themes emerged. ICD-10 is said to improve patient care and outcomes and reduce costs of care, yet no evidence is presented to support those contentions. Even ICD-10 proponents, justifying pressuring physicians to prepare now for ICD-10 implementation, grudgingly warn of reduced productivity, increased practice management costs, and time-consuming responses to endless coding “queries” until physicians and coders become more facile with it. I don't need evidence to believe that!

The course posited ICD-10 as a communication tool for physicians and payers, rather than a tool for care providers to communicate. It also stated that ICD-10 will insure that clinicians are more accurately (not necessarily better) paid for their work. With increasingly constricted health care budgets and pressures to reduce costs, I think it is unlikely that ICD-10 will increase compensation; more likely, it will “microredistribute” payments. So is ICD-10 another payer-demanded chore to support coding/billing rather than a tool to enhance patient care? My EMR experience has not enhanced communication with fellow physicians. It is hard to believe that integrating ICD-10 into the EMR will help. Some, perhaps many, view ICD-10 as a “solution in search of a problem.”

ICD-10, in addition to demanding markedly increased specificity of documentation, also requires remarkable certainty of consequence and cause. How certain am I of the cause of a patient's headache or abdominal pain after an initial 20-minute visit, or that any condition is absolutely a consequence of a certain disease? Internal medicine is often the home of many a symptom without an obvious cause.

Last and most practically, who will actually code? Will it be the physicians, or payrolled, office-expensed coders? If a physician's task is to document, why should I be tediously educated on the nuance of 150 different diabetic codes?

Physicians in Europe seem to get along well with ICD-10, but ICD-10 and their electronic medical records are not tethered to payers and payments, thus minimizing the burden. I fear that ICD-10 in the U.S. will evolve to another administrative cudgel wielded by the insurers and Medicare. If primary care leadership doesn't get out in front of proper implementation, and if ICD-10's track record does not inspire confidence, it will not be surprising to find primary care, again as usual, the most heavily burdened by it.

Michael E. Miller, MD, ACP Member
Boston

Dr. Centor responds:

Dr. Miller challenges ACP leadership, referring to the time issue, to develop “a proactive, action-based strategy to address this critical patient care issue that is the core of what we do.” In fact, ACP is developing policy papers and lobbying strategies to address a variety of regulations that create significant administrative burdens. We have elevated this problem to a major priority both this year and for the coming year. We hear your complaints and both understand them and will do our best to act on them.

Editor's Note: Dr. Centor is the outgoing Chair of the Board of Regents. His term expires at the conclusion of Internal Medicine Meeting 2015 in May. His opinions do not necessarily reflect the positions of the American College of Physicians.

Physician burnout and the Canadian experience

There has been a stream of articles describing the unhappiness of American physicians and the adverse practice environment, as described in “Students and residents are also burning out” in the January 2015 ACP Internist. Among other things, time-consuming electronic medical records (which are designed to dot the i's and cross the t's for medical billing and audits rather than for patient care) and productivity demands (including the expectation to order blood tests and imaging and generate referrals) contribute to the stress experienced by American physicians. Clinical evaluation, including taking a careful history and spending the time needed to talk to patients, has been pushed into the background. Instead, assembly-line medicine demands high turnover and additional investigations in an attempt to compensate for clinical deficiencies.

I have recently returned to Canada after practicing in the United States for almost 20 years and what a difference! I am once again obtaining fulfillment from the practice of medicine, and my colleagues in different specialties seem to be just as fulfilled. Among the factors that account for the difference:

1. Perhaps most important, most physicians here are self-employed and are therefore not responsible to hospital administrators for “productivity goals.”

2. Although there is a single payer in my province (Ontario), the fees allow for payment for time and complexity to some degree.

3. Electronic medical records are much more designed for clinical practice, rather than a defense against audits or lawsuits.

4. Sham peer review, the potential scourge of the employed physician, does not exist.

5. Maintenance of competence, for whatever it's worth, is more flexible and can be tailored to the specific clinical practice. Large extractions of income and time are not built in.

Altogether, I am once again deriving personal satisfaction by helping patients. Unfortunately, without a total reconstitution of the structure of medical practice in the United States, the prognosis does not look good south of the border.

Clive Sinoff, MD, FRCPC, ACP Member
Vaughan, Ontario, Canada