Bureaucracy is a giant mechanism operated by
pygmies. — Honore de Balzac, French novelist
The organizational culture of medicine used to be
dominated by the ideals of professionalism and volunteerism, which softened the
underlying acquisitive activity. The restraint exercised by these ideals now
grows weaker, the ‘health center’ of one era is the ‘profit
center’ of the next. — Paul Starr, author and sociology professor
at Princeton University
We cannot individually, perhaps, build the future of
medicine, but we can resist those changes that threaten the essence of our
profession. Unless the 1-year delay proposed by the Department of Health and
Human Services is accepted, as of October 2013 our practices will have to be
compliant with the new ICD-10 coding structure. If you haven’t heard about
the required transition, you soon will.
William T. Gerson
The latest revision to the International Classification
of Diseases began in the 1990s. Despite recent delays in the implementation
deadline, it is apparent we will be granted no more reprieves from this onerous
and misguided bureaucratic folly. While the offspring of the noble statistical
study of disease first begun in the 16th century, the current version as
worshipped in the United States is phantasmagorical. With five times the number
of codes as ICD-9, no consistent correlation with past codes, and such detail
that the estimate of permanent increase in physician documentation time is 3%
to 4% (for a total now to be 15% to 20% of our time), I’m sure you are as
excited about this change as am I.
Effect on finances
That truth cannot be had without mentioning the
financial effect of implementation. In 2008, Nachimson Advisors, retained by a
number of medical professional organizations (including the American Medical
Association), estimated that the effect on total cost of the ICD-10 mandate for
a typical small practice (three physicians and two administrative staff) would
be $83,290. For a typical medium practice (10 physicians, one full-time coder
and six administrative staff), the estimate is for $285,195. What size are
pediatric practices? Of single specialty practices in the United States in
2010, almost 40% were staffed by fewer than three full-time physicians; an
additional 30% had between three and six full-time physicians (Medical Group
Management Association).
For large practices — your referral hospital,
perhaps — of 100 physicians and their staffs, the cost comes in slightly
south of $3 million. But for this, you get to distinguish between shark and
dolphin bites, and whether the trauma was to the right or the left leg. Good
thing you recently invested in a new electronic health record and likely
welcomed reimbursement limitations, because you can now enjoy even tighter cash
flow in your practice.
Of course, the bureaucratic hope is that your quality of
care will increase proportionately with your angst. I think not. I was taught
that documenting a patient’s story in the chart was the first step in
understanding the patient, the reason they were there and the crucial threads
that you would ultimately weave together in your mind (and later document in
the chart) to uncover the underlying diagnosis. With yet another intrusion into
our exam rooms, I believe we stand to lose the most powerful quality
improvement project we possess — our minds.
Those of us of a certain generation will likely continue
to see patients in the same manner we always have. We will just add the
additional documentation time to the end of our office days, or more
insidiously to our evening and weekend family time — organizationally
efficient but not personally. We might be at home, but unavailable to family
members as we complete our tasks on a laptop on the dining room table. Current
trainees who have had protected time designed into their days will practice
under a new paradigm with efficiency coming from less time spent with the
patient, or more work being done by non-physicians. There is no other option if
efficiency is our paramount goal.
Barry Schwartz, a psychologist at Swarthmore College,
recently wrote in The New York Times of the danger of too much
efficiency. His comments were directed at our economic institutions, including
venture capitalism, but his message has import for the world of medicine.
Increased efficiency is the only way for a nation’s standard of living to
improve and one way for health care to become less expensive — but at what
true cost?
Efficiency as an enemy
Schwartz said friction in all of its forms is the enemy
of efficiency. Organizations, thus, attempt to decrease friction to increase
efficiency. In medicine, we are subject to this same standard, increasingly so
it seems, although we still largely manage to fail. Much of the failure is due
to those physicians who relish friction or even advocate for more. I
congratulate them.
A reference to Aristotle’s ethical doctrine of the
mean is made by Schwartz as he attempts to explain the potential dark side of
efficiency. To Aristotle, ethical virtues lie between extremes. Virtue is
intermediate between states of excess or deficiency, and not as Plato believed
a form of knowledge. Aristotelian ethics has relevance for physicians juggling
the pressures of efficiency. If efficiency is a virtue, then it cannot be
worshipped in excess. Trusting efficiency while discounting friction is a
mistake. Our challenge is to find the mean. Efficiency is important, but
let’s be honest about its implications — both to us and to our
patients.
Equity and access in health care affect how resources
will be used. Advocacy for just, efficient, effective and quality care in
medicine is virtuous. Virtue as a physician, however, lies with our own
autonomy. Maybe we can, and should, force a stop to ICD-10.
References:
Schwartz B. Economics made easy: Think friction. The New York
Times. Feb. 19, 2012;Opinion section:SR5.
- William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Gerson reports no relevant financial disclosures.