Are physicians being forced to focus on data over patient care?

This essay is part of Medical Economics' 2013 Physician Writing Contest. Click here to enter the 2014 writing contest.

I have never met a physician who went to medical school to become a business person. The unfortunate truth, however, is that physicians are put into business-minded situations everyday, whether hospital-employed or in private practice, and many without proper training. Despite the best intentions of medical schools, graduates have little preparation for the fiscal realities of medicine and the real world of numbers.

So, how high can you count? Formulas and calculations. Hours and minutes. Dollars and cents. From flashing digits on our alarm clocks to odometers counting the mileage of our daily commutes, numbers keep us moving, pushing us to do more in less time, all in the name of productivity. Though this numeric world may be tantalizing for mathematicians and accountants, for the practicing physician those numbers threaten the foundation of what we do:

• How many hours do you work?  Does your professional life compromise your home life?

• How many relative value units do you generate per session?  Is this above or below preset expectations?

•  Did you use the correct International Classification of Diseases, Ninth Revision (ICD-9) code for billing purposes?  How will you adapt to ICD-10 when it kicks into gear in 2014?

• Did you use proper Current Procedural Terminology codes to bill your office visits?  Are you secure from an audit and the possible fines that could result from one?

• Have you met percentage thresholds for meaningful use?  Pay-for-performance criteria?  Certification for a Patient-Centered Medical Home? How will they affect your revenue?

Every aspect of medical care has become consumed in numeric jargon.  While it is important to acknowledge these factors-our financial viability depends on them-focusing too much on these matters in the moment threatens to weaken the stronghold of medical practice, the patient-physician relationship. Distracted from the job at hand, many physicians cannot separate the cacophony of numbers from the person sitting before them.

WHEN IT DOESN’T ADD UP

Physicians practice in different specialties but they all share the same goal-helping people. If only that task were as easy as it sounds. Certain business models prevent a physician from doing what he or she feels will most benefit patients. Add to that the reality that some patients refuse services, while others demand what is unnecessary and you have a real quandary.

Faced with these challenges on a regular basis, medical providers can easily become disheartened. Too often, a fistful of minutes allotted to a patient visit evaporates and an opportunity to improve the lives of everyone in the exam room-the patient, his or her family, and the physician-dissolves into nothingness. The sad results oftentimes are burnout, cynicism, job turnover, and early retirement.

I once had a patient, Joe, complain about a bill he received for services rendered. To have someone challenge my work ethic and accuse me of overcharging insulted me to the core. Review of his chart showed that he was a new patient and his chart documented a detailed history-medical, surgical, family, and social histories, along with a review of medical records from his former primary care provider.  His blood pressure was acutely elevated. As a result, medications had been prescribed and a 1-week follow-up arranged. Coding guidelines showed that I had qualified for the level of visit I had billed, but to him this was still excessive.

Reflection led me to realize that Joe had a different set of numbers guiding his expectations. He had no understanding of ICD-9; he was not faced with 99214 or modifier 25s. For him, the cost of the office visit in relation to paying his other bills took center stage, the unpaid time he took off from work to attend the office visit. His personal experience had given him a unique set of priorities. For him, the numbers simply did not add up.

Similar feelings of frustration erupt when physicians interact with insurance companies and other payers. Government regulations and the ever-controversial sustainable growth rate formula have kept us up in arms for years. We are no different than Joe. The numbers do not always meet what we deem to be fair, and that is what ignites the need for healthcare reform.

One of the difficulties in modern medicine is its frequent lack of transparency.  Patients do not always realize all we are doing and why we are doing it. Likewise, many providers have not been educated on business models beyond a quick briefing on coding. They are being guided in the direction of accountable care organizations, not necessarily knowing if these organizations will generate long-term success for their practices. Meaningful use and the Patient-Centered Medical Home model are changing the fundamental dynamics of practice, adding to the already demanding numbers crunch.  Many providers simply jump through hoops now so they do not risk financial penalty later.

No one can understand the reasons until the process is explained to them.  As providers, we need to be more transparent with our patients to improve medical outcomes and patient satisfaction. As professionals, we need to seek information that justifies our business models and exemplifies best practices. As gatekeepers for healthcare in America, we need to be advocates on both ends. Unfortunately, we often feel too rushed and pressured to do just that. We are so exhausted we sometimes feel like we are drowning in the numbers. The distraction leads to more patient encounters that heighten anxiety levels for both providers and patients.

FINDING THE ONE

We are only human. Naturally, there will be times when we are overwhelmed by our patients and the external pressures that we face not only in medicine but in every aspect of our lives. What we need to learn is how to spin those unsavory situations in ways that bring us back to our origins, our altruism.

My inspiration first came to me by way of a 14-year-old girl, a sparkly teenager who bubbled with the kind of energy you wish you could bottle and share with the world.  Her name was Jenny. When we met as freshmen in high school, we had no idea her adolescent years would be tarnished by the cruel diagnosis of leukemia 6 months later. While the teenagers around her worried about the latest fashion trends or who would be taking them to junior prom, she struggled through the turmoil of cancer.

I watched her bravely face chemotherapy, watched her lose her flowing locks of hair, watched her oncologist support the family through each stage of treatment, and watched her victory into remission after a bone marrow transplant. I still remember her walking the hallways of our high school to show everyone she was back in the game, strutting as if to the Bee Gee’s “Staying Alive.” Unfortunately, her dream of graduating high school never came to fruition. On December 1, 1992, Jenny passed away.

Many physicians have a story that inspired them to pursue the long years of medical school, the rigors of residency, and beyond. For me, Jenny provoked that instinct to be more than I thought I could be. She brought that out in people. She was not a number. She was the number, the only number that matters-one of a kind. If I could find a way to focus on the one, to release the other numbers when I was with a patient, I knew I could make a world of difference.