The Practice of Medicine — Hazy or Invisible Lines

I went to college to compete in Division I cross country and track. After my sophomore season, it became clear that this would not be my future, so I committed myself to becoming a physician.

This new journey led me first to medical school followed by neurology residency, clinical practice, board certification, and staged academic advancements. While these various milestones were associated with graduation pomp and circumstance, much like the finish lines of the races I was used to, they were much more arbitrary. After 30 years of medical practice including considerable introspection and consternation, I have accepted that these finish lines I crossed before becoming a seasoned, practicing physician were merely mile markers. I was no more a doctor the day after I graduated from medical school than the day before. Likewise, there was still tremendous learning ahead after my board certification and continued maturation to this day.

This realization regarding the somewhat arbitrary nature of the finish lines in my personal career has led me to think about the application of such markers across the healthcare system. In particular, the integration of the electronic health record (EHR) into medical practice has occurred during my 30-plus-year career and has, in some ways, been complicated by the confusion between finish lines and mile markers.

These unforeseen twists and turns have frequently originated secondary to onerous governmental regulations, cost-containment private health insurance (PHI) contracts, and the development and evolution of the EHR, which I will elaborate upon, have created previously unbeknownst practice of medicine challenges with unbeknown finishing lines. Additionally, they have contributed to the growth of the number of healthcare administrators (suites) far outpacing the growth of the number of physicians (white coats) and, at times, adversely affected the medical practice environment and physician morale.

Despite herculean, admirable, and sustained effort promoting EHR adoption worldwide, the goal of improving quality of care, patient outcomes, reduction in medical errors, and improved communication among healthcare providers and patients has clearly not been achieved. The EHR is associated with physician burnout (B), usability (U), interoperability (I), and likability (L) issues, lacking productive physician direction (D) — or simply: BUILD it better.

Much interaction with EHR is frequently less than ideal. I sometimes hesitantly introduce the EHR computer to the innocent, unknowing patient, hoping and wishing they feel comfortable and heard and respect its presence, as I contemporaneously attempt to direct my attention to it and them. I, too, experience EHR distractions including confusing and unnecessary medical record notes, tech glitches and interruptions from the screen and its complicated spiderweb of tabs, buttons, links, and obscure prompts. “Meaningful use” criteria periodically make the patient evaluation and treatment starting line hazy and the finish line invisible.

My first professional taste of federal government involvement affecting the practice of medicine occurred in the early ’90s, precipitated by the resource-based relative value scale (RBRVS) created to provide a standard system of paying physicians’ services based on resource costs associated with patient care. The resource components are physician work, practice expense, and professional liability insurance resulting in payments, unfortunately based on effort rather than effect. Payments are calculated into relative value units (RVUs) based on recommendations by the American Medical Association/Specialty Society Relative Value Scale Update Committee, colloquially referred to as the RVS Update Committee (RUC), which is largely privately run. RBRVS presently serves as a foundation of the Medicare Fee Schedule system and many PHI plans. RVUs are often structured into physician employment contracts, and there are a plethora of RVU calculations and formulas determining physician reimbursement and compensation, which are not entirely straightforward and, too often, lack transparency between administrators and physicians whether intentional or not.

Reflecting on one of Sir William Osler’s most famous essays: “Aequanimitas” — recommending physician imperturbability and equanimity, the RBRVS has ignited debate and fading unanimity especially related to growing adaptation by PHI.

The starting line for evaluation and management coding (E&M) was established by Congress in the mid ’90s to facilitate medical billing by translating physician-patient encounters into 5-digit codes. Physician E&M authentication requires considerable effort, time taken away from the patient, and adds to the documentation requirement to receive insured patient payment. My experience reviewing neurology insurance claims for a global health service company years ago included considerable discussion scrutinizing subjective documentation technicalities, attempting to justify the submitted E&M code. The onerous administrative burden the E&M has created continues to evolve, with no end in sight.

Traditionally, PHI pays physicians at rates generally higher than Medicare, seemingly a reasonable starting line — but billing and collecting PHI payments, considering patient deductibles, coinsurance, and copays, which differ from plan to plan and within plans, has resulted in many physicians departing their independent practices for practice opportunities with hospital- or health system-employed medical groups.

The early 2000s and beyond have been clouded and fraught with prior authorization (PA) requests and issues, primarily impeding timely, efficient, and much-needed vital care. No line in the sand here, with the possible exception that, in general, PHI payers are denying rather than approving many requests. Most physicians report unfavorably that PAs have increased significantly, and many physicians believe the true motivator of PAs is economic benefit to payers, not advantages for patients. Last but not least, medical practice insurance contract negotiation with PHI payers have become more burdensome and, once completed, the signed contract requires ongoing oversight and monitoring.