Ron Ford

Posted in Doc's News

Morning Ron Ford,
I checked on the price of W/C insurance Wednesday and unfortunately because another branch of the Alabama government is trying to put me out of business (medical board) I cannot afford it right now due to legal fees We have a hearing next July 20th, hopefully I will be able to hire them back I layed off another employee Wednesday when checked the price with Craig Ford Now I have total of 3 full time counting me, and 1 part time employees Thanks for being so benevolent Dr H

Alabama Physician Writes Viral Letter Lamenting “Washington’s War Against Doctors”

Posted in Doc's News

A family practitioner from Decatur, Alabama, sent Representative Mo Brooks (R-Alabama) a letter that explained in detail how doctors are being put out of business by government bureaucracy.

For lack of a better phrase, Dr. Marlin Gill characterizes the current adverse environment as “Washington’s war against doctors.”

Here is the video of Mo Brooks reading Gill’s letter. The text of the letter is reprinted underneath.

 
 

Dear Congressman Brooks,

As a practicing family physician, I plead for help against what I can best characterize as Washington’s war against doctors.

The medical profession has never before remotely approached today’s stress, work hours, wasted costs, decreased efficiency, and declining ability to focus on patient care.

In our community alone, at least 6 doctors have left patient care for administrative positions, to start a concierge practice, or retire altogether.

Doctors are smothered by destructive regulations that add costs, raise our overhead and ‘gum up the works,’ making patient treatment slower and less efficient, thus forcing doctors to focus on things other than patient care and reduce the number of patients we can help each day.

I spend more time at work than at any time in my 27 years of practice and more of that time is spent on administrative tasks and entering useless data into a computer rather than helping sick patients.

Doctors have been forced by ill-informed bureaucrats to implement electronic medical records (“EMR”) that, in our four doctor practice, costs well over $100,000 plus continuing yearly operational costs… all of which does not help take care of one patient while driving up the cost of every patient’s health care.

Washington’s electronic medical records requirement makes our medical practice much slower and less efficient, forcing our doctors to treat fewer patients per day than we did before the EMR mandate.

To make matters worse, Washington forces doctors to demonstrate ‘meaningful use’ of EMR or risk not being fully paid for the help we give.

In addition to the electronic medical records burden, we face a mandate to use the ICD-10 coding system, a new set of reimbursement diagnosis codes.

The current ICD-9 coding system uses roughly 13,000 codes. The new ICD-10 coding system uses a staggering 70,000 new and completely different codes, thus dramatically slowing doctors down due to the unnecessary complexity and sheer numbers of codes that must be learned.

The cost of this new ICD-10 coding system for our small practice is roughly $80,000, again driving up health care costs without one iota of improvement in health care quality.

Finally, doctors face nonpayment by patients with ObamaCare. These patients may or may not be paying their premiums and we have no way of verifying this. No business can operate with that much uncertainty.

On behalf of the medical profession, I ask that Washington stop the implementation of the ICD-10 coding system, repeal the Affordable Care Act, and replace it with a better law written with the input of real doctors who will actually treat patients covered by it.

America has enjoyed the best health care the world has ever known. That health care is in jeopardy because physicians cannot survive Washington’s ‘war on doctors’ without relief.

Eventually the problems for doctors will become problems for patients, and we are all patients at some point.

Sincerely yours,

Dr. Marlin Gill of Decatur, Alabama

It is one thing for patients to bring their grievances to Washington. It is quite another when upstanding doctors enter the fray.

Will Washington listen or do anything to help doctors? Probably not. But at least the truth is finally being made known to American citizens.
 

The disturbing confessions of a medical scribe

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As a medical scribe working with a large, well-known scribe company, unnamed to protect my job, it makes me proud reading all the articles published about how much having a scribe benefits a physician, especially in the emergency department. I enjoy my job immensely and I am grateful for the opportunity to learn and engage in patient care. However, as a pre-medical student working next to several other doctor-hopefuls in a high stress environment, being a scribe frustrates me on an ethical level.



Let’s examine the structure and reasoning that has made medical scribe programs so successful. When EMR systems were first introduced, there was resistance, but it gave way to the push for efficiency. The biggest benefit of EMRs is easy: risk management. By allowing for documentation of every little part of a patient’s care, EMRs significantly decrease the risk of mistakes slipping through the cracks. It allows for better defense of the physician’s medical decisions, even months down the line.

For example, a physician I worked with was asked to go to court for a patient who had been assaulted by her boyfriend. The patient had been seen several months ago in the ED. Few physicians would be able to remember all the details of an encounter so long ago. His testimony was therefore entirely based on the medical chart, written by me and approved by him. The EMR allowed for comprehensive, detailed documentation of test results, discussions with the patient, and interactions with the police.

Unfortunately, such comprehensive medical records take time and effort to write. Physicians complain that they were becoming little more than data entry specialists, dedicating large portions of the time they should be spending with patients to clicking buttons. In comes the scribe. Usually students or recent graduates interested in becoming a medical provider, we become the physician’s right hand. Scribes are purported to decrease physician burnout considerably and increase ED efficiency. Better documentation also leads to better billing, so hospitals make more money. The physicians I work with, in a hospital who has been using scribes for over 3 years now, have all been grateful for the program.

Sounds great, right? The winning combination of EMRs and scribes. The road to increased efficiency, increased Press-Ganey scores, increased billing accuracy, increased fraud, increased profits for the administration. Happiness abounds.

How many of you missed the “increased fraud”?

Medical billing is based off charting and documentation, and that can have different levels. Level 5 charts are billed the most, when the provider offers the higher level of care. Ideally, EMRs make documentation more accurate, allowing for more level 5 charts for medical coding and billing. But when all it takes is a few buttons to increase your billing, how many physicians submit to small temptations and conveniences?

In Epic’s CareConnect, a widely used EMR, there is a small button that, when pushed, indicates the physician has counselled the patient to stop smoking. It adds a small amount ($20-30) to the billing, and the physician makes a little more.

I’ve been told by physicians, “If the patient is an active smoker, just click that button about the counselling.” Most of the time, the patient is counselled. Sometimes though, they aren’t. But if that button isn’t pressed, eventually, it comes back onto me.

“I told you to press it, so just press it.” At which point, I protest, “But you didn’t counsel them.”

The physician responds, “You probably just weren’t paying attention.” Or “It’s okay, just click it anyways.” As a “good” scribe, I don’t say anything and I click the button.

Similarly, physicians can make “macros” which autopopulate certain parts of the chart, such as the physical exam. It’s nice and saves time, and it is usually accurate. It ensures that there are enough areas input for the physical exam for the chart to be level 5. But sometimes, the physicians don’t do everything their macro says they’ve done. In those cases, I go in and take out the inaccurate information. Sometimes, I’m told to just leave it, that I must have missed when they did it.

How do I know it’s not me? Because as the physician’s right hand, I have been with them the entire shift, even during any breaks they take. I have paid incredibly close attention to everything they say or do so my charts are as complete as possible. That’s my job. I know they did not counsel the patient. I know they did not ask for social history. I know they did not listen to the patient’s heart rhythm or breath sounds. I know every time I “just leave it,” I am lying in a medical document.

I don’t blame the physicians. The pressure on physicians from the administration is incredible. If a physician only charts what they has done, that means their charts sometimes don’t reach level 4 or 5. When that happens too often, administration comes down, and they’re told to write better charts. They lose money when their charts get downcoded.

So what do they do? They click a few extra buttons for that higher level chart, because they’re seeing so many patients in a shift and it’s that much easier to just click a few buttons than double the time in a patient’s room when there are other acute patients waiting. Considering how much debt physicians are straddled with as a result of the insane cost of medical education, it’s clear why that extra $20 per patient counselled is so easy.

These are small, tiny transgressions. In the grand scheme of things, it probably does not matter that that the patient did not actually get counselled about smoking cessation. But small things add up and in the end, the burden of all this comes back onto the patient. More importantly, if thousands of small lies are okay and never brought to light, how many bigger lies are out there, hidden by convoluted billing, poor memories, and a healthcare system that lacks any semblance of transparency?

I will never regret being a scribe — as I prepare to apply to medical school, I know my experience as a scribe will be a core piece of my application. I am lucky to have this opportunity. I am also a person with bills to pay, and I don’t want to lose my job. As a “good” scribe, I understand that the chart I am writing is ultimately a reflection of the physician, and therefore at the end of the day, I will write whatever the physician wants me to write. It isn’t my job to say no. Whether or not it’s my responsibility to is undecided.

The author is an anonymous medical scribe.

Don’t take the damn EMR into the exam room

Posted in Doc's News

|TECH|

Do you believe that I have to mention this?  I can’t believe it either but since the advent of the EMR, this seems to be an issue; a really big issue.  Amazingly enough, you are there, as a doctor, to treat the patient and not the computer.  You would think it was the other way around with all the bogus quality indicators, meaningful use baloney and pay-for-performance nonsense being stuffed down our throats, but don’t let those who are now in charge of healthcare fool you.  It really is about the patients.



I am on my third EMR system but I never let the computer enter the room with me.  In other words, I preview the chart and then go in naked.  Ok, I wear a stethoscope but that is it.  Why?  Because I want to look the person in the eye.  Yes, you read that right, look at the patient.

Human beings are interesting animals.  They kind of like to interact with other humans, which includes their doctor.  Staring at the computer screen interferes with that.  Patients want to feel important.  They want to feel listened to. When you look at the patient, you acknowledge that.  You also listen better.  When you turn to the EMR screen, you don’t.  You may try to listen to them, but you are obviously searching the chart or typing in some information or prescribing a drug and guess what the patient is doing?  He is either still talking or he is getting his own thoughts interrupted.  This is not good care no matter how you rationalize it.

Maybe you are better than I am.  Maybe you can bring your laptop into the room and really isolate the interview part of the visit by truly listening fully to the patient and not turning to the EMR, who, by the way, is screaming at you inside his or her head, “Look at me!”

If you can pull this off then good for you.  It does not work for me.  Most of you, however, are like me and will succumb to the temptation of turning to the damn computer too early.   Sure, you will promise yourself you won’t.  You will fight the pull as hard as you can and maybe you will succeed for the first few patients of the day.  Unfortunately, your willpower will weaken and you will start cheating.  Trust me, once that happens there is no going back for anyone else on your schedule.  Been there, done that.  Listen to me, don’t take the damn EMR into your room. If it is already there, shut it off.

Yes, we all need EMRs.  Yes, with my way of not bringing the EMR into the room makes me leave at times to check on things but it also allows me space to think, time to look up stuff that I don’t know, and also stops the patient from interrupting me with more complaints that just popped into his or her head.

Lastly, if you would ask an old-time doctor whether looking at the patient was difficult to him then he would probably answer no and wonder whether you were an idiot.  And he would do this the whole time while … looking at you.

The Road to Serfdom is Paved with Good Intentions

Posted in Doc's News

by Marilyn M. Singleton, M.D., J.D.

What do TSA groping, NSA data-mining, and mercury-laced fluorescent light bulbs have to do with keeping your doctor? They are the products of seductively entitled but flawed laws. As Daniel Webster said, “good intentions will always be pleaded for every assumption of authority.”

The Transportation Security Administration and the National Security Agency restrain our liberty under the auspices of the Uniting and Strengthening America by Providing Appropriate Tools Required to Intercept and Obstruct Terrorism Act of 2001 (PATRIOT Act). The Energy Independence and Security Act is phasing out incandescent bulbs.

The Patient Protection and Affordable Care Act (ACA/ “ObamaCare”) sounds as though our best interests were at the heart of the legislation. But so far, the 400,000-word law that nobody read has spawned some 12 million words in regulations. Now these regulations that even fewer people read are coming between you and that doctor you were promised you could keep.

The modern-day mission creep began with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). To “safeguard the privacy of protected health information,” HIPAA’s Administrative Simplification Standard mandated the use of the National Provider Identifier (NPI) for “covered entities,” i.e., those who electronically transmit health information.

The NPI extended its reach to “non-covered” physicians who neither sent nor intended to send claims for services they furnished to private insurers or government programs. Without an NPI on the paperwork to refer patients for diagnostic testing, a claim could be denied. Obtaining an NPI was a small concession to Big Brother for physicians who were not enrolled in the Medicare program. After all, even if their patients chose to pay their personal doctor out of pocket, they had paid their Medicare premiums and deserved the benefit of that insurance for other services and supplies.

For the overlords at Medicare, an NPI was no longer sufficient. The ACA specifically requires physicians/practitioners to enroll in or officially opt out of the Medicare Program to order medical supplies and home health services and have these claims accepted. To “ensure program integrity,” a gem of a catchall ACA provision (section 6405(c)) gives the Secretary of Health and Human Services (HHS) unilateral authority to extend this mandate to “all other categories of items and services.”

Wasting no time, HHS added clinical laboratory and radiology tests to the mandate via regulations. Despite the longstanding policy of approving prescriptions dispensed under applicable state law, a new ACA-proposed rule adds medications covered by a Medicare Part D drug plan to the enroll/opt-out mandate. Physicians are bullied into bowing at the altar of bureaucracy or having Medicare deny payment for their patients’ claims for pharmaceuticals and other providers’ services.

So to protect their patients financially, physicians acquiesce to more rigmarole. In short, opting out requires making payment contracts with each patient that must be available for inspection, and filing a 12-point affidavit with the government. The entire process must be repeated every two years.

And add this little buried nugget to the pile. Next year, health plans may only contract with providers who have “mechanisms to improve health care quality as the Secretary may by regulation require.” Only Heaven knows how this will work. The current “voluntary” Physician Quality Reporting System forms are so complex that despite the specter of financial penalties few physicians respond. Studies have shown that the government with its mainly process-oriented quality measures differs with patients in their perceptions of quality care. Indeed, the government cautions that completing forms is no substitute for local quality-improvement efforts.

Physicians are regulated and disciplined by the medical boards of the states in which they practice. Nonetheless, the federal government wants to track physicians with their own Medicare GPS. Whether enrolled or opted out, the government’s mission is accomplished: controlling physicians through layer upon layer of paperwork.

The effort to control physicians and patients’ choices one rule at a time is backfiring. Patients are seeking out “high value” physicians who are willing to be innovative in providing individualized care and affordable payment options. They know that real “administrative simplification” is bypassing the middlemen with an open market that has transparent costs.



Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and Association of American Physicians and Surgeons (AAPS) member. Despite being told, “they don’t take Negroes at Stanford”, she graduated from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. She was an instructor, then Assistant Professor of Anesthesiology and Critical Care Medicine at Johns Hopkins Hospital in Baltimore, Maryland before returning to California for private practice. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers. Dr. Singleton recently returned from El Salvador where she conducted make-shift medical clinics in two rural villages.

Full Story and more info here