The Paper Chase

Back when Facebook was a new exciting thing, you’d have these outraged stories pop up once in a while, complaining about the way that Facebook kept changing their privacy settings, gave out their data to advertisers, and generally wasn’t that concerned about their privacy. The most cogent response I heard was that these users weren’t paying Facebook money, so they shouldn’t be too surprised that the company had to figure out how to find revenue elsewhere. “If you’re not paying money,” they said, “you are not the consumer. You’re the product.”

Well, when patients are in the hospital, they’re usually not the ones paying their own bills. And in many little ways, the way healthcare is set up really drives home the point that patients are not the consumer. The insurance companies are the consumers.  The patients are the products.

The simplest way to see this is just to look at how doctors spend their time throughout the day. The average day in a hospital looks something like this. I get in around 6:30 AM, get the report from the night intern about what happened with my patients overnight, and have a quick meeting with my resident about the plan for my patients that day. I then take an hour or so to examine all of my patients in person, giving them a little update on their status and our plans but spending no more than 10 minutes per patient. Most of the rest of the morning is then taken up with rounding with the attending (our senior supervising doctor), where we once again go over what we think is going on with each patient and what our plan is. Sometimes during these rounds we would actually go and examine some of the patients in question, but more often, we’d simply crowd around a computer or refer to our notes, and just talk about the patient as an abstract cloud of clinical data.

The entire second half of the day is spent in front of a computer. Some of this computer work is part of patient care – keeping an eye out for a crucial lab result, or pulling up an x-ray that was just taken. But mostly, what we’re doing is documentation. Reams and virtual reams of documentation.

In the old days, documentation meant simply scribbling a couple lines on a clipboard at the foot of the patient’s bed. Maybe something like “Bobby, 30 yo M, here with pneumonia.  Continuing IV penicillin (or whatever they used back in those days), appears to be responding.  Will observe for improvement.”  They’d mention any additional orders for the nurses, and move on.  Then as now, doctors were always in a terrible hurry, which is where we got the stereotype of doctors’ terrible handwriting. But each of them had a dozen patients or more apiece.  No matter how fast they scribbled, all this documentation might take a whole hour out of their day.

Nowadays, of course, technology has advanced, and most of our documentation is done on the computer. And with this great leap forward in technology, we call it a good day if we get our notes done in three hours.

What’s in all this documentation?  Well, it’s not the important clinical data – vital signs, lab results, and so on.  Those are recorded by nurses and lab techs – left in much more careful hands than ours.  Rather, what we spend our time on is the paperwork that ensures that the hospital gets paid.  As before, this includes brief reports like the update on Bobby the pneumonia patient.  But it also involves documentation with much less clinical significance – things like a mandatory review of ten organ systems (“Oh hi there Mr. Heart Attack Guy, just for billing purposes, have you had any skin rashes since last night?  Problems urinating?  Anxiety or depression?”) and exquisitely worded diagnoses corresponding to the official ICD-9 table.

These little details mean big money for the hospital.  If a patient comes in with heart failure, and we notice an unrelated ulcer in his buttocks, that nearly doubles the amount the hospital can bill the insurance company.  And so hospitals naturally throw a ton of resources at making sure that every last box gets checked.

This dynamic is also what’s driving the adoption of hugely expensive electronic medical records.  You see, the most part, EMRs are heavily optimized for billing.  Yes, the idealistic talk about electronic medical records revolves around nice-sounding things like improving hospital workflow, having better access for research, and making information portable between hospitals.  But in reality, DOS-level user interfaces abound, many EMRs are inaccessible for research purposes, and almost none of them let you easily take your information to another hospital.  But the one thing that every EMR worth its salt has done is improve compliance with insurance regulations, with hard-coded forms that ensure that every last insurance requirement gets met.  And for that, hospitals are willing to pay whatever it takes.

Back when I was in medical school, Duke signed a contract to purchase Epic, one of the most advanced EMRs, for $700 million.  Now that’s a lot of money, much more than an impoverished resident is used to visualizing.  To put that in perspective, SpaceX, a private rocket company currently sending supplies to the ISS and hoping to send astronauts soon, was founded with an investment of $100 million.  So for what Duke paid for that EMR, you could go to space – seven times over.  And I have every expectation that that was a totally reasonable expense compared with how much Epic will help the hospital improve its billing in the coming years.

But even after this expense, the game is still not done.  Hospitals also hire roving clinical documentation specialists, who virtually peer over our shoulders like English teachers marking up our papers with red ink.  We’d get emails politely inquiring “That patient with heart failure, could you specify whether it’s systolic or diastolic heart failure?” “That patient with a pressure ulcer, could we give a specific grade of pressure ulcer?” Now, to be fair to the documentation specialists, most of their corrections are relevant, and sometimes they’re even clinically meaningful.  But some of them end up sounding hilariously bizarre to medical ears.  I once received a call about a patient whose kidneys had failed and was on dialysis, asking me to specifically “document the extent of her kidney injury” (“Uh, complete and total kidney failure…which is why she’s on dialysis?”)

And for each bit of bureaucracy the hospital adds, with the goal of eking a bit more money out of the insurance company, the insurance company has an equal and opposite piece of bureaucracy, with the goal of denying payment to doctors and hospitals.  Sometimes these denials are for good reason, such as noting that a procedure was unnecessary or that care was substandard.  But often any excuse would do when it comes to saving money.  Some insurance companies throw up clouds of paperwork that need to be done every time an expensive test is ordered, hoping to discourage doctors from ordering those tests for fear of wasting time on that paperwork.  When there’s conflict over whether a procedure should be reimbursed, hospitals and insurance companies alike hire physicians as consultants to help them argue their case.  Like the trenches of WWI, both sides bring incredible resources to bear, and yet the front never moves.  And as residents we just do our duty and try to keep our heads down.

It’s worth emphasizing here that I’m not criticizing doctors or even hospitals for being callous money-grubbing businessmen.  All this effort is absolutely necessary to keep the lights on and be able to continue treating patients who need medical attention.  In fact, it’s a strong endorsement of the ethics of the medical profession that doctors care for patients as well as they do, given the high stakes of the distracting paperwork game.  We still check in on our patients daily, comfort them and address their concerns, and spend considerable time agonizing what treatment would be best for them.  None of this behavior is economically optimal, but we do it because we care.

Still, on a good day I get to spend maybe 20% of my time face to face with patients.  I wouldn’t be surprised if they secretly suspected we all go out golfing in the afternoons.