Earlier this week there were quite a few questions as to why doctors will perform the same set of tests on a patient even if there is documentation in the file indicating a diagnosis and a status. There are a couple of good reasons for this which are not just ’cause I get paid’ venal motivations. That probably has something to do with it, but as we move to accountable care organizations for all types of insurance as well as population health management, the cash in my pocket incentive decreases.
Mayhew Insurance offers Medicare, CHIP and Medicaid products to our region. Those products are risk adjusted so that plans with really sick members aren’t destroyed. The goal is to minimize the insurers’ incentives to cherry pick through marketing, plan design or hassle factor only healthy people. There are a couple of different risk adjustment methods, but they all rely on claims data with accurate diagnosis codes on the claims. A central processing body will count up the types of diagnosises, evaluate their projected costliness, and spit out a number that determines what type of side payment is needed to balance risk across multiple insurers. Exchange does the same thing.
As an insurer, our goal is to minimize the gap between reported health status via claims diagnosis and actual covered population diagnosis. That maximizes either our revenue gain or minimizes our contribution to the revenue re-allocation. One of the ways we do that is we pull claims data from our members for the several years to identify instances where there was either a diagnosis or a constellation of indicators (prescriptions, procedures etc) that show a costly disease a few years ago but where that diagnosis has not been entered on a claim in the past year. This gap list is then researched. Some of the gaps are coding issues and they are corrected by a sticky note being added to the chart to add diagnosis 250.01 to the known diabetic who is on three diabetes medications. Some of the issues are clinical judgements. For instance a doctor may judge that previously diagnosed manic depression is actually a combination of depression and ADHD which are both coded on the chart. Another case had a member whose disease was miscoded by flipping a 5 for an 8. Those make sense.
And then you get the doozies. A patient will have a code indicating an amputated leg three years ago but the current PCP sent a picture in of the patient with both legs. A patient will have had a diagnosis of multiple scheloris but the current PCP notes MS is not evident and the pharmacy claims backs her up. These are the big and obvious ones that had my minions/interns doing the outreach effort scratching their heads and asking why the data is not neat and clean like the books in college tell them it should be.
Most doctors don’t trust other doctors’ charts. It is not an electronic medical records issue, it is a trust across the profession issue. If a doctor can’t trust a major diagnosis like MS or leg amputation, they’re not going to trust fine details.
If Mayhew Insurance was risk adjusting the private group insurance market using the same methodology, I would show up. In 2013, I was reffing at a summer soccer tournament. It was a good weekend, but on the third game Sunday morning as I was running a line, I felt my left foot go from great to horrendous in three steps. I could not put any weight on it. Two of the other refs working that tournament are atheletic trainers. They checked me out at the ref tent and said it was either a nasty arch sprain or a stress fracture that went from hairline to notable. I needed an X-ray for that to be determined. I left the tournament and drove to an urgent care clinic. I told the doctor that I had intense shooting pain in my left foot. He asked if I had red meat in the past week. I had a great burger on Friday night. He diagnosed me with gout. I told him that two atheletic trainers had looked at me and said it was one of two things, and I knew exactly when my foot blew up on me… nope, it had to be gout, so I got a prescription for an extraordinarily expensive medication (not filled) and a cane.
I went to my PCP on Tuesday, he ordered a urine test to rule out gout, and then checked out my foot. I had an X-ray, and it was a nasty sprain with a month’s worth of physical therapy. For that one year, I would be risk adjusted as gout and be extremely “valuable” for that one year due to a bad diagnosis. Urgent cares and hospital ERs are the primary source of amazingly bad diagnosises but they are not the only source.
Valdivia
everyone wanted to know about Ted Cruz and his purchase of the ACA last night and hoping you could ellucidate, I think by acclamation you might have to do an explainer :)
ETA: I have had my fill of ERs and find it really is hit or miss depending who is on call. So far for the serious stuff we have been lucky.
JPL
Cruz was on CBS yesterday and was asked about ACA. What would he say to the 16 million who signed up on exchanges? He said that number was mostly medicaid who only get crappy insurance anyway.
He also mentioned that six million were kicked off their insurance and now have to buy crappy insurance on the exchanges.
When asked to say one thing that describes his campaign, he said he would always tell the truth.
JPL
Richard, If you have time, you might consider a column called Cruz and the ACA. He gave plenty of material on his beliefs, yesterday on CBS Morning News and Valdivia mentioned his having to buy on the exchanges.
this the link for the CBS interview
Snarki, child of Loki
@JPL: Cruz can always take a quick trip back to Calgary and make use of his Birthright Canadian Healthcare Plan.
Or Cuba, also, too.
Gin & Tonic
@Snarki, child of Loki: He formally renounced his Canadian citizenship.
Gin & Tonic
Richard, WRT to the “gout” issue, I wonder if at some point you could discuss the incentives in the US system as currently practiced, to diagnose not necessarily “inexpensively” (in terms of treatment) but to diagnose quickly. If that urgent care doc said gout, you were out of there rapidly, and that must have some tangible benefit.
I ask because a few years ago I presented with a complicated and relatively uncommon, but not life-threatening infectious disease, and even though I had a good long-term relationship with a primary care practice, it was clear they were trying to diagnose me quickly, and I ended up having to go back three times before they actually looked past generic viral infection and got the damn thing right.
WereBear
Pre-ACA, that gout “diagnosis” would follow you around the rest of your life and make you uninsurable, wouldn’t it?
beergoggles
And this is why I don’t trust doctors to diagnose anything without running tests. I went in for strep throat and the moment they heard I was gay the diagnosis was gonorrhea in the throat. Insisted on a throat swab and the test came back as strep. Ruptured a muscle, went into urgent care and was told it was a sprain and go home and take advil. Next day the whole area was blue from internal bleeding.
I honestly feel more comfortable diagnosing myself and just don’t trust doctors until I can see a test result I can verify for myself. Either any idiot can make it through medical school (see Ben Carson), or doctors just don’t care what they do to their patients and are a bunch of sociopaths.
Violet
Indeed. I was poorly diagnosed for years with several doctors missing a thyroid problem. The worst impact of that was when I had some medical treatment that would (and did) severely impact my thyroid. Honestly, I’m lucky to be alive because by the time I got to the doctor I could hardly get out of bed. Probably wouldn’t have except a person on the internet diagnosed me from my symptoms and insisted I get to the doctor, so I did. I’m forever grateful.
sam
Here’s one. My company switched two years ago from a “standard” insurance policy to one of those high-deductible/HSA policies. In general we all hate it because it means more work on the employee’s end to manage everything, rather than just paying the co-pay and being done with it. I’ve spent significant amounts of time having to straighten out billing snafus on the providers end (I blogged about the worst experience, but it’s been somewhat enlightening in other ways.
For instance, I’ve discovered that my PCP’s billing practices are a bit…unconventional. I went for a routine physical, with some extra bloodwork needed for another doctor. In the old days, this would have been a $20 copay plus whatever the lab charged. Now it’s part of the “free” preventative physical, plus the labwork, plus some random charges for some non-preventative care (not sure why a TB test isn’t included?), but…the billing office submitted 18 separate claims to my insurance company, For one visit. Many of which were duplicates/denied. I finally had to call the office and start questioning them about it (at which point they seem to have stopped). So I guess the whole “consumer-driven” is kind of working there.
the Conster
@beergoggles:
I’ve come to that conclusion too, sadly, that doctors by and large are in it for the money and don’t know how to heal. They study pathology, they have their specialist blinkers on, and really don’t understand what health is and how to get you there without a pharmaceutical. What I’ve been doing when I need a diagnosis is see a doctor and get them to run their tests or scans, then bring the results to the local wellness clinic where the guy has practiced Chinese medicine and nutrition counseling for 30 years talks to me, asks me lots of questions and recommends a course of action. Sometimes he recommends going back to the doctor, but mostly the fix is dietary and/or skeletal/muscular manipulation.
Brachiator
I have seen more urgent care facilities spring up here in Southern California, and thought this was a good thing (maybe relieving pressure of people going to the ER for non-emergency care), but your great example here of a sloppy and wrong diagnosis is very troubling. It was obviously easy to test for and to rule out the gout before giving you an unnecessary prescription and not providing for the proper treatment of your injury.
richard mayhew
@Gin & Tonic: Usually in and out, especially at urgent cares which is based on rapid churn, is a positive business incentive, but I was the only patient there for the entire 40 minutes from the time I started hopping from my car to limping back to the car.
beergoggles
@the Conster: I have no problem with them being in it for the money. I would just like them to be somewhat competent. They’re not the only ones capable of going through and reading the DSM. Right now they’re gatekeepers to treatment and it’s gotten to the point where I need to keep shopping until one of them allows me through to what I need to get. I think most of the asian countries have it better with prescription free access to non habit forming meds.
Brachiator
@JPL:
The Government Accountability Office has done an analysis of the results of the ACA. Some findings:
“The report found that subsidies expanded coverage among uninsured U.S. residents by as much as 5% in 2014. In addition, the study found that the subsidies reduced premiums by 76% between 2013 and 2014 (CQ HealthBeat, 3/23).
GAO also found that about 16% of nonelderly adults still are uninsured, noting that many will not face penalties under the ACA’s individual mandate because they are either undocumented immigrants or their incomes fall below the threshold.”
In short: expanded coverage but some lack of access to affordable plans.
I don’t know how to do a link with the setup I am using to post this, but a little google searching should find info and the study.
piratedan
well in short, the medical profession suffers from TL;DR syndrome, I saw it first hand with my father’s physician and since I deal with medical reports and the transmission thereof I can safely tell you that the majority of the physicians out there only have a passing acquaintance with Laboratory results and what that means to help diagnose a patient’s woes. While many of them are hardworking, earnest, and care about helping people get well, the amount of paperwork justifying damn near everything is staggering.
Anecdotally, back in the day when my father was being seen by his GP, he was in for some exploratory procedure the physician made an off-hand remark that he would be able to help my old man be an athlete as soon as they took care of the issue. Which caused my dad to do a double take and reply that he had been participating in sports, football, basketball, baseball, softball and volleyball pretty much since he could walk and had been getting treated for various strains and pulls by this guy for the last 15 years. Did the doc even really know who he was or was he just a name on a chart? He found a new physician.
In my job, physicians indicate that they scan the lab reports for any outliers to be found, namely any lab result outside of normal ranges, neglecting any kind of comparison between previous results and the current batch. Taking the whack a mole approach, if it sticks its head up as an anomalie, then address that but removed from any context of the overall picture.
Not a lot of time to really know what everything means and how it relates and its all related to the amount of time and documentation spent developing an audit trail that few ever see in the name of ass covering and financial compensation….
naturally, your experience may vary from mine
ARoomWithAMoose
As my spouse has gotten fitter from a few years of rather determined exercise and dieting, we’ve noticed that the couple of docs and specialist we use really don’t have any understanding of stuff that properly fits under sports medicine, a number of indicators in blood work can bounce around based on the previous few days’ workout variety/intensity.
The gout vs. sprain diagnosis is distressing, It’s a pretty standard x-ray plus palpitation of the foot for diagnosis, not a CT scan. Given you were mobile enough to get there on your own they could have taken the time to actually figure out if you were shopping for pain killers or not.
LongHairedWeirdo
I kinda get that. There’s a real coolness factor to making an interesting diagnosis (like gout) with Greg House-like precision.
I see it in IT frequently. I’m old enough to have weaned myself of it, but even I have the problem – I learn something REALLY COOL and OMG do I want to apply it and be the big brain who cracked the really tough case.
And so, yes, checking and re-checking is a good thing. Especially because there’s a lot of oddball differential diagnoses or multiple issues that can mimic another problem.
beth
Here’s an anecdote of a different kind – my kid had what seemed to be a nasty cold on the weekend that late Sunday night turned into a fever of 104, a cough so bad she couldn’t catch her breath and a headache so intense she begged to go to the ER. We went to our local ER, they originally thought meningitis and after tests, IV antibiotics, fluid and morphine, decided on a diagnosis of bad cold with sinus infection. We left with prescriptions for antibiotics and decongestants. The next morning the cough wasn’t better, we had no prescription for cough medicine so we went off to the local doc in a box who listened to her lungs for five seconds and diagnosed pneumonia which was actually double pneumonia confirmed by an x-ray. The ER totally missed it and for that I was billed over $3000, of which I had to pay $1200. Had she gone to the urgent care clinic first, it probably would have cost me a few hundred at most. I think the quality of the doctor working at the urgent care has a lot to do with your results.
Egilsson
I love misdiagnosis stories – I almost always win.
My 3 year old daughter was misdiagnosed with constipation when she actually had lung cancer. Think about that. She’s 19 now, and doing ok, but we had a terrible run of many years while she endured every treatment in the book, and then panicked waiting to see if it worked. Then a relapse, and we did that process again, except worse. It’s hard to describe how bad it can be, and how scary.
Not as cool as that, but still pretty bad, was the time I got sick. Really sick. I knew something was desperately wrong with me, but it was hard to describe. I showed up at the ER unstable and with my eyes moving erratically side to side in a way a normal person cannot replicate. A resident looking at me muttered something about cerebellar damage. An hour or two later, as I was still laying on the table, I heard the resident mention that to the ER doctor, who chastised him. He came in, and told me I had labyrinthitis, gave me some valium, and sent me on my way.
A couple of days later, I lost the ability to walk and couldn’t touch the tip of my nose with my finger. I was taken back to the hospital, where I stayed for 35 days, pretty darn sick with a rare neurological disease that damaged my cerebellum.
I love those ER doctors. I don’t blame the one that treated me as much as the one that treated her. They should look for horses when they hear hooves, not zebras. It just happened our conditions were rare, and we were the zebras.
The gout thing is really stupid because the gout is the zebra and the sprain is the horse.
grrljock
@Egilsson: The “think horses, not zebras” adage is precisely what I thought when reading about Richard’s gout “diagnosis”. As you said though, sometimes the sound of hooves does come from zebras, but I thought the whole point of consulting an MD is to have them rule out the horses first.I’m glad to hear that you and your daughter eventually got the correct diagnoses.
And Richard, thank you for pointing out that duplicate tests are sometimes ordered for the right reasons.