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On the forced use of medical boiler plate language rather than simple notes.
April 09, 2007
Subscribers Newsletter

Private Practice Reality Today: Forced Use of Medical "Boiler Plate" Language in Medical Documentation.
First published at www.Medical-Office-Management.com

Once upon a time, there were doctors, and there were patients, and life was simple, and life was good. That was then, and this is now. Today, there are multiple insurance companies and multiple bureaucracies standing between the doctor and the patient. The insurance carriers demand and receive huge amounts of money based solely upon transactions between doctors and patients. The bureaucracies expend increasing amounts of tax dollars while increasingly complexifying (if thatís a word) even the simplest transactions between the doctor and the patient. And there is a growing school of finned litigators beginning to circle, sensing the smell of money in the water, competing with a soaring flock of feathered litigators slowly circling above.

Medical insurance, like all insurance, is a form of gambling. When the employee and the employer pay the health insurance premium, they are, in truth, placing a wager. The insurance company is betting they will collect more in premiums than they will spend in claims per period of time. They pay highly specialized technicians called actuaries to very precisely compute and re-compute the odds on which they set their premium rates. Or, place their bets, if you will. Itís all based on highly complex mortality and morbidity tables that are constantly being built, updated, poked, prodded and computer-modeled by the actuaries.

But the simple odds are not the only factors in the game. Insurance companies compete with each other, and even gobble each other up. In order to come out ahead in the market competition, and not be gobbled up, they seek ways to either sell a better product, sell it at a lower premium, or both. Once premiums are cut to the lowest they can be cut, perhaps even at the actuarial break-even point, the only thing left for the insurance carriers to cut is claim payments to doctors.

The medical transaction begins with the money in the pocket of the patient, and ends with the money in the doctorís pocket. The insurance carrier only gets a shot at it before it goes into the doctorís pocket. To that end, we see the movement into so-called managed care with carriers and insurance conglomerates increasingly in the driverís seat, and even acting as intermediaries, with the transaction money passing through their hands before it even gets to the doctor.

To some, the worst aspect of this is the ridiculous increase in complexity of, not necessarily the medical process itself, except that complexity detracts from it and does not help it, but the record keeping of a doctor, of his own records. Itís one of the factors increasing the complexity of medical office management and detracting from a doctorís treatment time with his patient.

Permit me to quote from the Medical Burnout site:

Managed Care (and Medicare) are forcing medical records to become HUGE with increasing demands for documentation of minutia. The insurance plans are constantly searching for any excuse to pay doctors less, and one of the ways they do this is by downgrading the "E/M" code for the level of service the doctor provided to a patient and then paying only for a lesser code. Their stated policy is "If it's not documented in the chart, it didn't happen." The converse to that must then logically be, "If it's documented in the chart, it DID happen." Thank goodness for word processors and their ability to store endless blather and then spit it out over and over again. To illustrate how dopey this policy is, let's suppose I see one of my patients for a routine followup for high blood pressure we've had stabilized for years. Being a conscientious doctor with many years of experience I know what to check and what I'm looking for. Before managed care I might have dictated my exam into the patient's chart to read like this:
"Eyes-OK. Neck-normal. Lungs and heart-OK. Abdomen-normal. Extremities-no edema. Neuro-OK."
That's all the record I need because I know what I always check in a patient with high blood pressure, and the only time my record ever used to get more verbose was if I had found some abnormality. This made for quick dictation, quick typing, and clear, concise, easy-to-use records However, under managed care, if I don't document all the negatives (all the things I checked that were normal), I can be sure that if the insurance company audits my records, they will downgrade my charges. So now, for the same visit, I have to make a huge "boilerplate" entry into the patient chart that looks something like this:
"EYES-lids, sclerae, and conjunctivae normal. Extraocular movements normal. Pupils equal, round, and reactive to light and accommodation. Funduscopic examination reveals no papilledema, A-V nicking, or exudates. NECK-supple with no carotid bruits, adenopathy, or jugular venous distention. Thyroid is not enlarged. LUNGS-no dullness to percussion. Auscultation reveals no rales, rhonchi or rubs. HEART-normal size to percussion. The heart is in sinus rhythm with no irregular beats. There are no murmurs, gallops, clicks, or friction rubs. ABDOMEN-auscultation reveals normal bowel sounds and no bruits. The liver, kidneys, and spleen are normal size. No masses could be felt, and there is no tenderness or guarding. EXTREMITIES-there is no pedal edema. NEUROLOGICAL-cranial nerves II-XII are intact. Deep tendon reflexes are symmetrical and normoactive. Sensation and motor functions are normal. There are no pathological reflexes present."
What a bunch of gobbledegook, huh? It's all nothing but normal stuff, but it must all be typed into the record again and again every time the patient comes in for a routine blood pressure follow-up visit; or else I can be sure that some insurance company (or Medicare) auditor will inspect my records, downgrade my charges, and cause me to be paid even less than the company's normal paltry fees. Of course the reality is that we have all this stuff canned up in our word processor; so the transcriptionist can spit it all out with the touch of one key; but it's the absurdity of it that's so annoying. Of course any good doctor routinely checks all this stuff, but why are we required to waste time and money and paper creating a mammoth record of superfluous "boilerplate" normals just to please some high-school-educated insurance company "auditor" with a "no-brainer" checklist looking for documentation she can barely understand? Not only does all this fluff waste everyone's time and make the charts huge, but it also makes it much harder to pick the really meaningful stuff out of all the "filler". Managed Care is all about paperwork and insurance company profits, not about good patient care. If you don't do the paperwork right, doctor, [youíre not going to be paid for your services.]

(Original emphasis maintained throughout.)

Now, this is just one of many aspects of how medical doctors are being prodded and herded toward the simpler life of becoming a mere salaried employee of some MBA with perhaps a third or less education than them, and with no comparable medical expertise at all. As medical practice management becomes increasingly complex medical practitioners are discouraged from even remaining in private practice.

Those who think that a nationalized health care system will improve things are sadly mistaken. If you think things are bad now, replace the insurance rep standing between the doctor and the patient with a petty bureaucrat, and then just watch what happens next. Currently health care is supposedly free in higher-taxed Canada. Actually, what is free is the ability to stand in line for health care, not to actually get any of it. The average wait for a doctorís appointment there is 13 months, notwithstanding the fact that the average period of a human pregnancy is only 9 months.

Perfection is not of this world, but the next, and we donít claim to know what the answers to these problems are. What we do know is that the wrong people are in the health care regulation driverís seat. No one who hasnít taken the Hippocratic Oath and done his time in the medical trenches should be directing health care on such a massive scale. Thatís our opinion.

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