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    June 19, 2012 | Ropper, Amato, and Samuels

    Put away the red tape

    As sure as if Medicare had given every doctor in the nation a stroke, your physician has become paralyzed. A surreal series of demands from insurance companies and Medicare for increasing amounts of documentation on every patient has produced large inefficiencies in modern medicine. Intended to trim costs and improve care, these rules have instead burdened doctors with needless, time-consuming paperwork. As the state and federal governments look for ways to cut health care costs, adding more paperwork requirements can’t be part of the solution. Instead, it’s time for government to free doctors to spend their time doctoring — not checking boxes on forms.

    The insidious trend began 25 years ago when Medicare demanded that the record of an office visit include documentation of a specified number of items, whether they were relevant to a patient’s condition or not. For example, in our own specialty of neurology, it was necessary to examine every patient’s hearing and the power of their neck muscles in order to get paid a reasonable fee. Even a patient with a paralyzed leg or severe migraine has to have data dutifully recorded from 18 separate items that are entirely irrelevant to their problem.

    This mandate was met, for the most part, by a soft subterfuge in which boxes were simply checked off to show that the requirements had been fulfilled. However, the need for documentation of irrelevant material has engendered a culture of attention to process rather than to the patient. Already, many doctors sit facing the computer screen rather than engaging the patient.


    When this failed to reduce the cost of medical care, Medicare undertook arbitrary changes in the billing structure. Under existing rules, a specialist providing consultation to a hospitalized patient could be reimbursed for only one visit, no matter how many visits were needed for proper treatment. Sometimes, doctors have trouble getting even that single payment. Under another rule, Medicare limited the number of specialists who could be reimbursed for treating a hospitalized patient to just one. So a patient who required the attention of several specialists — for instance, infectious disease, cardiology, pulmonary diseases, and hematology — would get the services he or she needed, but only one of the providers would be reimbursed.

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    Now, two new Medicare rules unveiled in recent months are likely to bring yet more gridlock to medical practices. The first, which almost defies belief, is that a physician must guess in advance whether a patient requires a “real” admission to the hospital or can be admitted for fewer than 48 hours in a less intensive category of hospital care called “observation.” Observation may take place on the same ward that is used for any other patient, or in the emergency department, but the hospital is paid only a fraction of the full fee of a hospitalization. If the patient is being admitted for a complex medical problem, the doctor must indicate why they think this person could not be cared for in observation. Reversing the decision from observation to an admission is time-consuming and laborious. Reversing the decision in the other direction — that is, concluding after admitting the patient that the problem could have been taken care of under observation — means the hospital risks, if you can believe this, being paid nothing.

    Finally, here is the coup de grace. A Medicare plan to increase use of electronic medical records, cynically called “meaningful use,” is about to make the physician’s focus almost entirely a computer screen. Meaningful use refers to checking off boxes in the highly lauded electronic medical record in order to collect demographic, epidemiologic, and billing information for the use of Medicare bureaucrats. Here is what is required at every visit, including to a specialist such ourselves: the patient’s blood pressure, heart rate, height and weight must be recorded; his or her list of medications must be reviewed, recorded, and reconciled; allergies must be listed; whether the patient is smoking must be recorded; and a printed document that summarizes the visit must be provided to the patient. Most of these requirements duplicate what primary care physicians do and is again entirely irrelevant on most other occasions.

    The concept of meaningful use of the electronic medical record is unproven as a method to reduce cost or improve care, yet it is mandated by the Centers for Medicare and Medicaid Services, which provides incentives in the first few years followed by penalties thereafter. Not only must all this information be acquired, but much of it has to be reproduced in the doctor’s office note in order to avoid accusations of fraud in Medicare billing. No wonder that, as Spencer S. Jones and colleagues pointed out recently in the New England Journal of Medicine, information technology has greatly reduced our productivity.

    Taken together, the burdens increasingly placed on doctors are hurting patients. A medical bureaucracy is making ridiculous demands, and no one is willing to acknowledge that these demands are a central source of inefficiency and a loss of focus on the patient. For all the platitudes regarding quality of care and patient-centered medicine, there is now a culture of process over meaning, documentation over proper diagnosis and treatment, and a disruption of the intense encounter between a single patient and a single physician to provide answers, hope, and human consideration. Such mandates are meant to reduce the cost of medical care, to make physicians into a manageable workforce — but they certainly don’t, as proponents claim, improve quality.


    At no time has the government been held to account for its peculiar experiments in medical care. Also recently in the New England Journal of Medicine, an examination of “Pay for Performance,” another of Medicare’s buzz phrases, has been shown to be a manifest failure. Millions of dollars were spent trying to realign physician behavior in a failed attempt to ostensibly reduce medical costs.

    Sadly, young doctors and those in medical school and training have already been co-opted into that system that values form over substance. In order to allow doctors to get back to doctoring, social experimentation in the medical system should be restricted to demonstration projects and a commission should be established to reduce the waste and inefficiency introduced by regulations that pile up to the point of causing paralysis.

    Allan H. Ropper, Anthony A. Amato, and Martin A. Samuels are Boston-area neurologists.