The new article focuses on the role of electronic medical records systems and associated software in promoting upcoding - billing at higher rates - through features such as documentation cloning, templates, facility of making it look like work not done was actually performed, and deliberate algorithmic prompting of users to "do more" to "get more."
Now just a few days later, the New York Times reports similar, independently-reached concerns:
Medicare Bills Rise as Records Turn Electronic
By REED ABELSON, JULIE CRESWELL and GRIFFIN J. PALMER
New York Times
September 21, 2012
When the federal government began providing billions of dollars in incentives to push hospitals and physicians to use electronic medical and billing records, the goal was not only to improve efficiency and patient safety, but also to reduce health care costs.
But, in reality, the move to electronic health records may be contributing to billions of dollars in higher costs for Medicare, private insurers and patients by making it easier for hospitals and physicians to bill more for their services, whether or not they provide additional care.
Hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms, according to a New York Times analysis of Medicare data from the American Hospital Directory. Regulators say physicians have changed the way they bill for office visits similarly, increasing their payments by billions of dollars as well.
I am commenting on a few points that the NYT piece amplifies, and some interesting quotes from individuals:
Over all, hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010, the latest year for which data are available, compared with a 32 percent rise in hospitals that have not received any government incentives, according to the analysis by The Times.
Correlation is not proof of causation, but considering the issues I raised in my Feb, 2011 post "Does EHR-Incited Upcoding (Also Known as "Fraud") Need Investigation by CMS", and considering that physicians know EHRs facilitate grading of their performance as organizational "taxpayers" (i..e, bringing in revenue), and the feature of EHR's illustrated at that post on "encouraging" users to "do more to get more", I think further federal inquiry is justifiable.
Critics say the abuses are widespread. “It’s like doping and bicycling,” said Dr. Donald W. Simborg, who was the chairman of federal panels examining the potential for fraud with electronic systems. “Everybody knows it’s going on.”
The same applies for health IT safety risks, I add. Healthcare has a number of "anechoic" issues ongoing in addition to the ones already covered at this blog site.
When Methodist Medical Center of Illinois in Peoria rolled out an electronic records system in 2006, Dr. Alan Gravett, a former emergency room physician, quickly expressed alarm.
He said the new system prompted doctors to click a box that indicated a thorough review of patients’ symptoms had taken place, even though the exams were rarely performed, while another function let doctors pull exam findings “from thin air” and include them in patients’ records.
In a whistle-blower lawsuit filed in 2007, Dr. Gravett contended that these techniques drove up Medicare reimbursement levels substantially. According to the lawsuit, Dr. Gravett was eventually fired for ordering too many tests. He says he was retaliated against for complaining about the new system. The Justice Department is weighing whether to join an amended suit in Federal District Court in Central Illinois.
Retaliation against health IT whistle blowers is another "anechoicism." See for instance this essay about a physician/informaticist who complained that a new ICU system would kill people.
... Many doctors and hospitals were actually underbilling before they began keeping electronic records, said Dr. David J. Brailer, an early federal proponent of digitizing records and an official in the George W. Bush administration. [As the first Chair of ONC - ed.]
Where is data to support that contention?
Lacking such data, the rationale for such a statement, on its face, seems to be that increased billing with EHR's shows there must have been underbilling without EHR's - a logical fallacy (a particularly bizarre type of circular argument).
But Dr. Brailer, who invests in health care companies, acknowledged that the use of electronic records “makes it faster and easier to be fraudulent.”
Then, one might ask, why is the Federal Government hell-bent on pushing the technology before these issues are dealt with?
A spokesman for the Health and Human Services Department, however, said electronic health records “can improve the quality of care [not "will", as stated by ONC - ed.], save lives and save money.” Medicare, he added in an e-mailed statement, “has strong protections in place to prevent fraud and abuse of this technology that we’re improving all the time.”
Those statements are speculative, the money savings in doubt (e.g., see the Sept. 17 WSJ Op Ed "A Major Glitch for Digitized Health-Care Records" by Ross Koppel and Stephen Sumerai), and the "strong protections" obviously not so strong, or not used and/or enforced, or all of the above.
Some contractors handling Medicare claims have already alerted doctors to their concerns about billing practices. One contractor, National Government Services, recently warned doctors that it would refuse to pay them if they submitted “cloned documentation,” while another, TrailBlazer Health Enterprises, found that 45 out of 100 claims from Texas and Oklahoma emergency-department doctors were paid in error. “Patterns of overcoding E.D. services were found with template-generated records,” it said.
I have seen cloned progress notes and other documentation with my own two eyes, unfortunately in charts where grievous patient harms occurred in part as a result of other clinicians being misled by cloned notes of normalcy.
The Office of Inspector General is studying the link between electronic records and billing.
Maybe OIG can also investigate links between electronic records and adverse medical events.
One sophisticated patient witnessed the overbilling firsthand. In early 2010, Robert Burleigh, a health care consultant, came to the emergency room of a Virginia hospital with a kidney stone. When he received the bill from the emergency room doctor, his medical record, produced electronically, reflected a complete physical exam that never happened, allowing the visit to be billed at the highest level, Mr. Burleigh said.
The doctor indicated that he had examined Mr. Burleigh’s lower extremities, but Mr. Burleigh said that he was wrapped in a blanket and that the doctor never even saw his legs.
It's a good thing his legs were not a problem.
“No one would admit it,” Mr. Burleigh said, “but the most logical explanation was he went to a menu and clicked standard exam,” and the software filled in an examination of all of his systems. After he complained, the doctor’s group reduced his bill.
Which then can cause or contribute to others further down the continuum of care failing to perform their own exams, on the basis of believing the falsely documented exam, thus missing abnormalities.
As software vendors race to sell their systems to physician groups and hospitals, many are straightforward in extolling the benefits of those systems in helping doctors increase their revenue. In an online demonstration, one vendor, Praxis EMR, promises that it “plays the level-of-service game on your behalf and beats them at their own game using their own rules.”
I'm again stunned at the levels of arrogance of the health IT sellers; what were they thinking? These "promises" could expose them to, say, RICO issues.
But others place much of the blame on the federal government for not providing more guidance. Dr. Simborg, for one, said he helped draft regulations in 2007 that would have prevented much of the abuse that now appears to be occurring. But because the government was eager to encourage doctors and hospitals to enter the electronic era [e.g., via HITECH - ed.], he said, those proposals have largely been ignored.
“What’s happening is just the problem we feared,” he said.
This brings to life my observation that HITECH Act was ill-timed and represents social policy malpractice.
It appears OIG has their work cut out for them.
-- SS
