This great comment appeared yesterday:
GAMING THE SYSTEM – I want to seek an opinion as an extension of this post – What percentage of doctors try to game the system and to what extent? What is their motivation to do so? Is their any literature to predict who will game the system and who wouldn’t? Do only specialists do so and hospitalists/internists don’t or it’s just that specialists have more opportunity to do so?
Two types of gaming occur – intentional and unintentional. I personally believe that most gaming is unintentional. Physicians exhibit irrational decision making just as often as anyone else.
I do not think that oncologists are purposely gaming the system, rather this behavior occurs at a more subconscious level. This subject is complex and one would need to study social psychology, cognitive psychology and economics to fully understand the subject.
Most physicians truly believe that they are doing the best for their patients. The problem with gaming the system is that once we have a financial interest we have an implicit change in how we decide the indications for advancing that financial interest.
Hospitalists are the least likely to game the system because they are salaried. Internists and family physicians who have their own labs probably game the system unintentionally. Subspecialists are good people and good physicians, but the lure of money changes how most people act.
If we switched to time based pay, then we would have a different type of gaming, but I believe the problem would be less severe than our current system. We should dissociate physician decision making on tests from their own finances. This practice is currently ingrained in our system. Every time insurers change the rules, practices figure out ways to beat the new rules. We need a simpler system.
Paying for our time would be clean, straightforward and equitable. I would tweak the system to allow physicians to add a time surcharge – but that is another post.
What do other physicians think about gaming?
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A very wise physician once told me, “there’s a little whore in all of us.” Let’s not take a simple idea and make it worse. There is no excuse for gaming the system, but, in deferential disagreement with you, physicians do it intentionally all the time. They are well aware of what they are doing. Do I think they are horrible, malicious people? No. They are trying to maintain incomes in an extremely dysfunctional, broken system. The real problem is it’s easier to maintain the status quo than change to a sustainable business model.
Every time I am forced to document unimportant, irrelevant data for the purposes of achieving a level one or level two or level three hospital follow up visit, I am forced to game the system. If all I had to write was
“Patient is stable. No changes planned” But instead write:
S) No CP, No SOB
O) 120/80 80 98.6
RSR
CTAB
S/NT/ND/BS +
No C/C/E
Hgb 12, INR 1.1 ECG tracing reviewed-Normal ECG
A) POD #1 TKA
DMII stable no changes planned
HTN Stable, no changes planned
CAD Stable, no changes planned
A/C mgmnt
The first note doesn’t qualify for anything, not even a level one follow up. The second note qualifies for a high level hospital follow up.
Now, am I gaming the system? You bet. Was it medically necessary care? You bet it was. It will always be medically necessary. Do I have to game the system? You bet. If I want to get paid, I have to operate under the ridiculous rules I have been forced to play by. I will document till the cows come home if that means it is required to get paid.
E&M coding requirements are one giant game. According to the Medicare National Bank, If I didn’t document it, it didn’t happen. So I document everything. And I play by their rules, just to get paid. Nobody else cares about anything I’ve written. It’s only to get paid.
There is no fraud here, only unreasonable and irrational documentation requirements to get paid. And that documentation takes time. And my time is money.
I could probably triple the number of patients I see on a daily basis if I wasn’t forced to game the system every time I came upon a new patient’s chart.
There would be no change in outcomes if I wrote the first note vs the second note. The only difference is I wouldn’t get paid in the first one. I would get paid the highest rate in the second.
And that is the essence of the E&M game every doctor who doesn’t want to be accused of fraud must play.
So in answer to your question and thoughts, I believe the gaming is, to a great degree, intentional. It has to be because the rules established for it to be. It’s not fraud by any means. It’s just the game.
I’m going to link this post to my blog because I think it’s an excellent talking point with many ramifications about why physicians do what they do
If “gaming the system” means putting in a lab in our office since Medicare pays much better for tests than for time spent thinking, then yes, we game the system.
If you mean refusing to see more than 2 problems per visit and new problems at “physicals” because the nature of Medicare E&M billing is such that we don’t get paid for this additional work , then yes.
But ordering extra tests or scheduling extra visits on flimsy medical justification so we can bill more, no.
The best option now seems to be to avoid the Medicare system entirely and to play elsewhere.
If the cuts continue, the simple solution will be to see patients more often. Instaed of seeing the diabetic/hypertensive patient four times a year, five times will be the new standard. Patients will have to come in for all concerns to office visits. No more called or faxed prescriptions. Physicians can fight back, by refusing to do as much free paperwork and free phone care. Make your patients come in for visits. After all, you are liable for those free phone calls.
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