The Executive Suite: The CMS proposed rule: A fool’s bargain

Tuesday, September 18, 2018

The CMS proposed rule: A fool’s bargain

The CMS proposed rule designed to put patients over paperwork has physicians across specialties protesting. Studies showing that physicians spend more time on paperwork than they do on patient care has prompted the search for reduced complexity and volume of documentation. In theory, decreasing the volume of information in a visit note would help address this, particularly if the information cut is not important to the purpose of visit documentation. In reality, decreased documentation requirements combined with an average reimbursement that could be lower for the same care seems like a fool’s bargain.

Notes are long for a number of reasons, many of which will not be assuaged by changes to CMS regulations. Our patients, their medical issues, the number of diagnostic tests, and pharmacologic management of these conditions are increasingly complex. As a result, it can take many words, phrases, and sentences to describe the medications a patient with depression has tried or a couple of paragraphs to outline a patient’s cardiac testing and intervention history. EHRs remain largely set up like a series of discrete events, not as an individual’s health story. Therefore, each discrete event has to pull in and document information readily available in other parts of the chart for the note to tell the whole story related to the visit.

A physician’s good clinical judgment is no longer assumed. It becomes incumbent on the physician to document the how and why of his thinking so that the rationale for a treatment decision or diagnostic assessment is explicitly stated.

Quality care is assessed through clicks and discrete phases that can be mined from notes and visit documentation easily in order to report data. As a result, it is not enough to perform the diabetic foot exam and write “normal.” I must document it with a specific pre-formed phrase that the computer will recognize as satisfying the requirement to do an annual foot exam. In the most extreme derangement of documenting quality metrics, the quality of documentation is greater than the quality of care being provided.

As a result of these issues and others, it becomes increasingly easy to write a long, poor quality note that says a lot without actually saying much of anything. CMS’s attempt to minimize “note bloat” is laudable because the government is recognizing that quantity is not superior to quality, particularly as quantity becomes easier to automate and pre-populate. However, as long as the note’s length and detail are the basis for reimbursement, decreasing documentation requirements leads to decreasing reimbursement for the same amount of clinical work. This will not succeed in driving to value. The ways to manipulate this new formula for documentation and reimbursement are obvious.

With the goal of value over volume and patients over paperwork, the equation must be simpler. What is high-value must be defined. This is not as simple as a length of stay index or an A1C level, which is partially why the necessary transition is so slow. However, it is also not as simple as a long, overly-detailed note equating to high-value or high-complexity care. CMS must go back to the drawing board to reconfigure an approach that incentivizes hysicians to document the important elements of a visit’s history while emphasizing the non-documentation and non-paperwork parts of the critically important clinical work being done.