Hubert H. Humphrey Building
200 Independence Avenue
Washington, D.C.
Call to Order/Welcome/Introductions/Agenda Review - Dr. Detmer
Update from the Department -
Data Implications of Balanced Budget Act - Dan Waldo, Liz Richter
Update on Guidelines for Documenting Evaluation and Management (E&M) Services - Drs. McCann, Segal
DR. DETMER: All right. What we want to do is take a look at tab C. I assume you read it and, if not, please quickly do so.
What we had contemplated doing is talking over this, our review, comment, amendment, whatever, and then consideration of whether we wish to put this up on our web site as the committee's comments and reflections relative to the consumer protection bill of rights and responsibility document.
Then, after we talk about that, I would like to have us talk about what we may also wish to do relative to the quality document as well. Jeff Blair.
Agenda Item: Review of reports from the President's Commission on Consumer Protection and Quality in the Health Care Industry.
MR. BLAIR: The piece that I didn't quite understand -- maybe we went through it so quickly that I just got lost.
He was indicating that there should be a public and a private council or committee, I guess for focus. As he was saying that, I kept thinking of what NCQA is doing in the private sector in terms of trying to gather data to evaluate the value of health plans.
Quality is a component of that, that is being market driven. I was thinking of the Agency for Health Care Policy Research that has been working for a long time in many different ways.
I kept thinking, why is it that he didn't wind up saying enhance and strengthen the NCQA and the Agency for Health Care Policy Research.
Maybe I am missing something. Maybe there was a different focus or different element or role of those commissions, but I didn't understand that.
DR. DETMER: Let me hold that and come back to it. We want to talk about two things. One is the consumer bill of rights part and then the second part is the quality piece, and that comment relates to the quality piece.
I don't want to lose track of that, but we have a document in front of us that is in tab C. I would like to take comment on that and then, after we have done that, we will get back to Jeff's comment.
DR. STARFIELD: I have a couple of suggestions. I thought it was a terrific document and I just thought that it needed rounding out in a couple of places.
I actually rewrote some things. I inserted some things. I have a copy for everybody.
DR. DETMER: Good; that is great. If you would, let's hand it around. Then after it is around, maybe you could comment on your suggestions.
DR. STARFIELD: There are really four comments. One of them is just technical, and three other comments.
The one on evidence based I thought was really a good start, but I didn't think it went far enough. There are just so many problems doing everything on the basis of existing evidence that I thought that a couple of other things ought to be added.
First of all, the fact that evidence is lacking on a lot of things, which he mentioned, but even that could be extended.
The other thing is that evidence, even where it exists, doesn't apply to everybody. The gold standard for evidence is the randomized controlled clinical trial.
The randomized controlled clinical trial excludes people with the greatest risk of adverse effects and poor quality because it never includes people with comorbidity.
So, you get evidence that doesn't apply to a lot of people who have the thing that the study was done to look at. That is one of the things.
The other thing is the systematic absence of research in a lot of populations, which I mentioned this morning. Anyway, that first paragraph was directed at trying to fill out what the limitations of evidence-based medicine is, not that I am not in favor of evidence-based medicine.
DR. DETMER: Let's go ahead and comment on this paragraph and then we will go to the next one.
DR. IEZZONI: I think people are increasingly getting away from the RCT as being the gold standard, even though people realize that, yes, for efficacy trials it is.
I think that people are realizing that there are other research clinical trial approaches that are also being used for evidence base.
What I am concerned about is, if we pit ourselves as linking evidence based to randomized controlled trials, it is too far out on the edge from what people are now accepting as evidence.
So, it kind of makes us seem as if we are viewing evidence as too extreme. I think that is one, certainly, means of evidence, but I prefer not to just focus on the randomized controlled trial.
DR. STARFIELD: It is not that I want to focus on the randomized controlled trial, but it is that everybody else does.
DR. IEZZONI: No, I disagree.
DR. DETMER: I would tend to agree. I think meta analysis is now considered --
DR. STARFIELD: It has the same problems, the meta analysis.
DR. DETMER: Fine, but if so, we could make that comment.
DR. STARFIELD: That is all I am suggesting, that we ought to make the comment on what is evidence and where there is evidence lacking. That is the only thing I want us to recommend.
DR. MC DONALD: The alternative is just who has got the loudest voice. I think to demean the idea that we want to be rational about the process or to diminish it -- I think some of the words in here are really quite good, saying that we need to work toward it.
To argue that somehow there is another decision process that is more rational, it ends up being politics, made-up stuff, political belief, a lot of other stuff that doesn't necessarily get us to where we want to get.
DR. IEZZONI: Clem, frankly, for some people, you are demeaning what they might actually find valuable.
DR. DETMER: You could also argue, though, that you are arguing about what is evidence.
DR. IEZZONI: Right, exactly. That is why I put evidence in quotation marks here. I think underlying what you are thinking about as underlying evidence is an acute medical paradigm.
There are many people who may view certain things as very, very beneficial, but it is very difficult to prove that under an acute medical paradigm.
I just want to have -- in some sense I wanted to have it sufficiently vague that we wouldn't be positioning ourselves in one corner versus another, but also making clear that there are other ways about evaluating the benefit of services apart from the traditional paradigm.
DR. COHN: Actually, Lisa, I did like your paragraph and many of the reasons that you described. However, I am uncomfortable that we -- I guess I thought there needed to be maybe another sentence at the end that talked about coming up with parameters or encouraging that money be put into identifying parameters for these areas, so that they could be evaluated.
I am generally uncomfortable with services that we can't measure, because if you can't measure you identify quality or value.
Maybe they are not in the classic triad. Maybe there needs to be, other than just saying you can't do it --
DR. DETMER: I think we have a word smithing problem here as much as anything else, but maybe not.
DR. IEZZONI: I don't think I was saying that you couldn't measure. What I was saying is that you might measure it differently, like from the patient's point of view, rather than from taking calipers, for example, and measuring how far they can walk.
You might ask a patient how functional are they, that kind of thing, and that goes beyond the way that a lot of clinicians think about on standard medical trial outcomes.
DR. MC DONALD: This demeaning, counter-demeaning activity here, I am really saying that we had a pre-flexnor era where there was a lot of stuff that everybody knew was good, including radium.
I just think that -- I don't want to be cubbyholed into saying what we used to decide, but if we have the decision just be who yells the loudest or advertises the best, we are not in the best state.
I think we have a big opening for a whole lot of foolish processes. I am not talking about the ones that we are talking about, that could be, you know, funded, substantiated and you could draw funds away from more valuable things.
All I am saying is that this evidence basing doesn't presume, I don't think, any of the dimensions I have heard presumed.
DR. DETMER: That is I guess what I am hearing, too, is a question of really, let's define, though what, indeed, we are going to use as rules of evidence and then pursue those, and not do that so narrowly that we throw out what is, in fact, appropriate metrics for a specific question that may be at hand. Isn't that really what you are trying to get at?
DR. STARFIELD: That is what I am trying to get at. We need evidence, but we shouldn't not do things because researchers have not chosen to study certain things.
DR. DETMER: Maybe what we ought to do is talk our way through this. We may want to rewordsmith this a little bit and then come back in the morning with our usual kind of new look at it.
DR. IEZZONI: Let me just say in response to Simon, I am always happy if the final sentence is more research is needed.
DR. DETMER: Do you want to go to your second one?
DR. STARFIELD: Yes, I have a couple more. The next one is on information disclosure, page two, the third paragraph.
I guess, again, it is just word smithing. I am uncomfortable with terms like acute, chronic, post-acute. You know, I come from a primary care paradigm and primary care is thought to be acute.
I think a primary care challenge is chronic problems, because it is patients over time. So, I sort of think that is the notion we want to get into. We want to think about people over time, not about whether a condition is chronic or a condition is post-acute.
I have some word smithing there, but that is the thought about it. I don't want to use terms that I don't know what they mean, like post-acute or long-term. To me, primary care is long-term care.
DR. IEZZONI: Although I think, also, Barbara, we need to use words that -- like long-term care has a meaning to a lot of people.
So, I think that we need to have sentences that are clear, but we shouldn't go completely away from jargon that is fairly well established.
DR. STARFIELD: I don't think long-term care and post-acute care are fairly well established.
DR. IEZZONI: Not the post-acute care, but the long-term care, I think has been around.
DR. DETMER: You have long-term and person focused.
DR. STARFIELD: When people use long-term care they think about, I suppose, nursing home is first and foremost.
I think of primary care as long-term care. We all are increasingly recognizing that you identify a population and take care of it over time. That is long-term care.
DR. IEZZONI: That is longitudinal care.
DR. STARFIELD: That is longitudinal care. I will take longitudinal any day.
DR. DETMER: Continuity of care. Do you want to - - I see some heads nodding.
DR. STARFIELD: So, I think we mean long-term care but people will interpret that as nursing home care.
DR. IEZZONI: Maybe I meant nursing home care.
MR. NEWACHECK: I was just going to say, it is long-term sense of being either community based or institutional care; right; in the context?
DR. STARFIELD: What is community based? Care in physicians offices, you know, is community based; no?
MR. BLAIR: I was translating in my mind, when I was hearing you say long-term care, to continuity of care across the medical domains.
I think other phrases are continuous care and longitudinal care.
DR. IEZZONI: Let me be clear about what I meant by this sentence, because obviously I wasn't -- I did specifically mean developing quality measures for nursing homes, for home health care, for areas where -- medical rehabilitation, where there really has not been the concerted efforts to develop quality measures the way there has been for inpatient care and even increasingly for physician office care.
DR. DETMER: Maybe we ought to reshape it.
DR. IEZZONI: We can be clear about that, yes.
DR. DETMER: That is clearer. At least it is obvious what you are speaking to.
DR. STARFIELD: I actually agree, that there has been a lot of work on inpatient care. I don't think there has been a lot of work on long-term physician office-based care; that is, thinking about people over a period of time.
With managed care, we must begin to think about quality of care in that sense. So, I would like to help to try to get the right word, that doesn't only limit it to nursing homes.
DR. DETMER: I think we can also sort that one out, as far as that goes. Okay, what is your next one.
DR. STARFIELD: The bottom paragraph on page two. That is the participation and treatment decisions focus on satisfaction.
I think that we could add a couple of sentences there, about getting at not only what people feel about their care, but what their experiences with care are.
There is a fat literature now on the limitations of satisfaction as an outcome measures. What I think we are interested in is people's experiences, as well as what they feel about them.
DR. IEZZONI: The bill of rights specifically calls for satisfaction measures, though. So, I think that we are going to have to, you know, make the distinction.
I know that Paul Cleary at my institution has been one of the leaders in kind of trying to focus more on experience and satisfaction.
I didn't like the word satisfaction either, but that is the word that the commission uses.
DR. DETMER: I think this is pretty clear, though, what she has added. Do you agree?
DR. IEZZONI: Yes.
DR. DETMER: Is everybody comfortable with that piece? Okay.
DR. STARFIELD: A very technical thing, under the last item, chapter six, the confidentiality. I think we are on record as strongly supporting federal privacy legislation. That may be a fine point, but it says confidentiality. Privacy legislation specifically, rather than -- or privacy and confidentiality.
MR. GELLMAN: Neither term has any meaning whatsoever, so take your pick.
DR. DETMER: Certainly not between one another, that is for sure.
MS. GREENBERG: Actually, I thought that was the term.
DR. DETMER: Frankly, I did, too.
MS. GREENBERG: I took that from your letter, just when I added that.
DR. DETMER: We will check on that. Do others have other comments? I think we can try to word smith this between sessions and such.
DR. HARDING: Could you word smith one clause, I guess it is, the third paragraph on the second page. The second sentence says, while the CBORR does not explicitly delimit care settings.
I am not sure what that means. Could that just be kind of -- explicitly delimit.
DR. DETMER: Precisely defined; is that what we are trying to say?
DR. IEZZONI: It doesn't specifically say what care settings it is pertaining to. Implicit in the way it reads it is acute care hospitals and doctors offices.
DR. DETMER: So, you are saying explicitly identify --
DR. IEZZONI: Settings of care, yes.
DR. MC DONALD: I thought you were saying you want to call attention to these other care settings and have things done there.
DR. IEZZONI: Yes.
DR. MC DONALD: I almost worry that this might be so carefully worded that you may not get that.
DR. IEZZONI: This was not carefully worded at all. This was from a memo that I wrote to Marjorie, and she kind of -- so, people kind of revised it. So, none of these words have been chosen carefully, actually.
DR. DETMER: It is a draft, and we are comfortable with that. I think we can change that one. I guess the question is -- we will work on this and come back to you, but I think the issue is, I see some merit for having a statement up there that responds to it. I guess I am seeing a lot of you nod in agreement with that.
DR. MC DONALD: I am not disagreeing. I think in many paragraphs there is a very strong message that I think we call can agree with, but it might be said more strongly.
Basically we want to get measures for the other settings. I don't think that is going to jump out at the typical reader, because of the other words that are surrounding it.
I think you could do a paragraph and just say it, nursing home, rehabilitation and the --
MR. BLAIR: I would like to see it say something to the effect that we want to extend our ability to have clinically specific measures from the acute and primary care area to these other settings in a consistent manner.
DR. DETMER: Okay, get that, somebody?
MR. BLAIR: That we would like to extend our ability to have clinically specific data measurements from the traditional acute care and primary care settings, to cover these post-acute care areas in a consistent manner.
DR. STARFIELD: You obviously know what you mean by post-acute care, but I don't.
MR. BLAIR: I was just taking what I thought they were telling us yesterday, that they were including skilled nursing facilities, rehabilitation and home health care. I have probably left something out.
DR. DETMER: I think what we can do is list the various other settings that we were talking about as a way to try to come to grips with this, is what I was hearing from our earlier comments.
MS. GREENBERG: Do we have a little group here who wants to work on this revision?
DR. DETMER: Lisa and Barbara and I.
DR. IEZZONI: I didn't take notes because I didn't write fast. I would need some notes to help me replicate what was said.
DR. DETMER: So, you and I can work with Barbara and Lisa.
MS. GREENBERG: And Simon seemed to have -- I didn't write it down because I wasn't quite sure where it was going.
DR. DETMER: Then we will come back to that. Now, let's go to our second point.
MR. SCANLON: Don, one other point before you leave this. This is a fairly cautious paragraph-by- paragraph comments. Would the committee want to make some overall possible endorsement of the bill of rights?
DR. DETMER: Yes, I think that is a question. Do we actually think that this is a good thing or not, or do we want to comment on the fact that it has obvious cost implications or not and so forth?
I guess the question is, along your line, what do we want to do to it in general.
DR. COHN: I guess I personally would -- I strongly support this, and I have reviewed it pretty carefully. I don't have a lot of suggestions for even overall improvement.
I mean, there are a couple of areas, but I think we do need a paragraph at the beginning that really does state our strong support of the overall principles and ideas embodied in this.
Maybe that is the first paragraph within this other piece. Offering the following commentary is the next piece after that.
DR. DETMER: We have got a suggestion on the table. How do you feel, folks?
DR. IEZZONI: I think we should, but I still come back to what I chose to kind of lead with, that there are 41 million Americans who don't have health insurance.
I thought it was great that the commission really focused on that at the beginning. I am kind of curious as to why there would be people who wouldn't want this.
You know, the speaker before lunch said that there was one person who was adamantly opposed to it. Don mentioned cost.
Before we go forward on this, what are the other reasons that people would be opposed to this, something like this. Do people know?
DR. DETMER: I think there is some conflict on how do you have locus of control, if in fact you really are allowing people to independently make judgements on when they can go to a specialist and so forth.
It does make it difficult for one to really manage the care, if that is where one is coming from.
I think there are some functional aspects of these recommendations that I agree with very much at one level, but I can see where someone else might have some real problems in terms of trying to assess legitimate prospective costs, in such circumstances, and so forth.
DR. IEZZONI: Should we temper our overall endorsement by saying something like it will be important to evaluate the impact of a bill of rights?
DR. DETMER: I am not troubled by us being enthusiastic for us. I think the question is where is the committee on this. That is what I am trying to ascertain.
DR. HARDING: Having spent Sunday with a midwestern governor talking to him about these kinds of things -- I won't name him, but I will afterwards if you would like to know -- he would be concerned, in listening to him -- he is a Democrat -- about the idea of mandates that this brings up.
If this is mandates to states, that the states would stiffen on the idea of some of these proposals. That is what he would have said, if asked that question.
I don't know if the one individual who didn't like it, if that was their problem or not, but that would be one thing.
DR. FRAWLEY: I think it a very good document. I guess the first thing I would like to see, we really have only the one sentence at the front that talks about that we have reviewed the report with great interest, and offer the following commentary.
I am thinking, before we get into the commentary maybe we could just do a little bit more redrafting there.
I think that this is an opportunity to say that a lot of the issues that were identified by the commission, this committee has also reviewed.
It kind of just jumps into things, which is fine, but I don't think it really lays out the fact that the committee has had, you know, involvement in many of these issues.
I guess the other concern that I have is, once we have put this out, how do we follow up hearing from this morning some of the work going forward.
You know, how can we kind of work with their proposing an advisory group or --
DR. DETMER: That is the second issue. We will get to that in a moment. Kathleen?
MS. FYFFE: My impression -- and I will echo Don in some of my comments -- is that the Presidential Commission on Quality has received criticism because they didn't take a really good look at costs and what it was going to cost to implement all the recommendations.
I have heard, in fact, that the Executive Order that was signed by President Clinton might -- the cost implications of having the federal employee health benefit programs adhere to the principles of the patient bill of rights might involve some increases in premium.
Really, the whole approach from the beginning did not consider costs.
MR. SCANLON: Well, let me address that. Actually, the commission -- I am not defending them, but they did have all of their recommendations costed out. I think they would agree that this would add some additional money. You can argue about the amount to premiums, but I wouldn't argue that they didn't look at it at all.
MS. FYFFE: I stand corrected on that.
DR. DETMER: One thing we could say is that we have reviewed this with great interest and general support. A number of issues in the document have, in fact, been reviewed in the past and advice has come from the committee to the Secretary relating to some of those points.
A specific review does identify some specific additional concerns or issues that follow, or something. We could do a little hedging but also be supportive.
DR. MC DONALD: I agree with the hedging. I presented before the commission, and while I was there someone asked me a question, why were we worried about all the people who had this stuff, why didn't we worry about the ones that don't.
The answer was -- and I don't know if this is apropos -- was that they were specifically charged to look at sort of the paying customer and not health care reform.
The only thing is that if that was a specific charge they went in under, it may not be fair to beat them up for not having dealt with it.
DR. IEZZONI: No, I think that they did state in their introduction -- I am supporting the statement that they made. I am not beating them up about it at all.
I agree, on page 12, paragraph 2, they said this and I just want to underscore it.
DR. STARFIELD: Can I just ask a question about that? I thought the first paragraph was sort of a preamble, overall comment.
DR. DETMER: You mean the first paragraph of the preamble?
DR. STARFIELD: Yes, right. That struck me as excellent.
DR. DETMER: That is another option. We could beef that up or whatever or take out preamble and make it a little tighter. But that is an introductory paragraph.
All right, I think we have the sense of -- yes, Paul?
MR. NEWACHECK: The point about the committee generally supports this, that seems to me to be kind of a weak statement. I sensed around the table there was more enthusiastic support. Am I wrong about that? Could we say enthusiastically supports this?
DR. MC DONALD: Just supports, interest and supports.
MR. NEWACHECK: Applauds and supports.
DR. DETMER: Applauds and supports.
MS. GREENBERG: I want to ask Bob one thing because he reviewed it from the information and confidentiality or privacy or whatever perspective.
To what extent does this lay out the fair information practices aspect of confidentiality legislation?
MR. GELLMAN: I am not sure it did. I think it was a very general statement about confidentiality, as I recall.
MS. GREENBERG: The stuff about being information available and you can look at your records and all of that.
MR. GELLMAN: There is nothing inconsistent with that.
MS. GREENBERG: It supports that, I guess.
MR. GELLMAN: If you parse this thing real carefully, you can discover that it doesn't exactly match up 100 percent with the Secretary's recommendations.
If she doesn't care, you know, I don't see why we should. There is nothing inconsistent. It is just that the Secretary has a lot more detail than this thing did. It fits together.
You know, for the purpose of what this report is, it seemed to me it was just fine.
MS. GREENBERG: It reinforces it.
MR. SCANLON: They made some effort, actually, to ensure that the recommendations were generally consistent with the Secretary's.
MR. GELLMAN: I am just playing the lawyer.
DR. DETMER: Okay, I think with applause and supports, and with these changes -- we will be back in the morning and I think we can get pretty close to it.
Let's turn to the quality and the things that are yet to come out, and what we may want to relate to on that. If I understand your comment, Jeff, there are obviously groups that have been around for a very long time working very hard, and in fact, by most people's assessments, playing a useful role.
Instead of essentially just necessarily supporting them, they advocated formulation of two new groups.
MR. BLAIR: I may have missed some thinking behind some recommendations where they wanted to have a separate organization that would add additional focus or coordination?
DR. DETMER: Yes, they advocate two new groups; one an advisory group and then a forum that would actually advocate developing specific standards. So, there are two separate entities that they are suggesting.
MR. BLAIR: I don't know. Maybe that still has merit. My only concern was, I would hate to see it diminish, weaken or undermine the role of the existing organizations.
I guess I feel like they need as much support as possible, and that was my concern.
DR. DETMER: My sense of their draft is that they would not disagree with your assessment that these are important, and I don't think they want to undermine them in any way.
They do posit actually creation of two separate groups. Lisa?
DR. IEZZONI: I guess I wanted to respond, Jeff, to your earlier comment about why didn't they simply endorse NCQA or AHCPR.
I think that even though it looks increasingly like NCQA is de facto becoming the accreditor of managed care organizations, that is by no means a totally done deal.
There are other groups, such as the Foundation for Accountability in Health Care, or FAHC, even the joint commission has an interest in doing this. I think that I actually support them not specifying a particular organization.
Around AHCPR, I think that even though I certainly support and endorse AHCPR, I think that there has been some political baggage associated with the agency's perceptions in the past.
I can understand why they may not have said that this should be the focus of research in this area. So, I think that what they did was okay. I would support the way that they phrased it.
DR. COHN: I find it sort of difficult to comment on this one because we have various chapters of an overall piece, as opposed to being able to review the concept in its entirety.
I certainly believe -- I think we all believe -- that there is probably a role for private activity in this and a role for federal or public activity.
Like Jeff, I wonder if there is just increased redundancy by having a whole separate group created in the private sector.
I mean, I think I share your view on that, that certainly NCQA doesn't solve all the problems, but that is one of a number of other groups that, taken together as a whole, begin to solve all the problems.
There needs to be then some federal activity to help focus and sharpen that. Whether that is a private activity or something that a group that already exists could be doing, I think that is another question.
As I say, as I talk about this, I am just thinking out loud and I am just thinking that maybe we need to be a little bit higher level on this one, and come away with principles, supportive principles, questioning about actual tactical implications or implementation.
DR. MC DONALD: I just want to get clarification about which section we are talking about.
DR. DETMER: Page 5 in chapter four, but it also talks about actually these two committees, which is in chapter 5, the advisory group, the bottom of page one, and then they say a two entity approach on page five, proposed an advisory council for health care quality, and a forum.
Now, obviously they haven't even come out with their report or approved this. I think what we are doing today is really sort of discussing whether we want to try to weigh in before they have that, or just wait until they put it out and do the same thing that we have done on the consumer piece, or whether we want to say anything.
I mean, I think we have really got three options on this.
MR. BLAIR: Just refining my thoughts a little bit based on what you just pointed out, would it be useful for us to make a suggestion that the forum that they propose include representatives of the leading organizations that are active in health care quality assessment and promotion, including NCQA, JCAHO, FAHC and others?
DR. DETMER: What is your reaction, folks?
DR. STARFIELD: I would be opposed to doing that, mainly because I think it limits the paradigm of quality to something that has been around for a very long time and it may be time for new ones.
I don't think it serves any purpose, to give an imprimatur on those. That is my own personal view.
DR. DETMER: What is your pleasure? As I said, we have got really three options. One is to try to, if we wish, try to shape something that we get to them sooner. Two, shape something that we give our reactions later; or not formally respond in any way.
DR. IEZZONI: Also, having testified in front of this commission and knowing a little bit about how their working consensus was, Don, even if we got them something right now, I don't think it would change what they are hoping to present to the President next week.
I would feel a lot more comfortable if we had the entire document in front of us, rather than kind of a chapter-by-chapter read, went through it at a slightly more leisurely pace, and thought about whether we wanted to comment kind of just as good citizens at that point. That would be my vote.
DR. DETMER: I see heads nodding, at least on this side. I wasn't looking that direction. There are some over here, too. Kathleen?
DR. FRAWLEY: I agree with Lisa. I think it is important -- I would like to wait until the document has been formally released for the committee to offer comments.
It will also give us an opportunity to maybe identify to the Secretary ways that we think we can be involved in the process.
That is the piece I was asking about before. I think, again, that this committee could serve a valuable role.
I know that many of the people who went to testify before the commission that they were not as familiar with some of our ongoing work over the past year or two.
I think it would be better to get the report, formally weigh in on it, you know, send a letter to the Secretary with some recommendations.
MS. WARD: I think the reason I like that is, I agree with Lisa, that there isn't time for them, nor should they, rewrite the report based on just this committee's comments.
I would rather direct the letter the way Kathleen has, to the Secretary, in response to the report that has been delivered.
DR. DETMER: I think this is a sensible approach. It looks like we are pretty much agreed on that. It seemed to me, though, that if we were going to weigh in, we had to decide that today, and I think we have discussed it and I think what we are proposing to do makes a lot of sense to me, and it looks like there is consensus on it.
MS. GREENBERG: I was just going to mention that we did ask Kathy Coltin, with only these chapters in hand, to draft something that she may be bringing with her.
I mean, I think she would probably be comfortable with this decision, too. In fact, maybe she was uncomfortable with actually drafting anything. She wasn't able to come until later today, but she may have something she wants to discuss with the committee tomorrow.
DR. DETMER: We can take a peek at that, depending on when we come back to look at this other thing. Okay, I think this is good. Any final comments on that?
DR. IEZZONI: Yes, can I just ask a question?
DR. DETMER: Sure.
DR. IEZZONI: Is there any reason why we can't send our bill of rights comments in a letter format to Donna Shalala as well?
If our thought is to send a letter to the Secretary about the full report, I think maybe we could do the same thing here, especially since we are very supportive, or applaud and support the bill of rights.
DR. DETMER: What are your sentiments? It looks like there is a general sense on that, assuming we can agree on the language in the morning. But I think that sounds like a good idea.
Okay, I think that our colleagues are here, I believe. Okay, as I mentioned this morning, when we began -- and I don't think, Mark, you were here and I don't know if Bart was either, as far as that goes -- that what the HIPAA legislation mandated the committee to do over the next four years at the time they actually passed the law and it came into play, was to ask the committee to look at computer based patient records and look at essentially all the data relating to those, and advise the Secretary relative to that.
In that context, what we wanted to do was to get up to speed as a committee on what HCFA and AMA have been doing relative to the E&M code activity.
We have in our handbook the news release from the AMA, and that is essentially the documentation that we have.
We appreciate both of you being here. I don't know which of you wants to kick this off, but we appreciate it.
Agenda Item: Update on Guidelines for Documenting Evaluation and Management (E&M) Services.
DR. MC CANN: Thank you, Dr. Detmer. My name is Bart McCann. I am a physician in the Health Care Financing Administration, and my primary areas of responsibility are coding and payment policy.
I am actively involved in the Medicare fee schedule for physician services, commonly referred to as RBRBS, which stands for the Resource Based Relative Value Scale.
I am also HCFA's representative on the editorial panel of the AMA's current procedural terminology, commonly known as CPT.
Today, Mark Segal and I will address the issue of documentation guidelines for evaluation and management services.
What I would like to do is provide you with a brief history of the codes themselves. Then I am going to get into a brief review of the guidelines themselves, to hit some of the high points here -- what some of you might think are the low points, perhaps -- give you an overview of the importance of the guidelines from HCFA's perspective, relative to the appropriate administration of the Medicare program.
Then finally, I will specifically begin to address some of the controversy that has developed regarding the use of the guidelines.
Then at the conclusion of my remarks, Mark Segal will provide you, probably in more detail, the reaction of the medical community and the steps that the AMA is taking to make any necessary revisions to the guidelines.
Turning first, then, to the history of the E&M codes, for those of you who aren't familiar with this, E&M is the new term -- new as of 1992 -- for what you might think of as visits and consultations.
They are basically physician office visits, hospital visits and so forth.
Now, these codes are extremely important to the Medicare program and to physicians. They are widely used by all specialties.
In 1996, they accounted for 40 percent of part B payments to physicians, which is a significant amount, since we are approaching $50 billion. Forty percent is in the neighborhood of $20 billion associated with this small set of codes.
I brought my CPT book. Some of you may be familiar with it. It has almost 7,000 codes in it, everything from surgical procedures to anesthesia, to laboratory, to radiology.
Of those 7,000 codes, only about 90 or so of those codes are in the category of evaluation and management. So, several pages of this book accounts for about 40 percent of payments to physicians. Clearly, the codes are important.
CPT distinguishes these E&M codes in several ways. One is on place of service. Another is on whether or not the patient is known to the physician.
For example, in the place of service office, there are two categories of codes, one for office visits with new patients, and another set for office visits with established visits.
There are codes for initial hospital visits, which you might think of as admissions. There are codes for subsequent hospital visits.
There are codes for emergency rooms, nursing facilities, and so forth. Within each of those categories, there are between three to five levels of service.
By that I mean, within, as an example, office visits with new patients, there are five levels of codes to pick from.
Payments, which are based on physician work which I will touch shortly, increase as the levels go up. When you hear people refer to a level one code, they are probably referring to a lower level service, and level 5 being the highest.
The codes were first published by CPT in 1992. They replaced some old codes -- again, some of you may remember those. They had essentially one-word descriptors.
In the office visits they were minimum, brief, limited, intermediate, extended and comprehensive. The problem with those codes was that they were used widely in very different ways by different specialties and in different parts of the country.
In early work done by Dr. Shau(?) at Harvard on the RBRBS study, it quickly became apparent, it quickly became apparent, as he was trying to identify the work associated with those codes, that people had a much different interpretation of those words.
Now, the legislation that set up the fee schedule that was passed in 1989 required, at least part of it, at that point to be based on physician work, a concept that grew out of the RBRBS study where physician work really relates to the technical skill and physical effort, the mental effort and judgement, the stress and time, as the four predictors of physician work.
That legislation also required that department selected coding system, and was very explicit that we have a coding system for visits and consultations.
When this proposed rule is published, we announced essentially that we would be using CPT. At that time, CPT had already created the codes because the AMA also recognized that there were significant problems with the old coding system.
CPT used its advisors. It is supported by a committee structure with representatives from all the specialty societies who developed the codes, keeping in mind that the codes were going to be the basis of payment under an RBRBS system, a system which, by law, precluded Medicare from making separate payments based on specialty.
So, regardless of your specialty, under the Medicare fee schedule, the payment would be the same.
This meant that these codes, which in the past had been used differently -- you remember that I mentioned they had been used differently -- now had to be used by all physicians and by all specialties.
The basic structure of the E&M revolves around three key components of the codes, where all of the codes basically address one of these points.
It was put into CPT based on the judgement of the CPT advisors and the panel, with lots of input and many public meetings.
Those three key components are history, physical exam -- I always say physical exam, and I should say exam, because we have psychiatrists on this panel, I understand, and medical decision making.
Those three key components relate to the level of service and are important in selecting that level of service.
So, as the extent of history increases, as the extent of exam increases, and the complexity of decision making increases, the level of visit increases within a given category and, consequently, the payment by Medicare.
In 1992, HCFA, the AMA and the specialty societies mounted an extensive educational campaign for the proper use of the E&M codes.
It was a major departure from the older coding systems. It was one that put a significant amount of part B payments at risk, to the extent that the codes would be used improperly.
I can tell you now, seven years afterwards, that the use of the codes in the aggregate has been generally understood and these wide variations that we saw in different parts of the country no longer exist.
Now, at that time, in 1992, we also began to develop documentation guidelines, since it was clear right from the beginning that successful implementation of the RBRBS would require uniform use of the code across specialties and across different geographic areas.
Now, the guidelines provide specific definitions for physicians to understand what is meant by some of these key terms.
They are also intended to assist physicians in selecting the appropriate codes to report. They are also intended to be sure that when claims are reviewed, when documentation is reviewed by our carriers, that they will be reviewed in a consistent fashion from one part of the country to another.
As an example, in the older coding system where the highest level was a single word -- namely, comprehensive -- different carriers and payers interpreted that word quite differently.
In some parts of the country, if a rectal and pelvic exam were not performed, it was considered to be not a comprehensive exam and it was down coded. That no longer exists under these current guidelines.
What I would like to do, Dr. Detmer, if I could is turn to these slides. Some of this history I covered with you already.
The codes were developed and put into place January 1, 1992. The first sort of principles of medical record documentation, which was a relatively small document, was released in 1993.
The panel, the editorial panel and HCFA staff and others worked on documentation guidelines, the first version of which was published in the fall of 1994, put into place for Medicare purposes in 1995.
Again, there was an educational effort mounted at that point in time.
Now, one of the things that has happened is that there has been a revision in the guidelines, and those revisions came into place this last summer.
So, that is what the 1997 version is, and that is what has begun much of the controversy that some of you are familiar with, and I will get into that in a little bit more detail.
The documentation guideline booklet -- and Mark, you have a copy of that -- was published in CPT Assistant here.
In the front of the documentation guidelines, we have an introductory section to try to clarify the importance of documentation.
Frankly, some of it came from the earlier work of one of your subcommittees. Documentation and its importance, I think, is clear certainly to all of you, about the importance of recording facts and findings, to chronologically document the care of the patient, to facilitate evaluation and planning of treatment and progress.
Clearly, documentation serves as a communication and a basis of continuity of care among physicians and other health professionals.
It is used in claim review and payment. It is used in utilization review and quality of care. Finally, the data that is associated with these codes is important for research and education.
Let me turn to the part about Medicare, what do the payers want and why. It is important because many contracts, other than Medicare, some private insurers, it is important to understand what the site of service is, because specific benefit plans that patients are in may not cover certain services.
So, payers need to be able to validate the site of service. They also need to be able to determine medical necessity and appropriateness of care.
The Medicare statute, which is a big thick binding, has as one of its provisions, it says that notwithstanding any other provision, payment may not be made for services that are not medically necessary, that are not reasonably necessary for treatment of illness or injury.
So, it is important for us to be able to determine medical necessity by reviewing the records.
Finally, to be able to determine that the services that have been provided were accurately reported, this focuses in on was the correct level of service identified.
CPT identifies four types of history. The slides that I am going over with you now were extracted from an educational package that is much bigger than this.
I am going a little bit quickly and to be brief, so I am probably going to have some gaps that maybe we can cover in some questions.
There are four types of histories that are identified and these are the terms that are in CPT -- problem focused, examined problem focused, detailed and comprehensive.
Now, if you would think of a comprehensive history, I think most people would think of a fairly extensive history of present illness, a review of system, and a pass fail in social history.
I want to give you an idea of a documentation guideline -- and I am sorry that I left my little pointer at home -- but this is lifted from a documented related to a complete review of systems.
I put it in to try to illustrate how working on these guidelines we tried to strike some sort of a balance between too much in the record, too much of a documentation burden, yet being assured from Medicare's perspective, and from the perspective of other payers, that the services were, in fact, provided.
So, we have got up here a definition of a review of systems. What is the complete review of systems. The definition inquires about the systems directly related to the problems and the history of present illness, plus all additional body systems.
CPT defines 12 organ systems, by the way. So, you have to review at least 10, but the guideline -- DG stands for documentation guideline.
Those systems with positive or pertinent negative responses must be individually document. For the remaining systems, a notation indicating all other systems is negative is permissible.
There has been some sense that we are now requiring physicians to write out every single finding related to review of systems. That in fact is not the case. The guideline is as you see it here.
Now, examination -- I am sorry, I had to pull this one from two different things, so we have shifted colors on you here, too.
The same basic terminology here. The levels of E&M service are based on four types of exam -- problem focused, expanded problem focused, detailed and comprehensive.
Now, these are the words that are in CPT. You may sort of intuitively understand what those words could mean as you look at them. If you look in CPT, also, within each of the codes, with each of the levels there are examples, sort of clinical vignettes, like the level one visit might be someone getting a prescription refill and a level five might be someone with severe seizures and pneumonia. It sends a signal about the appropriate level.
In any event, if you would just focus on the expanded problem focused exam and detailed, the only difference between those two definitions is the word limited and extended.
We sort of fell back into our old definitions, where sort of the English language didn't quite help us. That was leading to some variation in the review of the records by our carriers.
So, we needed to have more specificity which, in part, is what led to the guidelines that came out in 1997.
The big difference between the 1994 version of the guidelines -- or the 1995 version I should say -- and 1997 relates to the exam.
There had been no specificity in CPT about what constituted a general multi-system exam or single organ exam.
At the highest level of the comprehensive visit, CPT acknowledged that the work of some specialists -- remember, to go back to the history, we weren't allowed to have a specialty differential in our codes.
To help account for that, the highest level was defined as being a general multi-system exam or a single organ system exam.
We needed to define what the content of those exams were, however, because, again, variation by physicians using the codes and variation by our reviewers in looking at them.
So, a fairly extensive effort took place between 1995 and 1997 to try to define the content of these exams.
Let me focus on this one right here, this comprehensive exam. This is listed from the documentation guidelines and I have brought it here to highlight where our problems are coming from, one of the major areas of controversy.
It is defined as -- this is a general multi-system exam. It should include at least nine organ systems or body areas.
Now, by the time the latest version came out, we were up to 12 organ systems and we had added two body areas for neck and breasts, as important parts to be examined.
The approach that we took to this was to think of providing, in a sense, some flexibility to physicians in performing a comprehensive visit that would not require every organ system be examined.
So, the flexibility that is built in is, instead of doing 14 organ systems and body areas, we will consider it to be comprehensive if you do at least nine.
With that in mind comes the next part here. For each area selected, all elements that are identified by a bullet -- I am going to give you an example in a minute -- should be performed, unless specific directions limit the content of the exam.
Then, for each area, documentation of at least two elements identified by a bullet is expected. So, let me show you one here.
This is from the gastrointestinal section of the general multi-system exam. These little squares or circles in the guidelines, those are what we refer to as bullets or elements of the exam.
So, the guidelines are saying, if you do a comprehensive exam, and the organ system that you identified that is important for this particular patient is the GI system, you will perform all of these elements.
In an attempt to reduce the documentation burden, we said that you only need to document two. So, you are expected to do all but only document two.
That has turned out to be quite a source of controversy. What happens, if you come down to the fourth bullet here, we have got examination of anus, peritoneum and rectum, including sphincter, tone, hemorrhoids and rectal masses.
There are cases when the physicians are examining the GI system where a rectal exam may not be appropriate. I think I heard from every emergency room physician in the country on this point, that these guidelines are forcing them to change the way that they take care of patients, because we are saying that you have to perform all of these and document two.
I have heard some people educate, sort of with a little wink, you know, you only have to document two, why are you worried about this.
In this environment that we are all in, that you all, many of you all, live in where there is concern about fraud and abuse, to not document things that you have done or to sort of not do them when you know the rules are otherwise creates a very significant amount of anxiety in physicians.
This is an area where we are really focusing a lot of our attention now. Is there some way that we can reduce the burden here and not require all these things to be performed; yet still be assured that the amount of work that is being performed is consistent with what is being billed.
The third piece is decision making. Remember, the three key components of selecting a level, history, exam, and decision making.
There are four types of decision making that are listed up here -- straightforward, low complexity, moderate complexity and high complexity.
This part of the coding system was the most difficult to work on in the development of the E&M codes. When all the advisors and the editorial panel and all the people that testified were trying to get a sense of the work that is involved in an evaluation and management service, we frequently came back to one of these things; that it may not be so important to do the exam as it is what is the decision making that is taking place.
So, the way that is measured and used in the documentation guidelines revolves around three things: the number of possible diagnoses and management options -- and as you look through here, if you can just picture, as that goes up, you move higher up, and the amount of complexity which moves you up to a higher level, the amount and complexity of records and tests and information that needs to be obtained and reviewed and analyzed.
The third one is the risk of significant complications, morbidity, mortality and comorbidities associated either with a patient's presenting problem, or the procedure or the management option.
So, that is the decision making piece. Here are three parts of one part of three. If you would think, where does risk fit into the selection of a level of service, it is almost as though it amounts to a ninth.
What is happening, as people are looking at these, they are starting to do these mathematical things and considering all the possible combinations of things that they need to learn, and are concerned that it is too complex.
The complexity, frankly, is built in so that we can properly recognize and distinguish between the levels of service, given the wide variation and the type of care that is provided.
Medicare implementation. There are three things that I will cover with you, our implementation plans, the CFO on it, and touch a little bit on teaching physicians.
DR. DETMER: Did you have a clarifying question?
DR. MC DONALD: It was just a comment. I am seeing patients. I have no idea what this rule is. I have read 16 documents on it. I think there is more intellectual activity required to do this stuff than it is to see the patient.
So, everything becomes a complex patient automatically. I mean, it is horrible for us who are in the trenches. It feels very stupid and irrelevant to what we are trying to do and half of the things that are important to specific patients it doesn't recognize. That is just a comment.
DR. DETMER: I take it that you wanted to make a comment.
DR. MC DONALD: I am a supporter.
DR. MC CANN: I only have a couple more minutes and then I would like to address Dr. McDonald's point. Let me back up and I will do what we refer to as a CFO audit first.
That is a chief financial officer audit. I know you all are uncomfortable about the IG and you might be happy to know that the IG also audits HCFA.
The CFO audit was, in fact, an audit of HCFA's performance. The CFO audit is required by law. One part of the audit that was done for fiscal year 1996 included a detailed review of the supporting documentation that supported the sample of claims.
It looked at about 3,000 claims and, based on their audit, they found that roughly 30 percent of them were incorrect.
When these audit findings were extrapolated to all claims, the total dollars paid in error were projected to be $23.2 billion, about 14 percent of the $168 billion in fee for service.
Now, I am describing all Medicare. This is not just physicians. Physicians were just one of six pieces here. This includes hospitals, home health, hospice, laboratories and others. So, there are physician payments in here.
The problems that were identified is that almost half the areas that were identified resulted from either insufficient or no documentation provided by the providers.
In response to these very serious findings, HCFA developed a corrective action plan that was shared with the Congress this past summer, that included an increase in the number of claims that would be reviewed and specifically included, for the first time, a random prepayment audit of E&M claims.
In the past, reviews for evaluation and management service were based on a post-payment review. That is, claims were paid and then carriers looking at patterns of visit codes by practitioner, by specialty, may identify someone who appears to be aberrant.
They are asked to provide records and those records are reviewed. If they support the level, there is no problem. Otherwise, there may be issues of overpayment.
A prepayment review that is going on now that began in October -- and it is done randomly across the country.
A claim will come in. Before payment is made, the physician is asked to submit documentation. That documentation is then reviewed and a decision about the level of service is made by the carrier, and payment made at that point.
That process began in October, which was the time when we were getting ready to use the new guidelines.
The think these two things occurring -- that is, the CFO audit and our intended use of the guidelines all along, plus an increased emphasis on fraud and abuse -- focused quite a bit of attention on these guidelines.
We recognize that there may need to be more education. So, in October we told physicians they could continue to use the older guidelines or they could use the newer guidelines.
For some specialties, such as psychiatry, ophthalmology, the new guidelines provided them, for the first time, a kind of safe harbor, if you will, about what is the content of a comprehensive eye exam or psychiatric exam.
So, we give the physician the benefit of the doubt, the old guidelines or the new guidelines.
We had intended to use the new guidelines only beginning in January of 1997. The outcry was beginning to build at that point.
Prior to the AMA's House of Delegates, which I will turn over to Mark to address in a moment, the AMA requested that we provide further extension, because they had a lot of concerns about the direction, and the speed with which we were going in that direction.
We agreed to put off the use of the newer guidelines again, until July of this year, July of 1998.
Maybe I will turn it over to Mark, if I could. I am going to come back to Dr. McDonald.
DR. SEGAL: I am Mark Segal. I am a vice president at the American Medical Association, responsible for our CPT activities.
It is a real pleasure to be here this afternoon with Dr. McCann, to provide you with an update on what we have been doing to deal with the documentation guidelines issue, and the outcry that has come from the physician community, that has been absorbing significant chunks of my time over the past couple of months.
Dr. McCann has outlined where the guidelines came from and their relationship with the E&M codes that came on line in 1992.
That is really critical in terms of the degrees of freedom that we have to deal going forward.
He also explained the context in which HCFA approached the development of the guidelines. Now, I would like to take a few minutes to outline the rationale of the nature of the AMA's involvement in this effort, as well as how we are dealing with the physician concerns that have emerged.
Now, our work with HCFA on the project involves our commitment to several principles: First, the need to define with precision the terms that are used in CPT, and Bart outlined some of the historical problems that keep creeping in when we use terms like limited or extended, without definition;
The desire to work cooperatively with the Federal Government -- particularly HCFA -- on the implementation of CPT; our obligation to assist physicians, HCFA and other interested parties with accurate and efficient implementation of the new E&M codes;
The importance for physicians to document the clinical care that they provide to their patients; the recognition that documentation also has uses beyond the clinical realm with respect to payment and utilization review.
A critical point for us, the need for physicians to have advance access to the review criteria used by Medicare and other payers, rather than black box review criteria.
That really lies at some of the genesis of our involvement here, because these documentation guidelines might not, in effect, ever have seen the light of day and might simply be being used by Medicare or private reviewers without any ability for input.
We recognize the importance of allowing the respective medical specialties to define the content of their single system examinations and the need for comparability across the specialties in the work associated with each level of service.
It involves the recognition that these guidelines must evolve over time as comments are received and as there is experience with their use.
As Bart indicated, the revised guidelines were issued last July and an education process began shortly thereafter.
I think, really, from June or July, they have been on the HCFA web page and are still there. They were featured in the AMA's quarterly publication, CPT Assistant, which for some reason is much thinner than if you get it off the web page.
At the same time, it is clear, certainly in retrospect, that the process both of informing physicians, giving them a chance to react, and educating them on the guidelines has really be insufficient and really has to be improved as we move forward.
Now, although the post-July period brought forward some suggested changes from a few specialties, some of which have already been integrated into the guidelines -- for example, I think the example Bart used was the examination of the rectum and the peritoneum has been made basically as indicated. There were some changes in the skin examination.
The initial dissemination really did not involve enough focused information and assessment.
Now, we recognized late last fall that a real problem was emerging. As Bart indicated, we asked for, and HCFA very quickly granted -- and we appreciated the speed with which they acted on this -- a six-month extension of the grace period.
Now in December, at our House of Delegate meeting, things really crystallized for us, and it became clear that more and better education on these wasn't really enough. That wasn't necessarily wholly the issue.
Our members had significant problems with the overall burden that they perceived imposed by the guidelines, as well as specific concerns, mostly with aspects of particular single system examinations; in some instances that too much was included; frankly in some instances that not enough was, relative to how that specialty defined the scope of its work.
Now, I should underscore that a guiding principle of the CPT editorial panel through all this was to allow the relevant specialty societies to determine the content of their own single system examinations.
The editorial panel really functioned in an editorial capacity here, to focus on consistency and content, comparability of work.
Essentially, we worked extensively with, and deferred to, the over 90 specialty societies that comprised the CPT advisory committee.
Now, this process took place over a three-year period. It didn't just sort of hatch last July. In fact, we had agreement from the pertinent specialties on the single system examinations included in the 1997 guidelines.
Now, as I mentioned, we in HCFA have also acted quickly on requests for further refinements that emerged after July. In fact, some of those requests have already been on the agenda of the CPT editorial panel prior to our Dallas meeting, I think most notably from the American College of Emergency Physicians, which had some serious issues.
Now, still, I think from our perspective it is clear that the guidelines in their present form are untenable, especially given physicians' substantial concerns with the heightened fraud and abuse climate, that they will be unfairly penalized for inadvertent coding or documentation errors or omissions.
Many physicians now see these guidelines as rigid rules that have to be followed to the letter in every instance, not as anything of a guideline, and they have to do this if very severe fraud and abuse penalties are to be avoided.
I think for example -- I am terrible with numbers, but I think there is the potential, once a pattern of fraud and abuse has been established for $10,000 per instance in recent legislation, there are real concerns there.
Now, the view of these as rigid rules was certainly never our intention. At one level the guidelines are intended to be a template for reviewers, who must evaluate medical records to assess coding accuracy and medical necessity, as well as a documentation-oriented guide for physicians and their staffs and that of other health care professionals about how one should code and document these services.
Clearly, physicians are overwhelmingly highly ethical professionals who do a very difficult job under extreme time pressures. Extreme time pressures obviously comes in with the time for documentation.
There has never really been any serious suggestion that I am aware of, let alone evidence, that physicians were or are a significant source of health care fraud and abuse.
Nor is there any evidence since the new E&M codes were put in place that physicians were unable to code reliably or are upcoding.
Indeed, what members tell us fairly consistently is that they are down coding, to play it on the safe side.
Moreover, we know that there is no single standard for documentation in the medical record, now really should there be.
If one reads the text of the guidelines, it is clear that they can accommodate a variety of modes of documentation.
Now, if the next version of these guidelines is to work, documentation should be, first and foremost, a function and a byproduct of clinical care.
Physicians and their staff should code, and be able to code, based on this documentation. Certainly the desirable sequence should be you document for clinical reasons, you code from that documentation.
Then, the physician, their staff or reviewers ought to be able to verify their code selection from the documentation in guidelines that are grounded in the CPT definitions.
Now, of course, one of the issues that we are facing, and I think that is responsible for a lot of the response in the health care professional community is that there are -- if one looks in CPT, in addition to these guidelines and all the various rules, there are clinical vignettes that were developed and have been validated -- I think Bart indicated a couple -- to help physicians to code reliably and accurately.
A physician I was speaking with the other day talked about that he codes by gestalt. I think there is a lot of that.
That doesn't mean that that isn't accurate or reliable. That means that, having studied the guidelines and studied the rules and knowing one's patient base, that one has an ability to accurately code, but not necessarily from documentation in every instance.
That is really sort of a dilemma here that we are all facing in terms of how much documentation is necessary for coding in each instance. That is clearly a perspective out there.
What are we doing to deal with the problem? Well, one is we are working closely with all elements of organized medicine to implement a three-pronged action plan that is described in the press release you have, to respond to both the immediate concerns and the longer term needs here.
The plan begins with advocacy, followed by the critical corrections to the guidelines, and then there is the process of education.
Now in advocacy, much of our focus is taking every necessary step to prevent physicians from being subject to unwarranted fraud and abuse penalties and sanctions for inadvertent errors or omissions in coding documentation.
We will demand, and are demanding that physicians be treated in this respect as ethical professionals.
In addition, in our view, claims reviewers must be required and empowered to exercise judgement as they review complex clinical documentation and evaluate related coding, and that they have to have the training to do so.
The current version of the guidelines -- I think as Bart indicated with respect to medical decision making -- recognizes that some elements of code documentation are, of necessary, subjective.
Physicians in our view, need to have the benefit of the doubt to some degree, certainly for payment purposes, and I think emphatically when one is getting at issues of fraud and abuse.
Now, our second priority, clearly, is to change the guidelines themselves. We are well aware that many physicians do not think that these current guidelines have a solid basis in what happens in the treatment room every day.
Our first step in this process was securing agreement from Dr. McCann and his colleagues at HCFA, that needed changes to the guidelines need to be identified systematically and then implemented, and we have been very pleased with HCFA's rapid acceptance of this premise.
Our next step was to ask the specialty societies, state medical associations, a number of organizations representing non-MD health care professionals and other interested parties to submit to the AMA, by the 15th of this month, their specific comments and suggestions for improving the guidelines.
We are going to collate and evaluate these data and use them as the foundation for a special fly-in meeting -- oddly enough to be held outside of O'Hare airport -- to be held with the specialty societies, and the states, and larger county medical societies on April 27.
It is my pleasure to invite the committee, or representatives of the committee, to attend. It is going to be a packed meeting. I think we are looking at anywhere from one to three. It is certainly be your pleasure, but we would certainly be delighted to have you attend.
Now, at this meeting, members of the AMA board of trustee, the CPT editorial panel, and AMA and HCFA staff, will be available to hear specific problems and to assist in developing workable solutions.
By that time, we also hope to have available for discussion some alternative formats in presenting these guidelines, that we would hope would ease their usage in a variety of clinical situations.
It is critical -- as I have on a number of occasions recently been reviewing these documents -- it is critical that we take a holistic approach to the revision process.
Not only should we address specific comments and specific dimensions, whether it is the review of systems or the history or the physical, but we have to look at the guidelines as a whole and how workable they are, to make sure they are efficient, accurate and non-burdensome.
Although specific comments, such as a particular element in the GI exam ought not be there, or was omitted, those are the most helpful and the easiest for us to deal with.
Certainly they seem more immediately helpful than a comment, this is too complicated. It is clear that the latter comment is really equally important, if not moreso, and has to be fully addressed.
I think the burden is on us and on HCFA to address the concern that, overall, these are too complicated.
Now, the editorial panel has, and will be, devoting a major portion of its February, May and August meetings to refining the guidelines based on the input that it received this month and in April.
The agenda, as I mentioned, already includes suggestions from ASEP with respect to the emergency department examinations.
The third part of our plan -- wrapping up here -- is education. We have already begun to work with the states and specialties to develop teaching materials and tools to help physicians increase the accuracy of their coding and reduce the burden of coding and documentation.
Once the guidelines are revised, we are going to make sure that these materials are widely disseminated. We also want to make sure that there is, in fact, enough time for education before the next iteration is mandatory.
We have already begun discussions with HCFA about an extension of this current grace period to accommodate that needed additional education.
I think, without any commitment having been made, I think we are optimistic that these discussions will come from a good result.
From the comments we receive later this month, we will have a better idea of the time that will be required to complete the revisions and, hence, how long this extension has to be for.
In conclusion, please be assured from the AMA standpoint, that as Dr. McCann indicated, we recognize that clinical documentation is essential to good patient care.
We hope that these new guidelines will ultimately encourage and assist physicians and other health care professionals in providing proper documentation.
We are also mindful that the time required for documentation beyond that which is clinically necessary can really only come out of patient care.
I think you heard some discussion earlier today about changes in the health care system. And patient/doctor relationships are already feeling the crush of time.
Moreover, through accurate information and needed changes in enforcement approaches -- and that is accurate information on what really is the situation legislatively and regulatory with respect to fraud and abuse -- physicians must be able to provide high quality, well documented patient care without laboring under the constant pervasive fear of unwarranted fraud and abuse penalties and prosecution, and we welcome your support for these propositions.
With that, I thank you for the opportunity to appear today and, with Bart, I would be happy to answer any questions that you might have.
DR. DETMER: Great. Before I open this to the committee, I just want to make a comment. First of all, I think it has been very useful to hear not only sort of the history of some of this in the past, but actually what is already in place and underway.
I think the thing, as I mentioned at the start, the HIPAA mandate talks about going to computer based records and how we would look at data relating to that.
This committee actually, over the years, has been as you know very much supportive of the importance of documentation.
I think actually you can look to us to be very supportive on that. I think the very interesting question -- and I would like to open it up in a second, but I would like, before we quit, to get your thoughts on this.
One of the things that I think is an interesting question as it relates to computer based patient records is the issue of how structured you want your data entry.
In fact, one of both attentions -- I would say one of the up sides of computer based records, if you do have structured data sets, is that they, in fact, do allow you to have a much more defined data base, to indeed -- we were talking earlier about evidence based medicine and the value of being able to try to find out better science when we can.
I think it also holds greater promise, actually, of progression in medicine also as a rider on that, if you have defined data sets and such.
It also does give you a better data base for research or payment for a variety of uses. I would be interested in your thoughts about how you could see this perhaps relating to that area of work, which is actually something that we are mandated to give the Secretary advice on.
With that, why don't we just open this for a little discussion. We probably will, in fact, want to track this with you, and in fact see how it does kind of move forward. As I say, I think it is very relevant to our challenge. So, let's open it up for questions or comments.
DR. STARFIELD: This discussion follows on a discussion we just had on quality of care from the President's Commission.
In a system such as this -- let's talk about perverse incentives. How do you keep physicians from doing too much? I take it for example that they basically get paid more the longer the rule-out list is, which is certainly going to encourage physicians to do a lot of unnecessary things. How do you deal with that?
DR. MC CANN: In working on the guidelines, we have tried to take that into account, to try to have a kind of balance, if you will, between what may be too much and too little. Let me use one example.
In the medical decision making slide that I showed you, one of the criteria is the amount of data that is reviewed.
Clearly, there is an incentive to order a whole bunch of tests. Some of the initial drafts or suggestions from some of the specialties would sort of give you credit for each element of chemistry.
If you did a sodium, potassium, chloride and CO2, that one is worth four times more than a potassium.
The panel felt that was really the wrong direction to go and sort of lumped it all. So, if there was some test in the laboratory section, one or 100, that would be an indication of more work, that you are ordering a test.
The guidelines are all built on sort of the presumption of medical necessity. We are very vulnerable on the point that you are making.
If people, in order to get a higher level, simply start ordering tests to qualify, I guess my answer to Dr. Starfield is that we try to strike a balance, and it is the same answer I was going to give to Dr. McDonald when he said these things are so complicated.
Medicare needs to be able to discriminate between the levels of service in a consistent way, looking at the records, and we want that to be the minimum documentation burden.
We expected or had hoped that what we had worked on was it. Clearly, with the outcry that we are having, we haven't gotten it yet.
We need to be able to do it with something that will allow us to distinguish between a level four and a level five, other than the number that was on the claim.
There are physicians who feel that way, by the way, that the only documentation they need is the code that they submit to Medicare. I think those days really are past now. I mean, there has to be some more accountability than that, and more documentation.
Anything we can do -- hopefully this meeting that the AMA is putting together will help us focus in on that. Frankly, having worked on it for so long, I think I have gotten tunnel vision.
DR. DETMER: Clem, you have concern with it. What advice, though, might you have?
DR. MC DONALD: You know, I love computers and all this kind of stuff, but just viscerally, and I imagine that is what you are feeling, it just feels like I am doing a paint by numbers game, in parallel, totally independent, totally unrelated to the care I am giving. It feels completely nonsensical.
DR. DETMER: I hear the criticism. How would you suggest we cure it.
DR. MC DONALD: I worry where it came from. There is this long history of medicine thinking this way. You know, we get all these experts, we think we know what we think and we don't test it. We don't run it through any kind of challenge until life, and then of course it comes back as a wave.
We did this back in the early 1970s in quality assurance. So, you get a panel of experts around they go, well, this is what you need for a urinary tract infection. They list 20 things.
Then they reviewed the charts and they found out, well, gee, everybody is a lousy doctor, and they only do five percent.
Then they reviewed the guys that made up the standards and they found they only did five percent. When they asked them they said, oh, this case is different and this case and this case.
This is like a fractile and you can't approximate it with these simple rules. You have got to go down different levels for different purposes. Give me a stop watch and a videotape and let me document it that way. I could back it up, what I am doing, that way.
Short of that -- it would be easier. We can just throw away the tapes, you know, they are cheap, and a stop watch is easier. I would be happier going back to time.
DR. DETMER: The legal profession has gone to time. They have used billable hours for years.
DR. MC DONALD: I would rather do it by time.
DR. COHN: First of all, Dr. McDonald, I would worry about videotaping and issues of privacy and confidentiality.
DR. MC DONALD: We could use invisible ink.
DR. COHN: I just wanted to make a comment or two, as I have listened to all of this, obviously I know something about the documentation guidelines.
First of all, you all are aware I am an emergency physician. So, I have sort of watched my own habits over the years. I have tried to use computers for documentation for over 13 years now, and sort of know something about this.
When I try to take care of a patient, there is very little that I find more frustrating than a note that says, okay, and a signature. It doesn't assist me in practicing medicine.
It doesn't matter to me what they code on, but that sort of documentation doesn't provide quality care.
Now, that is probably fine if the patient has nothing wrong with them, but if they have nothing wrong with them, they are only getting a very limited exam on the basis of what they could code anyway.
So, that probably handles that sort of simplistic situation. Certainly for anything that is wrong with the patient, if I am going to be caring for them afterwards, I want to know about them.
I actually looked through some of the guidelines, sort of comparing it to my own documentation. I actually found that it wasn't so far off.
I mean, my sicker patients actually I do tend to document more in many of the areas. Patients who aren't as sick I don't document as much.
As I listened to both of you talking, I do have to say that what struck a chord for me was this issue of how things are presented.
As I look at the documentation guidelines, first of all, I think every physician looks at that and says, I have got to code everybody at the most comprehensive level, and it makes you nuts.
Clem, I agree with you. If I tried to see a patient every 10 minutes or 15 minutes in a clinic environment, to do that sort of documentation is crazy.
On the other hand, most patients are somewhere in the middle range and documentation guidelines are quite appropriate.
I guess that is just sort of my own view of this as I look at it. I think there need to be refinements or some way of presenting this thing to people so that they can understand it, and I think that is really an education effort that I think the AMA has to lead off on. But there is nothing intrinsically wrong with pushing physicians to do better documentation.
Don, I agree with you. I think it provides a wonderful piece of a computerized patient record and some guidance in that area.
DR. IEZZONI: Can I respond to that? My colleagues are saying that the message with this is that they undercode, that they don't say they had comprehensive visits, but that they always code a level lower because they don't want the FBI or whoever the agents are that come and review the medical records to -- technically the fine is $10,000 plus three times the difference between what you would have gotten paid under the lower level and what you did get paid.
I have two questions. The first is that for some specialties, talking to patients and giving them counseling and advice is really how you spend a lot of your time.
Yes, you examine them, but comforting them, talking about their fears, addressing their questions with them and with their families, frankly, is how so much time is spent.
I think that you do have some accommodation for counseling. Can you just really briefly describe that, and then I have a second question.
DR. MC CANN: Let me give you a quick history. The codes really were built around these vignettes that were studied by Harvard, and there was a radiation oncology vignette.
DR. IEZZONI: That doesn't mean anything.
DR. MC CANN: The vignette was counseling of a woman with breast cancer, about treatment options. Clearly, looking at that vignette, as the panel did in creating the codes, there was not going to be any history -- there might have been history, but there was not going to be an exam.
From the beginning, CPT has allowed, in that situation, coding based on time, as Dr. McDonald has suggested.
When counseling or coordination of care -- and it can be counseling with either the patient and/or the family -- when that dominates the encounter, you can build a code based on the time that is in the code.
Each of the codes lists a typical time that is associated with it. So, if you spent 45 minutes counseling a patient in your office and it was an established patient, you could automatically code the highest level.
For documentation purposes, Medicare looks, to see if that is the basis of your coding, that you actually document the time of the counseling.
DR. IEZZONI: So, if all you do is write in the record, 15 minutes counseling, 40 minutes counseling, an hour and a half counseling, that is sufficient documentation?
DR. MC CANN: That is sufficient documentation with a little bit put in about what you counsel them about and why, so we can make this judgement about medical necessity.
DR. IEZZONI: I frankly find it somewhat offensive that some of these people can make a determination about medical necessity.
I mean, what is the training of the people who have, in the past, done the audits and are planning to do the audits?
DR. MC CANN: Most of the review of our carriers are done by nursing staff with support from the physicians.
DR. DETMER: They are basically getting away from the notion that we should just trust the report.
DR. IEZZONI: I guess I don't want to take up too much time here, because I do have a second question, but let me just say that I think that educating physicians about what is going on is really not happening in the right way right now.
What is happening -- for example, what happened at our hospital -- is that each of us had to sign in to a two-hour session of training about this.
I don't know if this has happened to other doctors around the table, where they have had to do this. You have a proprietary organization come in and tell you that it is "FBI agents" who are doing these record reviews and not nurses, and the FBI agents do not have medical backgrounds.
So, when people like me hear, oh, you know, the FBI is coming and they don't have a medical background, that sounds like it is misinformation, and it could be misinformation that might be the reason that is spurring this groundswell of upsetness among the physician community.
So, I am saying things in a hyperbolic way, perhaps, to just emphasize and underscore that there may be some misinformation in the physician community about what exactly is going on.
But I do have a second question and it --
DR. DETMER: Mark wanted to respond to that first.
DR. SEGAL: You are absolutely right, and let me say, though, that I have had several experiences talking to groups of physicians.
I tell them, and I think with some accuracy, that the odds of any physician's records being looked at externally for the level of documentation are very low.
I believe HCFA's random prepayment audits are one percent. In general, my understanding is that if a carrier reviewer is doing this and down codes it, those don't automatically get sent to the Inspector General, not the FBI. That resonates not at all.
DR. IEZZONI: Let me just say that I am at a teaching hospital that was a PATH audit. That is why you start with a certain level of paranoia.
DR. SEGAL: But I think the other point, though, is that a fair amount of the education that has been done, particularly by sort of for profit trainers, frankly, I think a certain amount of the marketing has emphasized the fraud and abuse, and the FBI no longer tracking the Russians, they are coming after doctors.
DR. IEZZONI: Exactly.
DR. SEGAL: You know, that perception is real. One of the things we are trying to do is ask HCFA and ask the Inspector General to very clearly -- we are going to be publicizing this information. As a matter of fact, I think it will be in the next American Medical News, what exactly is the situation.
I mean, there are threats. $10,000 is real. But I think there is a real gap between the perceptions and the reality and physicians need to have an accurate understanding.
But at some level, the damage has been done and undoing those fears is an uphill --
DR. DETMER: Actually, the session I attended in Charlottesville was not wildly different from what she described. As a matter of fact, it was a pretty scary kind of thing. And it was not really that helpful when it was all said and done.
DR. SEGAL: Say good-bye to your family now.
DR. IEZZONI: Right, exactly. That is what I said my husband asked, if I would still love him when he was in jail.
DR. HARDING: There are private practitioners who are being audited in their offices, and then a letter coming back from the Inspector General saying, you upcoded, you didn't verify what you did. So, send us $50,000 by, because we looked at 20 of your charts and extrapolated that to all your Medicare charts that you handled in the last five years.
Now, send us $50,000 by January 1 and we won't do anything, because we know that you did the service, but you didn't code properly. So, just send us $50,000 and we will forget about it.
That is coming now, and regularly, with people in the states, in private practice. That shakes you.
DR. DETMER: Is this discussed or happening?
DR. HARDING: That is happening. I can show you letters on that one, of people who have written to me saying, what do I do. I have been asked to send $50,000 to HCFA because I was doing 90855s instead of 9067 -- you know, that kind of stuff.
They say, if you don't send the money we will be glad to just hold all your Medicare payments until we have $50,000. They will work it out. They are friendly guys.
The issue is, what can we do to help doctors feel like they are doing the right thing by documenting better, and that it is helping their practice and helping their patients.
Nobody at this time feels that this is going to help their practice or help their patients or help anything other than be good boy scouts and fill out that paperwork right.
You know, doctors are good boy and girl scouts. That is how they got to be doctors. They will do the thing and fill in the lines, but it won't improve patient care, I can guarantee you. It will do the opposite.
What you will do, this doctor's performance will come down and the worst doctor's performance will come up, and you will have a bunch of blah.
DR. IEZZONI: I still have my second question.
DR. DETMER: That is true, go ahead.
DR. IEZZONI: Can I just ask a question about whether something would be acceptable, because we were told by our trainers that it wouldn't be.
Couldn't somebody program what basically is your Chinese menu, of you have to take nine of the above or seven of the above and then you get this and you calculate it.
Couldn't somebody just design software and have a checklist. So, if you had a computer based medical record you could just pull up the list and then check off the box as to what you did, or just not tick it off if you didn't do it? Can you do that, or would that not be considered adequate documentation?
DR. MC CANN: That by HCFA would be considered adequate documentation, as long as it was evident from the record that the physician had either done it him or herself or had acknowledged and reviewed what had been collected by others.
The use of a template is acceptable, and let me use that as an example of where some of our problems are related to education.
Because of the teaching, the PATH audits, hospital compliance officers are going and becoming much more zealous about documentation than HCFA or the IG, even.
That is causing problems, because it comes back to us, and the things that physicians are being told are just not consistent with our own rules. It is a problem that we need to work on with them as well.
DR. DETMER: That is useful. Michael, and then Kathleen.
MR. NEWACHECK: Every so often when I go back and pull together some information for an article or a presentation, I come across this same article time and time again. It is about the imperfectability of man.
It has some examples at the beginning about, lawyers have these standard paragraphs. Why don't we have more of these things that we just don't have to think about.
Well, two weeks ago Friday we had an ABIR contractor come in that we had funded to develop a quality assurance system, voice recognition.
So, they were going through the paces of voice recognition. You saw these things come up there, documented skin tone and this and that. At the end it said, this is level two. You need to investigate this body system or this and that to do level there.
I thought, what does that mean, because I didn't know very much about the E&M codes. So, it explained that the level of payment depended on what you had done.
Last week I went down to HMSS. You walk along the exhibitions which are as much fun as going to the sessions, trying to figure out which one is just a smoke and mirror and which one has a real product.
I stopped at one that had sold 80 systems to physicians. I said, what is the driving force behind these computer based patient records that you are installing. What do you think it is going to be for the future; improved productivity, letting off some of the history and physical to the nurse and then she comes in with a sheet?
He said, no, that is not number one. Number one is going to be E&M codes. I said, what are they. I keep hearing that. So, he explained a little bit about it.
So, I have done some reading about it between then and now, and I have had an even better education on it.
It seems to me, picking up on what Don said earlier, that products are going to come out that will prompt physicians -- whether it is voice recognition or not, I am not sure -- that will prompt to say, you are now at a level two. Here is what you have to do for a level three.
Now, is that upcoding? Only if someone does it when it is not needed. Try to prove that? I don't know.
It gets through some of the hassle of, is it likely to be down coded. So, technology is on the way. It doesn't solve the problem here and now and it doesn't solve the education problem. But I know I am going to keep reading that article over and over again, and it still rings true.
MS. FYFFE: One of the fears that I have heard from physicians, rightly or wrongly, is that they are going to be responsible somehow for the level of documentation or the quality of documentation done by their colleagues in a practice. Is that true at all?
DR. MC CANN: The only connection I can think of is if they are all sharing incomes and someone runs into problems. Then they are all going to share the pain, I suppose.
I don't know that there is any connection between an individual physician's documentation and another's.
DR. IEZZONI: Yes, there is in the sense that if you are part of a group practice and a patient is new to you, but not new to the practice, you can't code for an initial visit because that patient saw one of your colleagues.
That is what we are told, even if that colleague has long since left the practice. You can't code for a new patient visit if the patient has seen somebody in your practice in the last three years, I think.
DR. MC CANN: If it is the same specialty, that is correct.
DR. SEGAL: On the computerization issue, talking to a few folks who have seen the guidelines sort of integrated into the record, one of the things I think -- and I think it is very helpful, that HCFA's view on the templates, and if you can put in an abbreviation, why not be able to have a macro that translates that into a sentence, as long as -- and I think this is critical -- people treat this as the medical record and they are signing for it and attesting to its accuracy.
But one of the things, I think, to watch for is, some systems will overlay a checklist or a template over what, in effect, is a real record.
One can get into a situation -- and I think this is just something to watch for -- that the EMR, the CPR, what you have really documented in the record there is not, in effect, related or correlated to what was done in the checklist.
However these are used, they need to be looked at as tools to more accurately generate what, in fact, is the record and the documentation that is going to be used.
DR. DETMER: That is what I was trying to say. It sounds like what they are really also sending, though, is a very definite signal, we want clear documentation to back up what you billed for. If, in fact, you can't find it, you had better start doing it. That is clearly, in effect, a chunk of the message, isn't it?
DR. SEGAL: One other point, just on the incentive issue, though, I think it was Dr. Starfield that had mentioned, and Bart had talked earlier about the basis of some of this and resource based value scale.
The assumption or the goal here is that -- you will pardon the expression -- equal pay for equal work. Whether you are a neurosurgeon or a psychiatrist or a gastroenterologist and within a specialty, that you don't have these sort of glitches and notches where a particular way of spending 10 minutes is substantially more remunerative than spending another 10 minutes.
So, the payment levels and sort of the content with the different visits are, I think, intended to be calibrated so that if you look at what is in there -- recognizing that in some ways you can bump up -- I think in general, to go from one level to another and to do it correctly, in general it is supposed to require a substantial increment in additional time or work or effort or complexity.
DR. DETMER: That is what Simon, I think, was saying. Barbara, and then Clem.
DR. STARFIELD: I will respond for that. In fact, there is a built in incentive for specialists in this system, because a specialist is much more able to come up with a long list of rule out diagnoses than a generalist.
I mean, they may not, but there are 14,000 ICD codes. That is a lot of rule outs to go through. I think you have to worry about that. I mean, it is the whole business of, when you hear hoof beats, you look for zebras or horses.
DR. MC DONALD: Actually, I think we could find just as many diagnoses, but we don't have as many procedures. That is the difference.
I wanted to come back to whether this thing defined as documentation is what we are supposed to be doing in real life or would be doing in real life, if left to our own devices.
I think my own bias is it is completely non-productive work as an overlay. I write a long note and I type it, and it is probably half to a full page on an average visit, and that is probably bad for me in my own practice, but that is what I have always done.
I don't say all those things. I don't say all the review of systems. I don't say all the family history. I get students who give me a family history on a 90-year-old person, tell me all this good stuff that might happen to this patient.
I say, you can't tell me that. They have already read their tapes. We know what the DNA is going to say in that lady. We don't need the family history to say it.
So, there are a whole lot of complicated things. I think it is really silly school boy work. It is rote and it is medical student level and it doesn't have much to do with reality.
I think if you could get into the logic, that they have looked at the differential diagnoses, they have looked at this complex chain of events and decided which one came first and is causing it, and what happened first, the IV was given, or the patient fell out of bed.
All that stuff isn't showing up here. That is where all the hard work is, or dragging out of the patient what medicine they are really taking, you know, and what color is the pill they are taking on which day and they got dizzy after which one.
That is where we are spending our work. So, I think we have got this complete disconnect between this dream world of what medicine is and what it really is, and no testing to prove that is the case.
We are going to have a whole industry spring up -- which is going to be great for the industry -- doing all this documentation on top of all the rest of it, and it won't take doctors much time.
I will bet you any money, it is going to come out worse for Medicare in terms of dollars. They are going to jam more dollars out of you than they used to, because it is all documented.
DR. DETMER: Another argument for some time system or something else?
DR. MC DONALD: I think we just ought to be careful about presuming that we know the model when it is a very, very complex beast. We have done this over and over again, historically.
DR. DETMER: Michael, you referred to your article. The Mark Twain quote that I like relative to that is the definition of human beings, and that is creatures made by God at the end of the week when he was tired.
Thank you both. I guess, Mark, you used to be with this committee at one point. It is nice to have you back. It is nice to see you again. Good luck, and I think we may well want to take you up on the offer to come to the Chicago meeting. Thanks.
Okay, we are scheduled to have a break and then go to our subcommittee breakouts. One is in 303-A and the other is in 425-A.
Since we will be adjourning, actually, for the day after those meetings, I just wanted to see if any us wanted to get together for dinner tonight or not. What is your pleasure? Any interest in that?
If so, would you like to meet back here?
MS. GREENBERG: Let me ask something else. This group that was supposed to rewrite or work on the document, did they want to convene? I think we need to do that, before you go to dinner.
DR. DETMER: I understand. Do you want to meet here and then we will go from here? At 5:30 or something we will meet here and then we will go from there, decide what we will do.
MS. GREENBERG: Do you mean now?
DR. DETMER: No, wait a minute. Don't mix things up. The writing group is going to meet here. I am talking about for dinner.
DR. IEZZONI: What time should the writing group meet?
DR. DETMER: Now.
DR. IEZZONI: I have to go check my subcommittee.
MS. GREENBERG: See, they can't. They have their subcommittees.
DR. DETMER: Okay, then we will talk about it. I don't want to get two things on the plate here at once. We will meet back at 5:30 relative to going to dinner.
DR. IEZZONI: Can we meet here at 5:00 relative to writing?
DR. DETMER: That would be fine, or we could meet at 5:30 and we decide to go to dinner at 6:00.
(Whereupon, at 3:30 p.m., the committee meeting was adjourned.)