Earlier this week there were quite a few questions as to why doctors will perform the same set of tests on a patient even if there is documentation in the file indicating a diagnosis and a status. There are a couple of good reasons for this which are not just ’cause I get paid’ venal motivations. That probably has something to do with it, but as we move to accountable care organizations for all types of insurance as well as population health management, the cash in my pocket incentive decreases.
Mayhew Insurance offers Medicare, CHIP and Medicaid products to our region. Those products are risk adjusted so that plans with really sick members aren’t destroyed. The goal is to minimize the insurers’ incentives to cherry pick through marketing, plan design or hassle factor only healthy people. There are a couple of different risk adjustment methods, but they all rely on claims data with accurate diagnosis codes on the claims. A central processing body will count up the types of diagnosises, evaluate their projected costliness, and spit out a number that determines what type of side payment is needed to balance risk across multiple insurers. Exchange does the same thing.
As an insurer, our goal is to minimize the gap between reported health status via claims diagnosis and actual covered population diagnosis. That maximizes either our revenue gain or minimizes our contribution to the revenue re-allocation. One of the ways we do that is we pull claims data from our members for the several years to identify instances where there was either a diagnosis or a constellation of indicators (prescriptions, procedures etc) that show a costly disease a few years ago but where that diagnosis has not been entered on a claim in the past year. This gap list is then researched. Some of the gaps are coding issues and they are corrected by a sticky note being added to the chart to add diagnosis 250.01 to the known diabetic who is on three diabetes medications. Some of the issues are clinical judgements. For instance a doctor may judge that previously diagnosed manic depression is actually a combination of depression and ADHD which are both coded on the chart. Another case had a member whose disease was miscoded by flipping a 5 for an 8. Those make sense.
And then you get the doozies. A patient will have a code indicating an amputated leg three years ago but the current PCP sent a picture in of the patient with both legs. A patient will have had a diagnosis of multiple scheloris but the current PCP notes MS is not evident and the pharmacy claims backs her up. These are the big and obvious ones that had my minions/interns doing the outreach effort scratching their heads and asking why the data is not neat and clean like the books in college tell them it should be.
Most doctors don’t trust other doctors’ charts. It is not an electronic medical records issue, it is a trust across the profession issue. If a doctor can’t trust a major diagnosis like MS or leg amputation, they’re not going to trust fine details.
If Mayhew Insurance was risk adjusting the private group insurance market using the same methodology, I would show up. In 2013, I was reffing at a summer soccer tournament. It was a good weekend, but on the third game Sunday morning as I was running a line, I felt my left foot go from great to horrendous in three steps. I could not put any weight on it. Two of the other refs working that tournament are atheletic trainers. They checked me out at the ref tent and said it was either a nasty arch sprain or a stress fracture that went from hairline to notable. I needed an X-ray for that to be determined. I left the tournament and drove to an urgent care clinic. I told the doctor that I had intense shooting pain in my left foot. He asked if I had red meat in the past week. I had a great burger on Friday night. He diagnosed me with gout. I told him that two atheletic trainers had looked at me and said it was one of two things, and I knew exactly when my foot blew up on me… nope, it had to be gout, so I got a prescription for an extraordinarily expensive medication (not filled) and a cane.
I went to my PCP on Tuesday, he ordered a urine test to rule out gout, and then checked out my foot. I had an X-ray, and it was a nasty sprain with a month’s worth of physical therapy. For that one year, I would be risk adjusted as gout and be extremely “valuable” for that one year due to a bad diagnosis. Urgent cares and hospital ERs are the primary source of amazingly bad diagnosises but they are not the only source.