Thursday, June 16, 2011

PCP=Paperwork Completing Physician?

About 6 months ago, while on an inpatient cardiology service, I tried to do something nice for my patient and my patient's intern... I wrote a requested prescription for a wheel chair to save my intern a few minutes.  She went home, wheelchair delivered, everything fine.

Flash forward to today.  As I set to graduate residency (tomorrow) I have been tidying up some of the paperwork for my clinic.  I received a fax today from a medical supply company requesting that I fill out a form so that they could get paid for this wheelchair.  6 months later.  At first I struggled to remember details of the scenario, aided by our excellent medical record.

So why has it been 6 months?  I can only imagine that it has taken 6 months for the company to track me down to sign this ridiculous form (of course required by Medicare), was because her Primary Care Physician (PCP) either does not exist or refused to sign the form.  They eventually looked me up and found my information.  Interestingly, the form is addressed to me as though I were the patient's PCP.  (I am not, despite providing primary care for many others).

PCP, could it actually mean Paperwork Completing Physician?  This is usually the person to which forms are directed.  The one physician who is supposed to "know the patient best," which is doctor code for "deal with the problems/paperwork I don't want to."  It is an interesting role that has been created by the medical system, and surprisingly is not being filled.  Who would want to be ultimately responsible for all of the paperwork, necessary and otherwise?  More importantly, in this scenario, the paperwork did not directly benefit my wheelchair bound patient at all.  Rather, as I confirmed, the company needed my signature to be paid by Medicare for the wheelchair they had already provided.  My first thought, if they are dependent on my signature to get paid, do I get a cut?  Is it fraud if I ask, but perfectly acceptable if I do it for free? Would paying me to sign the form somehow change my behavior?  What would happen if I refuse to waste my time on this matter?

Effectively the company issued my patient a wheelchair on credit, certain that I would answer questions on a form for them in a manner that allows Medicare to pay.   I am curious on what assumption or faith this credit is based.  Perhaps their experience that doctors will eventually sign whatever you put in front of them if they believe it will help their patients.  And the purpose of all of this paperwork?  Fraud protection.

This minor situation is typical of the entire fraud/fraud prevention problems inherent in insurance, especially government insurance.  First, it is assumed that everyone trying to obtain insurance payments is a criminal attempting fraud.  Few are, but the costs of this assumption are staggering, and likely outweigh the costs of actual fraud.  The difference, of course, is that waste to prevent fraud is not embarrassing to a government official, whereas smaller losses due to fraud are inexcusable.  Second, the assumption that putting a physician signature on a form changes anything is ludicrous.  I wrote a small statement that I met this patient once and that the above were true to the best of my recollection, but that 6 months have passed.  How is that better?  It is certainly wasteful, that this company has had to extend credit for 6 months and that I have wasted my time. But does creating physician paperwork bottlenecks benefit patients or physicians?  If not, should we put up with it?  We already do enough to make the healthcare system work, you know, the diagnosing and treating part.  Attaching our signature to paperwork so others can be paid is wasteful, does not achieve the attending effect, causes anger and burnout, and ultimately costs patients what they want--time with their doctors.

And we wonder why we have a shortage of PCPs.

Tuesday, June 14, 2011

On Managing Innovators

I have been reading Alfred Sloan's My Years with General Motors on the advice of a mentor who referred to it as the exception to his rule of not reading business books.  I find it very interesting thus far, mostly waiting for car names I recognize, watching out for now canonical management points as they evolve, and generally appreciating Mr. Sloan's writing style.  On page 78 I came across the following letter from Mr. Sloan to one of his engineers, working on a new style of car and not finding success after a recent launch:
Dear Kettering:-
It is most important in our opinion that your mind be kept free from worries foreign to the development of the air cooled car and other laboratory work. 
In the development and introduction of anything so radically different from standard practice... it is natural that there should be a lot of "wiseacres" and "know-it-alls" standing around knocking the development.
In order that your mind be completely relieved as to the position of the undersigned... we beg to advise as follows:
1st. We are absolutely confident in your ability to whip all problems in connection with the development of our propos[al].
2nd. We will continue to have this degree of confidence and faith in you and your ability to accomplish this task until such time as we come to you and frankly state that we have doubts... you will be the first one to whom we will come.
We are endeavoring in this letter to use language such as will result in complete elimination of worry on your part with respect to our faith in you and this work and if this language fails to create this result, then won't you kindly write us quite frankly advising in what respect we have failed?
Due to the fact that criticism are bound to continue... would it not be well for you to agree with us that at any time you have occasion to pause and wonder about our faith and confidence in you... that you pull this letter out of your desk and read it again.

Wow.  Just, wow.  Talk about permission to try and fail, to succeed and know that you have either the full confidence of your leadership, or their explicit promise to find you as soon as they begin to waiver.  How much time must have been saved without Mr. Kettering having to wonder what others thought of him?   Management of innovation can be difficult, but I will list this amongst the great examples.

Thursday, June 2, 2011

Thanks to the sage advice and guidance of John G. Norman, lives on its own domain.

Thank you John!