Making It Easy To Do The Right Thing
Written by Cynthia M. Lipsitz, MD, MPH
There’s a subject getting a lot of popular interest these days, called behavioral economics.
There have been some suggestions lately that this principle can be very useful in health care; in fact, an article in the Harvard Business Review in March of this year cited behavioral economics as one of the top 10 innovations that will transform medicine in the future.
In a nutshell, BE is based on the fact that we often don’t do what we should, like exercise or eat healthy foods, or, as physicians, document our diagnoses and decisions clearly. But we can be nudged (also the name of a book on the subject) or gently guided into doing the right thing if it’s not too hard to do or it can be made a part of a routine. In other words, we can arrange things so that the easy choice is also the right one.
Using the principles of BE may be one of the ways to encourage improvements in physician documentation, and this is likely to help us reverse denials or even prevent them. As a result there’ll be not only improved patient care, but also an improved bottom line. Very often as a medical reviewer with Washington and West, I see denials that could have been prevented or more easily argued if there had just been better documentation.
So, here are some examples of BE in use in the health care setting:
1. The Harvard radiology department noted overuse of certain costly xray studies that really weren’t in keeping with recommended quality care. So they came up with an automated questionnaire that helps the doctor think through the need for the test, or for another one. As a result, the rate of ordering the test was decreased, even as the volume of patients increased.
2. In another example, at Dartmouth-Hitchcock Medical Center, standardized orders were created for cases of pneumonia that developed out in the community. These orders follow well-thought-out consensus guidelines by expert groups, like the Infectious Diseases Society of America and the American Thoracic Society, and they were also met Joint Commission and CMS quality performance guidelines. The ordering physician checked off the orders that they felt applied to their patient. They found that this improved compliance with guidelines and decreased lengths of stay and patient deaths. In other words, they made it easy to do things right.
3. At WW, we found that at one hospital there was a clear link between denials and the attending physician on the case. We didn’t do a formal study, but we did find that feeding this information back to docs and administrators in a de-identified manner, especially info on the dollars lost, really opened their eyes to what’s at stake when a case is denied. We suspect that most doctors aren’t aware of the impact of their insufficient practices on the bottom line. when for example they write a diagnosis of heart failure vs. acute systolic on chronic diastolic heart failure in terms of DRG determinations.
Considering how complex medicine is these days, and how much there is to consider when making patient care decisions, I’m definitely in favor of any help I can get to make the right choices. But it’s critical to acknowledge that each patient is different, and that in the final analysis the patient’s doctor is really the person who knows that patient best. So, it’s critical to assure doctors that they are not being required to practice “cookbook medicine,” that is, to be forced to follow a set of general steps that might not fit their patient’s needs.
To me this means that any guidelines or standard order sets must allow for alternative options that a doctor can choose. AND there must also be required documentation of why that alternative choice was right for the patient– as I wrote about previously in the RAC Monitor, the most important word in medical documentation is “because.” If we can’t document why we made a decision, it’s as if we made no decision at all.
Finally I just want to say that, more and more, funds are being tied to doing things smarter – making better choices of tests, better use of antibiotics, etc and not to doing more things as in the past. Not only that, but now there’s increased scrutiny for fraud and abuse. If a hospital can adopt practices or technology that will make doing the right thing easier, we think that they’re likely to see fewer denials.
About the Author
Cynthia M. Lipsitz, MD, MPH, is a Senior Medical Reviewer with Washington and West, LLC, an appeals and denials management company. In this capacity she maintains familiarity with current standards of medical care, Medicare and private payer hospitalization criteria, and coverage policies. Dr. Lipsitz has reviewed records and observed documentation patterns from a variety of hospitals across the country, and has a heightened understanding of issues that lead to denials. With over 25 years of experience in ambulatory and hospital medicine, public health administration, and health promotion software development, she brings an understanding of the realities of medical practice and administration to the field of denials management.
Contact the Author: c.lipsitz@washingtonwest.com