Bad Forms

...Management no longer exists...

...Consider just one requirement of the average insurance form doctors and other providers must contend with: supplying identification codes...

...The recent explosion of the health insurance bureaucracy to department-of-motor-vehicles-proportions has at its core—like most increases in regulation—a noble purpose: an effort by the insurance industry to curb the cost of health care by making doctors, hospitals, and patients report in detail how each dollar is spent...

...First, the increased scrutiny raises the cost of care—a cost that, naturally, gets passed along to patients...

...Doctors and hospital administrators argue that the hidden costs of the new bureaucracy easily outweigh the insurance industry's gains...

...But, in their Orwellian zeal, insurers are following the same costly, not to mention silly, path travelled by unthinking federal bureaucrats who, for example, in recent years issued regulations on the number of inches required between ladder rungs or the shape of stuffed teddy bears' ears...

...There's more...

...And there are diagnostic and treatment codes within codes...

...And nationwide, says Kylann Green of the Health Insurance Association of America, up to 10 percent of all doctors' requests are being rejected, not only saving money, but sparing thousands of patients unneeded treatments...

...It's s complicated...

...Confused yet...

...And what exactly eats up all the time and money...

...He doesn't, until Medicare returns the form pointing out a missing code...

...In another case, a private insurer questioned the medical validity of admitting to a hospital a man suffering from leukemia who had developed a 103-degree fever and had a dangerously low white blood count...

...Nicholas Macris, an immunologist at New York's Lenox Hill Hospital, "but that's just one part of the process...

...The pain inflicted by paper flood is especially relevant these days, because the foundation of the health care reform plan Biliary are leaning toward—managed competition—would rely on more and closer scrutiny of doctors and hospitals, which will, of course, mean more, more tedious, and more expensive paperwork for all...

...Since each hospital is given a pre-set amount to spend each year, doctors know that whenever money is wasted on a questionable treatment, another patient who truly needs care may be forced to go without...

...But, managed competition, like the current system, places a high premium on micromanaging doctors and hospitals, relying on insurance clerks and other non-medical "managers" to continue to oversee what types of procedures are acceptable, for whom, and when...

...Fortunately, there is a solution: Keep the best of managed competition—grouping patients into large, cost effective groups—while freeing doctors and patients from hyper-scrutiny...

...It's such a good idea that it's already been created—in Canada...

...But the more dangerous outcome is what doctors say is an unavoidable drop in quality and access to care...

...So illogical is some of the scrutiny that doctors and hospital administrators insist that the aim of insurers is less to catch wasteful spending than to defer paying out reimbursements for as long as legally possible...

...Now multiply that headache by, say, 20—the number of patients a doctor might see in an average day...

...Getting reimbursed was not...

...Then multiply that by 250—for each working day of the year...

...One Mount Sinai Medical Center immunologist, Dr...

...But when it came time to shell out the money after the September operation, the insurer balked...

...All of which means that the biggest losers are those the new regulatory fervor is intended to protect: patients...

...So it should come as little surprise that in Canada just 1.2 percent of all premiums goes to administrative costs of providing insurance, compared to 12 percent—or about $19 billion—that covers the administrative costs of insurers in the U.S...

...Compare that to Canada, where administrative costs hover around 8 percent of total health costs...

...At one point, the insurer even demanded a second accounting of Phillip's height...

...But that doesn't mean we should ignore the Insurance Purgatory we've created—where endless paperwork and jumping through itty-bitty hoops to collect health benefits have become routine...

...Curious, I fo lowed the advice on the form instructing those wii queries to contact the Office of Financial Manag< ment at the Health Care Financing Administration : Baltimore...

...Often, the nurses consult a checklist or log the responses into a computer to determine whether a treatment is considered valid and should be covered...

...So when a New York-based doctor—who is a surgeon (one with 15 years' experience and a faculty post at a major New York medical school)—diagnosed Phillip in the summer of 1992, he recommended surgery...

...While the Clinton administration has also stated that it expects to help develop a "standard claim form" to help eliminate some of the bureaucratic confusion, keep in mind that insurers have tried, unsuccessfully, for 20 years to create such a form...

...Of course, caring for America's 37 million uninsured should be—and is—the nation's top health care priority...

...The result isn't just fewer bureaucratic hassles, but a leaner system...

...Not all insurers use the same coding schemes...

...F. Warren Tingley, Travelers' national medical director...

...And wh...

...By January, Phillip along with his doctor had spent countless hours forwarding at least two copies of every X-ray, medical chart, invoice, and piece of medical history in the patient's file...

...If you have a group of cows and you want to limit how much they pasture, there are two ways to do it," explains Him-melstein, an advocate of a Canadian style plan...

...The average physician spends more than three and a half weeks a year filling out paperwork—more time than the average American spends on vacation, costing more than $4.5 billion...

...Of course, not all of that is a direct result of paperwork, but a lot is...

...Forms and discontent A few years back, insurers weren't so skeptical...

...Even though Chandler now prints in large block letters across the top of his Medicare claim forms "I DID 14 TESTS," Medicare remains unfazed, requiring him to refile every time...

...I told the live receptionist I w< having trouble filling out the form...

...For certain procedures, such as an electrocardiogram, Medicare requires two codes: the Medicare number of the doctor who performed the test and the ID of the physician who requested it (which, of course, means tracking down the other physician to get his code...

...Thus, Big Brother managers are not needed: Doctors and hospitals manage themselves...

...And while the insurance companies continue to claim that their hyper-scrutiny of doctors and hospitals is reducing health care costs, the reality is that we are paying ever more to keep their paperwork flowing...

...Doctors did whatever they wanted, and insurers simply paid," explains Dr...

...Form-less If Clinton has his way, this bureaucratic blizzard may actually get worse...

...Health care administration in the United States now costs more than $100 billion annually—nearly 20 percent of total spending on health care...

...1 be honest, I still haven't learned all the acronyms, she said, "and there's no reference to that one in oi instructions...

...We're being held up in a paper nightmare," explains Ilona Doyle, a member of the American Hospital Association's Uniform Billing Committee and patient account manager at Phoenix's Baptist Hospital and Medical Center...

...Health insurance is one of the only industries in America," says Dr...

...For hospital administrators, multiply it by hundreds...

...If keeping track of these codes doesn't cause vertigo, personal and other ID codes will: Each doctor, clinic, and hospital has its own state license number, private insurance provider code, CHAMPUS code, VA code, FECA code, Indian Health Service provider code (if you happen to treat an American Indian), and federal tax ID code...

...Others, especially Medicare, are notorious for reimbursing physicians for the wrong amount, then requiring a complete refiling of papers to set the record straight...

...When insurers rely on checklists and computers to second-guess doctors' diagnoses, mediocre medicine is all but certain...

...My experiences with certain companies were so uniformly bad that I decided to tax myself and not deal with patients on certain plans," explains Chandler...

...Ui fortunately," she went on, "the Office of Financi...

...There's no telling what it claim form wizards over at Medicare were thinkir when they came up with the possible responses f< "Patient Status"—not just your standard "Single" < "Married" but an option for "Other...

...Aetna Life and Casualty in Hartford employs 1,000 nurses in its review department...

...The Mayo Clinic in Rochester, Minnesota, for example, was forced in recent years to hire 70 full-time employees to field the more than 300 calls a week from more than 2,000 probing insurance companies, explains Mark Koch, a Mayo administrator...

...Long gone are the days when a sole receptionist handled a doctor's schedule, billing, and even had a few minutes to straighten out the magazines...

...There isn't a civilized country in the world," says Lewin, "that wouldn't immediately accept this as proper treatment...

...In fact, according to recent media reports, more and more frustrated doctors are cutting back on their hours, retiring, or leaving the practice altogether, specifically citing the "hassle factor" of dealing with the medical bureaucracy...

...all providers must reapply annually—via three page applications—to keep each of their Medicaid ID numbers...

...It is a game that has gotten out of hand...

...And it's not just the volume of data insurers d mand that's got doctors and patients in a lather, b the questions themselves...

...Lewin, echoing the sentiments of many colleagues, says she spends about one-half to one-third of her time "face-to-face with patients" and the rest up to her face in paperwork...

...Keeping doctors within the fence would also cut down on paperwork...

...But as any good doctor knows, raw data can be deceptive...

...What separates a good doctor from an ordinary one is often the ability to escape from a rigid checklist mentality...

...Welcome to the world of modern medicine...

...So, what about that "Other" optior "Maybe," she offered, admittedly unsure, "it's ft people who have more than one spouse...

...Doctors may rely on a mental checklist when diagnosing a patient," explains Dr...

...Just what illness would this patient need to merit coverage...

...The operation, which took place last September, was relatively simple and painless...

...by Christopher Georges You didn't have to be a brain surgeon, or a surgeon at all, to have suspected that Phillip (not his real name), a 34-year old man with size-C cup breasts, might have had a medical problem...

...And it's not just this case...

...And wasn't that the object of the medical-form frenzy in the first place...

...During the next three months, again and again, the insurance company called or wrote asking for additional information...

...I get one nonsensical request after another from insurance companies...

...When unhappy insurance buyers complained, the insurance industry blamed doctors...

...In January, the insurer matter-of-factly reversed its decision, ruling that the operation was "100 percent cosmetic in nature...

...In hospitals, it's even worse: It takes the average medical center 11 days to complete the paperwork for a single claim...

...Down on the forms How far out of hand...

...More and more physicians, such as Lewin, are refusing to take patients enrolled with certain insurers or Medicare...

...Yet as more physicians divert their attention from care to forms, more checklist medicine is what we're sure to get...

...Michael Chandler, who administers a series of 14 allergy tests to most of his first-time patients, explains that he is routinely reimbursed for just one...

...Blue Cross wouldn't say...

...David Himmelstein, an associate professor of Medicine at Harvard Medical School and national spokesman for Physicians for a National Health Program...

...Not only does this help explain why it's tougher to find a Marcus Welby these days, but, for some patients, to find a doctor at all...

...doctors' assistants now spend an average of one hour nursing each insurance claim...

...The insurer signed off on the procedure, agreeing to $6,250 in coverage...

...If the cost of health care administration continues to rise at the current rate, it will absorb approximately one-third of the nation's health care budget by 2000...

...With thousands of insurance company nurses and clerks now quizzing hospitals and doctors, someone has to man the other end of the line, which has meant creating an expensive medical community bureaucracy to mirror the insurance industry's...

...exactly is that "FECA code" the form asks for...

...No doubt some doctors were (and still are) abusing the system...

...Because these large pools would offer all members essentially the same type of policies, the cost and administrative hassle of keeping track of who's insured and with how much coverage would be streamlined...

...The patient is distressed...

...Armed with academic studies that reported more than $70 billion wasted annually on unnecessary procedures, insurers charged that physicians had grown test-and-treat-ment-happy...

...Insurance companies don't want to have to pay without a big fight...

...But she did promise to check and fin out...

...If the physician performed the test of his own volition, two codes are still required—his regular ID and his special self-referring ID...

...I'm distressed," says the surgeon...

...True, managed competition—the solution the Clinton administration seems likely to adopt—could reduce some of the paperwork burden by bundling patients into large groups...

...True, a single payer plan doesn't carry a whole lot of currency in Washington these days, but not only would it provide care for the uninsured, it would eliminate the paperwork overload, while controlling wasteful spending...

...The physician, Lewin, was required by the insurer to prove to insurance clerks that the admission was a valid one...

...For starters, each of the thousands of diagnoses, treatments, and tests has at least one code...

...You're telling me...

...Prior to surgery, both Phillip and his doctor painstakingly submitted an air drop of charts, photographs, and medical reports...

...Travelers Insurance, for example, finds that nearly 12 percent of 28 of the most common procedures, such as allergy testing and clotted artery surgery, have been deemed unnecessary, explains Dr...

...For example, as part of the pre-procedure screening (known as utilization review), doctors are quizzed, usually by phone, by insurance company managers, usually nurses or clerks, on why a test or treatment was prescribed...

...This thing's a mess," she sighed—referring t the Medicare form—a few questions later...

...I was soon on ff phone tour of the agency (by now my 15 minufc were up), finally being connected to a friendly fori administrator...

...Margaret Lewin, a New York internist and oncologist, "where being fast and efficient means losing money...

...The biggest bonus, however, is that the amount saved by reducing bureaucratic expenses through a single payer system in the U.S.—about $70 billion—would more than offset the added cost of fully covering America's uninsured—$64 billion...

...Yo know, there's a 20-page book that explains it...

...Chances are that even if your only contact wit your doctor is for the occasional check-up, you to 10 The Washington Monthly/April 1993 have run up against the medical-form frenzy— perhaps filling out multiple claim forms for a single procedure, battling insurance company clerks over how much they owe you, attempting to prove that your claim is valid, or waiting months for a reimbursement—if it comes at all...

...And how does the physician know which procedures require two codes...

...she said empathetically...

...That meant engineering an intricate system of checks on doctors and hospitals...

...The way to curb costs, they argued, would be to curb doctors by making them account for every dollar they spent...

...Research assistance for this article was provided by Mike Bach...

...They simply apply to one insurer (the government) and know at all times how to apply for reimbursement, what procedures will be covered, and by what amount...

...Not to be outdone, Medicare requires each hospital to have three codes: one for acute April 1993/The Washington Monthly 11 care, one for mental health care, and one for other types of care...

...Some require doctors to type out any handwritten notes—even records scrawled on emergency room charts—before even considering a claim...

...Phillip, although much trimmer, is now $8,000 poorer, and is filing yet more forms in an appeal to New York State's insurance commission...

...And don't think you can rest easy once you've collected all 50...

...Insurers say that for every $1 spent probing doctors before they order a test or treatment, $5 are saved...

...In one case, Blue Cross Blue Shield of New York refused to pay for a series of standard blood tests administered to an elderly man who was suffering from severe heart disease, had recently had an aortic valve replaced, and was being treated for blepharitis, an illness that causes pain and swelling in the eyes...

...Hospitals have to apply for up to 50 Medicaid ID numbers, depending on how many states they do business with...

...That's because in Canada hospitals are paid a lump sum (or global amount) to cover all operating expenses, and physicians bill the government directly for all fees...

...The result: Excessive regulation by insurers has created a paper swamp that ultimately has lowered the quality of—and access to—care...

...But as medical costs skyrocketed in the eighties, so did insurance premiums...

...And at some hospitals, such as Johns Hopkins, it costs more than $100 just to assemble the average patient's bill...

...You can simply put a fence around them, as they do in Canada, or you can do what we do here: Tie a string around the neck of each cow so that every time he bends down to take a bite, you feel the tug, run over, and make sure he takes the right amount...

...That, of course, sounds encouraging...

...For more than four months, both the physician, Macris, and the patient battled Blue Cross, providing the required documentation, only to be told the tests were either not related to any of the patient's illnesses or not "appropriate with regards to standards of good medical practice...

...The machine on the other end—my "automate receptionist"—offered nine push-button options, ii eluding one that would help me with details on tl "Clinical Laboratory Improvement Act," but nor for marital status...

...Many insurers require certain specialists, such as physical therapists and anesthesiologists, to list their services in 15 minute intervals...

...After all, billions of dollars, according to recent studies, are being wasted annually on unneeded hysterectomies or the it-doesn't-hurt-to-check-it-out sonograms...

...They sure don make it easy, do they...

...The fine print also assured me that tl form was designed to be completed in 15 minutes < less...

...Phillip is not one of the nation's 37 million uninsured, but he might as well be, considering the treatment he's received from his insurer...

...Since all citizens receive the same basic coverage, patients never fill out complicated insurance forms, and doctors' and hospitals' paperwork is minimal...

...Hang around the doctors' lounge and you'll hear enough stories of insurers' stubbornness to fill a med-school textbook...