The third leg of neurology training The business of medicine

Henry J. Kaminski, MD Neil Busis, MD

Correspondence to Dr. Kaminski: [email protected] Neurology® 2014;83:1778–1779

Comprehensive training of residents should involve the art, science, and business of medicine. In most neurology training programs, the focus is almost exclusively on the first 2 subjects. Limited or no attention is placed on the manner in which neurologists earn a living—effective practice management including proper documentation and coding and methods of billing and reimbursement. This situation is surprising given that academic departments and their leadership are charged with the financial health of their organizations and ensuring their residents succeed after they complete their training. Core competencies for resident education include systems-based practice and interpersonal and communication skills. Both of these areas require accurate documentation, which should contribute to optimal patient care. The most prevalent reimbursement system used today—fee-for-service—determines the level of service, and therefore the amount of reimbursement for that service, by the documentation of each patient evaluation and management (E/M) encounter, including elements of history, physical examination, and medical decision-making. These guidelines are precise and have been in place since 1997.1 In the medical record, a physician’s responsibility to effectively communicate with other health care providers intersects with the means by which he or she is paid by Medicare, Medicaid, and private insurers. In this issue of Neurology®, Jeff Waugh2 describes an educational intervention designed to improve documentation and billing practices of residents at his institution. A billing audit of Boston Children’s Hospital by its largest insurer found instances of documentation that were insufficient to justify the levels of the E/M services in submitted claims. This led to a financial penalty.3 The Centers for Medicare & Medicaid Services have made similar assessments of other academic medical centers and private practices.4 Such negative reviews not only compromise physicians and institutions financially, but also erode the public trust in health care providers. These developments emphasize the critical need for training programs to educate their residents in proper documentation and billing of patient services and procedures.

Dr. Waugh’s study compared trainees’ notes to the attending physicians’ notes, and inferred that the supervising neurologist was coding correctly. We know from experience that this is unlikely despite the many hours of training and auditing that institutions perform to assure billing compliance. Today residency documentation training will be within the context of electronic medical records, templates, and calculators that attempt to ensure correct coding and the level of service. Such tools should serve not only to satisfy the requirements of auditors or provide mindless ways to inflate medical billing by, for example, copying and pasting notes.5 Ideally, they should help assure a thorough patient assessment and development of an appropriate diagnostic and treatment plan. With the exception of the review of systems, Waugh did not specifically address whether attending physicians or residents used templates, and if they did, how they were designed and how providers were taught to use them. This limits the generalizability of his findings and recommendations. Major strengths of his study are that he used easily understandable methods and measurable outcomes, auditing notes for appropriate documentation before and after educational interventions, providing structured feedback to participants, and instituting a standardized review of systems form. Future educational studies should strive to have such clear methods and outcome measures. Waugh’s work highlights the gap between how we train our residents in the practice of clinical neurology and its documentation, coding, and reimbursement. Bridging this gap will be beneficial to our trainees, their future employers, and the financial health of academic medical centers and private practices. Adding training in the business of neurology is an investment in the future of our specialty. Businesssavvy neurologists will be better equipped to participate in formulation of improved health care processes and policies. For example, they will understand the misaligned incentives inherent in today’s coding and reimbursement system, where the elements of the medical record needed for appropriate

See page 1856 From the Department of Neurology (H.J.K.), George Washington University; GW Medical Faculty Associates (H.J.K.), Washington, DC; and the Department of Neurology (N.B.), University of Pittsburgh, PA. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the editorial. 1778

© 2014 American Academy of Neurology

reimbursement and for proper patient care are not necessarily the same. Aligning the incentives for documentation, coding, and patient care should increase career satisfaction and decrease physician burnout. Today, the fee-for-service model dominates health care reimbursement.6 However, we practice in a period of transition.7 To address deficiencies in our current health care system, payers are changing the incentives of physicians to reward value (roughly defined as quality of care divided by cost) instead of volume of care. There is new emphasis on population health and coordination of care. The new value-based reimbursement models will not eliminate the need for accurate documentation, but they will redefine what documentation is necessary and sufficient to determine whether or not physicians and institutions will succeed in the new systems.8 We will do best to educate our residents in the “3 legs” that support any health care delivery platform: the art, science, and business of medicine. They are mutually interdependent. Training programs will need to continuously adapt their educational objectives to match the evolving requirements of new health care reimbursement models. STUDY FUNDING No targeted funding reported.

DISCLOSURE The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.

REFERENCES 1. Centers for Medicare and Medicaid Services. Regulations and Guidance. Available at: http://cms.gov/Regulationsand-Guidance/Regulations-and-Guidance.html. Accessed June 10, 2014. 2. Waugh JL. Education in medical billing benefits both neurology trainees and academic departments. Neurology 2014; 83:1856–1861. 3. Office of Inspector General, Department of Health and Human Services. Audit (A-01-11-00530). Available at: http://oig.hhs.gov/oas/reports/region1/11100530.asp. Accessed June 10, 2014. 4. Office of Inspector General, Department of Health and Human Services. Centers for Medicare and Medicaid Services (CMS). Available at: http://oig.hhs.gov/reports-andpublications/oas/cms.asp. Accessed June 10, 2014. 5. Sheehy AM, Weissburg DJ, Dean SM. The role of copy-andpaste in the hospital electronic record. JAMA Intern Med 2014; 174:1217–1218. doi: 10.1001/jamainternmed.2014.2110. 6. Moses H III, Matheson DH, Dorsey ER, George BP, Sadoff D, Yoshimura S. The anatomy of health care in the United States. JAMA 2013;310:1947–1963. 7. Kocher R, Emanuel EJ, DeParle NA. The Affordable Care Act and the future of clinical medicine: the opportunities and challenges. Ann Intern Med 2010;153:536–539. 8. Pedley TA. Neurology at a crossroads: opportunities and challenges. JAMA 2014;311:1611–1612.

Neurology 83

November 11, 2014


The third leg of neurology training: The business of medicine Henry J. Kaminski and Neil Busis Neurology 2014;83;1778-1779 Published Online before print October 8, 2014 DOI 10.1212/WNL.0000000000000990 This information is current as of October 8, 2014 Updated Information & Services

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This article, along with others on similar topics, appears in the following collection(s): All Education http://www.neurology.org//cgi/collection/all_education All Practice Management http://www.neurology.org//cgi/collection/all_practice_management Billing http://www.neurology.org//cgi/collection/billing Methods of education http://www.neurology.org//cgi/collection/methods_of_education Other Education http://www.neurology.org//cgi/collection/other_education

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Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2014 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.

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