The Answer is: Money
A question from the comments:
Why do some specialists 'pad' their reports with superficial or even fictitious statements? Statements as you mentioned above, about performing certain physical tests, when the tests weren't done. Or embellishing what they say they explained to a patient. Are these specialists trying to impress the primary care doctor with their 'thoroughness', so as to keep the referrals coming? Are they trying to make themselves look better than their fellow collegues? Or are they simply filling out a quasi 'form letter' report, which is just slightly individualized for each patient?The answer, as always, is: Money.
A quick primer on how doctors get paid:
You go to the doctor. The doctor asks you what's wrong. You tell him. He asks questions to find out more details about what you've told him, and perhaps more questions about other things you didn't even realize had anything to do with what's wrong with you. This is called "eliciting a history." Then he examines you. This is called a "physical examination." At this point, the doctor has begun to formulate a pretty good idea of what's wrong with you, or at least has some idea of what he needs to do in order to find out. This is when tests -- which may include blood testing, imaging studies like x-rays, ultrasounds or MRIs, stress tests for your heart, lung function testing, etc. -- may be ordered (and why it is inappropriate to order these studies before the "history and physical" parts have been done.) Putting it all together to make a diagnosis and deciding on a treatment plan is called "medical decision making." Explaining it all to the patient and/or family is called "counseling."
Each of those elements of an encounter -- history, examination, medical decision making, and counseling -- comes in varying degress of complexity, as follows:
- History: Problem focused, Expanded Problem-focused, Detailed, Comprehensive
- Exam: Problem focused, Expanded Problem-focused, Detailed, Comprehensive
- Medical decision making: Straightforward, Low complexity, Moderate complexity, High complexity
- History: History of present illness, Review of Systems, Past/Family/Social history
- Exam: Each component of a physical exam has been listed as a "bullet point", and the number of bullet points determines the "level" of the exam.
- Medical decision making: takes into account the number of diagnostic or treatment options, Risk of complications and/or morbidity or mortality, and the amount and/or complexity of data to be reviewed.
There's more to it, of course. If it's a new patient (includes someone you haven't seen for three years or more) you use a different line on the grid, do a little more, but get paid more. If the encounter is at the written request of another doctor and you send that doctor a written report, it's called a "Consult", which pays considerably more (for each level of service.) If you don't actually do a history or physical, but have an encounter, say, entirely for the purpose of "counseling" (discussing the diagnosis and/or treatment with the patient) then you can code on the basis of time, as long as said counseling account for more than 50% of the face-to-face visit time. Here are the times in minutes for an outpatient encounter:
|Time||Level 1||Level 2||Level 3||Level 4||Level 5|
I swear I'm not making all this up (although those who know me wouldn't put it past me.) (cough*Kensington fan*cough) Check out this document to see what we're up against.
The whole point of this is that a Level 5 visit pays considerably more than a Level 2 visit, especially if it's a consult. So the advantage to the specialist who over-documents is that he can code a higher level of service and get paid more. If the flip side of that malpractice catch, "If it wasn't documented, it wasn't done" is the assumption that all documentation is accurate until proven otherwise, then I have no idea what can be done about it.
But that's the answer to "Why do they do it?" And it sure isn't because they care about primaries' or colleagues' opinions of them.