Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, November 19, 2007

This is How "Balls" Works

I'd like to expand on my previous post about surgeons abdicating their medical responsibilities by explaining what happens out here in the real world when surgeons (some; not all by any means) try to get other docs (cough*me*cough) to do their work for them.

First of all, to elaborate on the specifics of the incident discussed, which is quite typical:

Yes, it was a "standard" H&P form from the facility. Surgeons -- or, more specifically, their "surgery coordinators" -- tell me that it's the hospital or outpatient surgery center that "requires" them to use the form, and that it must be completed by the patient's PCP. That is, they claim that someone other than the surgeon is insisting on my involvement. Frankly, if I were a surgeon I'd be insulted that my facility didn't allow me to do my own H&Ps or trust my judgment about whether or not I need a second opinion about my patient's fitness for surgery (if it were really the case that the hospital is requiring the PCP to complete the forms, of course.)

Here's what's really happening, though: the surgeon -- or more likely an office staffer -- says to the patient, "You need to have your doctor fill out this History and Physical form." No difference between a 75-year-old on a dozen meds or a 22-year-old having pins removed from an old fracture. No hint that the surgeon is requesting anything specific of me. No indication that I'm to do anything other than fill out a form. It's just another piece of necessary paperwork (totally glossing over the importance of evaluating a patient preoperatively) that they can foist off on someone else, because otherwise the surgeon would have to do it. And so the patient is left with the impression that "this is how it's done," which is how he comes to my office.

The problem is that when I throw a hissy fit, the patient has no idea what's going on. I'm stuck in the middle as the bad guy who won't cooperate with dear Dr. Surgeon to help the patient get the care they need. And how can I explain the problem to the patient without bad-mouthing the surgeon?

The real problem is that it's the patient who is inconvenienced when I try to stand my ground. I've tried calling surgery offices, rarely getting to talk to the actual surgeon. ("He's way too busy.") The surgeries tend to be technically "elective", but they're things the patients need; things that having to re-schedule wouldn't be fair to the patient. Of course the offices that do this sort of thing are the ones that tend to be the least cooperative, telling me the patients can't have the surgery if I don't do it, and that I have to explain it to them; basically playing a nasty little game of chicken. They know that I have more to lose by pissing off the patients than they do. That's why I often end up going ahead and just filling out the damn forms.

Besides, as is so often the case, there's the issue of money.

If a surgeon wants my opinion about a patient's fitness to undergo surgery, that is called a "Consultation." It requires several things, including:
  • A written request for my opinion, and
  • My written report back to the surgeon containing my opinion and recommendations.
Unfortunately, it is explicitly stated that a simple H&P on a healthy patient does NOT constitute a "Consultation." In point of fact, it's considered an integral part of the surgical procedure, supposedly covered as part of the "global surgical fee." What's the difference? Money, of course: Consults pay significantly more than simple "evaluation and management" encounters to fill out forms.

Regarding that line of text about having discussed the surgery with the patient -- which I had not seen on other forms: I don't really think the surgeons are expecting me to obtain Informed Consent. I believe it's there as a backup in the event of a lawsuit if the issue of consent should come up. If the patient complains that the surgeon's informed consent was defective, they've got that line to fall back on: "Blame Dr. Dino. See; that signature right here says that everything was discussed with the patient."

(More later on how I try to get what I need to code these as Consults, if anyone's interested.)


At Mon Nov 19, 10:28:00 AM, Anonymous Anonymous said...

i'm interested in hearing your comments about consults. i would think a full consultation would suffice if the surgeon wrote on his short h & p that the full consultation was in chart.

i would disagree with one point and say the surgeon's have just as much to lose as you. maybe more since they are making thousands for their procedure and you are making one hundred for your visit. also if they treat you like crap, they probably aren't worth maintaining your relationship with.


At Mon Nov 19, 10:32:00 AM, Anonymous Anonymous said...

If the surgeon has sent the patient to you for medical clearance you should code it as a consultation, dictate the H&P (instead of the stupid form)and make sure your biller knows the surgeons name for the claim form. That is the only way to be paid for your expertise and time.

For a "consultation" you are not supposed to "manage" the patient intra operatively so that works to your favor. Informed consent is the responsibility of the surgeon.

I worry more about surgeons (or their PA's) who complete the forms and never really evaluate the patient's overall health and risks. That is where the smarter primary care physician can really play a role AND GET PAID A CONSULT FEE.

At Mon Nov 19, 10:53:00 AM, Anonymous Anonymous said...

I believe the real issue here is managed care. Capitated HMO plans offer no reimbursement for this service other then the usual office co-pay. PPO plans usually refuse to reimbuse PCP's for a consultation, only the usual discounted office visit fee. The primary care physicians essentially gets stuck performing a service that should be done by the surgeon without receiving fair reimbursement. The surgeon gets the full global fee. Fortunately with Medicare patients (but not Medicare HMO patients) you can properly tweak the report and get reimbursed for an appropriate level of consultation.

At Mon Nov 19, 12:46:00 PM, Blogger Jeffrey Parks MD FACS said...

I've found that referring docs get pissed if I do my own H&P and preop testing. Most of them like to do all that themselves. So I dictate an H&P for my office chart and send the patient to the PCP for "pre-surgical evaluation."

At Mon Nov 19, 07:45:00 PM, Anonymous Anonymous said...

Actually, this is more complicated a problem than you paint it. As a surgical specialist I have no problem doing my own pre-op H&P. I request problem oriented consultation with whomever seems to be up to the task of doing it in patients with multiple medical problems (generally the elderly, but not always). This most often becomes a request for "cardiac clearance" and can be done by the patient's primary if s/he feels comfortable doing so. If not, then it goes to the cardiologist.

The problem from the perspective of surgeons is this: the "clearance" is really for the convenience of the anesthesiologist. To this day I remain dumbfounded at how an anesthesiologist can walk into a room cold, review some pertinent facts on a patient and decide that administration of anesthesia won't be problem. They don't see the patients pre-op and expect everyone else to do that work for them. It seems to me that if a patient's cardiac or neurological status can present difficulties with an anesthetic, it should be up to the anesthesiologists to clear the patients for their own reasons.

I certainly wouldn't expect some other doctor to have worked out the surgical question for me so that when I walked n cold that morning I'd be 99.9% sure that that particular patient wouldn't pose any undue challenge to my task at hand.

Remember that anesthesiologists must play many of the roles of an average internist intra operatively (in fact, a good number of them ARE internists by training). Who better to work up the pre-ANESTHETIC needs of prospective surgical candidates than the person who's going to manage their vital functions during the operation??

I've had anesthesiologists cancel my patients the morning of surgery because none of us (surgeons of PCP's) anticipated THEIR needs. I've even had them then turn around and tell me I should institute a formal CONSULTATION to Anesthesiology in order to sort out their needs.

At Mon Nov 19, 07:56:00 PM, Anonymous Anonymous said...

PCP's and cardiologists DO NOT "CLEAR" a patient surgery. We risk assess and formulate plans that minimize the chance of an operative issue from a medical standpoint. Have any of my surgical collegues here read the AHA/ACP guidelines? It would be very instructive. I stongly recommend it.

PS: Any surgeon completing a surgical procedure without his/her H @ P is very foolish.

At Mon Nov 19, 09:57:00 PM, Anonymous Anonymous said...

What you are being asked to do is an outpatient consult for peri-operative risk assessment. Minute for minute that is the best paid use of your time. If they demand and EKG, bill the patient directly, not their insurance. "It's just what the surgical center wanted."

You will not be able to solve the nation's healthcare crisis. You can solve your own financial problems by giving into mindless bureacracy and billing and coding according to CMS' own rules. This is a case where doing something simple and easy actually makes you alot of money.

At Tue Nov 20, 09:03:00 PM, Anonymous Anonymous said...

OK, from now on I'll ask for "perioperative risk assessment
' from the patient's PCP or cardiologist.

At Wed Nov 21, 01:30:00 PM, Anonymous Anonymous said...

I like Anon's comment about Anesthesia. It does seem to be common practice for anesthesia to do their patient assessments the morning of surgery, and then complain if a lab they desire has not been ordered! Hey you want that lab, you order it and deal with the result before you screw up the surgery schedule for everyone including the patient!
I wonder how many anesthesiologist's are only children?

At Sat Nov 24, 10:30:00 AM, Blogger MedStudentGod (MSG) said...


No more than surgeons are spoiled children throwing temper tantrums.

At Sat Nov 24, 06:35:00 PM, Anonymous Anonymous said...

The answer is pretty simple, if you have more than one surgeon in the neighborhood.. find the one you get along best with, and discuss who's going to do what for your patients. The surgeons with the most difficult offices to deal with? Discuss the problem with the doctor DIRECTLY, and if you can't get satisfaction, stop sending them referrals. Letting the doctor KNOW why you don't refer to them helps.

One of the GI groups we refer to has a receptionist who gets snotty with the doctors who are doing the referrals.. and I don't think she's going to be there much longer. Seems the doctors didn't know she was being rude to the people who send them referrals.


Vincent Meyer, MD

At Thu Nov 29, 12:26:00 AM, Blogger Judy said...

I've been sent to my PCP prior to major, and occasionally minor, surgical procedures. I hope she bills for a consult. I have some fairly complex medical issues and she deserves that.

OTOH, the one time recently when I didn't get sent to the PCP, I was glad the surgeon had written his own H&P. He tried to convince the anesthesiologist (prior to the procedure) that I hadn't informed him of my latex allergy. I was able to point out that it was written on the H&P IN HIS OWN HANDWRITING.


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