Trojan Horse? The Patients Over Paperwork Initiative

The allusion of the Trojan Horse is often used (and maybe overused) to describe situations in business or politics in which the true motivation of an initiative or proposal is wrapped in something positive or innocuous. The "Patients Over Paperwork" initiative promoted by the Centers for Medicare and Medicaid (CMS) has all the hallmarks of that mythical wooden vessel the Greeks used to gain entry into the city of Troy.

Direct-care providers [physicians, nurse practitioners, physician assistants] are understandably vulnerable to buying into the arguments that reducing documentation requirements and updating guidelines for evaluation and management services (E&M) is a benefit to patient care because ostensibly, providers will have more time to spend with patients. Fair enough. The promise of efficiency that was supposed to be inherent once a practice implements an EHR has not been fully realized and many providers are spending more time than ever on their documentation obligations. Furthermore, accurately coding E&M services can be tricky and even trickier to defend upon audit. Pretty tempting to accept this initiative on it's face and 'open the gates' to the idea that lessening the requirements for documentation will liberate time for patients.

Revising documentation requirements and E&M guidelines is a great idea, but shouldn't be construed as merely a patient-centric effort. CMS is also proposing to eliminate the higher level fees associated with the highest level of E&M visit care. Does this incentivize providers to spend more time with the patient and less on paperwork? Or does this incentivize providers to increase the volume of patients they see, rather than the quality of time spent with current patients while reducing the quality of documentation? The CMS site devoted to this initiative states the program is meant to, among other things, improve the beneficiary experience.

What is the real goal of this proposal? Eliminating the higher level of reimbursement for level 4 and 5 visits, reimbursement levels designed to compensate providers for the time and work effort associated with the most complex patients certainly feels more like an effort to reduce Medicare expenditures than a patient-centric initiative.