Electronic Medical Records: Will They Really Cut Costs?

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The EMR makes money in ways like this, using cleverly designed "thought bins" that are put into the program by profit-maximizing, code-savvy administrators. EMR can inject more higher-paying codes into our patient contact and squeeze that much more money out of it — quite innocently too. It is, after all, a computer forcing these choices.

EMR, financially, is the mouth and esophagus of a hungrier billing animal. And not just in hospital practice. Private medical practices, whose incomes have been driven down over the years by decreasing insurance reimbursements, are hiring computerized record/billing companies in droves. Their promise? To create electronic medical records that comply completely with coding requirements. This way the practice can bill more and improve its bottom line, even after paying the billing company for its services, which run 6 to 10 percent of gross. The insurers got computers so the doctors are getting them too. It's an arms race — though, unfortunately one in which good patient care is watching from the sidelines. (Read "The e-Health Revolution".)

If hospitals and big clinics think they can make more money with EMR, why then does everyone from the President on down believe that computerized medicine will help contain costs rather than inflate them? Is it simply that better medicine should be cheaper in the long run and having all that information available should make for better medicine?

Though this tends to be the message, all too often the mechanism is much simpler. Computerized medicine means both more information — and less medicine. Less therapy, less surgery and less testing too. That's how it saves money. A variety of promising terms describe it — terms like targeted treatment, algorithmic patient-care, fiscally responsible medicine and evidence-based practice — but for doctors treating patients, one word describes how computerized records save money. Denial.

EMR has the potential to greatly increase insurance company denials of the tests and treatments that doctors order. In the old days, the tests we ordered were done first — though bills for them might not get paid. Now when findings aren't bad enough to "justify" expensive tests or treatments, (according to sources chosen by — you guessed it — insurance companies) the computer tells everyone, immediately, "you're going to eat this." Might this eliminate unnecessary testing and save money? Sure. But who determines what is necessary? Who should a patient trust to make her medical decisions? Can the government or an insurance company be as good an advocate as her doctor?

Doctors live with denials, some of them dangerous. I've ordered MRI's on hospitalized patients that somehow never got done, physical therapy and medication never delivered, because of "unmet requirements" picked up when codes are scanned. When the white blood count isn't high enough to "justify" the hospitalization for IV antibiotics, the physician whose judgment says "this patient is sick and belongs in the hospital" is told his services as well as the hospitalization will not be paid for. When a doctor is convinced a test or treatment is needed, (and his patient doesn't have the money to pay for it) he has just two choices: wait for the patient to get sick enough to "justify" what he wants, or join the game — and lie about how sick he is. It's just a matter of clicking a different item on a pull down menu.

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