Guest post: Dancing with the gorilla

By Howard Rodenberg, MD, MPH, CCDS

As I write this on a Monday in late August, it’s the day after the shootings in my hometown. Three dead, eleven wounded at a video game competition at the Jacksonville Landing on the north bank of the St. John’s River, and the good name of the city now linked forever with gunfire.

I live in Fleming Island, just south of the city. I drive downtown to work near the south bank of the river, and when I go to our main hospital campus, I can see the Landing across the water. The Jacksonville Landing is where I went on my first road trip with friends when I moved to Florida 30 years ago. It’s where I spent part of the first weekend away with she who is now my Lifetime Partner in Mischief. We still stroll by after going to a concert or play at the neighboring Times-Union Center.

I was out of town at the time, and found that it’s surprisingly difficult to be an ER doc away from the scene when something happens in your own backyard. You know you wouldn’t be needed, it’s nothing the local hospitals can’t handle, but you still feel like you need to do something. But I’ve also noted an innate ability to detach, as do the vast majority of my colleagues. (You can’t really last in this business if you don’t.) It’s just kind of strange, this mixture of dispassionate indifference coupled with the desire to be in on the action, to be of some assistance, to help save a life. I’m not sure that anyone except, ER folks, fire, police, or the military quite get it.

What happen4ed in Jacksonville is another in what seems to be an infinite series of mass shootings, another reminder that this nation has a real problem with gun violence and needs to do something about it. It’s time, again, to drop our defenses and talk about the 800-pound gorilla in the room. But we won’t, because it’s hard. We’ll find every way we can to dance around the issue to avoid the effort. Thoughts and prayers. Second amendment rights. Political posturing. Questioning the integrity of those who disagree. Which means nothing gets done, and another mass shooting happens.

But at least identifying the gorillas gives one perspective. It’s true in CDI as well. You may be aware that recently a lawsuit was filed in Federal Court for the Central District of California. The plaintiff was Integra Med Analytics, a data mining firm working on behalf of private insurance companies. The defendant is Providence Health Services, a multi-hospital healthcare system, alleged to have defrauded the government of over $185 million dollars through a systematic effort to boost Medicare revenue mediated by J.A. Thomas and Associates, a well-known CDI consulting firm.

I’m not taking a position on the merits of the suit. I don’t know the facts other than what’s in the brief, and the brief itself it authored by only one party in the dispute. I would be out of my league to pass judgement of any kind. I’ve been watching the internet, and reactions range from predictions of the demise of the entire CDI industry to thundering pronouncements that the case has no merit at all. But what I find most interesting is the way the conversation goes back and forth about the merits of the suit, dancing around the real issue, our own gorilla called “revenue.”

Let’s be honest with each other. I believe, as I hope you do, that CDI is one of the best ways to get more accurate information into the medical record, to best reflect a patient’s severity of illness and needs for care, and to enhance the overall quality of the healthcare system. But to anyone outside of our community, CDI is not about accuracy, quality, or any of the other plaudits with which we reward ourselves. The fact is that none of us would be in business if our work didn’t ultimately result in revenue for the hospital. Does anyone sincerely think that hospitals would be willing to invest six to seven figures in CDI staff and software simply to improve physician documentation if there wasn’t a pot of gold at the end of the rainbow? (I wish I was still young and naïve enough to believe it, but time and fortune have proven otherwise.)

I think if we are willing to recognize the silverback, it’s actually freeing. We can put things in perspective, and realize the core of why we do what we do. And more specifically, we can stop dancing around the edges, using dandified phrases to describe our efforts, and actually focus on the business at hand. I think that if we do, we’ll find it incredibly liberating. That way we can keep the reason for our work (revenue) in focus while nevertheless following our more altruistic intentions and develop better programs for our hospitals, our colleagues, and ourselves. Doing the best we can to generate revenue, whether gaining funds through improved physician documentation or preventing loss through enhanced compliance and quality metrics is not unethical in its own right as long as we are capturing the accuracy of the medical record. Keeping the ultimate focus on revenue allows us to apply those principles of business and professional ethics where they really belong—not out along the edges of our work, but straight into the heart of the effort.

If we’re going to go dancing, then let’s dance with the gorilla. (You can watch the video of Francesco Gabbani’s “Occidentalis Karma” for a primer.) Let’s recognize that the core of what we do is make money. And rather than tiptoe around the edges, let’s acknowledge what it’s really all about, and then endeavor every day to do it right.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.