Endocrinology Demands “High Utilization”

I have recently been informed that I am a “high utilizer.” What is a high utilizer, you may ask? It is someone who prescribes more expensive medications or orders more tests than the average physician.

To be honest, this is not the first time I have received such a letter. To be honest, I can’t remember if this letter is from the same insurance company that sent me the last one.  Here’s the gist of what they said: I order more diabetes testing supplies than the average physician.  Hmmm.  Let me think about that for a minute. I am an endocrinologist after all. And just who is this “average” physician? Are they comparing me to other endocrinologists? Other internists? Or are they throwing surgeons, gastroenterologists, and dermatologists in there? I would expect that as an endocrinologist I would prescribe more testing supplies than someone who is not. And since I am a firm believer that patients taking basal bolus insulin should be checking their glucose 4 times a day and am willing to fill out the ridiculous paperwork needed to get it approved by Medicare, I wouldn’t be surprised if I prescribe more than other endos, too. I have had patients come to me only checking 3 times a day because “that’s what Medicare allows.” I explain to them that Medicare allows 3 a day without question, but will allow more if there are circumstances (hypoglycemia, uncontrolled hyperglycemia) that warrant more frequent testing.

I’ve also been informed (by a couple of different payors) that I code more level 4 and 5 follow up visits than the average physician. Well, maybe it’s because see a lot of complicated cases. Maybe it’s (again) because I am endocrinologist, and since hormones influence nearly every other organ system, I really do need to do a 12-point review of systems and a thorough physical exam. Even for my uncomplicated hypothyroid patients (who quite honestly are usually a level 3), at a minimum I need to ask about or assess memory and concentration, fatigue, palpitations, bowel habits, hair and skin changes, edema, anxiety/depression, menstrual cycles, and changes in weight. For someone with diabetes, I need to ask about eyesight, chest pain and shortness of breath, GI symptoms (because of gastroparesis), parethesias, weakness, claudication, nocturia, poyluria, depression, changes in weight or appetite, other signs of complications and symptoms of hyper- and hypoglycemia. 

I’ve had some chart audits, sure. I have yet to have a payor tell me after looking at all I do that I am coding inappropriately. The day they do is the day I tell them that they can tell my patients that they want me to do an incomplete job. I can’t practice a field of medicine that is so all-encompassing and limit my history or physical exam. Patients deserve complete care. And I deserve to be compensated for such.