Look at the cover illustration. What do you think is going on in the picture? I was looking at it the other day in the process of preparing this issue for publication, and I kept seeing it in new lights.

1. It’s trivial. It’s nothing. I don’t mean to underestimate the difference between a level-III visit and a level-IV visit, but I’m writing a week or so after terrorists buried more than 5,000 people under hundreds of thousands of tons of rubble, damaged the Pentagon and killed four planeloads of travelers. Many pictures I look at now dissolve into the images that have recently been burned into our minds. It’s hard to maintain a “normal” perspective. But when I can achieve it, I see that the issue depicted here is not trivial.

2. It’s fraud. Is the doctor in the picture just realizing that he can add a couple of words to the chart to justify upcoding – that writing “no thyromegaly” could be worth a dollar a letter? That’s unlikely. This is an honest family physician realizing that he blew it. Which brings me to this:

3. It’s a mistake. This account of the illustration is more persuasive than the first two. The doctor may be realizing just too late that he had undercoded on the charge ticket – again! It’s not the few bucks he lost on this visit that cause him to slap his forehead; it’s the constant dribble of revenue he knows he’s allowing to slip through his fingers visit after visit. It’s his habitual timidity in coding. That’s what the cover story is designed to help with. But wait. Aren’t the guidelines actually intended to keep him timid?

4. It’s a plot. Sure. Why not? We’ve all heard the argument that the complex guidelines, paired with lots of talk about fraud and abuse, are really one big government ploy to keep physicians’ money in payers’ pockets. Tempting as that is to believe sometimes, I think it’s just anger and frustration talking. If there is a plot, it’s pretty lame. I suspect that payers feel trapped in the system as much as you do.

5. It’s wrongheaded. This is where my mind finally landed. Physician and payer are adversaries. Neither trusts the other. Each has incentives to bend the rules, to cheat. The proliferation of laws and regulations inspires a dedicated hunt for loopholes, which occasions the growth of further loophole-closing legislation in an almost talmudic effort to define a law that can (and must) be followed to the letter. Like you, the poor doctor on the cover is forced to worry about the arcane relationships between words in his progress notes and a mind-numbing array of five-digit numbers. This, when he should be worrying about how well his patient is doing. Level III or level IV? The question is far more important than it should be.

And that’s not even counting the fact that the massive, impenetrable system of discounted fee-for-service reimbursement is based on the visit – something that seems to be growing quickly outdated as the unit of care. When good care can sometimes mean wholesale use of the telephone or even e-mail and when evidence is mounting that group visits are more effective than individual ones in certain situations, reimbursement that is doled out by the visit may actually be preventing improvements in care, as the Institute for Healthcare Improvement argues.

We need a new system. In fact, nothing is likely to work until payers, physicians and patients can all somehow have their incentives aligned. And even then, we’ll still have to find some way to curb our infinite appetite for health care. The new system is probably out there now in somebody’s mind or in separate pieces that need to be brought together or in germinal form within some half-baked experiment. Watch for it; welcome it when you see it. Help it grow. The sooner it comes, the less forehead slapping you’ll have to do.