Published 5/1/2017
Eeric Truumees, MD

Patients, Paperwork, and Politics

Eeric Truumees, MD

"You did not enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers—and that's what our healthcare system should let you be."
—President Barack Obama, June 2009, speaking to the American Medical Association (AMA)

"Obamacare … is going to be amazingly destructive. … I have a friend who's a doctor, and he said to me, 'Donald, I never saw anything like it. I have more accountants than I have nurses. It's a disaster. My patients are beside themselves. They had a plan that was good. They have no plan now.'"
—President Donald Trump, June 2015, Presidential Campaign Announcement Speech

As healthcare reform continues to dominate headlines, these quotes reflect the views of our current and immediate past presidents that meaningful reform requires improved efficiency. Both suggest that health care should be simplified and that caregivers should be free to focus on skills earned through long years of classroom and clinical training.

President Obama's vision for healthcare reform pointed to electronic health records (EHRs) as tools that would allow care quality to improve while reducing administrative burdens on clinicians. The Affordable Care Act (ACA) would let doctors be doctors.

President Trump's quote implies (rightly) that the ACA had the unintended consequence of increasing administrative burdens.

As physicians, we recognize the impact of paperwork on patient flow through the office, wait times, and overall efficiency. Have the efforts to reform health care improved or hampered efficiency? The article on page 22 examines some recent studies and position statements on the impact that administrative duties have on physician practices.

From privilege to pettiness
It is an incredible privilege to be a doctor. It's an even greater privilege to be an orthopaedic surgeon. I love taking care of orthopaedic patients in the operating room and in the clinic. I think most of my colleagues would agree. So, why are so many of us unhappy with our practices? Studies suggest that a key source of dissatisfaction is the limited time we actually spend practicing orthopaedic surgery. Instead, we have increasingly become petty administrators, glorified data-entry clerks, and underqualified secretaries.

According to Susan Hingle, MD, of the Southern Illinois University School of Medicine, "Data document what physicians have long believed: The work of physicians has changed dramatically in recent years, at least partially due to EHRs." AMA Immediate Past President Steven Stack, MD, has said, "Data entry and administrative tasks are cutting into the doctor-patient time that is central to medicine and a primary reason many of us became physicians."

The evidence indicates that the problem is getting worse. According to one study involving more than 4,700 physicians, doctors spend, on average, 8.7 hours per week—16.6 percent of our working time—on tasks such as billing, obtaining insurance approvals, financial and personnel management, and negotiating contracts. "Although proponents of electronic medical records have long promised a reduction in doctors' paperwork, we found the reverse is true," concluded the authors.

The number of governmental departments and agencies that touch health care and the variety of programs offered are also problematic.Among the regulatory agencies that "flesh out" legislation with regulations are the Centers for Medicare & Medicaid Services (CMS), Office of the National Coordinator for Health Information Technology, Agency for Healthcare Research and Quality (AHRQ), Government Accountability Office, National Committee on Vital and Health Statistics, and Office of the Inspector General.

Well-meaning attempts to reform our healthcare delivery system have improved access for some, but certainly not by simplifying the system. The number of complex recent laws passed by Congress include the ACA, HIPAA (the Health Insurance Portability and Accountability Act), MACRA (the Medicare Access and CHIP Reauthorization Act). Longer-standing programs such as the Stark Laws and Federal Anti-Kickback Statute also place onerous administrative burdens on physicians.

To participate in government healthcare programs, physicians must meet unique administrative requirements and hassles. For Medicare, examples include the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBM) program, and the EHR Incentive Payment Program typically referred to as Meaningful Use (MU).

Each of these programs was established by a different law and uses different measures, reporting methodologies, and time frames. Although MACRA was intended to better align these programs for participants in Medicare Part B through the Merit-based Incentive Payment System, or MIPS, it remains to be seen if this realignment is helpful. Nonetheless, the rate of change in the rules and programs adds another burden in terms of educating physicians and office staff.

Impact on patients
The ACA increased access through the exchanges and Medicaid expansion. However, the administrative burdens of dealing with a host of new plans, unfamiliar to both patients and physician office staffs, are noteworthy. The reportedly high rates of patients who fail to maintain their insurance has negatively affected providers unaware of the lapsed status.

Administrative burdens on physicians may perversely reduce patient access, either through patient perception of value or throughpreauthorizations, waiting periods, and denials that may prevent physicians from even offering certain types of care. According to a Harvard Medical School study, the typical office visit took 121 minutes of the patient's day—37 minutes in travel, 64 minutes waiting for care or filling out forms, and only 20 minutes face-to-face with the physician. Based on the average person's earning capacity, this time was worth $43, while the average out-of-pocket cost for the care itself was $32. How many follow-up appointments are skipped due to these hassles?

Physicians might also choose less paperwork-intensive specialties, which also could affect access. As an orthopaedic surgeon, I am only in the office twice a week. I cannot imagine the negative impact these hassles would have on my morale if I dealt with them daily.

Arguably, the flip side of career satisfaction is physician burnout. Several studies have shown that burnout is more prevalent among physicians than other U.S. workers and is increasing. Although control, alignment, communications, and workflow are contributing factors, administrative tasks, EHRs, and externally imposed regulations are also related to increased stress and burnout.

What's next?
Clearly, using orthopaedic surgeons for administrative tasks robs us of both time and energy to spend on direct patient care and increases burnout. This, in turn, could jeopardize safety and access. Efficiency in care, cost reductions, and improved access could result from allowing each member of the care team to practice at the "top of their license."

Over the longer term, changes in the healthcare financing system may eliminate some of this work. According to the American College of Physicians, a truly value-based reimbursement model would eliminate the need for prior authorization procedures, because providers would have no incentive to order a low-value test or treatment.

The single-payer system is often cited as a way to reduce administrative work. David Himmelstein, MD, professor of public health at the City University of New York, has noted that the current health financing system is "demoralizing doctors and wasting vast resources." He calls for a "simple, nonprofit national health insurance system that lets doctors and hospitals focus on patients, not finances."

It is perhaps telling that surgeons who participate in medical missions often comment on the difference in practicing abroad. In one recent account comparing practice in Australia with that in the United States, the physician noted that "complexity, fragmentation, and unnecessary documentation are driving physician burnout, patient dissatisfaction, high costs, and suboptimal outcomes in this country."

Not all in orthopaedics—nor in medicine at large—would endorse the simplicity of centralized, single-payer health care versus the possibility of greater efficiencies from market forces or a focus on the value equation. No matter where you stand on that spectrum, the current model in the United States seems to favor the worst of both worlds.

Certainly, payers and measure developers must continue to improve measures and reporting systems (including relevant health information technology capabilities). In particular, those used within value-based payment models must measure the right things, move toward improved clinical outcomes, be patient- and family-centered, foster care coordination, and focus on population health and prevention. But they must also not lead to unintended adverse consequences.

Although many of the tasks that fill our days were initially added to save money or improve quality, there is little evidence that they achieved those goals. If, as physicians, we are being asked to provide evidence-based care, it seems reasonable to expect that any curbs or administrative boundaries placed on that care should have a similar evidence base. Simply put, we have to insist on a seat at the table when these demands are created. Perhaps an orthopaedic surgeon as the Secretary of the Department of Health and Human Services is a step in the right direction.

One area of immediate assistance lies in documentation support, a medical scribe, or dictation assistance. Several studies have suggested that this support reduces administrative burdens and provides more direct face time with patients.

Over the next several years, many experts predict improvements in EHR systems. But whether these improvements will facilitate patient management and care or be co-opted for other purposes is unknown. In the meantime, the assistance of a medical scribe will continue to be indispensable to a great many physicians who simply don't have the bandwidth for all the administrative tasks required by our current healthcare system.

Eeric Truumees, MD, is the editor-in-chief of AAOS Now.