When I first started working in medicine I was the Medical Director of an outpatient mental health clinic. We had a staff of 8 psychotherapists, 2 nurses, and 2 case managers. There were three transcriptionists to type up all of our notes. Every person I saw had a typed note to document the encounter and all of the charts were paper. There was no electronic health record. If a person needed a prescription, I would write one or call the pharmacy and that was the end of it. The majority of my time was spent speaking directly with patients and I could generally do all of the dictations in about 2 hours per day.
After three years I moved to a hospital setting. There were three inpatient units with 6 psychiatrists and two transcriptionists. One of the transcriptionists specialized in paperwork specific to probate court proceedings. There was an additional pool of transcriptionists available 24/7 on any phone in the hospital for immediate documentation of any clinical encounter. The admission notes were typed on two or three sheets and inserted in the chart. Daily progress notes were typed on adhesive paper and pasted into the chart. After I signed the note, a billing and coding expert came through and submitted a billing fee for the work that had been done. The same process was in place with pharmacies. Call them or send them a written prescription and it was taken care of. Every Sunday I would go to the basement of the hospital in the medical records department and sign all of the areas I had missed to complete the charts. It was the early 1990s and the administrative burden was certainly there but it was a manageable ritual.
Over the next decade things got much, much worse. Even in the blur of a retroscope it is hard to say what happened first. I would guess it was the political theory that health care fraud was the main driver of health care costs and the misguided effort by the federal government to crack down on doctors. That led to the elimination of the billing and coding experts. Doctors now had to waste their time in seminars devoted to making them experts in what is an entirely subjective process. No two coders agree on the correct bill to submit. How can you teach that lack of objectivity to doctors? The end result is that the billing and coding people were eliminated or reassigned and doctors took on another job unrelated to medicine.
The next phase was the electronic health record (EHR). It required that doctors learn the interface (more seminars and training). Once that was accomplished it was decided that they could also learn to enter their own notes - either really clunky ones using EHR derived phrases or more natural ones with a fairly frequent embarrassing typo using voice recognition programs. That eliminated the transcriptionists and required much more training. During the transition period I still went in to medical records every Sunday. I expected to see a staff person there who I had seen every Sunday for 15 years but one Sunday she was gone - a casualty of the EHR. The end result was doctors with a couple of new jobs and the elimination of both transcriptionists and medical records people.
At about the same time, managed care companies started to ratchet up the pain. In an inpatient setting you could get one or two "denials" per day. A denial is the managed care company saying that they refuse to cover the cost of care because the admission was not "medically necessary". That is managed care rhetoric for "we have decided not to pay you." These denials are purely arbitrary and have nothing to do with whether a person needs care or not. The best examples at the time were people with alcoholism or addiction who were suicidal and needed to be detoxed and reassessed. The standard managed care denial at the time was "This patient should be treated in a detox facility." The obvious problem was that not every county has a detox facility and those that do will not accept people making suicidal statements. So the next new job became battling with these companies who were essentially getting free care for their health plan subscribers if you did not jump through all of the hoops necessary to appeal.
Slightly later, managed care decided they could apply the same denial strategy to pharmaceuticals on the basis that cheaper drugs are as good and all drugs in the same class are equivalent. It turns out that nether of those assumptions is accurate, but in America today business and politics always trumps medical decision making. This prior authorization process created a blizzard of paperwork that ties up a lot of clinic time. One study estimated 20 hours per week (across all employees) per physician on average. That means if your clinic has 5 doctors in it - 100 hours per week of the total hours worked is used strictly to deal with insurance companies. It also adds another job to what the doctor already does.
So in the time I have been practicing medicine let's add the number of jobs that have been accreted into the administrative side of medicine for all physicians. Billing and coding expert + transcriptionist + EHR interface user + voice recognition user + utilization review responder + prior authorization responder totals 6 new jobs in the past two decades, none of which came up in medical school.
With all of that "efficiency" we should expect health care costs to plummet or at least stay the same. As we all know that has not happened. The politics and business interests driving this are in the business of making money. Physician and hospital reimbursement is essentially flat. One of the easiest ways to make a buck is to have the physicians doing way more administrative tasks and fire the employees that used to do them. You can also make money by putting up the usual obstacles to doctors doing their jobs of treating patients in hospitals or clinics until they just give up. I have been so burned out at times that I put a cursory note in the chart to say exactly what I did. That note did not meet coding requirements so I did not submit a bill. At some point you just have to stop working. I know that I am not alone in getting to that point.
So congratulations to all of the docs who are now laboring on this vast assembly line that we now call American medicine. It is the ultimate product of what Congress, the White House and big business can do. We can only expect continued "improvements" or "efficiencies" under the new health care law. It is an assembly line that discourages quality or innovation and that also makes it unique.
Happy Labor Day!
George Dawson, MD, DFAPA