Knowledge Workers

 

I wrote this editorial in 2010 for the Minnesota Psychiatric Society newsletter Ideas of Reference as part of my role as the President at the time. Since then, things continue to go in the wrong direction.  Some knowledge workers get more recognition from the business managers than others but it is based on income generation rather than the cognitive aspects of the job. And of course, psychiatrists are managed as if there is no cognitive aspect as all.  In an interesting development at the time, I was contacted by Canadian physicians after this editorial was published in the newsletter, but no American physicians.

 

Imagine working in an environment that is optimized for physicians. There are no obstacles to providing care for your patients. You receive adequate decision support. Your work is valued and you are part of the team that gets you immediate support if you encounter problems outside of your expertise. In the optimized environment you feel that you are working at a level consistent with your training and current capacity. That environment allows you to focus on your diagnosis and treatment of the patient with minimal time needed for documentation and coding and no time wasted responding to insurance companies and pharmacy benefit managers.

As I think about the problems, we all encounter in our work environment on a daily basis I had the recent thought that this is really a management problem. Most of the management that physicians encounter is strictly focused on their so-called productivity. That in turn is based on an RVU system that really has no research evidence and is clearly a political instrument used to adjust the global budget for physicians. Current state-of-the-art management for physicians generally involves a manager telling them that they need to generate more RVUs every year. Managers will also generally design benefits and salary packages that are competitive in order to reduce physician loss, but this

is always in the larger context of increasing RVU productivity. Internet searches on the subject of physician management gener­ally bring back diverse topics like "problem doctors", "managing physician performance", "disruptive behavior", "anger manage­ment", and "alcoholism", but nothing about a management plan that would be mutually beneficial for physicians, their patients and the businesses they work for.

In my research about employee management, I encountered the work of the late Peter Drucker in the Harvard Business Review. Drucker was widely recognized as a management guru with insights into how to manage personnel and information going into the 21st century. One of his key concepts was that of the "knowledge worker".  He discussed the evolution of managing workers from a time where the manager had typically worked all the jobs he was supervising and work output was more typically measured in quantity rather than quality. By contrast knowledge workers will generally know much more about their work than the manager. Work quality is more characteristic than quantity. Knowledge workers typically are the major asset of the corpora­tion and attracting and retaining them is a corporate goal. Physicians are clearly knowledge workers but they are currently being managed like production workers.

The mistakes made in managing physicians in general and psychiatrists in particular are too numerous to outline in this essay. The current payers and companies managing physicians have erected barriers to their physician knowledge workers rather than optimizing their work environments. The end result has been an environment that actually restricts access to the most highly trained knowledge workers. It does not take an expert in management to realize that this is not an efficient way to run a knowledge-based business. Would you restrict access to engineers and architects who are working on projects that could be best accomplished by those disciplines? Would you replace the engineers and architects by general contractors or laborers? I see this dynamic occurring constantly across clinical settings in Minnesota and it applies to any model that reduces psychiatric care to prescribing a limited formulary of drugs.

I think that there are basically three solutions. The first is a partial but necessary step and that is telling everyone we know that we have been mismanaged and this is a real source of the so-called shortage of psychiatrists. The second approach is addressing the issue of RVU-based pay directly. I will address the commonly used 90862 or medication management code. As far as I can tell, people completing this code generally fill out a limited template of information, ask about medication side effects, and record the patient's description of where they are in the longitudinal course of their symptoms and side effects. I would suggest that adding an AIMS evaluation or screen for metabolic syndrome, an in-depth probe into their current nonpsychiatric medications and how they interact with their current therapy, adding a brief psychotherapeutic inter­vention, case management discussions with other providers or family, and certainly any new acute medical or psychiatric problems addressed are all a la carte items that need to be assigned RVU status and added to the basic code. Although there are more, these are just a few areas where psychiatrists add quality care to the prescription of medicines. The final solution looks ahead to the future and the psychiatrist's role in the medical home approach to integrated care. We cur­rently have to decide where we fit in that model and make sure that we don't end up getting paid on an RVU basis while we are providing hours of consultation to primary care physicians every day.

Overall, these are political problems at the legislative, bureau­cratic and business levels. It should be apparent to anyone in practice that when political pressure succeeds in dumbing down the profession, it necessarily impacts adversely on work environ­ment, compensation, and most importantly the ability to deliver quality care. The continued mismanagement of psychiatrists by businesses and bureaucrats who have nothing more to offer than a one-size-fits-all productivity-based model, is the biggest threat to psychiatry today and a much more enlightened man­agement strategy is urgently needed. The Minnesota Psychiat­ric Society and the APA need a strong voice in that change.

 

George Dawson, MD, DFAPA

Mismanagement of Knowledge Workers

In a previous post,  I discussed Drucker's concept of “knowledge workers” and how that concept applied to psychiatrists and physicians. The basic concept is that knowledge workers know more than their managers about the service they provide, work quality is more characteristic than quantity, and they are generally considered to be an asset of corporations.  I pointed out that physician knowledge workers are currently being managed like production workers and referred to common mistakes made in managing physicians and psychiatrists. Today I will tell attempt to describe how some of that mismanagement occurs using examples that psychiatrists have discussed with me over the past several years.

Inpatient psychiatry has taken a severe hit over the past 20 years in terms of the quality of care. Many people have talked with me about the discharge of symptomatic patients occurring in the context of high volume and low quality. Depending on the organization, a psychiatrist may be expected to run an outpatient clinic in addition to a busy inpatient service or in some cases provide all the medical services to the inpatients with minimal outside consultation. Most hospital care is reimbursed poorly despite political suggestions to the contrary. Psychiatric DRGs are typically 20% less than medical surgical DRGs and they are not adjusted for complex care. Administrators generally "manage" psychiatrists in a way to make sure that inpatient beds are covered. That frequently means that psychiatrists who prefer practicing in an outpatient setting end up doing some inpatient care. An outpatient clinic may be canceled so that a psychiatrist is available to run an inpatient unit. There have been situations where inpatient beds or whole units have been shut down for lack of psychiatric coverage. The only explanation given is that there is a "shortage" of psychiatrists.

I had the pleasure of running into one of my residency mentors in an airport last May. I let him know that I was just finishing up 21 years of inpatient work and moving on to something else. He smiled and said: "Three months wasn't enough?".  I always liked his sense of humor but there is also a lot of reality in his remarks.

I don't mean to imply that it is any easier on the outpatient side. If you are a manager, what could be easier than having a unit of production that you could hold your employees to? It turns out there is something easier and that is being able to set the value of that unit of production. That is what RVU based productivity is all about. A standard managerial strategy these days is to have a meeting with an outpatient psychiatrist and show them how much they are "costing the clinic" based on their RVU production. Spending hours a day answering phone calls, doing prior authorizations, questions from other clinicians, curbside consultations, discussions with family members, and documenting everything doesn't count. I have had the experience calling a clinic at 7 PM and hearing keyboards clicking in the background. I have asked outpatient colleagues how they are able to produce outpatient documentation themselves and still get out of clinic on time. Now that I work in an outpatient setting myself, I know what they were telling me was accurate and that is the documentation gets deferred until later.

The mismanagement does not stop there. At some point in time medical schools decided that there were also going to start basing faculty salaries on clinical production. I suppose every medical school as a formula for converting teaching and research time into production units, but until I see those formulas my speculation is that any activity that does not result in billing leads to lower compensation. The days when physicians were hired as teachers and academicians seem to be gone.  Because of discriminatory reimbursement, departments of psychiatry will be disproportionately affected.

Within psychiatry there used to be an interest in organizational dynamics and how they impacted patient care. The dynamics in most organizations today are set up to promote the business. That has produced a focus on high volume-low quality or in some cases supporting the specialty with the highest reimbursement and procedure rates.   Associated dynamics are in place to select and shape an idealized corporate employee who will modify his or her practice according to the whims of the Corporation. It may be hard to believe but large medical corporations everywhere are trying to figure out how to recruit young physicians who believe in their models. Physicians who don't accept these ideas frequently find that the company is not very friendly to them. There are always various political mechanisms for ousting any dissidents and there is minimal tolerance for debate.  The dissent can be as mild as asking why consultants with less expertise than the physicians in the practice are being called in to critique them and come up with a plan.

When it comes to physician mismanagement there are few businesses that can equal the government. RVUs, the Medicare Physician Payment Schedule, pay for performance, and various failed political theories like fraud as the cause for healthcare inflation, and managed care amplifying all of the above and focusing all of that irrational management directly on physicians.  The result is obvious as enormous inefficiencies, job dissatisfaction, and demoralization. Governments partnering with businesses and placing business practices like utilization review and prior authorization in state statutes increases the burden exponentially. At the heart of this conflict is a physicians training to be a scientific critical thinker and function autonomously with the businesses interest of making a buck. Despite all the lip service to quality, business decisions are always made on a cost rather than quality basis.

It is often difficult to see any light through the blizzard of government and business propaganda that passes for the management of physicians and psychiatrists. Psychiatry has bore the brunt of mismanagement over the past 20 years and that has well been well documented in the Hay group study showing the disproportionate impact of managed care on our field. Inpatient bed capacity has dwindled and the beds that have not been shut down are managed for high-volume low quality work. Outpatient clinics including those run by and nonprofits are managed according to the same model.  Businesses and governments have provided the incentives for this type of practice.  The available consultants in the field only know an RVU based productivity model and nothing else. Rather than treating psychiatrists as knowledge worker assets, the available jobs frequently reduce us to micromanaged clerical workers utilizing about 10% of our knowledge.  It should be no surprise that the environment makes it seem like anyone can do the job.

One of my favorite quotes from Peter Drucker was: "More and more people in the workforce and mostly knowledge workers will have to manage themselves".   After all, only  the knowledge worker knows how to best complete the job.  Every psychiatrist that I know, knows how to get the job done and it is often at odds with what we are allowed to do. The best pathway to do this is to optimize the internal states of the knowledge workers and create environment where they manage themselves.  There are very few environments available where that can happen today for psychiatrists.

George Dawson, MD

Knowledge Workers

Imagine working in an environment that is optimized for physicians. There are no obstacles to providing care for your patients. You receive adequate decision-support. Your work is valued and you are part of the team that gets you immediate support if you encounter problems outside of your expertise.  In the optimized environment you feel that you are working at a level consistent with your training and current capacity. That environment allows you to focus on your diagnosis and treatment of the patient with minimal time needed for documentation and coding and no time wasted responding to insurance companies and pharmacy benefit managers.

As I think about the problems we all encounter in our work environment on a daily basis I had the recent  thought that this is really a management problem.  Most of the management that physicians encounter is strictly focused on their so-called productivity.  That in turn is based on an RVU system that really has no research evidence and is clearly a political instrument used to adjust the global budget for physicians.   Current state-of-the-art management for physicians generally involves a manager telling them that they need to generate more RVUs every year.  Managers will also generally design benefits and salary packages that are competitive in order to reduce physician loss, but this is always in the larger context of increasing RVU productivity.   Internet searches on the subject of physician management generally bring back diverse topics like "problem doctors", “managing physician performance”, "disruptive behavior", “anger management”, and “alcoholism”, but nothing about a management plan that would be mutually beneficial for physicians, their patients and the businesses they work for.

In my research about employee management I encountered the work of the late Peter Drucker in the Harvard Business Review.  Drucker was widely recognized as a management guru with insights into how to manage personnel and information going into the 21st century. One of his key concepts was that of the "knowledge worker".   He discussed the evolution of managing workers from a time where the manager had typically worked all the jobs he was supervising and work output was more typically measured in quantity rather than quality. By contrast knowledge workers will generally know much more about their work than the manager.   Work quality is more characteristic than quantity.   Knowledge workers typically are the major asset of the corporation and attracting and retaining them is a corporate goal.   Physicians are clearly knowledge workers but they are currently being managed like production workers.

The mistakes made in managing physicians in general and psychiatrists in particular are too numerous to outline in this essay. The current payers and companies managing physicians have erected barriers to their physician-knowledge workers rather than optimizing their work environments. The end result has been an environment that actually restricts access to the most highly trained knowledge workers.   It does not take an expert in management to realize that this is not an efficient way to run a knowledge based business.   Would you restrict access to engineers and architects who are working on projects that could be best accomplished by those disciplines?   Would you replace the engineers and architects by general contractors or laborers?   I see this dynamic occurring constantly across clinical settings in Minnesota and it applies to any model that reduces psychiatric care to prescribing a limited formulary of drugs.

I think that there are basically three solutions.   The first is a partial but necessary step and that is telling everyone we know that we have been mismanaged and this is a real source of the so-called shortage of psychiatrists.  The second approach is addressing the issue of RVU based pay directly.   I will address the commonly used 90862 or medication management code.  As far as I can tell people completing this code generally fill out a limited template of information, ask about medication side effects, and record the patient's description of where they are in the longitudinal course of their symptoms and side effects.  Many managed care companies will ONLY reimburse psychiatrists for this stripped down intervention.    I would suggest that adding an AIMS evaluation or screen for metabolic syndrome, an in-depth probe into their current nonpsychiatric medications and how they interact with their current therapy, adding a brief psychotherapeutic intervention, case management discussions with other providers or family, and certainly any new acute medical or psychiatric problems addressed are all à la cart items that need to be assigned RVU status and added to the basic code.   Although there are more, these are just a few areas where psychiatrists add quality care to the prescription of medicines and managed care companies do not.  The final solution looks ahead to the future and the psychiatrist role in the medical home approach to integrated care. We currently have to decide where we fit in that model and make sure that we don't end up getting paid on an RVU basis while we are providing hours of consultation to primary care physicians every day.

Overall these are political problems at the legislative, bureaucratic and business levels.  It should be apparent to anyone in practice that when political pressure succeeds in dumbing down your profession – it necessarily impacts adversely on your work environment, compensation, and most importantly your ability to deliver quality care.