A recurring theme on the ACP Advocate blog is the frustration internists have with paperwork. The "Happy Hospitalist" writes, "I could double or triple the number of patients I see if my daily reality wasn't controlled by third party rules and regulations that require me to document thousands of words in thousands of key places thousands of times a day." Dr. Jay Larson says that "Increased non-clinical paper work for primary care physicians is one of 3 major reasons medical students decide to choose a different career than general internal medicine." He notes that over 95% of the physicians in the Physicians Foundation survey reported increased non-clinical paper work over the past 3 years.
"Dr. JH07" paraphrases a quote from Forrest Gump, "'It rolls downhill', this became a reality for PCP's [primary care providers] with regard to referrals, preauthorizations of drugs and radiology studies, CMN's, care plans, letters of medical necessity, FMLA forms, scooter store forms, DMV forms, routine pre-op H&P forms on healthy patients who were to have surgery, signing orders for home care agencies to justify their care and existence, work notes, disability forms, nursing home forms..."
What can be done to reduce paperwork and the associated administration costs?
As I see it, the policy options are:
- Reduce the number of payers to one. Advocates of a single payer system argue that reduced administrative costs are one of its big advantages over the US's "pluralistic" system. A single payer would have one set of rules relating to benefits, eligibility, billing, and utilization review, unlike a pluralistic system where each insurer has its own requirements. Single payer systems, though, are quite capable of generating their own paperwork hassles for physicians. Consider all of the paperwork involved with traditional Medicare fee-for-service, which is "single payer" for elderly and disabled patients.
- Let physicians and patients set their own terms. Go back to the days when patients "contracted" with their physicians for services; the fee charged and the services provided were determined by the doctor and the patient. Eliminate price controls and "balance billing" limits. Provide health insurance coverage only when out-of-pocket expenses exceed a high dollar threshold (e.g. health savings accounts).
- Eliminate fee-for-service. Paperwork may be the consequence of paying doctors based on the volume of visits and procedures. Pre-authorization and retrospective utilization review, medical necessity and DME authorization forms, coding and documentation requirements - all these (and more) are designed to control "inappropriate" utilization. Paying doctors on a "bundled" or capitation basis, linked to measures of performance, could reduce the need to second-guess physicians' decisions. But physicians have been reluctant to embrace bundled payment systems and the associated financial risk it places on them.
- Standardize and simplify. Get insurers to agree to uniform credentialing, eligibility, billing and transaction systems, or require them to do so. Substitute retroactive claims review with "real time" claims adjudication. Go after and eliminate specific paperwork that does not make sense. (How about submitting insurers' utilization review to the evidence-based standards of effectiveness demanded of physicians?) It seems, though, that every time progress is made in eliminating one silly rule, another one crops up to take its place.
- Use technology. Imagine if every patient had a "smart card" that included their insurance eligibility, co-payments, deductibles, and covered benefits that could be "read" by every doctor's office? Or if all insurance transactions were billed electronically using a common platform? Or if interoperable and standardized health information technology allowed physicians, hospitals, and laboratories to seamlessly share patient information with each other, linked to patients' own personal health records?
The first two options - single payer or letting physicians and patients set their own terms - have strong proponents within the medical profession, but in my view are the least likely to be accepted by policymakers. More likely, a policy to reduce paperwork will involve alternatives to fee-for-service, standardization of insurance transactions, and health information technology.
Today's questions: Which of the above approaches do you believe would be most and least effective in reducing paperwork? Are there other options that should be entertained?