Friday, November 21, 2008

Paperwork, paperwork, paperwork!

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?


MD-JD said...

A single payor system would do little to curb the paperwork for physicians. The single payor would be the government and a large amount of our burdensome documentation occurs because it is mandated by the government.

Eliminating payment based on the ICD and E & M systems would do the most to reduce unnecessary paperwork for physicians. We fill our notes with large amounts of coding babble when we all know the Assessment and Plan is really all that matters. If I could simply see patients, review data and then document my A & P, I could effectively manage more acute care patients as a hospitalist.

The Happy Hospitalist said...

You know the payment system is broken when you frame your documentation around what is necessary to get paid. The patient's medical record has become nothing more than a giant invoice.

When the Medicare National bank determined that the Evaluation and Management guidelines (E&M) of 1995 were not complicated enough, they decided to create a second set of rules, the E&M Guidelines of 1997.

Now we, as physicians, can choose to document from either set of guidelines, picking and choosing as we see fit to "correctly" bill for our services rendered. It's insane.

As long as third parties pay the bills in a fee for service system, we will be guilty until proven innocent. And I will be forced to document that THE MOTHER of my 98 year old demented nursing home wheelchair bound end of life patient with 20 chronic end stage medical conditions has a history of coronary artery disease. Heaven for bid I don't document that critical family history in order to get paid for my services rendered. It's an irrational game we are forced to play.

If we are going to have the government pay for health care (via my taxes), I think we should have a government subsidized primary care tax credit(via a dollar for dollar tax credits) WITH mandatory patient copays to prevent patient abuse of the system. That's it. No insurance. No third parties. No nothing. The patient and the doctor determine the price. The government subsidizes the cost. Let the market control the supply and demand.

Take the paper out of the system. Let the market determine the price. Let the government support its citizenry in the process, if we believe they should, and many believe they should.

I presented my thoughts previously on my blog with
My 125 Billion Dollar Experiment

Toni Brayer, MD said...

Thanks for tackling what is surely the most irritating aspect of primary care medicine.

I am all for single payer for a number of reasons but I don't think it would lessen the paperwork. Most of our codes, irrelevant documentation requirements,compliance hassles, home health and durable equipment forms come from Medicare (and insurance follows).

If these hassles can't be eliminated, they need to be factored into the payment system so doctors are compensated for the time. Paying for the entire care of a patient might work, rather than only face-to-face time.

Electronic medical records will help in the office because the data can be gathered once and not repeated time and time again.

I hope this is solved before we have the unintended consequence of no primary care doctors to even care.

Arvind said...

Paperwork will not only remain, but will increase if we continue with the current (and proposed) system of ICD codes, etc. A whole industry is thriving based on this monstrosity called coding, preauthorisations, prior approvals, etc.

If ambulatory services were paid at the time of services, it would automatically eliminate 5-10% of costs (involved in billing/collecting) which could be passed on to customers.

Insurance contracts should be reduced to less than 4 pages, with language that does not require a law or business degree to understand. A huge amout of cost involved with contracting can be eliminated, and passed on to customers.

Contracting standards for IT vendors, etc should be standardised and monitored by a non-political agency (like a BBB) which will reduce costs to enhance use of higher end IT in medical practices, thereby increasing efficiency and effectiveness. This again reduces cost of doing business, that can be passed on to the customer.

Eliminate the need for redundant record-keeping, just to meet legal requirements by creating medico-legal court system or local community-level arbitration offices, where non-governmental bodies (consisting of local folks) can decide on merits medico-legal complaints. Medical complaints do not belong in the jurisdiction of standard jury pools that have no clue about medical matters. This will immediately reduce the cost of litigation, thereby reducing costs of providing care, which can be passed onto the customer.

If all these measures are in place, I could reduce the value of an office visit by about 30% (by a modest calculation) which will come out to about 110% of current Medicare allowable. I will be willing to accept this if I can get paid at the time of visit, I don't have the hastle factors involved with insurers second-guessing my decision, if I can eliminate my billing dept, if I can minimise my staff requirements, if I can reduce my liability insurance premiums, if I can resetablish trusting relationship with my patients, if I can have the flexibility of charging my patients based on their ability to pay, if I can have the option of keeping my charges in line with inflationary trends. We can only hope that organisations like the ACP would listen to our voices....

Jay Larson MD said...

Standardize and simplify appeals the most to me.

Another consideration would be to allow physicians to bill the requesting entity for the time it takes to fill out the form.

Anonymous said...

Clinical care should not be accountable insurers. We need to accountable instead to the community in which we deliver the care. This would greatly reduce the micromanagement that insurers impose and would empower the units that deliver the care to be accountable and responsible for the patient outcomes in our medical communities.

Insurers do not deliver medical care though they are held accountable for it by NCQA and purchasers. They should be accountable also, but for those functions for which they are responsible - enrolling participants and paying claims. They might hold medical communities accountable for the outcomes of the patients served in the community and let thre community itself take responsibility for the local care delivery.

This fundamental restructuring of care delivery is essential to a responsible health care reform. Providing coverage to more Americans without improving the system of care will only stress our dysfunctional system further. We must get the insurers out of micromanagement. We can do this only by assuming more responsibility ourselves. This is possible only by our medical communities stepping up to fill the void and take responsibility and control of the care process