Tuesday, August 16, 2011

Want less paperwork? Move to Canada.

If you ask internists and their patients what makes them bonkers about the U.S. health care system, paperwork will top the list. Many will point to the federal government as the culprit, citing the many forms, RAC audits, pre-and post-payment reviews, documentation and coding guidelines, HIPAA privacy rules, quality measurement and reporting, Part D drug formularies, and HIT meaningful use requirements imposed by Medicare and other federal programs. (Some put more of the blame on private insurers and pharmacy benefit managers.)

But if paperwork is associated with the degree of government involvement in health care, then Canada--a single payer system--should have more of it than the United States, right? Think again.

A new Health Affairs survey of U.S. physicians and practice administrators found that U.S. physicians spend almost ten times more interacting with health plans than their Ontario counterparts spend on interactions with Canada’s single-payer plan. The Ontario physicians and administrators spent "$22,205 per physician per year interacting with Canada's single-payer agency--just 27 percent of the $82,975 per physician per year spent in the United States. U.S. nursing staff, including medical assistants, spent 20.6 hours per physician per week interacting with health plans--nearly ten times that of their Ontario counterparts. If U.S. physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year." (The complete study is available on a subscription or pay-for-reprint basis).

Why do U.S. doctors spend so much more time and money on health plan interactions? "The notable difference between the United States and Ontario is that non-physician staff members in the United States spend larger amounts of time on billing and obtaining prior authorizations" than their Canadian counterparts. In the United States' "each health plan offers many different insurance products to consumers, and each may have its own formulary (or list of approved drugs); prior authorization requirements; and rules for billing, submitting claims, and adjudication. In contrast, Canadian physicians generally interact with a single payer that offers a single product, and they are subject to fewer managed care requirements." The authors acknowledge that there are "possible benefits" generated by having more payers and the associated higher administrative tasks in the U.S. system-- "for example, benefits that may arise from competition, innovation, and choice among insurance products."

The U.S. is not likely to adopt the Canadian system, and there is much that can be done to streamline and reduce paperwork while still preserving a pluralistic, multiple payer system of health insurance. (For all of the hyperbole about Obama's Affordable Care Act being "socialized medicine," it actually props up and subsidizes a pluralistic system of private and public health insurance, even as it requires insurers to standardize many of their administrative transactions.)

The Health Affairs study belies the notion that more government automatically leads to more paperwork and administrative costs, or the contrary narrative that less government leads to less paperwork. Our Canadian neighbors show us that it is possible to have a government-run health care system with far lower administrative costs and far less paperwork than the United States has with its multiple payers. (Although, if the U.S. were to adopt a single payer system, it might still impose more paperwork on physicians than Canada does--as the U.S. Medicare program already does in managing its drug benefit.)

It is also possible to imagine a system that expands the role of government and maintains a pluralistic choice of private and public health insurance options, but with administrative transactions standardized and automated--as the ACA promises to do.

Today's question: What do you think the Health Affairs study says about the argument that the answer to the paperwork pandemic is to get government out of health care?


ryanjo said...

The problem is not more government, it is OUR government. Excessive paperwork is just CMS's strategy to reduce utilization of healthcare dollars by placing roadblocks, wasting provider & patient time, introducing confusion and excessive restrictions, hoping that the recipient will either give up or at least be delayed in receiving the benefit or payment. As I have discussed in a prior post, the standard CMS document to appeal a denial of non-formulary drug requires the same information (name, date, drug) in 2 or 3 different places on the same page.

The standardization requirement in the ACA bill actually provides for more paperwork (of the same bad design, most likely). Dr. Don Berwick took over the top CMS post over a year ago, promising to listen to physicians and simplify bureaucracy, but has not even take the simplest of steps in that regard.

One third of the health care dollar for administration, and headed up!

Jay Larson MD said...

Since the Government covers 50% of the lives in this country, they are only half of the problem. "Paperwork" is metastatic in this country. As this non-reimbursed task has increased, so has office overhead. Has the Government or private insurance companies stepped up reimbursement to cover these costs? Nope. Are they the culprit for the costs? Yep.

Medicare is suppose to reduce paperwork for the docs. Any evidence of it so far? On the contrary, there is more paperwork to do now than when ACA became law.

Harrison said...

You return from vacation and you are focused on paperwork?
Okay, I guess.
It wasn't really a burning issue on my mind, but okay.

We certainly do a lot of paperwork.
It is a very real source of error. We get too many pieces of paper and it is impossible to read them all carefully and so we sign things that we are responsible for and that carry real orders for real patients, and yet, we don't exactly know what we are signing in all cases.

Canada has advantages, because they don't have competing insurers contracting with different companies for different things.

I most object to the pieces of paper coming from pharmacy manager groups that suggest with varying degrees of insistence that a drug be changed to one that is 'preferred.'
And sometimes patients want it and sometimes they don't.

Government generated forms can be annoying too.

I can't say that practically I've seen any difference in the last year.
If the ACA was supposed to enact something by now to reduce paperwork, that result has eluded me.


Rich Neubauer MD said...

First of all, this is a non- trivial, critical issue that devolves not just about paperwork, but the US preoccupation with the health care unfortunately becoming a vehicle for compulsive documentation versus what it should be - a means of communication and coordination between providers of care. In my rather extensive experiences as a patient, I can tell you with absolute certainty that this trend interferes dramatically with care, and seriously degrades the experience of having an illness. This manifests as long wait times, lack of coordination, degradation of the doctor-patient interaction, proliferation of erroneous information, and new types of medical errors.

Back to your question, it has long been evident for those of us who get to talk with our Canadian colleagues that they figured out how not to have this particular issue plague them, although they have problems of other sorts for sure.

As you aptly imply, it is not a given that our current obsession with documentation must accompany a single payer system, although it could be a difficult task to dissociate the two.

marcsf said...

Cash only practice has the least paperwork of all. How long before there is a mass physician exodus from Medicare?

Rich Neubauer MD said...

This is a crucial issue and devolves not just on paperwork, but our current. Obsession with documentation versus communication within the medical system.

As a physici an who has also had a complex illness, I can tell you with absolute certainty that this trend serially degrades the experience of getting care within our system. It contributes to long wait times, new types of medical errors, ironically - to poor communication between providers, increased cost not associated with benefit to the patient just to cite a few of many other issues.

Those of us fortunate to interact with our Canadian colleagues have known for some time that they suffer much less on these burdens although they have their share of other problems too.

Back to your question, I agree with what is implied in your narrative - that more government involvement (even to the point of a single payer system) does not necessarily mean there will be more paperwork, or more generally that the current obsession with documentation at the expense of communication will continue. However, dissociating these trends may prove to be difficult.

pamyamanishi said...

There are rampant opportunities to leverage electronic record meaningful use in this arena. As we have office staff entering ADLs into sites on the record, this should be transferable to Board and Care and other organizations, rather than rewriting. DMV reporting should populate from EHR, along with above items from pharmacy approval forms. I believe this will become a solved issue with the needs for safety and cost efficiency as the EHR vendors continue to create processes that interface, or print these forms directly.