One of the things Medicare-for-all won't cure

Medicare-for-All is not a panacea for many of the myriad medical problems. Some of these things exist in those countries that do have universal health coverage. In the past I have written about some of these things such as Electronic Health Records (EHR). To day we will discuss the administrative burden of running a medical practice, regardless of who pays.

We shall first posit that there will be no self-referral. This prohibition is in many locations obviated by hospital ownership of formerly independently own medical practices. Reasons for this are obvious to those in the health field but also easily comprehensible for those without such intimate knowledge. It is astoundingly easier to let a hospital assume many of the worries of an individual medical practice.

Some examples:

1. Hospital pays malpractice insurance--don't kid yourself, malpractice will occur whether the country or private insurers pay the bills.

2. Hospital pays for a practice's clerical staff including salaries and benefits. This is a mixed blessing because hiring and firing of unsuitable employees may have to go to the "Human Resources" departments, which all hospitals are required to have.

3. Hospitals know how to upcode (i.e., charge more) for procedures than most physicians' offices do. Medical coding is a complex situation and is worthy of a separate essay in its own right; this won't be discussed here.
Hospitals arrange for emergency back-up panels per specialty. This of course is not much value when there are only or two members of a specialty available.

4. Hospitals do self-refer: to their labs,to their imaging departments, to their therapists, to other specialists where available. Clearly, within limits, which generally are fairly broad, this is advantageous to the hospital--not necessarily to the physician or patients.

5. Hospitals benefit from volume discounted purchasing equipment including drugs. This is especially true of hospital groups. Don't be fooled--there is no such thing as non-profit hospital. The upper management always gets disproportionately greater pay than the serfs--which includes most of the physicians.

The points at issue here are administrative work that cannot be pawned off to non-physicians. Anecdotally, my own experience was that more than one day per week was devoted strictly to usually time-wasting tasks without which proper treatment could not be obtained. Even though private "insurers" expected a lot more of this than Medicare or Medicaid, bureaucrats got their noses into every place they could (and remember the saying about the camel's nose).

Let's define administrative task as per the American College of Physicians (ACP) position paper. from which most of the information is excerpted. By the way, the ACP is the society which encompasses internal medicine and family practice, primarily the former group. This group of physicians is the largest such medical group in the U.S., dwarfing membership of other groups. For example, cardiologists have 30,000 members (or more) and neurosurgeons have about 3,000.

What Are Administrative Tasks?
Defining administrative tasks in health care (also colloquially called hassles or burdens) is challenging—one simply knows a hassle when it appears. Tasks that become burdensome may differ from payer to payer; appear one month without notice, then reappear modified or changed the next; and often result from not using documentation that already exists in the medical record. Equally if not more challenging is to identify the best means to address these tasks to mitigate or eliminate their adverse effects on physicians, their patients, and the system as a whole. However, taking an analytic approach to defining and mitigating administrative tasks is critical to addressing them in a more comprehensive, cross-cutting, and holistic manner, rather than fixing one problematic task only to have another arise in its place.

This journal article gives numerous references plus provides clear explanation of their methodology. I will not dwell on the informatics pertinent to this as such would distract from the heuristic purpose of the essay.

Where does the demand emanate for administrative sources? Almost all such demands are external, by which is meant they are not required by the physician's practice but by other entities.

Sources of Administrative Tasks

External Sources.
The most numerous and well-known tasks faced by physician practices and other organizations that provide health care are imposed by outside forces. These external sources include, but are not limited to, public and private payers; governments and policymakers; private certification, accreditation, and recognition organizations; vendors and suppliers; health care consumers; and other clinician practices and health care provider organizations.

Public and Private Payers.
All payers, whether public or private, have their own approaches, rules, and requirements related to insurance eligibility verification; appropriate billing for services; prior authorizations for medications, procedures, and other services; appeals for lack of payment; reporting of quality and resource use measures, as well as feedback reports on those measures; referrals and treatment plans; alternative payment model (APM) participation; and many other areas.

Governmental Entities and Oversight.
Many governmental entities also impose administrative tasks on physicians—either directly or indirectly. During the past several years, Congress passed laws intended to reform and improve the health care system, including the Patient Protection and Affordable Care Act (ACA); the Health Insurance Portability and Accountability Act (HIPAA); the Stark Law and Federal Anti-Kickback Statute; and, more recently, the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act of 2015 (MACRA). With regard to the complexity of health care administration, these laws have changed operating rules for health plans, initiated and advanced quality and other reporting programs for physicians and other clinicians, and facilitated the development of value-based payment approaches and APMs. Once such laws are passed, the regulatory agencies, most notably the Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology, are responsible for implementing them. Other entities are involved as well, including the Agency for Healthcare Research and Quality (AHRQ), Government Accountability Office, National Committee on Vital and Health Statistics, and Office of the Inspector General. External advisory entities, such as the Medicare Payment Advisory Committee, Medicaid and CHIP Payment and Access Commission, and Congressional Budget Office, also provide input to both Congress and the agencies on issues related to health care payment and delivery system reform.

Let's drill down two of those phrases in italics, which I illustrated. They are not so simple as they would seem in the quoted paragraphs.

Feedback Reports

With the Federal requirement for EHR, feedback reports should be readily available from those mandated medical records. One might think that merely sending follow-up reports would suffice to satisfy that requirement. But many times, especially with private insurers, a separate, non-EHR report is requested, resulting in a physician-generated response. A massive time waster.

Affordable Care Act

Although now on its death bed, ACA help encourage me to stop practicing because of the not-insignificant financial penalty for NOT using EHR. Without going into the syndromic troubles caused by EHR, suffice it to say that it just work the way it's supposed to. The result is unmitigated crap.
EHR was not intended to track disease and treatment results, assisting with patient care, sharing information with other physicians or allied treaters. Instead it is ONLY useful as a tracking source by the bean-counters to ascertain that the "insurers" aren't getting ripped-off. What a joke (I'm not laughing).

When the ACA was enacted, the primary concern at the practice level was whether and how practices could accept a potentially large number of new patients, particularly those covered by Medicaid, and avoid a negative effect on their ability to provide high-quality patient care.

Outside the ACA, Medicaid also may be a source of burden for physicians and their practices, because it is administered under both state and federal regulations

HIPAA, also known misleadingly as Health information and portability act, was supposed to have the effect of easing inter-physician transfer of medical information while maintaining privacy rights of the individual. That leads to some interesting problems, some of which I have personally faced. The most egregious one is this: If a patient and close relative or significant other accompanies the patient to the examination, the care-giver is required by law to ask the patient if it is alright with companion to listen in on the procedure including post-examination discussion. This becomes particularly dicey when the patient may--or may not--be cognitively impaired due to a variety of causes (dementia, cancer, medication, brain injury, etc.) If the patient refuses, which does happen, the usual best witnessed is legally barred from the proceedings, thus introducing considerable doubts into the assessment and diagnostic plan. And appeal from this situation could;d theoretically involve a court-ordered competency hearing (at which I have had to testify a number of times). This is quite a drag on physician time. Admittedly, this is a relatively infrequent occurrence in specialties outside off psychiatry, neurology, and neurosurgery. But when it happens, you can write off a whole day of patient interaction other than the court hearing.

Oversight by Private Entities.
In addition to the government entities and oversight discussed earlier, physicians face administrative tasks resulting from oversight by private entities, including but not limited to certification boards and accreditation organizations. Approaches to board certification and maintenance of certification vary among specialties, with the American Board of Internal Medicine serving as the primary certification organization for internal medicine physicians. Although board certification and maintenance of certification technically are voluntary, they typically are required for physicians to practice in certain systems

The vast majority of prating physicians with whom I have discussed Continuing Medical Education (CME) agree it is largely a money-making racket. Medical progress occurs at an ever-increasing pace. It is now the case that even sub-specialty information cannot be digested by the most studious of sub-specialists. I am not suggesting that there should not be CME but the current structure is heavily influenced by "the party line", i.e., the dogma of a particular specialty board. Deviation from that line will earn you less points on your exam score and may even fail you, no matter how debatable the dogma is. These tests are almost always multiple choice, which does not lend itself to explanation of alternate opinions.

National Committee for Quality Assurance (NCQA)...accredits health plans and provider organizations, such as Accountable Care Organizations (ACOs), and certifies programs and specific services.

ACOs are another wasteful boondoggle, enriching administrators while again ensuring adherence to preconceived "standards". These standards take time to be modified, which is always the case with bureaucracies. ACOs can recommend to medical groups that they discipline or spank outliers of their preconceived medical standards if not adhered to.

Often, physicians in practice are unaware that their patients have been seen by other clinicians or providers, or they become aware too late to meaningfully contribute to or provide the needed follow-up care. When information is shared, it is not always relevant, appropriate, or helpful, or may not be what the physician needs to ensure high-quality care.

Even when a physician asks about intercurrent medical contacts patients often forget or withheld information because the patient did not think it relevant. Same applies to medication changes and procedures, invasive or non-invasive. EHR was supposed to fix this. See my comments above about this fairy-tale.

Woe to the physician who reports an adverse drug reaction to the FDA. Most of the time, instead of being thanked for their reporting, the FDA sends lengthy questionnaires to be absolutely sure, absolutely certain, absolutely irrefutably correct. Many times this is like the third degree. The reporting physician is made to feel like a medical pariah for such blasphemy which disincentivises a repeat performance. It's happened to me.

Internal Administrative Burdens

Two major internal sources of practice burden are inefficient workflows and lack of effective team-based care both within the practice and in interactions with other practices and health care organizations.

The good news here is that internal problems like these are easily remediable. The bad news is that the internal sources of administrative load are a small minority of total burden.

Classification of administrative burdens

As outlined earlier, the sources of administrative tasks are diverse. Likewise, their intentions are varied, but overall they may be classified into 5 main categories according to whether the task
• Provides and pays for products and services
• Ensures high-quality, high-value, safe, and effective provision of products and services
• Reduces excess and inappropriate costs and prevents or identifies fraud and abuse in the health care system
• Ensures financial security and potential profitability for the stakeholder
• Lacks a clear intent

Cost Reduction and Fraud Prevention.
Along with ensuring quality and safety, administrative tasks also intend to reduce excess and inappropriate costs and prevent or identify fraud and abuse in the health care system. These intents are common across all sources of administrative tasks

Sounds good, huh? In reality, the system of discovering fraud and abuse matches that of the military: not very damn good. Los Angeles is a hotbed of fraud and abuse. Since that city was my main referral area, I did learn about some of the schemes from colleagues and attorneys. You wouldn't believe some of these--maybe another essay, later.

More on EHR:

A recent study examining the productivity of physicians using EHRs in the emergency department found similar problems, with 43% of physician time spent on data entry and an average of 4000 total mouse clicks for charting functions and documenting patient encounters during a busy 10-hour shift (49).

ACP Policy recommendations:

1. The ACP calls on stakeholders external to the physician practice or health care clinician environment who develop or implement administrative tasks (such as payers, governmental and other oversight organizations, vendors and suppliers, and others) to provide financial, time, and quality-of-care impact statements for public review and comment. This activity should assess the questions outlined as follows and occur for existing and new administrative tasks:
a. Could the requirement interfere with or enhance the ability of clinicians to provide timely and appropriate patient care (both in person and remotely, in real time and asynchronously)? What are the expected or potential opportunity costs of the requirement in terms of its effect on time spent by clinicians providing care for patients and on any time spent by patients to address the requirement?

b. Does the requirement improve the quality of care delivered to the individual patient and/or to the population? If so, how?

c. Does the requirement have a financial impact on the physician practice, provider organization, patient and his/her family, and/or the health system that diverts resources from patient care? To what extent can this impact be quantified?

d. Does the requirement call into question physician judgment in terms of expertise, training, education, and experience? If so, what are the reasons these questions are being raised?

e. Overall, can stakeholders propose alternative approaches to accomplish their goal for consideration by the public?

There are numerous other recommendations which can be obtained by reading the article. Lots of references. Unfortunately lots of Acronyms which I consider one after the other bureaucracy--which bureaucracies will be difficult to eliminate, merge, or simplify. We might refer to these as the "deep state" of medicine.

APPENDICIES not the kind which are excised:

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It is bringing "technology" to the old guy's office. Right now, there is no email availability, tests are not online, etc. My biggest bitch is his medical biller. She hasn't a clue what she is doing. I've been fighting with her over three years. She double bills, doesn't bill, bills for a whole year at one time. 2015 I couldn't get a bill at all. I was so pissed the doctor told me not to pay, it was free. So I went online to BC/BS and added up what they said I owed this doctor and sent him a check. I asked him how he knew she wasn't ripping him off. If I was having so many problems with keeping track of her billing, how many people including him just trusted her?

I have a second GP that I also see. Ironically, she bought and moved into my other GP's old office suite. She is younger, female, and brings more treatments that are female-focused into her practice. She is with a different hospital than my other GP and has more technology. She has a person on staff who takes blood in the office for blood work, and she sends test results through in an email.

The difference between the two doctors and their practice is pretty amazing.

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"Religion is what keeps the poor from murdering the rich."--Napoleon

Alligator Ed's picture

@dkmich So the transition to a new care-provider has been smooth. The generational differences in practice you observed has a lot to do with those trained pre-computer-age and those post-computer-age. The earlier physician was also hampered by an inefficient and possibly dishonest secretary. Such behavior would be sniffed out in a minute by a hospital system. But what you didn't see and what you won't see is the administrative burden which occurs outside of patient view except for the horrible EHR systems which, unfortunately interjects the back of a computer monitor between patient and care-provider. That is a deplorable situation. Those goddam things (computers) should never be allowed to usurp patient-physician interaction, yet they do. This is not the fault of EHR but perhaps over-worked doctors trying to do their electronic paperwork during patient contact. This is wrong, wrong, wrong.

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Pricknick's picture

@Alligator Ed
you see many doctors today who have a medical transcriptionist with them doing the click-work.
Much better.

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Regardless of the path in life I chose, I realize it's always forward, never straight.

Alligator Ed's picture

@Pricknick The problem is that billing codes are tied into EHR reports two the correct boxes have to be clicked which is something a transcriptionist should NOT do. Dictated notes are better but the reality is that crappy EHR reports get less pushback from payers.

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studentofearth's picture

@Alligator Ed creates better data to slice, dice and sell.

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Still yourself, deep water can absorb many disturbances with minimal reaction.
--When the opening appears release yourself.

Alligator Ed's picture

@studentofearth but which IS easier to slice, dice and sell.

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studentofearth's picture

@Alligator Ed @Alligator Ed I was referring of ease of slice & dice, not quality of content.

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Still yourself, deep water can absorb many disturbances with minimal reaction.
--When the opening appears release yourself.

@Alligator Ed I just went to my GP today. She stared at the screen of her laptop, furiously typing for 75% of the visit. She is a good multi tasker but she still missed some of the points I had made in our discussion... discouraging.

I work for a large transnational corp and am familiar with requirements for organizational reporting. It's a colossal waste of time to fill out forms which no one reads, just so some managers feel better about getting their pound of flesh.

While I have "free market" coverage, i get no real choices. My employer subsidizes some of my insurance premium. I have to go to approved doctors, use their labs and facilities (they work for a hospital), buy medications from an online pharmacy rather than a local pharmacist who knows me. My choice comes in if I choose to pay a shit ton more money to go out of network.

Because I have some complex health issues, I am constantly getting referred to other doctors so they can compound billing. For example, I had a bone scan and the doctor threw in some in house xrays of the same area. He wound up telling me everything I already knew. I have no idea about the necessity of those xrays but you can bet his office knew all the proper billing codes.

Because xrays and bloodwork are not cross referenced with medical insurance explanation of benefits, I have to follow up with the HSA debit card folks to provide them with my documentation. They never advise me of this by the way, they just shut off the card until I get the docs they require. This triggers another need for me to generate more reporting to the HSA credit card to justify my prescription/copays that I made out of pocket while my account was suspended.

I am incredibly thankful that I have healthcare coverage and am paid enough to utilize an HSA. But our healthcare system is a disgrace and needs to be overhauled and insurance companies eliminated from the equation.

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Alligator Ed's picture

@Blueslide

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studentofearth's picture

US. The implementation of Affordable Health Care Act accelerated two trends . The shift of physicians as independent business owners to becoming employees. The growing power of hospital groups by creating monopolies in a number of health care markets.

During some of my more cynical moments I wonder if these were some of the unstated goals of the legislation. In the area I live there is now one hospital group, the next closest is 120 miles away. Independent physician practices, ancillary medical practices (home healthcare, physical therapy, etc)have to compete with the hospital self-referring to their employees. The physicians have been forced to upgrade or change software communicate with whichever EHR software the hospital is currently using.

I predict Independent medical practices will become as rare as independent pharmacies. Pharmacy was one of the first businesses to embrace software, now almost all pharmacist's are an employee.

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Still yourself, deep water can absorb many disturbances with minimal reaction.
--When the opening appears release yourself.

Alligator Ed's picture

@studentofearth and not an alligator by having an independent solo practice. I don't regret it but your observation is quite pertinent, and, sadly, also true.

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@studentofearth The software profession was devastated by flooding the market with cheap Indian H1-B's. I see that now almost all pharmacists are Indian and also many doctors, particularly in HMO's. Coincidence?

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I've seen lots of changes. What doesn't change is people. Same old hairless apes.

studentofearth's picture

@The Voice In the Wilderness Pharmacist's are not replaceable by HB-1 visa employees. Like most professions, with a long history in the US, state boards regulate the requirements necessary to practice the profession. Most boards are composed of individuals practicing the profession and they tend to be self serving by limiting competition for the positions available.

Pharmacy chains, hospitals and HMO are larger employees and impacted by federal anti-discrimination laws more than a small business. It is not fair, but Indian pharmacists and physician have better opportunities for employment and career advancement in less desirable working environments.

Software programmer is a new professional class. I am unaware of a state board ever created to protect the profession of programmer. Software companies have been pro-active at diluting the economic power of the profession.

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Still yourself, deep water can absorb many disturbances with minimal reaction.
--When the opening appears release yourself.

Alligator Ed's picture

@The Voice In the Wilderness However the best physician I have ever known was Indian as was the pediatrician for my younger two children.

The nationality of the software programmers is much less relevant to EHR. Whereas the best non-medical software is designed by geniuses to be used by idiots, like myself, EHR software is designed by geeks and only modifiable by geeks. Most physicians do not have adequate coding experience, though some are absolute whizzes at it. When your EHR breaks down, which frequently happens, expect a geek house call.

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travelerxxx's picture

@The Voice In the Wilderness

Where I live - northern Houston, Texas - I haven't seen a native English speaker working in the pharmacies for years now. These are the huge corporate firms such as CVS (especially) and Walgreens. It's hard for me to believe there isn't an H1-B program bringing in cheap foreign labor to staff these pharmacies. Something is happening, that's for sure.

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studentofearth's picture

@travelerxxx HB1 visa to hire pharmacists and physicians. CVS has applied for a significant number of visa's nationwide. CVS reputation of poor work conditions for pharmacists, goes back at least since the 1980s.

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Still yourself, deep water can absorb many disturbances with minimal reaction.
--When the opening appears release yourself.

travelerxxx's picture

@studentofearth

Thank-you for the links. Quite interesting.

Not hard to tell that these people are driven hard at my local CVS. I've watched them as they work, and I'd sure hate to be pushed as hard as those employees are pushed. It shows in the final product, too. My wife and I have far too many mistakes made in regard to our meds.

CVS has expanded very rapidly here in the Houston area. Seems there's a CVS or a Walgreen's about every two miles or so. Generally, there's both; one across the street from the other. They've run most of the small mom and pop pharmacies out of business long ago.

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and other "administrative" functions which are one of the main drivers of cost increases in both healthcare and education for the past few decades. My doctor and hospital belongs to a "network" which successfully increased the money it sucked out of insurance companies by 75% over only 7-8 years.

BTW this network famously almost went broke implementing Epic.

In the past, I've always thought the medical professions could benefit from a little business acumen. Private practices have been disappearing in a number of industries; just because you're good at law or medicine or financial advice doesn't mean you know how to run a business. In medicine in particular, the average person could walk into a doctor's office and encounter both the most educated and intelligent person they were ever likely to deal with--their doctor--working alongside the stupidest, most ignorant and incompetent person that still somehow was miraculously deemed to be a white-collar worker--the admin, secretary or receptionist. They weren't all this bad, but a lot were, and in many offices, they were the only people "running" the office.

Had these been normal times, professional business management could have offered some efficiency benefits. But these aren't normal times. The professional class has been corrupted utterly, and now the suits offer nothing other than fangs in the neck, draining lifeblood for their own parasitical benefit.

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Alligator Ed's picture

@Cassandrus One saying, very applicable to private practitioners, much more so than to hospital-employed physicians, is that "the receptionist IS your practice". A rude and/or stupid receptionist can ruin a practice without the physician even knowing.

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And as a patient, I've seen both sides.
My spouse struggled with Epic at first, and, I believe that it was implemented in her "non-profit" hospital early in order to get a significant EHR early implement bonus from the ACA.
It took a while to configure and figure out how to interact with patients without the interface getting in the way.
On the other hand, two things that I have seen with EHR's, my physician can notice my bp is a little high, quickly pull up on the computer a graph of my bp over the last 4 years or so, and note trends or outliers. It really can be an aid in making a health plan. The same with cholesterol levels etc.
The other thing about EHR that seems positive to me is interaction with the pharmacy. Scrips are faxed or emailed electronically to the pharmacy. No scribbled unintelligible paper. And there is a record of other drugs that the patient is on and any drug interactions that might have been overlooked can be alerted.
Alright those are a few positive things, and there are many negative as you already mentioned and I agree with.
In the end, it is follow the money and what is the motivation? If it can help provide better patient care, great. A part of EHR seems to be to justify a bill or protect an ass, to have a record of the thinking that went into a given treatment. The time spent..not so great. After the first year, the time is about the same as before. Doing EHR instead of voice dictations that were then transcribed.

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Alligator Ed's picture

@peachcreek But the GIGO ethic remains. An error once perpetuated tends to be mindlessly repeated by simply cutting and pasting one session's notes to the next. I have seen EHR visits reported in which the exact same data were recorded at each visit for a full year. Yeah, right. Even Robbie the Robot would not have such perfectly duplicable results. And insurers pay for this obvious bullshit. It is obvious. They don't read the report unless the coding requests more money than the previous visit.

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