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: