A physician friend commented recently that practicing doctors and nurses, the highly trained professionals who understand health care better than anyone else, are always too busy working to be involved in health care administration and reform. It is one of the most basic and profound problems affecting our health care system — one of the reasons that health care in America does not get better. And it got me thinking.
Once upon a time, the basic units of health care in America were a patient, a doctor, and a nurse. And everyone was pretty happy.We had the “best health care in the world.”
Then, regulators created complicated rules that dictated how doctors were to be paid. As a result, getting paid involved much more documentation, use of complicated codes and calculations, and many other extra steps, like fighting frequent denials. The regulators said the rules were necessary so that they could have better information about the work that physicians performed, to better gauge what the government was paying for when it came to health care.
But these rules were so complicated that doctors needed new staff, coders, and billers, to help them navigate the complexities of being paid. But with the additional expense of the new employees, doctors made less money. To compensate, they worked faster, trying to see more patients in order to keep up financially.
Then, the regulators created complicated HIPAA rules to help protect the privacy of patients’ medical information. But it was a lot of work to try and comply with these new rules. Again, to compensate for the added time and expenses, doctors had to see more patients to make the same amount of money.
Next, government regulators began to require that doctors purchase expensive electronic health record (EHR) software. The regulators also dictated that these EHRs be used in very specific ways, in a program called Meaningful Use, and required large amounts of data as proof of proper compliance. Unfortunately, these EHR systems often didn’t work well (still true), slowing doctors down considerably. Doctors also needed IT staff to help them implement and use the EHRs. Again, they were pushed to work harder and faster, despite the impediments that the EHRs created.
At about the same time, the regulators also began to require that doctors report clinical data for the government’s PQRS program. The data for all of these programs began to overlap.
All along, health care was becoming more and more expensive. As a way to control costs, both government regulators and private insurances began to use time-consuming prior authorization and approval processes to block medical testing, treatments, and referrals. Obtaining basic medical care for patients became more and more difficult. Some offices had to hire referral specialists to perform the extra work that was required.
Regulators were also becoming concerned about the poor quality of American medical care, as evidenced by the data they were collecting. American health care was high-volume, low-quality, they said. So, they began to push doctors to participate in new models of medical care like accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). As a result, there were lots and lots of new rules with which to comply, more data collection, and even more documentation requirements.
Finally, the regulators and administrators (the fastest growing employment sector in health care) realized that, with all of these new demands, that there was little chance that doctors and nurses could take care of it all, much less many of the most basic aspects of patient care. So they created a new position, the care manager, to handle some of the work that wasn’t getting done.
As a result of all of this, doctors’ offices and health systems now employ a sea of administrative staff, helping and pushing doctors to run as fast as they can from room to room attempting to keep up with all of the new demands and associated expenses.
And yet, in spite all of these rules, regulations, and requirements, and the new staff, American health care remains high-cost and low-quality. Or maybe, it is a direct result —
because all of the rules and regulations have robbed us of the most important determinant of the type of medical care patients receive: time.
We need fewer rules and less regulation — and more time — more time with patients, and time to re-think and re-organize medical practices to deliver better care. But doctors and nurses have no time. They are too busy complying with the dictums of the regulators and administrators, and cranking out the cash to pay for all the additional expenses.
And they are too busy practicing to be involved in making more effective (and less cumbersome) changes to the system. That is left to non-practicing regulators and administrators whose only response is to add more rules and regulations.
Practicing doctors and nurses, those who truly understand health care, need to get out from under the pile of bureaucracy, and be given more time to take care of patients and even specific time (and pay) to study and implement new strategies for health care delivery and practice re-design.
Before we can really work on issues of cost and quality in American health care, we need to wipe the administrative slate clean — to start over. There needs to be a moratorium placed on new health care regulation, and older regulations need to be re-examined, streamlined, updated, or simply eliminated.
Only then can we have truly effective health care reform. What we need, rather than so many rules and regulations, and layer upon layer of staff to administer those rules and regulations, is a little more time. With more time we could revolutionize American health care.
Matthew Hahn is a family physician who blogs at his self-titled site, Matthew Hahn, MD. He is the author of Distracted: How Regulations Are Destroying the Practice of Medicine and Preventing True Health-Care Reform.
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