A guest column by the American College of Physicians, exclusive to KevinMD.com.
In April, the American College of Physicians (ACP) released a position paper titled Putting Patients First by Reducing Administrative Tasks in Health Care, published in the Annals of Internal Medicine. The paper, part of ACP’s Patients Before Paperwork initiative, is a thoughtful look at the many administrative tasks that physicians face every day. It presents a framework for evaluating these tasks and calls on health plans, regulators, vendors, and others to consider this framework when they impose new requirements on physicians.
This position paper is not a “Hell, no!” declaration. It calls for stakeholders to work with physicians to assess the burden of each administrative task, consider less-burdensome alternatives (or eliminate tasks altogether), and for tasks that are implemented, explore ways of minimizing the negative impact on physicians and their patients.
I was particularly pleased to see that the paper mentioned the Quadruple Aim, a concept described by Drs. Christine Sinsky and Thomas Bodenheimer that adds provider satisfaction to the Triple Aim goals of improved patient experience, better population health, and lower cost. I wrote about the Quadruple Aim in an earlier KevinMD column and in a commentary in the Journal of Graduate Medical Education.
The ACP position paper joins a growing number of publications calling attention to the serious problem of physician burnout and career dissatisfaction. Administrative burdens are a major source of unhappiness. It is difficult for physicians to find meaning in the work they do when so much of that work lacks meaning.
Other contributors to physician unhappiness include the user unfriendliness of electronic health records, time pressures, decreasing autonomy, increasing demands of a sicker and more internet-savvy patient population, and payment inequities.
In addition to reducing administrative burdens, proposed interventions to prevent burnout include increasing physician resilience, improving office workflows, changing how physicians are paid, and holding health care organizations as accountable for provider satisfaction as they are for performance measures such as immunization rates.
In an accompanying editorial, Dr. Sinsky cites a major source of unnecessary physician work burden – the near ubiquitous need for a physician’s signature. She asks, “Does every hearing aid battery, cane, pair of diabetic shoes, mastectomy bra, ear wash, influenza vaccination, or lipid profile order need to pass through the physician’s inbox for a signature?”
How many times are we asked to sign documents that have little to do with medical care but more to do with playing “anti-fraud police” or the shifting of liability to the physician?
A few examples come to mind from my daily practice. I don’t routinely check my patients’ wheelchair tire tread or inspect their seats when they come to the office. Yet I get asked to “approve” replacement tires, mattresses, wheelchair seat cushions, and other “wear and tear” items used by patients whose diagnoses are permanent and known to the insurer from previous prescriptions. Why is that necessary? I commented on this phenomenon in a 2008 Sunday New York Times article where I stated that “I’m a doctor, not Mr. Goodwrench.”
One of my patients, who underwent a below-the-knee amputation several years ago, can’t get a replacement prosthesis without my signature. We know that the amputation is forever, and eventually, a prosthesis will need replacement. What value does the physician’s signature add to the process?
Another form that I encounter frequently in my Inbox is for adult diapers or ostomy supplies. I understand the need to verify diagnosis, which, again, is usually available to the insurer from other claims, but what additional knowledge am I expected to have on how many a patient uses per day or per month? I simply ask the patient how many they use, as opposed to sending a staff member to the patient’s house to check. Why can’t the insurer ask the patient directly and keep me out of it?
At the heart of these forms is our conscription into the army of watchdogs who are supposed to root out fraud and abuse. As a taxpayer and purchaser of health insurance, I appreciate the need to eliminate waste and inappropriate expenses, but what is so special about a physician’s signature? When I asked a representative of the regional Medicare office about this several years ago, she replied indignantly that it was about “program integrity” without answering why a physician needed to verify things that he or she was in no position to verify.
Patients and their family members are free to buy and consume over-the-counter (OTC) medications without my permission. My staff and I ask about their use routinely because of the potential for drug interactions, but I don’t have to sign forms allowing them to take two acetaminophen tablets for a headache. That is, unless they’re under the care of a home health agency. Even if I send the patient home from an office encounter with a visit summary documenting that I am aware of the OTC medication use, I can count on receiving a form to sign needing my attention “ASAP” within a day or two.
I’m sure that the regulations that led to this wasteful paperwork originated as well-intentioned efforts to protect patients, but they have devolved into a blizzard of forms that in the aggregate consume significant physician and staff time without a meaningful impact on patient care.
With these examples in mind, the recommendations in the ACP paper should be heeded by regulators, insurers, and healthcare organizations. Unlike the federal “Paperwork Reduction Act” alluded to in income tax forms, the College’s guidance, if implemented, should lighten our burdens.
Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
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