While there is an extensive literature on how tired, overworked physicians provide lower quality medical care, one thing that has been ignored by advocates of quality improvement is that overwork financially harms hospitals as well. Just as tired physicians sometimes fail to attend to certain clinical details, they are also more likely to commit errors when writing the notes which ultimately are used during the coding process. If hospitals consider the fact that lower quality clinical documentation negatively impacts their revenue, documentation quality improvement will become a financial imperative in addition to being a medical one.
The influence of fatigue on claim quality is quite dramatic. In a recent study that I did on the trauma center claims of a large medical center, I found that the average payment per claim dropped off the more patients a physician discharged. When a physician discharged two patients on a day, he or she produced on average 10% less revenue for each claim than would have been seen had only one patient been discharged. Physicians discharging three patients on a day produced about 33% less revenue per patient than they would have on a single discharge day. The lost attention to detail caused by the discharge of additional patients cancelled out much of the additional revenue that one might naively suspect additional patients would generate.
When hospitals have busy days, their performance degrades in a way that harms their profit. While initiatives such as resident work hour reductions may reduce the rate of medical errors, if they reduce the rate of billing errors, their true cost may be smaller than traditional estimates ignoring their impact on claim quality would suggest. Likewise, many physicians are under pressure to increase their throughput in order to make up for declining reimbursement per claim. Beyond harming patient care, rushing may have a negative impact on revenue, causing the benefit of adding an extra patient on a busy day to be far less than the benefit of adding an extra patient on a light day. The cost of doing a rushed job will soon become higher, as there is evidence that patients discharged on busy days are more likely to be readmitted. The Hospital Readmissions Reduction Program being put into place by CMS penalizes hospitals for these sorts of errors.
What can be done to reduce the harm that high workload has on patient health and provider revenue? While workload cannot always be changed, hospitals need to put into place programs to flag treatment occurring under distressed conditions and to maintain appropriate staffing levels. That way, once a bout of high workload subsides, providers can double-check their work to make sure that it is of the highest quality from a medical and financial perspective. While high workload is problematic, steps can be taken to mitigate its impact.
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