Last week my post, In Healthcare, Who Protects Us from Misinformation, I discussed the use of “sensationalism” to garner attention. I also mentioned as healthcare providers it is part of our role to join the conversation to ensure balanced and truthful information is shared. Recently an Op Ed appeared in the New York Times with a catchy title; “The Business of Health Care Depends on Exploiting Doctors and Nurses.” One of my colleagues, Edward A. Sandy II, MD, addressed this recent article in a very methodical and thoughtful way. I enjoyed his reaction to the Op Ed so much that I wanted to share both the Op Ed, and how my colleague breaks this piece down for healthcare professionals. Take it away Ed!
Edward, Sandy, M.D. & MBA, President of Sentara Rockingham Medical Group
“The Business of Health Care Depends on Exploiting Doctors and Nurses”
Now that’s an eye-catching title. Published in the N.Y. Times on June 8th Dr. Danielle Ofri, an essayist, author, and internist opines that the U.S. health system is “cynically manipulating medical professionals’ commitment to their patients to extract ever increasing productivity,” which she calls “not just bad strategy,” but “bad medicine.” The full article can be found here. I’ve read and re-read this article several times, and the comments by others about it as well. I decided to place the issue in a contextual manner to see if I could get beyond the emotion of the piece.
- There has been a dramatic shift of providers from independent practice to employed models.
- There has been a dramatic and continual downward pressure on reimbursements.
- Efficiency programs are industry-wide responses to this reimbursement pressure.
- There has been a dramatic and continual increase in paperwork and regulatory burdens.
- All current costs of care, including labor costs, have increased beyond most reimbursements.
- CMS requires the use of an electronic medical record.
- All electronic medical records are costly, as well as burdensome and poorly designed for the clinician end-user.
- Patients are sicker, and there are more of them; the Baby Boomers are aging into multi-visit patients.
- Medical training is VERY expensive, and there are not enough clinicians for our current care paradigms.
- Clinicians have a calling to patient care, not to a job. They will do what is needed to deliver that care.
- “Administrators” have a fiduciary duty-a “calling”-to preserve the healthcare offerings in their community, including maintaining a margin AND providing a clinician workforce to care for the community’s healthcare needs.
- The mandated adoption of Electronic Health Records (EHR) has exponentially increased the clinician workload burden without increasing the time available to attack that burden.
- The seemingly competing goals of quality, value, volume and more create initiatives, incentives and priorities that do not resonate with clinicians and compete with efforts needed for direct patient care.
- There is dramatic variability in care at all levels of care.
Rules and Policies
- Too many to list. Health care is the second-most regulated industry in the country.
- Dr. Ofri’s analysis of these facts, issues, rules and policies point to the electronic health record as the primary culprit in our health care dysfunction. The near universal adoption of this information platform has created additional workload that is simply not offset by any additional efficiencies it might provide in other areas of care.
- Dr. Ofri also finds the increase in the number of “administrators,” upwards of 3200% from 1975-2010, as another culprit. With approximately 10 administrators for every doctor (the author’s calculation), she believes “converting half of those salary lines to additional nurses and doctors, we might have enough clinical staff members to handle the work.”
Conclusion (My Opinion)
The difficulties in our industry are more complex than this opinion piece could address, but I agree that the HER in its present form is a major impediment to the doctor-patient relationship and has failed in its primary task of making health care easier, or in the popular vernacular, making doing the right thing effortless. Like so many technologies in medicine, the EHR was touted as a life saver, adopted quickly based on assumptions, and its design seemingly did not account for the end-user, the clinician. Interestingly, even its ability to capture charges and analyze data is continuously found to be lacking.
As for eliminating one-half of the “administrators” in the system, that seems akin to Shakespeare’s quote from Henry VI, “First, kill all the lawyers.” Feels good to say, but ill-informed and simplistic. I believe a start might be the suggestions of Dr. Veena Lanka, MD, of the Advisory Board:
- Launch clinician-directed efforts to streamline the EHR, removing meaningless alerts and documentation requirements. This is perhaps the hardest task, but the EHR is a stubborn fact that will not go away. We need to fix this from within, and perhaps ask our patients to join us in demanding better accountability from the EHR industry.
- Examine all programs and initiatives on an ongoing basis and regularly eliminate those that do not directly improve patient care or detract from provider well-being. Perhaps even adopting a stance of eliminating an existing project before approving a new one. Programs have a way of becoming immortal; this is costly and likely inflates the number of non-clinical staff in health care.
- Embrace care team models that allow everyone to work at the top of their license. From hospital bylaws to corporate policies to conflicting payer, state and federal regulations we are prevented from using every member of the team to their highest capacity. This is a huge task involving cultural change for both physicians and patients.
I might add a fourth suggestion:
Become a physician/nurse/APC leader. Our industry needs clinicians in leadership roles at all levels to bring the voice of our patients and providers into the conversation. Leadership is more than complaining, it is more than advocacy for a particular constituency. It involves gathering lots of information, finding solutions, deciding on the best solution, then communicating and implementing the best solution. Clinicians do that every day; that’s our wheelhouse. You’ve heard the saying, “If you’re not at the table, you’re on the menu.” Be at the table.
Thank you ED for your insights.