Inside Angle
From 3M Health Information Systems
Misery on the front lines of healthcare delivery
Health professionals should not have to choose between doing what’s right for their patients and doing well.
Health care in the U.S. is undergoing significant changes in the way we pay for services, the use of technology to support better care delivery and an increasing focus on important outcomes. Like any massive change, there are unintended consequences and I add my voice to those who warn that we must address the abject misery of so many physicians and others in the front lines of care delivery.
A stressed and unhappy healthcare workforce is not a good thing for our patients. The quite reasonable concept that we improve outcomes so that we can reduce unnecessary costs run aground on technologies and programs that fail to adequately support the work. Physicians and others who truly care about their patients and outcomes are decrying what they see as an impossible mix of micromanagement, inadequate resources and reporting requirements that get between them and the care their patients need.
The bottom line: We need technologies that make it easier to consistently deliver the care our patients need and programs that support that care delivery.
Chris Sinsky et al analyzed time and motion of 57 physicians in high functioning practices from various parts of the U.S.[1] The authors found that for every hour a physician spent with patients in a clinic, they spent 2 hours working on the electronic health record and other administrative tasks, not including the additional 1-2 hours of EHR work performed after hours.
What follows is part of an on-line conversation I have been having with one primary care physician who I have known for years and who delivers terrific care in a small practice. The issues he describes are not unique to his practice.
I think my big beef is that we are heading off a cliff. So much required paperwork. Escalating prices for vaccines with the reimbursement not keeping up. And spending tons of time tracking patients down and making them come in (for attribution) and making them appear as sick as possible (for acuity) and then checking all the boxes (to show high quality).
All of this sounds fine except we no longer care about the patient’s agenda or for that matter the patient–we are stuck on our agenda because we have been led to believe that if we check the boxes we are good physicians.
It’s all a game. A really terrible and tiring game where we use our patients to generate revenue, but are really not caring about them at all.
My purpose, the reason I became a physician and what I love about being a physician, is being torn apart one click and one electronic signature at a time.
I recognize things will likely get better, but when you are drowning, you don’t have much of a future to look forward to.
Today, I had to pay payroll, payroll taxes, my quarterly malpractice premium, and pay for a few immunizations. The total was about $10,000. By not paying myself, I was able to make it. But I need more HPV vaccines. I have to buy 10 at a time and it costs me around $1500. I don’t have the money, so my adolescents will have to wait until I do.
I am making some procedural changes in the office to see if we can boost revenue a bit, but as I run faster, my patients’ care suffers, and even if they do not recognize that is happening, I do.
So strangely, even as my practice increasingly becomes financially not viable, I am still choosing idealism over pragmatism. And perhaps that character trait, which I believe should be more heroic than foundering, is the real issue.
For instance: I could hire 5 NPs and 5 scribes and run people through like cattle. I can do team-based care as interpreted by systems–where patients are seen for 5-7 minutes, continuity is not measured in personal contact but by team contact, and all the boxes are checked (enhancing acuity and quality). I could make money by following Darwin’s law and “fitting in” and take both “health” and “care” out of the discussion and focus just on the finances. But my patients have come to expect more (and they should).
Once again: We need technologies that make it easier to consistently deliver the care our patients need and programs that support that care delivery.
We must move past the monolithic EMR mentality and allow true interoperability. We must seamlessly share data from disparate sources and stop with the notion that sequestering data in silos is OK. Technologies must test usability in the everyday workflow of the actual healthcare workforce, constantly improving based on feedback.
If we want world class outcomes at a cost we can afford we must fully fund the work of high-functioning primary care. We can afford this by delivering less unnecessary care. This is more likely when our compensation systems evolve past “do more = earn more.”
These are not easy changes but the pressure to move beyond nominal change is mounting. The costs of health care to individuals is rising at alarming rates; showing up as impossibly high deductibles, causing yet another rift as people wonder if they can manage finances by avoiding care.
We should not force patients to choose between their wallets and their health and a physician should not have to choose between doing what’s right for their patients and doing well in practice.
L. Gordon Moore, MD, is senior medical director for Populations and Payment Solutions at 3M Health Information Systems.
[1] Sinsky, Christine, Lacey Colligan, Ling Li, Mirela Prgomet, Sam Reynolds, Lindsey Goeders, Johanna Westbrook, Michael Tutty, and George Blike. “Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 SpecialtiesAllocation of Physician Time in Ambulatory Practice.” Annals of Internal Medicine N/A, no. N/A (September 6, 2016): N/A-N/A. doi:10.7326/M16-0961.
4 thoughts on “Misery on the front lines of healthcare delivery”
Leave a reply
L. Gordon Moore, MD
Former Senior Medical Director, Clinical Strategy and Value-based Care
L Gordon Moore, MD, is the former senior medical director of clinical strategy and value-based care for 3M Health Information Systems. In this role he bridges the intersections of quality,…
Thanks for writing Gordon
Star Trek has taught us about the Borg- resistance is futile There is no hope The solutions are in Washington and we know that legislators are incapable of conversation, compromise, or polite behavior but fight like cats. There might be a solution if physiciasn unified loudly- see the internal med MOC battle. and stopped working . Yes. Until then we apply lipstick to the pig and muster up our best radical acceptance skills and count the day til retirement or learn french to go up the road aways to work Soon NPs will not do primary care. And I hope not I would just as soon not try to find solutions No more modifers and baby sitting transition codes for me no more watching CMS send my MU money to an employer of a past or auditting me for 32.00- no no thanks .The best solution not in blogs It is in political action Do not hold yourbreath
Your comments likely resonate with the professional life of too many PCPs. Because high-performing health systems are founded on good primary care, we must absolutely fix these problems if we want better outcomes. Value based programs that fail to substantially correct these flaws are unlikely to achieve the outcomes we want. Time to move past tepid incrementalism.
I don’t see how better technology is going to help your physician friend. His problems are 1) inadequate pay for the valuable work he is doing (vaccines being one example), and 2) being required to do too much busy work (much of which falls under the heading of “population health”) that is not worth doing in the first place. Putting technology ahead of physicians and patients is what got us in the mess in the first place. Thanks.
I entirely agree that technology in itself is not the answer. As you state, primary care is woefully under-resourced and over-burdened by administrative tasks that distract from the time and care our patients need. Alan Goroll et al* proposed a 100% increase in primary care budgets. Since primary care typically accounts for ~5% of overall health care spending, this increase could be funded by decreasing the amount of unnecessary care occurring throughout the health care system (as I mentioned in the blog). Estimates of overall waste vary widely, some as high as 40% of overall spending – more than enough to fully fund the work of primary care.
While technology’s current manifestation is often frustrating and unhelpful (and many in the front lines would sat this is an understatement), if well designed it could become an enabler. Well-designed technology should make it easier for health professionals to deliver the care their patients want and need. That was my point regarding technology.
* Goroll, Allan H., Robert A. Berenson, Stephen C. Schoenbaum, and Laurence B. Gardner. “Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care.” Journal of General Internal Medicine 22, no. 3 (January 9, 2007): 410–15. doi:10.1007/s11606-006-0083-2.