One of the reasons I haven’t written as many posts as I’d like is that I spend a lot more time than I used to writing and typing stuff so I can get paid. Four years ago, I was all for it when the homecare agency I work for finally bought us clinicians some laptops and bought the whole agency some documentation software. It involved a massive outlay of money, effort, and training. And that was just the beginning. There were — and still are — the inevitable software bugs, crashes, server inadequacies, updates, errors, and just-plain-mystifying nonsense. There were — and still are — too many time-consuming emails, meetings, seminars, and phone calls needed to fix things. But still, I was psyched. At last, we were moving into the 21st century! At last, we could blast through our visit notes and spend more time actually helping our patients! Boy, was I wrong.
For me, there were further, unexpected ramifications. I had just returned to work, after acute cancer treatment was over, when all these changes began taking place. Within months of being back on the job, the long- and late-term side effects of cancer treatment forced me to cut back my hours, from full to part-time. First, I had to cut them in half. Eventually, I clawed my way through the murky side effects ditch back to working four days a week, instead of the five I used to do. However, thanks to our 21st century documentation, I still work five days a week. I just don’t get paid for it. Sometimes, when I’m tightening my belt yet again because it’s hard to pay my bills with one-fifth less income, I think about trying to return to full-time. But I know that if I did, I’d end up working 50 hours a week instead of 40, and I just can’t do that anymore. I’m also very well aware of being fortunate that, despite fatigue, pain, brain fog, financial stress, and the ever-present anxiety of cancer vigilance, I can do my job at all.
Ten Dollar Aspirins
This past week, Steven Brill wrote a piece for Time called Bitter Pill: Why Medical Bills Are Killing Us. It has been widely and justifiably shared on social media. The points Brill makes that have stirred perhaps the most outrage and discussion concern the “lopsided pricing and outsize profits” inherent in the system. If you examine an itemized bill for a hospital stay, that includes items like $29 for a few gauze pads that actually cost a nickel a pad, or $10,000 charges for one dose of a chemo drug that may cost the manufacturer $200, it’s hard not to feel like we’re all getting shamelessly gouged. Indeed, when you move into the realm of cancer care, you begin to understand the pressure cooker of spiralling costs to which both doctors and patients contribute. In her memoir, The Cost of Hope, journalist Amanda Bennett poignantly described how much it cost to treat, and ultimately fail to save, her husband from the ravages of kidney cancer. Over the seven years of his care, the motivation to do everything possible led to expensive duplication and redundancy of services. As she researched the details for her book, she found, in just one stunning example, that her husband had received a total of 76 CT scans. Bennet asked, “Were all of them useful and ordered for a good reason? I’m positive of that. Were all of them necessary? I’m just as sure not.”
As someone who has a foot in both camps, the patient camp and the clinician camp, what most interested me about Brill’s article was the first part of it, in which he discusses how much it costs to administer healthcare. And why. Medicare, for example, has to be more accountable for every dollar in its budget, and thus manages to spend less than 1 cent of every dollar it pays for actual healthcare delivery on billing and administration. In marked contrast, the average health insurance company — Brill uses the example of Aetna — easily spends 30 cents of every dollar just to process claims and pay its management. And that’s just the payer side.
Paperwork or Patient Care?
On my side, the provider side, every hour I spend trying to document what I do for my patients means one less hour I can spend actually doing it. And that does not include the hours my administrative colleagues spend, dotting all our i’s and crossing our t’s, so that my employer can satisfy the dozens of different requirements mandated by all the different insurers our patients use, and all their several insurance plans, each with its own set of rules, so that, ultimately, we can get paid to do what we do.
A book published a few years ago by the National Institutes of Health, called The Healthcare Imperative: Lowering Costs and Improving Outcomes, describes this insanity in detail. Studies conducted about ten years ago found that administrative costs for delivering care in U.S. hospitals comprised about 27% of their total revenue. For physician practices, the percentage was 24%. The authors describe three main factors contributing to this, dubbed complexity, variation, and friction. From the book:
The first is complexity. The insurance process has multiple steps, often demanding precise accuracy and attention to detail. BIR steps [or the activity involved in billing insurance companies] include contracting with insurers and subcontracted providers; maintaining benefits databases; determining patient insurance and cost sharing; collecting copayments, formulary, and prior authorization; coding of services delivered; checking and submitting claims; receiving and depositing payments; appealing denials and underpayments; collecting from patients; negotiating end-of-year resolution of unsettled claims; and paying subcontracted providers.
The second burdensome feature of managing insurance is variation. Due to consolidation of insurers in recent decades, a provider practice likely has fewer payers to deal with. However, each payer offers multiple products and often further customizes products to individual purchasers (such as a large employer). Each provider may have to deal with dozens to hundreds of different plans. Providers must track plan-specific benefits and reimbursement rules, maintain special databases and benefit experts, and conduct time-consuming checks of plan details prospectively and in response to claims denials. This situation is in stark contrast to privately administered plans in other developed countries, where there is typically a single primary benefits package.
The third feature is friction. Many BIR steps slow and complicate the process of getting paid. These include priority authorizations and formulary restrictions, high rates of nonpayment for initial submissions (10 to 15 percent), underpayments, and ultimate non- and underpayment (5 to 10 percent) (Gans, 2009). Providers express frustration and occasionally a suspicion that the process is kept complicated to lower ultimate payment levels.
Yup. Couldn’t have said it better myself. One of the things that was potentially supposed to help fix all this was the advent of electronic medical records. However, now that we have them, I can say, from both of the camps I occupy, that computerized health documentation is very far from living up to its vaunted potential for providing genuine efficiency or cost savings to patients and providers. A study published in Risk Management and Healthcare Policy outlines some of these potential benefits and real drawbacks. One of the obvious problems I see every day is that most of the myriad software systems in place are unable to ‘talk’ to one another. Despite the hours I spend every week typing patient notes in my laptop, I still have to fill out mountains of paper forms, write and send faxes, and make myriad phone calls to find out what I need to know. Last week, just obtaining a copy of the pathology report from my recent colonoscopy required me to make several phone calls, then physically drive to the hospital, and find my way through a labyrinth of corriders to sign a form that would allow a clerk to look up my record and print it out.
By all means, let’s keep the pressure on the makers of overpriced diagnostic equipment and drugs, hospitals that charge us five bucks for every 5-cent bandaid, and specialists who charge thousands to perform one procedure, to suck it up and cut their charges. But for heaven’s sake, it seems to me we should look at how much time all of us who deliver healthcare spend NOT delivering healthcare. And why. And how much it’s costing us all.