Reducing Administrative Burden a Must
"Darling, I'm a nightmare dressed like a daydream."
-- Taylor Swift
The regulatory framework that family physicians are required to comply with on a daily basis is daunting and, according to most of you, crushing and demoralizing.
Further complicating the work environment is a widespread opinion that many (if not most) regulations have limited impact on the quality of care provided to patients and, in some instances, actually slow down or prohibit access to care. Most health care regulations are developed based on a good intent, such as "improves quality," "prevents fraud," or "lowers cost." Others are developed and implemented in an attempt to improve patient access to health care services.
Regardless of a regulation's original aim, it is common for the scope of any given regulation to be expanded to an untenable level. To paraphrase the lyric above, most regulations are presented as items that are a "daydream" -- items that will require "minimal effort" but turn out to be a "nightmare" for family physicians and your practice.
The regulatory framework for physician practices has driven operating costs upward and profits lower. Without question, the administrative and regulatory burden is one of the top reasons independent practices close and is a leading cause of physician burnout.
Due to all of the reasons above, one of the most common questions that appear in the comments of this blog and other AAFP communication mediums is: "What are you doing to reduce the administrative burden for family physicians?" I wrote about this issue in a previous post that discussed how the AAFP was addressing the so-called "work after clinic" or WAC, largely driven by inefficiency of electronic health records (EHRs). Although we have a significant amount of work remaining, I believe our advocacy has resulted in some improvements in the regulations associated with the use of EHRs.
Reducing the administrative and regulatory burden on family medicine practices is a multi-faceted effort. The AAFP is actively advancing reforms with both public and private payers, but we also are advocating for reductions in burdens associated with the licensure and certification processes -- both of which have grown at a healthy pace during the past decade.
We see a renewed interest in this issue, and we have begun to increase our advocacy activity accordingly. In our Nov. 9 letter to then President-elect Donald Trump, the AAFP positioned administrative burden as a priority issue we would be advancing during the next few years: "Reduce the administrative burden by improving the functionality of EMRs, reducing the use of prior authorization and appropriate use programs, reducing needless documentation requirements, and streamlining workflow processes to ensure that patient care remains the top priority for family physicians."
The AAFP soon will be sending a new letter to President Trump, outlining the AAFP's agenda for regulatory and administrative reforms. This proposal identifies 10 administrative functions and regulatory compliance requirements that are crippling family medicine practices. I do not have space to outline each, but I will expand on the top three.
Prior authorizations are without question, the number one administrative burden identified by family physicians, and this is a priority issue for the AAFP. The frequent phone calls, faxes and forms you and your staff must manage to obtain prior authorization for an item or service not only create an uncompensated burden, but it makes patient care more difficult and certainly more frustrating. To address the negative impact of prior authorizations, the AAFP recommends the following:
- Congress and CMS should eliminate the use of prior authorizations in the Medicare program for generic drugs, create a single form that all Medicare Part D plans are required to use, and further limit or reduce the number of products and services requiring prior authorizations.
- All public and private health plans pay physicians for prior authorizations that exceed a specified number of prescriptions or that are not resolved within a set period of time; prohibit repeated prior authorizations for ongoing use of a drug by patients with chronic disease; prohibit prior authorizations for standard and inexpensive drugs; and require that all plans use a standard form.
Documentation Guidelines for E/M Services
The CMS Documentation Guidelines for Evaluation and Management (E/M) Services were written almost 20 years ago and do not reflect the current use and further potential of EHRs to support clinical decision-making and patient-centeredness.
The AAFP believes there should be changes in these outdated guidelines as well as the Medicare Program Integrity Manual. The changes would better ensure that the final entire medical information entered by the team related to a patient's visit would be considered in determining and supporting the submitted code.
To address the negative impact of current guidelines, the AAFP recommends that all documentation guidelines for E/M codes 99211-99215 and 99201-99205 be eliminated for primary care physicians.
Translation Service Costs
Since 2000, physicians have been required to provide translators for Medicare and Medicaid patients with hearing impairments or limited English proficiency, and on Oct. 17, new and costly limited English proficiency policies went into effect. Many family medicine practices operate on slim financial margins. We believe that Congress and HHS must procure the necessary funding to address and offset the estimated financial burden translation service requirements have on physician practices. We have significant concerns that primary care practices are already taking a financial loss for treating patients that require interpretive services because of the historical undervaluation of primary care services in the resource-based relative value scale system.
CMS must fund the increased costs practices will bear to comply with new translation requirements. If additional funding cannot be provided, then we call on CMS to eliminate the new translation service requirement.
One blog post does not allow space for a full description of all 10 recommendations, but I wanted to share items four through 10. These items, like the ones outlined above, also relate to the day-to-day activities that are frustrating each of you.
- quality measure harmonization and alignment;
- electronic health record interoperability;
- electronic care management documentation;
- appropriate use criteria alignment with the Merit-Based Incentive Payment System (unfunded mandate);
- Social Security number removal initiative (unfunded mandate);
- inconsistent claims review; and
- transitional care management services.
I recognize that this is not an exhaustive list of regulations that impact your practice each day, but this top 10 list does capture those regulations that family physicians have indicated to the Academy as the most time consuming and impactful. I will share more information on this effort in future posts, and you can follow our work on our administrative simplification resource page.
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