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Tuesday Jan 31, 2017

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

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.

Comments:

While you are at it, maybe you could reduce the costs of being an AAFP member

Posted by kurt lauenstein on January 31, 2017 at 11:16 AM CST #

It has become ridiculous to get prior authorizations for Amlodipine 5 mg when I can buy the medicine for less than 5 dollars. We ought to pass legislation that states that no insurance company can require a prior authorization for a generic drug that costs less than 100 dollars.

Posted by William Farr on January 31, 2017 at 11:31 AM CST #

It has become ridiculous to get prior authorizations for Amlodipine 5 mg when I can buy the medicine for less than 5 dollars. We ought to pass legislation that states that no insurance company can require a prior authorization for a generic drug that costs less than 100 dollars.

Posted by William Farr on January 31, 2017 at 11:47 AM CST #

Bravo AAFP!!
Also, please take not of the growing evidence that pay-for-performance initiatives don't work in health care, and are destined to fail. For example- http://www.vox.com/the-big-idea/2017/1/25/14375776/pay-for-performance-doctors-bonuses?_lrsc=a2f0ea13-a43a-449d-a94d-4853a22d6147
How are we not on a near identical path with our currently architected "value" based initiatives to replicate the decimation of primary care in the US as has occurred in the UK the past decade? They are now dealing with a humanitarian crises we need to avoid? http://blogs.bmj.com/bmj/2015/08/12/neal-maskrey-what-will-replace-qof/

Posted by Randall Oates, MD on January 31, 2017 at 01:43 PM CST #

Shawn,
Thank you so much for your ongoing advocacy on behalf of all family physicians and with this effort in particular, family physicians looking to remain in or move to independent practice.

Many of the policies mentioned in your blog dramatically increase the administrative burden on physicians and, in turn, increase the cost of overhead to an unsustainable level. They also suck every last bit of joy out of the profession of medicine.

I left my employed job 3 years ago... and, personally, almost left medicine entirely because being a physician had become so incredibly intolerable. I have now found my 'home' in direct primary care; my passion for patient care has been restored, my joy for being a doctor is back and, frankly, I am actually really glad I chose to be a physician. I would not have said that 3 years ago.

I am hopeful that we will hear more from the AAFP regarding real, on the ground, solutions to support independent practice and reduce administrative encumberments placed on physicians.

We need to let doctors doctor. And we need to stop allowing family medicine to be the cess-pool of business-generated hoop-jumping. Our physician colleagues need to pick up the mantle and do their own paperwork (why do I run PA's so the cardiologist can get paid?) and I am hopeful that the AAFP will lead us in being empowered, intelligent and proud of the great work we do.

Posted by Dr. Julie Gunther, MD, FAAFP on January 31, 2017 at 05:10 PM CST #

EHR itself is another bureaucratic burden imposed on family physicians. It decreases our productivity and increases distraction, frustration and burnout. Patients expect us to be reliable and trustworthy doctors, but we can't expect the same from unreliable computers. What are you guys doing when you have waiting room full of mumbling patients and your computers are down?... And where is the promised easy accessibility to old medical records? Patients move all the time and don't remember what was done and where. We can't even get any prev. adult immunization records or results of screening tests, like colonoscopies...

Another bureaucratic and financial burden comes from FP board certification process. Our board came with additional and unnecessary maintenance procedures mainly to assure them steady income between our board exams.

All this ongoing bureaucratization and dehumanization process in FP just chases new talented doctors away from family medicine. Who wants to spend 10 best years of his life in hard and expensive medical training, end up with astronomical debt just to become a worn out bureaucrat with horrible quality of life?! Believe in few years this country will run out of family doctors and will replace them with nurse practitioners. And quality of care will follow.

Posted by Louis Berec on January 31, 2017 at 10:07 PM CST #

AAFP needs to do everything possible to eliminate the progressive HEDIS interference in our daily work. HEDIS and pay for performance guidelines that we are being forced to incorporate into our patient records and billing in order to keep revenues from dwindling are causing us to become no more than administrative secretaries. Even worse, we are having to do the same tasks 2 and 3 times to meet the "incentive " requirements to maintain practice income. The worst fact is that commercial insurers will soon follow and escalate our nonmedical work requirements immensely in the future. AAFP needs to work diligently to get this type of government interference out of our offices.

Posted by Ray Gilbert on January 31, 2017 at 11:15 PM CST #

Finally you are addressing an issue that directly and deleteriously affects the delivery of excellent care to patients. The more administrative burden, the less attention and care patients receive. Simple; not a complex concept. Patient care is what stirs the hearts of most physicans. It is what retains them in their practicing medicine. Seriously, make no mistake on this matter. Let doctors practice medicine, and all will be well. Computations, attestations, reportings, metrics, authorizations, coding for dollars - those who represent medicine and promote such blight on health care delivery to patients are shamelessly corrupt. They are a menace to public health, because they hurt people by robbing physician attention to
patients who are suffering.

Posted by Bill Brophy on February 01, 2017 at 03:07 AM CST #

Prior auths don't bother me, they're done by someone else. It's all about the documentation in the EHR having to click buttons to tell the insurance what we've already documented in the office note. I'm not going to hire a scribe and have to see more patients to pay for another employee. Frankly, after 30 years, I still enjoy my work, but the details are causing undue pressure. You feel like you're under a microscope. Who is watching you and when are you going to get called on the carpet for not crossing a "T" or dotting an "i". There is an art to medicine that can not always to be documented minutia. And you can put all the physician extenders you like out there and let them practice medicine from their Iphones and laptops, it's not going to be the same quality and level of care you get from a physician. I'm seriously considering an alternative practice and payment model and just opt out of the medical-industrial complex.

Posted by Jeffrey Friedman on February 01, 2017 at 05:53 AM CST #

Thanks for working on our behalf to reduce admin burden. It is daunting.

I agree with others that we need to also be working to have patient satisfaction scores and pay for performance metrics eliminated. Let's allow patients to select or leave their doctors on their own. No reason to tie our compensation into the medical opinions of the lay public. If they don't like my decision making, then they can see someone else, but don't take money and time away from me for practicing solid, evidence-based care.

Posted by Thanks on February 01, 2017 at 06:40 AM CST #

Shawn, thanks as always to you and the AAFP for such staunch, well-defined and targeted advocacy on behalf of Family Medicine and the entire profession. We are fortunate to have you on our team. One of our members asked at the beginning of this trail of posts for AAFP to do the best they could to reduce dues. For my practice the combo of state and AAFP dues is just under $2 per day. Tax deductibility drops that to less than $1.50 daily and I gotta say access to AAFP modules/and tools and your advocacy alone is well worth that. Thanks for the relative bargain.

Posted by Gerry Harmon on February 01, 2017 at 02:05 PM CST #

Shawn, this post is extremely well-aligned with the reality faced by the threatened species to which I now belong, physician-owned primary care practices. Your team has captured the essence of the problem which is Step 1 to finding the solution. We have only the briefest period of time that private practice primary care still has a pulse, in which it can be saved before extinction. I would add as a follow up to these measures for advocacy that a shift in the practice model is going to be needed, as well - namely, we have made primary care into a 9-5 day job with functions that mid-level practitioners can largely perform interchangeably, and the system is reacting to that organically by reducing our value and our pay. While PCMH was a step in the right direction, it has largely failed as a truly disruptive innovation, and it is time to admit that and look to other models, such as 24/7/365 primary care clinics. Hopefully more on that soon. Meanwhile, bravo on these correctly-selected legislative priorities.

Posted by James Walker on February 02, 2017 at 06:24 AM CST #

I would like to second Dr. Gunther's comments as I too managed to save myself with Direct Primary Care just before planning to leave the practice of medicine entirely. Merely by making that change I was able to eliminate 9 out of your 10 stated FP-crippling regulatory burdens. And it happened overnight! Now I only have to contend with the prior authorization burden, but thankfully even that has lessened (due to the options available to DPC practices--like providing inexpensive medications and time needed to determine which meds are better covered by insurances, etc. . .)
I am glad the AAFP is striving to help those doctors still doing their very best toiling in the current traditional broken bureaucratic system. Any help to keep the independent and dedicated practice of family medicine viable is welcome.
But if you are miserable and MIPS and MACRA and scribes and EMR all make you sick to your stomach, consider the freedom to go back to patient care in its pure form--DPC.

Posted by cher jacobsen on February 04, 2017 at 05:43 PM CST #

Like most of you, I am drowning in a sea of paperwork, prior authorizations, and denials. I suggest that we get rid of everything that has an acronym (HEDIS, MACRA, P4P, PCMH, CMS, MU, EMR, etc...) None of them help me take care of my patients, and all present administrative hurdles to my practice. To paraphrase Sir Winston Churchill, "Fee-for-service is the worst form of medicine, except for all those other forms that have been tried from time to time."

Posted by Marc Darr on February 28, 2017 at 05:54 PM CST #

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About the Author



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.