A recent editorial published in the Wall Street Journal entitled "Doctoring in the Age of ObamaCare" provides a glimpse at a day in the life of an endocrinologist working in solo private practice. Dr. Mark Sklar has experienced the changing healthcare landscape over the past two-decades, and argues that “[t]he practice of medicine in the current environment is unsustainable.”
Today, doctors must demonstrate “meaningful use” of electronic health records, call insurance companies to pre-authorize drugs for coverage, and adjust to quality reporting requirements. Furthermore, doctors may have to front questions about their collaborations with industry as the Open Payments database goes public at the end of the month. All of these ancillary tasks, while potentially intended to help patients, have actually taken almost all the time away from one-on-one patient care.
“Although it is convenient to have patient records accessible on the Internet,” Dr. Sklar notes that “the data processing involved has been extremely time consuming—a sentiment echoed by most of my colleagues.”
Dr. Sklar was advised to enter data into the electronic record during his patients’ office visits, but he notes that typing in the data during the appointment was disruptive. “My eyes were focused on the keyboard and the lack of direct contact kept patients from opening up and discussing their medical and personal problems,” he states. “I soon returned to my old method of dictating notes and pasting a print-out of the dictation into the electronic record.”
The financial incentives (and now penalties) from Medicare, however, are based on doctors demonstrating "meaningful use" of the electronic record. Doctors must document that they covered a checklist of items during an office visit. Dr. Sklar notes that he spends “90 minutes each day entering mostly meaningless data. This is time better spent calling patients to answer questions or keeping updated with the medical literature.”
Unfortunately, all the work put into digitizing this information does not translate to interconnected patient records. “If electronic records ever allow physicians to obtain data from previous laboratory and imaging testing, it will improve costs and patient care,” Dr. Sklar states. “So far, however, the data in electronic records—like paper charts—can't be shared unless physicians work in the same health-care system.”
Dr. Sklar notes that he “quickly adopted the new Medicare requirements for electronically prescribing medications.” Often, however, he found that his patients did not want their prescription sent electronically. “They want a physical copy—either because they don't trust the Internet or because they don't need to fill the prescription immediately,” according to Dr. Sklar. “If I don't electronically prescribe for a certain number of Medicare patients, I am penalized with a decrease in reimbursement that can rise to a maximum of 5%. Patients should have a choice in how their prescriptions are delivered, and physicians shouldn't be penalized for how the patients choose.”
In addition to EHR requirements, Dr. Sklar discusses the time-consuming process of pre-authorization. "To prevent physicians from prescribing more costly medications and tests on patients, insurers are increasingly requiring physicians to obtain pre-authorizations," he states. "This involves calling a telephone number, often being rerouted several times and then waiting on hold for a representative. The process is demeaning and can take 30-45 minutes." Dr. Sklar believes that instead of requiring physicians to pre-authorize, the high cost of brand name drugs should be addressed.
Furthermore, to avoid Medicare penalties, doctors also must participate in the Physician Quality Reporting System program. "Initially, this involved choosing three codes during the patient visit to reflect quality of care, such as blood pressure or blood-sugar control, and reporting them to Medicare," states Dr. Sklar. "In 2015, the requirement will increase to nine codes."
Dr. Sklar also takes issue with ICD-10, which, while postponed from the October 2014 deadline, is still on a lot of doctors' minds. The present ICD-9 system has about 15,000 medical diagnostic codes that doctors use for billing insurance. The newer system will contain about 70,000 codes. "The Physician Quality Reporting System and ICD-10 requirements are intended to benefit population research," Dr. Sklar notes, "but the effect is to turn physicians into adjuncts of the Census Bureau who spend time searching for codes—and to further decrease the amount of direct contact with patients."
Dr. Sklar concludes:
The multiple bureaucratic distractions in my day consume so much time that I have to give up what little personal time I have in the morning, evening and on weekends if I want to continue to provide excellent care during office hours.
If high-quality medical care is the goal, the bureaucracies need to be tamed. Our government and insurance companies understandably want to measure outcomes of health-care dollars spent. However, if the health-care system rewards data entry, that is what it will get—the quality of care seems an afterthought.
While not addressed in Dr. Sklar's piece, the pending Open Payments release threatens to further drive a wedge in between the patient and the doctor. The Open Payments system will publicly show a doctor's financial relationship with pharmaceutical and device manufacturers. Collaboration between industry and physicians is often an essential element of innovation. However, without proper context in the news or in the system itself, physicians may be responsible for justifying their industry work to any patient who may ask.
Lance K. Stell, a medical ethics specialist and teacher at the Department of Internal Medicine at Carolinas Medical Center, recently spoke to this issue from a practical perspective given the immense strains on doctors' time.
He asks: “In our 10 minute interview, would you prefer that I spend more time discussing the details of my reimbursement, industry consulting and visiting with industry reps and
less time discussing your medical condition, test results & treatment options or the reverse?"
Last year, the Journal of General Internal Medicine published a study that found that internal medicine interns spent only a minority of their time directly caring for patients. The New York Times featured the study and noted that new doctors’ average face-to-face time with patients is around eight minutes. “Instead, current interns spend the majority of their time in activities only indirectly related to patient care, like reading patient charts, writing notes, entering orders, speaking with other team members and transporting patients,” the article stated.
“The dramatic decrease in time spent with patients compared with previous generations appears to be linked to new constraints young doctors now face, most notably duty hour limits and electronic medical record-keeping.”
Because most documentation must be done electronically, the study found that interns now spend almost half their days in front of a computer screen.