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.