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Craniectomy on May 28th, 2019 at 19:00 UTC »
Long rant coming, from a practicing neurosurgeon:
A large portion of burnout is caused by the growing bureaucracy, as stated in the title. Most of that bureaucracy comes from the government via CMS (Centers for Medicaid & Medicare). Even something like prior authorization has been adopted in the public realm. Medicare uses this now, allowing private plans to act as intermediaries between government money and the providers (part C & part D). These private plans utilize prior authorizations. Physicians already spend inordinate amounts of time on these prior authorizations. It contributes significantly to provider burnout. However, it has questionable utility in constraining costs. Necessary procedures will typically get approved because the physicians will fight for their patients. Some studies also suggest prior authorizations increase cost due to the increased administrative burden.
CMS also gets to arbitrarily decide what documentation requirements are required for different clinic visits, consultations and admissions. These documentation requirements are often very much divorced from clinical utility and add a further time burden to busy physicians. For example, a “level 5” clinic visit requires a complete 10-point review of systems, including a review of the genitourinary, psychiatric and integumental systems. Even the specialists must include this if they want to bill for their highest possible visit. This means time that could be spent focusing on the patient’s actual complaint is instead spent asking about (or completing paperwork on) a “review of systems.”
Billing for a complex visit is also easier if the note indicates that labs and imaging were reviewed. With electronic records those results can be automatically pulled in to the text of the note. That’s why auto-populated notes now pollute the medical record, providing little to no useful information to the clinician. These notes are written for the billers and coders because CMS decides what is needed in a note.
Recognizing the shortcomings of a fee-for-service model, healthcare has been trying to move to a model that reimburses value over volume. This was cemented in governmental reimbursement with inclusion of value-based purchasing provisions in the Affordable Care Act and MACRA. These incentivized providers with rewards or punishments based on outcomes. The outcomes measured, and how they were measured, is largely determined by CMS.
This introduced a metric fixation into everyday healthcare. Physicians must worry about their “statistics” when treating patients. The metrics are often arbitrary, and their introduction has been a prime example of the law of unintended consequences. Take, for example, incentivizing hospitals to lower readmissions. This incentive assumed that readmissions after cardiac events were due to poor care. If hospitals improved their quality of care, readmissions would decrease. Thus, if financial penalties were incurred for readmissions, hospitals would improve their care. What happened, though, was that hospitals would simply avoid readmitting patients who would otherwise need it. This lowered readmission rates but increased overall mortality.
That’s one specific example, but overall, the studies agree: value-based purchasing does not improve outcomes. It doesn’t save money either and it disproportionately punishes hospitals that serve the neediest patients. Furthermore, it significantly adds to the cost of care, as physician practices currently spend over $15 billion a year on reporting quality measures.
The reasons value-based purchasing doesn’t work are many. For one, the metrics chosen often don’t align with what patients actually value. Physicians that do what they believe is best for that specific patient are often penalized if it doesn’t align with an arbitrary outcome metric. Secondly, it leads to “cherry picking and lemon dropping.” Physicians are more apt to treat healthy, younger patients who will have better outcome to keep their statistics up. To combat this, defined patient characteristics are meant to risk-adjust the outcome measures. Physicians are not intended to be penalized for having a sicker patient population at baseline. However, the government decides the statistics used for risk adjustment, and the ones currently being used do not adequately adjust for baseline patient characteristics. It is unlikely that statistics can ever adequately risk-adjust, as there are multiple factors that account for patient outcome in which objective measurement is exceptionally challenging (socioeconomic status, familial support, patient motivation). Thus, the system gives better reimbursement to those that pick healthy patients (cherries) and divert or refuse to treat the unhealthy (lemons).
Additionally, the metrics being used often represent process measures and not outcomes. In fact, only 7% of the listed quality indicators represent outcomes of care. The remainder are process measures, which simply measure if the correct boxes were checked during patient care. Following algorithms can improve outcomes, and physicians are encouraged to do so, often by their specific specialty societies. However, with value-based purchasing, the government is mandating that physicians follow checklist-based medicine with no wiggle room for individual patient factors which may not be accounted for in the metrics.
I don't see a way out of this, either. CMS needs to severely roll back the amount of documentation requirements. Most hospitals that care about physician engagement and well-being simply hire scribes, but those are an additional employee that come with their own host of problems.
Edit, adding a TLDR: Physician burnout is largely caused by the documentation burden. Much of this is imposed by the government as ways to regulate payment, especially the newer push to "value based" payment models.
Oranges13 on May 28th, 2019 at 17:19 UTC »
I have a question about this:
Why do doctors, and medical students have to work shifts that span multiple days? Why don't they have normal hours? It seems dangerous to force people to work in conditions that would hinder their ability to learn / work, especially given sleep deprivation. I've never understood why we do this other than "that's the way it's always been done." Can someone explain?
ColtonPayneDallasTex on May 28th, 2019 at 14:16 UTC »
With the American healthcare system being a 3 trillion+ dollar industry, I thought the impact would be greater.