No one goes to medical school in order to sit in front of a computer typing and clicking small boxes all day long, yet this is what many doctors end up doing.
The business of medicine has changed in the last 10 years to focus on billing, documentation, and a “one size fits all” approach that works as well as the backless gowns patients sometimes wear for a physical.
These changes have decreased the amount of time physicians can devote to the patients’ active concerns during their brief appointment times. This has significantly contributed to increased burnout of physicians.
This time crunch frustrates both patients and physicians and is worsening. Every year health-care providers receive new mandates from federal and state governments as well as insurance companies that further reduce time for quality patient interaction and patient care.
These intrusions into the patient-physician relationship have hastened the premature retirement of many Tucson-area physicians. Meanwhile, more patients find themselves unsatisfied because they want more time with their physicians or they cannot find one in the first place.
If the mandates only focused on interventions that are shown to be helpful – e.g. asking if patients have had their influenza or pneumonia vaccines — most physicians would be ok with them. However, it seems frequently the questions we are required to ask — the boxes we must check — depend on the interests of the people making the rules without evidence of health benefit. Even when the mandated questions have been studied and not shown to be beneficial we are still obligated to ask so we can mark off the digitized checklists and commence patient care, at the cost of meaningful time to assess our patient.
In addition, physicians are increasingly tasked with proving how sick a patient is (Medicare uses the Risk Adjustment Factor, or RAF, score to do this). This is the component of value-based medicine where clinician reimbursements are scaled depending on how ill the patients are. On the surface this makes sense, but it has been implemented poorly.
It is far easier for health systems to channel resources into ensuring precise medical coding for maximal reimbursement instead of devoting resources to improving patient healthcare and outcomes. Diagnoses that increase the RAF score sometimes change annually and can seem arbitrary and illogical. Examples of diagnoses that increase the RAF score include: amputation of a hand (but not amputation of an arm) and mild depression (but not depression or a suicide attempt).
In addition to the cumbersome aspects of documentation in the era of near-mandatory Electronic Medical Records, there is increased administrative work in the form of obtaining prior authorizations for necessary tests or medications. A phone call to a single patient’s insurance company can take more than an hour to complete. For even generic medications, or medications that cost less than $25 a month, insurance companies may require extra documentation from the physician.
I have received letters from insurance companies stating that a medication for a patient was covered only to find out later that it was untrue when the patient attempted to fill their prescription; the pharmacist told the patient “your doctor made some mistake,” and a follow up call from my office to the insurance company confirmed the original letter would not be honored.
What is especially frustrating is when an insurance company tells patients that to obtain a certain medication their doctor “only needs to fill out a simple form,” despite the insurance company having already informed the provider in writing the medication would not be covered even after filing for a prior authorization.
Many physicians feel disconnected from the reason why they became doctors, and this is a reason why burnout rates are twice as high in medicine compared to most other fields. In one recent study 54 percent of physicians reported a symptom of burnout such as emotional exhaustion or depersonalization. The cost of replacing a physician is estimated to be between $500,000 to $1,000,000. If we work together we can meaningfully engage with and hopefully counteract the forces that erode the essential relationship between physician and patients.