The Inconvenient Truth About Physicians Ineffectiveness

Executive summary

Physicians/providers are the most valuable and expensive resource in healthcare facilities, however the unfortunate reality is that they are forced to spend much of their time inefficiently. They frequently engage in non-value added (NVA) activities, such as administrative tasks, paperwork, looking for supplies and staff, correcting care coordination mistakes, and waiting for rooms and equipment.

As a result, they spend less time engaging in surgeries, procedures, and face to face time with patients, leading to both patient and physician dissatisfaction.

According to the Mayo clinic’s study on Physician burnout rates¹ from 2011-2014, physicians in every specialty reported increased burn out rates. In addition, in 2015 alone Doctors could see an average reduction of 21.2 percent in Medicare reimbursement rates, according the Department of Health and Human Services². The need to see more patients to maintain financial strength is evident, yet physicians are burning out at increasing rates.

To solve this riddle, healthcare facilities need a comprehensive program focused on maximizing physician satisfaction and effectiveness to enhance access to care and patient satisfaction. The ideal solution should approach the problem across four major areas: 

1. Diagnose the problem: Where are physicians losing effectiveness? What are their top reasons for dissatisfaction? What processes are in place in the facility? What are the value drivers for patients?
2. Design a new strategy tailored to meet the needs of the department’s physicians by:
   1. Revising organizational structure and roles & responsibilities to maximize physician time spent on value-added activities, while eliminating and/or redistributing responsibilities to the appropriate roles
   2. Developing Lean processes, centralized schedules, high-impact management routines, and valuable KPIs and metrics to maximize service and quality for patients
   3. Optimizing revenue cycle management to improve clarity and transparency for patients, and increase profitability and financial viability of the healthcare facility
3. Implement the new strategy and focus on sustainability by developing mgmt. capabilities and commitment, and providing training and skill-building for physicians and support staff
4. Sustain the new strategy through post-execution support by auditing results and making rapid improvements when needed

The attached case study provides a deep dive into the experience of one of the USA’s leading hospitals with maximizing physician satisfaction and effectiveness.

A Snapshot of the Problem

Despite the healthcare industry’s best efforts to react to the implications of the Affordable Care Act (ACA), it still faces an underlying obstacle – physician inefficiency. If left unaddressed, it will make progress towards the industry’s new status quo increasingly difficult and costly.

An avalanche of government regulations requiring greater documentation and the use of Electronic Health Record (EHR) systems have added an additional layer of complexity to physicians’ work. In many cases, physicians work longer hours to complete, onerous administrative and non-value adding tasks.

On the other end of the spectrum, some physicians see fewer patients to work more manageable hours, and thus generate lower revenues and underutilize their support staff. No matter how a department chooses to address compliance it is clear that physician burnout is increasing across the board. According to the May clinic, compared to 2011, burnout rates were higher for all specialties in 2014.

In fact, nearly a dozen specialties experienced more than a 10 percent increase in burnout over those three years. (See Fig. 1) If this continues, dissatisfied physicians will seek out alternative employment options that highly value their skills such as: hospitals with better support, healthcare consulting firms, pharmaceutical companies, private practices, and academic institutions.

Moreover, while EHR systems have revolutionized the capabilities of health care facilities to track their patients’ health, their immature functionalities and design make their use time-consuming and cumbersome. As a result, physicians are seeing fewer patients and spending less face to face time with patients. A 2013 study at Hopkins found first-year residents in internal medicine spent just 12 percent of their time interacting with patients. That amounted to eight minutes to each patient, each day. While more than 60 percent of their time was spent on indirect patient care, such as placing orders, researching patient history and filling out electronic paperwork.⁴

Physicians are spending most of their visits facing the computer screen to check boxes, take notes, write orders, and provide signatures rather than focusing on one-on-one attention with the patient. A recent study published in the International Journal of Medical Informatics found physicians who use EMRs, as opposed to paper charts, look at their patients less.

The long wait times and lack of empathy from their physicians cause many patients’ dissatisfaction with the healthcare facility’s service. Paul Rothman, MD, CEO of Baltimore-based Johns Hopkins Medicine and Dean of the Johns Hopkins University School of Medicine, understands the consequences of the diminishing physician-patient relationship. "As we get efficient, and as we try to get healthcare costs out as we reform the system, probably the biggest risk is when the physician-patient relationship — which is unique and, I would argue, essential for healing — is put under the test."

Patients facing this level of service, even well-established ones, are leaving their physicians’ practice to find new physicians that will bring them better value. They are also much less likely to recommend that physician to friends and family experiencing similar symptoms.

On a different note, the increasing healthcare regulations and shift in payer landscape are decreasing reimbursements. The CMS is requiring premiums to be tied to quality of care. Providers must prove that they are providing superior outcomes to continue charging premiums. With the growing prevalence of standardized fees some health care providers will receive lower reimbursements per patient. This raises the importance of coding accurately to receive the correct reimbursements for services performed.  

The new healthcare regulations have also brought along a prevalence of high deductible plans with 24% of employees enrolled in employer-sponsored high-deductible plans in 2015, up from just 4% of employees in 2006, according to Kaiser Family Foundation.⁶ From 2011 to 2014, the number of consumer payments to healthcare providers increased over 190%.⁷

Additionally, there has been a 70% increase in the average out of pocket spending per patient from 2004 to 2014. Additionally, since 2000, U.S. hospitals have provided more than $502 billion in uncompensated care expenses, according to the American Hospital Association.⁹ As these trends continue, billing and collections departments must adapt to managing numerous B2C relationships with patients rather than the B2B relationships with insurers they are used to. Collections need to be processed more quickly and brought as close to point of sale (care) as possible to minimize bad debts and optimize cash flow.

Existing Solutions

Currently, there are three major approaches to addressing the problem of physician inefficiency and dissatisfaction: external consultants, internal consultants, and staffing agencies. 

External consultants

External consultants do not commonly offer comprehensive solutions that address physician effectiveness and satisfaction. The top 10 healthcare consulting firms¹⁰ provide bits and pieces of the solution across multiple offerings. They typically separate strategy, performance improvement, and technological optimization. Therefore, covering revenue cycle mapping, organizational structure revision, and implementation of new processes, would require the integration of at least 2 separate offerings. (See Fig. 2) Combining offerings tends to be more time consuming and costly. 

Internal consultants

Internal consultants are typically an existing resource in larger health systems. They will typically offer cost advantages when compared to external consultants. In some cases, they have an easier time working through bureaucracy due to their ties to hospital leadership. That same advantage is typically a weakness however, because in our extensive experience, most internal consulting teams have not been trained or empowered to customize solutions, but rather to provide a more generic solution hospital-wide.

This results in significant implementation issues when departments, teams, and physicians reject recommendations because they don’t believe that it accounts for the idiosyncrasies of their work and their patients.  Additionally, demand for projects often exceeds the capacity of the internal consulting team.  Without being able to take into account the specific idiosyncrasies of a department and the variation in the clinical needs of patients between departments, it is very difficult for internal consultants to provide solutions that improve effectiveness and satisfaction at the same time. 

Staffing agencies

There are numerous staffing agencies which provide trained medical personnel (scribes) to assist physicians with documentation, scheduling, and organizing their duties. Many claim to greatly increase productivity and efficiency, as well as to promote physician and patient satisfaction at a relatively low cost.

Furthermore, some agencies offer custom tailored programs, and are aware of the differences in processes across specialties. The staffing helps improve the efficiency; however, it doesn’t change any processes that are already in place. The scribes will adapt to existing operations rather than optimize them. This is a significant issue, as 99% of the time when you add resources to an inefficient process/structure, the situation only becomes worse.

Ideal solution

The ideal solution addresses the problem of physician inefficiency through a 4-step approach. 

1. Diagnosing the problem
The goal is to understand where physicians are losing effectiveness and their top causes for dissatisfaction. In order to answer these questions, Tefen recommends the following activities:

• Process mapping
• Revenue cycle mapping
• Multi-observational study (MOS) and time study
• Comprehensive schedule and scheduling analysis
• Benchmarking performance metrics
• Employee satisfaction surveys

2. Designing the solution
The goal is to develop a new strategy that maximizes physician efficiency and satisfaction. Tefen proposes the following solutions:

• Revising organizational structure with clearly defined roles and responsibilities, focusing on maximizing each role’s licensure to practice
• Optimizing support staff, such as scribes, medical assistants (MAs), mid-level providers (PA/ NP)
• Developing lean processes, including high-impact management routines
• Optimizing staff schedules, and introducing best practice scheduling rules
• Improving and simplifying coding and billing practices in order to decrease losses in reimbursement
• Optimizing revenue cycle to increase collection speed and minimize losses
• Introducing KPIs to maximize performance of providers and support staff

3. Implementing and Embedding
The goal is to implement the designed solutions aimed at maximizing physicians' patient facing time (or other Value-Added activities) and minimizing waste through the following actions:

• Implementing mid-level providers, MAs, and medical scribes according to a detailed staffing capacity model and scheduling design to remove up to 80-90% of NVA work from physicians
• Training and skill-building of providers and support staff in topics such as lean processes and efficient coding

4. Sustaining and Improving

After implementation, it is critical to maintain a constant state of evaluation and improvement. Tefen suggests auditing results and holding open forums with physicians and staff to align on rapid improvements to integrate.  Continuous improvement not only sustains efforts made in the previous 3 phases, but also provides a mechanism to make adjustments on an ongoing basis

Conclusion

As the ACA pushes the healthcare industry towards a value based approach, the issues surrounding physician ineffectiveness and dissatisfaction will rise to the forefront of health care administrators’ minds. They are witnessing and combating the consequences of the additional burdens brought on by the ACA’s compliance requirements for documentation and EHR use.

The industry needs a comprehensive approach that tackles all of the critical elements of this issue: org structure, processes, management routines, scheduling, and revenue cycle optimization. Only this fully comprehensive solution will provide the unique value health care administrators are seeking to take their facilities to the next level and succeed in the healthcare industry’s new status quo.

Consider this methodology and the significant advantage it will bring to the facilities during increasingly competitive times. If you would like to learn more about this approach and the work of Tefen Management Consulting, please email our Director, Brian Hsing, at bhsing@tefen.com

- Written by Brian Hsing

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¹ Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. (2015, December). Retrieved from http://www.mayoclinicproceedings.org/
² Matthews, M. (2015, January). Doctors face a huge Medicare and Medicaid pay cut in 2015. Retrieved from http://www.forbes.com/sites/merrillmatthews/2015/01/05/doctors-face-a-huge-medicare-and-medicaid-pay-cut-in-2015/#21e5c425c6dc
³ Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. (2015, December). Retrieved from http://www.mayoclinicproceedings.org/
⁴ Gamble, Molly. "Are We Trading Happy Physicians for Efficient Ones?" Becker's Hospital Review. ASC COMMUNICATIONS, 3 Mar. 2014. Web. 22 Aug. 2016.
⁵ "News." Do Doctors Spend Too Much Time Looking at Computer Screen?: Northwestern University. N.p., n.d. Web. 22 Aug. 2016.
⁶ 2015 Employer Health Benefits Survey. (2015, September 22). Retrieved from http://kff.org/report-section/ehbs-2015-summary-of-findings/
⁷ Trends in Healthcare payments annual report 2014. (2014). Retrieved from instamed.com/about/white-papers/
⁸ Payments for Cost Sharing Increasing Rapidly Over Time. Retrieved April, 2016, from http://kff.org/health-costs/issue-brief/payments-for-cost-sharing-increasing-rapidly-over-time/
⁹ AMERICAN HOSPITAL ASSOCIATION UNCOMPENSATED HOSPITAL CARE COST FACT SHEET. (2016, January). Retrieved from http://www.aha.org/
¹⁰ "2016 Best Consulting Firms for Health Care Consulting." Vault. Web. 22 Aug. 2016.
¹¹ McKinsey & Co, Deloitte Consulting, and Advisory Board websites