March 26, 2017

Dear Doctor: Tell Me What You Really Think

Every two years, one of the most interesting perspectives on medicine in America is published by the Physicians Foundation via its biennial physician survey.

In the 2016 survey, 17,236 physicians responded to a wide variety of questions about their practice, the state of the healthcare industry, and perspectives on specific topics, including ICD-10. Although ICD-10 was still relatively new in 2016, the responses raise a red flag. It’s not that ICD-10 is a problem in and of itself, but merely that it is one more issue physicians have identified as being problematic in the big picture.

For some issues, the same or similar findings have now been published for six years, with some minor fluctuations, but they appear to have fallen on deaf ears. These very same issues have been raised by numerous other industry stakeholders: that administrative simplification is an oxymoron, that many electronic health records (EHRs) constitute a barrier to quality care and the physician-patient relationship, that far too much time is spent on red tape and non-clinical work, that administrative burdens are overwhelming, that morale is low, and that both the patients and physicians have been lost in the quest for “quality” healthcare.

While each of the issues could be addressed individually, I believe we need to start by zooming out. ICD-10 is just one small piece of the quality picture. There are also the mandates enacted through the Patient Protection and Affordable Care Act (PPACA), the Medicare Access and CHIPS Reauthorization Act (MACRA), the Merit-Based Incentive Payment System (MIPS), the electronic health records (EHR) incentive program, etc. When you add in all of the other regulatory and clinical practice requirements physicians must meet, it is quite easy to see how quickly one can be completely overwhelmed. Unfortunately, each of these regulations seems to increase exponentially in complexity and difficulty as time goes on. The rush to implementation has taken precedence over getting it right.

One thing EHRs were supposed to do was greatly improve clinical documentation accuracy and thoroughness. As a result, we were told, diagnostic coding would be more specific, more accurate, and better reflective of patient care and outcomes. This would not only result in higher-quality care, but also in better data for analysis and more appropriate reimbursement. However, the physician survey results found that only 29 percent of responding physicians believe that EHRs have improved quality of care; 25 percent believe it increased efficiency, and a disheartening 11 percent believe that patient interaction was improved as a result. Sixty percent of responding physicians reported that EHR has detracted from patient interaction.

Specific to ICD-10, the survey results also reflect a failure to meet well-intentioned goals. Only 6 percent of responding physicians see improved efficiency as a result; 6 percent saw any increased revenue, and even more disappointing, only 5 percent believe patient care has improved because of the new code set. Although 52 percent of respondents said they saw no impact from ICD-10 implementation, 43 percent said it detracted from their efficiency.

It seems plausible that quality has gotten lost in regulatory requirements that impose additional time and non-clinical work burdens. Based on the survey, 21 percent of a physician’s time is spent on non-clinical work such as pre-authorizations necessary to meet payor reimbursement demands. Aggregated, that lost clinical time is estimated to be equal to the work that could be done by 168,000 additional physicians! It also seems plausible that when physicians consistently report that they are overextended, the time they do have is prioritized on their patient interactions and care, not becoming experts in all the regulatory demands and quality expectations. If EHRs are not efficient, clinical documentation improvement will fall victim to these issues. If clinical documentation improvement does not occur, the ICD-10 goals will also not be achieved.

Quality care, in the opinion of many physicians, has a much better chance of being realized when how, what, when, and why are not based on regulatory and idiosyncratic payor requirements. Will every physician agree with the findings? Of course not. But there is a strong message from more than 17,000 physicians that we should heed.

”The happiness of too many days is often destroyed by trying to accomplish too much in one day. We would do well to follow a common rule for our daily lives: Do less, and do it better.” –Dale E. Turner.
Holly Louie, RN, BSN, CHBME

Holly Louie is the compliance officer for Practice Management Inc., a multi-specialty billing company in Boise, Idaho. Holly was the 2016 president of the Healthcare Business and Management Association (HBMA) and previously chaired the ICD-10 Committee. Holly is also a national healthcare consultant and testifying expert on matters related to physician coding, billing, and regulatory compliance. She has previously held compliance officer positions in local and international billing companies. Holly is a member of the ICD10monitor editor board and a popular guest on Talk Ten Tuesdays.

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