The workday for internist Jeffrey Kagan, MD, doesn’t end when he leaves his Newington, Connecticut, office. He still has two to three hours of unpaid work ahead of him reviewing lab reports, X-rays and MRIs, as well as returning phone calls.
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Kagan says he spends 12 to 17 hours weekly on tasks for which he receives no compensation. This includes the work he performs each evening at home, plus unpaid tasks throughout the day, such as prior authorizations for insurance companies and research to identify the latest clinical treatments and closest centers of medical excellence that could potentially benefit his patients.
“It’s not unusual for me to leave the office around 7 p.m. because I’ve had enough, come home and eat dinner with my wife, and by 8 p.m. I’m on the computer,” he says. “I’m there through the 11 o’clock news.”
Like many physicians, Kagan uses personal time to complete tasks necessary to keep his practice running efficiently. To some degree, physicians have always done this. However, anecdotal data suggests that physicians are spending even more of their time on uncompensated tasks than they ever had in the past.
Is this pattern of uncompensated time simply the “new norm” in today’s practices, or can physicians somehow reign in these tasks for a better work-life balance?
Uncompensated time continues to increase
Physicians spend a significant amount of their workdays—probably 20% or more—on uncompensated tasks thanks to a barrage of regulatory requirements, says Joseph Valenti, MD, a board member of the Physicians Foundation, a nonprofit physician advocacy group.
This equates to at least $50,000 of lost revenue per physician annually, says Valenti. Four years ago the Physicians Foundation Biennial Physicians Survey found that it was $25,000, and that figure has easily doubled in the last four years, he says.
Nitin Damle, MD, MS, FACP, president of the American College of Physicians (ACP), says the lost revenue associated with uncompensated tasks could be even higher—closer to $60,000 annually per physician. This includes the time spent on uncompensated tasks as well as the costs associated with additional medical assistants, nurses or administrative staff employees to complete these tasks.
This magnitude of uncompensated time often leads to physician burnout and forces many physicians to close their practices, says Valenti. Eighty percent of physicians reported being overextended or at capacity, according to the Physicians Foundation 2016 Biennial Physicians Survey. Forty-nine percent said they often or always feel burnt out.
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In addition, only 33% of physicians now identify as independent practice owners or partners, down from 48.5% in 2012, according to the 2016 survey.
“So many independent practices are folding because they can’t keep their heads above water … I know doctors who are simply paying their staff, and they’re not even collecting a salary anymore just out of respect for the people who have stuck with them over the years,” he says.
Valenti suspects primary care physicians probably spend more time on uncompensated tasks than other specialists because they’re the ones who usually perform care management and coordination with other providers. They must also contact insurance companies to obtain prior authorizations.
“I really feel for them. It’s exceedingly difficult for them to do what they do every day,” Valenti adds.
Refocus on revenue-generating tasks
But experts say there are ways to combat the problem of uncompensated time. Consider these strategies to reduce—or in some cases eliminate—uncompensated tasks.
Address prior authorizations and referrals
Seventy-two percent of physicians indicate that third-party authorizations detract from the quality of care they’re able to provide, according to the 2016 Biennial Physicians Survey.
Kagan, a member of the Medical Economics Editorial Advisory Board, says he sometimes spends 15 to 20 minutes per authorization, especially when an insurance company requires a peer-to-peer call—something he says happens two or three times per month.
To reduce his uncompensated time, he uses buzz words he knows will gain approval from the payer simply to avoid these calls and potential denials. An example is getting a brain MRI approved by listing, “rule out multiple sclerosis.”
Damle says his practice hired a full-time staff member who focuses solely on obtaining prior authorizations. Although this prevents him from having to spend time on this uncompensated task, he admits that it isn’t a long-term solution because of the costs associated with this individual’s approximately $30,000 annual salary.
Primary care physician Deborah Winiger, MD, who practices in Vernon Hills, Illinois, says one of the challenges is that patients don’t always follow through in a timely manner (usually within 90 days) on tests or procedures for which she has obtained authorization. When this happens, she charges patients a nominal amount to obtain another authorization.
In Winiger’s practice, nursing staffers also keep an external log to track referrals in progress. Although this doesn’t decrease the time spent on returning calls, it does ensure that staff members don’t waste time on referrals that may have already been done.
Take control of paperwork
Physicians spend 21% of their time on non-clinical paperwork, according to the 2016 Biennial Physicians Survey. This includes forms for durable medical equipment, temporary disability, pre-employment physicals, sports participation, and the Family Medical Leave Act (FMLA), among others.
Damle, who spends five to six hours per week on what he calls unnecessary paperwork, uses an inbox into which staff place forms that require his signature. He signs forms in between seeing patients and during his lunch break and then places them in an outbox so staff can email or fax them to the appropriate party. He also uses an e-signature for electronic forms, although he says most forms he has to sign are still paper-based.
Winiger charges patients a nominal amount for FMLA and employer-required disability forms that don’t usually require an office visit. She says this fee helps recoup some of the costs associated with the time she spends on these more intensive forms and that patients understand she’s charging for the extra work required.
Streamline portal messages
These days, much-uncompensated patient communication takes place via EHR portals. Damle, for example, spends at least 40 minutes per day responding to patient messages that come in through the portal. Sometimes he replies directly to patients. Other times he forwards messages to staff members so they can reply to the patient (e.g. when questions are related to coverage, referrals, medication refills, scheduling, etc.) He anticipates implementing a triage system so staff members can monitor and respond to messages for all clinicians in the practice.
Raleigh, North Carolina-based internal medicine physician Patrick O’Connell, MD, says his office—which includes three other physicians and one nurse practitioner—has already developed a triage system for messages retrieved through the portal. This means he only reads and responds to messages that nurses already have deemed as requiring his attention. This translates to three to five emails per day at approximately three minutes per email.
Limit tasks to those that require a medical license
Physicians shouldn’t open the mail, answer the phones or room the patient, says Keith C. Borglum CHBC, CBB, consultant at Professional Management and Marketing and member of the National Society of Certified Healthcare Business Consultants. Instead, practices should hire non-clinical staff members to perform these tasks.
“What we’ve found is that the physicians who are better at delegating unlicensed tasks to others are the ones who tend to have the highest net incomes,” he says.
Be flexible with EHR documentation methods
Many physicians lament the time-consuming—and uncompensated—task of documenting in the EHR. Winiger says she saves time by working closely with her vendor to learn shortcuts. For example, she learned to use templated plans for routine physicals, which she edits for each patient.
Damle’s office employs three full-time scribes to assist with documentation. During a patient’s office visit, he documents on paper using templates. Scribes then enter the template data into the EHR.
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Although the scribes speed up the documentation process, they cost the practice a total of approximately $60,000 annually in terms of salaries, he says.
Even with a $10 to $17 hourly rate, scribes can increase a physician’s productivity and therefore his or her net income by 10% or more, says Borglum. “How can you afford not to do it?” he says.
O’Connell cuts down on the uncompensated time for documentation by typing narrative text into the EHR during the visit. He does this for both the history and exam.
“When the patient is done talking, I’m done documenting the history. I think it’s also a better narrative,” he says. He uses voice recognition technology for a narrative assessment and plan, and he types into templates for standard follow-up visits and normal exams.
Be mindful about family conferences
Unless the patient is present, physicians can’t usually bill for family conferences to discuss treatment goals. This isn’t always realistic, Kagan says, because some family members call frequently with questions and to discuss their loved one’s needs. He says he talks with family members several times a month usually for at least 30 minutes at a time—all of which is uncompensated.
To minimize his uncompensated time, Kagan often asks families to join him during the patient’s face-to-face visit or meet him in the hospital or nursing home where the patient is. When the patient is present, he can bill for the time he spends talking with family members.
Stay focused during the visit
To maximize reimbursement and cut down on uncompensated time, physicians must learn to keep their visits and communication focused and on track, says Borglum.
Borglum suggests placing a clock on the wall behind the patient. “It’s a constant reminder to keep moving,” he says, adding that physicians may see a 5%-10% increase in productivity just by doing this.
Communication training is also helpful, says Borglum, adding that YouTube includes many free videos on how to communicate with patients more effectively. “When you communicate more effectively, it requires less time to complete the patient visit,” he says. “That’s because you get patient agreement and compliance more quickly. It also brings the focus back to the diagnostic task.”