When it comes to the burdens facing medical practices, the challenges are many and varied.
When it comes to the burdens facing medical practices, the challenges are many and varied. To make matters worse, many of the biggest problems are interconnected: Regulatory compliance and the overall paperwork burden often rank high on the list of challenges practice face, but information often has to be either obtained from or filed through the electronic health record (EHR), which also ranks as a major issue for most practices. Insurance companies are requiring more prior authorizations (PAs) for even routine care, further exacerbating the paperwork challenge and slowing care delivery. Combine these burdens with the growing challenge of finding staff and you are left with practices being stifled by a series of interconnected problems.
In short, practices don’t have enough staff but still have to collect and file paperwork for payers and government agencies using subpar EHR systems. This leaves everyone overworked and frustrated, so it’s no wonder burnout is a problem not just for physicians, but also for nurses, medical assistants and anyone else working to deliver quality care.
So what can be done about it? Medical Economics spoke with experts and physicians to gather tips on how practices can cope with these challenges.
Solving the paperwork and EHR problem
The paperwork pile is an ongoing problem for physicians because it takes time away from patients while contributing to their own burnout. But there’s also no escaping the fact that the government, payers and health care organizations aren’t going to eliminate it, and a lot of that work hinges on the usability of the EHR.
Ira P. Monka, DO, MHA, president of the American Osteopathic Association, says he finds his EHR very time-consuming.
“The masses of info required to be reviewed daily leave you very little time to be efficient in your documentation,” says Monka. “(Artificial intelligence) may help in the near future to cut down on completing documentation in a more timely fashion, and spending more time with direct eye contact would improve patient satisfaction and decrease physician burnout.”
Owen Dahl, a consultant who works with medical practices, says that while paperwork is a burden, there will eventually be a financial incentive to master it and the data the EHR contains.
“The regulatory burden really focuses on the process of providing care as opposed to the outcomes,” says Dahl. “Eventually, according to the advance-payment models and value-based care, we’ll be able to monitor outcomes as opposed to the process. This is just a step that we are going through to get us to that eventual outcome.”
When that happens, practices with better outcomes will be paid more than those without. But for now, much of the paperwork burden ends up on the physician with little to show for it. Dahl says the question for many doctors becomes, How do I see the number of patients that are demanding to be seen, that need to be seen, and at the same time meet these regulatory burdens?
“The goal is to really step back and take a look at what the staff can do to help the provider in meeting those regulatory needs — and it’s what can the staff do and what can technology do to help reduce that immediate burden on the part of the provider,” says Dahl. “If we can come up with ways that the staff cannot necessarily eliminate, but certainly reduce that burden, then we not only gain that peace of mind as a provider, but frankly, if we can reduce that burden, we could actually see more patients or find better work-life balance.”
Dahl says the providers who have had the most success with this are those that focused on the process of seeing patients. Some use scribes to handle the note taking while others are proficient at notes and their EHR system.
“They understand what the formatting is in the EHR that they have so they can go and fill in the blanks as they’re actually looking at the patient, focusing on the patient to try to reassure the patient that they’re not just busy doing keyboard stuff,” Dahl says. “The efficient provider actually will complete the process within two or three minutes after leaving the exam so they don’t have that two-hour burden in the evening where they’ve got to fill in all the blanks and remember what they did for that first patient of the 25 they saw on that particular day.”
Dahl adds that not every physician will be able to be that proficient, and in those cases, it’s a matter of finding more ways the staff can help alleviate the doctor’s paperwork.
“There is no perfect EHR,” says Dahl. “Every EHR has its own flaws and difficulties but EHR vendors have done a better job of helping understand workflow. But with that being said, it still falls back to what happens with the flow in the office, and how do we better manage that flow?”
With the staff managing upward of 80% to 90% of the patient flow in the office, what they are doing is critical to overall practice success.
One method to boost efficiency not just with the EHR but with any documentation software is to have a member of the staff become an expert on the program, says Dahl. “The key is that the expert needs to be a very good trainer and needs to be someone who is not necessarily involved in patient care every minute of the day so they have time to help with the issues of the staff,” says Dahl. “If that expert can be a good communicator and becomes a coach or mentor to the rest of the staff so that they develop their skill sets, that will help the overall flow and functionality of the EHR and it will help the physician as well.”
Solving the prior authorization problem
According to the 2023 Medical Group Management Association (MGMA) Regulatory Burden Report, 89% of respondents rated prior authorization requirements as “very or extremely burdensome,” and 97% of practices reported that their patients have experienced delays or denials to medically necessary care due to prior authorization requirements.
“This area of medicine has become a burden on physicians — approvals for medications, radiology studies and referrals have been taxing staff and physicians for years, and the problem has only worsened in recent years,” says Monka. “The time wasted for all involved is abuse of the system.”
Teresa Hubka, D.O., an OB-GYN in Chicago, agrees, saying the system saves no money and causes delays in patient care and increases the cost and time to the physician’s practice. “In general, usually three denials occur per prior authorization request in hopes that the pursuit of the PA will be dropped,” says Hubka. “Thus, the patient does not receive the medication, procedure or consult that was medically determined appropriate by the physician. Finally, after numerous delays or denials, 95% of the time, these medical decisions are approved.”
Progress appeared to be imminent when medical professional groups and some health plans agreed in 2018 to a consensus statement outlining five areas in which progress could be made to improve the PA process.
“Unfortunately, to date, medical groups report that little to no progress has been made in any of the five areas,” says Andrew Hajde, CMPE, director of content and consulting, MGMA.
Despite the lack of voluntary progress, there is some hope coming from the federal government, at least for physicians serving Medicare patients. The Centers for Medicare & Medicaid Services has finalized rules to help streamline the process and the Improving Seniors’ Timely Access to Care Act has passed through the House Committee on Ways and Means. The act is bipartisan and bicameral and would modernize how Medicare Advantage plans and health care providers use PAs by establishing an electronic program and expanding patient protections.
Hajde says practices that are struggling with PAs should consider utilizing electronic submission methods instead of manual submission to save time and reduce errors. Practices can also implement technology solutions such as electronic PA programs or artificial intelligence/machine learning tools to automate repetitive tasks and streamline the process.
Reaching out directly to problem payers to address the issues related to denials may also help a practice learn what that payer is looking for or what the practice commonly misses when filing. Some practices have also reported that having the same person deal with a payer each time may help that staffer become an expert on what that payer commonly rejects and whether there are ways to avoid it.
Solving the staffing problem
Since the pandemic, staffing shortages have become a major challenge for practices. A short-handed staff creates a greater burden for those who remain, including the physicians who must handle more office tasks themselves. These shortages can lead to patient frustration and increase burnout for everyone.
Every practice wants to hire the best people and keep them, but Dahl says to be successful, you have to invest in the development of the staff. “That means that you recognize that each individual staff member has talents and skills that will complement the others and will be aligned with the focus and the culture of what the practice is all about,” says Dahl. “Today’s employee is really looking for personal growth and development and they’re looking for commitment to a purpose and a commitment to an organization and a direction there.”
Wages and benefits have increased in the last few years, and while those changes were important for practices to remain competitive, that’s just the starting point. Dahl says employees are looking for a culture they believe in that includes a strong purpose they can feel a part of, which in health care can often be providing a great patient experience that leads to positive health outcomes.
If the practice culture is about seeing 40 patients a day to hit a certain financial target, then the staff is going to be aligned with that. “You’re not going to be as effective. They’re going to be focusing on running people through and it won’t be a great patient experience for anyone,” says Dahl.
Practice leaders have to actively manage the culture, meaning they don’t delegate the responsibility and set the tone and direction for everyone else, and setting the tone means not only talking about it, but also living it.
Dahl says practices often struggle with culture when the physicians are not all on the same page and each does things a little differently.
“If you do things differently, that impacts the purpose or the culture, and then what you’re doing is sending a mixed message to the staff, and they get very confused about what really they should be doing and where the organization is going,” says Dahl. “It really requires the leadership to come up with a central focus and be able to not only talk about it, but to live it and to do it.”
If not all physician leaders are following new procedures, it sends a mixed message to the staff.
“And once that mixed message is out there, that permeates throughout the organization and it reduces the benefits of the decision made and the direction that the organization is going,” says Dahl.
Staff members become frustrated because they don’t know which direction the practice is going, the old direction some physicians are embracing or the new one that other physicians are implementing. The more the frustration builds, the more likely they are to leave.
Dahl says these situations occur when practice leadership doesn’t take the time to follow up on the new strategy or process to make sure it was implemented throughout the practice.
“Leadership may have made very valid decisions based on the data that they had based on the discussion that they had and then they make an assumption that it will be followed,” says Dahl. “But if the decision is made and then told to everyone, but there is no purpose, no training, no obvious benefit or, in many cases, without involvement in that decision, then it’s very difficult to get it implemented.”
One way to help create a culture that will boost job satisfaction and reduce turnover is ask the staff for input. “Instead of just lording over them and telling them, ‘This is what you have to do,’ you actually get them involved in making the decision,” says Dahl. “Even if you don’t get everybody involved, by involving some staff you still get mentors out there, you get past messengers out there who say, ‘This is what we need to do, and the benefit of doing this change is that we will improve the patient experience, we will improve patient care, we will be able to get home at 5 o’clock instead of at 5:45.’ ”
To fully engage employees and create an environment where they want to stay and grow, they have to understand the why behind decisions, either through being involved in the decision-making process or having the reasoning behind the change explained to them.
“Typically, what happens if you get into an environment where people are told what to do, they say, ‘I’ve got to find a different place to work; I’m looking for different kinds of things,’ and that retention model goes away.”