I just finished listening to a webinar discussing ways physicians and practices can deal better with the demands of Medicare’s QPP programs in order to avoid burnout (as well as optimize performance in those programs). As I listened to the large number of techniques, processes, special tips, and encouragements to buck up and go with it, I unavoidably felt my mind numb over and an overwhelming sense of discouragement set in. And I have always been a physician who wants to understand and optimize team function and administrative processes as well as the medical details. The webinar was very well intended and sincerely presented, but it made clear to me how much medical practice success these days depends upon skills not taught in medical school and not typically top priorities for physicians.
We physicians have often decried the way that administrators have taken over our medical practices and the need to hire more and more support staff. But the reality is that all the management and reporting demands for the new quality improvement and population health programs presents a huge work burden. EHR’s are not yet at the point of performing these tasks automatically and present a challenge of their own in needing constant updates and work-arounds to meet all the constantly changing and increasingly complex communication and data collection requirements. Then there are the onerous and ubiquitous “prior approval” and referral authorization processes required to get our patients’ insurance coverage for the care they need. Unfortunately, it is also apparent that those demands are not going to simply go away as efforts are made to improve our healthcare quality while lowering costs. Politicians, employers, insurers, and even patient advocacy groups are solidly behind those efforts, however crude they might still be. Along with the administrative burdens, the body of scientific medical knowledge has exploded over the past 2 decades, making it a full-time endeavor just to keep current. There’s only so much time in a day. So medical practices are presented with a choice. We can try to manage the vastly increased administrative burden ourselves at a cost of reduced clinical productivity and increased burnout, or we can hire extra help to perform those functions with the effect of reducing our own incomes (because healthcare budgets are not rising as fast as the cost of that help). Obviously, that’s a discouraging choice, especially as we face a future that promises continued high administrative burden for medical practices.
The clear solution on a functional level is to hand over the burden of designing and managing those “non-medical” tasks to someone who is trained, adept, and passionate about managing them well: an administrator. Given the huge number of issues a practice faces these days, I believe that this requires a full-time effort. But the added cost and complexity that can be prohibitive, especially for small practices.
The net effect, and solution to the dilemma of how to deal with all the administrative demands of practice, will be for solo and small practices to become large practices. The only way to survive financially will be to spread the administrative costs over a larger practice base, I think an unintended consequence of healthcare reform. That structure will also allow physicians to mostly concentrate on patient care and clinical population health management and not get hung up in laboriously creating, and day-to-day management, of all the processes required to support those efforts. For better or for worse, we’re already seeing that happening on an increasingly rapid pace.
The devil is in the details. I believe that physicians still need to define an organization’s goals for patient care as we are trained and best positioned to understand our patients’ needs, the primary driver of future healthcare delivery. The role of administration, then, is how best to accomplish those physician designed and approved goals while meeting the requirements of insurers (including Medicare), employers, and employees. It is not to tell physicians how to practice clinical medicine. It is also not about creating a huge administrative infrastructure. Everyone in a medical practice needs to focus together on controlling the cost of care, efficiency, and to show financial responsibility to support the organization. This should still be doable by focusing on delivering value to patients: the right care, by the right person, at the right location as well as effective preventive care, screening, and attention to the social determinants of health. I believe that our already swollen healthcare budgets should still allow for financial success if properly managed, carefully prioritized, and a lot of current waste is eliminated. This will require a skillset including vision, communication skills, and management expertise, the main province of our administrators.
There is another important note for administrators about budget. Each department's budget needs to be based on the actual work done (not RVU's which still miss a large portion of primary care work) and critical value to the organization. Then there can be further advantage from joining a large organization which chooses to apportion the total revenues more fairly among its different divisions rather than simply demanding that each department be self-sufficient by current reimbursement standards.
As a side note, I should also add that the same logic applies to creating healthcare teams to help the physicians accomplish all that is required on the clinical care side of practice these days. We need to keep our physicians productively working at a level that uses the full range of their professional training and expertise by having nurse practitioners, physician assistants, nurses, and medical assistants address the many other medical issues appropriate to their training that are involved in day-to-day patient care. This, too, will preserve physician satisfaction and also improve the quality of patient care.
So, rather than bemoan the number and influence of healthcare administrators (and others) in our current system, we physicians should appreciate the role they can and need to play to allow us to practice our craft in the evolving, ever-changing healthcare world. Success, and actually reducing physician burnout, will be all about working together effectively and pursuing a common goal, in this case, the best care for our patients.