Paperwork

As you can see from the recent dearth of posts on this blog, you may be wondering, is Benji still writing?

Well, the answer is I am writing more than I ever have. Ever. The posts I write now are called SOAP notes, on a type of blog called the “electronic medical records,” about people and their medical issues . I write about my experiences, and when I spend most days of the week experiencing patients, that’s what I write about. The blog is closed to the public, and not shareable except to the subjects who I write about and to those that have received a signed medical release from the subject.

Who knew that becoming a doctor also means becoming a writer. According to a 2016 Forbes Article, a study from Annals of Internal Medicine reveal that doctors now spend on average 27% of their time seeing patients and 49% of their time doing paperwork. And even while in the exam room, doctors spend 53% of the time examining and talk with patients and 37% on paperwork. The study included not just primary care physicians like family physicians and internists, but also specialists like cardiologists and orthopedic surgeons. And it wasn’t always this bad. According to this Annals in Family Medicine article back in 2005, before electronic medical records were common, medical charting and dictating accounts for just 11.5% of the time doctors spent in the office. 

What kind of paperwork is there? For every patient encounter, doctors document the patient’s complaints, our findings, our assessment of their issues, and our plan. There are specific rules we have to follow when writing our notes, as laid out in this 90-page document on the CMS.gov website, and the rules apply to both medicare/medicaid and private insurance patients. The notes we write serve as legal documents that can be used by other doctors, lawyers, social security office, insurance companies, and other multidisciplinary professionals. Fortunately, I enjoy writing, so I don’t mind writing visit notes since they remind me of blogging, but prior authorizations and FMLA paperwork are a different story.

Another paperwork we too often encounter is the prior authorization form. Just because a doctor orders a medication or diagnostic study doesn’t mean the patient will be able to get it through their insurance. Often insurance companies do not cover certain medications that a patient needs, for which the healthcare provider fills out prior authorization forms to explain why a patient needs that certain medicine and not another one that may be on the patient’s insurance’s preferred medication list. We also fill out formsf to insurance companies to explain why a patient needs speech therapy, physical therapy, a wheelchair, or some other equipment, on top of providing the notes from our encounters to the patient. We fill out pre-certification paperwork to order an MRI or ultrasound for our patients, only to get a rejection from the insurance company, then we try to appeal it with more paperwork. Approvals for medications, procedures, and diagnostic studies take time, delaying patient care and diverting the time we could be spending more with our patients.  Sometimes it takes 30 minutes to up to an hour on the phone with an insurance company to get something approved for a single patient. Imagine if you have to do several of these per day. 

In addition to our CMS-guideline-compliant visit notes and precertification paperwork for insurance companies, our patients often bring us their own paperwork to fill out, including disability forms, FMLA paperwork, housing accommodation forms, EED forms, IEP forms, and numerous other acronymically-named forms. Some people will ask for letters to the school excusing them for certain missed days or allowing them to have certain foods at lunch time. Others ask for letters to their work place to let them forgo a certain dress code or let them have certain number of bathroom breaks a day. Some ask for letters to their landlords to allow them to keep an animal for emotional support without paying a pet fee because it is medically necessary for their depression or what not, or a letter to their power company telling them not to shut off their power just because they can’t pay, because they need that power for their nebulizer or CPAP machine. 

As you can see, there is a lot of paperwork to be done, which requires a lot of unpaid time on the part of the physician.  There is a CPT code for filling out paperwork, but no insurance company in my experience has ever paid for it. The insurance company will only pay for face-to-face encounters with the patient and/or their family.  We don’t get paid by insurance companies to fill out FMLA paperwork, letters to schools, letters to housing authorities, letters to patient’s lawyers, letters of necessity to insurance companies, prior authorization forms, or any other letters — all of which takes time.

This is the practice of medicine today. More and more time-consuming paperwork is required for anything to get done. More and more, it seems that the doctor’s prescription is no longer enough for the patient to get a medication, without a letter explaining why they need it to the insurance company. And the doctor’s signed order for a study or a procedure is no longer enough to get the patient a study or a procedure, without a letter explaining why they need it to the insurance company. It’s no question that this loss of autonomy, increase in paperwork, and increase in bureaucratic tasks required by insurance companies that do not improve patient care lead to the increasing physician burnout we see today. 

What solutions do we have out there? Standardize and simplify the prior authorization process to make it faster and easier, or better yet, just get rid of it and let doctors have the authoritative direction in their patient’s care? Probably not going to happen. Make the electronic medical record universal and simplify the required documentation guidelines? That would be nice. Increase your practice’s overhead costs by hiring scribes to write the notes for you and nurses to fill out the prior authorization forms and other forms for you? If your business can afford it. It’s a little harder as a solo practitioner and as a primary care physician who isn’t paid as high as specialists who have the same amount of student loan debt. I don’t know of an easy solution that would be agreeable to everyone. 

So to all you all out there who are thinking about pursuing medicine, this is a reality you will have to understand and accept about the profession. Whether or not we like the rules of the game, we must play by them, and not lose focus of our patients.

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