I am old enough to remember a time when physicians could write an abbreviated note on a 3-x-5 note card that stated CHF (congestive heart failure) Rx (prescribe) Lasix 20 mg bid (a diuretic) and he or she would be paid in full. Submit documentation like that today, and payers will send it back as inadequate and not meeting criteria for any payment at all.
Over the past 40 years the complexity of documentation required for any payment—let alone optimal payment—has grown ever more complex. Physicians and advanced-practice practitioners (APPs) are required to spend increasing time at computer terminals doing work they were never properly trained for and that doesn't reflect the reason why they became clinicians in the first place.
Physicians spend up to 50% of their time doing non-productive work—both from a clinical and financial perspective, according to the American Medical Association. The American Nursing Association has reported even higher percentages (70%-75%) for nurses.
Some might wonder if physicians are required under federal law to perform documentation directly. But according to the CMS Conditions of Participation, that’s not the case. It says the task must be completed by a “a physician (MD/DO, DDS/DMD, DPM, DO, DC), oro-maxillofacial surgeon, or other qualified licensed provider in accordance with state law and hospital policy.”
Thus, per state law and hospital policy, many options are possible to complete this federal requirement.
There are four compelling business reasons why physicians and APPs should no longer do this work in a traditional way:
1. Lost operating revenue
Ask most chief financial officers, and they will tell you that the average full-time and productive physician (all specialties included) generates approximately $2 million operating revenue annually (obviously surgeons and procedurists will earn more, and generalists and primary care less). If you assume that the average physician now spends half of his or her time at clinical documentation entry, that number is cut in half. To put it another way, the organization is leaving up to $1 million in operating revenue on the table by utilizing physicians to perform non-revenue-producing work.
2. Poor revenue cycle management performance
When physicians perform clinical documentation, revenue cycle management will probably suffer in several ways:
- Physicians may or may not complete documentation in a timely way and may wait until closer to the 30-day post-discharge requirement—thus undermining accounts.
- Physicians are not trained in, nor do they naturally pursue, documentation of secondary diagnoses or co-morbidities, which add significantly to the complexity and severity of a case. For instance, a general surgeon managing an acute appendicitis may not document co-morbidities such as diabetes, hypertension, renal insufficiency or obesity because that doctor may not perceive them as being directly relevant to the case. But a failure to document will reduce the level of complexity considerably.
- Most physicians have no working knowledge of coding elements such as: hierarchical condition categories, critical care time, inpatient v. observation billing practices, the financial impact of specific terminology, definitions of evaluation and management codes and clinical modifiers, which may impact up to 35% of total reimbursement. Many of these elements can increase or decrease payment by more than 50% (particularly critical care).
3. Poor quality performance and reimbursement under-pay for value contracts
Once the documentation significantly underestimates the true acuity and complexity of a patient encounter, quality metrics and pay-for-value contracts get hit. This may show up in the predicted length of stay, morbidity/mortality indices (actual/expected), readmission rate, serious safety events, pre-existing conditions and cost of care (i.e. Medicare cost report).
4. Burnout and increased turnover of valued and expensive personnel
Finally, clinical documentation is well established as one of the top reasons for both physician and nursing burnout. Individuals committed to clinical work never signed up for a career in clinical documentation or revenue cycle management, so this "bait and switch" is often overwhelming for highly educated professionals who choose one career and are given another.
The best use of both physicians and nurses is in clinical decision-making and oversight. Failure to respect their professional choices will result in unnecessary and expensive turnover, which will impact not only the cost of care, but more importantly, the quality of care. It has been well established that increased turnover of physicians increases patients’ length of stay at the hospital and mortality rates, so this should not be seen as a pragmatic or even viable option.
An increasing number of healthcare organizations are now creating “clinical scribe” positions made up of individuals with a background in a specific clinical specialty who are interested in pursuing a career in coding and clinical documentation improvement by becoming certified coders. These individuals can not only improve the quality and timeliness of clinical documentation (imagine sending out a bill routinely on the day of discharge), but even more importantly, optimize productivity of clinicians (15%-25%), return on every clean claim (15%-35%), and retention of valued clinical personnel (up to 50%).
Each organization may have to provide training for these individuals through contracts with vocational technical schools., but many organizations pay for this training in return for a set amount of committed years of services. This provides an excellent career opportunity for clinical personnel who may want to go out on their own eventually or work from home. There will always be well-compensated work available for qualified CDI personnel. Physicians and nurses must have sufficient CDI knowledge to be able to oversee and manage these new positions, and they should be ultimately responsible for content developed and the integrity of revenue cycle management practices.
Clinical documentation requirements have increased in complexity over the past 40 years to the point that it is now time to reconfigure and redesign who does this work on behalf of your organization. The investment in clinical scribes makes good clinical and business sense and offers dividends in terms of: clinical quality, cost per case, return per clean claim, days in accounts receivables, and in the professional loyalty and retention of high-quality clinical personnel.
Jonathan H. Burroughs, M.D., MBA, FACHE, FAAPL, is a certified physician executive and a fellow of the American College of Healthcare Executives and the American Association for Physician Leadership. He is president and CEO of The Burroughs Healthcare Consulting Network and works with some of the nation's top healthcare consulting organizations to provide "best practice" solutions and training to healthcare organizations.