Shari M. Erickson, MPH; Brooke Rockwern, MPH; Michelle Koltov, MPH; Robert M. McLean, MD; for the Medical Practice and Quality Committee of the American College of Physicians (*)
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2697.
Requests for Single Reprints: Shari M. Erickson, MPH, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001; e-mail, firstname.lastname@example.org.
Current Author Addresses: Ms. Erickson, Ms. Rockwern, Ms. Koltov, and Dr. McLean: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.
Author Contributions: Conception and design: S.M. Erickson, B. Rockwern, M. Koltov, R.M. McLean.
Analysis and interpretation of the data: S.M. Erickson, M. Koltov, R.M. McLean.
Drafting of the article: S.M. Erickson, R.M. McLean.
Critical revision for important intellectual content: S.M. Erickson, B. Rockwern, M. Koltov, R.M. McLean.
Final approval of the article: S.M. Erickson, B. Rockwern, M. Koltov, R.M. McLean.
Provision of study materials or patients: S.M. Erickson.
Administrative, technical, or logistic support: B. Rockwern.
Collection and assembly of data: B. Rockwern, M. Koltov.
This American College of Physicians (ACP) position paper, initiated and written by ACP's Medical Practice and Quality Committee and approved by the Board of Regents on 21 January 2017, reports policy recommendations to address the issue of administrative tasks to mitigate or eliminate their adverse effects on physicians, their patients, and the health care system as a whole. The paper outlines a cohesive framework for analyzing administrative tasks through several lenses to better understand any given task that a clinician and his or her staff may be required to perform. In addition, a scoping literature review and environmental scan were done to assess the effects on physician time, practice and system cost, and patient care due to the increase in administrative tasks. The findings from the scoping review, in addition to the framework, provide the backbone of detailed policy recommendations from the ACP to external stakeholders (such as payers, governmental oversight organizations, and vendors) regarding how any given administrative requirement, regulation, or program should be assessed, then potentially revised or removed entirely.
Framework for analyzing administrative tasks.
BIR = billing and insurance-related; EHR = electronic health record; IT = information technology.
Taxonomy of administrative tasks external to the practice and health care environment.
Each circle indicates a characteristic of an administrative task.
Appendix Table 1. Complete List of Resources Used in Scoping Review and Environmental Scan
Example of using framework and taxonomy to determine whether an administrative task is worthwhile and should be kept.
ACP = American College of Physicians.
Example of using framework and taxonomy to determine whether an administrative task is unnecessarily burdensome and requires careful consideration of alternatives.
BIR = billing and insurance-related; EHR = electronic health record.
Appendix Table 2. Summary of Literature on Billing and Insurance and Other Administrative Effects
a. Could the requirement interfere with or enhance the ability of clinicians to provide timely and appropriate patient care (both in person and remotely, in real time and asynchronously)? What are the expected or potential opportunity costs of the requirement in terms of its effect on time spent by clinicians providing care for patients and on any time spent by patients to address the requirement?
b. Does the requirement improve the quality of care delivered to the individual patient and/or to the population? If so, how?
c. Does the requirement have a financial impact on the physician practice, provider organization, patient and his/her family, and/or the health system that diverts resources from patient care? To what extent can this impact be quantified?
d. Does the requirement call into question physician judgment in terms of expertise, training, education, and experience? If so, what are the reasons these questions are being raised?
e. Overall, can stakeholders propose alternative approaches to accomplish their goal for consideration by the public?
a. Payers, public and private oversight entities, and vendors and suppliers must work together and actively engage with clinician societies and frontline clinicians to harmonize their administrative policies, procedures, processes, and forms regarding such issues as prior authorizations, payment reviews, reporting requirements, and others.
b. Payers, public and private oversight entities, and vendors and suppliers also must be fully transparent with clinicians, health care provider organizations, and patients and families about their requirements in terms of their intent, expected effect, and specific implementation approaches (as described earlier).
i. Any approaches by external entities imposing tasks on clinicians that are determined to be fraudulent should be addressed swiftly and appropriately by the Office of the Inspector General or other relevant entities. (For example, a “bad actor” in the DME industry knowingly uses fraudulent tactics to fill unsolicited requests for patients. These requests result in tedious and confusing processes and procedures for clinicians and their practices and may not even be appropriate for the patient.)
ii. Further, any administrative tasks imposed by external entities that are intended to address fraudulent activity must be designed to swiftly and appropriately prevent such fraud with the minimum possible burden on clinicians (for example, prior-authorization forms and appropriate-use criteria.)
c. Evidence-based approaches that clinician practices and other health care provider organizations can use to best address internal inefficiencies that are a result of external regulations and requirements should be disseminated widely by all stakeholders involved.
a. Constant monitoring of the evolving measurement system also will be critical to identifying and mitigating any potential unintended consequences, such as increased clinician burden and burnout, adverse effects on underserved populations and the clinicians who care for them, and attention being disproportionately diverted toward the things being measured to the neglect of other critically important areas that cannot be measured directly (such as empathy and humanity).
a. All stakeholders must actively work to refocus the EHR system to ensure that its primary purpose is to support clinical care delivery. The use of EHR data collection capabilities for secondary or alternative purposes, such as for billing documentation, measure and public health reporting, regulatory compliance, and others, must be redesigned in a manner that does not distract or detract from patient care and that effectively and efficiently provides patients with access to their own information.
b. All stakeholders must work to ensure that reporting requirements are modified and standardized to take full advantage of the capabilities inherent in EHR technology. Reporting burdens would be reduced dramatically if all stakeholders agreed to use the same data and structure definitions. Decision rules could be programmed into EHR systems to eliminate the need for prior authorizations.
a. Physicians and other clinicians who demonstrate consistency in their performance on quality, cost, and/or patient experience measures should have the opportunity to receive decreased regulatory and other oversight through transparent and streamlined exception application processes.
b. Further, as physicians and other clinicians take on more innovative and evidence-based care delivery approaches (such as shared decision making, population management, and enhanced patient access) and progress along the continuum toward taking on greater financial risk tied to the health outcomes and experiences of their patients, they should be given exemptions from certain requirements that clearly are tied to the current fee-for-service system, such as prior authorizations.
c. Physicians and practices identified as outliers compared with their peers, after risk adjustment based on their patient population, with regard to their billing patterns, prescribing approaches, quality and cost of care, patient experience measures, and other factors, should be provided with transparent and streamlined appeal opportunities, as well as education and practical resources to address any identified issues.
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Edward Volpintesta MD
March 30, 2017
It is a good idea to require payers to submit the data collected from their evidence-based regulations to the public to demonstrate whether they improve healthcare.
It would also be a good idea to require legal scholars to present to the public any data which shows whether the questionable methods that attorneys use to sue doctors on scanty evidence (frivolous lawsuits) improve healthcare.
I suspect that both payers and legal scholars will find their efforts unconvincing in the public arena.
Thomas Jefferson University, Fellow
April 5, 2017
Emphasis on Patients
The medical student during her clinical rotations is often protected from administrative burdens, more informally referred to as "scut." However, as residency begins, she starts a career full of administrative burdens. It seems simple, the more administrative tasks, the less patient care and less quality of patient care. How then do we improve the system?This paper is an excellent step in the direction of advocating for our profession and our patients. "Excessive administrative tasks have serious adverse consequences for physicians and their patients. Stakeholders must work together to address the administrative burdens that fail to put patients first."We are doctors. We got into this profession to see patients and help improve their lives. We just want to be able to do our job. We are losing our colleagues to other areas because they just don't want to deal with clinical practice as it exists today. Why can't there be a better model? We need people to see things from the framework of patient care, and this paper helps with that.
Erickson SM, Rockwern B, Koltov M, McLean RM, . Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. 2017;166:659–661. doi: 10.7326/M16-2697
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Published: Ann Intern Med. 2017;166(9):659-661.
Published at www.annals.org on 28 March 2017
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