by Alison Shaw and Aaimee Johnson
In the ‘50s and ‘60s, a rural physician might have had one employee: the nurse who also checked you in and took your payment. Today, many more people are needed to run a clinic. Indeed, support staff is one of the greatest clinic costs today, in part because:
Insurance verification. Clinics today are paid by many insurance companies with multiple plans each. Staff must verify a patient’s insurance prior to each office visit to see if the patient is still covered, for what services, and if the deductible has been met. Happily, this information is online, but checking it takes time.
– Referrals for specialty care. Managed care insurances require patients to obtain a referral from their primary care physician in order to see a specialist. Different referral forms for each specialist must be completed, relevant parts of the patient’s record copied, and the whole packet faxed to the specialist’s office.
– Pre-authorization for testing and procedures. To avoid unnecessary tests, insurances require pre-authorization for certain procedures and advanced testing. This requires staff time entering the information online, nagging the company for fast approval when it’s urgent, sending the approval to both the patient and the facility that will perform the test, and often scheduling the patient for the procedure.
– Coordination of care. A family practice must be the patient’s “medical home,” reviewing and retaining all reports from hospitals and specialists. Scores of these reports must be scanned into patients’ medical records daily, and then reviewed and signed-off by the physician.
– State-mandated registries. Childhood vaccines and narcotics prescriptions, among others, must be entered into separate online state registries, in addition to being entered into a patient’s record. This duplicated effort takes additional time by the nurse or doctor.
– Medicare and Accountable Care Organizations. Medicare has encouraged hospitals and clinics to become ACOs to improve patient outcomes, reduce hospitalizations and cut costs. There are stringent standards of care for ACOs, like ensuring that patients receive timely follow-up, get regular screening tests and have access to their medical records online. These measures improve patient health and safety, but participation for clinics is costly in both time and money.
– Electronic medical records. The paper chart has been replaced by computer monitors, a server with multiple fire-walls,\ and very expensive software with costly annual licensing fees. With this, the physician can evaluate a patient’s status more thoroughly and more quickly. Parts of the EMR are available to patients online. Improved records cost money (for hardware, software, IT support) plus staff time for data entry.
– Information technology. IT advances come at a cost: hardware replacement, constant software updates and endless security patches. Staffing now includes an IT professional or paid contractor.
– Staff training. All the above require significant staff training on insurance and billing rules, quality management, complex software and the IT interface. It can take easily six months to fully train a new person to work the front desk. And as technology changes, staff must keep up. There is a high burnout rate, and replacing staff is costly.
Staff does most of these tasks in time outside the exam room to ensure best medical practices and patient safety. It’s very complicated. While there are ways to economize on some things, the items above cannot be ignored or cast aside. If we do that, we risk patient safety and quality of care.
Shaw is on the Coalition for Orcas Health Care and Johnson is clinic manager for Orcas Family Health Center.