Meaningful Use in the Real World — Is the Additional Administrative Burden Worth the Bonus for Small Practices?

An article in the April 10, 2010 New York Times entitled “Doctors and Patients, Lost in Paperwork,” brought attention to what may be, in the near term, the Achilles heel of the plan to incentivize doctors for the “meaningful use of EHR technology.” The article cited a study published in the Archives of Internal Medicine this past February, which asked a large cohort of physicians in internal medicine training programs about the time they were spending on clerical work, most of which is documentation in patient charts, both paper and electronic. A stunningly large 67.9% of the respondents reported that they were spending “in excess of 4 hours daily” on documentation, while only 38.9% reported spending an equal amount of time in direct patient care.

Now, I am fully aware that practice in the inpatient, hospital setting is not the same as practice in the office, clinic, or ambulatory care environment. Patients tend to be sicker and require more consistent attention while in the hospital, which often means more documentation is necessary. However, the study and the NYT article point to a real world problem that crosses all medical care settings and impacts physicians and other professional providers of all kinds: the enormous burden of documentation, clerical work, and administrative forms completion that impedes real care giving and makes health care less and less efficient even as we add more and more technology.

In both the inpatient and outpatient settings much of the time-consuming and bureaucratic red tape is the product of the fee-for-service health insurance system, in which there are multiple permutations of payment rules, including authorizations and other kinds of forms to be filled out, each health plans forms different from every other health plan. Particularly in the outpatient settings, and for small medical practices, the amount of paper and electronic data collection that must be done to be able to assure payment from a health plan can be staggering. One physician recently compiled this list of activities necessary for a “routine” office visit, CPT coded 99213: verify eligibility; check in; copay determination; get patient to nursing station; see physician; check out; claim to billing person; scrub claim; co-insurance; deductible; send bill to patient; collect remainder; scrutiny; privacy concerns; liability concerns; paperwork_paperwork_telephone calls_paperwork!

Here’s the point. In the real world, most physicians in private practice, and particularly those in primary care, feel that they are deeply under water and drowning in administrative trivia that contributes nothing to, but may often detract from, the quality of care experience that they are able to provide their patients. The administrative documentation is interruptive, mindlessly repetitive, often needlessly duplicative, and costly to the practice in terms of time, money, and nerves. This burden is one, and perhaps the major reason, that so many physicians are selling their practices to hospitals and integrated delivery systems. As one family physician recently put it to me, “I just couldn’t get to sleep at night worrying about all the insurance hassles. At least now that’s someone else’s worry.”

This is the thorny context into which ONC/HHS are launching the ambitious EHR incentive program legislated into existence by ARRA/HITECH, and which will pay physicians up to $44,000 over the next five years for the “meaningful use of certified EHR technology.” While I have expressed on several occasions my basic agreement with this program — in large part because it rewards the outcomes of the use of health IT and not just the purchase of software and hardware, and because I believe that it focuses health IT on quality improvement where it belongs — I have also raised the concerns of my fellow practicing physicians across the country, who must evaluate the incentive payments in terms that reflect their real day-to-day struggles to keep their practices afloat financially. Any additional administrative or bureaucratic burden placed upon the already nearly intolerable levels imposed mostly by the private insurance companies and health plans, is not being taken lightly by these doctors, I can assure you.

To be a “meaningful user” of EHR technology will undoubtedly be an easier task for some doctors, and a more difficult one for others. But let’s not fool ourselves. Meaningful use criteria include a significant number of new data entry/lookup/calculation tasks be taken on by all participating nurses and physicians, often using new and unfamiliar software programs and hardware devices. Meaningful use is at its core the obligation to collect a designated data set about each and every patient, using computers to store those data, and then assuming the obligation to perform a number of operations upon and with those data. The data include demographics, problems, medications, lab results, allergies, smoking history, and so forth. The operations include electronic prescription writing and refilling; sharing or exchange of the data with other providers for care coordination; reporting of quality measurements to Medicare; making available to patients pertinent personal health information and summaries of their visits; the use of clinical decision support tools and reminders for preventive care; and the recording of all orders for labs, referrals, medications, and radiological studies.

I want to be very clear that, in my opinion, were we to re-design health care in this country from the ground up, I would advocate that this set of data and this level of operational workflow using computerized systems would be nearly ideal as a starting point. Meaningful use puts the focus of health IT on some very fundamental information management tasks that are essential to knowing that the right things have been done for patients, at the right time, and with the right level of resources. It provides the basis for Clinical Groupware to flourish, which implies breakthrough improvement in care coordination and continuity. It is a system that could provide doctors with the tools to act smarter, not just harder, and for them to understand where their gaps in performance truly lie, which is the critical element in starting and sustaining an effort at improvement.

But here’s the rub. We’re not starting over. We’re layering these new requirements on top of an already dysfunctional, highly ingrained and overly-complex system that has shown itself remarkably and stubbornly resistant to reform. And in these circumstances, and for most physicians in medical practices today, Meaningful Use does not appear to them to be a way to practice smarter — it appears to be a path to just working harder.

Some might argue that today’s small medical practices represent a cottage industry that is entirely outdated and ought to be replaced by larger, corporate medical enterprises. They would say that it would be a salutary, even if unintended, outcome of ARRA/HITECH were small practices to be driven out of existence and the doctors, nurses, and staff in them integrated into larger and more productive groups. Perhaps there is some truth to this notion, and perhaps it is even part of the Obama administration’s and the ONC/HHS agenda.

However, I would argue that on balance just the reverse is true. Our nation’s small medical practices are the “canaries in the coal mine,” and their suffocation under the burden of bureaucratic complexity that is non-productive and simply cost-additive is a sign of real danger to everyone else in the industry, not just the smallest and most fragile among us. Forcing the small practices out of business doesn’t do anything to relieve the bureaucratic and administrative complexity in the system, it simply moves it to another location, where it will remain a drag on the new and larger units of care. We don’t have the numbers, but anecdotally it is evident that some physicians who sell their primary care practices to hospitals do so as a prelude to early retirement and as the last straw in a chain of events that has ended in failure, at least with respect to their expectations for a career as a physician. We may be actually undergoing an invisible shrinkage in our primary care work force right now.

What I would suggest is this: instead of rushing headlong into a clash that further extinguishes the ability of small medical practices to survive economically, and at worst may significantly diminish the nation’s primary care capacity at the precise time when we need more of it, the current Congress and White House should work together on a rational trade-off between insurance related hassles and the new work associated with adoption of EHR technology. Our national leaders should understand that unless duplicative, wasteful, and completely non-productive documentation is streamlined and significantly reduced, the nation’s small and medium size medical practices will likely sit on the sidelines of ARRA/HITECH — not because the money is too little, or the technical help offered insufficient, but because they simply don’t have the cycles to take on the new paperwork (even if it’s computerwork). If that happens Meaningful Use will be at risk of becoming a failed experiment that merely lined the pockets of the highest utilizing, and therefore highest profit, physician groups and hospitals, along with the legacy EHR vendors who they favor.

My guess is that physicians all across the country would applaud an all-out effort by Congress and the Obama administration to simplify administrative/claims workflow and reduce insurance paperwork, and that they would look at the EHR incentive programs with a much less jaundiced eye if they knew that their overhead costs for billing and claims submission were to be cut in half. It will take bold action to bring this about, but it’s time to do it. Insurance reform is meaningless unless we drive much of the administrative costs out of the system. And unless we do, asking America’s physicians to accept more paperwork isn’t realistic.

36 replies »

  1. I love reading practicing physicians true feelings regarding meaningful use. This is a great meaningful use manifesto, or “MUnifesto” as I like to call them 🙂
    I don’t know how this one didn’t get added to my original list. I will be sure to include it at ProfitableUse.com

  2. Dear David,
    I don’t completely agree with you on the point of incentives being futile for small practices.
    I understand that there is a lot of administrative procedures which are involved in availing these incentives but that I feel is just for the initial phase that too it can be reduced to a greater extent by employing the right tools and services i.e understanding the concept and challenges that posed by specialty of the medical practice.
    An appropriate specialty EHR takes care of most of these challenges.
    Looking at the profitability of the EHR investment, I think ROI is very important factor that should be duly considered when look achieve ‘meaning use’ out of a EHR solution. Though one may get vendors providing ‘meaning use’ at a lower cost, their ROI / savings through the use of their EHR might be pretty low when compared to costlier initial investment.
    Also having the right ( in terms of appropriate knowledge and experience) support function i.ey the introduction of REC’s through the HITECH act. is a great way to avail of quality EHR solutions at competitive prices. The stiff competition among not only these REC’s but also among EHR vendors ( to become a preferred vendor of a given REC) will result in lot of positives to medical practioners.
    Do you agree with me ?

  3. I’m amazed that educated adults still think the government is going to “reduce red tape”. Well, President Obama said it, so we expect it. Really?
    It’s like a decades-long session of self-hypnosis. At first, it’s amusing, then you wonder exactly how long the subject will be able to cluck like a chicken.

  4. I have to admit I haven’t read all of the responses here but I do believe if meaningful use were more of a sequential implementation rather than ” all or nothing” it would be more successful. Those who cannot affort the cost of the system will throw their hands up and give up. Others may choose to address the processes that meet financial goals getting around the true initiatives of gaining better healthcare for the people.
    There is much confusion, requirements still being ironed out and lack of vendor product certifications laying open upgrades and other nasty scenarios.
    Perhaps our inputs should have been during the “drawing board” period, but I guess I’d ask what can we do about it now?

  5. Great article as always, David; captures the essence of my rural practice challenges to a T. However, we waste time in wishing for the Wizard of Oz to simplify the system whilst we stepwise would adapt to the realities of EMR, PQRI, P4P, and accountable care – a wave that is necessary for medicine’s movement into modernity and sustainability. Our efforts should not be backpedaling but rather busying ourselves as physicians in the work of self-organization, participation in specialty and regional medical societies, helping each other implement and use EHR / HIE. Then – by embracing, not resisting full EHR integration – we will see the intended benefits in the federal and industry push towards digital, integrated, accountable, and interoperable healthcare delivery. And, as you aptly noted in another article, success in these areas here will hopefully mean the developing world will join too in the benefits.

  6. Randall: Trying to answer your questions: no, non-participating physicians cannot qualify for Medicare EHR incentive funds. Not quite sure about your other question, but who has paid for the EHR technology used by physicians isn’t a material issue in qualifying for Meaningful Use. So, those doctors who have received subsidies from hospitals under the Safe Harbor rules, would still be able to apply for either Medicare or Medicaid incentives. Hope that is helpful, DCK

  7. If we accept the premise that using electronic medical records will lead to a reduction in health care costs, while improving care, and that the ability to demonstrate meaningful use is an accurate outcome measure for the effective use of such technology, then it seems to me that ONC should be conducting research to identify existing practices who are already capable of meeting such criteria to identify the characteristics of such practices to provide an evidence base for those who wish to pursue this funding.

  8. If we accept the premise that using electronic medical records will lead to a reduction in health care costs, while improving care, and that the ability to demonstrate meaningful use is an accurate outcome measure for the effective use of such technology, then it seems to me that ONC should be conducting research to identify existing practices who are already capable of meeting such criteria to identify the characteristics of such practices to provide an evidence base for those who wish to pursue this funding.
    Those practices who lack the necessary qualities

  9. Reality,
    To be called a vendor, such a low blow!
    Actually I’m a care quality specialist, and I’ve seen how difficult it is for primary care practitioners to manage (even small scale) care delivery systems without adequate clinical information structures.
    Without the measurement opportuniuties that electronic HI systems “could” provide, most docs don’t know how well (or to whom – wothout a patient in fornt of them)they are doing on routine processes like lipid testing and urine albumins for patients with diabetes. Being well meaning and being able to perform well are two different things in a world where the volume and pace of work exceeds system capabilities. Dr. Kibbe’s post makes that clear. I differ only with the conclusion that because the system and its managing practitioners’ are overloaded, that now isn’t the time to implement tools that are essential parts of the solution. And effective and efficiently implemented EHRs are essential parts of the primary care solution.
    Is the current EHR “medicine” worse than the (administrative) overburden “disease”? Probably yes! At least for too many parings of practice and EHR systems. The waythings have been done in the past, vendors, with interest only in sales, have controlled too much of the certification experience; and they have failed to make many EHR adoptions efficatious. I doubt that many practices have had the tools and guidance (and possibly resources) to make the workflow changes that facilitate successful EHR adoption, or even to choose appropriate products and vendor support.
    I think it is necessary to separate frustration over a healthcare administrative structure gone out-of-control from consideration of a (hopefully effective) initiative to provide a tool to deal with all of this. Maybe the timeing of all this isn’t perfect, but if not now when?

  10. This just in from the MGMA:
    “Nearly 68 percent of 450 physician practices that responded to a questionnaire from the MGMA said that changes in practice operations necessary to meet the federal government’s 25 proposed criteria would slow physicians’ daily work. In addition, 31 percent said productivity would decrease by more than 10 percent.”
    source: http://www.mgma.com/press/default.aspx?id=33021

  11. David,
    My worry is once I buy the clunker the fuel will be changed to something I will need an adaptor for.

  12. The answer to #1 is No. You have to participate with Medicare, and moreover the $44,000 is only the upper limit. The actual incentive cannot exceed 75% of allowables.
    There is a Medicaid program which is nicer, because it is about $20,000 higher, and you don’t have to show meaningful use for the first year. To qualify, you need to have at least 30% Medicaid patients (20% for Peds).
    To the best of my knowledge, the answer to #2 is Nobody. If they got a non qualifying EMR from the hospital, they’ll have to replace it, if they want the incentive. Maybe the hospital will oblige. In any case they have to demonstrate meaningful use.

  13. I am a little unclear about the status of a couple of related issues:
    1. Is the ARRA Meaningful Use Bonus of $44k over 4 years available to physicians whose status is non-participating with Medicare as well as those who are participating?
    2. For the physicians who have had their EMR purchases subsidized by hospitals via the safe harbor exemptions to the Stark laws, and who are expecting ARRA bonuses, who will fill the gap if the physicians do not qualify for the bonus payments?

  14. twa,
    By and large, physicians want two things, acknowledging the same variations MD as HELL mentions: Take good care of patients and get paid appropriately for their work.
    One could and should argue with the definition of “appropriately” in this context, but the enormous amount of red tape put in place by government and insurance companies is ridiculous and strangely enough, I believe it is achieving the exact opposite of what it was designed to accomplish.
    If you are really concerned with patient care, then I am not too terribly convinced that organizing docs in efficient business models will lead to either better care or less expensive care.
    MD as HELL is absolutely right about EHR. Being a tool designed to operate in the current system, EHR is going to reflect the same exact BS that the paper system does, only this time on a shiny screen. If you want to fix the perception of EHRs, you need to fix the financial and regulatory system that drives the design of the tool. I believe you’ll find that physicians will be very supportive of such efforts.

  15. twa and others,
    Physicians have been gagged by CMS and by Stark and by insurance contracts for two decades. No one in power has wanted to improve MD collaboration. Every effort has been made to slow physician productivity. All this is in the name of slowing cash flow from payors to providers.
    Everyone in power with the ethics of a politician are worried about providers with the ethics of a doctor. Acknowledging exceptions bothways, the system has been poorly designed from the advent of managed care and the demise of the patient being responsible for 20% of costs.
    I could practice for another 25 years if I didn’t have to document the BS just to get paid. EHR is another load of BS I have to deal with. I am not exhaused, but I am getting cranky.

  16. David – thank you for your excellent post and your response. I do respect your knowledge and insight. Ironically enough, I protect my identity because it is not “politically correct” for me to espouse some of my strong feelings about health care and the practice of medicine in my position. Hency my feelings on this post, where I am essentially saying that for too long we bend over backwards for docs instead of patients. I have tremendous respect for physicians, and I respect your post and response as to the “realities” of moving the system. I just feel that we let doctors discomfort with changing business models keep us from making real advancements in medicine. I have worked with physicains too long not to know the reality of what drives their decisions – and our patience should be wearing thin at the their fixation on an out of date business model that precludes an honest conversation about how physicians might organize and run practices that are more advantaged as it relates to adopting technology and burdening doctors less with admin/paperwork and letting them focus on being doctors, not small businesses.

  17. Authorizations are one of the most time consuming tasks any practice has to deal with and, barring the end of managed care, it would greatly benefit from automation.
    I think we are mixing apples and oranges a little bit in this conversation. Yes, the administrative burden placed on physicians by the current system is obscene and yes, the reimbursement system needs a complete overhaul. But does this mean that the business of medicine is better conducted on paper, than on electronic devices?
    Yes, the Meaningful Use criteria are too much, too quickly, but computers are already providing some relief to the vast majority of docs (there are very few paper appointment books left out there), so maybe we could concentrate on alleviating the administrative burden first, which is something computers do very well, while in parallel the government can concentrate on fixing the actual system.
    While there are huge benefits in automating manual processes like forms, letters, claims, statements, referrals and, yes, authorizations, the current emphasis of Meaningful Use on alerts and CDS and quality reporting is a bit premature. An already overtaxed physician is not going to welcome a new method of harassment in the form of constant alerts that need to be responded to and reported to CMS.
    We need to realize that time is the most valuable commodity and allowing doctors a few more minutes with their patients would improve quality of care much more than reporting on a myriad of tortured quality measures.
    My suggestions are here http://bit.ly/bjtokV

  18. Thanks to all for your good comments and criticisms. I want to respond to “twa” whoever he/she is. (If I had my way, all commenters to THCB would have to use their real names. What could you be hiding?) The measure here is surely not “how hard it is for doctors.” However, if we are to realize the goals of quality improvement and cost efficiency from the “meaningful use” of EHR technology, then there is no way to go but through the relationship between providers and their patients. It really does have to happen one patient/consumer experience at a time, over time.
    The warning I am sounding that is that unfolding this grand experiment without the time, energy, education, and resources to win over the majority of physicians who practice in small and medium size medical practices could lead to a lost generation of health IT investment. (I borrowed that last phrase from David Brailer, who has issued his own warnings.)
    I do not want to see ARRA/HITECH and meaningful use fail. I want them to succeed, with flying colors. CS Smith’s comments are particularly accurate, in my opinion. Without payment reform that both decreases the number of payer agent (health plans), simplifies payment, and introduces population payment/capitation and rewards for quality of care, it’s unlikely that innovative programs for health IT acquisition and use will be sustainable. So, what’s the great hurry to prime the pump?
    As a kid, I had an old clunker of a car that needed to have it’s carburetor primed with a few whisps of gas to get the engine started. One day I couldn’t get the dang thing catch and stay running, no matter how much priming I sprayed into the carb. Then I discovered that the gas tank was empty! I could get the engine to turn over a few times, but without the fuel coming down the line, it was all wasted effort.
    That’s my worry. DCK

  19. InfoMark– you sound like such a vendor!
    twa– stop the political correctness. Practical considerations are what determine success vs failure. We can get as draconian as we want with physicians but they are the pillars of the healthcare system and probably deserve a lot more attention paid to their needs in order to serve their patients better

  20. Right now in real time I have an employee on the phone with the insurance company attempting to get authorization for an MRI. After 15 minutes with whomever, she is now being transferred to a nurse, still with no authorization. People, this is killing primary care. You want people to get care, but you won’t trust the doctors to give it.
    I have time to write this now because she can’t bring be another patient because she is on the phone.
    I suppose this would be time to document for the universe of voyeurs who need to have all this info.
    Finally she is off the phone. It was authorized. What was the point of having to making the phone call?

  21. Thank you for an excellent post, Dr. Kibbe. You have very accurately described the reaction to the proposed “meaningful use” parameters of every primary care doc I know.
    The AAFP’s response on this issue has been incredibly feeble, even for this notoriously ineffective organization. It is hard to imagine them (or any other primary care group) taking the lead in the aggressive bargaining that would be required to achieve significant reduction in administrative waste.

  22. twa,
    If it is too hard for doctors, then patients cannot possible be served,except in a restaurant.

  23. If it does not work for a solo practice, it does not work for a larger practice.

  24. Great post Dr Kibbe.
    Dr. Stevens, physicians should seriously unite and rebel. If we think the healthcare system is bad now, wait until the total failure of the recent reform initiatives begin to surface and is felt by the general public. Physicians are amazingly resilient and hardworking. It is one of the things that makes them special. But it’s also what makes them vulnerable to being taken advantage of.

  25. Making Use of the EHR Meaningful
    (1) Dictate all notes and have them pasted in the EHR. The only meaningful data elements in the note are the vital signs, diagnoses and orders which can be entered. This will save time and produce a superior document.If you want to save on dictation use Dragon speech recognition.
    (2) Utilize the good stuff : Registry functions allow you to find all of the outlying patients who need help; reminders are useful; escribe is worthy; patient portals are underdeveloped and a key to the future; A shared repository for the PMH/PSH/SH/Procedures/Meds/Allergies etc. with controlled access is key; communication portals between providers is helpful.
    (3) To truly drive integration change the reimbursement model for primary care to capitation, adequate capitation. Tax insurance premiums up to 10 % and make this money available to patients in the form of vouchers to purchase primary care. If we spend $8,000/person/year on healthcare, we should set aside an average of $800/person/year for a primary care system.This would probably range from $300 -$1500/year. Let the providers compete for these patients. Who knows what kind of innovations would be possible.
    (4) Push for a universal open source EHR platform upon which we can base Clinical Groupware.

  26. Medical care has been invaded by the programmers and unless the doctors rebel, medical care will be reduced to a practice of benefitting the robber barons.
    Meaningless unproven alterations of medical care will generate wide spread injury and death comparable to the organ transplant debacle in England.

  27. Best advice for the docs:
    Do not buy these meaningfully time consuming systems which remain meaningfully unsafe, with proven vacant outcomes and costs benefits.
    Start billing each patient an annual service fee (eg $300) to cover the nonsensically inane questions of such profiteering businesses as PBMs. They ask for a justification of a drug that has been prescribed for a decade, but is being questioned now because the PBM got a better deal…to enable the $20 million CEO compensation package.
    Report all adverse events and care screw ups to the DOH of your state and the FDA.

  28. So once again the measuring stick is how hard it is for doctors. What happened to a measuring stick of how well patient’s needs are served?

  29. In the ideal world, the administrative benefits and practice management efficiencies from a well integrated EHR and practice management system should more than off-set the effort to clear the meaningfuluse hurdles. Of course how many EHR implementors live in the ideal world (no concern about too many raised hands here)!
    How far the HRECs’ support might go toward increasing the number of small practices that might experience more idealic EHR implementations only time will tell, but it might be worthwhile to at least consider whether this much more systematic effort (than prior attempts) to implement electronic health records in our suposed firs-world healthcare system might have some potential for success.
    It is easy to be a critic, difficult to be a successful facilitator.

  30. I think Dr. Kibbe points to a clear case of unintended consequences. No one is arguing that the 25 meaningful use measures are bad: many are noble, laudable pursuits of health. I’d personally love to learn a new language or even improve my limited Spanish. To do so, I would need to block out time each day and create an effective schedule of individual studying and partnering tutorials with an expert. That time investment would require me to scale back elsewhere in my calendar, like family time, volunteering, or pleasure reading.
    Take this example, or your own personal goals, and then think about a clinician’s day. In order to add any task/time committment, something else must be scaled back or given up. Where does the doctor do that? Improved workflows may help, but how far can a small private practice tighten up? And how costly would such improved workflows be to implement (in both time and money)? How does the clinician recoup that cost/loss?
    These are questions I think the ONC workgroups are attempting to address, but the hectic timeline of HITECH payouts and the use of taxpayer money effectively tie their hands in many ways. This is an important issue that will not go away anytime soon. Those who are unable to meet Stage 1 will be even farther behind than their fellows once Stage 2 rolls out.

  31. This entire ARRA and healthcare reform is a fiasco thrown on the top of a system already under stress. On top of that, the REC program that was recently funded to the states hired a bunch of people to the tune of millions of dollars to people who do not have a clue with too little money per doctor to really make a difference. There is confusion in regard to physicians in rural communities that is also not clear as to who is elegible according to if they are employed with offices in the hospital or non employed or outside the facility. You have hundreds of different vendors and still have no certification established so you will have doctors going a hundred different directions and even worse training than before if the rush hits for ARRA. Then you have the issue of the $19B or whatever alloted in the plan which is going to go fast as with cash for clunkers. It is estimated by many that a conversion to the desired end result on a national level with cost between 250-300B$. Does anyone believe with the first EMR for dollars are used up that the government in its current status is going to offer the billions more? They are fighting over fixing the medicare and medicaid cuts to avoid doctors from stopping to serve these patients. The government is out of cash. When they see how badly this first funding is spent and the overall poor results that I think are inevitable, I doubt that anyone will want to vote to throw more money on it. Last, the EMR systems are built for the flawed system in place which everyone knows needs to be changed. If the changes are made, a lot of the point and click mess is going to become obsolete and those who buy now will end up replacing in a few years. I think making a decision now beyound wait and see makes little sense.

  32. I didn’t read Margalit’s reference in the bill, but I have read elsewhere something about moving to a standardized claim form? This would at least be a start. As a patient with recent experience with insurance obfuscation, in my darker moments I also suspect the insurance companies love the complexity b/c a certain percentage of docs and patients just give up on a complex claim – ergo, fewer $$ leaving the insurance cos.
    This is also one area where “collective bargaining” in a sense by physicians with insurance and/or the feds could be useful. The group could state what physicians need to practice more successfully and bargain to get it. Physicians do not yet understand that subjugating their individual opinions to present a unified front will help them, and are left with enlightened individuals such as Dr. Kibbe to try to help them. Are any of the colleges such as Family Practice or Internal Medicine working on this at all?

  33. Bravo, David!!!
    As you know, I have a soft spot for small practices, particularly primary care docs, not because they are cute, but because that’s where most health care is delivered. They are not just the canaries in the mine. They are the mine.
    I think Meaningful Use is not exactly what the President had in mind, or at least it’s not a good fit to his stated goals, one of which was to “remove red tape”. As I wrote a while ago (http://bit.ly/9jApxK ), I have no idea how we got here from there, and I pretty much think we’re missing the forest for the trees.
    My suggestion would be to relax the 100% Meaningful Use requirements and let docs pick, let’s say 50%, of the items they are most comfortable with. I guarantee very few will pick the quality reporting which, particularly for primary care, is convoluted beyond belief.
    Besides, meaningful and timely exchange of information between care providers is not even required to actually occur initially. This in my opinion is upside down and contrary to what was historically proven to work (http://bit.ly/9a2GoJ ).
    The other imperative would be to get to work quickly on TITLE I, Subtitle B, Sec. 1104. Administrative simplification, in the new health reform law. That’s where all the insane billing bureaucracy can be drastically reduced and the payers, starting with Medicare, must do their part.