Monday, May 05, 2008

Subspecialist Shortages and the EMR

The growing pay gap of non-procedurally-based subspecialties is threatening acute shortages of physicians in those fields:
A discipline built on spending time with patients to gather clues for a diagnosis, neuro-ophthalmology could become another casualty of a medical payment system that favors high-tech procedures over low-tech exams. The median income of a neuro-ophthalmologist at a teaching hospital is $200,000, according to the North American Neuro-Ophthalmology Society. That's a third less than most general ophthalmologists, who undergo less training but can see more patients, and do more pricey procedures, in a given day.

Many in health-policy circles have focused on how the current health-care payment system is helping create shortages among primary-care doctors, internists and others on the front lines of medicine. But often lost is how the system is endangering some of the country's most highly trained specialties as well.

Endocrinologists, rheumatologists and pulmonologists -- specialties that also don't involve performing many procedures -- face acute shortages. Many of the severest deficits affect children. Though nearly 300,000 children in the U.S. are diagnosed annually with juvenile arthritis, lupus or other complex rheumatic diseases, there are fewer than 200 pediatric rheumatologists to take care of them, according to the U.S. government's Health Resources and Services Administration.
And while this is concerning, it is only the beginning of the story.

New pressures are mounting on proceduralists (like gastroenterologists, cardiologists, radiologists and orthopedic surgeons) to increase procedural volumes. In multispecialty groups, the Medicare reimbursement system which devalues time with patients through its arcane and toxic documentation requirements shifts the burden of revenue generation to specialists to support other subspecialties that are less profitable. High-productivity specialists are now urged to do more to cover short-falls in revenue by their business managers. Even small fluctuations in practice volumes are seen in real-time thanks to electronic billing and the Electronic Medical Record (EMR).

The EMR has become not only the administrators' friend, but the proceduralists' as well. Thanks to text-generating "macros" (sometimes called "dot-phrases") the burden of the pre-op history and physical has been all but erased. If a patient has one cataract done thirty-two days ago (outside JCAHO's 30-day requirement), well then, no problem, just hit a few "dot-phrases" and presto! Away we go! "Dot phrases" can load up an empty history and physical form faster than you can say "operation."

But this push to increase procedural volumes, so easily tracked by the electronic medical record, puts additional burdens on today's procedural specialists and creates new patient-care conflicts. Increasingly, there is a push to tie physician compensation to "productivity." Productivity, then, becomes king. And for the patient who desires careful analysis of procedural options, careful decision making becomes clouded as salaries are increasingly tied to productivity.

So for doctors, the dark underbelly of the EMR for patient care is surfacing: despite its marvelous communication capabilities and efficiencies, the EMR has now become the quintessential business oversight tool and might just threaten the doctor-patient relationship as we've known it.



scalpel said...

I seriously doubt that "300,000 children are diagnosed annually in the US with juvenile rheumatic diseases."

Juvenile RA has an incidence of 10-20 per 100,000, for example.

Ian Furst said...

As a cardiac electrophysiologist you're not seriously arguing the "evil" side of good vs evil in technology are you? Yes, the boss can watch what we're doing but as a provider you can also monitor how long patients take to get an appointment, referral, bottlenecks, etc..... I've datamined all kinds of patients for higher rates of complications including association with time of day, nursing/doctor staff, and conucrrent meds (like coumadin & bisphosphonates).

I can think of a million good uses for EMR as a productivity dashboard. It just replaced billing codes from days past with more specific bottleneck areas and greater utility.

DrWes said...

Ian (waittimes) -

No, I can see all sorts of remarkable and lightning-fast efficiencies enabled by the EMR. But with those business and patient-care efficiencies come new stressors for the proceduralists in medicine. For today, they are the revenue generators that cover the costs of less-ecomonically viable subspecialties. With the EMR, specialists like myself are monitored literally day-to-day for their "productivity." Thanks to easy-to-generate "productivity dashboards," feedback e-mails are sent to providers about their latest monthly productivity. A lapse in productivity might mean a cut in pay. It's the ultimate "Pay for Performance," eh?

Like you, many extoll the benefits of the EMR for healthcare delivery and business purposes for, like it or not, medicine is Big Business. But we should not underestimate the potential impact to patient care that constant monitoring of day-to-day productivity tied to economic incentives imparts upon clinical decision making.

Ian Furst said...

what are you trying to say eh? (LMAO). I guess you can't have one without the other. From north of the border I see a means to shorten wait times. From south, a way to increase profit. Two sides of the same coin but it only affects proceduralists when profit is involved. Here it's hit cancer care, orthopods and optho hard because those are the populations with long waiting lists. I've always taken the stance that PFP only helps when the provider can control the outcome. Assuming you don't generate you're patients how much does PFP really increase the bottom line for hospitals. More than socialized medicine but less than in the financial sector? intesting post about the dark side. thx.

Anonymous said...

The EMR is the key to the sweatshop. Just wait. Once data mining technology is turned to EMR analysis, the screws will get tighter.

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