A Penny Saved, A Penny Earned?

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In an attempt to pry our attention away from the electronic health record’s computer screen and back towards our patients, physicians have employed scribes – a staff member whose sole job is to concurrently “document” the patient visit. Perhaps you have seen them in the Emergency Department or in your doctor’s office, dutifully following them around, furiously typing away like a rat on crack. An analysis of scribing, found in the Annals of Family Medicine, documents their financial cost and the continuing commodification of healthcare. 

The researchers considered two scenarios, in the first, the scribe or clinical documentation assistant (CDA), assists merely in recordkeeping, essentially taking dictation; in the other, a medical assistant fulfills the scribing role, accompanying the patient through their “encounter” alternating taking dictation and navigating the patient through laboratory work, X-rays, etc. In both cases the physician is able to have more “face time” with the patient; the first scenario requires only one scribe, while the second requires two medical assistants. Using averages based on national surveys and datasets they set out to calculate how the scribe alters the physician’s workload – after all, someone has to pay the CDA’s $26,741 and medical assistants $41,360 salaries. (By my calculation, approximately $15.20 and $23.50 hourly). 

The calculations incorporated training costs and the financials of patient care. Physicians saw 17.5 patients daily, at 24.4 minutes a visit, requiring 7.1 hours of time daily over 44 weeks annually (subtracting holidays and vacation). They also factor in, staff turnover, patient no-shows for appointments as well as payments. They were thorough.

In the first scenario, the CDA acting solely as record keeper, the cost was about $34,000 for the first year and $29,500 in the second year (no raises or cost of living increases). To break even, a practice “would need to save 3.5 minutes/encounter” redirecting the time to “add 317 visits per year.” Under a capitated system, where you receive one payment to cover all care during the year, this would require an additional 127 patients. In supporting one scribe, the physician workload needs to increase by 8%, adding patients and decreasing face time with our patients 14%, to roughly 21 minutes.

In the second scenario, the medical assistant keeping records and navigating the patient through their “experience,” the first year cost was $57,000 dropping to $53,000 subsequently. Now to break even, the practice needs to save 7.4 minutes, the cost saving opening up 720 new appointments. In the capitated payment system, a physician would need to see an additional 227 patients. In support of the medical assistants, physician workload needs to increase 13-19%, adding those additional patients/appointments and once again decreasing face time with our patients 30% to about 17 minutes. 

In the sensitivity analysis, where the researchers varied their assumptions to see how much their calculated outcomes change, one phrase caught my eye, “ if [the] strategies mitigated productivity losses associated with physician burnout, then overall net revenue would increase by $5,333 per year…” [emphasis added]. At last, the hidden calculus. Physician burnout, the increasing dissonance physician feel from their work, a dis-satisfaction that inevitably spills over into the day-to-day interactions with their co-workers and patients, that is a productivity problem, not a mental health concern for physicians or satisfaction issue for patients. 

In both scenarios, designed to improve the time physicians focus on patients not machines, the actual time we spend with patients decreases and physician work increases. This approach substitutes a distracted physician, entering data into the records for a more rushed physician seeing more people in less time. I am not sure we can reasonably expect better communications or less physician “burn out.” The only readily apparent benefit is that our focus improves and if the medical assistant approach is adopted, I would also expect enhanced patient satisfaction provided by these individual navigator/explainers. 

Welcome to the future of healthcare as described by our corporate overlords.

Source: Finance and Time Use Implications of Team Documentation for Primary Care: A Microsimulation Annals of Family Medicine DOI:  10.1370/afm.2247