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Tackling paperwork and red tape

A study recently published in the New England Journal of Medicine highlights what keeps US doctors busy when they are not seeing patients. The study took a rare, quantitative look into the mechanics of a busy primary care practice in Philadelphia, and found that each day, each doctor in the practice must address more than three dozen urgent but uncompensated tasks. These include answering telephone calls and email messages, reviewing lab test results, refilling prescriptions, and consulting with other doctors.

20 Jun 2010

By Dr Lesley Russell

A study recently published in the New England Journal of Medicine highlights what keeps US doctors busy when they are not seeing patients. The study took a rare, quantitative look into the mechanics of a busy primary care practice in Philadelphia, and found that each day, each doctor in the practice must address more than three dozen urgent but uncompensated tasks. These include answering telephone calls and email messages, reviewing lab test results, refilling prescriptions, and consulting with other doctors.

Primary care doctors are on the embattled front-line of US health care. And primary care is the centerpiece of the recently enacted health care reform bill, which provides incentives for doctors, nurses and physician assistants to enter this field. Health care reform means that 32 million more Americans will now have health insurance, and primary care providers are seen as the way both to improve the quality of medical care and contain spending. 

However, America’s primary care doctors earn about half the money of specialists, and this is not seen as a prestigious field; fewer than 10% of medical school graduates choose primary care, which includes general internists and paediatricians.

There is already enormous pressure – and more is coming, unless ways can be found to help primary care providers. The push is on for more compensation – or a different mechanism of compensation – to encourage and support primary care doctors to undertake preventive care and help patients to manage their chronic illnesses. 

This must all sound very familiar to Australian GPs, who are now wondering about the impact of the Rudd health care reforms on their practices.

In the Philadelphia practice, the five full-time doctors each saw an average of 18 patients a day, for which they were paid about $US70 a visit. In addition to patient visits, each doctor took 24 phone calls a day, about three-quarters of which were fielded by the doctor. One-third of calls concerned an acute medical problem and resulted in a prescription or an order for a test. The doctors also received an average of 17 email messages a day, about half seeking explanations of test results. 

Each doctor also wrote 12 prescription refills (in addition to refills that were part of a patient’s visit), read 20 laboratory reports, examined 14 consultation reports from specialists, visiting nurses, physiotherapists and other practitioners, and reviewed 11 X-rays and other imaging reports.

Whether the Philadelphia practice is representative of other primary care practices isn’t known. Only a few studies have attempted to measure the components of the ‘time budget’ of US doctors, which are filled with short patient visits and dozens of just-in-time interruptions.

What does a busy Australian GP think when they read this? My sense is that Australian GPs are just as busy as their US counterparts. But they have a number of advantages over them, including financial assistance to employ practice nurses and access to service incentive and practice incentive payments that reward GPs for services delivered and increase their income substantially. Moreover, they have an important if intangible asset: in Australia, general practice is not seen as the route taken when access to a specialty is denied; it is seen as a specialty in its own right.

Still, it is undoubtedly true that red tape continues to be a time-consuming issue for GPs.  The AMA, in its submissions to the Productivity Commission in recent years, has highlighted this, stating that GPs spend up to nine hours a week complying with red tape obligations, and suggesting that every hour a GP spends doing paperwork equates to about four patients who are denied access to the GP. Indeed, the accusation has been leveled that “the Commonwealth Government uses red tape as a blunt rationing mechanism to discourage medical practitioners from providing more services and in some cases actively limiting the number of services medical practitioners can provide to patients and thus contain health costs”.

And it is also undoubtedly true that, despite several reports and a Ministerial commitment to do something about red tape, very little has been done.  

The 2010-11 Budget contains a provision that restructures some 15 MBS items and that is touted as the Government’s response to the review of MBS red tape and simplification. The Government claims that this action “addresses doctors’ concerns that the current MBS is overly complex, encourages ‘six-minute medicine’ and fails to encourage preventative care, particularly for those with chronic illnesses”. I suspect that GPs see this as welcome, but too little, too late.

The Obama Administration sees e-health records, combined with changes in workflow and payments, as the pathway to relieving at least some of the burdens on primary care providers. Australian GPs will be looking for comparable reforms from the Rudd Government as it moves to implement the National Primary Health Care Strategy.

 

Dr Russell (PhD) is the Menzies Foundation Fellow at the Menzies Centre for Health Policy, The University of Sydney/Australian National University, and a Research Associate at the US Studies Centre at The University of Sydney. She is currently a Visiting Fellow at the Center for American Progress in Washington, DC


Richard Barron.  What’s keeping us so busy in primary care?  A snapshot from one practice.  NEJM (2010) 362; 1631-1636.

http://www.pc.gov.au/__data/assets/pdf_file/0004/86665/sub033.pdf


Published: 20 Jun 2010