SAN FRANCISCOVowing to go to Congress, if necessary, Lawrence H. Einhorn, MD, president of the American Society of Clinical Oncology (ASCO), called for changes in Medicare documentation rules that he blamed for increasing work hours for physicians and cutting job satisfaction.
Dr. Einhorn announced his presidential initiative at a symposium introducing the results of a survey answered by 2,493 ASCO oncologists. He cited several significant results.
Eighty percent of survey respondents said that their total hours increased during the last 5 years.
Seventy-four percent specified documentation as the reason for these increasing hours.
Asked to rate their concerns on a scale of one to five, the respondents put meeting Health Care Financing Administration (HCFA) requirements in first placeahead of long work hours, managed care organization paperwork, loss of income, stress in dealing with death and dying, and internal audits. (See Figure 1.)
Health Strategies Consultancy LLC in Washington DC designed the survey so that results could be compared to a University of Southern California (USC) study that assessed the workload of US oncologists from 1976 to 1978. The consultancy augmented the current surveys with data from 1,115 activity logs ASCO members kept for 3 days.
Health Strategies Consultancy researcher Jenifer Levinson listed several changes that occurred during the last 25 years. (See Figure 2.)
The oncologists’ workday grew from 10 hours to 13 hours, or from 13 hours to 18 hours, if on-call time is included.
Ninety-seven percent said documentation had increased during the last 5 years.
Time spent each day on documentation grew from 0.3 hours to 1.4 hours.
Thirty-eight percent said teaching time had decreased during the last 5 years.
Time devoted to research and teaching shrunk from 1.9 hours to 1 hour.
Although Ms. Levinson also reported that the number of hours with patients rose from 4.5 to 7.1 hours per day, she said that this change was not due to an increase in medical care provided to patients. Rather, it reflects an increase in the numbers of patients seen by physicians and time spent on unnecessary tasks done for purposes of defensive record keeping. These included taking patient history and performing physical exams that might not be done if not required for documentation.
"We have found that documentation is a major concern to oncologists," she said, "greater than the stress of dealing with death and dying and loss of income."
New ‘Cottage Industry’
Decrying a "new cottage industry of compliance officers" Dr. Einhorn complained that audits were being carried out on the assumption that physicians are guilty of fraud unless they can prove themselves innocent. "The Medicare program concerned with identifying fraud and abuse encourages Medicare patients to report their own doctors if abuse of the system is suspected and fosters a type of McCarthyism environment in medicine," he said. "I could envision a future in which physicians would appear before Congress and be asked, ‘Are you now or have you ever been guilty of incorrect coding and billing?’"
Dr. Einhorn targeted Medicare because he said it is driving the pressure for increased documentation. According to the study results, 90% of oncologists routinely follow Medicare guidelines because they are the most stringent. More than half the physicians surveyed had been part of an external audit in the past year, according to Ms. Levinson, and 70% had been through an internal compliance audit. "Medicare’s documentation requirements have bred more documentation and compliance efforts internally," she said.
The consulting agency has completed three of ten time-and-motion studies it is conducting with physicians around the country to provide additional information on how much of an oncologist’s day is spent caring for cancer patients. One issue it is still trying to assess is the effect on the quality of cancer care. Because documentation is entwined with time spent with patients, Ms. Levinson suggested that the survey results are probably conservative and may be underestimating the effects.
"Indeed, we are sometimes spending as much time documenting care as providing care for our patients and their families," said Dr. Einhorn, warning that ultimately the burden of regulatory requirements falls on patients as well as physicians.