According to the American Medical Association, “Physician burnout is a long-term stress reaction which can include the following:”
“Physician burnout is an epidemic in the U.S. health care system, with nearly 63% of physicians reporting signs of burnout such as emotional exhaustion and depersonalization at least once a week.”
“While many factors contribute to burnout, the burnout epidemic is often associated with system inefficiencies, administrative burdens and increased regulation and technology requirements.” One expert sums up the primary cause of physician burnout: “It’s been said that people don’t leave their jobs. They leave their bosses. But for physicians, physicians don’t leave their careers. They are leaving their inbox.”
At my own institution, the most common sources of dissatisfaction expressed by physicians are the electronic medical record (EMR), dealing with insurance companies, and other administrative duties that take physicians away from their patients. I will deal with each of these causes and demonstrate why the system – including the burnout created – is working as intended.
Contrary to popular belief, the EMR was not intended to make records easier to read, or to improve patient care. The EMR was created so that Centers for Medicare and Medicaid Services (CMS) could systematically and objectively deny payment for services. “If it wasn’t documented, it didn’t happen” has become the foundation for EMR. Physicians have been educated through mandatory indoctrination on how to document services to justify billing. Templates have been created to instantiate the mandatory documentation with a few clicks of the mouse. The result is pages of text that nobody ever reads. However, computers can scan the notes for the documentation and failure to detect the documentation provides CMS with an objective basis for denial of payment. Each service has multiple codes with higher code levels resulting in greater payment.
There are requirements to achieve each level of code. What the administrators do not acknowledge, however, is that the value of the time necessary to properly document each level of code (to the physician) far exceeds the increase in payment. The physician time has zero value to the administrator, so the administrators constantly harangue the physicians to spend more time on each record in order to generate higher payment. Some administrators do not understand this phenomenon; some do understand it but do not care. No administrator ever suggests that the solution is for the physician to spend less time on each record in order to see more patients or spend more time interacting with each patient. Physicians are regularly graded by Press-Gainey surveys of patient satisfaction. There will NEVER exist a Press-Gainey survey for physician satisfaction with CMS.
The insurance companies have merely taken the lead provided by CMS although the insurance companies have a different twist. The insurance companies require pre-authorization for expensive services. They deny authorization for reasons known only to the insurance company. The stated reason is always that the service is not medically necessary. It does not matter what the physician thinks about the necessity of the service. An appeal process is available, but the process is made as lengthy and as unpleasant as possible. The goal is obviously to make the process so unpleasant that physicians will not pursue an appeal.
The insurance company convinced me a long time ago, so I just document that the insurance company denied the service that I recommended. Many other physicians have the misconception that the barrier is lack of education or understanding, so that they can convince the insurance company of the rightness of the request. Their effort may even work on occasion, but the time and effort required will never be worth the result. If the existing treadmill does not reduce requests for services sufficiently, the insurance treadmill will just spin faster. Many physicians do not understand that the only way to win this game is to refuse to play it. There will NEVER exist a Press-Gainey survey for physician satisfaction with insurance companies.
Administrators claim to be very concerned about physician burnout. Their solution to physician burnout is to increase the administrative burden even further with questionnaires about burnout and mandatory education about burnout. The administrators will never acknowledge that the questionnaires and mandatory training are part of the cause of physician burnout rather than a solution. There will NEVER exist a Press-Gainey survey of physician satisfaction with the number of mandatory training sessions required.
What are the consequences of physician burnout? Physicians retire earlier or commit suicide. However, a decrease in the number of physicians solves more problems than it creates. The U.S. health care system pretends to eliminate the scarcity of medical services. It is not possible to actually eliminate this scarcity, so we have to pretend. Medical services appear to be “free” to the patient, but they are still scarce, so they are not actually free. One method of solving this imbalance between actuality and appearance is called rent dissipation. Rather than paying for services with money, patients pay for services with inconvenience, time waiting in lines, or time and effort travelling to services no longer available locally.
Another method of solving the imbalance between actuality and appearance of medical services is to decrease the number of physicians who order such services. Fewer physicians translate into fewer services which translate into lower payments by CMS and insurance companies. Another benefit of earlier retirement of physicians (or suicide) is there are more positions available for the excess number of physicians trained each year by medical schools.
As older physicians disappear, demand for post graduate residents increase, so the current imbalance between number of medical graduates and residency training positions can be reduced. Physician burnout is a problem for physicians, but it is a solution for CMS and other third-party payers of medical care. Given that CMS makes the rules, do not expect physician burnout to go away very soon.
To paraphrase Lenin, physicians sold CMS the rope by which they are being hanged.
Written by Gilbert Berdine, MD for The Mises Institute ~ August 18, 2023