Doctors Today Must Deal With Paperwork and Bureaucracy, OC Physicians Say
The kind of chatter Dr. Maria Minon used to hear among doctors lunching at the hospital cafeteria would be about the most interesting cases they had seen that week. Now, most of the conversations center on struggles to get reimbursed, not having enough office help and the stress of their daily routines.
“I’m not saying that they don’t talk about patients, but there’s just more frustration,” said Minon, vice president of medical affairs at Children’s Hospital of Orange County.
Doctors express dissatisfaction over long hours, a mixed public image, worries about lawsuits, and,above all,a constant pressure to hold down costs.
Although HMOs say that they’re being unfairly maligned for simply keeping healthcare costs under control and that doctors still make a good living, times have definitely changed for physicians. Many Orange County doctors will tell you their job just isn’t as much fun as it used to be,with most describing it as complicated and exhausting.
The Old Days
It used to be that a doctor could open an independent office, hang up a sign and the patients would come. Fee-for-service was the norm, with the patients covering the cost that insurers wouldn’t. Now, however, with the kind of managed-care penetration seen in Orange County, doctors don’t have much choice but to put up with the lack of autonomy, lower pay and a pile of paperwork.
According to a PricewaterhouseCoopers survey for the California Medical Association, 47% of California’s population is enrolled in an HMO,about three-fifths of those who are insured statewide. More than 85% of all Californians who receive health coverage through employers belong to HMOs.
The proliferation of HMOs has resulted in a paper maze for doctors, who must determine which procedures and services are covered by individual patients’ HMOs, keep the patients informed and keep on top of bureaucratic details. And with more patients enrolled in HMOs, doctors who have stayed independent find themselves under considerable economic pressure to contract with the organizations.
“You have 30 or 40 different formularies (allowed prescription drugs) from different health plans, and then you have to correlate it to the various patients, and then the formularies change on a yearly basis. Then you have to make sure the doses are the same,” said Dr. Ralph Cygan, a general internist and clinical professor of medicine at UCI Medical Center. “It really adds an unnecessary hassle factor to the care of patients. Physicians can spend up to four hours a day dealing with administrative backlogs.”
The headaches hardly end there. After the paperwork is processed, it’s time for reimbursement roulette. The standard HMO contract requires physicians to provide care for a flat, per-patient rate, known as a capitation fee. But doctors say the fees are too low in many cases to cover their costs,meaning they can actually lose money on difficult or unusual cases.
Meanwhile, the doctors also must bear the brunt of the dissatisfaction patients feel over the state of their healthcare. Many feel dehumanized and alienated, several physicians said. Even the terminology troubles some people, such as HMOs’ habit or referring to doctors as “providers.”
Dr. Brennan Cassidy, president of the Orange County Medical Association and a practicing physician, said patients also resent that their choices for doctors are limited.
“Because they’ve chosen to buy a less-expensive product, they have to choose from a list of physicians given them by the HMO,” said Cassidy.
Many doctors also are feeling anxiety over the rise in malpractice suits in recent years.
Trade Groups Clashing
Meanwhile, a few levels up from the examining room, the sniping between doctors’ groups and HMO trade organizations is getting worse.
The California Association of Health Plans denies that capitation rates have gone down and says physicians should stop blaming HMOs for problems created by a national climate that demands health costs be kept in check.
For its part, the California Medical Association last year sued eight HMOs for allegedly failing to provide adequate reimbursement to physicians. And its parent group, the American Medical Association, sued the federal government on similar grounds.
As this round-robin of claim and counter-claim suggests, if you’re looking for an oasis of contentment amid the vast contentiousness of the healthcare business, you’re out of luck.
And compounding all the economic discomfort they already feel, doctors say, is a need to keep up with rapid changes in medicine itself. Between biotechnology breakthroughs, new drugs and bold new research, “the pressures are enormous,” said Cygan.
Trying to Be Positive
What can doctors do about these multiple frustrations?
Basically, longtime physicians say, the best you can do is try to look on the bright side and focus on what brought you to medicine in the first place.
High hopes for physician practice management groups,associations of doctors banding together to jointly negotiate capitation rates with HMOs,have dissipated. MedPartners’ California woes are only one example of the huge difficulties that so-called PPMs have faced in staying solvent.
A new interest in unionization has so far produced more skeptics than converts.
Working Smarter
So what’s a doctor to do?
In an effort to reduce the amount of time spent shuffling paper and looking up records, Dr. Bruce Van Vranken, a Lake Forest family practitioner, and some 20 other doctors in the county are testing an electronic medical-record system.
Van Vranken carries around a computer tablet about the size of a laptop screen, which allows him to input and retrieve patient information, write prescriptions and tap into the Internet. The gadget is connected to four computers in his office. Recently, the doctor was required to pull the chart of every patient who had been prescribed a particular drug. The old method would have been for office staff to pull every single chart. With the electronic medical record, he completed the task in two minutes.
The system, made by a Boston company called Vectis, is now commercially available. Whether doctors will embrace this new technology is anyone’s guess.
“Doctors are creatures of habit. They have different ways of doing things,” said Van Vranken, who says he loves the new system and does not consider himself a computer geek.
Still Rewarding
The key to sanity, say some of the doctors, is to try to make the best of the situation.
“Try to adapt as much as possible and find the circumstance that is most satisfying for you,” says OCMA president Cassidy.
Don’t forget that “it’s still very rewarding and it’s academically challenging and you’re pretty well sure of employment,” said Dr. Marv Gordon, chief medical officer for Monarch HealthCare.
“I moan and groan and bitch like everyone else,” said Van Vranken, who has been practicing for 21 years. “There’s lot of chaos and high stress. But I wouldn’t change (my career choice) even with all the hassles that I know now.” n
Los Angeles Business Journal staff writer Ann Donahue contributed to this report.
