Opinion | Getting Back the Time We Lost

Just the other day, a colleague at work told me about 2 hours of her life that were lost.

There was a patient she had been working with, trying to convince them to go down the next steps for treatment of a certain medical condition.

Based on the best evidence, current clinical guidelines, and her medical opinion as the patient’s doctor, they decided to perform a specific test that in the end was incredibly powerful in helping guide the patient to make the next best decision for their health.

Unfortunately, the insurance company decided, after the fact, that they were not going to pay for it. There had been no mention when the test was ordered, or when it was processed or scheduled, that a “prior authorization” was required.

This was discovered only afterward, when the patient received a bill for the total cost of the test, along with a letter stating that this procedure was not covered by their insurance.

My colleague then followed the rules for a normal appeals process, which of course was denied. But she kept fighting.

The second appeals process, she discovered, was much more onerous, involving printing and faxing extensive chart documentation, lab results, and a review of the evidence for this test and citations from the literature, that all needed to be submitted to support her decision to get this test.

All in all, she told me she spent several hours putting together a package of documentation to support this second-level appeal, which she submitted late last week. She and the patient are still awaiting the outcome.

How much time do we waste performing inane tasks that have little to do with the practice of medicine?

Wouldn’t our time be better served by actually getting to take care of our patients, to think about their health issues, to spend time talking to them, to improve collaboration across their healthcare team, to make sure they have all their questions answered and can get to all of the things they need to be as healthy as they can?

We’ve built a healthcare system that’s upside down, that’s driven by forces beyond our control, full of rules and regulations that would never make sense to any clinician trying to design such a system.

Think of all the useless documentation that has been written over the past few decades in paper charts and electronic medical records in the name of billing and compliance. “A 10-point review of systems was negative except as noted above.”

Look at all the screening questions we are told we have to ask every patient at every visit, with little evidence that asking them helps our patients do better. Look at all the regulatory forms we need to fill out, tests to maintain our certification, online annual hospital certification quizzes, an endless stream of things that suck up our time and have never really been shown to make much of a difference in the doctor-patient relationship, or in the delivery of healthcare.

Perhaps it’s time we ask for this time back. I’m not suggesting that we all walk over to the offices of the insurance companies, or the pharmaceutical companies, or the pharmacy benefit managers, or the bureaucrats in Washington, and take up their busy time having them explain themselves. (Although perhaps in the name of advocacy, us letting them know a thing or two, giving them a piece of our mind, might be a worthwhile investment.)

This all reminds me of the scene near the end of the movie “Fast Times at Ridgemont High” (1982), where Ray Walston’s character Mr. Hand stops by the home of Sean Penn’s character Spicoli at the end of the school year, and lets him know it’s time for payback, time for Spicoli to make up for all the time that he had wasted in Mr. Hand’s class over the course of the school year.

Now the time has finally come for us to demand that these things that drain away from our ability to take care of our patients, that cut into our quality of life and lead to burnout, that shorten and shorten our clinical interactions with patients down to single-digit minutes, go away.

If we’re going to bring about changes to the healthcare system, we need to maximize our efficiency in ways that we think make us better doctors, and help our patients. A truly functioning healthcare system would not have doctors performing tasks that have nothing to do with clinical medicine, and everything to do with bureaucracy and clicking boxes.

As things in healthcare have gotten more and more complex, the powers-that-be that control these things have layered more and more tasks on top of clinical care, and the work required almost always seems to fall to the clinicians.

Give us the resources to get this stuff done, if you’re not going to take it away, so that we can get back to doctoring. This will have to take the form of more clinical support, more administrative support, and more people helping out by doing tasks that allow everybody to practice up to their license.

New creative ways of thinking about these problems, including developing smart systems that review messages and act on them; automating refills; eliminating prior authorization, haggling with insurance companies, and pharmaceutical concerns — all of this and more needs to be at the forefront of change.

Maybe flip the insurance or pharmacy appeals process on its head: make them come to us and prove to us why they should not pay for something we think is best for the patient.

At the end of every day, more and more clinicians are feeling like it’s just not worth it, that they come home from work at the end of the day having done little clinical care. They’re feeling more and more like bureaucrats and pencil pushers.

The time has come to give us our time back.

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