Quality reporting's toll on physician practices in time and money

Noting that the 1,500 clinicians in its multispecialty group were worn out by the hundreds of quality measures they have to track, Indiana University Health embarked on a multiyear effort to streamline the measures that front-line providers are expected to worry about.

The information reported to Medicare and insurers is intended to help monitor and improve the quality and safety of healthcare. But collecting it also saps resources.

“It's a lot of time and effort spent at the computer documenting things that don't impact patient care,” said Dr. Jonathan Gottlieb, the Indianapolis-based system's chief medical executive. Gottlieb also contends it's impossible for an organization to carry out focused improvement efforts when too many measures are tracked at once.

Researchers at Weill Cornell Medical College in New York City teamed up with the Medical Group Management Association to put a price on the time providers spend to enter the data into the electronic health record, keep track of newly introduced measures and create protocols to track and report them.

The answer is about $15.4 billion a year, according to their study published Monday in the health policy journal Health Affairs.

That's “a large amount of money being wasted on checking this box and that box,” said lead study author Dr. Lawrence Casalino, chief of the division of health policy and economics at the Weill Cornell Medical College in New York City. “It's time physicians could spend on not rushing a patient, or thinking about a diagnosis more carefully.”

Patient safety leaders have said not having enough time for clinical reasoning could be one factor leading to high rates of diagnostic errors, a problem deemed a “persistent blind spot” in the movement to make care safer in the U.S.

In the new study, the researchers surveyed 394 leaders from four specialties: cardiology, orthopedics, primary care and general internists.

They asked about how much time specialty clinicians spend on tasks associated with collecting quality and safety data. They then converted those hours into costs, based on how much specialists get paid.

Across all specialties, licensed practical nurses and medical assistants spent the most amount of time.

For example, between 2014 and 2015, licensed practical nurses and medical assistants employed in primary care settings spent an average of 7.8 hours per week on tasks related to reporting on external quality measures. In dollars, that's about $9,119 a year for each clinician. Primary care doctors said they spent about 3.9 hours per week on the tasks. In salary, that tallied to roughly $22,049 per physician each year.

The authors note several limitations of the study. Practices with stronger negative feelings about quality measures may have been more likely to respond, which could distort the estimates. Also, tracking how much time individual clinicians spend on tasks is not easy to do. The research was funded by the Physicians Foundation, a not-for-profit organization that supports research on the impact of the ACA on physician groups.

While there have been anecdotal reports about the burden of quality reporting, few studies have attempted to quantify the impact. “And it is enormous,” said Dr. Robert Wachter, interim chairman of the department of medicine at the University of California San Francisco, after reading the study.

Wachter has advocated for a national body to vet new measures and reduce redundancy. He also says EHRs need to be more user-friendly and efficient, “so that data are captured in the background while physicians deliver care, rather than requiring additional work.”

At IU Health, clinicians are nudged with a prompt in the EHR when they are required to input data for key metrics, according to Gottlieb.

The health system set up “mission control” in a conference room next to his office, where the clinical economics committee keeps track of what measures get reported, by which department or specialists, and what new penalties or rewards they face on the horizon for certain measures.

For clinicians, however, the team is striving to boil down all of the measures to the basics. By the beginning of 2017, IU Health plans to cut the number of measures specialty doctors will have to track to about 10 or less. The system did the same for its hospital measures last year, cutting the number of inpatient metrics clinicians input down from 199 down to 10.

“Someone needs to pay attention,” Gottlieb said. “But we want our doctors and nurses to focus on measures that contribute directly to the welfare of the patient.”

The consolidated measures for office-based physicians are likely to focus on patient experience, such as on how well the clinician communicates and the ease of access to care for the patient. “In the office setting it's not always about the procedure, but about the interaction,” Gottlieb said.

Leaders who responded to the survey by Weill Cornell and the MGMA did not hesitate to speak up when given the opportunity to provide “additional comments.” The survey generated 308 comments from 58% of the responding practices.

“Each small change made to reporting wastes extreme hours,” wrote one family practice leader. Consistency is needed, “otherwise we are always training on reporting, rather than improving care.”

An orthopedist said certain reporting requirements for that specialty were “a complete waste of time.” An internal medicine specialist feared that eventually the small practice would be “forced out of business due to all the requirements.”

Additional comments are included in the study's appendix.

The latter comment could be one factor driving the rapid pace of physicians selling their practices to hospitals and health systems. Facing a barrage of reporting requirements and performance incentives, many “just throw up their hands and say 'I give up,'” Casalino said. The jury is still out, he added, on whether the consolidation is beneficial.

Of the practices that responded to the survey, 81% reported that they spent more or much more effort dealing with external quality measures than three years ago. Only 27% said the current measures are moderately or very representative of the quality of care.