Results of the SWJPCC Healthcare Survey

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA 

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Julene R. Robbins, PhD, NCSP

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Lewis Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

Abstract

Debate is ongoing on how best to pay for healthcare, with a public option gaining increasing popularity. However, the Southwest US has traditionally been politically conservative and, although population demographics are rapidly shifting towards minorities, this shift is not reflected in the physician population. We conducted a voluntary, anonymous, on-line survey of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) readership to determine if their attitudes differed from the public and/or nationwide surveys of physicians. The respondents, nearly all subspecialty care physicians, were universally consistent in their opinion that healthcare costs too much in the US. About two-thirds felt healthcare is a right. Administrative costs and insurance companies were viewed by most as the culprits for the high costs and hospital administrators and insurance company personnel were perceived as overpaid. Few viewed the electronic medical record as helpful in healthcare. These results seem mostly consistent with other Nationwide physician surveys. 

Introduction

Most Americans continue to see healthcare costs in the U.S. as a major issue, with 79% dissatisfied with healthcare costs (1). Americans who are covered by Medicare or Medicaid are the least dissatisfied (29%), while dissatisfaction is highest among the uninsured (62%) and averages 48% among those with private insurance (2). This dissatisfaction has been reflected in the current political debates with proposals including public options such as “Medicare for All”.

Physicians have also become increasingly dissatisfied with healthcare (3). A variety of factors, such as electronic medical records, income instability and fairness, and the burden of regulations have been identified as affecting physician satisfaction and each is also affected by cost (3). Surveys have reflected this dissatisfaction but none has focused specifically on the Southwest US. The Southwest is undergoing demographic shifting, particularly in Arizona, with an increasing number of minorities, especially Latinos (4). However, this changing racial and ethnic diversity is not reflected in the Southwest physician workforce, with the vast majority remaining Caucasian, although an increasing number are now women (5).

To uncover if attitudes regarding healthcare costs differ amongst the Southwest Journal of Pulmonary and Critical Care (SWJPCC) readership, we conducted an on-line survey. The results suggest that healthcare providers agree that healthcare costs too much. Furthermore, the majority favored administrative costs/insurance expenses as the predominate contributors to the increase in costs.

Methods

Survey

An experienced survey designer (JRR) constructed a survey with the goals of determining US Southwest physician attitudes towards healthcare costs and the possible causes for the high cost. Another goal was to keep the survey brief, since previous experience was that long surveys usually have a poor response. A series of 8 questions was developed (Appendix 1).

Data Collection and Statistical Analysis

Data was collected October 9, 2019 through November 27, 2019. Most results were expressed as a percentage of the responses. There were insufficient respondents between different groups (physicians, nurses, patients, etc.) to allow statistical analysis

Results

Demographics

There were 66 respondents, of which there were 61 subspecialty physicians or residents and 5 others (2 patients,1 nurse,1 technician, and 1 other). This likely reflects the readership of a pulmonary, critical care and sleep subspecialty journal such as the SWJPCC.

Healthcare Costs Too Much in the US.

There was universal agreement (all 66 respondents responding in the affirmative) that this statement is true.

Healthcare is a Right.

Forty-three of 65 responses marked this as true (66%). Twenty-two respondents felt that this statement was false (34%) and 1 with no response.

Causes for the Increase in Healthcare Costs.

The perceived causes for the increase in healthcare costs are shown in Figure 1.

Figure 1. Respondents answers for the causes of the increase in healthcare costs.

Although the answers somewhat differed, the majority felt that administrative costs and insurance companies were important contributors to increasing healthcare costs (39 of 62, 63%). None felt that physicians’ fees contributed to the increase in healthcare costs. Other responses are given in Appendix 2.

Which Healthcare Personnel Are Over- or Underpaid. 

There were 87 answers as regards which personnel are overpaid. The healthcare personnel that were felt to be overpaid are show in Figure 2.

Figure 2. Respondents answers to which personnel are overpaid.

There was consensus that hospital administrators and insurance personnel were overpaid with 78 of 87 (90%) responding that they were overpaid (multiple answers could be accepted). In contrast, only 4 respondents felt specialty care physicians, and only one each, viewed nurses and technicians as being overpaid. None felt primary care physicians were overpaid.

Answers to the question “which personnel are underpaid” mirrored the answers to which healthcare personnel were overpaid (Figure 3).

Figure 3. Respondents answers to which healthcare personnel are underpaid.

Forty-five of the 116 (39%) answers felt that primary care physicians were underpaid. A smaller number felt nurses (37 responses, 32%), technicians (26 responses, 22%), and specialty care physicians (8 responses, 7%) were underpaid. None felt that hospital administrators or insurance personnel were underpaid.

Method for Healthcare Payment

Most (65%) favored keeping private insurance but adding a public option or “Medicare for All” (15%) (Figure 4).

Figure 4. Responses to how to pay for healthcare.

Only 4 (6%) favored keeping the present system and only 2 (3%) favored mandatory managed care plans.

Innovations that Have Improved Quality in Healthcare

Innovations that were felt to improve healthcare are shown in Figure 5.

Figure 5. Innovations that have improved healthcare.

Nearly half of the 126 responses (53 responses, 42%) felt better pharmaceuticals had improved healthcare. Many also felt that internet access for medical education, such as looking up specific questions, on-line education (27 responses, 21%), and clinical decision support (26 responses, 21%) had helped. Interestingly, the most widespread innovation in healthcare in the past few years- electronic medical records- received the least support with only 5 positive responses (4%).

Discussion

This survey of readers of the Southwest Journal of Pulmonary and Critical Care strongly reflects the concern that healthcare costs too much in the US. About two-thirds of respondents felt healthcare is a right. Administrative costs and insurance companies were viewed by many as the reasons for the high costs with hospital administrators and insurance company personnel viewed as overpaid. Few viewed the electronic medical record as helpful in healthcare.

The physician opinion that healthcare costs too much is consistent with the US paying the highest cost for healthcare in the world, at over $10,000 per capita in 2017 (6). The concept that administrative costs account for much of these higher costs has only recently become widely accepted. This late realization is despite rising administrative costs highlighted by multiple articles from Woolhandler and Himmelstein, beginning with a 1991 article in the New England Journal of Medicine (7). They referred to medicine as “a spectator sport” with doctors, patients, and nurses performing before an enlarging audience of utilization reviewers, efficiency experts, and cost managers. Many physicians have watched in horror as the trend pointed out by these authors nearly 30 years ago has steadily worsened. Reports of ultrahigh CEO salaries have recently drawn some attention in both the medical and popular literature accenting the high administrative costs (8,9).

The high costs of healthcare have led to an increasing number of patients and physicians supporting a public option. Previously, physician groups, such as the American Medical Association (AMA), have thwarted public health insurance proposals since the 1930s. However, as the next generation of physicians takes on leadership roles, even groups such as the AMA are now reexamining this question (10). A March 2018 New England Journal of Medicine survey found 61 percent of 607 respondents said single-payer would make it easier to deliver cost-effective, quality health care (11). This is similar to the 80% of our readership favoring a public option. However, in our survey, most (65%) favored keeping private insurance in addition to the public option. This likely represents a physician reaction to increasing regulatory burdens by the Centers for Medicare and Medicaid Services and the Department Veterans of Affairs, two US government agencies involved in healthcare. 

Despite the changing population demographics in the Southwest US, physicians still tend to be Caucasian, although more are now women (4,5). Our data suggests that support for a public option is high among physicians. We did not ask our readers their age, although younger physicians preferentially seem to be more likely to support a public option (10). Furthermore, most pulmonary physicians are now Democrats who tend to support a public option (12). We also did not ask where the physicians practice, although it seems likely most are in the Southwest US.

Our data are consistent with other surveys, although the Southwest US and the Southern US are often viewed as the home of US conservatism. However, even though most favored a public option in our survey, there seems to be sufficient distrust of “big government” to limit the choice to only a public option (13).

References

1. Jones JM, Reinhart RJ. Americans remain dissatisfied with healthcare costs. Gallup Poll. Nov 28, 2018. Available at: https://news.gallup.com/poll/245054/americans-remain-dissatisfied-healthcare-costs.aspx (accessed 12/17/19).
2. Saad L. Four in 10 in U.S. dissatisfied with their healthcare costs. Gallup Poll. Dec 12, 2016. Available at: https://news.gallup.com/poll/199298/four-dissatisfied-healthcare-costs.aspx (accessed 12/17/19).
3. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Rand Health Q. 2014 Dec 1;3(4):1. eCollection 2014 Winter.
4. Cárdenas V, Kerby S, Wilf R. Arizona’s demographic changes. Center for American Progress. 2012. Available at: https://www.americanprogress.org/issues/poverty/news/2012/02/28/11060/arizonas-demographic-changes/ (Accessed 12/17/19).
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7. Woolhandler S, Himmelstein DU. The deteriorating administrative efficiency of the US healthcare system. N Engl J Med. 1991;324(18):1253-8. [CrossRef] [PubMed]
8. Robbins RA. CEO compensation-one reason healthcare costs so much. Southwest J Pulm Crit Care. 2019;19(2):76-8. [CrossRef]
9. Andrzejewski A.  Top U.S. "Non-Profit" hospitals & CEOs are racking up huge profits. Jun 26, 2019. Available at: https://www.forbes.com/sites/adamandrzejewski/2019/06/26/top-u-s-non-profit-hospitals-ceos-are-racking-up-huge-profits/#48c7a4d119df (accessed 12/17/19).
10. Luthra S. Once its greatest foes, doctors are embracing single-payer. Kaiser Health News. August 7, 2018. Available at: https://khn.org/news/once-its-greatest-foes-doctors-are-embracing-single-payer/ (accessed 12/17/19).
11. Serafini M. Why clinicians support single-payer-and who will win and lose. NEJM Catalyst. January 17, 2018. Available at: https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0278 (accessed 12/17/19).
12. Frellick M. Physician specialties correlate with political affiliation. Medscape. October 12, 2016. Available at: https://www.medscape.com/viewarticle/870192 (accessed 12/17/19).
13. Robbins RA, Wang AC. Medicare for all-good idea or political death? Southwest J Pulm Crit Care. 2019;19(1):18-20. [CrossRef]

Cite as: Robbins RA, Gotway MB, Robbins JR, Wesselius LJ. Results of the SWJPCC healthcare survey. Southwest J Pulm Crit Care. 2020;20(1):9-15. doi: https://doi.org/10.13175/swjpcc074-19 PDF 

Brief Review: Dangers of the Electronic Medical Record

Richard A. Robbins, MD

Southwest Journal of Pulmonary and Critical Care

Gilbert, AZ

In 2009 then president-elect Barack Obama said he planned to continue the Bush administration's push for the federal government to invest in electronic medical records (EMR) so all were digitized within five years. "This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests," he said, adding that the switch also would "save lives by reducing the number of errors in medicine"(1). Now over 5 years on, it might be time to examine how EMR has impacted medicine.

Historically, similar arguments were made by Dr. Ken Kizer, then Undersecretary for Veterans Healthcare Administration (VHA), 20 years ago (2). As a physician who practiced the VA at the time, my colleagues and I welcomed EMR. It had to be better than a system where neither the chart nor the x-rays were available for pulmonary clinic most of the time (Robbins RA, unpublished observations). EMR improved this. In general, x-rays and records were available and I have little doubt that this improved healthcare. However, it came at a price. It's the later that is discussed in this review.

Waste and Red Tape

Elimination of waste and red tape are good things. However, does the EMR eliminate either? Most articles have been similar to Buntin et al. (3) who point out that "92 percent of the recent articles on health information technology reached conclusions that were positive overall". However, most represent a series of opinions, usually of healthcare administrators, rather than data. Studies which have examined efficiency data have not found such an improvement (4).

My experience suggests that EMR actually creates waste of practioners' time and increases red tape. The collection of the required superfluous information detracts from patient care. Asking every patient at every visit a family history, review of systems and reentering past medical history and surgical history is very unlikely to produce any new clinically useful information and detracts from practioners focusing on the patient's problem. The recent VA scandal resulted from a performance-measurement system through the EMR that had become bloated and unfocused requiring the recording of multiple measures (often tied to administrative bonuses) of dubious or meaningless significance (5,6). These additional clerical tasks contributed to too few physicians being unable to care for too many patients. The private setting has become similarly afflicted. Performing the ever increasing meaningless measures required for reimbursement by Centers for Medicare and Medicaid Services (CMS) or other third party carries is resulting in similar detriments in care and will likely result in outcomes similar to the VA.

In addition, the data must now be recorded on a template that is easily electronically retrievable. This saves third party clerical time because the clinic notes do not have to be abstracted. However, the clerical burden now falls onto the physician or office staff. It usually means the data is entered at least twice-once on the clinic note and once on the template. Everything from smoking to electronic prescriptions must be entered on a template. Sometimes this actually saves time but at others it is horribly detrimental. For example, yesterday my practice administrator and I spent 15 minutes trying to electronically send prescriptions to a local Walgreens pharmacy mostly because we could not electronically locate the store although we had the address and phone number. With the addition of these requirements, it now takes longer, in many cases much longer, to type the note and enter the data than it does to see the patient. This is driven by a requirement for the data to be entered in an EMR in order to receive reimbursement.

There are multiple commercially available EMRs. Each system may have its some unique issues and problems. The fact that institutions may decide to change from one EMR system to another, based on a number of factors, can have significant stress on the providers and may impact overall quality of care and safety during the “learning curve” to adapt to a new EMR. Even if the system stays with one product, there are frequent “upgrades” that require learning new processes. There is a limit to how many updates and changes can be effectively learned by physicians and other providers while maintaining efficiency. These issues need to be understood by health care administrators.

Duplicate Testing

It makes some sense that if results are available electronically that duplicate testing could be reduced. Unfortunately, the reality is that although the data might be recorded electronically, it is often not available. The various computers do not necessarily "talk" to each other and even when the do, retrieving the data can be problematic because of the multiple security hoops that need to be jumped through (remember HIPPA). Furthermore, sometimes the data is substandard. Yesterday, I saw a patient with COPD from smoking, a recurrent rectal carcinoma and a CT-PET scan positive for a 1 cm enhancing mass in the right upper lobe according to the radiologist. Yet, I could see no lesion on the small image that I could view on our computer. I decided the safest course of action was to repeat the test in 3-6 months. Had I been able to review an adequate image, the need to repeat the test might have been avoided. Similarly, other x-ray, laboratory and other data is frequently inaccessible.

CMS is largely responsible for this oversight. Although the federal government has spent over 30 billion in tax dollars since 2009 implementing EMRs, they are not standardized across facilities (7). Similar problems occurred at the VA. Although it was one computer system, multiple vendors who supplied radiology, pulmonary function, and other equipment were electronically incompatible with the VA system.

Save Lives By Reducing the Number of Errors in Medicine

This may eventually prove to be true, but the available data suggest that at least initially the opposite may be true at least for computerized physician order entry (CPOE). For example, a survey of the house staff at the University of Pennsylvania found that a widely used CPOE system facilitated 22 types of medication errors (8). More disturbing is data that mortality increased from 2.8% to 6.6% after CPOE implementation in one pediatric intensive care unit (9). Other studies have failed to demonstrate such an increase in mortality (10).

Unavailability of the EMR

It seems rather obvious but EMRs have to be as dependable as other electronic records such as banks. Unfortunately, this is usually not the case. For example, the VA system would periodically crash. Trying to care for a patient when no data is available and no orders can be written is problematic. Incidentally, the problem of the periodic crashes was because local administrators refused to increase the server capacity at the Veterans Integrated Service Network level (EMRs can utilize huge amounts of memory) until the system did crash. There seemed no consequences to those responsible when the EMR was unavailable.

Unauthorized Access to Patient Information

Equally obvious is data stored in EMRs is vulnerable to unauthorized access just as computers from the Pentagon, banks, Target and even Sony pictures have all been hacked. It seems unlikely that the data in the EMR is as well protected as military or financial data especially given the large numbers with access to the data and the need to access the data sometimes quickly in emergency situations. Interestingly, large breeches in EMRs at the VA seemed to have occurred not through healthcare professionals but through information technology (IT) or administrative personnel (11).

Rarely, medical computers are hacked with the intent of extorting money. The hacker encrypts the files and then demands money to unencrypt the data (12). Some physicians' offices who have been hacked now keep two sets of data, one electronic and another paper not only cancelling most of EMR's advantages but resulting in the time and effort of keeping two record systems.

Health Care Professionals Spending Less Time with the Patient

Although physicians complain about the time required to complete various aspects of the EMR (in my view justifiably), observations in the hospital suggest nurses may be even more affected. A never ending list of documentation facilitated by the EMR have robbed many nurses of what they found most satisfying about their profession, bedside nursing (13).

Poor Understanding of the Medical Record

Poor understanding of patient data remains a significant problem for everyone from the patient who may find the record confusing and frightening to the healthcare administrator who is not trained or skilled in the practice of medicine. A number of medical practices are utilizing “patient portals” in their EMRs that allow patients to review their records online. The knowledge that a patient will be able to review all information entered in their record seems likely to have an effect on physician documentation, particularly in certain areas such as potential substance abuse, mental health issues, or malingering. Review of the record by the patient may also create challenges in patient care. For example, a patient who has read a radiology report that states “malignancy cannot be excluded” may question a decision by the clinician not to do a biopsy because the risks of further testing or biopsy are not justified by what may be a very low likelihood of malignance. Confusion can result in numerous bad outcomes, but usually for the patient and/or the practioner. These are all new issues and the impact overall on patient care and the doctor-patient relationship are not clear.

Control

This might be the largest potential danger and most contentious aspect of the EMR. It revolves around who owns the medical record. Some believe patients should own their record, and similarly, administrators, CMS, insurance companies and practioners all believe that the EMR should be theirs, at least in part (14). Consequently, there are conflicts regarding what should and should not be recorded. Although this argument is far beyond this brief review, the implications are far-reaching and important.

Regardless of who is the ultimate owner of the medical record, it is quite clear that administrators in the hospital and large clinics and CMS and insurance companies can dictate both the content and form. Furthermore, it is quite easy to place requirements to complete the records or receive reimbursement. For example, completion of CMS' most recent "meaningful use" measures can be required for reimbursement, and similarly, information might be required before a document can be signed. This might be reasonable unless the requests are busywork or for predominately useless information. This can detract from the usefulness of the medical record. For example, at one hospital where I practiced there was an excellent gastroenterology department. They used a computer generated report for their procedures that usually resulted in about 5 typed pages. It satisfied all CMS, insurance company, JCAHO, and professional standards. However, it was difficult (some of my colleagues said impossible) to read and interpret timely and efficiently. Increasingly, we see office reports, consults, history and physicals, radiology reports, laboratory reports, and discharge summaries which approach the length of a Dostoyevsky novel and have little utility in conveying information useful in patient care. Furthermore, should any part of the medical tome be missing (remember bundles), CMS and insurance companies will gleefully deny payment while healthcare administrators will harass both nurses and physicians to complete the medical record according to CMS and the insurance company mandates. This results in practioner inefficiency. However, the solution is usually to hire more administrative personnel to make sure that the practioners work even harder and longer further decreasing efficiency both medical and administrative inefficiency.

Not usually mentioned as a danger, although it should be, is that the EMR can be alerted by the unscrupulous who may control the EMR. For example, Sam Foote told me a story that while at the Phoenix VA, he could place a request for back magnetic resonance imaging (MRI) but would later find that the order removed. At the time the hospital had overspent its fee basis budget and was actively discouraging the ordering of MRIs. Furthermore, we have seen radiology reports altered when a misreading was discovered without evidence of the original misreading present (Robbins RA, unpublished observations).

Conclusions

EMRs represent a potential boon to patient care and providers, but to date that potential has been unfulfilled. Data suggest that in some instances EMRs may even produce adverse outcomes. This result probably has occurred because lack of provider input and familiarity with EMRs resulting in the medical records becoming less a tool for patient care and more of a tool for documentation and reimbursement.

References

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Reference as: Robbins RA. Brief review: dangers of the electronic medical record. Southwest J Pulm Crit Care. 2015;10(4):184-9. doi: http://dx.doi.org/10.13175/swjpcc035-15 PDF