• In The Trenches

    Here's How We're Battling Administrative Burden for You

    "Late night, come home. Work sucks, I know."
    -- Blink-182,
    All the Small Things

    3d rendering of an isolated ball and chain lying broken near a leg shackle. Business boundaries. Freedom and rights. Legal help.

    AAFP members, through surveys and focus groups, have clearly told us that reducing administrative complexity and regulatory burden is their single most important issue. In fact, surveys show that the importance of addressing this issue is 25 percentage points higher than other issues listed as priorities by our members -- including increased payment.

    In December 2017, the AAFP Board of Directors adopted the "Principles for Administrative Simplification" and made reducing the administrative and regulatory burden experienced by family physicians the Academy's top strategic objective. Since then, we have been aggressively fighting for family medicine through our advocacy programs and direct lobbying with Congress, CMS and private health insurers.

    It is well established that administrative burden is directly associated with the growing professional dissatisfaction among family physicians. What is often overlooked are the loss of productivity and economic costs associated with administrative burden. However, it is becoming clear that the volume of administrative tasks imposed on family physicians represents the most immediate threat to the delivery of high-quality, efficient care to patients. Last month, the Council for Affordable Quality Healthcare released its annual CAQH Index report, Conducting Electronic Business Transactions: Why Greater Harmonization Across the Industry is Needed, which highlighted these key points. The report found that "spending on healthcare administration costs an estimated $350 billion annually in the United States due to its complexity."

    In this post, I am going to focus on the work the Academy is doing to bring about reforms that will ease, if not eliminate, the administrative burden imposed on family medicine practices.

    The AAFP has organized an internal, organization-wide team to drive a comprehensive set of activities aimed at reducing administrative burden. This group is bringing to bear the full resources of the Academy -- communications, public and private sector advocacy, continuing education and our research teams -- to identify solutions that will improve your practice environment through administrative burden reduction.

    Numerous studies have focused on the issue of administrative burden, but to better understand the views and opinions of family physicians specifically, we commissioned an evaluation, which included focus groups, to gather detailed information on the issue. Here is what you told us:

    • Administrative burden is your top concern, and you expect the AAFP to deliver results via advocacy and education/resources.
    • The top administrative burdens identified were documentation, prior authorization, quality improvement metrics and staff meetings. (I feel you on the staff meetings!)
    • What constitutes administrative burden is personal and localized. Family physicians feel their administrative burden is unique to them and is likely different from others'.

    There were several "attitudinal" or "soft" findings from the report. One was the perception that "the battle is too big." Another was the belief that the AAFP "can't help me." I believe both of these perceptions are false. (More on why below.)

    Finally, there was a "lack of awareness" about what the AAFP is doing to help members. I am here to shed some light on this specific item. As we continue fighting for family medicine, we are focusing our efforts on four broad categories of administrative functions: prior authorization, documentation and coding, electronic health records, and utilization review programs. Today I am going to share details on our efforts related to prior authorization and documentation and coding.

    Prior Authorization

    Without question, prior authorization is the single issue that most frustrates family physicians -- and for good reason. It is time-consuming, expensive and creates an unnecessary barrier to care for patients.

    According to the CAQH report I discussed above, "spending on prior authorization constitutes only 2% of the overall medical industry transaction spend ($631 million), but prior authorization is the most costly, time-consuming administrative transaction for providers. On average, providers spent almost $11 per transaction to conduct a prior authorization manually and nearly $4 using a web portal."

    The issue can seem overwhelming, but we have a series of goals we are pursuing aimed at achieving our strategic objectives:

    • Reduce, if not eliminate, prior authorization for family physicians. Strategically, we are calling for the immediate elimination of prior authorization for all generic drugs prescribed by family physicians.
    • Eliminate prior authorization completely for family physicians participating in a value-based payment program.
    • Establish a standardized form for prior authorizations in the Medicare Advantage program.
    • Call for a federal study that would evaluate the economic and productivity impact of prior authorization in the Medicare program.

    In addition, we are working closely with CMS and insurers to develop processes that would automate the majority of the remaining prior authorization system. This electronic innovation is starting to move into the practice setting in 2020, and MedPage Today recently had a good article on efforts to simplify the process.

    Documentation and Coding

    Onerous documentation guidelines for the Medicare program and commercial insurance plans continue to be a primary focus of our advocacy efforts. We have had success in our efforts to persuade CMS to reduce documentation requirements for physicians participating in the Medicare program. After we intensified our advocacy with the agency, CMS recently reduced documentation requirements further. An article in the January/February issue of FPM summarizes these changes as follows:

    "On Jan. 1, the agency began allowing physicians, physician assistants or advanced practice registered nurses who furnish and bill for their professional services to review and verify, rather than redocument, information added to the medical record by physicians, residents, nurses, students or other members of the medical team in all settings. This applies across all Medicare-covered services paid under the physician fee schedule.

    "This new guidance includes notes documenting the clinician's presence and participation in the services. While it changes who may document services in the medical record -- subject to review and verification by the furnishing and billing clinician -- it does not modify the standards or scope of documentation needed to demonstrate medical necessity of services or appropriate recordkeeping."

    Additional changes to documentation are coming in 2021, when the agency will implement a new policy that will permit physicians to choose the level of service based on either medical decision-making or time.

    This post outlines work the AAFP is doing to improve your practice environment and reduce the frustrations you face as you pursue your true mission, which is providing care to your patients. I know that some will respond that our efforts are "not enough" or "too little, too late." To you, I ask that you join our crusade.


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.