ABSTRACT
Purpose Medical scribes are known to increase revenue by increasing visits to a medical practice. We examined whether medical scribes are associated with markers of financial benefit independent of increased visits.
Methods We conducted a pre- and post-observational study with a control group, examining changes in the percentage of visits (1) coded as level of service 4 or 5, (2) with at least 1 hierarchical condition category code billed, and (3) at which orders for 3 pay-for-performance quality measures (screening for breast, cervical, and colon cancer) were placed, if due. We looked at changes in outcomes among scribed providers and compared them to nonscribed providers. We used generalized estimating equations with robust standard errors to account for repeated measures and the hierarchical nature of the data, controlling for patient demographics.
Results We examined 41,371 visits to 17 scribed providers and 230,297 visits to 78 nonscribed providers. In adjusted analyses, and compared to nonscribed providers, scribes were associated with an increase of:
- Frutiger LT Std9.2 percentage points in level-of-service 4 or 5 billing (Frutiger LT StdP < .001)
- 3.6 percentage points in hierarchical condition category coding (Frutiger LT StdP < .001)
- 4.0 percentage points in breast cancer screening orders (Frutiger LT StdP = .01)
- 4.9 percentage points in colon cancer screening orders (Frutiger LT StdPFrutiger LT Std = .04).
Conclusions This study suggests that scribes are associated with financial benefit in addition to increased visit volume. Primary care practices should consider the financial benefit of scribes independent of their ability to add patient volume.
Increasingly, medical scribes are used in ambulatory care settings across the United States.1 Scribes are trained personnel who accompany providers during visits to provide documentation support and assist with other administrative tasks. They are associated with reduced documentation time for providers2-6 and improved provider satisfaction,7-11 without detriment to4-16 (or with possible improvement in17-20) patient satisfaction in ambulatory care settings. At the same time, concerns remain that using scribes might inhibit patient communication, harm clinical reasoning, reduce the effectiveness of clinical decision-support tools, and simply serve as a work-around to fixing inefficiencies in the electronic medical record (EMR).21-23
A driving force for the increased use of medical scribes is the expectation that they reduce the cost of providing care. Cost-efficiency is typically described as resulting from a reduction in physician time per patient seen, which allows increased patient volume and, in turn, drives increased physician productivity.2,8,10,18,24-27 Whether scribes result in cost savings remains unclear; some papers suggest that scribes are cost efficient in ambulatory care,2,10,18 while others have been unable to identify cost savings, particularly in primary care.4
One reason why scribes might not be associated with cost savings is that their financial benefit might be undercounted. Studies that focus on increased volume miss the opportunity to capture financial benefits conferred through mechanisms that are independent of seeing more patients:
- Scribes might help providers address and document more, and more complex, medical problems, allowing higher level-of-service (LOS) billing. For example, a provider chooses a lower LOS because they have insufficiently documented a visit to support a higher LOS; by assisting with documentation, the scribe might allow the provider to choose a higher LOS.
- Scribes might prompt a provider to use decision-support tools for risk coding (using appropriate medical codes to capture the patient’s level of medical complexity), thereby increasing reimbursement.
- Scribes might extend the time available during the visit for the provider to address pay-for-performance quality measures, such as cancer screening.
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