Here is the list:
• Maintenance of certification requirements and testing. This is required every 10 years and one estimate was that the cost to register, take the test, and purchase review materials came to $2,800, with a time investment of about 50 hours. Some specialties are pushing back against MOC, and some physicians are forgoing board certification. Psychiatrists who subspecialize usually do MOC for general psychiatry and all their subspecialties.
• CME. Twenty to 50 hours per year depending on your state, and presumably physicians choose courses that enrich their ability to practice medicine. This can be expensive, depending on how the physician decides to get these credits, and many valuable learning events do not qualify for CME.
• Writing clinical notes. Again, this is part of routine medical care. Notes must justify the CPT codes on insurance claims, and very specific areas of inquiry and examination are needed to justify billing specific codes. Agency requirements may be different from what is clinically indicated for the care of the patient, and this uses some of the appointment time in a way that may not be helpful to medical care. Copying, faxing, or sending notes to other clinicians and time spent requesting records all add to the mix. One psychiatrist noted that the overall administrative responsibilities for seeing patients takes half an hour for every hour spent with a patient. Others estimated that anywhere from 30 minutes to 2 hours per day are devoted to writing notes, and some mentioned doing this in the evening at home. One child psychiatrist with a large high-volume practice noted that he is required to keep charts until a patient reaches adulthood, and that storing, locating, and shredding charts was a time drain.
• Billing the patient. One private practice psychiatrist estimated this takes approximately 8 hours a month, include record-keeping and rebilling patients who failed to pay. Some psychiatrists have a secretary or billing staff.
• Patient insurance. Time spent preauthorizing care, including time spent to preauthorize hospitalizations or to justify each day of inpatient treatment. (No time estimates were offered.)
• Filing claims. The psychiatrists I spoke with who participate with insurers all had support staff to do this.
• Preauthorizing medications. This was by far the biggest complaint by psychiatrists. One noted that it had taken her 2 hours the night before to get a medication authorized; another had spent an hour that day on it. Another rough figure I got was 20-60 minutes a week, and it was noted that preauthorization often is required for very inexpensive medications. Another psychiatrist said her office manager spends a couple of hours a week on preauthorizations and that she had to give her a raise to get her to agree to do it. Personally, I feel insurance companies should not be permitted to divert physician time away from care for inexpensive medications. Does it really make sense to have a physician spend 20 minutes of uncompensated time getting authorization for a medication that costs $10 a month?
• Paperwork related to being credentialed with insurance companies. This was estimated at 40 minutes every 3 months.
• Credentialing. Cost and paperwork for malpractice insurance varies by state and, some malpractice agencies require doctors to do specific forms of training. In addition, practicing requires renewal of a DEA number, CDS renewal (in Maryland), and state licensure.
• Electronic medical records (EMR). Medicare has provided financial incentives to doctors for the meaningful use of certified electronic health record (EHR) technology to improve patient care and now penalizes doctors who do not have this technology. One psychiatrist told me that she spent hundreds of hours working on this, but something went wrong so she is still penalized. Another said she spent 3 hours in a 3-month period attesting to her compliance with meaningful use. Everyone I spoke to said using an electronic record – related to Medicare’s meaningful use or not – increased the time it takes them to write notes. One psychiatrist reduced her clinical care to 1 day a week, and I left a community clinic when the effort of learning to use EPIC overwhelmed me.
• E-prescribing. One colleague in New York wrote, “E-prescribing takes up a lot of time, especially since I don’t do it during sessions. For a noncontrolled medication, it’s maybe 4-5 minutes per prescription. For controlled, it’s 3-4 minutes more, because I have to check I-STOP and use the token, and then record the I-STOP number. And for all prescriptions, I hand write an entry in the medication record, just for backup.” She noted it took several hours to set up the system. Most psychiatrists still spend significant time calling in prescriptions that patients have forgotten to request during appointments, and pharmacists often call to have refills authorized. This can be quite time consuming, and sometimes refills are requested automatically for medications the patients no longer take, and time spent on hold can be significant. My own experience was that e-prescribing took significantly longer than paper prescribing, and that handing a patient a prescription during a session is simply part of medical care and not a “drain,” per se.