The Invisible Work

Of the thousands upon thousands of pages of policy I’ve been reading for school lately about health care reform, one recurring theme is how primary care is going to save healthcare. With our almighty power of coordinating the care of patients, paying attention to their quality metrics, making them do preventive care, switching them to the cheapest generic meds on their health plans, and viewing the latest fancy high tech interventions with our skeptical scientific eyes, we, the simple heirs to the old GPs, favor the time tested and cost effective evidence based care over the shiny and glamorous expensive new stuff that pays for our colleagues' Italian sports cars but makes little difference in the quantity or quality of our patients' lives. In his account of the Affordable Care Act’s design and passage, one of the key advisors in the Obama administration, Dr. Ezekiel Emanuel (Rahm's brother) writes of the role envisioned for primary care doctors in the Accountable Care Organizations (ACOs) incentivized by the ACA:

These providers are organized to coordinate patient care, especially for patients with chronic illness, who account for the vast majority of costs. An ACO is supposed to break down the silos between primary care physicians, specialists, hospitals, home health care agencies, hospices, pharmacies, and other providers. The idea is that by coordinating providers and care, focusing on high-quality and lower-cost interventions and not just on what services are paid for, the ACO will be able to reduce duplication and unnecessary interventions and still keep patients healthy thereby reducing the need for treatments, referrals to specialists, emergency room visits, and hospitalizations. (Emanuel, 2014, p. 224)

He goes on to say:

The ACA will induce better coordination between the hospital and primary physician regarding hospital discharge, better posthospital care at home, and fewer readmissions. (Emanuel, 2014, p. 239)

 The American Journal of Public Health (while noting that expanded access to health insurance is historically associated with between 40 and 100% increase in ER utilization) writes of the hope that the ACA will bring about better “care coordination by engaging with community providers to improve the flow of patients through the continuum of care. Community level discussions between EDs and primary care providers about their respective roles providing acute unscheduled care could lead to national discussions about standard setting and best practice development, which would significantly advance the goals of the ACA “ (McClelland et al., 2014)

When I read this, I'm like, cool. It's nice to get a little credit for doing something that makes so much sense even when the financial incentives all tell me to do otherwise, just because it's the right thing for patients.

That's primary care.

Swimming against the tide, trying to responsibly sustain a profoundly flawed system and do right by our patients since before the Clinton administration.

Then I started thinking about it.

What does this actually look like, this "coordinating care"?

Managing my quality metrics? Staying on top of which medications are the cheapest for the 12 different health plans I am contracted with at any one time.

I'll tell you one thing, these activities are not happening when patients are coming in for scheduled visits. Never once in 20 years have I had a patient say "Hi doc, I just came in today to have you coordinate my care."

Or "My insurance plan's Pharmacy Benefit Manager gets rosuvastatin for $10 less a month than atorvastatin so I scheduled some time for you to review this and check to see if I have any contraindications to changing and if not you can rewrite and fax this to my pharmacy." Or "Hi doc, I know your billing office ran a list of your hypertension panel, I scheduled some time in your day so you and I can go through the list and maybe figure out who to call in, who we think has left the practice, and who has a medical contraindication to tighter blood pressure control."

The American Journal of Managed Care, a mouthpiece for people with reserved parking spots at the front of the hospital garage and who go home at 5, almost gets the point writing “Physicians acting alone will likely struggle to satisfy the PCC goals that are now routinely included in many value-based payment models. Organizational efforts to establish and enable such change are crucial.”(Weissman, Millenson, & Haring, 2017) But then they punch us in the gut by suggesting organizations help train physicians in “motivational interviewing” and practical goal setting with patients, a suggestion so profoundly out of touch with clinicians who have been doing precisely this for decades, that it’s stunning.

No, all of these cost-cutting, quality-enhancing, healthcare-saving activities show up in front of the provider in the form of electronic and paper documents, dozens, sometimes hundreds of them, in between patients, during our non-existent lunches, and at the end of our already exhausting days while our families are eating dinner and kids are going to bed.

And we hate this paperwork(MPH, 2016). We rush through it as fast as we can, literally throwing away what we can so we can get home after 11 hours instead of 12. We resent this work because it's not at all clear that we are actually being paid to do it.

Nationwide, 56% of primary care physicians own their own practices. Of the remaining, the vast majority are contracted employees of larger non-physician owned health care organizations. (PrimaryCareChartbook.pdf, n.d.) While we are starting to see more contracts that experiment with quality incentives, the primary driver for contract terms is unquestionably “productivity” or a specified number of hours of face to face billable patient contact hours per week (“Understanding the Physician Employment ‘Movement,’” n.d.). In the case of a self-employed physician, her salary is driven by what she bills. While codes exist for paperwork and care coordination, historically no insurance company pays these, and submitting separate claims for each of those 50 tasks you dealt with at the end of the day would be both cost and time-prohibitive. So all of this work we do is invisible and happens during unaccounted time.

 Well, it's not entirely unaccounted time. Ask any primary care doctor and they'll have a pretty good idea how much time they're spending on it. So will our spouses.

But importantly, the people who don't see this work are administrators, payers, and patients -- important stakeholders who might be able to do something about this problem, and who might care if physicians suddenly stopped doing this work.

Of course, there's some understanding on the part of the general public that doctors have some office work and there's usually a small allowance for this built into the schedule. But when you ask administrators and lay people about this work, they believe it's time spent on documentation (something I do in the exam room with the patient), or calling patients’ back (something I never do as a matter of policy), or, among the most cynical, sitting on hold with insurance companies (I'll sit on hold 10 seconds maximum before I need to go do something else with my time). The actual work that takes up our time is as invisible as the time it takes. My last contract defined "full time" as 32 patient contact hours per week, when I was easily spending 20 hours a week on non-face to face work, plus on call and hospital rounding responsibilities. Then, after a financial "crisis" hit, "full time" was unilaterally declared to be 36 hours per week by administration, take it or leave it. Many left it.

This shrinking proportion of non-face to face administrative time is a familiar trend across the country. Lean-thinking health care organizations believe they can engineer systems where physicians can stay busy as efficient little revenue-generating engines while administrators hire lower paid non-clinical staff to "coordinate care" and do "population health", largely motivated by value based payment schemes that pay 1% differential for showing better outcomes. But my experience is that without a clinical person advocating for the patient at the center of these efforts, none of it is doing anything meaningful. And since physicians’ only alternative to burnout is to make their work meaningful, they're still taking on the invisible, unpaid, unaccounted for work.

Speaking of burnout...the burnout epidemic has been steadily compounding the already severe shortage of primary care doctors and is threatening the rescue of the healthcare system. Overall, 44% of physicians are now experiencing long term feelings of unresolvable job stress, with exhaustion, felling overwhelmed, cynical, detached from the job, and lacking personal satisfaction. (“Medscape National Physician Burnout, Depression & Suicide Report 2019,” n.d.) For primary care specialties, the figure is around 50%.  More than 50% of physicians surveyed in 2019 have reduced work hours or left their jobs to deal with burnout. Medicine is now the profession with the highest suicide rate in the country. This is seldom mentioned in the policy literature and when it is, it’s a matter of “well we just need to figure out how to pay these people more so more go into it." And to be clear, the ACA does include some financial incentives such as loan forgiveness and expanded funding for the National Health Service Corps to bring people into underserved areas, like the ones I've worked in my entire career. But none of these incentives address the underlying working conditions that are causing physicians to leave by the thousands. The number one most frequently cited reason by primary care physicians who have left practice or are seriously considering leaving is the burden of paperwork and practice management followed closely by the number of work hours, loss of control, and emphasis of profits over patients.

But what if we physicians looked at this work differently?

Instead of an ever increasing intrusion into our personal lives, instead of endless "extra" meaningless busy work tacked onto a day that's already far too long, what if we took this on and said, “Yes, this is where the big gains in quality and efficiency and cost are to be had. This is a critical part of taking care of my patients. I just haven't been given the time or consideration to do this in anything but a totally half assed manner and at great personal sacrifice.”?

On the eve of the ACA’s implementation, October 2011, The Journal of General Internal Medicine published a hopeful article that reviewed the actual data supporting the implementation of the so-called Patient Centered Medical Home, a model of practice that emphasizes exactly the kind of coordinated quality enhancing measures that promote enhanced patient access with a stable clinician, and an emphasis on prevention and chronic care management such as the ACA intended. They found strong evidence that when financial resources were committed upfront in recognition of the infrastructure needed to provide more services, as was done at Group Health Cooperative in Puget Sound, Washington and Geisinger Health System in Pennsylvania, quality outcomes were better, long term costs were lower, and not insignificantly, physicians had lower levels of burnout and higher levels of job satisfaction. (Davis, Abrams, & Stremikis, 2011)

It’s so obvious.

Keeping track of our patients and helping them navigate a system as complex as US healthcare in 2019 appears to be an essential part of providing their primary care and we cannot do this work in time that doesn’t exist. We can agree to manage the hell out of our panels and make sure we have the healthiest, non-wasteful, and most satisfied patients out there. But we need to win over and get buy in from a critical mass of other stakeholders: our employers, our patients, our payers, and our policy makers. We need to stop doing the invisible work that is literally killing us. We need to get them to honor what we offer and pay us to do that as part of our critical work on the front lines of healthcare.



 Specifically, I am writing a policy proposal to examine ways to incentivize organizations to pay physicians to do this work. The Center for Medicaid and Medicare Improvement (CMI) was created by the ACA to investigate alternative payment programs that enhance patient care and cost effectiveness and there are a number of ways they could jump start this. As an example, they might provide enhanced reimbursement to health care organizations that establish programs for measuring and protecting physician office hours for care management. 

This is where I need help from my physician and advance practice colleagues. Policy proposals need to be marketed in order to find success. They need pithy titles and they need to be easily understood by neutral third parties or they go nowhere. I've just spent about 20 paragraphs with 8 citations explaining an idea that is emotional and obvious to any clinician and unnecessary or abstract to everyone else. The most important thing needed right now is a catchy, memorable, and accurate term for this activity, this "paperwork" that has the potential to transform patient care -- not just reviewing labs and consults and hospital reports but figuring out what to do and where to send people and then actually turning the gears of the system to make that stuff happen without having to drag a poor patient in just so I can schedule time to think and write the referral. You know what I’m talking about. The paperwork where a PBM identifies a drug interaction because of something the cardiologist started that affects the antidepressant I’m managing. The time it takes to explain that I agree with the orthopedist the patient saw, that the evidence is clear they won't benefit from surgery and they don’t need a second opinion and another MRI.


“Paperwork” doesn’t cover the idea that it’s meaningful work (and much of it isn't on paper). "Administration" sounds similarly non-essential. “Care coordination” comes closer but it’s sort of vague to a lay person and sounds like something a social worker could do. Maybe "Office hours”. Since this is a policy proposal that potentially would upend how a lot of medicine is practiced, it must be a term that is precise, and rapidly conveys meaning. I think it should be unique to primary care. It needs to go viral.

  What do you call it in your practice?


Every primary care doctor I know is overwhelmed by it and the way it’s falling on them. I've seen too many compassionate hard-working physicians leave their profession and too many patients lose their doctor. We DO make a difference in creating a rational healthcare system that works. It's way past time we address this.

Davis, K., Abrams, M., & Stremikis, K. (2011). How the Affordable Care Act will strengthen the nation’s primary care foundation. Journal of General Internal Medicine, 26(10), 1201–1203. https://doi.org/10.1007/s11606-011-1720-y

Emanuel, E. J. (2014). Reinventing American health care: How the Affordable Care Act will improve our terribly complex, blatantly unjust, outrageously expensive, grossly inefficient, error prone system (First edition.). New York: PublicAffairs.

McClelland, M., Asplin, B., Epstein, S. K., Kocher, K. E., Pilgrim, R., Pines, J., … Rathlev, N. K. (2014). The Affordable Care Act and emergency care. American Journal of Public Health, 104(10), e8-10. https://doi.org/10.2105/AJPH.2014.302052

Medscape National Physician Burnout, Depression & Suicide Report 2019. (n.d.). Retrieved October 23, 2019, from Medscape website: //www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056

MPH, M. T., MD. (2016, October 31). Physicians, paperwork, and paying attention to patients. Retrieved October 23, 2019, from Harvard Health Blog website: https://www.health.harvard.edu/blog/physicians-paperwork-and-paying-attention-to-patients-2016103110558

PrimaryCareChartbook.pdf. (n.d.). Retrieved from https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/PrimaryCareChartbook.pdf

Understanding the Physician Employment “Movement.” (n.d.). Retrieved October 23, 2019, from NEJM CareerCenter website: https://www.nejmcareercenter.org/article/understanding-the-physician-employment-movement-/

Weissman, J. S., Millenson, M. L., & Haring, R. S. (2017). Patient-centered care: Turning the rhetoric into reality. The American Journal of Managed Care, 23(1), e31–e32.