Can anything good arise from a heinous act?
I will make no cheeky comments about the recent murder of United Healthcare CEO Brian Thompson in Manhattan. Social media is already full of them. For my part, the end does not justify the means. A wife is now a widow; two boys have lost their father. It's a tragedy. Full stop.
Judging by the sheer volume (and virulence) of the anger expressed on social media vis-a-vis the insurance industry generally and toward United Healthcare in particular, it's distinctly possible that lawmakers at both the state and federal levels may (finally!) more closely examine (and hopefully rein in) the most egregious practices of United and other commercial health insurers. If that were to happen, it would be a boon to patients, hospitals, and clinicians. Indeed, I believe a major contributor to burnout among clinicians and hospital administrative staff is the structural, unrelenting stress caused by insurance industry practices. I'll return to this observation (and the evidence behind this assertion) later in this blog.
But first...
There is much to dislike about United Healthcare and, more broadly, the commercial health insurance industry in the US. The largest health-related company in the US (it's number 5 among ALL companies on the Fortune 500 list), United Healthcare Group reported revenues of $372 billion in 2023. Its insurance arm is notorious among patients and providers (both hospitals and physicians) alike for its aggressive approach to prior authorization and claims management. Indeed, at 30+%, United's claims denial rate is about twice the industry average (around 16.6% across the ACA marketplace). United's denial rate for post-acute care rose from 10.9% in 2020 to 22.7% in 2022. Other large insurers have also reported an increase in denials for post-acute and other services. Meanwhile, with almost 10 million Medicare Advantage subscribers, United Healthcare controls about 30% of the MA market across the US.
A 2022 survey by the American Hospital Association showed that 95% of hospitals reported increases in staff time spent navigating prior authorizations, some 62% of which were subsequently overturned on appeal; 50% of initially denied claims were also successfully overturned by hospitals on appeal. Think of the waste, both in terms of administrative and opportunity costs incurred by hospitals and physician practices as well as the physical, psychic, and financial costs to patients. Not surprisingly, given the almost flexive prior authorization hassles orchestrated by Medicare Advantage plans, about 16% of US hospitals plan to stop accepting Medicare Advantage plans within the next 2 years; another 45% are considering dropping MA contracts but have not made a final decision.
Let's be clear: health insurers do not manage care. They manage costs. The biggest and most efficient way for an insurer to hold more of the health insurance premium and reduce the insurer's cost is by reducing the outflow of payments to providers.
What's this got to do with burnout? Everything.
As readers of this blog and/or persons already active in the clinician burnout space already know, Maslach and Leiter decades ago identified 3 manifestations and 6 drivers of burnout:
MANIFESTATIONS
Exhaustion (physical and/or mental);
A feeling of inefficacy (e.g., "I feel powerless to act in the best interests of my patients", or "I am so frustrated that a third party is deliberately adding unnecessary time, steps, and costs to what ought to be a straightforward process"); and,
Cynicism ("What's the use of even trying? I'm just going to go through the motions because the insurance system over which I have no control is rigged against clinicians and patients.")
DRIVERS
Excessive workload and lack of resources
Lack of control (over decisions in one's role/responsibilities)
Insufficient reward or recognition (including intrinsic/psychic reward)
Loss or damage to community (workplace conflict eroding a sense of belonging)
Perceptions of unfairness
Values mismatch (between the individual and the organization or practices)
One does not need to be a rocket scientist -- or a clinician -- to see the connection between the commercial health insurance industry practices and clinician (and support personnel) burnout. Plainly put, the penchant for commercial health insurers to recreationally delay approvals and/or deny claims can and do contribute to at least 4 of the drivers (workload, control, unfairness, values) and all 3 manifestations of burnout. Don't take my word for it.
Here are the results from the 2023 AMA Prior Authorization Survey by the American Medical Association:
• 95% of physicians report that prior authorization somewhat or significantly increases physician burnout.
• 1 in 4 physicians report that prior authorization has led to a serious adverse event for a patient in their care.
• 94% of physicians report that prior authorization delays access to necessary care.
• Physicians and their staff spend 12 hours each week completing prior authorizations.
• 35% of physicians have staff who work exclusively on prior authorization.
The judicious adoption of AI -- both in the EHR and revenue cycle/claims management systems -- by provider organizations can be a helpful countermeasure. Such an investment will make a meaningful difference but it will not alone "cure" multi-factor burnout. A true "cure" will require making systemic changes to the clinical work environment and work practices by hospitals, health systems, and medical group practices; AND by successfully addressing noxious commercial insurance industry practices.
Solutions for Hospitals, Health Systems, and Medical Group Practices: Leadership-Driven Changes
The locus for curing clinician burnout and staffing shortages runs through the C-suite. Here are examples of leadership-driven changes to the workplace that my colleague Paul DeChant, MD, MBA and I often recommend:
> Regard clinicians as knowledge workers who are given significant latitude to make clinical decisions without unnecessary administrative encumbrances or delays
> Consistently apply one or more of the improvement sciences (Lean, Six Sigma, operations research, agile, design thinking) in consultation with front-line staff to improve workflow and reduce delays, waste, inefficiency, and job skill mismatches
> Expect all leaders, but especially senior executives, to do periodic job shadowing of front-line staff (where observing and deep listening are emphasized) in lieu of "rounding" (a largely ineffectual, if widely practiced activity)
> Create and require leader standard work (LSW).
> Develop and deploy a sophisticated, deeply ingrained, and rigorous daily management system (DMS) supported by visual display boards or monitors
> Judiciously invest in AI/ML solutions -- selected, tested, and endorsed by front-line staff -- that eliminate or at least markedly reduce data entry, administrative requirements, and/or repetitive tasks that are non-value add
> Support near-continuous optimization and remediation of the EHR (there's no such thing as "it's all set")
> Get rid of superfluous or outdated policies, procedures, redundant approvals, and other stupid stuff (GROSS)
Ready to transform your hospital or workplace?
Are you frustrated by adversarial relationships between front-line clinicians and senior leadership? Organizational Wellbeing Solutions was formed to enable senior leaders to identify the specific drivers of clinician burnout in their organization; and to support leaders in designing and executing a comprehensive plan to stop clinician burnout, increase retention, and improve operating results. A hallmark of our consultancy is correcting the all-too-frequent distrust and alienation Clinicians feel toward the C-Suite generally and the CEO in particular. Let us help you help your organization and its clinicians develop a more trusting, aligned, and productive working relationship.
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