Administrative Burden and Burnout in the COVID-19 Era

By Robert Hall, JD, MPAff

Like many of us, I’ve been speaking on more webinars lately, and one of the points I try to make as often as possible is that practice-level chaos is rampant.

Not the chaos caused by actually caring for patients, but the chaos caused by payers. This chaos is even more pronounced in a crisis like COVID-19, when policies are changing rapidly and weren’t uniform to begin with. I worry about the impact of this chaos on patient health and on the health of physical therapists.

I have found no studies examining the connection between the bureaucratic mess caused by multiple payers at the practice level and burn-out, but from anecdotal examples, I know that the vagaries of payer policies can be maddening for health care professionals. The practice profile survey from APTA shows that physical therapists in direct patient care roles conduct a little more than 50 visits per week, seeing around 30 patients. That means the possibility of having to conform with 30 different payers’ rules in order to be paid for providing high-quality physical therapy services. I’m certain that these challenges contribute to physical therapist burnout.

According to the FSBPT (Federation of State Boards of Physical Therapy), “The first systematic empirical studies on burnout were published in the late 1970s and early 1980s. It has been defined since then as physical or emotional exhaustion due to overwhelming workplace demands, usually as a result of prolonged stress or frustration.”¹ The Maslach Burnout Inventory (MBI) is the gold standard for assessing burnout, but it does not include questions about how many different payer rules you may be following. First published in 1981 and the primary basis ever since for most burnout research, the MBI includes 22 questions that measure three dimensions of burnout — emotional exhaustion, depersonalization, and feelings of low personal accomplishment.² I’m hoping you’ll take a moment to conduct the survey to determine how significant burnout is in your practice.

One of the most distressing aspects of the burnout survey is the research that proves that extreme burnout undermines patient care. Called “depersonalization,” this phenomenon occurs when clinicians feel distant and indifferent from patients. It also occurs when physical therapists feel like what they’re doing doesn’t matter. I can only imagine that this feeling amplifies when endless utilization management calls and prior authorizations are required before any real patient care can be accomplished or to navigate the Byzantine labyrinths of each payer to finally trigger payment.

So, what can be done about insurance policies that are amplifying burnout? Policies that are inadvertently amplifying burnout must be changed. The Affordable Care Act (ACA) required enormous changes in the way that many types of insurance worked with significant changes to make insurance more like a public utility than a loosely-regulated industry. We all know some of the policies on the list, including bans on exclusions for pre-existing conditions, requiring the coverage of essential health benefits including “rehabilitative and habilitative services,” caps on out-of-pocket expenses, no co-pay coverage for preventive care, and clearer disclosures to patients. However, one of the policies that may actually be exacerbating burnout in the physical therapy profession is also commonly touted as an important and helpful policy by ACA supporters. Many physical therapists believe that some of insurers’ heavier reliance on utilization management was originally created to try and make insurers spend more on actual health care – what insurers paradoxically call a “medical loss.” The Medical Loss Ratio (MLR) section of the ACA was implemented with regulations that have created a catch-22 allowing utilization management to be included in the same category as patient care (as opposed to insurers’ administrative overhead) when examining how many medical loss dollars are being sent to you as payment. Because insurers are generally loath to send back refunds to their members, some have plowed more resources into UR (utilization review) programs to stem their losses. MLR regulations need to be adjusted to address this problem.

Second, insurers need to be held to uniform standards of practice to smooth interactions with clinicians. It has been sadly unsurprising to see the scramble that many insurers have undertaken to try and pay for physical therapy provided via telehealth during the first wave of the pandemic. Some require specific codes to include a modifier (that violates CPT rules), others require that telehealth place of service codes be listed as “clinic” (even though a telehealth place of service code exists), and almost every insurer recognizes a different CPT code set for payment of telehealth services. I actually don’t fault insurers for much of this variation as everyone was scrambling at the start of the pandemic to make antiquated systems function. Like everyone, insurers shoe-horned strategies to try and help. But by now, payment should be much more uniform to make it easier for you to receive payment and patients to receive the right care.

Third, insurers need to recognize that their administrative hoops come at a cost and support payment for the hassle that these burdens create. From the signature requirement on plan of care documentation to variations in prior authorization policies, the most comprehensive way for burden to be decreased is to align all of the incentives in a health system to the health of the patient. This type of payment change was contemplated by Accountable Care Organizations in the ACA, and is being implemented under rules created by the highly-bipartisan Medicare Access and CHIP Reauthorization Act passed way back in 2015. These flexibilities need to be updated to adequately include physical therapists and eliminate all the unnecessary paperwork that catalyzes burnout throughout the profession. Ultimately, burnout could be stemmed with payment structures that recognize that keeping patients healthy is the ultimate goal of the health system. 

References:

¹Berry J. Occupational Burnout in Physical Therapy: Clinical Implications and Strategies for Reduction. Federation Forum. https://www.fsbpt.org/Portals/0/documents/free-resources/Spring2018ForumOccupationalBurnoutinPhysicalTherapy.pdf. Accessed June 15, 2020.

²Maslach C, Jackson SE. The measurement of experienced burnout. J Occupa Behav. 1981;2:99-113. https://onlinelibrary.wiley.com/doi/pdf/10.1002/job.4030020205

Robert Hall, JD, MPAff, is a senior consultant for PPS working to advocate with private payers. He may be reached at rhall@ppsapta.org.