Tuesday, June 28, 2011

The Evils of Admin

Business Planning Begins

I've been working on the business plan a bit the past few days. I am reading and reading about software for electronic medical records, electronic pharmacy prescribing, and policies needed for a private practice office amongst other things. My general conclusion is that health care is complicated out there, and it is amazing that we once traded services like a chicken for a cast. I think we went too far. I did read about one doc in Brooklyn who does house calls for fee for service and only takes PayPal. Apparently enough people either do not have health care or are so sick of the premiums that they prefer to go that route. I get that.

My husband seems a bit perplexed as to why I am starting to work so hard on this endeavor. I tell him about the myriad discoveries I unearthed; he tells me, "There are only a few forms we need. We can get them when (the time) its closer." It seems all of this mumbo jumbo I am wading through is either misleading me to "cover my ass" or my husband is underestimating what we should have organized and laid out for our office policies and planning.

I'd say I am more of the "let's try the monkey bars, oh, oh, let's try the swing, oooh, the tire swing!" but I am still on the playground kind of person. I like to know the limits, the edges, the options, the ups, the downs- ok, I like to read all of the details so I can assess wiggle room. I want to be able to ask the very expensive lawyer reasonable questions, if needed, when the time comes to set up the practice. If I waited until then, to get my head around what a practice is or should be, the details would not stick to anything. It is probably a good thing we ended up together- I worry about too much; he worries about nothing.

Navy Medicine Experiences

We've enjoyed a long run of socialized medicine courtesy of the U. S. Navy. We've had few premiums, co-pays, or access concerns. You just show your ID card and make an appointment. Sometimes you have to call a few times, but there is no fear of debt. On the other side, the worker bee side that is, there are few options to say "no" to more work. Usually the work you get to say "no" to is patient care since there is so much "admin" that needs to be done. Yes, take half of a day off of your clinical schedule so you can attend a meeting or collect statistics from your clinic and write up a justification for the eighth time as to why you need more help- a favorite at our dinner table. Let's just say the attitude is more "keep your head down, suck it up, do the real work of seeing patients because you know they are never going to send more help and that time you spend redoing all of the bullets they need, that aren't going anywhere, that time could mean you see your kids conscious instead of asleep for once."

If Navy medicine from a provider perspective just stopped trying to be like the big business civilian counterparts on the admin front, it might find it has more resources for patient care. From a patient perspective, I was disappointed to hear that two of the Surgeons that made "Captain" this year are not even Board Certified, but I bet they do a lot of "admin."

Recently there was an article about how "everything is on the table" for military health care changes because the Navy is so overburdened flighting wars and the budget is not keeping up so they are looking for ways to reduce costs. Some administrator should consider slashing admin work and time to an arbitrary number of say twenty percent and free the other eighty percent of the assets- time, docs, budget, etc.- for patient care- start living up to that "patient centered health care" motto.

I wish I could give you the real numbers, like charities do, to show how much money is spent administering versus doing patient care. I hope that before they start asking active duty personnel for their co-payments in the battle field, that they at least contemplate reducing admin loads. Big Navy is in position to say "no" to some of this admin stuff. If the kool-aid is that spending all day in admin is good, the target is, umm, patient care. Kind of hard to stay on target when you are swimming in the kool-aid.

I've got no complaints with the care or docs, but if the program costs too much, slash the admin work. Docs are pressued into taking on extra duties and committees for the "all is well" side by side comparisons to civilian business model. Doesn't Big Navy know that if it were a business, the stockholders would have sold their ships out from under them?


  1. I totally agree with your assessment. There are some major problems with Navy medicine, namely the insistence that a care-giving entity should act like a Surface Warfare model. In all branches of the military, one only advances if he or she can show "leadership". Personally, and I think you probably agree, leadership for doctors means outstanding patient care NOT collateral duties/admin work. An artillery guy in the Marines might take a desk job after 10 years of field work-but he's still developping his skills (tactical and leadership) in an admin position. Not so for a doctor. He must abandon the patient, his prime concern, to climb a ladder that he wasn't trained to climb in the first place. I can't believe that the Navy pays some of its specialists the bonuses they get and they haven't seen patients in 15 years! I can't believe those who can't be bothererd to be professionally accredited (or who can't pass muster) can advance to capitain! Talk about drinking the kool-aid! What is needed is a complete overhaul at the highest level of Navy Medicine--a complete rethinking which would treat the military hospital system as separate from the rest of the traditional military structure. Doctors and nurses promote because of patient and peer reviews as well as because of their professional accreditations. Admin officers are promoted for facilitating the doctor's/nurse's best care to the patient, as well as executing sound budgetary policy and complying with national safety standards. Like the Mayo clinic, if each Navy clinic had dual captains (one a doc and one a trained admin person), Navy medicine would be stronger than and the envy of anything it now tries to compare itself with in the civilian world.

  2. There is much to do, but the rumbling is in the ranks. I fear there is no Champion to lead the charge. Rats always know to flee a sinking ship. I wonder how the Navy is doing on the recruiting & retention of docs front?

  3. > It is probably a good thing we ended up together- I worry about too much; he worries about nothing.

    Isn't that just marital fit - he'd do more worrying if he didn't have you to do all the worrying for the team. Tell him you're having a day off and it's his turn to do bear the burden of doing some worrying. :-)

  4. I am not one to shy away from things I think about and a big chunk of my life is courtesy of USN Medicine so it goes that these thoughts percolate into my life. I am also a nurse and ANY hospital that is, is because patients need NURSING services- otherwise patients could just go to the clinic and see the doc. The point is that there are many aspects to medical care- nursing, medical, lab, administrative, etc. My particular whaling is that before the Navy threatens to make active duty members and their families pay for medical services so we can keep up with the civilians and their co-payments, the Navy should consider some of the resources (doctors, nurses, and others doing admin) not being utilized for patient care. The problem with admin is that there is never enough time for all of the admin that can be dreamed up! Fabulous as it is, it is not the point, patient care is the point. Some docs, some nurses, and some others do go on to champion admin causes and bless them for their work, but the Navy is not a business, it is a public service & it does not make money. Part of the conversation that is missing is about the difference between a public service and a business which more and more seems to be getting mixed up- so we get food corporations deciding on nutrition charts, drug companies running drug trials, less oversight for the public whether its the EPA or some other public protectorate, and Navy Medicine trying to run itself like a business. How about a dual track for docs & nurses- admin track & professional track- where you can at least continue with being a doc or a nurse focused on clinical outcomes, patient care, and professional development like presenting at national meetings, getting published in peer review journals, training residents, and generally providing expert medical or nursing leadership in specialty areas- that is lacking at present. Without clinical leaders to train residents you have civilian docs filling in that are clueless about military needs or issues- example, I filled out my overseas screening at Bethesda for my civilian fill-in who was clueless- that doesn't work either. Too many thoughts for this comment, but perhaps a few more will eventually work their way into this blog again. If I made you think even a tiny bit on this subject, then we have opened the thought of change some small smidgen somehow I think.


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