Financial impact of scribes

[JMC2010]

Does anyone have any information (research or anecdotal) regarding the financial impact of scribes on community docs? I have been looking for the last week and there doesn't seem to be much out there.

We have the option of having scribes and the $19/hour comes out of our RVU bonus (our group: set hourly rate, quarterly RVU bonuses).

Our shifts are 9 hours with 1 hour of overlap at the end. So figure 8 hours x 16 shifts (my usual) =$2400/month x 3 months =~$7500 from my quarterly bonus.

The data I have seen suggests 0.8 patients more per hour with a scribe. One paper mentioned 1 extra RVU /hour.

What has your experience been? Earn more, break even, lose money? Lose money but happier in the end?

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[DocEspana]

Literally just had a medscape article about this. http://www.medscape.com/viewarticle/820716 obviously need a medscape sign in to read this, but sign in is free for physicians.

 

[JMC2010]

Yeah, I saw that article however it's not specific to EM and the financial example they use is for a primary care office.

 

[namethatsmell]

One of our community sites has scribes. I don't have exact numbers, but the docs pay slightly less than what your describing and they all insist it helps them generate extra $ to cover the cost. Additionally it prevents most of them from needing to stay late to chart or do so at home.

FWIW, most of the docs there absolutely love having scribes.

 

[Lex81]

I think scribes are a great idea in theory. Your charting goes down exponentially, your charts to be done are greatly decreased at end of shift, you might be able to pick up another pt than usual, and they are usually very enthusiastic premeds who are pleasant to be around.

However, I think they can be very dangerous medicolegally. I've developed a what I think is relatively safe practice style, though structured around validated EBM and decision rules to back up a minimalist approach. The caveat is that the chart must reflect this, and unfortunately college students or even people early in their medical career just don't see the importance of charting something like "no hemoptysis" for PERC r/o, or "equal pulses b/l" for dissection r/o. You get what I mean. I worked a shift or 2 as a per diem w/ scribes and initially was enthusiastic about the potential for decrease charting, but beware, you are potentially opening the doors to medicolegal nightmares if you don't go through their notes with a fine toothed comb. At the end of the day, I've found its just quicker to chart yourself. But if you want to roll the dice so to speak, they will certainly cut down on your charting at the end of the day.

 

[deleted6669]

However, I think they can be very dangerous medicolegally. I've developed a what I think is relatively safe practice style, though structured around validated EBM and decision rules to back up a minimalist approach. The caveat is that the chart must reflect this, and unfortunately college students or even people early in their medical career just don't see the importance of charting something like "no hemoptysis" for PERC r/o, or "equal pulses b/l" for dissection r/o. You get what I mean. I worked a shift or 2 as a per diem w/ scribes and initially was enthusiastic about the potential for decrease charting, but beware, you are potentially opening the doors to medicolegal nightmares if you don't go through their notes with a fine toothed comb. At the end of the day, I've found its just quicker to chart yourself. But if you want to roll the dice so to speak, they will certainly cut down on your charting at the end of the day.

AGREE. my notes are much better than the scribes. you also pay them for the whole shift regardless of volume so you may be paying some 22 yr old kid 15-20 bucks/hr to watch youtube for a few hrs....

 

[doctorFred]

agree. i hate working with scribes. i'm a little more anal retentive, and in all honesty, my charting is often sparse, but when it comes to specific documentation from a medicolegal perspective (why i'm not working up X, in my own very intentionally chosen wordage), i want to write the chart myself. even if i dictate what i want the scribe to write, i'd have to double check it all afterwards.

i worked with scribes for a few shifts. never again. it's not worth my paranoia and needing to go back over every chart they document. it kind of defeats the point.

also, you have the occasional patient who's there for an ingrown toenail and you get an "oh by the way, i had some chest pain a few months ago.." as i'm discharging them. there are some things you just don't want to document.

 

[Birdstrike]

Interesting "confessional" post by a scribe on KevinMD recently, about being pressured to buff charts:

www.kevinmd.com/blog/2014/03/confessions-medical-scribe.html

 

[Arcan57]

$19/hr sounds very high for a scribe.

The economics of a scribe program are going to be based on a mix of improved charting from a billing perspective (which is highly variable depending on scribe and doc) and improved patients per hour vs. cost of the scribe. Having a scribe makes the most sense when the doc is the rate limiting factor in seeing patients. In those cases, I think of it as the step before adding additional midlevel coverage. If the doc is not the rate limiting step, there's very little economic incentive from the individual practitioner's standpoint. If you're paid hourly and you can bill for staying over on your shift, it may make since for the group to pay for a scribe if it shortens your time after shift by an hour or so.

 

[JMC2010]

Hmm, a net negative response to scribes? I'm surprised. Anyone out there psyched about their scribes?

 

[Hercules]

Hmm, a net negative response to scribes? I'm surprised. Anyone out there psyched about their scribes?

I have worked a good bit with scribes and a good bit on my own. I feel the same way about scribes that I do about midlevels. Great ones help and bad ones increase my work load. A great scribe that knows me and my preferences is a huge help. They make my quality of life at work exponentially better and enable me to keep seeing patients without getting behind on charting. A bad scribe takes so much time to teach and correct that I may as well do my own charting.

 

[Janders]

I am sure if I had a scribe, I could see a couple more patients a shift.

However, where are these patients coming from? We have a set number of patients a day. I don't think adding a scribe would let me cut our physician staffing. So we'd just be adding a cost. We already, as a group, chart very well vis-a-vis billing, so I doubt they would add much on that side. They would let me go home 30 minutes earlier most likely... except I need to proof read their charts! hrm.

Now if our volume went up 10-15%, and we were thinking of adding more physician/PA hours, perhaps adding scribes would be worth if from a financial perspective. Gotta be the right sized shop for this to work.

And like the above posters, I can be very particular in the diction I use in my charts, especially as far as informed consent and mutual risk-taking / patient deferring testing.

 

[JMC2010]

Yeah our volume is climbing and we are struggling to find ways to cope. We have hired several new PA's, but they are totally green. Our LWOTs are hovering in the 5-8% range...not good

 

[Janders]

Yes, in your case scribes could be a totally reasonable move.

 

[anbuitachi]

Yeah our volume is climbing and we are struggling to find ways to cope. We have hired several new PA's, but they are totally green. Our LWOTs are hovering in the 5-8% range...not good

I dont know much about practices, but how do PAs usually help with seeing more patients?? Don't the doctors have to see them anyway even if the PA saw them? What do they do that justifies adding 100k/PA salary onto your budget cost?

 

[Birdstrike]

I dont know much about practices, but how do PAs usually help with seeing more patients?? Don't the doctors have to see them anyway even if the PA saw them?

The physician doesn't necessarily have to see each PA patient, but to bill a full physician charge, they do. If the physician doesn't see the patient at all, you can't bill the full fee (not supposed to, anyways). Either way, there's always a physician name on a PA chart taking responsibility as "supervising," whether they've seen the patient or not. Even if there's no physician name specifically on the charge, there's always a general default "supervisory physician" who's on the hook for that specific PA.

What do they do that justifies adding 100k/PA salary onto your budget cost?

They have to either generate enough collections by seeing extra patients you wouldn't be able to see on your own, to pay their own salary, or ideally, generate more than that.

 

[Greenbbs]

You guys realize you're supposed to double check the scribe charts when they're done before you cosign them, right? It shouldn't matter who the scribe is. They're trained to basically create dictated charts based off your conversation with the patient and what you instruct them to put in it. If you want to be specific about MDM points and why you do or don't do something, just tell them when you're dictating things to them. If they're not doing this appropriately on a consistent basis, then you need to seriously re-evaluate your scribe program and the training they're getting. They get paid to do that, not interpret things in a way that they see fit.

We've had scribes for 3 years. I can't put a value on the level of added efficiency and personal satisfaction that knowing I'm not sitting in front of the computer doing busywork gives me. When I'm waiting for labs, etc, I go over my scribes charts. I'll add in whatever I think is necessary to make the chart better, but 90% of the time (and I may be unique, but I don't get the fresh off the boat scribes in our group...I only get the veteran ones due to how I function and work) I don't have to do much. I also am extremely specific in how I word my MDM, etc, and the scribes I work with all know that, so whatever I say, goes in the chart.

If you utilize the scribe appropriately, they're fantastic.

 

[anbuitachi]

The physician doesn't necessarily have to see each PA patient, but to bill a full physician charge, they do. If the physician doesn't see the patient at all, you can't bill the full fee (not supposed to, anyways). Either way, there's always a physician name on a PA chart taking responsibility as "supervising," whether they've seen the patient or not. Even if there's no physician name specifically on the charge, there's always a general default "supervisory physician" who's on the hook for that specific PA.



They have to either generate enough collections by seeing extra patients you wouldn't be able to see on your own, to pay their own salary, or ideally, generate more than that.

Oh cool I didn't know PA can see patients w/o doctor supervision. I remember always getting pissed when i book an appointment with dr. blah, and end up seeing his PA and not even seeing the doctors face. I guess it is allowed..

 

[Birdstrike]

Oh cool I didn't know PA can see patients w/o doctor supervision. I remember always getting pissed when i book an appointment with dr. blah, and end up seeing his PA and not even seeing the doctors face. I guess it is allowed..

Technically there must always be some form of "supervision." That doesn't necessarily mean the doctor physically sees the patient, but must be available in some form to discuss the case, ie, seeing patients side by side, or at least available by phone if at another location. This allows for the concept that a very simple case, easily handled by the PA does not need direct "in the room" supervision, but that as cases increase in complexity, the PA may need increasing levels of "supervision." This all hinges of course on two things, 1-A properly trained astute PA that knows when he/she needs help and when not (that's goes for all of us actually) and, 2- A doctor that is willing and available to provide whatever level of supervision the PA needs or requests. Otherwise, if the doctor needs to redo everything the PA does, the whole concept of "physician extender" falls apart.

Then from a medical-legal standpoint, even if a PA is work in complete isolation somewhere, on some computer screen or sheet of paper there is a "supervising physician" designated for that PA or group of PAs. Even if it's the ED director, the doc who signed up to be "chief of PA program", or whoever. Don't ever think, "The PA did it on his own," is a valid defense for anything. It is not.

Physicians have had their practices shut down and lost their own licenses for being the supervising doctor for improperly or unsupervised PAs in many cases now. (Those that come to mind are mostly outpatient; I can't think of any ED cases like this off the too of my head.)




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[bougiecric]

Any of you catch this article about scribes on kevinmd?

The disturbing confessions of a medical scribe

Where I'm at, the scribes are instructed by their corporate overlords to ALWAYS do a full ten point ROS. It's killing me. I constantly have to go over their charts to remove ROS elements, especially on complaints that are obviously not meant to be billed at level 5.

EDIT: Saw above that Birdstrike beat me to this article. Well worth a read because I think "up-charting" by scribes is likely prevalent.

 

[TooMuchResearch]

Any of you catch this article about scribes on kevinmd?

The disturbing confessions of a medical scribe

Where I'm at, the scribes are instructed by their corporate overlords to ALWAYS do a full ten point ROS. It's killing me. I constantly have to go over their charts to remove ROS elements, especially on complaints that are obviously not meant to be billed at level 5.

EDIT: Saw above that Birdstrike beat me to this article. Well worth a read because I think "up-charting" by scribes is likely prevalent.

One of those daily/weekly ACEP email lists linked to an article about scribes and fraudulent charting today.

 

[deleted6669]

I dont know much about practices, but how do PAs usually help with seeing more patients?? Don't the doctors have to see them anyway even if the PA saw them? What do they do that justifies adding 100k/PA salary onto your budget cost?

how many of a PAs pts are seen by a doc is related to the relationship and trust between the doc and the PA. With new PAs, seeing every pt makes sense. With someone who has been a PA for many years and with whom you have worked for years and whose practice style you know it makes less sense. In my group, the doc who cosigns the chart at the end of the day gets 50% of the RVU production bonus for that pt. so a doc working with 2 PAs basically doubles their production for that shift and may not ever see a pt. seen by the PA. I have been doing this for a while and, although not unwilling to present a case if needed, don't do so on a regular basis. Most of my shifts now I work solo and the only calls I make are specialty consults or when it's time to call the hospitalist to do the admit. Every year the PAs billings put several million dollars into the pockets of the physician partners in my group. If you pay someone 50-75/hr + benefits and they are generating significantly more it adds up to a lot of profit for the docs. One of my PA partners puts it this way: every year the PAs buy a new BMW for each physician partner. Courts recently have been willing to hold PAs entirely responsible for their actions if they did not involve a physician in the pts care with physicians being dismissed from these cases.
see this case in VT. : http://www.beckershospitalreview.co...oper-conduct-rules-vermont-supreme-court.html
I think this is appropriate. if a pa makes all the choices and they are wrong I belive the doc should be out of the loop when blame is handed out.

 

[Birdstrike]

how many of a PAs pts are seen by a doc is related to the relationship and trust between the doc and the PA. With new PAs, seeing every pt makes sense. With someone who has been a PA for many years and with whom you have worked for years and whose practice style you know it makes less sense. In my group, the doc who cosigns the chart at the end of the day gets 50% of the RVU production bonus for that pt. so a doc working with 2 PAs basically doubles their production for that shift and may not ever see a pt. seen by the PA. I have been doing this for a while and, although not unwilling to present a case if needed, don't do so on a regular basis. Most of my shifts now I work solo and the only calls I make are specialty consults or when it's time to call the hospitalist to do the admit. Every year the PAs billings put several million dollars into the pockets of the physician partners in my group. If you pay someone 50-75/hr + benefits and they are generating significantly more it adds up to a lot of profit for the docs. One of my PA partners puts it this way: every year the PAs buy a new BMW for each physician partner. Courts recently have been willing to hold PAs entirely responsible for their actions if they did not involve a physician in the pts care with physicians being dismissed from these cases.
see this case in VT. : http://www.beckershospitalreview.co...oper-conduct-rules-vermont-supreme-court.html
I think this is appropriate. if a pa makes all the choices and they are wrong I belive the doc should be out of the loop when blame is handed out.

We went over that case on a different thread. It's a board of medicine case, not a malpractice case. It would have zero bearing on malpractice. I think any doc that thinks he's absolving himself of responsibility by not seeing a patient that his PA (his "assistant") sees, is kidding himself.



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[anbuitachi]

So it is legal for a PA to just see the patients, and the doctor to wake up at 5pm come in the office and sign off all the charts? I've seen several doctors have multiple clinics, with PAs handling the clinics that they aren't at.

 

[SeekerOfTheTree]

So it is legal for a PA to just see the patients, and the doctor to wake up at 5pm come in the office and sign off all the charts? I've seen several doctors have multiple clinics, with PAs handling the clinics that they aren't at.

Wait till NYtimes hears about this...

 

[deleted6669]

So it is legal for a PA to just see the patients, and the doctor to wake up at 5pm come in the office and sign off all the charts? I've seen several doctors have multiple clinics, with PAs handling the clinics that they aren't at.

"Supervision" in many states means a % of charts reviewed within 1 month without a doc ever required to be on site. the doc reviewing the charts has to have a license in the same state and work in the same specialty as a pa ( a neurosurgeon couldn't review charts for a primary care or em pa for example). In NC (the "best" PA state) supervision = doc talks to the pa about their practice every 6 months for 30 minutes. that's called lunch or a round of golf. no chart review at all.
I have several friends working in very rural settings in alaska with no doc within 6 hrs by plane. the docs review the charts online and are available for phone consults. at 2 out of 3 of my current jobs I work without a doc on site. at the 3rd job I alternate charts with a doc from the same chart rack regardless of acuity. I should mention that the docs at all 3 of these jobs are FP, not EM, boarded for the most part, so my level of care is compared to an FP doing EM, not an EP doing EM. I'm well aware that most residency trained/boarded em docs could do my job better than I do. At the same time, I think I do it better than most fp docs. . in a perfect world every E.D. would be staffed 24/7/365 by a residency trained and boarded em doc. not gonna happen anytime soon.in the meantime a solid em pa > most non-em docs> most NPs.
I'm really surprised you guys don't know more about pa practice laws. you aren't surprised that NPs with significantly less training than we have can work in this fashion, but anytime someone mentions a pa working without a doc around it's like a major newsflash. We've been doing this for almost 50 years folks....

 

[anbuitachi]

"Supervision" in many states means a % of charts reviewed within 1 month without a doc ever required to be on site. the doc reviewing the charts has to have a license in the same state and work in the same specialty as a pa ( a neurosurgeon couldn't review charts for a primary care or em pa for example). In NC (the "best" PA state) supervision = doc talks to the pa about their practice every 6 months for 30 minutes. that's called lunch or a round of golf. no chart review at all.
I have several friends working in very rural settings in alaska with no doc within 6 hrs by plane. the docs review the charts online and are available for phone consults. at 2 out of 3 of my current jobs I work without a doc on site. at the 3rd job I alternate charts with a doc from the same chart rack regardless of acuity. I should mention that the docs at all 3 of these jobs are FP, not EM, boarded for the most part, so my level of care is compared to an FP doing EM, not an EP doing EM. I'm well aware that most residency trained/boarded em docs could do my job better than I do. At the same time, I think I do it better than most fp docs. . in a perfect world every E.D. would be staffed 24/7/365 by a residency trained and boarded em doc. not gonna happen anytime soon.in the meantime a solid em pa > most non-em docs> most NPs.
I'm really surprised you guys don't know more about pa practice laws. you aren't surprised that NPs with significantly less training than we have can work in this fashion, but anytime someone mentions a pa working without a doc around it's like a major newsflash. We've been doing this for almost 50 years folks....

wow 3 jobs. thats a lot. i guess its because NPs are louder

 

[deleted6669]

wow 3 jobs. thats a lot.

1 full time, 1 part time, and 1 per diem. all in underserved areas. (PAs don't get quality em jobs in major metro areas).

 

[anbuitachi]

1 full time, 1 part time, and 1 per diem. all in underserved areas. (PAs don't get quality em jobs in major metro areas).

this must be the key to getting rich in medicine. no wonder there are so many wealthy doctors.. open up 10 PA run practices in middle of no where and profit . . .

 

[deleted6669]

this must be the key to getting rich in medicine. no wonder there are so many wealthy doctors.. open up 10 PA run practices in middle of no where and profit . . .

these are all hospital based emergency depts., not clinics.
they staff either a doc or a pa interchangeably.
There are limits in every state to how many PAs an individual doc can work with. The range is 2-5 depending on location.

 

[EctopicFetus]

The physician doesn't necessarily have to see each PA patient, but to bill a full physician charge, they do. If the physician doesn't see the patient at all, you can't bill the full fee (not supposed to, anyways). Either way, there's always a physician name on a PA chart taking responsibility as "supervising," whether they've seen the patient or not. Even if there's no physician name specifically on the charge, there's always a general default "supervisory physician" who's on the hook for that specific PA.



They have to either generate enough collections by seeing extra patients you wouldn't be able to see on your own, to pay their own salary, or ideally, generate more than that.

The lower reimbursement is only with medicare. Not with medicaid or private insurance at least in AZ.

 

[EctopicFetus]

this must be the key to getting rich in medicine. no wonder there are so many wealthy doctors.. open up 10 PA run practices in middle of no where and profit . . .

There are a few practices I know of in arizona (peds specifically) where they take a ton of medicaid kids and staff with legitimately 10-20 midlevels and have 1 doc. Even at that crappy reimbursement you can make a killing. We know their practice cause their kids make up half of our peds volumes.