As health care becomes more complicated, the role of administrators becomes more important. Decisions made by administrators affect the decisions and activities of doctors and, by doing so, affect the patient care they deliver. Health care professionals have known this for years, but never had a name for the damage caused by administrative decisions. Now the problem has a name: Administrative Harm (AH).
One hundred years ago, doctors practiced by themselves or in small groups. They were independent of the hospitals to which they may have sent their patients. They and they alone made the decisions about what care their patients needed and how much time they should devote to each patient. Sometimes those decisions cost the doctors money, but it was a sacrifice they were willing to make. To say times have changed is an understatement.
In the years since World War II, we have seen the delivery of health care become a massive industry, employing millions and generating billions in income for those involved. Hospital chains expanded and began purchasing the practices of individual physicians and their groups. Private equity began buying physician practices. Health insurance companies became massive and began dictating what care they would pay for and what care they would not. Drug manufacturers became large as well and began raking in billions. The federal government became a big player through Medicare and Medicaid. Each of these newly powerful groups makes decisions which affect the care of millions of patients. Sometimes, those decisions, made in the pursuit of money or efficiency, harm patients. That is the essence of Administrative Harm.
The decisions made by doctors these days are monitored closely. How many patients did the doctor see? How much revenue did the doctor generate this week? How successful was the treatment delivered by the doctor? Was the patient cured? Did the patient need to be readmitted to the hospital? Did the patient die? How many patients did the doctor send to the hospital which employs her? Some of these metrics measure the economic production of the doctor while others measure the success of the doctor as a healer. When it comes to administrative decisions which affect health care, however, no one is monitoring these decisionmakers.
There are two parts to the analysis of AH. The first is to recognize the immense effect administrative decisions have on the doctors on the front lines and how they manage patient care. Many doctors are very unhappy with the instructions they receive about how to treat their patients. They are unhappy that their compensation, or even employment, is conditioned upon how many patients they see and how much income they generate for their employers. The more patients doctors are encouraged or required to see, the less time the doctor will be able to spend with the individual patient. Some patients require a lot of the doctor’s time. The doctor should not feel rushed and should be able to devote to the patient the amount of time the patient’s problem requires. Patients are similarly unhappy that doctors appear rushed and overloaded and unable to schedule the patient for an appointment.
The second part of the analysis is to figure out a way to measure how administrative decisions are affecting health care outcomes and then to reward or penalize administrators on the basis of those measurements. Right now there is no way to do that. We need to know whether and to what extent the drive to increase economic production by doctors is causing poor health outcomes. We need to know how Big Pharma is affecting patient outcomes with its incessant TV ads for expensive medications. We need to know how Medicare decisions are affecting outcomes.
The recognition of the existence of AH is an important step forward. The development of ways to measure the effect of administrative decisions has the potential to improve the delivery of health care in this country. Right now it is a mess, at least in part because of Administrative Harm.
