Administrative Burden in Primary Care: Causes and Potential Solutions

Abstract

• Issue: Primary care physicians (PCPs) provide services that address a wide range of patient needs and conditions. As a result, PCPs have substantial care management responsibilities and face greater administrative burden — like prior authorization requests and quality measure reporting requirements — than specialists do. These tasks distract PCPs from patient care, contribute to demoralization and burnout, and exacerbates the PCP workforce shortage.
• Goals: To identify the causes of and potential solutions to administrative burden in primary care.
• Methods: Environmental scan and interviews with 12 PCPs and primary care organization leaders.
• Key Findings and Conclusions: PCPs face growing administrative burden owing to complex insurance rules, implementation of value-based payment, poor usability of electronic health record (EHR) systems, and an overload of care quality measures. Chronic underinvestment in primary care, meanwhile, has made it harder for PCPs to hire support staff. Streamlining documentation, simplifying regulations, improving EHR usability, and reducing inbox overload could greatly ease this workload. Embedding forms in EHRs, easing prior authorizations, and refining value-based care metrics could help as well. Artificial intelligence, if deployed carefully, also could potentially ease burden. Improving PCP compensation could help offices hire additional staff to take on administrative tasks, allowing physicians to focus on patient care.

Introduction

Primary care physicians (PCPs) deliver accessible, ongoing, comprehensive, and coordinated care across a wide range of patient needs and conditions.¹ This central role, however, comes with substantial care management responsibilities and disproportionately high administrative burden for PCPs — especially when compared to their better-compensated specialist physician colleagues.²

In this brief, “administrative burden” refers to tasks like prior authorization (PA), quality reporting, and nonclinical email demands that neither require physicians’ expertise nor improve patient outcomes. Over the past two decades, this burden has grown significantly for PCPs, driven by increasingly complex health plan requirements, poor usability of electronic health records (EHRs), a proliferation of quality measures, and the way that value-based payment models are being implemented.³ Years of underinvestment in primary care have made it more difficult to hire support staff, further exacerbating these challenges.⁴

Consequences of Administrative Burden

Administrative burden takes time away from patient care, lowers morale, and worsens the shortage of PCPs.⁵ From 2012 to 2022, the percentage of new physicians entering primary care declined from nearly 22 percent to 20 percent. Meanwhile, the percentage of Americans without a usual source of care increased from 24 to 31 percent for adults and from about 9 percent to more than 12 percent for children.⁶

Administrative overload also pushes PCPs toward employment in large health systems and corporate entities with greater resources and administrative support, which reduces market competition and raises health care costs.⁷ Without intervention, the U.S. risks losing the very workforce needed to manage rising rates and severity of chronic conditions.

To better understand the causes of and potential solutions to administrative burden, we conducted an environmental scan of the peer-reviewed and gray literature, as well as prior evaluations of primary care value-based payment models from the Centers for Medicare and Medicaid Services (CMS). We also interviewed 12 primary care physicians and primary care organization leaders, whose insights point to actionable reforms that could reduce administrative complexity and help restore the viability of primary care. (See "How We Conducted This Study” for further detail.)

Findings

Frontline PCPs emphasized EHR documentation and information retrieval, the “inbox,” nonclinical forms, prior authorization, and annual changes to drug formularies (lists of payer-approved medications) as their leading causes of administrative burden. PCPs with more practice management responsibilities (such as those in small independent practices or in executive roles) identified more organization-level sources of burden, including contract negotiations as well as billing and claims management. Most participants, regardless of their role, mentioned onerous reporting requirements for quality measures and value-based payment models.

Below we describe these leading administrative challenges and explore potential solutions identified by the study participants.

Electronic Health Record Documentation and Usability Challenges

In the rush to implement EHRs given the regulatory requirements, participants felt that insufficient attention was given to designing systems that support primary care workflows.⁸ As a result, critical patient information often remains fragmented within EHRs, requiring PCPs to spend significant time reconstructing the full clinical picture of a complex patient. In addition, clinician notes are waning in quality and usability for primary care. Reasons include:

• inconsistent maintenance and use of templates
• copy-and-paste functions that replace information synthesis
• time pressures
• confusion about Current Procedural Terminology (CPT) codes for billing and documentation
• inadequate training on meaningful clinical documentation.⁹

Some participants described how well-meaning compliance, legal, and information technology (IT) departments overinterpret regulations or impose unnecessary documentation on PCPs.¹⁰

Solutions:

• In 2021, CMS sought to reduce documentation requirements for evaluation and management (E&M) visits to prioritize medical decision-making or total time. While this reduces the need to document low-value elements like templated review of systems and irrelevant physical findings, adoption of these changes has been slow.¹¹ Practices and health systems could embrace the updates and empower clinicians to write concise, thoughtful notes that clearly synthesize patient information. This would make it easier for all EHR users to access and interpret data to guide shared decision-making with patients. Primary care teams could also support documentation work and reduce physician burden by task-shifting.¹²
• EHR vendors and health care organizations could remove some templates (such as for the review of systems) that promote poor documentation habits and result in lengthy, low-value clinical notes. Vendors, however, face challenges as provider organizations attempt to blend different payers’ requirements into a single long, overarching template.¹³ Vendors could make data entry more intuitive and streamlined. They could also support the effective use of clinical decision support tools, risk prediction models, and data visualization features within the EHR.
• Health care delivery organizations and Medicare administrative contractors (MACs) — private health care insurers that process medical claims for Medicare beneficiaries — could avoid overinterpreting documentation requirements, as professional societies and others have recommended.¹⁴ Provider organization leadership could be held accountable for outcomes like clinician retention, so they are motivated to implement less burdensome documentation policies.
• Educators could enhance training on documentation by emphasizing how to capture the full picture of a patient’s health journey — including medical, psychological, social, and other factors, key events, treatments received, and what has or hasn’t contributed to improved health.¹⁵
• Policymakers could streamline regulations, so vendors can make EHRs more intuitive, efficient, and clinically useful. For example, improving interoperability could allow providers to transfer patient data between EHRs and thus change from one EHR to another. They could also support innovation by increasing competition in the concentrated EHR market.¹⁶
• Artificial intelligence (AI) has potential to streamline clinical documentation, and early work has found mixed results with clinician notes and other tasks.¹⁷ Participants, and the literature, emphasized that AI must be able to filter out irrelevant content and cautioned against premature adoption.¹⁸

Inbox Management Challenges

With the rise of EHRs and electronic communication, PCPs face an overwhelming volume of inbox messages, many of which are duplicative or irrelevant. For instance, a hospitalization or single emergency department visit can generate multiple admission, discharge, and transfer (ADT) notifications. PCPs noted also being distracted by myriad documentation requests for disability, family and medical leave, school, and housing accommodation letters. Few of these require physician expertise but demand their attention.¹⁹ Furthermore, specialists often refer patients to PCPs for these types of requests, and PCPs are frequently copied on communications intended for specialists, such as appointment cancellations, without context or clear action items.

PCPs are also inundated with prescription refill requests and patient portal messages. PCPs report that “payer-led care management forms” generated from home visits by Medicare Advantage (MA) plans’ care managers also add to their administrative workload without improving patient care.

Solutions:

• Health systems and other entities could implement intelligent medication refill protocols that automatically approve refills when appropriate and only route exceptions to the PCP.²⁰ Additionally, reducing the volume of patient-initiated messages through proactive digital patient education — such as post-visit videos on medication use — could prevent nonessential emails from patients.²¹
• EHR vendors could integrate commonly used forms, such as medical leave forms, into their platforms, allowing them to auto-populate with patient data.
• The government and health plans could reassess the need for physician signatures for some administrative forms, streamline clinician documentation responsibility, and compensate PCPs for these administrative tasks.²²
• AI could retrieve relevant clinical information so it’s available when a patient calls or when a PCP responds to a patient’s inbox message.

Prior Authorization Requirements

Payers assess the medical necessity of specific services before approving reimbursement through PA. Intended to reduce the harm and costs of unneeded services, PA can sometimes delay or deny needed patient care and adds enormous administrative burden for PCPs.²³

Participants raised concerns about PA for frequently ordered drugs, advanced imaging studies, and durable medical equipment for patients with chronic conditions. While some PA is automated, it is often manual, since information needed to justify “appropriate use” resides in different providers’ EHRs, which do not communicate with one another.²⁴

Solutions:

• By “gold carding” physicians, payers could waive routine PA for those who regularly have PAs approved.²⁵ Payers could also make their rules more transparent.
• Electronic PA processes based on existing national standards could help eliminate manual work.²⁶ Payers could also test how population-based payment models could be modified to decrease PA burden.²⁷
• EHR vendors could enhance the availability of patient information required to prove medical necessity at the point of care.²⁸

Annual Changes to Drug Formularies

Insurers’ prescription formularies change every January, so PCPs spend a lot of time during the first quarter of each year identifying which patients’ drugs must be switched to ensure affordability and treatment adherence. Some EHRs don’t integrate insurers’ drug formularies, creating further administrative work.

Solutions:

• Health plans could inform prescribers about covered alternatives when they deny a drug because of formulary changes. While some insurers do this, many do not.
• EHR vendors and plans could integrate all drug formularies in EHRs. Making formulary information (and PA requirements) accessible at the point of care in EHRs and pharmacy information systems also has consensus support.²⁹

Value-Based Payment Models: Reporting and Documentation Requirements

Participants felt that current value-based payment models exacerbate the administrative burden for primary care. Key contributors are quality metrics reporting and documentation needs for risk-adjusted payments and specific payer contracts.

Quality metrics reporting. Initiatives like pay-for-performance and alternative payment models have expanded the use of quality metrics. While some measures are helpful, experts have questioned the reliability, validity, and usefulness of many.³⁰

Since PCPs manage most chronic conditions, they spend significantly more time than specialists do in extracting and entering data for external reporting rather than for delivering patient care.³¹

Solutions:

• Payers could standardize and streamline quality measures and reporting.³² Attempts to align measures include the CMS “universal foundation” and the Core Quality Measures Collaborative (CQMC) founded in 2015. The CQMC is a public–private partnership of more than 70 organizations, including CMS, health plans, primary care and specialty societies, consumer and employer groups, and other quality collaboratives.³³
• Policymakers could set standard quality metrics for government-affiliated plans and impose fees on payers that deviate.³⁴
• Rather than imposing numerous quality measures on all PCPs, it could be less burdensome to focus on the outliers; standardized, digital quality measures could enable this shift.³⁵

Documentation for risk-adjusted payments and value-based payment reporting requirements. As participation in value-based payment programs has grown, PCPs have become increasingly frustrated by the documentation demands for Hierarchical Condition Category (HCC) risk scoring, which affects their payment. For example, PCPs must redocument diagnoses of chronic conditions (such as leg amputation) every year to ensure appropriate payment. Many clinicians also feel pressured to record diagnoses in the EHR in a way that increases HCC risk scores and maximizes value-based payments.³⁶ Furthermore, PCPs note that these documentation efforts do not inform care and take time away from caring for patients.³⁷

Solutions:

• Payers could support research to create a hybrid risk score that incorporates patient survey data along with a scaled-back set of HCC codes. Doing so could reduce PCPs’ coding burden while potentially reducing unnecessary documentation incentives for plans and providers.³⁸ Other potential solutions include deemphasizing prior diagnoses and making greater use of demographic characteristics, such as neighborhood income, in determining patients’ risk scores.³⁹
• Regulators could reduce regulatory complexity and organizational incentives that push PCPs toward unnecessary tasks.
• Participants noted that current PCP payment amounts, whether through fee-for-service or value-based payment models, are insufficient. Higher primary care payments, along with appropriate adjustments for patient complexity, could provide more resources for PCPs.

Complexity of Claims Management and Contract Negotiations

The large number of health plans in the U.S. contribute to physicians’ administrative burden because of plans’ varying fee schedules, documentation standards, and payment processes.⁴⁰ Lack of governance across Medicare, Medicaid, and commercial health plans exacerbates the problem, because health plans have no incentive to standardize or digitize contracts or claims management.⁴¹

Claims management and contract negotiations are particularly onerous for small, under-resourced independent primary care practices. Entities such as independent practice associations and management services organizations, which offer administrative and contracting support to clinicians, may not prioritize facilitating independent PCPs.⁴²

PCPs face disproportionate strain: As a participant said, “I think that the primary care claims [payments] are so much smaller than the specialist claims [payments], but getting paid accurately is equally hard, whether the claim is for $30 or $30,000.”⁴³

Solutions:

• Congress could establish a centralized clearinghouse for bill submission — like those in banking — which would reduce the costs of operating disparate systems across providers and payers. An entity such as the Council for Affordable Quality Healthcare would “first need to promulgate operating standards for the electronic submission of billing information.” Adhering to those standards could be required for any payer or provider participating in public programs such as Medicare and Medicare Advantage plans.⁴⁴
• A public or public benefit corporation could be created to develop and oversee the standardization of contracts and payments.⁴⁵ An expert suggested that this standardization could be implemented first for Medicare Advantage plans so that it might spill over to the rest of the market. Greater standardization could reduce barriers to new health plans’ market entry, increase competition, and drive down prices.

Conclusion

Primary care physicians identified EHR documentation and information retrieval, inbox management, nonclinical forms, and prior authorization as having the greatest impact on their administrative burden. Those in management roles also cited contract negotiations and billing, while reporting requirements for quality measures and value-based payment models were concerns across all roles. Multiple stakeholders — including health care organizations, government agencies, regulators, and EHR vendors — could help reduce the administrative workload for primary care physicians:

• Health care organizations could adopt 2021 E&M documentation changes, support concise clinical notes, and avoid overinterpreting documentation requirements.
• Policymakers could simplify regulations and support interoperability to allow more intuitive EHR design and foster innovation through increased market competition.
• To ease inbox overload, organizations could implement smart refill protocols, reduce duplicative notifications, add support staff, and enhance patient education.
• Reducing paperwork related to employment, education, and social services could involve reevaluating physician signature requirements and embedding commonly used forms directly into EHR systems.
• Health plans could streamline prior authorizations and ensure formulary updates are accessible at the point of care.
• Value-based payment models could reduce the number of quality measures and scale back risk scores.
• A centralized clearinghouse and standardized platform could improve claims and payment processes.
• AI could help improve information retrieval and reduce documentation burden, though such tools must be implemented carefully.
• Increasing primary care payments could support the hiring of staff to help with administrative tasks, allowing physicians to focus more energy on caring for people.

Of the causes of administrative burden discussed, some participants felt prior authorization and quality reporting were the two most feasible to address, given high provider interest, available solutions, and bipartisan congressional support. Yet participants cautioned that failure to address all sources of administrative burden risks further declines in patients’ access to high-quality primary care.