Will Quality Be Sacrificed For Profit?

This article was adapted from a posting on the sci.med.transcription newsgroup and then adapted for publication in the MT Monthly, Vol II, N 1 May 1999. This is that adaptation.

Do I think there are too many transcriptionists? That depends. There has been much publicity in the last several five years about medical transcription, and there are ads in many magazines telling readers, "Learn to be a medical transcriptionist in six months and earn good pay at home." As a consequence, there are a number of people who have taken courses, many quite bad and a few quite good. These graduates are trying to find jobs and some are having rotten luck. Many of these courses really do not train one to be able to perform on the job.

I used to recommend that people get into this job but not any more. Our wages are going down, generally, while the cost of reference materials, software, and training is going up. As I write this, I am sitting next to my reference shelf with several hundred dollars of books within arm's reach. Behind me is another shelf with thousands of dollars' worth of reference manuals on medicine, science, and computers. I have subscriptions to or regularly purchase several expensive magazines and journals. I subscribe to three online services and visit several news groups on the Internet. I feel the need to do all this just to keep up with this field, and it is more and more difficult to make money at this job.

Hospitals have outsourced to services. The services compete for the contracts, and too often, the determining factor is price. The service owners then feel they have to cut both their margin of profit and the reimbursement of the transcriptionist. There are also mergers going on among services, and the bigger ones are driving the smaller ones out of business. Many of the biggest ones are controlled by people who have recently gotten into the industry and really have no notion of what is required to produce the medical record.

The hospitals and providers are well organized and financed. The services are well organized and finnced. The transcriptionists are unorganized, atomized, individualistic, and tend to be loners. As you may have noticed from the stories in the press about financing of hearth care during the past five or so years, cost shifting is a big deal in the health care industry. The insurance companies shift the cost to each other and the patient. The hospitals shift the cost to the insurance or government programs. Government shifts the cost to the providers. How much of the cost gets shifted to any particular component of this picture is inversely proportional to the power the particular component possesses.

Medical transcriptionists have little or no clout because they are unorganized. Because the medical transcriptionists are so unorganized, they eat the costs. This cost-shifting to the hapless transcriptionist takes several forms, including the restructuring of pay rates, erosion and elimination of health and other benefits, vacation, sick leave, disability insurance, etc. It also takes other, more subtle forms.

When I worked for the hospital (at an hourly wage with full medical coverage, life insurance, and a retirement package), I could spend 45 minutes transcribing a four-minute dictation by Dr. Mushmouth. When I could not fill in a blank, I could ask someone else to listen. Sometimes two, three, or more of us listened. It did not matter. No one said anything about productivity as long as we got our 1000 lines a day--not difficult for the experienced transcriptionist. We got regular quality assurance reviews. We had educational meetings. We were encouraged to belong to AAMT (American Association for Medical Transcription) and attend educationals.

This is no longer the case. We now get paid between 5 and 10 cents a line, receive no allowances for reference materials, continuing education, etc. If we have a difficult dictator, we are faced with the choice of either taking an extra long time to do it or compromising quality.

It used to be in the hospital's financial interest to work with the worst dictators to clean up their act. A few hospital administrators even had the wit to realize the importance of quality and act on it. But now, it is AGAINST the financial interest of the hospitals or services to approach the bad dictators. Doing so costs money and threatens to alienate the doctor. And one must not forget that the doctor (and not the patient) is the customer that the hospital is geared to serve. So the cost gets shifted to the transcriptionists.

These are some of the reasons I do not recommend this type of work any more, although I love it and find it challenging and interesting.

The need for transcriptionists will almost certainly grow. The number of transcriptionists will not increase fast enough. And the hospitals and large services will do everything in their power to obviate the market forces that might raise our compensation. They do this now, which is why our compensation is going down while the need for our services rises.

The reason the need for transcriptionists will grow is the advent of the paperless medical record. By 2002, all hospitals must be on the paperless medical record. Most doctors will have to be on it too. Handwritten notes will not be acceptable. That means more dictation by more people--people like physical therapists, nurses, home health care staff, mobile transfusion companies, medical social workers, etc. Much of the current documentation of medical care is scattered and handwritten. The many doctors who are happy with little scrawls in their office charts will no longer be able to do business this way, and nurses and allied health professionals will either have to enter the data into a computer by typing, using sort of fill-in-the-blank templates, or voice recognition. Pen and paper will no longer be acceptable in a very short time.

Who knows how all this will end? Will quality be sacrificed in the name of economy? Will the transcriptionist be paid so little that only the least capable will be able to afford to stay in the field? Will your paperless record, which will be available 24 hours a day to any physician in the country who might have to treat you in a life-and-death situation, have been transcribed by someone not competent to do the job? I only have the questions, not the answers.