Follow The Money

Forty years ago, whenever children became too outspoken, their parents often warned about the dangers of having too many chiefs and not enough Indians in a family unit. In today's era of data networking and instant gratification,we seem to have reached a point where we have too many entrepreneurs and not enough truly qualified workers. Writing in the San Francisco Examiner, food critic and restaurateur Patricia Unterman complained of the shortage of qualified chefs in the San Francisco Bay area, noting that those who qualify often can’t afford to live here. Colleagues in the accounting profession bemoan the shortage of qualified personnel available for hire. School districts are having a desperate time finding qualified and experienced librarians. And in case you haven’t noticed, there is a stunning shortage of qualified and experienced medical transcriptionists.

Those who can remember as far back as 1991 might recall President Clinton’s campaign slogan “It’s the economy, stupid!” Back then things were not so good. Texas was just recovering from a major slump and California’s economy was a mess. With layoffs occurring right and left, few people were optimistic about the job front – much less embarking on a new career. The solution for many was to become self employed.

How ironic, therefore, to note that business is now booming and, in the face of a thriving economy, supply simply cannot meet demand. Why not? In the past decade the number of people using computers -- and logging onto the Internet -- has increased with astounding rapidity. And there’s no question that our population has grown in the past 40 years. The 1960 census registered approximately 178.5 million Americans. As of 08/30/99, the “Population Clock” estimated 273.4 million Americans -- an increase of 53%! Despite a surplus of physicians and hospital beds, that means more patients, more dictation and more documentation than ever before. The numbers don’t lie.

With managed care demanding more accurate documentation – and the pressure for fast turnaround time on transcribed documents having more to do with speeding up reimbursement from third party payors than actually taking care of patients – perhaps it’s time to stop and examine some of the cultural changes contributing to the drastic shortage of medical transcriptionists. Prior to the Kennedy assassination, the Vietnam War and the rise of the counterculture, the United States was a pretty innocent nation. Big business ruled the economy. There was a passion for higher education. Those who entered business or “vocational” schools were frequently looked down upon by college students pursuing a liberal arts education. People went to work for a large employer and were happy to stay with one job for 15 or 20 years. A steady income provided stability in the home, which was necessary for raising a family. Not too many people questioned authority.

By the time President Nixon was impeached we had become a nation of cynics battered by disillusionment, gas shortages, and a sagging economy. Racial unrest (combined with the flight of white collar workers to the suburbs) left many urban centers in decay. The melting pot that had once made America strong was becoming increasingly fractionalized as women, gays and ethnic minorities began to assert themselves. By the time Ronald Reagan took office, the rise of the “me generation” had led to families with a profound lack of control over their children. Even as the divorce rate kept climbing, HIV began to devastate a subsector of American society. A war on drugs was quickly launched and lost.

As the promise of a “trickle down economy” fizzled, a new class of unemployed people (slackers) joined the growing population of welfare recipients and homeless. And with the help of Republican conservatives, a new streak of anti-intellectualism took root in the nation’s consciousness. Attempts at social promotion led to a massive “dumbing down” of the nation’s educational system. Extracurricular arts programs were devalued and frequently dismantled. As Congress tried to eliminate the National Endowment for the Arts, tabloid journalism started to draw a wider audience.

While mergers and acquisitions in banking, aviation and other industries were building megacorporations, small business was becoming the engine that drives the American economy. Curiously, at about the same time, the American Association for Medical Transcription (AAMT) was formed in an attempt to improve the professional development and awareness of the work done by medical transcriptionists. Traditionally, medical transcriptionists have been educated to believe that:

• It's not about how fast you can type.

• It's not about how many lines you can bill out.

• It's not about your problems with carpal tunnel syndrome.

• It's not about your family, friends, love life, or any lack thereof.

• It's not about the side effects of professional burnout.

• It’s all about the patient!

As important as AAMT’s founding may have been, its influence pales when compared to the impact of the personal computer. Just as PCs and the Internet caused a revolution in the publishing industry, the computer’s capabilities have redefined the value and future of medical transcription. In recent years, a widening cultural divide has had a profound impact on medical transcriptionists throughout the United States. How so?

Those who approach medical transcription from a professional perspective are not just concerned with accuracy, terminology, and delivering a quality product. They still cling to the belief that quality medical transcription can and should have a direct impact on the quality of patient care. Because these people have had hands-on experience with the day-to-day process of transcribing, they understand the potentially lethal ramifications of a wrong word in someone’s medical record. They understand what can happen if someone is misdiagnosed due to a spelling error, a typo in someone’s chart number, an incorrect dosage or a tiny mistake in the spelling of a patient’s name. As professional medical language specialists, these people know how difficult it is to work with flawed language to produce quality documentation. They know the process which creates the product. But their voices are rarely heard because doctors think of them as “typists.” Managers think of them as “drones.”

Flash forward to the year 2000, where we face a glut of entrepreneurs lured to medical transcription by the promise of hot profits. Transcription teachers can’t produce enough qualified workers to meet demand. For every person who responds to some ad that promises $40,000 a year just to “sit at home and type for doctors,” there are ten people who view the medical transcription industry as rife with opportunities to make quick money. Why would anyone really be interested in words when the numbers look so promising?

Brokerage firms call to solicit my opinion on whether or not a certain publicly-held medical transcription company is a good buy for their investors. Even as that company has evolved through a series of mergers and acquisitions to become the biggest gorilla in the MT industry, new entrepreneurs (who sense an opportunity to compete with a bloated industry giant) are rallying investors to enter the field. It’s like two formulaic action sequels: “Revenge of the Nerds: The MT Version” paired with Arnold Schwarzenegger in “MBA Terminator.” In Hollywood parlance, it’s the suits and geeks headed for boffo box office statistics.

These people know how to crunch numbers. They know how to manipulate a business to increase their return on investment. Most important, they understand that the corporation which can sign a contract with a chain of 150 hospitals has access to a wealth of stored data. Data that rests in soft (electronic) format. Data that has value (especially if it is owned by the MTSO). Data which, like action figure characters that end up at Toys ‘R Us and McDonalds, can be spun off into separate revenue streams. These people know that part of the business scenario very well.

What they don’t know is how difficult it is to work with language. And because so many of them are also functionally illiterate, they don’t know how important language skills are to the success of any medical transcription business. All they see are numbers, operating costs, technology and potential profit margins. As a result, the people steering the future of medical transcription are much more excited by their ability to make money than they are by the medical transcription profession’s responsibility to protect a patient’s health with accurately transcribed documentation.

For today’s healthcare industry entrepreneurs, the future value of medical transcription lies not in providing quality transcription (whether it be performed by professional MTs or voice recognition software) but in the ability to warehouse, parse and manipulate the data contained in each transcribed report for market research purposes.

If you find this hard to believe, try to position a medical transcription company as part of today’s informational food chain. What was once strictly an in-house, hospital-based function(wherein hard copy data went straight from the transcriptionists' typewriters into the patient’s hospital chart) has evolved into an industry driven by administrative, technical and financial minds. Rather than the patient’s chart being the final destination for a physician’s dictated report, transcription is becoming a means to a totally new and different end. That end does not just merely rely on transcriptionists: it depends on coders, data crunchers, market researchers, MIS personnel and information resellers.

The reason we now see major transcription firms (as well as startup ventures in India and other third world nations) desperately trying to become information age behemoths is because their management understands that access to a large quantity of patient information can yield a prosperous new revenue stream if an MTSO can collect, store and sell qualified data to interested parties. If the volume of the data generated is large enough, it can even make an MTSO that has achieved critical mass a juicy target for acquisition by a wealthy pharmaceutical company.

The result is that, in the midst of today’s corporate mergers and acquisitions, a frightening new reality is coming into focus. Corporate financial health has superseded the patient’s health as the reason for dictating and transcribing reports. The bottom line? Nobody really cares about the patient anymore. Unless, of course, the patient can bolster the numbers in a spreadsheet.