Stop the hidden exploitation of home-based Medical Transcriptionists in MT Services (MTSO)

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Summary:  Tens of thousands of U.S. and Canadian home-based medical transcriptionist/editors (MTEs) work either as regular employees or independent contractors for various medical transcription service organizations (MTSOs) located throughout the country.  Their pay and working conditions have deteriorated in the last decade since the introduction of speech recognition technology, although the new technology did not prove as productive as forecast to warrant the reductions in pay at implementation, and did not replace the need for the same level of skilled workers.  Physicians and other healthcare providers don't get their pay cut when EHRs, robots or other technology help them to work more efficiently or with less strain and fatigue.  Healthcare facility-based MTEs doing the same work with the same technology, who may or may not have union representation, and often also work from home, are paid at least double to triple on average what their peers in MTSOs receive.  The difference is that workers in MTSOs are isolated from each other and unable to collectively bargain for their pay, performance measurement system, or other working conditions.  This petition calls for MTSOs to enable their employees to access their peers to organize for collective bargaining, and to utilize a fair, industry-standard performance measurement system and market-base pay system comparable to their counterparts in healthcare facilities.  It also calls on healthcare providers and administrators to support these efforts when considering outsourcing medical transcription.

Detail:  

In the last decade or so, MTSOs have been able to slash pay up to 60% based on the new technology of Speech Recognition (SR), which was projected to be far more accurate and productive than it actually turned out to be. (It was forecast as a 100% production increase, leading to cutting the pay rate in half of straight transcribing at implementation, versus an actual yielded productivity increase of approximately 20% to 30% in MTSOs, but not readjusting the pay rate upon this finding).  SR was made even less productive than forecast by changing from assigning single or backup accounts to assigning work across multiple, rotating, changing accounts to meet turnaround times, new account acquisitions or losses, and in some cases to train the SR for accounts to be off-shored later to India.  Production and quality are best maximized and maintained with familiar and unchanging conditions.  The change in technology did not reduce the skill level or knowledge base requirement of the workers, and in fact added new skills of editing.  

Performance measurement systems were put in place by MTSOs to pay MTs again by production, across all workers, even though there are varying software platforms with variable productivity features, and varying amounts and complexity of accounts, dictators, and work types, which is often not factored and adjusted fully or at all.  Despite the variability, all workers are held to the same standard, even though this is contradictory to best practices established by AHDI (Association for Healthcare Documentation Integrity).  

In recent years, QA standards in MTSOs have risen beyond industry standards from 98% to 99% or 99.6%, which requires more time, yet not necessarily adjusted for in line count requirements, and which are difficult to fully gauge.  In some MTSOs, pay rates for the entire week are often reduced if the QA or production standards are not met weekly, even if off by 1 line or 0.1% for a single audit in a week.  This practice is also not recommended by AHDI.  Performance audits are not averaged over time to allow for variability in work assignments, new technology or accounts, illness, life situations, etc.  Rather, each week, the MT must meet standards or lose pay that week and be set up for performance action planning and termination, even when the variability makes meeting performance standards on a weekly basis difficult, and regardless if their average scores over several weeks is actually above standard.  Workers are put in the frustrating position of not being able to gauge or control their performance, which is described by AHDI as the failing of this type of compensation system.  Go too fast, they may lose points in QA accuracy. Go too slow for accuracy and they may lose points for production. Again, this system is not recommended by AHDI as best industry practice.

Turnover is unnecessarily frequent due to rigidly-applied, erroneous standards, and the "luck of the draw" in work assignments, personal health and life situations, or a more or less lenient manager.  Many managers are pressured to adhere strictly to metrics, and those that are too lenient in making allowances for typically excusable circumstances become "no longer with the company." Some managers may manipulate the work to "justify" moving MTs around or out with changing "business needs." 

As a result of the work assignment and compensation methods, pay is often near minimum wage, or less, which the company has to mark up to pay minimum wage.  This then becomes a performance issue on the metrics spreadsheet, which is all these workers basically are, a number on a spreadsheet, that also includes line counts, quality, "force to QA rate" for blanks, and productive time (time on keyboard versus not keyboarding).  Though they are a skilled technical and knowledge base, and their counterparts in healthcare facilities are making double the pay in an hourly-pay or unchanging environment, they are kept to minimum wage.  Most MTs who have worked in the industry for awhile saw their wages fall to half of what they previously were before the misapplied technology of SR, and they can no longer make a living.  Though they may receive benefits such as health insurance, their wages are often so low they qualify for public-assisted healthcare, similar to what was found at Walmart or McDonalds.  Some MTSOs will overuse or misuse independent contractors (ICs), stretching the boundaries of their work requirements to avoid paying employee-status benefits or payroll service, and subjecting them to the same working conditions as employee-status MTs.

Beyond low wages for MTs in MTSOs (in which many MTSOs reap CEO salaries and profits in the multiple millions to near billions of dollars), the environment described above creates a pressure-filled and morale-challenged environment, with MTs often receiving feedback on minor errors and metric shortfalls on a daily to weekly basis, and living in fear of decreased wages each week or losing their jobs due to performance metrics.  There are often work shortages due to improper staffing and account work distribution, and staff are expected to make up time later or use PTO if they have it regardless of their schedules, and may end up short on payday.  Many feel they are on a treadmill, and not able to earn more in what is supposed to be an incentive pay system.  Many have had their savings depleted to make ends meet.  Others have simply left, some to find relatively better positions in other MTSOs, but which may ultimately end up being bought out by those same larger companies in what has become a monopolistic, noncompetitive (copying practice and pay) environment, and some MTs have simply left the industry altogether.  

Some report their experiences directly to management, others anonymously in places like Glassdoor, Indeed, MT Stars etc.  An article describing the situation was published a short while back in For the Record. Many will not say anything because they fear that more of their jobs will be off-shored to India or other countries, although turnaround time needs and time zones, proficiency gaps, and quality concerns continue to keep work in the states.  Some MTSOs refuse to offshore medical records due to varying concerns around quality, HIPAA security, privacy, and confidentiality, other regulatory violations, identity theft, fraud, extortion, logistics, and support for U.S. (and Canadian)-based employees.

We ask your help to petition the MTSOs to allow MTs full access to their peers including email addresses and meeting forums for the purpose of collaborating and collective bargaining, and to bring performance and compensation systems and wages up to the best practices of AHDI and the market pay of their peers in healthcare organizations.

We ask that healthcare consumers call on healthcare providers to keep their medical records in the United States (and Canada) where its citizens and MTs are rigorously trained, required and committed to follow stringent privacy and confidentiality laws as well as practice professional ethics.

We also call upon healthcare providers, hospital administrators, AHIMA, CHIMA and AHDI to show their support for the skilled, U.S. (and Canadian) home-based staff in MTSOs that work hard to alleviate the record-keeping burden of providers, providing high-quality medical records within needed time frames. We call on them to require MTSOs to improve their practice as we have requested. We ask them to withdraw support and patronage for MTSOs that engage in the aforementioned inhumane and poor management, erroneous and unjust performance and compensation practices, and offshoring work in an effort to cut costs, that in the long run does not return a savings and harms U.S. (and Canadian) citizen workers.  We call on them to patronize and support MTSOs that do not offshore their work and that provide fair performance measurement and pay commensurate with the skill and knowledge base of the position, the cost of living and comparative pay to their peers in healthcare organizations.

Additional References:

1. The EHR Burden needs to be Solved:
http://www.healthdatamanagement.com/opinion/why-the-ehr-documentation-burden-needs-to-be-solved

2. As Hospitals Go Digital, Human Stories Get Left Behind:
https://www.statnews.com/2016/04/06/electronic-medical-records-patients/?_hsenc=p2ANqtz-_Y7EyonE5dcNmjpoaLU-lVlimpUymZ483Wt1aSv2dNeLBtdXsb6SD_fG1odDC4ihMfl4oeC4DI1X2WhkHkqxsLDbpgcw&_hsmi=28168114


3. EHRs, Clerical Tasks Contribute to Physician Burnout:
http://www.medscape.com/viewarticle/865469

4.  Readers Write: It’s Time to Get Doctors Out of EHR Data Entry:
http://histalk2.com/2016/04/20/readers-write-its-time-to-get-doctors-out-of-ehr-data-entry/ 

5. Finance Leaders Rethink Transcription: Six Critical Criteria in a Changing Landscape: 
http://www.webmedx.com/corporate/about-us/CaseStudies/WhitePaper_CFO.pdf

6. Medical Transcription Services: How to Choose and Negotiate:
http://www.businessnewsdaily.com/8847-best-medical-transcription-services.html

7. Hidden High Costs of Offshoring Medical Transcription Work to India:
https://www.linkedin.com/pulse/hidden-high-costs-offshoring-medical-transcription-work-dawn-lindholm

8. Offshore Health Records May Pose Privacy Risk: 
http://www.modernhealthcare.com/article/20140418/BLOG/304189995

9. Offshoring and Privacy Protection:
http://www.citizen.org/trade/offshoring/privacy/

10.  The Truth About Medical Transcription:  
http://dailytwocents.com/truth-medical-transcription/#comment-35069

11.  Life at the Low End of the Pay Scale:
http://www.fortherecordmag.com/archives/0315p18.shtml

12.  The Sledgehammer Approach to Management (SLAPM):
http://www.wahlscribe.com/uncategorized/the-sledgehammer-approach-to-management-slapm/

13.  Five Tips To Better Measure Productivity:  http://www.fortherecordmag.com/archives/013111p8.shtml 

14.  Are Scorecards and Metrics Killing Employee Engagement?https://hbr.org/2011/07/are-scorecards-and-metrics-kil 

15.  Measuring Programmer Productivity is a Waste of Time [shift in focus from individual metrics to outcome or group metrics (turnaround time) and process bottleneck improvements]:  
http://nesma.org/2015/01/programmer-productivity-is-waste-of-time/ 

16.  Electronic record errors growing issue in lawsuits:  http://www.politico.com/story/2015/05/electronic-record-errors-growing-issue-in-lawsuits-117591 

17.  Exploitation is Exploitation is Exploitation:  
https://filmanddigitalmedia.wordpress.com/2015/11/16/exploitation-is-exploitation-is-exploitation/



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