MT Credentialing, Round 2

Wow, the article on Mandatory Credentialing certainly created quite a lot of dialogue. I'm always glad if I can spark some discussion and get people thinking in different ways.

The comments (here and at my Facebook wall) became so extensive and involved, I decided to post a followup on the same topic, to address some of the issues raised in the comments.

What is the purpose of credentialing?

Well, this seems to be an issue for everyone. MTs want it to mean that they get paid more. Lea Sims, Director of Communications and Publications for AHDI, posts in one of her comments:

Credentialing should not be embraced because it earns you more money or gives you a professional advantage… (snip) Credentialing is about moving the profession forward, not the individual.

Let's take a look at the reasons AHIMA gives in support of credentialing:

Let me highlight a few points there:

  • Whatever the reason, credentialing makes a professional a trustworthy and likelier candidate for gainful employment and career advancement.
  • Credentialed professionals receive better compensation from their employers
  • Greater chance for advancement in one’s chosen career

Can someone at AHDI explain to all us MTs “out here” why MTs shouldn't expect the same things HIMS professionals get from their credential?

I read this to my husband, who looked at me like someone had completely lost their mind, then said, “Well, what's the purpose of moving the profession forward if it isn't to make more money? It's always about the money.” You might want to disagree with that statement because he's an accountant, but he does have a point. There seems to be a big disconnect here between the esoteric philosophy and the practical reality.

Mandatory credential/licensing – again

I'm not at all opposed to credentialing. I am opposed to licensing and mandatory credentialing.

Lea also states: You don’t see nurses, therapists, techs, etc, balking about their mandatory licensing/registry exams.

This statement is based on the assumption that medical transcriptionists have as much responsibility in the patient care process as professionals who actually see the patient face-to-face. Apparently, my disagreement means I think MTs are just secretaries. Having been a secretary, I'm going to go out on a really unpopular limb and ask – what's wrong with being a secretary? I've done secretarial work, legal transcription, general transcription and medical transcription. I will note there were only 2 differences between the first 3 and the last .

  1. Medical transcription has a specialized vocabulary and format, just as legal transcription does.
  2. As a group, doctors are absolutely the most abysmal dictators I've ever encountered in my over 30 years of transcribing and secretarial work.

I'm sure this won't make me a lot of friends, but folks – I've done clinic, specialty, subspecialty, pathology, radiology, acute care, ER, operative reports – just about every type of medical transcription there is and it's just specialized secretarial work.

And I'm going to point out a reality: not only are attorneys as a whole really good dictators, I will argue that the documents they produce are JUST as important to the lives of people as the medical records and they, at least, understand that when they put their signature on a document, or advise their client to sign a document, the transcriptionist or secretary isn't the one responsible for what's in that document.

Bambi says:When I dictate my records, slowly and clearly of course, I don’t get to hang the phone up secure in the knowledge that the MT on the other end is qualified, sane, certified, or has a clue. [Emphasis added]

Let me tell you a story along those lines. Years ago, when I started my business, one of my large clients was a large insurance company. I did a lot of transcription for the risk management department. The director of that department insisted that I transcribe verbatim, with no corrections or changes. It drove me absolutely crazy. One day, when I complained to him about this, he told me something that has stuck with me ever since. He said he knows I'm smart and know what I'm doing and can make corrections and flag errors – but I don't transcribe all the reports, I won't transcribe all the reports, he has no idea which ones I will do and which ones someone else will do or how long I will even be transcribing for this insurance company – and his people need to be trained to dictate the reports so they are correct, regardless of who transcribes them.

Wow – imagine a dictator taking responsibility not only for the accuracy of the finished document, but the accuracy of the dictation! Why is it we feel we have to take responsibility off the shoulders of physicians when their dictation has far more impact than a manufacturing company's risk management assessment report? So we can feel like our role is more important? All I can say is – wow.

Are employers supporting credentialing?

My blog post started because someone stated something as fact, without supporting it. Here's another statement I'm not seeing supported in fact.

Lea Sims: Well, many employers are making it a requirement. Our CMT numbers are on the rise. Whether we will ever see that evolve to a mandatory credential remains to be seen, but again, it’s about demonstrating a unique value to healthcare delivery.

and

Julie – the first step was getting MTIA to release their position statement in support of credentialing. A small step, certainly, but an important one. Since that paper was released, we have seen a big influx of employer-sponsored RMT and CMT study groups. Webmedx, for example, has made the decision to get every one of their MTs credentialed by next year and to hire only credentialed MTs after that (or so I’m told). That’s not necessarily a trend, but all trends start small. I can absolutely tell you that credentialing was on the lips of every employer I talked to at the MTIA conference last week.

I'd say it's starting really, really small. A quick review of the various web sites indicates that a few employers are offering premium pay for the CMT, some offer test prep. I only found one (All Type) that reimburses an MT after s/he has passed the test.

Very few employers state a preference or requirement for the credential beyond the premium pay. The only company requiring it was Transcend/TRS, and then only for QA positions.

I could have spent more time looking but I'll leave it on the shoulders of the people who make the claim to provide links to show it's gone beyond boardroom discussion.

The employers need to do more than talk. If they support a credentialed work force, then they need to go all-out and make a commitment to getting MTs credentialed. It simply isn't going to happen down at the individual MT level to “advance the profession.” Why should Susie Transcriptionist care about “advancing the profession” when she's having a difficult time getting work, having her pay cut, and trying to juggle bills and schedules? Let's talk about the hierarchy of needs, here. If her employer isn't demonstrating a commitment to credentialing, why should she?

Is it too late?

So, just for the sake of argument (and clarity), am I hearing you say that you perceive the role of the MT to be primarily secretarial? One only of administrative support to the physician? If that’s the case, then I would agree that no credential would be necessary. I would also argue that such a role is the least valuable to healthcare right now and the most likely to be marginalized and automated. And explains why SRT and EMR vendors have been able to quite easily convince our end-users that MT can be replaced (afterall, it’s just a secretarial/clerical role).

OK, the question here is not whether or not we're going to be marginalized and automated – the question is whether we can turn back the clock. We've already been marginalized and we're on the way to being automated.

I'm going to argue that medical transcription has always been marginalized, not only because of the low entry requirements, lack of standards and lack of credentialing – but because any sector where the work is performed primarily by women is almost always marginalized. Will credentialing change that? In my opinion, it will only change it if the large employers stop talking and start walking in support of the credential, both with the work force and with the client base. As long as they continue to contribute to the marginalization with business practices that do nothing to “move the profession forward,” it's going to continue down the same road it's on.

Is there a case FOR credentialing?

Absolutely I think a case can be made as to why credentialing is a good idea – I just take issue with the approach and the reasons given for it.

Like I've stated over and over above – the big employers, the hospitals, JCAHO all need to show a commitment to credentialing because it simply isn't going to be supported at the individual MT level otherwise. All of this will be just more blather if employers SAY one thing and don't back it up with action. (If I was actually being paid to blog, I'd probably do a flow chart on all this and it might make more sense.)

As fas as the RMT, it would serve the purpose of raising entry requirements into medical transcription. Employers would have to be on board with saying that any MT graduating after a specific date must get an RMT within XX months. This doesn't alleviate the issue of getting experience and I don't think there will be many (or any) employers who are going to be willing to commit to hire RMTs with no experience, based on my discussions with employers on this issue. However, it does raise the bar, even a little bit. It also sets the expectation from the very beginning that this is something necessary if you want to be a medical transcriptionist.

The CMT is probably most similar to the CCS credential offered by AHIMA, which has no education requirement (beyond high school diploma) and requires 3 years' experience. Most coding employers require a credential. It isn't mandatory, but applicants who don't have one are not likely to be hired or the hiring will be conditional, pending passing the credentialing exam. As long as MTs can get a job without needing a credential and as long as they can continue working without a credential, there isn't going to be an incentive for them to get one. And I'm sorry – I agree with my husband and AHIMA on the reality that it is IS about the money – and I think most MTs would agree with me.

Related blog entries:

Related screen shots:

Medquist web site - careers page

Medquist web site: Careers

Focus Infomatics - careers page

Focus Infomatics web site: Careers

Webmedx web site - Careers page

Webmedx web site - Careers

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Spheris web site: Careers

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13 thoughts on “MT Credentialing, Round 2”

  1. and as well these companies that supposedly do reimburse people for CMT exams and such, how much do they pay people? A whopping 7-8 cents a line? What will they give them an extra 0.0001 extra per line for being a CMT? I think you mentioned it in your blog that even a newbie to MT with an RMT certification still faces the hurdle of lack of experience. So now those starting out have put out time and money for their education, time and money studying and taking a test for certification, which if it has not changed, you have to pay for all over again if you do not pass the first time, and then after that is done spend time hoping to find a place where they can get experience and start their career. Ridiculous!

  2. Why should I get credentialed when I’ve been doing this work for 30+ years? You will find that the new MTs just out of school do not question getting credentialed. You will find that the MTs doing this work for many, many years always question it.

  3. Julie, don’t have time to respond to each statement point-for-point, though quite honestly, I can’t say I disagree with much of what you’ve said. I wanted to clarify a couple of things I posted, however.

    First off, blog commentary is sometimes difficult to follow, and I should have been more clear about whom I was directing my question to. When I asked for clarification on whether “you” assumed the role of MT is secretarial, I was responding to the last poster (Bambi, I think). I don’t believe you made the suggestion that MTs are limited to that role. And I don’t disagree with your statements about secretaries – just that I’m not sure healthcare places a high priority on those roles right now.

    Second, when I said credentialing was about the money, I was solely referring to entry-to-practice exams (like the RMT). If it’s a benchmark exam designed to control who can enter the practice, then it shouldn’t be about money or advancement. Afterall, in theory such an exam levels the playing field for those entering. You wouldn’t get paid more or start out with a better title for having the credential. It would simply be required to practice. Now, specialty or advanced exams (like the CMT) absolutely should command a higher salary and more upward mobility. I believe that is happening already (to some degree) with CMTs, and I believe pressure should continue to be put on MTSOs to differentiate.

    Actually, voluntary credentialing can happen one of two ways. Either MTs self-regulate and credential themselves voluntarily, create a differentiating demarcation of expertise by doing so, where employers would begin to make the correlation between the credential and expertise (which would lead organically to preferential hiring practices) OR you have the reverse scenario where employers have to require it and force MTs to have it. The problem we’ve faced is that neither group has wanted to budge. Thus, we can’t ever reach a tipping point in the industry where it takes care of itself (like it has with the CCS).

    I believe you are absolutely correct that it has to happen (at least in this industry…given the “state” of the profession right now) at the employer level. This was a top priority for AHDI in our partnership with MTIA – to make some headway in the discussion around credentialing. While folks at the board room table were quick to agree that credentialing is important, it needed to be stated publicly. And you’re right. It’s a small step and it’s just a position statement. Position statements don’t change business practices or employer behavior and certainly not overnight. I personally believe that employers are missing the value proposition of having a credentialed workforce when it comes to negotiating pricing that is commensurate with the complexity of this process. They keep competing on price and TAT, yielding to the pressures of their customers to turn-it around faster and cheaper, and they’ve missed the bargaining chip of having a credentialed workforce to drive that pricing up.

    And finally, my point about nurses and techs wasn’t necessarily to compare the role of MTs to those practitioners in terms of patient responsibility. My point was that they are willing to be held accountable to and tested against a scope of practice. Not having a measurable scope of practice makes it hard to define the value of MT…it’s small wonder no one is exactly sure how important it is, whether it can be replaced or not, whether it should be measured/regulated or not, etc. It’s just entire too nebulous. That probably more than any other reason is why we’re trying to put some shape, definition, and purpose around this murky industry so we can communicate and advocate for it.

    Thanks for the discussion.

  4. As one of the few companies that rewarded the credential, TRS also offered a free prep course AND reimbursement of the exam fee. Now that we have been swallowed up by Transcend, we former TRSers have until July 1 to get ourselves “grandfathered in,” so to speak. They took away the prep course, but they are still going to reimburse the exam fee, assuming I pass it, and the credential will earn me a full 1 cent per line raise over the base level 3 line rate. And that’s in addition to the production incentive pay. So it’s hardly a pittance. But frankly, if it weren’t for the immediate financial reward, I wouldn’t care about the credential; it never mattered to me before, because nobody was offering to pay me more if I had it. Yes, I will freely admit it–it all comes down to self-interest; for the financial reward on my part, and for the employer to know they’ve got somebody who is going to give good value for the $$ they are paying, i.e. somebody who could pass the test.

    With 36-1/2 years of experience under my belt I took the RMT a few months ago, only because the company paid for the exam and offered a half cent per line raise for passing. I finished the entire test in just under an hour and walked out muttering that I’ve done harder work than that in my SLEEP…. So I would agree that the RMT at the very least should be a strong recommendation, if not a requirement, to get into the profession. (Frankly I thought the test was far too easy. But that’s just me.)

  5. “It would simply be required to practice. Now, specialty or advanced exams (like the CMT) absolutely should command a higher salary and more upward mobility. I believe that is happening already (to some degree) with CMTs, and I believe pressure should continue to be put on MTSOs to differentiate.”

    As much as it is a nice thought about CMTs being able to command a higher salary and all, I am sorry, I just do not see that happening. I purposely work as an independent so as to avoid the annoyance of lack of work and subpar wages that I experienced while working at a national company. Even as an IC, I do not see how being a CMT could allow me to charge a physician more for my services. It still comes down to cost and more than likely if an MD found my rate to be too high, he/she will choose someone with a lower rate, especially considering the economy right now. Even thought I am not a CMT, I most definitely take the nature of my work very seriously. I’m not just typing up any old record, I am making a person’s medical record. I always think about what if it was my record? How could an error in my medical record seriously affect my life?

  6. How would mandatory credentialing impact MTSO customers? What do MTSO customers want?

    • Low Price – Credentialing costs money. Who will pay?
    – MTSO – Gross margin for MTSOs range from 30 to 40 percent compared to over 50 percent for the business service sector in general. Lower margins will not attract sufficient capital for MTSOs.
    – MTSO MTs – MT wages have been stagnate or worse for years. MTs will not accept the additional cost of mandatory credentialing.
    – MTSO Customers – Providers expect quality reports although as noted below quality is inconsistently defined and measured. Purchasers of MTSO services generally want lower prices not increased prices.

    • Turnaround Time (TAT) – Mandatory credentialing would increase the barrier for MTs entering the workforce. Increases in productivity using speech recognition and increased acceptance of non-US MTs have created a temporary excess supply of MTs. When saturation of speech recognition and acceptance of non-US production is reached, the demand for MTs will again exceed supply. The demographics of an aging US population and aging US MT workforce have not changed. MTSOs will need to reduce barriers such as credentialing to secure sufficient MTs to meet demand. Workforce predictions by McColl Partners are:

    Demographic and healthcare-related growth trends will likely continue to drive attractive market forces for the healthcare documentation sector, including demand for healthcare documentation professionals. Employment in the domestic healthcare documentation sector is expected to increase by 16.4% from 268,000 professionals in 2006 to 312,000 professionals in 2016.2 Employment in this sector is expected to grow 6.2% faster than the national average. INDUSTRY UPDATE – Medical Coding, Transcription, and Billing by McColl Partners http://www.mccollpartners.com/assets/files/Q4%202008%20Industry%20Updates/Healthcare%20Update(1).pdf

    • Quality – I have not seen evidence that credentialed MTs produce better quality reports than non-credentialed MTS. There is even less clarity when one considers the lack of industry standards on the definition and measurement of quality. Reports are generally contractually required to be returned to the customer with acceptable quality. A MTSO may need to use lower skilled MTs with more proofing or higher skilled MTs with less proofing. The skills of the available workforce will dictate the appropriate approach applied by a particular MTSO.

    While the idea of mandatory MT credentialing may today look like a plum to some, it will in my opinion become a prune that, although edible, will be less palatable when MT demand exceeds MT supply.

  7. You have given us compelling and beautifully phrased arguments/questions. It would be nice to see the questions you raised answered in the same concise fashion 🙂

    Nae

  8. When I entered in transcription, credentialing was always the goal. It just made sense. It also made sense that the credential from the industry held more value to the industry than the “certificate” I received from my local college. My CMT status and investment has served me well in the last 10+ in the business.

    A more diverse skill set will be essential in the MT of today and tomorrow, to include more technical skills, a greater understanding of natural language processing, discrete data, coding, a truly functional EHR, and SRT editing. There is a career lattice and our current credentials are a beginning. RMT does set the stage for broad-based knowledge. CMT embraces an even broader set of skills to include much learned on the job. An associate’s degree shows some capacity for broader world knowledge. We also need master’s and PhDs for research and development.

    I agree a new compensation model is crucial and oftentimes unpopular. If MTs, whether ICs or employees, are going to evolve into the skill sets required, they must have the opportunity of “profit” and have greater incentives to stay in, start in or innovate within the industry. Granted, current economic times are restrictive, but this is temporary, capitalism will prevail.

    Truly though, this is a very diverse group discussion, with opposing views and historic disassociation. Here’s my true ask . . . and I beg your indulgence for my impatience. When are we going to start working together in collaboration and become truly innovative in what the industry of the future could be? We continue to have dialogue about how to survive in the now. While I know everything in this thread is a real topic, MTs of 20+ years ago figured out how to be progressive by offering outsourcing as an option. Many did well. Some still do. We marginalized ourselves by showing the customers we could beat their in-house costs and gained many opportunities in the process; we continue to marginalize ourselves now – some of this is the “American” way. Now we have vendors doing more than talking about once-and-done and beating the entire cost cycle of text-based documentation. They ARE selling it. EMRs are replacing narrative text. Are the customers happy about the product? Well, it depends who you ask.

    As smart business folk, I contend we need to rearrange our thoughts regarding our customer base. What is going to happen when the patients start seeing the inconsistencies, dare I say medical errors? The insurance companies are already asking the questions. Google and Microsoft see something there.

    I do think we need an entry into practice and for me in my short tenure with the industry it has always been about certification. I know nothing else. For my students, they want certification and they assume industry adoption. RMTs were getting the jobs sooner than non-RMTs to such a degree we had to revise the apprentice program. My CMT shows my commitment to lifelong learning, and I would take it to the next level that someday we actually re-test to quantify that knowledge every re-certification cycle.

    Any of the certification ideas I can think of all cost money, to the developers (so far AHDI), the users (the MTs or healthcare documentation specialists), the employers (MTSOs and facilities), the customers (stakeholders); they also save money, and someday I hope to see more research studies that put bite into our anecdotal claims. How about a certification in the privacy and security realm, are we willing to place our stake in the ground on that one?

    My point here is this. Is there any consensus that can be built within the MT community that takes us past our internal historic differences of opinion and catapults us into collaboration of tomorrow so we are not continuing to de-fragment our own sector today?

    Credit goes to Sean Carroll for his analogy to Horton Hears a Who; but I truly think the story rings true. How did the citizens of Whoville get off the dust speck? On the very same day, at the very same time, in unison they hollered . . . we’re here, we’re here, we’re here.

    The window is closing on our dust speck. Can we turn our autonomy to collaboration? Our adversity into synergy? Move the debate to innovation? Agree on some stake and rally around it?

    For AHDI, it is credentialing and a few other things. For MTIA, hopefully it will be DRT-enabled EHR and the Health Story Project and a few other things. For ATA, consider advocating with us to get our legislators to support funding for educating or re-training our domestic workforce. For individuals, what’s our next business plan? For retirees, promote the next generation rather than wilt their fire. For customers (as yet to be re-defined) perhaps actual authenticated accuracy? The prospects are endless and that’s why I’m here. To ask us to find common ground that includes the entire MT base, the MTSOs, the facilities, software vendors, patients, clinicians (stakeholders) and every single person on this thread to rally TOGETHER, creating some type of innovative success for all.

  9. Everyone brings up good points but I want to highlight Bob’s statements, from an MTSO point of view. I was reading the MedQuist 10-Q filing this morning and it is also very informative about what is going on inside the industry. I encourage everyone to read it.

    http://tinyurl.com/qe5l4q

    What I found most interesting was the specific pointing of a finger at CBay – who recently acquired a large share of MQ.

  10. Bob said: “I have not seen evidence that credentialed MTs produce better quality reports than non-credentialed MTS.”

    No one ever said (or at least they shouldn’t have) that CMTs produce higher quality reports than noncredentialed MTs. The only way we could possibly measure that is if every MT was required to take the exam, so that you could make a correlation between the quality of those who passed versus those who didn’t. Right now, there are just too many high quality MTs out there who have opted out of the credential. It’s little wonder (to Julie’s earlier point) that employers haven’t required it. I should reiterate here that, in my opinion, AAMT made a huge mistake early on in promoting the CMT exam by touting it as an “elite credential,” marketing it as something so prestigious that only a few had it. That was the wrong way to get the profession credentialed.

    This is one of the reasons why I said early on that unless the credential is mandatory, the best way to push credentialing into a profession is for MTs to self-regulate and not leave it up to the employers (though, as I said, we may sadly have reached the point where only the employers can make it happen). If we wanted to set standards for our own profession and determine who can enter our profession and who can’t, we’d embrace credentialing voluntarily. If every highly skilled MT stepped across the line and registered their skills through the exam process (whether employers required it or not), we would have organically demonstrated to employers that CMT = skilled. The marketing message of AAMT should have been something akin to Uncle Sam saying “We Need You.” The CMT (and now the RMT) will only mean something when every skilled MT capable of earning it has embraced it, not the other way around. That’s the only way you shape the thinking and understanding of industry employers about our skillset. You have to reach a tipping point with the credential where more MTs who are capable of having it actually do have it.

  11. Let’s consider a model where all MTs who possess the skill to become credentialed do in fact become credentialed and conversely all MTs who do not possesses the skill to become credentialed are not credentialed. Thus two types of MTs exist in our model: credentialed and non-credentialed.

    Let’s make two additional assumptions about quality for our model:

    – credentialed MTs produce higher quality reports than do non-credentialed MTs
    – reports prepared by non-credentialed MTs must be proofed 1.3 times to raise the level of quality equal to the quality of an un-proofed credentialed MT report

    If the cost of credentialing is to be justified, then the cost of credentialing must be less than the cost of the additional proofing required to make the reports equal in quality.

    Even if credentialing is determined to be justified in our model, the relative availability of credentialed MTs, non-credentialed MTs, and proofers will additionally determine the workforce mix.

  12. So, I received notification to recert my RMT on May 7, 2009:

    “Your recertification deadline is June 30, 2009. You must complete the RMT Recertification course no later than September 30, 2009.”

    Interestingly enough, I did not receive my RMT until October 2009. Now I see they say recert is due June 2009 but have graciously extended it to September 2009.

    No respone to email and this is not right. You want us to value the cert, but give only 3 months to take a new course and exam at a cost that may not be possible in this economy with such short notice. This recert course is a year overdue and now you want us to do it under AHDI timeframe.

    “The cost of the RMT Recredentialing Course is $100. RMTs can take the RMT Recredentialing Course any month after receiving their 6 month reminder but must complete the course before their deadline”

    I did not recieve a 6 month reminder. Shame!

    Hopefully staff will reply with answers. Thank you,

  13. Hi, Zazu. I appreciate your feedback on the RMT Recredentialing Course and thought I would post some responses to your questions on the process.

    You are absolutely correct that RMTs who took their exams during the Beta phase of the exam did not receive notification of their scores until October 2006. As you know, the purpose of the Beta was to ensure the quality and usability of the testing process and we were extremely fortunate to have people like you contribute to the Beta! One of the integral purposes of the Beta was also to establish a clear scoring method and this required having enough people test to be able to fairly establish the criteria. Once this data was finalized all test takers were contacted with their scores. Although I was not involved in the Beta process I was able to pull a copy of the document that was sent to all Beta testers to inform them of their scores and that document states that “your RMT credential will be good for 3 years from your exam date. In order to maintain your credential after the 3-year period, you will need to complete an RMT recertification course and pass the final exam”.

    With the RMT Recredentialing Course policies recently being finalized AHDI’s Credentialing and Education Department in conjunction with the Credentialing Development Team discussed the proposed deadlines at length. The parties involved agreed that in the light of the fact that all RMTs have been given proper notification of their recredentialing deadline, as well as what the recredentialing process would be, the 2 month extension on the deadlines would provide adequate time to prepare to complete the course.

    AHDI is committed to supporting continued excellence in the MT industry and is fortunate to have the support of credentialed individuals like yourself! If you or anyone else has any further questions please feel free to contact me via email at [email protected].

    – Cassie Uber, Credentialing and Education Specialist, AHDI

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