The topic at AHDI Lounge is AHDI and MTs. Basically, it’s a highlight for the more in-depth AHDI “Let’s Talk About…” series and Barb Marques’ AHDI and MTs (PDF) talk-about. While Barb Marques’ piece is interesting, for me the most interesting part of this AHDI Lounge post was the comments (as is usually the case).

The first comment refers to the impact the VBC (visible black character) standard (explaining why this isn’t really a standard is another discussion entirely) has had on medical transcriptionist’s pay rates.  To which Laura Bryan responds:

AHDI is not responsible for issuing the “VBC”. This standard was issued by MTIA and AHIMA.

Now, just to be clear: Laura Bryan has no official position with AHDI. As far as I can tell, she never has (and I’m quite certain I don’t need to invite anyone to correct me if I’m wrong, but please let me know if I am). At the very least, however, she’s a very vocal supporter.

To which I asked – why wasn’t AHDI part of the task force on the visible black character?

And Laura responds:

@Julie, the standard was intended to address BILLING, not compensation. The MTSOs and AHIMA are most involved in billing negotiations.

When I noted that billing and compensation are related, Laura elaborates:

@Julie, I didn’t say they weren’t related. But it is common knowledge that billing is not necessarily calculated the same way as compensation. The standard was not intended to address methods of calculating line rates for the purpose of compensation.

The way I understand this statement, Laura believes AHDI wasn’t involved in this task force because it was about billing, not compensation. This is a direct contradiction to the following statement by Barb Marques in the referenced Let’s Talk About… article:

We have few weapons in the arsenal to “force” employers to alter their compensation practices. As I shared above, sometimes the only way to impact something you can’t get your hands on is to chip away at the walls around it in hopes of a breakthrough. For AHDI, that means identifying and addressing marketplace drivers that impact billing, whose inarguable bedfellow is compensation. (emphasis added)

I don’t know about anyone else, but I would certainly classify the VBC white paper as a market driver that impacts billing. And let’s not get confused as to the difference between recommending compensation rates and setting standards. When the organization was AAMT, it most certainly was involved in all kinds of standards setting, including billing.

One goal of the white paper was to provide a standard that would give the customer base the ability to compare apples to apples when evaluating proposals from outsourced medical transcription services. However, that was only one goal.

The goal was to implement a standard for content measurement that health information management (HIM) practitioners can use to evaluate in-house transcription staff and external transcription service suppliers.

And makes the recommendation:

The task force recommends that this definition be adopted by all organizations producing medical transcription, including those using in-house staff to transcribe dictation.

That’s pretty clear intent, wouldn’t you say? Anyone who thought it wouldn’t impact transcriptionists working for the outsourced services is either brain dead or sleeping at the wheel.

AHIMA subsequently issued a FAQ (frequently asked questions) about the white paper, where it states that the white paper does not call for MTSOs to change compensation methods for medical transcriptionists.

Though adoption of the VBC unit for compensation of medical transcriptionists was neither the intent nor recommendation of this paper, we recognize that some will choose to adopt it for compensation and strongly encourage those service owners to engage in the same research and analysis outlined in this paper, as well as dialogue with their transcriptionists, in transitioning to this new methodology.

I read this as AHIMA backing down from what was actually published in the white paper. I question why the white paper would recommend adoption by all organizations and specifically include in-house staff if the intent wasn’t to apply the VBC to calculating compensation.

Additionally, let me point out something maybe Laura has forgotten: not all medical transcriptionists – not all members of AHDI, even – work for a hospital or transcription service. I’m not quite sure how Laura could forget this, since she runs a medical transcription service and is obviously a member of AHDI. The suggestion that AHDI would decide to bow out of a task force attempting to set standards involving billing units because it didn’t involve compensation suggests that AHDI isn’t representing the interests of all its members.

Perhaps AHDI didn’t bow out; maybe it was never invited to the table. If that was the case, it demonstrates the weak position AHDI has in the healthcare documentation community.

In all fairness, Laura does make the point that the “standard” is being applied in a detrimental way that was most likely not intended and that AHDI did say it was not in favor of the VBC without adjusting equivalent pay. This is, in fact, stated in the white paper:

Financial analysis must be completed to establish the equivalent VBC pricing in comparison with the existing rate and unit of measure. The company must then ensure the counting and financial applications are properly configured to support the new method for consistency and verifiability. As mentioned previously, comparative modeling showing each method side-by-side on invoices will more than likely be required.

The same problem came into play when the 65-character standard was enacted. But that doesn’t excuse AHDI from taking a back seat in any attempt to set standards that impact the industry. The fact that there were problems associated with the 65-character line standard, which AAMT ultimately backed away from as a result of these issues, isn’t a reason to bow out of any further attempts to set standards that will impact transcriptionists, the industry and compensation. I would argue, in fact, that it was an opportunity (now lost) to take the lead to make sure billing standards that could impact compensation would not be used to the detriment of transcriptionists.

This is an interesting question now being frequently posed in the medical transcription community on Facebook, in the forums, and elsewhere. It’s one I am frequently asked, as well.

And my answer is no – it’s not a career choice I encourage. This position has been questioned by some, especially when I say it in forums like MT Chat, because I own several websites for medical transcription (and, obviously, I blog about the medical transcription industry). My response to that is that I spent over 20 years in the medical transcription industry. I know a lot of people in the industry and support them, regardless of how I feel about the career.

But – if you’re someone looking for career choices, I am going to tell you to really do your homework before plopping down thousands of dollars on a medical transcription education.

Follow the money

For several years, my impression that medical transcription pay rates are going south has been anecdotal. Then, my friend Kathy Nicholls (who is much more data oriented than I am) did an excellent analysis of numbers, which you can read at MT Tools Online: A Salary Perspective Over 11 Years.

It doesn’t take a rocket scientist to read that information and see the writing on the wall for the working MT. Medical transcription pay rates haven’t kept up with even cost-of-living increases over the last 11 years. I don’t see that this trend is going to change. There are increasing reports from medical transcriptionists that pay rates continue a downward slide, with speech recognition editing paying half or less, while not delivering a breakeven proposition with increased productivity.

The line count pay rate isn’t the only factor affecting how much a medical transcriptionist can make. There are more and more MTs telling me that they fight a daily battle to eke out their daily line count minimum when there isn’t enough work in their employer’s system. These employees are expected to not only be available to work their scheduled hours, but to sit around and wait for work to be available on the system – without any compensation if there isn’t.

Whiners and winners

My decision to write on this topic came out of a Facebook discussion. Fortunately, you don’t have to be on Facebook because Kathy also wrote a blog post at her MT Tools site – Medical Transcription on Facebook: A Case Study. In my opinion, the most interesting response to the question posed came from Ava Maria George, the president-elect of AHDI.

In order to assure that pay is commensurate with our talents, we have to get out there and educate ourselves (yes, I mean bachelor’s degrees) and advocate for our profession. One cannot simply sit back and say, “Please Mister, give me more” and expect that will happen. Obviously, not advocating or speaking out has literally made us obsolete. So, what are we willing to do about it? Get out there or leave. Simply, those are your choices.

Call me crazy, but if someone told me I needed a bachelor’s degree to do medical transcription, I’d be laughing so hard, I’d be speechless. I mean really – if you had the time and money to get a 4-year degree, would you get one so you could be a medical transcriptionist?? I wouldn’t even do it if I had to get a two-year degree.

Now, the case might be made that even Starbucks pays more if you have a college degree and therefore we may draw the conclusion that medical transcription would pay more if practitioners had a college degree. However, it is not the degree itself that is driving higher pay rates – it’s the employers. Starbucks simply states that employees who have a college education are paid more than those who do not. It does not give preferential hiring to degreed applicants, but it does reward them for having a degree. (And it’s kind of a sad statement on the economy and the value of a college education when people with college degrees are working as baristas.) And employers in the medical transcription industry have not supported either higher education or credentialing.

Get out there or leave – seems to me that’s a predictive statement, especially when it comes to AHDI membership. Oh sure – they can point to growth, due to the KB membership, but their practitioner level membership numbers are shockingly low, just over 3000 members at the end of 2010. When I left the organization, the practitioner membership was over 7000 members. Apparently the answer to not finding your sweet spot in serving actual people is to come up with a product you can sell and tie it to a non-voting membership category so you can tell the people you used to represent that you’re tired of their whining and they can just go away.

Which brings me to the next statement made by Ava…

I’m not talking about staying traditionally an MT…we’re evolving. We will be looking at changing not only what we do, but hopefully in the process elevating our profession to one that is compensated at a professional rate. Think about it. Coders were in our position years ago. They decided to educate up, credential, and their salaries followed (higher). Now, they are at the same crossroads that we currently find ourselves…we either grow or go. It can be scary or it can be exciting. I’m betting on exciting….

I have a couple observations to make about this. First of all, I don’t know where Ava Maria George gets the impression that coders educated up. The requirement is, and always has been, a high school diploma or equivalent education.

And I’m going to argue with the interpretation of history here… coders did not, by themselves educate up and credential. AHIMA was successful in getting employers of coders to recognize the value of the credential and start demanding that coders be credentialed. The recognition of the coding credential was not a grassroots movement by the coders, but a top-level-down marketing campaign by AHIMA.

The same is true at HFMA. In the Southern states, more employers require their finance people to have an HFMA credential; therefore, there are more credentialed HFMA members in the Southern states. In the Western states, fewer employers require the credential and therefore there are fewer HFMA members in the Western states who are credentialed.

My daughter is a personal trainer. To get hired at a reputable gym, she must have a credential. No credential, no job. In addition, at the gym where she works currently, she must participate in additional inservice training in order to advance in pay. If she doesn’t participate or participates and doesn’t pass, she loses her job at that gym. Her reward for participating and doing well is not only higher pay, but continued employment.

I have a friend who works in the HIMS department of a major university hospital. She was given a drop-dead date for finishing her AA degree and passing the RHIA exam. If she did not, she was out of a job. She took the test on the Saturday and fortunately passed because after many years of working at this hospital, she would have been terminated on Monday if she hadn’t passed. And – she didn’t get a raise or a promotion, she just got to keep her job.

What AHDI seems to be missing in the entire credentialing discussion is that successful credentialing takes place from the top down, not the bottom up. The problem in the medical transcription industry is NOT that transcriptionists haven’t supported credentialing and education – it’s that employers haven’t supported it. How long do you suppose MedQuist would last if they terminated all MTs who didn’t get a credential by a certain date? The plain truth is that the transcription industry doesn’t have the guts to place such a stringent requirement on its workers, even if it had a financial incentive for doing so. And let’s face it – there’s no financial incentive. For the Record recently did an article on The MT Credentialing Debate, and this statement is indicative of why credentialing for medical transcriptionists has never gotten off the ground:

Dale Kivi, MBA, business development manager at FutureNet Technologies Corporation and a member of the board of directors for the Clinical Documentation Industry Association (CDIA), says he understands and appreciates the efforts of industry organizations that promote credentialing. However, he says organizations that purchase transcription services don’t seem to care whether the labor force is credentialed. Their interest lies in stipulating quality expectations and holding vendors to those levels, regardless of whether the staff are credentialed.

It seems all the blame doesn’t go to AHDI, but I’m tired of them point a finger at medical transcriptionists for not supporting the credential. A better use of their time and energy would be to use their partnership with CDIA (the organization formerly known as MTIA) more effectively.

Winners never quit

You know that saying: Winners never quit and quitters never win.

If you examine successful business people, you’ll find the above statement is erroneous. More than anyone else, winners know when to quit.

What really sets winners apart from quitters is the ability to escape dead ends quickly, while staying focused and motivated when it really counts. They don’t waste time and energy on a dead end. Winners do not keep chasing unprofitable ventures.

The biggest difference between quitters and winners is that when quitters quit, it’s an emotional decision. When winners quit, it’s a rational decision, based on objective data and analysis. Seth Godin has some interesting things to say about quitting and winning in his book: The Dip: A Little Book That Teaches You When to Quit (and When to Stick). Guy Kawasaki interviewed Seth about the book and asks:

Question: Other than hindsight, how does someone know when it’s time to quit?

Answer: It’s time to quit when you secretly realize you’ve been settling for mediocrity all along. It’s time to quit when the things you’re measuring aren’t improving, and you can’t find anything better to measure.

Smart quitters understand the idea of opportunity cost. The work you’re doing on project X right now is keeping you from pushing through the Dip on project Y. If you fire your worst clients, if you quit your deadest tactics, if you stop working with the people who return the least, then you free up an astounding number of resources. Direct those resources at a Dip worth conquering and your odds of success go way up.

What’s the worst time to quit? When the pain is the greatest. Decisions made during great pain are rarely good decisions.

Research and make your choice

Basically, medical transcription has been the one reliable (or, lately, semi-reliable) legitimate work-at-home opportunity. It works for people who don’t have other choices; they must work at home or they must have a more flexible schedule than a traditional office job allows; or they live where there aren’t many work opportunities. For those reasons, medical transcription will remain a career choice for some, while those with more and better options will choose something else. Blaming medical transcriptionists by telling them they’re a bunch of whining losers won’t make medical transcription a higher-paid career. Not only is that a lousy marketing tactic, it’s just putting lipstick on a pig and trying to convince everyone the pig is a something desirable.

As I had predicted – there’s no method that can’t be manipulated.

Whether the issues arise from manipulation or from the fact that the “Joint Task Force on Standards Development” issued a white paper, not a standard, and failed to use actual standard-setting methodology, is debatable. But – I was catching up on my reading and came across For the Record‘s article: “Buyer be Aware.” I’m sending a great big thank you to them for putting this online so everyone can read it.

My first bone of contention in this article is some of the quotes attributed to Dale Kivi, director of business development at FutureNet Technologies.

While many companies such as SPi say they prefer that providers adopt the VBC method, Kivi suggests that a good deal of the resistance has come from transcriptionists themselves. “Whereas HIM directors have been coming up to speed on adopting VBC, the understanding and acceptance at the MT [medical transcriptionist] level has not progressed as rapidly,” he says. “Some transcriptionists are wary of changing because there have already been so many changes to their compensation. They see any change as something that could reduce their pay for the same volume of work. And because the VBC method eliminates payment for spaces, they worry it will eliminate something from their salary as well, which of course it does not.”

Dale, obviously you don’t work in the trenches. Let’s count the number of MTs who comment on this and tell me that they were asked to convert to the VBC and either (a) didn’t get an increase in line rate to compensate for the lost characters, (b) weren’t advised that a change to the VBC without a compensatory increase in the rate paid per line would result in reduced pay for more work and/or (c) weren’t even advised that their company’s line counting software was being changed to the VBC.

And here we have a promotion of the biggest lie perpetuated by those promoting the VBC:

One of the most important benefits of converting to the VBC method is that it allows documents to be easily verifiable. With previous methods, there was room for improper billing practices to take place.

I have to keep beating this drum:

• There are no methods that can’t be manipulated
• Unless someone is counting – manually – all the visible black characters (note the importance of the word in bold), this method is no more accurate than any other method that uses software to count the billable units.

The assertion made by Kivi and others is that the VBC is much easier to audit because “what you see is what you pay for.” I would like to know from the industry leaders how many companies are auditing by actually counting the visible characters with no software. Because the bottom line is – the VBC is only more accurate if you actually sit and count each visible character on the document you are auditing and only easier if you were using an abacus to verify your invoices prior to going to the VBC.

Oh – but wait! Read on in the article and you see where the cracks are starting to show in the stressed-out “standard.”

Of course, nothing is ever 100% foolproof, and there are some bones of contention even when using VBCs.

Do tell!

“Headers and footers are one issue,” says Cohen [president of SPi Healthcare]. “Some clients are OK with counting headers and footers across all pages, since they are visual characters, while others may insist on counting the first page only.”

What a surprise – some people want to have their cake and eat it, too! Look, folks – either you pay for all the characters you see on each and every page – or this “standard” starts on that slippery slope to join the calculated line. It seems the demographics are joining the headers and footers on that slippery slope. It doesn’t at all surprise me that this issue has come up. There were reasons why the calculated line was abused and those reasons still exist in the industry. Those reasons didn’t go anywhere just because a joint committee got together and came up with a new way of counting billable units. At fault are both parties involved in the transaction (you know who you are).

Now here’s what I find to be the real kicker in the whole article:

Kivi agrees that it’s important for both parties to be clear about these types of details to avoid the perception that the transcription service is attempting to sneak something under the radar. In that regard, he considers communication to be a key to better billing.

No s***, Sherlock. And if this was the case across the board, there wouldn’t be a need for the VBC.

Back to my bottom line: you can use any method of calculating a billable unit as long as it is transparent and verifiable.

Oh yeah – and I’m just never going to understand how any of these people can claim the VBC is easier to verify. I’m begging Kivi or anyone else to explain it to me.

After reviewing my initial blog about the visible black character and having these discussions, something occurred to me and of course I’m going to share it.

The VBC is touted as the most accurate, most verifiable method of counting.

Let me point out the two fallacies of that assertion:

1. It assumes that the verification is done by actually viewing and verifying the characters with the naked eye.
2. IF that is the way it is verified, it is no more accurate than verification for characters that include spaces.

The argument made by those who support the white paper is that spaces can be manipulated because they cannot be seen. That argument becomes completely invalid if the verification is being done by physically counting the characters as they appear! We can all see a valid space – can’t we? So if we’re verifying by viewing a document, what doesn’t appear isn’t counted.

Let’s take a look at the sample I gave in the presentation:

Let’s look at the points where there might be extra characters inserted and convert those to visible characters:

I don’t know about the rest of the people in the medical transcription industry, but if I’m counting these characters by printing it out and counting what I can see, I’m not going to count all those spaces now displayed as slashes. I am going to count all the spaces that are appropriate – the ones not converted to a slash mark.

I’m going to make two assertions of my own:

1. Nobody is going to sit and verify a line count by printing out a document and counting the characters they see, especially in a high-volume environment that doesn’t even verify electronically.
2. There is no method that can’t be manipulated electronically and if the accuracy of the verification depends on #1 above, then the VBC is the most difficult method of counting/verifying. And as noted, no more accurate and verifiable than characters including spaces.

I will be updating VerifiableBilling.com with these screen shots and information.

The slide presentation is available at my LinkedIn page.