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September 10, 2012

MTs Seek a Fair Shake
By Lisa A. Eramo
For The Record
Vol. 24 No. 16 P. 22

In a buyers’ market, compensation for medical transcriptionists is a hot-button issue.

Anne Collins, CMT, manager of a large transcription department and a medical transcriptionist (MT) for more than 25 years, considers herself to be one of the lucky few in her profession. She earns a decent wage—a competitive hourly rate plus an incentive that’s the same regardless of whether she transcribes or edits a line above the required minimum—and receives health insurance and other benefits. Her employer, a large hospital system in Orlando, Florida, outsources some of its transcription within the United States and handles the rest in-house.

Sound like a utopian work environment?

For many MTs, it probably does. Experts say the majority of today’s MTs are earning less than they did five or 10 years ago even though they’re often working harder and longer hours. In some cases, MTs are barely making minimum wage. As the industry continues to evolve, MTs struggle to find fair and equitable compensation for the valuable—even crucial—services they provide.

More Work, Less Pay
Debbie Hahn, RMT, says compensation has been anything but fair throughout her seven-year career as an MT working for various transcription outsourcing companies. One outsourcing company for which she previously worked paid strictly based on production—a trend that experts say has persisted for the last decade or so and may continue indefinitely. Hahn says the biggest drawback to working for an outsourcing company was the fact that the flow of work was inconsistent.

“I didn’t think it was fair because there was downtime when there was no work at all and you just don’t get paid,” she says. On many days, there weren’t enough reports to support even a half-day’s worth of work.

Another MT, who wishes to remain anonymous, says when she began working at a small hospital in Oregon in the early 1990s, she had health benefits and was paid an hourly rate that equated to 9 cents per line for everything she typed. Nearly two decades later, she receives the same rate for transcribed reports; however, 90% of her work involves editing. For these assignments, she’s paid approximately one-half of the traditional transcribing rate: 5 cents per line.

“I feel lucky to be earning these rates,” she says. “I tried working as an independent contractor. At line rates of 3 to 5 cents per line editing and 6 to 9 cents per line transcribing, you simply can’t pay employer and employee share taxes, cover your equipment and Internet service, cover your health insurance premiums, and have anything left in your pocket at the end of the day.”

It’s not uncommon for MTs to see a 50% pay reduction when transitioning from traditional transcribing to editing, says Kathy Nicholls, CMT, AHDI-F, president of Nicholls Consulting Services. “In my opinion, technology vendors sell their systems with the claim that an MT can double his or her production. However, studies have proven this isn’t true for everyone,” says Nicholls, who has more than 30 years of experience in the transcription industry. “Those MTs who are highly productive already are not likely to double their output, thus creating a situation where they make less money for using the technology. This isn’t what should be happening in an industry of knowledge workers.”

Collins agrees: “To me, the big lie is that you can double your productivity, so they cut your pay in half. That’s just not true.”

The hospital at which Collins works saw a 25% increase in productivity after it implemented speech recognition technology. “That’s nowhere near 100%. Speech recognition is far from perfect,” she says. “We still need to have MTs who are knowledgeable and who have been trained extensively to be able to pick out the errors.”

In general, MTs have taken quite a hit over the last decade in terms of compensation; however, it wasn’t until recently that several professionals decided to take a stand publicly.

In May, 13 MTs filed an individual and collective class action lawsuit for unpaid wages and overtime pay against Transcend Services, Inc. The pending lawsuit alleges that Transcend violated the Fair Labor Standards Act by failing to compensate MTs at the federal minimum wage of $7.25 per hour. The lawsuit alleges that because Transcend compensates only for “hands-on-keyboard time” and not other activities essential to the accurate transcription and editing of lines, workers were ultimately not paid minimum wage per hour. The lawsuit also alleges that Transcend failed to pay MTs at a rate equal to time and a half for hours worked in excess of 40 per workweek.

The outcome of this lawsuit could have significant ramifications for MTs, says Jay Vance, CMT, CHP, of Superior Global Solutions, an outsourcing company in Plano, Texas. “Up until this point, as long as the transcriptionists are willing to sit back and take whatever is given to them in terms of compensation and working conditions, then that’s the way it’s going to be. But now that a group of people have actually taken a stand and said, ‘We don’t believe that this practice is right, ethical, or legal,’ now all of a sudden, everybody in the industry is waiting to see what’s going to happen,” he says.

The Transcend lawsuit already has encouraged other MTs to advocate for themselves, Nicholls says. “I have already heard from MTs from other companies who have contacted an attorney and begun discussions about similar practices where they are working,” she says. “I believe seeing a few MTs stand up for not only themselves but the industry as a whole has the potential to inspire others to do the same. I suspect this is only the first of many suits we will see about this issue.”

A Changing Marketplace
It’s clear that MTs are paid less today than they have been in the past, but why? Experts say transcription has undoubtedly become what many buyers see as a commoditized service. MTs are frequently paid using a production-based compensation model that values quantity over quality.

“In a marketplace that still has hundreds of vendors all claiming to deliver high-quality work, it has indeed become a commodity marketplace in the eyes of a buyer, which means it’s the lowest possible price for acceptable quality,” says Dale Kivi, MBA, director of business development for FutureNet Technologies, a dictation/transcription technology vendor. “If everyone is promising acceptable quality, it comes down to being a price-driven marketplace. In order for a service company or employee to survive, they have to pay or be willing to work for what the market will bear.”

One of the biggest challenges facing MTs is there simply isn’t as much work available today as providers scramble to implement certified EHRs, Kivi says. “These technology platforms, by definition, remove some of the clinical documentation that was previously delivered as narrative notes that were transcribed and replace it with electronic data that’s based on the physician selecting things off of a menu on the computer, such as diagnoses and procedures,” he says.

Physicians are dictating less, and the decreasing volume of dictation affects the amount of work available for MTs. “Even though the overall amount of clinical documentation is increasing, how it is generated is shifting from the manual process of dictation and transcription to the automated effort of the electronic health record,” Kivi says.

Electronic templates that are automatically populated with patient data (eg, patient name, birth date, medical record number) also have affected MTs’ ability to maintain certain work volume compensation, Kivi says. “This information used to be credited toward transcriptionists,” he says. “But now some technology vendors have actually pitted themselves against the labor force in order to gain the technology business.” Vendors tell hospitals and clinics they don’t need to pay MTs for this content even though MTs are still responsible for ensuring the accuracy of the content, he adds.

Offshore transcription poses another challenge. Such vendors often promise significantly lower labor costs, Kivi says. “Hospitals and clinics are under constant pressure to cut costs whenever possible,” he says. “So as long as there are people willing to do the job for less, buyers have to at least consider it.”

Collins says MTs often are recruited to edit speech recognition-generated documents until the technology begins to learn and perfect a dictator’s voice. At that point, many companies outsource the work offshore where labor is cheaper, leaving US-based MTs either without work or having to settle for low wages comparable to what offshore workers are willing to accept. “[Offshore vendors] have diminished our profession,” she says.

It’s a vicious cycle, according to Kivi. Offshore vendors have left many domestic service providers with no choice but to pass the market’s price cuts onto their labor force just to keep their doors open, he notes.

Speech recognition technology also is constantly shaping the profession. Kivi says many MTs have not made the leap from being a traditional transcriptionist to becoming a medical editor. For these individuals, there is less work available. “There is a flood in the market of those people looking for jobs but a smaller volume of work available,” he says.

Is there a difference between traditional transcription and editing text that’s been generated by speech recognition technology? Is one easier than the other? “It depends on who you ask,” says Linda Brady, CAE, CEO of the Association for Healthcare Documentation Integrity (AHDI). “The one common theme we hear from MTs is that it’s easier to transcribe a document from start to finish than to create multiple edits in a single report.”

“It takes a lot more concentration to edit a speech-recognized document because you have to pay such close attention to what the text is and what the physician is saying,” Collins confirms. “It’s easy for mistakes to get through. Speech recognition is way away from being perfect.”

Hahn agrees: “Speech recognition editing is more technologically oriented, and you need to be more computer proficient. Also, you really need to have a good ear to edit. It’s more complex than manual transcription. I think people should be paid more to do it.”

Although some MTs may benefit from using speech recognition technology, many will only find themselves working harder to earn less, Vance says. “For someone who is not a particularly fast typist to begin with, it’s entirely possible that they could see a fairly dramatic increase in their productivity switching from straight typing to speech recognition editing,” he says. “But the reality is that if you are already a prolific producer in terms of volume—and your rate for editing is half of what it is for typing—then you’re not going to maintain that same level of compensation. Once you get above a certain level of productivity, it’s physically impossible to double your output. It simply can’t be done. At that point, experienced transcriptionists are being penalized. In order to maintain the same level of compensation, they’re expected to do twice as much as what they were expected to do before.”

Inconsistency Fuels Inequity
Experts say one of the biggest barriers to equitable compensation is the lack of a consistent definition for a line, the standard unit by which MTs are paid.
Each employer may define a line of transcribed text differently; however, many of them use the visual black character (VBC) standard unit of measure, Brady says. Some employers may require MTs to transcribe a minimum of 900 to 1,500 lines per day and significantly more—even double that amount—if editing.

Although the industry typically uses VBCs as a unit of measure, it isn’t an official standard nor do all employers follow it, Vance says. “I can’t say that it has been adopted industrywide. Even if all the medical transcription service companies adopted it as the standard, in reality the clients are the ones who are making the final decisions. They’re the ones who decide how they’re going to measure and pay,” he says.

Moving from one method of measurement to another (ie, from lines to VBCs) is also somewhat controversial, Vance says. “From a transcriptionist’s point of view, you don’t want to lose ground when shifting from lines to visual black characters,” he says. “You certainly don’t want to take a pay cut for doing the same amount of work. It becomes very critical that the rate is set at an amount that does not result in a penalty for the transcriptionist simply because the client has chosen to use a new unit of measure.”

Although there is no official guidance regarding line definitions, the AHDI strongly advocates for full disclosure and open dialogue between employers and transcriptionists, particularly with regard to the definitions and formulas used to calculate compensation, Brady says. “Transcriptionists need the ability to verify those methods and the compensation figures derived from them,” she says.

Making Compensation More Fair
Moving beyond a production-based compensation model is crucial if the MT profession wants to attract and retain qualified workers, industry insiders note.
A shift toward hourly pay rather than a pay-for-production model would encourage quality transcription because it would allow MTs greater flexibility without compromising quality or accuracy, Hahn says, adding that an hourly rate of $14 wouldn’t be unreasonable for an experienced MT.

Brady says compensation models based solely on production may no longer apply as the role of MTs evolves commensurate with the EHR. “There could be a variety of ways in which compensation is handled. It will all depend on what the specific job entails. It probably won’t be a one-size-fits-all approach,” she says.

The AHDI is studying compensation models pertaining to various transcription-related roles, including performing quality assurance, creating templates, and serving as EHR trainers, that are emerging as a result of EHRs.

If compensation does remain production based, it would be helpful for the industry to be able to rely on a standard line definition, Vance says. “I think it would be helpful to have a standard that everyone could agree on in terms of measurement. I emphasize measurement because obviously there couldn’t be any sort of agreement on the rate per unit of measure,” he says.

Quality also should play a larger role in compensation, says the MT who wished to remain anonymous. “I worked for one MTSO [medical transcription service organization] that focused primarily on production at the cost of quality,” she says. “I worked as a fill-in lead sometimes, and some of the reports I saw sent in made my hair stand on end. It is a fine line for an MTSO to walk between optimizing production while maintaining quality.”

Some MTs believe those who work on multiple accounts per day should receive extra compensation for their flexibility and versatility. Others believe they should be paid more for working on weekends and holidays or when working overtime on reports that are more difficult to transcribe.

Another suggestion is for employers to consider the accuracy of speech recognition technology when setting line rates. For example, if the edited document and the document produced by speech recognition technology differ by more than 60%, MTs could be paid the higher rate for transcribing rather than editing the report. Likewise, MTs could earn more money for editing documents produced by difficult dictators and less for those who speak clearly.

Compensation should incorporate all tasks that MTs perform, such as checking e-mails, reviewing quality assurance reports, and researching demographics, Nicholls says. “These things all add to the hours in the day that an MT must work to meet their standards yet often are not considered reportable time for the purposes of their time sheet,” she explains.

Credentials should be a factor when deciding fair compensation. Requiring MTs to become registered or certified as a prerequisite for hiring might help raise awareness of the profession and even elevate pay rates, Hahn says.

Brady recommends taking into account all variables when deciding an equitable salary. “Compensation must reflect the skilled contributions, breadth, and depth of knowledge, experience, education, and credentials of the MT, whether working within a facility, contracting with an outsourced service provider, or as an independent contractor/consultant,” she says.

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in healthcare regulatory topics, HIM, and medical coding.


Let Your Voice Be Heard
Medical transcriptionists (MTs) play a crucial role in maintaining data integrity, ensuring patient safety, assisting with risk management, and enabling correct coding. Thus, compensation should reflect the unique skills that MTs possess, says Linda Brady, CAE, CEO of the Association for Healthcare Documentation Integrity (AHDI).

How can MTs advocate for more equitable compensation? Industry experts posit the following ideas:

Challenge reality. The first step is to realize that the commoditization of transcription services doesn’t need to persist indefinitely. “MTs have to stop accepting phrases like ‘this is just how it is today’ or ‘at least you have a job’ and start refusing to work for less than their skills should demand,” says Kathy Nicholls, CMT, AHDI-F, president of Nicholls Consulting Services.

Articulate your value. “MTs have to recognize the value they bring to the table. I’m not sure they all do,” Nicholls says. “They need to educate themselves about the electronic health record so they can articulate their value in the new world we are all dealing with today.”

The work that MTs perform is often misunderstood, which only fuels the lack of respect for what MTs do and the knowledge base they must possess to ensure data quality and accuracy, says Anne Collins, CMT, a 25-year industry veteran. “People assume that all we do is type, and they assume that anybody can do it. They assume that if you have speech recognition you don’t need to know anything to be able to do it, and that is so far from the truth,” she says. “We need to create more interest in [the AHDI] so that we’re recognized as being part of the healthcare team.”

It’s helpful to describe to others the intensive training MTs receive throughout their careers, Collins says. “It took years for me to be really proficient in this profession, starting in the hospital and really learning, studying, taking courses, and attending seminars, and becoming certified. We have to know all of the specialties. We have to know grammar. We have to know sound-alike words and the context in which they’re used. We catch errors constantly,” she says.

Initiate pay discussions. MTs need to work with their employers to develop a fair compensation model, particularly as EHRs and other technologies continue to reshape the profession. “The employer, in partnership with the healthcare documentation specialist, really needs to take a close look at the job functions being performed and make sure that the compensation model being used is fair, equitable, and in compliance with wage hour employment laws,” Brady says.

Keep an open mind. Smart business decisions are paramount as MTs continue to look for work in an ever-evolving marketplace, says Dale Kivi, MBA, director of business development for FutureNet Technologies. MTs must not only be receptive to new roles in which they might serve, but they should also ensure that potential employers will value their contributions as well as the interplay of human intelligence required to make speech recognition and EHR technology successful.

“You can either fight against the certified EHRs or recognize that there will always be a shifting balance between human contributions and technology. As an employee, you can hook your wagon up to a vendor that will have a path toward the emerging marketplace or one that doesn’t,” he says.