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March 2015

Life on the Low End of the Pay Scale
By Juliann Schaeffer
For The Record
Vol. 27 No. 3 P. 18

Several factors have led medical transcriptionists to be given short shrift. Why? Is it fair? What can be done to remedy the situation?

Salary and other pay gripes may be common water cooler fodder heard in nearly every workplace, but some may argue the health care industry has been squeezed more than most in the last decade. With more patients requesting care, in part due to the Affordable Care Act, and hospitals pinching pennies to do more with fewer resources, it's probably fair to say most health care professionals believe their paycheck doesn't reflect the true value of what they bring to the table.

Medical transcriptionists (MTs), via social media and other outlets, have been especially vocal about pay concerns, some claiming they struggle to make a living—or even minimum—wage. Factors such as outsourcing and speech recognition technology have led to many working under production-based pay, if they keep their jobs at all.

In October 2013, approximately 50 MTs gathered outside the University of Pittsburgh Medical Center (UPMC) offices in Erie, Pennsylvania, to protest the hospital's decision to outsource transcription to Nuance Communications in Massachusetts. According to a report in the Pittsburgh Post-Gazette, while hospital MTs were offered positions at Nuance, they would no longer receive $12 to $22 per hour. Instead, a production-based wage of eight cents per line was offered, compensation that left at least one employee struggling to meet minimum wage.
"[Cindy] Cromie, 56, who had worked for UPMC for seven years and had been earning $16.58 an hour, saw her income drop from $1,012 for two weeks of work to $330 with Nuance," the article stated. "Her production by the new standards was so low that the new employer had to add $26.86 to her paycheck just to keep her at minimum wage."

Are such conditions unfair to knowledgeable and often credentialed professionals who deserve better? Or is it simply a sad reality they must face under the strained economic conditions that continue across many health care spectrums?

New Job Skills, Less Pay
In addition to the ear training skills that are the foundation of traditional transcription, today's MTs often need speech editing prowess as well, says Carole J. Gilbert, RHIT, CHTS-IM, owner of Gilbert Medical Transcription Services, who also works part time as a speech editor for a national service.

"Speech editing requires additional skills that require the MT to focus even more on what is being dictated, and 'delete from the mind' incorrect words and phrases that have been placed into the report by the speech engine, accurately replacing what is dictated, including the 'small' words," she says.

In addition, EMRs require MTs to familiarize themselves with the various platforms that integrate with the technology. All things considered, Gilbert says today's MTs need more skills than ever to do their job well.

Janis Smith, RHDS, president of the Association for Healthcare Documentation Integrity's (AHDI) Florida chapter, agrees. "Other than the additional skill set of editing SR [speech recognition]-generated reports, health care documentation specialists (HDSs) still require the highly knowledgeable, detail-oriented duties they always have, but continuing education and skill development are crucial in order to adapt to the rapid-paced changes occurring in health care treatments, medications, technology, communications, compliance, [and] business models," she says.

Lee Tkachuk, CEO and president of Keystrokes Transcription Service, says transcribing requires the same unwavering pursuit of accuracy as a decade ago, noting that industry standards require MTs to produce a minimum number of lines per hour and maintain a quality assurance score of at least 98% on all accounts.

Despite needing to add new skills, today's MTs generally make less—sometimes far less—than was the case in 2005. "Salaries for transcriptionists are much lower than 10 years ago, often by as much as 30% to 50%," Tkachuk says. "The average salary for a transcriptionist 10 years ago was $55,000. Now, it is more in the $35,000 range."

She notes, however, that benefits have improved. "We now have better health insurance, life insurance, 401(k) plans, etc," Tkachuk says. "Ten years ago, many transcriptionists were independent contractors with no benefits."

Even taking into account improved benefits packages, Gilbert estimates most MT salaries have been reduced 33% to 50%. "I cannot speak from the corporate side, but from the production side, an estimated average yearly range for an acute care MT is $20,800 to $31,200 on production," she says, estimating that paid vacation and sick days may add another $1,000 to those figures.

Variables Abound
To be sure, there are many variables that factor into an MT's pay, according to Jay Vance, CMT, CHP, production coordinator for Keystrokes Transcription Service and AHDI president-elect. For example, he says in general, hospital-based MTs enjoy higher compensation and better benefits than colleagues employed by transcription service providers.

Account type (hospital vs clinic vs physician office) also can impact salary, Tkachuk says, noting other factors, including the following:

• modality (eg, radiology vs pathology);

• specialty;

• shifts worked (second or third);

• days worked;

• platform;

• whether the account is traditional transcription or back-end editing;

• experience;

• length of time with the employer; and

• credentials (Keystrokes pays a 5% premium to CMTs).

However, the biggest factor, according to Susan Whatley, program coordinator of medical transcription and medical coding programs and a professor at Polk State College in Lakeland, Florida, is the switch from hourly to straight production-based pay.

"When I went to work at a hospital 16 years ago, the starting salary was about $10 an hour," she says. "I also could earn incentive for anything over the minimum number of required lines. I also was paid time and a half for overtime. My employer offered a health benefit package, pension, and free life insurance."

Today, Whatley says most MTs are paid by the line—roughly eight cents per line. While that may equate to roughly the same hourly rate (eight cents x 1,000 lines is $80 per day x five = $400 a week x 50 = 20,000), she's quick to point out a distinct difference.

"Of course many MTs do more than 1,000 lines a day, so the pay is more," she says, "but the most important point about it is that when I went to work, I earned $10 an hour no matter if the work was low, the computer crashed, the power went out, or I had horrible dictations for the day and didn't reach 1,000 lines for the day, I still knew I was going to have a paycheck. With line-based pay, there are so many variables that come into play which affect the total lines transcribed in a pay period."

For example, difficult dictators can wreak havoc. "If one is on pure production, a difficult dictator can cause a loss of lines and affect pay," Gilbert says.

Other compounding variables that can affect pay include inconsistent work and speech recognition-specific pay, Whatley says. "Many of the MTs I worked with state that they log in and run out of work," she explains. "There are a lot of people on at the same time, and not enough for all to produce enough lines to live on. For an MT who is paid eight cents a line to earn $36,000 gross, he or she must transcribe 1,800 lines every day for 50 weeks out of 52. If there is no work, it is impossible to transcribe 1,800 lines in a day."

For MTs working in a speech recognition environment, it can be even more difficult, Whatley says. "Speech recognition pay is usually half of transcription pay," she says. "If an MT must transcribe 1,800 lines a day at eight cents, when that is reduced to four cents a line, it now becomes 3,600 lines a day of corrected documentation. Again, inconsistent work makes this impossible to consistently achieve."

Effects of Outsourcing, Other Factors
What does the picture look like when all of those variables add up to an MT's salary? Not good at all, Gilbert says. "Personally, I know of at least two services that have had to add to an MT's paycheck in order for them to make minimum wage," she says, noting that speech recognition software is often to blame for smaller salaries.

"When the speech editing technology came on board, the cost of the technology was paid for by lowering the line rate by one-third to one-half of what the MT made previously," Gilbert says. "This is in spite of the fact that it is often not possible to make up that much due to the data entry duties of the MT, jumping from platform to platform, difficult dictators, poor speech drafts, or for the simple fact that it may not be professionally possible to go at the rate required to make up the difference in order to provide an accurate report."

When three hospitals in Whatley's area outsourced their transcription in the span of 18 months, "almost all MTs lost their facility jobs. With those jobs went their hourly wage, retirement, and health insurance package," she says.

"The MTs in my facility are being paid by the hour for one year and then they will go on straight production," Whatley continues, noting that many aren't optimistic about their future in the field. "I have been contacted by several of them who indicate that after the year is up, they will not be able to make a living because of the variables that affect their daily pay. They are looking to move into coding or some other area of health care or to get out of the industry. They also are not able to afford the benefit package with their reduced wages."

Smith has experienced similar situations. "Many of the hospital-employed HDSs with whom I associate have had their pay and benefits drop year after year in their employers' efforts to try to retain their in-house HDS staff," she says. "Many hospitals have outsourced entirely because of pressure from corporate management to cut costs. Unfortunately, in the financial end of things, transcription is often considered a cost item that needs to be eliminated rather than associated with revenue, as coders and billers are, in spite of our major contribution toward helping ensure the integrity and accuracy of the patient's record."

Outsourcing may be a major reason for lower MT salaries, but it's hardly the only one, says Tkachuk. "Yes, I believe that outsourcing, especially overseas, has led to the lowering of MT wages," she says. However, increased taxes and the cost of health insurance benefits and new technologies as well as basic supply-and-demand factors all play a role, Tkachuk notes.

"We have gone from a high demand for MTs to the point of having a shortage to having a surplus of American MTs," she says. "Because of all of these factors combined, rates that MTSOs [medical transcription service organizations] charge to facilities have decreased dramatically, leading to the decrease in MT rates. Unfortunately, similar to the housing market, supply and demand drive costs and the market cannot handle rates as high as they were 10 to 15 years ago. Customers demand more for less, and they can find it."

Vance agrees, noting that while outsourcing has undoubtedly had a huge impact, the advent of technology such as speech recognition and EMRs and the widespread push for cost cutting across the industry have likely been larger factors.

What's Realistic
If current conditions aren't favorable—or fair, depending on your viewpoint—for some MTs, then what's the answer? Would an established minimum wage help?
While all MTs are entitled to the minimum wage of their respective employers, Vance says those at the lowest end of the pay scale are probably in the wrong profession or working for the wrong organization. "MTs must be proactive in seeking out employers who offer reasonable compensation and refuse to work for companies which seek to take advantage of their employees," he says.

Gilbert proposes a minimum wage of $15 per hour for MTs. "The skills to do this job accurately and reliably should be valued highly enough to be paid a living wage," she says. "With fast-food workers saying that $15 an hour is what they need for a living wage, compare their job description and responsibilities to that of a medical transcriptionist and see where the scales tip. In my opinion, what a credentialed transcriptionist brings to the table as far as patient care and the revenue cycle is the same that a coder brings to the same table, and the hourly pay and any incentives should be the same."

"I believe that all transcriptionists should be able to make a minimum of $15 per hour on any account," Tkachuk says. "We have transcriptionists who make less than that and many who make more than that—sometimes double or even triple that amount. It really depends on a lot of factors, including the account, volume, skill level, use of normal reports, templates and expanders, experience, and modality."

No matter what any one MT or transcription service CEO believes is the answer, ultimately it's the marketplace that determines rates, Vance says. "And the marketplace is a very complex environment," he notes. "Clients are constantly looking for ways to cut costs, and transcription service providers are caught in a downward spiral of price cutting in order to stay competitive. This in turn results in less money available for personnel.

"That is not to say there aren't MT service companies that take advantage of their employees," he adds. "But there are also companies who treat their employees fairly. Furthermore, there are MTs who are more skilled and/or motivated than others, so that's another factor that impacts compensation overall."

What are disgruntled and struggling MTs to do? Tkachuk recommends they take advantage of any free training, whether offered by employers, other MTs, AHDI, or AHIMA. The knowledge gained can help MTs become more efficient and thus take better advantage of production pay.

"Learn everything you can about increasing productivity through technology and set daily production goals," Tkachuk says. "Talk to your employer if you do not have enough work, if you are struggling to meet production goals, or if you'd like to cross-train on other accounts, modalities, platforms, and/or specialties."

Seek out an employer that offers better work standards, Gilbert says. "As with any other profession, if the MT wants to continue transcribing or editing, then they will have to continually search out those employers that value their skills enough to pay them well," she says, noting that moving to a similar position or profession, such as quality assurance or coding, is also an option.

To improve work conditions, Gilbert says it's important that MTs spread the word about the valuable work they provide. "Bringing attention to their concerns needs to be done at the professional organizational level, and right now that is AHDI, who can speak to both AHIMA and the American Medical Association about the value of having trained MTs as part of the documentation and revenue and risk management team," she says. "AHDI has been at the table for some of these meetings and is working on several tools and resources for these purposes."

Nevertheless, according to Vance, MTs hold the biggest wildcard—whether they will continue to work for what they deem unfair wages. "Refusing to work for substandard compensation is the best advice I can give," he says. "Many MTs struggle with taking a stand in this regard, either due to a fear of losing their jobs if they refuse to accept unreasonable compensation, a lack of confidence in their own abilities, or other factors which may come into play."

Vance admits the thought of becoming unemployed is frightening, but stresses that MT service owners are unlikely to change current pay standards as long as MTs are willing to accept substandard compensation.

Tkachuk believes MTs must take it upon themselves to find the right employer and develop the right skill set. "I believe that MTs need to be realistic about the future of transcription and accept that outsourcing, speech recognition, and other technology advances such as EMRs, structured data, and dictation markers are here to stay," she says. "Many facilities do not care about keeping work in the United States if the cost is low, but others do. Transcription is still going to be here, and it is going to continue to increase based on the sheer volume of patients entering the health care system each year.

"There is still a need for an accurate medical record, and there is still a need for the expertise of a transcriptionist behind accurate reports," Tkachuk adds. "MTs need to learn to be very efficient and productive, using their expanders, becoming very rigid on their work schedules, and continuing to learn new platforms and technologies. Those who strive for excellence and really care about patient care will continue to be successful. This will not apply to every transcriptionist, but the elite will continue to make excellent wages. For the others, it is time to either train for a new profession or make the commitment to change and improve."

— Juliann Schaeffer is a freelance health writer and editor based in Alburtis, Pennsylvania.