ONE WIFE, ONE PATIENT, AND THE HIDDEN LABOR OF AMERICAN HEALTHCARE
“Our care is better for patients when we don't feel
burned out. We make fewer mistakes when we don't feel burned out.” —
Christine Sinsky, MD, American Medical Association
Source: American Medical Association, Addressing the
rapid rise in physician burnout revealed by a new study.
There is a sentence in healthcare that sounds comforting
until you actually have to live with it:
“You're going home with services.”
Sounds good.
Almost luxurious.
Services.
Plural.
It has the ring of a concierge package.
Then you get home.
And discover that “services” may mean a nurse comes once a
week.
A physical therapist comes once a week.
And your spouse becomes the rest of the healthcare system.
That is the story of an unnamed husband and wife featured in
a recent 24/7 Wall St. report.
The husband went home needing help with wound care,
medications, mobility, meals, bathing and the ordinary things that suddenly
become extraordinarily difficult when someone is sick.
A home-health nurse came once a week.
A physical therapist came once a week.
Everything else belonged to his wife.
The article put the arithmetic bluntly:
168 hours in a week.
Professional home-health visits covered roughly two.
His wife was effectively responsible for the other 166
hours.
No dramatic operating room.
No billionaire startup.
No breakthrough drug.
No shiny AI robot.
Just a husband.
A wife.
A walker.
A medication schedule.
A 3 a.m. bathroom trip.
And a healthcare system that technically did what it
promised.
That last part is what interests me.
Because the system wasn't necessarily lying.
It was simply defining “care” much more narrowly than the
family experienced it.
And that should make every physician and clinic owner stop
for a moment.
Because we have our own version of the Other 166 Hours
Problem.
It happens after the patient leaves the exam room.
THE PATIENT LEFT.
THE WORK DIDN'T.
A physician sees a patient.
Maybe 15 minutes.
Maybe 30.
Maybe an hour for a complicated visit.
The patient leaves.
The door closes.
The physician moves to the next patient.
But somewhere behind the scenes, another patient is born.
The administrative patient.
This one has an insurance ID.
A CPT code.
An ICD-10 code.
A modifier.
A payer.
A claim number.
A status.
A denial code.
A deadline.
And eventually, perhaps, an appeal.
Nobody invited this patient.
But suddenly your staff is spending 20 minutes taking care
of it.
Then 40.
Then an hour.
Sometimes the physician gets involved.
Someone says:
“Doctor, the insurance company wants more information.”
You sigh.
You open the chart.
You look at the note.
You wonder why the payer couldn't simply read what you
already documented.
Then you remember:
Because apparently the healthcare system has invented a
second patient who exists entirely inside the billing department.
And that patient needs care too.
HERE'S MY CONTRARIAN TAKE
We don't have a physician productivity problem.
We have a system design problem disguised as a
productivity problem.
That distinction matters.
For years, healthcare has responded to administrative
overload by telling clinicians to:
Work faster.
Document better.
Learn the new rule.
Use the new portal.
Check another box.
Hire another staff member.
Try another vendor.
Download another app.
Attend another training.
And, naturally, take care of yourself.
Because nothing says “wellness” quite like another mandatory
45-minute webinar.
We keep asking:
How can physicians become more efficient?
I think the better question is:
Why are physicians being asked to perform so much work
that should have been prevented upstream?
That is a different question.
And it leads to a different kind of healthcare technology.
THE OTHER 166 HOURS EXISTS INSIDE YOUR PRACTICE
The caregiver story is powerful because the wife became the
invisible infrastructure.
The healthcare system provided professional services.
She provided continuity.
She provided context.
She noticed changes.
She managed the ordinary moments.
She was there when nobody else was.
The same phenomenon happens in physician practices.
Your staff becomes the invisible infrastructure.
They remember payer quirks.
They know which claims are always problematic.
They know which physicians document differently.
They know which payer portal is broken.
They know which authorization department never answers the
phone.
They know which denial code means:
“Good luck.”
They compensate.
They improvise.
They create workarounds.
They keep the practice moving.
And because they are good at their jobs, leadership
sometimes assumes everything is fine.
That is one of the most dangerous illusions in healthcare.
A system can look functional because excellent people are
constantly repairing it.
THE HUMAN COST OF “MAKING IT WORK”
Think about that phrase:
“We make it work.”
It sounds positive.
In medicine, it can be a warning sign.
“We make the schedule work.”
“We make the staffing work.”
“We make the billing work.”
“We make the payer work.”
“We make the old software work.”
“We make the new regulation work.”
“We make the denial process work.”
Translation:
Humans are absorbing the defects of the system.
And humans have limits.
That is where burnout enters the conversation.
The AMA's latest data show that 41.9% of physicians
reported at least one symptom of burnout in 2025. That is an improvement
from 43.2% in 2024 and 48.2% in 2023.
Improvement is good.
But 41.9% is still roughly four out of ten physicians.
That is not a rounding error.
And here's the part I find interesting:
We often talk about burnout as if it were an emotional
problem.
Sometimes it is.
But much of the time, burnout is also an operations
problem.
If the system generates unnecessary work every day,
eventually somebody pays for it.
Usually with time.
Sometimes with money.
Often with both.
THE RCM MACHINE HAS A STRANGE BUSINESS MODEL
Let's imagine another industry.
A customer buys something.
The company delivers it.
Then the company intentionally creates paperwork that
prevents itself from getting paid.
The customer says:
“Please prove you delivered it.”
The company provides proof.
The customer says:
“Please provide it in another format.”
The company does that.
Then the customer says:
“We still can't process it.”
The company hires 14 people to investigate.
Eventually everyone celebrates because the company
successfully received payment for the thing it already delivered.
We would call that business model insane.
In healthcare, we call it:
Revenue Cycle Management.
I'm not saying billing is inherently broken.
I'm saying we've normalized an astonishing amount of post-service
administrative friction.
And then we built an entire industry around cleaning it up.
That should make us uncomfortable.
THE DENIAL IS NOT THE PROBLEM
Here's another contrarian idea:
A denial is often not the problem.
It is the symptom.
The real problem happened earlier.
Maybe eligibility wasn't verified.
Maybe an authorization requirement wasn't identified.
Maybe documentation wasn't structured properly.
Maybe coding didn't reflect the clinical work.
Maybe the claim failed a payer-specific rule.
Maybe information was lost between systems.
Maybe nobody knew the rule had changed.
By the time the denial arrives, the system is essentially
saying:
“Congratulations. We found your problem.”
Thank you.
Could we have known this yesterday?
That is the question.
DOWNSTREAM HEALTHCARE IS EXPENSIVE
The traditional revenue-cycle model is largely reactive.
Something happens.
Then somebody fixes it.
Claim denied.
Work denial.
Missing documentation.
Chase physician.
Wrong code.
Correct code.
Payer requests information.
Find information.
Authorization missing.
Start calling.
This is the healthcare equivalent of waiting for the smoke
alarm before installing a fire extinguisher.
We need to move upstream.
Instead of:
Denial → correction
we should aim for:
Clinical encounter → validation → clean claim
Instead of:
Missing information → physician interruption
we should aim for:
Missing information → early identification
Instead of:
Payer rejection → investigation
we should aim for:
Payer requirements → pre-submission intelligence
That is the difference between reactive RCM and preventive
RCM.
AND THE DATA ARE GETTING HARDER TO IGNORE
MGMA's 2026 Regulatory Burden Report found that
approximately 95% of medical groups reported increased regulatory burden
over the previous three years.
The report identified audits and appeals as the
leading burden, while Medicare Advantage prior authorization, denials and
automatic downcoding were also among the top issues.
That isn't a technology problem alone.
It is a workflow problem.
A staffing problem.
A financial problem.
And eventually, a patient-access problem.
MGMA explicitly connects rising administrative burden and
declining reimbursement with physician burnout, consolidation and difficulty
maintaining patient access.
So when we talk about medical billing, we need to stop
treating it as the boring corner of healthcare.
It isn't boring.
It is infrastructure.
THE BILLING DEPARTMENT IS PART OF CLINICAL CAPACITY
This may sound strange.
But hear me out.
Suppose your billing team spends hundreds of hours every
month correcting avoidable claims.
That is labor.
If your physicians spend evenings answering documentation
queries, that is labor.
If your practice manager spends Friday afternoon fighting
payer portals, that is labor.
If your medical assistant spends 30 minutes tracking an
authorization, that is labor.
Every administrative task consumes capacity.
And capacity is finite.
Which means:
Administrative friction is a clinical resource problem.
Every hour spent fighting a preventable denial is an hour
that cannot be spent improving the practice somewhere else.
Maybe with patients.
Maybe with staff.
Maybe with growth.
Maybe with quality.
Maybe with sleep.
Yes.
Sleep.
We don't put that on the balance sheet.
Perhaps we should.
WHAT I BELIEVE ABOUT AI
I am a physician.
I am also building a healthcare technology company.
So naturally I have an opinion about AI.
Here it is:
AI is not magic.
Sorry.
There goes the keynote.
AI will not eliminate payer policies.
It will not make every claim payable.
It will not replace clinical judgment.
It will not automatically make a poorly designed workflow
intelligent.
And it certainly should not be used as an excuse to put more
work onto physicians.
The real opportunity is much less glamorous.
And much more valuable.
Use AI to prevent humans from having to do repetitive
work in the first place.
That's it.
Not sexy.
Very useful.
THE BEST AI MAY BE THE AI YOU NEVER NOTICE
Imagine an AI system that quietly notices:
“This documentation may not support the selected code.”
“Eligibility changed.”
“This payer requires additional information.”
“This claim has a pattern associated with previous denials.”
“This modifier combination deserves review.”
“This physician consistently encounters the same denial.”
That is not science fiction.
It is workflow intelligence.
And the best version of it does not shout:
LOOK WHAT AI CAN DO!
It quietly prevents the problem.
That is the kind of AI healthcare needs.
Less theater.
More infrastructure.
THIS IS WHY I BUILT ONNX
The thesis behind OnnX is simple.
The healthcare industry has spent enormous energy optimizing
what happens after the claim fails.
I believe we should spend more energy asking:
Why did the claim become vulnerable in the first place?
That moves the conversation upstream.
From billing to clinical-to-claims intelligence.
From correction to prevention.
From manual work to intelligent workflow.
From:
“Who can fix this?”
to:
“Why did we create this problem?”
That is a much more interesting question.
And frankly, it is the question I think healthcare
technology has avoided for too long.
THE THREE QUESTIONS EVERY PRACTICE OWNER SHOULD ASK
Forget the vendor demo for a minute.
Ask these first.
QUESTION ONE:
Where are we losing money?
Not theoretically.
Show me the last 90 days.
QUESTION TWO:
Why are we losing it?
Group the denials.
Look for patterns.
Do not accept:
“Insurance denied it.”
That's not a root cause.
That's a sentence.
QUESTION THREE:
Where was the problem first created?
This is the big one.
Because the place where you discover a problem is
often not the place where you created it.
A DENIAL DASHBOARD IS NOT ENOUGH
This is another industry habit I would challenge.
A practice installs a dashboard.
Beautiful charts.
Green arrows.
Red arrows.
Trend lines.
Someone presents it at the monthly meeting.
Everyone nods.
Then the same denial happens next month.
And the month after.
Congratulations.
You have successfully visualized the problem.
You have not solved it.
Analytics without intervention is expensive wallpaper.
The dashboard needs to lead somewhere.
A root cause.
An owner.
An intervention.
A measurable change.
FIVE METRICS I WOULD WATCH
1. CLEAN CLAIM RATE
How often does the claim get through the first time?
Simple.
Important.
2. DENIAL RATE
But don't stop there.
Break it down by:
payer, provider, procedure, diagnosis, modifier and
denial reason.
Patterns matter.
3. DENIAL TOUCHES
How many people touch the claim before it is resolved?
One?
Three?
Six?
If a $100 claim requires $200 worth of human labor to
recover, you have discovered something important.
4. PHYSICIAN ADMINISTRATIVE TIME
How many minutes per week do physicians spend dealing with
billing-related questions?
Track it.
You may not like the answer.
That's okay.
Bad information is still better than comfortable
assumptions.
5. DAYS IN A/R
Watch the trend.
Not just the number.
A rising A/R curve can be the smoke before the fire.
THE 30-DAY PRACTICE EXPERIMENT
Don't overhaul everything.
Pick one problem.
Just one.
DAYS 1–5
Pull 90 days of claims.
Find your top three denial categories.
DAYS 6–10
Choose the largest category.
Trace it backward.
Where did it begin?
DAYS 11–15
Interview the people who actually touch the workflow.
Not just executives.
Ask the person who fixes the problem every day.
They usually know more than the dashboard.
DAYS 16–20
Change one upstream step.
DAYS 21–30
Measure the result.
Did the denial rate fall?
Did staff touches fall?
Did physician interruptions fall?
Did A/R improve?
If yes, keep going.
If no, congratulations again.
You learned something.
That is better than pretending the first solution worked.
WHAT NOT TO AUTOMATE
This is important.
Do not automate everything simply because you can.
Clinical judgment should remain with clinicians.
Compliance decisions need appropriate oversight.
Exceptions need human review.
High-risk decisions need escalation.
And automated coding should never become a license to
inflate reimbursement.
The ethical goal is:
accurate representation of care.
Not:
maximum possible reimbursement.
Those are not synonyms.
THE LEGAL AND ETHICAL LINE
Healthcare technology lives in a world of privacy,
compliance and accountability.
If your system handles protected health information,
appropriate safeguards matter.
If AI influences coding or billing, auditability matters.
If a vendor touches sensitive data, contracts and
responsibilities matter.
If automation produces recommendations, someone must be
accountable for reviewing them when appropriate.
And if a system encourages unsupported documentation or
coding, that's not innovation.
That's a problem.
Technology should help practices become more accurate,
not merely more aggressive.
The best revenue-cycle system is not the one that finds the
most money.
It is the one that helps the practice accurately capture
the value of legitimate care it already provided.
HERE'S ANOTHER UNCOMFORTABLE TRUTH
Small practices are often told they need to behave like
large health systems.
More software.
More processes.
More dashboards.
More departments.
More infrastructure.
I'm not convinced.
Small practices have an advantage large organizations often
envy:
They can move quickly.
The problem is that they have less room for waste.
A large system can hide inefficiency inside a giant
organization.
A five-physician practice cannot.
If one employee spends half a day every week fixing the same
problem, you feel it.
If the physician spends two hours every Friday dealing with
claims, you feel it.
If $100,000 sits in avoidable A/R, you feel it.
The smaller the practice, the more valuable operational
clarity becomes.
THE REAL COMPETITIVE ADVANTAGE
I don't think the future belongs to the practice with the
most technology.
I think it belongs to the practice with the least
unnecessary work.
Think about that.
Not:
Who has the most AI?
Who has the newest EHR?
Who has the biggest billing department?
Who has the fanciest dashboard?
Instead:
Who can deliver excellent care with the least
administrative friction?
That's a better competitive question.
THE CAREGIVER WASN'T THE BILLING DEPARTMENT
Let's be clear.
The wife in the original story was not dealing with claims.
She was caring for her husband.
Her story is not proof that RCM causes caregiver burden.
That would be a ridiculous leap.
But her story illustrates something important:
Healthcare systems often count formal services while
families experience the total workload.
That distinction matters.
A nurse's visit is counted.
The spouse's midnight work often isn't.
A physical therapy session is documented.
The hours of supervision between visits aren't.
Healthcare measures encounters extremely well.
It is often much worse at measuring everything that
happens between encounters.
And that is exactly where a huge amount of healthcare work
lives.
BETWEEN THE VISITS
Healthcare happens between visits.
Between appointments.
Between claims.
Between payer decisions.
Between authorization requests.
Between phone calls.
Between portal messages.
Between discharge and follow-up.
Between documentation and reimbursement.
Those gaps are where friction hides.
And wherever friction hides, opportunity usually follows.
That's where healthcare founders should look.
Not necessarily at another flashy front-end app.
Look at the spaces between systems.
Look at the handoffs.
Look at the moments where information gets lost.
Look at the places where humans repeatedly compensate.
That's where the real infrastructure opportunity may be.
THE NEXT GENERATION OF HEALTHCARE TECHNOLOGY
I think we are moving toward a different model.
The first generation of healthcare software digitized
paperwork.
The second generation automated workflows.
The next generation should understand context.
It should know:
What happened clinically.
What needs to happen operationally.
What the payer expects.
What historically goes wrong.
What requires human judgment.
And what can safely happen automatically.
That's more than automation.
That's workflow intelligence.
THE FUTURE IS NOT “NO HUMANS”
That's the wrong goal.
Healthcare is human.
Always will be.
The goal should be:
fewer humans doing unnecessary work.
More humans doing work that requires judgment.
More physician attention where it matters.
More staff attention where it matters.
Less clicking.
Less chasing.
Less duplicate entry.
Less “Can you resend that?”
Less “The payer says they never received it.”
Less Friday-afternoon claims archaeology.
And, ideally:
fewer reasons for a physician to stare at a billing
portal after seeing patients all day.
THE QUESTION I WOULD ASK EVERY PHYSICIAN-OWNER
If you could eliminate one administrative task from
your practice tomorrow, what would it be?
Prior authorization?
Denials?
Eligibility?
Documentation queries?
Claim status?
Coding?
Payer portals?
Something else?
And here's the more important question:
Why does that task exist in the first place?
That second question is where innovation begins.
THREE THINGS I WOULD DO THIS MONTH
ONE: Find your most expensive recurring denial.
Not your most annoying one.
Your most expensive one.
TWO: Calculate the human labor required to fix it.
Staff time.
Physician time.
Manager time.
THREE: Move the intervention upstream.
Don't simply hire someone to work the denial faster.
Ask whether the next denial can be prevented.
That is the difference between scaling labor and scaling
intelligence.
THE BIGGEST MYTH IN MEDICAL BILLING
The myth is that the solution to administrative burden is
more administrative capacity.
Sometimes it is.
But not always.
If the system creates 1,000 unnecessary tasks and you hire
people to complete those 1,000 tasks, you have not solved the problem.
You've just become better at tolerating it.
Efficiency is not doing more work faster.
Sometimes efficiency means making the work disappear.
FINAL THOUGHTS
The husband in this story went home.
His wife stayed on call.
The healthcare system provided professional services.
She provided the rest.
There is something uncomfortable about that.
Not because the system necessarily failed.
But because the system's definition of “care” was smaller
than the family's reality.
Physician practices face a similar challenge.
The patient encounter may be 20 minutes.
But the administrative life of that encounter can stretch
for days.
The work doesn't disappear because the patient walked out
the door.
Someone carries it.
A biller.
A medical assistant.
A practice manager.
A physician.
Someone.
So perhaps the question isn't:
“How do we get our staff to work harder?”
Perhaps it is:
“How much of this work should exist at all?”
That is the question I want healthcare leaders to ask.
Because the future of healthcare won't be built simply by
adding more people to broken workflows.
It will be built by designing workflows that need fewer
unnecessary interventions in the first place.
THREE SENTENCES TO REMEMBER
Stop measuring how much unnecessary work your people can
tolerate.
Start measuring how much unnecessary work your system can
eliminate.
Give healthcare professionals their most valuable
resource back: attention.
GET INVOLVED
Now I want to hear from physicians and clinic owners.
What is the one administrative task in your practice that
makes absolutely no sense anymore—but everyone has simply learned to live with
it?
Tell me in the comments.
Don't give me the polished executive answer.
Give me the real one.
The annoying one.
The absurd one.
The task your staff complains about every Friday.
Share this article with another physician or practice
owner who has ever wondered why healthcare requires so much work to get paid
for work already completed.
And if you're building something better in healthcare, join
the conversation.
Question the workflow.
Challenge the “best practice.”
Measure the friction.
Fix the source.
FREQUENTLY ASKED QUESTIONS
Is the “Other 166 Hours” story about a real patient?
Yes. The August 16, 2026 24/7 Wall St. story describes an
unnamed husband discharged home with intermittent home-health services and his
wife providing the majority of his ongoing care. The publication does not
identify the couple by name.
Why use this story in an article about medical billing?
Because it illustrates the broader concept of hidden
healthcare labor. The caregiver experiences the full workload of care even
when the formal healthcare system measures only specific professional services.
The RCM connection is an analogy, not a claim that the two
situations are identical.
Is physician burnout improving?
Yes, according to the AMA's latest data. But 41.9% of
physicians reported at least one symptom of burnout in 2025, so the problem
remains substantial.
What is currently one of the biggest administrative
burdens for medical groups?
MGMA's 2026 Regulatory Burden Report identifies audits
and appeals as the leading burden and lists Medicare Advantage prior
authorization, denials and automatic downcoding among the major burdens.
Does AI eliminate denials?
No.
AI can help identify patterns, flag potential problems and
automate repetitive workflows.
But payer policies, clinical judgment, documentation and
human oversight remain essential.
Should physicians be responsible for billing?
Physicians should understand the connection between clinical
documentation, coding and reimbursement.
They should not have to become billing specialists.
The objective should be to make the system work better
around clinical care.
What should a practice measure first?
Start with:
clean claim rate, denial rate by root cause, denial
touches, days in A/R and physician administrative time.
Is outsourcing medical billing a bad idea?
Not necessarily.
The problem is outsourcing without visibility.
A practice should still understand its denial patterns,
collections, A/R, vendor performance, contracts and escalation processes.
What is upstream RCM?
Upstream RCM means identifying and preventing revenue-cycle
problems before they become denials, rework or delayed payment.
EXPERT PERSPECTIVES
CHRISTINE SINSKY, MD
Dr. Sinsky's work on physician well-being has emphasized the
relationship between clinician burnout and the systems in which physicians
practice.
The lesson for practice owners is straightforward:
Don't treat a system problem as a resilience problem.
If the workflow generates unnecessary administrative work,
redesign the workflow.
ANDERS GILBERG, MGMA
MGMA's senior vice president of government affairs has
highlighted the growing burden that regulatory requirements, Medicare Advantage
processes, denials and other administrative demands place on medical practices.
The broader lesson:
Administrative burden is no longer a side issue. It is a
practice sustainability issue.
THE AMA'S PHYSICIAN WELL-BEING RESEARCH
The AMA's current data show that physician burnout is moving
in the right direction, but remains widespread.
The lesson is not that healthcare can declare victory.
It is that system-level improvements can matter—and
that continued work is necessary.
THREE REFERENCES
MGMA — 2026 Regulatory Burden Report
MGMA's report documents the growing administrative burden
experienced by medical groups, including audits, appeals and Medicare
Advantage-related processes.
Read
the MGMA 2026 Regulatory Burden Report
American Medical Association — Physician Burnout
The AMA's latest data show 41.9% of physicians reported
at least one burnout symptom in 2025.
Read
the AMA physician burnout report
24/7 Wall St. — The Other 166 Hours
The original human-interest story that inspired this article
describes the gap between intermittent professional home-health visits and the
family's ongoing caregiving responsibilities.
Read
the original caregiver story
ABOUT THE AUTHOR
Dr. Daniel Cham is a physician, medical consultant
and healthcare entrepreneur focused on the intersection of medical
technology, healthcare operations, medical billing and practice sustainability.
He is the founder of OnnX, an AI-powered medical
billing platform focused on helping small and medium-sized medical practices
reduce administrative friction and improve the connection between clinical
documentation, coding, claims and reimbursement.
His work centers on a simple question:
What if healthcare technology stopped asking physicians
to work around broken systems—and started making those systems work around
physicians?
Connect
with Dr. Daniel Cham on LinkedIn
DISCLAIMER
This article is intended for general educational and
informational purposes and should not be interpreted as medical, legal,
compliance, coding or reimbursement advice.
Healthcare requirements, payer policies, contracts and
regulations vary.
Physicians, practice owners and healthcare organizations
should obtain advice from appropriately qualified professionals regarding their
individual circumstances.
CONTINUE THE CONVERSATION
The healthcare conversation should not end with the article.
Explore more perspectives on healthcare operations,
physician entrepreneurship, medical technology, revenue-cycle management and
healthcare innovation:
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Knowledge creates leverage.
Better questions create better systems.
Better systems give healthcare professionals more time to
do the work only they can do.
Start there.
FREE RESOURCE
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of my LinkedIn profile. No additional signup is required. If you are working to
improve your practice operations, take a look.
If this article made you think differently about
administrative work, repost it.
Another physician may need to see it.
Another practice owner may recognize their own
Friday-afternoon billing nightmare in it.
And maybe the next healthcare innovation won't be another
tool that adds work.
Maybe it will be the tool that finally removes some.
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