Heading into 2013, the Sustainable Growth Formula issue remains unresolved. Despite the enormity of the SGR, which proposes reduced payments to doctors, it isn't even foremost in the minds of some physicians because of so many other complicated dilemmas.
A few weeks ago, when top officials of The Physicians Foundation went to Washington, D.C., to visit Congressional offices, they were greeted with: "We know what you're going to be talking about," recalls Lou Goodman, PhD, the foundation president, in a recent conversation with HealthLeaders Media. Sure, it was going to be the SGR. If Congress doesn't impose a "doc fix" to avoid significant cuts, the shortfall is pegged at 27% beginning January 1.
Not so. "No, I'm not going to talk about the S-word," Goodman said, shocking them into listening.
Instead, Goodman wanted to talk about the foundation's annual Watch List, covering major issues confronting physicians. The list is based on a compilation of Physicians Foundation reports over the previous year. For 2013, much of the Watch List is focused on ramifications of the Patient Protection and Affordable Care Act, questions about physician autonomy, hospital consolidation, physician administrative burdens, and the impending 32 million more uninsured into the healthcare system, as well as the overall "despondency" and "unhappiness" of doctors.
The SGR didn't make the list because, Goodman says, it is "a symptom of other issues. It is something we have to figure out, and roll into what we do as we go forward." As more doctors become part of hospital systems and payment models such as bundling or gainsharing are evaluated, the "issue of SGR loses its significance, [and] really [becomes] a focus of individuals and private practice," he says.
As Goodman sees it, 2013 will be a "watershed" year. "So many doctors are unhappy and concerned what the future is bringing," he says.
Let's start with what The Physicians Foundation sees as the top five issues facing its members in the upcoming year. And I'm throwing in four concerns of my own, related to quality and clinical achievements.
- The "nebulous" PPACA. The foundation sees a swirl of uncertainty around a host of issues that contribute to widespread physician pessimism: accountable care organizations, health insurance exchanges, the Independent Payment Advisory Board, Medicare physician fee schedules.
- The consolidation movement. The foundation is worried that while large hospital systems and medical groups continue to acquire smaller/solo practices at a high rate, "increased consolidation may potentially lead to monopolistic concerns, raise cost of care, and reduce the viability and competiveness of solo/private practice," Goodman says. With everything from ACOs to hospital consolidation with practices, "We believe there's a mad rush toward getting bigger," he adds.
- The uninsured. As the PPACA expands eligibility for Medicaid and provides tax credits that make insurance more affordable, the Congressional Budget Office projects that 32 million people will have more insurance by 2019. By 2014, companies with 50 or more full-time workers must provide health insurance that the government deems affordable and fair. "As the 12-month countdown to 30 million continues across 2013, physicians and policy-makers will need to identify measures to help ensure [that] a sufficient number of doctors are available to treat these millions of new patients—while also ensuring the quality of care provided to all patients is in no way compromised," the foundation notes.
- Physician autonomy. The Physicians Foundation believes that physician autonomy—particularly related to a doctor's ability to "exercise independent medical judgments without non-clinical personnel interfering with these decisions"—is deteriorating. Add to that decreasing reimbursements and liability/defensive medicine pressures. In 2013, "physicians will need to identify ways to streamline these processes and challenges, to help maintain the autonomy required to make the clinical decisions that are best for their patients," the foundation says. Of all the issues facing doctors this coming year, "the erosion of physician autonomy concerns me the most," Goodman says.
- Administrative burdens. Increasing administrative and government regulations were cited as one of the chief factors contributing to pervasive physician discontentment, according to the foundation's 2012 Biennial Physician Survey. "We're not making widgets, but providing care and making life and death decisions," Goodman says. "We don't need to be involved in wearing green eye shades, but financial decisions need to be reviewed by doctors. Doctors have to be involved in the conversation."
- Overutilization. Whether it's stents, angioplasty, or spine and cardiovascular surgeries, excessive and unnecessary clinical procedures are creating a growing uproar among doctors themselves, as well as academics, and in some cases, government investigators. In a recent speech, Don Berwick, MD, former administrator for the Centers for Medicare & Medicaid Services, said 50% of stenting and coronary bypass surgeries performed today don't resolve symptoms and don't extend life or prevent heart attacks. Stents are under the microscope now more than ever, especially with the recent focus on the for-profit hospital chain HCA in the wake of a New York Times report. Then there's the tendency for physicians to fall in love with expensive medical devices, particularly implantable ones used in cardiology and orthopedic procedures, and the companies that make them. A General Accountability Office report points out potential problems of the physician–device maker connection.
- Embrace the data. More than 69% of primary care physicians reported using electronic medical records in 2012, up from fewer than 46% in 2009, according to a Commonwealth Fund report published in Health Affairs. Yet the presence of this technology is among the reasons U.S. doctors are moving out of their existing private practices and toward hospital employment, according to a report from Accenture. For physicians to fully embrace EMRs, health systems must improve record-keeping and quality controls, Goodman says. "From a doctor's perspective, they are being bogged down in collecting information as well as compliance issues," hesays.
- Malpractice malady. The HealthLeaders Media 2012 Industry Survey shows that a whopping 58% of physician leaders said they ordered a test for a procedure primarily for defensive medicine reasons in the past year. But their worries may make things worse, keeping mistakes under wraps or encouraging too many tests or procedures
- Teamwork. Team-based protocols and efficiency approaches are more and more important today. "One of the problems of medicine is that a lot of people are very stuck in their preconceived notions of what is right and wrong, and things are not as well understood as one would hope," neurologist Thomas Hemmen, MD, PhD, director of the stroke program at UC San Diego Medical Center, recently told me. Another physician leader, Michael J. Dacey, MD, FACP, senior VP for medical affairs and CMO for Kent Hospital in Warwick, RI. told me earlier this year that doctors "must be more collaborative, work as a team. There's a different-mindset."
For physicians looking ahead to the New Year, that about says it all.
Maybe politicians should take a page from this playbook, too?
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
