For months, Harris Methodist Fort Worth (TX) Hospital has been forced to turn away emergency patients with brain and spine injuries because of a shortage of neurosurgeons. The hospital, which is a level 2 trauma center, has just four neurosurgeons available to treat trauma cases and the problem could escalate if several key physicians follow through on threats to leave. As a result of the shortage, crews routinely are told to take victims of car wrecks and falls and others with serious neurological injuries to the publicly funded John Peter Smith Hospital a few blocks away.
Forget Hillary Clinton and Barack Obama. The political battle you want to keep an eye on this spring is the fight between two of healthcare's biggest associations over the merits of physician-owned specialty hospitals.
This certainly isn't a new debate. As the number of physician-owned hospitals has risen dramatically since the 1990s, hospitals and a handful of others in the healthcare industry have questioned the safety of these facilities and raised red flags about the potential for self-referrals and other financial conflicts of interest. Congress has looked into the matter several times and went so far as to impose a moratorium on physician referral to new specialty hospitals between 2004 and 2006.
But the hospital industry threw fuel on the fire in April when it lobbied to slip into an unrelated farm bill a provision to ban all self-referrals to physician-owned hospitals (the provision was later dropped). The flames were further fanned the same month when the American Hospital Association released a 12-page report criticizing "physician ownership and self-referrals in hospitals," and again when the AHA, along with the Federation of American Hospitals and the Coalition of Full Service Community Hospitals were accused of misstating key facts about safety in physician-owned hospitals in order to provoke Congressional action. The OIG sent an official letter of rebuke to the hospital associations for misrepresenting the research.
Clearly, hospitals view competition from physicians as a major threat and are doing their best to quash it. But physicians aren't taking it lying down. The American Medical Association, the nation's largest association of physicians, released a scathing critique yesterday of the hospital industry's "campaign to eliminate physician-owned hospitals," accusing the AHA of resorting to "smoke and mirrors."
"[This] has nothing to do with patients, and everything to do with eliminating competition," said William G. Plested, MD, immediate past president of the AMA. "Plain and simple—this is nothing more than a power grab by the hospital industry."
So who's right? Well, as is the case with most political disputes, both sides have a few valid points buried beneath layers of over-hyped rhetoric. Physician self-referrals in general present the opportunity for abuse and contribute to rising medical costs and should be a concern in all settings, particularly in hospitals where physicians have a direct financial interest. But physician-owned hospitals also expand access and provide patients with care options to choose from, and as long as there are checks in place to ensure safety, there's no reason to completely nix the concept.
Perhaps a better question: Is this really what the industry should be focused on right now? Lobbyists representing both sides are making their case to Congress; the AMA and AHA and other associations are spending money, time, and effort on this battle. That's money, time, and effort that could be spent working toward a better payment system or finding a way to cover the nation's uninsured or preparing for the upcoming physician shortage.
The most common office problems—many of them billing issues that can frustrate patients—can be traced back to failure to perform one of five tasks. Create policies to ensure that each of the following five steps takes place automatically:
1. Verify the patient’s current healthcare insurance coverage. For example, the patient may have changed jobs and returns to your practice later in the year with new coverage. The front desk staff assumes the old coverage is valid and does not ask for the new card. As a result, the insurance claim form is sent to the old insurance and is denied. The claim then becomes the patient’s responsibility. The process to finally get the denial from the correct insurance can take months. And often, the patient will get a bill in the mail that he or she is not expecting but is required to pay. This can result in a very dissatisfied patient calling the doctor’s office expecting an explanation. Even worse, the patient may leave the practice and find another doctor.
2. Capture the complete and correct list of all procedures performed. As more and more practices have EMRs, the procedures/services performed for the patient are not captured. For example, a patient receives an immunization during one visit that was never captured and may receive the same immunization on a subsequent visit. This may cause health problems and make patients unhappy.
3. Read the patient’s insurance card carefully and send the claim to the correct address. When staff members do not search for the most current company address, the claim may not reach its destination and must be sent again. While waiting for the claim to be paid, the patient may lose confidence in the practice and decide to change doctors as a result of this mistake. Communications with the insurance company and/or practice may also cost the patient a great deal of personal time.
4. Double-check that you spelled the patient’s name correctly and that it matches the name that appears on the insurance card. In addition, check that you know who the insured party is, as it may not be the patient. For example, staff members assume that the 17-year-old student who is seen in your practice is the insured, when in fact, it’s the patient’s father. As a result, the claim may be denied and the balance will be transferred to the patient. Now, the patient will get a bill for services he or she does not actually owe because he or she does have adequate coverage but the claim was filed incorrectly.
5. Make sure that a referral or preauthorization is obtained for all services that require them. For example, if a staff member schedules a flexible sigmoidoscopy before the patient comes into the practice, but doesn’t follow up to see whether the service is preauthorized with the insurance company, the procedure may have to be rescheduled, greatly inconveniencing the patient.
Shannon Sousa is the editor of The Doctor's Office. She may be reached at ssousa@hcpro.com. This story was adapted from one that first appeared in the March edition of The Doctor’s Office, a publication by HealthLeaders Media.
What makes physicians so unhappy? I ask myself this when I end angry phone calls with frustrated physicians or when a surgeon walks through the emergency department at my hospital spouting a tirade of profanity that makes the paint peel off the wall. And I wonder about it when I hear a potential medical student talk to a physician, who tells the bright eyed young man or woman, “Don’t do it!”
I have my theories. That’s because the ER is a great place to watch, listen, and learn. I trained in a large urban teaching center and have practiced in a busy, semi-rural community hospital for 15 years. What I’ve seen is a lot of frustration. The question is, what can we do to ease that frustration and create a happier, more functional medical workforce?
First of all, I don’t think that physician unhappiness has to do with patients. Every physician has his or her favorite story of the nightmare patient—like the one who calls at all hours for Viagra refills, the patient the who insisted to my partner that she be admitted for her bad perm, or the drunks who play with rattlesnakes. But patients have been difficult as long as anyone has pretended to be a healer. And frankly, they entertain us; the weirdness we see keeps us coming back, voyeurs of human silliness that we are.
Physicians are sometimes unhappy because we’re busy. We belong to committees, go to meetings, attend CME conferences, educate students and residents, see patients, volunteer in the community, and still try to squeeze in family time (often as an afterthought). We don’t often say no; certainly not often enough for our own good.
And, as always, there’s money. With reimbursement falling and the number of uninsured patients rising, turning a profit in medicine can be very hard. The costs of regulatory compliance, filing insurance, and paying malpractice alone are enough to make medicine unprofitable for many physicians; so they become more and more dissatisfied with their careers and lives. Some people think that’s the essence of physician unhappiness.
Breaking the cycle
Making money isn’t exactly the problem. For all our problems with reimbursement, physicians can still make a fair amount. The problem with making money is that we spend it. And when we spend it, we need more. And the battle is joined.
The cycle is understandable. Physicians start their careers in debt—the average medical student graduates with a burden of educational debt that is currently somewhere around $120,000 and starting residency salaries are only around $40,000. After residency physicians need to make an immediate income boost to catch up and cover debt. But he or she also wants to enjoy the money that’s finally in that bank account. So, doctors start to spend money like. . . doctors.
When we’re not careful, we throw money around like Columbian drug lords in Vegas. The problem is, their money does not depend on hours worked or patients seen; physician income does. We get our cash by seeing patients and performing procedures. We make money on effort, not on money itself. We more resemble factory workers or building contractors than bankers or investors.
So, in order to maintain wealth, we have to keep working hard. And if we spend more, we have to keep working harder to pay off debts. Working harder is tiring, and keeps us away from our families and hobbies. And the cycle goes on and on.
Then, if we wake up unhappy one morning, or realize our families are dissolving before our eyes, or if we feel a desire to cut back, we simply don’t have a choice. We are enslaved to a certain level of income. However miserable the practice may be, we’re stuck. If the partners are hard to work with, or the administrators won’t listen to our problems, we have to smile and keep coming back. If the patients are more and more complex and less rewarding, we have to continue seeing them. If the depression is overwhelming and we actually consider suicide (doctors have the highest suicide rate of any profession), we feel guilty admitting it or seeking help; after all, there’s work to be done and money that needs to be made! So we go on and on, falling deeper and deeper into misery.
In our unhappiness, we also mess up our relationships. This can be an expensive problem; just ask any physician who is now working twice as hard to pay for wife one and wife two, along with child support.
My point is this: It isn’t what we make, but what we need, that enslaves us. If physicians want to be free to enjoy life, free to move, free even to rebel or quit, they have to need less. And perhaps the wisest thing that our directors, partners, or even employers can do is to remind us of this. Frequently. Rather than encourage lifestyles that require large infusions of cash, we should encourage reasonable lifestyles that allow large infusions of time-off and happiness.
If we physicians can just learn, we’ll find that the happiness and contentment we want may be easier to attain than we think. If you’re just starting out on your medical journey, don’t spend money you don’t have in anticipation of how much you’ll make. Because if you do, the act of getting that money will be harder and more painful with every passing year. And the things you purchased as part of the ‘doctor life’ will give you less and less joy.
My friend Robby said it best, in his finest South Carolina accent. “Grandpa always said that the key to happiness wasn’t to get what you want, but to want what you have.” It doesn’t get any simpler than that, does it?
Edwin Leap is an emergency medicine physician and writer living in South Carolina. For more information, visit www.edwinleap.com.
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The Federation of State Medical Boards is working on a policy that would require physicians to demonstrate their continuing competence in order to get relicensed. The draft proposal would require physicians to take part in ongoing self-assessment and demonstrate competence in their areas of practice.
The U.S. Department of Justice has intervened in a whistle-blower lawsuit alleging improper financial kickbacks were arranged between a hospital and large medical group in Ohio. The lawsuit alleges that Christ Hospital, a full service Cincinnati-based hospital and formerly a member of The Health Alliance, and Ohio Heart, the largest cardiology group in that region of the state, devised a scheme that provided cardiologists improper financial incentives in exchange for generating revenue for the hospital.