In the tiny subspecialty of gynecologist oncologists, the Society of Gynecologic Oncologists conducts an extensive survey of its 1,100 practitioners every five years. This isn't your quick how-are-things-going type poll. It could take an hour for participants to complete, the society leaders say.
Why dwell on that? Well, Jimmy Orr, MD, former chairman of the SGO and current head of the survey task force, dwells on that. Of 900 or so letters that were sent out in the survey, more than 600 responded. "Who has 70% response rate?" he asks. "That's really huge. If it's 50% that's good, but 70%—that's a big deal." To Orr, it reflects the concern and dedication of gynecologic oncologists.
A bigger deal, of course, is what they said in the survey, Gynecologic Oncology 2010: State of the Subspecialty. Compared to five years ago, there were major differences in what was said about the evolving physician practice. And the survey revealed an evolving nature of the SGO itself.
The workforce is getting younger and a larger number of women are entering the field. In addition, there's a shift away from private practice and an increase in group or multi-specialty practices, not unlike other physician practices. In 2005, women represented 20% of practitioners, and now it's 33%. In 2005, the mean age of a practitioner was 51; now it's 47.
Orr, who is medical director of the Florida Gynecologic Oncology & Regional Cancer Center, in Fort Myers, FL, finds these changes significant.
Having younger practitioners will "propel the specialty forward," he says. "The same can be said of having more women in the field. Women have an understanding of women, and rounds out the whole picture of care, the treatment, surveillance, and family dynamics."
The survey revealed a definite move away from private practice, with 35% of the gynecologic oncologists calling themselves primarily private practice physicians, compared to about 51% in 2005. Twenty-five percent of the gynecologic oncologists now work for a multi-specialty practice/clinic, while only 13% are part of an individual practice.
And 77% say they are salaried employees, compared to 56% who classified themselves as salaried employees in 2005. More work in university or hospital-based teaching facilities, 62% compared to 55% in 2005.
The "security of salaried positions" is definitely reflected in the survey, Orr says. "It relates to the overall angst of what is happening in medicine. There's such a burden with the mechanics and paperwork of medicine. We are going to find an increasing number of individuals trying to integrate themselves into a larger group. The model of an integrated system is not fragmented, it's more efficient, and certainly cost reducing; what we have to look forward to in the future."
The survey shows a "continued dedication" to providing chemotherapy services to patients regardless of the changes in reimbursement rates, as well as the continuation of enrollment of patients into clinical studies rather than the more revenue neutral or industry-sponsored trials, Orr says.
According to the survey, there has been no real change in the percentage of gynecologic oncologists who routinely provide chemotherapy services in their practice (79%) in the 2010 survey compared to 80% in 2005.Those in a group practice (82%) and multi-specialty practice/clinic (82%) are much more likely to administer chemotherapy in their practice than those in an individual practice (55%), the survey showed.
Although 51% of gynecologic oncologists earn revenue from chemotherapy in addition to the E&M code, an overwhelming number of gynecologic oncologists (97%) plan to continue administering chemotherapy in the coming year. The majority of gynecologic oncologists also agree to treat new Medicare and Medicaid chemotherapy patients.
"In revenues and reimbursements for chemotherapy, it's been going down the past 3 or 4 years, and will continue to do so, like all medical reimbursements have been," Orr says. "But these physicians are saying we're in it for the long haul, we will continue to deliver excellent care, in a comprehensive approach for women. It's absolutely the right thing to do."
"These people are really attuned into what they are doing and that they want to contribute to the subspecialty," Orr says of his fellow practitioners. "When you look at the response to the survey, the attendance at our meetings, there are these high percentages because people want to deliver state of the art care."
Orr says he's been in practice more than 28 years, and hasn't looked back. "If I was 22 years old, and God said to me, "What are you going to do with your life? I would do exactly the same thing.
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About 15 years ago I was covering a political event in California, and I sat near the top row of an auditorium, with a curly haired gentleman behind me. I knew who he was right away, but I didn't bother him. He was writing on some scraps of paper.
At one point, he interrupted me in a somewhat gravelly voice, "Do you have any paper?"
"Sure," I said, and I lent him some scraps of my own paper. Two reporters just doing their jobs.
"Thanks," Norman Mailer said.
If we were covering that event today, probably no paper would be involved, and Mailer and I wouldn't have exchanged any words. Oh maybe, he would have been carrying a computer, and asked, "Is there any electricity?"
And for more and more physicians, the paper chase that the late author Mailer and I engaged in so long ago is nearing the end of the line.
The government is pushing EMR as an enhancement to healthcare. There are some conflicts, however. A recent study in The Journal of General Internal Medicine shows that "a gap exists" between policy makers' expectations that commercial EMRs can improve coordination of patient care and clinicians' real-world experiences with EMRs. The current fee-for-service reimbursement encourages EMR use for documentation of billable events, such as office visits or procedures, and not for care coordination, the study says.
In addition, the Center for Studying Health System Change states EMRs may have unintended consequences for care coordination, such as creating information overload that complicates providers' efforts to discern key clinical information. It adds that managing information overflow from EMRs is a challenge for clinicians.
Excuse me; have you tried to manage paper?
Larry Garber, MD, at Fallon Clinic in Worcester, MA, oversees the flow of records for his practice, and he's tried to do both over the years, paper and electronic, and he's seriously leaning on the electronic side, no joke. As well as being an internist, Garber is officially medical director for informatics at the clinic, which is an ambulatory, multi-specialty group with more than 20 sites across central Massachusetts.
He's implementing an EPIC system, which provides a computerized electronic health record for every person who visits Fallon. Generally, he's found that EMRs are working for patients as well as for the income of the practice.
Garber doesn't agree with the "generalization" in the Center for Studying Health System Change report that suggests "all" EMRs have problems, as opposed to just some EMRs. Garber says his practice is enthusiastic about its EMR system.
"I do agree that the way we're paid (based largely on the length of our documentation) forces physicians to create voluminous notes that can obscure medical meaning," he says. "This is no different than the paper world; but is just easier to accomplish in the electronic world. When all of the healthcare insurers switch to paying us for caring for a population of patients, then we can remove much of the documentation clutter."
The transition from paper to electronics doesn't happen over night. Fallon said his practice spent years implementing the program, and allowing time for members of the practice to get accustomed to it. Most did. Over the first three years of EHR implementation, which began in 2001, Fallon's group spent $24 million investing on the program. The investment has been worth it, he said, referring to its EPIC system. "We reduce information overload because in the paper world, hospitals send the primary care physician everything including numerous test results and consult notes that take place during the hospital stay," Garber says.
"But with EPIC, we file most of those silently into our electronic health records for future access if necessary," he says.
There are some stumbles along the way. As his physician group was moving toward an electronic system, there was a "surprising realization," Garber says. Doctors were still dictating their notes into a voice recorder, and they had to send out transcriptions overseas. So even though the practice was on an EPIC system, it was still spending an extra $10,000 per physician, not to mention the lag time in retrieving the documents. Not good, Garber says.
In 2008, Fallon Clinic launched a Dragon Medical speech recognition program, which provided 10 diverse physicians with medical to dictation directly into the EPIC system, versus typing, or traditional transcription support.
Among other things, it found a 99% reduction rate in the average number of minutes after a patient left for the final note to be placed in the EHR system. For the physicians, that meant the wait time went from an average of 3.8 days to 46 minutes. The net savings: $7,114 per physician each year, according to Garber.
Besides the inevitable cost savings, Garber says that the electronic records ultimately serve the top priority, the needs of the patients. Garber says he "diagnosed several (patients) with prostate (issues) that would not have been caught as early," thanks to the electronic health records. Because the records track a patient's history, he noted he received information about a patient's "motor vehicle accident that the person didn't tell me," he says.
So the electronic record is the way to go. Even Mailer did it eventually, in his own way. When he wrote his first book, TheNaked and the Dead in 1955, he typed it. Later he hired a secretary who eventually maintained what would become "all of the electronic records," according to the Harry Ransom Center, at the University of Texas at Austin, where Mailer's papers are maintained. Mailer died at age 84 in 2007.
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Their careers began mostly during the George H.W. Bush and Clinton administrations, and the general internists were on their way: All that hard work, all that money spent, and the promise of a lofty career ahead.
And now? Probably having a nice career, but, for many, not as a general internist.
About 17% of general internists who were originally certified in the 1990s have left their practice in mid-career, not necessarily dissatisfied by their careers, but looking for other options as a "stepping stone" for careers outside of internal medicine.
And when they left, they were happier that they did. Compared to internal medicine subspecialists, such as cardiologists or rheumatologists, in which 4% left, the general internists departed in droves.
Those are the findings are in a recent study conducted by the American College of Physicians and the American Board of Internal Medicine and its lead author, Wayne Bylsma, PhD, the ACP Vice President and Chief of Staff. We talked about the findings of the study, and some of its surprises.
The study focused on internists originally certified between 1990 and 1995 who are no longer working in general medicine or one of the subspecialties about a decade after original certification by the ABIM. About 6 % are working in another medical field; less than 1 % left medicine; 1 % retired, and 2 % are temporarily not working but plan to return to the workforce, though not necessarily in internal medicine.
"Where Have All the General Internists Gone?" published recently by the Journal of General Internal Medicine also found that, although most internists are satisfied with their career choice, a significantly lower proportion of general internists (70 %) than internal medicine subspecialists (77 %) were satisfied with their career. More than 3,500 physicians participated in the study.
In the so-that-isn't-very-new category, but worth repeating for context:
Bylsma and the other authors noted that existing research shows that some general internists may be particularly discontent and "more likely" to leave internal medicine as a result of a widening income gap between primary care physicians and many specialists and other factors, such as "increasing demands, growing expectations and accountability for care, and payment based on the ability to perform in a fast moving environment."
"General internists are major providers of primary care to adults in the United States, which faces a shortage of primary care physicians," Bylsma says. The ACP states that the shortage of primary care physicians may reach 46,000 by 2025, "greater than shortages predicted for any other specialty area."
Yes, we've heard that before. But there were some interesting surprises in the survey. Among those surprised were the report writers themselves, Bylsma says.
All the talk about doctors leaving medicine because of dissatisfaction with the job; well, that's only somewhat true, Bylsma says. In fact, the study was inconclusive about whether general internists leave internal medicine in greater proportion than internal medicine subspecialists because they are so unhappy, Bylsma says.
A more likely explanation is that many doctors simply viewed internal medicine as a launching pad for something else in their career, and in fact they thought about that prospect even when they began as internists. The average age of those surveyed was around 50, according to Bylsma.
"Most general internists and IM (internal medicine) subspecialists are satisfied with their career. While general internists are more likely to leave IM and are somewhat less satisfied than subspecialties, they may not have left because they were less satisfied," the study states. "Those who left IM are more satisfied with the current career than those still working in IM, but dissatisfaction with IM may not be the reason they left the field."
When those who left IM were asked why they left, only 22% indicated negative aspects such as "long hours, limited income or hassles," the report adds. "Most–57%-said they left IM "due to a change in interest or to take advantage of a preferred opportunity," according to the study.
While there was frustration and negativity expressed, they mostly expressed interest in a different career, in a seemingly "neutral" way, Bylsma says. "I guess the venting that you hear about private practice is more anecdotal."
Generally, "we were hoping to get a little better sense of ‘why' internists left their positions," Bylsma says. "The current study fell short of the conclusion for ‘why.'"
Among the other surprises, he says, were findings that doctors, for the most part, were opting to go into emergency treatment, and more willing to leave academia than private practice.
Bylsma says he keeps going back to the "stepping stone" theory, that people wanted to pursue other careers, more security, better hours, etc. His report is just another piece of the puzzle about the uncertain future of physicians, especially in primary care.
"Policies and organizational support should continue to focus on increasing interest in general internal medicine (GIM) among students and residents, but must also ensure the attractiveness of GIM practice among those working in the specialty," Bylsma said in the study.
The government is trying to provide incentives for primary care physicians to stay in their chosen field. Under the new healthcare reform law, for example, grant and bonus programs are being established for primary care physicians.
Bylsma noted that a national workforce policy will examine primary care practices, and new funding for demonstration projects centered on the medical home, "for a more physician and patient friendly environment."
In the study, there was one last surprise.
"We found that a sizable minority of interns–40%-who have left internal medicine are open to returning," says Bylsma. "Changes in the practice environment might entice them back in the field."
Will the internists eventually take that "stepping stone" back home?
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Using expressions like "drinking from a fire hose" and "classic sausage making," William Jessee, MD, sounded like he was talking about a local bar.
No. Just the healthcare reform laws.
But Jessee, president and CEO of the Medical Group Management Association, says that's just the way it is in the morass of legislation that is somewhat confusing, beguiling, daunting, uncertain, a little bit good, and some bad.
Weeks after Congress closed up shop on the Patient Protection and Affordable Care Act and its reconciliation cousin, the healthcare reform process is really just beginning, Jessee says. "Anybody who thinks healthcare reform was done when this bill was passed is sorely off base because this is the beginning of the healthcare reform," Jessee says. "It's likely to continue for the next decade at least, as we see additional legislation and changes in the delivery system."
Jessee and I talked recently about the healthcare reform legislation after he made a presentation about the measures at a Web presentation heard by about 1,000 physicians. In our discussion, we touched on a few issues that underscore the task ahead in putting together the regulations needed to carry out the laws.
Some are a bit quirky. Some may bubble up in controversy in years to come, and some are in the midst of raging controversy right now. As Jessee puts it, the law makes a "complex compliance landscape even more complex."
Let's start with a quirky one.
Under healthcare reform, in-office physician referrals for MRI or CT scans, for example, must allow for patient notification, in writing, of his or her right to receive care elsewhere.
The requirement, under the legislation passed in March, isn't one of those rules that become effective 2012 or 2014. It was supposed to go into effect Jan. 1, 2010, according to the law. That's not a typo—January—as in four months ago.
"You need to notify the patient of the patients' right to receive care elsewhere, and provide a list of alternative providers in the patients' area near their residence," Jessee told the physicians. "What's kind of perplexing about this one is that the effective date of the statute is Jan 1, 2010, which is two and a half months before this legislation as actually passed."
"I don't know of any way to actually tell a patient who actually had an MRI that they have the right to receive it someplace else," he says.
There is some debate that physicians will get a chance to procrastinate on the January 1 timetable because regulations have not yet been implemented. Still, MGMA believes it is something that "needs to be taken care of right away," Jessee says, sounding like a good doctor.
The issue is reflective of the entire regulatory climate involving the passage of the legislation. I was talking to a friend of mine at HHS shortly after the measure was passed. "And now the regulations . . . the regulations, man, are going to take forever to implement," he said.
Jessee agrees. "All I can say, I'm really glad I don't work at CMS," Jessee says, referring to the Centers for Medicare and Medicaid Services. "They are going to be up to their ears trying to get all the regulations out on the timetable specified in the legislation. I guess if history is any guide, they won't be able to do that.
"There is an excess of 1,000 references in the bills . . . (saying) the Secretary shall publish rules," Jessee says. "There is a huge amount of regulations."
Here's another issue that may bubble up in controversy in years to come:
The law creates an independent payment advisory board (IPAB) to develop and submit to Congress a report on matters related to Medicare. In certain circumstances, the IPAB would have the authority, beginning in 2015, to make binding Medicare policy recommendations and non-binding private payer policy recommendations to Congress.
Jessee worries about the future IPAB and what it could portend for physician payments. He likens its potential clout to that of the Base Alignment and Closure Commission in the military, which has enormous power over military bases.
"Empowering an IPAB with authority to make binding Medicare policy recommendations based on expenditure inflicts physicians with additional expenditure constraints," he says. He describes it as "MedPac (Medicare Payment Advisory Commission) on steroids."
Whether Jessee is right on this remains to be scene. But it swirls around physician pay, and so I'll transition right now to the continual "doc fix" problems. This is No. 1 on Jessee's agenda, and a significant reason for his disappointment in the healthcare reform laws. For Jessee, it's the controversy that continues to exist although headlines have died for awhile, at least until the next time around Congress acts.
Here's the latest: a proposed 21 % pay cut was halted through May 31, 2010, and Congress is expected to take up legislation to extend the current payment rate until Oct. 1. The House and Senate have passed separate bills to achieve this extension, and negotiations are continuing about how it will be paid for.
"All the word on Capitol Hill is they intend to do something to repeal the SGR and fix the problem," Jessee says. "Quite frankly, we've heard that story before."
Just another day in the sausage factory.
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A longtime pediatrician, Natalie Hodge, MD, was living the life of primary care despair.
For years she rushed from patient to patient in her office, giving them a few minutes here and there, doing a ton of insurance paperwork, and then decided enough was enough. Like many physicians, she felt drained and lost.
"People calling, people answering phones, people scheduling, people verifying eligibility, people checking on insurance, people . . ." she says. You get the picture.
It wasn't her style to sit still. Eventually, she founded Personal Medicine, essentially a concierge medical service, which avoids third party payers as much as possible, and adds its own unique touches, like specialization in house calls, and thriving on "virtual" communication. As she sees it, the mix is the bedrock for a "new reality for the future of primary care medicine," built around "emergent technologies." Curtailing insurance has cut costs about 80%, she says.
There are growing numbers in the medical arena interested in what she has to say. She was interviewed by the Associated Press, made a presentation to the Mayo Clinic, and in a few weeks she's preparing a speech about her practice before primary care physicians at the University of Kentucky on May 9. She tells me times are good.
If anything, these are certainly interesting times for concierge medicine, though whether it is the wave of the future remains to be seen. It's not an easy sell for everybody, either patients or physicians, who number about 5,000 in concierge practices. The medical establishment, too, has viewed concierge medicine skeptically though there are many out there who see it as worthwhile because physicians are continuing to work, and patients will be treated. That's OK, no?
Docs want to make money, and in concierge, they are making some headway. In a February survey by the Concierge Medicine Research Collective, an independent healthcare research center based in Atlanta, nearly 60 % of all current concierge physicians are doing "better" financially than a year ago. Still, 29% indicated there was no change; and 13 % fared worse, according to the poll.
An attorney, John R. Marquis, has written a paper recently stating that the new Patient Protection and Affordable Care Act "is going to cause serious problems for (concierge) practices and will require them to restructure in order to accommodate it." Fiscal restraints imposed by the law will impact physicians who remain in Medicare and charge a periodic fee as well as those who opt out of Medicare and then charge the patient a fee for providing all the medical care the patient needs, he said. Marquis discusses the health reform impact on concierge medicine physician practices, particularly related to Medicare, in his paper, "New Health Care Act Deals Serious Blows to Concierge Medicine."
Hodge said she had been unaware of the paper, but expressed little concern after reviewing it. "We are a network of physicians that create direct patient financial relationships," she says. "We do not have any interest, nor contractual relationship with Medicare or Medicaid. So this has nothing to do with our business. Lawyers also like to create a lot of mystery and fear around Medicare. PM has a contract with patients. PM has a contract with physicians, that's it."
She doesn't like the term concierge for what she does, preferring to call it direct medical practice.
"We are entering a whole new ballgame for healthcare strategic planning—the post reform era," she says. "The service line strategy moving forward must be integrating cash revenue stream opportunities and (personal medicine) is a way organizations may implement this as the third party payer pie continues to shrink."
While running her pediatric practice years ago in St. Louis, MO, she was seeing up to 35 patients a day for about 10 minutes each. "Once I realized how much time my staff was spending on third party payrolls, and then I added that cost up for the year and over the years, it was so sickening," she says.
That's when she decided to launch her personal practice, with a "six or seven house call day," she says. She is moving her business office to San Francisco, and hired a CEO to run the company, which includes about 10 physicians scattered throughout the country, as well as the Dominican Republic and Peru. There is one physician based in Chicago who's targeting executive healthcare, another in Iowa focusing on elderly care, she says.
"You have a completely paperless loop, between patient and physician," she says. "You have high level communications. Patients supplant their records from Google PHR or Microsoft or whatever. Patients pay membership fees like they do for their cell phones or other Web-based services." The average acceptable price for consumers is about $125 a month, she says.
"Patients of course still need some kind of health insurance, but they don't have to be exorbitant," she says. "They need a high deductible plan to cover them for cancer or being hit by a bus or being in the ICU for two months. Remember insurers don't provide services. I provide services. The physician."
My former physician, a terrific guy, told me a few years ago he was getting out of his practice, tired of the insurance hassles, and was opting for the concierge route. When he finally left, he invited me to join his other patients as part of his concierge business.
After our private conversation, he sent a letter. It was going to be a lot of money, the fixed amount, each month. In return, I would get his personal care, and lengthy individual appointments. I evaluated it. After some thought, I didn't think it was worth it. The last time I left his office, I thought, "Oh well, I'll be looking for another doctor."
I have a feeling Natalie Hodge wouldn't accept that, and would keep working to get potential patients like me on board.
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As a boy, I had a litany of allergies. Because of those allergies, and assorted other childhood ailments, my parents often took me to visit Saul Finkelstein, MD, at his pediatrician's office in Newark, NJ.
When I had to stay home, because of the flu or when I got the chicken pox, the good doctor came to our apartment. He had those big Clark Kent glasses, slick black hair, and a very authoritative voice. As I sat up in bed, he stuck a thermometer under my tongue, checked my chest, scribbled a prescription, and then he'd say goodbye. He carried out his black bag as he walked out the door, and was gone.
A primary school student at the time, little did I know that I was basically wrapped up in "primary care."
Across the country, the discussion continues about the primary care physician shortage, and the hardship of doctors trying to keep it all together in a small practice. The primary care physician is seen as a collective aging body.
Focusing on one element of the evolution of primary care, the New York Times reported a few weeks ago about a "quiet revolution" is taking place in healthcare, referring to an increasing number of young physicians opting against private practices and more older doctors selling their practices and moving in with other healthcare groups in bigger settings.
Mentioned briefly in the Times story was Parkview Health, a Fort Wayne, IN, health group that opened its doors for, among others, veteran doctors who sold their practice, and allowed them to remain in their buildings and hire staff there. The article noted that one physician who joined the Parkview staff had sold his practice across the street.
It's a sign of the times. Recently, I talked to three top officials of Parkview Health, who went beyond the small mention in the Times article, and gave some interesting insights and challenges of running a group in the immediate post-health reform era. They spoke highly of their reliance on running a tight executive board and committees in which physicians have great say.
And they maintained a firm belief in the evolution of primary care physicians, especially in the manner in which they run it, even though it's not practiced like the bygone day of my old physician, Finkelstein, a sole practioner.
The thing is—Parkview Health is growing like crazy.
Parkview Health is a not-for-profit community based health system that serves northeast Indiana, Western Ohio, and Southern Michigan and it is one of the area's largest employers with 7,500 full- and part-time employees, and has seven hospitals. In 2007, there were 45 physicians in Parkview Health, and now there are 175, an increase that is "pretty remarkable," says Ray Dustman, MD, a cardiologist and chief medical officer at Parkview.
In 2009, the Parkview Physicians Group was established, a physician-led and physician-governed division of Parkview Health, to, as Parkview officials tell it, "enhance the delivery of quality healthcare services." Parkview is not necessarily gobbling up the other physician practices in the area–that would mean there was some kind of forced maneuvers–but it is accelerating its numbers as independent physician practices go by the wayside. The Parkview strategy involves obtaining the best performing practices, not just the physician in the pre-retirement phase, or simply recruiting the newest physician in town, says Dustman, who is on the PPG board and manages the Parkview's cardiology business.
Referring to future hiring at PPG, Rick Henvey, regional chief operating officer at Parkview Health, observes, "We have about 50 to 75 [physicians] now in the pipeline, being evaluated/looked at, and we project another 50 or 75 the following year."
And the growth is in primary care. "Primary care is, you know, the backbone, and I think as we look at the expectations of the future, the primary care doctors will be at the forefront of that relationship with patients," says Dustman.
The idea is for "patients to be treated consistently based on evidence based approaches," Dustman said. "Physicians strive for the best protocol and best outcomes at the appropriate cost."
At Parkview, the work starts and ends with the leadership and the manner in which the board operates. In the physician group, 13 of 15 board members are physicians, he said.
"Organized under the board, we have a line of businesses that [have] similar specialties and work in a similar geography, each with its own executive committee. The majority of physicians are on each committee," says Dustman. They report to the physician groups "in terms of letting them be responsible and accountable in the decisions in what the practices are going to look like," he said.
"I would say some of the issues we had to address aggressively as a group involved the integration of culture, our vision–a lot of work has been done in that regard," he said.
Initially, the physician group was planned to be more administrative, "but at the end of the day it didn't accomplish the physician leadership to the depth we were hoping to accomplish," says Mark Nafziger, the Parkview Health chief operating officer and executive vice president, who oversees PPG operations.
In the aftermath of healthcare reform, "there are certain realities that all of us as healthcare providers face," said Nafziger. "Probably all the sources of funding aren't going to increase. We acknowledge that healthcare has to be more effective. There's going to be more of an emphasis on the role of the patient accessing the system through improved insurance coverage so there will be greater number of patients accessing primary care," Nafziger said.
No doubt the essence of primary care is far different than decades ago when Saul Finkelstein ran his practice. But he was a shrewd man, as my parents had recalled, and maybe he would have grown frustrated running his own practice in the modern era and would have decided to sell to a group like Parkview Health.
Something is lost in all this, and something gained.
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David Blumenthal, MD, has spent countless hours over his career using paper—writing down procedures, medication prescriptions, and evaluating x-rays.
Through the years, he resisted technology. In fact, the 61-year-old National Coordinator for Health Information Technology for HHS says his wife still runs the computers at home.
"My wife actually thinks it's a huge failure in vetting that I have this job," he joked about his overall skills.
He spoke a few weeks ago to members of the Patient Centered Primary Care Collaborative about how he was forced by peer pressure to embrace technology and for that, he's a better physician. His message is instructive to physicians everywhere, especially those who are resistant to change.
"Information is the lifeblood of medicine," Blumenthal said. "Any clinician is only as good as the information they have available to make decisions. The best way to circulate that information is electronic health information systems."
Whether it's electronic health information systems, or electronic medical reporting systems, physicians are caught in an electronic vortex. As Blumenthal sees it, changing information technologies is a must for physicians as well as hospitals and other providers to maintain proper healthcare delivery.
As the nation develops IT programs, there are physicians who will resist the change. Blumenthal's path is instructive to other physicians. He was someone who didn't necessarily shun technology, but he didn't embrace it either.
"I come to this insight as a clinician, I don't come as a technology aficionado, I was like many of my colleagues practicing primary care at Massachusetts General Hospital, happily using paper for most of my career," he said. "I liked my prescription pad, I was very comfortable with it. I liked those x-rays that I wrote out in triplicate. I was not looking for change."
It wasn't the bosses or the institution that made Blumenthal change. It was something inside him–the competitive spirit to keep up with people younger than himself.
"Gradually, with a lot of help from support systems, I came to see it was making me a better doctor," Blumenthal said.
Over time, Blumenthal says he could see the day-to-day difference technology made in his practice, as the memory of pen and pad became further distant.
"I knew the results of those biopsy moles when my patient would come in unable to find a dermatologist to get hold of the pathology report; it would be there in my computer. I knew the results of the mammograms. I knew the results of the blood tests. I was no longer scrambling through a paper record looking for specialists inevitably lost in the world of paper. I knew the medicine patients were on; if I had questions, I can contact them in the mail," Blumenthal added.
A singular incident stood out in his mind about the need for technology and how important it is for him as a physician. "I tried to discharge a patient from the hospital, and the patient had a urinary tract infection," he said.
Blumenthal looked at the computer and saw in "bright red letters"—a description of an allergic reaction. As he spoke, you get a feeling he was pretty shaken when it happened. Blumenthal said he avoided a "potential complication."
Since being named to the post by President Obama a year ago, Blumenthal has been assigned to lead implementation of a nationwide interoperable privacy-protected health information technology infrastructure as called for under the American Recovery and Reinvestment Act. Prior to his appointment, he served as physician and director of the Institute for Health Policy at the Massachusetts General Hospital/Partners HealthCare System.
Blumenthal is a leader in the health IT movement, but he understands the barriers to technology that doctors face. Changes in technology involve a change in outlook. For physicians who have been in practice a long time, it may not be easy. As for Blumenthal, he says he has used an electronic record to care for patients the past 10 of his "30 plus years" in primary care.
Blumenthal hopes to convince physicians on the fence change as a result of the American Recovery and Reinvestment Act of 2009, which includes billions of dollars in Medicare and Medicaid incentive payments to providers and hospitals for the "meaningful use" of certified IT products. Electronic medical records (EMR) need to be from a certified vendor. Providers need to meet the meaningful use requirements for EMRs as outlined in the HITECH portion of the act to claim their share of the incentive payments.
Change is difficult. Blumenthal referred to Surgeon General Regina Benjamin, a former primary care physician in a small town in Alabama who lost her paper records to Hurricane Katrina. When her small clinic was ruined, Benjamin laid out medical charts to dry out following the storm, according to the Huffington Post.
It was only the "second" time that her paper records were destroyed that Benjamin decided to go electronic, Blumenthal said, only half joking. "And her 78-year-old nurse became extremely proficient," he added.
At the conference, Robert Austin, MD, listened to what Blumenthal had to say, and said he wasn't sure what lies ahead. Austin, a Texas physician, told Blumenthal he has been in practice for 40 years, and wasn't necessarily resistant to the idea of change, "but to the voluminous process of change."
Austin noted that if a physician had a practice with an "office of 2,000 patients, and charts that are overflowing and falling on the floor," but no assistance, "one may think at that point it is time to get out of practice."
"We [can] lose some valuable practioners," Austin added. "Do we vigorously respond to this problem that is impacting our most needy patients?"
"We are trying to make those resources and supports available within the limits of our funding and legislative authorities," Blumenthal responded. "We are trying to blanket the country with supports, technology support."
Blumenthal posed questions for physicians who are sitting on the fence. It was one of those cut-and-save moments.
"Am I going to stay in my practice? If I stay in practice is an electronic health record in my future? If it is in your future, is there a better time than now when I have the federal government willing to make $44,000 or $63,000 available in extra payments to me?"
"Is that the transition that different from the tough challenges throughout my career? Do I want to stay at the top of my game?"
"All those calculations should be part of that decision," Blumenthal said. "We're certainly hoping that when all those things line up, the decision will be made to go forward—as hard as that may be."
For many physicians, the prospect of embracing the new health information technology is like a patient taking some new medicine. Blumenthal is betting that most take it–like he did.
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After he examined chest x-rays the other day, radiologist Bibb Allen, MD, mused about what he considers the positives and negatives of healthcare reform.
The positive: more patients. Reform will result in insurance coverage of 32 million more people. "We take all comers–I don't know who has insurance and who doesn't–we just take care of everybody," Allen says.
But the other side to healthcare reform has left radiologists like Allen extremely disappointed, and forecasting, in his words, "difficult and tedious times ahead."
"Certainly it seems that radiologists have been singled out as a physician specialty targeted for reimbursement cuts–it is the beginning of what may be a sizable number of dollars," says Allen, who does much of his work at Trinity Medical Center at Birmingham, AL.
Whether they are singled out or not, as radiologists review the 2,000-plus pages of the healthcare reform legislation, they get more and more uneasy, and I can see why. Overall, Allen, a member of the American College of Radiology's economics commission, estimates $3 billion in Medicare cuts related to radiology over a 10-year period.
Those budget cuts, anticipated to begin next year under the new law, are taken from a formula in reimbursement payments that assumes medical imaging equipment worth more than $1 million, including tomography scan (CT) and MRI machines, will be used 75% of the time during office hours in outpatient centers in 2011.
Currently, payments reflect the assumption that equipment is in use about 62.5% of the time–meaning the new estimates could mean major cutbacks, especially for rural facilities, whose equipment is not in use as much.
"There's no doubt about it–rural facilities don't typically have the volume that some of the urban facilities have," Allen says. "So many are operating on the margin already. Another 25 to 30% reduction will drive them out of business. They won't be hiring new people, new equipment. The whole cycle of having a quality operation is going to be impacted."
The formula is wrapped around the so-called equipment utilization rate assumption. That is the amount of time that scanners are presumed to be used during business hours. The higher the assumption, the lower per scan reimbursement, according to the ACR. The formula is a major factor in Medicare's technical component reimbursement.
There is keen irony for many radiologists because the cuts are reversing the trends over the years, where there was been an attempt to move medical care delivery out of the expensive hospital settings to the lower cost outpatient settings, according to Allen.
Since rural facilities use diagnostic imaging equipment on an average of 48%, funding for those facilities under the new law would essentially dry up, says Shawn Farley, ACR spokesman. Overall, the median usage rates for facilities nationwide is at about 54%, with non-rural facilities having a 56% utilization rate, which would still result in general cutbacks under the healthcare reform measure, he says. The rates were measured under a June 2009 Radiology Business Management Association Equipment Utilization Survey. "In a perfect world, the equipment utilization rate assumption would reflect that actual rate being utilized nationwide," Farley adds. "The RBMA survey placed that number at 54%."
Using 48% compared to 75% mandated under the health reform law is a "big difference," says Farley. "Many of the rural centers cannot absorb that big of a cut and will likely be forced to close. This means patients will be forced to travel farther to receive care and wait in longer lines to receive care," Farley says.
"These freestanding imaging facilities are often the location where women in rural or suburban areas get their mammograms," Farley says. "If these centers close, these women will have to go to a hospital, likely in a larger area, to get their mammograms."
"This means longer waiting periods to get mammograms because more women are seeing the same provider," Farley says. "Even for those centers in rural areas that remain, many freestanding imaging centers rely on reimbursement from MRI, CT, and other advanced imaging to allow them to offer mammography to their patients. These kinds of drastic cuts may leave them unable to continue to offer mammography."
Indeed, many urban hospitals and others may have to pick up the slack, and believe that's not necessarily a bad thing, allowing some hospitals to improve services and hire more technicians. So I asked Allen about more urban hospitals doing more radiology business at the expense of rural facilities.
"What you see is, obviously, some of this will get pushed to the hospitals. Is that a bad thing? Well, you don't know. Will it occur seamlessly? We don't know. In some places, hospitals aren't going to afford more scanners. It's very depressing."
Officials of the American College of Radiology say that medical imaging has been directly linked to greater life expectancy, declines in cancer mortality rates, and are generally less expensive than invasive procedures they replace.
The cutbacks, however, are coming during a controversial time for radiology, and that makes it a safer bet for politicians. Recently, the FDA issued an initiative designed to reduce unnecessary radiation exposure from CT, nuclear medicine studies, and fluoroscopy.
The combined procedures are considered the leading contributors to total radiation exposure in the US because they use higher radiation doses than others.
"I think CMS and Congress are in this mode, they want to see evidence that access to care is decreasing before they are convinced they have done enough cutting," says Allen.
As radiologists anticipate the budget cutbacks, Allen says, "We're trying to keep an eye on the big picture, and we're going to do what we can to ensure quality."
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After President Obama signed healthcare reform legislation last week, there was much joy for Democrats (at least for Democrats). For physicians who own hospitals, it meant upheaval.
As of now, there are about 260 physician-owned hospitals in the U.S. About 58 are undergoing construction and expansion plans, with an estimated $5 billion that has been expended or financed. With healthcare reform, those projects are frozen, going nowhere, or in the midst of confusion.
The new law restricts existing physician-owned hospitals from adding beds, procedure rooms, ORs and especially reduces funding for Medicare patients. Most of the physician-owned hospitals have an average of 2 % doctor ownership.
At least 28 new hospitals were scheduled to open by August 1, 2010, and another 74 are in the planning stages to open after that date. Dozens are trying to meet a Dec. 31 deadline to "grandfather" in some new hospital expansion plans or allow some new facilities. While some new hospitals may be approved, Molly Sandvig, executive director of Physician Hospitals of America, the advocacy group for physician-owned hospitals, says it doesn't seem current hospitals meet the complicated standards imposed to carry out billions of dollars in construction projects.
After Congress passed the healthcare bills, the calls started to pour into Sandvig's office in South Dakota.
The doctors' questions: What do I do now? What's next?
Sandvig has no real answers for the questions. "It's sad. These aren't run of the mill hospitals," Sandvig says, responding to critics who say the physician hospitals are inadequate. "These are top notch places that patients love to go to."
Sandvig is a mild-mannered lawyer and registered lobbyist who runs a small office in Sioux Falls. Her major opponents are behemoth lobbyists, the American Hospital Association and the Federation of American Hospitals, to name a few.
Guess who is winning?
The AHA, the FAH, and others wrote a letter to Congress in fall 2008, saying, "self-referral to physician-owned hospitals encourages the selection of healthier, less complex and insured patients for higher reimbursement." The letter added: "self-referral to physician-owned hospitals threatens community hospitals' ability to provide services such as emergency departments, neonatal intensive care units and burn units." Critics of physician-owned hospitals also point to a Congressional Budget Office report saying that cutbacks to physician-owned hospitals could save more than $2 billion for 10 years. Proponents of the physician-owned hospitals say the numbers are off-base.
Despite all the rhetoric, conflict of interest is the key here. There's another term that docs use and that's "cherry picking"—in which physician-owned hospitals would ensnare the most profitable patients.
I understand that, on paper. But you talk to Sandvig, do some research, and then discuss the situation with John Dietz, a spine specialist and chairman of the small Indiana Orthopaedic Hospital (IOH), and suddenly the federal action smacks of too much politics and too many patients left out in the cold.
The IOH has 42 inpatient beds and 10 operating rooms on a main campus in Indianapolis. The hospital has plans for a $47 million expansion, but shrewdly kept much of it on hold because of worries over the federal hold on construction, which unfortunately turned out to be true.
"We spent about $300,000," Dietz says.
There are plans in abeyance for four additional operating rooms, 20 beds, and dozens of jobs. "We're crushed by this," Dietz says. The hospital carries out 11,000 procedures a year—a "very busy place," Dietz says.
At an outpatient facility, the hospital has plans for a $27 million expansion. "We were two-thirds of the way there" in construction, Dietz says. But that's on hold, too.
"From the overall perspective, this legislation throws ice water on some of the most valuable and innovative hospitals in the country; they are completely shut off [from the funding]," Dietz says. "These physicians— like us—represent 1% ownership—and they have completely turned around many of these hospitals. And that's going on throughout the country."
"There are some things in the legislation we have no problems with," he says. "We're totally in compliance with the requirement to disclosure our ownership to patients. We're very happy to tell our patients."
Last fall, as Congress began debating the healthcare reform issue and took steps to cut down physician-owned hospitals, Sen. Dianne Feinstein, D-CA, warned that it would "result in harm to patient access to care in California."
Feinstein pointed out how ongoing hospital construction projects were urgently needed, especially to meet California's strict seismic standards. One hospital's construction project that appeared to be at risk was at Pacific Alliance Medical Center, a 142-bed full-service hospital that has "been the community's main hospital for 140 years and was purchased by a group of physicians 20 years ago after the existing hospital board planned to lose and demolish the facility," Feinstein said in the letter to Sen. Max Bauer, D-MT. "The hospitals' clientele is overwhelmingly poor and the hospital serves the second largest population of Medicare, SSI and Medicaid patients of any hospital, public or private, in the entire country."
Another hospital where ongoing construction projects were threatened by the legislation included Loma Linda University Medical Center–Murrieta, which serves Riverside County, CA. Expansion was seen as needed because the hospital has only 1.47 hospital beds per 1,000 people, "well below" the national average of 2.7 beds, Feinstein said.
Then Feinstein got to the core of the debate. "None of these facilities are designed to cherry pick the most profitable patients; instead they're innovative ways to fill communities' needs for additional healthcare facilities," Feinstein said.
Pick and choose. This time, physicians lost their hold on hospitals—and patients lost, too.
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Reforming payment structures for primary care "is absolutely essential to the implementation and sustained operation" of a medical home, according to the chairman of a payment reform task force for the Patient-Centered Primary Care Collaborative.
Allan H. Goroll, MD, professor of medicine at Harvard Medical School and PCPCC task force chairman, says payment reform is essential to sustain operation of the patient-centered medical home (PCMH), and a "blended strategy" may help minimize shortcomings of any single payment method. However, any reform would face considerable resistance because of fears of the unknown, Goroll says.
Goroll made his comments Tuesday during a meeting of the PCPPC held in Washington, DC, in which the medical home programs were touted. The PCPCC released a white paper that called for value-based insurance design (VBID) and the patent centered medical home (PCMH) to improve healthcare delivery.
The two health plan initiatives should be incorporated to help reduce costs, according to the PCPPC report's authors, who contend that "obvious synergies" between the two programs often go unnoticed because they are carried out separately.
"Although some medical home projects have gotten launched because you have dedicated physicians, and other healthcare providers, wonderful teams of ordinary people doing extraordinary things, their work is not sustainable nor is that model implementable on a wide-scale to others," Goroll says.
The task force is expected to issue a report soon for which he based his remarks on Tuesday, Goroll adds.
"The real question we face now is not that we can get the vanguard launched, but what is it going to take to move this from an interesting project to really transforming primary care in the US and hopefully healthcare?" Goroll says. "That's the backdrop of our payment reform task force."
PCPCC is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, and clinicians who have joined together to develop and advance the patient-centered medical home. That is an approach to providing comprehensive primary care in a healthcare setting that facilitates partnerships between patients, their personal physician, and when appropriate, the patient's family.
VBID is an employer-driven design strategy to optimize use of higher value healthcare services and reduce use of lower value services. The PCMH is a supply-side mechanism to enable clinicians to delivery better quality care more efficiently, according to the report.
Goroll says a transition to a "new system can be challenging."
"Despite the promise of a much improved payment mechanism, payment reform will face considerable resistance—stakeholders have figured out the rules of the old system and change entails unknown risks," Goroll says.
Goroll also outlined the task force's proposed payment reform principles and recommendations:
Payment reform is essential to establishment and sustained operation of the PCMH, especially regarding transformation and desired outcomes in patient experience, cost, quality, efficiency, safety, and professional satisfaction.
There is no one-payment system that is universally "best for the PCMH. Choosing an approach to payment reform should be based on assessment of its ability to foster key PCMH objectives and outcomes."
A blended strategy to payment reform can help minimize the shortcomings associated with any single method of payment. A thoughtful blending of methods helps to maximize benefits and minimize limitations.
Risk adjustment, incorporating both biomedical and psychosocial factors, is key to payment reform, protecting practices from actuarial risk and reducing the incentive to shun complex or difficult patients.
Pay for performance should foster accountability and transparency in cost, quality, and patient experience, and to the extent possible, be evidence-based and outcomes-focused.
Bonus payments funded from cost savings, as with many models that rely on shared savings, have the risk of getting ratcheted down over time as wasteful and avoidable spending decreases. A portion of shared savings should be folded into the base payment over time to avoid reductions in total pay.
PCMH sustainability depends on the breadth of payment changes in practices and their ability to fund the initial building and maintenance of the PCMH infrastructure and services; a substantial majority of the practice population needs to be covered by the payment reform, often necessitating multi-payer participation.
Payment reform should improve practice environment, and enhance professional satisfaction and the attractiveness of a career in primary care.
Payment reform should correct existing imbalances and distortion in physician payment and take into account value created by primary care, especially in the areas of cost, quality, care coordination, access, and patient centeredness.
Payment reform should encourage patient-centered, coordinated care by all providers, not just those inside the PCMH.
Administrative practicality is desirable, if not essential, though the transition to a new system can be challenging.
"Most discussion of the medical home model has focused on primary care practice reengineering and payment reform to align practioner incentives," said Andrew Webber, president and CEO of the National Business Council on Health, a national association of employer-based health coalitions. "Yet the role of consumers in advancing the medical home has been largely missing in the conversation to date."
