Tag Archives: Physicians

Obama’s Latest Bait and Switch for Docs: Medicaid Payments to be Cut by 40%

As we enter year two of the Affordable Care Act, we have seen many issues arise during implementation.  Through both executive order and executive memorandum, President Obama has unilaterally changed the law more than 100 times in order to advance his own political agenda.  When it became important to publicize enrollment and increased coverage of the uninsured, the President and the ACA provided for an increased payment scale for patients with Medicaid.  With the rapid increase of Medicaid insured patients due to the implementation of the ACA, the administration utilized the increased payments as an incentive to attract more physicians to participate in Medicaid programs.  According to the New York Times, the ACA has resulted in the largest increase in Medicaid covered patients in history–now nearly 20% of all Americans are covered under this plan.  Attracting physicians to cover Medicare patients has been critical in order to meet the demand for access to care and  to adequately cover the newly insured.  Now, unless changes are made this week, Medicaid reimbursements will be cut once again leaving many physicians to wonder if they can continue to treat the increasing numbers of Americans covered thru these programs.

Traditionally, Medicaid has reimbursed physicians at rates significantly lower than Medicare–making practices with large numbers of Medicaid patients financially non viable.  As the ACA was rolled out, a provision provided for significantly better Medicaid payment rates to physicians in order to help provide larger networks of care for the newly insured.  Now, there looms an automatic payment rate cut of nearly 43% for Medicaid payments to primary care physicians–many of these are the same physicians who agreed to expand Medicaid within their practices in order to meet demand.  According to Forbes, traditional Medicaid reimbursement averages just 61% of Medicare reimbursement rates (which is often significantly lower than private insurance rates).  In addition, many Medicaid patients require a disproportionate amount of time and resources from the office–doctors are caught between a “rock and a hard place”–between a moral obligation to treat these patients and a desire to avoid financial ruin.  These patients tend to be sicker, have multiple medical problems and have suffered from a long time lack of preventive care.

Finances are not the only piece of the Medicaid puzzle. Government regulation and paperwork and processing often delays payments to physicians and impacts their ability to run a financially sound business.   Interestingly, a study from 2013 published in Health Affairs suggested that while physicians welcomed an increase in reimbursement rates as incentive to treat Medicaid patients that quicker payment times, reduced paperwork and simplified administrative processes would also need to be a part of any type of reform.  (of course, none of these items were included in the incentive package).

Many primary care physicians stepped up to answer the call for increasing coverage of Medicare patients when the ACA was initially rolled out.  Now, these same physicians are contemplating the need to drop these patients from their clinics with the pending change in reimbursement.  As mentioned above, in addition to lower reimbursement rates, the Medicaid program requires an enormous amount of administrative work in order to file claims and these claims are often paid very late–those running a small practice are forced with more work for less pay and often have to make difficult budgetary decisions in order to  payroll for their staff each week.   While the administration touts the swelling numbers of Medicaid covered patients–nearly 68 million currently–I suspect access to quality care will soon become an issue.  Just as with every other manipulation of the ACA over the last two years, legacy and political agendas have taken precedent over what really should matter–providing quality medical care AND prompt, easy access to care for the formerly uninsured.  In an effort to tout swelling numbers of “covered” Americans, the Obama administration has failed to anticipate the impact of short term financial incentives for primary care physicians to accept increasing numbers of Medicare patients.  Even in states such as California, officials are bracing for a large number of physicians who have announced that they will likely drop out of Medicaid plans if the planned cuts are implemented as scheduled.

It is time for the Obama administration to stop playing political games with our healthcare.  If the mission of the ACA is to provide affordable quality healthcare for all Americans, then we need to ensure that there are quality, dedicated physicians available to provide that care.  The Medicaid “bait and switch” is just one example of our President’s shortsightedness and lack of connection to those dedicated physicians who work tirelessly to ensure that ALL patients have access to care (regardless of insurance type).  It is my hope that the new Congress will engage with the physician community and find real solutions to the US healthcare crisis–and no longer allow the President to place his perceived legacy over the healthcare of those Americans who are in need.

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Image adapted from The Peanuts comic strip by Charles Shultz

The Doctor Shortage of Tomorrow: Fact or Fiction?

This week in the New York Times, Drs Scott Gottlieb and Ezekiel Emanuel make the case in an Op Ed piece that there will NOT be a physician shortage as a result of the Affordable Care Act (ACA). Both have extensive experience in policy and have held respected positions in government.  Based on a projected need of nearly 90,000 more physicians by 2020, I have difficulty seeing how a shortage will not occur.  The Affordable Care Act has already demonstrated the ineptness of government to manage healthcare–the laughable website rollout, newly discovered “backend” issues with signups, inaccurate quotes and information and questionable security (and this is all since October).  Now, as the mandates loom, consumers are beginning to wonder where exactly they will be able to get care and who may be providing it…

How can there NOT be a physician shortage?

Using the Massachusetts healthcare plan as an example, Drs Gottlieb and Emmanuel argue that the shortage predictions are flawed.  However, Massachusetts is not at all representative of the entirely of the US–one cannot extrapolate the response in Massachusetts to the rural Midwest, or the Deep South or Sunny California.  Moreover, the provisions and funding of the legislation in Massachusetts are very different from those in the ACA.  (its like comparing apples to oranges).  They argue that the biggest driver of increased physician manpower needs is more related to an aging population rather than the impacts of Obamacare and the flood of new patients that are insured by either medicaid or the ACA Exchanges that are able to set reimbursement levels at new all time lows.  They state that the solution to shortage issues will come in the form of technology driven “remote medicine” and the use of non Physician extenders such as Advanced practice nurses and Physician assistants. Moreover, they go on to argue that the solution is NOT producing more doctors–rather it is getting those of us in current practice to become “more efficient”

Really?  We are already doing more every day with much much less than we have had in the past….

As doctors often do in clinical practice,  I respectfully disagree with their assessment.  Obamacare will soon flood the system with millions of newly insured patients.  As evidenced by the current climate in California, many physicians will choose NOT to participate in the exchanges due to very poor reimbursement rates.  Recent surveys in that state found that nearly 75% of doctors would not take the Exchange insurance or Medicaid due to the fact that the Exchange payments were far below the standard CMS Medicare rates.  Many practices are unable to maintain autonomy as payments continue to decrease–many are being integrated into hospital systems.  Overhead continues to increase in order to meet Federal requirements for electronic documentation and records as well as maintaining coding experts to keep up with the ever changing systems such as the newly minted ICD-10 to be implemented in 2014.   The concept of a completely free standing private practice will no longer exist within the next 3 years.  Whether in academic or private settings, all physician groups will be employees of health conglomerates.

What is ultimately going to drive the physician shortage and what are the potential solutions?

For starters…I certainly do not have all the answers….While I do agree that the aging population certainly presents a manpower challenge, I do not concede that this alone will be the driving force behind any potential physician shortage.  Medicine is becoming less attractive for young bright students considering a career in healthcare.  Training physicians is expensive–medical schools are pricey for potential students and post-graduate training (Internship, Residency and Fellowship) are costly for the academic centers where they learn.  Financially, students may no longer be able to incur the significant debt (in the hundreds of thousands of dollars) that continues to accrue when attending medical school when the job prospects promise declining financial rewards.  Once in practice, newly minted MDs will find that their hours are longer and the time that they spend with each patient will be more limited–increasing documentation requirements will result in more screen time and less time listening and bonding.

Physicians are essential to the delivery of care.  However, I also recognize the vital role that physician extenders play in healthcare today (and will in the future).  Nurse practitioners, Physician Assistants and Pharmacists are critical in ensuring that patient care is optimized.  These providers must work in concert with physicians–approaching the whole patient in a team care model will ultimately improve outcomes.  But, utilizing these allied health professionals in more independent and unsupervised roles as Drs Gottlieb and Emmanuel suggest is reckless.  Although well trained and expert in their scope of practice, these allied health professionals are not physicians–they have not completed the academic rigors of a four year medical school nor gained the experience of a 3-8 year Residency and Fellowship.  Replacing doctors with other provider types will NOT eliminate the need for physicians and will NOT forestall the expected physician shortage as we move into 2014 and beyond.  We must continue to work with physician extenders and other allied health professionals in order to meet the increasing demands of a busy medical practice–I do not advocate for the independent practice that is currently being considered in many states.

Remote medicine, telemedicine and remote monitoring are certainly complementary and extremely valuable in providing care.  In fact, as Drs Gottlieb and Emanuel suggest, these modalities may reduce the number of doctor visits and may play a major role in prevention.  While I am a real advocate for utilizing technology to engage patients and facilitate care, face to face interactions between doctor and patient must still be a part of the process.  We cannot rely on computers and other electronic devices in isolation–they can, however, enhance the delivery of care when carefully included in a comprehensive treatment plan.

Are We Simply Losing Our Way As Medicine Remains in crisis….

Ultimately, time will certainly determine the state of physician supply.  If we remain on our current course and continue to fund and implement (albeit haphazardly) the provisions of the Affordable Care Act, we will ultimately see the fallout of a significant physician shortage.  Long lines, significant wait times and scarcity of both newly trained primary care and specialty doctors will become reality.  Medicine in our country is at a crossroads. We must continue to advocate for our patients and protect our right to practice our noble profession in a way that provides the best possible outcomes for our patients today and in the future.

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Interpreting Physician Rating Websites: Garbage IN Equals Garbage OUT

In the past, learning about a good doctor or a pleasant hospital experience was a “word of mouth” phenomenon.  Today, more and more patients are going online for information about potential healthcare providers and hospital systems.  But exactly how accurate is the information they are accessing?  Recently, multiple surveys and research investigations have been published about the validity of online physician review sites.  Like most things that we find on the internet, the best advice is to take what you see there “with a grain of salt”.

A recent survey performed by the Pew Research Center asked participants a simple question.  “What percentage of adult internet users have consulted or posted online health reviews?”  The results are quite startling.  The minority of users actually post–but a fair number of users read and consult these reviews.

Source:  Pew Research Center “Health Online 2013”

So, as consumers of healthcare, how in the world do we interpret this data.  The fact that only 3% of the folks surveyed actually posted reviews suggests that the reviews are somehow biased–either good or bad.  This can certainly lead to misleading comments and ratings and can drastically change how a provider is perceived.  We must remember that these MD ratings sites are unregulated and not very well controlled or policed.  Typically, in any customer service industry, we find that most comments come from dissatisfied customers–it is rare in corporate America that someone takes the time to leave a positive comment.  There have been many published studies in the literature have shown that negative events are much more likely to elicit comments.

An article published in the New York Times in March 2012, discusses the neuropsychiatric basis for this very fact.  In the article, Stanford researcher Dr Clifford Nass states that the brain handles positive and negative events differently and in these events are even processed in separate locations within the cortex.  His research has demonstrated that we tend to process negative experiences more thoroughly and tend to ruminate about negative more than positive–in other words it takes many many positive experiences to overcome one negative interaction.  A recent study in the Journal of Urology evaluated the ratings of common sites such as Vitals.com, Healthgrades.com and RateMDs.com and found that from a random sample of 500 Urologists whose ratings were examined, the average number of evaluations for each was 2.4 ratings.  Many of the reviews focused more on the office experience (decor, wait times, etc) rather than the interaction with the physician or the providers knowledge or ability.  Obviously with very few respondents the results can be significantly skewed by either a remarkably high or a remarkably low rating.  The results suggest that physician rating sites are probably not the most effective way to evaluate your next  potential healthcare provider

What are some possible sources of bias in MD ratings?  The internet allows for anonymity and promotes the ability to say things that we normally may not say in a face to face interaction.  Disgruntled employees, angry family members or patients frustrated by their disease may provide unwarranted negative ratings to healthcare providers.  Conversely, family members and friends may also provide unwarranted high praise.  Altogether, these types of bias limit the utility of physician ratings sites.  Other options for choosing a provider include social media sites such as twitter.  There are disease specific tweet chats that promote interaction among patients.  Patients in the chat often recommend certain therapies, physicians and hospital systems.  These groups tend to be very well informed and the information is fairly reliable.  Ultimately, as an article on the NPR website last week suggests–we  may just have to go back to the prehistoric pre-digital era when it comes to rating and choosing physicians–we might just have to talk to one another!

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