Is Health Care Reform a Gathering Storm for Doctors?

Medicare and Medicaid Act of 1965, Section 1801: “Nothing in this act shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided…”

The excerpt above from the original Medicare and Medicaid Act legislation of 1965 crystallizes the ethos of a bygone age, and seems inconceivably anachronistic as a line from modern Federal legislation. It is interesting how in the 20th century medicine went from a profession riddled with quackery, inadequate standards and training to a revered profession that absorbed some of the best and most capable minds in our society, devising and using an explosion of technological advances that changed the world. Physicians of my vintage (1983 medical school graduate) entered a world that expected precision, skill and 8–10 years of complete personal and financial sacrifice and commitment after college, but promised respect, autonomy, and generous financial rewards later. Historically, up to 90% of physicians from the 1960s through the 1980s would recommend medicine to their children as a career. Doctors loved their work, with most working long hours and retiring late in life.

Perceived as the cause of runaway fees and costs for medical care, the Center for Medicare and Medicaid services (CMS) pursued the diagnosis related group (DRG) system for hospital reimbursement, and ultimately placed a limiting fee on cataract procedures, as the first physician fee limitation CMS sought. This became comprehensive with the Hsiao study and implementation of the Relative Value Scale (RVS) in 1992. Deeply flawed, the RVS boxed physicians into a zero sum game for fees and services, which via the oxymoronically named Sustainable Growth Rate (SGR) of the years from the 1997–2015 eroded physicians’ incomes on a year-to-year basis.

Commercial insurance has largely followed Medicare’s lead in these matters, with RVS-based reimbursement, using the power of contracting with a large percentage of the population to push physicians into “contracts of adhesion” that doctors generally have no ability to negotiate, and must simply sign or be out of network, limiting many patients’ access.

“This past fall I had the honor of presenting the Foundation lecture to my professional subspecialty society at the 46th annual meeting of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). I examined health care reform, challenges it creates for our specialty, the concerns of the ASOPRS members, and how they expect to respond to these concerns. Our branch of surgery has been under a CMS microscope for the past two years with pre- and post-payment reviews for functionally indicated upper eyelid surgery (blepharoplasty, ptosis repair and browlift). We have been subjected to unrelenting RAC and SMRC audits with updated, irrational and sometimes impossible to comply with Local Carrier Determination (LCD) policies. In my practice, apparently unending audits request an average of 5–15 charts per month for pre-or post-payment review (office + operating room). I respond with meticulous documentation and narrative explaining exactly how the documentation fully complies with the carrier’s LCD policy. I now stand at over 200 charts they have requested, with no payments lost by my practice, but the physician (me) is very aggravated and tired of this travesty. Clearly this process is not about preventing and reclaiming payments from fraud and abuse, but is simply about abusing the providers of medically necessary and approved services.

I performed an email survey in June 2015 regarding issues challenging the practices of ASOPRS members. The greatest threats related by members (in descending order) were decreasing payment for medically-necessary care, ACA and Federal-related regulatory expansion, time and aggravation of EHR compliance, increasing overhead, commercial insurance issues and decreasing income. “Mastering the growing body of oculofacial knowledge” was related as the next to lowest of 12 areas of potential concern, with the previously mentioned top areas of concern cumulatively being 23 times more important than maintenance of surgical competency to ASOPRS members. The revelation was that my colleagues are 23 times more concerned by a variety of largely Federal and commercial insurance-related issues than they are about maintaining technical competence. This survey also made me question why many of us were spending up to six days at our fall professional meetings. It would seem more rational for us all to spend a week in Washington lobbying our legislators.

Physicians have not proven to be the most effective at uniting and representing their interests on a national stage. The American health care system appeared to be broken at the time of enactment of the Affordable Care Act in 2009. Whereas the AMA rushed to endorse a concept, and gained nothing material for the practicing physician in the ACA, the pharmaceutical industry, insurance companies and hospitals were all big winners, harvesting benefits worth many billions of dollars to their industries. These interests maintained an intensive lobbying presence, obtaining administration and congressional guarantees of their priorities before supporting the bill. America’s middle class and physicians were big losers.”

The electronic health record (EHR) requirement of the ACA is a case in point. The federal incentives to adopt EHR don’t even come close to covering the true costs. Add to that the disruption of practice, patient contact and work flow, along with the approximately one hour EHR adds to every physician’s work day, and we have a mandate that has destroyed the remaining joy of practice for thousands of physicians (and was a final straw in many retiring). If the federal government wants doctors to complete EHR, they should pay us for the hour each day it takes. I don’t think a trade union would allow an hour to be added to every workday without compensation. Electronic medical records may eventually reap benefits in cost and patient care, although thus far these advantages have been illusory at best.

Other rules and areas of compliance, such as maintenance of certification (MOC) for board certification, as well as a litany of new rules and regulations drain unproductive time and add cost and expenses to patient care, often unreimbursed. This compliance and certification may be desirable from a patient protection perspective, but medicine has reached a point where additional layers cannot be added without relief elsewhere.

“Although we may still do well financially in our practices, the increasing drains including compliance eating into free time, loss of productivity, insults-hassles-irritations, loss of status, and declining income leaves most US physicians in a position where they see medicine as a career in decline (84%). Fifty-eight to ninety percent of physicians would not recommend medicine as a career to their children. As those of us with mature practices, savings, and a concierge, cash practice or funded retirement to retreat to prepare to feather our nests, it makes one wonder, who will be taking care of the patients?

Being doctors we all try every moment to “do the right thing.” For our patients and colleagues this often means selflessly providing care irrespective of family and personal demands or the patient’s ability to pay. We have acquired our skills with eight to ten years of additional education and training after college, and most physicians enter practice with significant debt. A palette of declining benefits and increasing liabilities in the practice of medicine are not an encouraging trend and must be reversed to keep medicine viable. It is incumbent on every physician to work in concert to save our profession. We must become advocates for ourselves and through our professional organizations, with tangible defined goals and a collective will to persevere and see these goals enacted.”

Biography

John B. Holds, MD, FACS, MSMA member sine 1991, is a Clinical Professor of Ophthalmology and Otolaryngology/Head and Neck Surgery at Saint Louis University, a former president of the Missouri Society of Eye Physicians and Surgeons, and a current legislative chair for that organization.

Contact: jholds@sbcglobal.net