Kerry Willis, MD, www.aihinc.com
Dear Mr President,
I hope you are enjoying all the fiscal cliff stuff with the budget and I wanted to make you're aware of the healthcare fiscal cliff and some of the stuff that many large practices and especially small medical practices are facing in the next few years as the healthcare reform act is implemented.
Just Asking...Have you found time to read the ACA yet?
The ACA is a large bill and despite my best efforts I haven’t been able to stay awake to read it but that’s apparently something I share with you and most of the members of Congress. It does seem to be pretty far reaching and has what I like to think are unintended consequences of the actions that are forced by it and other federal acts that are conspiring to threaten to close a fifth of the providers who see patients for their primary care needs currently.
I think it’s important to incorporate technology into your practice but making it exceeding difficult and implementing more change than most medical practices can bear threatens to close the doors of many of us in the next 24 months. Many of the physicians who will close are older physicians who have served their communities well and through the good times and bad and I can’t imagine that losing them to retirement will do anything but make the shortage of doctors much worse.
We already need 50,000 additional doctors or other providers in the next few years with the expansion of the Medicaid program, and despite what some policy wonks think a Nurse isn’t a substitute for a well trained primary care doctor. I do believe that Physicians Assistants and FNPs can be an important supplement to the healthcare team, but the heart of the team has to be a high performing Physician.
...Unless, of course, you go with a two- tiered system of healthcare where those who can afford to see a Physician get to buy their way into see the doc and everyone else gets what they can afford. I think we can and should do better!
Non-medical wonks are trying to manipulate the delivery of healthcare:
You see Mr President, we are facing penalties for not having an e-prescribe system, an EMR and not doing quality reporting at the same time. Now you add implementing ICD 10 coding that will cost practices, small and large, tens of thousands of dollars.
...The purpose of the coding changes appears to be so the wonks and widgets folks will know we have suffered a Macaw attack rather than a bird attack as would. I’m sure this information is vital to those who know nothing about the delivery of healthcare but by demanding this information shows that they simply want to try and manipulate the care provided to folks in the two tiered system we are heading toward.
Do you realize who's calling the shots?
At a certain point, realizing that the same folks who designed the legal and IRS systems are designing healthcare delivery systems should serve to keep you awake at night and give you severe heartburn. I’m sure the Doctor who takes care of you in the ivory tower of the White house can figure out how to help you with those problems!
What we really need is to divorce coding from our payment systems and figure out better ways of
paying folks like me that eliminate the 40% administrative costs that decimate small practices. I realize that you don’t mean to deprive folks in rural areas of their ability to access primary care doctors, but that is the net effect of the unintended consequences thingy.
The Good News:
There is good news; however, as I have some suggestions to help you fix some of these problems. I really don’t expect much from my solutions as you have completely ignored my advice in the past. Our government has focused on the whims of the policy wonks who continue to amaze me that they are able to turn the lights on in the morning and get their shoes tied but here goes anyway.
1. Adopt payment reforms that support the Medical Home Model and pay Doctors to make the transition to the model. There will be lots of whining from the wonks and the various academics that the model needs more study because it doesn’t have proven benefits in many of the smaller studies done. Most of the studies show an improvement in quality of care, and done properly, show reductions in ED visits and admissions as well as lower costs overall for readmissions to the hospital.
What we have proved with our current system is that it’s expensive, has limited access and it doesn’t serve the very sick very well at all. It’s loaded with excessive administrative costs and seems to be the play toy of every government agency that has spare time to harass and keep physicians from providing good care.
2. Eliminate the annual Medicare deductable and make it simple for patients and doctors to know how much is owed for office visits. I really only know a little about this topic, but it tells me that deductibles are barriers to obtaining care. It doesn’t seem to make sense to me to place barriers to care in front of folks we want to keep in the offices of Doctors rather than in the waiting rooms of hospitals. I just think that having patients coming to the office to prevent admissions for minor problems that become severe and end up with the patient admitted is a better idea than
our current system.
The complexity of administering the deductable system adds tens of millions of dollars to the administrative costs for patients and practices and the government. I just think there is a more understandable way to cost share than a 20% coinsurance after a deductable that changes every year is met with a fee schedule that is rarely set before Jan 14 each year.
3. Just for kicks and giggles, let me recycle and old suggestion: Eliminate the SGR formula. You can do this in a budget neutral way by paying all physicians on the same pay schedule who don’t work in a rural health clinic or FQHC Clinics. The savings eliminated from not allowing hospitals to be subsidized for buying practices will level the playing ground and make the rules the same for all physicians.
If you need some additional savings, you might want to consider a national fee schedule for procedures like CT scans and MRI exams for the whole country. While I’m sure there are some marginal differences between salaries in New York City and Beaufort NC where I live, the costs of the
machines and the facilities don’t differ a lot and there would be additional savings from not have to administer different charges in far too many areas of the country.
4. Eliminate Meaningful Use Three Rules and forget ICD 10. These two reductions would be associated with billions of dollars of savings for the government and our country and its healthcare providers and could be used to close the SGR gap if needed. Losing the ability to properly code a mail box accident might be a huge loss to the wonks and widgets folks but to those of us who see patients will be forever in your debt. MU 3 rules have little to do with actually improving care and the elimination of them might lead to increased adoption and utilization of EMR’s by small practices. Asking for adoption of the Medical Home Model would be a better use of the funds and lead to enhanced savings for the government. A Much Better Deal for the Money!
Well, I don’t want to overwhelm you with ideas all at once. I realize that my suggestions are the musings of a small town country doctor but you might want to consider them as they will fix many of the structural problems with our system. Most of them would prevent the death of small town Family Doctor practices in the future.
My best wishes for leading our government to actually advocate healthcare change that is positive and leads to savings for the government.
Let me know if I can help.