Healthcare Talent Transformation

Four Ways to Save $Billions on Healthcare

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.

 

Health Wonk Review: Brainy Edition

The Disease Care Management Blog is hosting for this edition of the Health Wonk Review. This is a linked summary of the latest and best postings from an informal community of health policy bloggers with informed insights that readers, business leaders, academics and policymakers won't find anywhere else. We invite you to sit back, get a beverage, enjoy a snack and feed your brain as you join thousands of your colleagues and competitors in gaining a deeper understanding of the U.S. health care system.

We also encourage you to read Dr. Kerry Willis' article (included in this HWR edition).

Challenge: Combine New Approaches with Old Models

Kerry Willis, MD, www.aihinc.com

I’m a big fan of the current DIRECTV ads. One of my favorites involves a guy who goes to a self-help seminar, becomes overconfident, goes to Las Vegas and loses everything, and has to sell his hair to eat. The ads are all based around the theme of avoiding mistakes by becoming something that you are not intended to become. I think there is much for doctors to learn from these ads and apply to the current opportunity with Accountable Care Organizations or ACOs. I think we could easily write an ad that says "don’t be attracted by money from evil people seeking to co-op you into their schemes to make themselves more money because when you do you sell your soul, you are owned by a devil."  I think we need to recognize that many devils exist and are trying to get us to sign up to sell our souls to them.

 
During the PHO debacle a few years ago, I reminded our physicians that the letters should represent the ownership and direction that these organizations should take as they developed. I frequently offered that they were really pHO’s with Big hospitals and Big organizations with little Physician control over the direction and quality that was important to us. I fear that the same is true with ACOs. If we are not vigilant in their formation and direction, then they will become AcOs with physicians being a small part of their governance but very accountable to their owners. They will be dependent on the revenue streams that spring from them. I see scenarios where physicians will profit but then be caught in a spider's web of their own design where they will be told how to practice and what kind and amount of care they can provide.  I guess you could claim that I don’t trust insurance companies and you would be wrong. I do trust them. I trust them to do what is best for the corporate profits and the nonprofit executives’ with bonus clauses at the end of a successful year.

I’ve been around for a while and lived through the evils of the uncontrolled HMO and the Physician Practice Management Companies and the various schemes that have attracted physicians like small fish to an archer fish’s light. While my personal opinion is that this period in our history represents perhaps the greatest opportunity for physicians to recapture the leadership role they long ago abdicated, real dangers exist that could make physicians little more than indentured servants doing the bidding of their overlords. Physicians need to be smart and develop business acumen and, for once, teach the business world that physicians can be and should be good business people as well as Great Doctors. One of the great lessons I’ve learned through the years is that other physicians are not my enemy. We may disagree, but most of us have the interest of our patients at heart. I would not make the same assumptions about other organizations or interest groups.

I went to medical school out of a desire to participate in the care of my patients. I love seeing my patients.  I love being their advocate and their guide through the maze of what we call a healthcare system. I still see patients every week and work hard to provide them with good care. I try to provide the type of care I would provide my own family members. I have no doubts that I am not perfect, which my wife reminds me of on a regular basis, but I do work hard and deeply care about the profession and the patients I have given my life to for the last 30 years. It’s from that background that I have developed severe concerns about the current ACO structure.

My personal vision of healthcare is a return to a system where my focus is on the contract to provide high-quality care between my patient and myself. I always remember an older general surgeon who used to tell me about the days when he practiced medicine without the interference of insurance companies and administrators who knew more than he did. I always listened and envied him for working in an era when the patient was his only focus. I think a return to such an era is possible and economically feasible. The patient centered medical home has demonstrated what high-quality primary care can provide as an impact to save unneeded and expensive care that often had poor results. The Concierge model of practice has demonstrated that alternative economic models can thrive and provide better patient satisfaction and access to care. The challenge is figuring out how to combine new approaches with old models that provided high-quality care and make them work. However, if we are not prudent in our evaluations, I suspect we will look like the coyote in the Road Runner Cartoons: we have built an elaborate trap that our target has eluded and we ourselves are trapped in a system of our own construction.

Dr. Willis is a practicing family physician in Beaufort, NC, where he founded East Carteret Family Medicine. He currently serves as Chairman and CEO of the largest and oldest self-sustaining physician-led network in NC, The Beacon Company, and Chief Operating Officer of Atlantic Integrated Health (AIH). A true believer in the need for healthcare reform, Dr. Willis believes that the best solutions will be community-based and provider-directed and are aimed at improving the affordability and accessibility of medical care by reforming the healthcare delivery. The need to consider new models that are patient-centered and eliminate many of the moving parts that cause waste are the driving goal for Dr. Willis and his organization. 

Dear Mr. President...Choose Wisely

Kerry Willis, MD, www.aihinc.com

Dear Mr. President,

If you have been reading my blog, you can tell that I’m a fan of old movies. I’m not a cult-classic type of guy and tend to watch movies for pleasure and relaxation and shun those that have any redeeming social message. I don’t go to the movies to think.  I’m beginning to wonder if some of those folks you hired in government go to work with the same approach that I go to the movies. I have little doubt that part of the problem is the same type of folks who created the financial systems that operate healthcare also created the tax code and the legal system. Anyway, I thought I make a few more suggestions for you to help fix some problems that can be fixed without great gnashing of teeth.

Our healthcare system has become a maze of gauntlets thrown down in front of its providers leaving them to navigate during their quest to find the holy grail of financial rewards and be able to make a living for yet another month. One of my favorite movies to compare to healthcare is Indiana Jones and the Last Crusade. In the movie, the forces for good and the American way embark on a quest to find the Holy Grail, the drinking cup of Christ which is reported to have the power to grant eternal life for those who drink from it. One of the final scenes involves the journey into the room where the Grail is kept and protected by the Knight Templar who has guarded it for hundreds of years. Indiana must navigate a life-threatening path of obstacles and then take a leap of faith and enter the room where the Grail is kept. After entering the room, a short battle ensues and the forces of evil make the first choice upon which he dies, dries up and blows away as if he never exists. The old knight observes that bad guy did not choose wisely and advises Dr. Jones to choose wisely when he makes a choice.

It pretty well sums up my personal quest to make a living practicing medicine each month. I see patients and enter my summary of the data into my billing system. I send the information to the wizard who reviews the claim and decides whether I will be paid or not. My seconds then embark on the quest with me as we submit claims and do battle with claim management and reconciliation experts and submit more information in our quest to get paid. We seem to face the similar obstacles that are thrown at us as we see if we will get paid or whether we will lose our heads electronically and be refused entrance to the kingdom of EOB’s. The trolls that guard the EOB kingdom seem to forget to pay some claims and send them back for no reason around 8-10% of the time. It’s a monthly quest that occupies 25% of the reward that we obtain for the trolls each month. Usually, the trolls decide whether they will pay me on a regular basis at all. Mr. President, to be honest the crusades were a once-in-a-life time deal for the Knights and it doesn’t seem far that small town Doctors like myself have to make this journey every month.

So here goes my other suggestions, Mr President. Maybe we need to focus Doctors back on practicing medicine and less on getting paid for the work they have already done. If the government simplified and standardized the forms required for my patients to obtain services, then I could spend less time on paperwork and more time on taking care of their healthcare needs. Currently it takes me two or three forms to complete to get diabetic supplies for my patient and a load of silly words added to my medical record. I think we should be able to get that task done with one form. I know that seems to be a radical change, but I don’t think the folks in government requiring all these changes know how hard it is to get folks to check their blood sugars at all. Making it difficult isn’t going to help me control their sugar and prevent the problems caused by diabetes. I guess I have different goals than some of your employees who write these rules. At any rate, standardizing the forms would help me get the task done easier and faster and one time. Now If you can get those infernal ads for electric wheelchairs taken off TV, we’re really talking an improvement.

We could make financial systems easier and more direct with less expense and paperwork. I realize a whole industry has grown around the healthcare system to make the system confusing but clarity and standard rules would improve the current systems especially the rules run by the government. For example, if I see a Medicare patient and provide them a service then I’m paid less than a physician who performs the same service who is “on campus” and owned by the hospital. Likely if that same patient has private insurance and is owned by the hospital then likely the hospital has leveraged its market clout to demand higher rates of reimbursement than small clinic can demand. Running small clinics out of business doesn’t seem to be a good thing especially when the end result is escalating costs. My solution?  Pay for the service equally and without prejudice to employment status. Finally on my list of solutions to make life better for everyone is the establishment of single source credentials verification services for all insurance lines. Each state should establish a database of credentialed physicians and the folks requesting the information can pay for the access and support the service. This would eliminate the myriad of request and forms and all the wasted time I have for these requests.

Remember Mr. President, the finishing of a quest is as important as the journey along the way.  These are significant problems that will earn you some credibility with physicians for being responsive to their needs if you can ask some good questions and take the leap of faith to enter the arena where decision can change the system. Despite what the physician politicians tell you, most of our concerns in the real world are finite and fixable. All that is required is to listen, think and then choose wisely when finishing out the quest. And thanks again in advance for getting the ads for electric wheelchairs off my TV.

Dr. Willis is a practicing family physician in Beaufort, NC, where he founded East Carteret Family Medicine. He currently serves as Chairman and CEO of the largest and oldest self-sustaining physician-led network in NC, The Beacon Company, and Chief Operating Officer of Atlantic Integrated Health (AIH). A true believer in the need for healthcare reform, Dr. Willis believes that the best solutions will be community-based and provider-directed and are aimed at improving the affordability and accessibility of medical care by reforming the healthcare delivery. The need to consider new models that are patient-centered and eliminate many of the moving parts that cause waste are the driving goal for Dr. Willis and his organization. 

Health Wonk Review: Spring Hath Sprung!

Spring hath sprung and so have many health wonky ideas!  Check out this week's edition of the Health Wonk Review hosted by InsureBlog.

Dr. Kerry Willis give a great opinion on hour physicians can be the President's "Huckleberry."  It is definitely worth the read. Check it out: I'm Your Huckleberry, Mr. President.

I'm Your Huckleberry, Mr. President

Kerry Willis, MD, www.aihinc.com

Dear Mr. President,

I love old westerns, and I’m a fan of some of the newer versions as well. One of my favorites is Tombstone and the one scene in particular where a bad guy is looking for a fight, Doc Holliday with his reply provides the answer to his questions. He is letting him know that Doc is the perfect guy to solve his problem. Well Mr. President, here’s a quick note to let you know that “I’m your huckleberry,” and I can help solve some of the problems in healthcare.

From a physician’s standpoint things have gotten very complicated. Most of us entered medicine because we felt we could make a difference in the lives of our patients. Mostly today, I have made a difference in the number of trees killed in the US as I have struggled through the mountain of paperwork that is required by our system. Sadly, I have failed in my attempts to slay the beast of bureaucratic entanglements and have spent far too much of my day signing forms and paperwork that will be repeated again in the future. One of my least favorite things to do is complete diabetic supplies forms. I work really hard to get my patients to take their blood sugar and adjust their regimen as needed. I fail to see any utility to these forms and wonder why they are all different. I’m pretty sure I could design one form that could be used by every doctor and would be glad to provide an electronic version to make signing easy. The standardization of many of the forms the government requires would make my life easier, and if we were really smart, the prescription and the form would be the same thing and wouldn’t that make life grand. You would think studies showing that 25% of a physicians' time is spent doing paperwork would mean something to someone. We could solve a large portion of the healthcare manpower shortage problem by eliminating uncompensated paperwork. I suspect being required to compensate physicians for much of the paperwork required by the government and insurance companies would solve much of the need for these forms.

Similarly much of my time is spent monitoring the business affairs of medicine in my office to be sure we have money to pay bills and meet payroll and such. Recent statistics  that I have seen reflect that as much as $30 is spent to collect the average office visit charge that runs around $75. This includes billing filing and electronic support and transmission charges and posting the charge to the proper account. It’s silly to think that this kind of administrative waste is acceptable. We seriously need to consider different models for primary care that don’t include filing claims.  A system where waste was eliminated would not involve spending a third of the cost of care on getting paid.  But as I said Mr. President, I’m your Huckleberry and I do have a solution. For every government program, let’s allow an option for patients to receive a voucher for their primary care needs and contract for their care with their doctor directly without any government involvement between the two. The patient could be allowed to use the voucher in a medical home setting where quality monitoring is part of the baseline arrangement and becoming an MBA to manage your business isn’t your primary concern.

There are many lessons to be learned from our current mess of a system that we have currently. One is its very complicated and two it doesn’t have to be that way. I fill out credentialing requests every year for the same companies and same agencies that are required to collect the same information required by our government. Perhaps our government should become part of the solution rather than causing the problem. Credentialing is becoming a huge problem. Why not require each state to develop and maintain a credentialing service for each physician in the state who is licensed to practice in that state? I could fill the forms out one time and the folks wanting that information could be allowed to query the state database for the needed assurances that I wasn’t a figment of the imagination. This would result in a uniform quality of credentialing and in fewer burdens on the individual practices. 

I hope Mr. President, that my thoughts have been helpful to you. I have some more ideas on cost savings that would increase the quality of care in medicine as do most of my colleges who don’t see the need of things required by the government just to make it happy and serve to delay care. I fervently believe that the best solutions will come from the ground level...from people working in the field every day. Most of us believe that we are your best “Huckleberry” and only wish we had a way of communicating our thoughts to you.

All the best,

Kerry A Willis MD

Dr. Willis is a practicing family physician in Beaufort, NC, where he founded East Carteret Family Medicine. He currently serves as Chairman and CEO of the largest and oldest self-sustaining physician-led network in NC, The Beacon Company, and Chief Operating Officer of Atlantic Integrated Health (AIH). A true believer in the need for healthcare reform, Dr. Willis believes that the best solutions will be community-based and provider-directed and are aimed at improving the affordability and accessibility of medical care by reforming the healthcare delivery. The need to consider new models that are patient-centered and eliminate many of the moving parts that cause waste are the driving goal for Dr. Willis and his organization. 

Health Wonk Review: Streaming

Check out the Streaming Health Wonk Review edition at Managed Care Matters. This issue has a real grab bag of topics, and a lot of them!

Dr. Kerry Willis elaborates on how achieving healthcare reform, improving quality and making it easier for everyone involved is possible. We all lack the courage and leadership to make it happen.  Read more in his article: Welcome to the New World, Mr. President.

Welcome to the New World Mr. President

Kerry Willis, MD, www.aihinc.com

One of my favorite movies involves a blue collar knight who becomes a jouster during medieval times who after unhorsing his arrogant aristocratic opponent went on to pronounce that he had been weighed and measured and found to be lacking. I believe that is the case with our healthcare system. The citizens of our country have weighed and measured and found that its costs are excessive and unsustainable as a portion of our national budget. They believe that better quality care can be obtained in a less complicated and more personal system than the one that has been fostered and patched and tweaked and served as a social experiment for every policy wonk who happened to be an advisor at the White House or who served as a healthcare staffer in Congress.  Given the current arguments in our country about healthcare, perhaps we should consider offering real reform to the public that will actually improve the system while benefiting doctors and patients as well as our government who, in large part, foots the bills. I realize that my view is from ground zero and not the typical flying at 40,000 feet view that is popular inside the beltway, but there may be some pearls to be gleamed in my words as I share my thoughts on what real healthcare reform would look like.

Healthcare costs at the macroeconomic level have become unsustainable and that is a foregone conclusion. What few people have the experience to know is that costs at the microeconomic [practice expense] level have become unsustainable as well. In my small, family practice office with three providers, we spent $17,000 alone in electronic expense associated with filing claims. I’m told that the actual costs of filing and collecting a claim average between $25-35 not counting appeals and refilling. Industry figures reflect that 10-20% of claim are rejected erroneously that should have been paid adding to the cost of getting paid even more. Our current model requires me to spend $30 on average to collect fees that average $75. I don’t think that kind of administrative cost is sustainable and indeed more and more physicians are leaving their practice to become employed by larger systems. The economics of that model are unsustainable as it depends on the government subsidizing “on campus” physicians at a higher rate than non employed physicians that is already threatening to be an excessive cost and has been targeted for elimination by MEDPAC. We need better models that are simpler and understandable that don’t choose winners and losers based on employment status.

Physicians are leaving the field or changing jobs at a rate never seen in the past. The pressures of running a practice are great enough from the medical standpoint. We have added to the difficulty by complicating the system to the point that one needs an MD MBA degree to survive and that seems wrong in so many ways. But as an example, The 5010 claims filing standards were recently implemented and my claims are being rejected because of the lack of the additional 4-digit zip code that is now required for no apparent good reason. If healthcare was about delivering packages instead of medical care, I could see the point but so far it evades me. The administrative costs of this implementation will likely be in the billions of dollars in costs that have little or no value. BTW, thanks for pushing the implementation of ICD 10 back two years along with its $2 billion implementation costs and endless hassle that will primarily benefit data mongers and little else. Most of our country is served by physicians in rural areas and mostly in practices of five or fewer physicians. Perhaps, it’s time to require that the implementation costs of the next policy wonks dream be revenue neutral at the microeconomic level as well as the national level.

I do have some ideas about the type of reforms that are needed. Let’s start with the repeal of the SGR formula. This problem has created such uncertainty  that physicians are unsure that they want to engage in any project. They are unable to predict if, what and when they will be paid and generally have been caught up in the gridlock that pervades our political system.  I understand their concern but I personally believe this to be one of the greatest entrepreneurial times in the history of medical care given the opportunities that are present with ACO and healthcare reform. The SGR idea is big government meddling with medicine in a manner that has never worked in any area it has been tried during our history. We don’t need to repeal it and replace it with another program that can’t work because it was designed from people flying at 40,000 feet to manage people at ground. Let it die the sudden death it deserves. Perhaps then tackling EMRs and ACOs and implementing the Patient Centered Medical Home Model will become projects that are possible rather than ones that are caught up in the uncertainty of the SGR Gap.  Practices can’t plan for the future when they don’t know if they will be in business in one year.

Given the background of my discussion above, let’s look at some real reforms that can be implemented easily.  One of the most common complaints I hear from doctors and patients is that they don’t understand Medicare and its maze of rules.  We have an annual deductible of around $175 before Medicare begins to pay for Part B services that primarily cover physician services. What we know about deductibles and primary care services is that they act as an impediment to patients seeking care for services. What we do in Medicare is threaten to fine doctors if they violate the rules that Medicare lacks a real time system to verify. We understand that minor conditions that could be effectively treated in an office setting are ignored and result in catastrophic costs as they get worse. We need a better system. Perhaps for Medicare, we should adopt the Federal Employees Insurance Model that eliminated deductibles for the outpatient office codes. Such a system could be weighted to allow simple and easily understood access to primary care and specialty services that would prevent patients from putting off conditions that could be treated easily when caught early. I would think that a program that allowed a $10 copay for primary care and a $30 copay for specialty services would promote appropriate care in the appropriate setting. There would be tremendous savings administratively for doctors, the Medicare system and for patients who would not need supplemental insurance to cover such services. The sustainability of such a system would be more likely than the confusing and overly costly system that is weighted towards spending revenue to capture revenue rather than provide and coordinate care.

Another reform that deserves attention is the promotion of the Patient Centered Medical Home concept. While the concept is relatively new, studies show that the model decreases costs and increases patient satisfaction with medical care. The PCMH builds in quality improvement and disease management as part of the concept. The problem is that we lack a model that values the services and compensates physicians properly for the changes that they must make in their practice style for it to work.  As I have pointed out, one of the biggest wastes in the system is the generation and collection of claims for primary care services. Spending huge amounts of money figuring out how to get paid and doing the billing to get paid doesn’t foretell of the sustainability of the small rural practices that most of our country depends upon. I do believe that there is no free lunch and primary care shouldn’t expect to get something for nothing. However, the PCMH model provides a vehicle for everyone’s goals to be accomplished. I would think that spending 10% of Medicare costs on primary care would be fair and reasonable if, in exchange, primary care doctors provided quality data and disease management data on a quarterly basis to the government. In exchange for a monthly fee of around $75 to $100 depending on the expense of practice already defined by the government along with a copay of $10 per visit, practices would complete all financial transactions with the patient at the time of the visit. Allowing resources to be focused on quality and patient care instead of claims expense would go a long way to fixing the problems that exist with our primary care system and improve access to those services. Eliminating claims costs for small procedures such as urinalysis and finger stick blood sugars as part of the global primary care fee would create savings for Medicare that would offset any costs of the new system.

Finally, we need to consider developing a voucher system for primary care services for all government services. If we examine the VA services we find that many Veterans are unable to access services because of expense involved in travel and lack of availability for those services. A fair voucher system could be developed to provide a fixed monthly fee to veteran to buy those services in their local community without the need for more bricks and mortar to be budgeted. Our Veterans could seek out and find the care they have earned tomorrow in a setting that promoted continuity of care with an established provider who would be available for urgent needs as well as their long term needs. A similar system would work for our active duty military families as well as our retirees from the military and promote better care in a better setting than the Emergency Department. Extending the model to Medicaid would be simple to administer and implement at the state level as well. Setting a fair fee for caring for these patients would shore up our primary care physicians and attract new physicians to the ranks of physicians as practicing in a small rural setting would become possible and plausible. Needless to say that implementing this model makes the savings desired by the Accountable Care Organization model possible rather than the pipe dream of policy wonks.

My character from my movie went on to observe that he had beat the odds and achieved his goal of becoming the best at what he did by introducing his opponent to the world where rising from modest means and becoming the champion of the people was possible and the elimination of the status quo was possible. Welcome to the New World Mr. President where achieving healthcare reform, improving quality and making it easier for everyone involved is possible. All we lack is the courage and leadership to make it happen.

Dr. Willis is a practicing family physician in Beaufort, NC, where he founded East Carteret Family Medicine. He currently serves as Chairman and CEO of the largest and oldest self-sustaining physician-led network in NC, The Beacon Company, and Chief Operating Officer of Atlantic Integrated Health (AIH). A true believer in the need for healthcare reform, Dr. Willis believes that the best solutions will be community-based and provider-directed and are aimed at improving the affordability and accessibility of medical care by reforming the healthcare delivery. The need to consider new models that are patient-centered and eliminate many of the moving parts that cause waste are the driving goal for Dr. Willis and his organization.

Merry Christmas, Mr. President

Kerry Willis, MD, www.aihinc.com

Dear Mr. President,

It’s me again. I realize you ignored my advice on the Sustainable Group Rate (SGR) fix, but I thought maybe if I kept writing that someone might read my letter and start thinking about healthcare issues in a rational manner. I wanted to take a moment to discuss the primary care shortage we have in our country and ways to improve the amount of care available to be provided quickly and without a massive new government program. I still realize that I’m an humble country doctor who is unwise in the ways of the world and I really need to join a think tank if I want to be taken seriously. However, that would take me out of practice and I really enjoy my patients and view medicine as my calling in life.

Out here in the real world we have a shortage of doctors who work and see patients. Some have chosen academic careers. Some have moved into the myriad of opportunities in administrative positions that have been created by the massive government programs. Combined with an aging population and a lack of new medical schools except primarily new DO schools, we have less doctors and more new patients who require care.

I have a suggestion. Let me return to taking care of patients and eliminate and streamline the paperwork needed largely for government programs. While I have grown efficient at filling out the four or five forms required to get CPAP or oxygen for a patient, I would think that one form would be enough. Recent studies have shown that up to 25% of a physicians' time is spent on uncompensated paperwork to help patients get the care they need. If we cut this in half, we could free up a lot of time that could be used more productively to see patients or do something mundane like eat lunch outside your office while signing forms and refills.

I look at our government and realize there are too many moving parts to fix when there are problems. For several years I have wondered why a tax code that is enough words in its volumes to fill up a large room is tolerated. I have considered the irony of a tax code that forces me to pay someone to tell me how much I owe the government and realize that our system has gotten way too complicated. It would seem to me that the purpose of a tax code is to raise money to fund the government. The purpose of our tax code seems to be to elicit bribes from lobbyists to contribute funds to the re-election campaigns of our politicians.

Is it any wonder that healthcare has been twisted by the same problems as special interest groups? They have moved us from providing care to making a quick buck on the system. We have too many moving parts and every solution is a bizarre collection of new programs and rules designed to replace the last mistake that was made by our government. If I express that I have little faith that the current experiments will provide improvement in a system that expends large amounts of money to provide care, would you call me cynical?

Recently I became enamored with the idea of examining the costs of our current system. I found that we spend billions of dollars to train people to become physicians like me. I also found that on average I spend 25% of my time on tasks that have nothing to do with taking care of patients.  They are usually related to the pipedreams of a somewhere MBA. Mr. President, it seems that you need more data which I should provide without compensation for the costs or has convinced someone that your plan to control my behavior would result in a savings in healthcare expense. Funny thing, I’m smart enough to get into medical school but can easily be manipulated by a clerk with a 6-week training course in prior approvals. I like to think I’m smarter and more dedicated to my patients than those folks seem to think I am but then I digress. I provide these examples as background to the following thought: Healthcare is in need of proven models and the end of grand experiments and a close examination of the costs and motivations for care to be provided.

We do have proven models that have demonstrated a cost savings while increasing the quality of care provided. It’s called the Patient Centered Medical Home (PCMH). We can reward practices for moving to this model and save money and improve the quality at the same time. We have trials, data and savings demonstrated everywhere the model has been tried. It’s portable, accessible and easy to understand and implement. And it’s being ignored in favor of ACOs where we have no data and no savings and no one is quite sure what they are or how they work. Why...because the powers that are the Center for Medicare and Medicaid Services didn’t think of PCMH.

Healthcare is in need of a dramatic simplification. We have too much expense tied up in claims processing and administrative tasks to properly restructure the system. The over-reliance on claims processing and large insurance systems/companies along with a lack of leadership for fixing the problems that exist have brought us to this place. Happily abandoning claims expense in favor of quality reporting from PCMH and leadership that demands real solutions to actually fix abuses of these system will lead us out of this place. All that is needed is the resolve to change.

Finally Mr President, I hope that you will demand Congress sign a bill to stop the SGR cut from taking place and stop the games that are endangering the access to care for millions of our citizens who depend on the Medicare system. You already have my thoughts on the matter in my last letter, but I will note that eliminating bad debt by the hospitals and implementing a single pay schedule for physician compensation as proposed by the Republicans seem to be fair and reasonable ideas to fill the gap while developing a permanent solution to end this problem.  Respectfully, continuing to kick the can further down the road shouldn’t be an option for solving the problem.

If I can be of further help to you with ideas for fixing these problems feel free to let me know. I tend to like fixing small problems without massive new programs needed to solve the problems. This approach is one the country can afford when we wind up with better care for the same or less money. At the end of the day, that shouldn’t be a bad idea. I am quite certain that someone will disagree.

Merry Christmas, Mr President. It’s been a rough year for you, and I suspect the next will be challenging as well. I do believe that solving some of the problems instead of quibbling over them would improve the public view of you and your administration.

Dr. Willis is a practicing family physician in Beaufort, NC, where he founded East Carteret Family Medicine. He currently serves as Chairman and CEO of the largest and oldest self-sustaining physician-led network in NC, The Beacon Company, and Chief Operating Officer of Atlantic Integrated Health (AIH). A true believer in the need for healthcare reform, Dr. Willis believes that the best solutions will be community-based and provider-directed and are aimed at improving the affordability and accessibility of medical care by reforming the healthcare delivery. The need to consider new models that are patient-centered and eliminate many of the moving parts that cause waste are the driving goal for Dr. Willis and his organization.

Dear Mr. President

Kerry Willis, MD, www.aihinc.com

Dear Mr. President,

I sense that you are struggling with managing the budget and it seems that you and the MEDPAC committee are having trouble finding ways to save money and increase the value to the system of providing medical care. I have good news . It’s really not all that difficult, and it can be done without cutting the throat of doctors who are currently underpaid by Medicare for their services.

For many years now, healthcare providers have taken advantage of a loophole in the payment rules and allowed hospitals to bill for their services. These services are identical to services provided by other physicians except that they are reimbursed at rates varying from 20-150% or more than identical services provided to Medicare beneficiaries. Apparently a long time ago, someone convinced the government that services provided in a hospital-based clinic were worth more than services provided by private practice physicians and considerations such as regulatory compliance should be an allowable expense to the Medicare system. I personally think this is hogwash and we should have one fee schedule for all physicians. If I have done the math properly, a few hundred billion dollars a year are spent on physician services. If 50% of the physicians in this country now work for hospitals then stopping this horrible overpayment will result in savings of tens of billions of dollars each year and will be more than enough to plug the sustainable growth rates gap without cutting rates for physicians who more than earn their money.

I will admit to being a simple country doctor and high finance isn’t my forte, but I believe this would help fix one of the looming problems in medicine. I am a simple man and I like simple solutions. Another problem with the current Medicare system is the gaming of the observation vs. 1-day admission rules. The current system encourages hospitals to over-document and stretch the rules that are used to review 1-day admissions. Outliers on the high end of costs compose about 3% of claims at some hospitals, but approximately 12-18% of admissions in hospitals are single-day admissions. This low-end anomaly costs the Medicare system hundreds of billions of dollars each year. The RAC system seems to be having a major impact recovering these over-payments. Since I’m a simple guy , I would propose that we pay all hospitalizations under Medicare and Medicaid at observation rates if they last less than 48 hours. The savings will be large and immediate and again in the billions of dollars range.

A similar problem is patients who are readmitted within 30 days. Eliminate the first-day charge differentials for all these admissions and require a comprehensive plan for avoiding these admissions at all at each facility providing acute care hospital services to patients. The personnel who are charged with gaming the observation rules can be refocused on managing patients for a revenue neutral proposal for the hospitals. Again the savings would be substantial since 20-30% of Medicare beneficiaries admitted to the hospital are readmitted within 30 days. A more reasonable rate of 10% should be easily achievable and create large savings for the Medicare program.

As I suggested, it’s not all that hard to create savings for services that are over-compensated and continuing to pay other physicians at fairer rates. I might point out that we have studied and have established that medical homes provide higher quality and better valued services to Medicare beneficiaries than non-medical home practices. Perhaps rather than experimenting with someone’s pipe-dreams, we should establish criteria for being a medical home and establish a fee schedule with savings from the above suggestions to fund this change and create more savings for the Medicare system. I’m not against experiments but perhaps we should go with tried and proven rather than follow the drug-induced whims of policy wonks who have no clue about how to fix the problems in medicine.

Mr. President, I hope my suggestions are helpful to you and lead you to better solutions that some of the Alice in Wonderland suggestions that have been provided by other advisors to you.

Lastly, I’d like to point out that Medicare, as it has been modified and added to, is a failed system. We need to reexamine the system in terms of current research and alter the program to correct design flaws to prevent costs of not being able to afford quality primary care services. Instead of a confusing 20% after meeting a deductible after allowable charges scheme, perhaps we should adopt the Federal employees and Medicare Advantage model and move to a no deductible co-pay system so patients know how much they owe and offices can easily explain the charges and owed amounts to the patient. By increasing access to quality primary care we should eb able to manage conditions and avoid unnecessary costs to the system such as ED visits and emergency admissions for UTIs and problems that can be easily managed as an outpatient. This increase in quality primary care costs should lead to a decrease in avoidable medical procedures such as cardiac services and cancer care that are largely avoidable or have the ability to be much less than current incidence rates of these conditions.

I realize that we will never eliminate all problems but correcting design problems in our current system would go a long way to fixing the problems. I hope my suggestions have been useful to you. They are a result of a medical career spanning 26 years in a rural area that have exposed me to a number of experiences that have shaped my thoughts. If I can ever help you or provide further information on my thoughts to you, please feel free to contact me.

Sincerely yours,

Kerry A Willis MD

P.S. I’m still waiting to hear from you.

Dr. Willis is a practicing family physician in Beaufort, NC, where he founded East Carteret Family Medicine. He currently serves as Chairman and CEO of the largest and oldest self-sustaining physician-led network in NC, The Beacon Company, and Chief Operating Officer of Atlantic Integrated Health (AIH). A true believer in the need for healthcare reform, Dr. Willis believes that the best solutions will be community-based and provider-directed and are aimed at improving the affordability and accessibility of medical care by reforming the healthcare delivery. The need to consider new models that are patient-centered and eliminate many of the moving parts that cause waste are the driving goal for Dr. Willis and his organization.