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Monday, July 2, 2012

Primary care: renewal or exodus?

Interesting post on The Health Care Blog the other day.

Equally interesting were some of the comments in response:
Dr. Mike says:
June 30, 2012 at 10:13 pm
It’s bye bye primary care for this FP doc. I could have done so many different things with my life – I was better at the educational system than most of my peers – but I chose FP even before I finished college because I thought that being involved in the health of the whole person and their family would make a difference. But I was misled and betrayed by the society I had hoped to serve. I’ll still be in health care but with a narrower focus and a fraction of the headaches. AAFP and AMA can go to you know where. I’m sure my patients will do just fine with their NPs (they have 400 hours of FP clinic experience after all – I’m sure my 12,000 hours of clinical training were just overkill).

John Ballard says:
July 1, 2012 at 2:38 am
What a painful comment. And even more painful conclusion. (I’m presuming that FP means family practice, not financial planner — though that may not be a bad alternative.)

So what is your Plan B? I’m only a bystander and it’s none of my business, but since this is a public forum you must find it okay to have a conversation about that. Without giving away any secrets, perhaps you can give out a list of alternatives. One that comes to mind is teaching (medical topics, of course — more NPs, nurses, techs). Another is “hospitalist” or other institutional employee not burdened with so many of the non-medical burdens of a smaller practice. I have seen other comments from you and you have a lot to contribute.

Dr. Mike says:
July 1, 2012 at 9:49 am
It is a matter of being worn down in private practice from the usual suspects – The nearly annual SGR debacle – not being able to take a salary for up to 6 weeks while CMS sorts out congress’s foolishness. The ever increasing pre-authorization hurdles (multiple faxes and 30 min phone calls to get a $4 drug approved). The process of going through meaningful use has been illuminating – stage 1 is a piece of cake compared to what I see coming in stage 2, and it is obvious to me that I cannot sustain even stage 1 meaningful use year after year and will face the penalties instead (up to 5%) [emphasis mine]. My profit margin is too thin to tolerate a 5% cut. The threat of an RAC/Medicaid audit is always there – they can ruin you over interpretation of coding that even government coders have been shown to be unable to agree on.

It can still be rewarding working with patients but increasingly I get blamed for what ultimately is the result of the policies of the insurance they carry. I see this getting worse moving forward, not better. And I just don’t see how the insurance policies offered on the exchanges can pay as well as the commercial policies and cash payments they will replace. I charge cash patients essentially medicaid rates but benefit from the lack of overhead insurance causes. Many of these patients will get medicaid now – good for them, not so good for me. I survive in practice only because I have enough commercial payers that pay higher than CMS rates – I see the delta shrinking over time, and not because CMS rates are going up.

No one can deny that these are some of the reasons driving small practices into the arms of large organizations like hospital systems. Some even celebrate this transition, seemingly unaware of the consequences that arise from monolithic health care. I personally cannot see my self working for a large system. I see so few that truly understand primary care – it’s the specialists that pay their bills after all. I have thought about an ideal micro practice (google it) but the uncertainty of the next two to three years makes it seem foolish to make a commitment to starting such a transformation.

So, what am I doing instead? I have stumbled into working for a mental health clinic doing basic psychotropic management and have recently started doing substance abuse treatment including suboxone detox. It has been extremely rewarding to see the transformed lives. I now have an opportunity to join another mental health clinic doing the same thing. At both locations I am a contract employee – I have zero overhead, the hourly wage is more than what I can make at my FP clinic. I have also been approached by a FQHC to purchase my practice and it seems likely that if that works out I will do some contract work with them in pain management and substance abuse treatment. My 20 years in family practice may be coming to an end. I will work less for about the same pay in a practice style that I can sustain for many more years.

Oh and I am not anti-NP. I employ two right now. It is just that I see a disturbing trend in that unexperienced new RN grads are going straight into NP programs. The programs haven’t changed – but there is a world of difference between an NP with 10 years prior experience in the ER or ICU and one with zero years of experience. You can’t tell me you know how to treat out-patient pneumonia until you have seen the pneumonia patient in the ICU. Woe to the patients who have as their providers people who don’t know what they don’t know.
Declining reimbursements, increasing compliance expectations (including Stage 2 MU), RECs on the wane...
'Meaningful use' requirements add red-tape challenges for providers
A major focus for healthcare providers this year is gearing up for compliance with new federal mandates related to electronic healthcare records. The EHR Incentive Program, commonly referred to as “meaningful use,” will reimburse medical facilities and practices for implementing electronic health records and complying with a host of reporting requirements.
The challenge with the program, according to healthcare professionals, is the complicated compliance process for demonstrating eligibility for reimbursement-as spelled out in a 274-page federal register-and the penalties attached, in the form of decreased Medicaid or Medicare reimbursements in a few years. The incentives will only cover only part of the expenses related to the implementation to EHR and some medical offices are having to move to the adoption of electronic records ahead of their planned schedule in order to receive the full available amount...
The problems aren't limited to primary care, either. to wit:

 Surgery & Work-Home Conflict

An article published ahead of print in Archives of Surgery [full text here], reported the results of a survey of over 7100 members of the American College of Surgeons. Over 52% said they had experienced at least one work-home conflict in the 3 weeks preceding the survey. Work-home conflicts were more common in those surgeons who were young, female and had young children.

Surgeons with a recent work-home conflict were more likely to have symptoms of burnout, depression, alcohol abuse/dependency, and were less likely to recommend surgery as a career option to their children...

For the third consecutive year, we asked physicians across America about some of the most important topics affecting them, their practices and their patients.

With the growing challenges posed by government programs, payment reform and the overall economic climate, this was a particularly compelling time to gather doctors' points-of-view. How much do physicians trust their EHR vendor's capabilities? What are their thoughts on the Affordable Care Act, and how it might affect patient care?

In the 2012 survey, conducted with Sermo across a variety of specialties and practice sizes, we examined physicians' concerns and opinions, and compared them to our findings in 2011.

Interesting. Various frustrations are taking their tolls.


From our friends at EHR Intelligence

Affordable Care and HITECH Acts are not as separate as some think
Ed Burns,  July 5, 2012

All throughout the Supreme Court hearings over the constitutionality of the healthcare reform law and even during the deliberation of the justices, commentators said regardless of the decision handed down, the government’s health IT initiatives would remain untouched. In the most technical sense possible this was true. The meaningful use program gets its funding through another law. Striking down the Affordable Care Act would not have affected this program. But at a more essential level this seems dishonest...

...Even if aspects of the Affordable Care Act and meaningful use were not directly linked, it would be hard to ignore the philosophical connections. Both have at their heart a desire to network physicians, encourage patient-centered care, and leverage innovation, all with the goal of making care more efficient and affordable.

The reform law seeks to accomplish these goals by organizing physicians into accountable care organizations. The meaningful use program gives physicians the tools necessary for operating in a more collaborative environment. The programs may not come from the same piece of legislation, but in a sense they are two separate legs of the same stool...
Well, the third leg needs to get crackin' if we're going to be around to keep the stool from falling over.

1 comment:

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