From the mouth of the MD

Area doctors on where the system is better than before, what keeps them up at night and what they wish we knew about their work

Policy and reimbursement changes regularly grab the headlines. What doesn’t get covered as frequently is how those new initiatives filter down to the front lines of care, the thousands of doctor’s offices around the country.

So we asked a handful of Middle Tennessee MDs for their take on the state of their practices and the industry. We send our special thanks to Rhonda Sides of Crosslin & Associates and Laura Folk of First Tennessee Bank for their help in framing the issues.
— Compiled by Emily Kubis

 
What part of the system is working well or better today versus five years ago?

Electronic payments and electronic prescribing have streamlined the collection process and medication prescribing, respectively. These are two parts of the system that have been successful.
— Michael Pagnani, orthopedic surgeon at Nashville Knee & Shoulder

 
Communication between physicians regarding patient-related matters has been made easier by the advent of electronic medical records. The ability to securely email or fax between physicians at the time of service can eliminate the multiple steps previously required between a dictation, transcription, printing and manually forwarding the same material.

Drug-to-drug interactions are increasingly better screened for by the pharmacy software that is now so easily utilized. Previously, a “from memory only” approach was what most health care professionals had to rely upon. More capable EMRs have allowed the patient chart to transition from a file cabinet to a truly “smart chart.” From automatically plotting pediatric growth charts, to tracking cholesterol or diabetes control, to reminder letters for annual physicals — EMRs have the potential to streamline many office functions for the average physician.
— Matt Perkins, pediatrician at Tennessee Medicine and Pediatrics

 
The health care system itself is no more efficient or effective today than it was five years ago. In fact, it is more complicated and confusing for patients, physicians and hospitals. It has not been easy to navigate for many years and needs a substantial reworking to reconnect the patient to the provider on the cost side of the equation. But increased governmental intrusion into the system only creates greater inefficiency and complexity. What has improved is the consumer’s awareness of how important it is to make meaningful changes to the over-complicated system.
— Bryan Oslin, plastic surgeon, Oslin Plastic Surgery

 
The emphasis on preventive care and the use of computers and EMR systems.
— Jeffrey Smith, family practitioner at Three Rivers Community Health

 
What are the financial and strategic issues that most concern you about your business?

Regulatory agencies now dictate how we run our practices. This burdens us with extra work, additional fees and expenses, and oversight by people who often have little exposure to the real world of patient care. A large majority of this regulation has no proven benefit and what has been touted to increase efficiency and to reduce cost (with electronic medical records being the prime example) has actually increased cost, slowed implementation of care, increased work, pulled providers away from interacting with their patients, and provided no meaningful “outcomes” to show who is providing the highest level of care.
— Pagnani

 
Congress refuses to provide a permanent fix to the SGR formula for physician reimbursement. Eleventh-hour fixes only kick the can down the road. While we are supposed to feel good about aborting a 20 or 25 percent cut in reimbursement, there aren’t even true cost-of-living adjustments provided to physicians. My overhead goes up each year, but decreased reimbursement per unit of work done does not. This is unsustainable, as the most common solution is to see more patient per hour, limiting the time between physician and patient. How does this improve care?
— Perkins

 
As insurance plans narrow physician panels on those plans, the physician has decreased exposure to patient populations. The reduced number of provider options for the patient is likely to frustrate patients over time.

For specialists, those who treat a patient on a short-term basis, this might result in a decreasing patient volume over time. Coupled with inherent increases in employee, lease, equipment and supply cost, the net outcome will be decreasing revenue in the long term. This trend, in addition to the general uncertainty on the health care horizon, will likely drive many physicians to the security (perceived) of salaried positions in hospitals.
— Oslin

 
The costs of acquiring and maintaining EMR systems as well as the costs of regulation. The training and extra documentation those initiatives need take extra time.
— Smith

 
What do you think are the main reasons for the increasing attractiveness of salaried positions?

The reason I looked for a salaried position is that I needed a way to be able to see a large amount of uninsured/underinsured patients (a personal goal) without undermining my income. In my opinion, incomes composed solely of what you collect from insurance companies become a conflict of interest, in a way, for many physicians. They want to do the right thing by seeing the patients in need but also very appropriately have to consider their own needs — legitimate needs, like feeding their families and maintaining an income to keep their practice running.

A salaried position, though it will probably be a net income less than what I might make at a competitive practice doing RVU-based income, will ultimately allow me to build the kind of practice I have always wanted to: one that accepts all comers and treats them equally.
— Savita Fanta, internal medicine and pediatrics at Three Rivers Community Health

 
As the practice of medicine becomes increasingly bureaucratic and as non-provider intrusions and regulations become more complex, more physicians have concluded that practicing in an employment setting makes more sense. Salaried positions are generally offered by organizations that provide professional management that is better equipped with sophisticated systems to adjust to and monitor the rapidly changing and unpredictable environment in which we currently practice.
— Pagnani

 
Physicians spend years learning to treat patients. There typically are no small business management classes in medical training. Physicians are sent out in to the world with a “build it and they will come” mentality only to find that medicine is an incredibly complicated business — one with many hazards and significant risk of not only financial failure, but civil and criminal penalties if done incorrectly.

Additionally, a physician/owner must run their business in their “downtime” because seeing patients is the only thing that generates operating revenue. Many physicians find it less stressful to subordinate administrative functions to an employer instead. Many of the headaches of daily practice are reduced, usually with a commensurate decrease in pay and autonomy.
— Perkins

 
If the ACA is going to be amended, what’s the first change you would want legislators to make?

Short of full repeal followed by substantial but incremental changes, the first change should be to allow increased competition with insurance sold across state lines, along with more freedom in offering patients the choice of limited coverage options.
— Oslin

 
Be honest about how much this plan is going to cost and about how much additional tax revenue will be necessary to pay for it. The program, while admirable in expanding care, will markedly drive up costs as a percentage of GDP in the medium term and long term. None of the “cost-saving” measures such as electronic medical records will prove effective at cutting costs.

In the end, we have four choices: Increase tax revenues, cut services, cut reimbursements to medical facilities or cut reimbursements to providers. Of these four, the last one is the most likely because providers have the weakest lobby and the others will be politically unpopular.
— Pagnani

 
Other than a complete repeal, I would remove the federal government from the administration of it. Private industry has always been cheaper and more innovative at any business if given reasonable amounts of regulation. Competition between carriers across state lines, combined with access to plans allowing a true menu of covered services would really allow costs to consumers to be affordable. Not every plan needs to offer maternity, chiropractic, psychiatric or gender reassignment benefits. A la carte works well in many other industries, why not health insurance? Health care costs with the ACA will grow exponentially in my opinion and we will have a less functional system in the end without better overall health outcomes.
— Perkins

 
What buzzwords do you think people will still be talking about in five years?

Unaffordable, as in unaffordable health policy.
— Pagnani

 
The cost of the system. I doubt legislators will have the courage to relinquish control of this segment of the economy and therefore allow the free market to work as well as it can. So we will still be worried about how increasing numbers of individuals can be covered in the face of increasing cost, wasteful inefficiency, and (likely) a decreasing numbers of physicians.
— Oslin

 
If you like your doctor, you can keep him/her. I think that we will all wonder where the good doctors went. Many of us will simply leave the practice of medicine or exit the third-party payer system to pursue concierge/boutique practices that limit access even further.
— Perkins

 
Computer assistance and robotics.
— Smith

 
What’s the one thing you wish every one of your patients knew before they walked into your practice?

Bring something to do or read and snacks while you wait… And bring your current medicine bottles or an up-to-date list of medicines to review during your visit.
— Smith

 
I would like them to spend a day in my shoes. I would like them to understand that, in an average day, I will see 25 to 28 patients in the office, handle calls from the ER and inpatient wards, address 15 to 20 telephone calls, review 25 to 50 lab reports, read and address five to 10 X-ray reports, review five to 10 reports from consultants, respond to at least three or four pharmacy benefit manager utilization inquiries, visit with three to 10 drug reps between patients, fill out two or three FMLA forms, write a letter or two for a patient, handle staffing issues from billing, reception, nursing and lab in addition to attempting to remain current on the medical literature. Somewhere during or after this process, I try to eat right, exercise, run my household, be a good husband and father, save for my kids’ educations, plan for retirement, go to church and dream of having a hobby.
— Perkins

 
We are their advocates. We are there for them and have unique insight into their conditions and the most effective ways to give them optimal outcomes. The government and payers still lack data to make treatment decisions based on outcome. As a result, these decisions are being driven today primarily by “value,” and “value” really means lowering costs to the government and payers. Adequate collection of meaningful outcome data in our field will take decades and will cost more than the care itself since data collected by centers on their own patients will be inherently biased and third parties will have to be the sources of any meaningful “outcomes.”
— Pagnani

 
That I still love what I am privileged to do as a physician.
— Oslin