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.
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?
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.
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.
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.
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 o