The Centers for Medicare & Medicaid
Services (CMS) EHR Incentive Program—also known as Meaningful Use (MU)—initially
provided incentives to accelerate the adoption of electronic health records
(EHRs) to meet certified program requirements. Many physicians were mandated to change over
to electronic records at the cost of tens of thousands of dollars. Electronic records have never been shown to
improve patient care or outcomes with statistical significance, the criteria
physicians routinely use when making care decisions.
Physicians who failed to participate in MU would
receive penalties in the form of reduced Medicare reimbursements automatically.
To avoid a penalty, physicians had to implement certified electronic health
records (CEHRT) and demonstrate MU of that technology through an attestation
process at the end of each reporting period.
There were 10 data specifications. Approximately 209,000 physicians were facing
penalties at the start of 2016, almost one-fourth of the U.S. physician
workforce.
By the end of 2015, CMS had stated it would
broadly accept applications for hardship exemptions because of the delayed
publication of the program regulations. Applications
for physicians were due by July 1, 2016.
A friend of mine opened a private practice in
October 2015 and thought she was on the right path toward submitting data and meeting
MU requirements. One of the most challenging
things about running a business is hiring excellent ancillary staff for support. Employees should be smart, capable, and well,
able to reliably submit data. It is
worthwhile to note physicians receive no business training in medical school,
so the learning curve is steep for all physicians including my friend, who is a
family practice doctor.
There are mistakes and triumph along the way
and my friends’ misstep was hiring an office manager who ultimately was not a
good fit – unbeknownst to the physician, she did not submit ANY data. The notification arrived in the mail that
this practice did not meet all 10 MU program requirements. “We had recently
acquired a new EHR (cost 6K) and were uncertain how to verify data had been
submitted. We were working on it.” She
contacted CMS and they denied any opportunity for appeal.
Welcome to the penalty box, with no term
limit. Every single visit, procedure, counseling session, or medical
intervention will have 2% shaved off the top.
The average family
physician receives about $100,000 a year in Medicare reimbursements, so a 2%
penalty for 2017 will become 3% in 2018,
and increase to 4% in 2019—a combined three-year total of $9,000.
This total overlooks the increased costs and overhead
of running a business. Staff members get raises; medical supplies cost more,
and even medical license fees continue increasing --- all while the physicians’
income is decreasing with no end in sight.
This young physician is working in her hometown
somewhere in Middle America, a small community, with a population of
13,000. She is there because her family
and friends are nearby. She loves her
patients; 50% of them are insured by Medicare and Medicaid. She provides high quality care; for which she
will be paid less and less each year.
This physician is neither lazy nor
stupid. She is just not a businesswoman,
yet. She opened her practice straight
out of residency and was under the impression she did not need to submit data immediately
while getting things settled. Once she began
“submitting” data, she trusted the office manager to do it, because she was
otherwise engrossed in seeing patients, (a part of our profession likely to disappear
in the near future.) The art of
practicing medicine will become an outdated and ridiculous notion at the rate
we are going.
My advice for every primary care physician in
this country is to opt-out of Medicare and Medicaid so our businesses can
survive. This particular physician
cannot do that as the hospital has guaranteed her salary for one year while she
gets her practice started. What a great
deal for the hospital! The primary care physician is left to their own devices,
to build a practice, and serve as a source of revenue feeding the specialists,
who are employed by the hospital in this particular scenario. The hospital did offer to employ her; however
the wage was far below the industry standard.
This family physician might reluctantly have
to close her Medicaid and Medicare panels anyway. If her business begins
failing due to the penalties being leveraged, she will opt out of both Medicare
and Medicaid. So will us all if this
punitive payment structure continues unabated.
This scenario is repeating itself over and
over across the country every day.
Private practice physicians are stuck between a rock and hard
place. Indentured servitude is on one
side and the freedom to independently practice medicine is on the other.
Financial analyst John Graham at Forbes wrote in April
of 2015 that MACRA was a “fiscally irresponsible approach to increasing the
amount the federal government spends on Medicare’s physicians’ services.” What should we do when working with a
fiscally irresponsible person? Do we
jump on board and begin a business partnership?
No. Then why are physicians acquiescing
to this abuse? MACRA penalties will
begin in 2019 at 4% and increase to 9% by 2022.
Who can afford to stay in practice at the rate of decline in
reimbursement?
In general, physicians tend to be
compassionate and empathetic, they are rule followers, and do the ‘right’
thing; traveling on the straight and narrow should not bring us to the point where
we cannot make more than we would working in a fast food restaurant. The answer is we must opt-out until changes
are made. Private practice physicians need
to realize we are on our own. The AMA,
ACP, and CMS are working in direct opposition to independent physicians fighting
hard to break the chains that bind us.
It is simply time to let go and walk away.
Suneel Dhand recently wrote, “it’s not just the ace of spades that
the doctor and patient are holding — but the entire deck.” He is right.
It is time for us to become dealers.
And I want to play dealers’ choice.
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