Going Rogue

Historically, the word Rogue was a descriptive term for elephants behaving in a dangerous way, often when injured or experiencing separation from the herd.  The expression today refers to a person who is displaying independence or failing to follow an expected script. As the reality of MACRA (Medicare Access and CHIP Reauthorization Act of 2015) looms, the pressure is on small practices to survive.  CMS plans to penalize 87% of solo physicians and reward bonuses to 81% of practices with more than 100 physicians.  It is time for passive resistance, defined as protesting against a law using peaceful methods such as refusing to obey or refusing to leave a building.  I am vehemently refusing to leave the building.

We are entering the era of Big Box medicine; where prices are cheap and quality will be questionable.  CMS will favor physicians at larger conglomerates because they will be able to keep up with overwhelming data reporting demands.  I do not agree that mountains of data are essential to providing high quality care.  Physicians are not in charge of our destiny.   What if we could be?  What if we buck the status quo and refuse to comply?

As of yesterday morning, mine is the last pediatric practice accepting Medicaid patients who are not newborns in my hometown.  In my county, 50% of the children are on Medicaid.  We have 3 fewer pediatricians than we did five years ago.  For a population of 260,000, 16 pediatricians remain.  Two of those currently practicing (including my father) are more than 80 years old.  Patients wait for months on our waitlist.  They are THRILLED to get in.  Sometimes I cannot believe how excited they are to walk through our door.  There are simply not enough of us to go around.  If this continues, children will not have access to a pediatrician when they need it.  Five years ago, I accepted 20 new patients per month.  Today, I accepted 10 and put 7 on the waiting list.  In ONE day.  The call volume is unbelievable.  This is our future if we do nothing.

The health disparity seen in my office every day is abominable; the need for basic care vast. A nine month old baby pulled off my waitlist after 4 months had eczema so severe he looked like a burn victim.  The thought of children not receiving necessary medical care so they can properly grow, develop, and thrive keeps me awake at night.  Our survival is paramount.

Which brings me to my point.

I am going rogue.  Market forces are on my side.  Physicians have a right to make a living.  A little civil disobedience is in order.  We need to stop following the guidelines and care for patients in spite of a system actively working against us.  If CMS leverages a penalty, I will need my Medicaid patients to pay that amount as an out-of-pocket fee; because it will keep my doors open.  I need to stay in business.  I must pay my staff, buy supplies, and pay rent.  I have four small children and a mortgage.  Those are standard life obligations.

Small practices have lower readmission rates and know their patients better than larger health care conglomerates.  I know my patients.  I know their parents.  Heck, I even know their grandparents.  I am exceptionally effective at keeping children out of the hospital.  My patients prefer my office to the local urgent care or emergency room.  If you wake up and your child is unexpectedly ill, you can walk in and be seen the same day.  If your child splits their head open at school, bring them down and I will stitch them up.  You might have to wait a bit, but the delay is less than at the local ER.  I provide excellent quality and service.

I know my families can afford $3 per visit.  I know they will be willing to pay it.  They already pay out of pocket for no-shows, typed letters, and FMLA paperwork.  They pay out of pocket for photocopies and after-hours nurse calls.  CMS Table 64 shows there are 102,788 solo practices and 123,695 practices with 2-9 physicians.  Can the government really go after almost a quarter million medical practices for disobeying the rules?

Abraham Lincoln said, “Government of the people, by the people, and for the people, shall not perish from the Earth.”  The decision of who provides good quality care should be in the hands of the people, not the government.  The people can vote with their feet and their pocketbooks, paying a small amount to make up for this outrageous government blunder.   Otherwise, many valuable small practices will close their doors.

Primary care physicians are the backbone of the health care system in this country.  A “CMS co-pay” in response to the $3- $9 per visit penalty is the best way to prevent our livelihoods from being destroyed.   We must stop being afraid.  We know health care.  We know our patients.  We trust in our abilities to save lives.  Physicians in solo and small practices will not perish if we let the people decide in whose hands they place their trust.  It is time to be mavericks.  If we work together, stop blindly following along, and put ourselves back in control of our healthcare system, we can passively resist until something changes.  Our health, Our people.  It is time to go rogue.