Top 10 Issues Confronting Physicians in 2014
J. Bendix, D. Verdon, A. Ritchie, D. Marbury
Each and every challenge is an opportunity.
And even though this list of ten challenges facing physicians would seem problematic and nearly insurmountable for smaller sized office-centered practitioners, many think there is tremendous upside for primary care doctors in leading healthcare delivery in the United States in 2014 and beyond. The result could imply more autonomy; it could indicate better quality of living for you and your clients, and hopefully result in less interference with the doctor-patient relationship.
But it’s going to take work, management gurus say. Physicians will need to reinvent their operations to produce efficiencies and thoroughly measure the revenue cycle to take full advantage of cash flow. That implies you will need to review payer commitment, and look at adopting technology to improve patient care. You may have to re-engineer workloads, workflows and workforce duties.
It is exactly this philosophy that Medical Economics is showcasing with this list of 10 challenges and opportunities facing physicians next year. We think that understanding the makeup of a transforming marketplace will ultimately help doctors shape it, adapt to it and succeed.
Over the course of this previous year, we have learned through interviews and research that you find remarkable professional satisfaction from helping clients improve their lives. In fact, it continues to be the reason you entered medicine, and the reason you will stay. At the same time there are developments outside of this relationship that are interfering with your time with clients and constantly threatening the fiscal viability of your practice.
Healthcare is in the throes of great change. And history has demonstrated that large-scale disruption incubates creativity. Our collective opportunity as a health care profession is to build a stronger healthcare delivery program rightfully directed by primary care that seeks to remain cost aware, effective in its delivery, and fairly rewarded for helping people obtain the most precious commodity of all—a healthy life.
—Daniel R. Verdon
Concern #1: Payment for medical services
ACA and changing payment trends
Healthcare’s troubled reimbursement system will likely take a turn for the worse in 2014, before it recovers.
And while 2013’s payment structure seems dehydrated to many physicians because of more restrictive negotiated payments by health insurers, increasing costs of doing business, and the seemingly infinite cascade of bureaucracy tied to payments, some believe relief won’t be felt for the cadre of U. S. doctors in office-based practices for some time.
Why? Healthcare is in the middle of transformational change in the way it is financed. 15 of the sixteen key provisions of the Affordable Care Act (ACA) will take effect in 2014, and they will most definitely impact the quantities of patients you see and the way you are compensated for medical services.
In spite of the flawed rollout of the insurance exchanges this fall, coverage for new health insurance enrollees will start on January 1. The new legislation stipulates that insurance companies cannot drop insurance policy coverage based on pre-existing problems. For states that have opted to expand Medicaid, that coverage also begins in January.
While more people are apparently enrolling in the exchanges, U. S. residents will be required to have qualifying health coverage or face financial penalties. Wellness programs allow employers to give employees rewards of up to 30%, perhaps increasing to 50%, of the cost of coverage for taking part in a wellness program and meeting certain health-related criteria. The ACA also creates a 10-state pilot course (by July 1, 2014) to observe and check achievements.
On March 31, the insurance exchanges close for 2014 enrollment, and we will have a barometer to determine how many newly covered Americans entered the market. Information connected to physician payments for services by health providers will also offer another indication.
Here are some of the keys to watch for the coming year.
The narrow networks squeeze
Payers are consolidating networks and repositioning in markets as a result of the ACA. We saw the outcomes play out from October through December as doctors received termination notices from key health insurance organisations in more than 10 states regarding network consolidation for Medicare Advantage. These moves have afflicted countless numbers of doctors and patients, and this tendency may not disappear anytime in the near future.
Narrow networks are assumed to offer payers more bargaining power in negotiating deals with providers and lowering costs of health care. Narrow networks likewise limit choice for patients with a scaled-down pool of providers and hospitals.
Quality and quantity
The year 2014 will be about cost control, says a recent review from consulting giant pricewaterhousecoopers (PwC) entitled “Medical Cost Pattern: Behind the Numbers 2014” despite one of the greatest healthcare insurance expansions in history. “For an industry that until recently had routinely seen double-digit growth, the on-going slowdown poses immediate financial challenges. At the same time, the imperative to do more with less has paved the way for a true alteration of the health environment, from fee-for-service medicine to customer-based care that rewards quality outcomes,” PwC says.
Conventional fee-for-service is moving to a payment structured leaning toward compensation based on final results. And many variations will likely surface. Models that will be further developed include:
bundled payments for services, (and in some cases bundled payments for numerous providers),
episode of care, (providers paid to deal with a particular problem over a period of time),
Physician Quality Reporting System (incorporating quality metrics), shared cost savings programs (doctors split savings with the insurer),
and Patient-Centered Medical Home
High-deductible health plans will also create business challenges for most practices and will require a more aggressive collection policy at the time of visit. PwC estimates that companies offering high-deductible plans as their only option has grown 31% since 2012.
And while the forecasts sound dire, there are lots of opportunities for primary care to assert its leadership, showcase its standing as a relative bargain among healthcare providers, and improve its mission to experiment with direct pay, supplementary services, and team up with employers and insurers to capitalize on innovative wellness products to enhance the health and wellbeing of your patient population and the practice’s bottom line. Primary care will need to reinvent its services to clients, reassess its utilization of technological innovation to better monitor population health and engage patients in innovative ways.
Concern #2: Government mandates
2014: The year of the federal mandate
When primary care physicians (PCPs) of the future look back on 2014, they might well recall it as the “year of the mandate.” That’s because PCPs will see their practices impacted by four significant government-sponsored requirements:
the use of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding system for billing, effective October 1;
the 2nd stage of the Meaningful Use incentive program (MU2) for electronic health records (EHRs);
modified rules for the Health Insurance Portability and Accountability Act (HIPAA) and;
the Physician Quality Reporting System (PQRS).
ICD-10: Convert or don’t get paid
Of these, the prerequisite to use the ICD-10-CM coding system will probably have the greatest effects, for the simple reason that practices not implementing the new code set will not be reimbursed by third-party payers.
The ICD-10-CM codes require a far more significant level of specificity than the current ICD-9-CM code set, and thus require training for coders, billers, and providers, as well as extensive modifications to—and testing of—billing software. A 2008 study estimated that conversion expenses will range from $83, 000 to $2. 7 million, based on the size of the practice.
Meaningful use: Attest next year or face penalties
The forthcoming year will likewise be important for doctors participating in the government’s Meaningful Use (MU) incentive program to undertake electronic health record (EHR) systems. All those who successfully attested to MU1 in 2011 or 2012 can choose any 90-day interval in 2014 to satisfy their MU2 goals and qualify for the next round of incentive payments.
In addition, 2014 is the last year in which physicians who have not previously participated in MU may do so and avoid fiscal penalties starting in 2015.
The biggest concern many doctors will deal with in attesting to MU2 is achieving the prerequisites for digitally exchanging patients’ health information with other providers, specifically those using a different EHR program. EHR vendors are working to incorporate information exchange functionality in their systems. Participating in a health information exchange network will also make it possible for physicians to satisfy the interoperability requirements, even though the networks are not available everywhere.
HIPAA: risk evaluation required this year, as well as more stringent penalties
HIPAA’s more comprehensive rule for guarding patients’ protected health details (PHI)—and more stringent penalties for failing to do so—started in September, but 2014 will be the first complete year in which medical practices feel their effect.
Among other things, HIPAA regulations require a practice to conduct and document a risk analysis for their PHI, review its practices and procedures for when PHI is lost or stolen, having the ability to send health data to clients electronically, and update its notice of privacy and assure its accessibility to patients. The HIPAA guideline also sets and describes the four groups of fees and penalties for rule violations and the dollar amounts for each.
PQRS: Reward next year, penalties in 2015
The ultimate mandate requiring PCPs’ attention in 2014 is PQRS, the government program that rewards physicians and practices for efficiently reporting on 138 outcome quality measures. That’s due to the fact 2014 is the last year in which the financial rewards—equal to 0. 5% of covered Medicare Part B Physician Fee Schedule (PFS) services—are available. Beginning in 2015, the incentive turns into a penalty equivalent to 1. 5% of covered Part B PFS services. The penalty rises to 2% in 2016.
To-date, physicians’ involvement in PQRS has been quite small. It remains to be seen whether the threat of a penalty will result in more physicians to report.
Concern #3: Payer headaches, and the small print
Navigating a convoluted payment maze
The health insurance landscape is more unstable now than it has ever been. Numerous physicians are feeling they are on uneven ground, with insurance companies having the upper hand when it pertains to how and if they can appropriately deal with the patients who decide to see them.
The Affordable Care Act has caused many insurance providers to make profound changes—dropping doctors from panels, causing individuals to scramble for new programs and new physicians, and making the entire process of finding quality healthcare even more puzzling and tedious.
Medical Economics recently polled doctors on their concerns for 2014, and dealing with payers was one of the major issues cited. “Getting done what patients need will be extremely challenging if we have to call for every little thing including for prescription drugs,” one physician told Medical Economics anonymously. “Paymentwise, MDs have no say. Take it or leave it. Like UnitedHealthcare thinks now patients are theirs and not doctors’.”
“Insurance providers determine which doctor, which medication, which examination, how much time in the hospital,” said another surveyed doctor. “Insurance providers have planted themselves between the affected person and doctors and on top of the money pile.”
United Health Care drops doctors
In a developing story, United Health Care cut doctors from its Medicare Advantage program, with plans to decrease its 350, 000-countrywide physician panel by up to 52, 500 in 2014.
Physicians in a minimum of 10 states have already gotten letters from several payers telling them they are no longer part of specific networks, according to the American Medical Association. Aside from class-action law suits, restraining orders, and appealing, which could take months or years, there isn’t very much a doctor can do to fight back against getting dropped.
Industry experts feel that the uncertainty surrounding health insurance policies will continue to fall on doctors—and that individuals will in the long run be the ones to suffer as a consequence. UnitedHealthcare is said to be the first of many payers who will start dropping Medicare Advantage doctors, and any other physicians who can’t adhere to rigid metrics that don’t fully look at quality of health care.
In the office, prior authorizations continue to sap time and money from practices.
With more time and staff committed to interacting with payers, prior authorization activities can cost a practice up to $3, 430 per full-time physician, according to a 2013 study released by the Journal of the American Board of Family Medicine.
“This all squanders a lot of our time, and it’s not reimbursed,” states Jeffrey Kagan, MD, an internal medicine specialist in Newington, Connecticut, and Medical Economics content adviser. “I think that if an authorization has to be executed the insurance provider should allow a higher level of billing for the visit or a surcharge. I’m positive lawyers don’t bring motions before a judge for free.”
With far more patients going into the healthcare system and additional payers involved with more physicians, the pressure from insurance companies is not likely to deliver in 2014 or in the near future.
Challenge #4: Time Finding time for patients despite escalating administrative noise
Primary care physicians (PCPs) pursued medicine because they want to assist patients. But each year, doctors complain they are spending less time with individuals and a lot more time coping with the noise that surrounds the business of medicine.
In 2014, it may be deafening.
So, what is the noise? It’s all the prerequisites that pull physicians away from seeing patients and helping them become or remain healthy. It’s the federal government regulations and private payer prerequisites they must satisfy; it’s the day-to-day frustration of trying to a manage a business, not have ample time.
Next year may be a perfect storm that causes physicians to spend even less time with their patients. The rollout of the Affordable Care Act means business uncertainty, new requirements, and perhaps floods of newly-insured individuals crowding already hectic patient panels. October 1 has been set as the date for the switchover to International Classification of Diseases, 10th Revision, Clinical Management (ICD-10-CM) coding language. Practitioners that don’t successfully make that switch will just not get compensated.
Also, practitioners will either be playing catch-up to satisfy Meaningful Use 1 or embarking on the much more challenges stage 2 requirements.
Medical Economics supplied doctors with an opportunity to make anonymous responses about the challenges facing primary care. Several were concerned that the onslaught of requirements are drowning out the enjoyment of why they selected medicine in the first place.
“I enjoy the patient interaction as much as ever but it is being slowly eroded by so many factors which are further than our control ” a doctor told Medical Economics. “I believe both the patient and the doctors are fearful about the future of medicine.”
Challenge #5: Technology costs
Sticker shock: The cost of technology
Practice owners can expect some major health information technology expenditures in 2014, as ICD-10 goes live in October, and continuing costs of electronic health records (EHR) systems and Health Insurance Portability and Accountability Act (HIPAA) compliance continue to be significant.
“We are still slowed down two-plus years after switching to an EHR, and there seems to be a never-ending steady stream of updates and various other expenses, not to mention the costs of the IT guys when anything goes wrong,” Rebecca Preston, MD, a family physician at Preston Family Practice in Western Springs, Illinois, told Medical Economics in a recent poll. “I dread the concept of ICD-10, especially when a good deal of it does not have anything to offer me as a primary care doctor.”
This is even much more of a problem when physicians see much of the technology they must buy as a burden, not a benefit, to their practice.
“Many practice-centered physicians will be challenged to find time and assets to fully understand all of these programs and affiliated operational implications, and put into practice new and updated assisting technologies while concentrating on their main role—patient treatment,” says Mickey McGlynn, Health Information and Management Systems Society EHR Association chair.
Though there are EHR holdouts—20% of primary care physicians still don’t have them, and 34% say they don’t plan on ever getting an EHR system, according to Medical Economics 2013 Continuing Survey—the actuality is that technology updates could make or break your enterprise in the coming year.
“Our industry is in a period of quick change. Physician practices are doing increasingly more to innovate and respond to our quickly changing setting to fulfill the needs of their patients, but with fewer options,” says Susan L. Turney, MD, MS, FACMPE, FACP, president and chief executive officer of the Medical Group Management Association.
Electronic Health Record cost
Challenge #6: Staffing and training
Higher personnel turnover implies new practice costs
Flexibility and proficiency—those two qualities will be essential for workforce recruitment and training in 2014. For a good number of medical practices, survival in the transforming healthcare panorama will require staff members to adapt to a team-oriented culture and take on new roles within the practice.
As reimbursements become increasingly tied to efficiency and patient outcomes, achievements will depend on practices operating as a team, and more will likely implement the Patient-Centered Medical Home (PCMH) or Accountable Care Organization (ACO) models.
“[These alterations] will place increasing pressure on primary care physicians (PCPs) to partner with other providers who share their concept of quality medical treatment. This may well be very difficult due to the independent thinking and personalities of PCPs, specialists, and other providers, who may have the ‘what’s in it for me’ bias,” one doctor wrote in a Medical Economics review.
But finding support personnel that satisfies the essential criteria is easier said than done. Another survey respondent shared their practice’s on-going challenge: “We can’t find primary care physicians, and the midlevels we are coming across don’t offer us much assurance. Our growth is significantly handicapped by the problems in discovering strong employees.”
Combined with hiring difficulties is the difficulty of retaining skilled employees once you find them. Earlier this year, the American Medical Group Association (AMGA) and Cejka Search released their annual Physician Retention Survey, which showed that the physician turnover rate hit a new high at 6. 8%. The same survey likewise predicts that the frustration of employing and holding onto doctors will likely intensify in the coming years, as the primary care physician shortage continues and more aging physicians start to retire from the workforce.
Training will also be extremely important next year for both existing and new personnel, particularly in preparation for the changeover to the International Classification of Diseases, 10th Revision, clinical management coding program. Practice owners need to anticipate extra hours and costs needed for personnel education.
Challenge #7: Placing control back in the hands of doctors
Stress, lack of autonomy sour perceptions about medicine’s future
It’s becoming harder for solo providers to keep their heads above water financially, and their love for practicing medicine seems to be fading. Results from the Medical Economics 2013 Physician Profile Survey regarding job satisfaction seem dismal, to say the least.
About a dozen doctors said there was “too much regulation.” More pointed to tension, anxiety, and workload. One physician summed up what many feel: “Training is too prolonged and too costly. Work hours are terrible. Reimbursement continues to fall. Regulation continues to increase.”
Doctors think they are doing a fine job when they are providing quality care, and according to a report by the RAND Corporation, productivity quotas and rules are roadblocks to job satisfaction.
Although it is widely assumed that improved working conditions are leading primary care doctors (PCPs) to flee to hospital employment, in truth most PCPs continue to own their practices. Close to 62% of internal medicine professionals are practice proprietors, while nearly 56% of obstetricians/gynecologists and 46% of internists are practice owners, based on the American Medical Association’s 2012 Physician Practice Benchmark Survey. The quantities decline when it comes to family practice (39. 8%) and pediatrics (37. 3%).
So in the face of increased rules, reduced reimbursements, and technology that interferes with the doctor/patient relationship, what is the motivation for doctors to sustain their autonomy? “Many physicians like the lifestyle that goes with owning a private practice. This extends outside of specialty,” Charles Cutler, MD, FACP, chair of the Board of Regents of the American College of Physicians said in the October 10, 2013 issue of Medical Economics.
One doctor from our survey offered this justification: “I love practicing medicine. I can’t imagine anything else that provides me the intellectual challenge, the capability to work with individuals and educate, and the physical chance to act and help individuals become better.”
Challenge #8: Transforming patient populations
Millions of Americans without health care insurance will soon have it mainly because of Medicaid expansion and other provisions of the Affordable Care Act (ACA).
What happens next is the vital question. How many of those newly-covered people will try to see a primary care physician in 2014? These patients will present new challenges to physicians with regards to both providing care and anticipating revenue.
The year 2014 is shaping up to be the year of the new patient and, perhaps just as importantly to practice owners, the year of the high-deductible health plan patient.
As Medical Economics described in its December 10, 2013 issue, as many as 80% of these newly-covered patients are at high risk of nonpayment. Medical Group Management Association (MGMA) President and Chief Executive Officer Susan L. Turney, MD, MS, FACMPE, FACP, says that the MGMA has determined collecting from self-pay, high-deductible, or health savings account patients is one of the most significant challenges determined by MGMA members.
As a consequence, more physicians will have discussions with patients that until recently were regarded as taboo. They are going to be talking about cash, and the price tag of treatments. This has ramifications for the healthcare system as a whole (evidence shows that merely talking about healthcare prices can force prices down) and for individual doctors, the majority of whom feel ill-at-ease talking about cash with patients or taking steps such as charging for treatment options beforehand.
That is going to change. “There aren’t a lot of industries that the customer pays so far after the service is performed. Doctors need to get out in front of the payment. This is a big change in the mentality for the industry. Providers won’t be able to afford to collect payments following service for very much longer,” Nate Davis, product director with ZirMed, a health care information technology and management solutions company in Louisville, Kentucky, informed Medical Economics as part of an article about high-deductible health plans.
Paging Dr. Google
A possible horde of new patients isn’t the only change in patient populations that doctors will have to confront. Today’s patients are much less likely to take what a doctor tells them at face value, and frequently go to appointments armed with a self-diagnosis backed up by data they obtain from WebMD and Google. Almost 60% of patients are considered “internet diagnosers,” based on the Pew Internet & American Life Project.
Pro-active patients are a normally good thing, but they provide new issues to physicians. “My desire is that patients will come in with questions, having done some reading,” Reid Blackwelder, MD, FAAFP, chief executive of the American Academy of Family Physicians, explained to Medical Economics for our Dec. 10, 2013 article on doctor-patient relationships. “It makes my function a lot easier in caring for that patient, but it does sometimes necessitate a different frame of mind for us doctors, because medicine has for a prolonged time been very patriarchal.”
The good news for doctors is that Dr. Google isn’t cutting into their business. The Pew project observed that more than one half of the “online diagnosers” consulted with their physician or a medical expert about what they found on the web.
Challenge #9: Primary care’s transforming position
Are PCMHs the future of primary care?
Several thought leaders in family and internal medicine think that the reforms brought on by the Affordable Care Act will ultimately generate a more unified, less fragmented healthcare system. The vision is that primary care physicians will lead the delivery of medicine and synchronize care through the maze of specialists.
It’s a future that isn’t steeped in the persistent bureaucratic complications that seem to be so pervasive today, but provides a broad vision of tomorrow that might ultimately alter how patients receive care and follow-up to it.
A lot of this vision is focused on the Patient-Centered Medical Home (PCMH). According to the U. S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ), the PCMH performs five functions:
1. Provides extensive care for prevention and wellbeing, serious and long-term care;
2. Treats the whole individual determined by his or her unique needs, culture, values and preferences;
3. Coordinates care among health care system (specialised care, hospitals, home health care, and community services and supports);
4. Provides greater access to services (with reduced waiting times for vital needs and enhanced in-person hours);
5. Commits to quality care and quality improvement using research-based medicine to guide shared choice-making with patients and family members.
“AHRQ recognizes the central of health information technology in successfully operationalizing and enacting the essential attributes of the medical home. Moreover, AHRQ notes that setting up a primary care delivery platform that the nation can depend on for accessible, reasonably priced, and high-quality health care will necessitate considerable workforce improvement and fundamental transaction reform.”
The challenge for primary care practitioners will lie in conducting a thorough evaluation of its organization, health information technology program, procedures, and guidelines related to coordinating care throughout the medical neighborhood, examining access to the practice, supporting self-managed care, and utilizing risk-stratified care supervision principles to manage patient populations.
It is a way different approach to medicine, and it will take some work to transform the majority of practices into a highly-successful PCMH, reports the American Academy of Family Physicians. In fact, Robert L. Wergin, MD, FAAFP, a family doctor in Milford, Neb., and president-elect of the AAFP, states that nearly three-quarters of the association’s members are working toward many of these PCMH tenets, such as expanded office hours.
If you are interested in the PCMH strategy, AAFP has put together a range of resources specifically to help family physicians at www. aafp. org/pcmh.
Here are a few of the concepts addressed:
Create and refine the group framework
Define the work connected with principles like care coordination
Rework job descriptions/duties
Budget and forecast for the future
Redefine the cultural based around functioning in a high-producing healthcare workforce
Health information technology:
Assemble a project team
Evaluate the practice’s preparedness communicate, share information, e-prescribe and evaluate trends within patient populations
Examine your EHR’s system capabilities
Establish new workflows where necessary
Create new policies related to email, use of smart phones, text messaging, etc.
Determine a planned care visit, and identify your group
Set group objectives
Set up a Plan-Do-Study-Act cycle to measure outcomes
Obtain and analyze information to enhance care
Setup same-day visits
Develop an online profile for your practice
Develop mechanisms to encourage patient self-direction
Determine patient satisfaction
Challenge #10: Work-life harmony Reconnecting with living outside of the office
There is no such thing as a 40-hour workweek for doctors. More than 73% of doctors surveyed by Medical Economics work more than 40 hours per week, and about 24% work more than 60 hours per week. The requirements of the occupation mean that for many physicians the work-life balance is tipped heavily towards work, and that’s not likely to change in 2014.
Next year, physicians will confront doubt as the Affordable Care Act takes full effect and emerging care and reimbursement models that put increased focus on patient results and accountability are pushed to the forefront. They will cope with complex federal mandates, such as the switchover to ICD-10-CM and more complicated stage 2 Meaningful Use incentive requirements. On top of that, practice owners will still deal with decreasing reimbursement challenge to keep their companies worthwhile.
The onslaught of these types of pressures can lead to the feared occupational threat: burnout. “I am so burned out from complying with regs, changing to new technology that is less than dependable, juggling an accounts receivable checking account and having to pay bills that I find myself coming home later and heading into office earlier each and every day,” states an anonymous physician responding to a Medical Economics questionnaire published in the November 25, 2013, issue. “I would like to have a better work life equilibrium but not having an income it’s hard to balance!”
And so doctors determine they need to work longer hours—and even second jobs—to stay afloat. About 36% of primary care physicians (PCPs) moonlighted on a 2nd job, according to Medical Economics survey results. Meanwhile, home lives are sacrificed and profession satisfaction declines. In excess of 30% of PCPs explained to Medical Economics that they would not recommend their child pursue a career in medicine. More than that, burnout is leading to many doctors to quit practicing medicine or cease working early, which only worsens the primary care shortage.
Maintaining a sensible work-life balance helps safeguard doctor wellbeing which “helps us serve as far better role models for our patients and as even more enthusiastic suppliers of care when we are physically, mentally, and psychologically balanced,” states Tim Sayed, MD, a plastic surgeon who serves on the Healthcare Information and Management Systems Society Electronic Health Record Association Executive Committee.
The unavoidable fact is that unsatisfied physicians make for a poorer health care system. Repairing the difficulties of doctor work-life balance is a major component to improving upon health care in the United States.