Thursday, October 9, 2014

Is assimilation inevitable for independent physician practices?

Fans of Star Trek: The Next Generation will recall that the most disturbing aliens encountered by the Federation were The Borg, a part-cyber, part human collective race that functioned as an integrated and cyber-connected whole that existed only for the good of the collective, rather than as distinct individuals with their own thoughts and personalities—much like honey bees work together as a collective for the protection of the queen and the survival of the colony.  When the Borg encountered a humanoid species, they would forcefully assimilate them and their technologies into the collective, or destroy them, preceded by only one warning:


The Borg did not consider themselves to be evil though, explains the data base, because “the Borg only want to ‘raise the quality of life’ of the species they ‘assimilate.’"

I expect that many physicians in independent practices feel the same way as the unfortunate humans that encountered the Borg: they are under unrelenting pressure to be assimilated into hospital-owned or other large group practices, giving up their independence in the process, with the promise (of course!) that assimilation will  “raise their quality of life”!

But is assimilation the only option for independent practices?  Is resistance futile?

My answer: No to the first, and yes to the second.

Let me explain.  I believe that independent physician practices can survive, and even thrive, because they offer something valued by most patients: an ongoing relationship with a physician who lives in the community, and who knows them and their families.  A practice where, like Cheers, everyone knows your name - from the front office receptionist to the practice’s physician assistant or RN to the physicians themselves.

 I don’t believe that patients want these practices and their physicians to be forcefully assimilated into large groups that may be located some distance from their homes, where when they arrive for an appointment they are forced to wait for a long time in an overcrowded waiting room, just take a number please, to be seen by someone—a nurse, or a PA, or maybe if they are lucky, a physician—who they never met before and won’t be around next time they need to be seen.  (Now, before I get angry comments about this characterization from ACP members in large group practices, I am not saying that this is how all or even most large groups operate—most provide excellent and personalized and attentive care, often in community-based practices—even though the individual physicians and have chosen to be part of a larger group.  And there are small practices where patients are treated brusquely by inattentive staff and physicians.  My point is that if assimilation into a larger group means the loss of a personal relationship with a physician they know and trust, many patients will be opposed).

But I also think that for independent practices, resistance is futile—if this means resisting making the changes that may be required of them to survive in an increasingly competitive economic environment. It is futile to reject participation in all performance measurement programs; physicians in independent practices should, however, insist on measures that measure the right things for them and their patients.  It is futile to reject the move to electronic health records, but physicians in independent practices should demand that government and private payers facilitate the creation of EHRs that are functional, interoperable, and useful.  It is futile for physicians in independent practices to try to hold onto FFS and summarily reject bundled payments, risk-adjusted capitation, and physician-directed models like Patient-Centered Medical Homes and Accountable Care Organizations. Instead, they should see how their practices can embrace these changes.  (Many independent practices have done quite well, for instance, by becoming PCMHs).   It is futile for independent physician practices to reject being accountable for their cost of care—especially when they may find, as one recent study concluded, that hospital owned physician practices have higher prices and higher levels of spending than physician-owned independent practices!  Armed with such data, independent practices can demonstrate to  payers that they are the best value in healthcare.

And while big is not always better, smaller independent physician practices should explore ways to share information systems, data, and even risk with other independent practices, achieving economies of scale without losing their independence.

Independent physician practices do not have to be assimilated, then, but they have to have to be willing to embrace changes that will better position them to be successful without losing their values, their relationships with their patients, and their independence.

For the unfortunate victims of the Borg, assimilation meant losing everything they valued—their independence, their creativity, their individualism, their personal relationships, their values.  But Star Trek’s Federation learns how to prevail against the Borg, not by becoming part of them, or defeating them militarily, but by showing that an independent Federation of free people, voluntarily working together for the public good, is a better model of survival then a cyborg collective that snuffs out innovation and creativity.  With the right support, I believe that independent physician practices, provided that they are willing to embrace innovation on their own terms, will be able to show that they offer something of extraordinary value to patients and payers, allowing them to survive and even thrive without losing their independence.

Today’s questions: Do you think independent physician practices will be assimilated?  Is resistance futile for them?

Thursday, October 2, 2014

Who’s to blame for unexpected doctor bills?

Patients are being stuck with huge and unexpected medical care bills in circumstances where they have no say in selecting the physician who is billing them, and no way for them to know in advance which services the physicians would render or what it would cost them, says the New York Times.
Mr. Peter Drier received a “surprise $117,000 medical bill from a doctor he didn’t know” for services relating to a 3-hour surgery for herniated disks, the Times reported.  “A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee,” the Times writes. “He was blindsided, though, by a bill of about $117,000 from an ‘assistant surgeon,’ a Queens-based neurosurgeon whom Mr. Drier did not recall meeting. ‘I thought I understood the risks,’ Mr. Drier, who lives in New York City, said later. ‘But this was just so wrong — I had no choice and no negotiating power.’"

And, it appears, Mr. Drier’s experience is just one example of what the Times calls “an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.”

Then, earlier this week, the New York Times reported on patients being stuck with unanticipated out-of-pocket costs for services provided by emergency room doctors who do not accept insurance.  “Patients have no choice about which physician they see when they go to an emergency room,” reports the Times, “even if they have the presence of mind to visit a hospital that is in their insurance network. In the piles of forms that patients sign in those chaotic first moments is often an acknowledgment that they understand some providers may be out of network. But even the most basic visits with emergency room physicians and other doctors called in to consult are increasingly leaving patients with hefty bills: More and more, doctors who work in emergency rooms are private contractors who are out of network or do not accept any insurance plans.”

Some physicians will be inclined to blame insurance companies for these situations, arguing that low payments leave them no choice but to opt-out of taking insurance and to charge patients directly the full amount of what they consider to be a fair fee for their services.

But here is the problem with the “blame the insurer” mindset: insurance payments may or may not be too low (does anyone really think that any physician is worth $117,000 for assisting in a three hour procedure!), but even so, it’s no excuse for physicians to take advantage of vulnerable patients.

Advocates for “private contracting” with patients, balance billing (charging more than the insurer allows), and direct cash practices (physicians completely opting out of insurance and their negotiated rates) argue that these will bring free market competition to health care while making it possible for physicians to stay in business.  Fine—except in the cases profiled by the New York Times, there was no choice and no free market.

These were situations in which patients had no say in selecting the physician, and no say in what services the physicians provided.  They had no say in who their surgeon decided to bring into the operating room for assistance.  They had no say in what the doctors charged them or in what the insurance company paid.  They had no ability to “negotiate” rates in advance, and especially for the emergency room visits, no chance to shop around for a better deal.

No, these arrangements don’t sound to me like free market competition, but rather as exploitation of vulnerable patients.  Sticking the patient with the bill for services by a physician they did not choose, and had no way of knowing what the physician would charge, is the antithesis of patient empowerment and patient-centered care.  And quite likely, a violation of professional ethics—ACP’s ethics manual states that:

"An individual patient–physician relationship is formed on the basis of mutual agreement."

"Financial arrangements and expectations should be clearly established. Fees for physician services should accurately reflect the services provided."

AMA’s Council on Judicial and Ethical Affairs states that:

"…the term "surgical co-management" refers to the practice of allotting specific responsibilities of patient care to designated caregivers...The treating physicians are responsible for ensuring that the patient has consented not only to take part in the surgical co-management arrangement but also to the services that will be provided within the arrangement. In addition to disclosing medical facts to the patient, the patient should also be informed of other significant aspects of the surgical co-management arrangement such as the credentials of the other caregivers, the specific services each will provide, and the billing arrangement." 

ACP’s policy on “private contracting” legislation—a bill that would allow physicians to bill patients directly for more than the fee allowed by Medicare—states that physicians must disclose their professional fee for professional services covered by the private contract in advance of rendering such services, with beneficiaries being held harmless for any subsequent charge per service in excess of the agreed upon amount. Further, we state that:

“Since patients in emergency or urgent care situations are not in any position to shop around for another physician, we believe that the bill should clarify that private contracting arrangements should not apply at a time when emergency or urgent care is being rendered, even if the treating physician and patient had previously entered into a private contract.

“The legislation should include a prohibition on private contracting in cases where a physician is the ‘sole community provider’ for those professional services that would be covered by a private contract. This protection is critical, especially in under-served areas of the country, because patients should not be obligated to enter into a private contract with a physician for health care services if there are no other physicians in their community to provide such care…In addition to emergency and urgent care and sole community provider situations, there will be other instances where a patient has no reasonable choice of physician, such as when a physician is assigned to them in a hospital or other institutional setting. We recommend that the bill state that no private contract can be entered into in any situations in which the patient cannot exercise free choice of physician.”

While the situations described by the New York Times mainly involved surgeons, primary care physicians and internal medicine subspecialists must also consider at what point balance billing and private contracting cease to be an understandable and appropriate response to unacceptably low insurance company rates and instead become exploitative of patients who cannot afford to pay more.  The key considerations governing such private contracting arrangements must be that financial arrangements and expectations must be clearly established in advance of services being rendered,  that patients and physicians must mutually agree to the rates and the relationships involved, that patients accordingly must have a real choice of physician and must be informed in advance what they will be charged and agree to it, and that balance billing (charging more than the payer’s approved rates) should not apply in emergency or other situations where there is no real opportunity for such choice and mutual agreement.

As Mr. Drier told the Times "…this was just so wrong — I had no choice and no negotiating power” when stuck with the $117,000 bill from a physician he had not chosen.  It is shameful for some physicians to exploit patients when they had no choice and no negotiating power—and it is up to the medical profession to say so, clearly and forthrightly.

Today’s questions: what do you think of patients being stuck with big bills when they had no choice of doctor?  What should be the medical profession’s response? The government’s?