The Angry Physician

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I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy.  Medicine is a calling, and I treated it as such.  I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals –  they would take care of the task of taking out the bad elements of our healthcare system and leaving the good.  I truly believed.  I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.

It took me two years to realize the meaninglessness of meaningful use.  I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope.  I thought – this was a first draft, improvements would come.  What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down.  There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march.  Except the road would no longer be paved and we would be walking uphill.

I watched as reimbursements were cut to physician practices, while hospital reimbursements were left alone. Independent practices collapsed only to reemerge in a hospital employed model. The landscape was changing seismically – and yet I saw no evidence that patients were safer, or that this new model was more cost efficient.

It is in this setting that MACRA arrives.  MACRA is the newest iteration of tying reimbursement to value instead of volume.  An admirable goal that is spelled out in a 962 page document.  It is filled with paragraphs like these:


This seems a daunting task for any practice to wrap their arms around.  This can’t possibly be deemed practical for small practices to implement.  Unfortunately this is exactly what the head of CMS – Andy Slavitt – is counting on.


Mr. Slavitt and his team actually believe that bad practices will be penalized and good practices will be rewarded.  In reality, practices with the resources to report on outcomes will be rewarded, and the small practices that don’t have teams to upcode risk, and check off and submit metrics as part of registries will be penalized.  The jobs that proliferate now are jobs working for large systems that demand we spend 12 minutes with every patient during the day, and do notes at night after the kids go to bed in a billing software that masquerades as an electronic medical record.  If you are in primary care you are doing all this for a salary that is less than a nurse anesthetist with north of $200,000 of school debt.  Is it really hyperbole to say this is anything but a war on the individual practitioner? Is it wrong for physicians to be angry?

Some are disappointed by this response.  Apparently it is OUR system that was screwed up, and WE need to fix it.  Yes, the same physician furiously treading water in piranha infested waters is apparently in charge of fixing the healthcare system as well.  This is akin to expecting the sons of liberty that dumped tea into the Boston Harbor to also put out a white paper on funding the East India Tea Company.   There is a place for anger here – we must not as a profession sit by any longer while bureaucrats that know nothing about health care delivery tell us how to deliver health care.  Put MACRA where it belongs – in the Boston Harbor.

Anish Koka is a cardiologist based in Philadelphia.

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34 replies »

  1. As a kid I watched the parent of my friends an neighbors who were physicians and had such great respect and admiration for the blessing they were for their communities . They worked very hard but their reward was job satisfaction . Not that they were the highest earners but they at least were able to make ends meet . They didn’t spend the majority of their time begging insurance companies and a person on the other end of the line ,that has by the way no medical training and no understanding of what good healthcare is even from a financial practical standpoint. Their barometer of competence is their ability to say no . And to watch the success of medical practice Hinge on how fast a physician can click boxes and what expertise your office staff has in ICD- 10 codes . At the same time you are tying to be an honorable physician an serve your community . And you wonder why Drs. Are angry ?

  2. It’s really sad how doctors in private practice are taking the hit. The system has put doctors in a corner with few options. Turning them into working for the system instead of being independent and practicing medicine. There are a few options available to doctors, but whether or not they use them is another story.


  3. I did a mid career switch because relevance in my work a day was missing so I became a primary care physician assistant. It was the perfect move and the docs that trained me and the ones I ended up working with were brilliant day-to-day company.

    Sadly, I have never been around a profession, or a group people, or individuals more incapable and unwiling to stand and defend themselves. Personally or professionally. Brutalized by lawyers and the legal system, tolerant of the constant contempt from hospitals administrators who, professionally, are just shy of JV status, unable to see dripping patronage of no regard from local politicans, whiney regarding the mafia maneuvers of the health insurance industry, and not wearing any kind of protection when frolicking with the pharmaceutical industry for a crappy free lunch…

    You guys are getting publically mauled while reading poems.

    How did we get here?, is a question that can be applied to many aspects of this American life. A history of “no pushback ever” seems always the best answer and that fits like a glove when it comes to health care providers that go by MD.

    It is incomprehensible that the vast majority of MDs are not only not seeing the some Medicare for All/single payer/universal care is not only the answer to the business concern because it shuts down all the thieves and bullies that weigh upon your business model and your self-respect – but is a way to recapture all that comes with practicing one’s calling.

    A physician’s calling and a citizen’s health security are two ideals that are unknowable in the U.S.

    The fix: A small army of lobbyist and some wickedly vicious self-hating but well paid, really smart lawyers and, importantly, a one or two person PR team that only needs to be smart enough is all it would take to turn it all around.

  4. No question, I see print-outs from EHR’s–because they don’t talk to one another, you see–and there’s a barrage of nonsense from “Patient verbalized understanding of medication” “patient wears seatbelt and had flu shot”–completely irrelevant to their liver biopsy–making it incredibly difficult to synthesize the relevance in actual patient care.
    A patient said it best, she brought in 4 pages of haphazardly arrayed pathology results and office notes from the patient portal from another medical office, and she lamented that it was so haphazard she “couldn’t make sense of it and couldn’t print a document”. YES!!
    Sorry about HIMSS vs HIMMS, I typed too fast to catch it. But I’ll have some fun with it–Helping Internists Materialize Sickness Scenarios, or Hurting Individuals Mentally Maneuvering Sideswipes…it really has done the same, in the end 🙂

  5. I advise all “angry docs” to read the proposed MACRA rules on APMs (Alternative Payment Models) carefully and to fight hard for smaller bore ones that would allow local practices to affiliate. The AMA and other med groups will likely do this but it will also be important for regular docs to comment on the proposed regs. I personally think the smaller, localized APMs are going to be hard to create but if you think you can do it, go for it. Will be one way to maintain control.

  6. MACRA, MIPS, MU, etc alphabet soup program… all centralized planning edicts with so little input and such little representation of the folks who are encumbered to implement, that it borders on the slave trade–doctors being enslaved by government edicts– with no recourse. I inform patients ( who have no clue of Epic’s epic political contributions to politicians–http://www.breitbart.com/big-government/2011/08/18/obamacare-wheres-the-investigation-of-epic-systems/ for PPACA and MU) of what’s happening and who is ordering it–such as the EHR fiasco, “providers’ typing into desktops and not looking at you, asking inane questions about seatbelt usage and flu shot when you’re there to have an upper endoscopy.

    In short, the federal grip on us must be thrown off, and doctors are angry because they don’t see how. I think with more and more doctors going concierge, and health systems using mid level providers for everything (overprescribing and running many more tests to cover their a**es) the human and financial cost will turn the tide. As it is, more and more patients are calling my office and asking if we use EHR “because they don’t want to get hacked” as happened with myriad health groups and hospitals. They are LOOKING FOR DOCTORS WITH OLD FASHIONED PAPER CHARTS. Wrap your heads around that one, HIMMS.

    They don’t want RNP/PA’s for all of their needs. There is a double tier of health care happening, and I suspect outpatient medicine will become much more like dentistry, where it’s cash only and your every wish is my command. Hospitals and big ticket procedures will be under the iron vise control of the alliance of corporate-government medicine.

  7. I think your #1. alone would very powerful…..even if only 10 or 15% of patients were in such plans. I don’t know the history of how idemnity type plans disappeared. State level health insurance regulations may be a barrier to such plans too?

  8. If the patient gains more power, his agent does too.

    Three ways for patient to gain more power:
    1. Claim payments go to patients first. Patient pays doc and hospital. Old indemnity system.
    2. Provider payments are delayed by 30 days. This takes care of quality issues as patient psychology and biologic healing suggest to patient how much to pay provider. This could be studied and made to 60 days if needed.
    3. Short term debts to providers are declared to be non-recourse loans to patients and the only collateral for loans are continued provision of services to patients. Provider cannot come after patient wages, assets, bank accounts, etc. If patient does not pay to satisfaction of provider, provider can terminate care. All patients incur short term debts to providers by law.

  9. Love your piece…and courage. We can’t get nailed with anti-trust if we form a union of patient agents….An MD-UOPA.We don’t fight for money or wages or benefits or ourselves; we fight for patients: simplicity in billing and EOBs, time spent with patients, hospital prices, absolute security of medical record, early discharges, quality of care in isolation settings….a thousand items await our UOPA battles.

  10. Hospitals create economies of scale by – as you said – exploiting or using labor. The labor in this case is the physician. PCP’s are used to capture marketshare and the all important downstream revenue that is generated from specialists doing procedures. In both cases there is a wide gulf between what the hospital is paid by the payers and what the hospital pays the physicians. We are told this is all due to the expense of running a hospital (marketing billboards that proclaim we are the best at everything, staffing 24/7, running ERs, etc.). Somewhat of a black box with regards to what the true cost is to run a hospital. I can tell you that everytime some well intentioned soul in govt. comes up with another regulation/metric – a new department is formed in the hospital to deal with it. I’m sure you’ve seen the administrators vs. physicians growth graph?
    Great comments/questions that get to the heart of the matter. What do you do? Feel free to reach out via email as well – anishkoka@gmail.com. Thanks!

  11. Wal-Mart benefits from huge economies of scale in dealing with suppliers as most of their cost structure consists of buying merchandise to stock their stores. Hospitals, by contrast, have surprisingly few economies of scale. Most of their costs are for employee compensation, utilities, insurance, etc. Supplies, which maybe account for 15% of the cost structure, are the only area where there may be some economies of scale for a multiple hospital system as compared to a single hospital.

    Interestingly, I’ve been told that even physician practices incur diseconomies of scale once they reach about six or seven doctors because they need to hire a practice manager at that point and start to incur other overhead. Since individual doctors are mainly selling their time and expertise, their business model can’t scale. To make significant money, they have to become entrepreneurs and own stakes in labs, imaging centers, PT centers, ASC’s and the like where they can earn a return on equipment and other employees’ labor.

  12. According to Singularity University, within a decade, healthcare will be flawlessly delivered by AI and robots, and will be “essentially free.”

    Not making that up.

  13. I appreciate the sentiment. I wonder now if we would have gone much further without the meaningful use ONC certified emr push. I started practice in 2013 – I was going to have an EMR regardless of the MU carrot. Perhaps your friends EMR is better than whatever I have now – its a shame. As to the comment about scribes/assistants – its a good one – though the margins certainly that most PCPs operate on may make even this cost fairly painful. This is exactly what specialists and hospitals have done. There has been an explosion of np’s and PAs for this very reason – to take the documentation burden off of physicians. (Not the only reason for physician extenders of course). This just raises the cost of doing business – and doesn’t make healthcare any less expensive. I know we’re not in Kansas anymore, and we’re probably never going back (nor perhaps should we)…but is there any wonder why a lot of folks like me pine for a reset button?

  14. Wait, you want to do what you think is best for the patient and society? That is dangerous talk. Remember physician autonomy is bad – variation is bad – stick with the templates and check boxes – you’ll get much further..

  15. Anish: Well written, and an important message. What has happened to primary care is a sin. I’m not knowledgeable enough to speak to the ins and outs of using EHRs and MACRA. I have a primary care friend who developed (with help) a unique EHR that he and his loosely organized group are now abandoning. Seems a shame.
    It is my impression that the value of EHRs is: (1) to have a complete and accurate medical record available when and where ever; and (2) to be interoperable so that the information can be shared appropriately. The goal should be to INCREASE physician face time with patients. Obviously, they are not yet. Perhaps, like lawyers, physicians need “secretaries” or “assistants” to handle the EHR aspects? Seems to be below their pay grade (such as it is). I know I’m wandering. Your pain is felt.

  16. Of course I’m biased, but I think there are clearly places where the small/independent doc can deliver higher value at lower cost. Our allegiance also lies with the patient rather than the health care system that employs us. Paul is spot on – I use the walmart example frequently. Walmart won against the mom and pop store because they provided the same goods at lower cost. Does anyone believe that’s what hospitals do? I hope the well intentioned folks leading this parade will come to this realization before its too late.

  17. That is painful to read. Early adopter, forward thinking, highly rated…now punished?

  18. Not really. Yes there are doctors who do lobby, but they frequently do not represent. The posture of the medical societies has become to sell you tools to negotiate the unreasonably complex medical environment while acting as a mouthpiece for central planners. And yes, that has been repeatedly voiced to them directly.

  19. Big agriculture wins because they produce food at much lower cost and higher quality…today hospital based services are higher cost…and who knows re quality….very different…the small independent docs could/can provide better service at lower cost….but they are being driven out of business as unintended consequences of “reform”….mainly driven by bureaucrat/congressional demands and requirements.

  20. We are and we are not represented. The AMA exists to represent “all” physicians, but does it so broadly that it is not very helpful. We have individual societies that usually do a much better job of representing us, but those often conflict with other specialties. Our practices and needs are often different.

    My broad view, as an older doc who runs a smallish group (about 100 providers) is that we docs largely abrogated this to other people. While I will agree that top down is often, not always, less efficient, the docs on the bottom just haven’t been solving the problems. My experience, working at a tiny critical access hospital, a medium sized community hospital and a teaching hospital (I split my time fairly evenly) is that the individual docs often fight against any change at all, even the ones that have overwhelmingly good evidence. (I had a cardiologist at a small hospital threaten to get me thrown off staff for insisting upon following the central line protocol.) Yes, I thought Meaningful Use obviously sucked from the beginning, but I honestly don’t know what my, or anyone else’s track record would be on predicting which changes have been good or bad.

    All that said, changing medicine is hard. I also hate the insularity of organizations like CMS, JCAHO and almost everyone else who regulates us. I wish they had more input from real practicing physicians. I wish there was a way to have that input. Unfortunately, as I alluded to earlier, that comes through our societies and even they don’t always represent us well as they are tilted, IMO, towards academia.

    As an aside, while we all have sympathy (empathy?) for the individual or small group doc, I wonder if you are going the way of the small farmer. Perhaps you can find your special slot doing the equivalence of growing specialty organic, heirloom tomatoes, but I suspect the economics are against you in the long run elsewhere.


  21. “Today’s EHRs are an arms race between giants.”

    I could not agree more. I cover all this “disruptive,” “transformative,” paradigm-shifting,” “disintermediative” (is that a word?) Health IT stuff for my blog. I’m not seeing it. The same handful of dominant incumbents remain rather firmly in place, and I don’t see them being dislodged and eclipsed anytime soon, all the cherubic chatter about the “post-EHR mHealth Patient-As-CEO” utopia notwithstanding.

  22. “As a professional, I believe it is my responsibility to figure out a way to improve the quality and reduce the cost of healthcare, both for my individual patients and society in general.”

    Oh don’t I wish that was a first year and last year medical school required course.

    I want primary care to be the base of our entire system and rewarded for it, but you’d better reconstruct the RUC – (the enemy is us). All this “meaningful” use is an attempt to change the cost curve without changing the cost curve because that’s too difficult politically.

    Physicians in Canada bargain collectively (and strike) for compensation and I suspect other issues. Maybe you should organize a union which would also work for patients, not just money for docs. When I was in Canada the public did not support docs in their contract disputes, mostly because docs ignored the fact that their compensation was not effected by economic downturns and that they never fought for anything else but money.

  23. If you’re angry, try being a patient on this crazy-train we call a “healthcare delivery system.” Payers gaslight you if you try to find out ahead of time what a tx or procedure will cost. Providers will either offer you meaningless-use of your own PHI via their portals (always ending up with an additional dx of poly-portalitis syndrome, which is still not coded in ICD-10), or tell you they can’t give you your info “because HIPAA.” And then there’s the whole shared decision-making and “don’t Google it” fight. I will say that the impetus to stay healthy stays strong in this person/patient, largely because I find myself made so very angry by the bushwa “the system” inserts between me and the MDs/NPs on my care team.

  24. Is there room in MACRA for a patient-centered health system? The current EHR setup is all about each institution and their EHR.

    With a patient-centered health record the “relationship and responsibility of a physician or applicable practitioner” would be evident and the outcomes would also be easier to evaluate. Up-coding of procedures would be reduced because the record would be transparent to various care-team members. The Directors would be working for the Doctors.

    Today’s EHRs are an arms race between giants. Manipulation of records is much harder when they are being kept by the patient rather than the combatants.

  25. I don’t think so… we aren’t organized, and we are certainly not unified. I am relatively sure most of the physicians that are involved in policy making would disagree with my views. The AMA certainly has not been out front when it comes to meaningful use. They seem to be more a lagging indicator than a leading one. The 962 page document is a diffiicult read – but there is a tremendous amount that is just not finalized…waiting for comment etc. I used to argue that someone would get the details right. I have come to believe that this just isn’t done well in a top down manner. Or at least, there seems to be little hope that the independent practitioner has a voice at the table when these policies are made. Read Steven Brill’s prodigious masterpiece – America’s Bitter Pill – Chapter 9 – that examines the backroom deals behind ultimate passage of the ACA. The players at the table were health insurance companies, hospitals,and big pharma. I have no idea how to get a seat at the table.. Any ideas are welcome 🙂

  26. As a solo practitioner, I feel your pain.

    Not that it matters, but the insurance companies rate me as a “Tier 1” physician which means that they think I provide high-quality and low-cost care. My patients rate my practice highly, as demonstrated by my Press Ganey Score. The EMR I created (ComChart) clearly meets the needs of my practice and the needs of my patients. (ComChart had the highest KLAS rating for the small ambulatory group of EMRs from 2004-2012 and was transiently certified for Stage 1 Meaningful use from 2011-2015. Unfortunately, as ComChart is no longer “certified,” there is no longer a market for it and it is no longer for sale.)

    I am now going to be penalized by Medicare unless I re-create my practice using an ONC certified EMR.

    As a professional, I believe it is my responsibility to figure out a way to improve the quality and reduce the cost of healthcare, both for my individual patients and society in general. Objectively, it appears that I have been able to do that and I hope I can do more in the future. But only a fool will believe that I can further improve the quality of care/reduce the cost of healthcare by abandoning nearly 3 decades of work and “rebuild” my practice using an ONC certified EMR.

  27. “If you are in primary care you are doing all this for a salary that is less than a nurse anesthetist with north of $200,000 of school debt.”

    HIMSS, on the other hand, is a “non–profit” business with revenue north of $81 million a year. It pays its CEO north of $1.1 million a year.

    I covered the “5th Annual AARP Health Innovation@50+ LivePitch™” conference in Silicon Valley this week for my KHIT.org blog. The amount of money being thrown at these Wunderkind (one of this week’s finalists startup CEO is all of 17) makes $200k in Med School debt and the typical PCP salary look like rounding errors.

    Maybe you should lend your “MD” shingle out as a nicely compensated “Medical Director” bauble to some startup(s) to add some sheen as these kids traverse their multimillion dollar Seed, Series-A, and Series-B VC rounds. ‘eh? Not like you’d have to actually DO much of anything. It’s all about the “Spray and Pray” IPO Exit dice roll.

    apropos, read Douglas Rushkoff’s new book ‘Throwing Rocks at the Google Bus.”

  28. Love this piece/his writing. What’s confusing how anyone ever thought any of this wld be anything BUT catastrophic

    via Mailbox

  29. Don’t doctors have lobbyists? If they do, the lobbyists need to get their information about what needs to be fixed or changed or eliminated from somewhere, presumably the constituents they represent. In the time it takes to compose an essay to post on The Healthcare Blog, one could compose a letter to the head of your lobbying organization that outlines your thoughts about need changes to the healthcare delivery and payment system. No?