Dear Mr. Slavitt, Please Come Visit My Office

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Andy, if you want to fix primary care you must do some field research.  Come spend one day, or even a week at my office or another small primary care physicians’ office.  You need to see what we do on a daily basis and actually understand the view from a small practice perspective. This knowledge deficit is at the core of CMS’s problem.  You cannot repair what you do not comprehend.

Once you understand what we are capable of doing, how we do it, and how it actually SAVES money in the long run, while still providing high quality, then you are ready to tackle Focusing on Primary Care for Better Health.  The bottom line:  you must pay us more for what we are doing if you want to increase our overhead expenses.  Tasking us with additional administrative burden in order to earn extra money is not actually paying us any more for our work.  We would be working harder, not smarter.  Do you understand that?

First and foremost, the largest stumbling block for reducing expenditures of a small practice is addressing the certified EHR. Why do you need all this data?  Your days at McKinsey & Company have hooked you on its necessity to make management decisions, but your background is in healthcare insurance and expenses is a far cry from the provision of primary health care or value-based care.

The EHR mandate has damaged our profession as a whole.  It has been destructive to the physician-patient relationship as well. Technology has not improved safety, efficiency, or patient satisfaction and has only served to increase physician dissatisfaction.  Physicians are overwhelmed, hopeless, and trying to get out of the practice of medicine altogether.  You do not belong between me (the physician) and my patient – move out of the way.  Please.

If you want me to collect mountains of data, then prove it actually increases quality, reduces cost, and decreases our workload before I get on board.  There is very little margin to work with in my office, and if I make a wrong decision, my practice (and many others) will be dead in the water.   Find technology that is useful to both physician and patient while being affordable at the same time.  Stop adding complicated algorithms and programs to increase reimbursement while expanding our administrative burdens.

Second, value will materialize if you pay us more for what we do.  Higher reimbursement allows us to slow down and talk longer with each individual patient.  Make our lifestyle something to which others want to aspire and you will find more primary care physicians wanting to work in smaller areas.  Primary care physicians, actually ALL physicians, deserve better.

Have you not realized small practices provide urgent and emergency care, acute and chronic care, plus everything in between?  Care coordination, we already do it!  Winging it when there is NO specialist to refer to at all, we already do! It is value, pure and simple.  You cannot get anything more out of us.  There is nothing more to give.  If primary care is rendered obsolete because we could not keep up with your overwhelming demands, access will be in jeopardy.  Access will be worse than it is right now.  What will you do then?

As to your Collaborative Care Model, supporting mental and behavioral health through a team-based, coordinated system involving a psychiatric consultant, behavioral health manager, and the primary care physician sounds like a dream come true.  My county with a population of 260,000 has NO psychiatrist.  Not one.  Many states all over are experiencing the same provider shortages.  Can you grow psychiatrists somewhere at an accelerated rate, like that clone army in Star Wars, and drop them randomly by plane throughout the United States?  That would be a good start.  They could be raised to believe indentured servitude is their destiny.  I think it could work if you put that on your task list.

CMS employees have not spent one day inside a small primary care practice.  It is necessary at this point in time that they do.  You talk about encouraging innovations to connect people with primary care.  Here is the thing Andy, primary care physicians do not need innovations to connect people.  We use phones, interact face-to-face with our patients, and chart to document the entire process.  If we were not good at connecting with people, we would not be successful primary care physicians.
There is a lot of talking as a primary care physician.  It is difficult to quantify the value of face-to-face interaction but it is a crucial part of health care.  If you are feeling socially awkward and experiencing difficulty connecting to people, again, please come visit me in my office.  I will rid you of your communication problems, pronto.  At the very least, please spend some time with one primary care physician in a small community.  It will show you all that can be good with health care.  It will also open your eyes to what you are about to destroy.

Niran Al-Agba is a physician in private practice in Washington State.

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26 replies »

  1. Their regulations and tools to improve healthcare have nothing to do with quality but money. The ‘public good’ is a tool to implement a big-business approach to healthcare – to practice medicine by statistics – all the while collecting huge amounts of money for themselves and their buddies in corporate America. You are not going to beat these people in the political arena as they own the media and the candidates. You can only beat them in the private sector, and it may come down to a black market. Eventually, though, this ‘noble’ approach by big government and big business will exhaust itself and collapse. Until then, providers will have to keep the embers burning. http://www.fixthebus.com

  2. Though you seem to assume the EHR=healthcare it doesn’t. How has their EHR corrected the VA’s problems that are quality related and would lead to lawsuits in the healthcare sector?

  3. Believe me, I feel your pain. This quote “we need to pay physicians for conversations” is mine. It has been my crusade and is the reason I keep writing. I am thrilled Mr. Slavitt heard me. It is the first step. Now that he realizes the most important part of medicine IS NOT running tests and prescribing medicine, the second step is to show us what he will do about it. Front line physicians have to keep fighting together until we are heard.

    Of course counting and clicking do not have anything to do with improving care or reducing costs, but these are business people with MBA’s, they are not physicians. They do not understand what we do every day. They believe they do. Our kind has been too complacent for too long. We should never back down, even if it requires a little civil disobedience for our practices to survive. Thank you for your comments. Do not give up!

  4. This is a perfect example of Mr Slavitt denigrating what physicians do and disrespecting us…his latest twitter post:
    “We need to get out of the mode of paying physicians just to run tests and prescribe medicines. We need to pay for conversations.”

    I mean, really, is that what medicare is currently paying for, just prescriptions and running tests? Come on. That is a total insult to me as a front line physician. It strikes right at the heart of the problem with CMS. THEY think they know how to practice medicine and what needs to be done, and they have NO idea. All these complicated games of number counting and check boxing and clicking has done nothing to improve care or reduce costs, or God forbid I say this, reduce provider burden.

    I suggest CMS stop penalizing everyone. Without a doubt that IS ill will and ulterior motives, to drive small providers out of practice and get them in large groups that CMS can further regulate. Instead, leave small practices along, just bonus those practices that want to “test” or “pilot” a new model, not have CMS flail out a new model and penalize hard working providers that have no problems with cost or quality. All these untested, unproven schemes cost significant money to set up, maintain and report. Not insignificant amounts of money. And all this number counting and clicking and attesting and such is a total waste. If it was such a great idea, then tell me how MU and PQRS has done all these wonderful things over the past 5 years.

    I think Andy and CMS need to change the tone and fast. The blowback is coming and you can feel the anger on the street level of providers. We are beat up and had enough of this. It does not help to keep punishing us.

  5. “They own the VA system. It is theirs. They should want to show us exactly what they desire for the rest of us by perfecting this as a model for the entire country.

    Yet, they are mum about this–what they are accountable for–because ???”

    This from an earlier article on THCB that shows how the VA does it – BETTER. They are not “mum” by any means. They also get to negotiate drug prices, unlike Medicare.


  6. This is fantastic news! If I could get Andy to visit a small rural practice in the Pacific Northwest we can really get the ball rolling.

  7. BREAKING: Slavitt suggests MACRA could be delayed
    By Shannon Muchmore | July 13, 2016

    CMS Acting Administrator Andy Slavitt told lawmakers Wednesday the agency is considering delaying the start date for Medicare payment reform which is set to go into effect Jan 1.

    Testifying before the Senate Finance Committee, Slavitt said the CMS is concerned that some physicians, particularly at small practices, may not be ready for the changes under Medicare Access and CHIP Reauthorization Act that replaced the much maligned sustainable growth rate formula…


  8. Paul, you are correct about passion. Healthcare is a life and death matter so passion is naturally a part of the debate which should be held, but to do so requires two parties. I wish Andy would have responded to some of the doctors concerns. It is his agency and him that are trying to change human nature and creating havoc while doing so.

  9. Bobby, these are critical issues, and the central powers are imposing changes….usually with no pilot tests or research…..that dramatically alter doctors’ careers as well as patient health….and almost always in a negative way that is degrading a noble profession (despite what are most likely good intentions). Passion about these issues is called for and helpful in my opinion.

  10. “Aspersions” is a little dramatic don’t you think? I neither attacked Mr. Slavitt’s reputation nor his integrity. This is a true heartfelt invitation to spend time at my office. He would enjoy the experience, and would be able to develop more perspective on what an old fashioned medical practice looks like — very efficient and able to keep costs under control.
    Bobby, if you wish to critique my literary style in the future, you will probably have to be less subtle. I missed it, as did Merle. Thank you for your comments.

  11. You misunderstood MY remark. Wasn’t accusing YOU of anything. I tire of the recurrent casting of aspersions toward people like Slavitt by others, both here at THCB and elsewhere.

  12. Thank you. We must emphasize intent to improve is not the same as true “outcome-based” improvement. Apples and oranges.

  13. Mr. Slavitt may share my goals and be a natural ally but I cannot help him unless he contacts me. There are so many easy ways to make care more efficient. Our phones and all technology are out today due to construction nearby. (Just another typical small town problem) Hopefully he calls tomorrow. I will absolutely test run your device. You might not think I’m so refreshing after you work with me. I’m fairly opinionated and passionate when it comes to quality care of children.

  14. Bobby, sorry you misunderstand my comment. I am not imputing anything. I merely object to a literary style that makes its point at the expense of others.

  15. I admire your passion and open expression of how you feel. You are truly refreshing.

    My objection was that you made your point by criticizing/challenging someone who I believe shares many of your goals and may even be your natural ally.

    And as you surmised, the alternative patient-focused system I described isn’t hypothetical. It’s very real and exists today.

    I greatly appreciate your comments about it will be delighted to have you try it with your patients. We would love to hear from other providers who wish to try it, too!

  16. While I appreciate the difficulty of Mr. Slavitt’s job and I do note the ‘listening’ in the recent chronic care management payment increases as well as the reduced reporting requirements, this is all still ensconced in a regulatory structure that sees physicians as cogs in a data collectors/population health machine. The higher reimbursement promised for the ‘weekend call’ does come along with reporting requirements, and are not promised in perpetuity. Mollifying the good physicians struggling to provide care in this framework will take more than a change of tone but a different language. While I am sure the policy folks put In a lot of work and that the intentions may be good, the ultimate judgement is necessarily based on outcome, not intent. Pointing this out is very much in Dr. Al-agba’s purview, and I applaud her for taking the time to do it.

  17. That is great to hear. Again, I would love it if he would read this and join me for a day.

  18. As part of the Massachusetts Medical Society’s efforts to improve the HIT situation, Mr. Slavitt had been invited to visit one of the MMS member’s office, where, I believe Epic is used. Mr. Slavitt did make that visit and it is my understanding that it provided him with important insights into our current HIT dilemma.

  19. You may not like me or my opinion, but I LOVE this idea! You had me at free! Absolutely Brilliant. A small cost to patients or insurance company, and it does not change how I care for my patients in my office.

    I do not know Mr. Slavitt personally either and am certainly not whipping him. Pointing out deficits in his knowledge base is known by most of us as constructive criticism. Physicians experience this frequently and we are humbled when we receive suggestions as to how we can do better.

    Mr. Slavitt’s post gave me hope that he is truly interested in fixing primary care. He cannot fix what he does not understand. Let’s be clear: He has a degree in Economics and English, also an MBA; that is a far cry from practicing medicine. He does not know what I do in my office every day but if he did, it could help him do his job better. That is the larger point.

    As far as the number of physicians he has spoken with, I am interested in how many are primary care physicians in underserved areas? That is what I am and those physicians need to be heard as well.

    As to your technological suggestion, I extend to you the same invitation. I would love to be a test site. I could easily allow patients to take a picture of their dictation after it is completed and upload to whatever device is created for storage. I already do allow my patients access because I have nothing to hide. It is their health record, in my opinion.

    I am not opposed to change, especially if it benefits patients and health care in general. I am opposed to waste.

    P.S. If you add 50K to my income, that would almost double what I made last year! Wow! That would really be something. Thank you for your comments.

  20. “Niran, I don’t know Andy Slavitt personally but from what I’ve read I think it grossly unfair to use him as a “whipping boy” to make your point. In the course of trying to make the government programs more useful and effective, he and Karen DeSalvo, MD have spoken with literally hundreds of doctors—probably more than you or most other physicians have done.”

    Imputations of ill will and ulterior motives are the norm here of late.

  21. Niran, I don’t know Andy Slavitt personally but from what I’ve read I think it grossly unfair to use him as a “whipping boy” to make your point. In the course of trying to make the government programs more useful and effective, he and Karen DeSalvo, MD have spoken with literally hundreds of doctors—probably more than you or most other physicians have done.

    Whether you agree with their conclusions, of course, is another matter — and you clearly don’t. Your basic point, however, raises serious questions about what can be done to help you do more of what you really want to do, namely, treat your patients.

    In that regard, I have a question for you and other docs reading this blog. Would it be helpful if the government abandoned the idea of trying to link individual providers’ EMR systems via health information exchanges — which we know has been fraught with major problems — and, instead, substituted a totally different way to achieve interoperability?

    The “different way” I have in mind would be to give patients copies of all their records from all their current and past providers on a secure electronic device they carry in their pocket and give to any provider at the point of care. As you examine your patient, you could search its contents with only two or three clicks and bring up any record(s) you need to better understand your patient’s issues and coordinate his/her care. And to sweeten the pot, following each visit you would be paid to upload a copy of your progress notes, test results, etc. to an encrypted third-party server from which your patient would download your notes to his/her device. (For sake of discussion, assume this “payment” could add $50K to your income or, if you are in a big practice, an ACO or a hospital, it could add $millions to your bottom line.)

    Such a patient-focused system, would be free to you; your patient or his/her insurer would pay less than $100 per year to cover the costs of the system and your upload payments.

    You would continue to use the charting system you prefer, even paper, and have the information you need to coordinate your patient’s care with his/her other providers and thereby avoid medical errors, unnecessary visits and the need to order unnecessary tests, procedures, studies, etc. At the same time, your patients would be able to read your notes to better understand what you told them and even add addenda to correct mistakes if there are any or add their comments.

    I appreciate that using such a system in parallel with your EMR system wouldn’t reduce the hours you must spend entering data and it may even sound like it would add to your clerical workload—but for now let’s assume it doesn’t. In addition to the benefits you would enjoy, your patients would save deductibles and copays as well as reduce the cost of health insurance their employers and insurers must pay.

    What do you think? Would such a system work for you and your patients?

  22. Thank you all for the kind words. I am glad I have been able to put how many of us in primary care are feeling down on paper . John, I hope you are right and I hear from Mr. Slavitt. A few days with me will change him one way or the other.

    I will be honest, wanting to dislike Mr. Slavitt is easy. His background, both educationally and experientially, was not proper preparation for the job with which he is tasked. After reading his post about focusing on primary care, however, I appreciate his efforts and have softened my stance. I truly hope he is genuinely interested in filling in his knowledge gaps. It is possible he has been unwilling to change his position because he does not know better. To know better is to DO better. Our healthcare system depends on his interest in the little guys.

    This morning I read on Medscape “MIPS: Can I ignore it or Avoid it?” that many physicians, (CMS predicts up to 225,600), will opt out of participating in MIPS because we cannot afford to invest in technology required to be compliant. That is one-fourth of the physicians in the United States! The article said we could do fine at the 4% penalty, however by the time we reach 9% in 2019, small practices would be forced to buy the infrastructure that they have been putting off. Most of us will close instead.

    If we can’t afford it, we cannot afford it! It, by the way, is technology that has never been proven to improve medical care for patients or physicians. I cannot afford it at 4% and still will not be able to afford it at 9%. I will have to work around it, as will many others if we are going to survive.

    I am not asking Mr. Slavitt to change his mind about the provision of valuable or efficient care, rather I am asking him to understand it can be accomplished without a computer program. I want him to figure out what he does value, and how these goals can be achieved with less data collection and less up-front investment for small medical practices that cannot pay for data systems period (which are unnecessary to begin with.)

    This business about fewer than 100 Medicare or Medicaid patients won’t cut it either. I have more than 500 Medicaid patients, and the list growing by the day due to poor access where I live. These children simply need basic care; they have real medical problems with cost-effective solutions if intervention is early.

    Valuable health care is about face-to-face interaction with another human being. We have to get non-physicians in charge to understand that basic tenet. Thanks.

  23. John, I too am sure Andy has been to a physician’s office, but whose office has he been to? Right here on this excellent blog we have had comments from experienced physicians whose offices Andy hasn’t visited. They have been kind enough to comment constructively so that Andy could hear more opinions from more physicians and locations than those he has already visited. Dr Niran Al-Agba is one of those physicians. It is obvious CMS hasn’t addressed the many different issues created by many different needs.

    I don’t blame Andy as he is a product of a culture working in a bureaucratic culture that I believe doesn’t understand the everyday physician’s need. We cannot bundle the experiences of many diverse physicians and then create the average physician. It doesn’t work, but that is what seems to be happening. Different population groups, areas, etc. require different remedies for different problems. Bureaucracies base much of their thinking by pretending they are dealing with widgets and that they can force a square peg into a round hold. Take note of the mandates, punishments and all the force the government uses to get what it wants. Working with one another and recognizing incentives works better.

    I saw Andy’s earlier post and appreciate it, but he pronounced what he and CMS were doing and didn’t address any physicians in the field, nor did he address patient concerns. I agree with your point about needing techs, but they also should be addressing the needs of physicians where it concerns how the physician practices medicine and not be so concerned with the bureaucracy that surrounds them or their own needs.

  24. I’m pretty sure Andy has actually been to a physician’s office.

    And I have a feeling Dr. Al-Agba will be hearing from him soon.


    “Unwilling to explain himself” seems a little unfair. I think it is more accurate to say Andy has been unwilling to change his position. On the other hand, CMS has changed what it is doing in response to critics. See Andy’s post on THCB.


    Are those changes enough? Probably not.

    For the record, I agree with much of what Dr. Al-Agba has written here. The tragedy of all this is that technology should liberate and streamline, not create new bureaucratic overlays and new levels of complexity ..

    We need new technologies that do this … My take is that this is a design and a political challenge –ideology + tech / design.

  25. Good, Allan. I agree this is a superb post.

    They own the VA system. It is theirs. They should want to show us exactly what they desire for the rest of us by perfecting this as a model for the entire country.

    Yet, they are mum about this–what they are accountable for–because ???

  26. Niran, thank you for this most wonderful post. Andy won’t visit normal physician offices because he is unwilling to explain himself or the position of CMS. We see that unwillingness with his lack of responsiveness to physicians that have written about the problems they face. He can’t. CMS has a dream that CMS wishes to become a reality. Dreams are for ideologues. Reality is for those that actually live in the trenches. Saving money isn’t the issue either. It is the ideology that counts. If money were the issue we wouldn’t see Medicare paying more for colonoscopies in the hospital than in a surgicenter and we wouldn’t see government attempting to prevent the growth of these less expensive private surgicenters. He also doesn’t wish to preserve the doctor-patient relationship rather he wishes to replace that relationship with the patient widget relationship while he mandates the type of care the patient is permitted to have.