After a 3 decade career in a solo private practice the healthcare environment shifted
As an employed physician, my institution’s policies hindered my ability to care for my patients
The consequent moral injury left me unwilling to re-engage with the healthcare industry
I retired early from the profession that I loved because the devolution of the healthcare system had made it impossible for me to provide care to my patients in a manner which met my own standards. The resultant “moral injury” left me leary of again becoming involved with our healthcare system in the near future.
My Early Career
Although I had originally planned a career as a physician-scientist, it became apparent toward the end of my training that this was not the best career path for me and I choose to pursue a career in private practice.
My first post-training job was as a physician working in a clinic owned by Blue Cross and Blue Shield (1989-1991.) After two years in this relatively low stress environment it became clear that taking care of young, healthy patients was not much fun nor interesting.
I then joined Dr. LP’s private medical practice where I learned how to run a private practice. It was in this setting that I began to create an electronic medical record program for my practice, ComChart EMR. ComChart evolved into a minor commercial endeavor, it was a hobby that earned me some money, and it connected me to many interesting physicians around the US, some of whom I continue to hear from to this day.
After a couple of years practicing alongside Dr. LP I decided it was time to strike out on my own. I built out a new office and soon thereafter added a nurse practitioner.
I walked into my exam room to see a patient I first met two decades ago. On presentation, his co-morbidities included poorly controlled DM-1, hypertension, hyperlipidemia, and a substance abuse disorder. Over the years our healthcare system has served him well as he has remained free of diabetic complications and now leads a productive life. Watching this transformation has been both professionally rewarding, personally enjoyable, and I look forward to our periodic interactions.
At this visit, he was sporting a MAGA hat. I was confused. How can my patient, who has so clearly benefited from America’s healthcare system, support a politician who has tried to abolish the Affordable Care Act, used the bully pulpit to undermine America’s public health experts, refused to implement healthcare policies which would mitigate COVID-19’s morbidity and mortality, and who minimizes the severity of the coronavirus pandemic every day. Why does he support a politician whose healthcare policies are an immediate threat to his health and longevity?
My brain says, “You are the physician this patient trusts to take care of his medical problems. You must teach him that COVID-19 is a serious risk to his health and explain how the President’s public health policies threatens his health. You must engage in a political conversation.”
I recently saw a patient who received a bill for an outpatient procedure for $333. The Medicare allowable reimbursement for the procedure was $180. I have seen other medical bills where the healthcare provider was charging patients more than 10 times the amount they expected to receive from Medicare or any insurance company.
one of my patients had an unexpected medical complication which necessitated a
visit to an emergency room. He received a huge bill for the services provided.
When I subsequently saw him in my office (for poorly controlled diabetes) he
told me he could not attend future office visits because he had so many
outstanding medical bills and he could not risk incurring any additional
medical expenses. While I offered to see him at no cost, he declined, stating
the financial risk was too high.
patient is required to pay the entire medical bill if they
poor quality insurance
a bureaucratic “referral problem”
an out-of-network provider, which means they have no contractural relationship with the healthcare provider/institution, as might result from an emergency room visit or an unexpected hospitalization.
physicians and other healthcare providers usually do not know what they are
going to get paid for any given service as they contract with many insurance
companies, each of which has a different contracted payment rate. Healthcare
providers and institutions typically set their fee schedule at a multiple of
what they expect to get paid from the most lucrative payer so as to ensure they
capture all the potential revenue. In the process, they create an economically
irrational fee schedule which is neither reflective of a competitive
marketplace nor reflective of the actual cost of the services provided.
The high cost, low quality and systemic inequities of the U.S. healthcare system have been the impetus for its redesign. Our healthcare system is now controlled by Consolidated Healthcare institutions, Insurance companies, Pharmaceutical companies and Health Information Technology companies (CHIPHIT complex). The CHIPHIT complex, along with the Federal Government, will create and control our future healthcare system. Ominously missing from this list are independent healthcare policy experts, independent healthcare providers and members of the general public.
Historical precedents have demonstrated that the CHIPHIT complex is
incapable of creating the healthcare system we need.
Thus, if we hope to build a low cost, high quality, egalitarian
healthcare system, physicians and their professional organizations must take an
emphatic stand against the CHIPHIT complex today.
Consolidated Healthcare Institutions
There are innumerable mandates which make running a small medical practice very difficult. As a result, many younger physicians will no longer attempt to start a new medical practice and existing profitable practices, which are looking to off- load their regulatory burdens, are being acquired by large healthcare institutions and private equity firms.
While these consolidated healthcare institutions vocalize their desire
to improve our healthcare system, many enforce a uniformity on the practice
environment which belies the reality of patient care; that there is no “best” practice model, nor are there
information technology tools which work well for all physicians. This imposed
uniformity stifles physician innovation, which is a necessary precondition to
improve our healthcare system.
Over the last several months, I have worked to make the following the official policy of the Massachusetts Medical Society:
That the MMS will advocate to our State and Federal Representatives to end all legal constraints and financial inducements arising from the use or non-use of Office of National Coordinator (ONC) Certified EHR Technology.
That the MMS will encourage our Massachusetts Federal Legislators to introduce legislation to end the ONC’s EHR certification program, and will ask the President of the United States to immediately request that such legislation be introduced.
While the MMS’s Committee on Information Technology voted unanimously to support the above proposal, the MMS rejected the above and choose instead to make the following official MMS policy:
That the MMS will work with appropriate government entities to foster EHR innovation, affordability, and functionality by modifying the certification process for EHRs to improve patient care.
Without a doubt, ONC’s EHR certification program has stifled innovation in EHRs in particular and in health information technology (HIT) in general. In addition, the data accumulated to date has shown these ONC’s Certified EHRs have failed to have a meaningful impact on either the cost or quality of healthcare.
The 6 December 2016 issue of Annals of Internal Medicine has an article which shows that for every hour a physician is involved with direct patient care results in an additional 2 hours of EHR work (in the office/clinic) and then more EHR work from home. No wonder MDs are so dissatisfied with the practice of medicine. The accompanying editorial (Ann Intern Med. 2016;165:818-819) concludes “Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the health care system ”
Massachusetts Medical Society President Dr. Dennis Dimitri sent the following comments on Meaningful Use Stage III and the Medicare Access and Child Health Reauthorization Act to CMS on Tuesday. THCB is pleased to feature them for our readers. If you agree, we urge you to share with your colleagues, your elected representatives and on social media. – John Irvine
Dear Mr. Slavitt and Dr. DeSalvo:
On behalf of the 25,000 physician, resident and medical student members of the Massachusetts Medical Society I am writing to provide our comments on Stage III Meaningful Use as it relates to the Medicare Access and Child Health Reauthorization Act. It is our understanding that the AMA is submitting extensive and detailed comments on specific aspects of the Meaningful Use Stage III, including a proposed revision of the program which we strongly urge the Department to consider going forward. Our comments will highlight several of the overarching problems with the meaningful use program as currently constructed and its impact on practicing physicians and our patients.
To put our comments into context I would like to underscore that Massachusetts physicians were early adopters of Electronic Health Records. The MMS has been committed to helping our members understand and implement successfully EHRs for well over a decade. We were one of the founding members of the MA EHealth Collaborative (MAeHC) and continue to support this important project which helps physicians choose and implement EHRs in their offices. We understand well the promise of this technology.
I am an IT geek physician. I have my an EHR which I created and control.
Today, I wanted to understand my diabetic practice a little more, so I dumped all my HbA1c data out of my EHR and into a spreadsheet where I was able to manipulate the data and learn a few things about my practice.
I learned that:
If my patient had a HbA1c ≥ 8, the likelihood that the HbA1c would be < 8 at the next visit is 68%.
If my patient had a HbA1c ≥ 8, the likelihood the HbA1c would be even higher at the subsequent visit is 29%.
If my patient had a HbA1c ≥ 8, the average change in the HbA1c at the next visit was -0.7.
If my patient had a HbA1c < 8, the likelihood that HbA1c at the subsequent visit would exceed 8% would be 15%.
Trends in US healthcare expenditures are financially unsustainable (1). I would like to propose two tweaks of the healthcare delivery process that may, in a small way, help rectify this problem.
Although there is a widespread impression that health information technology (HIT) will eventually “bend” the cost curve and put healthcare spending on a sustainable course, there is, as of yet, little data that convincingly supports this hypothesis (2).
Kaiser Permanente is a large, integrated healthcare delivery system which has invested heavily in HIT. George C. Halvorson, the chairman and CEO of Kaiser Permanente appears to have concluded that this investment will not solve the healthcare cost issue, when he was quoted in the New York Times (3/20/13) as stating “We think the future of health care is going to be rationing or re-engineering.”
Because HIT, as currently implemented, will probably not solve the healthcare cost problem, I would like to suggest a minor “re-engineering” of the electronic health record user interface which may help bend the cost curve.
At every office visit, the physician must make a myriad of decisions which incrementally effect the nation’s total healthcare expenditures. For example, the physician will have to decide which medicine to prescribe, and which radiology study or laboratory test to order.
In many situations, there is more than one acceptable choice. The physician’s ultimate decision will integrate their understanding of the disease process, the treatment’s side effect profile, their familiarity with the treatment options, patient preferences and many other variables.
I would suggest that every time a physician is about to order a test or a prescription, the cost of the test or prescription should be displayed to the physician. In the same vein, whenever a computer displays a test result, the cost of the test is immediately available to the reader. This information could then become an additional factor that the physician may choose to integrate (or ignore) at the moment when he/she is about to commit the patient and society (which is now paying >50% of all healthcare bills) to another healthcare expenditure. In terms of a risk/benefit analysis, I can see little downside to providing this cost information to physicians.
A recent RAND(1) study has concluded that the implementation of health information technology (HIT) has neither effected a reduction in the cost of healthcare nor an improvement in the quality of healthcare. The RAND authors confidently predicted that the widespread adoption of HIT will eventually achieve these goals if certain “conditions” were implemented. I do not believe that there is sufficient scientific data to support the authors’ conclusion nor validate the Federal Government’s decision to encourage the universal installation of “certified” electronic medical records (EMRs.)
As a “geek” physician who runs a solo, private practice and the creator of one of the older EMRs, I believe that I can provide a somewhat unique perspective on the HIT debate which will resonate with a large fraction of private practitioners.