Sunday, March 2, 2014

Challenges to remain a financially stable medical practice

I recently posted Top 10 challenges facing physicians in 2014 and was pleasantly surprised to see that it was one of the more clicked-on posts that day. Business Facebook pages allow administrators to see  total reach (yellow), post clicks (blue), likes/shares (pink). (The post with the overall largest was of course a cartoon of the hazards of shopping at Target... cartoons and memes are always popular.)

Why was I pleasantly surprised? Because I want people to know more about insurance issues and our office financial concerns. I don't know if people made it through the entire 10 concerns, so thought I'd summarize them.

Why do I want to spend time blogging about this?

I fear that people presume we will always be there for them, but historically bills often aren't paid by families for various reasons. In the past we at least collected from the insurance company and a smaller percentage was patient responsibility. With the higher number of high deductible plans this year, we are at serious risk of not collecting payments or having delayed collection of payments at a time that our practice is forced to spend significant money on government mandated things. We will be implementing new billing policies soon to help protect the financial stability of our office. I know we will hear complaints because no one wants to think about money when they are worried about the health of their child, but the reality is we need to implement these changes so that we can continue to be around to take care of your children. If I could have a wish granted, I would ask that all money is paid to insurance companies, from the policy charge for the insurance itself (like we pay now, often with the help of our employer) to the money owed to the physician or hospital for services rendered. This would allow doctors and other medical professionals to stay out of the money game. I hate having the money conversations when parents think they shouldn't have to pay something. We submit a bill for services rendered to the insurance company and the insurance company ultimately decides what the patient family owes, based on your contract with them. If we don't then bill you that amount, it is a contract violation on our part. If you don't pay that full amount (that may have already been discounted by your insurance company) you are violating your contract with them. The system is not good because we bill something that is due based on your contract with a third party. It would make sense if they had to collect all the money and they paid all the bills. That is my dream...

But I'm getting off track. I want to summarize the very long article referenced above and point out how it affects our office. You will find that many of their points interlink with each other, which seems redundant, but they are so intertwined, it is hard to separate them out.

Challenges to remain a financially stable medical practice

  1. Payment for medical services. Payment structures are moving more toward an outcome based system. If our patients get quality care and we can prove it with metrics, we will be payed at a higher scale. While in theory this is good, it is really hard for physicians to prove that they do good care. It takes staff time and money to run reports. And we have no ability to make patients follow recommended care. A popular metric to measure is asthma, since it is a common pediatric condition. I get insurance warnings routinely that a patient isn't filling preventative medications on schedule. Sometimes that is because they are using it as told because of overall good control and my desire to use as little medicine as needed for good control, but that is less than the twice/day general recommendation. Unfortunately, sometimes it is because the co pay for the medicine is too much and the family uses it less than needed because they can't afford it.  With new plans that have higher deductibles, I see that more often. I can direct patient families to programs that help with drug costs, but I can't buy their medicine for them. When they end up suffering with more asthma symptoms, they use ER and office visits for sick visits, and then I'm dinged by that same insurance company that set their rates too high for families to afford the best medicine.
  2. Government mandates. This year the coding and billing system that has been around for years is completely changing. This means that the computer systems on our end need to be updated and the computer systems on the insurance company end need to be updated. We will be required to use the new system, ICD 10, starting October 1st, but surveys are showing that it is very likely that insurance companies won't be able to accept those codes yet. This will delay processing of all bills submitted. Various experts say that payments may be delayed 3-6 months. How can any business survive if they make no money for that time? Not to mention the conversion costs to our practice. Estimates range from $83,000 to $2.7 million. Our practice is mid-sized, so will probably be somewhere in the middle of that. Where will this money come from? We are fortunate that we started using electronic health records (EHR) many years ago. That was a huge financial cost at the time, but I am glad we don't have to have that added expense now. (I'm not sure if EHRs will directly be required, but they certainly make it easier to meet all the other requirements now mandated.)
  3. Payer headaches, and the fine print. Physicians are being dropped from insurance panels at a time when there are more insured patients. This will make access even more difficult. Insurance companies are requiring more prior authorizations than ever for tests and treatments. This takes staff and physician time. That time is not reimbursed by the insurance company. 
  4. Time. I love to spend time with my patients, but with all these numbers adding up, I might have to schedule more visits per hour so that I can pay our office bills at the end of the month. This means less time with each patient. I don't know how that can be done and still provide good care, so altering my schedule will be one of the last changes I want to implement. 
  5. Technology costs. Many practices starting a new EHR will not be able to see the same patient volume due to the added time documenting in a new charting system. As I mentioned before, I am thankful that we took that plunge and ate those costs years ago. But we still have IT costs on a regular basis and are looking forward to more this year with all the changes, both described elsewhere here and things like Microsoft is no longer supporting the version of Office that we were on, so we have to upgrade. This upgrade is not as simple as it sounds because it alters the way our EHR interacts with it and some of our computers are older and must be replaced to support the new software.
  6. Staffing and training. We have been moving up the ladder in Patient-Centered-Medical-Home certification. Several staff members have put in significant time over the last few years building and implementing new practice policies and generating and reviewing reports. Our EHR has not always been able to generate the needed reports, so we had to find a company that could use data from our EHR to build them. Several times that we almost meet a metric, they update the rules, meaning new reports need to be generated. It has been a frustrating process, to say the least. I find that most of the things they want us to prove we were doing already, it's just that proving those things can be difficult. We are fortunate that we have a very low staff turnover rate. I hope all of our employees know how much we appreciate them!!!
  7. Putting control back in the hands of physicians. Physicians generally go into healthcare to help others, but with all the stresses described here, many are dissatisfied on the job. Some are leaving patient care and finding other employment. Some still practice, but their dissatisfaction probably impacts the care they give. Many are fearful of all these stressors and leave private practice to be an employed physician. I have friends who used to love their doctor, but now can't get the access they used to have because of the bureaucracy of the new office management. Our local children's hospital has wonderful physicians, but I hear complaints often about the problems with access and other business themes. If these same physicians were self employed, they would be able to control these problems more easily on a smaller scale. As more physicians become employed, I think these problems will magnify.
  8. Changing patient populations. More patients are opting for high deductible plans, meaning payment must first come from patients. This means the regular income physicians get from insurance companies won't happen until patients meet their deductibles. Most patients hope to never reach their deductibles. Now we will be relying on patients to pay their bills in a timely fashion. I personally hate talking money with patients. I want to provide the care that is recommended. While I think that having patients invested in their healthcare can make them more informed consumers and has the potential to help them make better healthcare decisions, it can also be a roadblock to good care. There is also the problem that I can't easily tell a parent how much it will cost. We can tell them what we bill, but their insurance will probably discount it. It might be covered in full by the insurance company and not cost the patient a dime. I don't know the patient's insurance payment requirements, and finding out information from the insurance company is difficult. We can provide the code so the parent can call the insurance company and ask, but at the time of service there simply isn't time to spend on hold with the insurance company to find out before the visit is over. Some parents have smartly called us ahead of time to ask what will be billed, but our staff can't know exactly what the physician will order at any visit. They can make best guesses based on the type of visit, such as an 18 month old well visit will have standard physical, vaccines, and autism screening. But if the child is tugging at an ear and there is wax obstructing the ear drum, we will remove the wax and diagnose either ear pain or ear infection plus impacted ear wax. None of that could have been anticipated based on the well visit scheduled. (Adding separate visits to a well visit is another topic entirely, since the well visit is often covered entirely by insurance, but the ear issue would be separate and fall to patient responsibility.) Using asthma again as an example (but it also goes for autism screenings, cholesterol screenings and more): I don't want to skip the spirometry for my asthmatic patient because the parent doesn't want to pay for it. That means I won't meet the metrics for asthma care, which puts me at a lower pay scale because I'm not a "quality" doctor. And more importantly, I'm not doing what I know is best for the patient's asthma management. How can I ethically treat patients with the standard of care I believe in only if they can afford to pay it? Should I lower the standards if they want to cut corners? That is a slippery slope I don't want to travel!
  9. Primary care's changing role. Primary care physicians are going to be more accountable for being the central member of the health care team. As part of the Patient Centered Medical Home, we will continue to offer full scale preventative healthcare as well as management of most illnesses. We are also required to follow up to be sure patients got into the specialist we referred them to, or that they did the labs as ordered. We must have easy access for same day visits and extended hours. We must show that we follow practice guidelines. Although my practice already does these things, we must prove that we do, which takes even more uncompensated staff time.
  10. Work life balance. This has always been a tricky thing for physicians. We cannot expect to work a 40 hour work week unless we are employed and there are shifts without any call requirements and all charting, follow up phone calls, review of labs, etc can be done while on the clock. Those of us who also own a practice must do business things when we aren't seeing patients. Either we cut our productivity and do business during business hours, or we see patients during business hours and do other business things after hours. This cuts into our family time. But we must be able to pay the bills... This explains the high rate of physician dissatisfaction and burnout. Physicians have a higher suicide rate than the general population-- up to 4 times the general population for male physicians by some estimates. This rate cannot support a healthy healthcare system, and with all the added issues with the 2014 changes, more burnout or sell out is to be expected.
In summary, there are many things that worry me and other physicians about our current healthcare climate. I still love my job, at least the parts where I get to take care of patients to improve their health and well being. I just wish we didn't have to worry about how to keep our office financially viable. Any time money comes into the equation, it can impact healthcare. I hope that all these changes help people take charge of their own health in new ways and that they can find ways to pay for all their healthcare needs. I also hope that all the regulations really do improve healthcare outcomes and help physicians provide better care, not just more documentation of care.

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