Today I spent my lunch hour listening to a webinar on the
highlights of what physicians need to know to be ready for MACRA (Medicare
Access and CHIP Reauthorization Act) implementation, specifically new CMS regulations
for the Quality Payment Program (QPP) that physicians accepting Medicare must
participate in starting in 2017 in order to not suffer financial penalties.
Despite the rather convoluted alphabet soup of acronyms and new regulations, I’ve
heard this topic presented by multiple sources over the past few months and am
starting to feel I have a fairly good grasp on the content, possibly even well
enough to present it to a colleague if necessary. Most would consider this
going above-and-beyond for me, if not completely unnecessary, given that I am
still completing my residency and working in an environment where I don’t
personally have to pay much attention to billing and quality metrics as someone
else is doing that part of the job and my not knowing wouldn’t affect my salary
or really how I interact with patients one bit.
The problem is, I won’t be in this environment forever. In
less than a year and a half, I will graduate and move on into the world where I
can prioritize my professional autonomy and would very much like to have my own
practice. Unfortunately, to do this requires a tremendous amount of knowledge beyond
what has been taught in any of my formal education to become a physician. So sacrificing
a peaceful lunch hour to further school myself on the ins-and-outs of avoiding
reduced payment for Medicare patients due to my own inadequate reporting is part
of the burden I must bear. Unless… I choose to practice differently and refuse
to participate entirely.
This whole situation causes me to reflect on a particular
moment of reckoning I had back in May 2016. I was giving a presentation at a
local elementary school to a group of parents to explain how the state of
California had recently expanded Medicaid eligibility to all minors under the
age of 19, regardless of immigration status, and how to ensure their children
would be properly and promptly enrolled. As is usually the case whenever a
physician opens herself up to a broader audience like this, I started getting a
lot of questions from those present about their personal family situations.
Though rather than focusing on the children which was the initial intent of the
presentation, it was regarding themselves or other adult family members who
were unable to access our inadequate patchwork of services open to undocumented
immigrant adults. I take great pride in understanding the complex interworkings
of government programs and have made considerable effort to keep abreast of new
developments, something I was doing long before even starting medical school. I
happily serve as a reference point for my peers and patients alike. But as I
was fielding what seemed like an endless stream of questions that night and
watching the defeated looks on the faces of these parents who were clearly
overwhelmed by the many steps, entry points, applications, and exceptions to
the various programs I was describing for their individual situations, I
finally realized just how absolutely crazy this all is.
What good is it for me to be an expert at the ins and outs
of the dozen different programs and services, each with their own applications,
billing, and reporting requirements, if the systems we’ve created are so
completely convoluted that my patients can’t even begin to access them? It was
at that moment that I knew for certain that I would need to find a way to
practice differently, in a manner that anyone could understand and all could
access.
Direct primary care is a beacon of hope in the insurance and
billing madness. This model of care is conducted by physicians who rather than
billing on a per-visit basis, instead charge a flat monthly rate to receive
service at their practice and forego billing insurance entirely. For the
physician, this substantially lowers overhead and administrative costs of the
practice, providing them with a fixed income stream and allowing more time to
participate in actual patient care. Most physicians currently practicing under
this model are able to offer visits from 30 minutes to an hour in length
(versus the 10 to 15 minutes typical in most traditional offices), have smaller
patient panels, and more easily accommodate patients for same-day sick visits.
Without the worry about lack of payment for certain services, these physicians
are even able to interact with their patients in whatever way makes the most
sense, whether that’s discussing symptoms over the phone or through video chat,
or possibly even conducting a home visit where warranted. With easier access
and more time to spend with your doctor, is it any wonder that these practices
have demonstrated significant improvements in patient health outcomes?
What if I told you that on top of providing better care that
these practices are even substantially reducing the cost of care? Consider that
a typical single office visit to a primary care physician is billed at upwards
of $150, excluding any additional tests or procedures. But many of the practices
serving in this model are able to charge a flat rate of just $50 monthly for a
typical adult, oftentimes providing further discounts for children or families.
Frequently, these practices have also negotiated special pricing with labs and
imaging centers to obtain tests much nearer to cost than the rates negotiated
with typical insurers and even lists of local specialists who have similarly
negotiated flat rate reduced fees for patients who will cash pay for services.
For years now, it has been a Republican talking point to
bundle high-deductible health plans with health savings accounts as a solution
to get patients to become more savvy consumers when it comes to healthcare. As
a self-identifying progressive, as a medical student, I used to rail at the
idea. It was completely dismissive of the fact that for low-income patients,
there was no way on earth they would ever be able to stash away $10,000 to
cover the potential deductible for such a plan. Until I realized that this was
happening anyway. For my undocumented patients who are without other resources
or methods of funding, they are frequently denied service for non-emergent
procedures until they can come up with a down payment, often in this exact
price range. Furthermore, even on the sliding scale fee schedules charged by
our county clinics and community health centers, just 3 or 4 visits could
exceed the cost of membership to a direct primary care practice for an entire
year. Not to mention, making the decision to pay $150 or $200 to see a doctor
when one is acutely ill is often much harder to stomach or even come up with
than a planned monthly fee similar to a cell phone or cable bill. A high
functioning primary care physician who is given the ability to dedicate ample
time and attention to her patients will find that the need to refer to
specialists becomes a rarity rather than the norm, no longer a dumping ground
for things I simply don’t have time to address in our 15 minutes together.
The benefits to both physicians and patients of such a plan
are undeniable. So why isn’t everyone doing it? Because for many of us, it
necessarily forces us to exclude some of our patients. Right now, California
state law treats a monthly fee charged for health care as a “health plan,”
meaning that the doctors taking part in these models open themselves to legal
exposure of potentially being treated like an insurance product even though the
fees they are charging are to cover services at that practice alone.
Furthermore, government and even privately funded health insurance programs
will not cover the monthly fee to practices in this model. Traditional Medicare,
our federal insurance for the elderly, specifically prohibits payment for this
monthly fee for membership-model practices despite the fact that it has proven
to be an effective and successful model for patients served by privately
administered Medicare Advantage programs.
My patients need simplicity. They need to understand exactly
how much things cost and what, precisely, they are getting for the amount they
are paying. Physicians need simplicity as well, not a never ending stream of
regulations and reporting requirements that do little to improve care and much
to limit our time focusing our attention where it would be better served. Even
for a policy nerd like myself, this is getting exhausting, and I recognize that
my longevity in practice will depend greatly on my ability to simplify things
and create a model where my attention can be focused on the health of my
patients rather than my ability to understand the latest initiative of a group
of bureaucrats who understand little to nothing about medicine.
