Thursday, July 21, 2016

Private Practice Physicians - Elephants in the Room
An “elephant in the room” is a subject  nobody talks about but everybody knows is there.  The elephant  tends to be a huge refractory problem that nobody wants to address because there are no glib answers.
Government and Private Practice Elephants
For health reform progressives the elephant in the room is private practice. About 30% of private physicians now practice solo and 50% are in groups of 6 or less.  These physicians are “fragmented” and do not uniformly follow government regulations.   For physicians, the elephant in the room are government regulations,  mandates, penalties, restrictions, and what CMS will pay for.
Private Practice – A Thorn in ObamaCare’s Side
These physicians are a thorn in the government’s efforts to develop a nation-wide integrated uniform standardized system based on data.     Electronic heath records (EHRs are the  pillar or such a system.   EHRs are the chief data gathering device justifying government policies that stress outcomes management,  evidence-based medicine,  pay-for-performance and other quality improvement schemes which have yet to bear statistical proof of their usefulness.   
EHRs -  A Pain in Private Practice’s Side
Private physicians resist and even detest  EHRs.   Clinicians complain EHRs are not ready for prime time,  are not clinically useful,  do not communicate with other EHRs,  distract from patient care,    do not offer information that improves outcomes or quality, and add  unnecessary overhead.  
What Is  CMS  to Do?
What  is  government, bent on reform,  to do?   Well, according to an article in the June  newsletter of the American Association of Physicians and Surgeons (AAPS)  ObamaCare and government policy wonks think the best way to slay the private practice elephant in the room is to squeeze the income and decrease the joys of private practice. 
Imposing Regulations and Penalties
How?  By systematically imposing a series of regulations and penalties on private physicians that take time away from patients (their chief revenue source)  lower payments for  CMS and ObamaCare patients (below those of private payers by 30% to50%,  and reimburse private physicians below the cost of staying in practice (by 10% to 20%).
Once You Have Them by Their Wallets
Once you have doctors by their wallets, policymakers thinking goes,   physicians’  hearts and minds will follow.  They will either quit practice early, become hospital employees,   join large integrated health system,  and become quiescent salaried employees,  anything to avoid becoming data entry clerks for government
Death by Regulation and Financial Suicide
The AAPS article calls this approach to discouraging private practice   “death by regulation”.  Rather than go this route and commit “financial suicide” doctors will choose other options.   Selling their practice to a younger physician is not an option since young physicians prefer the security and time-off and balanced life style of employment.
Here is how the article describes the situation as a 5 Act drama.
Act I
“Act I of the saga to socialize medicine and destroy private medicine in America began in 1965, with the passage of Medicare, then Medicaid. Almost immediately,  cost escalation began, as predicted by AAPS. Before 10 years had passed, the federal government was already violating the promises enshrined in the amendments to the Social Security Act that established Medicare, “
Act II

“Act II began in 1972 with “landmark” Professional Standards Review Organizations (PSRO) and more utilization review regulations, soon followed by Medicare fee caps and then the Resource-Based Relative Value Scale (RB-RVS).

“Act III was the bold Clinton initiative to expand federal control into all of American medicine, using the managed-care mechanism that had gotten a federal boost with the HMO Act of 1973. While the Clinton Health Security Act itself did not pass, the backup strategy worked: the State Children’s Health Insurance Program (SCHIP) plus the incorporation of essential elements of the Clinton Plan into the Health Insurance Portability and Accountability Act (HIPAA). These included vast expansion of the funding and powers of federal law enforcement, draconian civil monetary penalties, and harsh prison sentences for “healthcare” crimes that previously might have been called billing errors. In the guise of “privacy,” the foundation was laid for forcing adoption of electronic health records (EHRs), a necessary surveillance tool.”
Act IV

“Act IV, the Affordable Care Act (ACA), herded almost everyone into federally regulated third-party payment schemes. The costly bureaucracy drove increased hospital consolidation,  impelling independent physicians to join Big Healthcare systems. Largely thanks to ACA, the HHS paperwork burden has increased to 700 million hr/yr, up by 300 million since Obama took office. It takes 354,500 full-time private-sector employees to comply. There are 86 new ACA rules pending, one with an estimated cost of $41.8 billion.”
Act V

“Now comes Act V, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), with 962 pages of newly released regulations. This could be the coup de grâce. “

“The new physician payment rule would be “financial suicide” for small practices, said Farzad Mostashari, who spent 2 years leading the White House effort to implement EHRs. “
“Details of the Merit-based Incentive Payment System (MIPS), CMS estimates that 87% of the nation’s solo practices (nearly 103,000 physicians) will face a penalty in 2019, amounting to $300 million. Practices of two to nine physicians would pay about $279 million).”

The rules make the federal government and its proxies the arbiters of “quality” and “value,” and require physicians to allow CMS to access all medical records of all patients. A new class of intermediaries must keep the data for CMS audit for 10 years minimum, if not a lifetime in targeted cases, writes AAPS director Kristin Held, M.D., in a meticulous analysis of the rules.”
Chinese Water Torture and  Death by Chicken Pecking
In management circles,  the government approach of piling on regulations and penalties is known as either “Chinese Water Torture,” i.e.,  one, dropping water on the forehead of restrained person until it drives the insane or the case of doctors makes them insolvent,  or two,   being “pecked to death by chickens’  through  a steady stream of annoyances  or nuances which eventually exact such  a heavy burden  that it makes practice insufferable  and no longer gratifying or satisfying to a training professional interested in healing and relieving pain rather complying with government regulations.

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