HHS Secretary annouces historic reforms, as primary care burnout intensifies

"Today's announcement is about improving the quality of care we receive when we are sick, while at the same time spending our healthcare dollars more wisely," said HHS Secretary Sylvia Burwell this week. "We believe our goals can drive transformative change, help us manage and track progress, and create accountability for measurable improvement."

Through the ACA, the Health and Humans Service Secretary announced this week that Medicare was going to dramatically alter its physician payment model. Starting in 2016 (next year!) it is projecting that 85% of payment will not be based on revenue from direct patient visits. Although they did not explicitly say so, this would have to mean that payment for visits will be markedly cut back. In place, physicians will be paid for value and quality. What the heck does that mean? Quality refers to quality indicators, which, as we have discussed, are often clinically irrelevant measurements, tests, and treatments that Medicare has told us we have prove adherence to, typically by filling out template notes and other electronic forms. It also means that we have to employ electronic medical records (EMR’s) and, through a time consuming and arduous process, prove to CMS that we have used our EMR in ways that Medicare considers meaningful. By value, Medicare means we have to partake in ACA innovations such as Accountable Care Organizations (ACO’s) and medical home models and other similar programs not yet defined to demonstrate we can save Medicare money. Of course, even within those groups, our patients can exhaust as many Medicare resources as they want, and we still will not have the ability to treat our patients at home where it will be less costly, but we will be held accountable if our patients do spend too much Medicare money, not being given any tools to curb that spending. That is how we are graded on value.

I have written an op-ed about this issue that will be in the Baltimore Sun on January 30th. A copy of the op-ed will appear in my next blog.

Our group has done everything possible to stay in compliance with Medicare and ACA regulations and rules. Other than salaries, our cost for computers is the largest part of our overhead, and we have spent the time demanded (on average, and extra hour a day) to adhere to Medicare’s requirement for EMR meaningful use. We have complied as best as our conscience allows with Medicare’s quality indicators, although in many cases these quality measures are actually harmful to our elderly patients, as I discuss at length in my book. Most of this is busywork, detracting from patient care, and costing our practice time and money unnecessarily. Much of it we have still not figured out, despite our best efforts. But we keep plugging away, well knowing that our future survival relies on our ability to navigate these uncertain waters.

What has been the result? Last Spring our practice was audited by Medicare for seeing too many patients in assisted living facilities, which of course is a large part of our geriatric practice. After stress and time and money, we survived the audit. Just a few weeks ago, I received two more letters from Medicare. One declared that my 2015 Medicare reimbursement would be reduced by 3% because I was not deemed to have appropriately completed my EMR meaningful use requirements for 2013. The other declared that I was going to be audited for my 2014 meaningful use, meaning more hours of wasted time and unnecessary frustration, plus likely more lost income. All this work, all of this investment, and the result is a pay cut and another audit? It makes no sense. But this is our future in the ACA’s new innovative payment scheme where we will be rewarded for “value” and “quality” and not paid for our visits and work. The AMA and AAFP have already signed on, even while a host of doctors on internet sites such as Metscape have voice almost unanimous disapproval. But the people who orchestrate our medical future do not listen to those of us who actually practice medicine. They would rather listen to pundits and thought leaders and economists and politicians who tell us that they know better. Patients will be left with fewer doctors to care for them, as they sit in the exam room watching their doctor spend all his/her time plugging numbers into computers, ordering tests, prescribing medicines, and asking questions that have relevance only to complying with Medicare’s script. Doctors will be reduced to automatons who follow the commands delivered to them from above, hoping not to have everything stripped away by a bad audit or by not adhering to a certain regulation that they did not know about. That is quality and value.

A recent Medscape survey demonstrated that physician burnout has reached historic highs. US doctors suffer far more burnout than any other workers. In 2013 43% of primary care internal medicine doctors claimed to be burned out. In 2014 that number jumped to 50%. Primary care internal medicine doctors had the 3rd highest burnout rate of all physicians. Among the top five reasons for burnout were: too many bureaucratic tasks, feeling like a cog in the wheel, and increased computerization; implementation of the ACA was not far behind. It is known that 85% of practicing physicians feel powerless to impact their professional lives. With so many new rules being tossed on our laps, with our livelihoods and our ability to work with our patients dependent on the definition of quality and value cooked up by non-clinical leaders in Medicare and the ACA, no wonder our stress and burnout are escalating. As only 20% of medical students pursue primary care fields, while so many others are leaving amidst the onslaught, what will the medical landscape look like in 5 years? Perhaps not the paradise that that the ACA engineers and HHS Secretary Burwell has envisioned.

My own hope is that all of these predictions will fade away, and as 2016 moves to 2017 the existing pay-for-service status quo will trump Secretary Burwell’s reforms. Of course, preserving our current health care mess is not ideal, but it is more palatable than what our health care engineers have concocted. In my book I discuss simpler common sense solutions that could help repair our health care delivery system without such radical alterations. But the bottom line is that unless those on top listen to those of us on the bottom, then nothing constructive will be accomplished. Practicing primary care doctors must be directly involved in reforming Medicare. Otherwise, we will be left in a quagmire of acronyms, regulations, and the very antithesis of quality and value.


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