Inbox: Higher Deductibles Cramp Physicians, Patients

September 21, 2016

In our recurring blog "Inbox" we share comments from physicians and practice administrators telling us what keeps them awake at night.

Editor's note: We work hard to write about issues that will help physicians run their practices in a manner that is both prosperous and efficient, while still delivering quality patient care. And we are delighted when our readers let us know what they are thinking. This month we are excerpting an article by associate editor Erica Sprey on physician frustrations with the rising costs of doing business, and a blog by primary-care physician KrisEmily McCrory on why she thinks EHRs aren't really the problem. The articles has been edited for space and are followed by comments made by readers at PhysiciansPractice.com.

The Rising Cost of Patient Care

Physicians are becoming increasingly alarmed about the meteoric rise in costs to provide healthcare to their patients. Physician Practice's 2016 Great American Physician (GAP) Survey found that one-fifth of the 1,314 physician respondents say rising deductibles and cost sharing represent the largest barrier to good healthcare for their patients.

Pediatrician Terence McAllister and his spouse Leann DiDomenico McAllister, co-owner and practice administrator for their Plymouth, Mass.-based micropractice, Performance Pediatrics, say their practice and patients have been feeling the ill effects of a state decision to reel back reimbursement rates for the poorest patients. …

Complicating the financial picture, third-party payers are moving en masse to insurance products with higher deductibles, placing greater financial burdens on both medical practices and their patients. What can physicians do to navigate this trend and help their patients' better access care?

Deborah writes: This article leaves out a major point of contention for me - one which I am going to continue to scream from the roof tops. The insurance companies, the government, and now many of the medical societies continue to place administrative burdens on physicians and their staffs. At no point is anyone holding the insurance companies accountable for one simple solution: accurate benefits without a disclaimer. I get the reality of noncompliant patients. If you can't come to terms with that you should leave healthcare. Until mental, socio-economic issues are addressed you will not fix noncompliance.

We can fix the flow of accurate information. There is not one item in this country that you pay for after the fact except healthcare. You do not buy a car and receive a bill in the mail. Nor groceries or any other product. You want patients to understand their benefits? I have been an administrator and manager for 24 years and I still can't get a straight answer on most patients' benefits. We verify, educate, and collect up front. Insurance companies can still deny a surgery after the fact due to an unknown "policy exclusion." Patients would have to be attorneys to understand their coverage. The fix is simple, each insurance website should have the ability for providers to enter codes and received guaranteed benefits. No one should have to make medical decisions without proper cost determination.

James says: As stated by Deborah, administrative costs and burdens have skyrocketed with, for the most part, a negative effect on patient and physician lives. To paraphrase a quote from one of the administrative parasites cited in this article: "He says that the motivation for establishing Aledade was to give physicians the collective power to manage outside demands such as strict payer requirements, growing patient cost sharing, and government programs that aim to steer physicians toward value-based care." I would politely reply BULL$H! This guy simply wants to milk the system for more money. The business guys saw all the money in healthcare about 30 years ago and have been going at it with great success. There is no program to bilk like a government program! Unfortunately, we doctors have been sheep and allowed them to get away with it. A few of us will go concierge or direct pay, but the rest will remain cogs in the maw of the system.

Deborah responds: Exactly! We should not have to manage growing outside demands. We should manage the health of our patients. Aledade should [target] the government and health insurance companies for profits. We could provide "value-based" care if all our dollars were not going to the cost of recouping the stingy fee schedule amounts allowed by payers which decrease every year while all of our costs increase.

Leann writes: You make an excellent point. Healthcare happens in real time, but currently paying for it in the U.S. is weeks, months or even years later. Newborns need to be treated the day they are born, broken bones need to be set before they start to heal and communicable disease needs to be treated to not only make the patient feel better but to keep virus from spreading throughout the population. For me, all this points toward healthcare being a public good and not a private on. Public goods (i.e. the military, clean air/water, schools) are paid for with tax dollars. For me, single payer is the best solution.

Loera asks: 1.) How much profit margin do the insurance companies have? I know that our profit margin is very small and nearly at a loss. 2.) When are patients going to be responsible for their health situation? Diabetics eating cake and drinking cokes, hypertensive patients eating salted foods, patients with high cholesterol eating all sorts of fatty foods. Patients need to understand that, by taking a pill, doesn't mean they do not need to change their ways. The onus should be on the patient.

Does the full blame for rising costs lie with third party payers or government mandates? Tell us what you think.

'Why I Hate My EHR'

I don't really hate my EHR. I appreciate the ability to read office notes that would otherwise be illegible. I can find old orders, past lab results, and every phone message I have responded to. There is no longer a crowded chart room where I cannot find a misplaced chart that may or may not have actually had the information I needed because it was incorrectly filed. No more loose papers or Post-it notes. Having been a teenager in the 90s, I am not daunted by the technology and am not nostalgic for the "better" world of paper charts. Having been gone to medical school and trained in institutions during their transitions from messy paper charts to electronic records, I have not struggled to accept the inevitability of an EHR. I can see so much promise in going digital.

What I actually hate is the chaos and disaster that will be forever linked to the government requirement to use the oft-despised EHR. What we need are systems that work together in a way to permit a secure but accessible flow of information. As the medical world and ultimately patient care becomes more and more fragmented, what we are missing is interoperability and communication. However, instead of improving on the often disorganized paper charts, the forced use of the EHR system has created multiple, disconnected silos of systems that cannot talk to each other.

Romeo comments: If your current EHR forces you to fill in maddening check boxes, then the solution is to create a macro [template] to fill in a default choice; note this choice in a rubberstamped statement in the note, then enter the information you actually want to enter.

KrisEmily responds: That does not change the fact that I have to waste time filling in the rubber stamped statement.

Romeo says: EHRs would be better designed and would work far better if physicians refuse to accept health insurance. If you refuse to take health insurance, then you can ignore the check boxes. You can put in the data you want that you believe is the best for the patient - not the insurance company.

KrisEmily responds: That helps if you can take care of patients without insurance and still pay all your bills. Right now more and more physicians are employed (with more of those coming out of residency opting employed positions). I am a big fan of Direct Primary Care, but I haven't seen how it will play out in our current state where almost everyone accessing care either does so through insurance (private or government derived) or some form of charity care. Now if we could get all physicians to ban together we might have better leverage, but the government has squashed that in the past (anti-trust) and I suspect they would do it again.

Do you think the introduction of EHRs has hindered physician productivity and revenue? Tell us your thoughts.