How will repealing the SGR affect your practice?

The sustainable growth rate (SGR) formula was enacted into law in 1997 to tie Medicare payment for services to physicians to the overall status of the economy. Basically, if the U.S. gross domestic product (GDP) does well, doctors get more money, and if it does poorly, doctors get less money for the same service. A decade of tinkering with legislation for circumventing the application of the SGR formula, preferably a few days before or after it was due to take effect, resulted in failure to save $150 billion dollars over the last decade. For the next decades, the Congressional Budget Office estimates that avoidance of the SGR formula will fail to save us a mere $139 billion, so this should be a perfect time to let bygones be bygones and come up with a more gentle strategy to cut physicians’ Medicare reimbursement. More gentle, because if we do decide to cash in on our SGR savings on January 1st, doctors are looking at an approximately 24.4% cut in the Medicare fee schedule for 2014.

Building on H.R. 2810, the “Medicare Patient Access and Quality Improvement Act of 2013” approved by the House Committee on Energy and Commerce, the new proposal to fix the SGR comes from the House Ways & Means and Senate Finance Committees with support from both Democrat and Republican members, hence the bipartisan and bicameral labels. It is currently in draft form and it is open for public comment until November 12, 2013. This is a short document, and you should read it before it’s transformed into a 1000 page cleverly titled Act. The idea behind the proposal is very simple, and it is widely used in other service industries, where patrons pay a base price for the service, and discretionary bonuses, gratuity, or tips, are available to service providers based on quality of service. There is a small difference though, since the proposal is supposed to be budget neutral (i.e. a zero sum game). Thus, a sufficient number of physicians will need to be penalized to balance the bonuses awarded to better performers.

Below is a simplified summary of the eight point proposal to repeal the SGR, and replace the straight fee for service payment system with quality adjusted risk-based contracting:

  • The Medicare physician fee schedule will be (sort of) frozen for the next 10 years. After 2023, the fee schedule will be adjusted upwards by 2% annually if you take risk for your patients through an advanced alternative payment model (APM), or just 1% annually if you don’t.
  • The heart of the proposal consists of bundling the multitude of incentives and penalties currently enacted by CMS, into one Value-Based Performance (VBP) Payment Program, beginning in 2017. It’s not that you won’t have to report quality measures or be a meaningful user, you will have to do those things and more, but there will be a single aggregate score to trigger incentives/penalties, calculated as follows:
    • quality measures reporting — exactly what you think this is — weight 30%
    • resource use — similar to the CMS Value Based Modifier initiative, with an added requirement for claims self-reporting (subject to payment reduction) — weight 30%
    • clinical practice improvement activities — basically patient centered medical home (PCMH) or patient centered specialty practice (PCSP) certification — weight 15%
    • EHR meaningful use — it seems that all that is needed here is the use of a certified EHR — weight 25%
  • Practices that have very few Medicare patients are exempt and practices that have significant revenues in at-risk contracts (see below) are excluded from the VBP program. This is a budget-neutral item, meaning that high performer bonuses are directly proportional to the number of penalized poor performers. The pool available for bonuses starts at 8% of the total physician payments in 2017 and increases in subsequent years.
  • Since the stated goal of this permanent SGR fix is to eliminate fee for service, an additional 5% bonus will be made available to those who have significant revenues tied to at-risk contracts. The thresholds begin at 50% and go up to 75% revenue. Both Medicare and commercial payer revenues can be counted for this purpose. It is interesting that the thresholds are for revenue, not patients, and it is also interesting that private payers can be counted, although it is not clear if the bonus is 5 percent of Medicare payments, or 5 percent of all payments. A seemingly simpler alternative to obtaining the 5% bonus is to have a “significant share” of revenue in a patient-centered medical home (PCMH) model that has been “certified as maintaining or improving quality without increasing costs.” This will require some explanation in the final bill because PCMH is usually not tied to revenue shares, and because I am not aware of anybody with the ability to certify that a certain PCMH model will increase quality, but not costs.
  • For those practicing in a PCMH, or a comparable specialty model (e.g. PCSP), special care coordination codes will be created. The description here sounds very similar to the new Transitional Care Management CPT Codes following hospital discharge. Note that payment for these codes is also budget neutral within the physician fee schedule, so for each care coordination code paid out, someone or something else will be paid less.
  • Along with ending fee for service, the proposal will also improve the fee for service schedule, by thoroughly evaluating and “identifying and revaluing misvalued services” to facilitate “smooth downward payment adjustments” The yearly downward target is 1% per year, and if not enough misvalued services are identified, the entire fee schedule will be revised downward by the missing amount. If more than 1% reduction is found, the funds will remain in the budget neutral pool to offset bonuses and other changes.
  • The proposal will also ensure that physicians practice medicine correctly. Mechanisms will be put in place to make sure doctors consult appropriate clinical decision tools before ordering “advanced imaging and electrocardiogram services” (no idea why electrocardiogram of all things is specified here). The “tools” will report back to the Secretary of Health and Human Services that such consultation occurred prior to ordering. “Payment would not be made for the advanced imaging or electrocardiogram service if consultation with appropriate use criteria did not occur.” Physicians found to order too many of these services will be required to obtain prior authorization in the future. If things go well, other services will also become subject to appropriate use surveillance.
  • To support all these activities, qualified entities that are receiving Medicare and Medicaid data for public reporting, will be authorized to sell analyses and reports to physicians, as well as commercial insurance companies and employers too.
  • Transparency will be facilitated by publishing physician payment and various performance metrics measured through the program, so the public can search for physicians by name and get all the data they need to select providers.

Bottom line

Although right now this is just a proposal, it is very likely that sometime around January 15, 2014, this, or something very similar to it, will become the law of the land. For small independent private practice, the increase in bureaucratic burden will be significant and the reach of insurers into your everyday work will become palpable. Noncompliance with the new regulations means that your topline will remain flat for the next 10 years, minus any penalties, rejected claims and downward adjustments, which may or may not be significant depending on your specialty. Initially, this may only affect the Medicare portion of your practice, but it will not remain that way for long.

If you want to continue practicing medicine and remain independent, you have three basic choices:

  1. Join a larger entity, such as an accountable care organization, and accept risk for most of your patients in a managed care environment.
  2. Adapt to the new paradigm by getting yourself a certified EHR, obtaining PCMH recognition, and learning how to practice under increased supervision.
  3. Stop accepting insurance and switch to a direct pay model.

Since the program is slated to begin in 2017, you have 3 years to make an informed decision.

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

Comments are moderated before they are published. Please read the comment policy.

  • buzzkillerjsmith

    This is all pretty overwhelming, and I suspect it will continue the trend of having doctors cluster up in big organizations run by business people.

    It seems that the government wants to micromanage the practice of medicine, and I suspect doctors and patients will howl in protest. Some of this will stand, some will not. Although I have no crystal ball here, many docs that can will dump Medicare. Some will have nowhere else to go, and it is certainly possible that insurance will follow suit and clamp down too.

    These administrative mandates are absolutely crushing, even bigger morale killers than the prospect of less income, at least to my mind. This is a profession in very rapid decline. It is in many ways a horrid job, not because of the patients, although patients are getting more and more angry with us since we are the ones they see. Not because of diagnosis and treatment, but because of the clampdown. Retirement can’t come soon enough for this doc.

    How will the med students and the new docs respond to all this? I see even more part-time practice as docs run for shelter from all this. But again it is not clear. The huge med school debt and their own residual altruism and, frankly, desire for money may keep them on the line longer than most will want.

    “Taking the cure” , getting off the line by getting admin or non-clinical jobs, will increase. It might turn out that medicine becomes unattractive as a career for college students of the first rank.

    It’s rough to see my profession destroyed or at least degraded in this country, but there might not be a way out for us.

    • Dr. Drake Ramoray

      I have posted elsewhere that I am currently trying to minimize my exposure to these changes. We are aggressively developing a clinical research program in my practice. We are back to having a waiting list for Medicare. I am not optimistic that we will make it independent. I had always figured I had five years or so, now looks like about three. Even the path we are on now is sad for the community. The nearest Endo is about 2 hrs. away.

      Maybe I should just go get my MBA. Endocrinologist, private pratice and clinical research experience, then with business credentials. Long lunches, golf outings (I don’t play) with the CEO. A nice desk job, tell other doctors what to do and how to practice medicine. Maybe even see patient’s a one or half day a week or so. There are published studies that show millions of dollars that can be saved annually with tight glycemic control in the peri-operative setting (especially for CABG) with length of stay and infection rates at just a medium sized hospital. No beancounter has ever wanted to hear about it beyond paying Endo’s for E&M. (Inpatient Medicare E&M is laugable). Can’t make any headway as an MD on the issue and things don’t look to be getting any better.

      No way I’m ready to retire. Perhaps it’s time to join the coporate world.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Do you think you can actually do this? I am not questioning the validity, and it may very well be that if enough physicians make these types of transitions, they can at least steer things into a more reasonable direction… I’m just wondering out loud if it is possible to leave seeing patients behind and still be able to benefit patients from a different vantage point…

        • Dr. Drake Ramoray

          Well I started the post with the intent of being sarcastic, but as I got into the CABG literature and glycemic control component I started to slant it towards an actual idea.

          I’m not certain I could do it and be happy, if that is what you mean. I went into this profession, and particularly under-represented Endocrinology, because I like taking care of patients and find it very very interesting, so much like a puzzle. There is no real extra money in Endocrinology except for ultrasounds and nuc med so our income isn’t very different than internists or FP. Nobody goes into Endo because it’s extra training and no extra money.
          I also believe that a lot of people don’t choose endocrine because they don’t like taking care of diabetes. Some Endocrinologists don’t like taking care of diabetes.

          The problem is every day I like taking care of patients less and less. Not because of the patients but because of the hassles. I wrote a four page letter to an insurance company with medical citations why it was inappropriate for them to deny an MRI for a male patient on no meds with a high prolactin level. They claimed his testosterone level is not low enough (which is not the issue). Their response, a CC on a letter written to the patient asking if I had permission from him to appeal his case (You know the ordering physician and attending of record).

          Diabetes is one of the heaviest targeted diseases for upcoming mandates and already carries one of the highest burdens for paperwork and prior authorizations (at least in my field). Several Endocrinologists I know have gone to general endocrine or thyroid only practices and no longer see diabetes. There aren’t any PQRS criteria for hypothyroidism, thyroid cancer, hyperparathyroidism, adrenal, pituitary, or secondary hypertension problems.

          Medicare diabetes is likey the first on the chopping block for my small practice. We are literally running the projected numbers for stage 2 meaningful use and our EMR costs in comparison to our Medicare reimbursements both with and without diabetics. I would be close to wagering money at this point that by mid 2014 we will no longer use our EMR. Thousands up front 1200ish in monthly service fees. No improvement in patient care.
          I’m not sure I could become one of the beancounters. Honestly, if the research path doesn’t work out I’m not sure which way I will go. Probably academic center and teach. That would be he path of least reisistance with my connections.

          Regardless, I will not practice medicine with a third party telling me how I can practice medicine and then tying my payment to their grade on how my patient’s are doing based on what that third party made me do.
          In the end, if I have to, I will put myself in position to work higher up in the system than be the grunt at the bottom with all the liability, stress, and mandates descending down from on high. This not an altruistic I can help people type sentiment. I am beyond that. I will not practice medicine by dicate and administrative fiat. I did not train until my early 30′s to follow some algorithm or directive mandated by people who have never taken care of patients. The current system where the “peer to peer” review system where I’m forced to talk to a non-practicing nurse about the nuances of pituitary imaging is marginally more acceptable.

          Paying off all of my debt in the next 5 years. No debt whatsoever. At that point, no debt and college funds for the kids mostly in place, I can either join the enemy (get my MBA) and become one of the beancounters and hope I can make some difference in my community. Or I can open a very small thyroid only micro-practice. Ultrasound, a patient room, a phone, and nuc med equipment (maybe 60K for nuc med and thyroid ultrasound equipment plus the cost of rent and go concierge thyroid only. There will be some regulatory overhead from the NRC and such but it is doable as long as I can live off a lot less money. I’m positioning myself so that I can.

          Medicine on it’s current path is a disaster and that’s only from the non-proceduralist physician side. God help me when I develop a chronic medical condition (another reason to stay in the profession somehow for the connections.). Any student who is going into a non-procedure specialty needs to have their head examined. Back in the day psychiatrists had to go under their own psychoanalyzation sessions. Perhaps we can suggets that for entering an internal medicine or FP residency. Think of it as Dr. Drake Ramoray’s Modest Proposal.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            This may be a dumb question, but along the lines of a boutique thyroid practice, how about going against the grain and having a Diabetes only cash practice? The market is certainly bigger, and I think there may be enough folks who would want better care than what will be available within the “system”, and most could also afford it. Maybe a network of such disease focused concierge type practices, and it doesn’t have to be micro. I think somewhere in Christensen’s innovation theories, there was reference to condition specific practices, and unfortunately Diabetes seems like a great market opportunity

          • Dr. Drake Ramoray

            I don’t think so. As it currently stands it’s not just sugars for diabetes. It requires a lot of time and money to handle lipids, blood pressure, eye doctor visits, diabetes education etc. (no the free diabetes classes at your hospital are not what I’m talking about.). Besides what good is it to have a concierge diabetes practice if their insurance doesn’t cover the meds you want to prescribe. Nobody is gonna pay cash for some of the meds that cost $2-300 a month unless I work in Beverly Hills. Chronic diabetes is just too expensive and too time consuming to do concierge (also takes way longer from a concierge buisness model perspective). Many Endo’s argue it’s too time consuming now, even discounting all the paperwork.

            I have many patients with pretty good private insurance who would greatly benefit from an insulin pump but because it’s durable medical equipment it’s too expensive to get one (About 8-9K cash).

            Thyroid. Little over head minus ultrasound and nuc med equipment. People who can pay concierge can pay for branded medication if needed ($40ish dollars for branded Synthroid). So there are no formulary issues with medicatins. Methimazole and PTU are cheap. Currently ultrasound is about $200. I could make it $125 $150 cash pretty easily (the local hospital billed one of my patient’s $600 for the same ultrasound.)
            My only heavy hitter price I’d request people for would be nuc med but the hosptial mark up is 3-4x what I get now (which I could discount) and with high deductible plans they pay for it anyway.

            Thyroid would work. I don’t think diabetes would.

          • NPPCP

            Core diabetic medication s are very inexpensive. And the annual follow ups with optho and all that can be negotiated prices for your patients if you send them all. It saves the patient so much money. If they start going downhill many times they realize it is by their own hand.

          • Dr. Drake Ramoray

            True. But how would I make the transition or who would I send them too when they become too complicated for a concierge practice model? Great I’m the Endo who abandons you when your diabetes gets complicated.

          • NPPCP

            In my experience, people who pay even the amount above for their care are interested in doing things right. They are willing to understand that most of the time, the decisions they make affect their control greatly. So the majority of the responsibility is on them because they are truly fully invested health wise and economically. So if things go bad because of their unwillingness to comply, you offer more expensive treatments. That’s all you can do. I use old school insulin with my patients and let them know the costs and alternatives of every treatment. If the price becomes too great, you guide them to social resources such as Medicaid, disability, etc. There is nothing else you can do. I never refer to endo and manage them all in my clinic. Things have been working well being open honest, everyone understanding their responsibilities and being completely honest about options and costs. Hope I answered that without too much rambling.

          • NPPCP

            And concerning getting started, have a price for everything. Office visit, com, a1c, MA, whatever. My patients get a total price BEFORE their lab is drawn. It all works out well. There really isn’t a getting G started-negotiate fees with your local lab and base your charges on these. I look at online Labs and retail clinics to make our prices competitive. Works everytime.

          • NPPCP

            I’m typing on a smart phone. Sorry about all of these errors.

          • NPPCP

            Margalit is right!!!! Reasonably well controlled diabetics without insurance will gladly pay $250 or so every six months for lab and management. That is a steal and I have many of those patients. Don’t want sliding scale clinic but don’t want to deal with insurance. I positioned myself right in the middle.

          • Dr. Drake Ramoray

            Perhaps I will have to look into that then. I probably have some negative selection bias going on because since we are in such an under served area we only get the train wrecks. Off the cuff I would say less than 10% of my diabetics are not on insulin (and most of those are truck drivers who can’t and easily keep their jobs). I’d say less than 20 % aren’t on multiple daily injections. My comorbidity rate for nephropathy, neuropathy, retinopathy, or at least 3-4 other medical problems has to be at least 75%.

            My patients are the reason I fear pay for performance. They are the same reason I poo pood concierge with my given demographic. You are correct, I don’t have a good enough sense of who out there would want to see me. Something to consider.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Whad’ya know? maybe we can come up with some options here :-) Maybe we need some sort of simple, non threatening patient survey to figure out what patients would want, what their out-of-pocket situation is, what they value….
            Maybe folks that made the transition to direct pay wouldn’t mind sharing their preparation process….

          • Deceased MD

            My advice Drake. Get out of Dodge.

          • buzzkillerjsmith

            With all due respect to Dr. D., I have found that taking care of lots and lots of diabetics about as enjoyable as hitting myself vigorously and repeatedly about the head and shoulders with a large piece of wood. Just sayin’.

            Stunning amounts of work for a relative pittance. No offense, Dr. D.

          • Deceased MD

            It’s no wonder there are so few endocrinologists. And as Drake says, many that won’t even see DM. Another great example of a disease that doesn’t get the reimbursement it deserves. But they do pay for amputations.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Perhaps we can soften the wooden board if, say, you have only 500 patients, half of them diabetic, and each is paying, say, $1,000 per year, and your billing overhead is practically nonexistent… Would that work better? :-)
            I’m sure it will work better for them….

      • buzzkillerjsmith

        Don’t get an MBA. I won’t blame you if you do, of course, but then I would be more likely to get one too.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      A while ago, on some other blog here, in the comments section, somebody introduced the idea that doctors need to explain to patients what is really happening. At other times, folks talked about doing something and fighting back. Perhaps it’s not a half bad idea to create a good, non-biased, non-political, resource (on the web), sort of like a patient education site…. Just trying to think about ways to put up some resistance, which granted, may very well be futile.

      • buzzkillerjsmith

        Simplify it for me. I’m just a dumb family doc, focused on other stuff. Margarilit, you are very smart and are on the side of the angels. We all know that. Help us out. Give us some info here.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Oh, no you’re not :-) can’t get off so easily…. :-)
          People will be increasingly confused because things are shifting quickly now. I just think a group effort to present and gather information could be useful. This blog is chock full of insights, many of them yours. I wonder if we could rearrange the chairs a little bit and give folks some propaganda free insights… I don’t have it worked out, and I wouldn’t want to do it alone anyway :-) I would need the angels to at least show up….

          • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

            Problem is, Humans are reactionary.

            We wont fix global warming until it hurts to breath.
            We dont revolt until we’re starving.
            Patients wont come to our aid until they CANT get care or the cost is ridiculous (even though I thought we were pretty much there….)

            Interestingly….
            by allowing Medicare and Insurance companies to become the main payors in the 1960s the AMA cursed us all.
            He that holds the purse strings dictates. instead of it being the patients (like it should be!) it is the government and insurance companies.

            we provide the care and play their games. They turn around send the patient an EOB with the words “usual and customary” to the patient suggesting to them that our billed charges are “way out of line.” Patients think we get paid that and are justifiably angry.

            since Government and Ins dictates what patients see of the money flow, they make us look like the bad guys.

            the only way to fix the relationship is to return the financial relationship back to the patient
            or
            have a single payer.

            pros and cons to both. personally I think we need a system that is single payor for all at a rationed level with the option to pay out of pocket for more or better if you wish.

            seems to me, that would be consistent for all.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            we’re just an incredibly hopeful specifies, I guess

            They’ll be angrier now when they can’t afford to run down those god awful deductibles… maybe we will revolt sooner rather than later….

          • DoubtfulGuest

            As a patient, I completely agree. I’d be willing to volunteer some time for an effort like this. I’ve been trying to get up to speed.

            Most people I’m acquainted with would want to understand. There’s just a lot of misinformation and cultural conditioning to get past.

    • Rob Burnside

      I don’t know much about your profession, but many docs seem to agree there have been ways out all along, and they weren’t taken. What we seem to have now is a “court of last resort” but we’re not talking d.o.a. unless you make it so. It’s still possible to effect change for the better, but it will require a great deal of candor that hasn’t really been part of the equation until very recently. “Because I see alternatives, I have hope.” Ralph Abernathy

      • DoubtfulGuest

        Also, they could probably use some help? :)

        • Rob Burnside

          Yes, DG, hope and help do go together.

  • Deceased MD

    Forget practicing. I just never want to get sick. This kind of system could kill you.

  • southerndoc1

    Every proposal 100% evidence free.

    • NewMexicoRam

      Who cares about evidence? It’s all wrapped up in terms that tell patients “we care for you and we will make sure those greedy doctors tow the line.”
      It’s all about the money. Plain and simple.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        It is. No matter how they spin it, it is about cutting overall costs, and since it is a zero sum game, there will have to be losers, and the losers will be those with least resources, least power and least will to fight.

        • Dr. Drake Ramoray

          Better known as independent rural physicians working in marginally served areas. The new medicine. Think Walmart level of service (inferior impersonal product with high beancounting and oversite capabilities (Walmart is a true distributor to the consumer and is marginally a store)) with Nordstrom levels of prices. What do these policy people think when there is only one or two hospital systems in a community. These large institutions will use their market share to demand higher prices. The actual doctors get paid less and the administrative finance types make a killing.

  • Steven Reznick

    Thank you for the excellent synopsis and analysis. Much appreciated.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Dr. Reznick, does any of this affect your practice in any way, considering the model you chose?

      • Steven Reznick

        I believe it certainly will. This is the Birthplace of MDVIP and the competition for the concierge patient is fierce.There are 36 primary care concierge practices in the Boca Raton area and several medical specialty concierge practices as well. The original MDVIP model billed Medicare for patient visits in addition to the annual membership fee based on existing health care laws in Florida ( it was basically illegal to give one all inclusive fee without being considered an insurer and having to meet the financial deep pockets required of them.). If in fact we are now faced with becoming a medical home and meeting all those requirements or becoming a direct pay practice it will affect us. If we opt out of the Medicare system I believe there will be a dropoff in Medicare age patients who will choose to go to practices that accept the decrease in reimbursement and continue to practice as is. Here too there has been a large movement by hospital systems to purchase practices and form their own ACO’s and the Medicare Advantage Plans with lower pharmaceutical costs and deductibles are attractive to healthy seniors who prefer to use their fixed incomes for things other than health care and health insurance. If on Jan 15 this draft is passed we will need to change our model and use the time to educate our patients about the reasons for the change while making clear the value of staying in this type of practice.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          So you are still billing Medicare for visits. If this thing passes, then the worst case scenario, if you do nothing, would be a 8% to 10% reduction in reimbursement. Couldn’t you just increase the subscription fee a little bit to offset the reduction, and call it a day? I don’t know, but it might be more cost effective to your practice.

          • Steven Reznick

            Thank you for the suggestion. We have held the membership fee constant for ten years so an increase is a possibility. Will look at all the options since if I am fortunate enough to stay healthy, caring and competent I am hoping to practice for another ten years. At some point would love to sell my practice to someone who wishes to provide great care outside a conveyor belt type system.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Ten years is a long time. Things should get sorted out by then… Best of luck!!

  • Deceased MD

    Not sure how the govt could enforce all MD’s to take medicare. WHat about concierge practices? I suppose you could just say your practice has a long waiting list for any medicare pts. But I am not pushing my luck. Clearly these guys are up to no good. My spouse is from Holland. Maybe time to move. Everyone needs to have an exit plan.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I’m sure they could if they wanted to, but I don’t think anybody is contemplating that… at this point… :-)

    • Dr. Drake Ramoray

      Tying Medicare to licensure might be a little harder than Medicaid, although we all have NPI numbers now. Medicaid would be pretty easy. Just tie federal funds to the state medical board requiring that physicians have to see Medicaid. Perhaps tie numbers to a proportionate percentage of patients based on market penetration. Pretty easy to do with an EMR.

      Others have posted that Massachussetts and Virginia are looking into doing something on their own along those lines for Medicaid but I have no direct sources in those states.

      • psychotic MD

        LOL! Be careful. Now you’re thinking like an MBA type. But yes I suppose it can be done. But what I do notice with any sorts of government regulations is that they tend to be toothless watchdogs.
        Look at the Medical Boards. Generally they sound pretty lame from what I hear, such as docs leaving one state to go to another after trouble with the board.
        If they can’t enforce practicing medicine safely, how can they truly enforce physicians that are not complying? I mean they can withhold funds as you say, but if you are not seeing this population, there are no funds to withhold.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Regarding tuition, there is a piece in the new JAMA wondering about the tuition bubble, and concludes with:
    “That bubble will burst when potential students recognize that the costs of training aren’t matched by later returns.
    … At the extreme, we will march down the debt-to income-ratio ladder, through psychiatrists to cardiologists to orthopedists . . . until no one is left but the MBAs.”
    http://www.nejm.org/doi/full/10.1056/NEJMp1310778?query=TOC

    • Deceased MD

      great article. some idiot mba will probably just cut the training in half! problem solved.

    • buzzkillerjsmith

      Thanks for the link. Darn interesting article.

    • Rob Burnside

      No one but the MBAs–truly the bottom line of bad dreams!

  • buzzkillerjsmith

    God I hope not.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Hi Dr. Oates, I think we have a terminology problem… when you tell folks to increase their already insane volumes, it elicits rather “interesting” reactions, and I can totally understand why. We are not speaking the same language. Hope to finish my next post by Monday and see if we agree… :-)

    • Randall Oates, MD

      I am about docs decreasing the volume of data entry and administrative tasks. Those should be largely delegated. In the process, seeing 30 patients feels more like seeing 20 and allows docs to do what they enjoy and are trained to do. It is going to soon be economically nonviable to have docs spending 40-50% of their time doing data entry and 20-30% face-to-face with patients.
      I look forward to your next post.

  • Michael Wasserman

    The end of solo practice for sure.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I’m not so sure, that it’s the absolute end, Dr. Wasserman. It may need to be tweaked some, but it may survive just fine (see the link I posted below for Dr. Oates)….

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