As we close out on a tumultuous 2014 in healthcare, many physicians are looking forward to a better and more stable 2015. For most of us, 2014 has been marked by significant change. Many healthcare providers have seen their jobs and their patient care roles transform completely. Physician autonomy has diminished and regulation and mandated electronic paperwork has more than doubled. Many physicians find that they are spending far less time caring for patients and a greater proportion of their available clinical time is now being spent interfacing with a computer — both at work and at home on personal time.
During the last year, we have all been affected by the rollout of the Affordable Care Act (ACA), changes in reimbursement, as well as the implementation of a new billing and coding system (ICD-10). For many of us, it also marked a year of transition to system wide electronic medical record systems such as Epic and the growing pains associated with such a major upheaval in the way in which medicine is practiced. Many practices have continued the trend of “integration” with larger healthcare systems in order to remain financially viable. The American College of Cardiology estimates that by the end of 2014, nearly 60% of all physician members have integrated with hospital systems and this number is expected to rise even further in 2015 — ultimately defining the death of private practice as we know it.
Why have these changes occurred?
Ultimately, I believe that the changes to the way in which healthcare is delivered has come about due to 3 distinct reasons:
1. Declining Reimbursement
Currently, reimbursement continues to fall. Multiple government budgetary “fixes” have led to much uncertainty and instability in medical practices (much like seen in any small business with financial and market instability). In addition, the implementation of the ACA has resulted in the expansion of the Medicaid population in the U.S. — now nearly 1 in 5 Americans is covered under a Medicaid plan. Traditionally, Medicaid plans reimburse at levels 45% less than Medicare (which is already much lower than private insurance payments). While the Obama administration did provide a payment incentive for physicians to accept Medicaid, this incentive expires this week. Many practices are becoming financially nonviable as overhead costs are risking to more than 60%. As for the ACA, many exchanges have set prices and negotiated contracts with hospital systems — leaving many practices out of network. Both patients and doctors suffer — longtime relationships are severed due to lack of access to particular physicians.
2. Increasing Administrative/Regulatory Demands
With the implementation of the ICD-10 coding system, now physicians are confronted with more than 85, 000 codes (previously the number of codes was approximately 15,000). In addition, “meaningful use” mandates for payment have resulted in increasing documentation requirements and even more electronic paperwork. In addition, the implementation of new billing and coding systems has required increasing staff (more overhead) as well as intensive physician training. Sadly, the new coding system that has been mandated by the Federal government includes thousands of absurdities such as a code for an “Orca bite” as well as a code for an “injury suffered while water skiing with skis on fire”.
3. Electronic Medical Record Mandates
Federal requirements for the implementation of Electronic Medical Records and electronic prescribing have resulted in several negative impacts on practices. While in theory, the idea of a universal medical record that is portable and accessible to all providers is a noble goal, the current reality in of EMR in the U.S. is troubling. There are several different EMR systems and none of them are standardized — none of them allow for cross talk and communication. Many small practices cannot afford the up front expenditures associated with the purchase and implementation of the EMR (often in the hundreds of thousands of dollars). In addition, the EMR has slowed productivity for many providers and resulted in more work that must be taken home to complete — not a good thing for physician morale. Finally, and most importantly, the EMR often serves to separate doctor and patient and hinders the development of a doctor-patient relationship. Rather than focusing on the patient and having a conversation during an office visit, many physicians are glued to a computer screen during the encounter.
So, what is next in 2015?
While I have probably painted a bleak picture for Medicine in 2014, it is my hope that we are able to move forward in a more positive way in 2015. I think that there are several very exciting developments that are gaining momentum within medicine and healthcare in general. Innovation and medical entrepreneurship will be critical in moving healthcare forward in 2015. Physicians must continue to lobby for the tools and freedoms to provide better patient care experiences for all stakeholders in the healthcare space.
2015 begins with much promise. I am excited to see what we as healthcare professionals will be able to accomplish in the coming year. We must continue to put patients first and strive to provide outstanding care in spite of the obstacles put before us. While 2014 provided challenges, we must rise above the fray and continue to advocate for a better healthcare system in the U.S. today and in the future.
Kevin R. Campbell, MD, FACC is with Wake Heart and Vascular (WHV) in Raleigh, North Carolina. He is also Assistant Professor at UNC Department of Medicine, Division of Cardiology, and Director of Electrophysiology at Johnston Health. In addition, Dr. Campbell is President of K-Roc Consulting, LLC.