Should Medicare patients fear creeps

There has been considerable concern recently about the viability of physician's practices as they face a dramatic cut in reimbursement due to the need to slow the growth of health care spending.

No where is that more evident than with Medicare.

This last century era government administered health entitlement program now supplies medical coverage for a growing majority of American citizens. And the cost of this coverage is even exceeding its expected growth rate due to an ever aging and sicker population.

In typical bureaucratic fashion to legislate policy, Congress tied the cap on Medicare expenditures to the sustainable growth rate in an attempt to see that health care costs in the program did not exceed GDP (Gross Domestic Product).

This flawed calculation created in the Balanced Budget Act of 1997 has generally resulted in reimbursement rates to Medicare physicians that have not kept up with the real rate of medical inflation.

Yes, this last measure would have been a better metric to use in the calculation. But who knew in 1997.

Now we get to experience the implementation of this policy decades after the budget sensitive Congress of the 90's have mostly long gone. And the results aren't pretty.

Congress and physicians realized shortly after its passage that the SGR was a flawed system. Rather than solve the problem and change the way the Medicare system is funded, though, they have created temporary "fixes" virtually every year since its inception.

These "fixes" have only served to magnify and put off the eventual point where system implosion is expected to occur.

And that point may be here.

The latest physician hostage crisis of course occurred this year with an impending cut that threatened to throttle the rollout of Obamacare and the new federal health regulation. This fix expires on December 1st.

At that point physician reimbursement will be cut an arbitrary 23.6 percent with another 6.5 percent to follow on January 1.

So will the cut happen? (You can read my prior post: "Dear Santa: I want a Medicare fix")

But more importantly what will physicians do?

That is the question that is becoming more and more the topic of not only surgery lounges where physicians commiserate between cases but also the murmur outside the halls of medical meetings.

Certainly I've seen no organized conspiracy. But it is interesting that many physicians across the country are coming to the same conclusion: is it worth it to stay a part of the system.

Booklets and articles have been written about how physicians can leave the Medicare program. Even more concerning are the materials being produced for patients teaching them how to see non-Medicare participating physicians or even to form "direct contracts" with physicians so they can continue their care outside the system.

Historically and currently there doesn't appear to be a wholesale abandonment of Medicare participation. In my home state of Texas, unofficial numbers put the number of physicians that have resigned their Medicare number at less than 500.

But I don't see this as the real problem. I think more likely we are going to see something I like to call "creep."

Let me give you an example. Recently I was asked to provide some strategic review and planning for a practice in another state -- one with a large retired Medicare population. We prepared a detailed analysis of revenue and expense numbers as part of the consultation service, but the physician seemed to gravitate to one report more than the others.

It was a simple calculation that compared the payer mix of the practice based on the number of patient visits. The physician found that 59% of his office visits were Medicare, but that this group only provided 32% of his total revenue.

He became obsessed with the fact that most of his and his staffs work product was only generating a dwindling minority of his revenue. And without my well deserved consultant-paid-advice he reached his own conclusion that if he only made changes in his schedule and payer mix it could start to minimize his Medicare exposure, decrease his work schedule, and likely either see no change or a slight bump in his practice income.

That is the concern. Creep.

As physician practices get tired of the recurrent uncertainty about the future of Medicare payments, will they begin to find the solution may be to limit Medicare patients within their practice, that is to "creep" their schedules -- and not leave the system altogether?

This would have the effect of exaggerating an already access challenged Medicare population. And since we don't have good data on the clinic slots available to Medicare patients it will be difficult to measure the rate of creep until its too late.

Congress will take up the new fix soon, and conventional wisdom dictates that there will be another temporary solution to stabilize physician payments.

But will it satisfy a physician workforce that is tired of the recurrent stress of practice financial viability on an annual or now, even a monthly basis?

I guess we will get see it play out in the health care access of our Seniors.

Creepy.





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Location:Over El Paso, Texas courtesy of American Airlines

Texnology? -- Technology at Texas Dermatology

Technology invades our lives and our medical practice at Texas Dermatology is no exception. Over the last two years we have been on an aggressive campaign to upgrade our practice to include replacing virtually all of our hardware to create a paperless clinical environment.

We use a "cloud based" web software environment to handle all aspects of the clinical encounter from scheduling, checking on insurance eligibility, recording information in an electronic health record, and billing. It surprises many patients to learn that we use data centers all over the world to help us sort and keep track of clinical information. This allows us to rapidly, securely, and accurately file the thousands of pieces of data that are received by our practice every day.

One of the things I'm most proud of is our electronic prescribing rate. We only hand write a handful of prescriptions every month. Instead we send prescriptions to pharmacies directly which allows for patient convenience (its usually ready when they drive to pick it up!) and safety because we can cross check medications against both allergies and potential drug interactions. Refills are also automated and usually have a turn around time of less than an hour after the patient calls the pharmacy during business hours.

We hope that by the end of the year we will have a patient portal active which will allow patients access to some of their account and clinical information, scheduling, and even to submit and receive answers to their health questions.

So what would be the logical next step? A television studio of course.

Yes, its hard to believe but we have just completed construction of a state of the art broadcast studio in our Dallas office. Located in the "green room", we have lights, cameras, and action! We wouldn't have been able to do this project without the great folks at Dallas-based VideoTech and video genius Daryl Newman. He outfitted us with microphones, two broadcast quality cameras, and multiple cool LED lights -- as well as a some instruction!

But the heart of the system is a device from the San Antonio company NewTech. Its called a Tricaster and is sold as a "studio in a box" and that probably describes it well. We are able to mix multiple video inputs, internet feeds from remote broadcasts like Skype, and even local DVD video to make really cool live or recorded productions.

But probably the most exciting thing the device can do is to create "virtual sets". This is where we can use computer generated graphics to change the look and feel of the studio from a news room type environment to an auditorium for a PowerPoint presentation.

Why did we do this? We think it will add to the mission of our practice in communicating information to our patients and to that of our educational program and residency program.

Stay tuned to our website -- www.texasderm.com -- for more details as the project unfolds.


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Location:Kona, HI