By Wayne Lipton
MAY 9, 2013 — From time to time, I’ve shared letters and anecdotes about medical practice today from physicians I’ve come in contact with through our company.
Many of these physicians are those who I have talked to about joining a full-model or hybrid concierge program. For whatever reason, some of these physicians opted not to join, but we’ve stayed in touch over the years. One of these physicians sent me an e-mail recently and it mirrors closely what I hear lately from many doctors. As if practicing medicine itself wasn’t hard enough, now there is also the businessman second guessing, often resulting in assumptions about what doctors have been doing successfully for years.
Here’s a portion of the e-mail that shares this physician’s frustrations:
I received a phone call the other day from an assistant medical director of the regional accountable care organization that I’d reluctantly joined three years ago. He explained that my “profile” suggested that I was making too many specialty referrals, some of which were landing outside of the network costing “a bundle of money.” As a consequence, the network was forced to withhold my “shared profits” this year. He said he wanted to inform me personally so I wasn’t surprised when I received my annual report. Further, he reassured me that I was protected from a reduction in reimbursement this year but cautioned that next year the system would assess penalties for this pattern of referral.
When I received the lengthy report, the first thing I noticed were the names of patients I’d not seen for years on my list. Further, there were specialty consultations listed for familiar patients that I’d not approved and I had not received information from those specialists. The only specialty “utilization” that looked about right was neurology. I requested a face-to-face meeting with THE medical director and indignantly gathered a defense of my clinical practice.
Two months later we met after I had submitted my appeal in writing as requested. The medical director explained that although I’d not seen some of the patients recently, they’d identified me as their physician and were therefor included in my “panel.” Despite my objections, it appeared that I was somehow responsible for the choices patients made regardless of my advice or consent.
We then focused on the neurology consultations. He explained that I was referring headache patients far too frequently and this led to unnecessary testing and imaging which was driving costs. He suggested that I continue to care for these patients without seeking neurology consultation since the majority of these patients have benign disease and this way we could limit such costs. I pointed out that one of these young women had a brain tumor which was being currently treated; he had no response. The medical director continued to explain to me that primary care needed to take greater responsibility for common conditions or “we’ll all go broke!”
For the past few years, primary care has faced the largest increase in medical malpractice of all disciplines with a principal focus on failure to diagnose. Despite this, accountable care organizations are devising medical care delivery systems with increasing responsibility on primary-care physicians and their physician extenders. At the same time the medical legal environment is becoming increasingly critical of primary-care physicians for not aggressively pursuing patient complaints. Popular media is also driving greater concern in patients who are increasingly demanding of specialty referral and testing.
How are primary-care physicians supposed to practice medicine the way they were trained? In an environment of increasing scrutiny by patients and lawyers how are we supposed to “hold the fort” and, worse yet, bear the fiscal responsibility for this surge? On one hand, institutions want to see more lab, radiology, and surgical referrals; on the other hand they want us to reduce utilization but only for those patients who are part of risk sharing relationships! And this is in the face of increasing overhead, limiting reimbursements, and dwindling physician income. Concierge care is sure looking more and more appealing.
Obviously, the letter and the situation is disturbing. I’m not pinning the blame solely on the administrator, or on ACOs, or even large medical groups and health systems. I’ve managed physician practices — I know the need to run it as an efficient business. What I am saying is, here is a doctor who is obviously frustrated by the current system and could have avoided those headaches by opening a full- or hybrid concierge practice.
Yes, you still have to watch expenses in a concierge program and you still have to follow guidelines — and if you practice with other physicians, you will have performance metrics to meet. But as the person or persons steering the ship, you have a lot more control about what those efficiencies are, and how they are measured and implemented.
My advice to physicians is to think very hard before joining a large group. If you do join one, look for one that will respect your professionalism and experience and that is focused on patients — not just the bottom line. Remember, if you do get frustrated by a lot of rules and management processes, such an option may not work for you and there are alternatives — primarily concierge – you can and should consider.