Under Healthcare Reform, Where Do Practicing Physicians Go From Here?

Oct. 4, 2016
Physicians in all settings in U.S. healthcare—private practice, medical group management, and association leadership—are living through the inevitably messy transition to the new healthcare

It’s a fascinating time these days in healthcare, on so many levels. And discussions in the past week—mine and others’—have only underscored that fact.

First, there was my breakfast and interview with Scott Weingarten, M.D., the senior vice president and chief clinical transformation officer at Cedars-Sinai Health System in Los Angeles. Reconnecting with Scott Weingarten reminded me once again of what a vortex we’ve been flying into and through, lately in our industry. Southern California is one of the more advanced managed care markets in the U.S., and yet even there, change has proven to be challenging for physicians. And if anyone is in a position to know just how challenging all this is, it is Dr. Weingarten. As he told me a week-and-a-half ago, when asked what the key to helping physicians move forward to optimize care is, “It’s a combination of things. I think physicians want to do the right thing. They went to med school to help patients; they’re trained in the scientific method. And they need to know that what they’re doing is scientifically valid. If you can’t convince physicians that something is the right thing to do for patients, they’re not going to do it.”

Weingarten, who practiced for years as an internist before he went into administration at Cedars, then co-founded Zynx Health (which provides evidence-based guidelines), and then came back to Cedars two-and-a-half years ago,  told me this: “ I used to be a practicing physician; and if someone couldn’t convince me something was right for my patients, I wouldn’t do it, either. So they need to understand that all of this is good for their patients; and they need to understand all the changes taking place at the national and local level; and also to understand how change will help them better take care of their patients.”

Weingarten believes that the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law that eliminated the SGR (sustainable growth rate) problems under Medicare, and which mandates either participation in the new Merit-based Incentive Payment Program, or MIPS, or participation in alternative payment models, which push practicing physicians forward quickly, once they figure out their options. “We provide them with those resources to help them, because it’s very hard for physicians in small practices,” he noted, of his organization’s clinical transformation and performance improvement work at Cedars-Sinai, because “with MIPS—in 2019, physicians will either need to participate in alternative payment models, or in MIPS. Beginning 2019, they’ll get a 5-percent annual bonus for participating, whereas there could be up to a 9-percent downside under MIPS in Medicare reimbursement over time, and that could be very difficult for the physicians.” And of course, “A lot of physicians are trying to figure out what alternative payment models mean for them,” he noted, “so we try to explain to them what’s going on and what it means.”

Not every physician is practicing in an integrated health system like that of Cedars-Sinai, where senior executives are working assiduously towards clinical transformation—and even have a senior vice president for clinical transformation, in Scott Weingarten. Joseph Valenti, M.D., an obstetrician-gynecologist who practices at the Denton, Texas-based Caring for Women practice, recently told HCI Associate Editor Rajiv Leventhal, that physicians like himself are becoming stressed by some aspects of healthcare reform. Asked why he believes that some doctors are wary of joining accountable care organizations, Dr. Valenti said, “I think that a lot of physicians are not completely convinced that the data is out there to demonstrate that they could potentially develop the savings necessary, and prevent hospital admissions and readmissions. Much of the healthcare spending that is extreme right now is in hospitals, not clinician offices,” he said, “so the concern is, can you keep this person out of the hospital? Also in terms of Medicare ACOs, you’re going to be assigned 5,000 patients at least, and they could be the sickest patients out there, so there is no guarantee that you can make them well enough and be assured that they don’t need to come back to the hospital. So maybe you can’t demonstrate shared savings. And the ACO stats prove this; one-third of them are working, one-third are breaking even; and one-third are leaving the program. “

Meanwhile, electronic health records and other clinical information systems are fascinating in this context, because they are absolutely essential to moving forward on value-based care delivery and payment and clinical transformation, but the implementation of an EHR/EMR itself is really, as everyone says, “table stakes”—that go-live is only the first step in a very long process for physician practices. “As Dr. Valenti expressed it to Rajiv, “This is the story with EMRs—no one has compelled them to simply ‘come up to snuff.’ The concern is that I will put my whole future in the hands of this IT system, and maybe it will work but maybe it won’t. The cost of this for us was over a quarter of a million dollars, and we’re not as satisfied as we should be given the cost. We can’t believe the number of bugs and glitches with it,” he said. “There are eight providers in our group, and we do like the ability to access our EMR from anywhere when a patient calls middle of night. I wouldn’t go back to paper, even though I know a lot of doctors actually would—many have been jaded by EMRs that were not well supported and cost them a ton of money and time. I call these things unfunded mandates—things we must do but no one is funding anyone to do them.”

All these issues were definitely on the minds of the CMIOs and other medical informaticists gathered in Ojai, California last week for the annual AMDIS Physician-Computer Connection Symposium. There are so many “to-do’s” when it comes to optimizing the use of clinical information systems in order to really accomplish the clinical transformation that will be required to fundamentally reengineer the U.S. healthcare system in the coming years. As Doug Fridsma, M.D., Ph.D., of AMIA (the American Medical Informatics Association) noted in his AMDIS address, physician documentation processes need to be seriously revamped; regulations need to be made more focused in their approach; there needs to be greater transparency around EHR functions; and clinical IS innovation among vendors must be encouraged.

Referring to his association’s recently published “EHR 2020” report, Fridsma said of himself and his association with regard to the policy recommendations made in the report, “We said, if you’re going to focus regulation and increase transparency and encourage attempts to simplify documentation, make sure to keep your patient at the center, as the North Star.”

I think that that comment will be very important going forward, particularly with regard to helping physicians in practice to do the very difficult work of transforming patient care to improve outcomes around both care quality and cost.

Certainly, Scott Weingarten and his colleagues at Cedars-Sinai know that. Their challenge is to figure out how to optimally leverage IT tools to support physicians in creating their own clinical transformations while also contributing to broader processes of transformation across their integrated health system. And they’re learning as they go, in terms of ACO and population health development.

So here’s the thing: Scott Weingarten, Joseph Valenti, and Doug Fridsma are all very, very smart doctors. They’re all trying to do what they can in their organizations to move their organizations forward, and in some way, to move the physician community, and U.S. healthcare, forward.

And all this change-making is inherently, and inevitably, messy. Because for U.S. healthcare to successfully move into its next phases of evolution, we will need for federal policy mandates, private health insurer initiatives, hospital, medical group, and health system efforts, and individual physicians’ delivery process changes, all to move forward, in some broadly coordinated way. And yet, the reality never matches the theory—thus Dr. Valenti’s legitimate complaints about some of the challenges facing practicing physicians. In particular, he is quite right that demanding accountability from physicians for outcomes that are partly actually the responsibility of patients, is problematic.

Yet it is still in everyone’s interest for individual physicians in practice, whether solo (though few are left in true solo practice anymore) or in organized groups, to feel themselves to be a part of change, and to be “self-change agents,” as it were. And good medical practice governance, and good IT governance, will be essential to any such advances.

So how physicians move forward under healthcare reform (public and private alike) is a question that concerns all of us in healthcare. But only time will tell as to exactly how it all plays out. So stay tuned, because the kinds of discussions that I and my fellow editors at HCI have been having in the past couple of weeks speak to some of the deeper issues facing our entire industry. Personally, I can’t wait to see exactly how everything plays out. It certainly will be a fascinating next couple of years!

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