By Naveed Saleh, MD, MS
Times have changed. A century ago, most physicians were challenged by a lack of medical knowledge or innovation in their practice of medicine. Today, we have too much new medical information. In fact, the pool of medical knowledge is expected to double every 73 days by 2020. Compare that with 1950, when it took about 50 years for medical knowledge to double. These days, many of the biggest challenges that physicians face involve technology, policy, and administration.
Here we explore some of the biggest challenges that physicians face in everyday practice. Unfortunately, some of these would require bigger changes to the healthcare system in order to see any real change. As for the rest, we offer some solutions that may make practicing medicine just a little bit easier.
Oh, the purgatory of prior authorization! You went to medical school and completed postgraduate training. Now you have to make a case for your patient to receive necessary treatment.
The health insurance industry uses prior authorizations to save money on prescription treatments and lab testing. Insurers claim that the oversight ensures the best care. However, physicians fret over extra time spent, revenue lost, and the stress of bargaining over necessary medications and procedures.
Here are some findings from a 2017 study in which 1,000 physicians were surveyed regarding prior authorizations:
-86% thought that prior authorizations burdened clinical practice.
-28% said that the process resulted in a serious adverse event, including death, hospitalization, disability, etc.
-65% reported having to wait at least 1 business day for a response.
-26% reported having to wait at least 3 business days for a response.
-91% reported delays in access to care.
-88% reported that prior authorization burdens have gotten worse in the past 5 years.
As if reimbursement wasn’t complicated enough, the Centers for Medicare and Medicaid Services (CMS) changed its reimbursement process this year when the Medicare Access and CHIP Reauthorization Act (MACRA) replaced the Physician Quality Reporting System, the Value-Based Payment Modifier, and the Medicare EHR Incentive Programs. Per MACRA, performance is judged by four metrics: quality, use of resources, meaningful use of certified EHR technology, and clinical practice improvement activities.
According to the CMS, the new Quality Payment Program created by MACRA does the following:
-Repeals the Sustainable Growth Rate formula.
-Changes the way that Medicare rewards clinicians for value over volume.
-Streamlines multiple quality programs under the new Merit-Based Incentive Payments System (MIPS).
-Gives bonus payments for participation in eligible alternative payment models (APMs).
Physicians can choose whether to be reimbursed by MIPS or APMs. By the time doctors get accustomed to all these changes, CMS may very well change it again.
Maintenance of certification
In a nutshell, maintenance of certification (MOC) comprises the following four components:
-Professionalism and professional standing.
-Lifelong learning and self-assessment.
-Assessment of knowledge, judgment, and skills.
-Improvement of medical practice.
I have reported extensively on the hassle that many physicians find with MOC. As you may know, MOC testing often burdens physicians with annual fees, extensive preparation time, questions unrelated to daily practice, and more.
Negotiating with payers
The challenge of negotiating with payers over contracts may seem futile because negotiating may not even seem like an option. If you work in a solo or small practice, you may feel like payers will swallow you whole—that you have no standing to negotiate. Sometimes it just seems easier to accept what they pay out instead of banging your head against yet another wall.
Not true! You can negotiate for the rates you deserve—if you take the right steps. Here are some tips:
-Analyze finances and fee schedules to figure out your break-even point. If the insurer can’t meet this threshold, walk away.
-Research the payer and find out what entices them. For example, if they are keen on dropping readmission rates or decreasing hospitalization rates, bring data to support your commitment to these concerns.
-Show that your practice of medicine is valuable by presenting positive quality-of-care data and by demonstrating a pattern of keeping things low-cost. Additionally, you can tout how your practice serves as a necessary provider to underserved populations. You can also show off your patient reviews, and social media and community presence.
-Think outside the box when counter-offering. For instance, if you are unable to secure a boost in pay rates, consider asking for another valuable concession, such as a longer window to resubmit claims or an easier prior authorization process.
By using electronic health records (EHRs), you can share patient data with a colleague at your same hospital with no problem, right? But can you share the same data with a physician at another institution with a different EHR system? Ah, the conundrum of EHR interoperability.
The first part of the digital revolution in health record-keeping involved the federal government steering providers to get EHR, which practices did in short order. Now, providers want to use current EHR systems to hook up with new technology on different platforms, including telehealth and remote patient monitoring, as well as synching different sources of healthcare data to facilitate patient care. But systems have yet to catch up.
The amount of time physicians spend on EHRs alone is mind-blowing. Luckily, there is a way to make EHRs work for you.
Burnout, a term originally co-opted from 1970s drug slang, is a rampant problem in medicine that suffuses patient care in the form of medical errors and job attrition. After controlling for covariates like age and sex, researchers have shown that more than half of physicians feel the consequences of burnout in everyday medical practice, either directly or indirectly.
As a healthcare provider, there are several things you can do to combat burnout. One way you can increase your quality of life and decrease your risk of burnout is by opting for time off instead of increased pay.
Time with patients
Chances are that when you dreamed of being a physician, you didn’t fantasize about not having enough time to see your patients. With all your other responsibilities, extra time with patients is a luxury.
In a study that examined time allocation in clinical practice, researchers concluded: “For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours [are] spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.”
One solution some private practice and hospitals have implemented to combat this issue is hiring scribes to take care of EHR work so that physicians can spend more time actually practicing medicine.
Finally, one challenge that may not seem large but can be particularly insidious is patient wait times, which is exacerbated by the physician shortage. A patient could grow intolerable of the wait and leave without receiving proper medical care. Indeed, this exact scenario played out 322,000 times in emergency rooms in California in 2017.
Physicians who chose the profession of medicine understood that their career would be challenging—but perhaps not in the ways they expected.