South Florida Hospital News
Saturday February 24, 2018
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January 2006 - Volume 2 - Issue 7

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Medicine for the Year 2006

As 2005 is completed, we prepare to enter yet another year which brings hope, uncertainty, and goals. Decades ago, physicians would view a new year as an opportunity for growth. Another calendar year meant another year of experience, and that was typically associated with financial and personal rewards directly proportional to the effort invested in ones practice. Today a new year yields unanswered questions and innumerable challenges.

Health care in the public and private sector is no longer readily available. Access to Care is always an underlying theme and issue. In Palm Beach County, we have developed the infrastructure for Project Access, a monumental task that will provide broad spectrum care to those who can’t afford it. 2006 will likely result in greater numbers of people who cannot afford healthcare, and we will be charged with finding solutions to meet the needs of the public. Large health insurers continue to raise premiums to its subscribers, yet diminish returns to the providers who provide the services so integral to the health system. I was notified that my health policy for staff and employees would increase 15% in premium for 2006, yet I certainly have not appreciated this type of raise for services provided. In South Florida property values have risen dramatically. Fuel costs are seemingly rising on a weekly basis. Even the cost of stamps will rise approximately 5% in January. This rising cost of living will require adjustments to our staff salaries. Recruitment and retention of employees who cannot afford to live in our counties is likely to become problematic. What other industry exists where rising costs cannot be passed on to the consumer?

We face continued challenges at a local, regional, and national level regarding physician reimbursement. Each year there seems to be proposed legislation which threatens to reduce reimbursement through Medicare. As most readers realize, the 2005 Medicare Trustees report forecasts a 26% cut in Medicare physician payment rates from 2006 thru 2011. The cuts are mandated by an inequitable and unsustainable formula called the Sustainable Growth Rate, or SGR. This determines what Medicare physician payment will be. The SGR formula led to a 5.4% cut in 2002. Congress and administration intervened to prevent similar cuts in 2003 thru 2005. Once again we face a 4.3% cut on January 1st unless the politicians act immediately. At press-time for this article, the latest word from Washington is that the powers that be will not act to repeal the cut unless the physicians are willing to "strike a deal." The AMA leadership is lobbying aggressively to preserve current reimbursement, and in fact set a goal of raising payment rates to attempt to keep pace with costs. The "deal" is that physicians must be willing to accept certain "paid for performance" initiatives which are being proposed.

Pay for performance has become an increasingly common issue in health care. Recent surveys published in JAMA indicate that almost 100 pay for performance initiatives nationwide are now sponsored by a variety of health plans, employer coalitions, and government purchasers that are intended to improve the quality of care provided. The rationale, however, for pay for performance comes almost entirely from experience with incentives in other industries. Research in pay-for-performance is primarily observational. There are a number of confounding factors which will affect the implementation of these initiatives. Are these incentives for meeting "quality indicators" really a reward, or is this a system for penalty? There are environmental, organizational, and non-economic factors which will determine if this system succeeds. Regardless of our viewpoints of paid-for-performance, it appears that we will have to deal with this challenge.

Certain markers of paid-for-performance initiatives will clearly favor those practices with advanced information technology. A real-time reminder system may help several aspects of diabetes care. Those practices who have the financial ability to invest in electronic health records may see "rewards" thru the paid-for-performance system. Most insurers will be mandating electronic transmission of claims. The electronic medical record (EMR) is likely to be a significant issue in 2006. Potential legislation has been discussed which will mandate that all physicians use an EMR. Many practices have already made the conversion, but for those of us in small, individual practices it may be cost ineffective or even prohibitive at this time. Studies from the University of California suggest that start-up costs for an EMR average $44,000 per physician, with annual maintenance costs averaging $8,400 per year. Even with the potential for improved billing services with an EMR, it is estimated to take at least 2.5 years before the cost of the system is recouped.

Insurance payments and reimbursements have not kept pace with costs, and most physicians agree that we cannot absorb an additional 26% reduction in Medicare payments. Medicare cuts for physician services over the next 8 years is expected to exceed 12 BILLION DOLLARS in the State of Florida alone, exceeding all other 49 states in this country. These continued cuts may force physicians in 2006 to limit the number of Medicare patients they serve, or stop accepting new Medicare patients entirely. This will JEOPARDIZE access to care for the elderly and disabled Americans. The Medicare system will need an overhaul to prevent a major crisis, and 2006 will certainly cause many of us to evaluate our status as participating providers for this system.

Patient safety remains a priority. There are Constitutional Amendments which allow all medical records including peer review to be discoverable. Peer review is a previously sacrosanct process which granted us the opportunity to evaluate care rendered in certain situations. Physicians are now fearful of participating in this process due to potential litigation. The patient ultimately suffers, since lack of peer review may limit our ability to censor physicians scope of treatment. Supreme Court challenges to the constitutional amendments are looming, with legal challenges forecast in the coming months.

Constitutional amendments 3, 7, and 8 all began due to the perceived liability crisis in the 21st century. Unaffordable insurance premiums led to many physicians dropping malpractice insurance coverage while developing strategies for asset protection. Mutual antagonism between the medical and legal professions has reached a peak. The contentiousness recently has been exacerbated by a decline in physician authority over health care delivery and the rise of managed care. Both professionals share strong ethical codes and a concern for the individual they represent. We will likely not unite when it comes to issues of public policy or clinical duties. Attorneys and physicians share a concern for patient safety that could form common ground for future collaboration. Unrelenting antagonism is harmful to our patients, and may undermine formulation of effective health care policy. The perceived issues in the "malpractice crisis" still exist, but 2006 should see stabilization as the effects of amendments 3, 7, and 8 become more lucid.

Immediate health care concerns include availability of vaccines and medications in the event of a pandemic illness such as the flu. Government control of medications and their delivery systems affects our ability to administer routine health care to our patients, particularly our special needs population. Solutions to yearly issues such as availability of the flu vaccine are needed in 2006.

Next year will be busy. We have medical, legal, technological, and legislative initiatives which will affect the way we practice. The system becomes more and more complicated each year. We must find ways to meet these challenges. We must protect our special and noble profession.

Mark Rubenstein, M.D., President, Palm Beach County Medical Society, can be reached at (561) 832-5000 or mruben2@aol.com.
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