By Sharla Hooper
As we use this edition to look at the complex landscape of physician payment and reimbursement, we wanted to ask about physician perspective on how they experience these complexities. We thank everyone who participated in the survey and provided comments. Your input helped us create a picture of the challenges and frustrations that Arizona physicians encounter with payment models and reimbursement.
Of those who participated in the survey, 58.8% were in specialty care and 31.1% in primary care. The significant majority of our respondents, 69.1%, were male, 30.9% female. It is easy to assume that solo independent practice physicians are more aware of the business intricacies of payment – solo practice physicians accounted for 29.9% of our respondents. About 20% were employed by a physician-owned group, and about 15% by a non-physician owned group. Another 18.7% were hospital employed.
Of the 56.1% of respondents who feel they are not fairly compensated,
- 18 were female (about 43% of total female respondents)
- 56 were male (about 60% of total male respondents)
- 21 were primary care (about 49% of primary care respondents), and
- 49 were specialty care (about 61% of specialty care respondents).
About 78% of all solo independent practice physician respondents feel they are not fairly compensated. Between 44 and 48 percent of respondents in physician-owned groups, non-physician owned groups and hospital employed feel they are not fairly compensated.
Of the possible options for what presents the most significant challenges for payment and reimbursement, insurance/government reporting burdens and CMS policies including federal sequestration both were selected by 83.1% of respondents. Quality metrics based on patient compliance – and noncompliance – was selected by 67.7%; negotiating with payers, 64.6%.
What about the financial burdens of medical education and clinical training? As a medical student respondent pointed out, “When the barriers for entry to the field are so great including average medical student debt of nearly 170k, followed by residency years with a moderate pay, and the time sacrifices demanded by the field, a large compensation must be waiting at the other side to help offset the investments.” The respondent’s logic was, if physicians face lower compensation in quality metric reimbursement models, there should be correlating decreases in the financial burdens imposed during their extensive training process.
Quality measures and the problem of patient compliance
Our respondents had numerous comments describing concerns about how quality standards are established and measured, and how they impact payment. Despite their misgivings, about 68.7% did agree, either fully or somewhat, that compensation should be more quality driven. On the other hand, 26.7% completely disagreed with the concept.
Where are physicians in determining quality metrics and compensations? They need to be involved in the nascent formation of these objectives. Dr. Hamed Abbaszadegan states, “Administrators that are not associated with frontline clinical care do not always see the challenges with the complexity of delivering health care. As a result, the associated quality metrics can be unachievable even though the ideas sound solid in the executive suite. This notion of linking quality to pay must be done with the direct feedback of physician leaders. Only with concurrence of physicians can this be accomplished successfully.”
Physicians can be motivated by reasonable quality metrics, as Dr. Lilia Parra-Roide points out: “Most physicians have the best of intentions and would naturally improve performance in any area they are given believable, actionable and evidence-based metrics. Payment strategies need to avoid placing extra burden on physicians that does not actually result in better outcomes for patients.”
Several respondents shared strong suspicions about whether quality measures actually work: “There is no evidence that quality measures work. When calculated at the individual physician level, most docs have too few patients in any category to make valid comparisons.” And those metrics can be manufactured, “Some physicians are selecting patients with low comorbidities and risk for surgery to improve their “complication” rates.”
The entity imposing the quality measures makes a difference. There is skepticism about measures created by insurers: “I don’t trust quality measures by insurers. Many insurers have proven they are not trustworthy with data they gather about physicians. Further, their models of quality have not been shown to be accurate indications of quality.”
Patient compliance poses a serious complication to quality metrics that affect payment. “Basing it on patient satisfaction, a subjective matter can be quite damaging for physicians who practice standard of care and high-quality care,” Dr. Ross Goldberg observes. “Sometimes patients have to be told things they don’t want to hear, and they could respond by indicating poor satisfaction, which can negatively affect the physician, who was only doing their job and protecting the patient from harm.” This was cited in a specific example by another respondent, “I recently received a ‘bad patient satisfaction grade’ for refusing opioid medications to a patient.”
The role of prior authorization in quality
Prior authorization protocols were selected as a reimbursement challenge by 56.2% of respondents. Prior authorization requirements can delay care, sometimes indefinitely. One respondent sums it up, “The prior authorization process for even routine generic meds has become so burdensome that more time is spent on paperwork than with patients. I didn’t go into medicine to become an authorization clerk for an insurance company!”
Another points out that when insurance companies deny payment for pre-authorized care, this affects how patients judge the quality of care.
A regulatory environment and burdensome reporting
A recent study published in Health Affairs (April 2017) examined time spent on face-to-face medicine versus computer-related activities. Conducted between 2011 to 2014, the study found that a quarter of physicians spent less than two hours per day with patients; and only a quarter spent more than four hours on direct patient care.
It found doctors spent an average of 3.08 hours on direct patient care and 3.17 hours on a desktop. And many of the desktop activities, such as care coordination and emailing patients, are not reimbursed but are of high value to the health care delivery system, where care coordination is vital to penalized items such as readmission rates. Confirmed by a respondent who describes, “No compensation for work done when patient not in office. Consulting with other physicians, phone calls, reviewing records, etc.”
Simply stated by one respondent, “We are so bogged down with charting and metrics, that it cuts into the time that we could be contributing to patient care” – and the subsequent payments for that care.
Payment inequities & contracting
When considering several system models of physician payment, 36.6% of respondents felt that physicians will continue to deliver high-quality care with a salary based on national averages and no incentives in place; whereas 26.7% thought this type of model would fail. Asked about a model based on quality metrics tied to patient sign-up, there was a great of deal uncertainty about the potential for this model, 34.1%, and anticipation of its failure, by 27.9%.
One respondent, having worked in both environments, prefers a model not dependent on incentives. She described herself as “fortunate to be in a work environment where all physicians are paid the same rate per hour and there are no productivity bonuses. I’m glad to not have to deal with concerns about gender-based pay inequality or trying to rush more patients through the office to increase my wage. Could I be making more on productivity? Possibly, but I worked previously in an environment where my production bonuses were frequently denied, despite being the second-most productive physician in the organization.”
Knowing the market can increase physicians’ salary power within the employed model, as one respondent describes, “My employer increased our salaries by up to $50,000 when one physician found another job with Dignity Health that paid $50,000 more for the same amount of work. Fearing massive exodus, the employer increased the salaries. Physicians need to know the market value for what they do and should be more business savvy.”
Contracting with insurers is also fraught with reimbursement peril, particularly in the case of a self-described independent practice anesthesiologist: “Many insurance companies refuse to contract with solo practitioner anesthesiologists. Then, we are asked to deliver care to people who have a plan for which we are not contracted because there are no other anesthesiologists available for those cases. What next? Accept a payment from the insurance company substantially lower than that they put in their contracts with other physicians? The patient’s deductible and co-pay are usually withheld from the non-contracted anesthesiologist’s payment. Or, balance bill the patient? Or, maybe the insurance company will not pay anything since we are out of network. Is this fair? The insurance company loves it – it saves them money.”
Bigger is not better
Over the last 15 years, we have seen increased consolidation in the health care system. Could the tide be turning though? One respondent states: “The system is rigged toward big institutions with the illusion of better, high-quality care. New data are showing that small practices provide more efficient and quality care because they have greater control over the process and reputation builds their patient base.”