Arizona Physician

Arizona Physician

Understanding the Forest from the Trees: A Conversation on Business & Medicine with Michael Mills, MD

By Dominique Perkins

Dr. Mills was drawn to medicine for a variety of reasons: the allure of helping people as a basic career, an ongoing interest in the sciences, and the encouragement of an aptitude test which described healthcare as a good fit for his personality.

My medical education story is interwoven with my desire to also understand the business of medicine, capitalizing on my entrepreneurial traits and strong work ethic recognized in my youth from various jobs, including delivering the Arizona Republic on my Schwinn kick-back 2 speed,” he said.

After his undergraduate at the University of Arizona, Mills headed to New Orleans. He attended the Tulane School of Public Health & Tropical Medicine, and concurrently took Master of Public Health classes as electives and during the summer.

“This additional education shaped my view of healthcare delivery, understanding the forest from the trees,” he said.

For his specialty focus, Mills found the perfect balance of surgery and medicine in Gastroenterology, and he completed an internal medicine residency at the University of Colorado in Denver, and his fellowship took him back to Arizona, in a combined program at Good Samaritan (now Banner University)/ Carl T Hayden VAMC, and then completed in Tucson at the University of Arizona.

Mills initially began his career in academic medicine, joining the CU faculty as Assistant Professor of Medicine in Denver, Colorado. After a few years, however, he returned to his home state of Arizona to begin his own solo practice. Along the way he joined forces with Drs. Dave Drewitz and Fred Kenny to create Digestive Health Center of Arizona, which quickly grew into one of the largest GI supergroups in the country: Arizona Digestive Health.

Mills keeps busy, between practice and other responsibilities which include serving as Medical Director of Phoenix Endoscopy, the Physician Executive Director of the Digestive Institute, and also beginning an additional business, KDM Real Estate, LLC, to build and run his practice building.

“I have enjoyed leadership opportunities in my practice, our larger group, locally with various organizations, and nationally,” Mills said.

While he enjoys wearing many hats, his greatest satisfaction is still in helping individual patients.

Shortages

“Hanging your shingle” is becoming an increasingly daunting proposition for young doctors. Between the expense required to begin a private practice, the existing debt of medical student loans, and the extra (and complicated workload) inherent in running a successful practice, it’s no wonder the glamor of being your own boss is not always enough to offset the uncertainty.

There are dozens of factors that must be considered, Mills explained, including the difficulty of finding, hiring, and overseeing good help; careful billing, collecting, and accounting practices; expensive office equipment and systems; continuing improvement programs; and the limited opportunity to negotiate rates. Students are asking themselves why they would take on all of the extra work and risk when they could get a steady paycheck, plus benefits, by joining a hospital system.

Additionally, Mills said that we may be warning students and residents away.

“Residents have always responded quickly to perceived trends in the healthcare marketplace, being told that private practice will go the way of the dinosaurs,” he said.

Another trend residents are responding to is the pay gap between primary and specialty care. Mills said he feels projected shortages of physicians within the next 10 years are likely accurate, given the limited number of graduating medical students and spots for training to replace the nation’s aging practicing physicians.

“While I do not see a leveling of the pay grade between primary care and specialists, I suspect that primary care pay will be stable and specialist will see their annual revenue drop,” Mills said. “I believe that there needs to be a calling, a passion, about one’s own work, and to remove barriers for those who want a career in primary care, such as loan forgiveness for tracks aligned at the medical school.”

Mills also expressed that primary care may be an area that expanded scope of practice could be appropriate. However, he maintains that physicians should and must fight to preserve their vital role in delivering care to patients.

“We may find ourselves in a position to oversee a number of ‘midlevel’ providers, where we still can influence and impact best practices,” he said. “It is the inappropriate expansion of the scope of practice, such as pharmacists selling themselves as diabetic treatment specialists, where the battleground must be firmly hardened, advocating for our patient’s needs, not for our own turf.”

Arguing quality

Physician reimbursement is steadily moving in a “value-based pay” direction, claiming that this will place the focus on quality over quantity. Mills, however, feels that this position is an insult to the oath of the profession overall.

“Our profession’s ethics mandate is that we put the needs of our patients before our own personal financial gain,” he said.

“Thus, it irks me that those who promote a change from the fee-for-service model — not taking into account our oath as professionals — claim that physicians do more things to patients in order to make more money.”

Mills cited an address given by former President in Obama in 2009 (aired on CNN and in many subsequent YouTube videos) regarding healthcare reform, in which he suggested that Ear, Nose & Throat surgeons performed tonsillectomies that could have been diagnosed as allergies to pad their pockets, and firmly stated that the belief that doctors are somehow naturally predisposed to “game the system” is wrong.

Now, Mills also acknowledges that not all of the blame can be passed.

“We have no real mechanism in place for reprimanding the bad apples within our ranks who are not following our ethical code of conduct,” he said, adding that administrators are not bound by the physicians’ oath and are more likely to have their focus on the bottom line.

Ultimately, Mills wonders, are the correct metrics being used to define value, and quality?

“My biggest worry is that cost will become the major (or only) focus, with quality taking a back seat,” he said.

As we have seen, most of the buzzwords in government healthcare policy seem to focus on physician reimbursement – Medicare Access and CHIP Reauthorization Act (MACRA), Merit-Based Incentive Payment System (MIPS), Alternative Payment Model (APMs), etc.  And while plenty of program tuning will occur, Mills assured that they are here to stay. And, he said, quoting an article he wrote for Round-up Magazine, “You better play, or you’re gonna pay.”

The financial penalties and incentives place the reward of providing the highest quality of care at the lowest possible cost squarely on physician’s shoulders.

“The silver lining is that this is our chance to positively impact the quality and cost of healthcare in the US for our patients,” Mills said.

Negotiating value

Out-of-network ‘surprise billing’ has generated quite a stir this year at the Arizona Legislature, where lawmakers have submitted a bill that would require physicians to negotiate directly with insurance companies, via an arbitration process.

Mills said this is an issue that cuts both ways, since every physician should have the right to negotiate terms, sign the contract, or stay out of the network. However, he said that such a broad-based legislation would put physicians in an even more compromised position.

“If we do not have the right to walk away from a bad contract, or choose to not see patients with certain insurances, we lose our negotiating position and rates will plummet,” he said.

On the other hand, there is a reason most physicians contract to be in-network:

“To be listed (advertised/promoted) in their in-network brochures and thus get more patients through the door,” he said.

Understanding the business

With so many growing complications and regulations, it has never been more important for physicians to understand the business of medicine. We asked Mills what advice he would give to physicians in practice groups or operating independently to maximize their reimbursements, and he offered three key points:

  1. First, personally negotiate your contract with the payer. Fully understand the terms, including your obligations and payment parameters (which hopefully include built-in annual). I utilize a spreadsheet of my top 20 codes (by revenue) to create a weighted Medicare-base average for each contract, and know the percentage of my total business for each plan before heading back to negotiations. Having open and friendly relations with the payer representatives is helpful at understanding win-win opportunities. They may leave the company but not the industry.
  2. Second, have well-trained staff in your billing department with written financial policies and expectations. If you are a Medicare-accepting physician, you should treat every patient identically via the Correct Coding Initiative (CCI). Remember that “under coding” is viewed just as bad as “over coding,” so it makes sense to get it right the first time. Take a course in coding if you have not been taught along the way. Physicians are ultimately responsible for the codes that are billed, being subjected to fraud and abuse charges, large fines and even jail time. Open lines of communication are critical with your billing staff/billing company in clarifying charges. Silence is a bad sign. Most contracts require you to collect the co-payment prior to seeing the patient, and clear communication in writing with the patient about their financial obligation is required. Review monthly your accounts receivable aging report and percentage of bad debt right-off, both good markers of your billing department’s success in collecting every dime that you are due. Personally approve bad debt write-offs.
  3. Lastly, as those in private practice get paid with the money left over after everyone else is paid, review your staffing and overhead expenses to see where savings may be possible. Efficiency and a well-run office are paramount as we deal with decreasing reimbursements. Depending on the area of practice, you may be able to add new service lines at a better value to the patient and payer than otherwise is available in the marketplace. Always check with your attorney to determine if it is legal, and how the revenue must be treated in order to not get into trouble.

Mills also told how he has relied closely on the advice of experts such as his attorney (Bob Milligan) and accountant (Jim Fischetti) from the beginning of his practice journey, viewing those consultants as critical business partners to manage the complexities of contracts, healthcare law, retirement plans, billing and coding.

However, he said, if any hired experts advises you to break the law, turn and run!

“It’s hard enough to take care of patients at a high level, so get the best advisors that you trust, and follow their recommendations,” he said.

 

 

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