Every profession has its challenges, but in 2014, America's physicians will face a head-spinning array of economic hurdles. As the final days of 2013 ticked away, Medical Economics published its "Top 10 challenges facing physicians in 2014"(medicaleconomics.modernmedicine.com) and offered a peek into the near future.
"Every challenge is an opportunity," opined the authors of the report, who characterized the changing health care horizon as a potential boon for primary care physicians. After all, in many ways, the Patient Protection and Affordable Care Act would give primary care physicians the opportunity to lead the delivery of health care in 2014 and beyond.
Authors acknowledged that successfully adapting to the changing landscape would take much work on the part of physicians and could prove to be "daunting" and "nearly insurmountable" for small, office-based practices. Nevertheless, authors dispensed active verbs such as "re-create," "evaluate," "maximize," "review" and "re-engineer," as they urged physicians to kick into proactive mode.
- Medical Economics recently released its picks for the top challenges facing physicians in 2014 and put "payment for medical services" at the top of the list.
- Other items on the list include complying with government mandates, dealing with payers, absorbing technology costs and understanding changing patient populations.
- AAFP President Reid Blackwelder, M.D., acknowledged that 2014 would present challenges, but he pointed to significant progress on issues important to family medicine such as the patient-centered medical home and team-based care as cause for optimism.
2014, said the authors, would revolve around physicians' ability to deal with concepts such as cash flow, payer contracts, technology, work load, work flow and staff responsibilities in new ways. "We believe that understanding the dynamics of a changing market will ultimately help physicians shape it, adapt to it and succeed," wrote the authors.
Top 10 Revealed
According to the report, the challenges facing physicians in 2014, from number one to 10, are
- getting paid for medical services provided;
- complying with government mandates, such as ICD-10 and meaningful use;
- dealing with payer headaches and the fine print;
- finding time for patients amid administrative tasks;
- absorbing technology costs;
- mitigating staff turnover;
- regaining physician autonomy;
- understanding changing patient populations;
- accepting primary care's changing role; and
- re-instituting work-life balance.
It's no surprise that payment sits at the top of the list; after all, a family medicine practice is a business with the same cash-flow and overhead worries every business has. Throw in a rapidly evolving -- and sometimes shaky payment system -- and it's no wonder there's plenty of worry to go around.
"Health care's ailing reimbursement system will likely take a turn for the worse in 2014 before it recovers," predicted researchers. Furthermore, implementation of the Affordable Care Act is bound to affect both the number of patients on physicians' doorsteps and how those physicians are paid.
Authors pointed to recent examples of some of the nation's biggest health insurers trimming their physician networks, thus limiting patient choice. Researchers also noted that in 2014, cost and quality control methodologies, such as bundled payments and shared savings programs, would become more widespread.
They suggested that to cope with all the changes, "Primary care will need to reinvent its services to patients, reassess its use of technology to better monitor population health and engage patients in new ways."
Emphasis on Family Medicine Issues
Although every item on the list affects family physicians, some have caused particular consternation for the AAFP and its members. For example, the Academy has long challenged HHS' decision to move forward with its mandate for a nationwide transition to the ICD-10-CM code sets for outpatient diagnosis on Oct. 1.
Article authors put it simply: "Convert or don't get paid." They cited a 2008 study that estimated conversion costs for medical practices could range from $83,000 to $2.7 million.
According to AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., even as the Academy has worked to delay the ICD-10 implementation, it also has continually cautioned family physicians that the transition would eventually happen and urged them to prepare. "It really would make sense to delay this transition until everyone -- including payers -- was ready to roll out without delay, but unfortunately, I don't see that happening," said Blackwelder.
He acknowledged that FPs could dip into their financial reserves or take out loans to cover their ICD-10 transition costs. "Those are terrible options, especially for small practices that already are struggling, but that's what we're stuck with," said Blackwelder.
Report authors put the "sticker shock" of technology costs at number five on their list and spoke of a family physician who complained of an ongoing practice slowdown more than two years after implementing an electronic health record (EHR). She said glitch fixes and update costs were never ending.
"Physicians see much of the technology they must purchase as a hindrance, not a benefit, to their practice," wrote the authors. However, in reality, "technology upgrades could make or break your business in the next year."
Although family physicians have always led the charge on EHR implementation, Blackwelder acknowledged that for some small, individual practices, "the cost of implementing and updating an EHR system was probably untenable."
He pointed to cost-sharing strategies as a remedy. "One way for practices to make this affordable is to, whenever possible, share the cost with a larger hospital system, an accountable care organization or even with small practices in the same community. Family physicians need to look for opportunities to create those kinds of partnerships."
Payment Problems Persist
In challenge number eight, researchers wondered if 2014 should be dubbed "the year of the new patient." They noted that millions of previously uninsured Americans could soon have health insurance.
Authors pondered how many of those new patients would try to visit a primary care physician in 2014 and, just as importantly, how many patients with high-deductible plans would be able to pay their bills.
Researchers noted that as many as 80 percent of newly insured patients are at high risk of nonpayment -- especially self-pay, high-deductible or health savings account patients. They quoted an industry leader as saying "Physicians need to get out in front of the payment. …Providers won't be able to afford to collect payments after service for much longer."
But according to Blackwelder, this is business as usual. "There's not a change in mindset as far as collecting your copay at the time of services," he said. And family physicians always have had patients who couldn't pay their bills. In fact, an internal member survey showed that family physicians, on average, treated nine patients a week at reduced rates or for free," said Blackwelder.
"Some of those patients will have health insurance now," he added.
Blackwelder noted that patients with high deductible health plans would now have access to copay-free preventive services. But unfortunately, too many of those patients likely would still forego treatment for health problems. "Acute and chronic health issues can't be managed at the same time as a preventive services visit, and that's not good from a family medicine perspective," said Blackwelder.
He lamented the mindset of too many patients who just can't see the value of investing in their health care proactively and, instead, wait until a crisis situation. "It's shortsighted, but it's how some patients think. They hope a health crisis never happens, and when it does, they are hit with a huge hospital bill and that one big deductible."
On the other hand, ongoing primary care could help patients and their physicians address health issues before they become severe. Doing so would keep patients out of the hospital and make insurance deductibles more manageable for patients, said Blackwelder.
2014 will have its challenges, he conceded. But he pointed to significant progress in terms of the nation's embrace of concepts such as the patient-centered medical home and team-based care. "We have to keep pushing forward," he concluded.
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