Sep 15, 2016
President, Texas Medical Association
(This article first appeared in the KevinMD.com blog. Reprinted with permission.)
Physicians spend almost twice as much time each day typing on computers and filling out paperwork as they do seeing patients. That astonishing conclusion comes from research published this week in the Annals of Internal Medicine.
Just think about that. How would you feel if you spent two hours documenting every hour of work that you do? How would your boss feel about it? You’d be depressed and frustrated; your boss would probably be angry as hell.
Patients should be up in arms over this report. Taxpayers should be up in arms. Physicians already are up in arms because we already knew this was true — and we know it’s just going to get worse.
We know it’s going to get worse because we know what’s causing it in the first place.
And that’s what’s missing in this study. Why? Why do physicians spend just 27 percent of their time “on direct clinical face time with patients” and 49.2 percent on electronic health records (EHRs) and “desk work”? From my nearly 50 years in medicine and thousands of conversations I’ve had with my colleagues, I can guarantee you it’s not a willing choice.
But again, the question is “why.” Why is this happening? Part of it has to do with EHR systems that appear to have been designed by someone who never set foot in a physician’s exam room. They’re clunky, not intuitive, and don’t fit the flow of how we examine, diagnose, and interact with our patients.
But the bigger issue is why we have to enter all of this data into a computer system in the first place. It comes back to an alphabet soup of government regulations that definitely were written by someone who’s never been in the exam room with a patient. The Physician Quality Reporting System (PQRS), Meaningful Use (MU), and the Value-Based Payment Modifier (VBM) program all aim to “capture” the quality of care we’re providing and score us on the cost of that care. MU — the worst-named government program ever — actually cuts our Medicare payments if we don’t use an EHR.
A study published in Health Affairs earlier this year estimates the cost in physician time to comply with just one of those programs, PQRS, exceeds $50,000 per primary care physician per year. That’s a lot of money; but it’s also a lot of our time. That’s time the government has stolen from our patients.
And — as I mentioned earlier — it’s only going to get worse. The Merit-Based Incentive Payment System (MIPS), part of the Medicare Access and CHIP Reauthorization Act (MACRA), begins in January. MIPS is supposed to replace PQRS, MU, and VBM. But, as I wrote in this space in June, the new program looks to be far more costly, complex, and confusing than the costly, complex, and confusing programs it is replacing.
The Centers for Medicare & Medicaid Services (CMS) estimates MACRA will add $128 million a year in compliance costs above the costs of complying with the programs it is replacing. Texas Medical Association analysis finds that “official” number woefully low.
And all of that brings us to one more, even bigger question: Does the government know what it’s doing to physicians?
We went to medical school and dedicated our lives to helping people heal and stay healthy, not to become data entry operators. But that’s what we have become, and that’s taking a toll on physicians, our patients, and the entire health care system. Physicians are burned out and unhappy, patients have less time with their doctors, and everyone has to pay more to get less care.
I’ve been a patient — a seriously ill patient — and I owe my life to the physicians who helped me recover from West Nile virus encephalitis. Like every patient, I don’t want a burned-out, unhappy doctor who’s enslaved by his computer. I want a bright-eyed, engaged, and satisfied physician who has the time and energy to put me — and my health — first.
Jul 12, 2016
Shortly before a senior Medicare official came to visit his Dallas office in late June, Texas Medical Association President Don R. Read, MD, shared with Texas Medicine his thoughts on the agency's draft rules implementing the Medicare Access and CHIP Reauthorization Act (MACRA). Dr. Read compared changing complexity of Medicare rules to a progression from a simple game of checkers to a new game no one understands, whose rules are written in Mayan hieroglyph, and which "you cannot win."
Listen to the short audio clip, or read the full transcript below.
“This is how MACRA comes across to me. With original Medicare, we were playing checkers. There were some rules we didn’t agree with, some that were truly stupid, like you couldn’t pay for a TPN outside the hospital, which was much cheaper so we had to keep them in the hospital which was much more expensive, but you pretty much understand the rules. Then with PQRS and MU, we started playing chess. Kind of easy chess, but we were starting to play chess.
“And now you say, well we’re going to change the game. It’s not checkers; it’s not chess; it’s something new. The board’s got two more columns and two more rows. Some of the chess pieces are the same, but we’ve put new ones out there. And we’ve written rules. We started to write them in Mandarin Chinese, but we figured you’d be able to get an interpreter and interpret them, so we’ve written them in Mayan hieroglyphs to make sure you don’t understand.
“But you have to start playing right away, and don’t worry about the fact that you don’t understand the rules because we have deliberately set the game so that you cannot win.
“And by the way, two years from now you’re going to get penalized because you did not win.”
Jul 1, 2016
|Dr. Read: Without big changes, small practices|
"are going to fail" under MACRA
|Tim Gronniger, deputy chief of staff,|
Centers for Medicare & Medicaid Services
|Dr. Snyder presses Mr. Gronniger for an "independent practice pathway."|
Jun 21, 2016
By Don Read, MDPresident, Texas Medical Association
I joined physicians nationwide last year in cheering when Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Not only did it eliminate the congressional budgetary fiction known as the Sustainable Growth Rate (SGR) formula, it also promised to simplify and improve Medicare’s costly and complex programs that purport to measure the quality of care we provide to our patients.
Unfortunately, as we review the draft implementing rule, it appears that the net result will be neither simplified nor improved. Frankly, while we see the need for some legislative tweaks, this proposed rule is not what Congress ordered.
MACRA already has accomplished two of its intended goals. It reauthorized the Children’s Health Insurance Program for two years, and it removed the constant threat of SGR-driven Medicare payment cuts. The SGR’s faulty assumptions would have forced annual fee cuts for physicians for every one of the past 15 years. The obvious folly of that policy drove Congress to override each of those cuts since 2002, often in desperate, last-minute or retroactive circumstances. The associated financial threats and uncertainty about business viability created continuously hazardous conditions for physicians.
MACRA also promised to simplify the ever-tightening thicket of federal regulations that strangle physicians’ practices. The draft regulations that the Centers for Medicare & Medicaid Services (CMS) published on May 9 fall far short of that promise. If implemented as written, they would dump additional bureaucratic work on physicians and their practices, and would continue to impose onerous federal controls on physicians and their practices — with no data to show that they would improve the quality of or access-to-care for patients. The system devised by CMS is far more costly, complex, and confusing than the costly, complex, and confusing programs it is replacing. Compliance would be especially difficult for small practices who may end up with Medicare payment penalties even if they spend the time and money to jump through all the new regulatory hoops. The budget-neutral system of bonuses and penalties pits physician practices against each other, so that there will be annually anointed winners and losers regardless of how well all practices “perform” on these new quality standards.
When MACRA legislation was enacted, TMA had no reason to expect CMS would propose to continue flawed concepts from the current quality programs along with plans to diminish a physician’s worth down to a complex point system. More disappointing is to learn that CMS proposes to design a program that is stacked against solo physicians and small group practices in its first year of implementation.
CMS and proponents of the agency’s proposed plan say it will streamline the current quality reporting systems and simplify the transition to value-based care. CMS Acting Administrator Andy Slavitt says “we have to get the hearts and minds of physicians back,” and he claims MACRA will “put physicians back in control.” Our analysis of the proposed regulations reveals something much to the contrary.
Reporting and Compliance:
The compliance, documentation, and reporting requirements related to the new combined incentive programs are inordinately costly for many physicians. CMS’ own figures show the new programs will add additional compliance costs of $128 million above the cost of the programs it is replacing.
Timelines and Perverse Incentives:
CMS has failed to properly engage physicians and guide them to successful participation since the current program began in 2007. The replacement does little to reverse the problems in the current systems, and in fact immediately increases the requirements for “success.” The first year of implementation is not the time to raise the bar and increase the degree of difficulty in meeting quality reporting requirements.
Outside of Physician Control:
Vendors and patients, not physicians, have control over meeting MACRA’s standards and requirements. Physicians should not be penalized for the failures of their electronic health record (EHR) vendors or for the demographic or socioeconomic status of their patients.
Years Too Late:
CMS plans to use two- year-old data to determine whether physicians receive a bonus or penalty. Data from 2017 will be used in 2019, 2018 data in 2020, and so on. At no point in the process will physicians be provided feedback on their current performance data or insights within the current performance year on how to improve their status, and no objective standard will exist for physicians to target. Physicians should be given real-time and correct information on their practices.
Incentives to Create Massive Changes in Physician Practice Type:
The need for sophisticated support systems, the inflexibility of the measurement standards, and the lack of realistic incentives to change all create pressures for physicians to abandon small practices to join large ones — or to sell out to hospitals. In fact, CMS’ published data shows that payment penalties could decimate small practices, still the majority in Texas.
Without Benefit to Medicare:
There is no evidence that the incentives in the draft MACRA regulations are likely to be effective in improving care quality or increasing efficiency. Requirements should include only activities proven to actually enhance care quality, or to reduce cost with no adverse impact on quality, access, or productivity.
In general we are asking for time, fairness, simplicity, and flexibility. More precisely:
physicians who have no possibility of earning more than it costs them to report
data, and do not force physicians into unacceptably risky payment
- Establish objective and timely measurement and reporting systems that are simpler and less costly than those currently required. The focus should be improving care for all Medicare patients, not creating yearly physician winners and losers with payment affected two years after care has been delivered.
quality metrics that capture those activities that are under the physician’s
control and have been shown to improve quality of care, enhance access-to-care,
and/or reduce the cost of care. The focus should be on metrics that are most
meaningful to a practice and its patients, not on what will result in the best
physicians who want to shift to value-based care enough time to make this
transition in a way that actually benefits their patients and does not cause
undue collateral damage to their practices.
- Require EHR vendors to build and maintain products that meet federal specifications rather than forcing physicians to purchase and constantly upgrade expensive and often-balky systems.
This practicing physician is telling Mr. Slavitt his plan just will not work. Change it.
Jun 12, 2016
“It needs to be a physician-led team, whether it's CRNAs or primary care,” he said. “That is the hallmark of quality care.”
Mar 2, 2016
By Steve Levine
TMA VP – Communications
While much of the state was engrossed in the obviously engrossing Super Tuesday presidential primary results last night, the Texas Medical Association and TEXPAC teams were studying the legislative and congressional races that will have a big impact on medicine going forward.
Bottom line: we liked what we saw in the party primaries for the Texas House and Senate and U.S. Congress. The candidates who support patients and physicians, by and large, did well – some surprisingly well.
We have a few important runoffs coming up on May 24, and the November general elections will be important at the top of the ballot and for some local races. But most of the makeup of the 2017 Texas Legislature and the 2017 Texas delegation in Congress was decided yesterday.
As TEXPAC Board Chair Brad Holland, MD, pointed out last month, “With so few competitive districts around the state, the action is now, in the party primaries. The men and women who win their party’s nominations in the next few weeks very likely will be the people who will be making the final decisions in the legislature and in the courtrooms next year.”
Here’s our wrap-up of key TEXPAC victories:
Texas House of Representatives:
- Speaker Joe Straus won easily against an onslaught of money and words from outside his San Antonio district.
- State Affairs Committee Chair Byron Cook of Corsicana, Insurance Committee Chair John Frullo of Lubbock, and Insurance Committee Vice Chair Sergio Muñoz of Palmview all defeated strong challengers.
- Former State Rep. High Shine of Temple ousted Rep. Molly White of Belton, who had medicine's second-worst voting record in the 2015 legislative session.
- Key allies of doctors and patients – Reps. J.D. Sheffield, DO, of Gatesville; Jason Villalba of Dallas; Sarah Davis of West University Place; and Cindy Burkett of Sunnyvale – all came home winners.
- There will be another doctor in the House: Anesthesiologist Tom Oliverson, MD, of Houston won his primary and is unopposed in the fall.
- TEXPAC-endorsed candidates won in three other open House seats. In a fifth open seat to replace retiring Public Health Committee Chair Myra Crownover of Denton, the TEXPAC-supported candidate is leading going into the May 24 runoff.
- In Senate District 24, we couldn't ask for anything better. Both of TEXPAC’s endorsed candidates -- one an active TMA leader (ophthalmologist Dawn Buckingham, MD, of Lakeway) and one a nurse married to a TMA past president (Rep. Susan King of Abilene) – are headed to the May 24 runoff.
- The TEXPAC-endorsed candidate in Senate District 1 in East Texas is leading big going into the other Senate open seat runoff.
U.S. House of Representatives
- Ways and Means Committee Chair Kevin Brady of The Woodlands defeated three opponents to win. His committee has primary jurisdiction over Medicare.
- Medicine’s champion – Rep. Michael Burgess, MD, of Denton, the only TMA member in Congress, architect of the bill that repealed Medicare’s hated Sustainable Growth Rate (SGR) formula -- won handily.
- Rep. Gene Green of Houston – ranking member of the Subcommittee on Health – won his race.
Nov 10, 2015
The struggle with electronic health records (EHR) is real, and Congress needs to hear from physicians. But how can you make your story compelling? How can you pen a tale that cuts to the heart of the matter and inspires your members of Congress to take action? These seven elements of storytelling—recommended by an expert on engaging members of Congress—will help you craft the most potent version of your story.
Know what you want before you begin. Do you want your member of Congress to understand how EHRs have increased costs to your practice or impacted the delivery of care to patients? A good storyteller begins knowing what the end product should deliver emotionally.
Consider various tactics and methods to achieve your goal in the story. Your goal can be to flatter, surprise, or evoke empathy or urgency. You are the Steven Spielberg of your story. What effect do you want to have on your audience?
Your first sentence or two should make your reader want to know more. What is at stake for patients, their families or you as the physician providing their care? As much as possible, think about the effect these regulations have on your ability to deliver quality care to your patients.
Members of Congress are listening for the component that tells them, “If I don’t do X, then Y will happen.”
When you experienced the moment you are writing about, what did you see, hear, touch, taste and smell? These are the elements that will get your members of Congress involved in the story.
Remember to use adjectives to enhance the power of your narrative. Make it real. Be practical, specific and graphic—don’t hold anything back! What descriptive words could make your story compelling and interesting? For example, substitute “morose” for “sad” or use the word “devastated” rather than “upset.” These are the kinds of impact words that paint the picture of your story.
Identify the conflict. Real struggles in life are mental, philosophical, emotional, physical—even internal. Every story has a protagonist and an antagonist, and the interactions between these two is where the conflict lies.
Don’t hesitate to play the underdog. Members of Congress love to come to the aid of the underdog. They want to help David win the battle against Goliath. Play that strength.
What did you learn or realize in the moment of your story? Find this answer and deliver it when it will have the most impact. Then describe how that learning impacted your life, the lives of your patients, the future of your practice and your ability to deliver quality care.
You may not have a discovery, but is there a part of your story that might surprise the legislator? If you can add a twist—a moment that truly delivers the scope of your struggle—then use it.
Success in a story is when the hero or heroine wins the fight or struggle. Joy is when the audience can participate and take part in the celebration of victory. If you can hook your members of Congress into feeling the impact of success and the joy that will follow, they become a part of your cause.
Think: “Senator/Representative, we have the opportunity to ….” Then describe how that victory will enhance your practice and the lives of patients and their families.
As you end your story, come up with a last line your members of Congress will always remember. Be thoughtful when composing your final line. Write it out and make it perfect. Have your ending sentence memorized when you’re speaking in person. This way, your member of Congress will remember it for the rest of the day.
Fitch related a particularly salient example. While delivering his story to a Congressman regarding his inability to acquire necessary medication, a veteran described a moment when his granddaughter asked him, “Poppy, why do your hands shake?” He looked at the Congressman and said, “What should I tell her?” This kind of hook will tug at the heart strings of your members of Congress and stay with them.