Thursday, November 4, 2010

Primary Care

The practice of Internal Medicine, a type of primary care, has been a tricky financial trick to pull off in a small private practice setting in the last few years. The flat reimbursement rates, the increasing involvement of insurance in the personal management of medicine, and the new and evolving unfunded mandates from the government have conspired to make a successful go of it a challenge. The stimulus package from 2009 included the so-called Hi-Tech act, which incentivizes practices to use electronic health records (EHR), and more ominously, de-incentivizes practices after 2015 for not using such EHRs. The trend in medicine has been to integrate practices, either in group practice settings, or as alignments with hospitals.
Yet, despite all of this, the practice of medicine in a small setting continues to have its satisfying moments. I have good and important relationships with patients and their families, and I still feel that I have the ability to do good in a personalized way.
But, who am I kidding, the future does not bode exactly well. The trend line is still going down. And there is a new scare looming ahead that threatens to unravel the whole financial viability of such practices. SGR is an acronym describing the need for the Medicare program to square costs with reimbursements. According to the Balanced Budget Act of 1997, if Medicare costs go higher than the rate of inflation, those costs need to be recouped by decreased physician reimbursements. Now, mind you, these are total costs. So, if too many CT scans or MRIs are done, primary care physicians suffer as much as the radiologists. Because of the inherent concerns with decreasing doctor reimbursements (namely, that physicians would therefore leave the Medicare program en-masse), Congress has always decided to forgo the SGR adjustments and keep physician reimbursements where they are, occasionally even adjusting upwards for inflation. As these adjustments are not made, the bill for future adjustments keeps going up. Right now, if fixes are not made to the SGR, physician reimbursements are set to go down by 23%! in December.
Now here is the problem. If the lame duck session of Congress does not make a fix to the SGR, it will be left to the new Congress. You know, the Congress with all the new tea party members who are concerned with deficit spending. They may make an example of SGR, sticking it to the doctors taking care of Medicare patients.
If they do, I feel that the private practice of medicine will suffer a significant body blow from which it may not recover. And primary care will suffer the most. This, despite the fact that the new health care law did make an attempt to increase primary care pay.
The small practice is the example of a dying business, like the vacuum tube industry of old. There may be a small niche for it, but how long it lasts ill be unclear.

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