You may not agree with the recently
passed Patient Protection and Affordable Care Act of 2010, or certain parts of
it. You may not agree with the way it was passed. You may not like the
direction in which health care is headed. <o:p></o:p></span></p>
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<p class=MsoNormal><span style=’font-size:10.0pt;font-family:Times’>However,
health care reform is what it is, and we have to learn to live with it for now
and the foreseeable future. Currently, it is the law of the land. Any changes
to it are, at this point, opinions and conjectures. We need to work with the
facts in trying to determine what to do in the future.
With the renewed effort to fight fraud, significant pressure to cut costs, and strong movement to shift all health care into large delivery systems (accountable care organizations, bundled payments, etc.), your contracting, practice, and income are going to change. Expect to be paid less for each service you provide. In this new environment, there will also be opportunities for urologists, but they will take intelligence, organization, and initiative.
In this article, we will begin to address the business of your practice under the new direction of health care.
Intensified anti-fraud efforts –
The new law puts more teeth into fighting fraud by doubling the fine to $50,000 per incident and decreasing the burden of proof; the government no longer has to prove intent. Many are concerned that it will be “back to the Clinton days” for physicians. Dust off your compliance plans and prepare to spend time analyzing your coding and documentation practices, even if you are using an electronic medical record.
No longer will we be able to “practice as an island” or provide the care that we think is needed for our patients without the oversight of others. We will be required to follow the guidelines, determine the most cost-efficient care, and prove the quality and cost efficiency of our practice. Prepare by analyzing your practice data trends and working with the Physician Quality Reporting Initiative. Efforts are under way to ensure that all patients receive similar care; in other words, cookbook medicine is right around the corner.
Decreasing income –
The new legislation puts cost containment efforts on steroids. There will be a decrease in income from ancillary services and a continued decrease in payment for any service that is currently considered profitable. The recent changes in value for many radiology services and the soon-to-be-implemented requirements for accreditation are just the beginning.
Also, be aware that the sustainable growth rate (SGR) was not fixed in the health care reform law and that the projections for costs included the SGR formula. Any change to the SGR will require more money in the system. This does not bode well for physician service pricing in the current economic environment.
The movement for hospitals to employ physicians and to form larger delivery systems has been put on the front burner. This will expand rapidly. This does not make sense in the current model, as hospitals are the most expensive part of the system, and previous alliances between the hospital and physicians have been less than successful. One option for many physicians will be to form accountable care organizations to contract for the delivery of care. The closer you can get to the health care dollar, the fewer dollars you will lose to middlemen. Control of your own destiny will also be increased as you move closer to the health care dollar. The advantage is the “shared saving” component that will supplement the decrease in fee for service income.
There are two silver linings to this cloud. First, those who live in rural areas and in areas in which there is not a dominant hospital or health organization may be spared the move to consolidation for a long time or possibly forever. However, there will be a continued decrease in fee for service payments and a loss of ancillary income. Second, there is an opportunity for demonstration projects allowing groups of physicians to organize for contracting directly to provide care. Would it be possible for urologists to contract for urologic care or for chronic disease management for urologic diseases? We have already seen a move toward consolidation. It appears that strength in numbers will help in surviving reform.
Shortage of urologists –
Health care reform is only partly to blame for the shortage of urologists, but the shortage will be significantly exacerbated by the reforms. The increase in the number of potential patients resulting from increased coverage and the retirement of many older urologists due to increased governmental control and decreased income will certainly magnify the problem.
Advantages, disadvantages of shortage –
There are both good and bad aspects to the shortage. You will have to reorganize your practice in order to see more patients. However, you will also be able to tailor your practice to specialize in the areas of your expertise and interests. In addition, if you decide to negotiate with larger organizations, you should be in a good bargaining position because of the short supply and big demand.
The downside is that if you wind up on the wrong side of the contract, you may have to move to another area. In short, there will be winners and losers.
Heavier financial burden for patients –
As a result of reform, your patients will likely have higher co-pays. If your practice is not skillful at collecting from patients, your cash flow will suffer greatly. Of course, the move to place more of the financial burden on the patient will increase your “retail” behavior. Patients will be more demanding and more informed or misinformed as they attempt to spend their dollars wisely.
Higher co-pays also will likely lead to sicker patients, as they wait longer to deal with problems and more of a treatment burden is placed on providers with less training (physician assistants and nurse practitioners).
A shift toward preventive medicine and lifestyle changes will be strongly encouraged financially. The door is open to increase a urology practice’s scope to focus on wellness and treatment of underlying conditions. Money is targeted to increase for primary care. Is it time to add these services to your practice by hiring PAs or NPs—or even primary care physicians—to provide these services for your patients?
Carefully monitor business protocols –
We have consistently advised physicians to pay attention to coding and reimbursement protocols. You will also need to look at all your business protocols, including:
- making certain that services provided will be paid before they are provided
- improving billing and collecting by documenting accurately for all services provided, billing for all services, completely and accurately communicating to the billing staff, and appealing all denied services
- developing a robust compliance plan
- preparing to contract for care based on quality and cost efficiency of your practice
- preparing to live within a lower budget in the future.
Although it will be years before physicians and patients feel the full effects of health care reform, for urologists, the time to act is now. Clinging to the old ways of providing care, billing and collecting, and managing the practice will not work. By taking these crucial steps, your practice should be able to weather the many changes to the system.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook. Mark Painter is CEO of PRS Urology SC in Denver.
