Here Dr. Finkenberg discusses NASS' top six advocacy priorities and how the organization is pursuing these issues.
1. Medicare sustainable growth rate formula. The Medicare payment SGR caps payments when utilization increases above expected levels relative to the gross domestic product. NASS members, as well as many other physicians, feel it doesn't accurately keep pace with the cost of running a medical practice.
"We think the Medicare economic index has a greater likelihood to show how the costs of running a medical practice change," Dr. Finkenberg says. "It measures inflation and the increasing cost of physician-specific goods and services — the new Medicare payment system needs to utilize the MEI. The Medicare payment advisory commission has consistently agreed payments should be based on the Medicare economic index instead of the GDP. There are a few new Congressional plans coming out, and we are in the process of reviewing those to understand exactly how they work. The authors of these proposals have asked for our opinion and we plan to respond."
2. Medical liability reform. Medical liability is a huge issue across the country. If the government could do something about medical liability reform, it would save the government $62 billion over the next 10 years. Some experts believe that the costs associated with medical liability issues total as much as $850 billion dollars per year.
"When I go to Washington, I talk to our Representatives about the successes California and Texas have had since they limited non-economic damages," Dr. Finkenberg says. "That, in addition to implementing an arbitration system, keeps the courts less busy and keeps malpractice insurance significantly lower. My liability insurance is $30,000 per year but my colleagues on the East Coast pay four or five times that for medical malpractice insurance. What happens in those states is that the doctors start practicing defensive medicine. Costs for Medicare in these areas are spiraling out of control."
One way to control escalating Healthcare costs is to eliminate the practice of defensive medicine and encourage physicians to order directed diagnostic studies that will alter their treatment choices according to the study findings. "We are also asking that the government consider protecting physicians that volunteer in disaster areas or volunteer to cover emergency rooms to assist hospitals in fulfilling EMTALA mandated services," Dr. Finkenberg says. "Physicians want to provide needed emergency services but Medical Liability concerns and escalating malpractice insurance is a deterrent."
3. Independent Physician Advisory Board repeal. NASS is concerned about the unilateral power given to the IPAB Committee. IPAB is comprised of 15 members. None of the members are practicing physicians and only a few will have a medical degree.
"We understand the Board has been established, but we feel practicing physicians need to be involved and the Committee should only operate in an advisory role to Congress regardless of our Legislators ability to curtail Healthcare costs," Dr. Finkenberg says. "Interestingly, the repeal of the IPAB Board has bipartisan support. Patient concerns are voiced by their Representatives in Washington DC and empowering this Board to make unilateral decisions eliminates majority public opinion."
Legislators often focus on Physician payments as the primary reason for increasing Healthcare costs. Only 9 to 11 percent is spent on physician payments, which is only a small portion of the Medicare Healthcare dollar. Other areas should be explored, as they could bring greater cost savings.
"I would love to see the option for privatization," Dr. Finkenberg says. "Many seniors want to use their Medicare benefits as they have been paying for the privilege their entire career. Patients are willing to pay the balance of their medical bill in exchange for the opportunity to pick the Specialist of their choice. Many physicians who opted out of the Medicare system would consider re-enrolling if this option were enacted. We support patients being allowed to establish Defined Contribution Plans or Medicare Savings Accounts. We are hopeful that this is part of what's implemented."
4. Utilization review process. "The utilization review process has increased in the last several years. Insurers have created treatment guidelines established by their own medical panels in an effort to curb spiraling healthcare costs. The medical panels support their recommendations by claiming the medical algorithms are supported by evidence based medicine. Unfortunately, each of the guidelines (Milliman, Interqual, etc.) differ and physicians are not being told the details of the utilization review criteria by the insurers who state proprietary reasons," Dr. Finkenberg says. "Physicians need to be given the Guidelines and have an opportunity to appeal treatment algorithms if other Level I, peer-reviewed studies support alternative treatments."
If the doctor neglects to put in the patients physical exam or history that the reviewers are looking for, it's denied. Doctors can appeal this decision, but it requires a discussion with another doctor who is often not a specialist in the field of the physician appealing the denial. Many providers are frustrated because the utilization review process puts another step in the care process and it has not been established to result in better value or higher quality care.
"The delay in care is aggravating to the patient and physician, and is not warranted," Dr. Finkenberg says. "I've started participating as a utilization reviewer in an effort to improve the process. I believe that it is the responsibility of the reviewer to explain why the treatment is being denied and how the information found in the accompanying physical exam may be sufficient to allow approval if they had supported their request with that data. If the process is made more transparent, doctors will be less frustrated. I'm also pushing hard for same-specialty utilization reviewers."
5. Electronic medical records. Most surgeons understand how electronic medical records can assist physicians with sharing diagnostic evaluations and tests. However, the implementation of this technology has not been smooth. Examination templates have been established for primary care physicians and the creation of specialty centered-computer programs is progressing slowly. Unfortunately, he says, meaningful use is being monitored to establish provider quality of care. Spine specialists are being told that these quality measures will be published even though proof that being in compliance with these requirements to give higher quality of care has not been scientifically established.
"Typically when I make morning rounds, I meet with each patient for 15 minutes to discuss their surgery, examine their wound and answer questions they may have about their symptoms or care," Dr. Finkenberg says. "That's 12 minutes with the patient and three minutes on completing the progress note in the chart. Hospitals struggling to implement EMR systems are incurring growing pains, which are altering the physician-patient relationship. I now spend three minutes with the patient and 12 minutes with the computer. This time is now spent navigating through the EMR system trying to make sure the correct orders are being documented, nurses are being made aware of important treatment changes and labs/test results are being discovered."
Some Healthcare analysts believe physicians will play a different role in our healthcare system in the future. They will no longer be expert diagnosticians honing bedside history and physical examination skills, but instead will become health information managers.
"Everyone in medicine understands the need for eliminating duplication of effort, sharing medical history and diagnostic information, but none of us got into this occupation to be information managers only for our patients," Dr. Finkenberg says. "There is a lot more to being a doctor, and we don't want to give up that portion. When I talk to people in CMS, they also want to preserve the physician- patient relationship. They are interested in making the EMR systems an asset that simplifies the paper work, allows for decreased errors and affords time to establish better physician-patient relationships."
Currently spine specialists are modifying EMR programs set up for primary care physicians and with every modification, the system can go down for several days. "It's incredibly frustrating," he says. "It takes us away from the patient and puts us in front of a box."
6. In-office ancillary services. There is some talk from the Medicare Patient Advisory Commission about taking away the Stark law in-office ancillary services exemption. Under the current exemption, physician owners of group practices may refer Medicare patients for diagnostic tests, therapy and distribute durable goods within the practice while still remaining compliant with the Stark Law.
"We think doing away with the exemption is a mistake that could affect the quality of care for patients," Dr. Finkenberg says. "As an orthopedist and spine specialist, I frequently care for the elderly and disabled. It is not uncommon for them to require an X-ray, therapeutic injection, brace or ambulatory aid. Patients with spinal injuries need immediate care, and to have them sent some place else to get these diagnostic or therapeutic treatments is difficult for patients and their family. Many people forget that patients don’t always drive themselves to their appointments. Getting rid of the exemption would require patients to get X-rays or diagnostic tests in another location across town or maybe even farther away.
"We think there is a way to monitor costs by better identifying Medicare fraud and abuse and requiring utilization outliers to undergo a review process after established norm limits for that sub-specialty have been exceeded," he says. "The goal is to improve the value and quality of care and NASS believes this can be done without taking away the diagnostic and treatment facilities that streamline care and benefit patients."
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John Finkenberg, MD, is on the North American Spine Society's board of directors as the chair of the advocacy committee. He has practiced orthopedic surgery for 20 years while also staying active in laboratory and clinical research. Dr. Finkenberg advocates for NASS and the spinal field through frequent trips to Washington, D.C., to meet with Congressmen and discuss healthcare policy.
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