Physicians who see Medicare patients are practicing in very difficult times. The Obama administration wants to continue to not only cover the elderly who pay for an insignificant portion of their healthcare but to also add on an extra 40 million people who currently are uninsured. President Obama wants to 

 primarily through taxing the rich and Medicare cutbacks. 

The administration wants to set limits on payment growth for medications, hospitals, and physicians by implementing a nationwide certified EHR (c-EHR) system, which can be used to control physician independence, to further strain the physician—patient relationship, and to facilitate 

 by government bureaucrats of the way that healthcare is administered. 

On February 13, Congress passed the $787 billion economic stimulus bill, which, among other things, calls for up to an eventual 5% penalty for non-participation in new HIT mandates if 

 75% of physicians are “meaningful c-EHR users.” Through the bill, Congress wants physicians to pay for a c-EHR system that is costly in terms of software, hardware, and training. The Department of Health and Human Services (HHS) has yet to define what constitutes “meaningful use” of a c-EHR, but pundits say it will include e-prescribing, decision support, and quality data reporting, functionality that will require increased computer time for physicians and less face-to-face patient time. Adopting these technologies may well hamper a physician’s ability to see enough patients in order to maintain the financial viability of his or her practice. This administration wants to 

 who perform according to the stringent usage and reporting parameters up to a paltry $44,000 over five years, if they do manage to get paid at all. 

PC_HR.1_0409.JPGThose physicians who are not planning to comply with these new Medicare mandates have options that can actually stabilize, and possibly increase, their gross office incomes: 

1) Change your Medicare participation status from a participating provider to a non-participating provider, which allows you to legitimately increase reimbursement by charging the “limiting fees,” which represent the maximum allowable reimbursement (15% over Medicare’s approved amount). To learn more about the plusses and minuses of becoming a mid-level participant, check out 

www.acponline.org/pmc/ medicare_options08.pdf

2) “Opt out” and quit your Medicare participation altogether. Generally, you need to sign an opt-out affidavit that, among other things, states that you cannot re-apply for Medicare participation status for two years. The good thing is that you can then contract any fair payment arrangement directly with patients. 

3) Add an extra patient a day (say, $75 x 200 days) for an off set of $15,000 a year, or an increased income of $75,000 over five years. 

4) Start a cash-only ambulatory acute care clinic, which is associated with-on-the-spot payments and no third-party intermediaries. 

5) Start a “concierge clinic,” charging patients a yearly amount that covers issues such as availability and expediency. 

6) If you’re in a solo practice and it becomes untenable, but you still wish to provide patient care, then join a group, begin visiting nursing homes, become a hospitalist, or become a full-time clinical professor at your local medical school. There will be no overhead costs, and you’ll receive a stable paycheck. 

7) Change careers—become an author, a researcher, or a professor. 

These are all difficult choices, but the practice landscape is changing quickly, requiring all of us to make important, well-informed decisions regarding our futures. 

Whatever alternative choice you make will send a message to Congress that the bailout bill HIT provisions are driving out physicians from the Medicare program. 

Alberto Borges, MD, is in private practice and is an associate clinical professor of medicine at the George Washington University in Washington, DC. Check out his website at 

The opinions expressed in this column do not necessarily reflect those of 

Articles

Physicians who see Medicare patients are practicing in very difficult times.

Congress Passed the Stimulus Bill; What Should You Do Now?

President Obama has signed a stimulus bill that calls for eventually punishing physicians who do not “meaningfully” use a “certified” EHR system by imposing up to a 5% Medicare payment penalty—non-compliance penalties start at 1% in 2015, increasing to 5% in 2019, at the discretion of the Secretary of HHS, if the nationwide EHR adoption rate remains below 75% (

www.fmaonline.org/pages/practice/files/Stimulus_101.pdf

). CMS will use these penalties as a cost-cutting measure, which may force many physicians to consider withdrawing from Medicare. 

To understand why this may happen, consider a physician who in 2019 bills $100,000 to Medicare and gets punished the full 5% for failing to meaningfully use a c-EHR, and compare her situation over five years to a physician who successfully uses a c-EHR, and also to a physician whose use of a c-EHR fails to qualify as “meaningful”:

The non-complying physician will lose $5,000 per year for five years, for a total loss of $25,000.

The physician who fails to comply due to a poor c-EHR installation or who ends up de-installing the system will have a slightly higher total loss:

 for the estimated up-front cost of a c-EHR (plus $1,500 each month for maintenance fees; see 

 (penalty for non-compliance based on above math)

____________________________________________________

The physician who complies during the five years beginning in 2019 could end up incurring the highest losses:

 (cost of purchasing an EHR system, plus $1,500 per month for maintenance, multiplied by 60 months)

   (one-third of a full-time employee for reporting and documentation at an estimated $10,000/year for five years).

 in estimated workflow losses (say it takes an extra five minutes per encounter to capture required data. An office grossing $100,000/year in Medicare funds, at $100 per encounter, comes out to 1,000 encounters x 5 min/encounter = 5,000 minutes. That adds up to 250 “lost” 20-minute encounters, or another $25,000/year for five years.)

 Medicare reimbursement (if physician “meaningfully uses” c-EHR successfully)

	____________________________________________________

	The actual profit/loss calculation depends on the c-EHR that you end up buying. Some systems cost significantly less than the “average” cost stated above. Most vendors will promise a positive return on investment (ROI) due to perceived “efficiencies” gained by using their c-EHR systems. A minority of physicians on several discussion threads at Sermo, emrupdate, and other sites concur and state that they love their c-EHR software systems.

Only 17% of 2,758 physicians recently surveyed use the kind of EHR systems that Obama envisions for the whole nation, and just 4% use their EHR in a “meaningful way” (

). The reasons that the majority of physicians continue to dislike c-EHR systems include:

 Poor ROI; c-EHR systems are expensive, increase overall costs, and disrupt work flow.

c-EHR systems have not been shown to decrease errors. On the contrary, they have been shown to increase them, introducing 22 new errors in one study (

). According to the US Pharmacopeia’s 5th annual study of medication errors, in 2003, computer entry errors were the 4th leading cause of errors, accounting for 13% of total medication errors; handwriting errors were the 15th leading cause, accounting for only 2.9% of reported medication errors (

 Purchasing a CCHIT-certified EHR is associated with a 50% installation failure rate (

) and an 8% deinstallation rate thereafter (

 c-EHR systems increase quality only slightly, if at all, and secondarily lead to increased spending (

 Doctors generally dislike e-prescribing and CPOE (

These are turbulent times indeed for US physicians. Their ability to practice medicine is being encroached upon by government mandates based on unproven technology. I hope that physicians can make the right choices that have the least impact on their practices’ ability to survive financially.

Alberto Borges, MD, is in private practice and is an assistant clinical professor of medicine at The George Washington University School of Medicine and Health Sciences in Washington, DC. Check out his website at 

President Obama has signed a stimulus bill that calls for eventually punishing physicians who do not "meaningfully" use a "certified" EHR system.

The Costs of Medicare HIT Mandate Noncompliance

I work in the Washington, DC area in a private, two-physician, primary care practice. I am a believer in the intelligent application of healthcare information technology; the EMR system that I designed and have been modifying for the past 18 years works very well within my practice setting. However, I have noticed increased pressure on physicians to adopt CCHIT-certified EMR systems, e-prescribing, and other forms of health IT. The federal government, insurance companies, and vendors have been pushing ill-advised health IT policies that if implemented would be disastrous for physicians, especially those who practice in solo or small group settings. 

) provided several examples of the kind of dangerous thinking that is driving the debate over health IT. It presented many of the familiar top-level rationales supporting e-prescribing favored by many non-physicians, who don’t understand the complexities of patient care. Unfortunately, many politicians have been convinced that expensive EMR systems, with their ability to electronically prescribe, will save money and lives, and will generally be a good thing for healthcare in the United States. This apparently includes President Obama, who has sought advice on health IT from Allscripts CEO Glen Tullman; if Tullman’s views become policy, it would 

 in more unfunded and unproven health IT mandates. 

 article described Allscripts software as “being offered free to doctors.” Allscripts is not really free, because it does not integrate with the vast majority of EHR systems. If a physician does not buy the Allscripts EHR, then he or she will be forced into an unworkable double-entry situation, which will intrinsically increase the chances of making a prescription error. Providing free software is simply an Allscripts marketing ploy to get physicians accustomed to using its software. 

 article also noted that Allscripts software “displays a green smiley face next to generic and on-formulary drugs, and a red frowning face next to more expensive nonformulary drugs.” The implication being that this is an essential feature for promoting cost savings. Yet there are already several software programs (many of which, such as Epocrates, are available for free) that can be installed on almost any platform, including smartphones and PDAs, and that provide formulary data and drug-drug interaction alerts. Yet, despite the widespread availability of these applications, physician uptake has been slow. 

Physicians on the front lines must be aware of news and information about health IT that appears in newspapers and other media likely to be read and seen by patients and policy makers. Typically, these articles and news reports treat health IT as an absolute good and report on proposals to promote widespread implementation as if the big questions have already been settled and all that remains is to work out the details. As we all know, however, these accounts only provide a partial picture. They rarely acknowledge that most doctors do not want to buy or use CCHIT-certified EHRs or e-prescribing because they are expensive workflow killers that will make their lives more difficult. 

E-prescribing requirements have been pushed on providers by non-tech-savvy politicians and by EMR vendors who are trying to make a fast buck on the backs of physicians. They were 

 despite the lack of good prospective studies demonstrating that e-prescribing actually saves money and avoids errors in the ambulatory setting. In fact, the US Pharmacopeia 

 showed that data input errors far exceed handwriting errors (13% vs. 2.9%, respectively). We need more studies performed by neutral researchers before we can decide whether a forced and costly e-prescribing implementation mandate is really a prudent idea. 

We shouldn’t completely scrap the idea of full-scale e-prescribing, but we should push for a truly free, open-source product that can be used by virtually any EHR and is funded and provided by Medicare. But this cannot be an all-or-nothing proposition. CMS must still accept typed prescriptions that are printed out by basic EMR systems. Fax machines should also be reinstated as an e-prescribing option. 

We need to move forward with all health information technology, including e-prescribing, in small steps with continuous revisions and quality improvement along the way. 

An article published January 21 in the Wall Street Journal (WSJ) provided several examples of the kind of dangerous thinking that is driving the debate over health IT.

Alberto Borges, MD

Articles

Congress Passed the Stimulus Bill; What Should You Do Now?

The Costs of Medicare HIT Mandate Noncompliance

We Should Not Be So Quick to Rush into E-prescribing