Dear patients,

This is a hard letter to write, but it is important that you know about a major change that is coming for both of us in 2017, just a short year away.

As you recall, last year I left a large hospital group practice and opened my own office, and I want to thank you for your faithfulness in following me to my new location.  With the newfound freedom of running my own practice, I love being your doctor more than ever.

As a family physician in Southwest Florida, the majority of my patients are insured by Medicare, and you, my Medicare patients, are very important to me.  Not just for my financial livelihood, but because of the relationships that we have formed together over the last 15 years in this community.

I have welcomed you to Medicare with screening tests, explaining the risks and benefits, and keeping you up to date with the constant changes in guidelines.  I cared for you through various medical crises, and helped you to control your chronic diseases.  I was there to treat your acute illnesses, and coordinate your care with your various medical specialists. I requested prior authorizations when your preferred drugs weren’t covered, and helped you get free medicines when you were in the donut hole.  I did your preoperative clearances, your disabled parking forms, and the pages of paperwork you needed when we decided it was time to consider transitioning into an assisted living facility.  We’ve talked about end-of-life issues, and I’ve helped you understand advance directives and DNR forms.  I’ve visited you in hospice, and even held your hand as you died.

This is the side that you know about, and the part that is most important to both of us.  But unfortunately, what I have described is only half of my reality.  The other half is the regulatory burden that I have to bear in order to provide your medical care.

For every office visit that we spend together, I spend at least as much time on what Medicare deems as necessary documentation, especially a new program called meaningful use.  While the goals of meaningful use in improving quality of health care are admirable, the regulatory burden is intense.  To comply with Medicare requirements, I’ve had to spend thousands of dollars and massive amounts of time instituting electronic health records, adapting my practice to conform to the computer technology that wasn’t created to help me, your physician.

During and after every visit, I type away at my keyboard, clicking boxes to demonstrate to Medicare that I did my job.  My notes, which used to be informative and succinct, now include pages of irrelevant information, disclaimers and computer-generated statements to “document” that I am playing by the rules.

But even though I detest some of these new processes, I know that if I want to care for you, my Medicare patients, I must do everything that I can to follow the rules, no matter how burdensome.  You see, the problem isn’t just that the doctor doesn’t get paid if she fails to follow the letter of the law.  If Medicare detects any questionable billing processes or inadequate documentation, honest or not, the physician faces heavy fines and even jail time.

And I get it.  Costs have to be contained, and true Medicare fraud, unfortunately, does exist.  There is no doubt that medical costs have been spiraling upwards for years, and as our Baby Boomer generation reaches Medicare age, naturally our health care spending  will have to increase in turn.

Although physician payments only make up about 10 percent of the cost of health care in the United States, the government has looked to increasing regulation on physicians as a way of reining in cost.  And next year the whole ballgame changes for physicians as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) goes into full effect, with a complete paradigm shift in Medicare payment from “fee-for-service” (I send a bill for your medical care, Medicare pays me), to “value-based payment” (I submit a bill, and I get paid if Medicare thinks that I’ve done a good enough job).

Basically, in 2017, all doctors that care for Medicare patients will have to make a choice.  The first option is to join an accountable care organization (ACO), which is a large group that acts kind of like an HMO to control costs and accept financial risk.  Having just left a large hospital system with daily productivity reports and a glut of middle managers, this option does not appeal to me.

The second option, for those who choose to stay in solo or small practices, is for the physician to enter into a Merit-Based Incentive Payment System (MIPS), in which payment will be determined by where the doctor ranks on a physician scorecard.  The kicker is that the pot of money remains constant – so even if every doctor makes an ‘A’ grade, half of them will be paid less money, just by nature of this “budget-neutral” payment system.

And of course, this system begs the question: what happens to the doctors who care for sicker or less compliant patients?  Will doctors have to cherry-pick, dismissing patients simply because they choose not to take a statin drug for cholesterol?  What doctor will want to be paid less to care for patients in higher risk areas, such as centers of lower socioeconomic status, where patients may be inherently sicker?

And is there a conflict of interest when doctors are paid more to do less?   There is the potential not only for patients to suffer if doctors cut back on tests and treatments, but also for the physician to face malpractice lawsuits – the new Medicare law offers inadequate  liability protection for doctors who are being required to keep medical expenses down simply to get paid for their work.

Up to this point, I have managed to play by the rules that Medicare has set.  Yes, I’ve had to spend hours of additional work on documentation, and hire additional staff to help me comply with the new rules.  And yes, I’ve taken a pay cut from Medicare this year because I chose not to invest another $15,000 in an electronic patient portal, as required by the second phase of Meaningful Use.  But so far I have been able to absorb the increased expenses and decrease in payment, and I have been able to continue to care for my Medicare patients.

In 2017, this may no longer be the case.

I wonder if I will be able to afford to care for Medicare patients as a solo physician, not knowing if or when I will be paid, while my expenses remain fixed or increase with inflation.  On the other hand, I do not want to return to a large group, losing the freedom to run my own practice in the way that I feel is best for me, my patients, and my staff.

I understand that whoever pays the bills makes the rules.  The only recourse a player has is to choose whether or not to play the game, especially when the deck is stacked against them.

Perhaps the rules will change again before 2017, but it will take a loud voice not only from physicians and health care providers, but from you, my Medicare patients.

Sincerely,
Rebekah Bernard, MD

Rebekah Bernard is a family physician and the author of How to Be a Rock Star Doctor:  The Complete Guide to Taking Back Control of Your Life and Your Profession.  She can be reached at How to Be a Rock Star Doctor.

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