A futurist, a physician assistant and a cash-only doctor walk into a convention center. The futurist tells a large audience they are becoming increasingly robotic and speaks of gloom, doom and mosquitoes. Before smaller audiences, the physician assistant talks about making more money and standing up to insurance companies, while the doctor who doesnt take insurance money talks about how enduring some initial pain can relieve you of your present misery thats being caused, at least in part, by insurance carriers.
Well, thats the "Cliff Notes" version of the Medical Group Management Association conference in Philadelphia late last month. For me it included three different Philly cheese steaks in three days. But for others, the meeting at times was a discussion concerning the survival of our healthcare system in general and of primary care, specifically.
MGMA President and Chief Executive Officer William Jessee, M.D., set the tone for the meeting. In his opening remarks, he evoked the battling imagery of the famed fictional boxer from Philadelphia, Rocky Balboa, and the never-quit attitude of his hometown World Series-losing Colorado Rockies as he implored attendees to never quit fighting to fix the governments ill-advised formula for Medicare payments to doctors.
In a news briefing later that day, he announced that Medicare physician payment is No. 1 on our advocacy agenda, and in his closing remarks on Oct. 31 he pulled no punches in declaring that affordable healthcare is a basic human right and that its a national disgrace how nearly 47 million Americans lack health insurance. (Underscoring the scope of the challenge, later that week the CMS issued its final rule setting a 2008 Medicare physician payment cut of 9.9%.)
Calls to action were issued, but after hearing keynote speaker, futurist James Canton, attendees may have been wondering Whats the use?
Canton painted a bleak picture of an aging U.S. population with a decreasing fertility rate living in an environment that features an upsurge in local pandemics and rising temperatures that will help increase the worlds mosquito population. Although he said preventive healthcare will become more of a force by 2015, Canton also predicted that new technologies and scientific discoveries will emerge that will lead to the growing of new organs and humans becoming increasingly roboticized.
Personally, I think that would strike a blow to preventive care. Human nature being what it is, its doubtful people will take better care of their livers, lungs and kidneys if replacement parts are available.
Perhaps my thoughts were influenced by the two Philly cheese steaks I had the day before. One was at the pizza joint down the street from my hotel. It reminded me of a dry version of what we in Chicago call an Italian beef. But, instead of gravy (a.k.a. juice), the proprietor offered me ketchup. Hmm. No thanks. It wasnt bad, but I was left wondering what the fuss was all about. I figured maybe the sandwiches at a pizza place were just a sideline. If I wanted a real Philly cheese steak, Id have to consult a specialist.
A fancy-shmancy version of the local delicacy was served at the conferences opening reception Sunday night at the National Constitution Center. It had more and better cheese. But I know that I might have just liked it better because it was free. (And, because it was free, I had another.)
But I digress.
After Cantons speech on Oct. 29, Charleston, S.C., primary-care physician David Albenberg, M.D., described how he freed himself from corporate healthcare tyranny and set up his independent, mostly cash-only (insurance may cover lab and radiology services) retainer-based practice known as Access Healthcare.
To be sure, the conference was marked by the issuing of one gloomy economic factoid after another. (For example, the 9.9% cut in Medicare payment results in doctors being paid less in 2008 than they were in 1999.) But the presentations by Albenberg and others reflected the conferences Philadelphia-inspired themes of freedom and revolution.
Albenberg spoke of how he had been dissatisfied with his position as an employed physician, decided to do something different and opened his practice in March 2003. His personal savings dwindled as he didnt give himself a paycheck until July, and he sank some $125,000 into practice startup costs, including about $50,000 for information technology.
But Albenberg said it was worth it. If its not a painful change, he explained, It isnt enough to put you out of your present misery.
Albenberg said he now takes home $144,000 a year while seeing an average of only about 10 patients a day (including some house calls)compared with the 30 to 35 in his former practice. In summarizing his message, Albenberg said that his cash-only, retainer practice is a viable and sustainable business model. It includes short-term risks and sacrifices, but there are long-term and intangible payoffs for both providers and patients.
If there was ever a program with the potential to degenerate into a pity party, one entitled Latest Trends in Primary Care would certainly qualify. Fortunately, no such thing happened. While there was sober acknowledgment of foreboding economic forecasts, those attending this free-flowing, interactive session were more like warriors preparing for a do-or-die battle that they intended to win.
There was much rallying behind the medical home concept, as well as calls for partnering with hospitalists and retail clinics. They were a feisty bunch that was nowhere near ready to throw in the towel.
A presentation by the Certification Commission for Healthcare Information Technology was about as exciting as one could expect for an IT program held in a windowless room in the late afternoon. The effectiveness of my lunchtime coffee was wearing thin as CCHIT Chairman Mark Leavitt basically repeated the same presentation I had heard him give many times before. I could have skipped this session, but I wanted to let him know Modern Physician was keeping an eye on himeven if that eye was struggling to stay open.
Leavitt maintained the annoying policy of referring to his organization by its initials (C-C-H-I-T) instead of the pronunciation almost everyone else I know uses, see-chit, but it was fun to hear him also get feisty and somewhat combative when describing the reaction his organization receives. He noted that he has been treated like an enemy of the people, and that hes heard CCHITs electronic health record-certification process alternately described as too fast, too slow, too easy and too hard.
Its like stereo, he said, explaining that the feedback sounds just right when hes standing in the middle of it all.
Partnership was a core theme of the last session I attended. It was a presentation on how using nonphysician providersbasically, physician assistants and nurse practitionerscan enhance practice revenue and productivity. The presentation was given by Ron Nelson, president of Health Services Associates, a Fremont, Mich.-based practice-management consultancy, and a practicing physician assistant.
As a physician assistant, Nelson may be biased in his opinion, but he gave a convincing argument that the use of nonphysician providers has economic benefits for a practice. He predicted that their use will grow concurrently with the rise of pay-for-performance programs and the use of patient satisfaction as a quality indicator. Nelson explained that this is because these providers can handle the preventive care and disease-management tasks pay-for-performance programs mandate and that patients will appreciate shorter wait times and better access to care.
A stumbling block to wider utilization of nonphysician providers can be the arcane web of state and federal laws regulating when and how they can be used and how much they can be paid. Knowledge is the key, because, according to Nelson, some insurers will balk at these providers offering things such as medical consultations, fracture care andespeciallymental health services.
Carriers will argue they cant, but where does it say that they cant? Nelson asked, adding that unless a state law specifically prohibits nonphysician providers from delivering these services they can do so.
If there is any question over what services a physician assistant can provide, Nelson recommended people go to the summary of state laws and regulations posted on the American Academy of Physician Assistants Web site.
Before signing a contract, Nelson recommending consulting a professional with experience in the area. He cited an example of how a physician hired a local attorney to draw up a contract for his physician assistant and it included an annual salary of $90,000 and what he thought was a standard list of incentives. Nelson said the physician assistant worked very hard and earned $75,000 from the incentive package alonewhich was way more than the physician had intended to pay.
Needless to say, Nelson said, the physician and physician assistant are no longer working together.
Having a JD, CPA or MBA doesnt make you an expert in this area, Nelson said.
I was impressed by Nelsons presentation and decided to see a specialist myself. On my way to the airport, I stopped by the corner of South 9th Street and East Passyunk Avenue, where I was told I would find the epicenter of Philly cheese-steakdom. On one corner sits Genos Steaks, and on the other, youll find Pats King of Steaks, supposed bitter rivals each claiming to be the true home of an authentic Philly cheese steak.
According to legend (or, at least, according to Wikipedia), Pats opened in 1930 and invented the steak sandwich three years later. Genos opened in 1966 and they claim to have added the cheese.
Upon my cabdrivers recommendation, I went to Genos. He said his sister comes to Philadelphia each month from Connecticut specifically to visit Genos. Unlike the Chicago delicacy known as the Italian cheesy beef, which is usually made with mozzarella, I was offered my choice of American, provolone or Cheese Whiz. Acting on my belief that cheese should never come from a pump or be sprayed from a can, I chose the provolone. Again, in contrast to the Chicago sandwich, with comes with the choice of sweet or hot peppers, I was given my choice of raw or grilled onions.
Thinking uncooked may be a wee bit healthier, I chose the raw option and headed to the airport with my authentic steak sandwich and a handful of proud to be an American Genos Steaks pens. (I later learned that Genos was embroiled in controversy for posting a sign requiring that people speak English when placing their orders, but this didnt seem to bother my cabdriver who was black gentleman with a distinct foreign accent.)
I ate my sandwich at the airport bar, and found it delicious. The bartenders made comments about how they were jealous that I had a Genos sandwich, but I didnt really pay too much attention because I was watching President Bush on television introducing his choice to lead the Veteran Affairs Department: former U.S. Army Surgeon General James Peake, M.D.
The president had apparently also chosen to go with a specialist, I thought, but it was a shame he hadnt flown up to Philadelphia where the announcement could have been made among Dr. Peakes assembled peers and colleagues.
Perhaps it would have given the doctors one more reason to feel positive about the futureas they waited for the inevitable announcement of the Medicare pay cut.