From declining reimbursements to prior authorization burdens and concerns about AI, physician practices face an array of disruptions to care delivery and financial sustainability.
Seven physicians, practice managers and administrators joined Becker’s to discuss the biggest disruptions to physician practices.
Editor’s note: Responses have been lightly edited for clarity and length:
Julie Baak. Practice Manager of AiArthritis (St. Louis): As an independent rheumatology practice, the most disruptive trends are the delays and denials of specialty medicines for my patients. I care for 2,500 patients, of which 750 are on infusion therapy in my clinic, across several insurance companies, with several different [pharmacy benefits managers]. Their “formulary,” which I call the “Pay2Play” list, can change quarterly, which essentially delays stable patients’ therapy that allows them the ability to work and live.
As a physician office, my team is considered an unimportant independent contractor to Insurance companies, and our “letters of medical necessity” are frequently algorithm denied, our [peer-to-peer] calls are not clinical discussions but rather a “denier [for] hire” physician reading from an insurance policy script, demanding non-medical switches or change to another biologic despite the patient being stable on current therapy. We frequently are dealing with calling off-shore call centers that insurance/PBMs hire to slow down the care by inserting yet another layer of middlemen, doing none of the actual healthcare, siphoning direct patient care dollars away from the folks doing the work and into their profit centers, all off the backs of patients, employers and taxpayers.
We are all patients, and we have all experienced delays/denials from our insurance company. The access to healthcare is alarming, as the insurance companies continue to vertically integrate and purposefully narrow their physician networks, which delays care even more. There is a giant rheumatologist shortage nationwide and my office serves the marginalized patients in north St. Louis. It takes a team of 24 to support one physician because of all the administrative burdens of the insurance and PBMs.
Donald Graham, MD. Infectious Disease Specialist at Springfield (Ill.) Clinic: Patients are uncertain about what care they can afford. Insurance companies, Medicaid and Medicare, including Medicare Advantage, change their coverages frequently. As a result, patients delay, reduce or completely omit their care, whether for blood tests, radiology, biopsies, medications, immunizations or surgical procedures. A derivative problem is that patients and their physicians spend enormous amounts of time clarifying benefits from third-party payers. National events of the last [two] weeks have only heightened their anxieties.
Amit Patel, MD. Gastroenterologist at GI Alliance of Illinois (Evanston): The most disruptive trend for physicians is the decrease in reimbursement coupled with the increasing expenses. It is particularly concerning for Medicare patients. The economics makes it almost impossible to care for these patients. For example, it is difficult for a Medicare patient to obtain spine consultations and treatments. It also affects the specialties and number of physicians in regions.
It is also leading to the closure of private practice offices, and hence less options for patients. This is not limited to Medicare. Commercial insurers also base their reimbursement to physicians on Medicare rates and with the decrease year after year leading to a critical break point. Reimbursement is a major factor in the decrease and in some regions lack of obstetric care. Only time will tell to what extent this will continue. There appears to be no solution from our legislators, who neglected the issue in the annual budget this year.
Tchaka Shepherd, MD. Administrator at the Institute of Trauma and Acute Care (Redondo Beach, Calif.): The most disruptive trend currently facing physician practices is the increasing fragility of their economic foundation. Physicians across all specialties are experiencing a perfect storm: reimbursement rates are declining steadily while the costs of delivering care, such as staffing, supplies, malpractice insurance and regulatory compliance, are rising unchecked.
This unsustainable trajectory poses a significant threat to our financial stability and undermines our ability to provide the high standard of care our patients deserve. If left unaddressed, these challenges could severely impact the future of medical practice and patient care.
Easwar Sundaram Jr., MD. President of Texas Institute for Neurological Disorders (Dallas): The disruptive trend is without doubt failing small or medium-sized group practices and individual practices under the weight of declining revenues and rising costs. Private equity is the thing in vogue, and very soon all physicians will be employed either by mega-insurance companies or private equity. There will be consolidations all over, with just large groups with less access for patients.
Sheldon Taub, MD. Gastroenterologist at Jupiter (Fla.) Medical Center: It is hard to separate what exactly is the most disruptive trend that physicians face right now. The clinical role of medicine is being drastically changed by AI-powered diagnostic tools. This is especially true in the fields of dermatology, radiology and pathology. The role of physicians may shift from diagnosticians to interpreters of AI systems. Ethical and legal issues may come into play when AI makes an error and the physician doesn’t recognize it. AI may also affect patient expectations, causing a shift in the doctor patient relationships. While AI may eventually improve patient care, the speed of development is very stressful and where this all plays out at this time is still uncertain.
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