How physicians can deal with policy uncertainty

Physicians have always had to be keenly aware of changes in healthcare, from technological innovations to new approaches to patient care. But these days, palliative care internist Amy Davis, DO, is also keeping one eye on healthcare policy developments emanating from Washington, D.C.

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From the final rule for Medicare payment reform late last year to the election of Donald Trump as president, a lot has happened in a relatively short timeframe. These changes have created an air of uncertainty for Davis and other physicians nationwide, as they await the fate of the Affordable Care Act, wonder what a physician-U.S. Rep. Tom Price, MD-will do as head of the U.S. Department of Health and Human Services, and whether other programs and mandates that have shaped healthcare over the last eight years will change or disappear.

“It’s getting harder, not just to be a physician trying to figure out what to do, but also as a small business owner,” says Davis. “I need to keep the lights on and I need to pay my staff.”

In her solo practice located in suburban Bryn Mawr, Pennsylvania, 146 miles north of the nation’s capital, Davis has added counselor to her role of physician, for her patients as well as her staff. Both groups are worried about their own medical coverage and financial well-being.

Davis recalls a recent encounter with a Medicare patient in need of physical therapy. The patient feared that his yearly allocation of services-something so certain in the past-would change under a Trump administration.

“I said to the patient, ‘You are set for the year, don’t worry,’ and he said in return, ‘Trump is changing things in the middle of the game and waiting for people to challenge him legally. What if things change in the middle of the game for me?’” says Davis. “I had no reply. The rules don’t seem to apply to [Trump].”

Davis’ approach jibes with advice from Bob Doherty, senior vice president for governmental affairs and public policy for the American College of Physicians (ACP). Doherty told Medical Economics that physicians can’t completely reassure their patients about what’s to come.

“Doctors like to be reassuring and say: ‘Don’t worry about it.’ Clearly, that’s not the case,” Doherty says. “I think the best thing [physicians] can do is hear [patients] out and let them know that you have their back.” 

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Similar anxiety exists among Davis’ employees, worried about their health coverage and paychecks. To keep morale high, she brings in the occasional treat and constantly reassures them that they are in good hands. “I’ve told them that you will get paid before anyone else, including me,” she says. “A happy staff makes me happy.”

No strangers to change

Davis, like thousands of other physicians juggling their clinical and business duties, is no stranger to change. She acknowledges that it comes with the territory, and is maintaining an even temperament these days despite the unknown ahead.

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While used to change, physicians don’t necessarily embrace it, notes Mark Werner, MD, national director of clinical consulting for The Chartis Group, a healthcare consulting firm. “Physicians in general don’t tolerate uncertainty very well,” says Werner. “We work in a field accustomed to facts and information and things that are tangible. Now we find ourselves in a period where things are really pretty unclear and our comfort level as a profession with this level of unknown is a bit challenged.”

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Werner says the Trump administration will enact changes faster than its predecessor, making medicine more about price and cost, hence accelerating the importance of patient choice. The combination of President Trump and a Republican Congress will mean a more free-market environment, less regulation and empowering individuals to make more choices. Therefore, he says, practices must stay aware of what’s coming their way and how to take advantage of it.

Werner notes there is always opportunity in uncertainty, especially for physicians who are visionary and entrepreneurial in their leadership. “Luck favors the prepared,” says Werner. “Now is the time that will reward the more ambitious and the bolder-moving practices. Those that tend to be late adopters and more cautious-already finding themselves behind the curve-will find themselves more behind.”

In Hamburg, New Jersey, solo OB/GYN Fred Nichols, DO, is taking that approach. Three years ago, Nichols added weight loss services that were covered by insurance to his practice as an added revenue stream.  Now, anticipating some financial uncertainty, he’s adding more ancillary services to keep his practice thriving.

“I have to think outside of the box,” says Nichols, who has operated independently for 15 years. “As an OB, I never thought I’d be doing facial rejuvenation, but it is a cash-paying service.”

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Nichols has also taken on locum tenens work as a “little cushion” to help with the immediate future. “I used to be able to know, with some certainty, what patients and what revenue, were walking through the door,” he says. “I don’t feel that level of comfort anymore. If I see fewer patients, that means cutting staff and I don’t want to do that.”

Like Davis, he has dealt with the “huge cloud of uncertainty” dating back to before the election, but is a little more confident with a businessman running the country.

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“No matter your political views, at the end of the day, [Trump] has run very successful businesses,” he says. “So in a business sense, things have to be cut and curtailed and I understand that. So I have a little wide-eyed optimism.”

Going into ‘survival mode’

While Davis awaits the Trump Administration’s next move, she is also anxiously anticipating word from the Centers for Medicare & Medicaid Services (CMS) regarding her future reimbursement. Under the Medicare Access & CHIP Reauthorization Act (MACRA), practices like hers, with $30,000 or less in Medicare Part B charges, are exempt from data reporting provisions.

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“I’m still awaiting my ‘golden letter’ from CMS regarding my MACRA exemption,” she says. “By my records, I should be exempt … but what we have and what Medicare has for us is often incongruent.”

Davis has been on the phone with CMS frequently, starting in December 2016 when letters to qualifying providers were supposed to arrive. CMS then told her she’d find out in January, then that the letters were to come through Medicare Audit Contractors, so there would be yet another delay.

More recently, a CMS help desk attendant told her, “toward the beginning of February.” As of press date, Davis is still unaware if she needs to provide quality metrics or not. “For something that went into effect on January 1, this is quite a delay,” she says. “I have to pay salaries and there are other issues.”

Those other issues include replacing broken lab equipment and updating her practice’s electronic health record (EHR) system. Given the uncertainty of what’s ahead, both investments are on hold. Davis has also called her bank to ensure her line of credit is secure and to indicate that she might have to use it in the near future.

Davis likens the current feeling to what used to be the annual uncertainty of whether Medicare’s Sustainable Growth Rate (SGR) would take effect-bringing double-digit reimbursement cuts to physicians-or Congress would delay the cuts for another year.

“You have to go into protection mode, like we did pre-Obamacare and with the SGR,” she says. “You go back into that survival mode.”