Top tips for physicians to deal with uncertainty

Physicians have always had to be keenly aware of changes in healthcare, from new innovations to updated 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, curious as to 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 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 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, who 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 seems to jibe 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 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.”

Next: there is always opportunity in uncertainty

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 a steady 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.”

Werner says the Trump administration will enact change 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, much 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.

“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.”

Next: Going into 'survival mode'

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.

“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.”

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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.”

Five strategies to deal with the unknown

Mark Werner, MD, national director of clinical consulting for healthcare consultant The Chartis Group offers the following five strategies for physicians:

• Don’t hit pause
Being cautious with finances is one thing, but Werner advises physicians not to put their heads down and try to wait out any changes, especially when it comes to the Medicare Access & CHIP Reauthorization Act (MACRA).

“MACRA is here and it is here to stay,” says Werner. “I think there will be, at best, minor, if any, modifications [at all] … and those will likely be things that sort of slow its implementation. There was extremely strong bipartisan support for MACRA.”

So if your practice has already taken steps to prepare data for reporting, stay focused on that path, he advises.

• Figure out ‘no regret’ changes
Physicians should recognize the instability right now, but also take what Werner calls “no regret” actions, those that they believe will prove to be a good use of time and effort, regardless of how the next few months or years pan out

These actions can include continuously looking to reduce operating costs. Werner also recommends that practices understand and embrace the notion that population health is about “excellent access, strong patient engagement and creating and demonstrating value to those who pay for care … which includes your patients.” No matter what happens, this will be a constant, he notes.

Next: Looking to peers and technology

• Review your efficiency

Downward pressure on healthcare revenue will continue, says Werner, including in primary care.

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“As a result, we need to make sure our practices are working very efficiently, that we have given some really good [thought] to how well we are optimizing the clinical operational and financial performance of our medical group,” he says. One example is ensuring your practice is performing in the top quartile for clinical outcomes.

• Continue to invest in technology

Whether for MACRA or to manage the performance of your practice, investment in technology is a continual need.

“This is important both from a clinical operation and a financial point of view,” says Werner. “You need the tools for both.”

He notes that even if revenue is tight, practices should make the investments, which could require partnerships, being part of a clinically integrated network or even a learning collaborative. In any case, the focus should be on what technology the practice needs and how to get it.

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“Under MACRA, this will quickly not be optional but a core capability for success,” says Werner. “Many medical groups will clearly not be able to fund this off their operations and existing revenue.  That said, even simple EHRs have the ability to support quality improvement and decision support when used to their full extent.”

• Think about physician relationships

From clinically integrated networks to building referral management capabilities with other physicians, Werner recommends doctors look to peers in the community and solidify those relationships to aid with value-based care.

“This goes beyond the informal [relationship] to really thinking about what … relationships you will need with fellow physicians [to] support you and enable you to perform in a value-based or performance-contingent environment,” he says.