Are private practice specialists an endangered species? Given the mounting challenges of insurance reimbursements, government regulations, patient perceptions and administrative costs, Dr. Robert S. Forster, M.D. may be part of a diminishing breed.
Dr. Forster is an orthopedic surgeon with 25 years treating patients in private practice. The realities of primary care and specialization have changed dramatically since he started out, when the autonomy of the job and personal relationships with patients outweighed the difficulties of running a business, complying with government regulations and fighting for health insurance reimbursements.
Today, the disparities in medical coverage, excessive power of insurance providers, and pressures of running a small business and administrative overload are driving even more private practitioners to join HMOs and medical groups, on salary, or leave medicine altogether.
Despite the challenges of private practice, Dr. Forster chooses to persevere in the work he loves. I asked him about the day-to-day struggles and rewards of seeing patients, helping them improve their quality of life and sustaining a business. He offered a candid diagnosis of our nation’s present healthcare system and coverage. His prescription? More empowered patients and physicians.
What do you love about practicing medicine?
Most doctors I know enjoy taking care of people. The big thing about medicine is it incorporates science, investigation, being inquisitive and applying scientific principles, all in the pursuit of helping to make people better — make their lives better. When I see people who were incapacitated or crippled by some form of a disease and later they walk into the office with a big smile on their face and say, “I’m so happy”– that’s the kind of thing that really makes practicing medicine worth it.
Orthopedics has changed in the last 5 years. There’s always movement forward in terms of new technologies, new procedures, new innovations. The ability for an orthopedist to take care of an individual now is much better than it once was. We can perform minimally invasive surgery such as arthroscopy and limited incision joint replacements as well as enlist new structural bio materials that promote healing. The problems that previously required extensive surgical procedures and long periods of time for convalescence are much faster and easier now. Pain management has improved through incredible advances in pharmaceuticals and our understanding of pain. People are much more rapidly returning to work and hobbies.
What is a typical day in your practice?
On an average day I’ll see between 15 and 35 patients. With ER coverage that may increase because we’ll have to book in 4 to 5 patients. Potentially, there may be emergency surgery that day or that evening on someone who has come into the ER.
Typically in medicine, and particularly in orthopedic surgery your schedule for the next day involves seeing some returning patients and some new patients, and I can get a feel for how much time will be involved. But there’s always the unknown. There are the patients who are referred by primary care physicians. We treat them on an urgent or emergency basis; we do follow-ups or evaluations and hospital visits. And there are patients with complications. A typical day could involve 1 or 2 catastrophic problems that are going to take several additional hours to sort through.
How do you cope with the demands of insurance providers?
Most physicians want to take care of their patients. They don’t want to make millions or become part of a corporation. The trouble is that to make a living one has to deal with insurance companies that have a singular goal to make money; that is, to take in more than they pay out. The companies do not have a human interest in customers, despite their advertisements, but rather the pursuit of the bottom line. Physicians are the low hanging fruit and the easiest to eliminate. In medicine there is no collective bargaining and an individual practitioner can be pressured to accept continually decreasing rates of reimbursement or stop seeing patients with less than acceptable insurance.
The problem is that insurance companies uniformly set rates that are the same across the industry and there will not be a preferable insurer. To delay a payment they will indicate that the claim we submitted for a service wasn’t labeled correctly, that it didn’t have the right code. They’ll find varieties of reasons for not paying and when it comes to authorization they may delay or try to postpone or put off requests for patient procedures. There’s a big element of distrust between physicians and insurance companies.
Over the last 20 years insurers have gained power. Patients are fearful of losing insurance coverage and will stick with whatever their insurer offers. Insurers can no longer refuse to insure patients because of a pre-existing condition but they can still charge what they want. The insurer has to cover patient costs and reimburse doctors, but they don’t have to do it quickly. The most profitable way for insurance companies to make more money is to slow down reimbursement payments. In this country the plan of the insurer is to delay authorization and pay out as slowly as possible in order to hold on to revenues for as long as possible, or deny claims altogether.
The biggest problem that exists today is that people don’t know what they don’t know. The perception is that the vast amounts of money spent in healthcare should insure that providers will always be available. The reality is that physicians and other healthcare providers incomes have really dropped, and with continually increasing costs for in-office administration and staff salaries, the profitability is at the margin of business failure. Doctors are starting to quit their practices because of insurers’ reimbursement practices.
How do the disparities in medical coverage affect your practice?
Typically in our practice we rarely see uninsured patients unless they come through the ER. We actually receive a stipend to cover the ER at the hospital. But that became an issue because there are so many uninsured and minimally insured patients, and as doctors we have the responsibility to take care of those individuals no matter what. Hospitals can at least bargain with government agencies and make up for some cost deficits by charging more for services to paying patients.
The reimbursement through Medicare is so low that we cannot afford to see those patients without actually losing money due to the administrative costs. Provider networks and HMOs are the mainstay for revenue with a very few select insurers that continue to pay high reimbursement but allow cash payments from patients. Medicare is the common denominator and insurers use Medicare reimbursement rates as a base payment. They will pay at Medicare rates or slightly above and some below. And we are given or not given bonuses based on how little the orthopedists cost the system.
The big element that is missing in healthcare, as has happened in the banking industry, is regulation. Physicians no longer have input and to believe that a corporation will do the right thing is self-deception. The Affordable Care Act is exactly the smoke screen that insurers needed to allow them to hike rates to customers and drop payments to providers. Even as the legislation claimed to monitor “administrative costs” and payment toward patient care, the industry was very good about hiding the true profits.
What changes and challenges will ICD-10 bring?
This transition to ICD-10 theoretically should not be a big thing. For people who write software it means they put in a lot of work to actually change things over smoothly. Twenty years ago, when I first started my practice, the Orthopedic Surgery Academy had created a whole series of codes that were very specific to orthopedics. Our codes were replaced by Medicare’s version, which didn’t fully encompass the problems that we see. For example, say you had pain resulting from an injury in your hip muscles, considered lower extremity tendonitis; the previous ICDs didn’t allow you to be that specific.
ICD-10 has quadrupled the number of code numbers, from 15,000 to 72,000 codes, but it’s because things are much more specific (i.e., your left side, right side, something chronic, acute, specific muscle, tendon, joint, etc.). So in many ways it’s better and more comprehensive. Because medicine is becoming very compartmentalized, it’s not a bad thing to have a clear understanding of the incidence and treatment for various diseases. It will be work, but like the millennium transition a necessary step.
EHR or electronic health records are another example of good medicine at a cost. The government’s concept of efficiency and cost savings was entirely off the mark. Medical practices are spending hundreds of thousands of dollars to achieve the specified requirements and at virtually no cost savings. The beauty of the EHR is the portability of health care records and the ability to drastically limit errors in treatment that have occurred because patient health care records were not available. Again the healthcare system is spending billions on computer code and there is no real tried and true methodology. Private vendors are working by trial and error and at great cost. This is exactly the issue with the rollout of the ACA.
What changes would you like to see in our nation’s healthcare system?
Physicians don’t really have the ability to talk to an individual. They must see a lot of patients to remain solvent and it is much more expedient to just prescribe a medication. When it comes to talking to the patient about lifestyle changes such as exercise, and modified diet, primary care physicians and specialists don’t have the time. It’s a shame because there are so many ways we now know where the patient would do better without surgery or hospitalization, but the patients want to come in and get something quick and fast; and they do not want a lecture; they just want to get it done. They see it like dropping their car off at the shop.
I believe that our healthcare could be much better if there was a real universal healthcare program in this country with the option for individuals to buy additional coverage. There must be regulation as to how resources are used, just as in triage on the battlefield it is not possible to provide everything for everyone, but it is much more effective to supply insulin to an impoverished individual and prevent them from coming to the hospital in the last several years of their life, with costs of hundreds of thousands of dollars a day.
A tiered system would allow private insurance companies to exist, but provide real coverage above the universal care minimum. It would eliminate the smoke and mirrors of the corporate greed by creating true competition. People who are responsible and understand the value of healthcare could set aside money and buy the plan that they can afford and desire, but knowing that the basics of health care are already provided. Being out of work should not mean being uncovered for basic healthcare. Compensation for physicians will have to be made reasonable to continue to attract good candidates.
The road to becoming a physician is extremely difficult as it involves at least 6 years of intense post graduate training with high debt and high stress. Just as we would like to believe that the pilot flying our plane is dedicated and concerned for our welfare, we understand that they must be compensated appropriately to attract the individual that will. Healthcare is equally a concern with respect to the counseling and skill that will be needed to care for all of us throughout our lives. The vast amount of money that is spent on administration of healthcare needs to be funneled back to providing care. This will require real regulation or allowing the market place to be truly free and allow physicians and other providers to collectively negotiate with insurers.
The thrust of healthcare needs to be redirected toward preventative care, but with the realization that disease and injury will still need to be addressed by treatment.
An alternative to Universal Care or private practice is corporate medicine to compete with corporate insurance. Physicians in the corporate world are a commodity and placed in much the same position as engineers working for industry. The difference is that physicians have traditionally been an ongoing resource and stable touch point for patients, whereas in the corporate world, as long as the patient sees some provider the job is done.
You do not choose your surgeon or specialist, you have one provided. Your PCP will see you in the office if time allows, but you may see another and the job is done. Individuality and responsibility for care of your patients is replaced by the job. But —– you have “the company” to do the negotiating and making the decisions to get the money, and you take home a pay check each month. I believe that corporate medicine can work but it requires the innovative business leadership that companies such as Google and Apple have demonstrated in dealing with employees.
It is sad that the physician is being replaced by the healthcare provider. Robots will do the surgery and computers can provide all of the necessary diagnostics and we can text each other about our ills rather than talk to one another. And the corporations will keep on doing what they do best.