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Readers comment on independence, EHRs, tort reform
[Regarding “Is there a future for the independent ob/gyn?” January 2015 Contemporary OB/GYN]: After [being in] private practice for 24 years I can only say that being one’s own boss is far superior to being an employee. Being told I could not do infertility (by Kaiser) and [being forbidden by a hospital] to do any ob or gyn ultrasound on patients in the women’s clinic are 2 egregious dictates that burned my brain.
As a hospital employee I supervised 9 certified nurse practitioners. Based on that experience, and having a real grasp about what is coming for ob/gyns, if I were starting over I would limit my practice to either gyn or ob right from the start.
If I chose ob, I would hire 3 to 5 CNMs over the first year and have them do most of the work. Their volume would have to be unlimited for patients to be economically stable. That means a medical practice in a city of over a million residents, preferably in the Midwest. I believe that ob and gyn will have to be divided into 2 specialties for many good reasons. If I chose gyn, I would aim at advanced laparoscopic surgery and outpatient surgery.
Economic restrictions on fees, high education debt, dropping incomes, and [the expense of] starting private practice is forcing all doctors into indentured servitude. Concierge practice will be the only medical practice method for the future.
The primary cause of doctors becoming employed, quitting medicine, and becoming severely disappointed with their careers is that they cannot make enough money today to meet their financial obligations. And that is because they have never been taught anything about business and marketing that would provide them with the tools to succeed financially. Doctors have no idea how to get out of financial trouble, or to prevent it from happening, because they are business ignorant.
Curt Graham, MD, FACOG, FACS
Las Vegas, Nevada
Thank you for your commentary. We regret that employment has brought you so many personal and professional challenges. Unfortunately, many of our colleagues have had similar experiences. When queried, most articulate concerns with leadership, approaches to patient care and operations, and organizational values; hence our focus on the importance of corporate culture and creating alignment between your values and cultural expectations, and those of the people and organizations who are hiring you, or purchasing your practice. As we emphasize, while an opportunity may appear to have all the features of a great “deal,” in the absence of a cultural match, the relationship will ultimately dissolve into mutual dissatisfaction.
Robert Wolfson, MD, PhD
Steven Furman, MBA
[Regarding “Meaningful use 2? Just say no,” December 2014 Contemporary OB/GYN]: Finally! Somebody writes the truth! I have said from day one this EMR farce being forced on the medical profession is nothing more than a way for Big Brother to watch over what we do and use it as an excuse to pay us less. It has never been about improving patient care. Now it is coming home to roost.
We need not even bother to do stage 2 as it too much effort and too dependent on factors we cannot control (patient input). Take your pay cut and be glad that is all it cost you.
Our experience with stage 1 was even worse. We did what we thought was the correct process: spent hundreds of thousands of dollars to implement the EMR system (we got miserable education and training but did our best regardless), worked harder and longer than ever to make less money, and spent most days in frustration. Our reward was, 3 years after the fact, all 5 physicians were randomly audited by CMS and have been demanded to pay back roughly $90,000, plus penalties and interest, at the proverbial point of the spear.
Use the system to practice your craft, if you must, but other than that, it is nothing but EFMR: electronic fraudulent medical records. Probably not what some might think the F was for.
Scott Peters, MD
Oak Ridge, Tennessee
Thanks for responding to my article on meaningful use, stage 2.
It is clear you are one of the many providers who are passionate in their dislike of electronic healthcare records (EHRs). In my view EHRs improve care just by producing legible office notes, and keeping medication and problem lists current. Let’s not complicate EHR adoption and use by generating meaningless data for the Centers for Medicare and Medicaid Services (CMS).
I agree that many EHRs are overpriced, too complicated, and require too much button clicking and data entry just to document a straightforward patient visit. As is too often the case, following EHR adoption, office productivity declines and with it, office revenue. Also, if you and your EHR don’t get along well, [you may] spend unnecessary time after hours to finish charting. If you add meaningful use 1 and 2 documentation requirements then EHRs can becoming overwhelming!
There are solutions to most EHR-associated dilemmas. Scribes are a cost-effective alternative solution to doing your own charts. You can switch to an EHR that is more user-friendly, and make the time to learn how to use it correctly. It is very important to fine-tune your templates, as by doing so you can speed chart completion. I personally have found that using voice dictation software cuts the time required to complete my EHR charts nearly in half.
Many physicians don’t adequately document office visits to justify the level of service being billed, and this happens whether they use paper charts or an EHR. When documentation is inadequate, practices risk being subject to paybacks and penalties when audited. It is well worth your time to take a coding course so you always document your level of service correctly. Many such courses are available online. Also have your coders regularly audit your documentation of the level of service provided and you are likely to avoid needing to pay back funds.
Andrew J. Schuman, MD
[Regarding “Professional liability reform,” January 2015 Contemporary OB/GYN]: The states have long been a source of “demonstration projects” for various governmental attempts to change things. Seeing what works in one state helps other states to either replicate success or not waste efforts on governmental duds. I am somewhat surprised that Mississippi’s experience with tort reform has not been examined more by national media and researchers.
In 2003 Mississippi was in a full-blown medical liability insurance crisis. Access to care was being impaired significantly because of this. Previous efforts at tort reform legislation had been weak and ineffective. Haley Barbour was elected governor that year using tort reform as a major part of his platform. After a long hard political fight almost all of the reforms that Gov. Barbour, the medical community, and business interests wanted were enacted. Since that time frivolous suits have become almost non-existent, liability insurance rates have dropped by half, and the number of medical malpractice cases filed has dropped dramatically. The major parts of the reform package that led to this were venue reform and a cap on non-economic damages. Mississippi should be looked at as a tort reform success and a model for other states.
Sidney W. Bondurant, MD
I heartily agree that states should be the “laboratories of democracy” and that we have much to learn from one another. I only wish my new home state of Florida (I say “new” though my grandfather lived here for 40 years and my father was a Gator alumnus) would copy Mississippi’s approach to tort reform, which may well be among the most strict in the nation.
Whatever the current self-serving, highly suspect arguments proffered by trial lawyers against tort reform, the country simply can no longer afford the cost of defensive medicine. We risk rendering our companies non-competitive in an increasingly hyper-competitive global economy. I am glad to hear you are fighting the good fight on tort reform, which is far more salutary than stewing at home over the issue!
Charles J. Lockwood,