The reimbursement issues plaguing physicians

From inflation to mental health services, 11 physician leaders joined Becker's to discuss their biggest concerns regarding reimbursements. 

Question: What are your biggest concerns regarding reimbursements right now?

Editor's note: Responses were edited lightly for brevity and clarity. 

Timothy Babineau, MD. Principal at ECG Management Consultants: Continued downward pressure on reimbursement rates across all government and commercial payers even as hospital margins disappear. In addition, given the severe shortage of mental and behavioral health providers (all disciplines) in this country, there needs to be a recalibration of reimbursement rates for these professionals.

Thomas Castillo, DO. Ophthalmologist in Beaver Dam, Wis.: My biggest concern regarding reimbursements is that reimbursements continue to decrease while expenses increase to the point of not even meeting the increased cost of living. This leaves all healthcare providers with no way to hire and keep qualified employees when that physician is in private practice. The ultimate result will be that all healthcare will be provided though large systems or insurers or, God help us, the federal government.

Joel Cleary, MD. Orthopedic Surgeon at Memphis Veterans Affairs Medical Center (Grangeville, Idaho): Perceptions by politicians that doctors make too much. As I used to say at Montana medical organization meetings, legislators have little sympathy for "poor" doctors when they make five to 10 times what a legislator makes.

Divya Joshi, MD. Pediatrician in Lawrenceville, Ga.: No compensation for mental health! Lacking focus on prevention, lacking compensation for primary care. 

David Farkas, MD. Emergency Room Physician in Park City, Utah: As always, the poor reimbursement from Medicaid continues to push cost shifting and egregious charges. Medicaid patients are often treated at a loss. Expanding Medicaid to fund more patients only exacerbates the problem. Medicaid reimbursement should be equal to Medicare, as continuing otherwise continues to promote healthcare inequities.

Laura Lowenstein. Healthcare Attorney and President of oNet Systems:  Besides the obvious administrative hurdles — pre-authorizations and a myriad of claim follow-up obstacles — my central concern is that Medicare, which was never meant to be reflective of a true market rate, has become the de facto benchmark of both in-network contracting and out-of-network reimbursement. The result being an incredibly distorted reimbursement picture where everything is consolidating around a fixed government price that does not in any way reflect what would result from arms-length negotiated rates. This results in less patient access and more patient cost shifting to get their desired care. We need to move everything to a middle ground where rates are not dictated top-down and instead vary based on a whole array of regional, provider and employer-specific considerations. If we do not return to a disparate free-market system of healthcare spending, we will continue to get concentrated power in insurer epicenters that do not serve the public interest. The NSA has only accelerated this concentration and siloing of healthcare systems due to the (potentially unintended) destructive forces that it created in the out-of-network market. When the independent out-of-network providers are not there as a counterweight, you get total insurer capture of in-network bargaining leverage. It is arguable that the NSA has caused as much, if not more, harm to in-network providers than out-of-network ones. This is not a sustainable reimbursement system.   

Trevin Mayabb, MD. Family Medicine Physician at Ferguson Medical Group (Sikeston, Mo.): I feel like there is a lack of stability with regard to provider reimbursement. As we continue to move away from relative value unit-based payment models to alternative payment models (such as ACO), I believe there could be significant fluctuations for providers in terms of yearly income.  Some of this will be beyond the providers control.

Matt Mazurek, MD. Assistant Clinical Professor of Anesthesiology and Director of Quality and Safety at St. Raphael's Campus of Yale New Haven (Conn.) Hospital: Physician service reimbursement has declined year over year for decades, and inflation-adjusted compensation has drastically been reduced. Around 140,000 physicians quit or retired over the past three years and many physicians are looking for a way out of the healthcare system. Part of the problem is consistent downward pressure on reimbursement. Private practices can no longer afford to stay in business. It’s difficult for a physician to take a pay cut in this climate while large insurance companies have somehow leveled a nearly 3 percent increase for Medicare Advantage patients when these companies are making significant profits and executives are earning over seven-figure salaries. There is a disconnect in value and the value system. A physician colleague recently told me that no one goes to the emergency room and asks for the administrator on-call or who is in charge of my insurance plan. Administrators do not provide healthcare services. Nurses, physicians, nurse practitioners, physician assistants, lab techs, respiratory therapists and everyone at the bedside at 2 a.m. during a crisis provides care, while the administrators and insurance owners sleep at home. A downward drift in reimbursement for physicians with no change in compensation for executives foments resentment, anger and, frankly, a feeling of injustice. Medicine is a science, healing is an art, and healthcare is a business. Physicians are in the business of providing care in an environment that does not value the physician or patient. This is reflected in lower reimbursement for services rendered and higher out-of-pocket expenses for patients. There is a profound feeling of frustration from both patients and physicians. 

Dennis Quagliani. President and CEO of Healthcare Associates: The continued decline in professional reimbursement, the shift in payment models taking clinical decisions out of physicians' hands and the interference pharmacy benefit managers have on oncology practices by influencing policymakers to take away the ability of oncology practices to ship oral drugs to patients, thus forcing them to physically travel to their physician's offices. Many of these patients are very ill and struggle to travel. Many also do not have accessible transportation.

Overall, the numerous payment models implemented by payers are degrading the overall quality of healthcare in the U.S. A major shift has been underway transferring money in the healthcare system away from providers' ability to treat patients while healthy profit margins continue to grow in the for-profit sector of healthcare insurance companies. This is not a sustainable model that will improve health outcomes in the coming years for U.S. citizens.  

Mukesh Sharma, MD. Interventional Nephrologist at Sierra Nevada Specialty Care (Reno, Nev.): It is becoming harder and harder to get paid by the payers and the amount of resources and energy required (in terms of pre-authorization, claim filing, dealing with denials and refiling, and decreasing reimbursements for more complicated procedures) is just suffocating and choking the small and medium-size practices. 

Thomas Terndrup, MD. Professor of Emergency Medicine at the Ohio State University Wexner Medical Center (Columbus): Practitioners replacing physicians despite very limited training and knowledge. With administrators and their boards of directors overly focused on the bottom line, doctors are replaced with lower-paid personnel. Thus, medical decision-making suffers while protocols are largely written to protect liability concerns.

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