What effect will SGR repeal have on your practice?

Dr. Flanagan“The whole thing has been a farce from the very beginning, sort of a red herring to get doctors energized to call our congressmen. I’ve always been amused by the fact that it goes down to the last hour and you get a Western Union telegram that says, ‘Do everything you can to get your congressman on the bandwagon so the bill passes.’ It always passes. Even if you do nothing, it’s going to pass.

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It’s done to deceive us and take us away from what we need to be doing to help our patients. It’s going to pass anyway. We still get less reimbursement.

I’m not familiar with the exact wording of the bill. I stopped paying attention last year. I used to write my congressman, but last year I decided it doesn’t make a difference. We’re just jumping through hoops like trained circus animals.

This new bill doesn’t change the way I feel because I know we can’t succeed in doing anything for ourselves. It’s part of their ultimate plan to do away with private practitioners. I’m part of a dying breed in the solo practice of urology. Doors are being closed by these large insurance companies and hospital corporations, so we see less and less patients.

This bill doesn’t make me feel better because I still feel the pressure to comply with the majority rule. They want everybody following guidelines and doing what everybody else is doing. We don’t want independence of thought. Big Brother is still watching.

I hope this bill really does change things, but I’ll believe it when I see it.”

W. Patrick Flanagan, Jr., MD
Waukesha, WI

NEXT: "I haven’t been satisfied with anything the federal government has done since they started Medicare."

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“I’m 66 years old, and I haven’t been satisfied with anything the federal government has done since they started Medicare. When I started practicing in ’82, reimbursement for a TURP was $1,250, which I thought was a huge amount of money. In 1983, the Medicare reimbursement was frozen, and in 1993 it dropped to $870. It’s still less than $900 today. With Blue Cross Blue Shield, a TURP can be reimbursed $2,400 for the surgical fee alone. My biggest issue with Medicare is that it’s the only entitlement program without a means test. I don’t trust politicians. They’ve never taken a cut in their pay.

Read: Say farewell to fee for service

I have serious questions as to how they’re going to put value-based pay on certain specialties. How do you assess the quality of a TURP? I’m glad we got away from the brink, but I’m not sure this will be any better or much different.

There may be a half percent reimbursement increase each year, but do you know how much they’ll take away if you don’t meet meaningful use? 1%, 2%, then 3%?

I’m not convinced it’s going to do anything major. I’m not convinced it will have a good handle on value-based reimbursements, and we’re going to see more and more health care provided by non-physicians.  Good nurse practitioners and PAs refer sooner rather than later, but bad ones jump off on a workup that’s not focused and wind up with a lot of tests they don’t understand.”

Wm. Peter Horst, MD
Great Falls, MT

NEXT: "Fee for service... is not necessarily in the best interest of the patient."

Dr. Jaffe“I’m employed by the university health system, so these things have very little direct effect on me. Changes to physician reimbursements don’t hugely affect us because the health system provides a huge buffer. If Medicare cuts reimbursements 5%, the health system still makes enough money; it doesn’t affect our pay. For physicians in private practice, if professional fees go down 10%, they’re going to make 10% less money.

Also see: What is your practice doing to enhance its income?

Fee for service, where you get paid incrementally for everything you do, is not necessarily in the best interest of the patient. It’s more in the doctors’ interest. My dad was a urologist. Twenty or 30 years ago, he made 50% to 75% more than I make now, not accounting for inflation. So some doctors do marginally indicated things because they feel the need to make a certain living. I see this when patients want second opinions after seeing somebody in the community who wanted to do XYZ on them. You have a frank discussion and say, ‘You don’t need this.’ They tell you that’s not what they were told.

Another example is seeing GI physicians recommend colonoscopies every 3 to 5 years even though guidelines say every 10 years. There’s a lot of that out there, so that affects my take on fee for service.

Basing reimbursement on quality, however, is hard to do on a practical level. Many things in the field of urology would be hard to measure; for example, surgical outcomes. Patients we see here may be very different from the patients seen in the community.

In primary care, it’s easy to determine if doctors are performing specific tasks. But in the field of urology, we do different things. I only operate on people with benign disease; I don’t do oncology. How do you evaluate me, as opposed to a urologist doing radical cystectomies and nephrectomies who has patients dying all the time? I never have patients die, but that doesn’t mean my quality is better than his; it just means I’m doing different things.”

William I. Jaffe, MD
Philadelphia

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