What is Happening to
Independent Physicians in
Georgia?
The Medical Association of Georgia
Donald J. Palmisano, Jr., Executive Director/CEO
Medical Association
of Georgia
Founded in 1849
Leading voice for medical profession in Georgia
Nearly 7,500 physicians
MAG represents physicians in every specialty and
practice setting
 Leader in state legal and legislative arenas
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Building a Better State of Health Since 1849
Independent Physicians
and the Economy
 Independent physicians directly create 100,000 jobs
in Georgia
 Contribute $24.3 billion in economic output or sales
revenue, representing 6.1% of the total GDP
 Generate more than $15 billion in wages and benefits
 Generate more than $1 billion in state and local tax
revenue
Sources: Physicians strengthen Georgia’s economy, American Medical Association and Medical Association of Georgia (2011)
Positive Economic
Impact
2011 Economic Impact Study of Office-Based Physicians
Georgia
National
Total Number of Office-Based Physicians
16,802
638,661
Total Number of Jobs Supported by Office-Based Physicians
97,513
4.0 Million
5.8
6.2
Total Sales Revenue Generated by Office-Based Physicians
$24.3 Billion
$1.4 Trillion
Total Wages & Benefits Supported by Office-Based Physicians
$15.4 Billion
$833.1 Billion
Total State & Local Tax Revenue Generated by Office-Based Physicians
$1.06 Billion
$62.9 Billion
Average Number of Jobs Supported per Office-Based Physician
Sources: Physicians strengthen Georgia’s economy, American Medical Association and Medical Association of Georgia (2011)
Decreasing Private
Practices Nationally
2000-2013 (Thousands)
723
683
57%
2000
793
757
49%
2005
Total Number
43%
2009
33%
2013
Truly Independent
Sources: Ziskind, Andrew A. et al., Adapting to a new model of physician employment, Accenture Health Industry group (August 2011)
http://www.accenture.com/SiteCollectionDocuments/PDF/Accenture-Outlook-Physician-Trends-August-2011-No2.pdf
Factors Causing
Decrease
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Administrative burdens
Student debt
Patient Protection and Affordable Care Act
Medicaid and Medicare payments
Hospital/large practice group environment
Building a Better State of Health Since 1849
Prior Authorizations
 Costing U.S. health
care system $23
billion to $31 billion
per year
 Costing every fulltime physician
$82,975 to $85,276
per year
Sources: Standardization of prior authorization process for medical services white paper , AMA (June 2011)
Increased Costs
for ICD-10
Total Cost Summary: Implementing ICD-10
Typical Small
Practice
Typical Medium
Practice
Typical Large
Practice
Education
$2,405
$4,745
$46,280
Process Analysis
$6,900
$12,000
$48,000
Changes to Superbills
$2,985
$9,950
$99,500
IT Costs
$7,500
$15,000
$100,000
Increased Documentation Costs
$44,000
$178,500
$1,785,000
Cash Flow Disruption
$19,500
$65,000
$650,000
TOTAL
$83,290
$285,195
$2,728,780
Business Aspect
Sources: Nachimson Advisors, LLC, The Impact of Implementing ICD‐10 on Physician Practices and Clinical Laboratories (2008)
http://www.nachimsonadvisors.com/Documents/ICD-10%20Impacts%20on%20Providers.pdf
SGR Incentives
and Penalties
Year
Deficit
Reduction
Sequester
E-Rx
Health
HIT
Physician Quality Reporting
System, including
Maintenance of Certification
(MOC) Program
2009
2%
2%
2010
2%
2%
2011
1%
$18K
1% if no MOC; 1.5% if MOC
2012
1%
(-1%)
$12-18K
0.5% if no MOC; 1.0% if MOC
Value-Based Modifier
(Budget neutral increases and decreases in
payments based on cost/ quality data
measures with 2-year time lag)
2013
(-2%)
0,5%
(-1.5%)
$8-15K
0.5% if no MOC; 1.0% if MOC
Base year for 2015 VM in groups of 100+
2014
(-2%)
(-2%)
44-12K
0.5% if no MOC; 1.0% if MOC
Base year for 2016 VM in groups of 10+
2015
(-2%)
$2-8K
(-1%)
(-1.5%)
Base year for 2017 VM for all MDs; Groups of 100+ get
undetermined bonus or up to (-1%) penalty
2016
(-2%)
$2-4K
(-2%)
(-2%)
Base year for 2018 VM for all MDs; Groups of 10+ get
undetermined bonus or up to (-2%) penalty
2017
(-2%)
(-3%)
(-2%)
Base year for 2019 VM & undetermined adjustments
for all physicians
2018
(-2%)
(-3%)
(-2%)
2020 base year & undetermined adjustments for all
Contracts Burden
Sources: AMA
EHR Concerns
*Results of physician survey by Bipartisan Policy Center
Barrier
Major
Barrier
Minor
Barrier
Major or
Minor
Not a
Barrier
Inability for my EHR to communicate electronically
with other systems (lack of interoperability)
71%
17%
88%
12%
Lack of information exchange infrastructure
71%
17%
88%
12%
Cost of setting up and maintaining interfaces and
exchanges
69%
17%
86%
14%
Concerns about the liability associated with not
acting on the clinical data made available
25%
42%
67%
33%
Concerns about privacy and security
25%
39%
64%
36%
Concerns specifically about HIPAA
22%
36%
58%
42%
No business case to justify exchanging information
(e.g. no financial incentive)
22%
30%
52%
48%
Lack of ability to use the information given limitation
of time
19%
35%
54%
46%
Tradition (we just haven’t done it in the past)
16%
32%
48%
52%
State policies which limit the exchange of health
information
14%
35%
49%
51%
Concern that I can’t trust the data
8%
31%
39%
61%
Concerns about physician self-referral and antikickback laws
7%
25%
32%
68%
Sources: Clinician Perspectives on Electronic Health Information Sharing for Transitions of Care , Bipartisan Policy Center Health Information
Technology Initiative (October 2012) http://www.acponline.org/running_practice/technology/bpc_clinician_survey_100312.pdf
ACA and Private
Practice
How do you believe reform will affect the independent, private practice model?
Will enhance the viability of the private practice model
10%
Will have little to no effect on the private practice model
10%
Will erode the viability of the private practice model
80%
*Results of Physicians and Health Reform, a survey of 100,000 physicians
Sources: Health Reform and the Decline of Physician Private Practice , The Physicians Foundation by Merritt Hawkins (October 2010)
http://www.physiciansfoundation.org/uploads/default/Health_Reform_and_the_Decline_of_Physician_Private_Practice.pdf
Fraud and Abuse
Ten Things to Remember :
1) Whistleblowers will have relaxed standards for reporting
2) Providers must, within 60 days of identifying a Medicare or Medicaid overpayment, report and return it
3) The Anti-Kickback Statute no longer uses intent for or knowledge of law violation as a standard in judging whether
an individual has broken of the law
4) Doctors making referrals to in-office ancillaries must now give patients information about the ownership and a list of
alternative providers
5) Doctors must tell patients of the physicians’ ownership interest in a hospital, if patients are referred there
6) Doctors now have a self-disclosure process available to them under the Stark law, and an HHS representative will
have the authority to settle the matter
7) States may pass their own versions of the Stark law (and some already have)
8) The Recovery Audit Contract program now will be used with Medicare Parts C and D
9) Practices should check that the health and other benefit plans they offer employees comply with the healthcare
reform law
10) Proof of compliance is key: have a good and effective compliance program in place
Sources: Health Reform and the Decline of Physician Private Practice , The Physicians Foundation by Merritt Hawkins (October 2010)
http://www.physiciansfoundation.org/uploads/default/Health_Reform_and_the_Decline_of_Physician_Private_Practice.pdf
Georgia’s Health
Insurance Exchange
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1 – Blue Cross
2 – Blue Cross/Alliant/Humana/Peachstate
3 – Blue Cross/Alliant/Humana/Peachstate/Kaiser
4 – Blue Cross/Alliant/Humana
5 – Blue Cross/Humana
6 – Blue Cross/Humana
7 – Blue Cross/Alliant
8 – Blue Cross/Humana/Peachstate
9 – Blue Cross/Alliant
10 – Blue Cross/Alliant/Humana
11 – Blue Cross/Humana
12 – Blue Cross/Humana
13 – Blue Cross/Alliant/Humana
14 – Blue Cross/Humana
15 – Blue Cross
16 – Blue Cross/Humana
Sources: Georgia Commissioner of Insurance
Medical Student Debt
Year
Median education
debt of indebted
graduates
Percent
change from
prior year
Median
education debt
in 2012 dollars
Percent with
education
debt
Median education debt
of indebted public
graduates
Median education
debt of indebted
private graduates
1992
$50,000
2%
$81,729
81%
$45,000
$67,500
1996
$70,931
10%
$103,676
83%
$64,500
$91,013
2000
$90,000
5%
$119,860
85%
$81,000
$120,000
2004
$115,000
10%
$139,615
82%
$105,000
$140,000
2008
$155,000
11%
$165,100
87%
$145,000
$180,000
2009
$160,000
3%
$171,034
87%
$150,000
$177,500
2010
$160,000
0%
$168,274
86%
$150,000
$180,000
2011
$162,000
1%
$165,164
86%
$155,000
$180,000
2012
$170,000
5%
$170,000
86%
$160,000
$190,000
6.5%
5.3%
Compound
annual growth
rate from 1992
to 2012
6.3%
Sources: Physician Education Debt and the Cost to Attend Medical School, AAMC (February 2013)
https://www.aamc.org/download/328322/data/statedebtreport.pdf
Medical Student
Debt 2013
Medical Student Debt, Class of 2013
Public
Private
All
Mean
$162,736 (+4%)
$181,058 (-1%)
$169,901 (+2%)
Median
$168,000 (+5%)
$190,000 (0%)
$175,000 (+3%)
Sources: FIRST analysis of AAMC 2013 GQ data, AAMC (2013)
Medicaid
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No increase since 2002
Pays less than the cost of providing the care
Threatened cuts in payment to physicians in the past
Drop in physician participation of 15% since 2009
Physicians drawn to urban areas because of costs
Building a Better State of Health Since 1849
Medicare
Sources: Now is the time to transform the broken Medicare system , AMA (2013) http://www.ama-assn.org/resources/doc/nac/nac-medicarepayment-updates-gap.pdf
Medicare
 The Centers for
Medicare & Medicaid
Services Medicare fee
schedule regulation
shows that the 2014
relative values will only
cover 54% of the direct
practice costs for each
service.
54%
Sources: Now is the time to transform the broken Medicare system , AMA (2013) http://www.ama-assn.org/resources/doc/nac/nac-medicarepayment-updates-gap.pdf
Hospital/Large Practice
Group Environment
 All legal costs cheaper
 In-house coders
 Younger physicians
want stability in their
practice
Building a Better State of Health Since 1849
For more information…
www.mag.org
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404-312-9030
[email protected]
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Building a Better State of Health Since 1849