Policymakers should be listening to doctors

By Stephen B. Kemble, M.D.
Honolulu Star-Advertiser, Feb. 3, 2016

Hawaii has a severe doctor shortage and we are losing more doctors every year than we can train.

Doctors also have become increasingly reluctant to accept new patients with Medicare and Medicaid, and now a legislative bill has been introduced to require doctors to accept Medicare as a condition of licensure.

What many fail to understand is that these are not problems with greedy doctors refusing to care for the poor or elderly.

The real issue is abusive managed care practices by many health plans, including the Medicaid- and Medicare-managed care plans.

Now Medicare is pushing payment and delivery system reforms referred to as “value-based” payment, designed to reward doctors financially for delivering less care.

“Value-based” payment can encourage unethical behavior, and so far it is adding administrative burdens but not achieving any of its stated goals of improved care, improved health or reduced cost.

Doctors who fail to adequately computerize and report detailed data to Medicare will receive a 2 percent reduction in fees starting this month, escalating to 9 percent over the next five years.

Prior authorization and documentation demands have been worst for Medicaid managed care and Medicare, and now HMSA is jumping on the same bandwagon for the commercially insured. Physicians now must obtain prior authorizations for almost all advanced imaging studies and a high percentage of the prescriptions they write, including many generics.

Conversion to a much more complex diagnostic coding system last October, complex evaluation/management procedure codes, and data demands for pay-for-performance and risk adjustment, required by “value-based” payment, are forcing doctors to spend much more time on documentation at the expense of listening to and paying attention to their patients.

In my own practice, documentation time has increased by an hour a day since two years ago. My options are to see fewer patients, spend much of each visit charting instead of paying attention to the patient, or stay at work until 8-9 p.m. every night.

A recent Mayo Clinic study found that 55 percent of U.S. doctors suffer from “burnout,” up 10 percent since 2011. Another study showed 28 percent of physicians in training have clinical depression. These are frightening statistics for anyone needing medical care. They also explain why we are losing so many doctors to premature retirement.

Antitrust laws prevent doctors from negotiating collectively with health plans, so their only recourse is to restrict acceptance of abusive plans. If doctors were forced to accept Medicare or Medicaid, the plans would be free to slash fees below cost and implement any managed care policies they wanted, no matter how abusive or unethical.

Instead of forcing doctors to accept health plan abuse, the Legislature and major health plans should be listening to doctors about policies that would enhance their ability to provide better care to their patients. Successful health care reforms anywhere have always been led by physicians, not health insurers or hospitals.

The Abercrombie and Ige administrations and certain legislators have been listening only to the health insurers, resulting in recent health policy initiatives that are piling on administrative burdens, stripping physicians of their professional autonomy and ability to respond to patient needs, restricting access to care for patients, and driving Hawaii doctors out of practice. Meanwhile, the cost of health insurance is rising unabated.

The Hawaii Medical Association has repeatedly offered a physician advisory panel to assist the Ige administration with health policy, but there has been no response so far. The administration and Legislature need to be informed of the effects of policy on the actual care of patients.

Every Hawaii resident will need a doctor someday, so let’s stop driving them out of practice.

Stephen B. Kemble, M.D., is past president of the Hawaii Medical Association.