Over my 33 year career I have witnessed an unimaginable change in the practice of medicine. The certainty of where and how we practiced, relationships with the hospitals, the satisfaction in utilizing the skills which we learned as fellows, were all predictable. As I made the transition from fellow to attending from impatient and perpetual student to energetic teacher/practitioner, I became the second physician in our practice. My career seemed set. But as the next several years evolved and we grew to a four member practice, I began to feel that change was necessary for us, and change we did. The profession also began to change over the next decade as hospitals began their first foray into physician acquisition. Turf wars between competitive systems began as the artificiality of “certificates of need” gave way to competition from community hospitals against the historic monopolies of tertiary cardiac care by the academic medical centers. They in turn had to redesign their mission away from an emphasis on research and education to a more financially driven model, forcing academically inclined and research minded faculty to more closely resemble their community based clinical colleagues.
As cardiologists, we set the standards for the concepts behind evidence based large scale clinical trials which ultimately lead to a revolution in care delivery. This in turn sharply drove up the cost curve, both by increasing the average number of medications per patient, and an explosion in non-invasive testing. Urged by the Centers for Medicare and Medicaid Services (CMS) and others, these studies were moved from a typically hospital based environment to the more cost efficient and convenient office based site of service. By the new millennium, the growth in the cost of care was outpacing every other financial marker, forcing both CMS and local payers to come up with ever more draconian ways to reduce costs, often at the expense of one group of physicians to satisfy the needs of others. The alphabet soup of SGR, DRA, RBM’s, RAC’s, RUC’s and others were joined by new and creative accounting, leading to bundling of payments and a nearly 50 percent reduction in reimbursement in some cases. More concerning, this has not just imperiled the financial viability of the practice of cardiology, but also to the gradual and unmistakable erosion of the profession itself. Physicians feel that their patient time has been infringed upon by red tape, bureaucracy, documentation, attestation, scribing and charting rather than providing innovative care delivery, which has always been the hallmark of American cardiology. We have together succeeded in improving not only the quality of care, but also have been able to reduce admissions, procedures and most of all, mortality. We need to actively challenge each and every intrusion into our professionalism.
I am passionately dedicated to the survivability of the private practice of cardiology. That means battling complacency and being an advocate for our profession. Learn what is happening locally at your hospital, be personally involved in medical staff leadership, meet with hospital administration, meet with the division director, the department chair, and even the Dean. Get on committees; understand your local market and how it can affect your practice, your hospital and your profession. Become active in the governance of your practice as to how and why decisions are made. Use data to ensure high quality and know your own data; don’t assume others know it better.
Encourage dialogue with the payers in your market. Don’t assume that the status quo is forever. Try to be collaborative with them and offer advice, insight into inefficiencies of care, duplicate services and unnecessary costs. Prove the high quality you achieve and consider pay for performance enhancements to contracts. Learn about the impact of the potential changes from fee-for-service to other types of payment systems such as bundling, shared savings and even shared risk arrangements. Understand the impact of closed rather than open panels as well as economic credentialing which is going on in many markets and how it may impact your patient access. Become well versed in the requirements of your RBM’s, put in place to reduce over utilization by the payers, but not to reduce the appropriate imaging needs of our patients. Don’t accept pre-certification denials without demanding a “peer-to-peer” review. Utilize appropriate use criteria whenever possible and challenge those who don’t understand it, or use it as an unbendable rule rather than a guideline for the care of our patients.
Advocacy starts locally and evolves globally. Learn how your elected officials view the issues we face. Understand what the threat of repeal of the In-Office Ancillary Services Exception to the Stark law could mean to us all, and how to preserve it. Learn the nuances behind proposed legislation on site-neutrality and how it might become used as a weapon to devalue integrated practices. Become a political activist and do not necessarily accept that anyone as a non-physician knows better than you what is best for your patients, your practices and your profession.
Don’t assume that just because over 60 percent of cardiologists in America are now employed (and just five years ago that number was less than half) means that we shouldn’t still be involved in the constant debates and decisions being made on our behalf in administrative offices and board rooms. The transition of so many of our colleagues from private practice to an employment model is itself an excellent example of self-advocacy but it doesn’t end with the signing of the contract, for the next renewal cycle starts that same day, and whether it is a one, three or five year contract, make no mistake that advocacy for all the issues mentioned should never stop. It is essential to maintain a voice in the matter of care delivery and how it happens.
We are shameless advocates for our patients. That means we need to actively challenge each and every intrusion into our professionalism. Don’t accept the status quo! Anything, everything is possible when like-minded professionals work together. Make your voice heard.