Winter 2009 Volume 2009, Number 1
Is the doctor in?
Pushed Too Far: The 2008 Physicians Foundation Survey Florida’s Physician Workforce survey
When Dissenting Views Become Dangerous The True Cost of Medical School The Shell Game: Drug Diversion in Florida Your dwindling share:
What’s Reasonable About Usual and Customary?
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Helping Physicians Practice Medicine
Winter 2009
contents Your dwindling share:
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What’s reasonable about usual and customary? Late last year, the Physicians’ Foundation released a nationwide survey regarding the state of primary care medicine. The results were disquieting. Morale is low, and for many, the outlook is grim. Learn more about the declining state of affairs for primary care physicians and why so many are either leaving practice or looking for a way out.
When Dissenting Views Become Dangerous
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Last year, the Joint Commission (formerly JCAHO) planned to release new standards for hospitals to employ in dealing with so-called “disruptive physicians.” Unfortunately, according to many physicians, these and past standards lacked clear definitions, leaving them open to potentially unjust and politically charged interpretations. Take a closer look at this ongoing debate and who may be paying the consequences.
The Shell Game: Drug Diversion in Florida
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Every day in Florida, corrupt pharmaceutical wholesalers engage in a virtual shell game with prescription drugs. These criminals are filtering expired or counterfeit medications into the marketplace that end up on the shelves of pharmacies and ultimately in the homes of patients. Learn more about this growing problem and what state and local law enforcement are doing to curb it.
Pushed Too Far: The 2008 Physicians’ Foundation Survey
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In 2007, the Florida Department of Health began a census project to graph the state’s physician workforce, and Florida Medical Magazine offered an exclusive review and commentary on the data. We invite you to take a look at the combined data from this two-year survey, with exclusive analysis and discussion from a panel of Florida’s brightest minds in medicine. Find out what they’ve learned about the physicians of our state and what the future may hold.
Florida’s Physician workforce survey A Combined analysis of the 2007 and 2008 Statewide surveys
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Judging from our experiences in clinical practice and the anecdotal stories in newspapers, Florida suffers from an imbalance between physician availability and patient needs. Yet, we’re left with the obvious questions: how do we document this imbalance, and how do we develop solutions that will result in a better balance and improve access and quality of care for our patients?
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The true cost of medical school Our Primary Concern On the Endangered List E. Charlton Prather, MD: A Pioneer in Public Health Let the Government Bail You Out How Are Your Collections? Common Misconceptions on EHR Adoption
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President’s letter Executive vice president’s letter Editor’s letter
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Winter ’09
FLORIDA
MEDICAL O
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Board of Governors Harold L. Greenberg, M.D. District D
James H. Rubenstein, M.D. FMA PAC
James B. Dolan, M.D. President-Elect
Ralph J. Nobo, Jr., M.D. District E
M. Kamel H. Elzawahry, M.D. Specialty Society Section
Madelyn E. Butler, M.D. Vice President
Nabil A. El Sanadi, M.D. District F
Ashley E. Booth, M.D. Young Physician Section
Vincent A. DeGennaro, M.D. Secretary
Stephan Baker, M.D. District G
Joel R. Judah, M.D. Resident and Fellow Section
W. Alan Harmon, M.D. Treasurer
Silvio A. Garcia, M.D. At Large
Jeremy L. Tharp Medical Student Section
Neal P. Dunn, M.D. At Large
Diane R. Andrews, Ph.D., R.N. FMA Alliance
David J. Becker, M.D. Vice Speaker
Lisa A. Cosgrove, M.D. Primary Care Specialties
Donald F. Foy, Sr. Public Member
Karl M. Altenburger, M.D. Immediate Past President
Linda S. Cox, M.D. Medical Specialties
Karen Wendland, M.S. Council of Medical Society Executives
John N. Katopodis, M.D. District A
Alan S. Routman, M.D. Surgical Specialties
Eli N. Lerner, M.D. District B
Miguel A. Machado, M.D. Council on Legislation
David M. McKalip, M.D. District C
E. Coy Irvin, M.D. AMA Delegation
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Alan B. Pillersdorf, M.D. Speaker
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Steven R. West, M.D. President
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Editorial Staff Editor-In-Chief Marc J. Yacht, M.D., M.P.H.
Helping Physic
Ana Viamonte Ros, M.D., M.P.H. State Surgeon General Robert E. Cline, M.D. State Board of Medicine
Associate Editors Karl M. Altenburger, MD Thomas L. Hicks, MD
Managing Editor Lynne Takacs Publication Design Michael Calienes michaelc@transplant-1.com Staff Writer John Tyler Advertising Shawn Winship To learn more about advertising in Florida Medical Magazine, contact Shawn Winship
Winter 2009 (Volume 2009, Number 1) FLORIDA MEDICAL MAGAZINE is published four times a year (February, May, August and November) by the Florida Medical Association, Inc., located at 123 South Adams Street, Tallahassee, FL, 32301-7719.
at swinship @ medone.org, 1-800-762-0233, or visit www.fmaonline.org.
Copyright 2009 by Florida Medical Association, Inc. All rights reserved. Views expressed in this issue represent those of the individual authors and may not represent the views of the Florida Medical Association, Inc. The Florida Medical Association, Inc., does not represent the accuracy or reliability of any of the advertisers displayed in this publication and does not necessarily endorse any of the advertisers in this publication.
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Application to Mail at Periodicals Postage Prices is Pending at Tallahassee, FL. POSTMASTER: Send changes to: FLORIDA MEDICAL MAGAZINE 123 South Adams Street Tallahassee, FL 32301-7719
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Visit www.fmaonline.org for more information and updates or call 800.762.0233.
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t he ne x t life you s ave might threaten your very own.
Your pager vibrates. You set your knife
voice. That’s why we want you to become
and fork down on your plate. Your spouse
a member. Our physicians’ voices are the inspiration behind many tools we use to
knows. Your children know. Even your dog dashes to the door and wags his tail goodbye. Your body moves based on muscle memory. There’s hardly any
protect physicians and improve medicine in Florida. Tools like payment advocacy, continuing medical education, practice management assistance, and even expert help to ensure proper coding so
thinking involved. You’re on auto pilot. On your way to the hospital, you think about the delicate bal-
that payments for treatment are much less likely to be retracted.
ance of it all. Life and death. Family and profession. Yin and yang. This is the life you chose, and with good reason. You chose it because you wanted to help. You wanted to make a difference whenever and wherever you could. In times that require the most guided focus, the last thing that
I feel it is my duty to be involved with the FMA, and that every physician should feel as obligated. Strong membership gives us a louder and more effective voice. — Miguel A. Machado, M.D. Neurosurgeon, St. Augustine
should enter any doctor’s mind is the possibility of being sued,
Our Governmental Affairs Division represents you and your
of losing his or her license, of a
patients before the Florida Legislature. We develop pro-medicine
million other things that could
legislation geared toward creating a more friendly climate for
happen as a result of doing
doctors. We track hundreds of bills concerning important matters
the very thing they’ve been
like scope of practice and regulatory issues. We strive to lessen
trained to do.
the bureaucracy of medicine so doctors can spend more time
Malpractice suits have
with their patients. Quite simply, if it concerns your practice, it
become as commonplace as
concerns us. As a matter of fact, just this past year, the FMA
the common cold — a by-
helped push the very bill responsible for reducing the look back
product of treating patients.
period from 30 months to 12 — a victory that incited an audible
They threaten reputations,
sigh of relief from physicians statewide.
careers, families, and livelihoods. So where do we go from here? The Florida Medical Association provides some much needed
By adding your unique voice, experience, and perspective to the Florida Medical Association, we’ll be able to continue developing
advocacy and protection. It’s times like these when you need an
tools that are more
organization on your side that can take the industry’s pulse and
useful to you and our
provide actionable answers and solution-driven legislation. That’s
more than 19,000
us. That’s the FMA.
physician members.
We don’t have every solution. That’s why we need to hear your
Join today.
Join the Florida Medical Association. Call 800.762.0233, or visit www.fmaonline.org.
www.fmaonline.org
Florida Medical Magazine winter 2009
by Steven R. West, MD, FMA President
Making Florida
A Friendlier Place for You to Practice Medicine
Looking back,
2008 was a banner year for the Florida Medical Association (FMA). During last year’s legislative session, we experienced
great success, including the passage of our flagship Managed Care Bill. Also, thanks to the relentless efforts of my colleagues in leadership and the FMA staff, this organization has seen remarkable growth. Even in these difficult economic times, when many membership organizations are in decline, our membership numbers have only increased. The FMA now represents more than 19,000 Florida physicians.
This couldn’t have happened at a better time. As this issue of Florida Medical Magazine reflects, for physicians in this state, the road ahead is filled with many obstacles. None is more pressing than the decline of our workforce. In the November 2007 edition of Florida Medical Magazine, Robert G. Brooks, MD, and Nir Manachemi, PhD, wrote an article revealing the results of the first Florida physician workforce survey. The survey, conducted by the Florida Department of Health, made several startling discoveries. The greatest of these was that there are not enough physicians now, and unless we can find a solution, things are only going to get worse. Dr. Brooks and his colleagues have reviewed the 2008 physician workforce survey data and have again written an exclusive article for Florida Medical Magazine beginning on page 40. This article analyzes the first complete set of physician survey data for our state and reveals that the age of our physicians is a significant factor. As many Florida physicians near retirement, not
enough is being done to ensure that future generations will pick up where these fine individuals leave off. This is despite the fact that Florida has some of the finest medical schools in the country. Later this fall, six classes of first year medical students will matriculate across the state. We must do all that we can to encourage these bright, aspiring physicians to stay and pursue residencies and practice opportunities right here in our great state. As “The True Cost of Medical School” reveals on page 22, many of these students will face tremendous financial setbacks before they graduate. If Florida is to retain these valuable young physicians, we must find a way to alleviate some of these burdens and allow them to put their best foot forward. Though the workforce decline affects all specialties, it has hit some harder than others. A 2008 survey conducted by the Physicians’ Foundation made a startling revelation — roughly half of all primary care
The FMA will help physicians practice medicine by providing the legislature with the political will to increase Medicaid reimbursements. 4
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physicians would stop practicing if they could. You can read more about this groundbreaking survey on page 32. Whether in Florida’s medical schools, or in our medical practices, you can rest assured that the FMA is committed to rebuilding the physician workforce. I’m looking forward to the 2009 Legislative Session. Despite the current economic climate, the FMA will continue fighting to raise Medicaid reimbursement rates to those of Medicare. We also are looking to build on the success of our Managed Care Bill. Right now, managed care organizations (MCOs) often refuse to honor a valid assignment of benefits to an out-of-network physician. The FMA supports legislation that will require MCOs to provide reimbursement to these physicians directly. MCOs also currently have the power to deny claims that had received prior authorization, leaving physicians who provided services in good faith left holding the bag. The FMA will support legislation to hold these organizations accountable, requiring them to honor all authorized claims. Still another piece of managed care legislation the FMA is seeking deals with transparency in physician rating programs, an issue raised in the last edition of Florida Medical Magazine. As you are aware, several managed care plans have started publishing physician ratings. However, they are not publishing the criteria they use to develop these ratings. While our bill does not seek to prohibit these rating systems, we are seeking to require managed care plans to disclose to the patient and the physician the methodology used for the assigned rating. The Fall 2008 issue of Florida Medical Magazine offered a close-up look at the crisis of prescription painkiller abuse in our state. This session, the FMA is pursuing legislation that would implement a statewide mandatory prescription monitoring system. Similar concepts have proven effective across the United States and I am hopeful that this system would provide great results in Florida. From rebuilding Florida’s physician workforce, to passing these important pieces of legislation — all of this ultimately helps physicians practice medicine – our highest priority. Of course, none of this will come easily. It will require committed efforts on all fronts, and the FMA is up to the task. As our membership increases, the resolve and resounding voice of Florida’s physicians only strengthens. I remain confident that together we will make Florida a friendlier place for physicians to practice medicine. Sincerely,
Steven R. West, MD FMA President
www.fmaonline.org
Florida Medical Magazine winter 2009
FMA 2009 LEGISLATIVE I S S UE S TO S U P P ORT : ME D I C A I D TO ME D I C A RE
P O D I A TR Y
Increase the reimbursement rate for Medicaid to that of Medicare.
Support legislation that would conform current state statutes to the anatomical training and expertise of podiatrists, thereby limiting their treatments to the foot and ankle.
M A N A GE D C A RE
Expand the legislation that passed in 2008 to require insurance companies to honor assignment for out-ofnetwork physicians. Pass legislation that would prohibit insurance companies from denying claims that they previously authorized. Provide transparency and guidelines for any type of physician rating system.
O F F - S ITE EMERGEN C Y ROOM S
Support legislation that would impose a moratorium on the construction of any additional off-site emergency departments in Florida. F LORI D A KI D C A RE
ER S O V EREIGN IMMUNIT Y
Support legislation that would provide sovereign immunity to physicians who provide mandated treatment to patients in emergency rooms. E X P ERT W ITNE S S C ERTI F I C A TE
Support legislation that requires expert witnesses to become licensed in Florida and clarify that giving expert testimony is the practice of medicine.
Support the efforts of the Florida Pediatric Society to legislatively fix the Florida KidCare statute. P RO S T A TE C A N C ER S C REENING
Support legislation that would require health insurers to cover annual screenings for prostate cancer for men over age 40. S TU D ENT H E A LT H IN S UR A N C E
P RE S C RI P TION D RUG MONITORING P L A N
Support legislation that would require health insurance for each student in a state university in Florida.
Support legislation to implement a mandatory prescription drug monitoring plan in Florida.
MENT A L H E A LT H P A RIT Y
F LORI D A P A TIENT S EL F - RE F ERR A L A C T
Support legislation that would exempt physician-owned sleep centers from the direct supervision requirement of the Florida Patient Self-Referral Act.
Support legislation that would require insurance companies to provide the same coverage for mental illness as they do for other health care problems. F ET A L A L C O H OL A BU S E
Support legislation that would provide for voluntary admission of expectant mothers for alcohol abuse treatment services.
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AGENDA NI C A
F OREIGN P H Y S I C I A N LI C EN S URE
Support legislation that would expand NICA coverage to brachial plexus injuries as long as there is no increase in the nonparticipating physician assessment.
Oppose any legislation that allows a physician to practice in Florida without meeting the same requirements as all other applicants.
A LLI A N C E F OR A H E A LT H Y F LORI D A
P H Y S I C I A N P RO F ILE I S S UE S
Support legislation that would impose a $1 increase in Florida’s cigarette excise tax with the revenue to be used to increase Medicaid reimbursement rates to Medicare levels, to provide additional funding for the KidCare program, and to provide additional Medicaid services.
Oppose any legislation that makes the laws relating to profiles more onerous. H E A RING INTER P RETER S
Oppose any legislation that increases the cost of hearing interpreters.
P RIM A R Y S E A T BELT L A W
Enact legislation that would make seat belt violations a primary offense in Florida.
F A BRE C H A NGE S
Oppose any legislation changing current law relating to the Fabre doctrine.
I S S UE S TO o pp o s e : P H Y S I C I A N S U P ER V I S ION I S S UE S S C O P E O F P R A C TI C E E X P A N S ION S
Continue to oppose all scope of practice expansions including naturopaths, ARNPs, pharmacists, optometrists, psychologists, podiatrists, direct access to physical therapists, audiologists, and speech language pathologists.
Protect advances made relating to physician supervision of nurses and PAs. A RBITR A TION
Oppose any changes to the statutes/rules governing arbitration that would jeopardize the effectiveness of the FMA created physician-patient arbitration form.
P ROTE C T A BILIT Y TO S EL F - IN S URE
Oppose legislation that will remove a physician’s ability to self-insure or that will make it more difficult for a physician to meet the financial responsibility requirements for licensure.
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V A C C IN A TION S
Oppose any weakening of the requirements for childhood vaccinations in Florida.
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Making Florida a better place for physicians to practice medicine is our priority. SSOCIAT
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It’s not a secret – today’s physician faces numerous obstacles and uncertainties. With increased regulations, greater overhead costs, bureaucracy from managed care, shrinking reimbursements, a threatening medical malpractice climate, and limited time with patients, it is no wonder that physicians across our state are reporting their growing dissatisfaction and plans for leaving the profession altogether. While the state of medicine in Florida can seem bleak, it is important that you know that you are not alone nor has your plight gone unnoticed. The Florida Medical Association (FMA) is committed to you. It is this commitment that has been the driving force behind several efforts in recent months to retool and refocus the Association’s mission and ultimately, value, to you, our member. Last year, the FMA renewed its purpose and direction with the creation of a new mission statement: Helping Physicians Practice Medicine. While concise, these four words are powerful and set a new standard for how the FMA will serve you moving forward. Although executing this mission will be no small task, you can rest assured it is a charge your FMA physician leadership and staff are committed to. How are we going to help you practice medicine? We plan to focus our resources strategically to be your voice and provide you with tools to help you develop, grow, and maintain viable practices in our state. With this in mind, I would like to share with you the following five organizational goals and targeted strategies that we will employ over the next three years in order to better serve you.
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Values Advocacy: Serving as the voice for physicians and their patients.
Quality: Promoting the highest standards of medical care.
Professionalism: Delivering care with integrity and compassion.
Education: Promoting life-long learning and the education of future physicians.
Freedom: Maintaining choice in a freemarket system.
Healthy Floridians: Promoting comprehensive patient care and public health.
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P u b l i c P o l i cy A dv o cacy Strategy 1: Maintain a strong legislative and regulatory affairs presence aimed at making Florida a friendlier place for physicians to practice medicine. Strategy 2: Promote viable health care financing and delivery systems that improve access to care and preserve the physicians’ role as independent advocates for their patients. Strategy 3: Support policies that reinforce the physician as the leader of the health care team and oppose efforts to diminish that role through the inappropriate expansion of the scope of practice of allied health professionals.
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P r ac t i c e V i a b i l i t y Strategy 1: Work to ensure that Florida physicians receive prompt and fair reimbursement for their services. Strategy 2: Protect and strengthen the economic viability of medical practices in Florida. Strategy 3: Provide solutions to improve practice operations for FMA members.
Voice of Medicine Strategy 1: Serve as the trusted leader and voice of physicians in Florida. Strategy 2: Ensure a powerful and unified voice through growth in membership and strengthened relationships with medical schools, county medical societies, specialty societies, and other partners in medicine. Strategy 3: Increase public awareness and understanding of the important role of FMA members and their contribution to the patients and citizens of Florida.
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M e m b e r sh i p V a l u e Strategy 1: Increase value to members through programs and services that meet the evolving needs of practicing physicians. Strategy 2: Deliver knowledge to members that advances the medical profession and is accessible through virtual and physical experiences, including continuing medical education programs, an enhanced Web presence, high-quality publications, and a health policy research arm. Strategy 3: Develop cost-effective practice management products and other services exclusively for FMA members.
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O r g a n i z a t i o n a l Eff e c t i v e n e ss Strategy 1: Optimize the organization’s culture, structure, and resources to achieve excellence and support the FMA’s mission. Strategy 2: Be a data-driven organization using member/market research to identify issues, analyze trends, and evaluate opportunities in order to support effective planning and decision-making. Strategy 3: Utilize technology to create efficiencies and increase opportunities for member participation in the FMA. We have a lot of work to do. Yet, helping you practice medicine could not be more worthy. I invite your comments and am proud to be among those leading the charge to make Florida a friendlier place for you to practice medicine. Sincerely,
Timothy J. Stapleton
www.fmaonline.org
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by Marc J. Yacht, MD, MPH Editor-in-Chief
Community Health Watch:
A Welcome Change Our nation
remains mired in an unresolved war, a fractured economy, and a splintered
health care system. The public’s overall mood could be described as somber, if not outright shocked, fearful, and disgusted. One must feel some relief with this changing of the guard and the anticipation of a fresh approach to our country’s problems.
Historians will write the final chapter on the quality of the last administration. Most already have made their own assessment. Passions run high when finger-pointers seek culprits for America’s current state of affairs. Add visions of the American automaker executives flying around in private jets with their hands out and perceived empty pockets; one has to wonder, what’s next?
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At best, a few leaks are fixed through targeted programs. At worst, the dam is breaking and the flood is coming. Our health care system needs radical fixes. Intelligent
.
A sick and fragmented U.S. health care system stands alongside other significant national issues. Whether one wants to quibble with the ultimate number of uninsured, who does and does not have equitable health care, it
It appears that health care issues are back on the table with the incoming administration. This is good news. Whether they are doctors, patients, hospitals, or other providers; few are happy with the current state of health services. Physicians battle insurance companies, patients wail about medical bills, hospitals suffer the burden of the uninsured, emergency rooms flood with primary care, employers complain they can’t afford to provide coverage to their employees, and more Americans are losing their access to care.
C IN
If the election results are an indicator, I would say that the outgoing administration has received much of the public’s wrath. But whomever you blame for our nation’s ills, one thing is clear: politics as usual will not provide solutions. The challenges facing this nation have rocked its stability and sense of wellbeing. They have required us to reevaluate how America does business.
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is clear that the system leaves too many without. The overall health of this nation has been adversely affected. Academia recognizes the dilemma, and is closely watching health indicator data. The most significant indicator, U.S. infant mortality, dropped to 29th in the world with the most recent death rate of 6.71/1000 live births — a shameful result for our nation.
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Unfortunately, many believe that America’s political climate will never allow for the changes necessary to cure our health care system. planning and carefully designed policy must be constructed now, before things become worse. It would be most unfortunate if our health care system has to collapse before we can find the necessary solution. Although the new administration touts a fix for health care, the devil is in the details. Solutions must reduce administrative costs, provide pharmacy, end insurer abuses, regulate corporate profits, and insure Americans. Mental health and dental services must be included. As with the automakers and the banks, a joint private and public partnership may provide solutions. Let’s look at a successful effort. Fifty percent of emergency room visits could be served in a primary care office, yet almost 1/3 of these patients cannot pay. Aside from the cost of treating the indigent, true emergencies often are diverted from flooded ERs mired in nonurgent care. Pilot projects that divert these indigent patients to primary care centers have shown significant success. The Primary Care Access Network (PCAN) effort in Orlando exemplifies these efforts and receives significant financial support from Orange County. As for the millions of uninsured, they are sicker than ever and yet rarely receive equitable care. These patients are less likely to receive necessary hospitalizations and specialty care in spite of volunteer efforts. They are often billed more for their services and pharmacy than the insured, yet they are the most financially vulnerable. Combining this growing number of the uninsured with rising unemployment, health care providers face a progressively worsening environment to provide care.
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Unfortunately, many believe that America’s political climate will never allow for the changes necessary to cure our health care system. It has been suggested that until the system collapses entirely, effective solutions will not surface. I believe we can do better. We must do better. I am hopeful that the medical leadership, insurers, hospitals, and the other players in the provision of health care will work constructively with the new administration. The stakes are high and the American people must come before corporate interests. We are reeling from the effects of putting corporations first. It is simply not affordable or equitable to continue with the current model of health care. Good health care should be available to everyone walking the streets of America. Perhaps this is a step toward that end.
An Attorney with A unique perspective. Yours. KAHAN SHIR, P.L.
PHARMACIST ATTORNEY, Brian A. Kahan, R.Ph., J.D. Licensed Florida Pharmacist and Attorney Statewide Representation for Disciplinary/Regulatory Actions, Malpractice, Contract Disputes & More — 561-999-5999 bkahan@kahanshir.com — 1800 N.W. Corporate Blvd., Suite 200 Boca Raton, FL 33431
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Florida Medical Magazine winter 2009
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The future
of medicine Enrolling in undergraduate
pre-med courses is the beginning of a lifelong commitment to serving patients. Yet as aspiring physicians work hard to stay the course and enter the medical profession, many already are becoming entangled in a fight for their livelihood. Issues such as declining reimbursement rates and further scope of practice infringements make it painfully obvious that this is not yesterday’s medicine. These students are left to wonder who will be behind the scenes helping them in their future practice of medicine? Who is going to help them shape the future of Florida’s health care? by Diane R. Andrews, PhD, RN, FMA Alliance President
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Florida’s medical students and resident physicians are providing hope that your ongoing efforts to protect and improve the practice of medicine will continue. While they are learning, they too, need support. The FMA Alliance, in partnership with the Florida Medical Association, is working to provide this support to the future generation of physicians. As the cost of medical education continues to skyrocket, financial assistance has become even more critical. Today’s average medical student graduates with roughly $140,000 of debt. To help offset this tremendous financial burden, the FMA Alliance spent the holidays working with the AMA Foundation and the AMA Alliance to raise medical student scholarship funds through the annual Holiday Sharing Card. By combining greetings and well wishes to members of the medical family, each participant’s card was accompanied by a donation to the AMA Foundation. Every year, Alliances nationwide are able to raise more than $500,000 toward this end. Last year, our Alliance members alone contributed over $20,000. Keep in mind, the true cost of medical education involves more than tuition and books. Our future physicians increase their already staggering debt with travel expenses, coming to Florida for residency and fellowship interviews. In response, Alliance members across the state are opening their homes to traveling medical students and resident physicians. These gracious hosts mentor interviewees by educating them on the benefits of joining the FMA and FMA Alliance. They also provide information on the local area, should a resident or student wish to relocate there in the future. When there is no member conveniently located near an interview site, sponsorships provide funds to cover lodging expenses. In our especially
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difficult economic time, these generous efforts can make all the difference. The support doesn’t end there. The FMA Alliance assists medical students and their families through membership. Alliance members donate a portion of the cost of medical student and resident spouse dues each time they renew their own membership. Their generosity absorbs the cost of a medical student or resident physician spouse’s membership and provides travel stipends to Alliance events. Colleen Cole, a medical student spouse from Gainesville, joined the 2008 FMA Alliance Delegation to the AMA Alliance Annual Meeting in Chicago and took full advantage of the Alliance’s support. In return, Ms. Cole represented Florida and spoke to the AMA Alliance House of Delegates, highlighting one of the many issues set before the national delegates. Her leadership was invaluable to the entire FMA Alliance Delegation. Ms. Cole now serves as Medical Student Section Chair on the FMA Alliance Board of Directors. The FMA Alliance and our members are hard at work, shaping the future of health care in the spirit of the Florida Medical Association. We must work together to face challenges as a medical family. This requires a vision, which considers today’s needs, while addressing our common goals for tomorrow. The FMA Alliance has a long history of commitment to this vision, and with the support of all physicians’ spouses, we can continue to make this vision a reality. If your spouse is not currently an FMA Alliance member, I encourage you to ask him or her to support medicine and those working to enter the profession. To learn more on the FMA Alliance, call 1-800-762-0233 or email us at alliance@medone.org.
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You
dwindl Share: What’s Reasonable About Usual and Customary?
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issues t n e m e s r u b im e r y n a m Of the versial. Physicians
one is particularly contro facing physicians today, the , typically specialists in rk wo et f-n t-o ou s nt tie pa who choose to see nizations ount managed care orga am an id pa n te of e ar , emergency room in a given asonable� for treatment re d an y ar om st cu al, su consider “u acceptable method at an em se y ma is th gh ou geographical area. Alth on s to be just one more reas em se it ion ct pe ins r se first glance, on clo ts continue to dwindle. physician reimbursemen
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“When physicians ask these companies for a clear explanation, they get far more than they bargain for,” says Susan Franz, Florida Medical Association Medical Economics Specialist. “They’ll receive pages and pages of information and none of it makes sense.”
S o m e Exp l a i n i n g T o D o
Physicians who receive usual and customary reimbursement typically receive far less than they have billed. To make matters worse, the methods managed care organizations employ to determine their rates lack transparency, leaving physicians at a considerable disadvantage. “When physicians ask these companies for a clear explanation, they get far more than they bargain for,” says Susan Franz, Florida Medical Association (FMA) Medical Economics Specialist. “They’ll receive pages and pages of information and none of it makes sense.” “The bulk of the problem is happening in emergency care,” says Fraser Cobbe, Executive Director of the Florida Orthopaedic Society. In a place where reimbursement already is uncertain, the threat of becoming entangled with an insurer over usual and customary rates is driving specialists away from the ER. “Physicians bill the insurers and they come back with a drastically reduced payment,” says Cobbe. “The figures are terribly inconsistent, while physicians attempting to render a critically important community service are consistently underpaid.” In New York, Attorney General Andrew Cuomo launched an investigation to find out how managed care organizations determine what is usual and customary. This investigation uncovered a disturbing corporate arrangement. Cuomo found that Ingenix Inc., a so-called independent provider of health care billing information, was owned by United Healthcare, one of the nation’s largest managed care organizations. Insurers across the United States use statistics provided by Ingenix to determine usual and customary reimbursement rates. This includes companies operating in Florida, such as Aetna, Cigna, and Blue Cross Blue Shield. Last month, Cuomo’s investigation found that Ingenix was in fact producing fraudulent numbers to benefit insurance companies, costing physicians and their patients millions. Consequently, United Healthcare agreed to a $50 million settlement, which will go toward the creation of an independent non-profit organization to determine reimbursement rates in the future. Despite this considerable settlement agreement, United Healthcare maintains that Ingenix did not manipulate
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the data. Still, shortly after the agreement became known, American Medical Association President Nancy Nielsen, MD, issued a statement urging managed care organizations to cease using what she calls the “rigged Ingenix database.” In the statement, Nielsen said that managed care organizations “should act immediately to create an industry-wide commitment to end their use of the rigged Ingenix database and work to restore fair reimbursements to patients and physicians.” Ta k i n g A c t i o n
Physicians are not without legal recourse. Though some believe that this ability to pursue litigation provides leverage against insurance companies, others feel the deck is stacked against physicians so severely there is little point. “Lawsuits are a daunting task, particularly against insurance companies with significant resources,” says Lawrence Gorfine, MD, an anesthesiologist and interventional pain management physician from Palm Beach. “Class action lawsuits are usually the only ones that succeed, and yet physicians see so little return from those. You find yourself asking, why should I bother?” Another contentious legal issue is the statutory language. If there is a pre-established contractual rate between the carrier and the physician, they can simply abide by their contract. The controversy arises when no contract exists. According to Florida law, says Cobbe, managed care organizations can reimburse a noncontracted physician using one of three methods. First, the provider’s billed charges. Second, the two parties can negotiate a rate after the fact. (However, this is a most unusual outcome.) The third and most common result is the use of usual and customary rates. While insurers claim that Florida Statutes entitle them to provide usual and customary reimbursement, the letter of the law says something else entirely. “The statute defines it as usual, customary and reasonable charges, not reimbursements,” says Cobbe. This has given way to a multitude of litigation, none of which has resulted in a clear and definitive interpretation. In Florida, the Agency for Health Care Administration (AHCA) has begun to filter some dispute resolution cases through its Statewide Provider and Health Plan Claim Dispute Resolution Program. This program employs an
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“We can only take what we’re given, what’s in the best interest of insurance companies, and that isn’t fair to physicians or our patients.” independent contractor, MAXIMUS, to handle the arbitration. Unfortunately, this concept is problematic by design and functions at a significant disadvantage to physicians. The party bringing the dispute is required to pay for the review and any decision is binding. Thus, physicians relinquish all control to a third party, which then determines what is usual and customary. Worse still, without any available state funding, this program requires the non-prevailing party to cover all review costs. Physicians who take their grievances through this program run the risk of not only losing their case and being stuck with a short reimbursement, but with the final bill as well. This might explain why the number of claims reviewed under this process has declined significantly. S t a n d i n g t o R e as o n
“The issue is complex, to say the least,” warns Franz. Legislative efforts to correct this issue in the past have not been successful and litigation appears to be a dead end. “A big step forward would be to provide physicians with some anti-trust relief,” says Gorfine. Anti-trust law prohibits physicians from cooperating to address mutual
reimbursement concerns. Though the law exists to protect consumers, according to Gorfine, in this case they are eliminating healthy economic competition. “When it comes to reimbursements from government or managed care, physicians are not in a competitive marketplace,” he says. “We can only take what we’re given, what’s in the best interest of insurance companies, and that isn’t fair to physicians or our patients.” Ultimately, it’s just one more reason why physician reimbursements continue to decline. As legislation and litigation continue to prove unsuccessful, physicians must wait for a viable alternative to what is usual and customary. “This is not a problem we face alone,” says Gorfine. “And if we hope to see a change, we cannot continue to fight it alone.” Don’t miss important information from your Florida Medical Association. Submit or update your email address today at membership@medone.org
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When dissenting views become dangerous by John Tyler
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Eight years ago
the Joint Commission (formerly JCAHO), then responsible for providing the Centers for Medicare and Medicaid (CMS) endorsed accreditation to hospitals, created standards to address disruptive behavior among physicians. The Commission has renewed these standards, which went into effect on January 1, 2009. However, many physicians are concerned, underscoring that while the definitions refer to so-called “disruptive behavior,” they do not provide a clear definition. At a recent meeting, the American Medical Association (AMA) House of Delegates agreed to request that these standards be withheld for one year, in order for medical staffs to prepare. Their greatest overall concern was simple — these standards could lead to what they consider “arbitrary and capricious enforcement” against physicians.
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Florida Medical Magazine winter 2009
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“These standards basically say that any physician who impugns the reputation of a hospital, anyone who is critical, is considered disruptive.” Th e I n t i m i da t i o n F ac t o r
If you ask Arthur E. Palamara, MD, a surgeon from Hollywood. He’ll tell you this kind of enforcement is already happening. Several years ago, noticing a steady decline in the quality of hospital care, Dr. Palamara became an outspoken advocate for his patients. “There were so many inadequacies,” he says. “Nurse-to-patient ratios were inadequate, the staff in many operating rooms were under-qualified. All of this hurts our patients and hinders our ability as physicians to provide the best care for them.” After speaking up against staff in the operating room, Dr. Palamara was labeled a disruptive physician. Upon receiving this label, Memorial Regional Hospital took disciplinary action against him, pursuant to the undefined Joint Commission standards. “There was an implicit element to all of it,” he said. “One that cautioned against a dissenting view, which may be highly appropriate in certain situations.”
it wasn’t.” Further investigation revealed that the physician, working in an understaffed emergency room, was attacked by a violent patient. The physician bit the patient’s hand to escape. Th e N e w S t a n da r d
According to Dr. Palamara, the Joint Commission’s latest standards are wholly inadequate. “These standards basically say that any physician who impugns the reputation of a hospital, anyone who is critical, is considered disruptive.” He believes this is one of the reasons the Joint Commission, a private sector organization, has lost its CMS deeming status. Currently, the Joint Commission is in the process of applying for its former authority to proffer accreditation to hospitals. “I think CMS is addressing the lack of patient protection,” says Palamara. “This new standard only protects the hospitals.”
Last July, the Joint Commission released a sentinel event alert entitled “Behaviors that Undermine a Culture of Safety.” This document, referring to intimidating and disruptive behavior, offered examples such as “verbal outbursts,” and “condescending language.” During the AMA meeting, many delegates expressed their concern with the subjective nature of such descriptions.
Ultimately, Palamara believes the real problem is simple: In this country, approximately two avoidable deaths occur in hospitals every month. “It’s a problem we cannot afford to leave unsolved,” he says. Last November, the AMA Medical Staff Section presented the Joint Commission with a formal request that they retract their new standards in order to create a universal definition of disruptive behavior. According to Dr. Palamara, the next steps must be made in the hospitals.
Although instances of truly disruptive behavior among physicians are infrequent, according to Raymond M. Pomm, MD, Medical Director of the Professionals’ Resource Network, they certainly do exist. “We’ve seen legitimate cases,” he says. “Physicians becoming violent toward medical staff or simply walking out during procedures. Unfortunately, it happens.”
“No one is defending boorish behavior,” he says. “We’re defending those two patients who could have been saved. Hospitals need to begin listening to physicians.” In addition to their proposed one-year moratorium, the AMA hopes to pursue amended standards that provide greater physician autonomy and allow medical staffs to adopt their own disciplinary processes.
Yet even in situations where genuine disruptive or even violent behavior seems evident, it may not be so. “We got a disruption call about a physician who bit a patient,” says Pomm. “This incident sounded open-and-shut, but
“It’s too early to tell what will happen,” says Palamara. “But, I’m enjoying our ongoing discussions with the Commission. Patient safety is my first priority. It’s something I hope we can all come together on.”
“There was an implicit element to all of it,” he said. “One that cautioned against a dissenting view, which may be highly inappropriate in certain situations.” 20
Florida Medical Magazine winter 2009
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winter 2009
by John Tyler
Though Medical school
has never been an inexpensive undertaking, today’s typical medical student faces an astronomical financial burden. According to a recent study conducted by the American Academy of Medical Colleges (AAMC), since 2001, a medical student’s average debt has skyrocketed from $103,000 to more than $140,000. “Something has gone terribly wrong,” says Carl “Rick” Lentz, MD, FMA Past President and plastic surgeon from Daytona Beach. “I can’t think of any reasonable way this could have happened.”
T i m e s a r e C ha n g i n g
According to Lentz, one reason students were willing to endure the financial burden of medical school was the promise of a future financial reward. “Someone put it in the minds of these young people that they’ll make back whatever they take out,” says Lentz. “Today, that is practically a lie.” The AAMC study shows that the gap between a physician’s income and the total investment in medical education is narrowing at an alarming rate. According to the study, though physicians can defer their loans until after completing a residency, the interest on many will continue to compound for the duration. For example, students graduating from private medical school carry an average total debt of $160,000. If they defer for a three-year residency program, upon completion their total burden would breach $200,000. Even if these students choose to pay off their loans over 25 years, the payments for the
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entire duration would exceed $1,400 each month. The study goes on to point out that students who began their medical education in their early twenties will be making payments well into their fifties. This enormous and rapid growth overwhelms future projections of physician income. According to the study, even if the average physician’s income increases by 3 percent annually over the next 25 years, after taxes and expenses, the burden for recent graduates would be tremendous. Those seeing a ten-year payment plan would need to commit roughly 50 percent of their net income each month, while those choosing a 25-year plan would commit more than 25 percent. Worse still, the average income of primary care physicians is estimated to be 30 percent lower than the total physician average, which includes specialists. This does not bode well, given the current and considerable decline in students choosing to go into primary care.
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Carl “Rick” Lentz, MD “Someone put it in the minds of these young people that they’ll make back whatever they take out,” says Lentz. “Today, that is practically a lie.”
Th e N e x t G e n e r a t i o n
According to Mathis L. Becker, MD, FMA Past President and Director of Professional Relations at the University of South Florida College of Medicine, more and more medical students are influenced by the potential income of specialties. “We’re seeing a lot of students base their decision on how much they stand to earn, whether or not it’s what they intended to do,” he says. This is consistent with a 2008 survey conducted by the AAMC. The survey revealed that 37 percent of respondents were moderately influenced by potential income, while another 11 percent indicated income was a strong influence. Devin Bustin, a second year medical student at the University of Florida College of Medicine, does not believe finances will influence his choice of specialty. “I’d rather pay off my debt slowly and be happy than go into a field I’m less interested in,” says Bustin. However, he does admit that many of his peers have been influenced, particularly away from primary care. There may be more to this problem than increasing tuition fees. Dr. Lentz believes that many of today’s medical students are not as fiscally responsible as they could be. “When I was in medical Devin Bustin second year medical student at the University of Florida. school, I lived very carefully. By current standards I lived poorly,” he says. “The idea of using student loans to make car payments or have a night out would have been unthinkable.” According to the AAMC survey,
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Table printed with permission from the Association of American Medical Colleges
the average student enters medical school with more than $35,000 in loans. “My peers and I probably spend a little more than we should,” says Bustin. “With our schedules, we don’t really take time to consider the financial implications of our decisions.” This is consistent with the startling fact that more than 34 percent of graduates have personal debt in addition to their student loans. The average noneducational burden is in excess of $17,000. Though Dr. Lentz believes students need to become more responsible, he places some of the blame on lenders and universities. “There is supposed to be a caring, paternalistic relationship between a university and its students. Today’s lenders are downright solicitous, and our universities are either encouraging this or failing to stop it. We’ve somehow forgotten that an 18 year-old kid is a kid nonetheless.” W h o W i l l S o lv e t h e P r o b l e m ?
The overall cost of a medical education hasn’t helped matters. According to a 2004 study conducted by the American Medical Association (AMA), the average cost of tuition at public medical schools has increased
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Florida Medical Magazine winter 2009
Photo credit: Natalia Klosak
Table printed with permission from the Association of American Medical Colleges
312 percent, while tuition for private institutions increased 165 percent. Even with significant scholarships, tuition and fees alone are far more than the average student can afford. Dr. Becker has played a role in addressing the issue before the state and federal government. Recently he served on the AMA Council on Legislation, vetting congressional legislation that could one day provide relief. “One of the main problems is that the growing mountain of debt can seem less threatening to the students who borrow than it truly is. It seems like something they can worry about later,” says Becker, who now serves as the FMA Medical Student Section Advisor. “I’ve heard some students express concerns, but only in general terms.”
and the merit-based awards are highly competitive. I’m constantly applying, but the return is often small.” In Florida, Dr. Becker recognizes that insufficient funding for public universities is an ongoing problem. “These economic times have been hard on our schools,” he says. “But funding has always been an issue, and the legislature has consistently found ways to avoid addressing it.” He attributes this to the large and outstanding pool of eager applicants. “Our extraordinary students will not be willing or able to bear these enormous costs much longer. Unless we can find a way to lift some of the burden, and soon, the physician shortage – particularly in primary care – will continue to grow.”
Scholarships and other outside funding are available, but according to Bustin they are exceedingly difficult to come by. “I don’t qualify for need-based scholarships,
Mathis L. Becker, MD
Table printed with permission from the Association of American Medical Colleges
“I’d rather pay off my debt slowly and be happy, than go into a field I’m less interested in.” www.fmaonline.org
Florida Medical Magazine winter 2009
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The Shell Game:
Drug Diversion in Florida by John Tyler
Every Day, Florida’s Pharmacies fill prescriptions in good faith, assuming the medication they distribute is pure. Yet an alarming number of pharmaceuticals change hands multiple times in a virtual shell game of wholesalers. In Florida there are more than 400 licensed pharmaceutical wholesalers, while an additional 1000 wholesalers operating elsewhere in the country are licensed to sell their products in the state. All of these organizations buy and sell medication from one another, and a 2003 Grand Jury Report from the Florida Attorney General’s office revealed that many of these drugs become tainted along the way.
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Ta k e a P i l l
Finding the Source
Drug diversion is a rising problem in Florida and across the United States. South Florida in particular is becoming a hot spot for this activity. According to the report, “an alarming percentage of the drugs flowing through the wholesale market have been illegally acquired. That is, they have been stolen from shipments, pharmacies, clinics, and hospitals; purchased on the black market from recipients and health care professionals who are defrauding insurance companies or Medicaid with bogus prescriptions; or illegally imported from overseas.” Worse still, many of these drugs are mislabeled to conceal their expiration dates or to grossly exaggerate their potency. All of this undermines physicians’ confidence in prescribing medications and poses a significant threat to their patients.
Every year, hundreds of billions of dollars of prescription medications are sold and distributed in the United States. Less than half of these medications are sold directly to hospitals, physicians, and pharmacies. The remainder filters through a vast system of wholesalers. This system is broken up into three tiers, with three nationwide wholesalers handling 90 percent of the remaining drugs. The rest find their way to the 12-15 regional wholesalers or the growing market of smaller wholesalers a tier below them. Though the top-tiered wholesalers are generally reliable, in addition to selling to legitimate dispensers, they also sell to smaller wholesalers, who in turn sell to even smaller wholesalers. This makes the individual product extremely difficult to regulate, mixing pure and tainted drugs so effectively that, by the time it reaches patients, it’s nearly impossible to distinguish one from the other.
The drugs most commonly involved in diversion schemes are not your average drugs. They are typically drugs used to treat cancer and AIDS patients, or those used in organ transplants. These prescriptions are among the most expensive on the market, selling for hundreds or even thousands of dollars per bottle. Once moved and sold, even a relatively small amount of these pilfered drugs can lead to obscene profits for the criminals involved. The Grand Jury Report notes that one scheme, which involved 11,000 boxes of counterfeit Epogen and Procrit, resulted in a profit of $28 million for the counterfeiters.
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Furthermore, there is little or no effective regulation of this market at either the federal or state level. Wholesale licenses are easy to obtain. The Bureau of Statewide Pharmacy Services (BSPS) is responsible for reviewing applications. However, according to the Grand Jury Report, applications are checked only for the completeness of the information, while the information itself is never verified. Some wholesalers were issued permits despite felony convictions. In response, the
Florida Medical Magazine winter 2009
Florida Department of Health is requesting mandatory criminal background checks for future applicants. Though applicants must also pass a physical inspection of their storage facilities, the report states that “virtually any facility with a thermostat-controlled air conditioner, a burglar alarm and a refrigerator will pass.” Once permits are issued, enforcement of Florida Administrative Code requirements for pharmaceutical storage falls on the State. Unfortunately, there are currently only nine field inspectors in Florida responsible for reviewing the 422 licensed pharmaceutical wholesalers. This is in addition to inspecting the 1,500 retail oxygen distributors, the 91 over-the-counter drug manufacturers, 78 pharmaceutical manufacturers, 122 cosmetic manufacturers, and 155 manufacturers of medical devices. Given these numbers, it is not unreasonable to assume that criminal activity can go unnoticed and unchecked. S l i pp i n g Th r o u g h t h e C r ac k s
Last year, the Florida Statewide Prosecutor’s office tried a
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case against Jose Luis Perez, a/k/a “Papito,” for perpetrating a widespread drug diversion scheme. According to a press release from the Florida Office of the Attorney General, he was “convicted of trafficking prescriptions drugs, counterfeiting prescription labels, and fraud orchestrated through an organized criminal drug diversion enterprise.” During the case, a physician testified to the consequences a drug diversion operation can have on patient care. In situations where a given medication
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Florida Medical Magazine winter 2009
“This is serious crime with serious consequences,” she says. “The ruling in the Perez case sets a strong precedent and shows that judges are not taking drug diversion lightly.”
operation in Florida. “While fails, it may likely be the the paperwork led to New result of a tainted or Mexico,” said Hogan, “all of counterfeit product. the money and drugs came However, physicians are from Florida.” A fortunate unlikely to know or even series of events, including suspect this. “Drug the cooperation of several diversion schemes directly street-level members of impact physicians,” says Perez’s operation, led to a Assistant Statewide successful sting. Perez was Prosecutor Julie Hogan, arrested and a search who prosecuted Perez. His entire inventory was stored in sweltering conditions with reckless abandon. warrant for his warehouse “There are instances where facility in Hialeah was issued. drugs have been improperly stored, or expired and were simply There, police and other law enforcement agents made repackaged. When these drugs fail, physicians are likely a shocking discovery. Sensitive pharmaceuticals were to prescribe stronger medication, or the same one in a found in sweltering conditions, strewn about with higher dosage, both of which can be dangerous.” reckless abandon. This treatment can render medication utterly useless or even hazardous. “It was The Grand Jury Report tells of a case appalling,” says Hogan. “What’s more appalling is the in Michigan about a father who idea that these drugs might have reached patients who thought he was providing shots of truly needed them.” prescribed growth hormones to his son. When his son complained that the injections burned, the father Y o u r Tax D o l l a r s a t W o r k checked the vial. It contained insulin. Further complicating things, a considerable amount of This medication was purchased the medication found was paid for by Medicaid. legally from a pharmacy in Orlando. Though no A raid of Perez’s Investigations conducted by the Food accurate figure warehouse facilities and Drug Administration, in exists, according revealed stacks of cooperation with BSPS, revealed that to the Grand cardboard boxes filled with counterfeit the drugs had originated with one of Jury Report, of prescriptions, fraudulent the three major wholesalers, but had the $1.8 billion labels, and cash. circulated down to a small, paid out by the unlicensed operation. The entire Florida Medicaid investigation took only minutes. program in 2007, $218 million was According to Hogan, these cases are spent on the top typically made by following a paper ten most trail. The Perez case led investigators commonly across the country. Perez used a shell diverted drugs. corporation based in New Mexico to “You have effectively draw attention from his situations where Jose Luis Perez a/k/a “Papito” perpetrated a widespread drug diversion scheme.
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Florida Medical Magazine winter 2009
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Medicaid recipients purchase their medication and sell it immediately to street runners, who put it right back into the secondary wholesale market,” says Hogan. If any of these counterfeit medications end up on pharmacy shelves, they can potentially be purchased a second time by Medicaid. When you factor in corrupt physicians, clinics, and pharmacies in with street-level crime, the problem becomes overwhelming. In South Florida alone, the Florida Department of Law Enforcement and MiamiDade Police Department have seized more than $20 million in counterfeit medications. This has set the groundwork for multiple future prosecutions. Combating drug diversion remains a top priority for the Attorney General’s Office. Jose Luis Perez ultimately was sentenced to 20 years in prison. Julie Hogan believes
this is a sign of good things to come. “This is a serious crime with serious consequences,” she says. “The ruling in the Perez case sets a strong precedent and shows that some judges are not taking drug diversion lightly.” The Grand Jury Report ultimately proposes legislation, which would create an absolute standard of detailed pedigree papers for all pharmaceutical sales transactions, greater oversight from the Department of Health, and stricter enforcement. While the integrity of prescription drugs remains in question, Julie Hogan and other law enforcement personnel will continue their efforts to shut down these dangerous operations. “One door shuts and another one opens,” says Hogan. “We’re constantly pursuing new investigations.” It is a shell game that grows more challenging everyday, but if the outcome of the Perez case is any indicator, Florida’s law enforcement agents are playing to win.
“There are instances where drugs have been improperly stored or expired and were simply repackaged. When these drugs fail, physicians are likely to prescribe stronger medication, or the same one in a higher dosage, both of which can be dangerous.” www.fmaonline.org
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Pushed The 2008 Physicians’ Foundation Survey by Tim Norbeck, Executive Director of the Physicians’ Foundation
Physicians are facing a difficult time in this country and those in Florida are no exception. I cannot think of a better way to describe how physicians are feeling right now than to relate a true story from more than two hundred years ago.
During the colonial era, the United States Government sent General Benjamin Lincoln to negotiate a peace treaty with the Creek Indians. The chief greeted the general and asked him to sit down beside him in the middle of a long and narrow log. After sitting down, the chief asked the general to move over. Then he asked him to move again. The chief repeated his request several times until General Lincoln reached the end of the log, whereupon the chief said once more, “move further.” The general, clearly annoyed, said, “I can move no further.” “Just as it is with us,” said the chief. “You moved us all the way back to the water and then told us to move further.”
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d Too Far
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Florida Medical Magazine winter 2009
The Physicians’ Foundation Survey and Research Committee embarked on an enormous venture – an effort to provide physicians, particularly primary care physicians, with an opportunity to vent their considerable frustrations in their attempts to maintain and sustain viable practices in today’s climate of instability. The survey was mailed to all primary care physicians and 50,000 small independent specialty practices. We received nearly 700 responses from Florida, the fourth highest behind New York, California, and Texas. The information gleaned from the survey probably won’t surprise anyone, but it likely will confirm many things physicians are hearing from their colleagues. We received more than 12,000 responses to the survey and more than one-third of them took the time to include comments – ranging from one word, “Help” to six full pages. One physician actually sent a book.This survey holds huge implications regarding access to care for patients, only compounding an already serious primary care shortage. One of the biggest problem areas for primary care physicians involves Medicare and Medicaid reimbursement. Organized medicine must be relentless on this issue and make its case as often as necessary. The fact is, recent and future cuts will harm both physicians and their patients.
practices. Morale has plummeted. In Florida, the survey reveals that 44 percent of physicians find their colleagues’ morale very low or poor. This is slightly higher than the already troubling national average. The current physician workforce simply cannot meet the challenges of a faltering health care system when control lies elsewhere. To put it simply: physicians need help.
First of all, the Centers for Medicare and Medicaid Services (CMS) claim that their recent studies indicate that Medicare patients already have reasonable access to care and believe that threats by physicians to stop seeing Medicare patients are just that: empty threats. Our survey indicates the opposite, as 12 percent of physicians have stopped seeing Medicare patients and a startling 82 percent would be unable to afford their overhead with a 10.6 percent cut. If Congress fails to act, and current trends continue, physicians could see a 21 percent cut in just the next two years.
These are the words of a physician who has simply been pushed too far and our survey shows that this is reflective of most physicians in this country. I invite you to take a closer look at our survey’s key findings on the next page. They reveal in no uncertain terms that the very future of primary care medicine is at risk. If we are to preserve this vital element of our health care system, physicians must take definitive action and advocate relentlessly on behalf of themselves and their patients. Future generations of both are depending on it.
I don’t want to overreact, but I worry that unless representatives from organized medicine sit down immediately with the new Congress and other organizations, large and catastrophic cuts are in store for physicians all over this country. The survey also makes it very clear that physicians are hurting out there and struggling to maintain viable
Of the thousands of comments we received during this endeavor, one is particularly haunting. It states, “I regret ever becoming a physician. This is the only business in the U.S. with giant conflicts of interest where insurance companies set their fees, my fees and malpractice fees and govern the who, what, how and when patients will receive medical care.”
Fortunately, this advocacy already has begun. Physicians like FMA Immediate Past President Karl M. Altenburger, MD, are working hard to ensure the voice of physicians is heard, and to ultimately turn the tide of this growing crisis. Dr. Altenburger’s dedicated service and personal understanding of what physicians face every day make him an invaluable asset to the Physicians’ Foundation Board of Directors. With individuals like him on board, we all have reason to hope.
Tim Norbeck is the Executive Director of the Physicians’ Foundation. You can learn more about the Physicians’ Foundation online at www.physiciansfoundation.org.
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The Physicians’ Perspective: Medical Practice in 2008 Key Findings Th e D o c t o r S h o r t a g e
»» 65% said Medicaid reimbursement is less than
• An overwhelming majority of physicians – 78% –
their cost of providing care and 36% said
believe there is a shortage of primary care doctors in
Medicare provides reimbursement that is less
the United States today
than their cost of providing care
• 49% of physicians – more than 150,000 doctors nationwide – said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely. In that same time frame: »» 11%, or more than 35,000 doctors nationwide, said they plan to retire »» 13% said they plan to seek a job in a non-
»» Over 33% of physicians have closed their practices to Medicaid patients and 12% have closed their practices to Medicare patients Finances
• Only 17% of physicians rated the financial position of their practices as “healthy and profitable” • If they had the financial means, 45% of doctors
clinical health care setting, which would remove
would retire today
them from active patient care
Morale
»» 20% said they will cut back on patients seen »» 10% said they will work part-time
• “Patient relationships” rated highest on the list of things physicians find satisfying about medicine, while
• 60% of doctors would not recommend medicine as a
“reimbursement issues” and “managed care issues”
career to young people
rated the highest on the list of issues physicians find
P ap e r w o r k
unsatisfying about medicine
• 63% of doctors said non-clinical paperwork has
• Only 6% of physicians described the professional
caused them to spend less time with their patients
morale of their colleagues as “positive.” 42% of
• 94% said the time they devote to non-clinical paperwork in the last three years has increased Government
• “Declining reimbursement” rated highest on a list of
physicians said the professional morale of their colleagues is either “poor” or “very low” • 78% of physicians said medicine is either “no longer rewarding” or “less rewarding”
issues physicians identify as impediments to the
• 76% of physicians said they are either at “full
delivery of patient care in their practices, followed by
capacity” or “overextended and overworked”
“demands on physician time” »» 82% said their practices would be “unsustainable” if proposed cuts to Medicare reimbursement were made ABOUT THE SURVEY “The Physicians’ Perspective: Medical Practice in 2008” survey was conducted between May and July 2008 by physician search and consulting firm Merritt, Hawkins & Associates. It was mailed to 270,000 primary care doctors and more than 50,000 specialists – virtually every physician engaged in active medical practice in the United States today. The total number of responses received was 11,950. According to an independent analysis by Chad Autry PhD, Professor of Statistics at Texas Christian University, the margin of error for this survey is less than one percent.
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ABOUT THE PHYSICIANS’ FOUNDATION The Physicians’ Foundation seeks to advance the work of practicing physicians and to improve the quality of health care for all Americans. The Foundation is unique in its commitment to working with physicians nationwide to create a more efficient and equitable health care system. The Physicians’ Foundation pursues its mission through a variety of activities including grantmaking and research. Since 2005, the Foundation has awarded more than $22 million in multi-year grants. The Physicians’ Foundation was founded in 2003 through settlement of a class-action lawsuit brought by physicians and medical associations against private third-party payors. Additional information about The Physicians’ Foundation is available online at www.physiciansfoundation.org. Florida Medical Magazine winter 2009
35
OUR
OURconcern
primary by John Tyler
For years, primary care physicians have expressed concern regarding the declining state of their practices. The rapid expansion of bureaucratic and corporate influence has left them with little time and even less income. This declining state of the profession, coupled with the plummeting morale of primary care physicians, has led to anecdotal predictions that few would remain in, much less enter, this important field. Sadly, these predictions are proving true. According to a recent nationwide survey of primary care physicians and specialists by the Physicians’ Foundation, nearly half of respondents reported that they would leave the profession if they could. Others have already begun. www.fmaonline.org
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“Not only am I encouraged to see as many patients as possible, the constant increases in my overhead costs makes it almost a necessity.”
Yet this new focus on quantity has led many physicians to become more selective about which patients they can afford to see. They often are forced to make difficult choices, as the influence of Medicare and Medicaid has grown, while their reimbursement rates subsequently have declined. This is evident in the fact that, according to the survey, nearly a third of practices are closing their doors to Medicare and Medicaid patients.
Th e C o s t o f D o i n g B u s i n e ss
Th e N e x t G e n e r a t i o n
The transition to the HMO and PPO models of health care has played a leading role in changing the medical climate. According to Wilson, originally a consensus predicted this shift would create a surplus of all physicians by the year 2000. “The idea was that managed care would decrease the need for physicians,” he says. However, the opposite has proven true. While there is a greater disparity among primary care physicians, now all specialties are in a steady decline.
Even now, these problems are weighing on the next generation of physicians. According to a study published in the Journal of the American Medical Association, only two percent of medical students are planning to pursue a primary care specialty. Dr. Wilson is not surprised. He believes this results from two factors: lifestyle and, of course, income. “If I were coming out of medical school today, and having to consider buying a home and raising a family, it would be more difficult to choose internal medicine,” he says. “Young people want more control over their lives than primary care specialties will likely afford them.”
One of the most significant changes involved a dramatic increase in paperwork and other administrative tasks. The survey shows that 63 percent of physicians feel nonclinical paperwork is keeping them away from patients, while an overwhelming 94 percent say that their paperwork has increased substantially, particularly over the past three years. However, the greatest change concerns physician income. Reimbursement from both government and private insurers has continued to slide, making it difficult for many primary care physicians to keep their doors open. The survey revealed that only 17 percent of physicians consider their practices “healthy and profitable.” Yet even greater financial rewards would not be enough of an incentive for 45 percent of physicians, who said they would retire now if only they could afford to. William Kepper, MD, a primary care physician in Tallahassee, believes this declining state of medicine has been a long time coming. “Reimbursement for every
38
service I provide is set by someone else,” he says. “Not only am I encouraged to see as many patients as possible, the constant increases in my overhead costs makes it almost a necessity.”
Cecil B. Wilson, MD, FMA Past President and member of the American Medical Association Board of Trustees, has served as an internist in Winter Park for nearly 40 years. Even in his small, well-established group practice, the numbers are dwindling. “In just the past two years, we’ve gone from eleven physicians to only five,” says Wilson. “One has retired, one became a hospitalist, another went to work for the Centers for Medicare and Medicaid Services (CMS), and three others went into concierge medicine.” Physician exoduses like these have become a new and troubling reality. It is a reality that has left Wilson and others with great concern for the future of health care and the nation’s patients.
Florida Medical Magazine winter 2009
Dr. Wilson also is concerned that the current outstanding pool of medical school applicants will begin to diminish. “Competitive applicants to medical school are incredibly bright, young people,” he says. “If the debt-to-income ratio continues to widen, it can’t be long before they begin to reconsider the personal value of our profession.” For now, there remain bright and dedicated medical students who are determined to go into medicine and specialize in primary care. Jeremy Tharp, a fourth year student at the University of Florida College of Medicine, soon will become a family physician. “A significant number of people have tried to talk me out of it,” he says. During the course of his medical education, Jeremy considered other options, such as emergency medicine or surgery. “Whatever you choose to do in life, you have to support yourself. Unfortunately, in family medicine, it is becoming increasingly difficult to do this.”
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Yet, despite his doubt, Jeremy made the choice to go into primary care and has remained determined. “What brings me back to family medicine is my desire to have a personal and profound impact on the lives of my patients,” he says. “Building deep and lasting bonds and bringing positive change to others is the reason I chose medicine to begin with.”
“Unfortunately there is rarely ever one solution to fit every patient.” As a child, Dr. Kepper remembers a very different health care climate. Growing up, his family physician was also his father’s best friend. “Sometimes he was the only person who could talk some sense into him,” says Kepper, laughing. “I wanted to have that kind of impact on the lives of my patients today, but there just isn’t time.”
S i d e Eff e c t s
When physicians are able to spend additional quality time for patients, it’s usually off the clock. “Our income is now tied to coding, and yet there is no way to properly code many things physicians consider essential to providing quality care,” says Wilson. “There are no codes for careful advising or coordination of care.”
The Physicians’ Foundation survey, along with other indicators, has led the American Medical Association to predict an imminent national shortage of primary care physicians by the year 2025. The shortage is projected between 35,000 and 40,000. “The worst of it is, primary care physicians are only facing the steepest decline,” says Wilson. “Most specialties are seeing their numbers plummet, as well.” Dr. Kepper believes our nation ultimately needs to decide what kind of health care system it wants. Until then, he predicts the current level of chaos will continue, and perhaps grow. “The transition to the HMO and PPO models tried to standardize care,” he says.
Ultimately, physicians are still in search of a way to curb this decline. Though the debate continues, most everyone involved can agree that any solution is going to take some time. “First we must all answer one fundamental question,” says Kepper. “What is adequate health care? There are many things in this world that you can quantify, but the totality of health is not one of them.”
According to a study published in the Journal of the American Medical Association, only two percent of medical students are planning to pursue a primary care specialty. www.fmaonline.org
Florida Medical Magazine winter 2009
39
F
l
o
r
i
d
a ’ s
Physician Workforce Robert G. Brooks, MD, MBA, MPH Associate Dean for Health Affairs, Professor Department of Family Medicine and Rural Health Florida State University College of Medicine
40
Florida Medical Magazine winter 2009
Nir Menachemi, PhD, MPH Associate Professor Department of Health Care Organization and Policy School of Public Health University of Alabama at Birmingham
Myung Jin, MPA Program Consultant Division of Health Access & Tobacco Department of Health State of Florida
Mathis L. Becker, MD Director, Professional Relations University of South Florida College of Medicine
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A Combined analysis of the 2007 and 2008 Statewide surveys
Introduction Judging from our experiences in clinical practice and the anecdotal stories in newspapers, Florida suffers from an imbalance between physician availability and patient needs. Yet, we’re left with the obvious questions: how do we document this imbalance, and how do we develop solutions that will result in a better balance and improve access and quality of care for our patients?
One of the critical first steps to determining whether a problem exists and how to improve it, is to be able to document as accurately as possible the number, location, and specialty type of physicians practicing in the state. For years such basic information on the physician workforce was lacking in the state of Florida. In an effort to address this gap, over the last two years the state has embarked on a new initiative that includes surveying physicians who are undergoing Florida re-licensure. Medical doctors renew their license every other year. Thus, it takes a two-year cycle to capture data on all renewing individuals. An initial analysis of the first year’s survey data was written up in this journal in 2007 (Florida Medical Magazine, October, 2007, p 26-33), and the Florida Department of Health (FDOH) has recently released an analysis of the second year’s survey data (available at: http://www.doh.state.fl.us/ rw_Bulletins/WorkforceRept08.pdf). In the current paper, we combine both the 2007 and 2008 state of Florida physician workforce data in order to give a more exact picture of some of the important characteristics of physicians currently practicing clinical medicine in the state.
Methods This analysis comes from a combination of the 2007 voluntary and the 2008 mandatory physician surveys. The survey instrument was included in the mailing for licensure renewal to the approximately 50 percent of Florida allopathic physicians who were required to renew their license by January 31, 2007, and the remaining 50 percent by January 31, 2008. Physician participants could respond through a website or by return mail. The survey process did not include physicians applying for initial licensure (approximately 5,765 new allopathic physicians were licensed in 2007 and 2008). Although osteopathic physicians were also surveyed in 2008, this current analysis is only of allopathic physicians.
The survey itself was developed by the FDOH in conjunction with multiple partners including the Florida Medical Association, medical specialty societies, the Council of Medical School Deans, the Graduate Medical Education
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41
Committee, and other health care groups. The 2007 survey consisted of eight questions that inquired about the physician’s duration of practice in a given year, their county of practice, medical specialty, level of training (resident, fellow, practicing), coverage of emergency departments, and plans to retire, relocate, or reduce their work within the next five years. Although the 2008 survey contained additional questions, for purposes of this article the analysis is limited to the same eight questions as were obtained in 2007 so that results could be aggregated.
In our current analysis, we excluded physicians who did not have a practice address within Florida, those whose answer to the question on specialty-type suggested they were not in clinical practice (e.g., administrative or research only), and those who were currently in an internship, residency or fellowship program. Physicians who did not answer the question about training, however, were retained since it is possible they are currently in practice. Since more than one specialty could be chosen by physician respondents, for purposes of this study, we used the specialty which had the highest allotment of time (usually 81-100 percent, but occasionally 61-80 percent) indicated by the physician respondent. Using this method, we also categorized all medical specialists, all pediatric subspecialists, and all surgical specialists into unique groups to review. Lastly, the analysis included physicians who indicated they worked in Florida for any length of time during the year (95 percent of respondents indicated they worked more than five months a year in Florida.
Results The overall response rate when both the 2007 and 2008 surveys were combined was 47,563 out of 50,522 physicians (94.1 percent). This included an 88.7 percent response rate (22,035/24,840) for the voluntary 2007 survey, and a 99.4 percent response rate (25,528/25,682) for the mandatory 2008 survey. Physicians whose practice addresses were not in Florida (n=12,470; 24.7 percent) were not included in the analysis. We also excluded those who listed they were not in clinical practice and those who were in training. The remaining 33,337 physicians are included in the following analyses.
Table 1 lists the overall characteristics of the physician respondents. By frequency, those self-identified as practicing general internal medicine (14.2 percent) were the largest represented group, followed by medical specialists (14.0 percent), surgical specialists (13.6 percent), and family medicine (11.4 percent), physicians. Overall, the mean age of respondents was 52.0 years. Approximately 78 percent were male and the majority was White/NonHispanic (64.0 percent). Of note, only 4.5 percent of respondents were Black, 11.2 percent were Asian, and 15.5 percent indicated Hispanic ethnicity.
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Table 2 displays the number of physician respondents in medical, surgical, and pediatric specialties. Most common among medical specialists were: general cardiologists (n=1,232), gastroenterologists (n=717), and those that practice either hematology and/or oncology (combined n=575). Surgical specialists included: ophthalmologists (n=1,036), orthopedists (n=625 for the general category), urologists (n=553), and plastic surgeons (n=488). Pediatric sub-specialists included those identified in neonatology (n=189), adolescent medicine (n=85), and cardiology (n=84).
The distribution of Florida physicians by county for the 10 most populated counties in Florida is displayed in Table 3. The data in this table is particularly useful when examining the relative distribution of each specialty and how it differs around the state. For example, family physicians represent 12.5 percent of allopathic physicians in Miami-Dade County, but only 5.4 percent in nearby Palm Beach County. General pediatricians represent 8.1 percent of all allopathic physicians in Orange County, but only 4.2 percent of physicians in Brevard County. Surgical specialists represent 12.7 percent of allopathic physicians in Miami-Dade County and 11.9 percent of physicians in Duval County, but 17.8 percent of physicians in Lee County.
Coverage of emergency departments by physicians, by clinical specialty, is shown in Table 4. As expected, the highest percentage is noted for emergency medicine physicians (86.0 percent). Of interest, among the ten clinical groups that typically take emergency call, pediatrics (15.2 percent) and family medicine (12.8 percent) had the lowest coverage rates statewide. In the ten most populated counties displayed in Table 4, the rates of emergency room coverage ranged from 7.7 percent (11/143) for family medicine doctors in Palm Beach to 92 percent for emergency medicine doctors in Orange (70/76) and Duval (93/101) counties. From the county standpoint, rates for emergency room coverage for these ten clinical groups ranged from 24.8 percent in Miami-Dade to 41.4 percent in Brevard.
Finally, we reviewed the proportion of physicians who responded that they are planning to leave, or significantly reduce, practice within five years (see Table 5). When looking at state level data, the rates ranged from 9.5 percent for pediatric sub-specialists to 19.4 percent for general surgeons. From a county standpoint, rates varied from 10.6 percent for Orange, to 14.1 percent for Pinellas County. Individual specialty groups varied widely by county, with some specialties having no physicians indicating an intention to leave practice within five years (e.g., pediatric specialists in Polk or neurologists in Brevard), while in other areas more than 20 percent of physicians responding to the survey suggested they will be leaving practice within five years (e.g., general surgery in Broward, Palm Beach, and Brevard; emergency medicine in Palm Beach and Hillsborough; family medicine in Lee).
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discussion Patients, physicians, and policy makers alike have all recognized the need for the availability of well-trained doctors throughout all areas of a city, state, or country, in order to have a well-functioning health care delivery system. Despite this long recognized need, many historical factors have played a role in limiting the availability of physicians in all the geographical and specialty areas that would be necessary to allow quality health care to be delivered when and where it is needed by patients. The choice of practice location and specialty type is a complex decision that many physicians face, sometimes multiple times in their careers and often requires balancing complex factors such as lifestyle choices, family needs, geographical limitations, medical liability concerns, and, of course, fiscal issues such as debt repayment and reimbursement for services rendered.
Having information about the practice patterns of physicians in a state is very valuable as it allows us to see where gaps in coverage may currently exist, where future problems with access to care may occur, and to adjust policy to help address these gaps. Florida has been somewhat handicapped by not having current data about the nature of the physicians practicing in the state including where they are located, what their practice type entails, the services they offer, and their future plans (eg. retirement or decrease in clinical activity). The collection of a voluntary survey from allopathic physicians who were being re-licensed in 2007, and the subsequent mandatory survey for additional physicians re-licensing in 2008, has helped our state to fill this void and have an initial look at the demographics and practice patterns of Florida’s physician workforce. There are already two documents available for those interested in work on the individual survey years. In October of 2007, we reported on the initial 2007 voluntary survey results in this journal and, recently, the FDOH has reported on the 2008 mandatory survey. Beginning in 2007, the state has also had a Healthcare Practitioner Ad Hoc Committee that is working to assist the State Surgeon General and the FDOH with analysis of this physician survey and to develop a strategic plan for the state. Although two of this article’s authors serve on that committee (RGB and MLB), and one author (MJ) helps assist the committee, this article is independent work which does not reflect the views of the FDOH but, we hope, will complement the work they are spearheading.
We have chosen, in this combined (2007 and 2008) analysis, to focus on allopathic physicians who appear to be seeing patients in the state as determined by having a practice address in Florida. Doctors self-identified as being in training were excluded. Also of note, survey information is not available on the approximately 5,700 physicians who received a new (first) Florida license through the Board of Medicine in calendar years 2007 and 2008. Future attempts to accurately capture practice information on residents/fellows and new licensees is warranted and recommended.
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Given the limitations above, it appears that there are about 33,337 actively licensed allopathic physicians with a current practice in Florida. The mean age of the respondent physician was 52 years. Given the general concern of aging of the workforce of other health professionals (e.g., nursing), this important demographic characteristic will need to be tracked over time. Almost 78 percent of the practicing physicians in the study were male, a number which will likely be changing given the fact that the majority of students entering many medical schools are now women. Similar to last year’s estimate, with this year’s combined data, 64 percent of respondents identified as White, 15.5 percent as of Hispanic origin, 11.2 percent as Asian, 4.5 percent as Black, and 4.6 percent answered “other” to the question of race/ethnicity.
Much discussion has occurred in recent years regarding the question as to whether Florida has an adequate number of various primary and specialty trained physicians to meet its needs. The data at hand suggests that there are 10,471 primary care physicians (general internal medicine, family medicine, and pediatrics) among those undergoing re-licensure and responding to the survey. Although we have evidence from these results that the total numbers of these primary care physicians varies quite dramatically in the ten largest counties examined, more important will be a further analysis that defines these key providers of care by “catchment area” such as metropolitan statistical areas, or zip codes categorized by rural-urban commuting areas. These approaches will allow a better assessment of availability of primary care physicians in specific health care markets.
We also have a more accurate picture now of physicians who have been trained in particular specialties (Tables 1 and 2). These overall numbers should assist physician leaders and specialty societies with efforts to better define the workforce available in their areas of interest. For example, of the 4,590 physicians who self-identified as a medical specialist, it appears that about 575 (12.5 percent) are hematologists/oncologists or oncologists (adult care), and likely represent the workforce available in the state to treat patients with cancer (Note: an additional 49 respondents identified as pediatric oncologists). As another example, there appear to be 236 physicians who identify as neurosurgeons in the surgical subspecialty category. Further analysis will need to be done to ascertain where these individuals are located in the state, their coverage of emergency departments, intent to reduce practice in the future, etc., in order to better quantify current and future availability of neurosurgical services to patients around the state.
One of the critical functions performed by physicians is the coverage of emergency departments for urgent care. Evidence of gaps in coverage of Florida’s emergency departments is already occurring, and hospital and physician leaders are concerned about the impact this trend in coverage might have on the state’s acute care and trauma
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support systems. This initial analysis suggests that coverage of hospital emergency departments varies quite markedly by specialty and county. Interestingly, the three primary care specialties (internal medicine, family medicine, and general pediatrics) were the physicians least likely to cover emergency departments. This is likely associated with the recent national trend towards the use of hospitalists by primary care physicians. Equally interesting is the wide variability in emergency department coverage by county. For example, over 82 percent of general surgeons in Brevard County, and over 71 percent in Duval County, cover an emergency department, but only 41 percent in Miami-Dade County. In both of these cases above, Florida’s recent problems with medical malpractice insurance availability and cost may also be playing a role. Again, a more refined analysis of this data will be needed to help determine the extent to which the availability of physicians in certain specialties may be affecting patient care in emergency departments.
Also important is the extent to which physicians currently in practice intend to leave or significantly reduce their practice within the next five years. The combined years’ overall result of 13.0 percent planning such action was similar to that reported last year at 12.9 percent. More important for workforce planning, however, is the wide variation between different specialties. For general surgeons 19.4 percent stated such plans, as compared to only 9.5 percent of pediatric sub-specialists. Most of the specialties were relatively similar to last year’s (2007) analysis with the possible exception of general surgery, which had increased from 17.8 percent to 19.4 percent. Given the fact that the mean age of general surgeons in the state (54.2 years) is higher than most specialties, this trend needs to be carefully monitored.
Lastly, we want to re-emphasize the limitations of this data set. These data are self-reported and have not undergone any independent or secondary validation. Although we have collected a sample of about 94 percent of all allopathic physicians, we have chosen to exclude physicians who have out-of-state addresses, those who appear not to be currently practicing clinical medicine, and those that are in internship, residency, or fellowship. Also of note this analysis does not include the approximately 4,800 osteopathic physicians who completed the re-licensure survey this year (or the approximately 560 newly licensed osteopathic physicians in 2007 and 2008 who weren’t surveyed).
Despite these limitations, we believe this accumulated data represents the most accurate data that is currently available on Florida’s active physician workforce. This paper’s broad-brush overview, we hope, will stimulate conversations around the state about how the data can be further analyzed and how policy can be developed to better provide the right amount of physicians, in the right locations and specialties, to best meet the current and future demands of Florida’s population.
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Table 1: Descriptive characteristics of physicians responding to the survey
r ac e / e t h n i c i t y
Frequency (%)
Mean Age
% Male
% White
% Hispanic
% Asian
% Black
% Native Am.
% Other
Internal Medicine
4,634 (14.2%)
50.2
74.1
49.4
18.4
18.7
6.0
0.1
7.4
Medical specialties
4,590 (14.0%)
51.6
87.0
60.5
16.4
13.9
2.4
0.1
6.6
Surgical specialties
4,459 (13.6%)
53.1
92.9
81.1
8.4
5.2
2.6
<0.1
2.6
Family Medicine
3,729 (11.4%)
54.1
72.5
57.0
19.9
12.8
6.6
0.2
3.6
Pediatrics
2,108 (6.5%)
49.8
49.1
50.9
22.6
14.0
7.4
0.1
5.0
Anesthesiology
1,914 (5.9%)
50.2
81.1
66.4
14.2
9.9
4.4
0.2
5.0
Obstetrics/ Gynecology
1,553 (4.8%)
52.0
67.1
68.2
14.4
5.0
9.2
0.1
3.1
Psychiatry
1,550 (4.7%)
56.3
69.7
59.2
19.2
13.7
3.9
0.1
3.9
Radiology
1,524 (4.7%)
51.8
81.8
79.4
9.5
6.1
1.8
0
3.3
Emergency Medicine
1,440 (4.4%)
48.1
82.4
72.2
11.1
7.0
6.3
0.1
3.3
Pediatric subspecialty
744 (2.3%)
50.6
67.8
53.7
25.2
11.6
3.6
0
5.9
General Surgery
743 (2.3%)
54.2
91.7
71.8
13.8
7.0
3.7
0
3.8
Pathology
722 (2.2%)
54.2
70.6
69.5
12.8
10.8
2.8
0.3
3.7
Neurology
674 (2.1%)
52.7
83.3
63.4
17.8
11.3
2.0
0.2
5.4
Dermatology
659 (2.0%)
50.0
69.7
81.7
8.2
5.1
2.3
0.8
1.9
Other
1,639 (5.0%)
53.9
78.1
69.0
12.4
10.0
4.4
0.2
4.0
Total
33,337 (100%)
52.0
77.8
64.0
15.5
11.2
4.5
0.1
4.6
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Table 2: Numbers of select medical, pediatric, and surgical specialists who responded to the survey
Medical Specialty
Survey (N=)
Cardiology
Survey (N=)
Surgical Specialty
Survey (N=)
Neonatalogy
189
Opthalmology
1,232
Adolescent Medicine
85
Orthopedics
625
Interventional
135
Endocrine
61
Sports Medicine
135
Electrophsiology
40
Cardiology
84
Adult reconst.
59
Gastroenterology
717
Critical Care
71
Spine
83
Pulmonary Diseases & Critical Care Medicine
277
Hematology and Oncology
49
Hand
54
Pulmonary Medicine
161
Neurology
48
Pediatric
46
Critical Care Medicine
83
Gastroenterology
44
Trauma
61
Hematology and Oncology
418
Nephrology
25
Foot and ankle
8
Oncology only
107
Infectious Diseases
32
Musculoskeletal
8
Hematology only
50
Pulmonary
37
Urology
553
Nephrology
328
Developmental/ Behavioral
20
Plastics
488
Infectious Diseases
297
Rheumatology
6
Hand
32
Endocrine
249
Craniofacial
8
Geriatrics
257
Otolaryngology
384
Rheumatology
206
Neurosurgery
236
Thoracic
190
Vascular
211
Colon and rectal
79
Pediatric
46
Critical Care
49
Hand
27
General
48
Pediatric Specialty
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Table 3: Distribution of Florida physicians by county
T o p 1 0 f l o r i da c o u n t i e s b y p o p u l a t i o n Miami Dade
Broward
Palm Beach
Hillsborough
Pinellas
Orange
Duval
Polk
Brevard
Lee
State Total
Internal Medicine
718 13.9%
466 14.40%
461 17.5%
346 14.2%
290 15.3%
222 12.4%
212 11.0%
123 16.4%
145 16.1%
116 14.1%
4,634 14.2%
Medical specialties
692 13.4%
445 13.8%
418 15.8%
328 13.4%
290 15.3%
260 14.5%
308 16.0%
95 12.6%
111 12.3%
103 12.5%
4,590 14.0%
Surgical specialties
654 12.7%
451 13.9%
425 16.1%
321 13.1%
272 14.4%
255 14.2%
228 11.9%
90 12.0%
125 13.9%
147 17.8%
4,459 13.6%
Family Medicine
647 12.5%
251 7.8%
143 5.4%
197 8.1%
196 10.4%
214 11.9%
239 12.4%
101 13.4%
107 11.9%
73 8.8%
3,729 11.4%
Pediatrics
394 7.6%
207 6.4%
144 5.5%
184 7.5%
105 5.5%
145 8.1%
125 6.5%
43 5.7%
38 4.2%
57 6.9%
2,108 6.5%
Anesthesiology
278 5.4%
274 8.5%
126 4.8%
157 6.4%
111 5.9%
93 5.2%
131 6.80%
44 5.9%
62 6.9%
43 5.2%
1,914 5.9%
Obstetrics/ Gynecology
233 4.5%
170 5.3%
138 5.2%
143 5.8%
65 3.40%
108 6.0%
104 5.4%
43 5.7%
38 4.2%
43 5.2%
1,553 4.8%
Psychiatry
312 6.1%
131 4.0%
122 4.6%
127 5.2%
68 3.6%
75 4.2%
59 3.1%
30 4.0%
37 4.1%
31 3.8%
1,550 4.7%
Radiology
204 4.0%
149 4.6%
138 5.2%
103 4.2%
98 5.2%
57 3.2%
104 5.4%
32 4.3%
39 4.3%
34 4.1%
1,524 4.7%
Emergency Medicine
155 3.0%
142 4.4%
93 3.5%
85 3.5%
92 4.9%
76 4.2%
101 5.3%
47 6.3%
48 5.3%
47 5.7%
1,440 4.4%
Pediatric subspecialty
165 3.2%
123 3.8%
49 1.9%
72 2.9%
50 2.6%
63 3.5%
51 2.7%
5 0.7%
11 1.2%
18 2.2%
744 2.3%
General Surgery
118 2.3%
69 2.1%
51 1.9%
65 2.70%
25 1.3%
39 2.2%
39 2.0%
27 3.6%
17 1.9%
12 1.5%
743 2.3%
Pathology
97 1.9%
76 2.3%
57 2.2%
92 3.8%
51 2.7%
49 2.7%
35 1.8%
11 1.5%
16 1.8%
13 1.6%
722 2.2%
Neurology
101 2.0%
66 2.0%
56 2.1%
61 2.5%
46 2.4%
28 1.6%
56 2.9%
12 1.6%
22 2.4%
13 1.6%
674 2.1%
Dermatology
102 2.0%
65 2.0%
89 3.4%
37 1.5%
38 2.0%
17 0.9%
33 1.7%
17 2.3%
20 2.2%
23 2.8%
659 2.0%
Other
286 5.5%
151 4.7%
130 4.9%
127 5.2%
95 5.0%
96 5.3%
98 5.1%
31 4.1%
63 7.0%
52 6.3%
1,639 5.0%
Total
5156 100%
3,236 100%
2,640 100%
2,445 100%
1,892 100%
1,797 100%
1,923 100%
751 100%
899 100%
825 100%
33,337 100%
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Florida Medical Magazine winter 2009
49
Table 4: Percent of physician respondents who indicated they cover an emergency department
T o p 1 0 f l o r i da c o u n t i e s b y p o p u l a t i o n
50
Miami Dade
Broward
Palm Beach
Hillsborough
Pinellas
Orange
Duval
Polk
Brevard
Lee
State Total
Emergency Medicine
76.0%
87.2%
78.90%
85.90%
81.30%
92.00%
92.10%
89.40%
87.20%
89.40%
86.00%
General Surgery
41.9%
56.50%
47.10%
50.80%
64.00%
60.50%
71.80%
51.90%
82.40%
75.00%
58.80%
Surgical specialties
47.0%
52.20%
55.70%
52.20%
55.60%
58.10%
65.50%
63.50%
68.00%
59.60%
56.60%
Obstetrics/ Gynecology
25.7%
29.00%
33.30%
22.10%
50.80%
26.20%
57.30%
45.00%
52.80%
50.00%
37.90%
Pediatric sub-specialty
29.4%
38.20%
35.40%
40.80%
30.60%
33.30%
23.50%
40.00%
18.20%
44.40%
32.10%
Medical specialties
20.9%
23.20%
20.30%
22.80%
26.60%
31.50%
35.60%
43.90%
51.40%
33.00%
29.50%
Internal Medicine
14.6%
17.00%
18.70%
15.10%
18.40%
19.60%
24.00%
24.30%
32.90%
17.10%
20.90%
Psychiatry
13.0%
16.80%
16.40%
16.70%
29.40%
13.30%
25.40%
24.10%
13.50%
9.70%
15.60%
Pediatrics
10.7%
15.80%
12.60%
7.60%
8.70%
12.10%
11.40%
24.40%
42.10%
19.30%
15.20%
Family Medicine
11.8%
12.40%
7.70%
9.60%
9.20%
9.90%
11.80%
16.80%
15.90%
8.20%
12.80%
Average for above
24.8%
31.60%
28.40%
26.60%
32.50%
30.00%
37.80%
38.50%
41.40%
36.20%
Florida Medical Magazine winter 2009
www.fmaonline.org
Table 5: Percent of physician respondents planning to leave or significantly reduce their practice within next five years T op 1 0 florida c o u nties b y pop u lation Miami Dade
Broward
Palm Beach
Hillsborough
Pinellas
Orange
Duval
Polk
Brevard
Lee
General Surgery
12
24.6
20
15.4
12.5
18.4
17.9
15.4
23.5
16.7
Obstetrics/ Gynecology
15.2
12.5
18.8
14.9
16.9
13.2
9.6
16.7
13.2
21.4
Emergency Medicine
14.4
14.4
21.7
21.2
17.4
9.3
13.9
17
14.6
14.9.
Psychiatry
19.3
17.7
13.2
13
14.7
10.7
13.8
6.7
19.4
22.6
Pathology
15.6
10.7
21.1
6.6
25.5
16.7
5.7
18.2
6.3
7.7
Radiology
16.8
12.9
10.4
13.6
16.7
10.5
12.7
15.6
12.8
23.5
Surgical specialties
16.8
14.2
14.7
11.3
14.9
14.3
14.4
15.3
11.6
15.9
Family Medicine
14.2
17.4
10.5
15.3
11.3
14.2
11.4
14.7
13.2
20.5
Neurology
9
10.6
18.2
13.1
21.7
7.1
14.3
20
0
15.4
Anesthesiology
12.3
5.5
11.1
15.9
18.2
1.1
13.2
11.4
13.7
16.3
Dermatology
8.9
14.1
10.2
13.5
13.2
11.8
18.2
17.6
10
8.7
Internal Medicine
11.5
14.5
9.8
10.7
15
9.5
7.7
2.5
4.1
7
Pediatrics
13.3
8.7
8.5
11
5.7
9.9
14.4
7.1
10.5
3.5
Medical specialties
11.5
9.3
8.9
8.7
11.1
6.6
8.1
9.9
Pediatric subspecialty
6.7
5.7
2.1
13.9
16
4.8
9.8
0
9.1
16.7
Other
13.1
18.2
15.4
11
9.7
14.7
9.4
16.7
19.4
11.8
Total % per column
13.6
12.6
12.3
12.3
14.1
10.6
11.5
11.9
11.2
13.3
www.fmaonline.org
11.7
7.3
Florida Medical Magazine winter 2009
51
On The Endangered
List
by John Tyler
52
Florida Medical Magazine winter 2009
www.fmaonline.org
A former solo practitioner James B. Dolan, MD, President-Elect of the Florida Medical Association (FMA), considers himself a dinosaur. “There are a few of us still hanging on,” says Dolan, “but for the most part, solo practices are going extinct.” In Florida and across the United States, a vast majority of physicians who once proudly hung their shingles are either forming or joining group practices. “I prefer the term ‘endangered’,” says Ralph J. Nobo, Jr., MD, an obstetrician and FMA Board Member from Bartow. “It’s happening to young and old physicians alike. Whether we’re starting practices, or just trying to keep our doors open, the challenges never seem to end.” While there are a variety of reasons why, they all stem from one fundamental problem: the cost of practicing.
FMA President-Elect James B. Dolan, MD “Whether we’re starting practices, or just trying to keep our doors open, the challenges never seem to end.”
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Florida Medical Magazine winter 2009
Th e C o s t o f D o i n g B u s i n e ss
“It’s very simple,” says Dolan. “The expense-to-income ratio has been tilting increasingly toward expenses. It’s just not something most physicians can afford.” According to Fred Whitson, Esq., FMA Director of Medical Economics, an economic shift in both the private and public sectors has led to this substantial decline. “When Medicare and Medicaid began to make their cuts, the private insurers soon followed,” says Whitson. “But what increased were government regulations. These new requirements called for greater resources, technological upgrades, increased ancillary services, and specialized staffing – all of which cost more money. It added up fast.” In Florida, the cost of professional liability insurance is also part of the equation. With the state’s heated liability climate, Florida ranks among the worst in the nation for physicians, making premiums notoriously high. Large group practices are able to cover these expenses far more easily by sharing space, equipment, and the total cost of overhead. “Today a large group practice can house dozens of physicians,” says Dolan. “The more physicians you have, the more you can spread the costs.” According to Dolan, this has led to widespread restructuring of most medical practices. “Even fifteen years ago, a group practice had maybe three doctors,” he remembers. “A
large group practice had five. Now, a large practice can have twenty or more. The very nature of practice changed in a very short period of time.” A W ay o f L i f e
According to Nobo, another factor is lifestyle. Group practices can afford physicians greater freedoms. “Solo practitioners have to be available all the time and finding coverage can be difficult. Taking time off frequently is impossible.” Nobo ran a solo medical practice for the first 15 years of his career. “When you aren’t seeing patients, you still have to support your staff. Groups share these responsibilities, they are able to take the weight off of each other’s shoulders.” Curious about these apparent advantages, Nobo left his solo practice and tried working in a group setting for two years. He certainly noticed the benefits. “There was such camaraderie,” he says. “You don’t get that in a solo practice, obviously. Not to mention it was great not to have to worry about buying toilet paper or changing the light bulbs. I didn’t miss that.” Yet, after two years, he was ready once again to hang his shingle. According to Nobo, it all stems from an independent spirit. “For me, it was about building the practice I wanted. It’s an honor when patients come to you and they remain your patients. Unfortunately, this kind of loyalty is becoming rare.” B i g C ha n g e s
The rise of managed care in the mid 1990s created a significant increase in patient volume. Practices that once focused on building lasting relationships with patients saw a sudden shift toward expansive, however less personal care. To meet this demand, group practices became almost a necessity. Additionally, managed care organizations, which were eager to fill their physician panels, approached group practices first. “By the time they came to the solo physicians, their networks were full,” says Dolan. “They were able to put us in a position to either take or leave what they offered, which wasn’t much. By the time they came to us, they had all the physicians they needed.” This shifting health care climate forced physicians to reevaluate things. For Miguel
Florida Medical Magazine winter 2009
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Ralph J. Nobo, Jr., MD: “Now, patients don’t simply look for a physician. They go where their insurance company tells them to go.”
Machado, MD, Chair of the FMA Council on Legislation, who still operates a solo neurosurgical practice, it has been a challenge since day one. “I began my practice in St. Augustine in 1999,” says Machado. “Right from the start, I had to be creative to find ways to keep my overhead as low as possible.” Starting a neurosurgical practice in a small community, Machado found himself alone in his specialty. “I’m still the only neurosurgeon around here,” he says. “Whenever I want to I leave town, I have to find someone to cover my patients.” In order to keep his expenses low, Machado works out of an unusually small office. He employs just one staff member, who serves as office manager,
secretary, and transcriptionist. All of his billing is handled by an outside company. This type of outsourcing is becoming a popular option for physicians looking to save the cost of additional space and staffing. Despite his ongoing efforts to cut costs, Machado’s location and specialty provide some unique advantages. As the only neurosurgeon in the area, his liability insurance and emergency on-call coverage are paid for by his hospital. “I’m very fortunate,” he says. “Many of the reasons I can keep my doors open are circumstantial. In a big city like Miami, most neurosurgeons are in groups. For family physicians and pediatricians, even in a small town like this, it just isn’t feasible.”
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A growing number of solo practitioners also have found success in concierge medicine. Commonly referred to as “direct care,” concierge medicine involves more personal, often innovative, patient care. This may include options like weight loss treatment, nutritional advice, and other spa-like amenities. Physicians practicing concierge medicine typically see a limited number of patients, who retain their services for an annual fee, in addition to per-visit costs. Concierge medicine only recently has become a viable form of practice, but it is growing at a remarkable rate. According to a 2004 survey conducted by the Government Accountability Office, there were only 146 concierge practices open nationwide. A recent survey conducted by the Society for Innovative Medical Practice Design revealed that the number has grown to more than 5,000, with the highest concentration found in coastal regions, particularly in south Florida. In fact, one of the nation’s largest networks of concierge physicians, MDVIP, was created in Boca Raton. Richard B. Raborn, MD, an internist and third generation Florida physician in Boynton Beach, joined MDVIP five years ago. Prior to this, he and his wife, a nurse practitioner, ran a solo practice. Overwhelmed by the sheer volume of patients, Raborn became exhausted and needed a change of pace. “Before, I was seeing somewhere between 2500-3000 patients,” he says. “I didn’t have time or energy left to do many of the things I valued most.” Still, Raborn had to let a significant number of his patients go. “We’re talking eighty to ninety percent of them,” he says. “It was certainly difficult.” Nonetheless,
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Florida Medical Magazine winter 2009
www.fmaonline.org
Richard B. Raborn, MD: “I can focus more on patients, on a far more personal level and build an enduring bond.
he believes a reduced patient roster has made him a better physician in many regards. “I can focus more on patients on a far more personal level and build an enduring bond. These are patients who will stay with me.” In addition to providing this personal level of care, Raborn serves as the Chief of Staff at Bethesda Memorial Hospital and works actively with the Caridad Clinic, providing care to south Florida’s large indigent population. “At Caridad, I’m working with medical students, mentoring them in the profession,” says Raborn. “These opportunities simply were not possible before I made the transition.”
The Florida Medical Association congratulates the new FMA PAC Officers!
Coming to a Close
With few exceptions, indicators suggest that solo practices will continue to diminish. “It’s attritional,” says Dolan. “Physicians like myself, who’ve been there, who’ve operated solo practices, are on their way out. For future generations, I doubt if it will even be a consideration. The time has come and gone.” In some ways, it’s an unfortunate change. For Dolan, the decision to pursue solo practice held a personal significance. “I wanted to determine my own fate,” he says. “I think most physicians do.” Nobo agrees. “When I came out of medical school, it was all about building a practice, making it on your own. Now, patients don’t simply look for a physician. They go where their insurance company tells them to go. Solo practices do not suit this climate very well.” Still, he and other solo physicians continue to beat the odds, day in and day out. “It’s an ongoing challenge,” says Machado. “Sure we have to do without a lot of conveniences and advantages we might have as part of a group practice, but it is worth it every day. Absolutely.”
www.fmaonline.org
Madelyn E. Butler, MD President
John Katopodis, MD Vice President
Alan D. Mendelsohn, MD Treasurer
Ralph J. Nobo, Jr., MD Secretary
Join us today at www.fmaonline.org/fmapac
Florida Medical Magazine winter 2009
57
by John Tyler
E . C ha r l t o n P r a t h e r , M D
a pioneer
58
Florida Medical Magazine winter 2009
in Public Health
www.fmaonline.org
E. Charlton Prather, MD, (far right) with former Governor Reubin Askew (far left) and Sidney A. Berkowitz, former Director of the Bureau of Sanitary Engineering for the Florida Divison of Health
After reading a book
recommended by his high school librarian, E. Charlton Prather, MD, knew exactly what he wanted to do with his life. “The book was called Microbe Hunters,” says Prather. “The detective work that went into the earliest efforts in epidemiology was so exciting to me. I knew that was what I wanted to do and I never looked back.” Looking forward, however, Dr. Prather couldn’t have known that this path would lead him to become a distinguished Florida physician.
Beginnings
“Few have done more to protect and preserve Florida’s public health than Dr. Prather,” says E. Russell Jackson, Jr., Senior Vice President of the Florida Medical Association (FMA). “I’ve known and worked with him for many years and can say he is a true hero as a physician and public health advocate.” As a young student, Prather intended only to pursue science. “The science,” he says, adding emphasis, “Microbiology.” Growing up in Jasper, he spent many hours with a local doctor, looking at germs under a microscope. His high school principal, aware of Prather’s keen interest in science, contacted the Chair of the Microbiology Department at the University of
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Florida and opened a door that would change Prather’s life. He was able to arrange for Prather to travel to Gainesville and attend summer classes in the department between his tenth and twelfth grade years. This experience ultimately led Prather to enroll at the University of Florida and receive his bachelor’s degree in Microbiology in 1952. He then enrolled in a master’s program after graduation and also began working with the Florida State Board of Health. “At the time,” he says, “the only doctor I had any interest in becoming was a Ph.D.” However, Prather’s mentor at the State Board of Health and Director of the Bureau of Laboratories, Albert V.
Florida Medical Magazine winter 2009
59
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Hardy, MD, PhD, DrPH, led him to see things differently. Understanding Prather’s desire to fight infectious disease, he believed a career in medicine would allow him to make a far greater impact. “Dr. Hardy told me I needed that ‘union card’ before I could enter into relationships with patients or work in hospitals,” says Prather. “Those were the two things I really wanted to do.” At the time, there were no medical schools in Florida, but there was state funding available to aspiring physicians who wanted to pursue their medical degree out of state. Dr. Hardy encouraged him to take advantage of this, even paying his application fees. “When Johns Hopkins interviewed me, they said I was too focused on the sciences,” says Prather, laughing. “They suggested I go back to Florida and study some humanities.” Prather ultimately enrolled at the Bowman Gray School of Medicine at Wake Forest University, due to their cutting edge research in microbiology. “They gave me a marvelous education,” he says. “My senior year, I was invited to serve as a hospital epidemiologist, a new position at the teaching hospital.” At the time, several infectious diseases, such as staph and atypical tuberculosis, were reaching new heights in the Southeast, particularly in Florida. Prather conducted groundbreaking research on these and other diseases before he graduated in 1959. A C a r e e r i n Pu b l i c H e a lt h
While in medical school, Prather was on a leave of absence from the Florida State Board of Health. Rather than completing his internship and residency, he returned to his position there, much to the dismay of his medical school professors. “It was worth it, though,” he says. “There was too much going on with regard to epidemiology. For two or three years, I was conducting fascinating research. I was able to follow my passion first and foremost.” Prather did complete his residency shortly thereafter (in 1962) at Jackson Memorial Hospital at the University of Miami. Then, abiding by Dr. Hardy’s continuing counsel, Prather went back to North Carolina to receive his Master’s degree in Public Health at the University of North Carolina at Chapel Hill.
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“Medicine and public health are interwoven,” says Prather. “Each provides essential support to the other, and organized medicine plays an integral role.”
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Even with his formal education complete, Prather never went into private practice. He returned to Florida and the State Board of Health, and soon after was appointed the State Epidemiologist. During this period, Prather became a member of the Florida Medical Association, and went on to publish numerous articles on topics of public health. He also joined the local medical society in Clay County. In due course, he was elected president, serving two consecutive terms.
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“Medicine and public health are interwoven,” says Prather. “Each provides essential support to the other, and organized medicine plays an integral role.”
As state epidemiologist, he often traveled the state, speaking to medical societies and other groups on issues of public health. N o t My D e pa r t m e n t
Prather’s career ultimately led him to be appointed as Florida’s State Health Officer in 1974, overseeing the State Board of Health’s successor, the Division of Health in the Department of Health and Rehabilitative Services (HRS). The FMA had led the way in 1885 for the provision of the State Board of Health in Florida’s Constitution to be headed by a physician State Health Officer. In 1968, a constitutional revision removed this provision and a year later the Legislature abolished the State Board of Health, transferring its function under the huge umbrella social services agency, HRS. However, just six years later, in 1975, a massive reorganization dismantled the Division of Health even further, leaving matters of public health fragmented throughout HRS and subordinating Prather as State Health Officer without line authority over the state’s public health system. Rather than reporting to the Governor as his predecessors did, the State Health Officer reported to the Secretary of HRS and later to an Assistant Secretary. “HRS changed everything,” says Jackson. “It collapsed all health concerns in with unrelated social matters, creating a complex, disparate, and dysfunctional organization at the expense of Florida’s nationally recognized public health system. HRS became the largest state agency in the United States.” For the remainder of his term, Prather quietly advocated for the creation of a new, separate Department of Health. “Florida’s public health had lost its medical direction and badly needed to be extracted from HRS,” says Prather. “Statewide issues of health that only a physician would understand fell under the authority of bureaucrats.”
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Unfortunately, Prather’s insistence did not fall in line with the plans of HRS. Late one night, he received an unexpected phone call. “I was in Tampa,” says Prather. “It was 10:30, and I got paged on the announcement system in the Tampa airport to take a phone call. It was from my boss’ office, telling me to see him as soon as I got back into town. A lot of others who were unhappy had been let go, and I thought, you know, maybe this is my time. Turns out it was.” But his efforts didn’t stop there. Decades later, his hand in Florida’s public health remains evident. In cooperation with the FMA and other advocates, Prather passionately continued his efforts to improve and restructure Florida’s state health affairs. Finally, Prather’s dream was realized. The Senator William G. “Doc” Myers Public Health Act of 1996, legislation that Senator Myers, FMA Past President Alvin Smith, MD, and other leaders in the House and Senate fervently supported, was unanimously passed by the Legislature and made its way to Governor Lawton Chiles’ desk, where it was signed into law, creating the new Florida Department of Health.
“At the time,” he says, “the only doctor I had any interest in becoming was a PhD.” Today, the Florida Department of Health is one of the finest in the country. In March of 2000, by act of the State Legislature, the Florida Department of Health’s headquarters building in Tallahassee became the Prather Building, an unprecedented honor. Dr. Prather and his wife, Lou, attended the ceremony, which was hosted by then Department of Health Secretary Robert G. Brooks, MD. Members of the FMA Board of Governors were also in attendance. It was a proud day, following a remarkable career of service to Florida’s physicians and their patients. “The climate of public health, and arguably medicine, wouldn’t be what it is today without Dr. Prather,” says Jackson. “He has always been, and continues to be one of the finest advocates for the profession of medicine.”
Florida Medical Magazine winter 2009
61
Let the Government 62
Bail You Out
Florida Medical Magazine winter 2009
www.fmaonline.org
by Carole C. Foos, CPA, and David B. Mandell, JD, MBA
The recent national economic decline has left many Americans with less wealth than they had only one year ago. The value of homes and stock market investments has decreased, and it may be years until they return to previous levels. Meanwhile, the federal government has agreed to spend hundreds of billions of dollars to bail out poorly run or mismanaged corporations, sending the bill the taxpayer.
However, there is hope. Though strategic management of investments is vital in this type of market, physicians can employ a few tactics for regaining some lost wealth by using tax benefits, beginning with a simple two-step strategy. First, physicians can reduce their taxes, which will provide them with the capital to supplement a short-term investment portfolio. Second, they can focus on building future longterm wealth in a more tax-efficient manner. R e d u c e Y o u r Tax e s N o w
By paying less taxes in 2009, physicians may be able to recover some of their losses. The question remains: how is it possible to reduce taxes so significantly? Consider the following techniques, which can be used by any practice, no matter the size: A. USE the right entity for your practice Many physicians today are using the wrong ownership form for ideal tax planning. Choosing the right entity among “S” or “C” corporations, or limited liability companies, could turn into tax savings of $10,000-$45,000 annually. B. Consider non-qualified plans, in addition to pensions/401(k)s Non-qualified plans are relatively unknown to many doctors, despite the fact that most Fortune 1000 companies make non-qualified plans available to their executives. This type of plan should be very attractive to physicians because employee participation is often limited and inexpensive. Further, nonqualified plans generally allow larger annual contributions from the owners than traditional qualified plans do. Some plans can offer annual contributions as large as $100,000 to $200,000 per participating owner or executive. C. For larger practices, consider captive insurance companies Closely held Captive Insurance Companies (CICs) are great tools for successful medical practices interested in liability protection, risk management, or tax and wealth accumulation benefits. The typical CIC is a very small insurance company that primarily would insure your practice. These companies enjoy
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Florida Medical Magazine winter 2009
63
Federal Income Tax Rates Ye a r
To p Ma rg i n a l F e d e r a l I nc o m e Ta x R a t e
1920
73%
1930
25.0%
1940
81.0%
1950
91.0%
1960
91.0%
1970
71.0%
1980
70.0%
1990
28.0%
2000
39.6%
2008
35.0%
2011 >>
39.6%
Source: Citizens for Tax Justice, May 2004
beneficial tax treatment, allowing the owners an opportunity to build wealth, as opposed to passing profits along to insurance companies. Any of the above techniques, as well as numerous others, could help physicians to reduce taxes. While this may help to recover some immediate losses, for long-term wealth recovery, long-term tax strategies are in order. L o n g - T e r m Tax - Eff i c i e n cy f o r R e t i r e m e n t & B e y o n d
Spreading investments across different classes of investment provides protection. In the event something negatively impacts one company or industry, your total portfolio will not take significant losses. With tax diversification, a similar theory applies. By maintaining some investments that are taxed as ordinary income, some that are taxed at capital gains or dividend tax rates, and some assets that may not be taxable, a physician’s portfolio can remain flexible. The concept is simple: a properly tax-diversified portfolio minimizes the risk of loss when taxes increase and provides flexibility that can afford savvy taxpayers the opportunity to minimize the total taxes paid over a lifetime of investing. For this reason, it is advisable to spread your wealth among multiple tax “buckets” – each with its own tax treatment. If applied properly, this strategy alone can account for a significant amount of a physician’s net losses. W i l l Tax Ra t e s R i s e o r F a l l i n t h e F u t u r e ?
Federal Income Tax Rates Ye a r
To p F e d e r a l Capital Gains Ta x R a t e
1940
30.0%
1942-1967
25.0%
1970
32.3%
1977
39.9%
1980
28.0%
1990
28.0%
2000
20.0%
2008
15.0%
2011 >>
20.0%
Source: Citizens for Tax Justice, May 2004
64
Florida Medical Magazine winter 2009
Tax diversification is especially important for the long term because taxes today are extremely low. Study the federal income and capital gains charts on this page. Given their history, income tax rates are close to the lowest they have ever been, and capital gains taxes are the lowest they have ever been. Given this, physicians who wish to recover wealth from recent losses over the long term should assume that tax rates will go up, not down. A r e M o s t A ss e t s S u b j e c t t o F u t u r e Tax S w i n g s ?
Too many physicians only maintain their wealth in two buckets: (1) qualified retirement plans, like pensions, 401(k)s or SEP IRAs; and (2) personally-held taxable assets, like personal securities investments and real estate. The problem with both of these asset classes is that they are subject to future increases in income tax rates, capital gains tax rates, or both. Whether a physician is planning to take funds out of a 401(k) or SEP IRA in retirement, or planning to sell stocks or live off of bonds, there is no way for them to know now what the tax rates will be on that income in the future. If the charts are any indication, it may be at a much higher tax rate than today. Us e a n I n v e s t m e n t “ B u c k e t ” t ha t i s Tax - I m m u n e
Unfortunately, far too few individuals have diversified enough into a nontaxable wealth “bucket.” By doing so properly, not only can physicians insulate much of their wealth from future tax increases, they can also earn back much of their recent losses over the long term.
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“Tax immune” buckets may range from Roth IRAs, to non-qualified plans, to private placement life insurance. As an example, one non-qualified plan is actually treated as a hybrid plan – with both qualified and non-qualified elements. It is a flexible plan with numerous benefits for medical practices. The contributions are partially deductible and partially taxable from the outset. From a current tax perspective, this is much more attractive than “personally held taxable investments,” which offer no deduction, unlike qualified plans offering a 100% deduction. In the non-qualified plan, the funds grow tax-deferred, which is the same as the qualified plan and better than the “personally held taxable investments” class. When a physician is ready to access the funds, they can draw from a nonqualified plan without any tax liability. In this way, the plan avoids the risks of future income and capital gains tax rate increases in a substantial way, providing ideal long-term recovery for lost wealth. Hybrid plans also offer the following attributes: »» The plan can be used in addition to a qualified plan like pensions, profit-sharing plans/401(k), or SEP IRAs »» The funds in the plan can grow in the top (+5) asset protection environment in most states and always in a good (+2) environment at minimum
»» Maximum contribution levels are $100,000 per physician in practices with 10 employees or less. In larger practices, these levels can be even higher »» In a group practice, not every physician needs to contribute the same amount – this is extremely beneficial for group practices with physicians who wish to “put away” differing amounts »» There are no minimum age requirements for withdrawing income (no early withdrawal penalties) »» The transfer of assets at the physician’s death is income tax-free to heirs Conclusion
Everyone has taken financial losses in the past year. The key to future financial success is looking forward and finding ways to recover and grow. Using these strategies, physicians can get a jump on those waiting for change and build greater wealth than they may have ever thought possible. Carole Foos has over 20 years as an accountant and runs the tax management department of O’Dell Jarvis Mandell. David Mandell is an attorney and author of nine books, including “For Doctors Only: A Guide to Working Less and Building More.” As a special member benefit, you can get this book for $20 ($75 retail) by calling 1-877-656-4362. To learn more about O’Dell Jarvis Mandell, go to www.ojmgroup.com.
Comparing Different Investment Options – Tax Diversification
Qualified Plan
Perso na lly H eld Ta xa ble Investments
“ H ybrid” No n-Qua lif ied Plan
Contributions
100% deductible
No deduction
40% deductible
Growth
Ta x - d e f e r re d
Taxable (can be ordinary inco me o r ca pita l ga ins)
Ta x-def erred
W i t h d r awa l s
O rd i n a r y i n c o m e
Ca pita l ga ins
Ta x-f ree
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Florida Medical Magazine winter 2009
65
How Are Your
Collections?
Florida Medical Magazine winter 2009
www.fmaonline.org
by Jerry Hermanson, MBA, CHE
(One report can help tell you what you need to know.)
Effective Collections are the life blood of any medical practice. When I ask physicians about their collections, many will tell me they are doing well, but do not know for certain. Most physicians will know if they have collected enough money to pay their overhead, but this is not an indication that they are collecting all that they are entitled to receive. For these physicians, one report can make all the difference: the Accounts Receivables (A/R) Aging Report.
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Florida Medical Magazine winter 2009
67
A/R reports provide an overview of the age of uncollected claims and typically organizes open accounts by 30-day increments. This report also reveals how many dollars in uncollected charges are:
Less than 30 days delinquent (current) 31-60 days delinquent 61-90 days delinquent 91-120 days delinquent More than 120 days delinquent
A/R reports then sort the outstanding receivables by payor, listing each managed care company and private pay patient. Virtually every practice management or billing software company provides this report, in addition to most billing companies. Physicians can start with an initial A/R aging report and apply benchmarks obtained from outside sources, comparing their medical practiceâ&#x20AC;&#x2122;s performance with others. One source of these benchmarks is the Medical Group Management Association (MGMA). These comparisons can provide a strong indication as to the effectiveness of a collections process. However, it is important to note the generalized nature of these benchmarks. They do not account for the unique nature of each individual medical practice. Reviewing and comparing accounts by payor can also show which managed care companies pay the fastest, and conversely which pay the slowest. If one company has started to pay more slowly, physicians may contact that company and encourage them to speed up their claims processing. If one company falls behind the state-mandated payment time frames, they can be reported and face possible fines and
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other penalties. However, before making any attempt to challenge a particular managed care company on their payment record, physicians must make sure their facts are accurate and that their medical practice has done nothing to slow down the payment process.
report carefully. Physicians should note any changes and ask their office manager or practice administrator to research the causes. A good manager will have reviewed these reports in advance and be prepared to answer questions even before they are asked.
To optimize A/R aging reports, physicians should track any changes in the percent of outstanding accounts by age bracket from month-to-month. This may indicate either problem areas that have hurt collections or areas of effective growth. A general increase in the age of accounts may point toward a problem in a physician’s overall collections process. It is possible that charges are not being entered into the system in a timely fashion, thus pushing collections back. This also may occur during holiday periods when billing and collections staff are working fewer hours.
Physicians looking to improve their collections should certainly give A/R aging reports a try. There is simply no better way to take control of the process, address problem areas, and find effective solutions.
If there is a notable increase in the age of accounts in one particular payor class, such as with an individual managed care company, this may suggest a slow down in their payment process. It may also indicate a change in payment policies, such as increased denials for certain types of services or procedures. To begin an ongoing analysis of the A/R aging reports, physicians should ask their office manager or practice administrator to provide these reports at the end of every month. They also may ask them to prepare a simple spreadsheet, which can aid in tracking any changes from month to month. It is essential to review each monthly
Reviewing and comparing accounts by payor can also show which managed care companies pay the fastest, and conversely which pay the slowest.
If you’d like to compare your practice’s collections with others, contact the MGMA: 104 Inverness Terrace East Englewood, CO 80112-5306 Web: www.mgma.com Phone: 877-ASK-MGMA E-mail: service@mgma.com
www.fmaonline.org
Jerry Hermanson, MBA, CHE is a practice management consultant with more than 28 years of experience. He is Chief Executive Officer of HealthCare Integration Consultants, Inc, with offices in Highlands, North Carolina Ft. Lauderdale, Florida. To learn more, go to: www.healthcareintegration.com.
Florida Medical Magazine winter 2009
69
Common Misconceptions on EHR Adoption by EMDs
Although most physicians are aware of the advantages, conveniences, and long-term financial benefits associated with Electronic Health Records (EHR), there is still an industry-wide reluctance to adopt this technology that has the potential to improve the way medicine is practiced. While many accept the generalities of “saves time” and “improves patient care,” the excuses for not upgrading remain. We address some of the most common misconceptions.
Florida Medical Magazine winter 2009
www.fmaonline.org
RE S I S T A N C E TO C H A NGE :
â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re used to pulling paper charts.â&#x20AC;? Change is unsettling â&#x20AC;&#x201C; even change for the better. The good news is that you donâ&#x20AC;&#x2122;t have to do it all at once. Some EHR products are composed of modules for the different parts of a practice (billing, scheduling, charting). A practice can implement the area best suited for the change. Decide what functionality you would have in a â&#x20AC;&#x153;perfectâ&#x20AC;? electronic environment, then find an established product and vendor that can help you gradually get there. If the EHR has separate clinical, billing, and scanning modules, for example, those can be implemented incrementally, decreasing the disruption in your practice and your staff. Your practice basically grows your EHR at your own pace. This transition also can be easier if staff members are enlisted to assist in making it a success. Find the staff members who are more comfortable with computers and technology and use them as advocates to assist less enthusiastic staff. If the advocate is you, be aware of the technical limitations of your staff, assuring them that the process will be paced so that everyone will be able to keep up with the transition. Be willing to invest in training.
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TIME :
â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m too busy to learn a new program.â&#x20AC;? You cannot do something new without learning something new. Wouldnâ&#x20AC;&#x2122;t it be great if implementing an EHR meant merely adopting new processes to perform the same tasks youâ&#x20AC;&#x2122;re accustomed to doing?
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Find a “physician-friendly” software, built with intuitive, easy to use interfaces. Some products are built with the guidance and support of physicians, ensuring that workflows are intuitive and the terminology is industry-standard. Again, be willing to invest in training. The minimal time you and your staff will spend learning to use the software will be recouped in time saved and increased productivity. UN C ERT A INT Y :
“Which product is best for my practice?” Do your homework. You may be new to the EHR industry, but the EHR industry has been around for a few years. Research the names you’ve heard or ask peers who have implemented an EHR about the strengths and weaknesses of the product (and vendor) that they selected. You also should look for national criteria, such as industry surveys and comparisons like the AAFP User Satisfaction Survey. There are certifications available, such as CCHIT (Certification Commission for Healthcare Information Technology). The CCHIT Certified seal ensures that a product meets certain national industry standards. You should do thorough research on the company that sells the product. How long have they been in business? Are they financially sound? Are they investing in the future of the product, building on the latest technologies, and adhering to industry standards?
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COST:
“We can’t afford an EHR system.” Many websites offer ROI statistic sheets that give estimates of the money that can be saved. A quality EHR that is implemented and supported properly can pay for itself in months with: • Faster workflows • Streamlined clinical and financial management • Increased reimbursements • Staff reductions As you and your staff become more proficient and paperless, the benefits only accelerate. Also to be considered is the political push, nationally and internationally, for the adoption of EHRs as a more secure, proficient, and cost-effective means of managing health care. In the US, federal and state entities are offering grants, low interest loans, and other incentives to spur the adoption of EHRs. For example, Medicare has announced mandates requiring e-prescribing that was effective in January 2009, and with relaxed Stark legislation in place, many health care organizations, such as labs and hospitals, will subsidize up to 85 percent of the cost of an EHR. A reputable EHR vendor will guide you through these opportunities.
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