Why some docs will 'just say no' to MU

'This disruptive need to fulfill meaningful use criteria interfered with my ability to care for my patients'

August 8, 2014

Thousands of eligible providers are working diligently toward EHR incentive payments, but some practices are choosing a different route: abandoning meaningful use altogether in favor of their own solutions, and finding ways to make up for the penalties they’ll incur down the road.

Some 6 percent of physicians, in fact, will be “abandoning meaningful use after meeting it in previous years,” according to the Medscape report on EHR use in 2014. In surveying nearly 20,000 doctors, Medscape found another 16 percent admitting that they would never be attesting to meaningful use in any capacity. 

And although those numbers may seem small now, chances are they won’t stay that way for long as MU requirements become progressively more stringent, said Art Gross, CEO of HIPAA Secure Now.

Technophobia isn't the issue

Providers pushing back against the MU system aren't your typical renegades. They don't have an overall disdain for regulatory expectations and they aren’t opposed to the technologies and ideals fueling MU requirements. What they do have is a concern that patient service may be compromised by the demands of the mandate.

"This disruptive need to fulfill meaningful use criteria interfered with my ability to care for my patients, and despite the consequences, I stopped (attesting)," said James Legan, MD, a Montana-based physician who has opted to pay MU penalties.  

Legan said the decision has opened up his practice to a whole host of opportunities that would have been overlooked otherwise.

"By not being encumbered with the process of MU, I decided to try out new technology to improve efficiency to offset the significant cost of the penalty," Legan said.

These technologies included patient portals and a Chromebook workaround that enables EHR projection and presentation, which have both contributed to "a significant improvement in workflow and patient satisfaction."

"I have had the time and freedom to do two extremely transforming paradigm shifting maneuvers in the office, which make the meaningful use incentive and penalty meaningless because, first and foremost, I was able to cater to what was best for my patient and, as a result, it has been very productive," Legan explained.

Not for everyone, but definitely for some

But while Legan has been able to find value without meaningful use by integrating individual technologies such as the Chromebook front-end and a faxing/portal solution, he admits that the penalty route may not be for everyone.

"Unfortunately, unless you are in a small office setting and call your own shots, this solution may be difficult to mimic," Legan said. "Nonetheless, I am practicing at a level I never imagined possible just a few years ago when taking the blind leap into the realm of the electronic record."

Whereas Legan’s approach may look like trailblazing at the small practice level today, Gross expects that others will follow suit in due time.

Early indicators from the Centers for Medicare & Medicaid Services suggest he could be proven right. On Wednesday, CMSrevealed the latest attestation rates for Stage 2 of meaningful use and while the 1,898 eligible professionals and 78 eligible hospitals that have attested to Stage 2 as of July’s end are up slightly since last month’s paltry numbers, they do trigger questions about when we may start to see attrition away from meaningful use.

"I don’t think we’ll see the big push in dropouts until next year or the following year," Gross said, "because it does get harder and harder."

Topics: Meaningful use, Electronic Health Record (EHR), Workforce Management, Patient portals, Medicare, Medicaid,Centers for Medicare & Medicaid Services (CMS)

Frontiers in Medicine 2014

Digital Health Space explores innovations in Human Resources and Medical Education for Primary Care Physicians...Will you doctor be a 'real M.D, or are the bean counters changing basic medical education?  Can student doctors be mature and ready to make clinical decisions, or will more and more education and training be transferred to residency training?

Increased need for Primary Care Physicians---

Details of UC-Davis Pilot Program

An accelerated medical school program already is being tested at the UC-Davis School of Medicine in conjunction with Kaiser Permanente. The first six participants began classes in June (California Healthline, 7/21).

The program -- called Accelerated Competency-based Education in Primary Care -- cuts out electives, summer vacations and the search for a residency slot. Studies already completed at various other Medical Schools have been published (see below)

Academic Medicine:

September 2007 - Volume 82 - Issue 9 - pp 895-899

doi: 10.1097/ACM.0b013e31812f7704

Careers in Medicine

Tonya Fancher, director of the program, said the initiative aims to increase the number of primary care providers in California amid a growing shortage of such providers ("Shots," NPR, 8/7).

Manpower and Human Resource Planning in the 21st Century

The Affordable Care Act has catalyzed many drastic changes in medical education to improve accessibility, not just affordability for patient care.  These changes will further increase expenses without concurrent financing. Who will bear the burden ?

Calif. Doctor Shortage Could Lead to Higher Rates on Exchange Plans

AMA funds new Three years medical school at UC Davis  

Brown Signs Accelerated Degree Bill To Address Doctor Shortage  

Calif. Physician Workforce Increases, but Regional Disparities Exist

Technology and  Hospitals of the 21st Century.....They're here now

Palomar Medical Center is California's poster child for hospital innovation. Planning and implementing from scratch created a fertile system for inserting new technology as well as hospital design to improve efficiency, decrease cost and improve safety.  Even in the short term while the facility was constructed some features became obsolete even before the hospital opened. The advances in remote monitoring, biosensors gave new meaning to constructing facilities to incorporate more innovations in future years.  At some point one wonders how to anticipate as yet unknown breakthroughs with unknown possibilities.

Palomar Medical Center Photo Tour click here for further photos.

Google Glass                                                                          Electronic Health Record

                                                            Cyborg Rounds
 Patient Registration Lobby                                                       Remote Biometric Sensors

IOM Graduate Medical Education Report: Better Aligning GME Funding With Health Workforce Needs

Our prior blog posting, Medical Education Financing---Another iminent Fiasco  indicated that studies have been undertaken for revising Graduate Medical Education (GME) funding, by the Institute of Medicine (IOM) and others. The IOM is a highly respected and very influential group of leaders in medicine, headed by prominent scientists and physicians, such as Ben Carson M.D.

The IOM is part of theNational Academy of Sciences (NAS)

• National Academy of Engineering (NAE)
• National Research Council (NRC)

After nearly two years of deliberation, the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education (GME) has issued its report. It presents a strong case for the need for change and a strong case for its recommendations.

Issues related to GME financing have been contentious for many years. In 1965, Congress included GME financing under Medicare reimbursement in what was intended to be a temporary arrangement. Nearly 50 years later, we are still trying to find a permanent and more rational way to finance and pay for the training of physicians as an alternative to the current complex, arcane formula built on Medicare inpatient days. Despite the well-documented shortcomings of the current system and numerous studies, attempts to find agreement on how to change and improve GME financing have been unsuccessful. 

Since the creation of the Medicare and Medicaid programs in 1965, the public has provided tens of billions of dollars to fund graduate medical education (GME), the period of residency and fellowship that is provided to physicians after they receive a medical degree. Although the scale of govern­ment support for physician training far exceeds that for any other profession, there is a striking absence of transparency and accountability in the GME financing system for producing the types of physicians that the nation needs.

Graduate Medical Education That Meets the Nation’s Health Needs

Medical Education Financing....The Next Fiasco

Report Touches Off Fight Over Doc Training $$

The Affordable Care Act will have profound effects on the financing of both undergraduate and postgraduate medical education, 

Behind the scenes is the relative paucity of primary care physicians, especially in rural underserved regions. 

A high-level report recommending sweeping changes in how the government distributes $15 billion annually to subsidize the training of doctors has brought out the sharp scalpels of those who would be most immediately affected.

The reaction also raises questions about the sensitive politics involved in redistributing a large pot of money that now goes disproportionately to teaching hospitals in the northeast U.S. All of the changes recommended would have to be made by Congress.

Released Tuesday, the report for the Institute of Medicine called for more accountability for the funds, two-thirds of which are provided by Medicare. It also called for an end to providing the money directly to the teaching hospitals and to dramatically alter the way the funds are paid. 

Since the creation of the Medicare and Medicaid programs in 1965, the public has provided tens of billions of dollars to fund graduate medical education (GME), the period of residency and fellowship that is provided to physicians after they receive a medical degree. Although the scale of govern­ment support for physician training far exceeds that for any other profession, there is a striking absence of transparency and accountability in the GME financing system for producing the types of physicians that the nation needs.

The IOM formed an expert committee to conduct an independent review of the governance and financing of the GME system. The 21-member IOM committee concludes that there is an unquestionable imperative to assess and optimize the effectiveness of the public’s investment in GME. In its report, Graduate Medical Education That Meets the Nation’s Health Needs, the committee recommends significant changes to GME financ­ing and governance to address current deficiencies and better shape the phy­sician workforce for the future. The IOM report provides an initial road­map for reforming the Medicare GME payment system and building an infrastructure that can drive more strategic investment in the nation’s physician workforce.

The funding in question is for graduate medical education (GME), the post-medical school training of interns and residents required before doctors can be licensed to practice in any state.

"We recognize we are causing some disruption," said Gail Wilensky health economist and co-chairwoman of the panel that produced the report. "But we think we are doing so in a thoughtful and careful way," including phasing in the payment changes over 10 years.

Some of the major players in medical education don't see it that way, however.

"Today's report on graduate medical education is the wrong prescription for training tomorrow's physicians," the American Hospital Association said Tuesday. "We are especially disappointed that the report proposes phasing out the current Medicare GME funding provided to hospitals and offering it to other entities that do not treat Medicare patients."

The panel specifically proposes that funding for medical education be expanded beyond hospitals to clinics and other training sites in the community. "Most, if not all residencies must train physicians to treat a wide range of patients -- many of whom are under age 65 and not eligible for Medicare coverage," the report says.

The American Academy of Family Physicians welcomed the proposal "to shift funding away from the legacy hospital-based system to more community-based training sites; including allowing funding to go directly to those organizations that sponsor residency training," AAFP President Reid Blackwelder said in a statement. "By giving these organizations more control over how they train residents, the financial investment will better align with the health needs of a community.

But the broader-based doctor group, the American Medical Association, reacted negatively, saying: "Despite the fact that workforce experts predict a shortage of more than 45,000 primary care and 46,000 specialty physicians in the U.S. by 2020, the report provides no clear solution to increasing the overall number of graduate medical education positions to ensure there are enough physicians to meet actual workforce needs."

That's because Wilensky's panel didn't agree with studies projecting a shortage of physicians. "There was not a consensus that there is a shortage going forward," said Wilensky, noting that rapid changes in medical practice, including sharply higher use of nonphysician health professionals such as physician assistants and nurse practitioners, might be enough to provide care to aging baby boomers and those obtaining coverage under the Affordable Care Act.

And even if a shortage occurs, the medical education system needs to better manage training since it now produces more specialists than primary care providers and leaves major areas of the country with too few practitioners, said Malcolm Cox, who recently retired from running the medical education program for the Department of Veterans Affairs. "Will an unregulated expansion produce the right physicians with the right skills in the right areas of the country?" he said at a panel discussion of the report.

Wilensky, who ran Medicare when Congress overhauled the physician payment system in the early 1990s, said the chances for making such changes depend very much on lawmakers from states that currently get less funding -- which is most of them.

Given the fact that a disproportionate amount of current funding goes to institutions "in New York, New Jersey, and Massachusetts," Wilensky said she's surprised "that everyone else has tolerated this peculiar distribution of funds" for so long.

Whether change happens will depend on "whether some of the have-not states are willing to say 'wait a minute,'" she said.

The New York teaching hospitals, in particular, are well-known for their clout on Capitol Hill.

"They are fantastically great in terms of their protection of their turf," said Bill Hoagland, a longtime Senate Republican staffer and now senior vice president of the Bipartisan Policy Center. "People talk about the third rail of politics as not touching Social Security. I have found that you touch anything dealing with medical education you get bombarded."

By far the most heated criticism of the report's recommendations came from the Association of American Medical Colleges, which represents medical schools and the teaching hospitals they affiliate with.

"While the current system is far from perfect, the IOM's proposed wholesale dismantling of our nation's graduate medical education system will have significant negative impact on the future of healthcare," said AAMC President and CEO Darrell Kirsh. "By proposing as much as a 35 percent reduction in payments to teaching hospitals, the IOM's recommendations will slash funding for vital care and services available almost exclusively at teaching hospitals, including Level 1 trauma centers, pediatric intensive care units, burn centers, and access to clinical trials."

But those supporting the IOM's recommendations say the system is in major need of change. "The current system is unsustainable," said Edward Salsberg, a former top official at the Bureau of Health Workforce at the Department of Health and Human Services. "Healthcare is moving to the community, but our system of financing graduate medical education is tied to inpatient care."

In any case the responsibility for Medicare, HHS and the taxpayer falls disproportionally on government funding, without support from private health payer insurance entities.