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The Healing American Healthcare Podcast
The Healing American Healthcare Podcast

Episode 10 · 10 months ago

Family Physician Care In America

ABOUT THIS EPISODE

Ed Eichhorn sits down with Dr. Tom Bellavia, MD to discuss issues that family practice physicians are facing and what the business of being a primary care physician in the US is like nowadays. 

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Music: 

"The Discovery" 

by The Lemming Shepards 

Exzel Music Publishing (freemusicpublicdomain.com) 

Licensed under Creative Commons: By Attribution 3.0 

http://creativecommons.org/licenses/by/3.0/ 

Welcome to the healing American healthcare coalitionpodcast. Our goal is to provide you with timely, insightful information and interestingperspectives on healthcare in America. Our mission is to be a trusted, objectivesource on issues that impact the wellbeing of all Americans. My name is EdIchorn and I am the founder of our coalition and the host for today's podcast. Today we are very pleased to have Dr Tom Bellavia with us to discussissues that family practice physicians are facing every day. Dr Bell of via isa product of the New York City school system. He graduated from NY useWashington Square college with a BA in biology, after which he immediately entered the Universityof Rome Medical School and did his post graduate training in medicine at theHackensack University Medical Center in New Jersey, after which he joined the United Statesarmy medical core and was stationed in Texas and Virginia. He reached the rankof major while being the chief of professional services at Kenner Army hospital, afterwhich he returned to being attending at Hackensack University Medical Center. Dr Bella viahas been an adviser to both the State of New Jersey and federal government onhealthcare issues and was recently invited to serve as the Chairman of the New JerseyDepartment of Health and Senior Services Task Force on chronic kidney disease. He isboard certified in Family Medicine and Correctional Medicine. He is a senior attending in theDepartment of family practice and attending in the Department of Medicine and associate professorat the University of Medicine and Dentistry of New Jersey. Dr Bellavia is amember of the board of Trustees of the New Jersey Academy of Family Practice andits foundation, and he's also a member...

...of the American Academy of Family Physicians. He is chairman of the Board of Austar Health, the company that providesHippo Compliant Health Information Technology and application integration services for physicians, hospitals, patientsand insurance providing he is also active in many additional organizations with philanthropic missions.Dr Bellavia began his practice of family medicine in Woodridge, New Jersey, andlater created heights medical associates in Hasbard Heights, New Jersey, where he still seespatients every day. Hello, Dr Bellavia, thanks for joining us today. Nay, I wanted to ask you what the approaches are the primary physicianreimbursement that are currently in use ear under consideration in New Jersey and around thecountry. Sure that basically there are three different types of reimbursement for primary care. One is fee for service, the second is a salary physician and thirdis a capitation. So fief for service goes back, you know, sincetime immemorial and it's been very coarsely to the government, and so the governmenthas tried to have different opportunities of reimbursement to help save money and get betteroutcomes. So with the advent of managed care, capitation came into place andat first blush it sounds like it's a good thing because a provider could havea bona fly cash flow, knowing how much money is getting in every monthand work accordingly. However, in the past capitation in primary care did notwork out for various reasons. It's a question of what is covered what isnot covered under under the capitation. It was a worry of under usization becauseyou got paid in advance for service and if the patients didn't come and getthat service, you made more money, so that that kind of went away. Unfortunately, government has not learned from...

...history, because I think that nowC MS is trying to push a capitated program for primary care again, andthat's I think it's fraught with a lot of danger. In fact, Ithink it's even more complicated now than it was in the past. One isthey're going to average your expenses in Medicare patients, for instance, and basedon the Year of two thousand and twenty, the year of the pandemic, wherepeople didn't get their care, the course with down. So if youstart out at a very low number, that's going to be detrimental to physicianstoo. You're going to have to I don't believe that they can do thereconciliations that they talk about every month, so that at the end of themonth, if you've always spent your allotment, they have to do a reconciliation tofind out what they can pay you over that course, what on theunderside, if you didn't spend all that money, they're going to be aless next month. The government can't do this now in a yearly basis,much dos on a monthly basis. So all these value based programs have beenthe physicians have to work hard to get their patients to do all the thingsnecessary to get better outcomes at the same kind of reimbursement and then hopefully thatthere was a course savings. But it took fifteen months from the first dayof the contract to the time whether perhaps you had any extra money in thatkind of reimbursing model. Besides that, the contracts, I think we're madewith doctors, doctors not being exactly the best business men in the world,that some of these conditions were almost made it impossible for doctors to really succeedin that. To give an example, even today, that if in valuebased model you will have to reduce utilization, I mean legitimately redtation, get betteroutcomes, at patient satisfaction so on, we should be able to have aprofit and share that profit with the health plan at the end of fifteenmonths, that is twelve months, and then three months run after the plankstogether. So, however, what's happened...

...to visitsues them and that model isthat courseralization. The course of these services that the hospitals have negotiated with thehealth plans have been terribly detrimental to the providers. So when the doctors wentinto these contracts, of course we're different and so we know that, forinstance, that these health clans really need the hospitals and then that work somany of the doctors so they can succumb to all of the requests of thehospital, these board hospital systems. So most of the practice is in NewJersey being defeated by the cost the unit course, to health care, eventhough they had performed movelously well in increasing the quality of care, increasing theoutcomes of all these patients. It's in all Chrinic diseases and having patient satisfactionand it's forsing them of fortune. And then they're earning any real money.In terms of this change that you're talking about. If you go back tothe beginning of you know, complicated programs many, many years ago in theHM home and started building was simplus the compared to what it could be ina fee for service mark, could these new programs that you're describing sound likethey may be a bigger burden in terms of the bureaucracy of your practice?Is that really the case or not? I believe that's going to be absolutelytrue. Can you imagine a practice that has a myriad of programs, valuebase programs, capitated program but freefure service program and the idea of following eachone of these different kind of reimbursement models in an office practice is going tobe different and it's going to be difficult, especially when you looking for a reconciliationon a month to month basis. I really don't believe that they cando that. Okay, and put your model you're talking about. I'm assumingthat when you talk about computation for Medicare or for private insurance, the camptationmodels could be different between Medicare, between...

...private insurance and even between the plansand one private insurance company. That's absolutely so. The fact is is thatthat would practice has to be equipped to handle multiple types of reimbursement programs inin their mrs and billing systems, because it's keep track of this. It'sgoing to be a nightmare and I don't think that. And then you goingto see the differences of the opinion. If a doctor on over his capitationfor valid reasons, what you're going to have to do to provide proof thatthis was done? It's the same thing. It's just a it's just a nightmarefor practice to go forward with this. I think, think that this iswhat cms is pushing right now. I think they're going to get theirway. I don't know what the outcome is going to be as far aswhen that happens. Our group, for instances, told our major contractor thatwe are not interested in that kind of a capitation program and which trying tonegotiate something different. But it will be successful in that their entire programs?Hard to say, but it's certainly for with a lot, a lot ofdanger. Do you let the programs and private insurance could, for lack ofa better term, Dr Belvie would have a basis of capitation with fee forservice on top of that, which would also be quite complicated, or isthat something that's sun on in the mix right now? Well, that's whatwe have that now. You know, we have patients and health plan thatare still in to NHMO, so they're capitated. We still have capitated patientsin each one of these these self clans. Was the fee for service. Idon't believe in it's going to be the way to go. Now.If you're a salary physician, which is the other way to just reimbursement.Then this may be okay, especially if you're hospital based program owned by ahospital, because makes still difference to that doctor comes five o'clock, he's leaving. There's no incentiveve him to do one. I would have bid well less,more or less for anybody, because he's not sality if you send peoplea day or a hundred people days in the same shaluity. So it doesn'twork. There, though, it's much better for these doctors and for hospitalsystems because they don't lose anything. They...

...get there. They referrals from theirown primary yet doctors to their specialist and today hospital. So I believe thecaptivating primary care is counted to it to what we really know and what welearned in the past. I think that they're going to capitate anybody. Let'scapitate the high cost people. Let's capitate the specialist. Now that's where yousee a lot of churning. Was in New Jersey. It is not muchchurning on privory guest side. We have a lack of physicians in New Jersey. I mean it's a terrible situation for New Jersey as another whole topic.But if you want to make capitation work, in our opinion, is have totake specialist. Let's stop that. Every patient that comes in thirty fiveyears old which slightly the chest pain as a normally kg it's well, that'snormal. Will maybe need an echo quart agram. Now will you ext normal? Still have a muscle pain? Oh well, let's see, let's getto cat you know. So this is what we call churning. Also,what we're finding in the churning is especialist as well, and we just correctedthat with one of our health plans. Specialist on now as seeing. I'lltake quarter alogy for instance. A quarter allus sees a patient with hi cholesteroland high pretension. He said heart attack in the best. So now hesees that patient every three months, rather than having the primary gift physician seethat patient, who certainly equipped to take care of the high pretension and theycan the high cholesto, and we all know it's primary gift physicists. Wecan accomplish that. We will then send that patient back the specialist. Sowhat's happening is that the health plans now or saying well, now this patientsis going to the specialist, also at a higher rate of lost. Sotherefore let's attribute him in the Value Bas spoken to the polityologist. So thepatient De flimary hit provider loses heut and the VALUEA's program as well. Wow, they slowly. It's all the any chance of from surviving. In thisI understand, and I hope our listeners understand, the complications that you're explainingto them about the business of being a primary care physician from your perspective andseeing your patients. How do you think, or what is your opinion on howapplication programs and the CMS, computation...

...programs or self referral to specialists,as you just describe? How does that affect the patient experience in a practicelike yours? So if I'm responsible for the phone course to care and thissenior citizen is going to the specialist to be a higher cost at to myoffice, I got a loss that specially suspending the money a lotted to walkpractice to take care of that patient unnecessarily. And then it may be this isis if we punderance to visits by it that specialist, that patient mayno longer be attributed to the primary care physician. Therefore it's attributed to thespecialist who then doesn't have the capability of taking care of that patient as ahoope. How would the patient experience change for a patient that stays within apractice that goes from fee for service to capitation? Do they have a differentexperience or where they have the same experience? Generally speaking, I know that's,you know, asking unusually. I generally speaking, I think they getthe same experience. There's no doubt about it. So you know, primarycare doctors in the pist several years have been trained to watch you loization stop, to waste its in the system and they do the job with that.Now, just like I said before, most of the groups, or thegroups that I know of, have scored in a nineteen percentile in quality.Of course, to all factors in any chronic disease, which is any fivepercent of the course, right. So if we've been able to save moneyby getting these people better, they can shure they do all in this serioustest will prevent this stuff. They say out of a hospital reduces the course. Of course, even in infharmacy is less. So the primary kids positionhas no knowledge of the courst related to drugs, for instance. So whatcan we do? We can say in the beginning to go go from frombrand to generic to save some money. Today Generic Score stums as much asbrand. And then you have all these high costs, biologicals, right,and even the injectable anti cholesterol medicines,...

...which was to fortune, which wehave absolutely no control, and yet we're responsible for that cost and yet nobodydoes anything. So now another issue, high course. Give you an examplehow hospitals can be great to health plans. There's the issue of observation units inhospitals. So for patient mind goes to the hospital, seen by emergencyin physician and they say, well, maybe we'll emit the spatial let's putthem in observation. So what does that mean? That means if a highschool has a Drg plan on the payment and reivers in to the hospital fromthe health plan. Anything done in the time and observation is fee for service. So what the hospital does is racks of the fees charges fee for servicerather than DRG contracted rate. And by that time I'll tell you what itclosed those of medical history. Eight million dollars in horsed that were spent ona whim just because the hospitals and the health plans have to be together,plus the fact the hospitals don't allow the primary get physician into that observation unitto help control the course. So primary get positions in New Jersey, whichI think is a shame of really being short changed by a system from headto tell, especially in a state like New Jersey in which the amount ofprimary get physician is very low. In fact I think it's a ninety percentspecial tempers in primary in New Jersey. If you live at the Gothlin study, any state that has a propundence of primary carec that's done two things.Has provided better outcomes at lower courst so if the state New Jersey wants todo something about cappitation, even federal government capitate the high course people who havea tendency to turn and course the system a lot of money. So that'soff position now. Unfortunately, don't think the word is going to be strongenough on the long run to counteract with C MR is going to do,but I think they haven't learned by history and I think it's going to bea horrible situation. But we will keep...

...trying our best to bring these issuesforth to let people know. The second part of the capitation now as wecan give you these things. Is that puts the primary kiss you shouldn't risk. Now, of course, this is what goverment would like to do andhelpful and to like to do. They shift more of that risk over thedoctors and to patients, which they've done already. So even on these competitionprograms, when these patients have very high deductables, and for instance, ifpolinoscopy is one of the criteria of testing on outcomes and a patient tends togo and get it and the guest you are drones as well. That payme thirty five hundred up front because it's funny deductable. It's what they do. They don't get it done and I can't tell you how many calls Ifad like that. Now I do protect the physicians. I'm looking this isyour course. Situt a capitation is due, deductible, your responsible. So youcan plant the doctor risky for the advance, but it has so manyoperational difficulties it puts the doctors at terrible risk. Now, primary kid doctorsdon't mind taking risk, but why it is an even playing field. So, for instance, why don't help plants in New Jersey, for tail,where they pay for let meage now sitting there. For example, let's comeout up and said that they will not pay for any outpatient Immigi studies beingdone in an aspell set, and the reason for that is in a hospitalsitting it's five times of course, says, into an independent place in New Jersey. So why can't the health plans help by restricting these places of fivecost? You know, I wanted to ask you about that as well becauseyou know, we wrote our book hewing American health care and years ago andone of the things we called for in helping control cost was if you hada cpt code for an MRI, whatever it might be, if the averagecost in an outpatient setting is three hundred fifty dollars for that, CPD code, if you get it done in the...

...hospital, should be three hundred andfifty dollars. It's exactly it should not. Should have a flat billing rate forthings like that. Colonoscopy running a doctor's office, as they have beenin the past, cost thirty percent of what they cost in the hospital becausethey're allowed to charge the facility billing fee. And I'm thinking you get a ColonoscarBey in the hospital, fine, it's going to cost four hundred seventyfive, just like it's going to cost when you get it, and that'sactually good. That show you into the hospital set to be do stiff feesdown to with the kind of marketes is costing. But there's no help fromthe health plans. Why? Because they didn't debt it. I think thataspel is a strong relationship to the hospells, especially the conglomerates of hospitals we havein New Jersey. It's so baaliful. Well, that's where the challenge reallyis. Over the last five years in the United States, as hospitalsbecome conglomerates, they have a better negotiating position with into absolutely and their actualcosts have gone up by twelve to seventeen percent a year for the last fiveyears because they can do that. You know now that, on the otherhand, the hospitals that are not part of conglomerates, when the Insurance Companysays we're going to reduce the feast by six percent, they could argue andquibble, but they're going to take to reduce be because they don't have theleverage. That makes right exactly. So there's a lot of things that canbe done by health plans. If they would flets they muscle even put someglad rails on some of these courts. So what does the primary kid doctordo? We try to steer them to the same quality as a hospital system, to an AD patients sitting that's not owned by a hospital. So we'recaptured by the hospitals making ton of money on observation units. They just buypissed a DRG contract that they've had and I don't see in Whitey health planscan't fight that. was coming at it. I it's coming at it at patiencepockets. It's going at a patient spots. It's an exciting topic andwe all we want to talk about it almost at the same time. Observation. It's would it be possible for insurance...

...companies to capitate them now, tosay it's a tick speed you're going, you go in and its sex dollarsa day and that's what you got period. Well, that's the same thing.So if they do that, to the same as the DARG contract?Yeah, right, yeah, in other words, the D Rg contract isreally a form of captation. It's just to the hospital. Under this diagnosisis spaces when state these many days. This is why hospital tried it foryou at Asfol a lot earlier and now they even though they get fined ifthey send you know, with thirty day we rule of going back to thehospel. They get fined for that. So it is a lot of greensystem, is not that? We just found out that one of the majorplans here in New Jersey has found out that the cost of of Chiropractic careand physical therapy in the state of New Jersey is rampant because most of thesecompanies are out of network. So we argued incessantly in our contract because wetold course of care. But again I don't have the ability to know whatthe courst is. So we went to the health lends and said, look, we know that chiropractic cares a lot of money. Let us try andget some of our chiropractic friends in the system, in system right, notbeing at a network at anymore, and maybe you give them a little increasingfee so that they had that difference between the lower rate of reimbursements on theplan versus fecion out of network. So what they did they went to contractwith an outside company on natural basis. They got very well all of thechiropractice. We try to get into the system and they still can get theplan because, don't be turned it down. Not only did they turn it down, but they find that company three hundred and Fiftyzero dollars. So withthe primary here, doctors are trying to help with the high course areas arefalls on the death you. So now we've been told that in the comingcontract the cost of Chiropractic care and physical therapy will be excluded from our contractbecause they realize they have no control over...

...those course and they can't lay thatno control over those posts on us. So that's one thing that's come outof negotiations in the last few months. From my last contract. It iscontract and Co courst to care and I'd like to get out there observation becauseI have absolutely no control of the course and observations M and close to aton of money. So all of these ideas of trying to save the governmentmoney in health care. Okay with a country and health gives acause it's sucha high course, the fineness. Well, I wanted to ask you to workquestions. With all your experience and all this negotiation, if you coulddesign a system for the future. What was the system be from reversement fromprimary care positions? And that is a great question. That is an absolutelygreat question and I've been pondering that answer for a while for two reasons.I'm still struggling which would I think would be the best of all and whichwould be not only the best of all, but can it be achievable? SecondPart, and I'm giving that a lot of thought right now, becauseI do want to get back to the federal government. You know, Iwas on the National Council of Physicians in the Congress before it was disbanded,where we had doctors from a course the country. The best part of thatwas that we had access to our legislatives in Congress. We met with variousCongressmen and senators, all interesting health care. We were successful in changing some ofthe things in Washington as well. So this is the reason why I'mpondering on what is the best possible situation for reimbursement the primary care I wantto revive that committee and bring it to Congress. I think that if wecan have a system in which the patients themselves are involved, are involved intheir actual health care, in costs, and make them educated consumers, andI think one of the ways they can...

...do is the HSA. Let's saygive the patient to x number of dollars per year. This is your healthcare cost, nearly. I don't know the exact numbers of it, justin general hundred thousand foot level. Let them responsible to spend in money wisely. That does a couple of things. Let's say the patient needs an echocartigre and they want to shop it. Now go to cardiology, stay,of course, five hundred Studiologis to be six hundred dollars. In pudiologist,see, it's nine hundred dollars. But if they have greater faith in audiologist, see, let them spend a month. It's their money. If they are, and this is I'm talking about qualities, equal quality, let themtake care of their own dolls and healthy and they'll do a great shot.I think patients know how to spend their money wisely. You know, there'sprograms out there called choose wisely for patients to do and then have them havea catastrophe fund. You know, spotted that money be outfit to take careof catastrophes and so on. This way the patient decides what's covered in with'snot cup. They want to spend some of their money five glasses and whereif they got the kind that they got the insurance company? To An employeethat doesn't want a couple glasses, it's had a party. So that's oneof the ways that they think we could refine it, by putting the patientsin decision making process, even financially. And then what does does to physicians? It makes them more competitive. So if I am now known as agood physician in the community and I have a great reputation, even people maywilling to pay five or ten dollars what they come to me, then tosomebody else does. That's a competition that makes perfect sense. But competition helpsevery industry, makes every industry better because you got to do better than yournext guy. So that's one of the issues I'm struggling with. But Ihave to give room what thought to give you a better answer, and Ihaven't got haven't got that damn pad yet. It sounds like a good answer tome. Well, thank you, Dr Bellevia. Very a very interestingsession today and sharing the information about all...

...of the issues that primary care physicianshave to pay in this complicated market today. But I wanted to ask you onelast fundamental question. You know, the Association of American Medical Colleges hasreported over the last few years that we can see a shortage of as manyas thirty five thousand primary care physicians by the Year Two Thousand and twenty five, and they've called for a number of things that just really haven't happened.They believe we need more residency program and there was an article in the NewYork Times recently that said there are a number of Americans who've gone to foreignmedical schools, as you did when you started your career, who are havingdifficulty getting into residency programs now. So what are your thoughts about how toincrease the number of physicians in the United States? Listen, impending shortage thatwe're going to see over the next several years. Well, the show toget physicians, especially primary kids physicians, has becoming about over over several yearsnow. The issue of foreign medical graduates, I think is is very important andI think would out the foreign medical graduates that you have in the countrynow, or hell, care assistant would be down to toilet. There's alwaysbeen the past at conception that the people who graduate from foreign medical schools andthat is qualified as as physicians geduating American schools. We can see that throughthe years many people are graduated from foreign medical schools that reached the highest elementsin the hierarchy of American medicine and if avated a great deal. I thinkthat they're going to have to reach out to foreign medical students if they stillwant to come here. Now I understand that they may not even want tocome here anymore to do to the status of a present condition of the UnitedStates, but maybe it's not that great to come here anymore. They notgoing to get that same kind of the US to have in the pass.But if they don't open this to and make it easier for foreign medical graduatesto come here, it's going to be disasted because as physicians get to retirementage, I don't think there are enough...

...of them to fill those those blanksand they're out. The second part is it is only recently that there's beenan increase in the number of slots in medical schools. Some medical schools andthe one thousand nine hundred and fifty only admitted a hundred hundred students. InTwo thousand and twenty one in long your mid a hundred, ten maybe students. So that's being very stricted. Secondly, the high course of Medical Education UnitedStates is another fact that I think it's you know, today, doctorsgraduating between medical school and residency, they come into practice looking at deaths ofup to four hundredzero dollars and with the with the reimbursement models that are outthere for primary care, people are not going to stay in the hideas placeslike in New Jersey. They go to places like Texas and so on,and with this place is where they can get a hire reimbursement. New Jersey'sis actually one of the worst. We actually train a regular residents. Themajority of residents that we train in the state leaf. They can't foot theliving. Yeah, no, there. I'm just to share with you asas you probably know and maybe help our listeners. In two thousand and seventhere was a law pass that said if you spent ten percent of your disposedBo income on your educational debt for twenty years, the rest of the debtwould be forgiven. So people are doing that, but the problem is onaverage when they get to the twenty year period, is still oh fortyzero.So when the fortyzero debt is relieved. The IRS counts at his income.So the average physician who goes out twenty years and pays the bill spends tenzeroin taxes to get rid of the debt in the last year. And thereare thirty people in America who, because of interest rate changes and how muchthey borrowed, have done this and when they get twenty years out they'll stillowe a million dollars. Absolutely means to...

...patch rate for there was going tobe two hundredzero in that last year. You know, the the New JerseyAcademy family physicians, has tried desperately to a lobby for a loan, youknow, Lone Relief and so on, on medical students. If you dothat then they get shows the income tax made hit through that. You can'tget these loans off because it's a mixture between with the federal government will allowand with the states will allow. There are areas right here in New Jerseythat don't have physicians because the positions that we train here on that staying here. And it's been impossible in at least in my experience that I've been involvedin the last ten years, that a single iota has been accomplished to solvethat problem, whether it's the flow to the legislature or whoever that just lettingthis go and it's just the downhill stream and either to say that Brimary CarePhysicians to the academy have tried desperately to help this problem, to get onethe course down. The loans evaporated, some some matter of fashion, butnobody's listening. Wow. Well, I hope you continue to work on theseproblems. I want to thank you very much for being with us today andI want to remind everyone if you want to learn more about healthcare and theissues that physicians and nurses face, join us at the healing American healthcare coalitionand get a hold of our book healing American healthcare. Thanks again and we'llcatch you the next time I'm the healing American healthcare podcast. Thank you,and by now.

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