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The Healing American Healthcare Podcast
The Healing American Healthcare Podcast

Episode 10 · 1 year 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. 

Want to join our mailing list? Text HEALHEALTHCARE to 22828 to get started. And be sure to go to healingamericanhealthcare.org to learn more about The Healing American Healthcare Coalition™. 

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 coalition podcast. Our goal is to provide you with timely, insightful information and interesting perspectives on healthcare in America. Our mission is to be a trusted, objective source on issues that impact the wellbeing of all Americans. My name is Ed Ichorn 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 discuss issues that family practice physicians are facing every day. Dr Bell of via is a product of the New York City school system. He graduated from NY use Washington Square college with a BA in biology, after which he immediately entered the University of Rome Medical School and did his post graduate training in medicine at the Hackensack University Medical Center in New Jersey, after which he joined the United States army medical core and was stationed in Texas and Virginia. He reached the rank of major while being the chief of professional services at Kenner Army hospital, after which he returned to being attending at Hackensack University Medical Center. Dr Bella via has been an adviser to both the State of New Jersey and federal government on healthcare issues and was recently invited to serve as the Chairman of the New Jersey Department of Health and Senior Services Task Force on chronic kidney disease. He is board certified in Family Medicine and Correctional Medicine. He is a senior attending in the Department of family practice and attending in the Department of Medicine and associate professor at the University of Medicine and Dentistry of New Jersey. Dr Bellavia is a member of the board of Trustees of the New Jersey Academy of Family Practice and its 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 provides Hippo Compliant Health Information Technology and application integration services for physicians, hospitals, patients and 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, and later created heights medical associates in Hasbard Heights, New Jersey, where he still sees patients every day. Hello, Dr Bellavia, thanks for joining us today. Nay, I wanted to ask you what the approaches are the primary physician reimbursement that are currently in use ear under consideration in New Jersey and around the country. 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 third is a capitation. So fief for service goes back, you know, since time immemorial and it's been very coarsely to the government, and so the government has tried to have different opportunities of reimbursement to help save money and get better outcomes. So with the advent of managed care, capitation came into place and at first blush it sounds like it's a good thing because a provider could have a bona fly cash flow, knowing how much money is getting in every month and work accordingly. However, in the past capitation in primary care did not work out for various reasons. It's a question of what is covered what is not covered under under the capitation. It was a worry of under usization because you got paid in advance for service and if the patients didn't come and get that service, you made more money, so that that kind of went away. Unfortunately, government has not learned from...

...history, because I think that now C MS is trying to push a capitated program for primary care again, and that's I think it's fraught with a lot of danger. In fact, I think it's even more complicated now than it was in the past. One is they're going to average your expenses in Medicare patients, for instance, and based on the Year of two thousand and twenty, the year of the pandemic, where people didn't get their care, the course with down. So if you start out at a very low number, that's going to be detrimental to physicians too. You're going to have to I don't believe that they can do the reconciliations that they talk about every month, so that at the end of the month, if you've always spent your allotment, they have to do a reconciliation to find out what they can pay you over that course, what on the underside, if you didn't spend all that money, they're going to be a less 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 been the physicians have to work hard to get their patients to do all the things necessary to get better outcomes at the same kind of reimbursement and then hopefully that there was a course savings. But it took fifteen months from the first day of the contract to the time whether perhaps you had any extra money in that kind of reimbursing model. Besides that, the contracts, I think we're made with 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 succeed in that. To give an example, even today, that if in value based model you will have to reduce utilization, I mean legitimately redtation, get better outcomes, at patient satisfaction so on, we should be able to have a profit and share that profit with the health plan at the end of fifteen months, that is twelve months, and then three months run after the planks together. So, however, what's happened...

...to visitsues them and that model is that courseralization. The course of these services that the hospitals have negotiated with the health plans have been terribly detrimental to the providers. So when the doctors went into these contracts, of course we're different and so we know that, for instance, that these health clans really need the hospitals and then that work so many of the doctors so they can succumb to all of the requests of the hospital, these board hospital systems. So most of the practice is in New Jersey being defeated by the cost the unit course, to health care, even though they had performed movelously well in increasing the quality of care, increasing the outcomes of all these patients. It's in all Chrinic diseases and having patient satisfaction and 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 to the beginning of you know, complicated programs many, many years ago in the HM home and started building was simplus the compared to what it could be in a fee for service mark, could these new programs that you're describing sound like they 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 absolutely true. Can you imagine a practice that has a myriad of programs, value base programs, capitated program but freefure service program and the idea of following each one of these different kind of reimbursement models in an office practice is going to be different and it's going to be difficult, especially when you looking for a reconciliation on a month to month basis. I really don't believe that they can do that. Okay, and put your model you're talking about. I'm assuming that when you talk about computation for Medicare or for private insurance, the camptation models could be different between Medicare, between...

...private insurance and even between the plans and one private insurance company. That's absolutely so. The fact is is that that would practice has to be equipped to handle multiple types of reimbursement programs in in their mrs and billing systems, because it's keep track of this. It's going to be a nightmare and I don't think that. And then you going to see the differences of the opinion. If a doctor on over his capitation for valid reasons, what you're going to have to do to provide proof that this was done? It's the same thing. It's just a it's just a nightmare for practice to go forward with this. I think, think that this is what cms is pushing right now. I think they're going to get their way. I don't know what the outcome is going to be as far as when that happens. Our group, for instances, told our major contractor that we are not interested in that kind of a capitation program and which trying to negotiate 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 of danger. Do you let the programs and private insurance could, for lack of a better term, Dr Belvie would have a basis of capitation with fee for service on top of that, which would also be quite complicated, or is that something that's sun on in the mix right now? Well, that's what we have that now. You know, we have patients and health plan that are still in to NHMO, so they're capitated. We still have capitated patients in each one of these these self clans. Was the fee for service. I don'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 a hospital, 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 people a day or a hundred people days in the same shaluity. So it doesn't work. There, though, it's much better for these doctors and for hospital systems because they don't lose anything. They...

...get there. They referrals from their own primary yet doctors to their specialist and today hospital. So I believe the captivating primary care is counted to it to what we really know and what we learned in the past. I think that they're going to capitate anybody. Let's capitate the high cost people. Let's capitate the specialist. Now that's where you see a lot of churning. Was in New Jersey. It is not much churning 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 to take specialist. Let's stop that. Every patient that comes in thirty five years old which slightly the chest pain as a normally kg it's well, that's normal. Will maybe need an echo quart agram. Now will you ext normal? Still have a muscle pain? Oh well, let's see, let's get to 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 corrected that with one of our health plans. Specialist on now as seeing. I'll take quarter alogy for instance. A quarter allus sees a patient with hi cholesterol and high pretension. He said heart attack in the best. So now he sees that patient every three months, rather than having the primary gift physician see that patient, who certainly equipped to take care of the high pretension and they can the high cholesto, and we all know it's primary gift physicists. We can accomplish that. We will then send that patient back the specialist. So what's happening is that the health plans now or saying well, now this patients is going to the specialist, also at a higher rate of lost. So therefore let's attribute him in the Value Bas spoken to the polityologist. So the patient 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 this I understand, and I hope our listeners understand, the complications that you're explaining to them about the business of being a primary care physician from your perspective and seeing your patients. How do you think, or what is your opinion on how application programs and the CMS, computation...

...programs or self referral to specialists, as you just describe? How does that affect the patient experience in a practice like yours? So if I'm responsible for the phone course to care and this senior citizen is going to the specialist to be a higher cost at to my office, I got a loss that specially suspending the money a lotted to walk practice to take care of that patient unnecessarily. And then it may be this is is if we punderance to visits by it that specialist, that patient may no longer be attributed to the primary care physician. Therefore it's attributed to the specialist who then doesn't have the capability of taking care of that patient as a hoope. How would the patient experience change for a patient that stays within a practice that goes from fee for service to capitation? Do they have a different experience or where they have the same experience? Generally speaking, I know that's, you know, asking unusually. I generally speaking, I think they get the same experience. There's no doubt about it. So you know, primary care 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 the groups that I know of, have scored in a nineteen percentile in quality. Of course, to all factors in any chronic disease, which is any five percent of the course, right. So if we've been able to save money by getting these people better, they can shure they do all in this serious test will prevent this stuff. They say out of a hospital reduces the course. Of course, even in infharmacy is less. So the primary kids position has no knowledge of the courst related to drugs, for instance. So what can we do? We can say in the beginning to go go from from brand to generic to save some money. Today Generic Score stums as much as brand. And then you have all these high costs, biologicals, right, and even the injectable anti cholesterol medicines,...

...which was to fortune, which we have absolutely no control, and yet we're responsible for that cost and yet nobody does anything. So now another issue, high course. Give you an example how hospitals can be great to health plans. There's the issue of observation units in hospitals. So for patient mind goes to the hospital, seen by emergency in physician and they say, well, maybe we'll emit the spatial let's put them in observation. So what does that mean? That means if a high school has a Drg plan on the payment and reivers in to the hospital from the 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 service rather than DRG contracted rate. And by that time I'll tell you what it closed those of medical history. Eight million dollars in horsed that were spent on a 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 unit to help control the course. So primary get positions in New Jersey, which I think is a shame of really being short changed by a system from head to tell, especially in a state like New Jersey in which the amount of primary get physician is very low. In fact I think it's a ninety percent special 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 to do something about cappitation, even federal government capitate the high course people who have a tendency to turn and course the system a lot of money. So that's off position now. Unfortunately, don't think the word is going to be strong enough 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 be a horrible situation. But we will keep...

...trying our best to bring these issues forth to let people know. The second part of the capitation now as we can 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 and helpful and to like to do. They shift more of that risk over the doctors and to patients, which they've done already. So even on these competition programs, when these patients have very high deductables, and for instance, if polinoscopy is one of the criteria of testing on outcomes and a patient tends to go and get it and the guest you are drones as well. That pay me 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 I fad like that. Now I do protect the physicians. I'm looking this is your course. Situt a capitation is due, deductible, your responsible. So you can plant the doctor risky for the advance, but it has so many operational difficulties it puts the doctors at terrible risk. Now, primary kid doctors don'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 come out up and said that they will not pay for any outpatient Immigi studies being done in an aspell set, and the reason for that is in a hospital sitting 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 five cost? You know, I wanted to ask you about that as well because you know, we wrote our book hewing American health care and years ago and one of the things we called for in helping control cost was if you had a cpt code for an MRI, whatever it might be, if the average cost 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 and fifty dollars. It's exactly it should not. Should have a flat billing rate for things like that. Colonoscopy running a doctor's office, as they have been in the past, cost thirty percent of what they cost in the hospital because they're allowed to charge the facility billing fee. And I'm thinking you get a Colonoscar Bey in the hospital, fine, it's going to cost four hundred seventy five, just like it's going to cost when you get it, and that's actually good. That show you into the hospital set to be do stiff fees down to with the kind of marketes is costing. But there's no help from the health plans. Why? Because they didn't debt it. I think that aspel is a strong relationship to the hospells, especially the conglomerates of hospitals we have in New Jersey. It's so baaliful. Well, that's where the challenge really is. Over the last five years in the United States, as hospitals become conglomerates, they have a better negotiating position with into absolutely and their actual costs have gone up by twelve to seventeen percent a year for the last five years because they can do that. You know now that, on the other hand, the hospitals that are not part of conglomerates, when the Insurance Company says we're going to reduce the feast by six percent, they could argue and quibble, but they're going to take to reduce be because they don't have the leverage. That makes right exactly. So there's a lot of things that can be done by health plans. If they would flets they muscle even put some glad rails on some of these courts. So what does the primary kid doctor do? 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're captured by the hospitals making ton of money on observation units. They just buy pissed a DRG contract that they've had and I don't see in Whitey health plans can't fight that. was coming at it. I it's coming at it at patience pockets. It's going at a patient spots. It's an exciting topic and we 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, to say it's a tick speed you're going, you go in and its sex dollars a 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 is really a form of captation. It's just to the hospital. Under this diagnosis is spaces when state these many days. This is why hospital tried it for you at Asfol a lot earlier and now they even though they get fined if they send you know, with thirty day we rule of going back to the hospel. They get fined for that. So it is a lot of green system, is not that? We just found out that one of the major plans here in New Jersey has found out that the cost of of Chiropractic care and physical therapy in the state of New Jersey is rampant because most of these companies are out of network. So we argued incessantly in our contract because we told course of care. But again I don't have the ability to know what the courst is. So we went to the health lends and said, look, we know that chiropractic cares a lot of money. Let us try and get some of our chiropractic friends in the system, in system right, not being at a network at anymore, and maybe you give them a little increasing fee so that they had that difference between the lower rate of reimbursements on the plan versus fecion out of network. So what they did they went to contract with an outside company on natural basis. They got very well all of the chiropractice. We try to get into the system and they still can get the plan 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 with the primary here, doctors are trying to help with the high course areas are falls on the death you. So now we've been told that in the coming contract the cost of Chiropractic care and physical therapy will be excluded from our contract because they realize they have no control over...

...those course and they can't lay that no control over those posts on us. So that's one thing that's come out of negotiations in the last few months. From my last contract. It is contract and Co courst to care and I'd like to get out there observation because I have absolutely no control of the course and observations M and close to a ton of money. So all of these ideas of trying to save the government money in health care. Okay with a country and health gives acause it's such a high course, the fineness. Well, I wanted to ask you to work questions. With all your experience and all this negotiation, if you could design a system for the future. What was the system be from reversement from primary care positions? And that is a great question. That is an absolutely great 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 which would be not only the best of all, but can it be achievable? Second Part, and I'm giving that a lot of thought right now, because I do want to get back to the federal government. You know, I was 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 that was that we had access to our legislatives in Congress. We met with various Congressmen and senators, all interesting health care. We were successful in changing some of the things in Washington as well. So this is the reason why I'm pondering on what is the best possible situation for reimbursement the primary care I want to revive that committee and bring it to Congress. I think that if we can have a system in which the patients themselves are involved, are involved in their actual health care, in costs, and make them educated consumers, and I think one of the ways they can...

...do is the HSA. Let's say give the patient to x number of dollars per year. This is your health care cost, nearly. I don't know the exact numbers of it, just in 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 echo cartigre 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 them take 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's programs out there called choose wisely for patients to do and then have them have a catastrophe fund. You know, spotted that money be outfit to take care of catastrophes and so on. This way the patient decides what's covered in with's not cup. They want to spend some of their money five glasses and where if they got the kind that they got the insurance company? To An employee that doesn't want a couple glasses, it's had a party. So that's one of the ways that they think we could refine it, by putting the patients in decision making process, even financially. And then what does does to physicians? It makes them more competitive. So if I am now known as a good physician in the community and I have a great reputation, even people may willing to pay five or ten dollars what they come to me, then to somebody else does. That's a competition that makes perfect sense. But competition helps every industry, makes every industry better because you got to do better than your next guy. So that's one of the issues I'm struggling with. But I have to give room what thought to give you a better answer, and I haven't got haven't got that damn pad yet. It sounds like a good answer to me. Well, thank you, Dr Bellevia. Very a very interesting session today and sharing the information about all...

...of the issues that primary care physicians have to pay in this complicated market today. But I wanted to ask you one last fundamental question. You know, the Association of American Medical Colleges has reported over the last few years that we can see a shortage of as many as 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 New York Times recently that said there are a number of Americans who've gone to foreign medical schools, as you did when you started your career, who are having difficulty getting into residency programs now. So what are your thoughts about how to increase the number of physicians in the United States? Listen, impending shortage that we're going to see over the next several years. Well, the show to get physicians, especially primary kids physicians, has becoming about over over several years now. The issue of foreign medical graduates, I think is is very important and I think would out the foreign medical graduates that you have in the country now, or hell, care assistant would be down to toilet. There's always been the past at conception that the people who graduate from foreign medical schools and that is qualified as as physicians geduating American schools. We can see that through the years many people are graduated from foreign medical schools that reached the highest elements in the hierarchy of American medicine and if avated a great deal. I think that they're going to have to reach out to foreign medical students if they still want to come here. Now I understand that they may not even want to come here anymore to do to the status of a present condition of the United States, but maybe it's not that great to come here anymore. They not going 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 graduates to come here, it's going to be disasted because as physicians get to retirement age, I don't think there are enough...

...of them to fill those those blanks and they're out. The second part is it is only recently that there's been an increase in the number of slots in medical schools. Some medical schools and the one thousand nine hundred and fifty only admitted a hundred hundred students. In Two 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 United States is another fact that I think it's you know, today, doctors graduating between medical school and residency, they come into practice looking at deaths of up to four hundredzero dollars and with the with the reimbursement models that are out there for primary care, people are not going to stay in the hideas places like 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's is actually one of the worst. We actually train a regular residents. The majority of residents that we train in the state leaf. They can't foot the living. Yeah, no, there. I'm just to share with you as as you probably know and maybe help our listeners. In two thousand and seven there was a law pass that said if you spent ten percent of your disposed Bo income on your educational debt for twenty years, the rest of the debt would be forgiven. So people are doing that, but the problem is on average 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 tenzero in taxes to get rid of the debt in the last year. And there are thirty people in America who, because of interest rate changes and how much they borrowed, have done this and when they get twenty years out they'll still owe a million dollars. Absolutely means to...

...patch rate for there was going to be two hundredzero in that last year. You know, the the New Jersey Academy family physicians, has tried desperately to a lobby for a loan, you know, Lone Relief and so on, on medical students. If you do that then they get shows the income tax made hit through that. You can't get these loans off because it's a mixture between with the federal government will allow and with the states will allow. There are areas right here in New Jersey that 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 involved in the last ten years, that a single iota has been accomplished to solve that problem, whether it's the flow to the legislature or whoever that just letting this go and it's just the downhill stream and either to say that Brimary Care Physicians to the academy have tried desperately to help this problem, to get one the course down. The loans evaporated, some some matter of fashion, but nobody's listening. Wow. Well, I hope you continue to work on these problems. I want to thank you very much for being with us today and I want to remind everyone if you want to learn more about healthcare and the issues that physicians and nurses face, join us at the healing American healthcare coalition and get a hold of our book healing American healthcare. Thanks again and we'll catch you the next time I'm the healing American healthcare podcast. Thank you, and by now.

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