‘Health in­sur­ers are re­fus­ing to pay fair mar­ket rates’

Modern Healthcare - - Q & A -

Last month, emer­gency physi­cian Dr. Steven Stack be­came the 170th pres­i­dent of the Amer­i­can Med­i­cal As­so­ci­a­tion. Stack, who prac­tices in Lex­ing­ton, Ky., has been the med­i­cal di­rec­tor in mul­ti­ple emer­gency de­part­ments, in­clud­ing St. Joseph East in Lex­ing­ton. Stack has served on a num­ber of fed­eral ad­vi­sory com­mit­tees for HHS’ Of­fice of the Na­tional Co­or­di­na­tor for Health In­for­ma­tion Tech­nol­ogy and is a for­mer sec­re­tary of the eHealth Ini­tia­tive. Mod­ern Healthcare re­porter Steven Ross John­son and other MH staff mem­bers re­cently spoke with Stack about the AMA’s po­si­tion on pos­si­ble changes to the Af­ford­able Care Act, its stance on elec­tronic health record mean­ing­ful-use rules, and his views on reg­u­lat­ing sur­prise outof-net­work med­i­cal bills. This is an edited tran­script.

Mod­ern Healthcare: What are the AMA’s pri­or­ity is­sues for the com­ing year?

Dr. Steven Stack: The AMA has three bold ini­tia­tives. One is to im­prove health out­comes for the na­tion, specif­i­cally for peo­ple with di­a­betes and hy­per­ten­sion. We’re go­ing to work very hard to min­i­mize the num­ber of peo­ple who con­vert from pre­di­a­betes to di­a­betes, and to bet­ter rec­og­nize and treat hy­per­ten­sion. The sec­ond thing is, we’re work­ing very hard to ac­cel­er­ate change in med­i­cal ed­u­ca­tion. We strive to rad­i­cally trans­form med­i­cal schools so that the doc­tors of to­day and to­mor­row have the skills and the knowl­edge they need to pro­vide 21st-cen­tury care. The third thing is to re­store joy to the prac­tice of medicine, and to en­sure that physi­cians are in sus­tain­able prac­tices where they have the re­sources and sup­port they need to pro­vide high­qual­ity care to pa­tients.

MH: What is the AMA do­ing to ad­dress the loom­ing doc­tor short­age?

Stack: We be­lieve the fed­eral gov­ern­ment needs to in­crease res­i­dency slots. Med­i­cal schools are in­creas­ing the num­ber of stu­dents they train and teach, and new med­i­cal schools have been founded. But there’s a bot­tle­neck when grad­u­ates reach the res­i­dency por­tion of their train­ing, and we need to make sure that bot­tle­neck is not an im­ped­i­ment to hav­ing a suf­fi­cient work­force. We need more res­i­dency slots funded, and the pro­fes­sion needs to work with pol­i­cy­mak­ers to en­sure that pa­tients have the doc­tors with the skills they need to suc­ceed.

MH: What is the AMA’s po­si­tion on pos­si­ble changes to the Af­ford­able Care Act?

Stack: We would say that ev­ery Amer­i­can needs to have ac­cess to high-qual­ity care when they need it, where they need it, and at a price that they can af­ford. We’ve had con­tin­ued, qual­i­fied sup­port for the cur­rent ver­sion of the ACA. We sup­port what it strives to achieve—to di­min­ish the num­ber of unin­sured Amer­i­cans. There’s a need for fur­ther im­prove­ment and fur­ther ac­com­plish­ment, be­cause as much of a won­der­ful suc­cess as it is to have 10 mil­lion or more Amer­i­cans now in­sured, we still have 40 mil­lion more left to get in­sured. We’re com­mit­ted to find­ing a way to get those other 40 mil­lion Amer­i­cans into a sys­tem of cov­er­age. We would be happy to work with Congress and the ex­ec­u­tive branch to find paths for­ward through statute and reg­u­la­tion to en­sure that the most peo­ple get the best pos­si­ble ben­e­fit. Our sup­port is not con­strained by a spe­cific piece of leg­is­la­tion, nor will it be lim­ited go­ing for­ward to just that piece of leg­is­la­tion.

MH: Why does the AMA want the CMS to de­lay im­ple­men­ta­tion of Stage 3 mean­ing­ful use of the EHR pro­gram?

Stack: We have con­cerns with the mean­ing­ful-use pro­gram be­cause we feel it is overly bur­den­some and pre­scrip­tive. It doesn’t ac­count for the vari­a­tions in the way healthcare is de­liv­ered or in how pa­tients re­ceive it. We don’t feel that, as they have pro­posed it, Stage 3 will be at­tain­able for most providers. There’s great need to mit­i­gate the pro­gram and have it fo­cus on in­ter­op­er­abil­ity and on giv­ing physi­cians ac­cess to EHRs that are use­ful and sup­port their prac­tice rather than in­ter­fere with it. We’re sup­port­ive of the Obama ad­min­is­tra­tion’s mod­i­fi­ca­tions of Stage 1 and Stage 2 mean­ing­ful use. For Stage 3, we’re com­mit­ted to work­ing with the ad­min­is­tra­tion to have it fo­cus on in­ter­op­er­abil­ity and the us­abil­ity of EHRs, and, if needed, to dis­cuss the tim­ing of the dif­fer­ent rules and stages and when

“In­sur­ance reg­u­la­tors would do well to fo­cus on the be­hav­iors of the in­sur­ance in­dus­try first.”

they go for­ward. Ev­ery physi­cian in the coun­try would be grate­ful to know that CMS it­self has said this is the fi­nal stage. That’s im­por­tant be­cause doc­tors and hos­pi­tals need to turn their at­ten­tion to mak­ing these tools work and to re­al­iz­ing the prom­ise that they of­fer, in­stead of all of these bar­ri­ers and im­ped­i­ments that they cur­rently throw up in the way of our care.

MH: What will the AMA do if there is no de­lay in Stage 3 re­quire­ments?

Stack: Right now, we’re very con­cerned be­cause par­tic­i­pa­tion in the mean­ing­ful-use pro­gram has been de­clin­ing pre­cip­i­tously. Our eye is on how to help physi­cians right now, in 2015 and 2016, to suc­ceed and use these tools to pro­vide bet­ter care for pa­tients. We wouldn’t pre­sup­pose what CMS will come out with in their fi­nal rule, but what­ever it is, we’ll con­tinue to ad­vo­cate with CMS that we have to at­tend to the im­pact these tools are hav­ing on physi­cians, and right now it’s not good. Our ef­fi­ciency is di­min­ished and pa­tients are get­ting frus­trated, just like doc­tors are, with the in­tru­sion into the time the physi­cian has to spend with them. Pa­tients would rather have their doc­tor look them in the eye and hear their con­cerns, in­stead of click­ing away with a key­board or a mouse, which is the ex­pe­ri­ence to­day with the cur­rent EHRs.

MH: What are your thoughts about state reg­u­la­tory ef­forts to pro­tect pa­tients from sur­prise med­i­cal bills when they un­in­ten­tion­ally re­ceive care from out-of-net­work providers such as emer­gency physi­cians? For ex­am­ple, New York has re­quired providers and in­sur­ers to work out the is­sue through in­de­pen­dent dis­pute res­o­lu­tion.

Stack: It’s a big is­sue. The real crux of the prob­lem is that health in­sur­ers are re­fus­ing to pay fair mar­ket rates for the care pro­vided. Then they turn and say to the physi­cian who is billing to get value for ser­vice that’s ap­pro­pri­ate, “You’re the bad guy.” The pa­tient sees the physi­cian as the bad per­son be­cause that’s who in­ter­acts with (them) and that’s who they get the bill from. When that hap­pens, it’s en­tirely disin­gen­u­ous to say that it’s the physi­cian try­ing to bill the pa­tient for more money, when it’s the in­surer re­fus­ing to pro­vide the ben­e­fi­ciary with an ad­e­quate ben­e­fit. I can’t com­ment specif­i­cally on the New York ap­proach. But putting in a method­ol­ogy to co­erce physi­cians through yet another way to not re­ceive suf­fi­cient pay­ment doesn’t help pa­tients, and cer­tainly is not fair to physi­cians. In­sur­ance reg­u­la­tors would do well to fo­cus on the be­hav­iors of the in­sur­ance in­dus­try first. In­sur­ers should ei­ther be re­quired to pay physi­cians fair mar­ket rates or else dis­close to their mem­bers that they pay un­der-mar­ket value and of­fer an in­ad­e­quate provider net­work.

MH: What are your thoughts on im­ple­men­ta­tion of the ICD-10 cod­ing sys­tem in Oc­to­ber now that the CMS has given doc­tors more flex­i­bil­ity?

Stack: If CMS and oth­ers de­cide to move for­ward with it, we are com­mit­ted to work­ing with them to try to mit­i­gate and plan for those po­ten­tial dis­rup­tions, to do the very best we can to make sure that they don’t im­pact physi­cians and their pa­tients.

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