It's that time of year... again

© W.Scott McGill - stock.adobe.com

I began writing this article just before the assassination of United Healthcare’s CEO. It has taken me two weeks to coalesce my shifted thoughts.

My initial draft contained the following:

I just realized something. Congress is mostly to blame for the demise of private practice. It’s not the payors, it’s not the hospitals, and it’s not private equity. It’s Congress that has eroded private practice.

Permit me to explain.

The Medicare Conversion Factor is, in shorthand, the measure of your work’s worth. It will be set at $32.3465 in 2025. Guess what it was in 1998? $36.6673. Your work is valued at 12% less than it was 27 years ago.

Inflation? It’s up 93.66% since 1998. The Medicare Conversion Factor and Inflation are going in opposite directions. To keep pace with inflation, the Medicare Conversion Factor should be $71.0099.

1998, actual: $36.6673

2025, proposed:$32,3465

2025, inflation adjusted:$71.0099

The Agency for Healthcare Research and Quality reported an average of 8,986 RVUs for a doctor in 1998. I will use that figure, 8,966 RVUs as my baseline.

8,966 RVUs in 1998 is the equivalent of 19,447 RVUs today (8,966 * 1.12 * 1.9366). To equal one’s 1998 income, a doctor needs to work more than twice as much in 2025. That, in a nutshell, is why private practice has eroded. Congress has spent more time worrying about reelection than fixing a system they have known is broken.

Private payers follow Medicare, and it is common for discuss payment rates as a percent of Medicare. Had Congress corrected the Medicare physician payment algorithms and paid physicians appropriately, private payers would have followed suit. Thus, I blame Congress and not private payers for the demise of private practice.

Quick aside: the fumbling of the Medicare Conversion Factor has resulted in physicians providing services historically relegated to hospitals, saving patients – and Medicare – hundreds of millions of dollars.

Quick aside two: Medical groups were forced – I cannot think of another word – to use EHRs in the past fifteen years. One unintended consequence has been a 25% increase in the use of levels four and five E&M codes.

There are other factors that warrant consideration.I will leave those topics for another day. Instead, permit me to talk out of both sides of my mouth.

I believe there is a place for authorizations, provided private physicians, public health physicians and others have seats at the table. I wonder why this has not happened. I also wonder how the aggregate costs of the authorization process compare to the money saved; put another way, is the (presumed) reduction in healthcare insurance premiums worth the angst they cause patients and the time/expense they costs medical practices?

I believe health insurance companies should not be publicly traded entities. There is a misalignment between Wall Street and Main Street where patients are the ones in the middle.

I believe there is too much variation in healthcare by physicians (e.g., variations in c-section, ADR, and stenting rates within groups and between communities).These inconsistencies, unmoored and unaddressed, are a reason payers have resorted to mechanisms such as prior authorization.

I believe payers are arbitrary and anything but transparent in their use of measures such as prior authorization. There should be benchmarks for exempting physicians from certain authorizations (often referred to as ‘gold carding), such as exempting a neurologist from brain MRI prior authorization when 95% of her requests are routinely approved. However, I have had pushback from physicians who would not accept gold carding unless it was for the entire group. Gold carding must occur at the individual physician level to be effective.

Finally, I am disgusted by the automated denials replete in the authorization review algorithms of several payers. If a medical director spent 1.2 seconds reviewing and denying a request on behalf of a loved one, I would be furious. Mad enough to kill someone? I would like to say no, but I have not been in that position. Patients pay a lot for their healthcare; they deserve better.

Lucien W. Roberts, III, MHA, FACMPE is a veteran contributor for Physicians Practice.He can be reached at lroberts@theinfusionsolution.com.