Career and Life Planning Guidebook for Medical Residents

SECTION I: T MINUS THREE YEARS Still, many doctors have no interest in this new pool of Medicaid patients. Throughout the country, some doctors are trying to lower their percentage of both Medicaid and Medicare patients or even eliminate them entirely. Some doctors will also avoid the new Medicaid patients because they feel that dealing with government insurance programs is a snarled tangle of frustrating paperwork. Some physicians in more affluent areas are going into “boutique” practices that don’t accept insurance at all and are made up exclusively of self-pay patients who either pay per service or pay a monthly fee to have a doctor at their beck and call. This, however, is still a very small minority of physicians; we don’t see it as something that would grow to more than 10% of physician practices across the U.S. This is, however, another example of how physicians are reacting to the current environment. Most physicians don’t have these choices. A lot of physicians operate on very short margins and are unable to cut their overhead. They get paid relatively little per patient visit and need to have volume. Yes, there are premier practices that won’t accept insurers offering less than Medicare rates, but they are the exception rather than the rule. Shifting Medicare and Medicaid Financial Risk to Providers The exploding interest in accountable care organizations (ACOs) sparked by the health reform legislation represents a sea of change in the way hospitals and physicians currently function. An ACO is a clinically integrated healthcare group (various models, including hospitals with an employed physician group, or a physician group that has contracted in some way with a hospital or health system) that assumes responsibility for the quality of patient care as well as the cost decisions behind that care. ACOs receive one “bundled” payment for an entire episode of care (from the initial doctor visits to the procedure in the hospital, to the follow-up visits, etc.). The ACO is then responsible for dividing that single payment across the various providers involved in the episode of care. The majority of ACOs participate in Medicare programs, and the bundled payments vary depending on patient outcome (i.e., positive outcomes and lower costs will receive higher payment; thus the ACO is accepting risk). However, this model is expanding beyond Medicare to private payers, and research is showing that moving faster to two-sided risk (in which the ACO receives both increased payments for reaching/exceeding quality and cost targets and also must pay penalties for not meeting targets) will make a larger impact. In the long term, most experts assume that this will be the primary direction most payers will move towards, not just Medicare. This has opened up new challenges and opportunities for physicians in practice and those in new leadership roles. Physician career paths will reflect calls tomove into a newmix of clinical practice and leadership roles for such diverse positions as: Traditional medical staff leadership Health system clinical care councils Care management committees Clinical service line management in hospital systems Health plan care management Medical directorships for many functions within integrated healthcare systems CAREER AND LIFE PLANNING GUIDEBOOK FOR MEDICAL RESIDENTS 98