Home Forums Discussions General Discussion Health care law

For the last year, I have kept my distance on the potential impact of the health care law. I realized that this was probable a hot topic a year ago - but I am finally getting my head out of the ground and looking around. I am an independent Nurse Practitioner in Washington State. I am not a medicare provider due to being an independent NP. I am not eligible for any incentives. I guess my question here is --what is going to be the impact on the small practices?? I am assuming that most AC uses are also small practices. Are we going to become absolete to the big "Whole Care Centers" like Kaiser? If possible, would it be possible for someone to summarize what the impact might be. Thank you.

The most sobering assessment of the impact of the 2010 ACA that I have read is the Annals of Internal Medicine article The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges. The authors were from the National Economic Council, the Office of Management and Budget and the Office of Health Reform in the Obama White House.

The bad news for solo practitioners and small groups: The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups.

Although the American College of Physicians was roundly attacked for publishing the article in their journal, few challenged the conclusions that the ACA is likely to accelerate the decline of small private practices. I am certainly witnessing this in my region.

I think there are too many variables to be able to guess much of anything. First of all, you may well have already carved out a niche market for yourself. You are an independent NP, not part of Medicare, very possibly not deep in the pockets of managed care. If you are making it under those circumstances, then I think very possibly little will change in the short to medium haul. I think it also greatly depends on the kind of area in which you practice. Articles such as the one John describes are very applicable to an urban setting, but much less so in a rural area. Marysville may be far enough away from Seattle to insulate you, although the big clinics are very hungry, and happy to set up satellites.

Add to that the uncertainties of the eventual fate of he Affordable Health Care act, and there is still just a huge question mark. But, there is certainly cause for concern if you are within striking range of the big Seattle clinics.

Here in Massachusetts we're ahead of the curve as an ACA-like law has been in effect since 2006. As the state comes to grips with how to pay for it, they are embracing Accountable Care Organizations (ACO's) which are integrated networks of doctors and hospitals paid on a per-capita basis rather than fee-for-service. The days of the solo practitioner such as myself appear to be numbered. Meanwhile, I'll just continue taking care of patients... :-)

The ACO and Medical Home models are just such a rip off for doctors. They shifts the risk of insurance from the insurance company to the doctors, while adding a bunch of requirements. I dont see why any doctor would sign up for these things. And if all of you reject them, they go nowhere fast. But I guess there's always a few professional prostitutes out there.

It is a sobering thought that the small clinics may become something of the past (especially when I just completely remodeled the clinic!). I have noticed that the some of the solo clinics around here are beginning to merge with larger organizations. I am not ready to give up my small rural clinic.
I appeciate the information.

I am an NP also (in rural northeast GA) and have had a clinic for a couple years now... I DO NOT participate in Medicare, Medicaid, or any insurance plans! I do not bill patient or insurance company..services are strictly "cash and carry" if you will... In my area we have 3 types of patients 1)Insured 2)Underinsured (high dedeuctible plans) and 3) Uninsured... I have focused my services toward the latter two... Still get insured patients with acute illnesses because it is cheaper for them to see me than go to ER or urgent care... In an urban environment, this plan might not be the best but for my area is is working quite well (knock on wood!)... I keep the overhead low and charge reasonable fees for services $40 a visit and then tests, injections, procedures, etc.. are extra... For example, if one presents for the flu... they are in and out for $70 which includes the rapid flu test... if a CBC is needed $20, CMP $30, etc... People are willing to pay, they are just programmed to believe that they cannot afford it without insurance...

NOTE: It is a walk in acute care type clinic...different scenario when you throw in chronic care or specialty care.

T[quote=crbfnpPeople are willing to pay, they are just programmed to believe that they cannot afford it without insurance...

NOTE: It is a walk in acute care type clinic...different scenario when you throw in chronic care or specialty care.[/quote]


Chet, that is exactly our finding, even in an internal medicine practice. Scans and procedures are one thing, but office charges are a family meal at a steakhouse and a bottle of wine.

I'm also solo family physician, sole proprietorship like many of you. ACO's may ultimately rule the day for awhile, like HMO capitation used to be very popular (before my day in medicine), like the cash payer model was decades before.

I can see full circle swing for those of us that are small and remain small. By remaining "name branded" the concierge practice model might serve some of us well. It will not work in all geographic locales. There needs to be a good enough financial base to attract patients that can afford a $1,000-1,500 retainer fee. There needs to be enough public distaste for what little ACO's and the "big-guys" provide. Under the right circumstances, patients will happily pay this fee in order to keep you the doctor/provider they trust. Patients are doing this all across the country. As insurance companies and the government continue to ruin health care in the nation, concierge practice models will grow and thrive.

Remember, this is America where people want it all. We are a consumer society. People want quality service and they want it yesterday. There are increasing numbers of people who realize the standard quality of care stinks. They want a better doctor, and people call my office by the dozens every day to get into our practice. They can't because we are closed. I do good work and people want to get in. You do good work and they'll want to stay with you.

When the ACO's come to town and the big insurances stop paying me, I'm going concierge. I think there will always be a niche for a name-branded physician/provider. People wear name branded clothing with pride. I have many patients that have a name-branded physician that talk to their friends about me with pride. As long as that type of relationship exists between you and your patients, a concierge model or straight cash based payment model will remain viable.

I believe there will always remain hope. Why? People will always be ill. They will always need health care. And it's impossible for the U.S. government to provide health care to everyone in this country. We can bank on the fact that our government is too screwed up to do anything correctly. They will never fix health care. As long as it remains broken, there will always exist the possibility to go to a straight cash or concierge type practice. My father successfully practiced for 37 years in medicine. He told me there was only one guarantee in this profession..."it will change." 8 years out of residency, I see his wisdom every day I go to work.

Or in my neck of the woods... a weeks worth of necessities like beer and cigarettes!

And I always love the stragglers that don't have the money to come in but magically have money to pick up a prescription they want you to call them in

We've started taking a harder line with those pt's who don't want to pay the office visit to get a prescription. Our policy follows newer and stricter rules of the Osteopathic Board of Licensure in Maine. New rules state we are advised not to prescribe without seeing a patient except under extenuating circumstances. They cite the example that if a patient were in the north woods of Maine or out of state AND does not have reasonable access to medical facility, we could call in an antibiotic.
They require that we follow reasonable medical monitoring or chronic conditions when prescribing medication. In general they intend that we need to see patients at minimum once yearly to continue generating prescriptions for them.
I find the ERx renewal requests helpful because the staff are prompted to see who is seeking Rx and then look to see when the last office visit was. If over one year, we authorize 30 days and require the patient come in to get additional Rx.
Frequently patients grumble to staff but it's rare they gripe to me. We sell it to them in a very polite way of saying "hey it's not MY rule, it's the GOVERNMENT requiring this, so lay off." Again we don't phrase it this way, but it takes the burden of explanation off me and my staff.

Adam,
We do almost exactly the same except if a patient says they cannot get to the office to get a script we ask them how are they going to get to the pharmacy to pick it up? (Only a few of the local pharmacies still deliver here). If they say someone will pick it up for them later in the day or tomorrow, we reply, "but if you are that ill to require a script, you really need to start the medicine immediately". 9/10 times, they make an appointment that day to be seen.

that's awesome Leslie.
I used to call in scripts all the time "to be nice," or try to maintain good patient relations. It actually lead to patients taking advantage of my office, and I frankly don't want to risk a board of licensure inquiry if a patient had a bad outcome.

I recall seeing a patient once who belonged to another doctor. The patient says they called for an antibiotic, it didn't work so called back for another antibiotic and it didn't work. The patient went to the E.D. with pneumonia a few days later. I was seeing this new patient in followup. I am 100% certain the patient didn't want to be seen by their doctor, and I also know 100% for a fact the doctor's office asked him twice to come in for the antibiotics, and the patient refused. Of course in retrospect the patient retold the story differently. He said "the doctor didn't even want to see me, he prescribed two antibiotics and never bothered to make me an appointment." Ever since that day over 7 years ago, it made me realize patients remember the story they want told...not always the factual truth. When it comes to board complaints, I don't want to face a patient who wants to recall a story of convenience. I'd rather face that board complaint with office notes to back up my side of the story.

I use that excuse too... Georgia has similar laws..which is good practice..I don't give anyone a Rx for a new problem without seeing them...Another good one for those who like their narcotics is telling them that the pharmacy/drug inspector is auditing prescriptions/providers and as much as you would like to "help them out" you cannot put your career on the line for them...it usually gets them off your back fairly quick...In my area we do have a pretty tenacious inspector that loves busing patients and providers...everyone is hoping for his retirement soon

Like you Chet, we do similar thing with narcotics.
In fact we keep a registry for patients prescribed chronic narcotics. We record name/diagnosis/narcotic medication/status of narcotic contract/date of last office visit/date of last urine drug screen/date of the last run Maine Prescription Monitoring Program (PMP) report. This helps us keep track of our prescribing habits.

If patients ask why we are drug testing them or why we run the Maine PMP report, we tell them it's for their protection. I say something to this effect: "If a Maine DEA agent came into our office with a warrant to review your file, having a narcotic contract, clean urine drug screen, and proof that you are receiving your medications from only one physician will protect both you and I." Patients are receptive to this. Especially when I tell them that the state PMP registry is used by the Maine DEA to investigate patients with suspicious activity (multiple prescribers or unusually large Rx quantities).