The title of the U.S. House of Representatives Subcommittee on Investigations, Oversight and Regulations' hearing, "Health Care Realignment and Regulation: The Demise of Small and Solo Medical Practices?" telegraphed the message physicians from small groups and solo practices drove home in testimony: If declining reimbursements don't kill them, electronic health record (EHR) implementation and meaningful use compliance will finish the job.
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"Established physicians have cited declining reimbursements and increasing regulations, such as the reporting requirements for health information technology and the push toward accountable care organizations (ACO), as reasons small and solo practices have become economically unsustainable," said subcommittee chair Mike Coffman (R-CO) in his opening remarks.
The trend toward IT-intensive ACO adoption was a hot topic for debate in the hearings, but physicians more frequently mentioned national health IT implementation led by the Office of the National Coordinator for Health IT (ONC) as causing more financial difficulties for small practices.
EHR implementation cost: A lot more than software purchase
While the federal government has provided incentives for physicians to implement EHR systems, many still find it difficult to do so due to lack of time or available expertise, said Mark Smith, president of Merritt Hawkins, a Texas-based physician search firm.
"The necessity of implementing information technology is a prominent example of how the resources, expertise and time of small medical practice owners is being taxed in today’s increasingly complex and demanding medical practice environment," Smith said.
Many doctors are still mired in paper, he said, because they either don't have time, don't have the expertise, or feel EHR systems won't increase efficiency in their practices. Furthermore, he said, others eschew EHRs because of patient privacy and security concerns -- and fear of running afoul of HIPAA rules.
ICD-10 fingered as another culprit
Health IT initiatives, including the pending ICD-10 implementation across the U.S. health care system, also comprise one of several trends driving consolidation in the market. Some 60% to 70% of the American College of Cardiology's 40,000 members has decided to forego independence and integrate with hospitals, according to testimony from Columbia, Mo., cardiologist Jerry Kennett.
If declining reimbursements don't kill independent physician practices, EHR implementation and meaningful use compliance will finish the job.
IT-intensive initiatives such as ACOs and bundled payment payer reimbursements will require specialized staffing to administer and report, once EHRs get up and running. So far, even that's proven to be a barrier: EHR implementation itself is a productivity killer for cardiologists, he said.
"The payments offered under the EHR incentive program for those who qualify can offset some of these costs," Kennett said, "but the challenges of making the upfront investment, retraining staff and physicians, and marshaling the necessary expertise can be too much for an independent practice to manage on its own."
Physician spokesmen for the American Osteopathic Association (AOA) and American Association of Orthopaedic Surgeons (AAOS) also testified at the hearing. AAOS member Louis McIntyre, M.D., who practices in Westchester (N.Y.) County, said that although the small group had implemented an EHR before the HITECH Act incentivized it, the cost of compliance far exceeded the incentive checks, with no hope of increased reimbursements after the group attested for meaningful use.
Realigning CMS program requirements could help
Joseph Yasso, who has a family practice in Independence, Mo., said CMS needs to better align its incentive programs. This includes the Physician Quality Reporting System and value-based payment projects, as well as the EHR and e-prescribing incentive programs.
"The AOA appreciates CMS' efforts to align its various programs; however more steps are needed to streamline the requirements, such as the various data submission deadlines," Yasso said. "These deadlines and other reporting requirements must be better aligned to eliminate the administrative burden and confusion caused by the current demands."