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First, Do No Harm

Will some of the requirements of the health-reform law spur older physicians to call it quits?


Wavering: Older physicians.(Spencer Platt/Getty Images)

Iris Grace Snider, a 68-year-old pediatrician in eastern Tennessee, has seen plenty of challenges in 36 years of doctoring. She takes all patients, more than half of them on TennCare, Tennessee’s Medicaid program. But some of the requirements that the 2010 health care law places on physicians have her thinking twice about continuing.

“I am at the point where, if they give me enough problems, I’m going to say the hell with it and walk away,” she said in an interview.


Snider, who in 2010 was chief of the medical staff at the Athens Regional Medical Center, said her hospital experience gives her an idea of how difficult it might be to deal with some of the law’s mandates. For instance, one change will halt Medicare reimbursements to hospitals for treating patients who get certain infections while they are hospitalized.

If these types of issues trickle down to her own practice, Snider says, she’s not sure how long she will stay in medicine.

Nearly 250,000 doctors age 55 and over are facing the same choice—take on time-consuming obligations to document quality care and the real possibility of cuts in what the government pays them if they slip up, or just get out before penalties kick in. These older practitioners make up 32 percent of the physician workforce, according to the American Medical Association’s data from 2009, the most recent year available.


Early retirement could worsen what the Association of American Medical Colleges already predicts will be a shortage of 63,000 physicians in 2015. And that’s before an estimated 30 million more people sign on for health insurance in 2014, many of them seeking out a regular doctor for the first time.

The health care law and the 2009 economic-stimulus package transformed some now-optional programs for doctors—such as using electronic health records or tracking quality of care—into requirements for treating Medicare patients. Where the federal government now uses carrots, mostly in the form of bonus payments to participating physicians, it will start to use sticks in a few years. Doctors will face cuts in their reimbursement from Medicare if they don’t successfully use electronic medical records and report on their quality of care. In 2015, doctors will lose 1 percent of their Medicare reimbursement for not using electronic medical records, and 1.5 percent for failing to report quality data, such as whether they checked patients’ blood pressure or blood-sugar levels. Every year you miss the goals, the penalties go up.

The requirements aim to make the anachronistic U.S. health care system more efficient, and the vast majority of doctors would say they want to provide high-quality care. Providing better care will also bring down overall costs by keeping patients healthier and preventing duplicative tests. But as doctors cope with these new requirements, they also must deal with others that will change how they run their practices. For starters, they’ll have to switch to a new medical-coding system by October 2013 that balloons from 18,000 codes to nearly 140,000 to describe medical services.

Physicians also face the perennial uncertainty of Medicare reimbursement levels because Congress has repeatedly failed to agree on a permanent solution. Unless Congress acts—and lawmakers often wait until the last moment to pass the “doc fix”—physicians will absorb a nearly 30 percent cut in 2012.


Dr. David Nash, a founding dean at the Jefferson School of Population Health at Thomas Jefferson University in Philadelphia, has dedicated his career to developing quality care. But even he is not sure that the nation’s doctors are ready for all of the changes coming. Physicians just starting out are most likely to embrace new programs such as ordering prescriptions online, Nash said, while those nearing retirement are more likely to question the benefits of investing money and time in electronic medical records and systems to report on quality measures.

“High-quality care costs less, and that is what we are attempting to do. But operationalizing this process is an incredibly complicated thing,” Nash said in an interview. “Are doctors ready, willing, and able to do this? The answer is a resounding maybe.”

One big stumbling block: How to measure quality. While larger specialties such as cardiology have well-developed standards for tracking quality care, smaller specialties are still figuring out exactly what constitutes “best practices,” and whether they have the evidence to decide.

The health care law aimed to gather such evidence by setting up registries to collect real-time data on how patients are treated and how well they are doing. That kind of information can help determine whether “quality” measures actually make patients healthier. But Congress gave that program no money, and, given the current spending environment on Capitol Hill, it is likely to remain unfunded.

Dr. Mark McClellan, former head of the Food and Drug Administration and the Centers for Medicare and Medicaid Services who is now at the Brookings Institution, chairs a committee formed under the health care law that is working to establish a national strategy for developing quality measures.

“Many performance measures traditionally have been based on things that are easy to calculate. So are a lot of administrative measures. The challenge with these measures is that they often don’t capture everything that patients care about,” McClellan told an audience gathered at an insurance conference on Tuesday.

Dr. Bruce Bagley, the medical director for quality improvement at the American Academy of Family Physicians, cited one other reason that younger doctors may sign on to the changes more quickly than older ones. Physicians nearing retirement would already have a full patient base, so the few percentage points they would lose here or there from Medicare by not participating wouldn’t make or break their practice. Newer physicians, he said, would not have that luxury. “You wouldn’t want to start out eliminating an entire patient population,” Bagley said.

This article appears in the September 17, 2011 edition of National Journal Magazine.

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