"Member Voices" is a new series of articles that examines issues facing dermatologists in various regions. In this first article, the AAD talks with Albert Reynaud, MD, about the challenges he faces as a member of a multispecialty group in Billings, Mont.
AAD: Dr. Reynaud, accountable care organizations (ACOs) are a centerpiece of the Affordable Care Act (ACA). As you know, ACOs are designed to offer doctors and hospitals financial incentives to provide quality care to Medicare beneficiaries while keeping costs down and better coordinating health care services. The Billings Clinic, where you work, is an ACO and was an early adopter of the integrated health care concept. What has been your experience working in a multispecialty environment?
Dr. Reynaud: Personally, I wish I was still in private practice. I joined a multispecialty group in 1987. In 1991, when we were told everything was going to be an HMO, our leadership convinced the partners that we needed a new model, so we merged with the not-for-profit hospital and became employees. What we were told back then didn’t actually happen. I worry that what we’re being told today about ACOs won’t be true either. But the fear factor back then forced a lot of people to approve a merger with the hospital and we all became employees. The hospital administration runs everything and you’re just a cog in the wheel. The fear of not meeting all the governmental rules and regulations has caused a lot of practices to scramble to implement them.
It wasn’t so bad when I first started. We were smaller then. I knew most of the other physicians at the clinic and if I needed a consult, I could just walk down the hall and talk to a specialist. But as the organization grew, we lost much of the opportunity and congeniality of working with physicians in other fields. So, we lost much of the benefit of working in an integrated environment. The bigger the organization, the harder it is to know all of the docs in the other specialties.
The Affordable Care Act is driving me batty.
AAD: Dermatologists are being encouraged to join ACOs to grow their practices. In theory, being part of an ACO or a patient-centered medical home (PCMH) will lead to more referrals from other specialists in your group. Do you find this to be true?
Dr. Reynaud: Self-referrals make up about 90 percent of my practice. Referrals from other physicians are only a small part. So, no, working in a multispecialty practice hasn’t significantly increased referrals.
AAD: You’ve recently decided to scale back your practice in preparation for retirement. Why are you considering leaving your practice?
Dr. Reynaud: The Affordable Care Act is driving me batty. I absolutely hate what’s going on today. There’s so much government intrusion. Here’s a good example: We’re being forced to get weight and height measures on every patient, as if that’s going to do any good. I can tell by looking at a patient if he or she is overweight. It’s stupid, bureaucratic stuff. Knowing and understanding medicine seems to be second to doing business and the almighty dollar. None of these things are having a positive effect on the specialty or medical care in general.
The clinic gets a lot of funding from CMS, and about 40 percent of my patients are on Medicare. So, the ACA and Medicare fee schedule changes are having a huge effect on the clinic’s financial landscape. We provide about $40 million annually in unreimbursed care and, under the ACA, the clinic may be forced to make another $25 million in cuts. As a non-profit our margin is very small, even before these enforced reductions.
The good old days of medicine are gone. We’ve been almost completely taken over by government entities.
AAD: You paint a fairly bleak picture. Do you see any respite from oppressive regulation?
Dr. Reynaud: I recently took a part-time job in a small practice in north Idaho and I saw the other side of medicine. I was able to focus on treating patients and not worry about being overregulated by the administration or be forced to use an EHR. I am no longer working there, but they have recently instituted an EHR, which is specialty-based, and I think is working for them.
The idea behind the EHR, as I understand it, was to have ways to communicate securely between practices, but the EHRs are so different and complex, that hasn’t happened.
I hope that all this new governmental regulation manages to work, but I’m not holding my breath.
Albert Reynaud, MD, has been a dermatologist at the Billings Clinic since 1987. He attended the Texas Tech University School of Medicine in Lubbock, Texas, and served his residency at Walter Reed Army Medical Center in Washington, D.C.
We’d like to hear your thoughts on issues facing our members. If you’d like to be interviewed for "Member Voices," please email the Member to Member editor at firstname.lastname@example.org.