Caring directly for the people

A direct primary care physician embraces an entrepreneurial spirit and leaves insurance behind.

By Marcia Travelstead | Career Move | Fall 2019

 

An entrepreneurial drive and desire to take control of her practice led Julie Gunther, M.D., to open a direct primary care business. – Photo by Two Bird Studio

Name: Julie Gunther, M.D., spark MD, Boise, Idaho

Education

Undergraduate: Harvard University

Med school: University of Washington School of Medicine, Seattle

Residency: Ball Memorial Hospital, Muncie, Indiana

Gunther opened her direct primary care practice, spark MD (sparkmd.com), in downtown Boise in 2014. She is a board certified family physician who is passionate about her relationship with her patients. A Boise native, Gunther lives with her husband, two daughters and an extremely obedient three-legged Golden Retriever.

What do you like about being a direct primary care physician?

I didn’t realize how important nor how restorative autonomy is to being the doctor I wanted to be. I had a great moral conflict when my name was on the door of a clinic but I had no influence into a patient’s experience. I absolutely love having my own business.

I opened the spark MD by myself with a loan and a dream. My first patient in 2014 was a previous patient of mine who fell and needed care before I was open. The space I was going to move into wasn’t renovated yet, so in the meantime, I moved into a space without air conditioning. My patients waited in their cars. Later, when I acquired more patients, my former nurse joined me.

Is there anything you don’t you like about being a direct primary care physician?

Direct primary care is a superior health care delivery model in my opinion, both for patients and providers. But just because I’ve changed to this model, it doesn’t mean the accountability with people is very different. There are still patients who struggle to take care of themselves. Still people who don’t regard time or boundaries. Still people who want more from you than you can give. No matter what health care model you work in, you have to face the truth about whether you still want to take care of people. People are exceptionally imperfect. There are a lot of physicians looking for alternative business models, but what they need to ask themselves is, “Do I still want to be in clinical medicine?”

One thing that’s different and may be uncomfortable for some is having the patient pay you. Also, growing a direct primary care business is slow. You have to believe in yourself and have a plan and, to be quite simple, to learn not to take things personally.

What surprised you about direct primary care?

One thing is how much work entrepreneurship is. I’m a workaholic, and I can take a beating. It doesn’t bother me; I just work harder and faster. But direct primary care can be a steep climb.

Another surprise is how the stress is different. This has been a nice surprise. I’m still stressed at work, but it’s not the stress that feels like it’s taking bone marrow from me. For me, owning my own clinic is empowering. It’s freeing. It’s work and stress, but it doesn’t feel like it’s killing me.

Another surprise about DPC is how much it lets patients see behind the scenes and learn what physicians really do. I have the opportunity to represent my profession to patients very differently. Another surprise was the direct primary care community, which is amazing in terms of mentorship. A few physicians who led the charge early on in this movement have set a remarkable standard of cooperative learning. When I found out about direct primary care, that put all of the pieces in place.

What advice would you give someone who wants to practice direct primary care?

Step one for anyone with interest in direct primary care is that you must fundamentally ask yourself if you still want to be a physician. That’s a really scary and hard question because physicians feel tired, trapped, burned out, scared… They don’t realize there is so much out in the world, so much they can do.

My recommendation is to take time off, think about what brings you joy. You can become something else if you no longer want to be a doctor. Entrepreneurship has so many forms.

Step two is to go to dpcfrontier.com, which has a map of all the declared direct primary care practices in the country. Find someone near you, call them, take them out to lunch and make arrangements to go see their clinic. From there, plug yourself into the direct primary care community. Google the phrase “direct primary care.” There are videos, talks and how-to books (one of which I’ve written) that’s all readily available.

Step three is to stop being afraid. I think the biggest risk is staying in medicine while hating it, and having it jeopardize your health, your marriage or your future. If you need to get out, get out and make your situation better.

Anything else?

I believe that one of the rewards that we owe ourselves is to find joy in our work. There are people who are so grateful for what a normal doctor tries to do. Physicians are deserving of joy, and moments of joy are one of the greatest things about being human. I encourage my physician colleagues to be brave and believe in themselves. If they’ve grown away from the vision they had of being a doctor, they can get it back. They can get out there and be a great doctor, and people will pay for that.

 

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Kavita Mehta, M.D.

Anesthesiologist

Fall 2019 | Snapshot

 

“PracticeLink helped me narrow down jobs that would fit my needs,” says Kavita Mehta, M.D. – Photo by Katelynn Dow

Employer: Dr. Kavita Mehta, PSC; Louisville, Kentucky

Residency: University of Louisville

In practice since: 2000

Mehta enjoys reading, traveling the world, playing badminton and doing yoga.

What surprised you about your first post-residency job search? I was focused on a very limited region of the country for my practice and therefore had narrowed my search down accordingly.

What’s your advice for residents who are beginning their job search? I would strongly advise residents to start their search early. It is very helpful to start a search with learning the pros and cons of practice in different states along with practicing in a university academic institution vs. private practice.

What was the most important factor in your search for a new job? I wanted to stay with my family, so I narrowed my search to a certain region only within a commute drive from my home.

How did you find your job? PracticeLink helped me explore available jobs within my interest region, and at the same time made it possible to make comparisons to other parts of the country. That gave me a much better perspective on what suits my needs. This saved significant time and energy for me, as I was then able to focus on other aspects of my job hunt—like contracts and negotiations.

How did PracticeLink help you in your job search? I have been extremely clear on what I have required regarding job searches, and PracticeLink helped me narrow down jobs that would fit my needs.

Any other advice? I really hope that residency training in the final year also teaches the business management on how to look and compare different job opportunities so as to suit one’s own needs. 

 

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How tight is the job market in your specialty? Fall 2019 Issue

The PracticeLink Physician Recruitment Index can help you gauge the relative ease or difficulty of your job search.

Fall 2019 | Vital Stats

 

What’s your competition like? For job-seekers of all kinds, it can be hard to know. A simple PracticeLink.com search for opportunities in your specialty will give you an indication of the demand for physicians like you, but without knowing who else is vying for those jobs, it’s hard to get an accurate picture of supply.

How many other candidates in your specialty are actively looking for jobs at the same time? And how does that number correspond to the number of opportunities available?

That’s where the PracticeLink Physician Recruitment Index comes in. The Index is a relative indication of the ease or difficulty of job searches in various specialties based on supply and demand information gathered by the PracticeLink system quarterly. The larger the “jobs per candidate” number for your specialty, the better your potential standing in the market.

The change in rank reflects the specialty’s movement since last quarter.

The Most-Challenging-to-Recruit Specialties are those specialties with the highest demand-to-supply ratio in the PracticeLink system. The specialties on this list likely won’t come as a surprise to candidates; they’re often narrow fields.

The Most-In-Demand Specialties represent the specialties that have the most jobs overall posted on PracticeLink—specialties for which the demand for physicians is highest. For the Index, we then rank those in-demand specialties according to the supply. Those at the top represent specialties with the most jobs available and the fewest candidates per job.

After reading these Indexes, ask yourself: Do these Indexes match my experience of searching for a job in my specialty? Do I need to widen or narrow my job-search parameters as a result.

This PracticeLink Physician Recruitment Index was pulled July 1, 2019. Candidate ratios include physicians who have registered with PracticeLink.com within the past 24 months.

 

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A physician’s billing primer

What you need to know to understand about how you’ll get paid.

By Jeff Hinds | Fall 2019 | Financial Fitness

 

To provide the most advanced care for your patients, you’ve spent years of grueling study and practice in preparation for a future in health care. You’ve learned life-saving techniques, researched complex diseases, and perfected your listening skills to become a better diagnostician. Completion of your medical training nears, and at this point you feel medically groomed and ready to develop your own practice. Screech, halt, back up the bus.

For physicians, business billing acumen is another critical area of knowledge needed to evaluate an employment contract and to run a successful practice. Unfortunately, acquiring business knowledge is often sidelined until the ball is in play and headed down field.

As with any business, success in a medical practice is defined numerically—amount billed and amount collected. Physicians who don’t get the first down in understanding medical billing rules, regulations and collections are setting themselves up for serious financial challenges; the consequences are even more dire if you are embarking upon a solo practice.

Why billing matters

Just as medicine has a language of its own, accounting also has terminology specific to its practice. As a physician, you straddle the fence between learning the first extremely well, while understanding enough of the second so that you can impart financial information to all stakeholders.

Becoming knowledgeable in the “foreign language” of accounting ensures that you know enough to limit practice losses from patients who are uninsured or underinsured, while still providing the patient care that’s needed.

In a business where medical professionals want to care for individuals without regard to economics, keeping the balance sheet in the black becomes even more critical. Approximately $125 billion goes uncollected by U.S. medical providers each year. Part of that delta comes from individual health care consumers who have been handed a heftier financial burden from insurance companies due to rising out-of-pocket costs.

As a result, the payment shift has altered financial policies at most medical practices; physicians now place even greater emphasis on patient communications, while the practice has an eagle eye on revenue cycle management.

Because billing and collections are crucial for practice sustainability, expect that your salary and compensation as a physician will likely be tied to this accounting quagmire in one of three ways.

1 Billings or Accounts Payable (A/P): The process of submission, follow up and appeal of claims with health insurance companies used to obtain payment for medical testing, treatments and procedures.

Payment formulas based on billings will likely pay you a percentage of the money billed for the work you have performed.

2 Collections or Accounts Receivable (A/R): The amount of money your practice has a right to collect in return for services rendered and billed. The medical care, already provided to the patient, is given on credit and will be paid at a later date, hopefully sooner rather than later.

Considering the recent payment shift where individuals shoulder more of the cost of care, a collection-based payment formula requires more due diligence because your pay will be dependent upon the employer’s billing capabilities. In this scenario, the practice must first be paid, before you receive compensation for your work.

3 Relative Value Units (RVUs): A value assigned by the Centers for Medicaid & Medicare Services (CMS) to each CPT/HCPCS code. That value represents the cost for providing the service.

RVUs represent a combined total of three components, each individually adjusted based upon geographic location. As such, these units require more calculations and can often overwhelm those first exposed to them. Those three components are:

  • Physician work: Time and clinical skill for treating a patient during a visit
  • Practice expense: Labor costs, administrative costs, building expense
  • Professional liability insurance expense: Malpractice insurance premium costs

RVU-based compensation formulas only count patient encounters. For physicians practicing in a hospital setting, the amount of required administrative duties, all unpaid under this payment structure, must be weighed carefully.

Most employers don’t place physicians in an “eat what you kill” position for pay. Instead, productivity compensation is provided as additional incentives on top of base pay. Therefore, understanding how these numbers are calculated, knowing the history and average of practice collections, as well as the nuance involved in A/R numbers, will help you weigh one job offer against the next and have a financially healthier practice as your medical career blossoms.

Net 30/60/90­—or never

One thing is known about spreadsheets and balance sheets: You don’t get a full picture from only one number. In evaluating the financial health of a practice, you must look at several A/R variables.

Days in A/R: This number results from dividing the total A/R by the average daily charges for the practice. (For example: 30 days in A/R means that the practice is due payment for the equivalent of 30 days of work.) One caveat: This number does not include the age of any payment.

A/R by Age: This number represents the time since billing for a particular service. Bookkeepers and accountants place payments due for services in specific buckets. You’ll find a 0 to 30-day bucket, 31 to 60-day bucket, a 61 to 90-day bucket and so on. Once a bill passes 90 days, the chances that a practice will receive full (or any payment) significantly declines. To calculate ongoing collection performance, divide the A/R in each bucket by the total A/R to get a percentage.

Bucketed A/R month over month: Monitoring the percentage of total A/R in each bucket every 30 days and comparing it to prior monthly performance will give you a landscape view of the practice’s financial health.

For new physicians who want to dig deeper into this “business of the business” area, check out the Healthcare Financial Management Association (HFMA). The organization’s website provides a wealth of information from its members, comprised of health care executives and financial managers from provider organizations, physician practices and health plan markets.

By investing the time now to learn about cash flow, balance sheets and accounts receivable, you will be in a better position to stay in control of working capital wherever your medical career takes you. 

Jeff Hinds, MHA is president of Premier Physician Agency, and has guided hundreds of physicians through the dizzying job search process. He helps secure ideal practice opportunities for physicians, and with the help of a team of experts, provides security for physician contracts worth millions.

 

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What recruiters want you to know before talking money

Follow, don’t lead the conversation—and do your homework first.

By Therese Karsten | Fall 2019 | Job Doctor

 

Recruiters understand that you have very little, if any, education about compensation packages as you enter the job search. Even if this is not your first job out of training, chances are still high that you are looking at an entirely different set of circumstances from the last contract you signed.

Hospital employment contracts are very different from private practice employment, and the differences among markets can mean that the vocabulary you need for one city is useless for a market with a markedly different payer mix. Stark Law throws a unique set of handcuffs into contract construction if hospital financial support is involved. The growth of large national employers now drives alignment of local contract structure and verbiage with national physician services agreements. Bottom line…There really isn’t any point in reading up on every type of structure you might encounter. So what can you do to prepare?

1 Determine if you can live there

First, control one element that only you can control: Determining whether or not the community is a viable fit for you and your household.

Have an idea of the compensation range for your specialty in the area.

Ask your program coordinator for names of physicians from your program who have settled in this market in recent years. Reach out to them and ask for an appointment to ask what they see happening in the area. Ask recruiters the same questions. Even if it is too early to ask about salary and sign-on bonus for the job you clicked through, it’s never too early to ask questions about the market compensation.

  • What do you the think is the compensation range is going to look like in the market in 2020?
  • Have recent recruits ramped up quickly? Are they on track to earn bonuses as projected?
  • What factors explain the low- and high-end outliers?
  • Where does this metro area fall relative to Medical Group Management Association (MGMA) benchmarks?
  • Are base salaries increasing or decreasing?
  • Are sign-on bonuses typical? If so, how much?
  • Do you have an education loan payback program?

Research the cost of living in the area.

Enter “cost of living calculators” in any search engine and compare that market with one you know, like where you grew up or where you are training. Talk with your spouse about his/her absolute must-haves so that you are on the same page about minimum number of bedrooms, size of lot and commute time.

Do you have a special needs child? Will you need to budget for private school for a gifted/talented child if the group puts you in site A, but there is a great magnet public school convenient to site B? Perhaps the realtor’s pre-qualification process projects that you will need $20,000 for a down payment and you will need that money at closing, several weeks before your start date. The recruiter needs to know that before any draft contracts are developed. Be ready to discuss your progress in assessing how your needs fit with your household’s projected cost of getting settled in the community during the compensation discussion.

Know what your monthly education loan payment will be.

You do not need to share this with the recruiter, but your realtor needs to know. That number is not what you hope it will be after you get it restructured, or what you dream it might be after a generous loan repayment deal, or what your spouse thinks it will be based on original paperwork you completed years ago. Use realistic numbers.

These activities will give you a general idea of whether or not you can afford to live in a particular market. That is an important step in narrowing your focus to the one or two offers that make sense.

Physicians withdraw from discussions all the time, at whatever point they feel certain there will not be a meeting of the minds. Withdrawals are a perfectly normal part of the process. Employers do not stop interviewing and do not expect you to stop exploring until there is a mutual decision to move forward. The scenario everyone wants to avoid is the heartbreaking realization that you, the physician, have burned interview days and spent many hours of precious time negotiating a contract that you cannot sign because you and your spouse will never have peace of mind with the tradeoffs that will have to be made. By then, the employer has lost other candidates and may lose patients and miss budget targets if they were counting on the start date for which you were interviewing.

2 Talk compensation

Good questions are the key to a productive compensation talk . “What is the pay?” is not going to get you disqualified, but it does not cast you in a flattering light. The conversation will naturally lead to discussion of the potential range of first-year compensation and a better understanding of how compensation is structured. Follow, rather than lead, the discussion.

Ask how the compensation structure reflects the employer’s values.

The explanation will help you understand what the group prioritizes. Hundreds of management and physician leadership hours have been expended on developing and tweaking the compensation structure. Let them explain how it works. Ask how long the structure has been in place and ask them if they and the physicians feel it is working for the practice. Are any major changes coming soon?

Ask where they expect you to be in year one in terms of production.

Year two? Year three? In order to hit those targets, how many patients a day will you be seeing? Ask physicians when they typically arrive and leave. Is a day off really a day off, or do physicians use half of it to catch up on calls and charting? How many PTO days will you have, and how do they calculate holidays? What happens if you underperform?

If you intend to work part time or need more PTO than normal due to mission trips, introduce this parameter early in the talk.

Employers feel manipulated when they learn about limitations after compensation for a full-time, full-bore position is on the table.

The answers to these will help you know if this job is going to be the right fit in terms of practice style and pace. If getting to the expected threshold to support the salary level is going to entail a lot more hours per week or a pace much faster than is comfortable for you, this job is simply going to be too stressful to be sustainable. If the practice is slower paced or more of a “lifestyle-focused” group of physicians, it won’t be long before you’re chafing at carrying more than your fair share of the load.

Your recruiter’s job is to consult, educate and explore the fit with you. Asking questions is your most important job as a candidate. The more you ask, the better we understand your situation and can help you get into the right fit for you and your family. 

Therese Karsten is director of physician recruitment for HCA Physician Services Group-Continental Divison.

 

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Don’t ask, don’t tell

Your contract’s non-solicitation provision guides your communication when it comes time to leave the practice.

By Bruce Armon | Fall 2019 | Legal Matters

 

Most employers and employed physicians understand their employment contract may include a non-compete clause prohibiting the now-former physician employee from “competing” against the now-former employer within a certain geographic radius for a certain period of time.

One of the issues often overlooked by employers and employed physicians are the scope of “solicitation” activities that may occur following the separation.

Don’t tell patients

As a general principle, the patient always has the choice of who should be the patient’s treating physician. The challenge for you is what you can and can’t tell a patient before or following your departure. Your employment contract may include specific language regarding the permitted “solicitations” that can and can’t occur, such as:

During the term of the Agreement and for two years following the termination of physician’s employment, physician shall not directly or indirectly solicit any patient of employer treated by physician during the final two years of physician’s employment.

Depending on your specialty, you may have regularly scheduled appointments with the patient, including visits that are scheduled on dates following your planned departure from the practice.

Be very careful to avoid saying, “I won’t be here for your next appointment.” Your employer may regard such a statement as an “indirect” solicitation because you’re basically inviting the patient to reply to this statement by asking, “Why not? Are you leaving the practice? How do I get in touch with you?”

This is exactly what the practice has instructed you not to do. You are best served by not saying anything to the patient, even if you know the patient has a follow-up appointment scheduled following your departure date.  

The non-solicitation clause in your employment contract may also include language stating, “The physician may not send announcements or publications regarding a new office or affiliation to the employer’s patients.” Language like this can be tricky to navigate and may have unintended consequences.

Ideally, you and the practice both agree on the “script” that the practice will communicate to any patient who learns that you’re leaving or have departed the practice.

The script may be as simple as:

Thank you for asking about Dr. [Name]. Dr. [Name] is [leaving our practice] or [no longer with our practice]. We wish Dr. [Name] the best. We are happy to continue to care for your medical needs. If you would like to contact Dr. [Name], call [phone number]. Thank you.

The practice may use a printed card to share this information or instruct all front desk staff and others who interact with patients to follow this script. The staff should not deviate from the script, and ideally you and the employer agree how long post-separation the script will be used.

An exception to the blanket non-solicitation clause may be appropriate if you had an established patient base that followed you to your current practice. You may be able to grandfather those patients who have historically followed you to ensure there can be direct communications with them.

As a practical matter, a patient often has the ability to independently locate you even if your former employer makes it more difficult for patients or claims to have no knowledge of your new practice location.

Your new employer would be wise to publicize your arrival in various forms of media—without mentioning the name of your former employer. An employment contract may specifically prohibit you from mentioning your former employer.  

A patient who elects to follow you to a new employer will have to complete a patient authorization to forward the patient’s medical records to a new employer. There very well may be a charge for the copying of these records, which is often governed by state law. Be aware there may be a delay in transferring the patient’s medical record; plan accordingly to ensure no interruption in patient care or adverse consequences.

From the practice setting’s perspective, there needs to be an awareness and sensitivity to not creating a patient abandonment situation. If the departing physician is the only physician in the practice setting with the ability to appropriately treat the patient (for example, you’re the only physician in that specialty in a multi-specialty practice), the practice must make arrangements to appropriately care for patient needs—which may include a referral to you. State law may describe what constitutes abandonment.  

Don’t invite staff to come with you

In addition to confronting patient non-solicitation issues in your employment contract, your contract may also include a staff non-solicitation clause that prohibits you from employing, engaging, contracting or soliciting the services of any employee of your former employer to work with you at your new practice. For some physicians, not having the ability to solicit or hire staff as colleagues in a new venture can make a professional transition even more difficult. Staff, like patients, have the freedom to work where they choose. However, if your employment contract includes a staff non-solicitation clause, be very careful about the outreach to staff asking them to follow you to your new employment setting. 

Start fresh on professional relationships

The third bucket that can be included in your non-solicitation clause, besides patients and staff, are for the practice’s professional relationships. Professional relationships could include referring physicians, professional advisors, nursing homes, surgery centers, ancillary facilities and any other entity with whom your practice setting regularly interacts.

Essentially, your current practice setting is instructing the departing physician to start “fresh” without the benefit of any of the professional relationships that helped make the practice setting successful.

Non-solicit clauses in your employment contract are just as if not more important than a non-competition clause. Understanding the impact of the language in the non-solicitation clause is critical. When departing from a practice, be careful to frame responses so that interested people don’t ask how they can find you in your new practice setting in a way that causes you to violate the terms of your employment contract and invite a dispute.

Bruce Armon is the chair of the health law practice at Saul Ewing Arnstein & Lehr LLP.He regularly provides legal advice to physicians and medical groups, hospitals and academic medical centers, and speaks to audiences about health care legal issues.

 

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Traveling to a specialty conference?

Your trip can help you strengthen your network or even find a new practice.

By Chris Scites | Fall 2019 | PracticeLink Tips

 

Every year, in cities across the nation, it happens.

In places like Philadelphia, New Orleans, San Francisco and many others, the denizens of these fine cities wake up one day to find that their downtowns have been inundated by thousands—sometimes tens of thousands—of physicians and other medical professionals. They swarm around convention centers and nearby hotels and restaurants. The younger ones often carry tubes on their backs, talking to each other in the mysterious language of their specialty. Entire blocks of downtowns are sometimes shut off so that vendors of various tools and potions can pay tribute to these practitioners. And then, in a few days, as quickly as they came, they disperse…until next year.

OK, so that may be a little dramatic. But specialty conferences—especially the annual conferences of large organizations like the American College of Physicians (ACP) or Society of Hospital Medicine (SHM)—are a big deal. There is a lot going on at each conference, starting early in the morning and often running late into the evening.

You’ll find lectures about new developments in your specialty and numerous opportunities to earn CME credits. If you can get to one, they are well worth your time—especially if you are looking for your first or next practice.

Work the room

Almost every specialty conference, both the large and the small, have exhibit halls. This is more than the place to stock up on free pens or register to win the latest Apple Watch. With a little planning, you can jump-start your job search and get preliminary interviews with several different potential employers while you’re at the conference.

Most conferences publish a list of exhibitors online before the event. Many of these exhibitors will be hospitals or groups attending the conference specifically to recruit clinicians in your specialty.

Study this list. See if there are any employers in which you’re interested. Before the conference, take some time to tailor a CV and cover letter to each of the employers that interest you.

Draft a list of specific questions. The conference will be the perfect opportunity to skip past emails and phone calls and get face-to-face with a representative who is there specifically to find good candidates.

Contact the organization ahead of time, and ask the physician recruiter if you can set up a specific time to talk. If you’ve done your homework and take a proactive approach, you’ll stand out among the other candidates. Those first impressions can go a long way in helping you land a job there.

PracticeLink can help

PracticeLink attends about 20 specialty conferences each year. Stop by the PracticeLink booth while you’re in the exhibit hall.

We can share your interest with employers that match your job-search criteria, and our physician relations representatives can provide free job-search help.

Specialty conferences provide many great opportunities. They are, of course, helpful for earning CME credits and looking for new opportunities. But they are also great places to network and make new contacts.

Chris Scites is PracticeLink’s director of physician relations. Reach his team at (800) 776-8383 for free job-search help.

 

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Medicare for all

The likelihood of expanding Medicare to cover all Americans in the near future is close to zero, but the proposal will be prominent.

By Jeff Atkinson | Fall 2019 | Reform Recap

 

“Medicare for All” is the banner under which a variety of Democrats present their plans for reforming the health care system. Sen. Bernie Sanders (I-Vt.) was among the earliest and most prominent advocates of universal health care. In the 201718 Congress, he introduced the Medicare for All Act. Earlier this year in the House of Representatives, Rep. Pramila Jayapal (D-Wa.) and more than 100 cosponsors introduced another bill for Medicare for All.

Four-year phase-in

Sanders’ plan for expanded Medicare would be phased in over a four-year period. The program would cover all residents of the United States. The U.S. Secretary of Health and Human Services would issue regulations regarding who is eligible as a “resident.”

Medicare for All would cover all treatment that is “medically necessary or appropriate.” Unlike the current traditional Medicare program, Sanders’ proposal also would cover oral, audiology and vision services, as well as prescription drugs.

To help make sure that the government health plan is truly universal, insurance companies and employers would be prohibited from offering coverage that duplicated coverage under the act.

The act provides there shall be “no cost-sharing, including deductibles, coinsurance, copayments, or similar charges” for benefits under the act. Some exceptions are allowed, including for prescription drugs and biological products, provided the purpose of the exception is to encourage use of generic products and the cost-sharing does not exceed $200 per person per year (adjusted for inflation).

Effect on physicians’ pay

Physicians and other providers who enter into a “Participation Agreement” with the government would be prohibited from making any charges to patients for covered services other than for payments authorized by the act.

Compensation for physicians and other providers would be likely to drop under Medicare for All. The government would set the payment rates, and Medicare rates are usually less than payments currently paid by insurance companies. On the other hand, compensation for treating patients who had been covered under Medicaid probably will increase since Medicare rates generally are higher than Medicaid rates.

Funding for the program

Under Sanders’ proposal, funding for the program will come from existing health care dollars, plus an undetermined amount of new taxes. Payments that would have been made to the existing programs for Medicare, Medicaid, Federal Employees Health Benefits, and other federal health programs will be deposited into a new Medicare Trust Fund.

Since the new program covers all U.S. residents and not just the current Medicare population, additional revenue will be necessary. Sources of that revenue could include an increase in the Medicare tax or higher income taxes.

Advocates of Medicare for All project substantial savings in some categories of expenditures compared to the current system. Estimates of savings have ranged from $1.5 to $5 trillion over 10 years.

Since there will be a single payer rather than hundreds of payers, administrative costs will be much less. In addition, under the Sanders proposal, the government will negotiate (or dictate) the amount it is willing to pay for pharmaceutical and medical supplies, thus dropping the cost for drugs.

On the other hand, the shift of more than 155 million people who are currently covered by employer-based health plans to a government health plan could increase federal spending by at least $32 trillion over 10 years, according to the AMA.

Level of public support

A survey by the Kaiser Family Foundation found public support for the broad concept of Medicare for All. The labels used in the surveys affected the level of support. “Medicare for All” drew the most positive response (62%); “national health plan” received a 57% rating. When the term “single payer” was used, support dropped to 48 percent.

If respondents to the survey were given more information about tradeoffs for the added coverage—such as higher taxes and increased government control—support dropped further.

Multiple industry groups oppose Medicare for All. Those groups include insurance companies, pharmaceutical companies, some hospital groups, and the AMA. A statement from the AMA said basing payments on Medicare rates and global budgets “raise significant questions as to whether physicians and other health care providers would be able to sustain their practices under Medicare for All.”

As long as Republicans have control of the Senate, the House, or the White House, passage of Medicare for All is very unlikely. The issue, along with alternative proposals, will be prominent in the coming campaigns.

Jeff Atkinson is a professor for the Illinois Judicial Conference and has taught health care law at DePaul University College of Law in Chicago.

 

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Apps for physicians and patients

Some of the apps in this issue’s Tech Notes are great for both sets of users.

By Iltifat Husain, M.D. | Fall 2019 | Tech Notes

 

In this edition of Tech Notes, the apps I cover are geared more toward the geriatric patient population. Two of the apps featured in this column are from large government agencies, and both have done a fantastic job leveraging their resources to create slick apps that will help their patient populations.

Price: Free. iPhone, iPad: apple.co/2N4YAGn Android: Not available.

The Frailty App

Even those not in medicine know that people age differently. Everyone has their example of an 85-year-old patient who can run circles around a 65-year-old. So when you’re trying to assess a patient’s vulnerability to poor outcomes or ability to thrive, you can’t just use a patient’s age. There are now several frailty assessment tools that exist, and we’ve even highlighted them before in Tech Notes.

This particular app and protocol are from a group of Canadian providers in Halifax who have pioneered what they call the Palliative and Therapeutic Harmonization (PATH) assessment. The app they have released, called The Frailty App, can be used not only by providers, but also by family and friends.

Overall, I’m impressed by the types of questions in the algorithm for PATH’s frailty assessment tool. These questions touched on cognitive questions, social and interpersonal questions, physical ability questions and more. They did not just focus on the patient’s functional ability.

Antidepressant Proposer

Price: Free. iPhone, iPad: apple.co/2J4D1jO Android: Not available.

The Antidepressant Proposer app was created by Theodore Huzyk, M.D., a psychiatry resident from the University of Southern California, to help those prescribing gain a better familiarity with antidepressants. Huzyk makes it clear the tool is for educational purposes, and not meant to be an authoritative clinical decision-making tool.

Antidepressant Proposer assigns scores for 32 different antidepressants based on 20 different commonly encountered patient factors and drug measures.

When you open the app, you are given three screens: side effects, special populations and Cipriani 2018 measures. Within the side effects section, you are given options such as anticholinergic, drowsiness and more. You can toggle to desire or avoid.

In this way, the app combines patient factors and drug side effects with results from medical literature to create a unique list of drug options based on your inputs. Once you have answered all the questions, the list of drug options are presented in a ranked fashion.

Medicare: What’s Covered 

Price: Free. iPhone, iPad: apple.co/2KFAuzK Android: bit.ly/2NeBFIQ

Medicare: What’s Covered is the official Medicare app from the United States government to help you understand the health coverage offered by Medicare Part A (hospital insurance) and Part B (medical insurance).

Kudos to the development team; the Medicare app is slick, easy to use and packed with information.

Some of the key questions this app can help answer are: How much will I pay for prescription drugs included in Medicare Part B coverage? Does the part B deductible apply to cardiac rebab? What percent of the Medicare approved amount will I need to pay for colorectal cancer screening?

Notably though, there are key things the application does not cover, such as information on Medicare Advantage Plans, Medigap, and other Medicare health plans.

The most glaring omission was that CPT code searches and reimbursements are not covered at all.

Overall, this is a fantastic app to further understand what Medicare covers, especially when it comes to preventive services.

NHS 24 MSK Help

Price: Free. iPhone, iPad: apple.co/2X41RFm Android: bit.ly/2X3b7K5

NHS 24 MSK, from the National Health Service in the U.K., provides quality videos and materials to help patients with musculoskeletal conditions. The app includes several MSK conditions commonly seen in primary care, urgent care and emergency medicine settings.

When you open the app, you are presented with three buttons: exercises, self help and reminders. The exercises section is where a bulk of the time is spent, and where the app truly shines.

For example, click on the neck section to find exercises and videos for how to help whiplash.

This is one of those apps that can be used by both providers and patients. Providers can use it to review and educate their patients on the different types of physical therapy exercises their patients can do at home. Patients can use the calculators and questionnaires to create custom therapies. There is even a calendar section that patients can use to remind themselves to do their exercises, take their medication and keep track of their appointments. 

 

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The truth about student loan repayment

How physicians can tackle their biggest burden.

By Jason DiLorenzo | Fall 2019 | Feature Articles

 

Student loan repayment programs have evolved even since Larry Burchett, M.D., graduated med school in 2006. – Photo by Simone Anne

Larry Burchett, M.D., remembers graduating from medical school in 2006, excited that he’d matched to his preferred emergency medicine program and begin training.

“But that first year, it’s hard, man,” says Burchett. “I didn’t expect that; $42,000 doesn’t go very far in California.”

Burchett graduated medical school with about $160,000 in federal student loans, which he still carries today because his rates were fixed at nearly 2% in 2010.

Fast forward to today, where a debt load of roughly $200,000 is the average for physicians graduating from a public medical school, and often well over $250,000 from private or osteopathic programs. With fixed rates as high as over 7%, it’s easy to surmise that Burchett’s profile would be envied by most medical graduates today.

But fortunately for those who are keeping up on an ever-evolving and complex student loan repayment marketplace, relief is available for early-career physicians today.

Evolving options

Increasing physician debt levels and available federal and state repayment and forgiveness options have dramatically changed the economics of becoming a physician, and these factors are beginning to impact the career decisions of young doctors.

Jared Wenn, D.O., is one such graduate; the surgeon is the sole breadwinner supporting his family of four on a training salary.

“I needed to borrow more money than I thought I needed through school,” Wenn says, resulting in federal student loan debt of more than $400,000. Now, with five years of residency ahead and possibly up to four more years of fellowship, Wenn could reduce his out-of-pocket student loan payments by over $350,000 by pursuing the Public Service Loan Forgiveness Program. Burchett, by comparison, didn’t have this program available when he graduated in 2006.

Medical trainees today can uniquely position for this program by using an Income-Driven Repayment plan while training with a non-profit hospital.

The repayment landscape

For graduates entering training, going into a standard or extended-term payment plan at today’s average debt level and rates isn’t affordable ($200,000 on a 10-year plan is roughly $2,250 monthly), so early-career physicians often seek payment relief throughout training.

REFINANCING

Refinancing is an option for many graduates today. Simply explained, refinancing means a private lender or bank pays your federal student loan debt, and you’re committed to paying a set amount monthly for a set term, at hopefully a lower rate than your federal loans. When federal benefits such as reduced payments, interest subsidies and loan forgiveness become no longer available, that’s the point when many physicians today can and should lower the cost of their debt by refinancing if possible.

The issue comes with how to leverage the market to find the best rate. Most lenders advertise the same broad range of rates, but the only way to get firm offers is to go through the application and underwriting process, which can be cumbersome and often involves a hard credit pull.

Refinancing products, rates and participating banks have evolved rapidly over the past few years, so it’s important that you have a good understanding of the current marketplace, or have a reliable advocate who can assist with the process and help determine when refinancing is suitable.

Mike Greenberg, M.D., sought out help to understand the nuances of Public Service Loan Forgiveness. – Photo by IHNY

INCOME-DRIVEN LOAN REPAYMENT

Now let’s spend some time on the newest and most complex of the federal repayment options today: income-driven loan repayment (IDR).

Of the five income-driven repayment plans available today, there are really three that are most suitable for today’s house-staff and early-career physicians with federal student loan debt: Income-Based Repayment (IBR), Pay As You Earn (PAYE), and the newest available program, Revised Pay As You Earn (REPAYE). Where the term IDR is used below, it is a reference to all of these programs.

INCOME-BASED REPAYMENT

IBR was launched in 2009 and is a federal repayment program that limits monthly loan payments to 15% of your discretionary income.

To be eligible, a partial financial hardship must exist, which means that this 15% of your discretionary income, calculated on a monthly basis, is less than what you’d be required to pay on a 10-year standard repayment plan. This hardship exists for most trainees with federal student loan debt, as 15% of the discretionary income for a single resident with a $50,000 salary would result in roughly a $400/month payment. The 10-year standard monthly payment on $220,000 of debt, by comparison, would cost about $2,500/month. Clearly, a hardship exists.

IBR is also a qualifying repayment plan for the Public Service Loan Forgiveness (PSLF) program. Taxable loan forgiveness is granted through IBR after 25 years of repayment. However, payments in IBR are capped at the 10-year standard payment amount established when the borrower entered IBR. Because of this cap, many attending physicians would pay off their loans through IBR before the 25-year forgiveness period expires.

IBR is least used by today’s graduates with the introduction of these next two options.

PAY AS YOU EARN

PAYE was launched in 2012. PAYE limits payments to 10% of a borrower’s discretionary income (instead of 15%), and taxable loan forgiveness would be granted after 20 years of repayment.

The payment cap is also the borrower’s 10-year standard repayment amount, and PAYE is a qualifying repayment plan for PSLF as well.

Only borrowers who have no outstanding balance on a federal student loan issued prior to October 1, 2007, and who took out a federal student loan on or after October 1, 2011, are eligible.

REVISED PAY AS YOU EARN

REPAYE become available in December of 2015, and it may make sense for continuing housestaff to consider entering it. It offers:

  • 50% of accruing interest paid by government (unsubsidized loans become partially subsidized!)
  • 10% of discretionary income required (just like PAYE), and also PSLF eligible. If you switch into REPAYE from IBR, the 10-year forgiveness clock won’t reset (unless you consolidate)
  • Household income will be used regardless of how you file taxes
  • 25-year taxable forgiveness for graduate students
  • No cap to payments (10-year standard in IBR & PAYE)

Once you enter one of these IDRs, you cannot be removed from it (although you can switch between them as appropriate), even if the hardship that qualified you does not exist after training. (Hopefully the hardship does not continue, and you have an increase in income!) Therefore, a critical part of your repayment strategy is to perform an analysis and determine the best course of action based on your salary and sector of employment after training.

Paying more

I’m often asked, “If I can afford to make larger payments than required in an IDR while I’m in residency or after, should I?”

This is an important question, and my answer is somewhat counterintuitive. I generally believe you should NOT pay more than required through an IDR during training, because those overpayments likely compromise both your subsidy savings and potential loan forgiveness. In addition, unlike in forbearance, interest is not capitalized while you’re in training and have the hardship that qualifies you for these programs.

Instead of overpaying on your loans, I would suggest placing that extra in a money market or savings account. Even if you get 1% return on these funds, it’s actually outperforming the accruing interest on your loans because the interest isn’t capitalizing during your training.

If your employment after training no longer positions you for significant loan forgiveness, you’ll be able to apply this savings toward the repayment of accrued interest before it capitalizes.

If you remain employed by a non-profit or government entity after training, this savings can be retained and allocated to other vehicles.

PUBLIC SERVICE LOAN FORGIVENESS

Often the most generous federal program young physicians can leverage today is the Public Service Loan Forgiveness Program (PSLF).

Approved by Congress in 2007, this program provides tax-free loan forgiveness for anyone employed by a federal, state or local government organization, or directly by a 501(c)(3) nonprofit.

For a majority of medical graduates, full-time qualified employment combined with 120 monthly payments (10 years) under an income-driven repayment plan (IDR) can result in a much lower out-of-pocket cost than the amount borrowed.

Many medical graduates begin pursuing this program at the onset of training, as their residency years usually count as public service, and the IDR plans make economic sense during that time. As a result, there are an increasing number of physicians who are seeking PSLF-qualified job opportunities post-training today. Due to an evolving legislative climate, recent and proposed changes may impact the appropriate action plan to maximize PSLF, and understanding this marketplace can only help you.

Understanding your salary equivalent

An overlooked yet critical consideration for medical trainees today is what I call the “PSLF salary boost.” Though it’s understood that academic positions typically offer lower salaries than private practice roles, “the gap between academic and private salaries is closing,” says anesthesiologist Mike Greenberg, M.D., who graduated from St. George’s University in 2014 and transitioned to an academic position at Johns Hopkins after four years of PSLF-qualified training.

“For me, pursuing PSLF was a no-brainer,” Greenberg says. But several years ago, misinformation and a lack of education at medical school graduation left many graduates unaware or misinformed about how to maximize this opportunity. Greenberg took it upon himself to learn about the PSLF program and eventually found Doctors Without Quarters (DWOQ) to guide him while he focused on his training.

As Greenberg can attest, student loan savings should be factored into the economic analysis of any PSLF-qualified job. This can often make nonprofit roles more economically attractive than for-profit opportunities.

In the chart above, the salary “boost” is represented for a graduate who had $250,000 in debt at graduation, did four years of training with a PSLF-qualified employer, and then was offered two jobs: one with a nonprofit at $175,000 in starting salary, and one with a for-profit at $200,000.

For the six years following training, the nonprofit salary was worth an additional $73,000 per year when PSLF savings was contemplated as a pre-tax salary boost.

The risks of repayment plans

Recent headlines about 99% of Public Service Loan Forgiveness applications being denied have created unnecessary alarm for many graduates pursuing PSLF. These headlines certainly do not inspire confidence for those purposely paying the least amount possible with hopes of having their debt forgiven tax-free, but these headlines were no surprise to this author.

The PSLF program was introduced 11 years ago with little media attention and even less guidance from the U.S. Department of Education and their loan servicers. Borrowers likely pursued PSLF without reading the details of how the benefit worked. Here’s a quick list of the reasons PSLF applications are denied:

  • Ineligible loans: Only federal direct loans are eligible for PSLF. Federal Family Education Loans (FFEL), Perkins, private and other types of loans are not eligible.
  • Insufficient payments: People applied for forgiveness prior to making the necessary number of payments, thus increasing the number of denials.
  • Wrong repayment plan: We have seen many new clients using extended and graduated repayment plans that are not PSLF eligible.
  • Paperwork errors: Of the denied applications, 28% were due to missing or incomplete information.

By using the Employment Certification Form for PSLF, available from the Department of Education, graduates with direct loans using an IDR while working full-time for a qualified employer receive confirmation of qualified payments along the way.

Regarding future changes to PSLF, borrowers at nonprofit programs should be reassured by a few things. For one, the Master Promissory Notes you signed to borrow each loan for medical school included language about PSLF and your right to utilize the program. Thus, a legal contract between you and the federal government says you borrowed under the assumption that you’d be able to utilize the PSLF program under the terms of the program at the time you took out the loan.

Secondly, if you’re actively working towards repaying your loans through the PSLF program and have made economic decisions based on the program’s details, you’ve demonstrated a reliance on the terms as they exist today. As such, the federal government may be obligated to grandfather you and others in the same situation through any changes to the laws.

Even if you do everything right in the pursuit of PSLF, there’s still risk associated with waiting 10 cumulative years before applying for this tax-free forgiveness.

For example, a client of ours who was six years into practice with a 501(c)(3) hospital was recently notified that his employer was being bought by a for-profit organization. Through no action of his own, once his paycheck is being issued by the hospital’s new owner, he’s no longer PSLF-eligible and would need to change jobs to remain on track for forgiveness.

Physicians should always be saving money to grow alongside accruing interest while they are making reduced loan payments through an IDR in the case of unforeseen circumstances that disqualify them from loan forgiveness.

Navigating the complexities

If you’re not staying abreast of your options as you progress in your career, be sure to identify and work with an advocate incented to help you maximize your savings vs. those who may have a conflict of interest, such as a lender or servicer. Also, take note that traditional financial advisors, including those with CFP designations, are usually not trained on the concepts covered in this article.

The student loan repayment marketplace has become much more complex over the past decade. And though debt levels are high, unique and often substantial opportunities for savings exist for those who navigate the marketplace strategically.

Jason DiLorenzo is the founder of Doctors Without Quarters LLC, a national student debt advisory firm dedicated to the financial wellness of early-career graduate health professionals.

 

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