Eyeworld

EW NEWS & OPINION 38 September 2015 Insights by J.C. Noreika, MD, MBA "Well, I don't like it. Practic- ing ophthalmology used to be so enjoyable, gratifying. I loved my clinic days. But now it's more about keyboards and codes, patient portals and copays. I just want to practice medicine." "And you still can. Somehow doc- tors survived Henry J. Kaiser, the cre- ation of the Blues, LBJ's Medicare and Medicaid, Hsiao's RBRVS, HMOs and capitation. Smart and innovative, they seem to find a way. We'll be fine. But it'll be different. Opportunity revels in change. Because of technology, research and clinical advances, this is medicine's golden age. Your memory is selective. The good old days weren't always that great. They only necessitated different choices." EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com according to Census Bureau stats. In comparison, we're doing OK." "But our organizations should've negotiated harder. What about balance billing? And malprac- tice? Don't individuals share respon- sibility for their vices and habits? The Affordable Care Act has raised deductibles and copays. Collecting those is like trying to get blood out of a stone." "Be careful what you wish for. Physicians who opted out of Medicare found a finite pool of patients waiting to pay directly for services. The price competition of the LASIK market proves Adam Smith's invisible hand holds true for surgeons, too. And medical orga- nizations that signed off on MACRA? What were the alternatives? Union- ization? Please. How has it worked in other countries? How's that local teachers' strike sitting with your neigh- bors? The few legislators who feel the physicians' pain concede they got the best they could. The country is going broke on the rack of entitlements, kind sir. Surveys show patients who worship you personally think doctors make too much money." meet MU requirements and dollars are clawed back. I am financially penalized because my patients don't use a convenience I provide, support and pay for?" "Not my problem. It's a cost of doing business. Why do you think docs just out of residency are opting for jobs in large institutions that take care of all that stuff? Many are happy to sacrifice the myth of physician autonomy for a more balanced lifestyle. You know, family, career, avocations. Have you looked at the statistics regarding medi- cal school attendees? Have you seen the pictures in bulletins from your residency program? Diverse, eager, intelligent fac- es … and lots of women. Is it surprising that some may have different agendas when it comes to career expectations? "I'm working harder now than I did when I was 40. Income-wise I'm barely keeping up, and there is no end to the increasing costs to run the practice. And this fix of the SGR—what's it called? MACRA? Bu- reaucrats say it shifts fee-for-service from volume to value. Physicians will be rewarded and penalized for hitting or missing yet-to-be deter- mined standards. Do you mean to say that I haven't provided value and quality of care for the thousands of patients whose vision I've saved over the years? Is it fair that my cataract surgery is now compensated less than a plumber's house call?" "You might want to be careful about 'fair.' Was it 'fair' when you were doing 4 or 5 phacos an hour at $1,850 a pop in 1986? (That's $4,028 and change in 2015 dollars.) Or a YAG laser capsulotomy for $585? My peers weren't part of that "golden age" but we sure know it ain't coming back. And MACRA? At least my employer has a good idea what its reimbursement will be from year to year. They will have economic incentives to follow guidelines and best practices. Is there a problem with that? I've heard how Darwinian private practice can be. Well, I'm all in about demonstrating competence instead of paying for media ads to self-attest to my skill. Income? Most private practices are small businesses. Small business is difficult. Look at the storefront vacancies on Main Street. According to the Bureau of Labor Sta- tistics, less than half make it through their fourth year. In Pennsylvania, the median family income for a husband and wife in May 2015 was $57,870 Physician morale is beleaguered by falling income and increasing oversight, mandate, and regulation. Is this an issue of demography or something more serious? T hese are times that test one's soul. Miracles per- formed in the clinic and operating room are over- shadowed by the specters of autonomy's loss, compensation's reduction and regulation's burden. Frustration fulminates daily. Psychologists teach that what we believe is construed from our thoughts, feelings, and actions regarding events. External matters are interpreted from our personal vantage points. Might opinion on controversial subjects conflict be- cause of demography? What might an interior dialogue reveal if con- ducted between my present self in career's twilight and my 35-year-old gray-matter doppelganger? "Meaningful use, electronic health records, ICD-10! Can't they just let us practice medicine? What good is this stuff anyway? They're a waste of time and money. They hamper my ability to treat patients." "Well, pops, you're showing your age. I can't imagine medical school and residency training before touch pads and electronic records. Using a comput- er to retrieve information is something Millennials have been doing since we were toddlers. It's no big deal. In fact, I've seen some of your paper charts. You need a Rosetta stone to translate those hieroglyphics. Talk about hampering patient care. How can you treat patients if you can't decipher the note?" "But the cost! If you don't adopt electronic records, reimbursement gets dinged by the Feds, and if you do adopt them, the practice has to jump through ludicrous hoops. Let me get this straight. If patients don't use my portal, the practice won't A discussion from within J.C. Noreika, MD, MBA

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