[I]ndependent doctors and leaders of community health centers are wary of Gov. Peter Shumlin’s health care agenda this year.
Nearly a dozen primary health care providers unaffiliated with hospitals testified on Shumlin’s major initiatives in front of the House Health Care Committee and the Senate Finance Committee on Wednesday.
The two major policy proposals are a 2.35-percent tax on independent doctors and dentists, and an initiative known as the all-payer model that would encourage doctors to coordinate care under an accountable care organization.
The proposed provider tax exposes a divide between hospitals and independent doctors: Hospitals have the market power to control how much money they make, while independent doctors run small businesses and say they can only control which types of insurance they take, not how much the insurers pay.
The all-payer proposal brings up another power differential: Two academic medical centers own the organization that is widely expected to absorb nearly every health care payment in the state under all-payer, and essentially form a regulated monopoly. Independent doctors may eventually join that regulated monopoly model, but they say they’re already buried in paperwork from similar health reform initiatives.
Provider tax
With the 2.35-percent provider tax, the Shumlin administration expects to generate more than $10 million from doctors and more than $6 million from dentists for a total of $17 million in state money.
The federal government would match that revenue with $20 million in Medicaid money, and the state would use the total pot of money to both fill in the Medicaid deficit and increase how much Medicaid pays doctors and hospitals.
But HealthFirst, a nonprofit organization of independent doctors, says the “financial burden” of the 2.35 percent tax “is greater than the potential income from improved Medicaid reimbursement for nearly all independent physicians who currently care for Medicaid patients.”
According to documents the Shumlin administration provided to the Joint Fiscal Office, Medicaid pays doctors and other providers 75 percent of the cost of a service; Medicare pays providers about 87 percent of the cost; and commercial insurance often pays 143 percent of the cost.
The proposal in Shumlin’s fiscal year 2017 budget would spend $4.8 million from the state’s general fund to increase Medicaid rates. The federal government would roughly double that amount, but the Medicaid rates would still be less than Medicare rates.
Additionally, each government program and commercial insurer pays independent doctors at a substantially lower rate than academic hospitals, and the highest paid doctors work for academic medical centers. Community health centers, whose official name is “federally qualified health center,” are paid a fixed rate for Medicaid patients, and often get grants and donations.
Dr. Daniel McCauliffe, a dermatologist in Rutland, told the Senate Finance Committee that he gets most of his business treating senior citizens with skin cancer. He said the increased Medicaid rates would not help him considerably because the majority of his patients use Medicare.
McCauliffe said the federal government sets Medicare rates, and those numbers keep going down. He said he cannot pass on any cost, including the provider tax, to customers using a so-called “cost shift” because he has too little bargaining power with insurance companies to raise what he charges.
“Do you realize that I have no negotiating clout?” he asked. “I circle a code and Blue Cross Blue Shield pays me. Do you think I can go to Blue Cross Blue Shield and say, ‘We’re going to negotiate because you don’t pay me enough’?”
Dr. Paul Reiss, the chief medical officer for HealthFirst who practices at Evergreen Family Health in Williston, said the provider tax would be unbearable because there is no parity for how much independent doctors are paid.
“If we had reasonable pay, equal pay, for the same services provided, we’d be in a different place right now,” Reiss said. “We have no negotiating power with the commercial payers. We can’t pass our cost onto anything. If you tax us, this money comes out of the physicians’ pocket.”
At Reiss’ practice in Williston, he said the 2.35-percent tax would cost about $75,000. “That’s about an $18,000 tax on our independent providers, their personal income,” he said. “There’s no way you can move that to anyone else.”
McCauliffe, of Rutland, said independent doctors face growing demands every year, and the 2.35 percent tax would come just shy of putting people out of business. “If anyone around this table wants to kill independent practice, just raise the tax to 6 percent,” he said. “Just put us out of our misery.”
All-payer reform
The state’s proposed all-payer model would encourage almost every health care organization in the state to work under a giant accountable care organization, which may be the one currently known as OneCare, owned by the University of Vermont and Dartmouth-Hitchcock medical centers.
The other popular option is for the state’s two smaller organizations, which represent community health centers and independent doctors, to merge with OneCare to create something new. (On Thursday, the chief executive of OneCare said his organization may join with other stakeholders to create a new organization called Vermont Care Organization.)
The accountable care organization, however it unfolds, would help doctors and other providers coordinate care, reduce unnecessary procedures for patients, and use data to improve patient outcomes. Right now, independent doctors who participate in smaller versions of ACOs must use electronic health record systems to report dozens of data points on quality to the ACOs. Independent doctors are wary of the possibility of answering to a hospital-owned ACO and seeing an increase in paperwork.
Dr. Fay Homan is a family doctor at Little Rivers Health Care in Wells River, a federally qualified health center. Homan said she and her peers deal with so much documentation doctors have little time to see their patients and less room to take on financial risk.
“The last 10 years have been soul-sucking for this profession,” Homan said. “The amount of time we spend clicking boxes and documenting as compared to looking at patients and spending time with them is completely skewed.”
Homan said she has two full-time people who follow her around all day to help with documentation, and she said one of her major duties is to click boxes to document whether she performed quality measures for an accountable care organization.
One box asks whether she did a foot check for a diabetic patient, but “it doesn’t say right foot or left foot, or if you even have a right or a left foot. That’s not quality. That’s not improving communication.”
Dr. Tim Tanner, a family doctor at Northern Counties Health Care in Danville, said there are ways to make all-payer better for family doctors. He said that might mean making sure doctors are filling out documentation that will increase health care quality.
“I get really irritated when there are inefficiencies, and there are a lot of inefficiencies related to documentation, and there’s a lot of different documentation that has very little to do with the patient who’s in front of me,” Tanner said.
Tanner used the example of a patient in chronic pain who uses a TENS unit, or electronic nerve stimulation machine, who currently needs to come in every week so he can sign off on the fact that the patient is getting better.
He said if the all-payer system means he can get a lump sum, or “global budget,” to treat that patient, it might save him from filing paperwork every week with that insurance company and give him more time to spend with patients.
“There’s a lot of documentation that goes into being able to bill at a certain level that has nothing to do with the patient, so if there were a global budget and that could go away, that would be great,” Tanner said.
