Regulations, reimbursement, prior auths, advocacy: ACP and the state of U.S. health care

Many physicians in private practice have a short list of top priorities: patient health.

But doctors aren’t the only ones drafting the health care to-do list, a list that can be lengthy and aggravating when it gets in the way of healing.

Jason M. Goldman, MD, MACP, is president of the American College of Physicians (ACP). His day job is treating patients in private practice in Coral Springs, Florida, and he knows well the challenges that independent practices must deal with.

Recently Goldman spoke with Medical Economics about a range of issues, including the current waves of vaccine skepticism and medical misinformation and disinformation sweeping the nation. Those are important, but not the only issues affecting American health care system. For example, the health leaders in the administration of President Donald J. Trump, including Health and Human Services Secretary Robert F. Kennedy, Jr., and Medicare Administrator Mehmet Oz, MD, MBA, specifically targeted insurance companies in hopes of streamlining the prior authorization processes that delay care for patients.

This transcript has been edited lightly for length and content.

Medical Economics: In U.S. healthcare, because you're a physician who has worked in private practice, what do you feel are the greatest challenges for private practice physicians right now?

Jason M. Goldman, MD, MACP: I've been a solo, independent, private medical practice physician, owned my own practice over 25 years. I've worked in a hospital, initially in my career, and then opened up my own practice for close to 25 years. One of the biggest challenges is honestly the government regulations and in how health care is seen. The reimbursement rates have not been increased in over 30 years. We're still getting paid, when you account for inflation, essentially 1990s rates. And it's not even about making money. It's about keeping the doors open, paying my staff, being able to see my patients. The health system has created such a cumbersome, burdensome administratively latent amount of paperwork and hurdles to overcome that you need to hire staff just to understand the administrative regulations without even understanding how to take care of patients. So there's all of this waste that we have to deal with in dealing with different insurance companies, with government regulations, and fee schedules before we even take care of the patient. Some estimates are 50, 60% are all administrative burden. Less than 4% of the health care dollar goes to primary care physicians, yet we're constantly being cut every single year automatically. The government has created budget neutrality, where, if they increase payment to one specialty, they decrease it to others, which is inherently unjust and unfair. Yet we're the ones who are having all of the burden without any of the recourse. And if this continues, we're not going to have physicians left to take care of patients. The National Academy of Science, Engineering and Medicine report showed that investment in primary care reduces hospitalization, promotes life, and is an investment in public good. So as an internal medicine specialist, we are actually making a healthier population, but all of these regulations and payment issues are preventing us from doing what we're meant to do, which is simply take care of the patients and make them healthier.

Medical Economics: When we're talking about those different challenges, how do you envision the American College of Physicians helping to address those?

Jason M. Goldman, MD, MACP: We have always been advocates in the American College of Physicians. We have tremendous policy papers. I co-authored “Better Is Possible” with some of my colleagues, outlining how we envision a better health care system to be able to make sure that we have health care that both the patient and the country can afford. We know that if there is a healthier population, we all win. It reduces cost, it reduces hospitalization, it reduces expenditure. There are so many ways we can fix the system. What does the American College of Physicians do, aside from just writing the policy papers? We advocate, we go to Washington, we go to our members of Congress. And I encourage everyone to vote, to talk to their members of Congress, to talk to their senators, their representatives. We live in a country where we have the right to petition the government for redress of grievances, and we should. We should use our voice. So the college uses its voice to advocate for the patients and the practice of medicine. We make sure that when we see something that is not right, we speak out whether social media press releases interviews such as this. We make sure their membership knows what we are doing, and we have even done judicial advocacy for where normally we don't comment on individuals, but the actions of the secretary of Health and Human Services were so capricious and arbitrary and endangering the public health that we joined with several other groups in a lawsuit against the secretary of Health and Human Services for his actions. So that is a new avenue of advocacy tools that we're using in the college but we have always been advocates to speak up for our patients, to ensure a more equitable health care system for all.

Medical Economics: Our audience constantly deals with prior authorization, and the administration has announced an initiative with insurance companies to streamline the prior authorization process. Have you seen any noticeable changes so far? And what would you like to see done to improve that?

Jason M. Goldman, MD, MACP: I'm certainly hopeful that the administration will tackle these issues. Prior authorizations are one of the many problems we face, especially in primary care. As physicians, we know what's best for our patients. We take care of them. If we believe a medication works, we should be able to prescribe it, the patient should be able to take it, and we shouldn't have to go through a series of medications that we know won't work just to go through the hoops that the insurance companies create, in order to get to the place where we know what works. We should be reimbursed fairly and equitably for the work that we do, and we should have less of the insurance companies being able to have their retroactive denials. I don't know any other field, any other service, where you perform a service, you get paid for it, and then a year later they can just take the money back and say, we changed our mind, even though they paid you originally. Like, I don't know any other field where you can perform a service at an agreed-upon rate, and they turn around and say, we're just not going to pay you that, and we're going to lower it, or come up with rules and change their policies without warning or notice to say we're just not paying you for the work that you've done. I haven't seen any improvement. I've seen it getting much worse. I see the insurance companies, at least here in in Florida, continue to cut reimbursements, to not negotiate with physicians at all, to take money back arbitrarily and change the rules without notice in how we get reimbursed. So I am hopeful that the administration will fix some of these egregious problems that have been created through the insurance issues. I have not seen it yet, but hope springs eternal.