Technological Burdens, Regulations Spur the End for Venerable Austin Internal Medicine Associates
Practice Management Feature — September 2015
Tex Med. 2015;111(9):33-38.
By Joey Berlin
Four decades ago, when the practice that later adopted the name Austin Internal Medicine Associates (AIMA) first opened its doors, medicine was a different profession.
Cut to 2015, and in the eyes of many physicians, being a doctor is less about patient care and more about navigating an avalanche of health records, government technological requirements, and administrative red tape.
Physicians who view those realities as a temptation to hang up the white coat for good might admire the four doctors who make up AIMA — because that's what they're doing.
AIMA will close its doors on Sept. 4, ending 40 years of service and more than 20 years together for its internists — Ace Alsup, MD; Isabel Hoverman, MD; R. Scott Ream, MD; and Frank Robinson, MD.
Appropriately enough, AIMA set its closing date to avoid anticipated technical difficulties — specifically, the Centers for Medicare and Medicaid Services' (CMS') requirement that all practices switch to the controversial ICD-10 medical billing and coding system on Oct. 1.
"Obviously, it's gotten a lot harder to run a small personal practice, and that's because of all the regulatory and EHR [requirements] and things like ICD-10 and new HIPAA regulations," Dr. Ream said. "I mean, you could just go on and on about what we have to really worry about all the time."
The EHR Money Pit
There's more to AIMA's closure. All four physicians are retiring, and about a year after closing the practice's doors, three of them will be 70 years old, Dr. Ream says.
Dr. Alsup began the practice in 1975. Dr. Ream joined him in 1978, Dr. Robinson came on board during the 1980s, and Dr. Hoverman joined in 1992. AIMA began operating out of its current building in 1984.
Kunjan Bhatt, MD, a cardiologist at Austin Heart, P.A., who sends referrals to AIMA, says Drs. Alsup, Hoverman, Ream, and Robinson remain conscientious of cost savings and always do right by the patient while maintaining the highest quality standard.
"The fact that we have taken care of generations of people and families — grandmother, mother, daughter, grandson, aunt, uncle — and that people send their friends makes us all feel that we have done a good job and that we have responded well to our patients' needs," Dr. Hoverman said.
However, in recent years, circumstances of the modern medical landscape made AIMA's closure inevitable. The practice holds a meeting early each year to evaluate its current situation, and Dr. Hoverman says the physicians began thinking about closing AIMA last year.
"But at our meeting [this year], it really became obvious that the administrative burden had really escalated even further, to the point that it had gotten just overwhelming," she said.
One big factor was the increasing prevalence of the widely maligned electronic health records (EHRs). AIMA has never maintained an EHR system, a decision the practice made based on its available resources.
In considering whether to install an EHR system a couple of years ago, Dr. Ream says, AIMA determined doing so would cost hundreds of thousands of dollars in equipment and personnel, as well as the "cost of just having to cut back when you first initiate things to the point where we'd probably be lucky to break even for several months."
He explains that many EHR systems "want you to cut back to about two-thirds of your normal practice. And at our stage of practice, it didn't make any sense to do all that."
This year, for the first time, foregoing an EHR also hurts a practice's Medicare bottom line. Beginning on Jan. 1, 2015, CMS deducted 1 percent off physician payments for Medicare-eligible professionals who aren't meaningful users of certified EHR technology. CMS will deduct 2 percent in 2016 and 3 percent in 2017 for those who don't comply with meaningful use.
Meanwhile, dealing with EHR data from other practices has been a trial for AIMA. Dr. Hoverman says EHRs are just now beginning to become useful, adding that many of the practices that have maintained EHRs for a long time have refined their systems to include more helpful, less redundant information. But many of the records AIMA gets from practices that are relative EHR newcomers are "just full of junk," she says.
"I recently had a number of notes from a practice where a patient had a simple, straightforward problem, and the note had every negative for every system in the body, including things the patients didn't have — like vaginal discharge in a man," she said. "Check boxes can be time-consuming and make it difficult to focus on the problem at hand, so that note reflects only that day's complaint, instead of data that are not relevant to the visit. There is a huge learning curve for physicians as well as the IT [information technology] team that is designing and implementing the EHRs."
Dr. Ream says the advent of EHRs presented a great opportunity for physicians, but their implementation was problematic. He says AIMA's old-fashioned approach is usually superior to EHR documentation.
"Our records are clearly better than the majority of electronic health records, but that doesn't matter," he said. "[In] ours, it's easier to find why they were here the last time, when they had different [medical issues]. You can find it nearly instantaneously if you know how our charts are organized."
Office Management Challenges
The mounting administrative requirements of running a practice have placed an increasing burden on AIMA office manager Jan Ream.
"She's the IT person; she's the one who has to deal with all the vendors. She's the one who has to call the plumber and the air conditioning guy," Dr. Hoverman said. "And without some giant administrative sugar daddy in the sky to take care of those things for us, it's very difficult to survive in this current environment."
Earlier this year, AIMA, a nonparticipating group in Medicare, turned to the Texas Medical Association for help after Ms. Ream noticed a discrepancy between AIMA's fee schedule-based charges and the explanations of benefits she was receiving. TMA discovered that technical errors in a draft of Medicare's 2015 Physician Fee Schedule had made their way into payment notices, making it look as if health professionals were overbilling patients. (See "TMA Uncovers Medicare Mistakes," July 2015 Texas Medicine, pages 24-31.)
More recently, Ms. Ream dealt with a situation in which Medicare sent AIMA a mysterious electronic payment for about $8,600. She queried Medicare, which determined CMS meant to send the payment to another provider. CMS sent a demand letter for return of the payment.
Insurers keep the office on its collective toes, too. On one day in mid-July, Ms. Ream says, AIMA received letters from two insurance companies. One provided notice that it would require more primary care doctor preauthorization for certain tests. The other insurer gave notification that its fee schedules would change in October, and the fee schedules would be online on Oct. 1.
"Well, Oct. 1 is when it's changing, and that's when I'm going to be able to find it online? Okay, that's very helpful," Ms. Ream said. "And I'm thinking in my mind, I'm so glad I can throw those things away because I've already sent our resignation letter to them."
ICD-10 Brings the End
Earlier this summer, CMS alleviated fears many doctors had about the ICD-10 transition when it announced a plan to give physicians help and flexibility in implementing the system by the Oct. 1 deadline.
But physicians still expect ICD-10 to bring headaches, and before the CMS announcement, AIMA's doctors decided they didn't want any part of those headaches, announcing the practice's closing in an April letter to patients.
With 26 days of breathing room between its closing date and the date CMS requires the switch to ICD-10, AIMA will keep the coding in its records clear of any transitional hiccups.
"Of all the hassle factors, it's down the list a ways, but it's definitely why we chose that day," Dr. Ream said.
Dr. Hoverman says ICD-10 would require internists to learn about 100 codes they use on a regular basis, "and that's not overly burdensome. But then the other side of it, which is the administrative side of it, [there's] the issue of how to make your system ready for coding and get all those codes in there. There are additional concerns about whether vendors will be able to handle the new codes and if all insurers will be using the codes immediately."
In July, CMS and the American Medical Association announced the organizations would work together to make sure practitioners are ahead of the transition, offering educational webinars, articles, and conference calls, as well as on-site training. CMS also announced several grace-period measures designed to make transition-related errors less punitive, including a one-year span during which CMS would not deny Medicare claims solely on the specificity of ICD-10 codes if the physician submitted a code from the appropriate family of codes. (See "ICD-10 Grace Period Doesn't Let Doctors Off the Hook.")
TMA policy supports permanently delaying the implementation of ICD-10. The association also has tools and resources to help physicians prepare for the coding transition. (See "ICD-10 Help From TMA.") The CMS/AMA announcement came after TMA joined medical organizations in three other states in asking for ICD-10 relief, including a request for a two-year grace period. TMA President Tom Garcia, MD, said in a statement the CMS announcement slightly eased a "giant burden."
"Having a year to convert our medical practices — and the entire American health care infrastructure — to this gargantuan new coding system without as many penalties for errors will allow us to spend more time practicing medicine and focusing on patients," Dr. Garcia said.
Epitome of a Healer
Dr. Bhatt feels the impact of AIMA's 40 years of service when he sees the patients he shares with the practice. He says those patients have been saddened since the announcement of the closing.
"When I see our mutual patients in follow-up, I have come to appreciate how close and sacred these relationships are between the physicians of AIMA and their patients," he said. "They are role models for the younger generation of physicians. They are the epitome of the 'physician healer.'"
A younger physician who's never known a world without EHRs, Dr. Bhatt says implementing one is a Herculean task for a practice of any size, but doing so poses additional challenges to practices that have used paper charts for a long time. He says the challenges can become insurmountable when you consider the penalty Medicare now imposes for practices that don't use EHRs.
Dr. Hoverman, however, holds a somewhat optimistic view of the relationship between medicine and technology and says of the changes in the profession over time, "I think eventually, we'll figure it out.
"Every generation worries about the changes, that you're going to lose something, and I think every generation has always worried that we will lose the personalization of the doctor-patient relationship," she said. "We as physicians have to make sure we don't let technology and regulations get in the way of how we interact with, relate to, and care for our patients."
Getting to know his patients is one of the aspects of the job Dr. Ream will miss most.
"They're much more like family and friends, and that's going to be difficult," he said. "On the other hand, everywhere I look tells me it's time to retire."
Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.
ICD-10 Help From TMA
The Oct. 1 ICD-10 implementation deadline is right around the corner. The sooner you learn to code claims and document services to the full level of specificity, the sooner you can get paid most accurately. Call (800) 523-8776 to learn more.
Here's how TMA is helping:
ICD-10 Grace Period Doesn't Let Doctors Off the Hook
On July 6, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association responded to concerns over the transition to the ICD-10 medical billing and coding system by announcing a "grace period" to help physicians implement ICD-10. CMS requires physicians to use the new coding system beginning Oct. 1.
Elements of the grace period include: