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Four years ago, a series of articles in The Rheumatologist talked about the practice of rheumatology in rural settings. Since then, changes have occurred, with the passage of the Affordable Care Act (ACA), differences in reimbursement and the trek toward value-based payment systems.
One major concern expressed in the original article was the fact that many of those practicing outside the urban areas were reaching retirement age. Of the six people interviewed, only three are still practicing.
Difficult to Find Associates
Another worry, especially for those in solo or small group practices, was an inability to recruit physicians to help relieve some of the burden or, perhaps more importantly to many of these doctors, to take over care of their patients when they retired.
“The trials and tribulations are about the same as four years ago, only magnified,” says Karen S. Kolba, MD, a rheumatologist in solo practice in Santa Maria, Calif. “I am still unable to find an associate to bring in.”
She notes that doctors now graduate with huge debts, limiting their ability to undertake the business risks inherent in rural, solo practice. She isn’t in a position to guarantee them a salary, and they aren’t in a position to risk defaulting on their loans.
“Many newer graduates are not willing to take on a small practice workload,” she continues. “Many want 40-hour weeks, and honestly so do I, but that isn’t the way you run this kind of business.”
Selling the Practice?
Another way other specialties have coped with changes is by selling the practice to an area hospital. This makes the physician an employee of the facility, easing many administrative and financial burdens. Especially in rural areas, the local healthcare system may be the only buyer.
So far, most practice purchases have been to control primary care networks or those specialties that are frequent admitters. Rheumatology does not send many of their patients to the inpatient side and may not be an enticing takeover target.
Robert Jackson, DO, is president of Premier Specialty Network (PSN) and a rheumatologist at rural hospitals in multiple states. PSN partners with local hospitals to establish satellite clinics. The physicians work for PSN and have control over their time while being sheltered from some of the financial aspects.
Too Few Practicing in Rural Areas
“The ACR notes that currently less than 10% of rheumatologists practice in rural locations,” says Dr. Jackson.1 “The College is concerned, because if you don’t live in an urban area it can be a 200 or more mile journey to get needed care.”
PSN partners with rural hospitals to provide an infrastructure to support the rheumatologist. He notes, and Dr. Kolba agrees, that many of the changes brought about by healthcare reform are burdening physicians, cutting into their productivity and ability to care for patients. When it is possible to relieve some of these burdens, it becomes easier to get people to rural areas.
Medicare Changes Death Knell for Small Practices?
Dr. Kolba thinks that changes in Medicare reimbursement coming in 2017 may end up being the death knell for the small group practitioner. Practice modifiers for quality will determine whether a practice gets a bonus or has to pay a penalty. The problem is that there seems to be no consensus on what the indicators are and how they will be implemented.
“I can tell you for sure that if these changes go into effect, I will retire,” she says. “It is set up as a zero-sum game, so for everyone [who] gets a bonus, there has to be someone who is penalized. I see that as a completely untenable way to practice, because you have no way of knowing how the Centers for Medicare and Medicaid Services is going to make [its] judgments, so you risk a haircut that you can’t plan for.”
Dr. Kolba is not sure about the viability of solo or small group models going forward.
“I think many of the changes are going to finish off a lot of us solo or small practices,” she says. “This is more of a feeling than anything, but it seems most of the new grads are expecting to be employees and don’t want to run their own practices. It is an interesting change in the mentality and outlook of many doctors to not even consider doing things on your own.”
Things are not all bad.
The ACA added insured people to the rolls, meaning those that may not have been able to see a rheumatologist before now have the resources. For many physicians, at least as important a consideration is that more of their patients can afford medications and be treated to standards of care.
In those states with expanded Medicaid—an important component of the payment structure in rural healthcare—additional reimbursement opportunities are available.
“In my state, MediCal payments were equalized with Medicare for specialties like rheumatology, with a high level of Evaluation and Management codes,” says Dr. Kolba. “So instead of being paid $10, the state pays me $75.”
Impact of Hospital Closures
Another consequence of reform has resulted in an increase in the closures of rural hospitals. Because rheumatologists aren’t heavy users of inpatient services, they may actually be better able to stay involved with their communities.
“Critical access hospitals and Qualified Federal Healthcare Centers are found in many rural settings,” says Dr. Jackson. “They are allowed to reimburse physicians at a fee-for-service rate. So working with these facilities means patients who are money losers in urban settings can actually make money when seen in rural and dependent areas.”
Kurt Ullman is a freelance writer based in Indiana.
Editor’s Note
ACR staff is available to assist members as they navigate the changes in Medicare reimbursement and quality reporting. For more information, contact [email protected] or visit Practice Quality.
References
- American College of Rheumatology. Press Release: Shortage of rheumatologists—In some U.S. regions closest doctor may be 200 miles away. 2013 Nov 6.
