Jane M. Orient, MD is an author, a practicing physician who maintains a solo practice of general internal medicine, a clinical lecturer at the University of Arizona College of Medicine, and the executive director at the Association of American Physicians and Surgeons.

Orient recently penned a piece titled "Shall We Take the Liberty of “the 1%”?," which highlights a number of pressures facing physicians. In a recent interview, MD+DI asked Orient about that article and how she expects healthcare reform legislation to impact physicians in the United States. 

MD+DI: How do you feel healthcare reform will affect physicians' ability to practice medicine?

Orient: What is called “healthcare reform” is really a government takeover of medicine. Beginning with the health insurance industry, by requiring people to buy a government-dictated form of insurance with this promise that if you like your insurance plan, you can keep it. But if you read the first ten pages of the [Patient Protection and Affordable Care Act], it is apparent that the legislation makes it impossible for standard insurance plans to even exist.

The legislation imposes huge additional compliance costs on physicians. And, already physicians are subjected to price controls under Medicare. For many of them, they are hard-pressed to bring in enough revenue to cover even their costs much less to pay them for their work. So what many physicians are having to do is to think about changing their occupation or changing their practice in such a way that they can survive.

MD+DI: It is interesting you say that: I’ve heard a lot about a coming physician shortage and a fair amount of anecdotal evidence suggesting that a significant number of physicians are leaving the field of medicine. What do you think are the main drivers of this?

Orient: There are a lot of threats and and many physicians are saying if things are going to get any worse they are going to quit. What is happening for sure is that many physicians are giving up their independent practices and they are becoming employed by hospitals. And so they are not working for their patients any longer. And this means, in order for them to get paid, they have to satisfy their employers. Their employers get paid based on health plans’ bottom line or the government’s latest priorities. And if they are to deviate from that, by putting their patients first, they could be really putting their jobs at risk.

But the question I was really asking in my article is: "do the 1% of people, or whatever small percent it is  of people who have the medical skills to provide care that we need or want, should we really allow them the liberty to decide for themselves how they want to practice? 

Right now, they are responding to a lot of financial constraints. But more of them are saying “I can’t really do my job,” “I hate what I am doing,” “I can’t wait to retire,” “but what I would really like to do is to go back to the old-fashioned way of practicing: opt out of Medicare, tear up my insurance contracts, and just going back to seeing to the patients.”

And I believe the government is getting concerned about that they might [do that]. In fact, they are complaining that they don’t know enough about the doctors who have opted out of Medicare—whether Medicare beneficiaries still have access to care. So there is this threat that physicians will be required to work for a health plan or Medicare or for some other government-approved entity.

Just like American patients are going to be forced to buy the type of insurance plan that the government wants, will physicians be forced to work in the type of enterprise that the government wants under pain of just not being able to work at all?

MD+DI: Can you give me some example of how all of these constraints, and Medicare, in general, affects clinical decision making?

When you file a claim on a patient, then, you have to go by these AMA codes and you send in the claim. Increasingly, CMS will be denying the claims saying: “this was a medical unnecessary service” or “this procedure that you gave doesn’t really match the diagnosis you put down, so we are not going to pay.”

Or, they might say “you are an outlier, therefore you are providing more of this complicated service than the average, therefore, we suspect you have Medicare fraud, therefore we will come and audit you. And, we’ll take a little sample of your charts, and then we’ll extrapolate for your whole practice.” And they might do that and come back and say “we’ll, you’ve miscoded 30% of the time, so we over-paid you by this much in those cases. We’re going to multiply the amount that we overpaid you in this sample by your whole practice volume.” And then they might say: “You owe us $50,000 and we’ll give you 30 days to pay.”

Something like that...

Physicians are really constrained as to how many Medicare patients they are willing to accept, what services they are willing to offer them, they churn them through as quickly as possible so they can bring in more low-coded visits because if they spend more time and try to get paid for more time with patients, they could really be jeopardizing themselves.

MD+DI: The Sunshine Act has been getting a fair amount of attention lately. What are your thoughts on that piece of legislation?

Orient: In general, [people with inititiatives like this] seem to always start it by saying, ‘oh, it is just this tiny little burden’ and you start to fill out the forms. And you realize that these things become more and more complex and you realize that every time you fill out a form, you are in danger of committing a crime because you might have made a mistake. You can’t just spend your whole day doing something and documenting it with just exactly the form that the government bureaucrat wants. So I just think, for one thing, it is not going to accomplish anything except just add one more busywork task to our already crazy schedules.

MD+DI: I recently saw an account of an ER doc complaining about electronic medical records (EMR). And he was saying that it was having a negative influence on patient care. Could you provide some perspective on how EMR affects physicians’ ability to see patients?

Image by DavidShutter.

Orient: Some physicians who have implemented this elaborate system to meet the government’s requirements say it cuts productivity by 25% permanently. It is not just getting used to the system. The doctors find that they can’t really have good eye contact with the patients because they are constantly having to put stuff into the computer the way the computer wants it. There is so much junk [in EMR] that physicians have trouble finding the important things. Often the systems are so rigid that they have to pick from a menu. They can’t just enter free hand what their observations are.

I think eventually, these systems will be such that they will constrain what physicians are allowed to do because you have to pick from a menu. You can’t just write an order for what you think is best. But you are restricted to whatever number of choices there are. And if you want to deviate from that, it’s another federal case to try to justify it. You are under suspicion to begin with and it is so much trouble to try to justify something. And then they might say “no.” People who don’t even know how to spell what procedure you are trying to do might say “no,” this patient isn’t eligible for that procedure. So the EMR, I think, is really a trap.

MD+DI: I heard recently a quote by Daniel Kraft, MD, who said “[Now] we don’t really practice evidence-based medicine. We practice reimbursement-based medicine.” What are your thoughts on that characterization?

Orient: Well, we are supposed to practice evidence-based medicine just as though we didn’t used to do that. But now what we are doing is protocol-based medicine based on what these expert committees decide is or isn’t good evidence in medicine. If you look now at the articles in medical journals that detail the protocols, they are so dense that it is difficult to read them. And the whole last page, in teeny-tiny microprint, is the list of conflicts of interest that the authors have. So, if you want to get your drug prescribed by everybody under the sun, you get on one of these committees and it becomes the best practice for patients with a certain condition

MD+DI: I noticed some similarity in your writing to Ayn Rand. How do you think she was at predicting the current situation in medicine?

Orient: A lot of people think of her as a prophet. That a lot of the things she described back in the 1950s in Atlas Shrugged are happening today. And I think that she was maybe going by what she had observed in her early life in the Soviet Union where you had these commissars who were the least capable people in the community and thus dependent on the Party since they couldn't do anything successfully on their own. So they got a little drunk on power and liked to push people around. And those were the people you had to kowtow to or your life would be absolutely miserable, if it wasn’t miserable enough, just having to look over your shoulder all of the time and do what you thought would get you by.