Independent Practice Decline Due in Part to EHRs, Study Claims

Kerry Dooley Young

February 28, 2018

The Trump administration twice last week demonstrated its interest in simplifying the administrative burden of electronic health records (EHRs) for physicians. Separately, a major new study suggests these high-tech medical reporting systems have so far failed to reduce the cost of billing.

As part of its 2018 economic report, released February 21, the White House drew a direct connection between physicians' struggles to purchase and operate EHR systems and the increase in consolidation among hospitals. Reduced competition among hospitals is widely seen as a driver of healthcare costs. On February 22, top federal health information technology officials hosted a listening session in which they heard directly from physicians about their struggles with EHRs.

Centers for Medicare & Medicaid Services (CMS) officials have been grappling for years to strike the right balance with EHR rules. They want to use them as tools to improve medical care, yet avoid unnecessary intrusions into the time physicians spend with their patients. In 2016, then-acting CMS chief Andy Slavitt acknowledged that the federal "meaningful use" EHR initiative had fallen short, saying that his agency must work to get "the hearts and minds of physicians back" in support of health information technology (IT).

"There was a realization in the Obama administration of those challenges, but I think there were other priorities that they were working on as well," Steven Waldren, MD, director of the American Academy of Family Physicians' (AAFP's) Alliance for eHealth Innovation, told Medscape Medical News in an interview. "It seems now that administrative simplification is one of the top priorities" for the Trump White House, he said.

Current CMS Administrator Seema Verma is now pushing for what she calls "meaningful measures" initiatives. In a tweet this month, she said these measures should focus on tracking what happens to patients after they receive medical care rather than on process steps. In the past, physicians often complained about the CMS' emphasis on whether they established an email connection with patients, with many arguing that many senior citizens were not tech savvy enough to want this.

"When a provider has to spend more time looking at a screen than engaging with a patient, or spend more time reporting data than actually providing care, then we're collecting measures at the expense of patients," Verma tweeted last month.

On February 22, CMS officials joined colleagues from the Office of the National Coordinator for Health Information Technology (ONC) to host an all-day listening session about reducing the burden of EHRs on physicians. Among the government hosts of the meeting was John Fleming, MD, ONC's deputy assistant secretary for health technology reform. Fleming earlier served as a Republican member of the US House of Representatives, representing a Louisiana district. That background could prove helpful in securing legislative changes to federal EHR rules, AAFP's Waldren said. ONC officials also will hold several sessions in March at a conference of the Healthcare Information and Management Systems Society, a top gathering of medical IT professionals.

Expensive in More Ways Than One

The federal government has financial interests in making it easier for physicians to cope with EHR requirements, according to President Donald J. Trump's 2018 economic report.

"Small physicians' groups and solo providers could not afford to purchase and maintain electronic medical records and comply with government reporting requirements," the White House report states. "As a result, hospital mergers are booming, leading to horizontal integration, and large hospitals are buying up physicians' practices and outpatient service providers to form large, vertically integrated healthcare networks."

Many regions of the country now have only one or two large hospital systems. Because of this market dominance, prices are sometimes 15% higher than those in markets with four or more hospitals, the report shows. Medicare often pays more for identical services when provided by a physician affiliated with a hospital than it does for the same care given by a solo practitioner or member of a small independent practice.

Lawmakers and policy experts once expected a different outcome from increased use of EHRs, seeing them as a tool to cut back-office costs as well as to improve quality of care. Yet, a study published February 20 in the Journal of the American Medical Association suggests that EHRs haven't made a dent in these operating expenses.

The study, which was reported by Medscape Medical News, shows that billing costs consumed significant chunks of revenue even at a large academic center with a fully implemented EHR system. They represented about 14.5% of costs of primary care visits and 13.4% of costs for ambulatory surgical procedures.

"These findings suggest that significant investments in certified health information technology have not reduced high billing costs in the United States," the authors emphasize in the report.

"Daunting and Often Demoralizing"

The authors of the study attribute the high costs partly to the complexity of billing systems for many insurers. Waldren of the AAFP noted that this is a challenge for physicians as well in their efforts to adapt to various EHR requirements.

"There's not harmonization across the industry," he told Medscape Medical News. "A family doc may have a diabetes measure from United, one from Medicare, and one from Aetna, and all have a slightly different definition of what diabetes is for that particular measure. It becomes unwieldy to be able to manage that. And diabetes is just one condition."

AAFP has asked CMS to look for ways to simplify what's now a "daunting and often demoralizing" payment framework. In a letter regarding CMS' February 22 listening session, AAFP said many family physicians work with 10 or more insurers. It cited a retrospective study that concluded that primary care physicians spend almost 6 hours daily, or nearly one half of their workday, interacting with EHRs during and after clinic hours.

"Physicians are forced to navigate rules and forms for each payer," AAFP President John Meigs Jr, MD, wrote in a February 7 letter to CMS. "As a result, physicians spend needless hours reviewing documents and literally checking boxes to meet the requirements of each health insurance plan. This is time that physicians could better spend caring for patients."

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