As just about everyone knows by now, perhaps the most frequently discussed topic in health IT circles for the past year has been how electronic health records (EHRs) and other technology have contributed to physician burnout. This has been a major area of concern from the federal government all the way down to the physician practice level.
At the core of many of these conversations is the Englewood, Col.-based Medical Group Management Association (MGMA), an industry association with a membership of more than 40,000 medical practice administrators, executives, and leaders. As Halee Fischer-Wright, M.D., president and CEO of MGMA since 2015, explains, MGMA once had a reputation for being an association that represented small practices only, but the current trend is that the membership’s average practice size is actually what’s defined as “large physician practices” across the U.S. Fischer-Wright notes that MGMA’s membership base is now 50 percent larger systems, 30 percent larger practices (meaning 100 or more physicians), with the remaining 20 percent smaller practices, meaning less than six full-time physician FTEs. Says Fischer-Wright, “There has been a significant shift” in our membership.
Fischer-Wright is a nationally recognized healthcare executive and a physician leader. In her new book, Back To Balance: The Art, Science, and Business of Medicine, She describes the crisis American healthcare is in—with the average American physician spending two hours on paperwork for every hour spent with patients; with one in twenty patients being misdiagnosed daily; and with only thirty-four percent of Americans expressing “great confidence” in the leaders of the medical profession.
To this point, a very recent MGMA survey found that medical groups are increasingly feeling the pressure of regulatory burdens, with the vast majority of physician practices finding it difficult to comply with the Merit-Based Incentive Payment System (MIPS) under MACRA (the Medicare Access and CHIP Reauthorization Act of 2015). The survey had some startling findings, perhaps most notably that 82 percent of medical practices identified MIPS as “very” or “extremely” burdensome; and that nearly half of respondents reported spending more than $40,000 per FTE physician, per year to comply with federal regulations.
Fischer-Wright recently spoke to Healthcare Informatics about these physician burden issues, what possible solutions might be, and other healthcare challenges that MGMA’s membership are facing. Below are excerpts of that discussion.
Halee Fischer-Wright, M.D.
I’d like to start with a personal question since your career has been so fascinating. How have your past endeavors led to becoming CEO of MGMA?
I have had a diverse career; I never exclusively practiced medicine. I started my own practice with a partner when I was 29 and I as there for 19 years. During those years I also functioned as a practice management consultant, and I was president of a large physician group for 14 of those years. I was also a management strategy leadership consultant in many other industries other than healthcare during that time. And I was also a chief medical officer for two years prior to my role at MGMA. So I would best describe my career as asynchronous. It’s with that diversity of perspective when the opportunity came to apply for the CEO of MGMA, the broad experience I had—including in non-healthcare sectors, like financial services, real estate, oil and gas—gave me a unique view on the role.
What do you see as healthcare’s greatest challenge today?
Our biggest challenge right now, and you see this playing out in the political landscape regardless of what side of the fence you are on, is we’re seeing people becoming aware that healthcare—which was always assumed as something that people purchase—is something that’s a societal need. What we see in the political landscape right now is that while we may not support this or that policy, the idea that there might be [so many] people who might not have health insurance is undesirable regardless of what side of the fence you are on. I think that will force rapid change. Healthcare has been in a transition in the last 5 to 10 years at a high velocity, but I think this will help us completely rethink how we approach healthcare from a policy and economic standpoint. So we have only begun to take on the upheavals that lay in front of us.
We have been hearing a lot about physician burnout and specially the burden that IT puts on doctors. What’s your take on how burdensome EHRs can be?
I can view this from many different perspectives, including as a physician who used eClinicalWorks for seven years, Epic, and [others]. The way physicians approach EHRs is that they feel that the [technology] acts as a relationship barrier between them and their patients. Over and over again, we see physicians who feel like they have been employed by their EHR rather than liberated by it to engage in meaningful patient care. We are not looking enough at the end-user focus. When talking about burnout, the physician experience is [right now] an obligation to fill the boxes in. The goal of EHRs shouldn’t be to remove the human from the equation, but rather to empower the physician. That’s the differential from where EHRs are today compared to where they need to be in the future. We do see physicians leaving in record numbers, but with the rise of millennials entering the workforce as clinicians, they won’t tolerate EHR systems that are not focused on the end user. They are accustomed to more of an Amazon-elegance in their systems. I think millennials will actually drive the transition that EHRs need to be more of a compassionate tool as opposed to a barrier.
We have also been hearing about how federal healthcare officials are prioritizing reducing this burden on doctors. How can this realistically happen through government regulations?
One of the things my organization really focuses on is that we’re dogged and rapid champions of decreasing administrative burden. One of the downsides of government regulation is that we get more of it, but no one ever says let’s get rid of the regulations that actually no longer contribute to the safety, quality and cost of clinical care. So the one thing we can do is eradicate things that are no longer adding value to the clinical experience. Believe it or not, probably 20 to 30 percent what we do day-in-day-out as clinicians, as it relates to regulations, is not directly valuable to quality, safety or cost in the practice experience.
To this point, were you pleased with the MACRA Quality Payment Program proposed rule for 2018?
The challenge that I will fight to the death is how can you administrate a quality program if you’re not giving real-time feedback? The [issue] that I have with MACRA is not with the intent nor the concept behind it, but we have suddenly moved from a quality bonus phase to a quality penalty phase, and our reporting periods are still 18 months asynchronous from the point of care. Until we get real-time data, this is not program that really syncs with what’s going in in the office.
Do you think the speculation about MACRA forcing some solo and small practice physicians to retirement or to be scooped up by larger health systems is real?
I have been in practice since 1997, which is when the Stark [Law] came in, and I have been hearing for 20 years [since] that government regulations will force the end of small practice and the purchase into large practice. Is this going to be what [finally makes] that happen? No, I don’t think so. For the older physicians who don’t want to participate in MACRA, there are still alternative payment models, and that’s probably the wiser way for them to go anyway. There is pendulum of systems buying practices and releasing them. From 2010 to 2012 there was a massive buy of practices, and now we’re in a phase of actually divesting those practices.
When the original MACRA originally came out, there was a table about how small practices will become untenable due to a decrease in funding. We have not seen that bear out nor can we create an economic model that substantiates that statement.
If your members had one wish collectively, what would it be?
I would go back to end-user design because it’s so important. There is a disconnect between the design of healthcare IT and the end-user experience. We have to somehow synchronize that in a way that’s effective. We have to step back, ask ourselves what are the outcomes that we genuinely want, and we need our health IT systems to empower humans to deliver those rather than serve as a barrier for humans to deliver them.
And I think the onus is multi-factorial. If you look at healthcare across the board, you have good intent. I was at a conference in 2005, and it was said that our intent was to have fully interoperable EHRs by 2007. That conference was 12 years ago; the thought was that [interoperability] was only two years away. The intent was good, but we have added more layers, more regulation, and more vendors. I always advocate to step back and [think about] the reasons why we actually have healthcare IT. Is it coming from a business perspective or is it coming from a healthcare delivery perspective? What has driven the complexity has been the business aspects of it more than the clinical aspects of it.