On the Hot Seat

As focus on costs grows, doctors face tough decisions

Dr. Alice A. Tolbert Coombs, president, Massachusetts Medical Society. Dr. Alice A. Tolbert Coombs, president, Massachusetts Medical Society. (John Ioven/ Globe Staff)
By Robert Weisman
Globe Staff / October 24, 2010

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Dr. Alice A. Tolbert Coombs, who began a two-year term as president of the Massachusetts Medical Society this year, is a critical care specialist at South Shore Hospital in South Weymouth and an anesthesiologist with South Shore Anesthesia Associates. Long active in organized medicine, Coombs has led an antismoking campaign for South Shore youth and has been a driving force behind an American Medical Association program that brings doctors into schools to get young men and women, particularly in minority communities, interested in health care careers. She spoke with the Globe’s health care business reporter Robert Weisman on a recent visit to the newspaper.

How is the business environment for doctors in Massachusetts today?

There are a number of challenges. One is how they cover the costs of doing business in Massachusetts. As you know, the cost of doing business here is higher than most states. Just keeping an office open is more expensive. Doctors struggle with the overhead. The administrative costs of hiring an individual for filing claims is another component. Malpractice premiums are a challenge for some specialties more than others. Those are some of the overhead challenges and struggles that physicians are having.

In terms of caring for the patients, most doctors seem to balance their work life and take care of patients the way they want to. But the piece of it that’s very difficult is how they manage their office in terms of patient visits and the amount of time they have to spend doing laborious paperwork and dealing with claim denials.

Hospitals in the state have laid off hundreds of employees this year, while the major health insurers are losing money. Have physicians shared in the industry’s pain?

It depends if the physicians are hospital-based, if they’re salaried, or if the physicians are independent contractors — if they’re independent private practice doctors who work within the confines of the hospital. One of our greatest concerns is the sustainable growth rate adjustment that has come before Congress. It involves a cut in Medicare reimbursements [by] as much as 28 percent by the end of December if there’s not an appeal, or a fix, or, as we say, a stay of execution.

If that Medicare rate goes into effect, hospitals as well as providers are going to be affected, because many of the hospitals that employ docs now have had a decrease in their amount of reimbursements. So that’s going to adversely affect physicians.

Also, the physicians who take care of a lot of Medicare patients will have to make decisions within their offices in terms of cutting back personnel. And that involves not just the clerical or administrative staff but also the practice’s case managers or nurses.

In addition to the Medicare cuts, the state Medicaid program that insures low-income residents is cutting reimbursements. Have doctors begun not accepting Medicaid or Medicare patients?

Doctors have had to make choices. I’ve spoken to many physicians who have said, “I’ve long taken care of Medicaid, but I’m having a difficult time being able to maintain the right case mix in order for me to be able to cover my overhead.’’ So doctors have had to make choices.

What role do you see doctors playing in addressing the escalating medical costs in Massachusetts?

We have talked about how doctors can do the best thing in terms of bending the cost curve. There’s a couple of things we think are really important. The practice of defensive medicine is a driving force for cost. If physicians know there is some kind of relief in terms of litigation, in terms of claims being made against them, then that can impact the cost curve. If there was implementation of a waiting period before litigation can transpire, so there’s root cause analysis of adverse events, those are innovative ways in which we can decrease the practice of defensive medicine.

In addition, if physicians can be reimbursed to spend more time or hire more personnel to educate patients about wellness, that is a good thing. Imagine if you could impact obesity at an early age. But we have got to be able to build systems that allow physicians to do that.

How do physicians feel about payment reform, specifically the idea of managing patients on a budget rather than fee for service?

It’s a mixed view. Many feel like, if they had the infrastructure, they could probably do this. But the problem that we have is not that payment reform occurs. The problem is how it’s done. Physicians need to have the clinical support in terms of being able to have electronic medical records. If doctors are already struggling to cover their overhead, implementation of a $30,000 to $50,000 electronic medical record system in their office is another struggle in terms of their bottom line.

As hospital systems consolidate, do you see doctors’ practices changing their affiliations?

You know, with this transformation that is occurring, there will be physicians who feel like they need to align themselves with larger institutions. But there are other physicians who certainly will want to be in a practice that allows them the same liberties that have been afforded them over the years. So we can’t make our medicine into a cookie-cutter-style medicine. One size doesn’t fit all.

Governor Deval Patrick capped insurance rates for small businesses and individuals last spring, touching off months of finger-pointing among insurers, providers, and regulators. Was this a smart move and did it help to rein in costs?

While the [insurance] premiums are considered a cost driver, and are a significant cost driver, there are other things that are cost drivers as well. One is what we mentioned earlier, the practice of defensive medicine. There are some drivers that are inherent in the system, such as where you are cared for. If it’s in the emergency room, that is a significant cost driver. And those cost drivers have to be addressed as well.

Dr. Alice A. Tolbert Coombs
president, Massachusetts Medical Society