In spite of working more than 100 hours a week, forsaking vacations and days off, Nacogdoches, TX, neurologist Stephen P. Busby, MD, found his practice expenses were outstripping revenues. Most payers had cut their reimbursements and some had stopped paying at all, refusing to honor their contracts. Malpractice insurance had risen fivefold, his office rent had gone up, his secretary had asked for a well-deserved raise, and his practice management vendor had demanded $20,000 for the software upgrade needed to make his billing system HIPAA-compliant. With three children in college, the pressure of trying to make ends meet was overwhelming.
“I once thought that going into medicine would guarantee me a living. I never envisioned that, at 54, I would be working harder than ever and going broke,” Dr. Busby said. When he read an ad in his local paper for a weekend course in tractor-trailer driving that would pay a much better salary, he decided to call it quits.
According to the AAN and American Medical Association (AMA) survey released last March, 11.2 percent of neurologists had left their practice. Much has been written about physician burn-out causing exhausted doctors to close shop, but the neurologists who spoke with Neurology Today all said that they loved their jobs. So why did they quit? Their stories – while not necessarily representative of the field as a whole – underscore today's challenges in managing neurology practices.
“Many neurologists today face the same ethical dilemma I faced,” said Judith A. Willis, MD, who left the job she loved after 20 years of practicing neurology in Santa Barbara, CA, when she felt that government and insurance regulators were dictating the care of her patients.
“We have lost the authority to make the best decisions for our patients with regards to tests, medications, and procedures,” Dr. Willis said. “This control has been relegated to the number crunchers, forcing us to compromise what we neurologists believe is best. It is hard to tell patients that the options they are permitted are not the ones you think are best for them.”
“I used to cherish the collegial cooperative relationship with my patients where I knew them as individuals and could adapt their treatment to their unique needs, lifestyles, and goals,” Dr. Willis added. “Now it is just finance.”
FLAWS IN THE SYSTEM
“The system is flawed down to its roots,” said Thomas Swift, MD, President-elect of the AAN. “To see a new Alzheimer disease patient and speak to his or her family takes about 90 minutes and Medicare pays only $62.50 – whereas a dermatologist taking 7 seconds to apply liquid nitrogen to a senile keratosis gets $100. If neurologists see new patients all day long, they are certain to go out of business.” He added: “The cognitive specialties, like ours, are most hurt by the current system.”
John H. Lossing, MD, a solo neurologist in Washington, DC, whose practice consisted entirely of cognitive services, saw his reimbursement rates shrink tremendously just as the numbers of denials for services rose rapidly. He found it was taking longer to write a letter of appeal to an insurance company than it was taking to see the patient in the first place. By 2001, he found he could no longer pay his only employee, his secretary of 12 years. “She was spending so much time on the telephone fighting with the insurance companies, she didn't have time to schedule patients,” he said, “Finally, at age 57, facing a negative income, I decided to quit. I was not willing to pay my patients in order to see them.”
Some believe a single-payer system is the answer to this crisis, but Canadian neurologists, who have worked under such a system, cite its own problems. Irena Danys, MD, had practiced neurology and specialized in sleep disorders in Ontario for 10 years, working 80 hours a week between her practice and running a sleep laboratory. But, when she relocated to New Hampshire, she was not sure she wanted to continue at that pace.
“I had spent much of my time begging, pleading, wheeling and dealing in order to get tests approved for my patients,” Dr. Danys said. In Canada, she explained, a newly diagnosed multiple sclerosis patient often needs to wait nine months for approval for an MRI. At the same time, she was concerned about patient demands in the US. “Canadians are more realistic about what the medical system can provide. Here, not only are expectations much higher, but there is more litigation when they are not met.”
All too often neurologists sign managed care contracts without analyzing whether they are money-losing propositions. “Neurologists are motivated to sign these contracts because they are afraid of being left out and losing patients,” Dr. Swift said. “It's not until they do the practice analysis – if they ever do – that the truth sinks in and they opt out.” But the decision is complex, said Dr. Swift, who warned that the consequences may be greater than initially perceived since higher-paying procedural income is forfeited as well.
Some neurologists have decided to pull out of plans completely. Dr. Lossing withdrew from all managed care plans before he gave up his practice, but as a result, he lost most of his patients. And finding it undignified to ask patients for payment, he eventually quit entirely. But others have seen more success with this strategy. Solo neurologist Craig J. Johnson, MD, of William Bay, WI, had been in practice for 12 years when he decided to leave managed care. “It was aggravating trying to keep up with all the individual payer rules and regulations,” he said. Now, four years later, he refers to the financial consequences as a “pleasant accident.”
“My income is up, my hours are down, and my professional and personal satisfaction levels have risen substantially,” Dr. Johnson said. “We have been programmed to believe that if we withdraw from managed care plans, we will be put out of business, but that was not at all the case for me.” He now schedules follow-up appointments at 30-minute intervals, adding: “I actually have time to talk to my patients.”
Cincinnati physicians took a different course of action after a March 2003 analysis for a coalition of employers, health plans, and systems verified that the reimbursement crisis – perhaps one of the most serious in the country – had contributed to shortages of 14 kinds of specialists, including neurologists. A subsequent survey in April 2003, sponsored by the Academy of Medicine of Cincinnati, revealed that about half of the physicians planned to cut back hours, close their practice to new patients, or close practice altogether. The Academy of Medicine of Cincinnati also filed lawsuits against four separate insurers alleging that they had colluded for years to keep doctor payment rates low; in October 2003, one insurer, Humana Health Plans of Ohio, settled their lawsuit for $100 million.
“In Cincinnati, we have been plagued with reimbursements as low as anywhere in the country,” said neurologist James J. Anthony, MD, member of the AAN Medical Economics and Management Subcommittee. Dr. Anthony has also served for five years on the Practice Expense Advisory Committee, fighting on behalf of the AAN for adequate reimbursement for CPT codes, as well as served as an advisor to the AMA committee charged with developing relative value units recommendations for new or revised codes.
“We made efforts as a group to show the community that economic circumstances had damaged medical practice in the city so greatly that it had become a threat to access to care. After several front-page newspaper articles showed how disastrous things were here, we finally began to get a response.” Dr. Anthony speculated: “Perhaps because I practice in a mixed group that includes neurosurgeons – specialists that are leaving the area at a high rate – we were also able to renegotiate a new contract with another insurer for 160 percent of Medicare.”
Dr. Swift has defined the reimbursement issue as a top priority for his AAN presidential term. He is in the process of forming a coalition with other societies of affected physicians including the general internists, family practitioners, psychiatrists, and pediatricians. He is also enlisting the support of patient groups. “Our patients are not getting the care they deserve,” he explained “By including them as allies, we intend to seek congressional reform.”
FOLLOW-UP: THOSE WHO LEFT
What has happened to the neurologists who quit? Dr. Willis ultimately went back to school and got an elementary school teaching credential and a master's degree in education. She now teaches fifth grade in Santa Barbara and finds it extremely fulfilling. She is using her background in neuroscience and brain-based educational research to make presentations to educators, concerned citizens, and legislators, and she serves as a consultant to the National Science Foundation. Dr. Lossing is currently working as a Clinical Professor of Neurology at George Washington University Hospital. “I love neurology and continue to teach, but I miss seeing patients,” he said. Dr. Danys, who decided to pursue a lifelong passion and open a specialty coffee shop, is keeping her medical certifications up to date and hopes to return to neurology practice in the future.
Finally, after Dr. Busby was forced to shut down his practice last January, he did not become a commercial truck driver, thanks to a timely call from a locum tenens company that offered him work. Over the last year, he has temped as a neurologist in several cities across the US. “I like my job again. I have no worries about overhead, a guaranteed salary, and little or no call.”
But Dr. Busby is concerned about the future of our specialty, adding: “Nowadays, practicing neurologists fit into two categories: those who have quit or those that want to quit but don't know how. Our specialty is under grave threat of extinction.”