MS. JENNIFER GOLBECKFrom WAMU 88.5 at American University in Washington welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. I'm Jen Golbeck from the University of Maryland sitting in for Kojo. More than half of all doctors were in private practice just over a decade ago. That number's been dropping. It's now just 39 percent. As technology, billing and insurance become more complicated and the new health care law adds what's required of medical practices, more doctors are finding it difficult to remain independent.

MS. JENNIFER GOLBECKA number are being absorbed by large health organizations or hospitals. Others are developing new models to share costs and administration. And many who remain in private practice say they can do so only if insurance isn't part of the picture. Joining us to discuss we have Alice Fuisz, a physician with the Washington Internist Group in D.C. She's also the governor of the American College of Physicians, D.C. Chapter. Good to have you here, Alice.

DR. ALICE FUISZThanks for having me, Jen.

GOLBECKWe have Peter Petrucci who's a surgeon with Johns Hopkins Community Physician Surgery at Foxhall. He's also vice-president for medical affairs at Sibley Memorial Hospital. Thanks for being here, Peter.

DR. PETER PETRUCCIThank you for asking me.

GOLBECKWe have Denny Tritinger. He's the executive director of Orthopedic Medicine and Surgery, which is part of a consortium of orthopedic practices based in our region. Thanks for coming.

MR. DENNY TRITINGERThanks, Jen. Great to be here.

GOLBECKAnd Teresa Stone who's an internal medicine specialist with Medstar Physicians Partners. Thanks for being here.

DR. TERESA STONEThanks for having me.

GOLBECKWe have a lot of questions. I think callers are going to be really interested in this and this is something that affects all of them. But Denny, let's start with you. The trend is clear, doctors continue to shift away from private practice. Before we get to each of your individual experiences, what are some of the factors driving this?

TRITINGERWell, as you mentioned early on in the beginning of the segment, it is the reduction of reimbursements from all of the payers that is driving this, but also the Medicare, the ACA, the -- what is being called the Obamacare, the requirements for additional costs from the doctors, the cost of the electronic medical records and their practice management systems.

TRITINGEREverything that has to do with private practice is going up in cost thereby requiring some consolidations in the market.

GOLBECKSo it's really not an issue of patient care. It's an issue of all the overhead and administration that doctors have to deal with?

TRITINGERWell, you know, I think that -- at least our motto and I think this is what's best for our orthopedic surgeons that joined our model -- it is a cost basis reason we're coming together, but it is -- our focus is on patient care. Our first and only focus is on patient care. In order to maintain that -- I think that everyone in this room would say the same thing, but in order to maintain that focus on patient care -- at least for our doctors the best way to do it is to come together in a consortium of doctors that we've created.

GOLBECKPeter, you had an independent practice for a long time. Tell us about why you made the change.

PETRUCCIWell, I would add to what Denny has to say in that the overhead requirements of expense continue to go up while reimbursement goes down. And that's not a good model. The other part of it is the regulatory requirement. So the government requires various compliance issues to be met which the average office just has difficulty doing. When you try and do it well it's expensive and sometimes you just don't do it. And that's not a good choice either.

PETRUCCISo the bottom line is that most of us who went to medical school went to be good doctors, not to be businessmen. And it's much easier to practice medicine if somebody else is dealing with the business of medicine.

GOLBECKSo the business of running a medical practice has changed a lot since you started in 1978?

PETRUCCIDramatically. Yes, exactly, dramatically.

GOLBECKYou can also join the conversation. Is your primary care doctor in private practice or part of a bigger health care system? How busy is your doctor's practice and what does it mean for your care? You can join us by calling 1-800-433-8850 or email us at kojo@wamu.org.

GOLBECKTerry, you were private for seven years and then you joined Medstar Health. Why did you make the shift?

STONESo I was in a small group of about seven or eight doctors and we were starting to see difficulty with reimbursement and an increase in overhead. If some of the older doctors retired the younger physicians were having to -- were having an increased difficulty maintain the overhead. So in 2006 I joined Medstar Health and a lot of the business of medicine was taken over by another entity.

GOLBECKAlice, you're still in private practice. Presumably if you wished you could go and work for a hospital, you could. Why did you choose to remain independent?

FUISZWell, I went into private practice in D.C. in 2000. And back then all of the doctors in my group were participating with a lot of different insurances. And I was just getting started building up my practice. And I figured out a couple years into it there was really not going to be any way with how low the reimbursements were to keep maintain a private practice and still participate with insurance. And so what I did at that time was slowly backed out of the different insurance plans.

FUISZAnd now I'm in a group with four doctors. We don't participate with any health insurance plans so it's a pretty old fashioned model of having basically a relationship directly with the patient in terms of the payment. And they can then get reimbursement from their insurance. But it takes away the worry about the reimbursements dropping, dropping, dropping overtime. So we've been able to keep it going. And we do see a lot of our colleagues either shifting to working for a hospital or working in a concierge's medicine model where patients are paying, you know, a retainer to be part of a practice. But we're still a small-group practice and it's going fine, but it's hard.

GOLBECKYeah, it's interesting because I had a doctor that I really liked. And his practice, which probably had 12 doctors, shifted to I think what you would call a concierge's model where you would pay, I think, 2 or $3,000 at the time to get in. And then they also didn't take insurance. At the time I was a grad student. I couldn't afford that so I found a new doctor. But about six months after they sent that announcement, everybody got letters saying, you know, never mind. We're going back to like it was before.

GOLBECKSo I think it's interesting that you've actually been able to maintain a patient base and operate like this. But not every doctor can do that.

PETRUCCII think that's an important point. I think the model of not accepting insurance -- and our practice actually did that for a period of time. Ten or twelve years ago we started doing that and it worked out very well. But the issue is that as the older more experienced doctors begin to slow down and retire and you bring new people into the practice, it's very difficult for a new person in a practice to maintain a position where patients will come to them and pay out of their pocket. They don't know that person. He has no reputation. He has no standing in the community. And so it's much more difficult to bring new people into a practice in that environment.

GOLBECKAlice, you wanted to comment.

FUISZI was just going to say -- and this may be a naïve comment -- but I think one of the reasons why so many primary care doctors have been able to not participate with insurance is because all we offer is our time. And that can only cost so much money. It may be too expensive for some patients to afford but we're not ever taking them to the operating room and having, you know, expenses that are into the thousands of dollars. And so I think that's one of the differences that makes it possible, even for newer doctors in internal medicine, to do...

TRITINGERExactly. Following up what Alice is saying, what Peter is saying, that the model that we've developed is a model of doctor-lead, large-sized practice. We're 128 doctors in 50 locations. But we do have the burdens that you all have with reimbursements reducing to centralize those things and look at reduction of costs. So we found a model that works where the doctor remains in control sort of like Alice's private practice model. That's our model. But also Peter's model of finding a way to lessen the burden on an individual doctor for these administrative burdens that all practices have.

GOLBECKI'd like you to talk a little bit more about that Denny. You're the executive director of a new consortium of orthopedists. Can you just describe for us the premise of the group and how it works?

TRITINGERAbout three years ago we -- there was a formation of about three practices. Coming together with the changes in medicine they need to form some other type of organization other -- either be purchased -- they couldn't stay in private practice. They knew that. They thought there was an end to that coming. Or they could become part of a large institution. So rather than that they found some consultants who helped us through the process of getting together and forming an organization that allows enough autonomy with each individual division, which are the previous groups, but still have centralized services and centralized back office-type functions to reduce costs.

TRITINGERSo they've worked very hard and been very collegial in their working together. And I've been very animated and surprised about how well they've come together as not often doctors do. It's maybe a different model than they've ever seen before.

GOLBECKYou can join the conversation. How happy are you with your doctor's practice? Or are you a doctor who shifted from an independent practice to employment at a hospital? You can join us by calling 1-800-433-8850 or emailing us at kojo@wamu.org. Terry, you've noted that internists are very in demand in our area. So do you think that makes a difference in the options that are available to them?

STONEYes. There is a shortage of internists and primary care physicians in the area. And sometimes we -- because I still take insurance sometimes we get pretty full. And it may take quite a long time to come into the office, maybe six months for -- if someone's calling for a physical.

GOLBECKWow.

STONESo there is quite a huge demand for internal medicine in D.C. And we've seen tremendous growth in GW and some of the new Medstar satellite offices.

GOLBECKAnd, Alice, do you think this demand is partially due to -- or related to your ability to be successful as well?

FUISZI think so. What I find is that there are less and less doctors in private practice at this point. And so patients have a lot less options if what they want to do is see someone who's not affiliated with a hospital and not in, you know, a hospital setting.

GOLBECKPeter, you wanted to comment?

PETRUCCIYeah, but the demand for primary care has been there for a long time. It's been underserviced for many years. But if you think about the number of physicians who have gone to the concierge's model where they may have been taking care of 3,000 patients prior to that, they're now taking care of 5 or 600. That other 2,000 patients are looking for primary care physicians. So that changes the dynamic in the primary care market.

GOLBECKSo I have a question for Peter and Terry. It seems the pace of change in clinical practice is continually stepping up. So how does belonging to a larger group affect your ability to keep up with that and do it?

PETRUCCIWell, it's a good question. It's one that's difficult to answer easily. You know, most physicians and their ability to maintain quality care is related to their own effort at continuing education. There are certain requirements obviously that are regulatory requirements. But for example for myself, you know, the areas that I'm interested in that I focus on, I try and spend as much time as I can reading, going to meetings and things like that that allow me to keep up -- keep abreast of what I'm doing.

PETRUCCII don't know that the change in our practice has made that any easier or harder. You know, being part of the Hopkins family gives us access to more ongoing medical education programs but it doesn't give us the time necessarily to take advantage of those programs.

GOLBECKTerry, your thoughts?

STONEOne thing that helps being affiliated with Medstar is that with the Accountable (sic) Care Act there's some things called pay for performance and meaningful use. And so we have people inside that help us obtain meaningful use. And that means that with electronic medical records, there's certain metrics that we have to reach.

GOLBECKCan you give an example?

STONESure. How many patients have pneumo vaccines? How many patients have -- get a form after each visit? How many patients get e-prescribing? So we have someone inside the system that helps us maintain the metrics. And that helps us spend more time with patients.

GOLBECKDenny, did you want to comment?

TRITINGERI did, thank you. Along with what Peter had to say about the education. Within our group, because we're a specialty group of orthopedic surgeons and muscular skeletal physicians, we're going to see, we believe, a very big increase in the -- across sort of pollination of that information -- clinical information back and forth between the group on that specialty. And we know that in that we have -- there's probably one best hand surgeon in our group. That best hand surgeon will help to form a center of excellence around that hand surgeon and the rest of them and cross educate each other.

TRITINGERSo I think that there's a lot of advantages, even in our model, that you mentioned in the Medstar and Johns Hopkins models.

GOLBECKWe'll continue our conversation about doctors' practices after this short break. You're listening to "The Kojo Nnamdi Show." I'm Jen Golbeck sitting in for Kojo.

GOLBECKWelcome back. I'm Jen Golbeck from the University of Maryland sitting in on "The Kojo Nnamdi Show." I'm talking with Alice Fuisz, Peter Petrucci, Denny Tritinger and Teresa Stone about doctors' practices. You can join the conversation by calling 1-800-433-8850, by sending email to kojo@wamu.org or check us out through Facebook and sent Tweets to @kojoshow. We have a number of callers and so I'd like to go to them now. Let's start with Dorothy in Alexandria, Va. Dorothy, you're on the air. Go ahead.

DOROTHYHi. Thank you for taking my call. This is not a setup. I did not know Dr. Fuisz was going to be on the show today, but I am a patient of hers. And I just wanted to say that although I'm not financially in a position where it's very easy for me to have stuck with her, I have done so because of the quality of care issues around having an ongoing relationship. I mean, she really does know me at this point. And I'm old enough to have gone through, you know, years when my insurance changed every year and so I had to find a new doctor every year. And there was just not continuity of care there.

DOROTHYAnd the other thing is, she's able to spend time with me and you can probably tell already that I'm a talker. So by the time -- you know, to have the time to explain what's happening and for us to talk about it together and work out what's appropriate is really important to me, although I must say not always easy to do financially.

GOLBECKDorothy, I'll say that Dr. Fuisz, I think, knew who you were as soon as I put you on the air. So Alice Fuisz, I'll let you comment on that ringing endorsement.

FUISZIt was definitely not a set up. She did not know I was going to be on -- I appreciate it, Dorothy, and I did recognize your voice immediately. You know, I think for me the -- there's a tradeoff in terms of being in private practice. You have the autonomy to be able to figure out how long each patient visit will be, how many patients you see in a day. And the tradeoff is one of security and stability. So I don't get a paycheck every month from the place I work for. And so I have to sort of make those decisions independently.

FUISZBut what it allows me is the freedom to, as she said, spend a lot of time with my patients. And it's certainly very rewarding as a career to be able to do that and to know people for a long time.

GOLBECKWe got an email from Theresa in Falls Church that says, "My doctor just sold her practice to Virginia Hospital Center. Right away I noticed the lists of specialists she kept for referrals now only lists hospitals -- only lists that hospital's specialties. Her list used to have lots of doctors all around. I got stuck because the doctors on her list were not in my network. I was left on my own to find a specialist without even a suggestion list. I feel like the new lists are only created to send patients to the mother ship."

GOLBECKSo, Terry, why don't we start with you? What are your thoughts about that? How do you see that in your own practice?

STONESo I recommend that she probably call her physician back and she'd probably be happy to give her some input in another -- from her old list. With our system at Medstar, it's not a closed system. It's an open system so we can continue -- the nice thing about that is that we can continue referring to the specialists that we've always referred to.

GOLBECKPeter, what are your thoughts on this?

PETRUCCII think that's true. Obviously the situation that she found herself in is part of the reason why hospitals buy practices, because they're trying to draw patients to their hospital and to their specialists that are employed by the hospital. But I also believe and feel that it's appropriate for most practices that even though they're part of a system, to have the physicians be able to refer to those doctors they feel most comfortable referring to.

GOLBECKDenny.

TRITINGERYeah, I'd like to follow up on that, Peter, and say that -- and also what Alice had to say about maintaining the private practice relationship with the physician and the patient. In our model we participate in all major and some of the more less known payers. And in that model we like to say that nothing's changed in your relationship with your doctor other than the logo on the door. And reduction of costs we'll see through the process of consolidating -- you know, grouping together in a combined group.

TRITINGERBut that's -- you know, that's the advantages of our model. And, you know, allowing the patients to, you know, tell the doctors, their primary care which physician they'll see as a specialist. And still in both models, they're open models I believe and so they have the option to do that. If they've seen a doctor before and they like the specialist they're going to they should continue to try to maintain that relationship.

GOLBECKTerry.

STONEAnd as more of the specialists have joined some of the physician -- some of the systems are accepting more insurances, I, as a primary care physician have seen an increase in access to care. Before when I had a patient with Blue Cross and it's sometimes hard to find a specialist that they could see. And now with more of the specialists, the surgeons, the orthopedists are seeing -- are accepting the insurance it's much easier.

FUISZI'm seeing the same thing in my practice in terms of referring people to other specialists. It's getting easier.

GOLBECKInteresting. Let's take a call from Tina in Ellicott City. Tina, you're on the air. Go ahead, please.

TINAHi. I want to put in a view point for patients who have -- I have three very, very autoimmune and hematology disorders. And so besides specialists in Howard County and down at Johns Hopkins Hospital, I have a primary care doctor family practice who's in solo practice. And last year I was in the ER four times and hospitalized once for quite a while. So my family doctor can see me for a ten-minute appointment or a couple times a year. If I'm really ill, she's seen me for up to an hour.

TINAWhen I had to see an internist with a huge group in Columbia, some commercial group, they only had 15-minute appointments. And I had a family practice doctor who was on vacation in India and calling the Johns Hopkins emergency room several times to make sure I got the right care. I don't -- I'm an RN and an MBA in health care administration and I don't see the professionalism and the care for the patient in these big practices.

GOLBECKOkay. Thanks for your call, Tina. Who would like to comment first?

PETRUCCIWell, I'll tackle that. I think that there is -- and this is part of the whole discussion -- this subject. If you think about the motivation of most doctors when they start out in medical school it's basically they want to do good for patients. Secondly, they are basically small businessmen and thirdly, they expect to be compensated fairly.

PETRUCCIThe model has changed because the compensation is no longer fair. And because that model has changed, the -- you know, we all have certain expenses, certain overhead that we expect to maintain an income. When you see your income going down every year, you have to do something to change that model. And it does mean that some physicians end up seeing more patients than they would like to see. And that's the only -- I mean, that's one of the downsides of the employed physician model.

PETRUCCIThe upside of the private practice, you know, is they can make that determination. Are they going to see more patients or not? And so it is a difficult choice, but it's part of what's happened in medicine.

GOLBECKSo Terry, let me turn to you with a question on that topic. When we hear that someone's given up private practice to work in a big hospital system or health care network, we get this image that tends to be negative, like it goes from Norman Rockwell to a corporate office. So what's the reality been for you?

STONESo my reality is I'm in a two-person group. It's a small group and we're downtown. I'm actually right across the street from Alice. We're not forced to see large numbers of patients or anything like that. We see about, you know, 15 or so patients a day. And we are -- you know, we go into internal medicine to develop relationships with the patient. And that’s the key to medicine.

GOLBECKWhat were some of the concerns you had about shifting out of private practice to a large health care operation like Medstar?

STONEAgain, I was concerned like everyone else about losing autonomy, about, you know, seeing large numbers of patients, about not having control of staff and things like that. What we find in this smaller group, just like Denny said, the only thing that's really changed is the logo. So we, you know, run it like a small business but we just don't have a lot of the risk that someone in private practice would have.

GOLBECKYou can join the conversation by calling 1-800-433-8850 or emailing us at kojo@wamu.org. Alice, do you have colleagues who found hospital employment to be focused on productivity, this concern that we seem to see coming up?

FUISZI don't think I can answer that question. I mean, I know people that have gone to work for hospital systems and they absolutely have that concern, as Terry sounds like she did when she joined Medstar. That, I think, is the big fear people have when they're looking at employed -- being an employed physician is that they're going to be asked to see someone every 15 minutes. And they won't be able to extend the visit to a longer visit for a patient when that's necessary. But I'm not sure if that is the reality for physicians in those practices or not.

PETRUCCII would agree with that. And certainly that hasn't changed in our practice. But, you know, we have to realize that it's unfortunate that our income is based on productivity. For anybody in private practice or anybody in employed practice there is an element of that. But I think that is actually changing and that's one of the models that we will see changing going forward is that it'll go from a productivity model to a value-based model. And I think that's already beginning to happen so that the patient care experience will be -- the payment for that will be based on quality of care as opposed to just the number of times a patient's seen.

GOLBECKDenny, go ahead.

TRITINGERWhich is another reason I think for our group coming together the way they did, that this value-based idea that we're going to be moving -- changing from a fee-for-service basis of reimbursement to another productivity- or value-based -- outcomes-based. We can do that in a large group. That's very difficult to do in a very small group. You have the -- just because of the size of the group, we have the results of clinical trials and alternatives.

TRITINGERAnd also, you know, I do want to say that our in our model, the doctors are in control. And so that -- maybe that's good, maybe that's bad -- we tend to believe that it's good. They make all the decisions. We remove the administrative burdens for them to be able to make the decisions. But in the end it's the doctors making the decisions that we think are the best model for us for the best patient care for their patients.

GOLBECKAlice.

FUISZI just wanted to mention something else that hasn't come up today. There's something called -- the model called a medical home model. And there are a lot of pilot projects going on backed by Blue Cross as a payer and looking at Medicare possibly paying physicians for providing sort of all around services. So that's something that's really, really hard to do if you're in a solo practice or a two- or three-person practice like mine. But if you are even private or you're at a hospital and you've got 10 to 12 doctors, you can then have some affiliated nutritionists and someone who's a pharmacist who looks at medication management.

FUISZAnd so there are a lot of projects going on looking at changing the model from the one doctor, one patient every 30-minute visit to paying the doctor for providing those services. So that's something that's coming down the pike.

GOLBECKAnd we have another call about these changing models from Bradley in Washington. Bradley, you're on the air. Go ahead.

BRADLEYHi there. I work with a consulting firm that works with a lot of doctors. But I was noticing, especially for the ones that are entering new into practice, they're looking for more models like a Kaiser Permanente. So, you know, our firm has opinions on this but they're more focused on those RVU models as opposed to the collections-based model. I was wondering, especially for younger physicians, the group -- that's the group we work with a lot at Larson (sp?) . Do you think that that's going to continue moving that direction?

GOLBECKI'd love to get an answer from that and also a definition of an RVU and to collections-based model for those -- the uninitiated amongst us.

PETRUCCISo RVU stands for relative value unit and it's basically defined by Medicare. And it is the amount of the value applied to a service. So for example, if you spend 15 minutes with a patient for a consultation, that service has a specific value assigned to it. And that's where the RVU comes from. And the RVU is used to measure productivity. So that's one way of telling how much you're producing in the course of a given day. And that movement is real. People are moving to that kind of model.

PETRUCCIThe other model was based on reimbursement, meaning how much you actually collected. That's much more difficult to maintain if you're in a small private practice or by yourself. And when you move into a larger practice it's easier to measure your work based on the actual relative value units.

GOLBECKSo Bradley brought up this issue of Kaiser. Kaiser is a closed system I believe. But Terry, you work with Medstar which is an open system. So can you talk a little bit about if you're referring someone to a specialist, do you have any incentive to keep them within the system? Can you refer them to whoever you want?

STONEYes. So we're not limited to just sending someone to Medstar. But if they do stay in the Medstar system we can communicate through electronic medical records. So we're affiliated with Georgetown Washington Hospital Center. There's about eight hospitals in the Baltimore area. Also I think 103 community offices around the Washington and Maryland area. But actually we also -- I also have close relationships with other physicians that are not in the Medstar system. And it's perfectly fine to refer them there.

GOLBECKGreat. We have a call here from Mike in Arlington. Mike, you're on the air. Go ahead.

MIKEYes. Thank you for taking my call. I recently probably about a year or so ago received a message -- a letter from my internist, which is a practice in the Arlington-Alexandria area. And they're pretty established. They decided to go the concierge way. And when I read the letter, which is a nice two-page letter basically saying we're switching and it's not your choice to switch it. They said that was, you know, for the better. And they gave all the virtues of it and they gave the cost.

MIKEAnd after I read it I realized that they were offering things that I didn't necessarily need as a 40-year-old, these added benefits, and I didn't necessarily want. But they made it sound like it was the best choice for me and I had to go with it. On the back of the letter there's a line or two that said basically that if I didn't want to go the concierge way I could still stay at the practice. But at some point they might basically kick me out or something to that effect, or I wouldn't be able to see doctors very easily.

MIKESo I just wanted to say, as a consumer of that, I didn't really appreciate it. I guess I understood that their business model needed them to make more money basically or earn more money that way. And so far I haven't done it, but at some point, I think that they're going to make me go that route if I want to stay with them, which I find to be a real disappointment.

GOLBECKSo that's interesting. Mike raises negatives associated with people remaining in private practice and changing models as opposed to shifting to hospitals. Alice, what are your thoughts on this as someone who's gone this route?

FUISZMy -- did the practice say that they were limiting the number of patients they were going to see?

GOLBECKWe don't have Mike on the line. Sorry.

FUISZOh, he's not on the line anymore. Okay, sorry. So I'm not sure what the exact model is that that practice was using. So people that stay in private practice basically have a couple options. The doctor can continue to participate with however many insurances they want to have contracts with. Or they can have what would be called a purely fee-for-service practice where the patient certainly is likely to have some form of insurance and will request reimbursement from their insurance. But the relationship really is just between the patient and the doctor.

FUISZAnd then the third option is this concierge model which generally means the patient is expected to pay a fee for being a member of the practice. And some of those practices still participate with insurance and still build the insurance for the visits. And others, as you said in your practice, Jen, don't build the insurance for the visit and also charge a concierge's fee. My impression of that model is usually the doctor will limit the number of patients they see, and that's the tradeoff for the patient. So if you're one of the 600 patients that stay with the practice, you're going to have a lot more access to your doctor than you did when that doctors 2,000 or 3,000 patients.

GOLBECKWe'll continue our conversation about doctors' practices after this break. I'm Jen Golbeck, and you're listening to "The Kojo Nnamdi Show."

GOLBECKWelcome back. I'm Jen Golbeck from the University of Maryland sitting in for Kojo Nnamdi. I'm talking with Alice Fuisz, Peter Petrucci, Denny Tritinger, and Teresa Stone about doctors' practices in DC. If you'd like to join the conversation, you can call us at 1-800-433-8850. Denny, what are some of the specific requirements of the Affordable Care Act, and how do they affect doctors' practices?

TRITINGERThere's requirements that the doctors have electronic medical records. That's probably the main requirement in there that increased the costs to the practices. And all of us, and all our groups that have now become divisions, the 25 of them in the Centers for Advanced Orthopedics are looking at -- we all have separate, at this point I've Peter and Alice and Terry that we all have about 18 different systems. There is a cost to consolidating those systems, and we'll have to incur those costs as we go on, but, you know, just the continuing cost of that technology that is there for each of the doctors is an important item in the Affordable Care Act.

GOLBECKPeter.

PETRUCCISo Terry mentioned earlier the Meaningful Use Guidelines, and what that is around is exactly that, and that is, the Affordable Care Act, one of its guidelines was that there had to be meaningful use of an electronic medical record once it was implemented, and that meaningful use includes multiple different measures that have to be met. But the good news was that the federal government made a payment to those physicians' offices that met the meaningful by -- for -- to help defray the cost of the electronic medical records.

PETRUCCISo there was a little give and take there. But it is still a huge expense, not only from the standpoint of the electronic piece itself, the hardware and the software, but it usually takes additional personnel because no matter what anybody says, it may be a better system for medical care, but it's slower. It's not as quick as anything else, as what we used to do. So the electronic medical record is a problem. The Affordable Care Act though, is another issue entirely, and is so complicated that most of us physicians don't really understand everything that it includes, and that's been an ongoing problem.

GOLBECKOkay. So another thing that it does include is a focus on incentives for better outcomes for treatments and procedures. So what does that mean for a doctor's practice? And that's a question for all of you, but we'll start with Terry.

STONESure. So the pay for performance outcome means that it's an incentive from insurers that physicians are paid more if the blood pressures are in better control, diabetes is in control, patients have appropriate vaccinations, and even includes body mass index weight.

GOLBECKHow is that for you to implement as a private practice?

STONESo the electronic medical records helps us monitor it and check it. And then if we have -- let's say if you have a lot of diabetics that are in appropriate control, you -- we have people in our system that will help us, you know, obtain the data, obtain the metrics, call patients to come back in and monitor our patients better.

GOLBECKSo Denny, you actually have an organization in place to help doctors with this, right?

TRITINGERWe do. Well, we're starting it. We're just a brand new company, so we're starting it. We have a quality improvement committee that is very active and will be very active with the payers in finding ways to improve outcomes and to establish protocols that will decrease costs and improve outcomes. But I think we're on that track. I think that all of us are really trying to struggle with this, what does it mean in the different specialties. I think it's more clear in the primary care than it is in the specialty case as to what that means.

TRITINGERAnd I think that what we want at the Centers for Advanced Orthopedics is just to have a voice in that process of defining that protocols are important, and I think as a larger group practice, as a group of 128 doctors in specialty practice, we can, you know, we can have voice in the future of medicine and what this all means to us.

GOLBECKAnd Alice, you're in really a totally different situation kind of being by yourself. How are you finding it getting in compliance with all of these requirements from the Affordable Care Act?

FUISZWell, most of the requirements such as the meaningful use are requirements that are linked to payments from insurers like Medicare. So I'm sort of out of the loop on that. But we still are involved in quality improvement projects, and that is because of board certification. So I have board certification that I have to recertify every 10 years, and part of that process is to do quality improvements, so to survey patients, for example, about -- that have hypertension about the quality of care we're providing, and then come up with something to improve on, and implement it and then resurvey.

FUISZSo we still go through that process even though we're not participating with the insurance and getting the benefit from Medicare.

GOLBECKWhat -- oh, go ahead, Peter.

PETRUCCIThat's okay. Excuse me. For surgeons, most of their quality measures are based in the hospital because that's where most of their activity takes place. But there are Medicare guidelines which pay for performance already that if you meet those guidelines you already are being reimbursed better, or money is taken away from the hospital if the guidelines are not met. So it's beginning to have an impact already.

GOLBECKInteresting. Let's take a call from Mark in Alexandria. Mark, you're on the air. Go ahead.

MARKGood afternoon. This is fascinating. I went to see my family doctor this morning for my six-month checkup, and he introduced me to this new concierge model, and I didn't know the term until today listening to your show. I am 57 and I like the idea of preventative. He's going to do all kinds of screening, he's taking his patient load from 2500 or 3,000 down to 4 to 600 patients. I bit, and I'm excited to be part of it. I can't wait until he gets to the point where we can do the screening and learn more about preventative instead of invasive surgeries to fix a problem after the fact.

GOLBECKSo Alice, you're nodding your head in response to Mark's call.

FUISZThe physicians that I know that have gone into a concierge model such as that have been very, very happy with it, and the patients that stayed with the practice have as well. I have had the group MDVIP approach me on numerous occasions. They're one of the biggest concierge groups, and they generally have said that if you have a lot of patients that in the 58 -- 50 to 60 year old age range, you're a good doctor for concierge, because those patients understand the value of having more access to you as a physician, having longer physicals, having the ability to call you, you know, directly on your cell phone at night.

FUISZAnd so it does work for both people involved. For myself, one of the reasons I haven't considered going into a concierge model is that I actually want to still be able to take care of that 40 year old that called earlier and said I don't think I need that. I want to have in my practice a breadth of patients, some that are very complicated with multiple problems that I can spend a lot of time with, and then some people that are, you know, just finishing college and just need to see me for a sore throat. I like that variety.

GOLBECKYou can join the conversation by calling 1-800-433-8850, or sending us an email to kojo@wamu.org. Let's take a call from Eileen in Burke, Va. Eileen, you're on the air. Go ahead.

EILEENThank you. I wanted to make a comment based on my 35 years' experience in the health insurance, HMO, managed care, et cetera. I think the administrative costs, not only to the physicians but also to the insurance companies are not a small part of the overall cost of healthcare services that are delivered. You have, in contrast to the 1970s, you have multiple payers, i.e. insurance companies, et cetera, multiple plans, multiple reimbursement amounts from those plans, staff that is required by not only physicians in order to manage all of this, but staff required by the insurance companies to have people go out and negotiated these arrangements.

EILEENYou have physicians who are in and out of a network based on the patient's change of health plan, and that impacts patient care. You have many of the same consultants consulting to both physician practices, hospitals, and to insurance companies over the years with no appreciable improvement overall in the outcome of healthcare costs. You have patients who are forced to change doctors if they want to be able to have a certain healthcare coverage. That will impede the care that is being delivered.

EILEENI think that was brought up earlier. Also, patients being forced to change specialists. This also results in duplicate services possibly being provided. In addition to that you have the growth of pharmacy benefit managers that have sprung up over the last 20 years supposedly to help negotiate the cost of healthcare -- excuse me, of pharmaceutical drugs. And we all know that in order to give a discount to these pharmacy managers, the pharmacy company simply increased the price in order to accommodate that...

GOLBECKSorry. I think we lost Eileen there, but we're getting the point, right? There's a lot of cost that goes into actually administering this. Denny, I'd like to turn to you and also find out how much of this administration with insurance is the insurance company trying to fight paying the doctors for services.

TRITINGERWell, yeah. I think it's -- we were fighting on both sides. The doctors want to be reimbursed more and the other side is wanting to pay less, and I think -- and until we level the ground a little bit by forming large groups or joining health systems, the insurance companies were winning. In our group we have been successful in negotiating contracts with all the large payers because of the size of it. I think purely because of the size of our group at Centers for Advanced Orthopedics.

TRITINGERBut I also think there's another incentive for the payers to work closely with large groups like ours, and that is that in the future of this change we're talking about, the outcome-based and protocol-driven type of reimbursement, I think that they're seeing -- and I've talked to the United and some of the large payers, that we'd like to work with them to find ways to streamline costs and reduce costs to patients, and work closer to them, not butt heads with them as we always have in the past.

TRITINGERAnd unless we change relationships, and we're trying to do that and they're trying to work with us as a large group, it will continue into the future for the smaller groups. I just think that the model we've chosen works for us, and it will work -- we'll be working closer with the payers.

GOLBECKLet's do another call from Aleece in Prince Frederick, Md. Aleece, you're on the air. Go ahead.

ALEECEThank you so much. I've enjoyed the show and I appreciate all of the input that the doctors have shared with us. My concern is the poor. With the Recovery Act, the Affordable Care Act, it's so complicated it's just unbelievable. And it's really designed to help those millions of patients who can't afford healthcare. I'm not real sure if it's working. But my real question is, when a patient comes to any practice who is poor, and they aren't an informed patient, they can't articulate what is actually wrong, and really is relying upon an expert in the doctor to tell them what's wrong.

ALEECEAnd I find through my experience that many doctors aren't able to help those patients or maybe they are able, don't want to help those patients to -- with their medical care. I mean, the concierge medicine is a wonderful idea for people like me. I believe in preventive. I do everything to help to improve my health, screening and all of that is great. But for the person who can't afford that, what really is going to happen?

GOLBECKLet's let Terry take a shot at answering that. Terry, go ahead.

STONEThe American Medical Association just reviewed the increase in the number of employed patients, and they just addressed what the caller said is that with the increase in the employed physicians, there's an increase of access to care to particularly Medicaid patients.

GOLBECKOne of the big discussions around the healthcare law has been keeping medical costs under control. How has that affected your practices, and what do you see going forward? Peter, do you want to take a first shot at that?

PETRUCCIWell, I could try. I think controlling costs is, you know, there are two sides to that equation. One of it is that, as was mentioned earlier, the insurance companies just basically say this is how much we're going to pay and you do what you can with it. So this is a part of the bigger picture, what we're talking about. So our ability to control costs had become a problem because of being a relatively small practice. And joining a larger organization allows us to take advantage of that organization's management skills, purchasing skills, and other infrastructure that we didn't have in our practice before. And that's, for us, the best way to control our individual costs.

GOLBECKDenny, what are your thoughts on this?

TRITINGERI think that an example for us as we've had a reduction of 30 percent in our malpractice costs just by consolidating. We've had decreases of between 16 and 20 percent reductions in our supply costs because of the consolidation. So I think following on what Peter's saying, in a large group in this type of setting we can big reductions which then translates into reduced costs to the patient in the end and better patient services. So that's what we're all looking forward to is reduction of cost, better patient services.

GOLBECKTerry, one last quick question for you. A lot of this conversation has shown us that doctors are working very hard, both at taking care of patients, and taking care of all of these administrative things. Burnout is an issue, and so I'd like you to just give us a quick, like 30-second talk about some of the ways that practices are trying to address that component.

STONEThat's a good question. There was recently a New York Times article discussing that very issue with decreased reimbursement, increase in paperwork and the electronic medical records increase in doctor burn out. Some -- there's a new study going on right now in Georgetown where they're teaching physicians small relaxation techniques.

GOLBECKSo that's something that hopefully we'll see more of you doing going forward so you can relax. I'd like to thank all of our guests for joining us in the studio with this fascinating conversation. I'm Jen Golbeck sitting in for Kojo Nnamdi. Thanks very much for listening.