Leading With a Happy Face by Pat Conrad MD

The movie “Rocky IV” featured everyone’s plucky southpaw in an ideological proxy fight with evil communism, in the person of Drago, the USSR’s engineered perfect man. In the climactic fight, Rocky beats Drago by perfecting the little-used boxing technique of smashing his face repeatedly into the Russian’s fist, until the latter is knocked out. This tactic apparently has apparently inspired Medical Economics magazine.

Last month’s cover story from senior editor Jeffrey Bendix titled, “Fighting Back – Overcome the challenges of Independent Practice” advances a similarly curious approach. The discussion begins by noting how crappy it is to try to keep an independent practice going, what with “the growing shift towards value-based payment…need to stay abreast of new technologies…growing competition from new types of providers.” An interesting statistic herein: “independent practice owners decreased from 62% in 2008 to 35% in 2013, according to the 2014 Physicians Foundation Survey of American Physicians.” The magazine “asked physicians and practice administrators to share their strategies of overcoming the challenges” and got these:

• “accept that electronic health records are necessary to function in today’s healthcare environment…”
• “look for ways to differentiate your practice in the eyes of payers in … efficiency and outcomes.”
• “make population health management part of your care …[by] tracking quality data.”
• “EMBRACE GOVERNMENT REPORTING MANDATES AND USE THEM AS OPPORTUNITIES TO SEE WHERE YOU CAN IMPROVE PATIENT CARE.” (I put that last in caps to avoid actually screaming).

So the lead off for a strategy to survive as an independent is to do as you’re told and wear a happy face.

• “Experts say staying independent likely requires teaming up with other independent practices through vehicles such as accountable care organizations (ACOs).” Am I the only one smelling a little irony here?

Designated medical commissar Nitin Damle, MD FACP, president-elect of the American College of Physicians can’t smell anything but puppies and sunshine: “I think once you recognize that this new direction really has value, you can jump on board and in the end you’ll feel like your life and professional satisfaction will be improved because you’ll see that you’re taking better care of your patients and that you’re able to spend more time with them.”

Independent (ahem) doctor Chris Apostol, DO looks to embrace the benefits of EHR’s in his group practice: “No matter who is seeing the patient, the encounters now look pretty much the same, because the same quality measures are going to be met and the same information is going in the same spots.” Just read THAT quote again, and try to imagine the smooth level 4’s.

• Yul Ejnes, MD says, “EHR’s also make it possible for practices to collect and generate the data needed for population health – a requirement for many of the value-based payment models.”

At this point in “Rocky IV”, the protagonist’s face is starting to become a featureless, punished mass of red with a sideways nose, that seeks out his opponents fists and launches at them repeatedly. A surprisingly accurate version of Premier Gorbachev in the balcony begins to seem concerned, as the Soviet champion appears winded.

The article on fighting back closes by embracing “evolving practice models”, which turn out to be getting paid based on quality measurements and pay-for-performance. The featured (sigh) independent joined with a much larger group, and began cranking out the stats required by the payers. I think his definition of “independent” and mine are quite different. His means, “The likelihood of transition from paying for volume to paying for value meant that I was going to need the resources to measure statistics better…You’re not going to get far with payers if you don’t understand what value you can present.” And yes, in fairness, that approach earned that provider “better compensation rates and care coordination fees from two major commercial payers.” Call me a cynic, but in all of this I think “independent” really means that you are responsible for your own overhead, but otherwise you still have to do the same dance in a prison dress as the rest of your cellmates. In the end Drago falls, and Rocky, who has miraculously retained his powers of speech, such as it is, pleads with the crowd, “If I can change, and you can change, then everybody can change!”

It was a stupid movie, criminally stupid, and stupid as telling physicians that they can retain their independence by rushing into the embrace of Big Insurance and the government, leading with their faces, expecting a win.