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Opinion and Commentary from TMA

Why I'm Building a Solo Practice — Again

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Solo_Practice_blog

This post was originally published in the AAFP News Leader Voices Blog. Reprinted with permission of the American Academy of Family Physicians.

It shouldn't be this hard.

Three years ago, despite obvious trends to the contrary, I decided to go back to the practice model where I truly belong: independent, solo family medicine.

SweglerEarly in my career, I spent two years in a multispecialty group practice where I was expected to see 30 (or more) patients a day. It wasn't for me, and the time-limiting approach wasn't ideal for patients, either. I spent the next 16 years at a small, independent group practice that offered more freedom and autonomy, but it still wasn't quite the same as the solo practice where I started my career.

So here I am, starting over more than 30 years into practice. Has it been worth it? I'm practicing at the highest level of my training, devoting more time to each patient and making decisions based solely on what's best for patients without being beholden to a health system and its financial goals.

I've been here before. When I completed residency in the 1980s, I was a solo doc for several years, doing full-scope family medicine, including obstetrics and inpatient care. It was tough but rewarding work.

Building a solo practice has been even more challenging the second time around. In today's economy, there is a dearth of capital to help launch an independent practice. In the past, a physician might have had a relationship with a local banker, but now decisions are more likely to be made from a corporate headquarters and less likely to consider the significant economic impact a single physician can have on a community. Many banks don't seem to understand health care financing and aren't eager to get involved.

When you get an independent practice up and running, more challenges await. Payers have not kept up with the costs of running a practice. For example, when I was a new-to-practice physician, Medicare paid $3 for a lab draw, and private insurers paid $12. My expenses have increased, but the reimbursement is now even lower; Medicare pays $2.76 and private payers pay $3.

For some perspective on inflation, a U.S. consumer should expect to pay nearly $7 today for something that cost $3 in 1986. Just don't expect payers to do the same.

An independent OB/Gyn last year told the Los Angeles Times that her rent was increasing 3 percent each year, and her utilities had increased 18 percent in the previous year. Still, one payer was reimbursing her at the same level as it had seven years earlier. When she protested, the payer told her to take it or leave it. Her practice was small, she was told, and it wouldn't affect the payer if she dropped her contract.

There are options for small practices. Accountable care organizations give small, independent practices the ability to come together and have more influence based on quality improvement and value.

Small physician practices should matter not only to physicians and patients but to payers and policymakers, too. Studies have shown that small, physician-owned practices have lower costs, fewer preventable hospital admissions, and lower readmission rates than larger independent and hospital-owned practices. In fact, large hospital systems with integrated delivery networks have increased costs without evidence of improving quality.

Despite those jarring truths, hospitals have bought out independent physicians at an alarming rate. Among all specialties, the number of doctors who were practice owners or partners shrank from 62 percent of the physician workforce in 2008 to 35 percent in 2014. Growing administrative and regulatory burdens likely have tipped the scales even more in the four years since that Physicians Foundation survey was taken.

According to AAFP survey data, 71 percent of Academy members were employed in 2017. Of those, 49 percent worked for hospital systems, compared with 17 percent in group practices.

The AAFP has advocated for site-neutral payments, which lower costs for patients, level the payment playing field for physicians, and leave less incentive for hospitals to buy out independent practices.

So what incentive do family physicians have to join me here in the shrinking minority? Well, aside from autonomy, lower costs for patients and higher quality, how do you feel about lower rates of burnout? According to a recent study in the Journal of the American Board of Family Medicine, that independence and autonomy contributed to physicians in small, independent practices having a lower burnout rate than their peers at larger practices. Specifically, 13.5 percent of physicians in the small practices studied had experienced symptoms of burnout, compared to a national rate of 54.4 percent.

An Annals of Family Medicine study recently showed that a broader scope of practice, which is more likely in independent practice, also lowers burnout risk.

Clearly, with lower costs and better outcomes, payers should be motivated to support small, independent practices. Unfortunately, the health care system has undervalued primary care for years. There was once such a large primary care base that it was easy to take for granted. When the resource-based relative value scale was implemented in 1992, it incentivized physicians and health systems to emphasize complicated procedures rather than prevention. The subsequent widening gap in payment between primary care and subspecialty physicians has contributed to the primary care physician shortage, and access has become a challenge for patients.

Payment reform is essential for family physicians, especially for those in solo and small practices. The AAFP is advocating that spending on primary care increase by 15 percent. Insurers must find ways to pay family medicine and primary care better and differently. One example is the alternative payment model developed and proposed by the Academy

Despite the challenges, I have no regrets about my change in practice models. Every day I come to the office and have time to take care of my patients. No, I will not make as much money as some of my colleagues, but close. (Survey data indicate the pay gap may be closing between employed and independent health care professionals.) I have the satisfaction of taking care of my patients by placing their needs first. I am not beholden to a hospital that needs more CT scans or that wants me to refer procedures I am qualified and capable of doing just to feed its system. I can practice to the highest level of my license and ensure that my patients have only the right, appropriate care they need.

I look forward to seeing my patients every day, and I love what I do. Would I like to be more appropriately compensated? Of course, but I do have the privilege of working for the best interest of my patients every day without interference, and that has been a blessing.

I am working hard. Experts say it takes four to five years to fully develop a practice. I am betting my retirement that I will succeed.

Erica Swegler, M.D., is a family physician in Austin and a member of the AAFP Board of Directors.


Why Marijuana Will Not Fix the Opioid Epidemic

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Cannabidiol

By Kenneth Finn, MD

Reprinted with permission, Missouri Medicine, the Journal of the Missouri State Medical Association, Volume 155:3, 191-193

Marijuana has been used for health purposes for thousands of years, when the plant had THC content of 0.5-3 percent. Currently, the most common reported medical use is for pain. As of this writing, 30 states and the District of Columbia have some form of legalized marijuana, with eight states having legalized it for recreational use. 

The United States is currently in the grips of an opioid epidemic, which has been growing over the last 20 years and began with “pain” being termed the “5th vital sign.” At the time, it was reported that people in pain did not become addicted to opioids, and the number of opioid prescriptions started to increase over time, followed by an increase in opioid overdose deaths.1

Kenneth_Finn

There has been a lot of discussion about how the use of cannabis will help curb the opioid epidemic.2 It has been reported that medical cannabis laws are associated with significantly lower opioid overdose mortality rates, and others have suggested that legalization may result in fewer opioid overdose deaths.3 Other studies have reported that medical marijuana laws were associated with a decrease in Medicare prescriptions, saving millions of dollars.4 The same authors followed up with another report suggesting that medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population.5 Cost savings in this day and age of health care is very important, but it was noted that “the researchers themselves cannot say if people switched from opioid prescriptions to using a medical marijuana product.”  It is difficult to translate population-level analyses to individual marijuana-opioid substitutions, and this patient population is a rather small percentage of people who may be using opioids and/or medical marijuana. In 2017, Colorado had a record number of opioid overdose deaths from any opioid, including heroin, and Colorado has had a medical marijuana program since 2001.6

In the face of the opioid crisis, the medical providers should utilize other ways for people to avoid the use of opioids. Treatments such as physical therapy, acupuncture, chiropractic, massage, and cognitive-behavioral therapies are some of the standard treatments in the management of people with pain. Other naturopathic remedies have been suggested and tried but not proven.7  

There is some evidence that components of the marijuana plant may have therapeutic medical value.8 Cannabinoid and opioid receptors belong to the rhodopsin subfamily of G-protein-coupled receptors and are synergistic.9 Both are localized primarily at the presynaptic terminals, and when activated, reduce cellular levels of cyclic adenosine monophosphate (cAMP) by inhibition of adenylyl cyclase, which effects neurotransmission. Receptor activation of both also modifies the permeability of sodium, potassium, and calcium channels, and receptors of both systems coexist in the central nervous system, with overlapping distribution in the brain, brainstem, and spinal cord.10 Both receptors co-localize on GABA-ergic neurons with potential coupling to second messenger systems, and receptor stimulation can suppress inhibition, suppress excitation, as well as inhibit the release of several neurotransmitters, including L-glutamate, GABA, norepinephrine, serotonin, dopamine, and acetylcholine, therefore modulating pain pathways and potentially provide antinociception.  Opioids and cannabinoids share pharmacologic profiles and both can cause sedation, hypotension, hypothermia, decreased intestinal motility, drug-reward enforcement, and antinociception.

There are several reasons as to why any reported benefit will be outstripped by lack of benefit and increased risk of harm, and why cannabis is contributing to ongoing opioid use, and subsequently, the opioid epidemic. There is evidence in animal models showing adolescent rats exposed to THC will develop enhanced heroin self administration as adults11, which may be due to activation of mesolimbic transmission of dopamine by a common mu opioid receptor mechanism.11,12  More than 90 percent of heroin users report a prior history of marijuana use compared to a prior history of painkiller use (47 percent).13 Prospective twin studies demonstrated that early cannabis use was associated with an increased risk of other drug abuse.14 This study was conducted when the THC content was much lower than today's products, which can reach 95 percent THC.

The currently accepted body of evidence supporting use of cannabis in pain consists of 28 studies comprised of 63 reports and 2,454 patients.15 Additional articles relying on this primary paper misleading stating that “there is substantial evidence that cannabis is an effective treatment for chronic pain in adults.”16 Both articles noted that products typically studied are not available in the United States (nabiximols, Sativex) or were with available synthetic agents (dronabinol, nabilone), and were studied in less common pain conditions: neuropathic and cancer pain. Currently there is no widely available or accepted medical literature showing any benefit for pain with dispensary cannabis in common pain conditions.17 Dispensary cannabis is a generic substance containing multiple components that may have physiologic activity in the body. The College of Family Physicians of Canada outlined potential prescribing guidelines of medical cannabinoids in primary care.18 They strongly recommended against use for acute pain, headache, osteoarthritis, and back pain, and also discouraged smoking.  

There is currently a large and growing body of evidence showing that cannabis use increases, rather than decreases non-medical prescription opioid use and opioid use disorder, based on followup of more than 33,000 people.19 Concurrent use of cannabis and opioids by patients with chronic pain appears to indicate a higher risk of opioid misuse.20 Closer monitoring for opioid-related aberrant behaviors is indicated in this group of patients and it suggests that cannabis use is a predictor of aberrant drug behaviors in patients receiving chronic opioid therapy.

Inhaled cannabis in patients with chronic low back pain does not reduce overall opioid use, and those patients are more likely to meet the criteria for substance abuse disorders, and are more likely to be non-adherent with their prescription opioids.21 It has been found that patients with chronic pain participating in an interdisciplinary pain rehabilitation program using cannabis may be at higher risk for substance related negative outcomes, and were more likely to report a history of illicit substance, alcohol, and tobacco use.22 A more recent study of 57,000 people showed that medical marijuana users are more likely to use prescription drugs medically and non-medically, and included pain relievers, stimulants, tranquilizers, and sedatives.23 There is also evidence that state medical marijuana laws lead to the probability people will make Social Security Disability claims.24

There is sufficient and expanding evidence demonstrating that medical marijuana use will not curb the opioid epidemic. There is further evidence that marijuana is a companion drug rather than substitution drug and that marijuana use may be contributing to the opioid epidemic rather than improving it. Although there are patients who have successfully weaned off of their opioids and use marijuana instead, the evidence that marijuana will replace opioids is simply not there. Medical provider and patient awareness, utilization of prescription drug monitoring programs, widespread availability and use of naloxone, and increasing coverage for atypical opioids and abuse deterrent formulations are only some of the other factors that hopefully will contribute to any impact on the opioid crisis. Education and prevention efforts as well as medication-assisted therapies will be additional benefits to impact the opioid epidemic. 

Physicians should continue to monitor their patients closely, perform random drug testing to detect opioid misuse or aberrant behavior, and intervene early with alternative therapies when possible. Marijuana alone is certainly not the answer.

Kenneth Finn, MD, is with Springs Rehabilitation, PC, Colorado Springs, Colorado. He is Board Certified in  Physical Medicine and Rehabilitation and Pain Management and Medicine.

References

1. National Institute of Drug Abuse, Overdose Death Rates, Revised September 2017

2. Bachhuber MA, Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010  JAMA Intern Med. 2014; 174(10):1668-1673

3. Livingston, M; Recreational Cannabis Legalization and Opioid-Related Deaths in Colorado, 2000–2015; American Journal of Public Health; 2017; 107(11): 1827-1829

4. Bradford, AC;  Medical Marijuana Laws Reduce Prescription Medication Use In Medicare Part D;  Health Affairs. 2016;35:1230-1236

5. Bradford, AC;  Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population JAMA  Intern Med. 2018; April 2, 2018: E1-E6

6. Colorado Department of Public Health and Environment, Vital Statistics Program 

7. Soeken, KL;  Selected CAM therapies for arthritis-related pain: the evidence from systematic reviews; Clin J Pain. 2004 Jan-Feb; 20(1); 13-18.

8. Whiting, PF;  Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA 2015; 313(24); 2456-2473

9. Robledo, P; Advances in the field of cannabinoid--opioid cross-talk. Addiction Biology. 2008 13: 213-224

10. Scavone JL;  Cannabinoid and opioid interactions: implications for opiate dependence and withdrawal; Neuroscience 2013; 284: 637-654

11. Pickel VM; ChanJ,KashTL,etal.Compartment-specificlocalizationof cannabinoid 1 (CB1) and mu opioid receptors in rat nucleus accumbens. Neurosci. 2004;127:101–112. 

12. Tanda G;  Cannabinoid and Heroin Activation of Mesolimbic Dopamine Transmission by a Common µ Opioid Receptor MechanismScience 27 Jun 1997 (276); Issue 5321: 2048-2050

13. National Survey of Drug Use and Health, 2013 & 2014 

14. Lynskey MT;  Early onset cannabis use and progression to other drug use in a sample of Dutch twinsBehavior Genetics. 2006; 36(2): 195-200

15. Whiting, PF;  Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA 2015; 313(24):2456-2473

16. National Academies Press; The Health Effects of Cannabis and Cannabinoids:  The Current State of Evidence and Recommendations for Research; 2017

17. Nugent SM; The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms, A Systematic Review; Annals of Internal Medicine; 15 Aug

18.  Allan GM;  Simplified guideline for prescribing medical cannabinoids in primary care Canadian Family Physician Vol 64, February 2018: 111-120

19. Olfson M; Cannabis Use and Risk of Prescription Opioid Use Disorder in the United States;  American Journal of Psychiatry. 2018; 175(1): 47-53

20. DiBenedetto DJ; The Association Between Cannabis Use and Aberrant Behaviors During Chronic Opioid Therapy for Chronic Pain; Pain Medicine 2017; 0: 1-12

21. Smaga S; In adults with chronic low back pain, does the use of inhaled cannabis reduce overall opioid use?; Evidence Based Practice 2017; 20(1), e10

22. Craner SA;  Medical cannabis use among patients with chronic pain in an interdisciplinary pain rehabilitation program: Characterization and treatment outcomes. J Subst Abuse Treat. 2017. Jun; 77:95-100

23. Caputi TL;  Medical Marijuana Users are More Likely to Use Prescription Drugs Medically and Nonmedically; Journal of Addiction Medicine, April 2018; 1-5

24. National Bureau of Economic Research, February 2018

 

Governor Recognizes 15 Years of Texas Tort Reforms

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It’s a milestone so big for Texas medicine, it was worthy of official recognition from the governor.

Gov. Greg Abbott honored the 15th anniversary of Texas’ medical liability reforms on Sept. 1 with an official proclamation.

“Passed in 2003, Texas’ medical liability reforms have been nationally considered the gold standard for medical liability legislation,” the proclamation says. “Tort reform has significantly reduced lawsuits and liability costs in our state and contributed greatly to the increasing number of doctors practicing in Texas.”

House Bill 4, the Medical Malpractice and Tort Reform Act of 2003, went into effect on Sept. 1 of that year, thanks to advocacy by the Texas Medical Association, Texas Alliance for Patient Access (TAPA), Texas Medical Liability Trust (TMLT), and others. The same month, Texas voters approved Proposition 12, an amendment to the Texas Constitution that authorized the state legislature to cap noneconomic damages in health care liability cases.

That vote protected the law’s $250,000 limit on noneconomic damages against individual physicians, and a total “stacked” noneconomic cap of $750,000 if health care institutions also are found liable. The law features other crucial protections, such as providing personal immunity to physicians working for governmental entities, including state medical schools. There is no cap on economic damages.

“Texas’ medical liability reforms have been nationally considered the gold standard for medical liability legislation,” Governor Abbott said today. “Tort reform has significantly reduced lawsuits and liability costs in our state and contributed greatly to the increasing number of doctors practicing in Texas.”

The September issue of Texas Medicine looked at how those reforms have shaped health care in Texas, including adding to an influx of physicians in the state.