Dr. Baraf said he frequently hears doctors say that if it weren’t for speaking engagements and other ways of supplementing evaluation and management income, they wouldn’t be earning a living. That kind of outlook doesn’t sit well with him.
“I’ve got to tell you, it’s pathetic, because the most important service we provide is patient care—face-to-face patient care, office visits, decision-making, counseling,” he said. “And if we can’t protect the value of that, what do we have, and what’s the future of the specialty?”
Managed care has brought about a stagnation in fees, carve-outs for ancillary services, inequalities in negotiation, a feeling of powerlessness, patient dissatisfaction and backlash, and a failure of the “resource-based relative-value scale,” which equates office visits with surgery in an attempt to redistribute wealth, Dr. Baraf said.
The Three As
He boils the essentials of managed-care contracting down to the three As: attitude, analysis, and action.
- The right attitude is having the expectation that you’ll be paid fairly, in a way that accounts for staff salaries and benefits and other overhead, and things like being able to pay off your medical education debt, pay for your children’s education, and saving for retirement. “The payer will give you as little as you’re willing to accept,” Dr. Baraf said. “That’s the contract that you signed.”
- An analysis of your business should include evaluating whether your time spent seeing patients who are in a particular plan is in proper portion to the revenue you receive from that plan. The effect of carve-outs for ancillary services you provide, of hassles like automatic downcoding of office visit services (e.g., converting level 4 visits to level 3) and of preauthorizations, and the length of your waiting list should all be part of the equation. “You’ve got to analyze your business,” Dr. Baraf said. “It’s fundamental to practice health. You’ve to do it on a periodic and ongoing basis.” Doctors also have to assess what’s happening in their markets—whether other practices are merging, whether hospitals are buying practices and what they’re offering, and the impact of accountable-care organizations—and what these observations mean for their practices.
- When it comes time to take action and negotiate with a private payer, don’t let it scare you, Dr. Baraf says. You already negotiate all the time with your family, staff, and vendors.
It’s important to be prepared, to stay focused on your goals in a negotiation, to sell yourself realistically but with humility, to understand the other party’s constraints, and to keep up the momentum when negotiations begin, always setting the next meeting at the end of the current meeting. “Everything is negotiable if a plan needs you,” he said.
