What to Expect from Obamacare

“I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them.”

-Thomas Jefferson

The Supreme Court decision is in and the election is over. Obamacare, or the Patient Protection and Affordable Care Act (ACA), will become reality, but questions remain on what it will look like. ACA had three goals: 1. Expand coverage to the poor; 2. Control costs; and 3. Improve care. These are all laudable goals but it is unclear if they can be achieved. Experience from Federal-run health systems such as Center for Medicare and Medicaid Services (CMS) and the Veterans Administration (VA) provide some clues as do recent Federal actions and the Massachusetts health care system.

Expand Coverage to the Poor

The US has about 60 million uninsured and one of the ACA goals is to come as close as possible to achieving universal healthcare coverage. In order to do this, the ACA depends heavily on Medicaid, a joint Federal-state health benefits program, to reach the goal of near-universal health care. If every state participated, 17 million uninsured people would gain coverage through Medicaid and the Children's Health Insurance Program between 2014 and 2022, according to the Congressional Budget Office (CBO). These are often the poorest of the poor. The Federal government usually pays for about half to two-thirds of the cost of Medicaid. To encourage states to participate in the ACA, the Federal government upped payment to 100 percent of the cost of covering newly eligible people from 2014-6, after which the share will gradually go down to 90 percent in 2022 and later years.

However, the Supreme Court decision in June, which mostly upheld the ACA, gave states the right to opt out of the Medicaid expansion. At the time of this writing, roughly a third of the states have decided not to participate, a third will participate and a third are undecided (Figure 1).

 

Figure 1. State commitment to expand Medicaid eligibility as of 12/12/12.

Some governors have asked Health and Human Services if they partially expand Medicaid will the Federal Government still pay for the expansion. In response, Health and Human Services Secretary, Kathleen Sebelius, has written a letter to the Nation’s governors saying it is all or nothing. According to the CBO this lack of participation leaves up to 3 million of the poorest Americans without health coverage. Placement of bureaucratic obstacles to discourage eligible persons not to sign up as well as political bickering and their inevitable subsequent lawsuits are likely to further delay care for the eligible. Therefore, it is unclear to what extent the ACA will increase coverage to the poor but it seems unlikely to bring the US any where close to universal healthcare.

Reduce Costs

Clearly medical care costs too much. In order to control the growth in costs it is necessary to know where the growth in spending has occurred. The latest data available is from 2010 and has been the subject of a previous editorial (2). Although there are many categories of health care expenditures, the four largest and their percentages of healthcare expenditures are hospital care (31.4%), physicians (16.1%), pharmaceuticals (10.0%), and net cost of insurance (5.6%). The largest increase in absolute costs was in hospitals which accounted for 39.4% of the increase of the $101.15 billion increase compared to 2009. The largest percentage increase was in net cost of insurance at 8.4% which was much higher than the 3.9% increase overall. Drug costs were not markedly increased at a1.2% increase but the top 12 companies had 310.8 billion in sales and 49.3 billion in profits in 2012 suggesting that the pharmaceutical industry is healthy and profitable (3). Although the Obama Administration often talks tough about reducing costs, especially insurance company costs, it seems unlikely based on their history that there will be a reduction in any of these three categories.

On the other hand, physician salaries have fallen. While the income of dentists, pharmacists, registered nurses, physician assistants, and health care and insurance executives rose by an average 10.2% in 2005-10 compared 2000-4, the income of physicians decreased by 5.8% (4). Although the hourly wage of physicians remains high ($80.00/hr) and remains higher than dentists ($70.64/hr) and lawyers ($54.21/hr), the gap is closing (5-7). This is despite a shortage of physicians (5). Even though the greatest physician need is in primary care physicians, pediatricians, family practioners and general internists remain the lowest paid physicians (8).  

Based on these trends, it seems likely medical costs will continue to rise. However, payments to physicians will probably remain static or decrease. Although the consequences are unclear, the cuts in payment to physicians are not sustainable and will likely drive many physicians, especially primary care physicians, out of private practice. The other consequence may be that some physicians, most likely specialists, may not take insurance with low reimbursement such as Medicare and Medicaid. This would mean that those that can afford to pay out of pocket will receive health care while the poor, the very people the ACA was intended to help, may not. Regardless, it is unlikely that the continual focus on physician reimbursement to control costs will be successful in controlling overall medical expenditures. The 16.1% of healthcare costs attributable to physicians is simply not large enough to reduce the overall costs, especially since physicians have born the brunt of the cuts for the past few years.

The ACA also proposes to reduce costs by paying only for value- and evidence-based care based more for outcomes than procedures. However, this is the approach that has been in place for some time at CMS and has yet to reduce costs. Committees far removed from medical practice have often made poor decisions. For example, patients who need self-catherization were at one time allowed only 4 catheters per month. Some patients had excessive and expensive hospital admissions for urinary tract infections. Presumably the catheters were not properly cleaning their catheter prior to reuse which resulted in the excess hospitalizations. The policy has now been changed to allow up to 200 catheters per month.

Another example is computerized healthcare records. In a January speech, President Obama evoked the promise of new technology: “This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests," he said. However, rather than reduce costs, the opposite happened. With better documentation, physicians billed at higher levels actually increasing costs (9). Response blaming physicians was swift implying physicians committed fraud (10).

Physicians and their patients may find themselves directed to cheaper care even when evidence points to a better but more expensive alternative. As a personal example, I have congestive heart failure and take carvedilol. My insurance company, Blue Cross and Blue Shield, has denied payment for the carvedilol despite evidence that it is superior to their recommended alternative, metropolol (11). The VA and Medicare have had similar policies in place. The difference in cost is about $1/day. I pay for my carvedilol out-of-pocket because in the COMET trial it reduced mortality from 40% to 34% (11). My judgment was that a 6% increase in survival was worth the extra cost. Patients are likely to find themselves in similar situations where if they want care that is not in the guidelines, they will need to pay for it themselves whether it is evidence-based or not.

Improvement in Care

A clue to how the Obama administration plans to improve care was in the 2010 summer recess appointment of Don Berwick as Administrator of the Centers for Medicare and Medicaid Services. Prior to his appointment he was President and Chief Executive Officer of the Institute of Healthcare Improvement (IHI). IHI was a group who convinced many hospitals to adopt a number of their guidelines. These guidelines had two common themes-most were physician focused and many very weakly evidence-based (12,13). CMS began tying reimbursement and compliance with the guidelines. The financial disincentive to accurately report data induced many hospitals to lie about their data (14). Not surprisingly, compliance improved but there has been little evidence for an accompanying improvement in outcomes (14,15). Witness the recent example of central line associated blood stream infections (CLABSI). Based on hospital self-reported data, CMS announced its program reduced the rate of CLABSI (16). Within a month an article appeared in the New England Journal of Medicine reporting the program did nothing to reduce infections or any other outcomes (17).

However, there may be a glimmer of hope. Although there is a continued reliance on weakly evidence-based surrogate markers, CMS has begun looking at mortality, morbidity, length of stay and readmission rates. These patient-centered outcomes have real meaning to patients as well as affecting costs. This may finally force health care administrators to address real care issues rather than performance of surrogate, weakly evidence based guidelines such as administration of pneumococcal vaccine to adults, telling smokers not to smoke without any follow up and providing discharge instructions.

Conclusions

Overall it appears that the ACA will have minimal impact on its goals of expanding care to the poor, reducing costs or improving care for the foreseeable future. It will likely continue to cost shift reimbursement away from physicians while costs continue to rise. Almost certainly it will be entangled in political bickering, eligibility challenges and lawsuits reducing many of the benefits of the law. However, we can probably be assured that CMS will continue to rely on inaccurately reported data, quickly declare their programs successful and stay their course, despite the programs doing little to nothing for patients. When their programs focus on outcomes such as mortality, morbidity, length of stay and readmission rates, real progress can be made in improving patient care rather than “spinning” dubious results.

Richard A. Robbins, MD*

References

1. Kliff S. White House to states: on Medicaid expansion, it’s all or nothing. Available at http://www.washingtonpost.com/blogs/wonkblog/wp/2012/12/10/white-house-to-states-on-medicaid-expansion-its-all-or-nothing/  (accessed 12-13-12).
2. Robbins RA. Follow the money. Southwest J Pulm Crit Care 2012;4:19-21.
3. Fortune. Available at: http://money.cnn.com/magazines/fortune/fortune500/2012/industries/21/ (accessed 12-13-12).
4. Seabury SA, Jena AB, Chandra A. Trends in the earnings of health care professionals in the United States, 1987-2010. JAMA 2012;308:2083-5.
5. US Bureau of Labor Statistics. Avaiable at: http://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm (accessed 12-13-12).
6. US Bureau of Labor Statistics. Available at: http://www.bls.gov/ooh/healthcare/dentists.htm (accessed 12-13-12).
7. US Bureau of Labor Statistics. Available at http://www.bls.gov/ooh/legal/lawyers.htm (accessed 12-13-12).
8. Medscape. Physician compensation report 2012. Avaiable at: http://www.medscape.com/sites/public/physician-comp/2012 (accessed 12-13-12).
9. Haig S. Electronic medical records: will they really cut costs? Time 2009. Available at: http://www.time.com/time/health/article/0,8599,1883002,00.html#ixzz2FF0XBf5d (accessed 12-16-12).
10. Carlson J. HHS inspector general's office quizzes providers about EHR use. Modern Healthcare 2012. Available at: http://www.modernhealthcare.com/article/20121023/NEWS/310239946 (accessed 12-13-12).
11. Poole-Wilson PA, Swedberg K, Cleland JG, Di Lenarda A, Hanrath P, Komajda M, Lubsen J, Lutiger B, Metra M, Remme WJ, Torp-Pedersen C, Scherhag A, Skene A; Carvedilol Or Metoprolol European Trial Investigators. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet. 2003 ;362:7-13.
12. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
13. Hurley J, Garciaorr R, Luedy H, Jivcu C, Wissa E, Jewell J, Whiting T, Gerkin R, Singarajah CU, Robbins RA. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care 2012;4:163-73.
14. Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med 2012;157:305-12.
15. Robbins RA. The emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care 2012;5:203-5.
16. Agency for Healthcare Quality and Research. Available at: http://www.ahrq.gov/qual/clabsiupdate/ (accessed 12-13-12).
17. Lee GM, Kleinman K, Soumerai SB, Tse A, Cole D, Fridkin SK, Horan T, Platt R, Gay C, Kassler W, Goldmann DA, Jernigan J, Jha AK. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med 2012;367:1428-37.

*The views expressed are those of the author and do not necessarily represent those of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. What to expect from Obamacare. Southwest J Pulm Crit Care. 2013;6(1):23-28. PDF 

The Terrific Twos! Annual Report from the Editor

With the end of 2012, the Southwest Journal of Pulmonary and Critical Care (SWJPCC) completed its second year of operation. Our first manuscript was posted on November 11, 2010. We posted 8 manuscripts our first year, 68 during 2011, and 113 during 2012 (Table 1).  

Table 1. Postings by SWJPCC 2010-2.

 

Accompanying our increase in manuscripts, our readership has steadily grown to about 3000/month unique IP addresses and about 9000/month page views (the number of files that are requested from a site, also known as “hits”) (Figure 1).

Figure 1. Growth of unique IP addresses and page views by month during 2012.

We had some big changes in 2012. Some of which are listed below:

• New Mexico and Colorado Thoracic Societies partnered with Arizona in SWJPCC.
• SWJPCC is listed in the Directory of Open Access Journals.
• The Case of the Month was expanded to cases by including a Pulmonary and Critical Care Case of the Month in addition to Imaging.
• A Sleep Board Review Question section was added.
• A “News” section was launched.
• A Medical Image of the Week section was inaugurated.

Many need to be thanked. First, thanks to our authors. You took a chance on a new journal and we appreciate the opportunity to publish your work. Second, thanks to our reviewers.  SWJPCC, like all journals, relies upon expert reviewers in order to publish the highest quality manuscripts. We thank the reviewers for their time and effort in the prompt submission of their reviews. A list of reviewers for 2012 is below.

• David Baratz
• Lee Brown
• Richard Carlson
• John Costantino
• Steven Curry
• Thomas Daniels
• Venu Gopal
• Michael Garrett
• Mark Gotfried
• Michael Habib
• Michelle Harkins
• Steve Klotz
• Kenneth Knox
• Manoj Mathew
• Rakesh Nanda
• Huw Owen-Reece
• James Parish
• George Parides
• Lillibeth Pineda
• Stuart Quan
• Robert Raschke
• Richard Robbins
• Clement Singarajah
• Allen Thomas
• Dona Upson
• Laszlo Vaszar
• Zahid Virk
• Carolyn Welsh
• Lewis Wesselius

Our gratitude goes to the Arizona, New Mexico, and Colorado Thoracic Societies for their support. Thanks to our associate editors who have put in much more work than we had the right to ask. A special note of thanks to those who continue to do regular features in SWJPCC-Bob Raschke and Manoj Mathew for the critical care and pulmonary journal clubs; Mike Gotway, Lew Wesselius and Bob Raschke for the cases of the month; Rohit Budhiraja for the Sleep Question of the Month; and Ken Knox for the Medical Image of the Week; and Peter Wagner for his wine column, Slurping Around with PDW. SWJPCC acknowledges the Phoenix Pulmonary and Critical Care Research and Education Foundation which has provided the monetary support for SWJPCC. Last, and most importantly, thanks to our readers. Please visit as often as you can and feel free to provide us with your input.

What’s ahead for 2013? Yogi Berra was probably right, “It's tough to make predictions, especially about the future.”  We hope to improve the content, especially the scientific content, for 2013, but we will continue to emphasize clinical medicine and education. With the help of Ken Knox, Skip Harris, Mike Gotway, Lewis Wesselius and Clement Singarajah, we hope to begin offering Continuing Medical Education (CME) in the early part of 2013. Although we have learned that the is future hard to predict, we sincerely believe that with your help the SWJPCC will continue to grow and improve.

Richard A. Robbins, MD

Editor, SWJPCC

Reference as: Robbins RA. The terrific twos! annual report from the editor. Southwest J Pulm Crit Care 2013;6(1):1-3. PDF 

Maintaining Medical Competence

“I am free, no matter what rules surround me…because I know that I alone am morally responsible for everything I do.”― Robert A. Heinlein

I recently renewed my Arizona medical license and meet all the requirements. I far exceed the required CME hours and have no Medical Board actions, removal of hospital privileges, lawsuits, or felonies. None of the bad things are likely since I have not seen patients since July 1, 2011 and I no longer have hospital privileges. However, this caused me to pause when I came to the question of “Actively practicing”? A quick check of the status of several who do not see patients but are administrators, retired or full time editors of other medical journals revealed they were all listed as “active”. I guess that “medical journalism” is probably as much a medical activity as “administrative medicine” which is recognized by the Arizona Medical Board. This got me to thinking about competence and the Medical Board’s obligation to ensure competent physicians.

Medical boards focused on preventing the unlicensed practice of medicine by “quacks” and “charlatans” in the first half of the Twentieth Century. The Boards evolved over time to promote higher standards for undergraduate medical education; require assessment of knowledge and skills to qualify for initial licensure; and develop and enforce standards for professional practice. Beginning with New Mexico in 1971, nearly all state medical boards require a prescribed number of continued medical education (CME) hours with Colorado being a notable exception. Colorado’s lack of CME requirements goes against the recent trends. In 2010 the Federation of State Medical Boards (FSMB) House of Delegates voted to adopt a framework for maintenance of licensure to address concerns among policymakers and regulators (1). The FSMB’s framework contains three components: 1. reflective self assessment; 2. assessment of knowledge and skills; and 3. performance in practice.

Self-reflection has long been a mainstay of good medical practice. However, the requirement is vague and most evidence suggests that physicians are not very good at it (2). Assessment and reassessment of knowledge and skills has been present in most medical specialty and subspecialty boards for some time. Furthermore, actively practicing physicians are required to undergo periodic peer review and reapplication for hospital privileges. Further testing and assessment seems costly and largely unneeded. However, medical licensure is above all about seeing and treating patients. What is new is FSMB’s recognition of the importance of active medical practice in determining medical competence. In many instances, policymakers such as chiefs of staff, hospital board members, administrators or members of guideline writing committees have been non- or very limited practicing physicians. Their decisions have often been fundamentally flawed. Quality has been frequently politically defined rather than patient centered and evidence based. In too many cases, hastily adopted guidelines are proven wrong and even potentially dangerous to patients (3).

A physician who directs care should be subject to the “Continued Competency Rule” which is used in Colorado (4). This rule requires that a physician, “if not having engaged in active practice for two or more years…be able to demonstrate continued competency”. It needs to be recognized that those who meet this standard are only competent in their own area of practice. For example, a pulmonary and critical care physician has no business directing neurosurgical care or formulating orthopedic guidelines. Administrative medicine, and for that matter, medical journalism, would do not meet this standard of competency since neither involves taking responsibility for the care of patients. The requirement for physician administrators to be really active in the practice of medicine may be one key to improved medical care and competence. At least it should make them think about directing care or mandating a guideline that they, themselves have to follow.

Richard A. Robbins, MD*

References

1. Chaudhry HJ, Talmage LA, Alguire PC, Cain FE, Waters S, Rhyne JA. Maintenance of licensure: supporting a physician's commitment to lifelong learning. Ann Intern Med 2012;157:287-9.
2. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 2006;296:1094-102.
3. Robbins RA, Thomas AR, Raschke RA. Guidelines, recommendations and improvement in healthcare. Southwest J Pulm Crit Care 2011;2:34-37.
4. http://www.dora.state.co.us/medical/ (accessed 11/5/12).

* The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. Maintaining medical competence. Southwest J Pulm Crit Care 2012;5:266-7. PDF

Interference with the Patient–Physician Relationship

“Life is like a boomerang. Our thoughts, deeds and words return to us sooner or later, with astounding accuracy.”-Brant M. Bright, former project leader with IBM

A recent sounding board in the New England Journal of Medicine discussed legislative interference with the patient-physician relationship (1).  The authors, the executive staff leadership of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American College of Surgeons believe that legislators should abide by principles that put patients’ best interests first. Critical to achieving this goal is respect for the importance of scientific evidence, patient autonomy, and the patient-physician relationship. According to the authors, lawmakers are increasingly intruding into the realm of medical practice, often to satisfy political agendas without regard to established, evidence-based guidelines for care.

The article goes on to cite examples including:

1. The Florida Firearm Owners’ Privacy Act, which substantially impaired physicians’ ability to deliver gun-safety messages to patients.
2. New York legislation requiring physicians to offer terminally ill patients information and counseling regarding palliative care and end-of-life options.
3. A Virginia bill requiring women to undergo ultrasonography before an abortion including mandated transvaginal ultrasonography in some instances.
4. Pennsylvania, Ohio, Colorado, and Texas legislation limiting a physician’s ability to disclose information about exposure to chemicals such as benzene, toluene, ethylbenzene, and xylene used in the process of hydraulic fracturing (“fracking”).

The authors condemn these actions that undermine physician autonomy and the fundamental principles of respect for patient autonomy, beneficence, nonmaleficence, and justice that shape physicians’ actions and behavior. The authors go on to state that “laws and regulations are blunt instruments… that reduce health care decisions to a series of mandates …for political or other reasons unrelated to the scientific evidence and counter to the health care needs of patients”. However, these legislative actions are an extension of the trend where multiple individuals and groups have increasingly dictated patient care.

It would be remiss not to point out that those clinician groups have been as guilty of dictating healthcare as some of the politicians by publishing or endorsing mandates for care. As the authors state mandates “do not allow for the infinite array of exceptions-cases in which the mandate may be unnecessary, inappropriate, or even harmful to an individual patient”. Although the authors would likely argue that they publish guidelines rather than mandates, their guidelines have as much authority as laws given that both threaten a physician’s ability to practice. Penalties for noncompliance with guidelines such as removing hospital privileges, reducing payments or listing physicians in the National Practioner Database are as much a threat to physicians as legislative action.

These clinician groups would also likely argue that their guidelines are evidence-based and in the patient’s best interests. However, there are multiple instances where the mandates are not evidence based and ineffective (e.g., pneumococcal 23 polyvalent vaccine in adults) (2-4) or even harmful (e.g., tight control of glucose in the ICU) (5). Patient autonomy and individual needs, values, and preferences must be respected. Physicians must have the ability and freedom to treat their patients “freely and confidentially, to provide patients with factual information relevant to their health, to fully answer their patients’ questions, and to advise them on the course of best care without the fear of penalty” (1).

These clinician groups should speak out against political mandates or when the scientific evidence is premature, weak or contradictory regardless of the source. Medical guidelines should have patients' best interests at heart and not political agendas whether from politicians or others. Importantly, these clinician groups should “recognize the infinite array of exceptions” to each mandate or guideline. Finally, they should condemn the practice of allowing regulatory agencies to promote a political or financial agenda by threatening physicians to conform to the ever increasing numbers of mandates and guidelines that are based on poor quality evidence. Those that are members of the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, or the American College of Surgeons who agree that mandates undermine the physician-patient relationship and ultimately adversely affect patient care should speak loudly to their executive staff leaders to ensure their voices are heard. Better ways of informing clinicians of best current practice are needed, but also needed are ways of making the accomplishment of best practices easy and rewarding, rather than punitive.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Weinberger SE, Lawrence HC 3rd, Henley DE, Alden ER, Hoyt DB. Legislative interference with the patient-physician relationship. N Engl J Med 2012;367:1557-9.t
2. Fine MJ, Smith MA, Carson CA, Meffe F, Sankey SS, Weissfeld LA, Detsky AS, Kapoor WN. Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials. Arch Int Med 1994;154:2666-77.
3. Dear K, Holden J, Andrews R, Tatham D. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Sys Rev 2003:CD000422.
4. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ 2009;180:48-58.
5. Robbins RA, Singarajah CU. Critical care review: the high price of sugar. Southwest J Pulm Crit Care 2011;3:78-86

The views expressed in this editorial are those of the author and not necessarily the views of the Arizona, New Mexico or Colorado Thoracic Societies.

Reference as: Robbins RA. Interference with the patient-physician relationship. Southwest J Pulm Crit Care 2012;5:253-5. PDF 

Guidelines for Starting Today’s Private Practice

Starting a new practice may seem like a daunting task. The purpose of this editorial is to demystify the process of creating a new practice from the beginning. The cardinal rule is to keep costs low and not to outsource work that can easily be performed by any competent physician and staff. You do not need a manager, lawyer, business partner, coder or biller individually; you may be able to perform many of these services yourself. What you do need is a commitment to making your practice a success. 

Do not spend too much on your office space, furnishings or equipment. Start with the bare essentials. Immediately start applying to all insurance companies especially Medicare. Request an employer identification number. Set up a basic business banking account and submit the account number to the insurance companies you plan to work with.

You can purchase an entire electronic healthcare record (EHR) system or you can create your own EHR using basic word processing software, a free electronic prescription account and inexpensive billing software. Purchase malpractice, business and personal health insurance. Consider using a temp agency for staffing. 

High quality notes and good physician communication is paramount to success. Give community lectures and grand rounds at local hospitals. Introduce yourself to physicians by joining the local medical society, visiting other practices, applying for medical staff privileges and mailing an introduction letter. With the help of this paper you will be able to create your own private practice without delay.

Evan D. Schmitz, MD (evandschmitz@gmail.com)*

April Y. Schmitz, RN*

Hoan P. Tran, MD**

* The authors are in private practice in Richland, Washington and have no conflict of interest to declare.

** The author is in private practice in Yakima, Washington and has no conflict of interest to declare.

The views expressed are those of the authors and do not necessarily represent the views of the Arizona, New Mexico or Colorado Thoracic Socieities.

Reference as: Schmitz ED, Schmitz AY, Tran HP. Guidelines for starting today's private practice. Southwest J Pulm Crit Care 2012;5:229. PDF