Published by Meg Fry on NJBIZ
Lisa Marie Sheppard said health care used to be based on what the doctor thought was best.
“Now, care is based on group population costs,” she said.
Sheppard, a radiologist specializing in women’s imaging, is the owner and medical director of breast imaging and intervention at Pink Breast Centers of Paterson and Flemington, the owner of Personal Touch Radiology in Princeton Junction and medical director of Pennsauken Imaging in Pennsauken.
She is very close to the subject as both a physician and a women’s advocate. And she feels some of the decisions being made by government agencies are bad for small health care businesses and women’s health care.
“The leading thought now is, ‘If we let women get cancer, it is cheaper to treat them than to provide mammograms.’ Well, I don’t want to get cancer. I don’t want to hear that it is cheaper to treat me than it is to screen me.”
There’s a lot at stake — and a lot of conflicting information — when it comes to managing women’s health care in New Jersey moving forward.
Recommendations put forth by the U.S. Preventive Services Task Force, or USPSTF — and enforced, as of next year, by the Medicare Access and CHIP Reauthorization Act — are making it difficult for women to advocate for their own health in a state where the costs to both practice and receive care are already high due to dwindling funding and ongoing restructuring.
“Women need to be made aware and start writing in to their local congressmen and state representatives so that coverage will continue to be mandated,” Sheppard said.
The USPSTF is not gender-balanced. And it does not include a radiologist.
And therein lies a problem, Sheppard said.
“It is a black box committee,” she said. “No one knows how you get appointed. And they are the ones deciding what Medicare and insurance companies will pay for.”
The USPSTF currently recommends that women only between the ages of 21 and 65 receive screening for cervical cancer every three to five years — and that women only between ages 50 and 75 receive screening for breast cancer every other year, unless there is hereditary risk.
According to Sheppard, the USPSTF buried the release of information stating that coverage currently mandated by the Affordable Care Act for biannual mammograms for women over 40 was going to be reviewed.
“It was a mini-announcement smack dab in the news covering the presidential primary election in May,” Sheppard said. “I only noticed it because I am in the business.”
Then, just last month, Sheppard said, the USPSTF again buried information concerning the review of the necessity of annual “well-woman” pelvic examinations.
“They announced (it) the Friday before the Fourth of July this year,” Sheppard said. “How do you even know you’re at risk for ovarian cancer unless your gynecologist tells you?
“Every time I hear these things — ‘Mammograms won’t be paid for except between the ages of 50 and 75 every other year; Pap smears are needed only every five years’ — that to me is a concerted march toward poor women’s health.
“These (recommendations) are being pushed and that is a problem.”
Health care professionals are divided on how these recommendations affect the way the industry is structured.
Dr. Mary Campagnolo has quite a resume. She is a past president of the Medical Society of New Jersey and a family physician, geriatrician, medical director for graduate medical education and chair of the department of family medicine for Virtua North within the Marlton-based Virtua Health System.
Campagnolo said she sees both the benefits and challenges of relying on research-based recommendations to decide how care is reimbursed.
“The U.S. Preventive Services Task Force is a multidisciplinary group, fairly stringent in their academic vigor, that is trying to balance and decipher what is scientific literature, what is in self-interest and what is true evidence,” she said.
“MACRA, in theory — which most physicians agree with and advocate for — pays based on value rather than volume of care. Federal regulations are now being carefully reviewed and physicians are uncertain about how to approach the requirements, including use of their electronic health records, and how best to report quality metrics for patient care.”
Linda Schwimmer, CEO and president of the New Jersey Health Care Quality Institute in Princeton, believes MACRA, which is expected to be finalized by Nov. 1, is one way to reduce unnecessary health care costs.
“Moving forward, whether it’s the government or private insurance, all payers will be paid based on outcomes as opposed to volume of procedures and visits,” she said. “They will be looking at doctors and asking, ‘Are they providing the best evidence-based medicine? What are the outcomes of their patients?’
“We don’t want to subject women to tests, stress or radiation they don’t need. That simply increases costs for the overall healthcare system. We are asking physicians to pay more attention to these things and not deliver care that is contrary to evidence.”
With health care spending approaching 20 percent of the national budget, Schwimmer said, payers, providers and patients all need to be “better stewards of (our) resources.”
“We squeeze out other services like education and transportation,” she said. “We should be spending money on evidence-based treatments that make sense — not tests or procedures that physicians themselves say are of little value.”
While MACRA will further encourage the positive development of preventive care methodologies, Campagnolo said, some of the USPSTF recommendations are controversial and are still being evaluated.
“The difference between picking up your cancer this year and picking up your cancer next year is a difference in spades in terms of long-term survival,” Sheppard said. “Through the noise, women have to be concerned and listen to what is being said. For example, we now have treatment-resistant (sexually transmitted diseases), but the health insurers are saying, ‘Don’t worry about it — you do not need a pelvic exam. We’ll pay for your infertility treatments. Maybe.’
“As a woman, I’m flabbergasted.”
Sheppard already is noticing a difference in how women are accessing health care. She said she has seen a reduction of patients due to the recommendations that the USPSTF has put forth.
“We have seen less women coming in for screening because their insurance is telling them they have to come every other year,” she said. “From a cost-benefit standpoint, (practitioners) are saying, ‘Why are we doing (mammograms)? Women don’t want them, so we’re not going to do them.’ You will see less and less availability as women stop getting them.”
Sheppard also anticipates that the number of specialists in New Jersey will continue to decrease.
“What is a gynecologist going to do now, if women don’t need breast exams, pelvic exams or Pap smears?” she said. “You really only need them to deliver babies, but, there aren’t that many babies being delivered anymore.
“We are going to start seeing less gynecologists. Use them or lose them.”
Other health care professionals say the recommendations are not causing the loss of patients but the instability of the industry itself due to constantly changing policies and procedures.
“More and more pressure is being put on having the infrastructure to support the (MACRA) process by using electronic health records and having a large enough staff that can reach out to patients, make sure that they are coming for appointments, and provide support via text messaging and after-hour phone lines and consultations,” Schwimmer said. “All of these things are very difficult for solo practitioners to provide.”
While Schwimmer said this process ultimately will result in better care, patients of solo practitioners may be deterred from continuing to see their physician if they have joined a larger group or hospital system to mitigate additional costs and paperwork that is no longer convenient or in-network.
According to Medscape’s 2016 Physician Compensation Report, the numbers are virtually identical to last year’s: 23 percent of women and 35 percent of men are self-employed.
But younger physicians in particular, Schwimmer said, are heading toward employment rather than private practice in order to avoid the business side of medicine and to obtain more predictable work schedules.
“Doctors graduating now are more interesting in having a balanced lifestyle, particularly in obstetrics and gynecology,” Schwimmer said. “Women have babies 24/7 — solo practitioners are joining hospital-based practices or larger groups to help facilitate that.”
Some of these larger groups and hospital-based practices are attempting to attract those patients who have lost their primary physician or gynecologist due to restructuring.
“Virtua, for example, has been trying to increase the number of women who seek access through our system,” Campagnolo said. “We have developed primary care practices for women, which have been very popular. We have one practice and are expanding to three.”
Sheppard said the loss of clinics and solo practitioners comes at a cost for both providers and patients.
“We believe in what we do and we provide very good care at Medicare rates,” she said. “We give discounted rates to cash-paying patients just like they do at insurance companies.
“But it’s not like in hospitals, where they charge exorbitant numbers to go to a hospital breast center —they charge three to one what we charge.”
Sheppard said the USPSTF recommendations make it that much more difficult for her to continue care at her current rates.
“If we charge $166 a mammogram, and I have to pay my technology staff plus pay for their benefits, then I have to pay for the equipment, then I have to pay for the rent, then I have to pay malpractice —it is a very tight budget,” she said. “Every time they cut reimbursements, it’s like, what do we do now?”
Sheppard said she’s trying to do her part outside of the doctor’s office.
She often speaks on panels and at conferences to encourage women, despite having to navigate the tumultuous health care industry, to get mammograms.
“If they shop around, a mammogram at the Medicare rate is the cost of dinner for four at Applebee’s, and it can save your life,” she said.
“I feel our insurance industry should be covering our Pap smears, our mammograms, our pelvic exams — we are half the population. We need to demand it. And we need to use it when we have the coverage, because otherwise, that gives them reason to say, ‘Women aren’t using it anyway, so we’ll take it out of the plan and see what happens.’”
Under the mandate put forth by the Affordable Care Act, mammograms are currently covered in New Jersey.
“Women should go and get one,” Sheppard said. “They should be very tenacious about using their coverage right now.
“In the next 18 months, the mandate will be reviewed to determine if it’s going to be taken away. This is the period of time where women need to say, ‘We want them. Make sure they are covered. Oh, and we also want to be screened for cervical cancer.’ It should all be covered.”