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This episode of the MGMA Consultant’s Corner series features MGMA Consultant Chris Senkowski, MD, FACS, Professor and Chair of the Department of Surgery at Mercer University School of Medicine Savannah Campus.
Dr. Senkowski has more than 15 years of experience in physician compensation, valuation and practice management, and more than 20 years in the areas of coding, valuation and reimbursement. He has served on the legislative committees for SAGES and SSO and has worked in the public policy space as an advisor to the Robert Wood Johnson Foundation, the RAND Group, and the CMS/Acumen MACRA project, as well as authored numerous articles and a textbook on surgeon reimbursement.
MGMA Sr. Editor Daniel Williams, MBA, MSEM, had a robust conversation with Dr. Senkowski on addressing healthcare staffing challenges in rural areas, improving physician leadership, and the biggest current challenges in coding and reimbursement.
Editor’s note: The following Q&A has been edited for length and clarity.
Q. Talk about your role at Mercer University School of Medicine at the Savannah campus. What are the goals that you're striving for at the medical school there?
A: The medical school here developed out of a need for more physicians in rural areas. … The mission is to create more primary care involvement, including general surgery. When we think about the shortage of general doctors for our population, it’s primary care physicians, pediatricians, OB/GYNs and general surgeons. A big part of our mission is to create a core training program for physicians in the rural or more rural areas of Georgia over urban areas.
We're seeing that when we talk about the expansion of the role of an advanced practice provider (APP) versus a physician, is that because there are not enough physicians around, or is it because the supportive roles are necessary? I think those are getting blurred because of the shortage of physicians right now. Mercer specifically addresses that rural need.
Q. Had you identified that need for rural physicians as you transitioned into this job, or is this something that's come about over time?
A: The 1997 Balanced Budget Act that locked out residency spots in terms of funding is coming back [to bite us], as reported in The Washington Post. In a lot of hospitals, I have a hard time recruiting physicians, whether that be in primary care or in specialties, and we're realizing that you have a better shot at putting physicians in rural areas if they are from a rural area or from particularly that rural area.
A lot of medical schools are now training people with a preference toward those rural areas, particularly from that state or that area, because those are the ones [who] can go back and take care of their communities. We need that desperately in many parts of the country.
Q. When you’re wearing your MGMA Consulting hat, what gets you charged up about that role?
A: Advocating for myself and my partners and my patients drew me into the field. Now as a consultant, I feel like it's easy for me to look at a practice or an issue and snapshot it, and then either drill down the data myself utilizing MGMA resources or teach them how to drill down on that data. And I was humbled by the fact that the knowledge I have — I thought everybody had, and it's not true. It's really gratifying to show a practice where the value is.
Q. Regarding your consulting work with physician leaders at the beginning of their careers, where do you think we still have room for improvement in helping them become better leaders?
A: Currently I'm really concerned about the profit motive in medicine and the private equity influence. I had a senior anesthesiologist last night tell me that only a doctor can practice medicine, but a lot of people can own doctors and tell them how to practice medicine. We must push back against that. We have to remember that as we become employed, we're losing some of our independence and ability to make it happen. Whereas, now the private practice world is probably waning — we don't have the resources, and [tracking] quality metrics is more difficult, but we must command the realm of patient care. Quality and value need to be more of a micro-assessment than a macro-assessment.
Q. When you're consulting with practices, are you hearing some recurring themes regarding their pain points?
A: So, you're looking at a big practice — that's a private practice that still essentially employs their physicians, whether they're partners or not — or you're looking at a larger practice that is part of a bigger system. There's too much emphasis on our revenues. People are realizing it, and they're struggling with how to break out of it. So, for example, maybe a private practice is still working the old method with every payer — they're trying to fight the different systems, the components of how they get their contracts negotiated — very difficult. They're looking at different revenue streams: if they're a specialist, how do they cover the hospital when they don't have time anymore? They're short, so how do they advocate for resources at the hospital level for case management or throughput? How does an outpatient primary care practice look at covering all those quality metrics and IT updates that they can't cover with a conversion factor for Medicare that's going down?
I always talk about the disconnect: If you look at the MGMA numbers on dollar per relative value unit (RVU) compensation, for example, they're generally trending upward for most specialties, and yet the conversion factor is down. There's a value judgment that someone's paying because we were valued, and they didn't pay us, necessarily. Anytime I go into practice, I try to make them understand that connection: You're not an RVU, so you have to figure out where your value comes from and how you maximize it and understand the game so your patients can get proper care.
Q. You are also chair of the American College of Surgeons (ACS) coding and reimbursement committee, and you've authored numerous articles and a textbook on surgeon reimbursement. What are the biggest challenges you're seeing out there right now for coding and reimbursement?
A: We fight the RVU game, and we do believe that the RVU is a metric. I often say it's the currency, but it's not the economy. Many physicians are learning about RVUs, and we struggle to maintain RVUs that are the appropriate values, whether it's a new procedure or we're in the process of valuing telemedicine visits — giving them an RVU value that will translate into payment. But at the same time, we understand that we can't keep running on this hamster wheel of RVUs.
One of my biggest concerns now is quality metrics. In the future, I think we need to understand quality. Does a higher quality surgeon get paid more? I think it's not true. ... We don't really know at the individual level if quality physicians really get reimbursed for what they're doing. We also don't know the basket of motivators for what a physician really wants. Do they want more RVUs, or do they want a more streamlined office process that brings the patients in more effectively? Those are the kinds of issues I'm looking at in the reimbursement world.
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