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Fraud and Abuse Facelift: Proposed Changes to Stark, AKS, and Beneficiary Inducements CMP

Fraud and Abuse Facelift: Proposed Changes to Stark, AKS, and Beneficiary Inducements CMP

As part of its “Regulatory Sprint to Coordinated Care,” the Centers for Medicare and Medicaid Services (“CMS”) and the Health and Human Services Office of Inspector General (“OIG”) released proposals to modernize the Medicare Physician Self-Referral Law (“Stark Law”), Anti-Kickback Statute (“AKS”), and Beneficiary Inducements Civil Money Penalty (“CMP”) (collectively, the “Proposed Rules”). The Proposed Rules add five new Stark Law exceptions, seven new AKS safe harbors, and an additional exception to the definition of “remuneration” under the CMP. Several of the new Stark exceptions and AKS safe harbors relate to value-based arrangements and largely mirror each other. Other new exceptions and safe harbors relate to the donation or use of cybersecurity items and beneficiary incentives in the coordination of patient care. These proposals are by no means final (stakeholders have until December 31, 2019 to comment on them), but if finalized, they may provide more flexibility for physicians and other providers to pursue value-based arrangements, as well as greater clarity with respect to existing Stark Law requirements.

 

Value-Based Arrangements under Stark and AKS

Three new Stark exceptions and four new AKS safe harbors relate to value-based arrangements in which one or more participants in a value-based enterprise (“VBE”) pursue one or more value-based activities and purposes. Value-based purposes include coordinating and managing care, improving quality, reducing costs or growth of expenditures (without reducing quality), and transitioning from fee-for-service care to quality care for a target patient population. Value-based activities include providing items or services (not including a referral), taking an action, or refraining from taking an action, in furtherance of a value-based purpose.

There are separate exceptions and safe harbors for value-based arrangements involving: (i) full financial risk, (ii) meaningful/substantial downside financial risk, and (iii) remuneration for improving quality, health outcomes, and efficiency. Full financial risk means that the VBE is prospectively financially responsible for the cost of all patient care items and services covered by the applicable payor for each patient in a target patient population over a specified period of time. Meaningful/substantial financial downside risk means that a physician is responsible to the VBE for specified percentages of the value of the remuneration paid to the physician or is responsible on a prospective basis for the cost of all or a defined set of patient care items and services for each patient in the target patient population over a specified period of time. For value-based arrangements incentivizing improvements in quality, health outcomes, and efficiency, the proposed Stark exception would allow both financial and in-kind remuneration related to value-based activities and meeting objective and measurable quality and performance targets. By contrast, the similar proposed AKS safe harbors focus more on in-kind remuneration, including anything of value given either to VBE participants to help coordinate and manage patient care and patient engagement tools and supports given to patients to address social determinants of health and incentivize the patient’s participation in their health care. In addition to the mirror exceptions and safe harbors generally described above, the AKS Proposed Rule sets forth an additional safe harbor for remuneration exchanged between participants in a CMS-sponsored model, such as an ACO or bundled payment model.

There are common requirements for each of the exceptions and safe harbors listed above. For instance, the VBE must generally set forth in a signed writing the terms of the value-based arrangement, including a description of the nature and extent of the risk assumed under the arrangement, the value-based activities involved, the target patient population, and the type and cost of the remuneration involved. Additionally, the VBE or VBE participant offering remuneration under a value-based arrangement must not take into account the volume or value of referrals or otherwise condition the remuneration on referrals of patients who are not a part of the target patient population or business not covered by the value-based arrangement.

 

Other Stark Additions and Clarifications

The Stark Proposed Rule contains an additional exception for nominal payments to physicians ($3,500 annually, indexed for inflation) for the provision of items and services to an entity. The new exception applies even if there is no written agreement, provided the compensation does not relate to the volume or value of referrals or other business generated by the physician, does not exceed fair market value, and is commercially reasonable, among other requirements. The Stark Proposal also modifies certain existing Stark exceptions and clarifies a number of definitions. For instance, it adds flexibility to the “Electronic health records items and services” exception to include nonmonetary remuneration in the form of cybersecurity software and services. It also purports to clarify the meaning of “fair market value” and “commercially reasonable.” Although additional clarification of these terms would probably be useful, the Stark Proposed Rule at least clarifies that an arrangement does not have to result in a profit for one or more of the parties in order to be commercially reasonable.

 

Beneficiary Inducements

The Proposed Rules provide additional protection for remuneration to beneficiaries under AKS and the CMP. Under a new AKS safe harbor, beneficiary incentive payments to beneficiaries assigned to an Accountable Care Organization (“ACO”) under the Medicare Shared Savings Program (“MSSP”) would not constitute “remuneration” for purposes of AKS, if they meet the ACO beneficiary incentive requirements under MSSP. Somewhat similarly, the provision of telehealth technologies to patients with end-stage renal disease (“ESRD”) is not considered “remuneration” for purposes of the CMP if the technologies contribute to the provision of telehealth services related to the patient’s ESRD, is not of excessive value, and meets other requirements.

 

Conclusion

This article simply provides a high-level overview of the concepts addressed in the Proposed Rule. A more in-depth review of the Proposed Rules reveals additional requirements and subtle differences in the rules that will be material to parties trying to navigate them successfully.  Again, these rules are far from final. However, they indicate an intentional shift toward value-based care and relaxed regulatory requirements to help foster such care. Physicians and other providers have an opportunity to provide feedback on these proposals and hopefully refine them to workable exceptions that will enable the further adoption of value-based arrangements which are being promoted by current payment policy.

Article submitted by Christopher L. Richard, Esq. with Gilpin Givhan, PC in Montgomery, AL.

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Medical Association Opposes Scope of Practice Expansion Executive Order

Medical Association Opposes Scope of Practice Expansion Executive Order

President Trump issued an executive order on October 3, 2019 as an alternative to “Medicare for All”. Initially, the order was titled “Protecting Medicare From Socialist Destruction” but was changed to “Protecting and Improving Medicare for Our Nation’s Seniors.”

The executive order does include some items that the Medical Association of the State of Alabama supports; however, there are concerns that the language within the order appears to expand the scope of practice of non-physician providers.

President Trump directed the Secretary of Health and Human Services, Alex Azar, to propose a new regulation within the next year that would “eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions, and all other licensure requirements […] that are more stringent than applicable federal or state laws require and that limit professionals from practicing at the top of their profession.”

Possibly the most alarming language found within the order is that President Trump gave Azar only one year to propose regulations that would “ensure that items and services provided by clinicians, including physicians, physician assistants, and nurse practitioners are appropriately reimbursed in accordance with work performed rather than the clinician’s occupation.”

Mark Jackson, the Executive Director of the Medical Association, believes the language within the order should raise serious concerns for physicians in Alabama. “We believe that medical school matters and physicians should always be the head of the healthcare team,” Jackson says. ”Our mission is to promote the highest quality of healthcare for the people of Alabama. Therefore, we fully support physician-led team-based care and will be co-signing a letter with the American Medical Association as well as working closely with our Congressional Delegation to address our concerns.”

View the letter here.

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CMS Is Expanding Its Enforcement Ability

CMS Is Expanding Its Enforcement Ability

Pursuant to a new rule, entitled Program Integrity Enhancements to the Provider Enrollment Process, the Centers for Medicare & Medicaid Services (“CMS”) is expanding its ability to combat fraud and abuse within the healthcare industry.

Under the new rule, CMS will be able to identify individuals and entities that pose a fraud and abuse risk solely based on “affiliations” with other entities that have been sanctioned by CMS. CMS can then take steps to prevent such identified individuals and entities from participating in the Medicare program. At the request of CMS, enrolling providers will disclose
any current or previous “affiliation” with an organization that has uncollected debt (regardless of amount and regardless of appeal status), experienced a payment suspension, been excluded, or had its billing privileges denied or rescinded (regardless of the basis). As used within the new rule, “affiliation” would include, among other things, an individual with 5% or greater indirect or direct ownership interest, officer, director, individual with operational or managerial control, or any reassignment relationship.

The provider community has expressed a number of concerns with this new rule, as the new rule gives a large amount of discretion to CMS without comparable notice or remedy to the provider. Consequently, in light of this new rule, Medicare providers and suppliers need to carefully and thoroughly examine any individual with whom it has an “affiliation” relationship to
avoid negative consequences.

The rule takes effect on November 4, 2019.

Kelli Fleming is a Partner at Burr & Forman LLP practicing exclusively in the firm’s healthcare industry group.

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Guidance on Practice and Ethical Issues

Guidance on Practice and Ethical Issues

The Medical Association’s Office of General Counsel can help guide members on certain practice and ethical issues.  The Office is comprised of the General Counsel, Cheairs Porter, and Paralegal, Angela Barentine.  The General Counsel is the chief legal advisor to the Board of Censors, and provides legal advice daily to the Executive Director.

Mr. Porter, a Montgomery native, started as General Counsel of the Medical Association in December 2012.  He currently has over 23 years of related legal experience, including an advanced legal degree in health law and substantial practice in regulatory health care matters.

Ms. Barentine, a Milbrook native, graduated Magna Cum Laude in 2002 with a B.S. from Auburn University.  She began work with the Medical Association in April 2015.  She has a Master of Public Administration with a concentration in Health Care, and a Certificate in Non-Profit Management and Leadership.  Ms. Barentine has 20 years of related experience.

While the Office is very busy handling a wide mix of contracts, business issues, legislative, administrative law (agency) matters and matters coming from various departments, as well as staffing the Council on Medical Services, it also can provide general guidance on the law in particular areas, such as:

  • Separation from a practice;
  • Starting a practice;
  • Medical records policy;
  • HIPAA issues;
  • Certain prescription drug matters;
  • Overpayments;
  • Ethics;
  • Medicaid; and
  • Some billing and charging issues.

If you are searching for general guidance, please feel free to contact Cheairs Porter at (334) 954-2540 or Angela Barentine at (334) 954-2541 for assistance.

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All Things 401(K): Participants Education, Plan Structure and Assessments

All Things 401(K): Participants Education, Plan Structure and Assessments

The ultimate goal of any retirement plan is for participants to prepare for retirement, but Physicians must also maintain the appropriate structure of the plan. How can you be sure everything is handled correctly? Below, one of our 401(k) plan experts, Jack Adams, answers a few frequently asked questions about 401(k) plan education, structure and design.

Question: How do we prepare our participants for retirement?

Answer: With participants, one of the most important things you want to do is talk to them about the reason they need to save for retirement. Other advisors seem to focus on the investments, but if a participant isn’t properly saving for retirement, they will never reach their ultimate goal. What we do in our retirement meetings, from an education standpoint, is focus on how much a participant needs to be saving to accomplish their goals. Typically, we tell them they need to save eight to ten times their salary, because they will live off about 80% of their pre-retirement income when they retire. This money has to last them 20 to 25 years. So again, getting them to start saving and then try to increase the amount saved each year is going to be important in reaching those retirement goals.

You also want to talk to participants about Social Security. Many people believe Social Security is going to be a large portion of their income at retirement.  During our retirement meetings, we show them an estimate of the percentage of their income that will come from Social Security and what percentage has to be made from their private sources.

I think it is important to educate participants along the way to ensure that they are not surprised when they are 65 years old and ask “am I going to have enough to retire?” The last thing we try to incorporate in every one of our meetings is a retirement estimate. That is something we put on the fourth quarter statement for our clients. We calculate a projected retirement income based on their personal contributions, along with their employer contributions.  When you look at this calculation each year, if the number has gone up, you’re doing the right things.  That number is what you can expect to live on, along with social security, during retirement.

Question: Tell us about the different kind of structures that could be in place for a physician practice.

Answer: Typically, the ultimate goal is to try to get as much of a contribution into the physician’s account as possible while attempting to minimize the required contribution to the rest of the staff. There are different ways you can structure a plan depending on which safe harbor contributions you choose to make. The two options we see most often include a 3% non-elective contribution, which means that every participant would receive a fully-vested 3% contribution based on their compensation or a basic safe harbor match of 100% on the first 3% they defer and 50% on the next 2% deferred. Which scenario a practice chooses depends on the ultimate goal of the practice. If the practice is going to make a profit-sharing contribution in addition to the safe harbor contribution, then choosing the 3% safe harbor, non-elective contribution is often the better approach.  This is because this 3% contribution counts towards satisfying the practice’s minimum required non-elective contribution that each eligible participant is required receive in a cross-tested profit-sharing plan. The two most common types of physician practice profit sharing plan designs are the aforementioned cross-tested design or the integrated design. Depending on the age of the physicians and their ultimate goal, we can look at each plan design to ensure the maximum benefit at the lowest cost.

Question: What can Physicians do to ensure they have the right plan? 

Answer: We recommend that you review your plan or have a professional assist, periodically, to better understand your fees structure, plan design and investments.  When it comes to fees, it can be difficult to understand where they’re coming from, what they’re for and how the they are paid.  In particular, understanding the different ways that fees are structured can reveal some areas for cost savings.

We suggest you find out how your plan advisors are compensated.  They’re often compensated through a 12b-1 agreement or some type of commission-based arrangement within the fund options. Also, it’s a good idea to find out if there is an amount contributed towards record keeping.  We offer plan assessments where we look at your plan’s design, fees, investment diversification, investment performance and your investment policy statement.  We want to make sure your plan is appropriately designed to get the maximum benefit. During our assessments, we typically find that people determine what they like and don’t like about the plan, and from there, we give them recommendations. The goal is just to understand your plan better.

Article contributed by Jack Adams, Asset Management Member & Retirement Plan Consultant. Warren Averett is an official Gold Partner with the Medical Association.

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RODEO (Real Old Doctors Eating Out) Night at the Bluegill

RODEO (Real Old Doctors Eating Out) Night at the Bluegill

Physicians enjoy each other’s company. Ever since the first day of medical school, physicians have had a shared experience that cannot be equaled in other walks of life. In training, physicians study together and eventually will share call duties during house staff years. Then either in practice or academics develop a bond and camaraderie based on the challenges of the practice of medicine and serving their patients.

In retirement years physicians seek each other’s company in a number of ways including social events, medical associations, and educational forums.

In Birmingham, there are a number of senior physician groups that meet on a regular basis. One such group is referred to as RODEO (real old doctors eating out). For two years, this group has met at the Fish Market in Hoover for lunch once a month. There is no speaker or program for this lunch event, it is just a way for doctors who practiced together for years to stay in touch. I’m told that 15 or more people generally show up for each monthly event.

The Jefferson County Medical Society hosts an event for senior physicians in the Birmingham area the third Tuesday of every month nine months out of the year. This is held at the Jefferson County Medical Society building and is directed by Dr. Pink Folmar. This is generally both a social and educational experience and the speaker will deliver a lecture from 8:30 until 9:30 AM.

Another organization is the New Horizons where medical topics are discussed by senior physicians. Dr. Dick Esham has a similar organization in Mobile, Alabama for senior physicians.

I would like to hear from members of the Medical Association of the State of Alabama about any other groups of physicians that meet on a regular basis throughout the state. It would be worth considering educational programs at your local medical society for senior physicians or other events such as social events that would group these physicians together to enjoy each other’s company.

Please let me know as these groups develop and I will publicize them through the Medical Association of the State of Alabama.

***Pictured in the above photo from left to right

First Row: Bill Jeansonne, Izzy Pike, Floyd Fraser, Joe Fontenot, Frank Long, Green Megginson, Bill Mosley, C. B. Smith, Mike Huddle

Second Row: Conrad Pierce, Dick Esham, John B. Howell, Knut Mueller, Marc Gottlieb, Allen Oakes, Bill Lightfoot, Phillip Butera, David Warren, Dan Reimer

Attendees Not Shown: Bert Park, Ken Brewington, Glenn Gallaspy, Lloyd Gardner, Henry Koch

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Young Physician Conference Agenda Announced

Young Physician Conference Agenda Announced

The Medical Association of the State of Alabama wants to recognize our young physicians and provide them with an opportunity to learn and connect with other physicians who are in a similar stage of life. We understand that the responsibilities of practicing medicine, raising a family, paying off student loan debt all overlap through this time frame, and make burnout a large threat to the physician’s health and well-being.

We are hosting a two-day conference at “The Lodge at Gulf State Park”, a brand new resort on the beautiful Alabama coast. We hope that the relaxing atmosphere will allow our young physicians to recharge and learn at the same time, coming back to their homes and patients full of hope and energy.

Attendance is free for members, and $325.00 for non-members. Spots are limited and once they fill up we will have to close registration. If you have questions contact Meghan Martin at mmartin@alamedical.org.

You can register for the conference at this link. The full agenda can be viewed by clicking here.

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Alabama Medicine Receives Third 2019 APEX Award

Alabama Medicine Receives Third 2019 APEX Award

Alabama Medicine magazine has received its third international award for publication excellence. The APEX 2019 awards were based on excellence in graphic design, editorial content and the success of the entry – in the opinion of the judges – in achieving overall communications effectiveness and excellence.

With 1,278 entries were evaluated in this international competition, there were 507 APEX Awards of Excellence given to recognize excellence in 100 individual categories. In Alabama Medicine magazine’s category of Magazines, Journals & Tabloids, there were 261 award recipients. This category had winners from Singapore as well as the United States, and Alabama Medicine magazine was the only winner in this category from Alabama and one of two winners in the entire 2019 APEX Awards competition from Alabama.

APEX 2019 is the 31st Annual Awards for Publication Excellence based on excellence in graphic design, editorial content and the ability to achieve overall communications excellence. This international competition is sponsored by Communications Concepts.

Alabama Medicine is the official magazine of the Medical Association of the State of Alabama. For more information about the magazine, please contact mjackson@alamedical.org.

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In Memoriam: John Kendall Black Jr., 1939-2019

In Memoriam: John Kendall Black Jr., 1939-2019

Dr. John Kendall Black, Jr., 79, of Huntsville, passed away Wednesday. He was born on August 26, 1939, in Birmingham, Ala., the only son of John K. and Ruby W. Black. In fact, for 13 years, he was the only grandchild in the family.

Dr. Black was educated at Central Park Elementary School and Ensley High School in Birmingham. He graduated with honors from Ensley and received a National Merit Scholarship Award.

In 1956, he entered the University of Alabama in Tuscaloosa on a Combined Degree Program. While at the University, Dr. Black was a member of Kappa Sigma Social Fraternity, Alpha Chi Sigma Chemistry Fraternity and the American Chemistry Society. He received the honorary President’s Medal from the Army ROTC program at the University.

After three years of pre-medical studies, Dr. Black was accepted to the Medical College of Alabama in Birmingham. He began his studies in 1959 and was awarded the Bachelor of Science degree from the University of Alabama in 1960. He graduated from the Medical College in 1963. During his tenure in medical school, Dr. Black also served as a student extern at the Jefferson Hillman Hospital, Caraway Methodist Hospital, and South Highland Hospital.

He served a mixed Medical Surgical Internship at the Jefferson Hillman Hospital’s program from 1963 to 1964. Upon completing his internship, Dr. Black entered the United States Air Force on what was then known as the Berry program. He spent two years on active duty and then six years on reserve duty with the Air Force. While stationed at Maxwell Air Force Base in Montgomery, Dr. Black continued his civic duties by working as an outpatient emergency room physician at St. Margaret’s Hospital.

In 1966, Dr. Black and his family moved to Jacksonville, Fla., where he spent the next four years training in an Orthopedic Surgery Residency with the Jacksonville Hospital’s Educational Programs and the College of Medicine of the University of Florida. During this time, Dr. Black served both as a junior resident as well as the Chief Resident for the Orthopedic Surgery Program. While serving as a resident, Dr. Black also found time to continue his activities as an insurance physician for several of the insurance companies in Jacksonville.

Dr. Black also authored two papers while serving as chief resident: “Leiomyosarcoma of Apparently Vascular Origin,” which was presented to and published by the Duval County Medical Society after being selected the number one research paper for the resident group. He also authored a paper on “Vertical Fractures of the Patella,” which was presented to the Southern Medical Association meeting and published in the Southern Medical Journal.

In 1970, Dr. Black and his family moved to Huntsville where he entered practice with Doctors Denton, Robinson, and Mitchell. During this time frame, Dr. Black served as an attending physician for the Alabama Crippled Children’s Clinic Services in the Huntsville region. In 1971, he was selected to be first team physician for Grissom High School where he served for several years.

As his children grew to be of high school age, Dr. Black was fortunate to be associated with Dr. Bob Sammons as a team physician for Huntsville High School. This association lasted for approximately 15 years, and involved attendance at a great number of athletic competitions both in and out of town, as well as to areas of competition in the high school playoff system.

Dr. Black was certified by the National Board of Medical Examiners in 1964, the Medical Licensure Commission of the State of Alabama in 1964, and the American Board of Orthopedic Surgery in 1972.

He became a member of the Madison County Medical Society in 1970 where he served as chairman of the Madison County Health Industry Committee, a member of the Board of Trustees, Vice President, President, Member of the Board of Censors, and a member of the Madison County Board of Health.

He was also a member of the Medical Association of the State of Alabama since 1970 until his death. He has served as the Chairman of the District 3 Peer Review Committee, a member of the University of Alabama Medical School Advisory Board, and a member of the Medical Scholarship Awards Committee.

Dr. Black served as a member of the House of Delegates and College of Counselors for the Medical Association of the State of Alabama. During this time, he served on the Council of Public Affairs, a member of the Board of Directors of the Alabama Political Action Committee, and became a lifetime member of the College of Counselors. It was also during this time that Dr. Black served as Vice-President of the Medical Association and became its President in 1981.

During his tenure as President, Dr. Black presided over a reorganization of the House of Delegates and College of Counselors which resulted in the development of a Vice Speaker and Speaker position within the Medical Association. He was honored by selection as the first physician to hold each of these positions with the Medical Association of the State of Alabama.  It was also during this time frame that Dr. Black became associated with and mentored by a number of wonderful people in the Huntsville area. They introduced him to others and educated him in the motto “Pay Your Civic Rent”.

As a result, Dr. Black served as a member of the Board of Directors of Blue Cross/Blue Shield of Alabama and served on the Committee that developed the Preferred Medical Doctors Program. In Huntsville, he served as a member of The Huntsville Chamber of Commerce where he also served on the Huntsville Leadership 2000 Committee Development Committee, ultimately serving as a General Chairman for the Leadership 2000 Program.

In 1990, he was appointed Chairman of the Board of the initial Downtown Redevelopment Committee, and in 1996, was selected to a term on the University of Alabama Huntsville Foundation Board.

In 2005, Dr. Black was diagnosed with prostate cancer which required surgery, radiation and other medical treatments. As a result, he directed his energies into serving on the Leadership Council of The American Cancer Society for the North Alabama region. He served as a member followed by election to the positions of Vice-President then as President in 2012. Dr. Black was selected as a community volunteer for the Mid-South Division in 2013. In 2015, Dr. Black was one of 21 volunteers throughout the USA selected to receive the St. George Medal for Service to the ACS.

Dr. Black practiced General Orthopaedic surgery 47 years in Huntsville-Madison County. During this time, he found time to hunt, fish, as well as play golf and tennis.

Most of all, he loved his family, particularly his beautiful wife, Debbie; children, Elaine and her husband, Gaius, and Kendall III; as well as Debbie’s children, Misty, Brad, and Chad. He and Debbie have nine grandchildren: Abby, Patrick, Bailey, Ashlyn, Elise, Marley, Brayden, Addison, and Hendrix.

Visitation will be from 1 to 3 p.m. on Sunday, July 28 at Laughlin Service Funeral Home. The memorial service will follow in the chapel with the Rev. Coy Hallmark officiating. A private family burial will follow.

In lieu of flowers, memorials may be made to the American Cancer Society.

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What Does “Physician Retirement” Truly Mean?

What Does “Physician Retirement” Truly Mean?

*Editor’s Note: This is the first in a series of articles from the Senior Physician Section. This first article is contributed by Jack Hasson, M.D., Senior Physician Representative.

Physicians do not retire. They may leave the practice of medicine, but they remain physicians throughout their entire life. It is their inner being…their soul.

Most of us enter our profession as a calling to care for people, and we develop skills that would allow us to help others, using those skills to make a better and healthier life for our patients.

Thus, physicians may leave the practice of medicine, but they never stop being physicians, because medicine is their life. There is then a subtle distinction between medicine as work, which may change over time including retirement, as opposed to medicine as a calling, and a compassionate drive to care for others that never leaves us.

This transition of our practice of medicine over time should be planned, but this is rarely done as we do with other things in our life such as planning for long-term financial security. Physicians have no guidelines for long-term practice security, and this issue needs to be addressed.

I will try through these publications to have senior physicians discuss their success in the continuation of the practice of medicine as they age. Through these different but in their own way successful transitions of the practice of medicine over time, younger physicians can begin to think about long-term planning for their continued enjoyment of their goal of serving patients throughout their lifetime.

My own story is about the practice of pulmonary and critical care medicine as I left my training, which was very demanding, including a demanding call schedule with late nights in the ICU. As a young physician, I didn’t miss a beat, balancing family, my running schedule, community service, and hospital committees and offices with no loss of energy or fatigue. It was not until I was in my 50s that I would tire more easily, especially after a long weekend call, and as with most of us, I didn’t want to admit I was aging. After all, I was still healthy and running marathons. In my 60s, I realized I could not sustain the pace of my practice and consider retirement, but I still felt healthy and still enjoyed the practice of medicine. I was fortunate in the ability to be able to make the transition to a pulmonary clinic practice with no hospital duties are night call and this was a game changer for me. I was young again and never fatigued, and was able to continue the practice and love of medicine, but with a pace, I could handle without tiring. I was lucky. This was not a planned move on my part but aging forced the issue.

I would recommend a career planning process for young physicians. They should make these plans just as they make financial plans for their future. Making transitions to different types of practice that will not stress or fatigue one as you age should be made earlier rather than late before burnout consumes a love of medicine that may not be rekindled. Looking back, I would have earlier in life planned my options for new careers in medicine that over time would be less stressful to me and more enjoyable as I aged. Ideally, a seamless transition to these less stressful options would be best.

I was once told by a physician that wisdom comes with age, but sometimes age shows up all by itself. Let’s hope without professional life choices, we show a little wisdom as we age, and choose a path that keeps us as practicing physicians in some capacity throughout our life.

For Medical Association members interested in more information about the Senior Physician Section, please contact Lori M. Quiller, APR.

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