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Conversation With: TMA President Dr. Rick Snyder Wants Physicians to ‘Be More Like Lawyers’

The Dallas cardiologist on why nurse practitioners shouldn't be independent and why healthcare should embrace artificial intelligence.

Dr. Rick Snyder is one of the most active advocates for physicians in the state and wants other physicians to recognize the importance of advocacy to help guide care in Texas. He is now in the early days of his term as Texas Medical Association president after being elected last year.

Snyder is the president of the Dallas-based cardiology group HeartPlace and has previously served as vice-chair, secretary, and chair of the Texas Medical Association board of trustees. He is active in TEXPAC, TMA’s political action committee, is a past president of the Dallas County Medical Society, has chaired the department of medicine at Medical City Dallas, and served as medical staff president and board trustee there. D CEO magazine profiled him and his wife, Shelley Hall, a heart transplant cardiologist at Baylor Scott and White, last year. He got his start in advocacy through the American College of Cardiology and hasn’t looked back.

As this year’s legislative session moves into a special session, Snyder spoke with D CEO Healthcare about what he sees as the most pressing legislative, regulatory, and legal issues facing physicians in Texas and how the physician community has and can work with the city and county for future health emergencies.

D CEO Healthcare: How did you first get into physician advocacy?

Snyder: “My first official involvement in organized medicine started with the American College of Cardiology and our medical liability crisis in the early 2000s when I realized that science and education were not the preeminent factors determining access to care. It’s literally etched in stone in the national headquarters for the American College of Cardiology in D.C.: ‘Quality care through science, education, and advocacy.’ Advocacy is, in my opinion, far and away the most important part because, at the end of the day, it doesn’t matter if you have a patient who meets every clinical indication and has no exclusion criteria. it doesn’t matter if their clinical confidence  intervals are clean and the p value has six zeroes. If that test or procedure isn’t covered, it will not happen.”

D CEO Healthcare: How have Dallas physicians come together in the past to solve problems for the region?

Snyder: “When I was DCMS president, we had the West Nile crisis that year. What triggered the county medical society’s involvement because in June of that year and we already had around 18 to 20 people who knew who had gotten it, and several had died. The doctors came together to save the city. It had nothing to do with the science because the science was clear; we needed to spray from the air. But when our doctors met with Dallas County Health and Human Services, they said we’re absolutely not going to spray from the air. It had nothing to do with science and everything to do with politics. That’s when we got involved, and we met with Clay Jenkins. He even said what changed the tide was the county medical society getting involved (Read D Magazine’s 2013 feature about how doctors came together to save the city here).

D CEO Healthcare: Where could the physician community grow to become more effective?

Snyder: “Advocacy is the one area where doctors need to be more like lawyers  For lawyers it is a universal part of their culture, like it is part of their DNA to be part of the political process and advocacy. There used to be the old Norman Rockwellian vision of a physician. I know that it’s almost heresy to say doctors need to be more like lawyers, but this is the reality. As physicians, we have just as much impact, if not more, on the health care our patients receive through our work in legislative chambers as we do in exam rooms and operating rooms. We need to make the hallways and the capitol buildings in Austin and D.C. as familiar as those in our own hospitals.”

D CEO Healthcare: There is a lot of discussion about improving healthcare coverage and expanding Medicaid. What is the debate missing?

Snyder: “We know there’s a lot of discussion about coverage in the legislature, and for us, it is thinking about the wrong thing. It shouldn’t be coverage–it should be access, access, access. Coverage is not the same thing as access, and access to a waiting list is not the same thing as access to healthcare. If your coverage plan affords you the ability to see a physician two counties away or two months away, that’s not meaningful access to care. Timeliness is as much a quality factor as any other. Dak Prescott can throw a perfect quality spiral 60 yards down the field, getting the exact spot he intended, but if it gets there late, it’s incomplete, or worse, it’s intercepted. So timing is critical. Our gold standard must always be timely access. Rural broadband is going to be key for access to the rural community because Texas has a lot of unique challenges to the delivery of healthcare because of its size and geography. You can expand Medicaid all you want, but if it doesn’t translate into meaningful access, it does not matter.”

D CEO Healthcare: Nurse practitioner advocates argue that one way to improve access is to allow nurse practitioners to practice independently as they do in dozens of other states. Why do you disagree with this change?

Snyder: “Most patients are going to want someone who’s had clinical training of 7,000 hours versus 600 hours. A lot of what we do is experienced based. An MD goes to medical school for four years, has an M.D., and has several thousand hours of clinical training, and if they want to practice as a clinician, they still have to go on and do an internship and residency. There are a lot of legislative efforts to allow nurse practitioners and physician assistants who have six to seven hundred hours of clinical training to have an independent clinical practice. We don’t let medical students with M.D.s do that, so we need to push back on that. We had a lot of nurse practitioners, and PAs start seeing patients with chest pain come into the ER. They would make the clinical decision, and we found out the cost of seeing those patients went up dramatically. You need six to seven thousand hours of experience to know when a patient’s chest pain is not their heart and have the competence to send them home as opposed to admitting everybody and getting a CT scan and nuclear strategy in a hospital admission.”

D CEO Healthcare: How are finances impacting the physician-patient relationship?

“Many physician practices are under a lot of strain to stay open. We see a lot of independent practices folding because they cannot stay economically viable with our current medical economic system, and many of them are becoming employed by hospitals employed by payers. We, as the TMA, have to stand up for them and to ensure that their patient-physician relationship and those models enjoy clinical autonomy and are independent. There are a lot of third parties that are trying to insert themselves in that patient-physician relationship and insert themselves in applying regulations that are not based upon science but upon economics and politics. Insurance companies especially are trying to diminish what it means to be a physician and redefining and relegating the physician role to that of a provider and replacing us with nurse practitioners and PAs.”

D CEO Healthcare: What is site neutrality, and why is it an important priority for TMA?

Snyder: “On the cost efficiency issue, one of the key issues is site neutrality. For Medicare, there are two different fee schedules. One is for the hospitals, and another is the physician fee schedule. If a hospital buys a physician practice, they can then apply the hospital fee schedule, so an echocardiogram in my office is $132.70, but the exact same procedure in the hospital outpatient departments is $503.13. The difference in the Medicare allowable for nuclear stress tests is $410.56  in my office vs $1,607.33 in the hospital outpatient department. For many codes  it is 3-4x  more expensive. If my group were employed by a hospital system, the  increased cost to the federal government on a yearly basis  is $16.7 million doing  the exact same echocardiograms and nuclear stress tests in the exact same offices by the same patients by the same doctors. If you enact national comprehensive site neutrality in totality, it would be  $300 billion in savings over 10 years.”

D CEO Healthcare: AI is increasingly impacting every industry. What are your thoughts about how the healthcare industry should work with the change?

Snyder: “We’ve had AI interpret our EKGs, and I’ll tell you easily 10 to 20 percent of it is wrong. Not only wrong but wrong in a big way. We still have the EKGs with the computer interpretation, but we still have a physician read over them. We’re talking about maybe forming an ad hoc committee on AI (in TMA) on how we integrate AI into clinical practice because I think this is something we need to embrace. I think it is the future. I think there are a lot of benefits with AI if it’s rolled out appropriately, and I see AI as something which assists and augments the physician. If you’re reading a scan, your eye cannot see all the different pixels or discern some changes in pixels that a computer can see. I don’t think it’s ever going to replace a clinician, but I certainly think it could assist and augment our thought processes.”


Will Maddox

Will Maddox

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Will is the senior writer for D CEO magazine and the editor of D CEO Healthcare. He's written about healthcare…