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Medical Economics

The New Tr AND pre um side p nt’s imp act on doc tors

That’s what doct uman connect.” ors are good at. ion. ” —Melissa Lucarelli, MD

MedicalEconomics.com

DECEMBER 25, 2016

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VOL . 93 NO. 24

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TOP 10 CHALLE NG ES OF 2017

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D ECE M B E R 25, 2016

SMARTER BUSINESS. BETTER PATIENT CARE.

FIRST TAKE

BY KEITH L. MARTIN

President-elect Trump: It’s time to bring doctors to the table resident-elect Donald J. Trump campaigned on a promise to “repeal and replace” the Affordable Care Act with better health plans and healthcare for all Americans. Trump’s details are sparse, but most U.S. physicians will not be sad to see the law abolished, if the recent results of our “Obamacare Report Card” (July 25, 2016) are any indication. Just as specifics of this new healthcare plan are a mystery, so are the experts advising the next president. Many media outlets—this one included—sought out these individuals during the campaign, but were never given names or interviews, just word that there are good people working on it behind the scenes. So let me offer the President-elect some advice: Turn directly to the men and women practicing medicine every day. Similar to the American electorate who channeled their frustration and desire for change into the ballot boxes in November, there is a very passionate group of physicians in this country disenchanted with their profession and eager for meaningful reform. Repealing Obamacare is just the beginning. Medical Economics hears regularly from doctors frustrated with third-

P

READ MORE INSIDE

MedicalEconomics. com

party interference with their patients’ care and the numerous hoops they must jump through on a daily basis. The flame inside that keeps them dedicated to medicine is starting to flicker and they are seeking some kind of outlet to express their displeasure with the current state of healthcare.

“There is a very passionate group of physicians in this country disenchanted with their profession and eager for meaningful reform.”

And while I’m sure Presidentelect Trump and his advisers will turn to the usual sources of guidance—the American Medical Association, specialty associations and even federal healthcare agencies— that should be just the start of the effort. I implore him to repeat the efforts of his campaign and connect with those across the nation to get a feel for physicians’ specific pain

points and true barriers they face to providing quality care. These doctors are not hard to find, either. The President-elect can send out a tweet, as he is wont to do, looking for help, give physicians a website to visit, or hey, Medical Economics would be happy to help. The point is that repealing and replacing Obamacare needs to be the first chapter in reforming healthcare, not just a campaign promise to check off. And the new administration shouldn’t worry about knowing what to tackle next. This same cadre of physicians will point them in the right direction, from flaws in “no outcome, no income” care to taking a hard look at some of the questionable practices of health insurers and drug manufacturers. There’s a lot to be done to “make healthcare great again.” If something is amiss with your health, you go see a doctor, not a bureaucrat. So I’d urge our next president to do the same. If you are serious about promoting change for the next four years, this is a good place to start. Keith L. Martin is editorial director for Medical Economics. What other healthcare issues would you like to see the new administration address? Tell us at [email protected]

The top challenges facing doctors in 2017 PAGE 26

MEDICAL ECONOMICS]DECEMBER 25, 2016

5

DECEMBER 25, 2016

VOLUME 93 ISSUE 24 Referenced in MedLine®

Top 10 Challenges of 2017 Doctors discuss solutions to the pressing issues

PAGE 26

40 Chronic care coding

17 Lunch is for losers

Coding experts tackle physician questions about chronic care

Committing to patients is the reward of medicine

D. C. CORNER

Sen. Warren pushes advanced illness care Physicians, not the federal government, should decide what’s best for patients with advanced illnesses, according to proposed bill. PAGE 34

25

42 The doctor shortage Growing the ranks of primary care physicians is of utmost importance 46

IN EVERY ISSUE 8 Your voice 9 Interactive 16 Vitals 61 Advertiser index

25 Avoid visual hacking

62 Funny bone

Seven ways to protect patient data from prying eyes

Temporary work is growing in popularity. Is it right for you?

39 Marketing on facebook How social media can build the practice’s brand

46 Payment deadlines Avoid financial troubles by following these five simple steps

51 The Trump factor How the president-elect may reshape healthcare policy

MEDICAL ECONOMICS (USPS 337-480) (Print ISSN: 0025-7206, Digital ISSN: 2150-7155) is published semimonthly (24 times a year) by UBM Medica, 131 W. First St., Duluth, MN 55802-2065. Subscription rates: one year $95, two years $180 in the United States & Possessions, $150 for one year in Canada and Mexico, all other countries $150 for one year. Singles copies (prepaid only): $18 in US, $22 in Canada & Mexico, and $24 in all other countries. Include $6.50 for U.S. shipping and handling. Periodicals postage paid at Duluth, MN 55806 and at additional mailing offices. Postmaster: Send address changes to Medical Economics, PO Box 6085, Duluth, MN 55806-6085. Canadian GST Number: R-124213133RT001 Publications Mail Agreement number 40612608. Return undeliverable Canadian addresses to: IMEX Global Solutions, PO Box 25542 London, ON N6C 6B2 CANADA. Printed in the USA. © 2016 UBM. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including by photocopy, recording, or information storage and retrieval without permission in writing from the publisher. Authorization to photocopy items for internal/educational or personal use, or the internal/educational or personal use of specific clients is granted by UBM for libraries and other users registered with the Copyright Clearance Center, 222 Rosewood Dr. Danvers, MA 01923, 978-750-8400 fax 978-646-8700 or visit http://www.copyright.com online. For uses beyond those listed above, please direct your written request to Permission Dept. fax 440-756-5255 or email: [email protected] advanstar.com. SMARTER BUSINESS ■ BETTER PATIENT CARE is used pending trademark approval.

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UBM Medica provides certain customer contact data (such as customers name, addresses, phone numbers, and e-mail addresses) to third parties who wish to promote relevant products, services, and other opportunities that may be of interest to you. If you do not want UBM Medica to make your contact information available to third parties for marketing purposes, simply call toll-free 866-529-2922 between the hours of 7:30 a.m. and 5 p.m. CST and a customer service representative will assist you in removing your name from UBM Medica’s lists. Outside the US, please phone 218-740-6477. Medical Economics does not verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damages incurred by readers in reliance of such content. Medical Economics cannot be held responsible for the safekeeping or return of unsolicited articles, manuscripts, photographs, illustrations, or other materials. Library Access Libraries offer online access to current and back issues of Medical Economics through the EBSCO host databases. To subscribe, call toll-free 888-527-7008. Outside the U.S., call 218-740-6477.

MedicalEconomics. com

Cover: JStone / Shutterstock.com (Trump)

35 The locum tenens option

PREVENTION

IS REALITY Sexual History

Testing

Condoms Medication

While traditional HIV prevention methods remain essential and effective, the epidemic continues.1 We have entered an era of HIV prevention in which the National HIV/AIDS Strategy, clinical studies, and the latest federal and global health guidelines (including those from the CDC and WHO) recognize the importance of a comprehensive prevention approach.2-6 Be part of this prevention movement. You can help protect your patients by utilizing a comprehensive approach. Be proactive. Combine routine HIV and STI testing with sexual history conversations and education on the importance of condoms. For HIV-positive patients, initiating and adhering to treatment helps prevent HIV transmission to negative partners. For HIV-negative patients at risk of HIV infection, consider additional prevention methods such as behavioral counseling, PrEP (pre-exposure prophylaxis), and PEP (post-exposure prophylaxis).3 Learn more about using a comprehensive prevention approach, and help end the HIV epidemic.1

Visit PreventHIV.com for more information. CDC=Centers for Disease Control and Prevention; STI=sexually transmitted infection; WHO=World Health Organization. References: 1. Centers for Disease Control and Prevention. Today’s HIV/AIDS epidemic. http://www.cdc.gov/nchhstp/newsroom/docs/factsheets/ todaysepidemic-508.pdf. Published February 2016. Accessed May 16, 2016. 2. Centers for Disease Control and Prevention. HIV prevention in the United States: new opportunities, new expectations. http://www.cdc.gov/hiv/pdf/policies/cdc-hiv-prevention-bluebook.pdf. Published December 2015. Accessed May 16, 2016. 3. Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States—2014: a clinical practice guideline. http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf. Published 2014. Accessed May 4, 2016. 4. World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. http://www.who.int/hiv/pub/arv/arv-2016/en/. Published June 2016. Accessed June 27, 2016. 5. White House Office of National AIDS Policy. National HIV/AIDS strategy for the United States: updated to 2020. https://www.aids.gov/federal-resources/national-hiv-aids-strategy/nhas-update.pdf. Published July 2015. Accessed May 4, 2016. 6. Centers for Disease Control and Prevention. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016. https://stacks.cdc.gov/view/cdc/38856. Published April 18, 2016. Accessed June 1, 2016. GILEAD, the GILEAD Logo, and the PreventHIV.com Logo are trademarks of Gilead Sciences, Inc. or one of its related companies. © 2016 Gilead Sciences, Inc. All rights reserved. UNBP2388 07/16 333 Lakeside Drive, Foster City, CA 94404

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Mostashari’s DPC take is ‘absurd’ n one of your articles, Dr. Farzad Mostashari (“Mostashari’s biggest Meaningful Use regret and health IT’s future,” August 25, 2016) gave some advice to physicians on how to avoid burnout: “The key is two things. One, if you’re in a kayak in the rapids, you have to lean in and dig your paddle in and push ahead. If you lean back, you’re done. You’re going to flip over. So be more active. Don’t be passive. Take control. Step two is join together with others to increase your power, increase your control, increase your ability to have someone else help you deal with that crap, deal with the quality reporting, deal with the EHR optimization, deal with the ACO regulations. So I think that’s the solution—not to retreat into some direct primary care model.”

I

I am a family physician who has operated a direct primary care (DPC) practice for nearly five years. In that time, I have met hundreds of physicians planning or operating DPC practices, many of whom I now consider good friends. While they each have a unique story and perspective, your comments are not remotely reflective of the mindset of doctors opting for DPC. I honestly wonder whether you have ever talked to a single one of them. These DPC physicians are among the most courageous, creative and determined men and women I know; the exact opposite of what you describe. They have each taken huge risks—professionally, personally and financially— in an attempt to “take control” as you suggest. Most have sacrificed hundreds of thousands of dollars in pursuit of becoming the caregivers they envisioned while in medical school.

Despite giant obstacles and an uncertain future, DPC physicians forge ahead. Our vision for the future of primary care may be naive to you Dr. Mostashari, but to claim we are passive or “retreating” is flatly absurd. I do agree that a major driving factor behind the DPC movement is physicians feeling powerless to deal with an ever growing pile of “crap.” Can you blame them? Older physicians have lived through many decades of initiatives purporting to improve the practice of primary care— only to realize the newest barrage of alphabet soup was keeping them even more distracted from patient care. DPC physicians have bravely climbed back in their vessels and are now trying to rescue others, hopefully before we all go over the waterfall. W. Ryan Neuhofel, DO, MPH LAWRENCE, KANSAS

ABMS has become too powerful for its own good It is good as, pointed out in “Physicians take MOC fight to state level” (August 25, 2016), that Oklahoma, Missouri, Kentucky and Michigan are fighting to limit the powers of maintenance of certification (MOC). It is necessary and to be expected in our democratic society. Clearly, the power of the American Board of Medical Specialties (ABMS) has extended far beyond what the founding fathers of the boards had intended. They intended the boards to be voluntary and never meant for

8

them to threaten physicians’ livelihoods or to be a source of unhappiness and anxiety. Concentrated power has always created distrust in our American way of life. This is why our Constitution has a Bill of Rights. The founders of our country could not foresee all the possible ways that citizens’ freedoms could be limited or taken away. And the Bill of Rights and the amendments that followed were added to protect the rights of all citizens that might in certain instances be restricted.

MEDICAL ECONOMICS]DECEMBER 25, 2016

The lack of any restrictions or “amendments” to the powers of the ABMS is probably its biggest defect, though I doubt that its leadership would ever admit to that. The present furor against the ABMS should be used by its leadership to rethink its place in physicians’ lives and reconsider what its founding fathers had in mind when they established the boards. Edward Volpintesta, MD BETHEL, CONNECTICUT

MedicalEconomics. com

INTERACTIVE

WWW.MEDICALECONOMICS.COM FACEBOOK.COM/MEDICALECONOMICS

@MEDECONOMICS

Bloggers

MedicalEconomics.com

“While online patient communities won’t replace healthcare professionals, they can be a valuable resource for people dealing with chronic health issues.”

EHRs must deliver on promises or face ONC scrutiny

— Henry Anhalt, DO, who is in private practice treating pediatric patients with type 1 diabetes.

“Obviously, I’m not losing sleep over the insurance companies’ well-being but there is a very real economic impact of allowing everyone to get coverage, regardless of a pre-existing condition. Keep in mind that not only can you not be denied coverage, but the insurance company can’t charge you more for that coverage.” — Jonathan Kaplan, MD, MPH, is a boardcertified plastic surgeon based in San Francisco, California.

MORE ONLINE

Visit the Blog section at MedicalEconomics.com

PA R T O F T H E

MedicalEconomics. com

As physicians continue to maneuver through the electronic health record (EHR) maze, they’ll soon start to see more oversight from Uncle Sam. Following the recent final rule announcement that allows the Office of the National Coordinator for Health Information Technology (ONC) to bolster transparency and accountability and preserve patient health and safety through the ONC Health IT Certification Program, many physician groups expressed approval of the plan, but questions still remain on the full details of its reach. “What this rule says is the government needs to be the ultimate backstop here ... for example, if there’s a risk to public health and safety ... for the government to act directly and immediately,” Farzad Mostashari, MD, former National Coordinator for Health Information Technology, tells Medical Economics.

MACRA resource center

Top headlines now

Top 10 challenges facing physicians in 2016 As the calendar flips to 2017, take a look at the challenges physicians faced this year.

Everything physicians need to conquer Medicare payment reform in 2017 MedicalEconomics.com/ tag/macra

5 strategies to reduce malpractice lawsuit threats Malpractice lawsuits can’t be avoided completely, but they can be mitigated and reduced with some helpful strategies.

Medical Economics is part of the ModernMedicine Network, a Web-based portal for health professionals offering best-in-class content and tools in a rewarding and easy-to-use environment for knowledge-sharing among members of our community.

MEDICAL ECONOMICS]DECEMBER 25, 2016

9

Vitals

THE

Study: Retail clinics aren’t keeping patients from the ED Trends in the rate of ED visits for low-acuity conditions, by primary expected payer

Mean rate of ED visitss (per 1,000 total visits)

Medicaid

Private

Uninsured

STUDY SNAPSHOT Researchers generally found no connection between the opening of retail clinics and visits to emergency departments for the low-acuity conditions, even when retail clinics began opening up near emergency departments.

Medicare

200

150

2,000

The number of emergency departments the study authors examined, across 23 states, over a five-year period.

100

50

6 million

0 2007

2008

2009

2010

2011

2012

The number of patient visits retail clinics across the United States receive each year.

Data sources were 2007-2012 State Emergency Department Databases, merged with data on retail clinics from Merchant Medicine.

W

hile there was the belief that opening retail medical clinics near hospital emergency departments would help lower healthcare costs for patients, a recent study finds this is not the case. “One hope for retail clinics was that they might divert patients from making expensive visits to the emergency department for minor conditions such as bronchitis or urinary tract infections,” said Grant Martsolf, lead author of the study and a policy researcher at RAND, a nonprofit research organization. “But we found no evidence that this has been happening.” Instead of lower costs, Martsolf said retail clinics may be substituting for care in other areas, such as primary care practices, or encouraging patients to seek care for problems they would have treated on their own.

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MEDICAL ECONOMICS]DECEMBER 25, 2016

The study’s researchers used information from the federal Healthcare Cost and Utilization Project State Emergency Department Databases from 2006 to 2012 to combine emergency department use with information about the opening of retail clinics obtained from Merchant Medicine, a research firm that tracks trends in walk-in medicine. “Retail clinics may emerge as an important location for medical care to meet increasing demand as more people become insured under the Affordable Care Act,” said coauthor Ateev Mehrotra, MD, an associate professor at the Harvard Medical School and an adjunct researcher at the RAND Corporation. “But contrary to our expectations, we found retail clinics do not appear to be leading to meaningful reductions in low-urgency visits to hospital emergency departments.”

MedicalEconomics. com

2016

Operations

Physician Writing Contest HONORABLE MENTION

Lunch is for losers

Taking a customer service approach to practicing medicine means happier patients and physicians by E. M ICHAE L R E I S MAN, M D Contributing author

M

edicine is changing,” said my general surgeon father. “Medicare is not what it used to be and private insurance companies respond with three letters when I submit a bill for surgery: 1) payment pending, 2) payment pending, and 3) payment denied. This was his response in 1975 when I told him that I wanted to go to medical school. The more things change the more they stay the same. Nearly every medical student has a little Albert Schweitzer in him or her. Like Schweitzer, they think they can learn it all and take care of everyone. All medical students slowly realize that they need to narrow their focus and, thus, specialization occurs. Even family practice physicians are considered to represent a specialty like cardiology or radiology. Gone are the days of the true general practitioner or general surgeon who took care of everything. I chose to become a pediatric urologist. I know, many of you do not even know that roughly 350 full-time pediatric urologists practice in the United States. In the course of becoming a surgical specialist for pediatric genitourinary issues (seven post-medical school years of training), I met all kinds of mentors along the way.

MedicalEconomics. com

As a third-year medical student on my first rotation, I met the chief resident, Steve. Tall and confident, he taught the other residents, medical students and me the trials and tribulations of obstetrics and gynecology.

As physicians, it is our job and our honor to give patients and our customers what they need and what they want.” During our first hours with him, we watched him answer pages and phone calls every two to three minutes with the ability of a master bookie. It was incredible how he could juggle it all with aplomb and control. Several times, he uttered five magic words, “Send the patient right over!” “Reisman,” he also said, “Lunch is for losers.” I quickly learned to keep cheese crackers and candy bars in my white coat pocket for the entire two months of my first rotation, and, throughout my career. During my medical school general surgery rotations, another remarkable mentor

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

17

Operations

2016 Physician Writing Contest

...the team knew that I would not be happy unless our ‘customers’ were happy. We missed a lot of lunches, but were sustained by remarks such as ‘Thanks for seeing us right away.’ ”

E. Michael Reisman MD, was a very busy pediatric urologist in the Tampa Bay area for the last 25 years before recently retiring. He enjoys family, friends, water skiing and playing racketball.

came into my life. Ed was just three years older than me and was like John Carter of the television show ER. He was from a wealthy family that could not imagine why he would want to touch people, let alone blood, pus or feces for a living. “Reisman, (here we go again, they never called you by your first name) the highest honor anyone in this world can bestow upon you is to sign a piece of paper and ask you to cut them open with a knife and fix them. Don’t ever forget that and don’t ever complain about working too hard … you chose this.” Getting this advice early in my medical career proved to be fortuitous. While others complained about working hard, I never did. Not that I liked being up for days at a time or missing family events (birthday parties, weddings, bar mitzvahs, even the funeral of my best friend’s father who was like my own father). But if forewarned is forearmed, then that is what I was. I also found a very smart, very independent and very beautiful woman (if I may say so myself) to marry me. She understood me and my chosen profession and in the 33 years we have been together in medicine, she never complained once about my schedule. This relieved a lot of guilt on my part. One can see how so many marriages end when this is not mutually understood. It took me many years to realize that my very first supervising resident’s straightforward words would set the tone of my own private practice. Steve’s perspective was clear, “Our job is to take care of the patient.” I quickly realized that taking care of the patient included taking care of their families

and the referring providers’ (customers). My grandmother was in the chicken business for 40 years. She always said, “You have got to know your customers.” Not every person wanted the same thing from you and it was up to you to figure out what they needed and give it to them to be successful. I took this wisdom and applied it to medicine. What did the customer need or want? In pediatric specialty practice the customer was usually the referring physician/practitioner or the child’s parents, not the child. Once I realized this, I adopted his mantra of, “Send the kid right over” and made sure my staff supported that mantra. I wasn’t like many doctors who have “gatekeepers” that restrict access. My nurse, Joanie, and the team knew that I would not be happy unless our “customers” were happy. We missed a lot of lunches, but were sustained by remarks such as “Thanks for seeing us right away. You have no idea how much this meant to us.” If I was in the operating room and none of my partners were available, Joanie, the world’s best office nurse, would “walk them over” and I would see the child in a treatment room between operations. Perhaps, others would say that they need the down time over lunch to recharge or do administrative work. For me, it was more stressful knowing there was a patient (or customer) that needed attention. As physicians, it is our job and our honor to give patients and our customers what they need and what they want. Adopting this perspective will help lead to success and a feeling of satisfaction. The alternative is unacceptable.

MORE ONLINE Read the winners of the 2016 Physician Writing Contest at: MedicalEconomics.com

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MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

MedicalEconomics. com

Tech Talk Clean desk policy

7 tips to protect patient data from visual hacking

Adopt an office-wide clean desk policy. Have everyone handling PHI remove papers from their desks and close records on monitors each time they step away. Also, have papers kept in folders when not in use, and files stashed in cabinets or drawers. Be sure to promptly pick up papers from fax/ copier/printer devices.

Shut doors When possible, see that doors to offices are shut.

Limit access by M I LLY DAWSON Contributing author

32 Pixels / Shutterstock

With a major hack of an insurance company’s database having made front-page news not long ago, it’s natural that many physicians focus on electronic data when they think about guarding patients’ protected health information (PHI). However, low-tech violations of patient data security actually occur far more often, have the potential to cause harm and, sometimes—though very rarely—incur serious penalties. So-called visual hacks can occur when employees leave paper records on a desk or allow a monitor to be seen. Such low-tech slip-ups occur often, and they warrant both concern and preventive action. “Though the press focuses on a big insurer losing control of millions of records, recent research confirms that the vast B O RTE N majority of healthcare breaches involve smaller numbers of records,” says Kate Borten with healthcare security firm The Marblehead Group.

MedicalEconomics. com

Limit access to areas with computer monitors or workstations that display PHI. Position monitors so that the data is easily viewed only by the person directly in front of that monitor. If necessary, use privacy filters to keep unauthorized persons from viewing monitors inappropriately. These block peripheral reading of the screen by anyone not positioned directly in front of the monitor. Borten says that soon-to-bereleased technology

will have a built-in electronic screen that a user can enable or disable with a simple keystroke.

Timeout Ensure systems that display PHI on monitors have an automatic shutoff feature that kicks in when there is no activity.

Guard against prying eyes Be aware of others close to you when you are working with PHI on a mobile device outside of your regular work environment. Protect device screens from unauthorized views everywhere, not just in the office.

Staff training Train staff not to be too trusting. Someone may show up claiming to be from IT, and wanting to be nice, your office staff may not question them. Educate staff to make certain that anyone requesting access is entitled to it.

Compliance To ensure proper procedures are being followed, schedule regular walkthroughs.

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

25

TOP 10

CHALLENGES

OF 2017

13.3%

1. Surviving reimbursement changes (especially under MACRA) PAGE 27

9.9%

2. Time/energy required for prior authorizations PAGE 29

8.5%

3. Lack of negotiating power with payers PAGE 47

7.8%

4. Remaining dedicated to medicine PAGE 48

7.6%

5. Maintenance of certification time & money investment PAGE 49

7.4%

6. Lack of EHR interoperability PAGE 50 7. Rising costs for patients PAGE 52 8. Non-adherent patients’ impact on quality care PAGE 53 9. Changing patient attitudes PAGE 54 10. Effect of patient satisfaction scores PAGE 55

26

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

6.8% 6.6% 6.3%

READER SURVEY

For our 4th annual issue exploring the top challenges facing doctors in the New Year, Medical Economics polled our physician readers on what issues keep them awake at night.

6.3% MedicalEconomics. com

by J E FFR EY B E N DIX, CHAR LOTTE H U FF, ROSE SCH N E I DE R KR IVICH, CH R IS MAZ ZOLI N I, MARY PRATT and TODD SH RYOCK

2016 was a challenging year on many fronts for healthcare providers. Physicians have just started to digest the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its changes to physician reimbursement. A long presidential election finally reached its conclusion, but the consequences of a Republican Congress and President-elect Donald J. Trump for U.S. doctors and patients remain unclear. And running a private practice did not get any easier. Balancing the need to deal with patients who won’t listen or won’t pay while also seeking positive patient satisfaction scores remains a daily struggle for many. These were just some of the challenges physician readers told Medical Economics they experienced this year and anticipate continuing for the foreseeable future. For the fourth consecutive year, Medical Economics reveals its list of obstacles physicians will face in the coming year and, more importantly, how to overcome them. For this latest presentation, we asked readers to tell us what challenges they face each day and where they needed solutions. Here are their responses, starting with the biggest challenge of the coming year.

CHALLENGE 1 MACRA “MACRA is the biggest thing that’s hit healthcare payments in a generation,” says John Goodson, MD, an internist at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School. “This is going to be transformative.” And even though MACRA begins taking effect January 1, many physicians still don’t know what they need to do to comply. “Each practice needs a Paul Revere to ride through shouting, ‘MACRA is here, change is here,’” says L. Patrick James, MD, chief clinical officer, health plans and policy and medical affairs for Quest Diagnostics, a healthcare technology provider. “Physicians need to get together and accept it. If you haven’t already started, you need to get started ASAP.” Experts recommend the following: Accept reality. Healthcare reimbursements are migrating from volume to value. MACRA will most likely serve as the road map for other payers, so get used to the re-

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The Trump factor

porting requirements, says James. “Physicians have gotten a lot better over the years with electronic health records (EHRs), but it’s going to be even more important that physicians aren’t just ‘doing’ but documenting,” says James. Documenting and reporting every treatment through a certified EHR or other approved method is the only way physicians can get paid for services.

The election of Donald Trump as the next President of the United States will impact the way physicians will practice and be paid in the new year. Here’s what experts believe the Trump Administration will have in store for physicians. See page 51

Get educated. The law directs physicians to choose one of two reimbursement paths—advanced alternative payment models (APMs) or the Merit-based Incentive Payment System (MIPS). Most small practices probably will opt for MIPS, which measures quality, advancing care information (meaningful use) and clinical practice improvements to start (resource use will be included later.) “Figure out what you are already doing that you can get credit for under MIPS that you haven’t declared,” says John Squire, president and chief operating officer of Amazing Charts, an EHR vendor. “Many are based on

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

27

TOP 10 CHALLENGES

MIPS Payment Breakdown for 2017

60%

Performance calculat ulated on completingg fo four clinical practi actice improvem vement activities.

Clinical Quality

Advancing Care Information

Performance calculated based on quality measures chosen by the clinician.

“MACRA is the biggest thing that’s hit healthcare payments in a generation. This is going to be transformative.” —JOHN GOODSON, MD, INTERNIST, ASSOCIATE PROFESSOR OF MEDICINE, HARVARD MEDICAL SCHOOL

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15%

Clinical Improvement Activities

25%

Perfo formance calculated basedd oon five EHR use-relate ated measures, including security se risk analysis, e-pr prescribing and patient access.

treating diseases to improve outcomes and using prevention screening—most physicians are doing that today.” Understanding these gaps between what you already do and what MACRA requires is key to a successful transformation. “Take a deep breath and don’t panic,” Squire says. “It can be daunting when you look at your todo list, but you don’t have to do it all at once.” Develop a plan. MACRA compliance isn’t going to happen without a commitment to change management, says James. “Create a vision, get your practice together and develop a plan,” he says. This includes making sure all services are billed properly, says Goodson. Ensure that every diagnosis is part of the billing for that patient, and that all ICD-10 codes are attached to the bill. With the focus on patient wellness, make sure the plan includes scheduling annual wellness visits and transitional care management (TCM) visits, when appropriate. “For TCM visits, there are few documentation requirements and they are quite reasonable,” says Goodson. “These visits benefit both the patient and the physician.”

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

The increased contact also helps enhance overall engagement, which makes for happier patients and better outcomes, he says. “The better the relationship between doctors and patients, the better the doctor can manage resource allocations for those patients,” Goodson adds. This is one area small practices may have an advantage over their larger competitors, because physicians may know their patients better and know where they can influence behavior and where they can’t, Squire says. When planning for MIPS, remember that some easy points are available just by following good practice procedures, says Squire. As an example, he cites the practice improvement category, which accounts for 15% of the total MIPS performance score. The category offers easy wins for those who plan and document for steps such as reserving time for same-day appointments, performing medication reconciliation and communicating with patients via a portal or messaging. Under MACRA, in addition to the 15% for improvement activities, quality accounts for 60% and advancing care information is 25%. (Cost won’t be counted until 2018.) This composite score is used to calculate financial bonuses and penalties. “Make sure you know the components of the MIPS scores and plan for them,” Squire says. And remember, the healthcare industry will be developing products and services that support MACRA, so talk to vendors to find out how they can help. Squire suggests starting by seeing what technology your EHR vendor can deliver to assist with the changes, and branch out from there. For example, talk to lab vendors to find out what they can do with lab results or digital images to help with the advancing care information score. Don’t procrastinate. MACRA was originally supposed to take effect at the start of 2017, but the Centers for Medicare & Medicaid Services (CMS) has delayed full implementation until January 1, 2018, allowing practices to submit partial information or participate only for part of 2017. “Have a plan for 2017, but be ready to go in 2018,” says Squire. “The delay was a reprieve, but CMS is not rescinding the rule. Don’t ignore it.”

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TOP 10 CHALLENGES

CHALLENGE 2

Prior authorizations Prior authorization requirements have increased steadily in recent years, and the growth trend shows no signs of abating in 2017. That’s the bad news. The good news is the growing array of products and services available to medical practices that are designed to speed up the prior auth process. There is also the possibility that value-based payment models could reduce the number of drugs and procedures that need approval before payers will cover them. In the meantime, prior auths remain an unpleasant—and increasingly common— fact of life in healthcare. For example, a 2015 Kaiser Family Foundation analysis of Medicare data found that 23% of drugs in private drug plans covered by Medicare Part D required prior authorizations, up from 8% in 2007. During the same period, the percentage of drugs carrying some type of utilization management restriction more than doubled, from 18% to 39%. The proliferation of prior auths is largely a function of cost, says Jack Hoadley, Ph.D., a health policy analyst at Georgetown University’s McCourt School of Public Policy and the lead author of the Kaiser study. “As drugs get more expensive, especially drugs where the use is complicated or has questions about appropriateness, then we see plans and PBMs [pharmacy benefit managers] increase their use of prior authorizations,” he says. The nation’s changing demographic profile is also playing a role, notes Randy Vogenberg, Ph.D., principal of the Institute for Integrated Healthcare in Greenville, South Carolina. As more people become eligible for coverage under Medicare Part D, he says, drug costs rise, and plan administrators turn to prior auths as a way to control costs. Physicians see the increase in prior auth requirements in their practices. George G. Ellis Jr., MD, an internist in Youngstown, Ohio, and Medical Economics’ chief medical

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adviser says his practice spends about 32 hours per week handling prior authorizations, up from 25 hours two years ago. Kevin de Regnier, DO, a solo primary care provider in rural Winterset, Iowa, says his practice’s weekly authorization requests are up between 40% and 50% compared with 2014. While there isn’t much that individual providers can do to stem the rising tide of prior auths, technology may help minimize the amount of practice time they consume. The e-prescribing company Surescripts, for example, has developed a software that integrates with electronic health record systems to streamline the prior auth process. Looking longer term, Vogenberg predicts that the growth of value-based payment models will limit the growth of prior auths, or possibly end the need for them entirely. Prior auths are a process, he says, but the healthcare system is moving toward rewarding outcomes. “So while it’s true you’ve still got a lot of prior auth activity going on, I think we’ll soon see the rigidity of the prior authorization system being loosened, and at some point it’s just going to be incorporated into your outcomes measures,” he says. De Regnier expresses a similar desire. “I do hope that as we move into more qualitybased payment methodologies, especially those involving downside financial risk for physicians, insurance companies will understand that with physicians having real skin in the game, they can get out of our way a little,” he says.

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%

of drugs carrying some type of utilization management restriction in 2015.

Source: Kaiser Family Foundation

TOP CHALLENGES FOR 2017 Get even more leverage with payers with a few simple steps

47 MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

29

D.C. CORNER

BY JOSEPH BURNS

Bill would give physicians lead on advanced illness care hysicians, not the federal government, should decide what’s best for patients with advanced illnesses or who are close to death, according to a bill before the U.S. Senate. The bill would allow Medicare to establish 20 “advanced care collaboratives” of healthcare providers and community-based social service organizations in a demonstration project to test alternative forms of care for patients who are dying or who have serious advanced illness. The bill also addresses the hurdles physicians face when putting patients in hospice care. In June, Senators Sheldon Whitehouse (D-Rhode Island) and Elizabeth Warren (D-Massachusetts) introduced the Removing Barriers to Person-Centered Care Act of 2016. The U.S. Senate’s Special Committee on Aging referred the bill to the chamber’s Committee on Finance, where it has remained. Whitehouse hopes to move it out of committee for a vote next year. “For years, Rhode Island patients and providers have told me over and over that certain Medicare rules and regulations make it difficult to treat patients with advanced, serious illness in the right setting at the right time,” Whitehouse tells Medical Economics. He says the bill would reduce unnecessary and costly treatment now required under rules from the Centers for

P

Medicare & Medicaid Services (CMS) by encouraging better coordination of care among physicians and community social service agencies, he added.

“There are horror stories all around about people who end up losing everything they have before they can get the care they need.” For example, CMS requires a threeday inpatient stay before a patient can move to hospice care, says David Grube, MD, a retired primary care physician. “If I had a patient who was too sick to stay home but not so sick that she needed to be in the hospital, the ideal place of care would be a nursing home or a skilled nursing facility,” says Grube. “But under Medicare rules, that patient couldn’t go into a nursing home or a [skilled nursing facility] without first paying out-of-pocket for a three-day hospital stay.” Requiring a three-day hospital stay before Medicare will pay for a transfer to a nursing home or skilled nursing facility is counter to the ideal of providing optimal patient care, adds Grube, who volunteers for Compassion and Choices, a Denver, Colorado, nonprofit

READ MORE The physician shortage: Is it a real problem?

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MEDICAL ECONOMICS]DECEMBER 25, 2016

that works to improve care for the terminally ill. When a patient can’t afford to pay for a three-day stay, physicians often have no way to get the care that patient needs, he says. “Patients make decisions based on how much the care will cost rather than what’s best for them. There are horror stories all around about people who end up losing everything they have before they can get the care they need,” Grube says. Under current regulations, a patient being treated for a terminal illness cannot go into hospice without first stopping all other treatment. “What we need is a transition benefit so that when it becomes clear that treatment is not working well, the patient can begin to get hospice care while physicians continue to treat the patient’s illness,” Grube explains. “You shouldn’t have to stop all treatments just to move into hospice.” If Congress passes the bill next year and it’s signed into law, applications for the collaboratives would be accepted in 2018 and contracts for the collaboratives would be signed in 2019 or later. But Medicare could implement elements of the program sooner, Whitehouse says. Joseph Burns is a journalist in Falmouth, Massachusetts. How can Medicare improve access ? Tell us at [email protected]

PAGE 42

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IN DEPTH

Operations

Locum tenens offers wellpaying change of pace work Attractive to early- and late-career physicians as well as those with nomadic streak by E D FI N KE L Contributing author

HIGHLIGHTS The quickening pace of locum tenens growth in recent years has occurred for several reasons, but the major one from facilities’ standpoint is physician shortages, especially in rural communities. Locums need to arrange their own health insurance and retirement savings.

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AFTER MORE than a quarter of a century, internist Walter Mulchin, MD, retired in 2000 having led emergency departments in New Orleans and Bentonville, Arkansas. With his daughter grown and out of the house 10 years later, he returned to practice as an internist and has been working mostly in state-supported living centers in Texas, Oklahoma and Arkansas. Mulchin is among an estimated 44,000 locum tenens physicians who are working in temporary positions for hospitals and other healthcare facilities, says Melissa Byington, president of the National Association of Locum Tenens Organizations and president of Salt Lake City-based CompHealth. For Mulchin, the lure is that he can work where he wants, when he wants—and to say no if he doesn’t want the assignment. He prefers jobs that last a couple of months so he can take time off and return to his wife, Sandra, in Arkansas, although sometimes she travels with him. “The biggest fun I have is that I don’t have to do it 100% of the time,” he says. “If you don’t like something, you can always refuse in the future.” The estimate of 44,000 locum tenens physician dates to 2014 and is up from 26,000 in 2002, according to an annual survey conducted by Staff Care, a locum tenens agency,

which estimates the number “based on the number of locum tenens physicians who work through us and our knowledge of the temporary physician staffing industry.” The dramatic increase has come about partly because doctors appreciate the autonomy that comes from not being tied to a specific position, and the internal politics and administrative responsibilities that often comes with it, Byington says. The desire for autonomy has increased as a result of the Affordable Care Act (ACA) and the growing number of mergers and acquisitions of healthcare practices, she adds. “Physicians have gone from being their own boss to becoming employees of a health system,” Byington says. She also cites a CompHealth study of physicians conducted earlier this year showing that more than 40% of physicians are taking secondary jobs such as locum tenens to help combat declining incomes, maintain their lifestyles and pay off debt. The 2015 Staff Care survey shows that 91% of hospitals use locum tenens, up from 73.6% in 2012, and that 36% of respondents worked at hospitals, 17% at medical groups and 12% at Federally Qualified Health Centers.

BENEFITS FOR DOCTORS The quickening pace of locum tenens growth

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

35

Operations

Locum tenens

has occurred for several reasons, but the major one from facilities’ standpoint is physician shortages, especially in rural communities, Byington says. Other reasons healthcare facilities use locums include as fill-ins for doctors on vacation or pursuing continuing medical education, meeting the surge in patients due to the ACA, staffing up during peak usage times, and maintaining the flexibility to increase or reduce staff numbers as needed, according to the Staff Care survey. From physicians’ standpoint, the main reason is often lifestyle-related. “Doctors want to get their lives back,” she says. “You

How Do Locums Get Licensed? Locum tenens physicians often practice in more than one state as they move around from client to client. Since medical licensure is a state function, they need to become licensed in each state. But licensing requirements and procedures vary from state to state and to some degree from position to position. Locum tenens provider CompHealth provides these key points: ❚ Licensing requirements and the resulting time frame can differ by state. Some states can license a physician in just a few weeks—for example Arizona, Indiana, North Dakota and Montana—whereas others, such as Washington and Virginia, can take several months. ❚ Several states offer licenses specifically for locum tenens, which helps doctors get started with a job more quickly. These include Indiana, Maine, Nebraska, New Hampshire, Wisconsin and Wyoming. ❚ Physicians usually can use any state’s license for locums assignments with federal government agencies such as the Department of Veterans Affairs, Indian Health Service and Department of Defense. ❚ Staffing agencies have dedicated licensing departments to help doctors get a license for a new state. They often can do so more quickly than doctors can on their own because staffing companies work regularly with the licensing boards in all 50 states, know exactly what is required and have built relationships with each board.

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MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

get to drop in, practice medicine and see patients, and then when you leave, you’re off.’” Other benefits for doctors include higher hourly pay than salaried positions or additional pay when used as a second, part-time job. Beginning physicians, those easing into retirement and even some who are mid-career appreciate the ability to work for a period of time and then take time off without having to answer to anyone, Byington says. Locumtenens.com provides temporary physician and other healthcare practitioner staffing in all 50 states. Like other agencies, it provides benefits to physicians such as the ability to choose their own schedules, the desired work-life balance, higher hourly pay, a lack of bureaucracy as compared with a permanent position. It also offers the ability to try different settings, such as larger versus smaller hospitals, or urban versus rural care, says Amelia Vietri, vice president of primary care recruiting for Locumtenens.com. In some cases, physicians try a particular employer and decide to stay permanently once the contract ends, Vietri says. For hospitals, she adds, “It does give them a great opportunity to try out a physician.” Val Jones, MD, took that path. She is now medical director of admissions at St. Luke’s Rehabilitation Institute in Spokane, Washington, after spending six years as a locum, the last two for various periods of time at St. Luke’s. Jones got into locum tenens work as a way to keep her clinical skills fresh while working full-time in an administrative job, but she found locum tenens extremely appealing because it allowed her to get away from work completely. “The treadmill of clinical work these days is set to 12, and you can’t dial it down,” she says. “I realized I was a happier person, a better doctor and enjoyed my work more when I could do it in chunks of two, three, four weeks. When I took time off, it was truly off. It allowed me to focus all my attention on patient care.” The “try before you buy” aspect is especially appealing to physicians who have just finished residency and aren’t quite sure what kind of work setting they want, Jones says. “A lot of young physicians are pressured into making con-

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For patients with minor OA pain

A 6-hour dosing gap can be a painful experience.

• The Extra Strength Tylenol® label warns about acetaminophen overdose if patients take more than 4 g a day • To address this issue, it voluntarily reduced its daily dose from 4 g to 3 g—so patients may experience a 6-hour gap when pain persists for 24 hours

Strong pain relief, without the dosing gap. Recommend ALEVE , with the strength of naproxen sodium. ®

Give your patients all-day relief from minor OA pain with just 2 doses.

*



*Reflects latest OTC label dosing for Extra Strength Tylenol for adults and children 12 years and older—maximum daily dose reduced from 8 pills (4000 mg) to 6 pills (3000 mg), with a dosing interval change from every 4 to 6 hours to every 6 hours, unless directed by a doctor. † Each ALEVE tablet can last 12 hours.

Strong on pain. Long on relief. Use as directed. ALEVE is indicated for minor arthritis pain. OA=osteoarthritis. The Bayer Cross, ALEVE, and All Day Strong are registered trademarks of Bayer. Tylenol is a registered trademark of Johnson & Johnson. © 2016 Bayer February 2016 61736-PP-AL-BASE-US-0908

Operations

Locum tenens

36

It expands your horizons. It can offer you great job satisfaction in a place you never thought you wanted to be.”

—VAL JONES, MD, MEDICAL DIRECTOR OF ADMISSIONS, ST. LUKE’S REHABILITATION INSTITUTE, SPOKANE, WASHINGTON

tractual commitments to hospitals” before they know what they’re getting into, she says. There are other benefits to locum tenens, she adds. “It expands your horizons. It can offer you great job satisfaction in a place you never thought you wanted to be. A lot of people like the traveling aspect,” Jones says. Michal Gross, MD, a New York-area native, wanted to see other places and other types of medical systems and experience how they managed diseases based on their resources and cultures. She also wanted a two-year bridge from residency to fellowship without tying herself down in one place with one organization. Working through locumtenens.com, the internist has spent time at a 25-bed facility in Wolfeboro, New Hampshire, with only one other doctor, no subspecialties and limited imaging capability. In September, she was working as a temporary hospitalist at Doctors Medical Center in Modesto, California, an academic trauma center with multiple specialties and residency training. Gross suggests balancing new experiences with some stability, because staying in one place allows doctors to deepen their knowledge of a given system, consult more effectively with nurses and fellow physicians, and learn the electronic health record (EHR) system more thoroughly. Locums work requires flexibility to learn different cultures and different EHR systems, adds fellow internist Mulchin. The benefit, though, is “You’re less stressed because you don’t have that connection with the higher-ups, the administrators. You can stay in the background.”

WORDS TO THE WISE Staffing agencies and doctors who practice as locums offer some cautions to those considering the arrangement. For starters, locums need to arrange their own health insurance and retirement savings. Those who do not work through locum tenens agencies also need to handle their own credentialing, state licensing, hospital privileges and malpractice insurance, as well as housing and travel arrangements. Second, to work steadily, you must be willing to live a nomadic lifestyle, Byington says. “You have to be really adaptable and have great communications skills,” she says.

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MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

“You can add your expertise, but you have to adapt to what works for them.” Another challenge, especially at the outset of a new placement, is that hospitals and healthcare facilities sometimes don’t do enough orientation for locums. They don’t stop to think that new person doesn’t know where supplies are, how referrals work or how the EHR system is set up, Byington says. Be sure you know why a hospital or healthcare facility needs locums help, Jones advises. Usually it’s for perfectly understandable reasons. But in some cases it’s because a hospital is under investigation by its state health department. “Local people don’t want to touch them with a 10-foot pole,” she says. “I ran into a situation like that once and found out the hard way that I needed to do a close inspection.” Gross suggests vetting your agency closely. The first one with which she worked kept promising positions that didn’t come. Then they told her that not having a license in advance wouldn’t matter, but a potential employer rejected her because she didn’t have one. Locum tenens positions also can be unpredictable, given that most contracts allow facilities to cancel with 30 days’ notice. Jones says. “I was in a situation where a hospital canceled on me in two weeks,” she says. “I complained to the agency that that wasn’t fair, we should be able to recoup two more weeks’ pay. The agency said, ‘Our policy is to pay you those two weeks when we recoup, but we rarely recoup.’ Caveat emptor.” John Thieszen, MD, was serving in the Air Force and decided in 2008 that he needed extra income, so he took on weekend assignments as a hospitalist. Since then, he has left the military and worked in eight hospitals across Colorado, Wyoming and Montana. Echoing Gross’s experience, Thieszen advises those considering locums work to vet their contracts. Although he’s had nothing but good experiences with CompHealth, Thieszen says he’s heard about locums agencies that don’t vet their clients, so that doctors find situations very different from what they had expected—seeing 10 times as many patients, or with no housing lined up, for example. That said, Thieszen agrees that locums need to be flexible. “You don’t want to show up and say, ‘This is how I do things.’ ”

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Practical Matters

Marketing a medical practice using Facebook Four years ago, I started a cash-only, direct primary care practice. Like most businesses, my best advertisement is word-of-mouth recommendations from happy patients. Beyond that, I’ve found that my most effective marketing tool, by far, is Facebook.

Setting limits I need to make it clear that I am talking about a Facebook page for your practice, not a personal Facebook account. It is unwise, in my opinion, to interact with patients using their personal Facebook accounts, as it gives an intimate level of access to information about you, your family and your friends. These pages are easy to set up, and allow you to provide easy access to general information about your medical practice (office hours, location, etc.), post pictures of your office (and staff, if they give permission), and make general announcements, such as closings for holidays.

The next level Having a static Facebook page with basic information about your practice–basically an online billboard–is only the first level of social media marketing. One of the keys to successful

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marketing on Facebook is to make your page interesting. Post material on it frequently, sharing information about your practice, but also sharing articles and pictures that you think people will find interesting. This takes time and a little bit of thought about what information is worth sharing. This makes your page a place of discussion, interaction and somewhere people can go to find interesting stuff. If you really want to reach out to potential patients, Facebook allows you to “promote” posts that you put on your page, meaning you can make them visible to more than just people who have “liked” your page. This does require a small amount of money, but for

3 BONUS TIPS So what tips would I give to successfully use Facebook for marketing?

$20 I can make a post visible to thousands of people and usually get a surge in “likes” after promoting content that is especially interesting.

Creating a positive image My patients love my Facebook page. I post articles, make jokes, talk about squirrels in our attic at the office, advocate for flu shots and generally act like a likable human being in a public setting. Patients will often share the posts with their friends, as if to brag, “My doctor’s cooler than yours.” These are two of the most powerful parts of marketing: improving word-ofmouth communication, and raising the intangible “cost” of leaving my practice.

Robert Lamberts, MD, practices in Augusta, Georgia, and is board certified in internal medicine and pediatrics. This article originally ran in our partner publication, Physicians Practice.

1 2 3

Be real.

If you are funny, use humor. Share candid photos of yourself and your staff. Do whatever you can to show that you are the kind of person people would want as their doctor. Don’t talk about specific medical information.

Facebook should never be a place to answer people’s medical questions. I’ve had a few people try, but they always understand when I tell them I can’t help them in that setting. Make your page one that’s something worth following.

Many physicians’ pages I read are as interesting as a phone book. Other physicians use Facebook as a soap box on which to lecture the general public. People don’t want that. They want interesting information, and many out there are desperate for a doctor who they can be proud of.

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

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Coding Insights

Coding chronic care the right way

Q:

How is “general” supervision different than “direct” supervision for chronic care management services? Does this mean that a clinical staff member other than the physician can create the plan of care?

A:

No, the incidentto guidelines still must be met, meaning the physician/ practitioner is responsible for creating the plan of care. This is clearly defined in the 2014 final rule, which can be found at Federal Register Final Rule 2014. CMS has defined general supervision as 1) the supervising physician does not have to be in the same office suite as the person providing the service when services are provided outside the normal business hours, and 2) the supervising physician need not be the same physician or other practitioner that determined the care plan. The rule states: “Other than the exception to permit general supervision for clinical staff, the same requirements apply to CCM services furnished incident to a practitioner’s professional services as apply to other incident-to services.”

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A comprehensive care plan typically should include, but is not limited to: ❚ Problem list; ❚ Expected outcome and prognosis; ❚ Measurable treatment goals; ❚ Symptom management; ❚ Planned interventions and identification of the individuals responsible for each intervention; ❚ Medication management; ❚ Community/social services ordered; ❚ A description of how services of agencies and specialists outside the practice will be directed/ coordinated; and ❚ Schedule for periodic review and, when applicable, revision of the care plan.

Q:

What date of service should be used on the physician claim and when

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

should the claim be submitted?

A: The service period for CPT 99490 is one calendar month, and CMS expects the billing physician/ practitioner to continue furnishing services during a given month as applicable after the 20 minute time threshold to bill the service is met. However, practitioners may bill at the end of the service period or after completion of at least 20 minutes of qualifying services for the service period. So once the 20 minute threshold is met, the physician/practitioner may bill on that date instead of holding the claim until the end of the month.

Q:

When we are coding for diabetes mellitus and the patient has more than one complication, do we code all of them? Which code takes precedence? For example, we have a patient with type 2 diabetes with neuropathic arthropathy (E11.610) and a foot ulcer (E11.621).

A: You should code both conditions. ICD-10 guidelines instruct to “assign as many codes from [diabetes code] categories E08-E13 as needed to identify all of the associated conditions that the patient has.” Your code order depends on the primary reason that the patient is being seen, unless payer policy dictates otherwise. Diabetes complication codes “should be sequenced based on the reason for a particular encounter.”

Renee Dowling is a coding and billing consultant with VEI Consulting in Indianapolis, Indiana. Send your coding and billing questions to [email protected]

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The cure for physician burnout:

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EHR | Practice Management | Patient Engagement | Care Coordination

IN DEPTH

Policy

Solving the nation’s primary care shortage Increasing the number of U.S. physicians means tackling many complicated issues on numerous fronts by CHAR LOTTE H U FF Contributing author

HIGHLIGHTS A number of forces are leading to regional disparities in physician access. It’s still unknown, Erikson says, how adding care managers, social workers and other non-physicians will impact how many patients a practice can treat.

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THE SUPPLY OF primary care physicians needed to bolster the move toward qualitydriven reimbursement models is becoming increasingly stretched. And as the emphasis on prevention and chronic disease management increases, more strain will come. By 2025, the country will require as many as 35,600 more primary care doctors, and as many as 94,700 physicians overall, to meet the increasing demand of a growing and aging population, according to data released by the Association of American Medical Colleges (AAMC) earlier this year. The projected shortage might have a benefit for primary care doctors, with salaries already on the upswing. But it’s still uncertain to what extent, if any, team-based care and the training of other clinicians will offset the burden for physicians faced with overflowing waiting rooms. Moreover, the shortage will occur just as accountable care organizations, readmission penalties and other changes in practice design and reimbursement place a premium on better care coordination and other steps to keep patients out of the hospital, says Clese Erikson, deputy director of the George Washington Health Workforce Research Center in Washington, DC. “There’s been a lot of effort to study the impacts on quality and costs,” she says. “But

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

very little explicitly looking at the demand for physician services.” To ease the pressures on physicians, health systems and large practices are taking steps such as hiring more non-physician practitioners and emphasizing broader, team-based care, say Erikson and other researchers studying issues related to physician supply and demand. Improvements in technology, they hope, also will play a role. But whether those efforts will expand the number of patients each doctor’s practice can treat is still unclear. Meanwhile, the projected shortage must be tackled on several fronts, starting with increased federal funding for residency slots, says Janis Orlowski, MD, chief healthcare officer at the AAMC. To meet the looming primary care demand, the reality and the perception of the career path also will need a makeover, says Orlowski, citing feedback from medical students that it’s not “a fulfilling” work life. “What they see is primary care doctors, who in order to make a good living and/or pushed by other productive measures, are not spending time and attention in providing care to a patient,” she says.

BOOSTING THE SUPPLY While some of the projected demand for

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both primary care doctors and subspecialists can be traced to expanded coverage under the Affordable Care Act, the main drivers are the nation’s aging demographic profile, along with anticipated retirements by physicians, according to the AAMC. Within the next decade, the number of adults age 65 and older will increase by 41% compared with 5% for the population under age 18. The doctors needed to treat them also are aging. By 2025, slightly more than one-third of doctors currently working will be 65 or older, according to the AAMC. But the number of federally-funded residency training slots has been frozen since the late 1990s and thus has not kept pace with those trends, Orlowski says. And while Congress has proposed legislation to boost the number of residency slots by 15,000 over five years, more physician residents does not necessarily translate to more primary care providers, research indicates. Just one out of five residents graduating from internal medicine programs reports that he or she will pursue a career in general medicine rather than a subspecialty, according to a 2012 study published in the Journal of the American Medical Association. Denise Dupras, MD, a study coauthor and general internist at the Mayo Clinic in Rochester, Minnesota, notes that residency programs with designated primary care tracks fared better. “But even in the primary care track, only 40% of those folks reported staying in a general internal medicine career,” she says. “So simply increasing the number of those programs may not be the solution.” General internists and hospitalists are in the greatest demand, along with family physicians and psychiatrists, says Travis Singleton, a senior vice president at Merritt Hawkins, a healthcare recruiting and consulting firm based in Dallas. One challenge is that hospitalists are sometimes poached from the existing pool of internists, winnowing their numbers further. In addition, some general internists are diverted to hospital medicine during their training, Dupras says. “There is a group of people who may have in the past done internal medicine because they enjoy the breadth of medicine, the challenge of making the diagnosis,” she says. But, she adds, “They don’t particularly want that piece of the continuity of care or the follow-up of care.” The good news is that increasing de-

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Policy

mand—for reasons ranging from demographic changes to population health needs—is boosting primary care salaries, according to a Merritt Hawkins analysis. Starting salaries for general internists increased 14% in 2016 and averaged $237,000 compared with $207,000 the prior year. The 2016 offers for general internists ranged from $195,000 to $320,000, based on recruiting searches conducted from April 2015 through March 2016. (Hospitalists were not included in that group.) Family physician pay was up by 13%, averaging $225,000 versus $198,000 in 2015. Most subspecialists still earn far more, however. But Dupras argues that pay is only one piece of the career decision equation. Research hasn’t yet sorted out what attracts and keeps doctors in primary care, she says. But the hospital-based rotations that tend to dominate academic training can sometimes exert a “hidden curriculum,” sending subtle messages that “somehow primary care isn’t as prestigious or as valued.” Perhaps the solution is to start even earlier in the training process, Dupras says. If

PRIMARY CARE STRAIN The nation’s increasing and aging U.S. population will challenge all specialties, but especially primary care, according to the latest projections for 2025 from the Association of American Medical Colleges: Between 14,900 and 35,600 more primary care doctors will be needed, including general internists, family physicians, pediatricians and geriatricians. A shortage of 61,700 to 94,700 is projected across all specialties. The rate of physician retirements is projected to have the greatest impact on supply;

more than one-third of doctors will be at least 65 years old within the next decade. Other uncertainties include: the influence of emerging practice and reimbursement models; the role and growth of nurse practitioners and other physician extenders; and work-life balance decisions that influence hours practicing.

Source: Association of American Medical Colleges: The Complexities of Physician Supply and Demand: Projections from 2014 to 2025, April 2016

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Policy

%

81

of physicians reported working at capacity or being overextended Source: Merritt Hawkins

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researchers could determine what types of traits and interests primary care doctors are more likely to exhibit, then medical schools could search for those among applicants.

and team-based care at one of its clinics, the physicians involved ended up reducing their patient panels from 2,300 to roughly 1,800.

PROMOTING PRIMARY CARE

EXTENDERS TO THE RESCUE?

Increasing the number of primary care residency programs and where they are located might ease the shortage, says Paul O’Rourke, MD, a general internist and assistant professor at Johns Hopkins University School of Medicine in Baltimore, Maryland. O’Rourke, who recently completed an analysis of national matching program data, argues that there is a pent-up interest in primary care. For each slot in a primary care internal medicine program, there were six applications compared with 1.7 for nonprimary care slots. O’Rourke and his colleagues reported that residency matching data in a related study, published recently in the The American Journal of Medicine. It showed that nearly 61% of the 104 internal medicine primary care programs were located in the northeast, compared with 10.9% in the southeast and 9.4% in the midwest. The researchers also found that the geographical regions with the lowest ratio of primary care physicians to population had few or no programs. Already, signs of regional shortages are emerging. In seven states, the supply of primary care doctors relative to population is less than 85% of the national rate, according to an analysis by America’s Health Insurance Plans published in July. In a Merritt Hawkins survey of more than 20,000 physicians, 81% reported working at capacity or being overextended. The trend of hospitals and health systems employing physicians can amplify turnover problems, Singleton says. “When you were private, you built the building, you bought the equipment,” he says. But employed doctors, he says, may not be as emotionally and financially tied to their practices, making them more vulnerable to being lured away. One key uncertainty: how will shifting reimbursement models drive the need for more primary care doctors? It’s still unknown, Erikson says, how adding care managers, social workers and other non-physicians will impact the number of patients a practice can treat. There’s some reason for caution. When one health system piloted a patient-centered medical home

Erikson is optimistic that some of the work doctors currently handle can be assumed by other team members over time. “Right now, there’s a real cultural barrier in some practices with being comfortable in trusting your team members to take on greater and greater roles,” she says. Additional help for primary care could come from nurse practitioners and physician assistants. From 2003 to 2014, the number of newly certified physician assistants increased 75%, from 4,337 to nearly 7,600, according to data published last year in a Health Affairs blog post. The growth in nurse practitioners was even stronger, from 6,611 new graduates in 2003 to 18,484 in 2014. But other data show about half of physician assistants and nurse practitioners ultimately practice in primary care rather than a subspecialty field. Brian Ring, chief operating officer at Henry Community Health in New Castle, Indiana, says hiring nurse practitioners has significantly improved patients’ access to care in the county’s system, which includes a 49-bed hospital and an outpatient primary care practice, among other services. “There is a difficulty in recruiting physicians,” he says. “But we have a responsibility to care for our community and meet their expectations on access.” To help fill the anticipated primary care shortage, internists themselves bear a responsibility “to do more advocating for why our profession is something that medical students would enjoy,” O’Rourke says. O’Rourke adds that it’s likely easier for primary care physicians to develop a healthy work-life balance than it is for doctors opting for even more time-consuming specialties. Dupras was initially intrigued by the subspecialties of oncology and pulmonology. She changed her mind after working in Mayo’s outpatient clinic as a resident, where she was assigned a panel of patients with whom she developed a relationship. “What are the things that make working hard worth it? For me, it was ... the relationship that I was able to forge with these patients,” Dupras says.

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

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Financial Strategies

5 WAYS MISSING A PAYMENT DEADLINE HURTS Between patient appointments, running a practice, trying to fit in continuing education and dealing with personal obligations, staying on top of bills can be challenging. Add to that a doctor’s office feeling a cash crunch due to slow reimbursements, emergencies or other unexpected expenses, and putting off scheduled payments might seem like the best solution at the time. Or maybe a bill was simply overlooked. The process of getting back on track from late or missed payments can be embarrassing and time-consuming. More importantly, they can affect a physician’s ability to secure credit in the future.

In the end, it will cost you more. Miss a payment on anything from a mortgage to a medical student loan to a credit card, and it’s likely you could be charged a late fee. If you miss more than one payment, these fees can add up. Some credit card issuers increase the interest rate, which could be applied to both your current balance and new purchases.

2

Collection agencies will call … and call. Nobody likes a collection call, even if it’s the most polite call you receive all

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3

It can hurt your credit report. Late or missed payments on loans, credit cards or mortgages can be a factor as you apply for credit going forward. Once a creditor reports payment lapses to any of the three credit reporting agencies, nega-

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

tive accounts can stay on your credit report for seven years. In order to get these “bad marks” removed sooner, you must work with the creditor to whom you owe late payments, or simply wait it out.

4

Your FICO score can drop. According to myFICO, payment history is the largest of five factors used to determine your FICO score (35%), the standard credit score used in the

U.S., so it pays to keep up with your credit accounts. The strength of your FICO score is an important factor for potential creditors and helps determine the terms and rates you’ll be offered on new purchases or refinancing loans.

5

You’ll feel the stress. Knowing your bills are paid late is stressful. Lapses in payment and potential penalties will just add more stress to your busy life.

April Brissette is chief lending officer at Bankers Healthcare Group, a financing and loan provider to healthcare professionals. Send your finance questions to [email protected]

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1

day. If you have multiple consecutive missed payments, you may start to hear from collections. Their goal is to get you to pay, so expect continual calls. But you have patients to see. Do you really want to spend time on the phone explaining why you missed a payment, giving your checking account information, or promising to pay by a certain date?

TOP 10 CHALLENGES Continued from page 29

CHALLENGE 3

Negotiating with payers As payers move to consolidate, physicians find themselves facing the prospect of declining reimbursement and narrowing provider networks. Many doctors lament that payers now come to the table with a “take it or leave it” approach, forcing physicians to agree to one-sided contracts to maintain their patient head count. But while the ability to negotiate remains a challenge, and varies to some extent by region and payer, it remains possible. One key: physicians should focus on the value they provide to patients, their successes and why the payer needs them. “The payers need you to take care of their beneficiaries,” says Elizabeth Woodcock, MBA, FACME, a healthcare consultant and author with Woodcock & Associates. “One of the things I recommend is to create a fact sheet, a pitch, for your practice. Here is your pitch, here is your value in the community. You want that one sheet in your back pocket when payers start talking about quality and narrow networks” One physician finding success with these techniques is Melissa Lucarelli, MD, a solo physician in Randolph, Wisconsin, and member of the Medical Economics editorial advisory board. She enlists the help of her staff to build payer negotiations considerations into her weekly workflow processes so that she can be prepared when it’s time to negotiate. It starts with a spreadsheet containing all of the practice’s payer contracts and some key information for each, including termination clauses, how quickly they pay and reimbursement rates for commonly-used codes. As the time for contract negotiations approaches, Lucarelli meets with her clinic manager to review some of the problems the practice encounters when working with the payer and discuss potential opportunities for enhancing the practice’s value to that payer, such as quality data and star ratings assigned by payers. “I always try to figure out for this com-

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pany, what are they valuing and monitoring, and how are we measuring up?” Lucarelli says. And it’s not the time to be timid: If the practice is doing well at taking care of the payer’s patients, “It’s not unreasonable to ask to be rewarded more,” she says. Woodcock acknowledges that it’s not always possible for physicians to negotiate significant reimbursement increases. Furthermore, too many physicians focus on that goal and ignore other crucial areas. For example,

“It’s not unreasonable to ask to be rewarded more.” —MELISSA LUCARELLI, MD, SOLO PHYSICIAN, RANDOLPH, WISCONSIN

physicians should pay attention to claim filing deadlines and “take-back” provisions— essentially how long after a claim is filed that the payer can revoke payment because of a mistake. All of those items are negotiable, Woodcock says. Even physicians attempting to negotiate in markets with heavy payer concentration, still have some strategies they can use. Woodcock suggests going bold: Find the large employers in the markets and talk to their benefit managers, share data about the practice’s successes in taking care of their employees and the focus on quality. “Sometimes employers call payers and say, ‘You need Dr. Smith,’” Woodcock says. “I can’t say it will always work, but it will turn heads.” And don’t rely on e-mail and other impersonal communication methods. Get on the phone and talk. Remember, negotiations occur between people, and building a relationship between the physician and the negotiators for the payers can only help strengthen the doctor’s position, Lucarelli says. “I can make a human connection,” Lucarelli says. “That’s what doctors are good at, so move this uncomfortable business stuff into our playing field.”

Contract details 5 ITEMS TO KEEP AN EYE ON

1. Claim-filing deadlines The contract will stipulate the time period in which claims must be filed. Anything shorter than 60 days is too short, says Melissa Lucarelli, MD, a solo physician in Randolph, Wisconsin, and member of the Medical Economics editorial advisory board.

2. Takeback provisions This is exactly what it sounds like, essentially allowing a payer to reclaim payment after the fact if it discovers a mistake. This is negotiable, Lucarelli says, so seek a term of no more than 12 months.

3. Termination clauses Many payers have complicated procedures if a physician wants to terminate a contract. Learn what they are and follow them to the letter.

4. Mediation Payers pushing for mediation by an arbitrator in the event of a legal dispute is becoming more common. Lucarelli says she negotiates to have these clauses removed.

5. Hidden fees The growth of quality care means some payers are seeking to attach “quality fees” in their contract. Pay attention and remember they are up for negotiation, Lucarelli says.

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

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TOP 10 CHALLENGES

CHALLENGE 4

Staying motivated to practice medicine

“It’s a cumulative effect of wellintended efforts adding up to a burden of work that no one anticipated. Physicians feel they’re spending their days doing the wrong work.” —CHRISTINE SINSKY, MD, INTERNIST, VICE PRESIDENT OF PROFESSIONAL SATISFACTION, AMERICAN MEDICAL ASSOCIATION

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Like everyone else, doctors want to enjoy their work, but they are finding it harder to do so. Physician professional dissatisfaction has been steadily growing in recent years, driven by increasing workloads and frustration at being unable to spend sufficient time with patients. While the larger forces driving physician unhappiness aren’t likely to change soon, experts say there are steps doctors can take on the practice and individual levels to combat burnout and maintain their enthusiasm for practicing medicine. In the most comprehensive study of physician dissatisfaction to-date, published in the December 2015 issue of Mayo Clinic Proceedings, 54% of the physicians surveyed reported at least one symptom of burnout in 2014, compared with 46% in 2011. The percentage of respondents reporting satisfaction with their work-life balance declined from 49% to 41%. In contrast, the study found minimal changes in rates of burnout or dissatisfaction with work-life balance among other working adults in the U.S. By now the causes of physician unhappiness are well known, says Christine Sinsky, MD, FACP, an internist and vice president of professional satisfaction for the American Medical Association (AMA), who coauthored the study. They include ever-increasing amounts of time spent on administrative tasks and documentation, frustration with the demands imposed by electronic health records and the feeling they are having to cede control of their practices to government regulators and third-party payers. “It’s a cumulative effect of well-intended efforts adding up to a burden of work that no one anticipated,” says Sinsky. “Physicians feel they’re spending their days doing the wrong work, and that leads to burnout.” To address the problem, the AMA has created a series of online tutorials—which Sinsky calls “transformation toolkits”—designed to help practices operate more efficiently and enable physicians to gain more

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

control over their workday. Many of the tutorials focus on ways doctors and practices can save time, such as renewing all of a patient’s medications once a year, or spreading documentation and data entry among members of a care team. “By doing some of this reengineering, within the constraints imposed by EHRs and regulations, doctors can create a lot more room in their day for enjoyment,” she says. Along with making changes in their work environment, doctors can combat burnout by employing stress reduction techniques, such as mindfulness—the state of “living in the present moment, in a compassionate way, without judgment,” says Gail Gazelle, MD, FACP, an internist and executive coach for physicians. Gazelle cites the example of a doctor starting his day knowing he faces a full schedule that includes difficult patients and frustrating tasks, such as dealing with prior authorizations. That leads to fears of getting home late, having to stay up late finishing the day’s work and memories of being unhappy when that’s happened before. “Worries about the future, ruminations about the past, all these things pull us away from the present,” Gazelle says. “When we can pay attention to what’s actually in front of us, without the overlay of what might happen or what should happen, it often isn’t that bad.” Meditation, the practice of keeping one’s attention focused on one thing—such as breathing—can help people achieve mindfulness, Gazelle says. And while the common perception is that meditation requires setting aside large blocks of time, in reality it can be practiced while performing everyday activities, such as paying attention to the feelings in your feet as they lift off of and touch the ground while walking. By developing the habit of focusing on the here and now, Gazelle says, “doctors become more resourceful for their patients and their staffs, and can be a little kinder and gentler to themselves.”

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TOP 10 CHALLENGES

CHALLENGE 5

Maintenance of certification More changes are on the way for physicians certifying in their sub-specialties through the American Board of Internal Medicine’s (ABIM) maintenance of certification (MOC) process. Richard Baron, MD, ABIM’s president and chief executive officer says the new wave of changes are designed to ease the stress recertification has on physicians. “The biggest change that doctors need to know about is a partnership with the American Council on Continuing Medical Education (ACCME) through which many, many more CME programs can count for MOC points,” he says. “We’ve heard a lot from physicians that they would like to be able to use some of the activities they’re already doing for credit. We’ve come up with a very streamlined and physician-friendly way for them to do it.” Once physicians complete a CME program, Baron explains, they will automatically get MOC points because ABIM and ACCME will use the same system to communicate. Now, physicians have to manually confirm completion with both systems, which can cause problems if they forget to check if both systems’ points were counted. ABIM is also working with several medical societies that are developing tools to help doctors get credit under Medicare’s recent payment reform and have that count for MOC credit as well, Baron adds. Enhancing the recertification exam itself is another top priority going into 2017, according to Baron. “[We want to] make the content much more relevant,” he says. All of ABIM’s board-certified members were invited to comment on the blueprint of the test, he explains, and the organization is currently examining these results and how to implement the suggestions and views stemming from the results. But despite Baron’s positive outlook on ABIM’s changes, many physicians continue to have difficulty keeping up with them. “ABIM is saying, ‘Well the reason we’re do-

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MOC 2017 changes ABIM notes the following changes it is considering for 2017:

ing these things is to make better, safer doctors for the public,” says Christopher Unrein, DO, an internist and hospice/palliative care practitioner in Parker, Colorado. “[But] one, they have no data that any of this stuff does any of that, and two, if they keep changing it, how are they ever going to get data that proves this is making patient outcomes better and making better doctors?” Unrein says the financial burden of recertification adds to the stress physicians already experience from the many requirements of EHRs, Meaningful Use and now MACRA. W. David Smith, MD, an internist in Cincinnati, Ohio, is frustrated by ABIM’s continual website updates, which he says are very difficult to follow. “I can’t figure out what in the world I have to do,” he says. Physicians also feel as though a “board certification industrial complex” has been created by ABIM and MOC, Unrein says. “Our profession’s very own medical societies, that we pay significant amounts of membership dues to, turn around that membership to sell us products in order to pass the exams and/or gain MOC points,” he says. “So not only is MOC a busy-work, anxiety-laden process, it is also one of financial opportunism. Physicians preying upon physicians—it disgusts me, as we are supposed to be a profession that cares and looks out for others.” Regardless of how physicians feel, Unrein says they have no choice but to continue taking the exams or they will see an end to their careers. “I can’t avoid being called board certified if I want to make a living,” he says. However, Smith says there may be some hope for the future, as pressure mounts from state medical boards and alternative boards for ABIM to abolish MOC, and competition grows from other certifying organizations. In the meantime, he suggests physicians not wait till the end to complete their recertification requirements and study for the exam.

Conducting a survey about the proposed alternative pathways to take the exam. Will continue through the end of the year, when ABIM plans to release more details about potential pathways that would look different than the 10-year exam. Improving its website and portal login for physicians to be more user-friendly. Collaborating with ACCME to recognize the tasks physicians do in their dayto-day routines and to help them locate activities for which they can earn dual CME/MOC credit. ABIM notes that these are changes as of press time and more may come in 2017. For more information, visit Transforming.abim.org.

“Not only is MOC a busy-work, anxietyladen process, it is also one of financial opportunism. —CHRISTOPHER UNREIN, DO, INTERNIST AND HOSPICE/ PALLIATIVE CARE PRACTITIONER, PARKER, COLORADO

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TOP 10 CHALLENGES

CHALLENGE 6

Lack of EHR interoperability Yul D. Ejnes, MD, MACP, estimates his practice could save hours of work daily if EHR interoperability were further along. Ejnes says he can’t yet electronically transfer all the information he needs to share, and even when he can, the process is often cumbersome, requiring him to switch screens, log in to new systems and manually enter data. “We’re still faxing a lot of things. We still have to manually enter information that comes in from labs. We still get data electronically, but it’s not usable so we have to re-enter it,” says Ejnes, an internist at Coastal Medical Inc. in Cranston, Rhode Island, and past chairman of the American College of Physicians’ Board of Regents. Ejnes’s experience is typical. Very few physicians have complete interoperability, which the nonprofit “We don’t need every advocacy organization Center for bit of data to move Medical Interoperability defines as ability to share information everywhere. We need “the across multiple technologies.” the critical information In fact, a study released by KLAS Research in October finds that a to be given to the right mere 6% of healthcare providers can folks at the right time. effectively and efficiently share paThat it doesn’t now, tient data with other clinicians who an electronic health record (EHR) that’s the frustration use system different than their own. for physicians.” While true interoperability is still years away, doctors and information —JON WHITE, MD, DEPUTY technology experts say clinicians NATIONAL COORDINATOR can employ targeted solutions and FOR HEALTH INFORMATION specific fixes within their practices TECHNOLOGY, ONC to exchange data electronically with colleagues and other organizations. “Interoperability can happen on a micro level,” says Robert M. Tennant, director of health information technology policy at the Medical Group Management Association. IT experts say doctors should start by working with colleagues to ensure they can efficiently move data locally, where there’s usually the greatest volume. As an example, Ejnes cites the work being done by hospital

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MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

near his practice. The hospital is deploying technology that will allow affiliated doctors to move patient data in and out of their EHR systems with just a few mouse clicks. Doctors should consider adopting EHRs from the same vendor as area colleagues and local medical institutions to better enable data sharing among providers, says Steven Stack, MD, immediate past president of the American Medical Association (AMA). Stack says other interoperability options are also available to providers. He cites Carequality, an organization working to develop a common technical framework to enable electronic healthcare data exchanges. He points also to SMART Health IT, an open, standards-based technology platform that healthcare organizations can use to build applications to share data. The AMA is also pushing for the Office of the National Coordinator for Health Information Technology (ONC) to refocus its certification program on testing the interoperability of EHRs. Other solutions can help doctors with targeted interoperability, Tennant says. For example, doctors should maximize use of existing portals, such as those created by insurance companies. Likewise, Jon White, MD, deputy national coordinator for health information technology at ONC, suggests doctors maximize the functions they have within their EHRs to better enable data exchange. Doctors should make electronic data exchange part of their practice workflow by maximizing the use of the functions already included in their existing software systems, White says. Those functions may not meet the full definition of “interoperability” but they can help move close to that goal. They should tap vendors and other IT support services for training to ensure they know how to fully utilize the capabilities embedded in their systems. “I like to talk about targeted interoperability,” he says. “We don’t need every bit of data to move everywhere. We need the critical information to be given to the right folks at the right time. That it doesn’t now, that’s the frustration for physicians.”

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TOP 10 CHALLENGES

D

onald Trump’s surprising win in the presidential election has put a renewed focus on healthcare and what will happen under his administration. For now details are scarce, but one thing president-elect Trump has emphasized throughout his campaign is repealing the Affordable Care Act (ACA) and replacing it with something better, saying in some stump speeches that it will happen on his first day in office. Republicans have tried to repeal the ACA, or Obamacare, since its inception, but now with control of both houses of Congress and the presidency, they have the power to do so. Repealing the ACA would result in 22 million people losing health insurance, according to the Congressional Budget Office, raising the question of what happens to those affected, and what, if anything, would replace the ACA. Based on last year’s Republican repeal attempt that President Obama vetoed, there are some clues to what provisions of the ACA might be repealed and which ones might remain in some form. The vetoed bill would have eliminated:

How will the Trump administration change healthcare?

❚ programs providing Medicaid coverage for Americans near or below the poverty line, ❚ subsidies that helped people buy insurance on the exchanges, ❚ taxes that fund the ACA, and ❚ penalties for not having insurance.

Parts of the law would have remained, including requiring insurance companies to cover young adults on parents’ policies and to sell insurance to anyone, regardless of medical history. Medicare reforms also would have remained. Whether next year’s Congress will follow this blueprint remains to be seen. In speeches, Trump mentioned replacing the ACA, but offered few de-

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an exciting ride through the removal of useless regulations that counterintuitively will improve patient care,” says H.L. Greenberg, MD, a Las Vegas-based dermatologist. “Physicians will be happier and have more time to focus on caring for patients ...” The potential for less regulation has Christopher Claydon, MD, a Scottsboro, Alabamabased internist, hopeful as well. “There is finally a glimmer of hope that the crushing burden that government has placed on medicine may be lifted under a new president,” he says. “I am stunned at the results but grateful we have a proven business owner elected to take the helm of a broken country. Get the bureaucrats off our backs and out of medicine.” Carla Lambert, MD, a Beltsville, Maryland-based family physician, says Obamacare is flawed, but thought it was moving in the right direction. She wonders what will happen if the ACA suddenly disappears in the early days of Trump’s presidency. “Unless he creates something to replace the current system, roughly half of my patients will be affected and likely be without insurance once again,” she says. “I’m really not sure my solo practice can survive an abrupt change like that.” The lack of a defined plan has many waiting for details. Along with repealing Obamacare, Trump’s website lists six healthcare objectives:

by TODD SH RYOCK

tails on what that would look like. His official campaign site makes no mention of replacing it, but states that his free-market principles “will broaden healthcare access, make healthcare more affordable and improve the quality of care to all Americans.” Besides the ACA, the fate of the Medicare Access and Chip Reauthorization Act of 2015 (MACRA) that goes into effect January 1 remains unknown, as it has not been mentioned as a target for reform or repeal by the Trump campaign. However, the law was passed with bipartisan support, making an immediate repeal unlikely. Reaction from physicians to the election outcome has been mixed, with some excited about the possibility of fewer regulations interfering with their practice of medicine, while others wonder how those currently covered under the ACA will pay for care. “If Donald Trump does what he said he was going to do, medicine is in for

“If Donald Trump does what he said he was going to do, medicine is in for an exciting ride...”

❚ allow health insurance to be sold across state lines to increase competition, ❚ make individual health insurance premium payments tax deductible, ❚ make some changes to how health savings accounts work, including allowing them to be passed on to heirs, ❚ require price transparency from all healthcare providers, ❚ giving Medicaid funding to the states in the form of block grants and allow them to manage the funds, and ❚ remove barriers to entry into free markets for drug providers.

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TOP 10 CHALLENGES

CHALLENGE 7

Patient frustration with rising costs The rapid rise in copays, deductibles and prescription drug prices is causing concern among physicians who see patients skipping care as a result of these increasing healthcare costs. A study by CEB and DirectPath that looked at the health plans of 750 major employers showed individual plan deductibles rose 40% in 2016 and inpatient copays increased 68%. Faced with patients not filling prescriptions, or skipping procedures or referrals because of financial concerns, physicians can help by becoming savvy shoppers on their patients’ of Individual plan behalf and providing education deductibles rose in 2016. about costs. “Just as we would do appropriate research when buying a new car, we need to do our research when shopping for healthcare—and this applies to medications, lab tests and even radiologic studies and surgeries,” says Carmela Mancini, DO, MPH, FACP, an internist in Marof inpatient copays blehead, Massachusetts. increased in same year. Mancini has a contract with Source: CEB/DirectPath a nationwide laboratory that gives the practice cash pricing on all labs, and passes the savings on to patients. A cholesterol test costs less than $6—if using insurance, the same test would be between $75 and $150 for the patient, she says. An inEducate patients about costs of care. dependent radiology company offering cash pricing recently Encourage patients to discuss financial saved one of her patients $2,000. barriers to care. Similar discounts may be Help patients find cheaper options for available at hospitals and surthings like lab tests and prescriptions. gery centers, even if it means sending the patient out of state. For patients with high-deductible plans needing non-urgent surgery, the travel costs may be less than a procedure performed locally, says Mancini. Peter Ubel, MD, associate director of health sector management at Duke Univer-

40% 68%

TIPS FOR HELPING PATIENTS

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MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

sity, says saving money can be a team effort. Physicians should make sure they know about copay assistance programs available from pharmaceutical companies and nonprofits, and to coach patients to speak up if price is an issue. “Patients often don’t know there might be an alternative drug or are embarrassed to discuss problems with costs,” Ubel says. Physicians also need to keep in mind that under high-deductible plans, a procedure such as an MRI early in the year may have to be paid for entirely by the patient, Ubel says. Encouraging the patient to discuss financial barriers gives doctors the opportunity to work with the patient either to find other treatment options or identify a less-costly service provider. It also prevents a lot of wasted physician time. “If the patient doesn’t get the tests or medication prescribed because of costs, then the doctor is wasting a lot of time recommending things that aren’t going to happen,” Ubel says. “It’s good to spend a little time to check on costs, if you can.” Financial education can also come before care is rendered. For example, Anas Daghestani, MD, chief executive officer of Austin Regional Clinic in Austin, Texas, says the practice sends a letter once a year to patients explaining when it’s appropriate to visit an emergency department. Also, when procedures are scheduled, a financial counselor explains the potential out-of-pocket expenses, so there are no last-minute surprises that can lead to cancellations due to inability to pay. Daghestani says these efforts contribute to better patient understanding and transparency. “When you book an airline, you don’t have to guess the fees—you log in to compare different options,” he says. And saving money does not mean a patient is getting inferior quality or compromised care, says Mancini. “If you could purchase a new car for $10,000 at car lot A, but you get the same exact car for $8,000 at car lot B, why would you shop at car lot A? We need to apply this same savings mentality to healthcare,” she says.

MedicalEconomics. com

TOP 10 CHALLENGES

CHALLENGE 8

The non-adherent patient and “quality” care Patients who dismiss medical advice are nothing new, but that attitude increasingly threatens to cost doctors as quality metrics become tied to compensation. Sometimes patients can’t afford healthier food or even their prescribed medications, says George G. Ellis, Jr., MD, a general internist in Youngstown, Ohio and chief medical adviser for Medical Economics. In other cases, he says, they may simply prefer to spend their cash on potato chips or cigarettes. “It’s about priorities,” Ellis says. “But we’re being penalized for their lack of concern for their own well-being.” In early 2016 CMS, America’s Health Insurance Plans, (the commercial insurers trade association,) and other groups tried to rein in the proliferating number of quality metrics by establishing a set of core measures broken down by specialty. For primary care doctors it includes 20 metrics—ranging from patient compliance with cancer screening recommendations to the frequency of eye and foot checks for patients with diabetes. But consolidating measures doesn’t address the problem of the disengaged patient. A 2004 meta-analysis of 569 studies published in the journal Medical Care found that one-quarter of patients didn’t adhere to treatment guidance. A physician’s ability to connect with patients can help improve adherence, at least to some degree, according to another metaanalysis of 106 studies published in Medical Care in 2009. Researchers reported that patients whose physicians communicated well had a 19% higher rate of treatment adherence than those who didn’t. Some opportunities begin with making sure the patient receives the optimal drug for their symptoms and their personal circumstances, says Trissa Torres, MD chief operations and North America programs officer at the Institute for Healthcare Improvement in Cambridge, Massachusetts. Help patients to succeed, whether that means getting transportation to the pharmacy or discussing ways to incorporate exercises. To that end, she says, a practice can start

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collecting information about their patients’ financial, transportation and other barriers to achieving quality care. Ask questions to determine if a patient is following through, but in an open-ended way that encourages discussion, says Kelly Haskard-Zolnierek, Ph.D., author of the 2009 meta-analysis on physician communication and a health psychologist at Texas State University in San Marcos. “You could say something like: `Many patients forget to take their medication sometimes. How often does this happen to you?’” Time-pressed doctors shouldn’t shoulder this extra work, says Torres. Instead, ask other team members, from receptionists to nurse practitioners to assume a role. Don’t give up, stresses Torres, who believes that truly resistant patients “are a very, very small minority.” None of these quality metrics assume that doctors can achieve 100% success, she notes. “So that small percentage [of resistant patients] is actually irrelevant to the overall metric.” But Ellis disagrees with that “very, very small” estimate, at least in the economically challenged region in which he practices, where daily stressors and long cold winters can reduce patients’ opportunities to stay

“It’s about priorities. But we’re being penalized for [patients’] lack of concern for their own well-being.” —GEORGE G. ELLIS, MD, INTERNIST, YOUNGSTOWN, OHIO

NUDGING CHANGE Encouraging obstinate patients to change is never easy, but many organizations provide resources, including: HealthBegins (www.healthbegins.org): Provides a social network and topic guides for clinicians, sometimes dubbed “upstreamists,” who want to better understand and counteract the upstream causes of health problems, whether that’s lack of fresh air or a stressful job. Informed Medical Decisions Foundation (www.informedmedicaldecisions.org): Suggests resources to better connect with patients, including a “six steps” card to shared decision-making. Institute for Healthcare Improvement (www.ihi.org): Offers whitepapers, virtual training and other resources on everything from quality metrics to communication techniques.

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

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TOP 10 CHALLENGES active and sap their motivation to change, he says. He sticks with patients who struggle to improve their health despite limited income or other circumstances beyond their control. He tries motivational questioning, brainstorms ways to overcome hurdles and gives out free drug samples to patients on limited incomes. Still, Ellis says, “I’d say there are probably 20% of my patients that I can’t move the

needle on, no matter what I do. I have told patients just to leave.`If you’re not going to be compliant, don’t waste my time, don’t waste your time.’” While Ellis was willing to discharge patients who wouldn’t help themselves even before metrics became a factor, now he worries that more physicians will resort to that step if noncompliance impacts their bottom line. “And then who is going to care for these people?” he asks.

CHALLENGE 9 Changing patient attitudes

“Patients feel more empowered to take control over their own health and consider the doctor an adviser. Doctors have to adjust from being in an elevated position to more of a coaching and advising role.” —JOSEPH E. SCHERGER, MD, PRIMARY CARE PHYSICIAN, LA QUINTA, CALIFORNIA

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Today’s patients are educating themselves more, presenting both a challenge and an opportunity for primary care physicians. Google searches make it easy for patients to arrive at appointments armed with selfdiagnoses, and consumer advertising means they often have questions about the new, brand-name drugs they see on television. Some, newly insured by the Affordable Care Act, may be coming to the doctor for the first time, and have questions and concerns they expect their new physician to answer. Other patients are angry. A recent Medical Economics reader poll suggests physicians are seeing that anger manifested during office visits as frustration with the cost of healthcare, from deductibles to surprise charges. Other patients are taking a consumerist approach to healthcare, looking for convenience and quick access. As healthcare changes so quickly, and becomes a relentless hamster wheel for providers, many physicians are searching for the best way to reach today’s patients. The solution, some physicians believe, is to get back to basics. “I think it all comes down to establishing trust with your patient,” says Rick Greco, DO, an internist who spent two decades as an office-based physician and now works as a hospitalist. “I think that’s a problem we’ve created. We’ve downplayed the value of that.” That’s an old-fashioned notion, but one that has grown in importance as patients become more knowledgeable and want a partnership with a physician, says Joseph E. Scherger, MD, a primary care physician in La Quinta, California, and member of the Medical Economics editorial advisory board. “Patients feel more empowered to take

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

control over their own health and consider the doctor an adviser. Doctors have to adjust from being in an elevated position to more of a coaching and advising role,” Scherger says. Fortunately, there are strategies that physicians can use to better communicate and connect with patients. Greco says part of the solution is tone. When patients come in speculating about their condition or asking about homeopathic techniques, physicians should consider the patient’s perspective when they respond. “I think physicians fall into a trap of saying, ‘You can’t believe everything you read, there’s more to it than you know,’” Greco says. Instead, he suggests physicians acknowledge they have heard of that approach but add, “If the technique doesn’t seem to be working for that patient, perhaps we could try this.” Greco and Scherger both embrace shared decision-making, a technique that takes this approach. Everything from medication decisions to referrals for testing or procedures can be a collaboration with patients. While many might assume shared decision-making is important when discussing serious medical conditions such as cancer treatment or end-of-life care decisions, it can—and should—also apply in routine care decisions. “I think that doctors need to look into [shared decision-making] and reflect on it and adapt to it, rather than fight it,” Scherger says. “I think physicians have to really understand there is value to being the doctor, not a technician,” Greco says. “I think you have to put yourself in the patient’s situation, and maybe we need to do a lot more education for physicians about that.”

MedicalEconomics. com

TOP 10 CHALLENGES

CHALLENGE 10

Patient satisfaction scores Patient satisfaction has become an increasingly important factor in how physicians are treated by their employers and insurers, thanks in part to government regulations. Moreover, many patients now come to their appointments with a laundry list of tests they want done or diagnoses they have made themselves from information they found from web searches, and demand their physician respond to their findings, according to Gerald Maccioli, MD, chief quality officer for Sheridan Healthcare in Fort Lauderdale, Florida, Dealing with the internet-savvy patient— but also attempting to make a personal connection with them—all while entering the data correctly into the practice’s electronic health record (EHR) system is a daunting but necessary task because of value-based care. Even if physicians wanted to hide from patient satisfaction scores, websites such as Yelp, RateMDs and Healthgrades.com make doing so difficult because anyone can look up a doctor’s name and see what other patients had to say about their experience. So it is not surprising physicians are feeling conflicted over how best to handle patient satisfaction scores. “[Prior to EHRs], those were the days when medicine was practiced in a way patient satisfaction wasn’t really an issue,” says Henry Anhalt, DO, a pediatric endocrinologist in private practice in Hackensack, New Jersey. “Patients were drawn to physicians who felt that there was a personal bond. What’s happening now, he says, is a result of the current payer environment, which has harmed the personal relationship patients used to have with their physicians. But focusing too much on patient satisfaction scores can also have dire consequences, Maccioli warns. The opioid epidemic has been one of those consequences, he says, as the emphasis on making patients happy led some doctors to over-prescribe the medications. According to 2013 research by the Ohio State Medical Association (OSMA) in conjunction with the Cleveland Clinic Founda-

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tion, more than three-quarters of responding physicians agreed or strongly agreed that the emphasis on patient satisfaction is leading providers to overuse expensive testing. Furthermore, 58% reported that pressure from hospital administrators to improve patient satisfaction regarding the treatment of pain had increased, which has led to prescribing opioids. Nevertheless, there are several methods physicians can use to help ease the burden of patient satisfaction scores. Asking satisfied patients to post reviews is a great way to boost online scores and stay ahead of value-based payment, says Lee Ann Van Houten-Sauter, DO, a family physician at Pine Street Family Practice in Williamstown, New Jersey. Putting yourself in the patients’ shoes is another way to ease the anxiety of dealing with Dr. Google-type patients, Maccioli says. “It really comes down to the rule of treating others the way you yourself want to be treated,” he says. “If we approach ev— GERALD MACCIOLI, MD, CHIEF QUALITY ery interaction with the paOFFICER, SHERIDAN HEALTHCARE, FORT tient’s perspective in mind LAUDERDALE, FLORIDA [they’ll lead to better outcomes].” Physicians also need to start accepting the changing world they live in, he says. “This is a change that is here and isn’t going anyway, so we need to embrace it.” he notes. Anhalt agrees, saying having more empathy truly is key to solving the satisfaction dilemma. “The power of listening can’t be overstated,” he says. “You must listen to your patients and you must be empathic because how you see their disease is not how they see their disease. Patient satisfaction is truly a reflection of the job that a physician is doing.”

“It’s a new world for physicians. This is a change that is here and isn’t going anyway, so we need to embrace it.”

MEDICAL ECONOMICS ❚ DECEMBER 25, 2016

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❚ Primary care’s future: Value-based care will signal the beginning of major changes for physicians. We’ll look at what else is on the horizon.

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❚ ONC’s next chapter: B. Vindell Washington, MD, reflects on where the agency is now with a new administration bringing new leadership over health IT regulation.

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