High-value care - Modern Medicine
Medical Economics APR I L 10, 2015 H IG H-VALU E CAR E STRATEG I ES APRIL 10, 2015 VOL. 92 NO. 7 2015 physician writing contest: What caring means 32 Managing conflict with patients ■ 18 HOW TO USE DI R ECT M ESSAG I NG 42 ■ Using Direct messaging to improve information exchange JOI N I NG AN I PA 47 Joining an IPA: What you need to know first 51 Insurance coverage every physician needs High-value care STRATEGIES Guiding patient conversations to optimize care, reduce cost PAGE 26 LOW-VALUE TREATMENTS What to watch for PATIENT DIALOGUE STARTERS GEORGIANN DeCENZO Executive Vice President 440-891-2778 / [email protected] KEN SYLVIA Vice President, Group Publisher 732-346-3017 / [email protected] Twitter Talk Other people and organizations tweeting about issues that matter to you R ICHAR D VAUG H N M D @RVAUGHNMD Good read. “smallest independent primary care practices, physician owned, provide better care at lower overall cost” http://bit.ly/1qNNnm0 DAVID A. DePINHO Publisher/Group Editor 732-346-3053 / [email protected] PUBLISHING & SALES EDITORIAL MONIQUE MICHOWSKI GEORGE G. ELLIS JR., MD, FACP National Account Manager Chief Medical Adviser 732-346-3098 / [email protected] JEFFREY BENDIX, MA ANA SANTISO Senior Editor National Account Manager 440-891-2684 / [email protected] 732-346-3032 / [email protected] CHRIS MAZZOLINI, MS TOD McCLOSKEY Content Manager Account Manager, Display/Classified & Healthcare Technology 440-891-2797 / [email protected] 440-891-2621 / [email protected] JOANNA SHIPPOLI Account Manager, Recruitment Advertising ART 440-891-2615 / [email protected] ROBERT McGARR DON BERMAN Group Art Director Business Director, eMedia MOU NT S I NAI HOS PITAL @MOUNTSINAINYC #Obesity is one of the most important risk factors for #cancer, second to tobacco” - Dr. Paolo Boffetta @ TischCancer http://bit.ly/1uOrM3i 212-951-6745 / [email protected] 440-891-2628 / [email protected] MEG BENSON PRODUCTION Special Projects Director KAREN LENZEN 732-346-3039 / [email protected] Senior Production Manager GAIL KAYE Director of Marketing & Research Services AUDIENCE DEVELOPMENT 732-346-3042 / [email protected] JOY PUZZO Corporate Director CHRISTINE SHAPPELL Director WENDY BONG Manager HANNAH CURIS Sales Support STE PH E N SCH I M PFF, M D @DRSCHIMPFF Physician frustration is rampant but lets reframe the resolution question http://bit.ly/1s1rcyk #primarycare KEN TERRY GAIL GARFINKEL WEISS Contributing Editors RENÉE SCHUSTER List Account Executive 440-891-2613 / [email protected] REPRINTS MAUREEN CANNON 877-652-5295 ext. 121 / [email protected] Outside US, UK, direct dial: 281-419-5725. 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PATR ICK JONAS, M D @APJONAS Report: Recruiters have trouble filling primary care openings http://sbne.ws/r/q85a #FMREVOLUTION UBM Advanstar JOE LOGGIA Chief Executive Officer TOM EHARDT Executive Vice-President, Life Sciences GEORGIANN DeCENZO Executive Vice President CHRIS DeMOULIN MIKE ALIC Executive Vice-President, Strategy & Business Development TRACY HARRIS Senior Vice President DAVE ESOLA Vice President, General Manager Pharm/Science Group MICHAEL BERNSTEIN Executive Vice President Vice President, Legal REBECCA EVANGELOU FRANCIS HEID Executive Vice President, Business Systems Vice President, Media Operations JULIE MOLLESTON Vice President, Treasurer & Controller Executive Vice President, Human Resources ADELE HARTWICK UBM Americas SALLY SHANKLAND Chief Executive Officer BRIAN FIELD Chief Operating Officer MARGARET KOHLER Chief Financial Officer UBM plc TIM COBBOLD Chief Executive Officer ANDREW CROW Group Operations Director ROBERT GRAY Chief Financial Officer DAME HELEN ALEXANDER join us online facebook.com/MedicalEconomics twitter.com/MedEconomics PA RT O F TH E 6 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. 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Robert C. Scroggins Insurance must-haves 32 MANAGING CONFLICT WITH PATIENTS 10 11 12 16 55 57 Strategies for talking with patients about certain matters can help alleviate conflict points. ME ONLINE EDITORIAL BOARD FROM THE TRENCHES VITALS ADVERTISER INDEX THE LAST WORD 40 UNDERSTANDING THE STARK LAWS What physicians need to know about the rules regarding physician self-referral. Healthcare reform will cost billions less than anticipated, according to an analysis by the Congressional Budget Office. M I S S I O N S TAT E M E N T Cover: Getty Images/iStock/360/marigold_88 Medical Economics is the leading business resource for office-based physicians, providing the expert advice and shared experiences doctors need to successfully meet today’s challenges in practice management, patient relations, malpractice, electronic health records, career, and personal finance. Medical Economics provides the nonclinical education doctors didn’t get in medical school. C O V E R STO R Y | TR E N D S Guiding patient conversations to optimize care, reduce costs. starts on page 26 Low-value treatments: What to watch for ] Patient conversation starters ] Guidelines for primary care ] MEDICAL ECONOMICS (USPS 337-480) (Print ISSN: 0025-7206, Digital ISSN: 2150-7155) is published semimonthly (24 times a year) by UBM Advanstar, 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. MedicalEconomics. com 42 DIRECT MESSAGING: WHY PHYSICIANS HAVE NOT EMBRACED IT YET While Direct messaging can help physicians meet meaningful use 2 goals, there are challenges to using the service. 47 WHAT TO CONSIDER BEFORE JOINING AN IPA Independent physician associations can be a buffer zone between physician practices and the challenges of remaining independent. 51 INSURANCE EVERY PRACTICE SHOULD HAVE All physicians should consider these kinds of insurance to protect the financial health of their practices. 57 ACA COST ESTIMATES ON THE DECLINE Healthcare reform will cost billions less than anticipated. MEDICAL ECONOMICS]APRIL 10, 2015 7 MEDICALECONOMICS.COM SMARTER BUSINESS. BETTER PATIENT CARE. EXCLUSIVE ONLINE CONTENT AND NEWS. online I N-D E P TH C O V E R A G E THE RISING COST OF GENERIC PRESCRIPTIONS In spite of federal efforts, the cost of healthcare continues to rise. A recent PricewaterhouseCoopers report predicts a 6.8% increase in costs in 2015, in part because of costly specialty medications.But it’s not just breakthrough drugs accounting for escalated costs. Almost no part of the pharmaceutical industry is escaping the trend—including generics, formerly the go-to for low-cost care. Read more: http://bit.ly/1bbE7I7 Twitter Talk Follow us on Twitter to receive the latest news and participate in the discussion. FACILITY FEES The increasing use of facility fees force physicians to talk money with patients http://ow.ly/G8oTO ELECTRONIC HEALTH RECORDS Is your EHR use as efficient as it could be? Learn 5 key factors in our eBook. http://bit.ly/1y9iS0M HEPATITIS C TREATMENTS Top Headlines Now @MEonline WHY EMPATHY MAY BE THE BEST RISK STRATEGY ME App. DOWNLOAD FREE TODAY. When a mistake occurs, showing compassion and discussing clear next steps with patients can prevent lawsuits. Read more at: Get access to all the benefits Medical Economics offers at your fingertips. The Medical Economics app for iPad and iPhone is now available for free in the iTunes store. http://bit.ly/1Fb2kHN MedicalEconomics.com/app Are practices ready for ICD-10? Read full story: #2 ICD-10 TESTING RESULTS http://bit.ly/1za5R3z Cholesterol lowering resource center Find the latest research and information on medication and treatment strategies. #3 DIABETES PATIENTS NOT LEARNING SELF-CARE Find out why at ow.ly/Gm2cn MedicalEconomics.com/cholesterol PA RT O F TH E 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. 10 MEDICAL ECONOMICS ❚ APRIL 10, 2015 Health plans have been excitedly awaiting an alternative to the extremely costly #Sovaldi for treating #hepC http://ow.ly/Ghi7Z DIABETES #Diabetes is the leading cause of #visionloss in working-aged Americans http://ow.ly/GcAUT CORONARY DISEASE #Coronaryheartdisease is estimated to kill more than 385,000 persons a year. http://ow.ly/G97Dz REIMBURSEMENTS Getting paid for chronic care under Medicare’s new program http://ow.ly/G8oHa MEDICAL MALPRACTICE The future of malpractice reform http://ow.ly/G8oNd join us online facebook.com/MedicalEconomics twitter.com/MedEconomics MedicalEconomics. com The board members and consultants contribute expertise and analysis that help shape the content of Medical Economics. PAGE 51 An umbrella policy can extend coverage where there are gaps in other policies.” —Robert C. Scroggins CONSULTANT the Advisers EDITORIAL CONSULTANTS PRACTICE MANAGEMENT Judy Bee www.ppgconsulting.com La Jolla, CA Keith Borglum, CHBC Professional Management and Marketing Santa Rosa, CA Kenneth Bowden, CHBC Berkshire Professional Management Pittsfield, MA Michael D. Brown, CHBC Health Care Economics Indianapolis, IN EDITORIAL BOARD Frank Cohen, MPA www.frankcohengroup.com Clearwater, FL Virginia Martin, CMA, CPC, CHCO, CHBC Mary Ann Bauman, MD Elizabeth A. Pector, MD Healthcare Consulting Associates of N.W. Ohio Inc. Waterville, OH Internal Medicine Oklahoma City, OK Family Medicine Naperville, IL Rosemarie Nelson MGMA Healthcare Consultant Syracuse, NY Mark D. Scroggins, CPA, CHBC Clayton L. Scroggins Associates Inc. Cincinnati, OH Gray Tuttle Jr., CHBC John L. Bender, MD, MBA Patricia J. Roy, DO The Rehmann Group Lansing, MI Family Medicine Ft. Collins, CO Family Medicine Muskegon, MI Healthcare Management and Consulting Services Bay Shore, NY Michael J. Wiley, CHBC H. Christopher Zaenger, CHBC Z Management Group Barrington, IL Karen Zupko Karen Zupko & Associates Chicago, IL Maria Y. Chandler, MD, MBA Joseph E. Scherger, MD Business of Medicine, Pediatrics Irvine, CA Family Medicine La Quinta, CA TAXES & PERSONAL FINANCE Lewis J. Altfest, CFP, CPA Altfest Personal Wealth Management New York City Robert G. Baldassari, CPA Matthews, Carter and Boyce Fairfax, VA Todd D. Bramson, CFP George G. Ellis Jr., MD Salvatore S. Volpe, MD North Star Resource Group Madison, WI Internal Medicine Youngstown, OH Internal Medicine-Pediatrics Staten Island, NY Insurance consultant New York City Glenn S. Daily, CFP Barry Oliver, CPA, PFS Thomas, Wirig, Doll & Co. Capital Performance Advisors Walnut Creek, CA Gary H. Schatsky, JD David C. Judge, MD Craig M. Wax, DO IFC Personal Money Managers New York City Internal Medicine Cambridge, MA Family Medicine Mullica Hill, NJ Schiller Law Associates Norristown, PA David J. Schiller, JD Edward A. Slott, CPA E. Slott & Co. Rockville Centre, NY HEALTH LAW & MALPRACTICE Barry B. Cepelewicz, MD, JD Jeffrey M. Kagan, MD Garfunkel Wild, PC Stamford, CT Internal Medicine Newington, CT Wheeler Trigg Kennedy, LLP Denver, CO John M. Fitzpatrick, JD Alice G. Gosfield, JD Alice G. Gosfield and Associates Philadelphia, PA James Lewis Griffith Sr., JD Fox Rothschild Philadelphia, PA Lee J. Johnson, JD ask us Have a question for our advisers? Email your question to [email protected]. MedicalEconomics. com Mount Kisco, NY Lawrence W. Vernaglia, JD, MPH Foley & Lardner, LLP Boston, MA MEDICAL ECONOMICS ❚ APRIL 10, 2015 11 from the Trenches Whatever future shape and direction the ABIM and the other primary care specialties take on, doctors must include rigid safegurards to protect their professionalism. Lacking them, the risk is great that after a grace period the ABIM will resume its aristoractic airs and promote its influence...to control doctors. Edward Volpintesta, MD, BETHEL, CONNECTICUT ABIM MUST CHANGE ITS APPROACH TO MOC For “about face” to have meaning that will help doctors and will heal the bitter feelings that for too long have festered will require extensive changes in the philosophy of MOC (maintenance of certificaiton) and the modus operandi of the leadership of the American Board of Medical Specialties: (“ABIM does about-face on changes to MOC” (Medical Economics eConsult, February 4, 2015). To begin with, after passing their initial board exams doctors should never lose their certification and become decertified. That this has happened is clear evidence of how even the very organizations that are supposed to help doctors can lose their focus and be harmful. The implications and uncertainty over MOC have undermined physicians’ peace of mind for far too long. Being exploited and treated with indifference has made many doctors lose faith in the ABIM to treat them fairly. It will take years and positive action to restore the faith that has been lost. Without it future success and acceptance are impossible. To show their commitment to rapprochement with the medical community, the primary care boards (internal medicine, family medicine and pediatrics) would do well to allow anyone who has failed their last recer- 12 MEDICAL ECONOMICS ❚ APRIL 10, 2015 tification to retake them free of charge. Whatever future shape and direction the ABIM and the other primary care specialties take on, doctors must include rigid safeguards to protect their professionalism. Lacking them, the risk is great that after a grace period the ABIM will resume its aristocratic airs and promote its influence with the public, state medical boards, the Federation of State Medical Boards, hospitals, and medical societies to control doctors. The primary care specialties (internal medicine, family medicine and pediatrics) require special attention because many primary care doctors, after finishing training and passing their initial boards, tailor their practices to the demographics of their communities and the availability of specialist care. As a result no one knows better than they which areas of they need to update their knowledge in. They should be allowed to choose their own updating. It will be interesting to see what the future of MOC will look like. Right now it is still an ugly duckling. Edward Volpintesta, MD BETHEL, CONNECTICUT REGULATORY BARRIERS HINDER GOOD PATIENT CARE Regarding the letters in your February 10, 2015 issue concerning medical malpractice: MedicalEconomics. com from the Trenches Regulators and third-party payers never were, and never will be, the experts who best define necessary medical care, let alone preventive measures. Those issues are best addressed within caring relationships and with the support of those with the knowledge, experience, and interest in serving all their fellows. J. Kimber Rotchford, MD, MPH, PORT TOWNSEND, WASHINGTON Discussions of defensive medicine and malpractice costs are important. But they can deflect our attention from more important barriers to cost-effective medical care. To the point, regulatory liabilities and our payment system are the most important barriers to cost-effective medical and preventive services. Providers are threatened with criminal charges if billing errors occur. In Washington State Medicaid recently settled with a large non-profit organization for $3.65 million over Medicaid billings.The non-profit involved has a long history of providing essential cost-effective medical and preventive services. There are complexities and controversies in billing codes and documentation. Honest mistakes happen. What’s more, billing and documentation often do not accurately reflect the nature of services provided. It seems to not matter whether services, even life-preserving ones, are effectively provided. What matters most to third parties and regulators is who provided the service and whether the bill was properly coded and documented. Another example of regulatory concerns is found in the drug enforcement administration. Secondary to their involvement in medical care, I think appropriate medical care is compromised more than protected. The public health implications are huge. Physicians and the public benefit from oversight MedicalEconomics. com regarding professional behavior. As to the rest, I wonder? Regulatory concerns are likely secondary to how the system reimburses care. The likelihood of getting an x-ray even before seeing the physician is not simply an issue of malpractice concerns. The real driver is what third parties pay for. Imaging, laboratory procedures, and other diagnostic or therapeutic procedures are clearly where the money is. Procedures subsidize essential clinical care. Even charting is most often about what it takes to get paid or avoid liabilities rather than cost-effective outcomes. Regulators and third-party payers never were, and never will be, the experts who best define necessary medical care, let alone preventive measures. Those issues are best addressed within caring relationships and with the support of those with the knowledge, experience, and interest in serving all their fellows, including the poor and disenfranchised. Team approaches are best and the rules of the game demand the best clinical and public health expertise. They also encourage promising innovations. The best and most cost-effective medical care cannot be reduced to billing codes, chart notes, and reimbursement schedules. We all know this. TELL US [email protected] Or mail to: Letters Editor, Medical Economics, 24950 Country Club Boulevard, Suite 200, North Olmsted, Ohio 44070. Include your address and daytime phone number. Letters may be edited for length and style. Unless you specify otherwise, we’ll assume your letter is for publication. Submission of a letter or e-mail constitutes permission for Medical Economics, its licensees, and its assignees to use it in the journal’s various print and electronic publications and in collections, revisions, and any other form of media. J. Kimber Rotchford, MD, MPH PORT TOWNSEND, WASHINGTON MEDICAL ECONOMICS ❚ APRIL 10, 2015 13 theVitals STUDY: 9% OF PHYSICIANS SAY THEY WILL NEVER USE AN EHR Electronic health records (EHR) use has steadily increased among officebased physicians, but new studies indicate that the number of physicians who don’t or plan to participate is substantial. A new study conducted by Mathematica Policy Research and published in the Annals of Internal Medicine seeks to reveal more information about those physicians to understand better why they don’t participate. In 2011, 44% of those polled had an EHR system that met basic criteria, with another 19% adopting basic EHR systems between 2011 and 2013. By 2013, 20% more were in process of implementation, and another 8% planned implementation within the next two years, according to the report. Nine percent had no plans to adopt an EHR system. That 9% consisted mostly of older physicians and those most likely to work in independent or solo practices. Most non-adopters also used fee-for-service as their primary compensation model. 16 Examining the News Affecting the Business of Medicine MEDICAL SOCIETIES CMS needs ICD-10 contingency plan The American Medical Association (AMA) and dozens of other physician advocacy groups have written a joint letter to express concern to the U.S. Centers for Medicare and Medicaid Services (CMS) that its ICD-10 “contingency plans may be inadequate if serious disruptions occur on or after October 1,” the day of the transition. “Physicians are being asked to assume this signficant change at the same time they are being required to adopt new technology, re-engineer workflow, and reform the way they deliver care,” the letter reads. The advocacy groups’ concerns fall into three areas: claims testing, impact on quality measurements and risk mitigation from disruptions related to the coding transition. Physician solutions about ICD-10 transition issues Testing CMS should release more detailed end-to-end testing results broken out by the type and size of providers who tested, number of claims tested by each submitter, percentage of claims successfully processed, and specific details about problems encountered. MEDICAL ECONOMICS ❚ APRIL 10, 2015 Quality measurement CMS should provide details on how it plans to ensure that the measure calculations for the Physician Quality Reporting System and meaningful use programs are not adversely impacted by the transition to ICD-10. Risk mitigation CMS can mitigate risks of payment disruptions by granting “advance payments” to physicians experiencing dire financial hardship as a result of changing to ICD-10. Read the full letter: http://bit.ly/1ENLP66 MedicalEconomics. com theVitals Next-generation ACO offers higher risk, but more potential rewards A NEXT-GENERATION accountable care organization (ACO) model that encourages greater coordination between providers and beneficiaries has been launched by the U.S. Department of Health and Human Services (HHS). The new model is linked to HHS’ intention, announced on January 26, to shift 50% of provider payments into alternative payment arrangements such as ACOs by 2018. ACOs are provider-led groups in which payments are linked to quality improvements for a defined population. If providers reduce expected spending while meeting quality metrics, they receive a portion of the savings. In certain models, they are also liable for losses if benchmarks aren’t met. The “Next Generation” ACO model carries more risk for participants than HHS’ Shared Savings ACO and Pioneer ACO, but the Sylvia M. Burwell. “This model is part of our larger effort to set clear, measurable goals and a timeline to move the Medicare program -- and the health care system at large -- toward paying providers based on the quality, rather than the quantity of care — HHS SECRETARY SYLVIA M. BURWELL they give patients.” According to the Centers for Medicare and Medicaid Services (CMS), the model will consist of three initial potential rewards are also performance years and higher. two optional one-year “The Next Generation extensions, two risk ACO Model is one tracks and four payment of many innovative mechanisms. One track payment and care will put the ACOs at delivery models created near 100% risk. Patients under the Affordable enrolled in the model will Care Act, and is an have more control over important step towards their healthcare, see no advancing models of care change in benefits, and that reward value over “keep their freedom” to see volume in care delivery,” any Medicare provider. said HHS Secretary “The Next Generation ACO Model is ... an important step towards advancing models of care that reward value over volume in care delivery.” HOW TO JOIN CMS will accept ACOs into the Next Generation ACO Model through two rounds of applications in 2015 and 2016, with participation expected to last up to five years. For round one consideration, interested organizations must submit a letter of intent no later than 11:59p.m. EDT on May 1, 2015. Round one applications must be submitted electronically no later than 11:59p.m. EDT on June 1, 2015. Round two Letters of Intent and applications will be made available in March 2016. The round two Letter of Intent must be submitted electronically no later than 11:59p.m. EDT on May 1, 2016, and the application no later than 11:59p.m. EDT on June 1, 2016. MORE ONLINE Visit CMS for more info on how to submit: http://1.usa.gov/1HwHXGh MedicalEconomics. com ARE EHR VENDORS HOLDING PATIENT DATA ‘HOSTAGE’? When the Health Information Technology for Economic and Clinical Health (HITECH) Act created the Meaningful Use Incentive Program, it was a well-meaning move toward obtaining the complete medical histories of patients efficiently and costeffectively. But one major oversight in the creation of the requirement to use electronic health records (EHR) systems is that, while it was intended, the law never specified how systems should be interoperable to enable data exchange. Niam Yaraghi, Ph.D., a fellow at the Brookings Institution Center for Technology Innovation, writes in a new blog post that EHR vendors have taken patient data “hostage.” That’s because even though it was the intended second step to EHR implementation, vendors are claiming that their systems can’t be interoperable without making costly fixes to technical problems. “This prevents physicians from sharing their patient records with other doctors,” Yaraghi says. “The vendors are proposing hefty charges to allow data sharing between their own customers.” MEDICAL ECONOMICS ❚ APRIL 10, 2015 17 SPECIAL R EPORT Medical Economics is proud to unveil the second-place entry in our 2015 Physician Writing Contest. We believe the three winning essays exemplify what connecting with your patients is truly about, and demonstrate the levels of heart, determination, and empathy you strive to bring into every exam room, every day. Thanks for reading. To care always SECOND PLACE WINNER Kenneth Moon, MD is a family physician who lives in Silver Spring, Maryland. I s it bad?” Of all the questions to be asked, that is certainly one of the worst, particularly when you’re a junior resident on Christmas Eve, and you know that, in fact, it is. Yet there he was, gently tugging at my sleeve from his hospital bed, voice held low so his wife across the room would not hear. And there I was, leaning over him, poised to move his St. Christopher medal so I could listen to his heart. I could have evaded it, avoided the responsibility and said we should wait to hear what the consultants would say. But we had already discussed it, in advance of the family meeting that would be starting any minute. And here was Mr. Davis, my patient, asking for an honest answer, and I knew what it must have cost this silent, stoic man to ask that simple, terrifying question. “Yes,” I said quietly. “I’m sorry.” He nodded, and fell silent. Lying there in bed, he looked well enough, so long as you didn’t ask him to stand without his wife’s and daughter’s help, and if you ignored the plastic tubing emerging from his upper abdomen. The drain had relieved his itching and the yellowed tint of his skin, but would not fix the baseball-sized mass nestled with- in the head of his pancreas. The family meeting was to discuss what could next be done. Unfortunately however, it seemed that there would be very little to offer. The rest of the team arrived: the other residents and the attending, followed by the gastroenterologist and the oncologist. Earlier that morning we had scrutinized his imaging and testing, and had agreed that this was not something that he could survive. But now, as the talk moved past the test results, to the concern for advanced pancreatic cancer, to the treatment options, the real issue of prognosis seemed to have been left behind. The consultants were good physicians, and they had the best intentions, but no mention was made of his inevitable decline and the final outcome, or of ensuring the quality of the time he had left. Instead, the conversation focused on the need for additional testing before deciding on the best treatment plan, behind which lay the unspoken yet implied promise of a cure. In the back of the room, I frowned to myself. Could I have misunderstood our earlier discussions? Could Mr. Davis actually have a fighting chance? It now sounded as if the outcome was not so certain after all. And if I, who should have known better, was left with that impression, what must Mr. Davis and S U P P O R T E D BY 18 MEDICAL ECONOMICS ❚ APRIL 10, 2015 MedicalEconomics. com 2015 Physician writing contest his family think? The patient and his family listened, but didn’t have many questions. As the meeting ended, I excused myself and hurried out after the exiting consultants. I caught up with one of them at the charting station as he was writing his note. “Excuse me,” I said, “back there it sounded like you felt that he had a pretty good chance of coming through this. Do you actually think that he might be okay?” He snorted. “No. He’s going to die.” He finished his note and walked off, adding, “He’ll be lucky if he lasts six months.” I was still standing there as the rest of the team emerged from Mr. Davis’s room. The attending and senior resident began planning the next steps, while the junior residents silently waited for their instructions. Between arranging for biopsies and additional imaging, and when any actual treatment might begin, it looked as if Mr. Davis could expect to be in the hospital for quite some time, especially given the holiday season. They were still hammering out the details when someone interrupted them. “We should send him home.” I hadn’t really meant to speak, but there it was. The attending and senior resident stopped and turned towards me, surprise on their faces. There was no turning back. “It’s Christmas Eve. And tomorrow’s not only Christmas, it’s Saturday. When do we think these tests will actually get done?” No one answered, but they didn’t need to. We all knew the chances of getting tests and studies done around holidays or long weekends. I looked around at the team. “We can’t fix this. And this is his last Christmas. Spending it in the hospital, waiting to get testing done, won’t get them done any faster. I say we send him home, let him spend Christmas with his family, then bring him back next week to get the tests done. “ My words seemed to freeze in the air. I MedicalEconomics. com SPECIAL REPORT No one chooses medicine out of a desire to hurt others. But sometimes, our desire to prevent suffering may actually have the opposite effect if we forget that the scope of our patients’ lives consists of more than their medical ailments.” had just recommended a plan that I had never heard anyone propose during my short medical career, much less actually order. The attending continued staring, and I felt my career fading away into the silence. At last, the attending spoke. “Let’s do it,” he said. Within a few hours, he was on his way home. He returned the next week as planned, had the additional tests done, and then went home again. He died at home, about a month later, surrounded by his family. I still think about how, ultimately, we had very nearly failed him. No one chooses medicine out of a desire to hurt others. But sometimes, our desire to prevent suffering actually may have the opposite effect if we forget that the scope of our patient’s lives consists of more than their medical ailments. Over two thousand years ago, Hippocrates is supposed to have said: “To cure, sometimes; to help, often; to care, always.” I suppose that even today, we have to accept that sometimes one out of three isn’t so bad after all. CO M IN G N EXT ISSU E Medical Economics unveils the third-place entry in the April 25 issue: “From the other side” BY RASHMEE PATIL, MD “As I move forward in my career as a physician, I am forever changed by my experience. I approach my patients now with more compassion and less judgment.” MEDICAL ECONOMICS ❚ APRIL 10, 2015 19 Clinical Economics Allergic Rhinitis Key coding considerations he Asthma and Allergy Foundation of America estimates that 50 million Americans suffer from allergic rhinitis, which includes hay fever and seasonal or perennial indoor/outdoor nasal allergies. These conditions are thought to affect up to 30% of adults and 40% of children, according to reports from the American College of Asthma Allergy & Immunology. This represents a marked increase over past decades; in the 1940s, hay fever was estimated to affect only 1% of the U. S. population. Hay fever is the fifth-leading chronic disease for adults and a significant cause of work absenteeism, resulting in nearly four million missed workdays each year at a cost of over $700 million in lost productivity. In addition, hay fever results in significant presenteeism, with poor performance while at work due either to the symptoms of the condition itself or the effects of medication used to treat those symptoms. Overall, allergies are responsible for nearly $14.5 billion in medical costs each year. More than 11 million outpatient office visits occur annually to address allergy, primarily in the spring and fall. What these statistics fail to show is the significant effect allergies can have on many patients’ quality of life, given that allergy symptoms can have a greater impact even than diseases such as asthma. Despite the burden associated with allergic symptoms, studies have shown that only a small percentage of patients actually seek medical advice regarding treatment. A review of data from the National Medical Expenditure Survey found that only 12.4% of patients with allergic rhinitis visited their physician to manage the condition, while others used home Continued on page 24 Annual outpatient office visits: 11 MILLION to address allergy, primarily in the spring and fall. Overall annual medical cost of allergies: $ 14.5 BILLION HAY FEVER Work absenteeism 4 MILLION missed workdays each year with a total cost of $700 MILLION OVERVIEW PAGE 25 MORE THAN PAGE 24 MORE THAN Patient management tips NEARLY Overview in lost productivity PATIENT MANAGEMENT TIPS SEE PAGE 24 Evaluate effectiveness Define allergy triggers Individualize a treatment plan and educate accordingly Optimize allergen and self-management techniques Establish regular follow-up appointments Know when to refer Providing effective, efficient counseling on management and medication is key to helping patients manage their seasonal symptoms. Source: American College of Asthma Allergy & Immunology MedicalEconomics. com MEDICAL ECONOMICS ❚ APRIL 10, 2015 23 Clinical Economics: Allergic Rhinitis Continued from page 23 remedies or over-the-counter medications. Even with these attempts at treatment, about 50% of patients with allergic rhinitis report symptoms lasting more than four months per year, and 20% have symptoms lasting at least PATIENT MANAGEMENT TIPS Evaluate effectively. A complete history will help clarify the patient’s chief concerns and symptoms, including symptom triggers, seasonality, and chronicity; environmental, home, and occupational exposure; and current coexisting conditions and medications. Specifically, asking patients about pollen and animal exposure can have positive predictive value for diagnosing allergic rhinitis. It is also important to establish how symptoms affect a patient’s quality of life. Nasal examination, while important to supporting a diagnosis of allergic rhinitis, is not necessarily sufficient by itself to defining the condition. Perform a physical examination of all organ systems that may be affected by allergies, especially the lower respiratory tract. It is also important to ask about the presence of comorbidities and other related conditions during the patient examination. Patient issues commonly associated with allergic rhinitis can include asthma, sleep disturbances, sinusitis, otitis media, ocular symptoms, abnormal breathing patterns that can alter facial growth in children, and effects on cognitive function that can manifest as falling school grades during allergy season. Define allergy triggers. Identifying a patient’s allergy triggers provides crucial information for successful management. Common triggers of allergic rhinitis include animals, dust mites, fungi, insect emanations, and pollens. Pollen types can vary widely based on climate and locale, and fungi are ubiquitous organisms that can produce clinically significant allergens. Therefore, patient education regarding avoidance of 24 MEDICAL ECONOMICS ❚ APRIL 10, 2015 Overview Patient management tips Key coding considerations nine months. Clinicians play an important role in helping patients alleviate their allergy symptoms. “While there is no cure for grass pollen allergies, they can be managed through treatment and avoiding exposure to the pollen,” says Karen Midthun, MD, director of the U.S. Food and Drug Administration’s Center for Biologics Evaluation and Research. Thus, effective, efficient patient counseling on management and medication is key to managing patients’ seasonal symptoms. PATIENT EDUCATION RESOURCES lergic rhinitis that does not respond to other forms of treatment. American Academy of Allergy Asthma & Immunology: Outdoor allergens bit.ly/1BzDnEX Harvard Medical School: Patient education center bit.ly/18DLdD7 Mayo Clinic: Seasonal allergies mayocl.in/1oyrNB3 established allergic triggers is essential. Individualize a treatment plan and educate accordingly. Successful management of allergic rhinitis typically requires a combination of allergen avoidance, patient education, pharmacotherapy, and possibly immunotherapy. Patient management and monitoring should be individualized based on reported symptoms, physical examination, comorbidities, and patient age and preferences. A strong physician/patient/family partnership will provide the most effective framework for treatment success, and education is a key element in facilitating adherence and optimizing treatment outcomes. Patients should understand how to avoid environmental triggers, as well as the appropriate use of over-the-counter or prescription medications. Pharmacological management often requires a step-up approach when therapy is inadequate for symptom control, or a step-down approach when symptom relief is achieved. Therefore, clinicians and families should agree as to when escalation or de-escalation of therapy is appropriate. Targeted immunotherapy may be necessary for symptom control in patients with moderate or severe persistent al- Optimize allergen and self-management techniques. Patients with allergic rhinitis should avoid known allergic triggers such as pets, as well as general respiratory irritants such as cigarette smoke, perfumes, and paint fumes. Nasal irrigation with saline can be a beneficial selfmanagement technique for alleviating symptoms, and may be used alone or as adjuvant therapy. Some suggestions for controlling exposure to specific allergens include: Animals: avoid contact Dust mites: use dust covers for bedding, control humidity, vacuum carpets frequently, use high efficiency particulate (HEPA) filters. Indoor fungi: remove sources of moisture, replace contaminated materials, use diluted bleach solution to clean nonporous surfaces Pollen: limit time outdoors when pollen counts are high Tobacco smoke and other irritants: minimize exposure Establish regular follow-up appointments. Consistent follow-up can allow for timely recognition of complications, increase therapeutic success, and improve compliance. Follow-up visits also facilitate regular review of a patient’s treatment plan so that it can be modified as necessary based on symptom control and quality of life. Know when to refer. Referral to an allergist/immunologist can be helpful when there is a need to identify more specifically the allergens affecting a patient so that stricter environmental control can be achieved. Additionally, specialist consultation may be necessary when patients with MedicalEconomics. com Clinical Economics: Allergic Rhinitis allergic rhinitis have inadequately controlled symptoms, report a decrease in quality of life, or experience reduced ability to function. Additional reasons to refer include adverse reactions to medications, the presence of comorbid conditions such as asthma or recurrent sinusitis, or when immunotherapy is being considered as a treatment option. —Written by Nicole Klemas, ELS —Reviewed by Phil Lieberman, MD Allergy & Asthma Care, Germantown, Tennessee KEY CODING CONSIDERATIONS The current procedural terminology guidelines state that you should code signs and symptoms when a definitive diagnosis has not been confirmed. Therefore, you will need to document and code the signs and symptoms that a patient presents with at his/her visit. Common diagnosis codes for allergy-related signs and symptoms include those listed below. You should also assign the appropriate E-code(s) for any external causes that can be identified. Before choosing the treatment that best suits your patient, there are several types of tests that can help determine what the patient is allergic to, including: ❚ Antibody testing (86000-86063), ❚ Challenge ingestion testing (95076-95079), and/or ❚ Allergy tests (95004-95071). After running one or more of these tests, you should be able to assign the definitive diagnosis(es). Those specific to allergies are listed elsewhere on the page. Keep in mind that once a definitive diagnosis has been confirmed, you should no longer bill the sign and/or symptom of that diagnosis. —Written by Renee Dowling MORE CLINICAL ECONOMICS ONLINE For more information on patient management and coding tips for different conditions, visit: http://www.modernmedicine.com/tag/ clinical-economics MedicalEconomics. com Overview Patient management tips Key coding considerations Symptom and condition codes ICD-9 Code Description 379.92 478.0 478.19 564.89 729.81 780.79 781.1 782.0 782.1 782.2 782.9 784.2 784.91 784.99 786.07 786.09 786.2 799.22 ICD-10 Code Description Swelling or mass of eye H57.8 Hypertrophy of nasal turbinates J34.3 Other diseases of nasal cavity J34.89 and sinuses J34.9 Other functional disorders of intestine Swelling of limb Other malaise and fatigue R09.81 K59.8 M79.89 R53.81 R53.83 Disturbances of sensation of R43.8 smell and taste R43.9 Disturbance of skin sensation R20.8 R20.9 Rash and other nonspecific skin R21 eruption Localized superficial swelling, R22.0 mass, or lump R22.9 Other symptoms involving skin R23.8 and integumentary tissues R23.9 Swelling, mass, or lump in head R22.0 and neck R22.1 Postnasal drip R09.82 Other symptoms involing head R06.7 and neck R06.89 Wheezing R06.2 Other dyspnea and respiratory R06.00 abnormalities R06.09 R06.3 R06.89 Cough R05 Irritability R45.4 Other specified disorders of eye and adnexa Hypertrophy of nasal turbinates Other specified disorders of nose and nasal sinuses Unspecified disorder of nose and nasal sinuses Nasal congestion Other specified functional intestinal disorders Other specified soft tissue disorders Other malaise Other fatigue Other disturbances of smell and taste Unspecified disturbances of smell and taste Other disturbances of skin sensation Unspecified disturbances of skin sensation Rash and other nonspecific skin eruption Localized swelling, mass and lump Other skin changes Unspecified skin changes Localized swelling, mass and lump, head Localized swelling, mass and lump, neck Postnasal drip Sneezing Other abnormalities of breathing Wheezing Dyspnea, unspecified Other forms of dyspnea Periodic breathing Other abnormalities of breathing Cough Irritability and anger Coding for allergic rhinitis ICD-9 Code Description ICD-10 Code Description 477.0 477.1 477.2 J30.1 J30.5 J30.81 477.8 477.9 995.3 Allergic rhinitis due to pollen Allergic rhinitis due to food Allergic rhinitis due to animal (cat)(dog) hair and dander Allergic rhinitis due to other allergen Allergic rhinitis, cause unspecified Allergy, unspecified not elsewhere classified Allergic rhinitis due to pollen Allergic rhinitis due to food Allergic rhinitis due to animal (cat) (dog) hair and dander J30.2 Other seasonal allergic rhinitis J30.89 Other allergic rhinitis J30.0 Vasomotor rhinitis J30.9 Allergic rhinitis, unspecified T78.40XA Allergy, unspecified, initial encounter MEDICAL ECONOMICS ❚ APRIL 10, 2015 25 IN DEPTH Cover Story High-value care STRATEGIES Guiding patient conversations to optimize care, reduce costs HIGHLIGHTS 01 Providing high-value care centers on the two-way conversation and relationship between physician and patient. 26 THE PUSH IS ON FOR PHYSICIANS to embrace the concept of high-value care, providing patients with appropriate treatment while avoiding wasteful or unnecessary tests. But high-value care requires physicians to navigate many pitfalls, including lack of time to talk with patients and malpractice pressures. After years of being told about the importance of lowering blood sugar levels, it can seem a bit jarring for older patients to learn that they don’t need to be quite so vigilant, says David Shute, MD, a Portland, Oregon internist. So Shute tells his patients that this new approach, which no longer pushes most adults ages 65 and older to achieve A1c levels below 7.5%, comes from the American Geriatrics Society. He explains that the MEDICAL ECONOMICS ❚ APRIL 10, 2015 professional group has determined that the hypoglycemia risk outweighs the benefits of such tight control. Its backing, he says, “is actually very helpful in terms of me reeducating a patient and getting them confident in going down that road.” That blood sugar guidance is one of more than 300 medical recommendations developed through the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, part of a broader and burgeoning national discussion surrounding high health costs and the most appropriate medical care. As much as $750 billion annually, or 30% of healthcare spending, can be attributed to unnecessary care and other wasteful spending, including fraud, according to a frequently cited 2012 Institute of Medicine report. From federal officials to professional MedicalEconomics. com Getty Images/iStock/360/marigold_88 by CHAR LOTTE H U FF Contributing author High-value care groups, the distinction is being drawn increasingly between what’s dubbed—depending on the jargon involved—low- and high-value (or quality) care. Cost-effectiveness efforts lie at the heart of Medicare’s Shared Savings Program, as well as numerous other guidelines and initiatives. To date, the Choosing Wisely campaign has compiled at least 365 recommendations, issued by 66 medical societies. Also in recent years, the American College of Physicians has been pursuing a high-value care initiative, with related publications and tools built around the twin goals of providing optimal and reducing unnecessary costs. Meanwhile, both primary care physicians and specialists face practical and emotional pressures, including scant time to flesh out treatment options, an interest in preserving the doctor-patient relationship and malpractice pressures, among others. One recent study in the journal Neurosurgery found that neurosurgeons were 50% more likely to practice defensive medicine in states considered to have a high-risk versus a low-risk liability environment. Some technology-related solutions, via electronic health records, are being implemented in the hopes of steering doctors away from low-value care. Even so, the heart of the decision involves a two-way conversation and relationship, says Harry Gewanter, MD, a pediatric rheumatologist in Richmond, Virginia. A common scenario in his office: parents concerned that Lyme disease might be the source of their child’s aches and pains. Gewanter will explain why a test is not recommended, given the lack of any red flag symptoms or exposure, and that the subject can be revisited if symptoms persist. Frequently he’s successful. But he’s also gone ahead and ordered the test. “Sometimes you are going to do something that you may not exactly agree with, but you know for that family it’s a very important issue,” Gewanter says. “If ordering a lab test is going to lower everybody’s stomach acid and help keep them from going to another doctor and another doctor and another doctor, then you do it.” DEFINING VALUE At the heart of this evolving discussion is what constitutes value: to what degree should the cost of care, rather than clinical evidence MedicalEconomics. com Low-value treatments to watch out for 1 Imaging for low back pain Avoid imaging for low-back pain within the first six weeks unless certain red flags are present, including severe or progressive neurological deficits. Imaging for low back pain does improve outcomes but increases costs. 2 Antibiotics for sinusitis Do not routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms grow worse after initial improvement. Most sinusitis in ambulatory care is due to viral infection, but accounts for 16 million office visits annually and $5.8 billion in healthcare costs. 3 EKGs for low-risk patients There is little evidences that detecting coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes, and false-positive tests can lead to unnecessary invasive procedures, over-treatment and misdiagnosis. 4 Pre-operative chest radiography Unless cardiopulmonary symptoms are present, pre-operative chest radiography rarely provides any meaningful changes in patient management or outcomes. 5 Pap smears on women younger than 21 Most observed abnormalities in adolescents regress spontaneously, so Pap smears for teenagers can lead to unnecessary anxiety, testing and healthcare costs. 6 Routine PSA testing Convincing evidence exists that prostate-specific antigen (PSA) testing leads to substantial over-diagnosis of prostate tumors. Physicians should not order PSA screening unless prepared to engage the patient in shared-decision making that enables an informed choice. 7 Pelvic exams for oral contraceptives Data do not support performing a pelvic or breast exam before prescribing oral contraceptives. These medications can be safely prescribed based on medical history and blood pressure measurements. 8 CAS screening Good evidence exists that the harm of screening for carotid artery stenosis outweighs the benefits in adult patients with no symptoms. Screening can lead to unnecessary surgery and health complications. Sources; Choosing Wisely, American College of Physicians, American Academy of Family Physicians MEDICAL ECONOMICS ❚ APRIL 10, 2015 27 High-value care WE’VE ALL BEEN SORT OF SCARRED BY THESE VERY RARE, CONTENTIOUS ENCOUNTERS WITH PATIENTS WHO REALLY WANT ANTIBIOTICS. WE OVERGENERALIZE THAT EXPERIENCE TO ALL OF OUR PATIENTS.” — JEFFREY LINDER, MD, MPH, GENERAL INTERNIST, BRIGHAM AND WOMEN’S HOSPITAL, BOSTON, MASSACHUSETTS alone, be part of the equation? Shifting semantics complicate the issue, Gewanter says. “People I think are using value and quality and cost interchangeably,” he says. Another factor: who is the judge? “The problem with healthcare is that the value is defined by the patient, not by me,” says Kevin Bozic, MD, MBA, chairman of the Council on Research and Quality at the American Academy of Orthopaedic Surgeons. Still, considerable opportunity exists for cost-effective improvement, according to findings from several recent studies: ❚ Despite repeated initiatives related to antibiotic overprescribing, the percentage of adults with sore throat getting the drug has remained stable, at 60%, from 2000 to 2010, according to findings published in JAMA Internal Medicine. Yet only 10% of sore throats are caused by group A Streptococcus. ❚ The use of expensive imaging tests (CT scan or MRI) to assess headache symptoms jumped significantly over a decade period, from 6.7% of headache-related visits in 1999-2000 to 13.9% in 2009-2010, according to findings in the Journal of General Internal Medicine. (The American College of Radiology recommends against imaging for uncomplicated headache, saying incidental findings can lead to additional procedures and expenses.) ❚ In a 2012 survey, 85% of 261 U.S. internal medicine residency programs agreed that medical education could play a role in curtailing healthcare costs, according to results published last year in JAMA Internal Medicine. But just 15% of programs had developed a cost-conscious curriculum; an additional 50% were working on one. The Choosing Wisely campaign, launched by the non-profit foundation that’s affiliated with the American Board of Internal Medicine, has been developing its recommenda- 28 MEDICAL ECONOMICS ❚ APRIL 10, 2015 tions based on clinical evidence rather than the price tag, according to a spokesman. Some of its primary care targets that have been defined as low value: imaging studies for non-specific and recent low back pain; annual electrocardiograms for low-risk patients without heart symptoms; routine pre-operative testing for low-risk surgeries; and annual checkups for adults not complaining of symptoms. The recommendations are not absolutes, but guidelines for initiating a conversation, says Shute, who consults on the campaign. “It leaves room for professional judgment and it leaves room for some patient choice,” he says. Imaging and related services in particular are frequently cited on the Choosing Wisely lists, according to a 2014 analysis in the New England Journal of Medicine that analyzed recommendations from the first 25 medical groups. Half involved either radiology or cardiac testing, while the remainder concerned medications (21%), laboratory or pathology tests (12%) or other services (18%). Another trend, cited by the 2014 NEJM analysis, is that medical groups tend to name services as low-value if they fall outside their own specialty’s purview. Primary care groups tend not to cite cognitive services as low value, with the notable exception of discouraging the annual physical, the researchers wrote. They also called out the American Academy of Orthopaedic Surgeons for not including any major surgeries and only one minor procedure in its list of five recommendations. In a statement issued following the NEJM analysis, the medical organization defended its choices, noting that its advice to limit the use of glucosamine and chondroitin for joint relief targeted spending that exceeds $2 billion annually. One challenge in developing the recommenda- 30 MedicalEconomics. com Make a successful transition to ICD-10 now with Kareo. Change can be hard. In some cases, ridiculously so. Our ICD-10 100% Success Plan helps you transition your private practice as quickly as possible. We’re the ones you can trust for a complete ICD-10 plan, fully integrated medical software and services, and a team dedicated to your success. Don’t wait until October 1. Prepare now, with your partner, Kareo, at 866-231-2871 or kareo.com/icd-10. High-value care FOR PHYSICIANS TO MAINTAIN THEIR COMMITMENT TO THE PATIENT’S BEST INTERESTS, IT REQUIRES CONVERSATIONS TO BE HAD VERY CAREFULLY.” — MATTHEW DECAMP, MD, PHD, INTERNIST, ASSISTANT PROFESSOR, THE JOHN HOPKINS BERMAN INSTITUTE OF BIOETHICS, BALTIMORE, MARYLAND. 28 tions was the limited number of higher-quality studies available, says Bozic, who chairs the group’s Council on Research and Quality. Bozic also expresses a broader critique of what he views as the absolutist approach of such lists of treatments to avoid. “That’s the old-fashioned paternalistic view—that I’m the doctor and I know what’s best,” he says. Instead, patients should be given more nuanced information—Bozic points to a battery of clinical guidelines on the AAOS website—that allows them to sort through the matrix of options and costs. A patient might decide to try a procedure deemed of more limited value if he or she has exhausted other treatments, he says. NAVIGATING CONVERSATIONS As doctors initiate these sorts of conversations about value and relative necessity, they should give their patients some credit until proven otherwise, says Jeffrey Linder, MD, MPH, a general internist at Boston’s Brigham and Women’s Hospital and coauthor of the JAMA Internal Medicine study on antibiotic prescribing. Issues surrounding antibiotic prescribing are a great example of this. “We’ve all been sort of scarred by these very rare, contentious encounters with patients who really want antibiotics,” he says. “We over-generalize that experience to all of our patients.” But the vast majority of patients primarily want reassurance that a more serious infection hasn’t flared, as well as short-term help with their respiratory miseries, Linder says. Once the risks are explained, typically they don’t want to take anything that won’t help them, and could be potentially harmful, he says. Along those lines, Gewanter adopts a two-stage approach. He explains why a patient’s symptoms don’t appear to be bacte- 30 MEDICAL ECONOMICS ❚ APRIL 10, 2015 rial in nature and he makes clear that the patient can call his office in a few days if symptoms change or worsen. For patients he knows well, he might write a prescription and ask them to fill it within 48 to 72 hours if they develop a higher or unrelenting fever, among other symptoms. What he’s trying to avoid, Gewanter says, is creating a communication breakdown in which the next time a frustrated patient might seek the antibiotics he or she desires at a retail clinic or urgent care center. That outcome results not only in potentially unnecessary tests and costs, but also the patient might not reveal having sought care elsewhere if forced to return to Gewanter’s office with diarrhea or some other side effect, he says. Doctors who don’t have a long-term relationship with their patient face the challenge of building trust quickly, says Christopher Moriates, MD, a hospitalist at University of California, San Francisco. “As there’s more discontinuity in care, I think that’s one of the reasons that it’s easier to order a test to reassure yourself and the patient because you don’t know the patient and they don’t know you.” This is particularly challenging when public awareness hasn’t caught up with a change in practice, Moriates says. He recalls one exchange with a patient who wanted a blood transfusion, which he was accustomed to receiving during prior gastrointestinal bleeds. Moriates told the patient that transfusions were no longer recommended by the Society of Hospital Medicine for stable patients because they’ve been found to cause adverse reactions. He told the patient—who, he recalls, was sizing him up a bit—that his gastrointestinal bleed was being followed closely, appeared to be stabilizing, and was not severe enough to require transfusions. “He was definitely trying to figure out, MedicalEconomics. com High-value care `Do I trust this person? Why are they telling me this? I know my experience from the past. Why is this doctor telling me something different?’” Moriates recalls. PRACTICE STRATEGIES In discussing medical options with patients, finding the balance between cost and quality is far from a new conversation, says Matthew DeCamp, MD, PhD, an internist and assistant professor at the John Hopkins Berman Institute of Bioethics in Baltimore. What’s different is that there is a broader cost-effectiveness focus across the health system, such as by practices affiliated with accountable care organizations, he says. “For physicians to maintain their commitment to the patient’s best interests, it requires those conversations to be had very carefully.” THE GOALS OF HIGH-VALUE CARE 1 Helping physicians to provide the best possible patient care. 2 Reducing unnecessary costs to the healthcare system Being open with patients about the heightened focus on higher-value care is key, not just in individual conversations, but also at he practice level, DeCamp says. One approach might be to create related educational materials, highlighting the practice’s values and criteria. A referral to a particular cardiologist could be accompanied with details about how the doctor rates on quality metrics, he says. A plan for treating lower back pain could explain why physical therapy is preferred as the first step, before ordering an imaging test. Building guidance into electronic health record systems also holds potential for en- MedicalEconomics. com couraging broader changes in habits, says Mitesh Patel, MD, an assistant professor of medicine and health care management at the University of Pennsylvania and an author on the recent JAMA Internal Medicine study looking at cost-conscious curriculum. In another study that Patel published last year in the Annals of Internal Medicine, he and his fellow researchers found that a simple change in the default mechanism in the health record could promote more generic prescribing. By changing the setting, so that the generic option would be the first one visible—the physician could always opt out—generic use was significantly increased for statins and beta-blockers. Further efforts to incorporate appropriateness criteria for imaging into electronic systems also are gaining steam. In 2017 a law is slated to take effect requiring doctors to consult physician-developed criteria when ordering advanced imaging tests for Medicare patients. The American College of Radiology already has developed a package of appropriate use criteria that as of press time included 149 guidelines involving more than 1,200 indications and clinical scenarios, according to spokesman Shawn Farley. The details are free when accessed online for educational purposes. They can also be integrated into a hospital’s electronic health record for a licensing fee. “The intent is to help primary care physicians to choose the right tests and help them do it quickly and safely for their patients,” says Debra Monticciolo, MD, FACR, chair of the American College of Radiology Quality and Safety Commission. But Monticciolo, who specializes in breast imaging, says that patient preferences still come into play. Take a patient discussion involving the aspiration of a cyst in the breast, a procedure that Monticciolo performs hundreds of times each year. When the fluid emerges clear with no signs of blood, she shows it to the patient and explains that the chances are “virtually zero” that a pathology analysis would find anything worrisome. But, Monticciolo says: “I don’t want to throw the fluid away unless the patient feels comfortable.” A few times each year, the patient will decide that she’d prefer to pay the extra cost to allay any nagging worries. So Monticciolo sends the specimen to the lab. $750 BILLION AMOUNT SPENT ANNUALLY ON UNNECCESSARY CARE, OR 30% OF ALL HEALTHCARE PROVIDED IN A GIVEN YEAR. SOURCE: INSTITUTE OF MEDICINE MEDICAL ECONOMICS ❚ APRIL 10, 2015 31 STARK LAWS IN DEPTH What physicians need to know about the ban on self-referrals. [40] Managing conflict with patients Effective communication is vital to managing disagreements with patients to resolve tension and prevent negative outcomes by B ETH THOMAS H E RTZ Contributing author HIGHLIGHTS 01 When discussing sensitive matters with patients, strive to maintain a steady voice, use terminology patients can understand, and ensure they understand what you have told them before they leave. 02 Although it can be time-consuming, asking open-ended questions is often the only way to get to the heart of a patient’s actual problems. 32 Saying no to a patient request can be a challenge. Physicians strive to maintain good relationships with patients, while not wanting to agree to anything not medically indicated. While this is certainly not a new problem, it is likely expanding due to inaccurate information on the Internet and direct-to-consumer advertising can increase patient requests for specific things. PATIENT ENCOUNTERS that often lead to hard feelings can include denying a request for narcotics or antibiotics that are not warranted, refusing a request for a prolonged excuse from work, or declining to order costly tests that are not needed. Many experts say that good communication is the key to managing these encoun- MEDICAL ECONOMICS ❚ APRIL 10, 2015 ters in a way that does not escalate into bad feelings, anger, and poor patient outcomes. 1/ Diffusing the situation David A. Fleming, MD, president of the American College of Physicians, says he believes conflict occurs because when the patient and physician 35 MedicalEconomics. com Managing patient conflict 32 disagree, the patient feels vulnerable and distressed. “We need to recognize the power differential that is present,” Fleming says. “Patients are often fearful and uncomfortable and we need to help them work through that.” Fleming says he often knows when an encounter is going to lead to conflict, and he follows a few guidelines to diffuse it. First, always remain professional. “Address the patient respectfully. Don’t get reactive or respond in an emotional way,” he says. Next, be empathetic and compassionate but do not be swayed from solid decisionmaking, Fleming advises. Explain clearly the evidence-based practice guidelines you are following. Third, support and inform the patient. “Information can be powerful. Often conflict arises because there is lack of communication about the information that has been provided, either from the patient giving information to the physician or the physician convening information back to the patient,” says Fleming, who is also professor of medicine at the University of Missouri School of Medicine and chairs the Department of Medicine and is director of the MU Center for Health Ethics. Always maintain a steady voice, use terminology patients can understand, and ensure they understand what you have told them before they leave, Fleming adds. Catherine Hambley, PhD, an organizational psychologist with LeapFrog Consulting, recommends evoking the teamwork nature of the relationship at times like these. “Say, ‘I am your partner in your healthcare,’” she advises. “Do not say ‘I am the doctor’ because ultimately it is the patient who decides what they are going to do about their health, not you.” 2/ Calling them out Robert A. Lee, MD, a family physician in Johnston, Iowa, and a member of the board of directors of the American Academy of Family Physicians, says that sometimes a physician needs to call out a patient who is getting angry. “Some people are just nasty and they don’t get along with anyone, and you may just need to call a spade a spade,” he says. MedicalEconomics. com I remind the staff that the patient may have other issues going on at home or work and we should try to give them as much leeway as we can.” ARVIND R. CAVALE, MD, FEASTERVILLE, PENNSYLVANIA “I may tell them I know they have difficulties with relationships and if they want this relationship to work, here’s what I need from them and here’s what they can expect out of me. Open it up and have that frank discussion.” He uses pointed questions, such as asking about their relationships with their co-workers and their family. Do they have friends? Their answers can be very revealing, to him as well as to the patient. “When they start running through this, they make the connection,” he says. Lee will sometimes say “you seem angry with me today.” This puts the focus on him, not them, which can lower their levels of offensiveness. “They may agree that they are being demanding,” he says. Diffusing the situation at the time helps avoid patients developing the expectation that they can demand whatever they want from him in the future. “Some of my most rewarding patient relationships started with us being at loggerheads, but once we worked through it, they are very loyal patients,” Lee says. “It feels great for me to earn their trust and for them to know I have their back.” 3/ Wanted: An explanation Arvind R. Cavale, MD, a specialist in diabetes and endocrinology in Feasterville, Pennsylvania, believes that patients who express anger or frustration at a denied request usu- MEDICAL ECONOMICS ❚ APRIL 10, 2015 35 Managing patient conflict Removing a patient from your practice? Do it the right way Provide written notice The physician should issue a written termination letter to the patient prior to the effective date of termination. The letter should clearly state a termination date (we suggest 30 days in advance) and the reason for termination. Include a list of suitable alternative providers The letter also should include a list of alternative healthcare providers in the area, and if appropriate, referral to the patient’s insurance network. Time the termination properly Avoid withdrawing from treating the patient when the patient is in medical crisis, unless the patient requires the services of a different specialist and arrangements are made for transferring the patient’s care to such specialist. Examine managed care contracts and communicate with health plans If you are a participating provider in a managed care network in which the patient is covered, contact the payer, explain the situation, and ensure everything is done properly per the contract to prevent problems later. Provide record access Offer to send a copy of the discharged patient’s medical records to the patient’s new doctor. Numerous states have laws which require that records not be withheld solely because of a patient’s inability or refusal to pay. Communicate Be sure to apprise all physicians and office staff members of the termination to avoid inadvertent reestablishment of the physicianpatient relationship. Source: Eve Green Koopersmith, JD 36 MEDICAL ECONOMICS ❚ APRIL 10, 2015 ally just want a thorough explanation. Patients often ask him for a medication they saw advertised, such as testosterone. They complain that they are tired and the drug seems like a solution. Sometimes their primary care physician has even suggested testosterone and referred the patient to him. He tests them for low testosterone levels but often finds no justification for the medication. When this happens, he often has to “go back to the basics.” “I tell them everyone is tired. No one sleeps well,” he says. “I ask them when was the last time they felt well. It is important that I understand their issues because what they really want is to feel better, not necessarily use a certain medication.” This can be time-consuming, but asking open-ended questions is the only way to get to the heart of their actual problems. “Once we do that, we can provide alternative options, in most cases,” he says. “We need to give them a reason to be optimistic when they leave.” 4/ Preemptive policies Jonathan Weiss, MD, an internist and pulmonary medicine specialist in Monticello, New York, doesn’t see a great deal of conflict in his office. He attributes at least part of that to his policy of not prescribing narcotics for new patients unless they have cancer. “My office staff tells them this when they call, so we set the expectations upfront that narcotics are not on the agenda,” he says. “I used to engage in debates and negotiations about this with patients, but having a general rule short-circuits the whole conversation.” Patients are told that Weiss is happy to work with them to manage pain, of course, but that he utilizes other approaches, such as physical therapy or referrals to an appropriate specialist, such as pain management, orthopedics, or psychiatry. “I would employ this policy in other areas of my practice if I felt it was needed, but narcotics is the area in which it most frequently arises,” he says. 5/ Insurance Several physicians noted that insurance can also be a factor when facing inappropriate patient requests. While they are willing to fight to get an approval for a legitimate pa- MedicalEconomics. com Managing patient conflict Some of my most rewarding patient relationships started with us being at loggerheads, but once we worked through it, they are very loyal patients. It feels great for me to earn their trust and for them to know I have their back.” — ROBERT A. LEE, MD, JOHNSTON, IOWA tient need, they do not want to expend the time and energy for ones they do not think are necessary. They let an insurance rejection speak for itself. Matthew P. Finneran, MD, a family physician in Wadsworth, Ohio, finds that changes in insurance can actually be helpful when denying a request for tests that he feels are excessive. “The economies of healthcare today make it easier to insist on following evidence-based guidelines,” he says. “Plus, with many patients facing high deductibles, they are less adamant about doing something they will have to pay for.” In fact, he sometimes finds this dynamic can make conflict run in the opposite direction, as some patients have to be convinced that a test is worth the out-of-pocket expense they will face. “This is always easier with a long-time patient who knows and trusts me already,” he says. 6/ Train your staff Some unhappy patients will attempt to talk a staff member into giving them what they want. Weiss says he tries to counsel his staff to be as patient as possible when dealing with such requests. He offers occasional pep talks when staff morale seems to be flagging under the pressure. He also offers to take a call off the staff member’s hands if he is nearby and feels the staff member is being particularly challenged. “Sometimes, if I offer to talk, it helps deflate the situation,” he says. He understands that staff members need to vent to each other sometimes, but encourages them to do it in private so they can maintain a happier face to the public. “We are not always successful but we do our best,” Weiss says. MedicalEconomics. com Cavale says he works to instill his practice principles into his staff, and tries to empower them to interact with patients to the best of their abilities. “They can’t make everyone happy but we should try to help them as best we can,” he says. “I remind the staff that the patient may have other issues going on at home or work and we should try to give them as much leeway as we can.” 7/Leaving the practice Some patients will choose to leave a practice if their requests are not granted. Most of the physicians interviewed said they will help them make arrangements to do so, if they want. “Maybe they will find that someone with a fresh eye will give them a different message, but often they still will have the same issues,” Lee says. On occasion Weiss has told patients that they are welcome to find another physician if they did not feel he was meeting their needs. “This is usually a final play. Most do not take me up on it,” he says. 8/ Call a time out Hambley says that, rarely, some patients can get so upset with the physician that they may be unable to continue the conversation in a civil manner. In those instances, she suggests the physician offer to go to see the next patient, giving the distraught patient a few moments to gather his or her thoughts before resuming the visit. “Acknowledge their anger and stress that you want to get on the same page,” she says. “If you can really convey that message, it is much more likely that you will develop a trusting relationship in the future.” MEDICAL ECONOMICS ❚ APRIL 10, 2015 37 LEGAL ADVI C E F R O M TH E E X P E RTS Legally Speaking AVOIDING SELF-REFERRAL: UNDERSTANDING THE STARK LAWS by HAYD E N S. WOOL, J D, and D E N N I S BAR R ETT, J D Contributing authors Physicians today must understand a myriad of laws and regulations that govern not only how they practice medicine, but also how they bill and refer their patients for services both within and outside their own practice. Among the most significant, and often difficult to understand of these laws is the physician self-referral law, more commonly known as the “Stark Law,”named for its champion and co-sponsor, U.S. Representative Fortney H. “Pete” Stark of California. The Ethics in Patient Referrals Act of 1989, the original name for the Stark Law, was initially designed to limit/prevent physicians from referring patients for clinical laboratory services under the Medicare Program to entities in which the physician or a relative had a financial interest. The rationale for the law was a concern that physicians were more likely to order tests if they had a financial stake in the provision of such services. The law and its corresponding regulations have expanded significantly in the past quarter century thanks to passage of an amendment to the law in 1993 and the promulgation of a substantial number of regulations in three phases 40 (commonly referred to as Stark I, Stark II and Stark III) between 1992 and 2007. The commentaries explaining the three phases of regulations issued by the Center for Medicare & Medicaid Services (CMS) between 2001 and 2007 and the 2015 Physician Fee Schedule are thousands of pages long. This regulatory maze has made complying with the law very difficult for even the most well-intentioned of physicians. Among other things, the expansion increased the list of services that fall under the law’s purview (known as designated health services or “DHS”) to include: ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ ❚ clinical laboratory services; physical therapy services; occupational therapy services; radiology services; radiation therapy services and supplies; durable medical equipment and supplies; parental and enteral nutrients, equipment and supplies; prosthetics, orthotics and prosthetic devices and supplies; home health services; outpatient prescription drugs; inpatient hospital services; and outpatient hospital services. Elements of the Stark prohibition The basic elements of the Stark self-referral prohibition are as follows: A physi- What is the Stark Law? The Stark law is a limitation on physician referrals. It prohibits physician referrals of designated health services for Medicare and Medicaid patients if the physician (or an immediate family member) has a financial relationship with that entity. MEDICAL ECONOMICS ❚ APRIL 10, 2015 cian may not make a referral to an entity for the provision of DHS for which Medicare payment may be made (and the entity may not present a claim for services provided as a result of such referral) if the physician or an immediate family member has a financial relationship with the entity unless either the referral or the financial relationship is “excepted” from the Law’s coverage. The scope of the law is broad enough to include, without limitation, referrals by a physician to a hospital with which the physician has a financial relationship as well as a referral by a physician to the physician’s own practice. Each of the key terms have specific meanings within the prohibition. For example, a financial relationship is defined broadly to include both a direct or indirect ownership or compensation arrangement. An immediate family member is defined as a spouse or a child, sibling, parent, grandparent, stepchild, step-parent, step- STARK LAW RESOURCES American Medical Association “The Stark Law Rules of the Road” http://bit.ly/187RuqV U.S. Centers for Medicare and Medicaid Services Physician self-referral resources http://go.cms.gov/1GBd6dU U.S. Department of Health & Human Services Fraud and abuse laws http://1.usa.gov/1n91ZPF MedicalEconomics. com LEGAL ADVI C E F R O M TH E E X P E RTS sibling, and the spouse of any of the aforementioned individuals. The exceptions to the law are outlined in the regulations and rules issued by CMS. Penalties The Stark law is a strict liability law, which means that the intent of the offending party is not taken into account and a physician can be found guilty of violating the law without intending to do so. If a physician makes a referral under the law and none of the law’s exceptions are met, then the Stark law has been violated. While the Stark law is not a criminal statute, the civil penalties for violating the law can be severe. Penalties can include: ❚ denial of payment for the service billed, ❚ a $15,000 civil penalty for each claim submitted as a result of an improper referral, ❚ refunding every payment received for services that were referred in violation of the law, ❚ a $100,000 civil penalty for entering into a scheme designed to circumvent the law, and ❚ exclusion from federal health care programs and possible additional liability under the Federal False Claims Act. State violations While physicians must be aware of the federal Stark law, it is imperative that they also understand that many states have adopted their own self-referral laws that can differ significantly from the federal Stark Law. The New York state law regarding healthcare practitioner referrals (commonly referred to as New York’s “State Stark Law”) provides an apt example. The list of providers subject to the state Stark law is much broader than the federal Stark law. However, the list of DHS under the state’s law is much more limited. In addition, while the federal Stark law is limited to Medicare (and arguably Medicaid), the state Law applies to all payers. Consult a specialist The sheer size and scope of the Stark law makes it increasingly difficult for an inexperienced attorney, not to mention a practicing physician, to grasp the law’s nuances. In order to protect yourself and your practice from what could potentially be crippling fines and sanctions under the Stark law, it is important to always contact a health law specialist when encountering any issues that you think could fall under the Stark law’s shadow. Hayden S. Wool, JD (pictured) is a partner/director and Dennis Barrett, JD, is an associate at Garfunkel Wild, P.C., in Great Neck, New York. Send your legal questions to [email protected]. Physicians’ Alliance of America (PAA) is a nonprofit Group Purchasing Organization (GPO) serving medical practices of all sizes and specialties nationwide for over 20 years by giving them free access to savings on a full range of goods and services from over 80 vendor partners covering every area of practice operations. FREE Membership! No Contract! Vaccine Rebate Program! Savings! www.physiciansalliance.com 866-348-9780 IN DEPTH How to get started with Direct messaging Many physicians don’t use or are unaware of Direct secure messaging, but it can help improve care coordination— provided you can navigate its challenges. by KE N TE R RY, Contributing editor HIGHLIGHTS 01 E-faxes, which many physicians use to exchange records among providers, are less secure than Direct messaging. 02 About 10 million Direct messages were exchanged in the second half of 2014. The number of Direct exchanges is increasing as more organizations use them to attest to meaningful use. 42 Direct secure messaging (Direct), a standardized protocol for exchanging clinical messages and attachments, has not caught on significantly among physicians. Even advocates of the secure messaging system acknowledge it is still in an early stage of adoption, comparable to the first year of electronic prescribing. THIS SLOW UPTAKE of Direct is somewhat surprising, given the government’s promotion of the secure messaging protocol. The latest version of EHR certification requires Direct messaging capability, and physicians can use Direct to meet the Meaningful Use stage 2 requirement that they exchange clinical summaries at transitions MEDICAL ECONOMICS ❚ APRIL 10, 2015 of care. In fact, physicians who use Direct at this point seem to be doing so mainly to obtain Meaningful Use incentives. Physicians interviewed by Medical Economics say that most of their colleagues either are unaware of Direct messaging or are uninterested in it. “Most physicians have zero understanding of what Direct is and MedicalEconomics. com Direct messaging have no interest and hope that some administrator will take care of it,” says Medhavi Jogi, MD, a Houston endocrinologist who exchanges Direct messages with physicians in a few other practices. Cindy Dunn, a healthcare consultant with the Medical Group Management Association (MGMA), says that none of the groups she works with use Direct. Even doctors who do send Direct messages may use it in ways for which it was not intended. For example, Jeffrey Kagan, MD, an internist in Newington, Massachusetts, and a Medical Economics editorial advisory board member, said he sends Direct messages from his EHR to an electronic mailbox in the local healthcare system, where most of the specialists he refers to also have mailboxes. They must log in to the hospital system to pick up the messages, and he has no idea whether they actually do. So he also faxes the same referrals to those specialists. “We’re still using our current system to send referrals,” he says. “We’re just using Direct to appease CMS” [the Center for Medicare & Medicaid Services]. E-faxing has become commonplace in physician offices, notes Dunn. Secure texting, which offers some of the advantages of Direct, is also growing rapidly. And new standards are being developed to allow physicians to search for patient information across communities. So the future of Direct may depend on whether it meets a need that no other technology does. BARRIERS TO DIRECT In the near term, Direct’s success hinges on building a critical mass of adopters in individual communities. Consequently, doctors’ lack of awareness of Direct is a major obstacle. While the Office of the National Coordinator of Health IT (ONC) helped create Direct, neither ONC nor CMS has undertaken a full-scale campaign to educate physicians about the technology. In fact, ONC’s new “interoperability roadmap” downplays the potential of Direct messaging. Some EHR vendors provide no Direct training to doctors. Jogi had to figure it out on his own, for example. The Direct messaging tool can also be hard to find, notes MedicalEconomics. com WHAT IS DIRECT MESSAGING? D irect messaging is essentially email, but with some key differences. Instead of the email server being maintained for the addressees/subscribers by an employer or by an email provider like Google or Yahoo, an agent known as a Health Internet Service Provider (HISP) handles the email exchanges. The HISP carries out the encryption/decryption and digital signing of each message. Direct messages can have any type of file attachment, and both message and attachments are encrypted along the entire route from sender to receiver to protect the privacy of the content. Each sender and receiver in Direct exchange must have a unique Direct address, much like a regular email address, but with the word “direct” in the address line, e.g. YourName@direct. YourMedicalGroup.com. In fact, this format for a Direct address is not a mandatory requirement within the DirectTrust community; however, it is a strong convention that is widely followed. Source: DirectTrust David Kibbe, MD, president of DirectTrust, a trade association that accredits the health information service providers (HISPs) that convey Direct messages between providers. The functionality may be buried in an EHR referral module and may be unavailable for any type of communication not related to referrals, he says. Even if physicians can find the Direct module and know how to use it, they might have difficulty locating other doctors with whom to exchange Direct messages. Terry Hashey, DO, who practices family medicine with one partner in Jacksonville, Florida, says he has been unable to find any primary care or specialty practice or hospital that accepts Direct messages. Jogi says he asked about 60 physicians to exchange Direct messages with him. Although they all had Direct addresses, only a handful responded to his request. He doubts the others even saw his messages. MEDICAL ECONOMICS ❚ APRIL 10, 2015 43 Direct messaging other physicians who use different EHRs through a web portal. But that means that the messages don’t go directly into his colleagues’ EHRs, and they have to interrupt their workflow to visit the portal. An article last summer in the newsletter iHealthBeat found that some vendors were making it difficult for physicians to use Direct messaging to facilitate the flow of clinical information. eClinicalWorks’ HISP, for example, had not joined the DirectTrust network, so many other HISPs would not exchange Direct messages with it. Similarly, Epic had designed its EHR so that it would accept only Direct messages that had attachments of clinical summaries in the CCDA format. That ruled out text or PDF documents and imaging reports, as well as messages without attachments. (Epic has since upgraded its Direct module to accept other kinds of messages.) Blair says he doesn’t believe that vendors are purposely obstructing Direct. Neither does Kibbe. “It’s hard to make the case that they’re deliberately trying to screw this up,” he says. Docs want to communicate with other doctors more effectively around patient care. And this is something that’s about more than just the technology; It’s about workflow and care coordination.” — DAVID KIBBE, MD, PRESIDENT, DIRECTTRUST The overall situation is not as dire as these anecdotes imply. According to Kibbe, about 10 million Direct messages were exchanged in the second half of 2014. While that’s just a “trickle,” he says, the number of Direct exchanges is increasing as more organizations use them to attest to Meaningful Use and as health information exchanges move patient data via Direct. John Blair III, MD, chair of DirectTrust and chief executive officer of MedAllies, a leading HISP, points out that it takes time to introduce something as complicated as Direct. Currently, he says, most physicians are just finding out about Direct and activating their EHR’s Direct functionality. Next, they must reorganize their workflows so that their practices know how to handle Direct messages. When a significant number of practices do that, which he predicts will happen over the next two years, there will be a big jump in use of the Direct messaging protocol, he predicts. ARE EHR VENDORS ABOARD? Workflow is not the only obstacle that must be overcome, however. Dunn believes that the cost of using Direct is discouraging some practices. On average, Blair says, HISPs charge from $100 to $200 per provider per year. But some EHR developers may tack on extra fees, he adds. The vendors either contract with one or more HISPs or operate their own HISP. But they don’t necessarily encourage the use of Direct to exchange information with practices that use different EHR systems. Jogi says that his EHR vendor so far has allowed him to exchange Direct messages only with other users of its system. He has learned how to exchange Direct messages with a few 44 MEDICAL ECONOMICS ❚ APRIL 10, 2015 DIRECT ADDRESSES To send and receive Direct messages, a physician must have a Direct address and must be able to access the Direct addresses of his or her trading partners. According to DirectTrust, the 38 HISPs in its network have “provisioned” more than 650,000 Direct addresses to healthcare professionals in 33,000 healthcare organizations. But finding those addresses can be a challenge. The problem is that each HISP has a directory of its customers’ addresses, but doesn’t have access to other HISPs’ directories. Consequently, physicians can view only the addresses of the physicians who use the HISP owned or hired by their EHR vendor, unless other addresses have been loaded into their EHR. An existing standard called HPD could enable physicians to search all HISPs’ directories from their EHRs. But HPD is still be- MedicalEconomics. com Direct messaging MOBILE MESSAGING ing tested and won’t be available for use for another year, Blair says. Currently, he notes, MedAllies has a database of about 200,000 Direct addresses, including those of its 60,000 customers. When MedAllies signs up a new practice, he says, the company asks the practice to identify their providers’ trading partners. About half of those partners’ Direct addresses are typically in MedAllies’ database; the company can get most of the rest from EHR vendors and other HISPs. Then it loads them into their customer’s EHR. To eliminate this time-consuming task, DirectTrust is trying to create its own central directory for in-network HISPs. But Kibbe says some HISPs have told him they can’t participate because of contracts with EHR developers that don’t want their customers’ addresses to be made public. WHY SHOULD YOU USE DIRECT? Assuming that all these obstacles can be swept away, Direct still won’t succeed unless you and your colleagues use it. Here are some of the pros and cons. Direct messaging can only “push” data from point to point; it can’t be used to search for information in other EHRs. But Blair says that would be sufficient for many physicians. “If you can send relevant referrals with pertinent information, docs will do a backflip over that,” he says. Jogi says that if Direct worked the way it is supposed to, he’d be delighted, because “it’s faster and easier to communicate with Direct. There would be a lot less redundancy in lab testing and imaging. I’d be wasting a lot less time trying to find out what was going on with this patient who has been referred to me,” he says. But from the viewpoint of many other physicians—including Jogi’s own partners— Direct fixes a nonexistent problem. They’re used to sending computerized faxes with referrals and consultant reports, and their offices are “hardwired” for that process, notes Jogi. This system works well for Kagan, who e-faxes a note and a clinical summary when he refers a patient to a specialist. The entire process, he says, takes place within his EHR, and someone on the staff slots incoming e- MedicalEconomics. com What to keep in mind 1 2 3 4 5 Decide whether mobile devices will be used to access, receive, transmit, or store patients’ health information, or used as part of your organization’s internal networks or systems. Consider how mobile devices affect the risks (threats and vulnerabilities) to the health information your organization holds. Identify your organization’s mobile device riskmanagement strategy, including privacy and security safeguards. Develop document and implement mobile device policies and procedures to safeguard health information. Conduct mobile device privacy and security awareness and training for providers and professionals. faxes into patient records. Both Kagan and Dunn say that the e-faxes are encrypted and Health Insurance Portability and Accountability Act (HIPAA)-compliant. But Ron Sterling, a health IT consultant in Silver Spring, Maryland, says that e-faxes, while HIPAA compliant, are less secure than Direct messages. E-faxes are sent securely from an EHR to a fax server, which should be encrypted to protect health information. However, the transmission from the fax server to the fax machine in another practice is not encrypted and doesn’t have to be. Fax transmissions, which go directly from one phone number to another, fall under the HIPAA privacy rule but not the security rule, Sterling points out. SECURE TEXTING ALTERNATIVES Kagan also uses a secure texting service that the hospital has provided to him and his colleagues. “It seems to be a more efficient way to communicate,” he says. “A lot of doctors have embraced it and found it to be very helpful.” MEDICAL ECONOMICS ❚ APRIL 10, 2015 45 Direct messaging Most physicians have zero understanding of what Direct is and have no interest and hope that some administrator will take care of it.” an ED physician he knows with a brief description of the patient’s condition and history and will ask the doctor to text him a brief note about the disposition of the case. Case managers also text Segal to let him know when one of his patients has been discharged from the hospital. — MEDHAVI JOGI, MD, ENDOCRINOLOGIST IN HOUSTON, TEXAS, WHO USES DIRECT MESSAGING WHAT’S AHEAD FOR DIRECT? Robert Segal, MD, a family physician and medical director of ambulatory informatics for the Scottsdale/Lincoln Health Network, a five-hospital system in Scottsdale, Arizona, also uses secure texting and likes it very much. All of the health system’s employed physicians and the independent doctors who belong to its ACO have secure text access, so he can communicate easily with most of the specialists he refers to. Moreover, he can attach an image or a document to his texts by snapping a picture of it on his smartphone. For example, Segal recently saw a patient for a preoperative exam and performed an electrocardiogram that proved to be abnormal. “I took a picture of it and I sent it through [secure text] to the cardiologist,” he recalls. “I said, ‘Can you have a look at this? Is this anything that requires further evaluation before I clear it for a surgery?’” In addition, Segal uses secure texting to monitor the care of patients he sends to the emergency department (ED). He’ll text Secure text messaging services to consider There are a number of secure text messaging services that offer HIPAA-compliant products that physicians can use to communicate with their staff and other providers. Here are some companies that offer these services: The lesson of secure texting is that when a new technology is simple to use and meets an immediate need, physicians will use it. Direct messaging is nowhere near as intuitive and simple as regular email or Facebook, Jogi says. And while proponents regard Direct as a big improvement over faxes, the workflow changes needed to make it function properly are likely to discourage some practices from using it. What will happen to Direct messaging after the need to show Meaningful Use has passed? Kibbe believes that it will continue to grow, mainly because of the increased importance of care coordination in valuebased reimbursement arrangements. In Kibbe’s opinion, this will provide the business case that healthcare providers need to adopt Direct messaging. But it will be large healthcare systems, not small physician practices, that will lead the way, he says. “Docs want to communicate with other doctors more effectively around patient care,” he says. “The business case has to be for the larger organization they’re working with: the hospital, the health system, the ACO. Because individual practices have a hard time creating any sort of system. And this is something that’s about more than just the technology; it’s about workflow and care coordination.” MORE ONLINE Meaningful use 2: Mission impossible? http://bit.ly/1BB83rO TigerText www.tigertext.com MiSecureMessages www.misecuremessages.com DocsInk www.docsink.com qliqsoft qliqsoft.com Getting paid for chronic care http://bit.ly/1b2bVHq Coding insights: What you need to know about chronic care management http://bit.ly/1Br67ku 46 MEDICAL ECONOMICS ❚ APRIL 10, 2015 MedicalEconomics. com PROTECT YOUR PRACTICE IN DEPTH Business insurance coverage every physician should have [51] IPAs: Joining forces to retain independence Independent physician associations can help doctors meet the business challenges of independent practice, but do your homework before joining by E LI ZAB ETH WOODCOCK, M BA, FACM PE, CPC and CAS EY CROTTY Contributing authors HIGHLIGHTS 01 Because many organizations have already operated as risk-bearing provider networks, IPAs are well positioned to take leading roles in the development of ACOs or serve as sustaining member organizations 02 Not all markets have IPAs, and the ones that do vary in scope and services. If there is an IPA functioning in your market, evaluate the benefits before joining. MedicalEconomics. com If you want to retain your independence while finding some shelter from the storm of regulatory challenges and cost increases facing primary care physicians today, joining an independent physician association (IPA) may be an option to consider. THE STEADY DRUMBEAT of reports about health systems, hospitals, insurance payers and other corporate entities buying up independent practices may give you pause. A growing number of physicians are responding to the changing reimbursement and regulatory landscape by opting for alternatives to traditional independent practice arrangements; indeed, the “2014 Survey of America’s Physicians” by the Physicians Foundation, an advocacy group, found that 53% of physicians were hospital or medical group employees compared with 44% in 2012 and 38% in 2008. Between the challenges of keeping up with government incentive programs, payers’ threats to eject you from their networks, and declining reimbursement, is it even possible to operate independently any longer? If you’re an independent physician, employment may appear to be the only sensible route out of this turbulence. If employment is right for you, then by all means, explore it. However, if you want to retain your independence but also be sheltered from the storm, joining an independent physician association (IPA) may be your best option. MEDICAL ECONOMICS ❚ APRIL 10, 2015 47 IPAs Questions to ask before joining an IPA Physicians should consider many factors before joining an IPA. They include: how long the association has existed, its track record, member benefits, resources, and even less-quantifiable factors such as the opportunities IPA membership may offer for networking with other physicians. Q: What is the legal structure of the IPA? If forprofit, how are shares distributed? Q: What are the dues and obligations to join the IPA? Are there different membership levels or classifications? Q: Does the IPA negotiate payer contracts on behalf of its members? If so, how is negotiation for reimbursement handled between the member, the payer, and the IPA? Q: What are the services offered by the IPA? Are these services included with membership or do they require additional fees? “The reputation, competence and trustworthiness of the IPA staff are important, of course, but is that staff accessible to the members—available for questions and assistance, and responsive to requests?” says Ann Bellah, the executive director of Pueblo Health Care in Colorado. Q: How is the IPA’s Board of Governance structured? How many board members and of what specialties? What is the makeup of the executive leadership? Q: Does the IPA require a complete integration of the medical practices or participants? If so, how does the IPA define “integration”? What other contractual obligations are there? Q: Is the IPA considered an “exclusive” or “nonexclusive” organization? Do the members have the opportunity to participate in all, some or none of the payer contracts? Are members able to affiliate with other networks as well? IPA BENEFITS An IPA is an association of independent physicians. It offers members a way to improve cooperation with insurance companies and reduce the administrative burdens of negotiating payer contracts, while continuing to maintain independent practices, and, importantly, make their own decisions about reimbursement. “Another major benefit from being a part of an IPA is that it can assist in keeping physicians and offices from being isolated because a good IPA can also provide access to networking, resources, education and training that would otherwise be difficult to obtain,” says Ann Bellah, MBA, executive director of Pueblo Health Care, an IPA with 265 physicians in southern Colorado. An IPA may be an association, but there 48 MEDICAL ECONOMICS ❚ APRIL 10, 2015 is nothing casual about its structure as a legal entity. An IPA may be structured as a nonprofit entity, a limited liability company, a corporation or other type of shareholderowned entity. The structure of most IPAs also allows participating members to continue caring for patients outside of the contracts the IPA maintains with payers. An August 2013 study published in Health Affairs reveals that 24% of small-to-mediumsized practices participate in an IPA or a physician hospital organization (PHO), a similar model that includes a hospital. Typically tied to a specific geographic location, an IPA enables independent physicians to exert greater influence over contract terms in a marketplace typically dominated by a handful of payers, but not infrequently by just one payer. MedicalEconomics. com IPAs Considerations before joining an Independent Physician Association Anti-trust considerations ACO conversion Many IPAs can face antitrust issues because they include competing healthcare providers, says Peter Pavarini, JD, partner at Squire Patton Boggs LLP in Columbus, Ohio.“There are no fixed limits on IPA size; however, Federal Trade Commission and Department of Justice guidelines and policy statements define safety zones in terms of percentages of competing physicians [by specialty] who are included in an IPA, ACO (accountable care organization), or other kind of provider network. Non-exclusive networks can generally be larger than exclusive networks,” Pavarini says. A growing number of IPAs are converting to ACOs, a structure requiring more formal legal, management, and leadership structure, along with shared savings arrangements between providers and payers. Find out if the IPA you are considering is making this change before joining. While IPAs come in all shapes and sizes, they nearly always bring an important value proposition to their members: negotiating power for contracting. Particularly in the western United States, IPAs negotiate riskbearing, capitated medical services agreements on behalf of their members, working as an entity somewhat akin to a health maintenance organization. Many IPAs, especially those that are clinically integrated, have already converted to an accountable care organization (ACO)–or provide the infrastructure for their members to organize as one. Because many of these organizations have already operated as risk-bearing provider networks, IPAs are well positioned to take leading roles in developing ACOs or acting as sustaining member organizations. Even if the physician organization has operated in a fee-for-service environment, an IPA can bring expertise regarding contracting, analytics and management. In addition to payer relations, an IPA may offer management services organization (MSO) amenities such as payroll, bookkeeping, benefits management, group pur- MedicalEconomics. com Do your homework Check with legal counsel before signing on to an IPA to make sure it abides by antitrust and price fixing laws, and also to ensure its management fees are reasonable, says Alan S. Gassman, JD, of Gassman Law Associates P.A. in Clearwater, Florida. chasing, and compliance. The IPA can serve as the information technology platform for all automation, often offering the capability of connecting disparate EHR technology, or perhaps just linking practices with a data warehouse. These administrative services can be shared across the IPA membership, thereby reducing costs for individual members. For those who think employment or affiliation with a hospital or health system requires surrendering too much control, an IPA may offer a viable alternative. An IPA structured as a risk-bearing entity can be especially useful to physicians who may want to participate in risk contracts but don’t have the time or administrative support to hammer out the many details required for such arrangements. Using an IPA, physicians can work directly with payers on reimbursement issues pertinent to their practices—even opt out of a risk contract arrangement—while maintaining access to the IPAs menu of other administrative services. While IPAs may bring substantial advantages from a contracting and administrative MORE ONLINE How to survive in independent practice http://bit.ly/1wykdjN Collaboration is key to small-practice survival http://bit.ly/18evgn8 Monopolizing medicine http://bit.ly/18evmeu MEDICAL ECONOMICS ❚ APRIL 10, 2015 49 IPAs By the numbers IPAs IN THE UNITED STATES 677 Number of IPAs represented by the Independent Physicians Association of America (TIPAAA) 2,900 Number of affiliated IPAs also represented Source: TIPAAA perspective, the most powerful opportunity may be their unique position in the changing healthcare landscape. The director of care coordination for the Connecticut State Medical Society-IPA, Inc., a statewide IPA with 7,000 physician members, Kelly Ann Pappa, RN, agrees. “No truer an expression than ‘there is strength in numbers,”’ Pappa says. “IPA members expect to provide a high level of service on behalf of their patients; however, many providers feel overwhelmed by the myriad of administrative regulations and reporting criteria that they must meet in order to receive just compensation for the quality of care that they deliver.” IPAs may offer the opportunity to participate in quality programs that reward improved outcomes that are often not otherwise available to the independent or solo practitioner. Critical to the achievement of success in these programs and practice transformation is the improved communication, coordination and resource sharing brought by the IPA.” With an engaged membership, an IPA can serve as the platform for independent practices to participate in coordinated care. An IPA can provide the infrastructure for physicians in small-to-medium-size practices to make unified efforts to coordinate care by gathering, analyzing and reporting quality data across the continuum of patients’ care; and effectively deploying population health management strategies. In supporting initiatives to coordinate care, IPAs can also: ❚ develop protocols for point-of-care clinical decision support; ❚ send reminders to patients for recommended preventive or follow-up care; ❚ use registries to monitor patients with chronic illnesses; and ❚ employ or contract with nurses to serve as patient care managers. Elizabeth Woodcock, MBA, FACMPE, CPC, (pictured) is a consultant, speaker, trainer and author with Woodcock & Associates in Atlanta, Georgia. Casey Crotty is chief executive officer of Suan Juan IPA in New Mexico. 50 Connecticut State Medical Society (CSMS)-IPA, Inc., for example, provides opportunities for its member physicians to use value-added services that improve the quality and cost-effectiveness of their care and receive additional compensation from payers for their efforts. Recent relationships established with commercial payers bring CSMS-IPA, Inc. members additional compensation for MEDICAL ECONOMICS ❚ APRIL 10, 2015 attesting to pre-determined metrics. Regardless of the specific services an IPA provides, its presence enables independent physicians to leverage their data to build business intelligence about their patients’ care. The Health Affairs study offers quantifiable proof of this value: physicians participating in IPAs or PHOs provided approximately three times as many care management processes for their patients with chronic conditions as did nonparticipating practices: 10.45% compared with 3.85%, according to the survey of 1,164 practices with 20 or fewer physicians. DRAWBACKS That said, IPAs are not for everyone. Not all IPAs are created equal; some may have grown too quickly and do not have a sufficiently experienced management team in place. The number of processes and tasks tied in with information technology—not to mention the swift pace of change in the field—means that the technology solutions an IPA offers may outpace, or lag behind, its members’ needs, or willingness to pay. Some physicians may feel out of step with their IPA’s approach to customer service quality, marketing or internal communications. In addition, an IPA does not free its physician members from all of the time commitments and responsibilities of maintaining the business of a medical practice. Not all markets have IPAs, and the ones that do vary in scope and services. If there is an IPA in your market, evaluate the benefits of joining. (See Figure 1 for questions to ask during your decision-making process.) Contact colleagues who have joined the IPA, probing them for both the qualitative and quantitative benefits they receive. Recognize the contracting opportunities, but compare them to what you already receive. In other words, do your homework before proceeding with an IPA affiliation. Get the IPA agreement for membership in writing. Before you join, consult a healthcare attorney to review the contract and all relevant documents. The IPA model is gaining new attention as more physicians look for ways to stay in independent private practice yet not feel forced to sail today’s blustery seas completely alone. An IPA may just be your perfect shelter from the storm. MedicalEconomics. com F I NAN C IAL ADVI C E F R O M TH E E X P E RTS Financial Strategies BUSINESS INSURANCE COVERAGE EVERY PHYSICIAN SHOULD HAVE by ROB E RT C. SCROGG I N S, J D, CPA, CH BC and N ICK BOGAN, Contributing authors Your biggest risk and greatest exposure as a physician is in the area of professional services. Consequently, most doctors are well aware of the particulars of coverage in this area. Liability also can arise when it comes to the business side of a medical practice, however, and it is in this area where other types of coverage become highly important. IN CONSULTATION with a reputable and knowledgeable general insurance agent, we encourage our clients to consider the following types of coverage: Non-owner (hired) auto Your practice may own automobiles used by the doctors, in which case it is natural to have a policy covering those vehicles. However, coverage for employees sometimes is overlooked when they are using their personal automobiles to conduct business for the practice. Staff members handling bank deposits, errands, and other activities away from your practice can give rise to liability in the event of an accident. MedicalEconomics. com Non-owner auto coverage protects you when your employee or a third party is injured while carrying out business duties for your practice. Standard coverage is typically $1 million and is coordinated with an umbrella policy. It is typical to identify specifically and limit the staff members who are permitted to run errands for the practice. ERISA/fidelity bond This is coverage specific to your practice’s retirement plan. The Employee Retirement Income Security Act (ERISA) requires a plan sponsor to carry coverage for employee dishonesty with respect to the retirement plan’s assets. The amount of required coverage is the lesser of $500,000 or 10% of plan assets. The policy covers those responsible for managing the plan in a fiduciary capacity as well as those who handle investment assets in the plan. Employee dishonesty This is another type of fidelity bond coverage. This coverage is analogous to an ERISA bond, in that it provides protection in the event that a staff member steals or embezzles money or property from your practice. Often this coverage can be designed to satisfy the ERISA bond requirement via an endorsement. In most medical practice settings, the potential for theft is present with respect to both accounts receivable and accounts payable. In general it is recommended to have base coverage of at least $100,000. In addition to insurance, it is very important to establish good internal cash controls to reduce the possibility of an employee misappropriating practice assets. Employee theft of sensitive customer data This coverage, in the case of a medical practice, is typically and primarily designed to protect against the misappropriation of sensitive patient information. In most cases It would also cover the situation of a non-employee hacker (sometimes referred to as a “cyber breach”) as well as the accidental interception of sensitive information, for example, in the case of a failed network firewall. Coverage, particularly in the case of a cyber breach, typically extends to the injured party to provide assistance to recover from the incident such as restoring credit and other related identity theft repairs. MEDICAL ECONOMICS ❚ APRIL 10, 2015 51 F I NAN C IAL ADVI C E F R O M TH E E X P E RTS Financial Strategies Employment practices This type of coverage addresses human resourcerelated allegations such as wrongful termination and employee misconduct such as sexual harassment. Coverage protects the physician owners as well as claims against staff (essentially covering those responsible for handling human resource-related issues.) Basic coverage is for damages, but separate coverage can also be secured for legal expenses involved with defending a claim. Umbrella This policy ties into the other types of coverage to protect against claims that exceed the limits of the other individual policies. An umbrella can extend coverage to gaps under other policies, such as covering the cost of legal expenses to defend a claim. Because this type of policy supplements other coverage, you will want enough to protect practice earnings, assets, and outstanding liabilities— enough, in other words, to recover from an event that might otherwise drain the assets of the practice. Business overhead expense This type of disability insurance is particularly helpful in a smaller practice 52 AN UMBRELLA CAN ALSO EXTEND COVERAGE WHERE THERE ARE GAPS UNDER THE OTHER POLICIES, SUCH AS COVERING LEGAL COSTS TO DEFEND A CLAIM. setting and very important in the case of a solo practice. If a physician is unable to work due to a disability or other issue, the insurance provides cash flow to continue paying overhead expenses such as payroll, rent, and utilities. The elimination period typically is fairly short, perhaps even 30 days, and the coverage does not usually go beyond a couple of years. The policy pays overhead expenses needed to keep the business running. Life and disability (“key man”) Considerations when selecting an insurance policy 1 Find a reputable insurance company. You can research company ratings using services such as Fitch, Standard & Poor’s Insurance Rating Services and others. 2 When selecting a disability insurance policy, find policies that allow the physician to identify your specialty. 3 Look for flexible plans that allow you to adjust coverage in the future. 4 If you find different employment, does the plan come with you? 5 Consider the tax implications of various insurance types and plans. the life and ability to work for those in key positions. For a medical practice, this would include the physician(s) and any other significant incomeproducing providers important to practice revenue. Life and disability insurance for those in key positions are secured for the purpose of providing cash flow while the practice replaces the lost production. For practices with significant value, key man life and disability coverage is also important to provide cash to pay the estate of the deceased or acquire the ownership interest of a disabled physician. If the practice must support a buyout payment without the help of insurance coverage, it can wind up in a position of double trouble since the lost production capacity hurts top-line revenue and the required buyout obligation is above and beyond normal overhead expense. Robert C. Scroggins, JD, CPA, CHBC (pictured) is a management consultant and principal with ScrogginsGrear, Inc., in Cincinnati, Ohio. Nick Bogan is vice president of SenourFlaherty Insurance in Cincinnati, Ohio. Send your practice management questions to [email protected]. 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Contact Wright’s Media to find out more about how we can customize your acknowledgements and recognitions to enhance your marketing strategies. For information, call Wright’s Media at 877.652.5295 or visit our website at www.wrightsmedia.com Search for the company name you see in each of the ads in this section for FREE INFORMATION! MedicalEconomics. com MEDICAL ECONOMICS ❚ APRIL 10, 2015 53 P r o d u c t s & S e r v i c e s SHOWCASE FINANCIAL ADVISERS FOR DOCTORS Those companies listed in Medical Economics 2014 Best Financial Advisers for Doctors display this symbol in their ads. 2014 Best Financial Advisers for Doctors ★ NEW JERSEY Howard Hook, CFP®, CPA (pictured on left) Fee-Only Comprehensive Financial Life Planner (609) 921-1016 | [email protected] Proactive Planning. Sound Portfolio Strategies. Unbiased Advice. As a fee-only comprehensive financial life planning firm, we do not accept commissions or referral fees. All recommendations are free from conflicts of interest and focused on your needs and goals. We care deeply about making a positive difference in the lives of our clients and have been serving doctors for more than 25 years. 601 Ewing Street | Suite A-7 | Princeton, NJ 08540 | eksassociates.net ★ NORTH CAROLINA Matrix Wealth Advisors, Inc. Giles Almond, CPA/PFS, CFP®, CIMA® $IBSMPUUF/$t [email protected] t Minimum Portfolio Value: $1MM Shouldn’t your financial advisor be a fiduciary - someone who works solely for your benefit, adheres to the highest professional standard, and avoids conflicts of interest? Since 1990, Matrix Wealth Advisors has built a trusted reputation among physicians by providing excellent service, creative and sound portfolio strategies, and a clear direction for clients’ financial lives. 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SHOWCASE & MARKETPLACE ADVERTISING Contact: Tod McCloskey at [WPFFORVNH\#DGYDQVWDUFRP MedicalEconomics. com MEDICAL ECONOMICS ❚ APRIL 10, 2015 55 M A R K ET PL AC E Advertiser Index TRANSC R I PTION SE RVIC ES athenahealth Corporate ................................................................. 8 – 9 Kareo......................................................................... 29 Physicians Alliance of America ........................................ 41 Repeating an Ad Ensures It will be Seen and CAREERS Remembered! TEXAS * Indicates a demographic advertisement. 8I\EW*EQMP]4VEGXMGI-RXIVREP1IHMGMRIMW WIIOMRKE4L]WMGMERJSVXLIMVFYW]TVEGXMGI 'SQTIXMXMZIWEPEV]JVIWLKVEHYEXIJVSQ XVEMRMRK[MPPFITVIJIVVIH -RXIVIWXIHGERHMHEXIWWLSYPH GEPP SV IQEMPOLERHSG$LSXQEMPGSQ FOR RECRUITMENT ADVERTISING Contact: Joanna Shippoli at 800.225.4569 x 2615 [email protected] 56 MEDICAL ECONOMICS ❚ APRIL 10, 2015 MedicalEconomics. com TH E B R I D G E B ETWE E N PO LI CY AN D H EALTH CAR E D E LIVE RY The Last Word AFFORDABLE CARE ACT WILL COST BILLIONS LESS THAN PREDICTED by EVAN ROSS Contributing author Provisions of the Affordable Care Act (ACA) will cost $142 billion less— or 11%—over the 2016–2025 period than originally estimated by the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT). ACCORDING TO revisions released in March from the CBO, the reduction is based on two primary factors: a slower growth of private health insurance premiums; and differing sources and numbers of people gaining insurance through the ACA. In January, the original estimated cost of the ACA was expected to be more than $7.6 trillion from 2016 to 2025. New estimates place that number at $7.2 trillion. Factors that led to lower overall budget projections stemming from the number and type of health insurance gained under the ACA include: ❚ A lower estimate of the total number of people with employment-based coverage; ❚ An increase in the estimate of workers employed by businesses with 1,000 or more employees; ❚ A decrease in the estimate of the number MedicalEconomics. com of people who had no health insurance at all; and ❚ Higher Medicaid enrollment before 2014 than previously estimated. The CBO and the Joint Committee on Taxation (JCT) lowered their estimates of private health insurance premiums for the 2016 – 2025 period based on new information on national health expenditures. “Spending by private health insurers on health care and administration rose less in 2013 (the most recent year for which data was available) than in preceding years and by much less than the agencies had expected for 2013” concluded the CBO and JCT, the result of the continuing trend of “relatively” slow growth in healthcare spending. After removing the effects of overall inflation and adjusting for population changes, the CBO and JCT estimated that private health insurance spending per enrollee only grew an average of 1.8% per year between 2006 2013, compared to the rate of 5% per year between 1998 - 2005. Estimates of spending-per-enrollee are expected to grow 2.2% between 2014 - 2018 and 3.1% between 2019 - 2025. The slower rate of growth in premiums is also expected to impact the excise tax on “Cadillac plans.” Fewer plans will have to pay the “Cadillac tax,” which will decrease the projected revenues by more than 40%. The lower rate of private health insurance cost affects the amount of money the government needs for healthcare exchange subsidies. In 2010, the CBO predicted that health insurance subsidies would average $5,200 per person in 2015. The new estimate puts hat total at $3,960, a 20% reduction. Medicaid costs are expected to be $847 billion in the next decade, down 8% from the January estimate. BY THE NUMBERS $7.2TRILLION The cost of the ACA from 2016 through 2025, according to the latest estimates. $3,960 The per person cost of healthcare insurance subsidies, down 20% from the previous estimate. 8% Expected percentage decrease in Medicaid costs over the next decade. MEDICAL ECONOMICS ❚ APRIL 10, 2015 57
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