O E S T LIN ICE TIP AM ACT RE PR E 33 ST UR PAG YO Medical Economics JAN UARY 10, 2015 PAYM E NT OUTLOOK FOR 2015 JANUARY 10, 2015 VOL. 92 NO. 1 ■ TH E PROM ISE OF E LECTRON IC PR IOR AUTHOR IZATIONS 16 ICD-10: Will it be delayed again? 24 How smart negotiations with payers can pay off The promise of electronic prior authorizations 38 Evaluation and management codes to know in 2015 53 Fixing the referral process with better protocols ■ 26 PAYMENT OUTLOOK FOR 2015 Your guide to solutions to help your practice thrive PAGE 18 B USI N ESS PLAN N I NG: STR EAM LI N E YOU R PRACTICE Plus Bolster your revenue with: Chronic care management Telemedicine Quality measures magenta cyan yellow black ES544312_ME011015_cv1.pgs 12.16.2014 21:17 ADV NEW 7.5 mcg/hour Now Available Butrans — 7 Days of Buprenorphine Delivery Butrans is a Schedule III extended-release opioid analgesic WARNING: ADDICTION, ABUSE and MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL EXPOSURE; and NEONATAL OPIOID WITHDRAWAL SYNDROME Addiction, Abuse, and Misuse Butrans exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk prior to prescribing Butrans, and monitor all patients regularly for the development of these behaviors or conditions [see Warnings and Precautions (5.1) and Overdosage (10)]. Life-Threatening Respiratory Depression Serious, life-threatening, or fatal respiratory depression may occur with use of Butrans. Monitor for respiratory depression, especially during initiation of Butrans or following a dose increase. Misuse or abuse of Butrans by chewing, swallowing, snorting or injecting buprenorphine extracted from the transdermal system will result in the uncontrolled delivery of buprenorphine and pose a significant risk of overdose and death [see Warnings and Precautions (5.2)]. Accidental Exposure Accidental exposure to even one dose of Butrans, especially by children, can result in a fatal overdose of buprenorphine [see Warnings and Precautions (5.2)]. Neonatal Opioid Withdrawal Syndrome Prolonged use of Butrans during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available [see Warnings and Precautions (5.3)]. Parentheses refer to sections in the Full Prescribing Information. magenta cyan yellow black ES543218_ME011015_CV2_FP.pgs 12.12.2014 02:01 ADV Butrans® (buprenorphine) Transdermal System is indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. Limitations of Use: Because of the risks of addiction, abuse and misuse with opioids, even at recommended doses, and because of the greater risk of overdose and death with extended-release opioid formulations, reserve Butrans for use in patients for whom alternative treatment options (eg, non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain. Butrans is not indicated as an as-needed (prn) analgesic. CONTRAINDICATIONS Butrans is contraindicated in patients with: significant respiratory depression; acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment; known or suspected paralytic ileus; hypersensitivity (eg, anaphylaxis) to buprenorphine ■ WARNINGS AND PRECAUTIONS Addiction, Abuse, and Misuse ■ Butrans contains buprenorphine, a Schedule III controlled substance. Butrans exposes users to the risks of opioid addiction, abuse, and misuse. As modified-release products such as Butrans deliver the opioid over an extended period of time, there is a greater risk for overdose and death, due to the larger amount of buprenorphine present. Addiction can occur at recommended doses and if the drug is misused or abused. Assess each patient’s risk for opioid addiction, abuse, or misuse prior to prescribing Butrans, and monitor all patients during therapy for the development of these behaviors or conditions. Abuse or misuse of Butrans by placing it in the mouth, chewing it, swallowing it, or using it in ways other than indicated may cause choking, overdose and death Life-Threatening Respiratory Depression ■ Serious, life-threatening, or fatal respiratory depression has been reported with modifiedrelease opioids, even when used as recommended, and if not immediately recognized and treated, may lead to respiratory arrest and death. The risk of respiratory depression is greatest during the initiation of therapy or following a dose increase; therefore, closely monitor patients for respiratory depression. Proper dosing and titration of Butrans are essential. Overestimating the Butrans dose when converting patients from another opioid product can result in fatal overdose with the first dose. Accidental exposure to Butrans, especially in children, can result in respiratory depression and death due to an overdose of buprenorphine Neonatal Opioid Withdrawal Syndrome ■ Prolonged use of Butrans during pregnancy can result in neonatal opioid withdrawal syndrome which may be life-threatening to the neonate if not recognized and treated, and requires management according to protocols developed by neonatology experts Interactions with Central Nervous System Depressants ■ Hypotension, profound sedation, coma, respiratory depression, or death may result if Butrans is used concomitantly with other CNS depressants, including alcohol or illicit drugs that can cause CNS depression. Start with Butrans 5 mcg/hour patch, monitor patients for signs of sedation and respiratory depression, and consider using a lower dose of the concomitant CNS depressant Use in Elderly, Cachectic, and Debilitated Patients and Patients with Chronic Pulmonary Disease ■ Closely monitor elderly, cachectic, and debilitated patients, and patients with chronic obstructive pulmonary disease because of the increased risk of life-threatening respiratory depression. Consider the use of alternative non-opioid analgesics in patients with chronic obstructive pulmonary disease if possible QTc Prolongation ■ Avoid in patients with Long QT Syndrome, family history of Long QT Syndrome, or those taking Class IA or Class III antiarrhythmic medications Hypotensive Effects ■ Butrans may cause severe hypotension, including orthostatic hypotension and syncope in ambulatory patients. Monitor patients during dose initiation or titration Use in Patients with Head Injury or Increased Intracranial Pressure ■ Monitor patients taking Butrans who may be susceptible to the intracranial effects of CO2 retention for signs of sedation and respiratory depression. Avoid the use of Butrans in patients with impaired consciousness or coma Please read Brief Summary of Full Prescribing Information on the following pages. magenta cyan yellow black Application Site Skin Reactions ■ In rare cases, severe application site skin reactions with signs of marked inflammation including “burn,” “discharge,” and “vesicles” have occurred Anaphylactic/Allergic Reactions ■ Cases of acute and chronic hypersensitivity to buprenorphine have been reported both in clinical trials and in the post-marketing experience Application of External Heat ■ Avoid exposing the Butrans application site and surrounding area to direct external heat sources. There is a potential for temperature-dependent increases in buprenorphine released from the system resulting in possible overdose and death Use in Patients with Gastrointestinal Conditions ■ Avoid the use of Butrans in patients with paralytic ileus and other GI obstructions. Monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms ■ ADVERSE REACTIONS Most common adverse reactions (≥5%) reported by patients treated with Butrans in the clinical trials were nausea, headache, application site pruritus, dizziness, constipation, somnolence, vomiting, application site erythema, dry mouth, and application site rash Visit Butrans.com for more information or to print the Butrans Trial Offer and Butrans Savings Cards The first transdermal system to deliver 7 days of buprenorphine ©2014 Purdue Pharma L.P. Stamford, CT 06901-3431 J8365-A 8/14 ES543217_ME011015_001_FP.pgs 12.12.2014 02:01 ADV for transdermal administration BRIEF SUMMARY OF PRESCRIBING INFORMATION (For complete details please see the Full Prescribing Information and Medication Guide.) WARNING: ADDICTION, ABUSE and MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL EXPOSURE; and NEONATAL OPIOID WITHDRAWAL SYNDROME Addiction, Abuse, and Misuse BUTRANS® exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death. Assess each patient’s risk prior to prescribing BUTRANS, and monitor all patients regularly for the development of these behaviors or conditions [see Warnings and Precautions (5.1) and Overdosage (10)]. Life-Threatening Respiratory Depression Serious, life-threatening, or fatal respiratory depression may occur with use of BUTRANS. Monitor for respiratory depression, especially during initiation of BUTRANS or following a dose increase. Misuse or abuse of BUTRANS by chewing, swallowing, snorting or injecting buprenorphine extracted from the transdermal system will result in the uncontrolled delivery of buprenorphine and pose a significant risk of overdose and death [see Warnings and Precautions (5.2)]. Accidental Exposure Accidental exposure to even one dose of BUTRANS, especially by children, can result in a fatal overdose of buprenorphine [see Warnings and Precautions (5.2)]. Neonatal Opioid Withdrawal Syndrome Prolonged use of BUTRANS during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available [see Warnings and Precautions (5.3)]. 4 CONTRAINDICATIONS BUTRANS is contraindicated in patients with: • Significant respiratory depression • Acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment • Known or suspected paralytic ileus • Hypersensitivity (e.g., anaphylaxis) to buprenorphine [see Warnings and Precautions (5.12) and Adverse Reactions (6)] 5 WARNINGS AND PRECAUTIONS 5.1 Addiction, Abuse, and Misuse BUTRANS contains buprenorphine, a Schedule III controlled substance. As an opioid, BUTRANS exposes users to the risks of addiction, abuse, and misuse. As modified-release products such as BUTRANS deliver the opioid over an extended period of time, there is a greater risk for overdose and death, due to the larger amount of buprenorphine present. Although the risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed BUTRANS and in those who obtain the drug illicitly. Addiction can occur at recommended doses and if the drug is misused or abused [see Drug Abuse and Dependence (9)]. Assess each patient’s risk for opioid addiction, abuse, or misuse prior to prescribing BUTRANS, and monitor all patients receiving BUTRANS for the development of these behaviors or conditions. Risks are increased in patients with a personal or family history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major depression). The potential for these risks should not, however, prevent the proper management of pain in any given patient. Patients at increased risk may be prescribed modified-release opioid formulations such as BUTRANS, but use in such patients necessitates intensive counseling about the risks and proper use of BUTRANS, along with intensive monitoring for signs of addiction, abuse, or misuse. Abuse or misuse of BUTRANS by placing it in the mouth, chewing it, swallowing it, or using it in ways other than indicated may cause choking, overdose and death [see Overdosage (10)]. Opioid agonists such as BUTRANS are sought by drug abusers and people with addiction disorders and are subject to criminal diversion. Consider these risks when prescribing or dispensing BUTRANS. Strategies to reduce these risks include prescribing the drug in the smallest appropriate quantity and advising the patient on the proper disposal of unused drug [see Patient Counseling Information (17)]. Contact local state professional licensing board or state controlled substances authority for information on how to prevent and detect abuse or diversion of this product. 5.2 Life-Threatening Respiratory Depression Serious, lifethreatening, or fatal respiratory depression has been reported with the use of modified-release opioids, even when used as recommended. Respiratory depression, from opioid use, if not immediately recognized and treated, may lead to respiratory arrest and death. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status [see Overdosage (10)]. Carbon dioxide (CO2) retention from opioid-induced respiratory depression can exacerbate the sedating effects of opioids. While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of BUTRANS, the risk is greatest during the initiation of therapy or following a dose increase. Closely monitor patients for respiratory depression when initiating therapy with BUTRANS and following dose increases. To reduce the risk of respiratory depression, proper dosing and titration of BUTRANS are essential [see Dosage and Administration (2)]. Overestimating the BUTRANS dose when converting patients from another opioid product can result in fatal overdose with the first dose. Accidental exposure to BUTRANS, especially in children, can result in respiratory depression and death due to an overdose of buprenorphine. 5.3 Neonatal Opioid Withdrawal Syndrome Prolonged use of BUTRANS during pregnancy can result in withdrawal signs in the neonate. Neonatal opioid withdrawal syndrome, unlike opioid withdrawal syndrome in adults, may be life-threatening if not recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available. Neonatal opioid withdrawal syndrome presents as irritability, hyperactivity and abnormal sleep pattern, high pitched cry, tremor, vomiting, diarrhea and failure to gain weight. The onset, duration, and severity of neonatal opioid withdrawal syndrome vary based on the specific opioid used, duration of use, timing and amount of last maternal use, and rate of elimination of the drug by the newborn. 5.4 Interactions with Central Nervous System Depressants Hypotension, black profound sedation, coma, respiratory depression, and death may result if BUTRANS is used concomitantly with alcohol or other (CNS) depressants (e.g., sedatives, anxiolytics, hypnotics, neuroleptics, other opioids). When considering the use of BUTRANS in a patient taking a CNS depressant, assess the duration of use of the CNS depressant and the patient’s response, including the degree of tolerance that has developed to CNS depression. Additionally, evaluate the patient’s use of alcohol or illicit drugs that cause CNS depression. If the decision to begin BUTRANS therapy is made, start with BUTRANS 5 mcg/hour patch, monitor patients for signs of sedation and respiratory depression and consider using a lower dose of the concomitant CNS depressant [see Drug Interactions (7.2)]. 5.5 Use in Elderly, Cachectic, and Debilitated Patients Life-threatening respiratory depression is more likely to occur in elderly, cachectic, or debilitated patients as they may have altered pharmacokinetics or altered clearance compared to younger, healthier patients. Monitor such patients closely, particularly when initiating and titrating BUTRANS and when BUTRANS is given concomitantly with other drugs that depress respiration [see Warnings and Precautions (5.2)]. 5.6 Use in Patients with Chronic Pulmonary Disease Monitor patients with significant chronic obstructive pulmonary disease or cor pulmonale, and patients having a substantially decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression for respiratory depression, particularly when initiating therapy and titrating with BUTRANS, as in these patients, even usual therapeutic doses of BUTRANS may decrease respiratory drive to the point of apnea [see Warnings and Precautions (5.2)]. Consider the use of alternative non-opioid analgesics in these patients if possible. 5.7 QTc Prolongation A positive-controlled study of the effects of BUTRANS on the QTc interval in healthy subjects demonstrated no clinically meaningful effect at a BUTRANS dose of 10 mcg/hour; however, a BUTRANS dose of 40 mcg/hour (given as two BUTRANS 20 mcg/hour Transdermal Systems) was observed to prolong the QTc interval [see Dosage and Administration (2.2) and Clinical Pharmacology (12.2)]. Consider these observations in clinical decisions when prescribing BUTRANS to patients with hypokalemia or clinically unstable cardiac disease, including: unstable atrial fibrillation, symptomatic bradycardia, unstable congestive heart failure, or active myocardial ischemia. Avoid the use of BUTRANS in patients with a history of Long QT Syndrome or an immediate family member with this condition, or those taking Class IA antiarrhythmic medications (e.g., quinidine, procainamide, disopyramide) or Class III antiarrhythmic medications (e.g., sotalol, amiodarone, dofetilide). 5.8 Hypotensive Effects BUTRANS may cause severe hypotension including orthostatic hypotension and syncope in ambulatory patients. There is an increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume or concurrent administration of certain CNS depressant drugs (e.g., phenothiazines or general anesthetics) [see Drug Interactions (7.2)]. Monitor these patients for signs of hypotension after initiating or titrating the dose of BUTRANS. 5.9 Use in Patients with Head Injury or Increased Intracranial Pressure Monitor patients taking BUTRANS who may be susceptible to the intracranial effects of CO2 retention (e.g., those with evidence of increased intracranial pressure or brain tumors) for signs of sedation and respiratory depression, particularly when initiating therapy with BUTRANS. BUTRANS may reduce respiratory drive, and the resultant CO2 retention can further increase intracranial pressure. Opioids may also obscure the clinical course in a patient with a head injury. Avoid the use of BUTRANS in patients with impaired consciousness or coma. 5.10 Hepatotoxicity Although not observed in BUTRANS chronic pain clinical trials, cases of cytolytic hepatitis and hepatitis with jaundice have been observed in individuals receiving sublingual buprenorphine for the treatment of opioid dependence, both in clinical trials and in post-marketing adverse event reports. The spectrum of abnormalities ranges from transient asymptomatic elevations in hepatic transaminases to case reports of hepatic failure, hepatic necrosis, hepatorenal syndrome, and hepatic encephalopathy. In many cases, the presence of pre-existing liver enzyme abnormalities, infection with hepatitis B or hepatitis C virus, concomitant usage of other potentially hepatotoxic drugs, and ongoing injection drug abuse may have played a causative or contributory role. For patients at increased risk of hepatotoxicity (e.g., patients with a history of excessive alcohol intake, intravenous drug abuse or liver disease), obtain baseline liver enzyme levels and monitor periodically and during treatment with BUTRANS. 5.11 Application Site Skin Reactions In rare cases, severe application site skin reactions with signs of marked inflammation including “burn,” “discharge,” and “vesicles” have occurred. Time of onset varies, ranging from days to months following the initiation of BUTRANS treatment. Instruct patients to promptly report the development of severe application site reactions and discontinue therapy. 5.12 Anaphylactic/Allergic Reactions Cases of acute and chronic hypersensitivity to buprenorphine have been reported both in clinical trials and in the post-marketing experience. The most common signs and symptoms include rashes, hives, and pruritus. Cases of bronchospasm, angioneurotic edema, and anaphylactic shock have been reported. A history of hypersensitivity to buprenorphine is a contraindication to the use of BUTRANS. 5.13 Application of External Heat Advise patients and their caregivers to avoid exposing the BUTRANS application site and surrounding area to direct external heat sources, such as heating pads or electric blankets, heat or tanning lamps, saunas, hot tubs, and heated water beds while wearing the system because an increase in absorption of buprenorphine may occur [see Clinical Pharmacology (12.3)]. Advise patients against exposure of the BUTRANS application site and surrounding area to hot water or prolonged exposure to direct sunlight. There is a potential for temperature-dependent increases in buprenorphine released from the system resulting in possible overdose and death. 5.14 Patients with Fever Monitor patients wearing BUTRANS systems who develop fever or increased core body temperature due to strenuous exertion for opioid side effects and adjust the BUTRANS dose if signs of respiratory or central nervous system depression occur. 5.15 Use in Patients with Gastrointestinal Conditions BUTRANS is contraindicated in patients with paralytic ileus. Avoid the use of BUTRANS in patients with other GI obstruction. The buprenorphine in BUTRANS may cause spasm of the sphincter of Oddi. Monitor patients with biliary tract disease, including acute pancreatitis, for worsening symptoms. Opioids may cause increases in the serum amylase. 5.16 Use in Patients with Convulsive or Seizure Disorders The buprenorphine in BUTRANS may aggravate convulsions in patients with convulsive disorders, and may induce or aggravate seizures in some clinical settings. Monitor patients with a history of seizure disorders for worsened seizure control during BUTRANS therapy. 5.17 Driving and Operating Machinery BUTRANS may impair the mental and physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery. Warn patients not to drive or operate dangerous machinery unless they are tolerant to the effects of BUTRANS and know how they will react to the medication. 5.18 Use in Addiction Treatment BUTRANS has not been studied and is not approved for use in the management of addictive disorders. 6 ADVERSE REACTIONS The following serious adverse reactions are described elsewhere in the labeling: • Addiction, Abuse, and Misuse [see Warnings and Precautions (5.1)] • Life-Threatening Respiratory Depression [see Warnings and Precautions (5.2)] • QTc Prolongation [see Warnings and Precautions (5.7)] • Neonatal Opioid Withdrawal Syndrome [see Warnings and Precautions (5.3)] • Hypotensive Effects [see Warnings and Precautions (5.8)] • Interactions with Other CNS Depressants [see Warnings and Precautions (5.4)] • Application Site Skin Reactions [see Warnings and Precautions (5.11)] • Anaphylactic/Allergic Reactions [see Warnings and Precautions (5.12)] • Gastrointestinal Effects [see Warnings and Precautions (5.15)] • Seizures [see Warnings and Precautions (5.16)] 6.1 Clinical Trial Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. A total of 5,415 patients were treated with BUTRANS in controlled and open-label chronic pain clinical trials. Nine hundred twenty-four subjects were treated for approximately six months and 183 subjects were treated for approximately one year. The clinical trial population consisted of patients with persistent moderate to severe pain. The most common serious adverse drug reactions (all <0.1%) occurring during clinical trials with BUTRANS were: chest pain, abdominal pain, vomiting, dehydration, and hypertension/blood pressure increased. The most common adverse events (≥2%) leading to discontinuation were: nausea, dizziness, vomiting, headache, and somnolence. The most common adverse reactions (≥5%) reported by patients in clinical trials comparing BUTRANS 10 or 20 mcg/hour to placebo are shown in Table 2, and comparing BUTRANS 20 mcg/hour to BUTRANS 5 mcg/hour are shown in Table 3 below: Table 2: Adverse Reactions Reported in ≥5% of Patients during the Open-Label Titration Period and Double-Blind Treatment Period: Opioid-Naïve Patients Open-Label Double-Blind Titration Period Treatment Period BUTRANS BUTRANS Placebo MedDRA (N = 1024) (N = 256) (N = 283) Preferred Term Nausea 23% 13% 10% Dizziness 10% 4% 1% Headache 9% 5% 5% Application site 8% 4% 7% pruritus Somnolence 8% 2% 2% Vomiting 7% 4% 1% Constipation 6% 4% 1% Table 3: Adverse Reactions Reported in ≥5% of Patients during the Open-Label Titration Period and Double-Blind Treatment Period: Opioid-Experienced Patients Open-Label Double-Blind Titration Period Treatment Period BUTRANS BUTRANS 20 BUTRANS 5 MedDRA (N = 1160) (N = 219) (N = 221) Preferred Term Nausea 14% 11% 6% Application site 9% 13% 5% pruritus Headache 9% 8% 3% Somnolence 6% 4% 2% Dizziness 5% 4% 2% Constipation 4% 6% 3% Application site 3% 10% 5% erythema Application 3% 8% 6% site rash Application 2% 6% 2% site irritation The following table lists adverse reactions that were reported in at least 2.0% of patients in four placebo/active-controlled titration-to-effect trials. Table 4: Adverse Reactions Reported in Titration-to-Effect Placebo/ Active-Controlled Clinical Trials with Incidence ≥2% MedDRA Preferred Term BUTRANS (N = 392) Placebo (N = 261) Nausea Application site pruritus Dizziness Headache Somnolence Constipation Vomiting Application site erythema Application site rash Dry mouth Fatigue Hyperhidrosis Peripheral edema Pruritus Stomach discomfort 21% 15% 15% 14% 13% 13% 9% 7% 6% 6% 5% 4% 3% 3% 2% 6% 12% 7% 9% 4% 5% 1% 2% 6% 2% 1% 1% 1% 0% 0% The adverse reactions seen in controlled and open-label studies are presented below in the following manner: most common (≥5%), common (≥1% to <5%), and less common (<1%). The most common adverse reactions (≥5%) reported by patients treated with BUTRANS in the clinical trials were nausea, headache, application site pruritus, dizziness, constipation, somnolence, vomiting, application site erythema, dry mouth, and application site rash. The common (≥1% to <5%) adverse reactions reported by patients treated with BUTRANS in the clinical trials organized by MedDRA (Medical Dictionary for Regulatory Activities) System Organ Class were: Gastrointestinal disorders: diarrhea, dyspepsia, and upper abdominal pain General disorders and administration site conditions: fatigue, peripheral edema, application ES543184_ME011015_002_FP.pgs 12.12.2014 02:00 ADV site irritation, pain, pyrexia, chest pain, and asthenia Infections and infestations: urinary tract infection, upper respiratory tract infection, nasopharyngitis, influenza, sinusitis, and bronchitis Injury, poisoning and procedural complications: fall Metabolism and nutrition disorders: anorexia Musculoskeletal and connective tissue disorders: back pain, arthralgia, pain in extremity, muscle spasms, musculoskeletal pain, joint swelling, neck pain, and myalgia Nervous system disorders: hypoesthesia, tremor, migraine, and paresthesia Psychiatric disorders: insomnia, anxiety, and depression Respiratory, thoracic and mediastinal disorders: dyspnea, pharyngolaryngeal pain, and cough Skin and subcutaneous tissue disorders: pruritus, hyperhidrosis, rash, and generalized pruritus Vascular disorders: hypertension Other less common adverse reactions, including those known to occur with opioid treatment, that were seen in <1% of the patients in the BUTRANS trials include the following in alphabetical order: Abdominal distention, abdominal pain, accidental injury, affect lability, agitation, alanine aminotransferase increased, angina pectoris, angioedema, apathy, application site dermatitis, asthma aggravated, bradycardia, chills, confusional state, contact dermatitis, coordination abnormal, dehydration, depersonalization, depressed level of consciousness, depressed mood, disorientation, disturbance in attention, diverticulitis, drug hypersensitivity, drug withdrawal syndrome, dry eye, dry skin, dysarthria, dysgeusia, dysphagia, euphoric mood, face edema, flatulence, flushing, gait disturbance, hallucination, hiccups, hot flush, hyperventilation, hypotension, hypoventilation, ileus, insomnia, libido decreased, loss of consciousness, malaise, memory impairment, mental impairment, mental status changes, miosis, muscle weakness, nervousness, nightmare, orthostatic hypotension, palpitations, psychotic disorder, respiration abnormal, respiratory depression, respiratory distress, respiratory failure, restlessness, rhinitis, sedation, sexual dysfunction, syncope, tachycardia, tinnitus, urinary hesitation, urinary incontinence, urinary retention, urticaria, vasodilatation, vertigo, vision blurred, visual disturbance, weight decreased, and wheezing. 7 DRUG INTERACTIONS 7.1 Benzodiazepines There have been a number of reports regarding coma and death associated with the misuse and abuse of the combination of buprenorphine and benzodiazepines. In many, but not all of these cases, buprenorphine was misused by self-injection of crushed buprenorphine tablets. Preclinical studies have shown that the combination of benzodiazepines and buprenorphine altered the usual ceiling effect on buprenorphine-induced respiratory depression, making the respiratory effects of buprenorphine appear similar to those of full opioid agonists. Closely monitor patients with concurrent use of BUTRANS and benzodiazepines. Warn patients that it is extremely dangerous to self-administer benzodiazepines while taking BUTRANS, and warn patients to use benzodiazepines concurrently with BUTRANS only as directed by their physician. 7.2 CNS Depressants The concomitant use of BUTRANS with other CNS depressants including sedatives, hypnotics, tranquilizers, general anesthetics, phenothiazines, other opioids, and alcohol can increase the risk of respiratory depression, profound sedation, coma and death. Monitor patients receiving CNS depressants and BUTRANS for signs of respiratory depression, sedation, and hypotension. When combined therapy with any of the above medications is considered, the dose of one or both agents should be reduced [see Dosage and Administration (2.2) and Warnings and Precautions (5.4)]. 7.3 Drugs Affecting Cytochrome P450 Isoenzymes Inhibitors of CYP3A4 and 2D6 Because the CYP3A4 isoenzyme plays a major role in the metabolism of buprenorphine, drugs that inhibit CYP3A4 activity may cause decreased clearance of buprenorphine which could lead to an increase in buprenorphine plasma concentrations and result in increased or prolonged opioid effects. These effects could be more pronounced with concomitant use of CYP2D6 and 3A4 inhibitors. If co-administration with BUTRANS is necessary, monitor patients for respiratory depression and sedation at frequent intervals and consider dose adjustments until stable drug effects are achieved [see Clinical Pharmacology (12.3)]. Inducers of CYP3A4 CYP450 3A4 inducers may induce the metabolism of buprenorphine and, therefore, may cause increased clearance of the drug which could lead to a decrease in buprenorphine plasma concentrations, lack of efficacy or, possibly, development of an abstinence syndrome in a patient who had developed physical dependence to buprenorphine. After stopping the treatment of a CYP3A4 inducer, as the effects of the inducer decline, the buprenorphine plasma concentration will increase which could increase or prolong both the therapeutic and adverse effects, and may cause serious respiratory depression. If co-administration or discontinuation of a CYP3A4 inducer with BUTRANS is necessary, monitor for signs of opioid withdrawal and consider dose adjustments until stable drug effects are achieved [see Clinical Pharmacology (12.3)]. 7.4 Muscle Relaxants Buprenorphine may enhance the neuromuscular blocking action of skeletal muscle relaxants and produce an increased degree of respiratory depression. Monitor patients receiving muscle relaxants and BUTRANS for signs of respiratory depression that may be greater than otherwise expected. 7.5 Anticholinergics Anticholinergics or other drugs with anticholinergic activity when used concurrently with opioid analgesics may result in increased risk of urinary retention and/or severe constipation, which may lead to paralytic ileus. Monitor patients for signs of urinary retention or reduced gastric motility when BUTRANS is used concurrently with anticholinergic drugs. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Clinical Considerations Fetal/neonatal adverse reactions Prolonged use of opioid analgesics during pregnancy for medical or nonmedical purposes can result in physical dependence in the neonate and neonatal opioid withdrawal syndrome shortly after birth. Observe newborns for symptoms of neonatal opioid withdrawal syndrome, such as poor feeding, diarrhea, irritability, tremor, rigidity, and seizures, and manage accordingly [see Warnings and Precautions (5.3)]. Teratogenic Effects - Pregnancy Category C There are no adequate and well-controlled studies in pregnant women. BUTRANS should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In animal studies, buprenorphine caused an increase in the number of stillborn offspring, reduced litter size, and reduced offspring growth in rats at maternal exposure levels that were approximately 10 times that of human subjects who received one BUTRANS 20 mcg/hour, the maximum recommended human dose (MRHD). Studies in rats and rabbits demonstrated no evidence of teratogenicity following BUTRANS or subcutaneous (SC) administration of buprenorphine during the period of major organogenesis. Rats were administered up to one BUTRANS 20 mcg/hour every 3 days (gestation days 6, 9, 12, & 15) or received daily SC buprenorphine up to 5 mg/kg (gestation days 6-17). Rabbits were administered four BUTRANS 20 mcg/hour every 3 days (gestation days 6, 9, 12, 15, 18, & 19) or received daily SC buprenorphine up to 5 mg/kg (gestation days 6-19). No teratogenicity was observed at any dose. AUC values for buprenorphine with BUTRANS application and SC injection were approximately 110 and 140 times, respectively, that of human subjects who received the MRHD of one BUTRANS 20 mcg/hour. Non-Teratogenic Effects In a peri- and post-natal study conducted in pregnant and lactating rats, administration of buprenorphine either as BUTRANS or SC buprenorphine was associated with toxicity to offspring. Buprenorphine was present in maternal milk. Pregnant black rats were administered 1/4 of one BUTRANS 5 mcg/hour every 3 days or received daily SC buprenorphine at doses of 0.05, 0.5, or 5 mg/kg from gestation day 6 to lactation day 21 (weaning). Administration of BUTRANS or SC buprenorphine at 0.5 or 5 mg/kg caused maternal toxicity and an increase in the number of stillborns, reduced litter size, and reduced offspring growth at maternal exposure levels that were approximately 10 times that of human subjects who received the MRHD of one BUTRANS 20 mcg/hour. Maternal toxicity was also observed at the no observed adverse effect level (NOAEL) for offspring. 8.2 Labor and Delivery Opioids cross the placenta and may produce respiratory depression in neonates. BUTRANS is not for use in women during and immediately prior to labor, when shorter acting analgesics or other analgesic techniques are more appropriate. Opioid analgesics can prolong labor through actions that temporarily reduce the strength, duration, and frequency of uterine contractions. However this effect is not consistent and may be offset by an increased rate of cervical dilatation, which tends to shorten labor. 8.3 Nursing Mothers Buprenorphine is excreted in breast milk. The amount of buprenorphine received by the infant varies depending on the maternal plasma concentration, the amount of milk ingested by the infant, and the extent of first pass metabolism. Withdrawal symptoms can occur in breast-feeding infants when maternal administration of buprenorphine is stopped. Because of the potential for adverse reactions in nursing infants from BUTRANS, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother. 8.4 Pediatric Use The safety and efficacy of BUTRANS in patients under 18 years of age has not been established. 8.5 Geriatric Use Of the total number of subjects in the clinical trials (5,415), BUTRANS was administered to 1,377 patients aged 65 years and older. Of those, 457 patients were 75 years of age and older. In the clinical program, the incidences of selected BUTRANS-related AEs were higher in older subjects. The incidences of application site AEs were slightly higher among subjects <65 years of age than those ≥65 years of age for both BUTRANS and placebo treatment groups. In a single-dose study of healthy elderly and healthy young subjects treated with BUTRANS 10 mcg/hour, the pharmacokinetics were similar. In a separate dose-escalation safety study, the pharmacokinetics in the healthy elderly and hypertensive elderly subjects taking thiazide diuretics were similar to those in the healthy young adults. In the elderly groups evaluated, adverse event rates were similar to or lower than rates in healthy young adult subjects, except for constipation and urinary retention, which were more common in the elderly. Although specific dose adjustments on the basis of advanced age are not required for pharmacokinetic reasons, use caution in the elderly population to ensure safe use [see Clinical Pharmacology (12.3)]. 8.6 Hepatic Impairment In a study utilizing intravenous buprenorphine, peak plasma levels (Cmax) and exposure (AUC) of buprenorphine in patients with mild and moderate hepatic impairment did not increase as compared to those observed in subjects with normal hepatic function. BUTRANS has not been evaluated in patients with severe hepatic impairment. As BUTRANS is intended for 7-day dosing, consider the use of alternate analgesic therapy in patients with severe hepatic impairment [see Dosage and Administration (2.4) and Clinical Pharmacology (12.3)]. 9 DRUG ABUSE AND DEPENDENCE 9.1 Controlled Substance BUTRANS contains buprenorphine, a Schedule III controlled substance with an abuse potential similar to other Schedule III opioids. BUTRANS can be abused and is subject to misuse, addiction and criminal diversion [see Warnings and Precautions (5.1)]. 9.2 Abuse All patients treated with opioids require careful monitoring for signs of abuse and addiction, since use of opioid analgesic products carries the risk of addiction even under appropriate medical use. Drug abuse is the intentional non-therapeutic use of an over-the-counter or prescription drug, even once, for its rewarding psychological or physiological effects. Drug abuse includes, but is not limited to the following examples: the use of a prescription or over-the-counter drug to get “high”, or the use of steroids for performance enhancement and muscle build up. Drug addiction is a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and includes: a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal. “Drug-seeking” behavior is very common to addicts and drug abusers. Drug-seeking tactics include emergency calls or visits near the end of office hours, refusal to undergo appropriate examination, testing or referral, repeated claims of loss of prescriptions, tampering with prescriptions and reluctance to provide prior medical records or contact information for other treating physician(s). “Doctor shopping” (visiting multiple prescribers) to obtain additional prescriptions is common among drug abusers and people suffering from untreated addiction. Preoccupation with achieving adequate pain relief can be appropriate behavior in a patient with poor pain control. Abuse and addiction are separate and distinct from physical dependence and tolerance. Physicians should be aware that addiction may not be accompanied by concurrent tolerance and symptoms of physical dependence in all addicts. In addition, abuse of opioids can occur in the absence of true addiction. BUTRANS, like other opioids, can be diverted for non-medical use into illicit channels of distribution. Careful recordkeeping of prescribing information, including quantity, frequency, and renewal requests, as required by state law, is strongly advised. Proper assessment of the patient, proper prescribing practices, periodic re-evaluation of therapy, and proper dispensing and storage are appropriate measures that help to reduce abuse of opioid drugs. Risks Specific to the Abuse of BUTRANS BUTRANS is intended for transdermal use only. Abuse of BUTRANS poses a risk of overdose and death. This risk is increased with concurrent abuse of BUTRANS with alcohol and other substances including other opioids and benzodiazepines [see Warnings and Precautions (5.4) and Drug Interactions (7.2)]. Intentional compromise of the transdermal delivery system will result in the uncontrolled delivery of buprenorphine and pose a significant risk to the abuser that could result in overdose and death [see Warnings and Precautions (5.1)]. Abuse may occur by applying the transdermal system in the absence of legitimate purpose, or by swallowing, snorting, or injecting buprenorphine extracted from the transdermal system. 9.3 Dependence Both tolerance and physical dependence can develop during chronic opioid therapy. Tolerance is the need for increasing doses of opioids to maintain a defined effect such as analgesia (in the absence of disease progression or other external factors). Tolerance may occur to both the desired and undesired effects of drugs, and may develop at different rates for different effects. Physical dependence results in withdrawal symptoms after abrupt discontinuation or a significant dose reduction of a drug. Withdrawal also may be precipitated through the administration of drugs with opioid antagonist activity, e.g., naloxone, nalmefene, or mixed agonist/antagonist analgesics (pentazocine, butorphanol, nalbuphine). Physical dependence may not occur to a clinically significant degree until after several days to weeks of continued opioid usage. BUTRANS should not be abruptly discontinued [see Dosage and Administration (2.3)]. If BUTRANS is abruptly discontinued in a physicallydependent patient, an abstinence syndrome may occur. Some or all of the following can characterize this syndrome: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis. Other signs and symptoms also may develop, including: irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate. Infants born to mothers physically dependent on opioids will also be physically dependent and may exhibit respiratory difficulties and withdrawal symptoms [see Use in Specific Populations (8.1)]. 10 OVERDOSAGE Clinical Presentation Acute overdosage with BUTRANS is manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, bradycardia, hypotension, partial or complete airway obstruction, atypical snoring and death. Marked mydriasis rather than miosis may be seen due to severe hypoxia in overdose situations. Treatment of Overdose In case of overdose, priorities are the re-establishment of a patent and protected airway and institution of assisted or controlled ventilation if needed. Employ other supportive measures (including oxygen, vasopressors) in the management of circulatory shock and pulmonary edema as indicated. Cardiac arrest or arrhythmias will require advanced life support techniques. Naloxone may not be effective in reversing any respiratory depression produced by buprenorphine. High doses of naloxone, 10-35 mg/70 kg, may be of limited value in the management of buprenorphine overdose. The onset of naloxone effect may be delayed by 30 minutes or more. Doxapram hydrochloride (a respiratory stimulant) has also been used. Remove BUTRANS immediately. Because the duration of reversal would be expected to be less than the duration of action of buprenorphine from BUTRANS, carefully monitor the patient until spontaneous respiration is reliably re-established. Even in the face of improvement, continued medical monitoring is required because of the possibility of extended effects as buprenorphine continues to be absorbed from the skin. After removal of BUTRANS, the mean buprenorphine concentrations decrease approximately 50% in 12 hours (range 10-24 hours) with an apparent terminal half-life of approximately 26 hours. Due to this long apparent terminal half-life, patients may require monitoring and treatment for at least 24 hours. In an individual physically dependent on opioids, administration of an opioid receptor antagonist may precipitate an acute withdrawal. The severity of the withdrawal produced will depend on the degree of physical dependence and the dose of the antagonist administered. If a decision is made to treat serious respiratory depression in the physically dependent patient with an opioid antagonist, administration of the antagonist should be begun with care and by titration with smaller than usual doses of the antagonist. 17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use). Addiction, Abuse, and Misuse Inform patients that the use of BUTRANS, even when taken as recommended, can result in addiction, abuse, and misuse, which could lead to overdose and death [see Warnings and Precautions (5.1)]. Instruct patients not to share BUTRANS with others and to take steps to protect BUTRANS from theft or misuse. Life-Threatening Respiratory Depression Inform patients of the risk of life-threatening respiratory depression, including information that the risk is greatest when starting BUTRANS or when the dose is increased, and that it can occur even at recommended doses [see Warnings and Precautions (5.2)]. Advise patients how to recognize respiratory depression and to seek medical attention if breathing difficulties develop. Accidental Exposure Inform patients that accidental exposure, especially in children, may result in respiratory depression or death [see Warnings and Precautions (5.2)]. Instruct patients to take steps to store BUTRANS securely and to dispose of unused BUTRANS by folding the patch in half and flushing it down the toilet. Neonatal Opioid Withdrawal Syndrome Inform female patients of reproductive potential that prolonged use of BUTRANS during pregnancy can result in neonatal opioid withdrawal syndrome, which may be lifethreatening if not recognized and treated [see Warnings and Precautions (5.3)]. Interaction with Alcohol and other CNS Depressants Inform patients that potentially serious additive effects may occur if BUTRANS is used with alcohol or other CNS depressants, and not to use such drugs unless supervised by a health care provider. Important Administration Instructions Instruct patients how to properly use BUTRANS, including the following: 1. To carefully follow instructions for the application, removal, and disposal of BUTRANS. Each week, apply BUTRANS to a different site based on the 8 described skin sites, with a minimum of 3 weeks between applications to a previously used site. 2. To apply BUTRANS to a hairless or nearly hairless skin site. If none are available, instruct patients to clip the hair at the site and not to shave the area. Instruct patients not to apply to irritated skin. If the application site must be cleaned, use clear water only. Soaps, alcohol, oils, lotions, or abrasive devices should not be used. Allow the skin to dry before applying BUTRANS. Hypotension Inform patients that BUTRANS may cause orthostatic hypotension and syncope. Instruct patients how to recognize symptoms of low blood pressure and how to reduce the risk of serious consequences should hypotension occur (e.g., sit or lie down, carefully rise from a sitting or lying position). Driving or Operating Heavy Machinery Inform patients that BUTRANS may impair the ability to perform potentially hazardous activities such as driving a car or operating heavy machinery. Advise patients not to perform such tasks until they know how they will react to the medication. Constipation Advise patients of the potential for severe constipation, including management instructions and when to seek medical attention. Anaphylaxis Inform patients that anaphylaxis has been reported with ingredients contained in BUTRANS. Advise patients how to recognize such a reaction and when to seek medical attention. Pregnancy Advise female patients that BUTRANS can cause fetal harm and to inform the prescriber if they are pregnant or plan to become pregnant. Disposal Instruct patients to refer to the Instructions for Use for proper disposal of BUTRANS. Patients can dispose of used or unused BUTRANS patches in the trash by sealing them in the Patch-Disposal Unit, following the instructions on the unit. Alternatively, instruct patients to dispose of used patches by folding the adhesive side of the patch to itself, then flushing the patch down the toilet immediately upon removal. Unused patches should be removed from their pouches, the protective liners removed, the patches folded so that the adhesive side of the patch adheres to itself, and immediately flushed down the toilet. Instruct patients to dispose of any patches remaining from a prescription as soon as they are no longer needed. Healthcare professionals can telephone Purdue Pharma’s Medical Services Department (1-888-726-7535) for information on this product. Distributed by: Purdue Pharma L.P., Stamford, CT 06901-3431 Manufactured by: LTS Lohmann Therapy Systems Corp., West Caldwell, NJ 07006 U.S. Patent Numbers 5681413; 5804215; 6264980; 6315854; 6344211; RE41408; RE41489; RE41571. © 2014, Purdue Pharma L.P. This brief summary is based on BUTRANS Prescribing Information 303385-0A, Revised 06/2014 (A) ES543186_ME011015_003_FP.pgs 12.12.2014 02:00 ADV 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 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] ana santiso 440-891-2684 / [email protected] national Account Manager 732-346-3032 / [email protected] 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 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 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 JeFFrey bendix, Ma Senior Editor chris Mazzolini, Ms Margie Jaxel Content Manager Director of Business Development, Healthcare technology Sales 732-346-3003 / [email protected] 440-891-2797 / [email protected] donna Marbury, Ms Content Specialist tod Mccloskey 440-891-2607 / [email protected] Account Manager, Display/Classified & Healthcare technology alison ritchie 440-891-2621 / [email protected] Content Associate Joanna shippoli Account Manager, recruitment Advertising 440-891-2615 / [email protected] 440-891-2601/[email protected] ken terry gail garFinkel weiss Contributing Editors don berMan Business Director, eMedia 212-951-6745 / [email protected] art robert Mcgarr Group Art Director Meg benson Special Projects Director 440-891-2628 / [email protected] 732-346-3039 / [email protected] Production karen lenzen gail kaye Director of Marketing & research Services 732-346-3042 / [email protected] Senior Production Manager audiEncE dEvEloPmEnt hannah curis Joy puzzo Corporate Director christine shappell Director Joe Martin Manager Sales Support renée schuster List Account Executive A. 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PAGE 38 With an estimated 264 new codes [for 2015], now is the time to prepare.” —Renee Dowling CODING 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 Pittsfeld, MA Michael D. Brown, CHBC EDITORIAL BOARD Health Care Economics Indianapolis, IN 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. Gosfeld and Associates Philadelphia, PA James Lewis Griffith Sr., JD Fox Rothschild Philadelphia, PA Lee J. Johnson, JD ask us Mount Kisco, NY Lawrence W. Vernaglia, JD, MPH Have a question for our advisers? Email your question to [email protected]. MedicalEconomics. com magenta cyan yellow black Foley & Lardner, LLP Boston, MA MEDICAL ECONOMICS ❚ JANUARY 10, 2015 ES544316_ME011015_005.pgs 12.16.2014 21:37 5 ADV Referenced in MedLine® Volume 92 Issue 01 JANUARY 10, 2015 IN DEPTH 24 PROACTIVE PAYER CONTRACT NEGOTIATION Why it’s important to analyze and efectively negotiate payer contracts to sustain revenue. 26 ELECTRONIC PRIOR AUTHORIZATIONS PAYMENT OUTLOOK FOR 2015 STARTS ON PAGE 18 COLUMNS PA G E 38 CODING I N S I G HTS Renee Dowling Preparing for 2015 coding changes PA G E 40 The promise of electronic prior authorizations, and whether they can help the process become more efcient for physicians. P R A C TI C A L M AT TE R S David Switzer, MD How to fne-tune the operations of your front desk, clinical area and admistrative ofce. 38 CODING FOR 2015 Preparing your practice for changes to evaluation and management codes this year. 40 THE IMPORTANCE OF STAFF MEETINGS Why in-person, efciently run staf meetings are key to practice success. 42 EMPLOYEE HANDBOOKS How an employee manual can help mitigate risks and save money. C O V E R STO R Y | M O N EY Your guide to solutions to help your practice thrive. starts on page 18 Bolster your revenue with: 43 THE DEFENSIVE MEDICINE DILEMMA How physicians can navigate the decisions of when and when not to recommend tests and procedures. Chronic care management ❚ Telemedicine ❚ Quality metrics ❚ 53 REFERRAL PROCESS NEEDS OVERHAUL Primary care physicians make millions of referrals to specialists each year, yet there is little protocol to follow. 6 EDITORIAL BOARD FROM THE TRENCHES ME ONLINE VITALS ADVERTISER INDEX THE LAST WORD Primary care physicians make millions of referrals to specialists each year, yet there is little protocol to follow. M I S S I O N STATE M E NT Medical Economics is the leading business resource for ofce-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 fnance. Medical Economics provides the nonclinical education doctors didn’t get in medical school. MEDICAL ECONOMICS (USPS 337-480) (Print ISSN: 0025-7206, Digital ISSN: 2150-7155) is published semimonthly (24 times a year) by Advanstar Communications Inc., 131 W. 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MEDICAL ECONOMICS ❚ JANUARY 10, 2015 magenta cyan yellow black 5 8 10 16 52 53 Cover: Getty Images/iStock/Getty Image Plus/pxhidalgo (binoculars); Getty Images/E+/malerapaso (currency); Getty Images/E+/blackred (currency) The importance of efficient meetings 33 TIPS TO STREAMLINE YOUR PRACTICE MedicalEconomics. com ES544408_ME011015_006.pgs 12.16.2014 22:30 ADV Advertisement not available for this issue Advertisement notdigital available for this issue of the edition of the digital edition www.medicaleconomics.com/resourcecenterindex MedicalEconomics.com Facebook Twitter www.MedicalEconomics.com/HIMSS2012 www.MedicalEconomics.com/ACA MedicalEconomics.com Facebook Twitter See medicaleconomics.modernmedicine.com/himss2012 resource centers related to our Business of Health series You’ve gotYquestions about the Affordable ou've got technology questions. Care Act. as well as topics such as Patient-Centered Medical Homes, accountable We’ve got answers. answers. We've got care organizations, and our EHR Best Practices Study at the above link. from the Trenches I have never heard that any other software needs continuous certifcations and of users paying a penalty for not using such software. Do any other small private businesses excluding medical practices pay a penalty for not using software? If current practices remain in effect, it will certainly ruin small practices. Smiljka Stojanovic, MD, Americus, GeorGiA ehR RequiRementS will Ruin Small pRacticeS Editor’s note: Te following is excerpted from a letter the writer sent to the Centers for Medicare and Medicaid Services and is reprinted with the permission of the writer. I work in private solo practice as an internist in an underserved area. Five other internists left this area recently, and currently I am the only internist here. EMR [electronic medical record] software slows down my work. Tis is bad for patients and for my practice. Perhaps it can be useful for statistical purposes that you need for practice evaluation. I have asked many other physicians about EMR software and none of them recommend using any software available at this time. On the other hand, if you consider EMR to improve medical practice, why do you penalize [physicians] for not using it? Maybe it is just your excuse to cut reimbursement. Each health professional would like to be maximally efcient, but available EMR software does not serve that purpose. It is clear that all health professionals are forced to use EMR, but you should reconsider having some exception with small practices in underserved area, where investment in EMR is not cost- efective. For example, all private businesses with less than 50 employees are not required to ofer health insurance, but every medical practice is required 8 Medical econoMics ❚ January 10, 2015 magenta cyan yellow black to show meaningful use of EMR or will be penalized. My husband is a software developer and can make highly efcient EMR for my practice. Tis is not cost-efective either, since EMR needs to be certifed. I have never heard that any other software needs continuous certifcations and of users paying a penalty for not using such software. Does any bank or insurance company pay a penalty for not using software? Do any other small private businesses excluding medical practices pay a penalty for not using software? If current law remains in efect, it will certainly ruin small practices. I hope you will seriously reconsider the possibility of hardship exceptions for small practices. Smiljka Stojanovic, MD Americus, GeorGiA Some Still chooSe family medicine I just read the article on physician families in the November 25 issue of Medical Economics. (“When medicine runs in the family,” November 25, 2014.”) I am a family physician in a small community in Northern Wisconsin and have practiced here for the past 40-plus years. I did everything from delivering babies, newborn care to nursing home care. MedicalEconomics. com ES544412_ME011015_008.pgs 12.16.2014 22:37 ADV from the Trenches Doctors have conditioned themselves to practice defensive medicine for at least the past two decades and the result is that for many of them defensive medicine has become so habitual that many consider it good medicine. Unfortunately, this bad habit will take a long time to break regardless of the...malpractice reforms put into place. Edward Volpintesta, MD, BeTHeL, coNNecTicuT Our two children, a son and daughter, saw the lifestyle and the time commitment needed, both as a member of a clinic group and as a solo practitioner. Tey spent time in the offce, came to the emergency department, and came on rounds with me. Our son was committed to medicine from grade school on and went on to medical school, residency in family medicine and is in practice in Washington state. Our daughter started college with plans to teach high school math. At the end of her freshman year she announced that she was changing her major to chemistry and biology and was going to medical school. She spent a year in graduate school in pharmacology and then on to medical school and a residency in family medicine. She now is in family medicine in Duluth, Minnesota. Both love working with their patients but are frustrated with the regulation and the workings of the large healthcare systems. My wife and I put no pressure on them to go into medicine, or family practice. Tey obviously liked what they saw and made their own choices. William E. Raduege, MD, ABFM WooDruFF, WiscoNsiN malpRactice Study’S ReSultS aRe flawed I disagree with the conclusions reached in MedicalEconomics. com magenta cyan yellow black “Study: Weak Link Between Malpractice Fears And Defensive Medicine” (Medical Economics, November 25, 2014.) Tey are misleading because the study did not take into account that doctors have conditioned themselves to practice defensive medicine for at least the past two decades and the result is that for many of them defensive medicine has become so habitual that many consider it good medicine. Unfortunately, this bad habit will take a long time to break regardless of the type and number of malpractice reforms put into place. Moreover, the time span of the study (1997-2011) is much too short to draw any valid conclusions from it. And it did not mention whether the magnetic resonance imaging and computerized tomography scans that were not done in the emergency department were performed later as outpatients by their primary care doctors or whether the intensity (and cost) of the visits were lessened because the patients were referred to specialists or to their primary care physicians to complete their evaluations. Much more study needs to be done before it can be said that malpractice reform has not been as efective as expected. Clearly, malpractice continues to be the “X Factor” that drives the cost of health care. 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. Edward Volpintesta, MD BeTHeL, coNNecTicuT Medical econoMics ❚ January 10, 2015 ES544321_ME011015_009.pgs 12.16.2014 21:39 9 ADV online MedicaleconoMics.coM Smarter BuSineSS. Better Patient Care. exCluSive online Content and newS. o n li n e exc lu s ive online PHYSiCiAn rAting SiteS gAin in imPortAnCe About 60% of patients say online physician reviews are “very” or “somewhat” important factors in their choice of a primary care physician, according to a survey published recently in the Journal of the American Medical Association. In another survey, from practice management consultants Software Advice, 44% of respondents were willing to go out of network to see a doctor who had gotten positive reviews online. See more details at bit.ly/1vcwh7I Twitter Talk Follow us on Twitter to receive the latest news and participate in the discussion. challenges for 2015 View our list of the top 15 challenges facing physicians in 2015 ow.ly/FUAzf medicaid #Medicaid is growing, but patients are having problems finding doctors to treat them ow.ly/FUyBt practice management Top Headlines Now @MEonline is another icd-10 delay in the offing? Me app. download free today. Get access to all the benefts Medical Economics ofers at your fngertips. The Medical Economics app for iPad and iPhone is now available for free in the iTunes store. MedicalEconomics.com/app immunization resource center Stay up-to-date on the latest developments in immunization and vaccination therapies at MedicalEconomics.com/immunization magenta cyan yellow black #CMS proposes more two-sided risk #ACO models ow.ly/FUAXp stroke risk #2 aco risk sharing could be delayed employment offers A proposed government rule would give some accountable care organizations more time before having to share in downside financial risk. See details at bit.ly/1qT0dpb #3 medical societies slam congress over sgr inaction AAFP, ACP, AOA want formula repealed. More at bit.ly/1IXiLKN Risk of #stroke doubles for every successive decade over the age of 55 years. ow.ly/FJjt1 6 ways physicians should evaluate employment offers ow.ly/FJcYw affordable care act Obama administration faces scrutiny over #ACA transparency ow.ly/FJcvz billing and coding New modifiers physicians need to know for 2015 ow.ly/FBKtC join us online facebook.com/MedicalEconomics Medical Economics is part of the ModernMedicine Network, a Web-based portal for health professionals ofering best-in-class content and tools in a rewarding and easy-to-use environment for knowledge-sharing among members of our community. Medical econoMics ❚ January 10, 2015 accountable care organizations Medical societies want Congress to postpone the October 1 start date. Find out more at bit.ly/1Aec01k pa r t o f th e 10 More practices will offer digital selfscheduling in the next five years ow.ly/FJeCY twitter.com/MedEconomics MedicalEconomics. com ES544184_ME011015_010.pgs 12.16.2014 19:23 ADV Advertisement not available for this issue Advertisement notdigital available for this issue of the edition of the digital edition www.medicaleconomics.com/resourcecenterindex MedicalEconomics.com Facebook Twitter www.MedicalEconomics.com/HIMSS2012 www.MedicalEconomics.com/ACA MedicalEconomics.com Facebook Twitter See medicaleconomics.modernmedicine.com/himss2012 resource centers related to our Business of Health series You’ve gotYquestions about the Affordable ou've got technology questions. Care Act. as well as topics such as Patient-Centered Medical Homes, accountable We’ve got answers. answers. We've got care organizations, and our EHR Best Practices Study at the above link. theVitals ICD-10 supporters rally to prevent another Delay The American Health Information Management Association (AHIMA) rallied supporters to tweet members of Congress asking them not to delay ICD-10 implementation any further. Using the hashtag #ICD10Matters, more than 5,000 tweets were sent. AHIMA launched the campaign after the American Medical Association (AMA) and other regional medical societies started a letter writing campaign to Congress asking legislators to include a fourth ICD-10 delay in the current lame-duck session legislation. Though there has yet to be ICD-10 delay language in any legislation, AMA could lobby for a delay as part of any legislation next year concerning Medicare sustainable growth rate legislation. Supporters who want to keep the ICD-10 implementation date at October 2015 noted how the current ICD-9 coding system does meet the needs of today’s healthcare system and the costs that another delay would bring. 16 Government report StateS Lack payer competition In at least 37 states, the three largest insures account for 80% of total health plan enrollment, according to a new study by the U.S. Government Accountability Offce (GAO). as payers leverage rates down. GAO analyzed enrollment data from 2010 to 2013 that was reported to the National Association of Insurance Commissioners (NAIC) and the Centers for Medicare and Medicaid Services (CMS). Te agency provided the report to the U.S. Health and Human Services Department (HHS), but didn’t make any recommendations or comments. In ten states, a single insurer had more than half of all enrollees, and in fve states, one insurer had at least 90% of either the individual, small group or large group enrollee segment, according to the report. A highly concentrated market, where a small number of insurers enroll a signifcant portion of the population, can impact physician’s reimbursement Payer comPetition states with least payer competition NH WA OR MT ID NV CA ND WY UT AZ VT MN WI SD IA NE CO IL KS OK NM AR NY MI IN OH KY MO MS AL GA HI Source: Government Accountability Ofce RI VA NC DE SC NJ MD DC FL AK MA CT WV TN ME PA LA TX Medical econoMics ❚ January 10, 2015 magenta cyan yellow black Examining the News Affecting the Business of Medicine Alabama Vermont Rhode Island North Dakota states with greatest payer competition California New York Michigan Pennsylvania Wisconsin MedicalEconomics. com ES544080_ME011015_016.pgs 12.16.2014 04:17 ADV theVitals American elderly still lag in many healthcare metrics Despite the universal healthcare coverage Medicare provides, America’s elderly still lag on many—but by no means all—measures of health and care access compared with other industrialized nations, a new survey fnds. Te authors of the 2014 Commonwealth Fund International Health Policy Survey of Older Adults note that while Medicare ofers better coverage than most other health insurance in the United States, “it is still clearly less protective than the universal coverage ofered in the health systems of Te authors note that none of the 11 nations surveyed— Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States—are able to ofer their older adults accessible, coordinated, and patient-centered care on a consistent basis. Nevertheless, the fact that elderly U.S. residents are sicker than the elderly in comparable nations “will pose critical challenges for U.S. policymakers in years to come,” the authors write. other countries surveyed.” Its shortcomings most likely refect “limitations in Medicare coverage, including substantial deductibles and copayments, especially for pharmaceuticals.” Lack of limitations on catastrophic expenses and long-term care coverage also contribute. America had the lowest percentage of respondents reporting that a healthcare professional had not reviewed their prescription medications in the past year (14%) or experienced gaps in their hospital discharge planning in the previous two years (28%.) AmericAn heAlthcAre the good ❚ Wait times of four weeks or less to see a specialist (86% of respondents). ❚ Having a treatment plan for their condition that they could carry out in their daily life (83%). ❚ Having a healthcare professional whom they could easily contact with questions or for advice (84%). ❚ Having a discussion with someone regarding healthcare treatment they want if they become very ill and can’t make decisions for themselves (78%). MedicalEconomics. com magenta cyan yellow black the bad ❚ American seniors are the most likely (87%) to have a chronic condition. ❚ The most likely (19%) to have costrelated problems in obtaining medical care. ❚ The most likely (23%) to report that their medical records and/or test results were not available at a scheduled appointment or that tests were duplicated. ❚ The most likely, along with Canadians (39%) to have obtained care in an emergency department during the past two years. Study: diabeteS patientS aren’t learning Self care New diabetes patients aren’t participating in education and training programs that can help them control the chronic condition, according to the Centers for Disease Control and Prevention. Fewer than 7% of newly diagnosed diabetes patients take part in diabetes self-management and education training (DSMT) that teaches them how to monitor diet, exercise and glucose levels, according to data from the Marketscan database, which collects private insurance claim information. Analysis of Medicare patients’ claims found that only 4% of those newly diagnosed with diabetes participate in DSMT programs. The study, which looked at data from more than 95,000 patients, found that almost 26% of newly-diagnosed diabetes patients are not prescribed medications, so lifestyle monitoring is even more important to deter any further complications. The Academy of Nutrition and Dietetics suggests using both DSMT and medical nutrition therapy to complement diabetes care, as they provide diferent techniques to patients. Medical econoMics ❚ January 10, 2015 ES544081_ME011015_017.pgs 12.16.2014 04:17 17 ADV PAYER NEGOTIATIONS IN DEPTH How to get the most leverage you can [24] Cover Story PAYMENT OUTLOOK FOR 2015 Your guide to solutions to help your practice thrive by J E FFR EY B E N D IX, MA Senior Editor and E LAI N E POFE LDT Contributing author HIGHLIGHTS 01 Current Procedural Terminology code 99490 allows practices to bill for time spent developing a plan for, and managing the care of, patients with two or more chronic, potentially lifethreatening conditions. 18 WHAT CHANGES will 2015 bring for your practice’s reimbursements? Like so much else in business and medicine, the answer is, it depends. If, for example, your practice includes many patients with multiple chronic diseases, or has remote treatment capabilities, you have the opportunity to boost your revenues. On the other hand, if you’re not participating in the government’s Physician Quality Reporting System (PQRS) or meaningful use program, 2015 will be the year you start feeling fnancial fallout from that decision. Medical econoMics ❚ January 10, 2015 magenta cyan yellow black And regardless of what else you do or don’t do in your practice, you could be facing a 21% cut in your Medicare reimbursements, unless Congress acts to fx the sustainable growth rate (SGR) formula. In this article, Medical Economics explores some of the major payment changes and potential hurdles that physicians face in 2015, in order to help readers better understand the opportunities and challenges they will confront in the next year, and beyond. 1/ Chronic care management Apart from the ever-present possibility of an Getty Images/iStock/Getty Image Plus/pxhidalgo (binoculars); Getty Images/E+/malerapaso (currency); Getty Images/E+/blackred (currency) Despite the reimbursement challenges primary care physicians will continue to face in 2015, new initiatives will provide primary care physicians with opportunities to grow and better manage patient health. MedicalEconomics. com ES544476_ME011015_018.pgs 12.17.2014 00:27 ADV 2015 payment outlook SGR-related cut, probably the biggest story of 2015 is the inclusion of a code for chronic care management (CCM) in the 2015 Medicare Physician Fee Schedule. Current Procedural Terminology (CPT) code 99490 allows practices to bill for time spent developing a plan for, and managing the care of, patients with two or more chronic, potentially life-threatening conditions. Te decision to begin paying for CCM services is part of the government’s longterm strategy to encourage a greater focus on quality of care and patient outcomes, rather than the volume of services provided, says Raemarie Jimenez, CPC, CPB, vice president for member and certifcation development with the American Academy of Professional Coders. “From the provider’s perspective, it takes a lot of work to be proactive and get their patients the diferent kinds of care they need to stay healthy. Tis [code] gives them a reportable way to do that,” says Jimenez. CPT code 99490 pays $42.60 for 20 minutes of staf time, and can be billed once per month per patient. Its use, however, comes with numerous scope-of-service and billing requirements, some of which may require changes in practices’ workfow. (See “Getting paid for chronic care” in the December 25, 2014 issue of Medical Economics for a complete description of the CCM code.) 2/ Telemedicine opportunities Another opportunity to grow revenue may come from the addition of new codes for telehealth services in the 2015 fee schedule. Medicare began paying for some telehealth services for eligible benefciaries living in rural health shortage areas or outside Metropolitan Statistical Areas in 2000, and has been expanding the range of covered services since then. Te newest services include: ❚ Psychoanalysis (CPT codes 90485, 90846 and 90847), ❚ Prolonged evaluation and management services requiring direct patient contact (CPT codes 99354), and ❚ Annual wellness visit (HCPCS codes G0438 and GO439) 3/ Misvalued codes Te Afordable Care Act mandates that the Centers for Medicare and Medicaid Services MedicalEconomics. com magenta cyan yellow black Codes you may have overlooked Primary care physicians (PCPs) often are unaware of services they commonly provide for which they can bill separately. Below is a list of new or frequently-overlooked codes for use by PCPs: CPT 99490 chronic care management: New for 2015 in the Medicare physician fee schedule, this code is for time spent developing a plan of care and managing care for patients with two or more chronic, life-threatening diseases. The code pays $42.60 for 20 minutes of time and can be billed once per month per patient. CPT 99091 collection and interpretation of physiologic data: Digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualifed health care professional, qualifed by education, training, licensure/ regulation (when applicable), requiring a minimum of 30 minutes of time. The code pays $56.92. CPT 90845 Psychotherapy CPT 90846 Family psychotherapy without the patient present CPT 90847 Family psychotherapy, conjoint psychotherapy with the patient present G0439 subsequent AWV: This code is used in years following submission of the G0438 code, even if the patient has a new doctor. (Note: Medicare pays for only one initial AWV per benefciary lifetime. All subsequent wellness visits must be billed using code G0439.) CPT 99495 Transition Care Management: Billing requirements include a face-to-face visit with patient within 14 days of discharge from an inpatient facility, medical decision-making of at least moderate complexity, and communication (phone call, email exchange, or face-to-face) with patient or caregiver within two business days of discharge. CPT 99496 Transition Care Management: Billing requirements include a face-to-face visit within seven days of discharge from an inpatient facility, medical decisionmaking of high complexity, and communication with patient or caregiver within two days of discharge. CPT 99354 prolonged service in the ofce or other outpatient setting requiring direct patient contact beyond the usual service; frst hour (List separately in addition to code for ofce or other outpatient EM service) CPT 99355 prolonged service in the ofce or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (List separately in addition to code for ofce or other outpatient EM service) G0402 Initial preventive physical examination (IPPE): Also known as the “welcome to Medicare” visit code, it is for use only when the services are provided during the frst 12 months the patient is enrolled in Medicare Part B. The deductible and coinsurance are waived. G0438 annual wellness visit (AWV): For use after the benefciary’s frst 12 months of Medicare Part B coverage and if the benefciary has not already received an AWV or IPPE during the previous 12 months. CPT 99497 End-of-life directives: First 30 minutes of explaining and discussing advance directives with the patient, a family member, or designated surrogate. CPT 99498 End-of-life directives: Subsequent 30 minutes of explaining and discussing advance directives with the patient, a family member, or designated surrogate. Medical econoMics ❚ January 10, 2015 ES544475_ME011015_019.pgs 12.17.2014 00:27 19 ADV 2015 payment outlook PQRS nancial incentives are turning into penalties,” Medical Economics, September 25, 2014.) While it’s too late to avoid penalties for this year and next, practices can avoid having their 2017 Medicare reimbursements docked by participating in PQRS in 2015. CMS has changed some of the participation and reporting rules, however. For example, it has eliminated 50 of the measures practices can report on, but added 20 new ones and two measures groups. In addition, avoiding 2017 fnancial penalties requires: Beginning this year, practices that had not reported PQRS data in 2013 will be docked in their Medicare reimbursements. 1%** .5%* .5% 2013 2014 2015 2016 * if no MOC ** if MOC † if no successful reporting for 2013 1.5%† 2% Source: American Academy of Family Physicians (CMS) periodically identify, review, and adjust values for potentially misvalued codes. Te latest review produced code decisions in fve areas, including: ❚ ❚ ❚ ❚ ❚ hip and knee replacements, radiation therapy and gastroenterology, radiation therapy, epidural pain injections, and flm to digital substitution. In the latter, which is probably of greatest interest to primary care providers, CMS updated the practice expense inputs for X-ray services to refect the fact that X-rays now are performed digitally, rather than with analog flm. 4/ PQRS Te PQRS program paid bonuses to medical practices in 2013 and 2014 for reporting quality data. Starting this year, however, that carrot becomes a stick, in the form of a 1.5% penalty for practices that did not report 2013 data. Te penalty rises to 2% in 2016. (For more detailed information, see “Time’s up! Fi- 20 Medical econoMics ❚ January 10, 2015 magenta cyan yellow black ❚ eligible professionals (EPs) and group practices that use claims or registries to report, and who see at least one Medicare patient in a faceto-face encounter to report on at least one measure from a newly cross-cutting measures set, in addition to any other measures that the EP is required to report, ❚ all group practices of 25 or more EPs using the Group Practice Reporting Option (GPRO) web interface to report measures on a benefciary sample of 248 patients, and ❚ group practices of 100 or more EPs that are registered for the GPRO to report on the Consumer Assessment of Healthcare Provider and Systems Survey for PQRS, regardless of the reporting mechanism the practice uses. 5/ Medicaid Although not part of the Medicare physician fee schedule, developments in the Medicaid program will afect reimbursements for many physicians in 2015. Te legislation that raised Medicaid reimbursements to Medicare levels for two years was set to expire at the end of 2014. Absent any last-minute Congressional action to extend it, Medicaid reimbursements will return to their 2012 levels—which in most states are well below those paid by Medicare and commercial insurers. On the other hand, the number of states expanding Medicaid eligibility—a provision of the Afordable Care Act rendered optional in a 2012 U.S. Supreme Court decision—has been slowly growing. By the end of 2014 27 states and Washington, D.C., had done so, and several more states were either considering doing so or exploring other ways of expanding healthcare coverage to their residents. Consequently, doctors in these states may start receiving at least some reimbursement for care they had been providing for free. MedicalEconomics. com ES544472_ME011015_020.pgs 12.17.2014 00:27 ADV 2015 payment outlook 6/ Medicare Shared Savings Program changes One of the most important developments to watch in 2015 is the fact that there are now both hospital- and physician-owned Accountable Care Organizations (ACOs) in the third year of the Medicare Shared Savings Program, says Brian Croegaert, chief executive officer of Sage Technologies in Rockford, Illinois, a consulting frm which provides managed services involved with Afordable Care Act implementation to clients including large integrated health systems, ACOs, and independent practice associations. Tis program aims to encourage coordination among providers to improve the quality of care for Medicare fee-for-service benefciaries and reduce unneeded costs. Medicare shares the savings with the ACOs as an incentive and allows the ACOs the chance to receive a bigger payment provided they are willing to take on a greater risk if their performance is not up to snuf. CMS reported in November that the current participants found $417 million in savings. Tese early participants in the program received $460 million in sharedsavings payments. “At the end of the third year under status, they will be required to decide whether or not they want to move forward into `full risk’ or risk sharing,” Croegaert says. Te physician fee schedule makes changes to ACO reporting requirements in 2015, allowing ACOs to earn bonus points by demonstrating year-to-year improvements in quality. CMS’s changes to the shared savings program for 2015 in order to “refect up-to-date clinical guidelines and practice, reduce duplicative measures, increase focus on claims-based outcomes measures, and reduce ACO reporting burden,” reads an American Academy of Family Physicians summary of the fnal fee schedule. Te earlier proposed fee schedule would have changed the quality measures ACOs report by adding new measures and removing some existing ones. Tat proposal was scrapped in the fnal fee schedule released in late October, and the reportable quality measures will remain at 33. However, CMS has increased the number of quality measures calculated through fled claims and lowered the number of metrics that ACOs must report through CMS’ web inter- MedicalEconomics. com magenta cyan yellow black Chronic care management services BILLING REQUIREMENTS Te billing requirements for CPT code 99490 include: Informing the benefciary about the availability of the CCM services from the practitioner, including the benefciary’s authorization for the electronic communication of the patient’s medical information with other treating providers as part of care coordination, providing the benefciary a written or electronic copy of the care plan and documenting in the electronic health record that the care plan was provided to the benefciary, informing the benefciary of the right to stop the CCM services at any time (effective at the end of a calendar month) and the effect of a revocation of the agreement to receive CCM services, and documenting in the benefciary’s medical record that all elements of the CCM service were explained and offered to the benefciary, and noting the benefciary’s decision to accept or decline the service, informing the benefciary that only one practitioner can furnish and be paid for these services during the calendar month service period. Source: CMS face. New measures that will be evaluated based on claims include: ❚ avoidable hospital readmissions for patients with multiple chronic conditions, heart failure and diabetes, ❚ depression remission, ❚ readmissions to skilled nursing facilities, ❚ documentation of current medication at every visit, and ❚ stewardship of patient resources through the care team’s discussions of prescription medicine costs with patients. Medical econoMics ❚ January 10, 2015 ES544474_ME011015_021.pgs 12.17.2014 00:27 21 ADV 2015 payment outlook Telemedicine and private payers: A state overview While Medicare has been making it easier for physicians to get paid for telemedicine services, what about private payers? The map below shows which states have legislation that mandates some private payer coverage of telemedicine. NH WA MT OR ID WY NV CA UT AZ VT ND MA WI SD IA NE CO ME MN IL KS MI IN RI PA CT VA NC DE WV TN AR MS AL TX OH KY MO OK NM NY NJ MD SC GA DC LA FL AK HI Some private reimbursement Proposal pending No private reimbursement Source: American Telemedicine Association, as of November 21, 2014 7/ Private payer trends As changes sweep government insurance programs, the shift from fee-for-service to value-based care is shaking up the commercial insurance landscape as well. Commercial payers have been paying close attention to the Medicare Shared Savings Program. “More and more physicians will see insurance companies coming to them with contracts that will ask them to join a formal accountable care organization or they will receive a contract from their insurance company saying you can enhance your earning power by doing these quality things for us,” Croegaert says. “I see a lot of those contracts.” For many smaller practices, negotiating with private insurers is likely to remain a challenge. Pamela Carrington-Tribble, DO, a private practitioner in Half Moon Bay, California, says that scanning through her existing contracts with private payers shows “how much they don’t value my services. Tey are paying me less than it costs me to 22 Medical econoMics ❚ January 10, 2015 magenta cyan yellow black buy a vaccine for a patient,” she says. Like many independent physicians, Carrington-Tribble is trying to remain in private practice. “If at some point it gets to the point I can’t pay my staf, I’ll have to totally think about changing things,” she says. “Somehow, I’m staying afoat.” 7/ SGR showdown coming A year ago, it had become conventional wisdom among healthcare analysts and legislators that Congress would repeal the SGR formula, thereby removing the ever-present threat of drastic reductions—currently 21.6%—in physicians’ Medicare reimbursements. And while bipartisan legislation repealing SGR passed in both houses of Congress a year ago, the legislation foundered at the last minute over the issue of how to pay for SGR repeal. In its place, Congress passed—for the 17th consecutive time—a one-year “patch” that raised Medicare reimbursements by .5%, and left the question of a permanent fx unresolved. At the close of 2014 the fate of SGR repeal remained uncertain. Many observers believe Congress will try to arrive at a long-term solution again this year. “Te bipartisan, bicameral doc fx that was introduced in early 2014 will likely form the starting point for what they work up in 2015,” predicts Scott Gottlieb, MD, a member of the U.S. Department of Health and Human Services’ health information technology advisory committee and a resident fellow at the American Enterprise Institute. Repeal eforts may have gotten a boost from the Congressional Budget Office, which recently lowered its estimate of the cost of SGR repeal through 2024 to $119 billion, or $5 billion less than its previous estimate. Nevertheless, as last year’s experience showed, predictions of SGR’s demise are usually premature. Stay tuned. MORE ONLINE Code with confdence http://bit.ly/1AetqLl The role of staff in meeting quality metrics http://bitly.com/1uKNwLN MedicalEconomics. com ES544473_ME011015_022.pgs 12.17.2014 00:27 ADV Call for SubmiSSionS 2015 AnnuAl PhysiciAn Writing contest t hi S y e a r ’S t op ic: “Connecting Care” We are seeking your real-life stories that can move, teach, and inspire other physicians. Your StorY Could Win $5,000… Maybe in providing care you connected with a patient in a unique and meaningful way. Maybe you actively engaged a patient in their own care and/or successfully involved their family. Maybe you efectively coordinated care across settings or collaborated as a care team with powerful results. Share your story of how you or others on your care team provided a more connected care experience for your patients. First Prize $5,000 gift card second Prize $2,500 gift card third Prize $1,000 gift card Winning entries will also be published in the March 25th, 2015 issue of Medical Economics and featured on the Modern Medicine Network. Here are some suggested story ideas to get the creative juices fowing (but don’t let these limit your thinking). Consider a time when you: Connected with a patient as a provider in a unique and meaningful way Incorporated successful health team strategies for providing seamlessly coordinated care Efectively integrated your patient portal Used communication methods or skills Leveraged technology for a more connected care experience Involved a family in patient care How to Enter Send us your story in 800 to 1,200 words Submissions must include name, contact email, address, and telephone number Submissions can be sent to MedEc@ Advanstar.com or by mail to: Medical Economics Writing Contest 24950 Country Club Blvd. North Olmsted, OH 44070 Deadline for Submissions All entries must be received by January 31st, 2015 for consideration. S u ppo rte d by Medical Economics Writing Contest Ofcial Rules (NO PURCHASE IS NECESSARY TO ENTER OR WIN) The Medical Economics Writing Contest (the “Contest”) starts on December 18, 2014 at 12:00 a.m. Eastern Time (“ET”) and ends on January 31, 2015 at 11:59 p.m. ET (“Contest Period”). ELIGIBILITY: The Contest is open to licensed physicians who are legal residents of the ffty (50) United States or the District of Columbia, of legal age of majority in their jurisdictions of residence (and at least 18). Employees, temporary workers, freelancers and independent contractors, and their immediate families (spouse and parents, children, siblings and their respective spouses, regardless of where they reside) and those persons living in their same households, whether or not related, of Medical Economics (“Sponsor”) and athenahealth (“Supporter”) and their respective parents, afliates, subsidiaries, participating vendors, promotion or advertising agencies are ineligible to enter or win the Contest. By participating, entrants agree to be bound by these Ofcial Rules and the decisions of the judges and/or Sponsor, which are binding and fnal on matters relating to this Contest. Void where prohibited by law. Contest is subject to all applicable federal, state and local laws. HOW TO ENTER: During the Contest Period, write an 800 to 1,200 word essay that shares your successful strategies, approaches, and/or experiences to providing a more connected health care experience for patients and/or actively involving patients in their own care and send to [email protected] or Medical Economics Writing Contest, 24950 Country Club Blvd., North Olmsted, OH 44070, along with your full name, contact email address, mailing address and telephone number (collectively, an “Entry”). All Entries must be received on or before January 31, 2015. Limit one (1) Entry per person. Entries received in excess of the stated limitation will be void. If handwritten, Entries must be legible. All Entries become the sole property of the Sponsor and will not be returned. Entry must (i) be your own original work, (ii) be in English, (iii) cannot be previously published or submitted in connection with any other contest, (iv) be in keeping with the Sponsor’s and Supporter’s image and (v) not be ofensive or inappropriate, as determined by the Sponsor in its sole discretion, nor can it defame or invade publicity rights or privacy of any person, living or deceased, or otherwise infringe upon any person’s personal or property rights or any other third party rights (including, without limitation, copyright). Without limiting the foregoing, Entries must not contain any confdential or personally-identifying patient information. Sponsor reserves the right to disqualify any Entry that it determines, in its sole discretion, does not comply with the above requirements or that is otherwise not in compliance with these Ofcial Rules. JUDGING: All eligible Entries received by the Sponsor will be judged by a panel of qualifed judges based equally on the following criteria: practicality of solutions ofered, clarity and quality of writing, and level of detail to enable other physicians to apply your solution to their practices. The three (3) Entries with the highest scores, as determined by the Sponsor in its sole discretion, will be deemed the frst, second, and third place potential winners. In the event of a tie, an additional, “tie-breaking” judge will determine the winner(s) based on the criteria listed herein. Sponsor reserves the right not to award all prizes if, in its sole discretion, it does not receive a sufcient number of eligible and qualifed Entries. Prize awards are subject to verifcation of eligibility and compliance with these Ofcial Rules. Judges’ and Sponsor’s decisions are fnal and binding on all matters relating to this Contest. 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Sponsor reserves the right in its sole discretion to cancel or suspend any portion of the Contest for any reason. REQUEST FOR WINNERS LIST: For the names of the Winners (available after March 2015), send a self-addressed, stamped, envelope to: Attn: David A. DePinho, Advanstar Communications, 24950 Country Club Blvd., North Olmsted, OH 44070. ES544520_ME011015_023.pgs 12.17.2014 02:20 ADV F i nan c ial advi c e F r o m th e e x p e rts Financial Strategies StrategieS for proactive payer contract negotiationS by Raj u Ku R u nthottical, Do Contributing author In order to sustain viable revenue, it is prudent to analyze and effectively negotiate healthcare payer contracts. Cost analysis should be performed in an organized way to establish dollar value on tangible and intangible items. You need to have a clear understanding of business principles, current market trends, and the cost of delivering quality healthcare. HealtHcare contracts are legal documents and need to be reviewed carefully. Many physicians sign payer contracts without negotiating. Often the payer will say, “This is what we are paying in your market. Take it or leave it.” We must understand that the terms in the contract are not immutable. We have to create and demonstrate value in terms of data, quality of care and costefective, long-term goals that beneft the team as a whole. Even if the practice is run efciently, with low overhead, if the payer contracts are not properly negotiated or worded, it can result in a loss in net revenue. There is a beneft in 24 numbers, the larger the organization, the greater the leverage. The organization can do SWOT analysis, which is assessment of strength, weakness, opportunities and threats to the practice. For example, internal strengths can be analyzed by reviewing: the number of new patients enrolled in the plan, utilization of revenue and expenses with quality measurements, patient satisfaction reports, benchmarking quality and efciency, providing service that is unique and new in the current market and networking with peers at state and national levels. In looking at weaknesses, we need to analyze the fee schedule, which is a percentage of the current Medicare fee. Medical econoMics ❚ January 10, 2015 magenta cyan yellow black To help reveal the rates and overcome payment inequities, we can create a utilization report to capture and review data. Using a spreadsheet, determine the frequency of a current procedural terminology code and the number of times it was billed to that payer. Multiply that by the current payment amount. Determine the break even point. This is done by adding overhead and physician compensation by total frequency of all codes for that payer. The results are weighted average cost. Compare the weighted average cost to weighted average reimbursement. Threats are when contract start and end dates are not monitored. We need to know how much notice is required to make any changes. It may be advisable to start discussions with the payer representative 150 days before the contract term ends. It helps tremendously when the communication is channeled through one individual from the health plan with whom a business relationship has been built. In preparation for negotiations, we need to set a bargaining range that includes optimum and minimal target goals. The optimum goal is where the terms are ideal. The minimum goal is the point which absolutely has to be met. The target is the point where you would like to be at the end of negotiation. It would be advisable to meet face-to-face with the payer representative and present clear data and requests for change, and to listen to what the representative has to say. The person who has the most experience with complex negotiations should do this. It would also help to know the issues of concern to the payer. For example, if the payer’s concern is with high use of ancillary services, it would help to point out how efectively MedicalEconomics. com ES544385_ME011015_024.pgs 12.16.2014 22:00 ADV F i nan c ial advi c e F r o m th e e x p e rts Severing a payer contract you manage the use of these services. You can show cost control and forecast the predictable costs. Share practice data that shows compliance and improved outcomes. Demonstrate the efciencies that reduce costs, and that the goal of this business relationship is to provide cost-efective healthcare. This can be done by showing the payer how many of their members avoided hospital re-admissions because of the efective, quality healthcare you provided. There are other items to negotiate in the contract. The prior authorization process can be made easier. The period for submitting a claim may be extended. Improvement and ease of the appeal process is helpful. Timely payment and interest on late payments need to be clarifed. When presented with a well-documented and organized data analysis, the payer may be able to recognize the value your practice brings to its members. This, in turn, will help increase the revenue generated, anywhere from a 3% to 10% increase in reimbursements. In conclusion, it is essential that payer contracts are carefully reviewed for their fee schedules and the provisions that can alter MedicalEconomics. com magenta cyan yellow black 1 Review your contract Contract termination is governed by the terms of your participation agreement with the health plan and by applicable law. You must always carefully review the terms of the participation agreement and all subsequent amendments, as well as any relevant statutory or regulatory requirements. 3 Find out when you can cancel All contracts require a reasonable notice period prior to the efective date of a termination. Many may limit your ability to get out of the agreement to one date per year. If you miss the notice period, you could be stuck in the agreement for another year. 4 Additional termination rights Many agreements may contain one or more provisions triggering an additional right to terminate. For example, a contract may provide that a regulatory change or a unilateral amendment to the provider’s participation agreement that has an adverse efect on the provider may give rise to an additional right to terminate the agreement. 5 2 Avoid mistakes Having an appropriate basis for terminating or not renewing an agreement means little if you get the mechanics wrong, so also make sure you consult the terms of your agreement that govern the provision of “notices.” Make sure that notices are sent to the right contact and address and by the proper method of delivery. Breach of contract All contracts will have a provision permitting you to terminate the agreement if you believe the health plan has breached a material term of the contract, and the health plan fails to cure the breach within a specifed period of time. 6 Terminating one line of business In some cases, the agreement may permit the provider to terminate participation with one or more of the health plan’s lines of business, while remaining a participant in all other lines. Source: Robert Schiller, JD the net revenue a practice generates. Research shows that larger corporations have an added advantage in using volume of providers that service their clients. If there are clauses in the contract that the insurance companies won’t negotiate that afect your break even point, a letter of intention to discontinue the contract should be sent. Ultimately, the payer may come to realize that a large portion of its members would not have care providers and would thus reconsider their position. Raju Kurunthottical, DO is a family physician who practices in Round Rock, Texas. This essay was an honorable mention in the 2014 Medical Economics writing contest. Medical econoMics ❚ January 10, 2015 ES544456_ME011015_025.pgs 12.16.2014 23:22 25 ADV In Depth Electronic prior authorization The solution to physicians’ headaches? Efforts are underway to find technology solutions to the efficiency problems physicians experience with prior authorizations by Ke n Te r ry Contributing editor HIGHLIGHTS 01 For electronic prior authorization to become viable, it must be available within electronic health record systems as part of the clinical workflow. 02 Electronic prior authorizations may improve patient outcomes because patients will be more likely to get their prescriptions filled if they’re pre-approved. 26 Are you tired of dealing with health plans’ prior authorization requirements for certain prescription drugs? If so, you have a lot of company. But you and your colleagues may soon have the opportunity to reduce this burden on your practices and increase patient satisfaction at the same time. It’s not that health insurers have suddenly decided they don’t need to pre-approve coverage of these medications. What has happened is that two technology companies, Surescripts and DrFirst, have begun rolling out solutions that embed electronic prior authorization (ePA) in the e-prescribing process. According to the companies, this approach will allow physicians and their stafs to request approval from pharmacy beneft managers (PBMs) and health plans Medical econoMics ❚ January 10, 2015 magenta cyan yellow black inside their electronic health records. Surescripts says that practices may receive electronic responses within minutes in many cases. Consultants and physicians say this approach not only could reduce the work and cost involved in prior authorizations, but should also make patients happier. Instead of being forced to wait a day or two for a pre-authorization to arrive, usually after an unsuccessful trip to the pharmacy, pa- MedicalEconomics. com ES544425_ME011015_026.pgs 12.16.2014 23:19 ADV Prior authorizations tients may be able to get a prescription approved leaving the physician’s ofce. At the least, notes Miami gastroenterologist James Leavitt, MD, physicians will be able to fnd out which drugs require prior authorization and inform patients about that in advance. Going to the pharmacy and discovering that a medication needs pre-approval, he says, “is a huge patient dis-satisfer. So from the patient’s point of view, this will be much better. It will set their expectations, because they’ll know what’s going on.” David Boles, DO, a family physician in Clarksville, Tenn., likes the idea of having prescriptions approved while the patient is still in the ofce. “Tat would be awesome,” he says, adding that it’s about time. “It’s amazing how long this has taken.” Dueling SolutionS Two distinct ePA solutions have been developed by companies that are well known in healthcare. Surescripts, the frm that connects physician ofces online to pharmacies for e-prescribing, is ofering an end-to-end electronic service, CompletEPA, that links practices to four PBMs, including CVS/Caremark and Express Scripts. According to Surescripts, these four PBMs have contracts from health insurers to administer the drug benefts for 210 million people. All of these health plan members would potentially be eligible for ePA. Surescripts is using a new ePA standard from the National Council for Prescription Drug Programs (NCPDP). In the year since it was adopted, says David Yakimischak, executive vice president/general manager of medication services for Surescripts, “We’ve gotten commitments from both PBMs and physician EMR [electronic medical record] vendors to use the NCPDP standard.” Cameron Deemers, president and chief executive ofcer of DrFirst, which sells e-prescribing software and has imbedded its solutions in nearly 300 diferent EHRs, applauds Surescripts’ all-electronic initiative. But he points out that many health plan and PBM information systems are not yet ready to accept NCPDP-based prior auth transactions. “We’re trying to provide a universal solution so a doctor doesn’t have to go through two or three diferent workfows, doing some prior auths electronically, some by fax, and some by phone. We’re trying to get away from that and provide a consistent user ex- MedicalEconomics. com magenta cyan yellow black 5 benefits of new electronic prior authorization standards 1 2 3 4 5 Leverages eligibility and formulary data to notify providers of medication prior authorization requirements before e-prescribing. Instead of forms, specific prior authorization questions are sent to the electronic health record system, based on patient, health plan and medication. Pre-population of required patient information adds efficiency and accuracy to administrative tasks. Real-time communications with pharmacy benefit managers to complete prior authorization review before sending e-prescription. Pre-approved e-prescriptions routed to pharmacy and won’t be subject to prior authorization block. Sources: HIMSS, NCPDP, Surescripts perience for prior authorization.” DrFirst’s EPA solution, Patient Advisor ePA +, uses the hybrid service of CoverMyMeds to connect practices with payers. CoverMyMeds allows physicians to submit prior auth requests electronically, then sends those requests to payers in whatever form is acceptable to them, including by fax and online using the NCPDP standard. DrFirst is also integrating other ePA services, including Surescripts’ CompletEPA, and it will connect practices directly with some health plans and PBMs. “Surescripts has a piece of the market, and CoverMyMeds has some kind of connection to every payer in the country,” notes Deemers. “We want to give the doctor the ability to do electronic prior auth no matter what, and that means we have to have multiple sources available.” getting eHR venDoRS on boaRD For ePA to become viable, it must be available in electronic health records (EHRs) as part of the clinical workfow. DrFirst is including Patient 31 Medical econoMics ❚ January 10, 2015 ES544422_ME011015_027.pgs 12.16.2014 23:18 27 ADV Advertisement not available for this issue Advertisement notdigital available for this issue of the edition of the digital edition www.medicaleconomics.com/resourcecenterindex MedicalEconomics.com Facebook Twitter www.MedicalEconomics.com/HIMSS2012 www.MedicalEconomics.com/ACA MedicalEconomics.com Facebook Twitter See medicaleconomics.modernmedicine.com/himss2012 resource centers related to our Business of Health series You’ve gotYquestions about the Affordable ou've got technology questions. Care Act. as well as topics such as Patient-Centered Medical Homes, accountable We’ve got answers. answers. We've got care organizations, and our EHR Best Practices Study at the above link. Prior authorizations 27 Advisor ePA + in the EHRs of all its vendor customers, which include Greenway, GE Centricity, LSS (part of Meditech), and Healthland, as well as several smaller companies. It upgraded about half of these products in October and will add the ePA solution to the other EHRs later, Deemers says. DrFirst is also including Patient Advisor ePA+ in its standalone e-prescribing programs. Surescripts scored a big win recently when Epic Systems, the largest EHR vendor, agreed to incorporate CompletEPA in its EHR. An Epic spokesman tells Medical Economics that this will happen in the frst quarter of the year. Surescripts also has signed deals with several small vendors, and Yakimischak forecasts that other leading vendors will soon follow Epic’s lead. Other observers agree that ePA, if it works as advertised, is likely to sweep the industry because practices will demand it. In fact, ePA is the top priority of physicians in regard to e-prescribing, according to Yakimischak. Currently, some PBMs allow practices to use their websites to make prior auth requests. But that’s outside the EHR workfow and is a manual process requiring completion of prior auth forms online, notes Cindy Dunn, RN, FACMPE, a health IT consultant for the Medical Group Management Association (MGMA). ePA, in contrast, takes place in the EHR and is partly automated. As described by Surescripts, the ePA software can pull data from the EHR to pre-populate patient demographic information on the prior auth form. Te PBMs, via Surescripts’ benefts and formulary feature, can supply the patient’s drug coverage and the plan’s prior auth requirements. And the NCPDP standard automatically tailors the questions on each prior auth form to the patient’s demographics, skipping the irrelevant ones. All of this speeds up the request process, says Yakimischak. In a pilot of ePA with CVS prior to the NCPDP standard being adopted, he adds, it took only about fve minutes, on average, for practices to fll out prior auth forms. Rosemarie Nelson, an MGMA consultant in Syracuse, New York and a Medical Economics editorial consultant, questions how practices would adapt their workfow to ePA. She wonders whether some physicians would choose to wait for a response MedicalEconomics. com magenta cyan yellow black StateS that require Some form of electRonic PRioR autHoRizationS NH WA OR MT ID NV CA ND WY UT AZ VT MN WI SD IA NE CO IL KS NM TX MI IN AR OH KY MO OK NY PA WV TN MS AL GA VA NC SC ME MA RI CT NJ DE MD DC LA FL AK HI to an online prior auth request, lengthening the patient visit. But she notes that if the approval didn’t come right away, physicians could wrap up the exam and delegate the task to their nurses. She and Dunn predict that practices will welcome ePA, regardless. benefitS of ePa Currently, practices spend a lot of time and money on prior authorization of all kinds, including the pre-approval of prescriptions. According to a 2009 study, prior auth takes up an average of 1.1 hours per week for primary care physicians, 0.8 hours per week for medical specialists, and 0.7 hours per week for surgeons. And that doesn’t include the amount of time they devote to formularies, which are intertwined with prior auth. Primary care nurses spend an average of 13.1 hours per physician per week on prior auths and 3.8 hours per week on formularies, the study found. Nelson points out that ePA would allow these clinicians to convert most of the prior auth time to patient care duties. Noting that 90% of prior auth requests require a phone call or a fax, Surescripts estimates the cost of completing these requests at between $2,000 and $14,000 per physician per year. Yakimischak adds that prior auths are required for 2% to 4% of prescriptions. Considering that billions of prescriptions are Medical econoMics ❚ January 10, 2015 ES544418_ME011015_031.pgs 12.16.2014 23:19 31 ADV Prior authorizations [PrIor auTH] IS a HuGE PaTIEnT dIS-SaTISFIEr. So From THE PaTIEnT’S PoInT oF vIEw, [ELEcTronIc PrIor auTH] wILL bE mucH bETTEr. IT wILL SET THEIr ExPEcTaTIonS, bEcauSE THEy’LL know wHaT’S GoInG on.” — JamES LEavITT, md, GaSTroEnTEroLoGIST, mIamI, FLorIda ordered every year, that adds up to a great deal of extra work. Leavitt says he gets half a dozen requests for prior auth each week. He turns them over to his secretary, just adding a bit of clinical information and signing the forms after she completes them. “But it’s still a pain in the butt,” he says. Boles says prior auth is a “big deal” in his practice. He tries to avoid the problem whenever possible by prescribing generics, he says, and his nurse is very adept at flling out prior auth forms when necessary. But some of his younger colleagues spend a lot of time on this task, he says. ePa coStS ePA can to reduce the amount of time that practices spend on prior auths by 70%, according to CoverMyMeds, but it is not without its own costs. Surescripts is charging EHR vendors a monthly fee that it expects they will pass on to physicians, Deemers says. Yakimischak acknowledges this, but declines to specify how much these fees are. DrFirst opposes charging physicians for ePA, Deemers says, because “doctors shouldn’t be charged for doing something they don’t want to do in the frst place.” Nevertheless, DrFirst is ofering Surescripts’ ePA product alongside its own free solution to see how the market will respond to the combination of price and service. Boles thinks his EHR vendor won’t give him a choice of ePA solutions. But he says he’d rather not pay anything for ePA, because he’s already being asked to pay extra for many other EHR features, such as his formulary checker. Leavitt, by contrast, says that he’ll compare how well the two solutions work if he has access to both of them. “If one is functionally better, and the price is minimal, I 32 Medical econoMics ❚ January 10, 2015 magenta cyan yellow black don’t care [about the cost],” he says. effect on outcomeS? Today, because physicians don’t usually know what requires pre-authorization, the process is “retrospective,” Yakimischak says. Tis means that pharmacies return prescriptions requiring a prior auth to the prescribing physician. Surescripts’ and DrFirst’s solutions are set up to handle that scenario, but they also allow “prospective” prior auth requests. In that model, physicians are informed in their e-prescribing workfow that a medication requires prior auth and can act accordingly. Tis might improve patient outcomes, Yakimischak notes, because patients will be more likely to get their prescriptions flled if they’re pre-approved. “Tere’s a high abandon rate for prescriptions that have prior authorization at pharmacy. We want to nip that in the bud and improve the efciency of the prior authorization and speed up the time to approval, so patients get the medicine in their hands quickly,” he says. Dunn agrees that ePA will increase the chance that a patient will fll a prescription. “In many cases, when they have to wait for preauth and it doesn’t come quickly, they lose their desire to take the medication. What also happens is that it never gets approved. So what happens to the patient? Tey don’t get their medication.” Leavitt feels that patients would beneft if he could tell them which drugs required prior auth at the point of care. But the main issue for his practice, he says, is that payers are “narrowing down dramatically” the prescriptions that they’ll cover without pre-approval. “We have no way of knowing what requires pre-auth,” he says. “And there’s more and more of this. Tis is a really critical problem for us, so electronic prior authorization is a welcome solution, for sure.” MedicalEconomics. com ES544423_ME011015_032.pgs 12.16.2014 23:18 ADV In Depth Coding in 2015 EffiCiEnt mEEtings Risk managEmEnt Evaluation and management changes [38] Conducting productive staf meetings [40] How an employee manual can help avoid liability [42] Streamlining your practice Why upgrading the workflows of your front desk, clinical practice and administrative functions are necessary to improve efficiency and gain time by E li zab Eth W. Woodcock, M ba, FacM PE, cPc and d E borah WalkE r kE Egan, Ph d, FacM PE Contributing authors HIGHLIGHTS 01 Put in writing all of the steps you would like taken before your office opens each day. 02 Assign a member of the clinical team to carefully review the records of upcoming patients, noting any tests, consultations or other orders placed at the patient’s previous visit. 03 Make sure you monitor your key billing metrics, to include the percentage of accounts greater than 90 days in receivables outstanding, net collection rate, claim denial rate, and bad debt rate. MedicalEconomics. com magenta cyan yellow black Efcient workfow isn’t natural. It’s earned. With so much riding on a well-tuned ofce— from the most efective use of your time to creating the best patient experience—now is an opportune time to focus on streamlining the business operations of your practice. BEfoRE dElving into specifc work functions, let’s focus on some key management principles of a successful medical practice. First, it is important to recognize that your time is your practice’s greatest asset. Terefore, make sure the infrastructure of the practice is geared toward optimizing it. Second, your prime directive is to care for patients. Terefore, each work function must be patient-centric and support this imperative. Here are some key dos and don’ts to transform your front ofce, mid-ofce and back ofce into a successful medical practice. 1/ The front offce: Directors of frst impressions Recruit well. Start by taking a deliberate approach to new employee orientation. Pay close attention to the quality of the training you provide to front ofce employees, just as you do for clinical staf. Te front ofce plays a critical role in how your practice is perceived by your patients. Provide resources. Don’t tolerate slow computers, inadequate workspaces or haphazard foor plans. Give employees the Medical econoMics ❚ January 10, 2015 ES544537_ME011015_033.pgs 12.17.2014 12:16 33 ADV Streamline your practice Keep a pulse on the practice. Te sched- Key principleS of practice streamlining Standardize your practice’s work processes, but recognize that every day will be a bit diferent since you cannot predict all of the events that need to be addressed. Healthcare is complex and the needs of patients often fall outside of routine processes. Make your expectations for performance crystal clear to employees, and hold your team accountable for results. Share outcomes with the team so they learn of their successes as well as opportunities for improvement. never tolerate a “virus.” The team member who gossips or tears down others’ eforts destroys everyone’s morale in the long run, reducing productivity and service. Everyone in a medical practice has an important role to play but no one should be considered indispensable, particularly those employees who are not team players. ule is dynamic, but it can’t be flled without good communication between all employees. Put a process in place so that if a patient cancels his or her appointment or the triage nurse sends a patient who has a scheduled appointment to the emergency department, the front ofce team is alerted to fll that patient’s appointment slot from a list of patients seeking a walk-in or “earliest opportunity” visit. Track wait times for appointments to ensure you are accommodating patients within your targeted timelines. Te supervisor in this sector of the practice should create a daily action plan and share it via your intranet or a white board so that the entire team understands the nuances of the day. Ask patients to prepare for their visit. To Prepare for each day. In other words: if you can predict it, you can manage it. Create a process map of what’s done every day, from opening the ofce doors in the morning to shutting computers of in the evening. This clarifes the work that needs to be performed, while serving as a checklist to ensure completion. don’t give up. Expect that at least a quarter of each day will involve the unexpected, but don’t relinquish managing the remainder. Controlling the majority of each day is a great goal that typically can be achieved. adjust expectations. Perfection is not possible, regardless of how much we want it. What’s important is to meet and exceed standards. Always remember that your practice is a service business where a measure of fexibility ensures that the needs of the practice–and your patients –are met. Mistakes will be made; if they’re not, you’re not trying hard enough to be better every day. the front office truly sets the tone. These key team members are the face of your practice. If they are discourteous, your practice is perceived as rude. Don’t leave the front ofce to chance; give these frontline workers clear expectations and the tools they need to do their jobs and do them well. resources they need to get the job done efciently. Install computers with high processing speed and dual monitors to facilitate efcient access to systems, and install topnotch workstations. At least once a quarter, ask each employee the question, “What is the one thing I can get you so that you can do your job better?” Develop a start-of-day checklist. Put in writing all of the steps you would like taken before your ofce opens each day. Requesting employees to “turn on your computer” and “switch the phone of of the service” may seem trite, but stumbling over these basics is where problems start. 34 Medical econoMics ❚ January 10, 2015 magenta cyan yellow black prevent delays at the front ofce, put information requests into the registration packet. Transmitting these requests to patients before they arrive produces a faster and more complete patient registration and intake process. It pays of with fewer delays and, potentially, the snags that cause claim denials Focus on accuracy. Mistakes happen, but often they are the result of poor training or lack of understanding regarding the importance of the work. Recognize that investing in your front ofce means saving money later on. If your business ofce is busy correcting errors made by your front ofce employees related to patient demographic and insurance information, you are spending a lot of money on rework—and delaying your reimbursements. Avoid claim denials and delays caused by messy or incomplete patient information by providing education to your front ofce team and tracking and monitoring the quality of their work. Receive the patient in the scheduling system. With the advent of electronic health records (EHRs), the root word of receptionist—to receive—seems to be lost. Teach the front ofce team how to appropriately greet patients and ensure that each patient gets due attention, without overlooking important business processes, such as collecting patient balances and copayments, verifying coverage and other details. Te front ofce is truly the director of frst impressions. 36 MedicalEconomics. com ES544534_ME011015_034.pgs 12.17.2014 12:16 ADV magenta cyan yellow black ES543199_ME011015_035_FP.pgs 12.12.2014 02:01 ADV Streamline your practice 2/ The mid-offce: 7 steps masters of effciency to process improvement 1/ Pick a process Look for something that has a clear beginning, middle and end. Reducing days in accounts receivable is not a work process; submitting each day’s claims by 5 pm is. 2/ Break it down Separate the process into discrete steps that report everything that requires an action by your employees or the technology they use. 3/ Get input Don’t rely on the manager; ask everyone in the workfow chain how to improve the efciency of the process. Eliminating even one step — just one piece of paper — is a victory. 4/ Focus on processes, not people The idea is to improve process efciency, so lay out the current process and then brainstorm a new, improved process. Next, identify staf roles for the new process. 5/ Implement Start with the most obvious and easiest workfow improvements, then work your way up to the more difcult, time-consuming items. Deciding to wait for three months to improve a billing process while a new practice management system is selected and implemented is a lost quarter. Many other processes can be identifed for improvement that do not rely on the new system. 6/ Monitor Make sure the improvement idea becomes a reality. If it isn’t working, make adjustments or, if that fails, put it on hold until you can develop a more successful solution. 7/ Repeat Return to step one and select another process. Be sure to engage your employees for suggestions, because they conduct the work process day-in and day-out and have insights to improvement. Every wasteful process you eliminate is another step to a more efcient practice. Every tedious process you replace with something faster and more engaging improves morale as well as your practice’s bottom line. Once the patient is seated in the reception area, focus on streamlining the workfow that takes place around the clinical team’s eforts to get ready for the patient. Preparedness is the overriding principle of efective patient fow. Preview charts. Streamlining patient fow actually starts the day before the patient’s arrival. Assign a member of the clinical team to review the records of the following day’s patients, noting any tests, consultations or other orders placed during the patient’s previous visit. Tis serves as an early warning for any missing results. Assess any clinical alerts—an overdue screening exam, for example—and make notes, pull together forms, patient education materials or other paperwork that may be needed in connection with the visit. Huddle. Gather your team each morning for a brief, stand-up meeting. Peruse the schedule, noting any necessary preparations (an interpreter is needed for Ms. Smith at 2:30, for example), predictable no-shows (Mr. Jones was admitted last night), and opportunities for add-ons. Always conclude the huddle with a quick review of the previous day’s mistakes—and how to avoid them in the future. Tese brief overviews will help instill the spirit of performance improvement that, over time, should become embedded throughout your practice. Develop a standard intake process. Put the rooming criteria in writing, including patient gowning and vital signs, based on reason for the visit. Create standing orders based on patient complaint ( for example, request urine sample if the patient complains of frequent urination). If deployed efectively, these standing orders can save precious time for you, your employees, and your patients. Standardize exam rooms. Ensure that every exam room is set up in a uniform manner, with supplies, forms, and equipment in the same place in all rooms. Stock exam rooms before the morning starts; assess their status at mid-day as well. Create a flow station. Popping into your ofce between patients consumes a lot of 36 Medical econoMics ❚ January 10, 2015 magenta cyan yellow black MedicalEconomics. com ES544535_ME011015_036.pgs 12.17.2014 12:16 ADV Streamline your practice time. Instead, develop a fow station that has access to your EHR, as well as a telephone. Te fow station may be an anchored workstation or it could be a workstation on wheels or computer on wheels. Route messages via your EHR’s task function, noting that time-sensitive ones should be printed and tucked into a designated red folder on your workstation, or another such alert system. Stop by this area when between patients and encourage your employees to use it to communicate with you. Tis permits work to be conducted in an asynchronous fashion rather than requiring a face-to-face interaction with your nurse or medical assistant, thereby improving productivity. By executing an efective patient fow strategy, the mid-ofce can successfully achieve the status of masters of efciency. 3/ The back offce: administrators of working smartly What’s the use of streamlining workfow and patient fow if you don’t get paid? Apply the same principles of efciency you’ve brought to your front ofce and mid-stream areas to the back ofce so you can get paid what you deserve. Leverage technology. Determine every opportunity to leverage technology. For example, turn manual lists into an online database that can be sorted and accessed by multiple users. Use online access to payers in lieu of phone calls to streamline the work. Share important resources and tools rather than require each employee to reinvent the wheel. For example, retain appeal letters and other documents in an organized, shared intranet-based “library” for employees to use repeatedly. Meet with employees to look for ways to better harness your system. From replacing manual payment postings with automated remittances to using automated work queues in lieu of manual accounts receivables, there are many functions in which technology can be deployed successfully. Track key billing metrics. Make sure you monitor your key billing metrics to include the percentage of accounts greater than 90 days in receivables outstanding, net collection rate, claim denial rate, and bad debt rate. Create specifc targets, and track and trend these metrics over time. MedicalEconomics. com magenta cyan yellow black Time is your practice’s greatest asset. Therefore, make sure the infrastructure of the practice is geared toward optimizing it. Revise work processes due to healthcare reform. Even though the majority of your patients may have insurance, many today also have a high deductible health plan. Tis means that they are truly “self pay” until they have met their deductible. Revise your work processes to determine the patient’s unmet deductible and either attempt to capture that at the time of service (provided your contracts permit) or shorten your patient collections cycle to ensure timely revenue. Optimizing patient payments is now “mission critical” for medical practices. Deliver feedback. Don’t let employees work in the dark. Share performance data with them to include revenue, aged trial balance and days in receivables outstanding, for example. Hold regular discussions of key performance indicators. If employees know what you expect, they are more apt to deliver the “work smart” performance that ensures you get paid what you deserve. Remember, streamlining strategies presents routes to greater efciency throughout the practice. Improving workfow takes time and efort, but the pay of is well worth it. Elizabeth Woodcock, MBA, FACMPE, CPC, (top left)is a consultant, speaker, trainer and author with Woodcock & Associates in Atlanta, Georgia. Deborah Walker Keegan, PhD, FACMPE, (bottom left) is a healthcare consultant and president of Medical Practice Dimensions, Inc., in Asheville, North Carolina. Medical econoMics ❚ January 10, 2015 ES544536_ME011015_037.pgs 12.17.2014 12:16 37 ADV C o d i n g an d b i lli n g advi C e f r o m th e e x p e rts Coding Insights PreParing for 2015 evaluation and management code changes Q What are the 2015 Current Procedural Terminology (CPT) updates that will affect our primary care practice next year? A: With an estimated 264 new codes, 143 deleted codes, and 134 revised codes in 2015, now is the time to prepare. Thankfully, most of the changes do not afect primary care physicians. However, the Evaluation and Management (E/M) section does include signifcant changes in advance care planning, E/M prenatal visit guidance and care management services. So let’s take a look at each of these in more detail. Advanced care planning The two new advanced care planning codes (99497 and 99498) are used to report the face-to-face service between a physician or other qualifed healthcare professional (QHCP) and a patient, family member, or surrogate in counseling and discussing advance directives, with or 38 without completing relevant legal forms. As you can see, a faceto-face visit is required but doesn’t have to include the patient. The CPT manual defnes an advanced directive as, “A document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.” Some examples of advance directives include: ❚ health Care Proxy, ❚ durable power of attorney for healthcare, ❚ living will, and ❚ Medical Orders for LifeSustaining Treatment (MOLST). These are time-based codes, with 99497 to be billed for the frst 30 minutes, and 99498 for Medical econoMics ❚ January 10, 2015 magenta cyan yellow black each additional 30 minutes. Because the purpose of the visit is the discussion, no active management of the patient’s problem(s) is performed during the time of these visits. Additionally, these code(s) can be billed in for the following E/M services: ❚ new and established patient ofce visits (99201-99215), ❚ observation initial, subsequent and discharge care codes (99217-99220, 9922499226), ❚ initial, subsequent and discharge hospital service codes (99221-99233, 99238-99239), ❚ observation or inpatient admit and discharge on the same date (9923499236), ❚ outpatient and inpatient consultations (9924199255), ❚ emergency department ❚ ❚ ❚ ❚ ❚ ❚ visit codes (9928199285), initial, subsequent and discharge nursing facility care codes (9930499316), annual nursing facility assessment code (99318), new, established and discharge domiciliary or rest home visit codes (99234-99337), new and established patient home visit codes (99341-99350), initial and periodic preventive medicine codes (99381-99397), and Transitional Care Management Service codes (99495-99496) However, these codes cannot be billed with: ❚ critical care codes (99291, 99292), ❚ inpatient neonatal and pediatric critical care codes (99468-99476), or ❚ initial and continuing intensive care services (99477-99480). Be careful: Medicare has indicated that it will NOT pay for codes 99497 or 99498 in 2015. Check with your commercial payers to see if they are reimbursing for these codes. MedicalEconomics. com ES544384_ME011015_038.pgs 12.16.2014 22:00 ADV C o d i n g an d b i ll advi C e f r o m th e e x p e rts E/M prenatal visit guidance The maternity care and delivery guidelines were revised to specify the following: ❚ pregnancy confrmation during a problemoriented or preventive visit is not considered a part of antepartum care. Report using the appropriate E/M code for that visit. ❚ Antepartum care includes the initial prenatal history and physical examination. Care management services The section title of “Complex Chronic Care Coordination” has been changed to “Care Management Services” with an addition of a new subsection, “Chronic Care Management Services” to better refect the management services described by new code 99490. The new code requires chronic care management services that take at least 20 minutes of clinical staf time directed by a physician or other qualifed healthcare professional, per calendar month, with the following required elements: ❚ multiple (two or more) chronic conditions expected to last at least MedicalEconomics. com magenta cyan yellow black MEDICARE HAS INDICATED THAT THEY WILL NOT PAY FOR CODES 99497 OR 99498 IN 2015. CHECK WITH YOUR COMMERCIAL PAYERS TO SEE IF THEY ARE REIMBURSING FOR THESE CODES NEXT YEAR. 12 months, or until the death of the patient, ❚ chronic conditions that place the patient at signifcant risk of death, acute exacerbation/ decompensation, or functional decline, and ❚ comprehensive care plan established, implemented, revised, or monitored. Medicare has announced that it will reimburse for 99490 instead of the initiallyproposed G-code, and the Work Relative Value Unit (wRVU) is 0.61. Keep in mind that chronic care management services of less than 20 minutes in a calendar month are not reported separately. The 20 minutes is in contrast to at least 60 minutes of complex chronic care management service that would be reported by a code 99487. Also, the add-on code 99489 should not be reported for service of less than 30 minutes in addition to the frst 60 minutes of complex chronic care management services during a calendar month. According to the American Medical Association, in addition to the above criteria for care management services, the requirements for complex care management services include: ❚ establishment or substantial revision of a comprehensive care plan, ❚ moderate or high complexity of medical decision-making, and ❚ 60 minutes of clinical staff time directed by a physician or QHCP per calendar month. Patients may be identifed by practice-specifc or other published algorithms that recognize: ❚ multiple illnesses, ❚ multiple medication use (and potential for drug interactions), ❚ inability to perform activities of daily living, ❚ requirement for a caregiver, and/or ❚ repeat admissions or Emergency Department (ED) visits. MORE ONLINE New modifers physicians need to know for 2015 http://bit.ly/1wd5yrT Evaluation and management codes under scrutiny http://bit.ly/1B867nl How physicians can avoid denials using modifer 25 http://bit.ly/1vOwQ87 Understanding proper use of time-based coding and billing http://bit.ly/1yyyBZ1 Incident-to billing: Physician coding questions answered http://bit.ly/1qv0Q8a The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting, in Indianapolis, Indiana. Send your coding and billing questions to [email protected]. Medical econoMics ❚ January 10, 2015 ES544386_ME011015_039.pgs 12.16.2014 22:01 39 ADV P r acti c e manag e m e nt advi c e f r o m th e e x P e rts Practical Matters The imporTance of in-person sTaff meeTings it. Corollary Tip 1(a) –Don’t cancel the meeting except under extreme duress. The importance of the meeting and its content for everyone else will in part follow from the importance they perceive it has for you. There is no better way to diminish sense a of importance than by frequent cancellations. clerical resolution, and combining the minds of everyone is crucial when difculties arise. By the way, do you know who always has the critical insight needed to resolve an issue? The person who is not at the meeting. Any idea who is not going to buy into and therefore undermine the solution to a problem? The person who is not at the meeting. I know that in larger practices with ambiguous team delineation, complete inclusion is particularly challenging. Of course, quitting smoking is pretty challenging, too, but if you’re a smoker, you should still work as hard as you can to make it happen. Include 2Involved Everyone in the 3for Prepare an Agenda Yourself Major Processes Take a page from the book of our patients: Write out the list of things you wish to discuss ahead of time and check them of as you cover them. You don’t have to distribute it. It is merely a personal tool to keep you on track. The point is that these meetings should be treated like the valuable opportunities that they by Davi D Switz e r, m D Contributing author Ever wonder why itÕs taking forever to get your patientsÕ vital signs? Or why your no-show rate is so high? The answers to these and other questions may be found by talking to your staff. I have found no better way to sit down and talk to my staff than to sit down and talk to my staff. Yes, IÕm talking about meetings. If no provIder in your practice is leading regular meetings with your colleagues and your staf, you should start now. Although all of us have been tortured throughout our professional lives with painful, pointless meetings, I have found this to be vitally important. You will be amazed at how the most vexing and perplexing conundra melt into pools of simplicity when you ask hard-hitting group questions such as: “Was there a problem with our phones in the last few days?” Epiphanies abound when the clerical and the clinical congregate. (We’ve never assigned ultimate responsibility for ordering the rapid strep tests? No wonder we always run out!). Much like the 30 40 minutes of aerobic exercise fve times per week we recommend to all of our overweight patients, I know that not all of my suggestions will be logistically easy. But following these tips, based on years of my experience as a physician, will ultimately be gratifying as you watch your staf come together and become a better care team. It Every 1 Have Week Do you know what the diference is between a minor glitch and a major crisis? About four weeks. If you want to have your best chance at catching a practice management problem while it is still a smoldering ember rather than a catastrophic confagration, give yourself more opportunities to fnd Medical econoMics ❚ January 10, 2015 magenta cyan yellow black Moving patients and their communications from the clerical (check-in, phone answering) to the clinical (nursing, provider) realm and back out again is a complex endeavor with numerous opportunities to go awry. Consequently, many problems do not have a purely clinical or purely MedicalEconomics. com ES544400_ME011015_040.pgs 12.16.2014 22:26 ADV P r acti c e manag e m e nt advi c e f r o m th e e x P e rts are. Exerting the efort to make them happen and not realizing their full potential is almost tragic. Too Short, 4 Not Not Too Long You need enough time to cover your personal agenda and let everyone speak to any additional topics that concern them. I am sure the requirement varies across practices, but I have found that no less than 20 minutes, but no more than 30 minutes, works well for me. This will also be easier to accomplish if you follow Tip 1. The longer you go between meetings, the longer the meeting will be, and the greater the likelihood that issues or problems will go unaddressed. Record Action 5Yourself Items for Gathering as a group is indeed productive. Listening to the perspectives of others is educational for you, and a chance to be heard is generally appreciated by your co-workers. However, if you do not record for future reference the specifc actions required to resolve the problems covered, you are likely to prolong or even fail to execute the resolutions themselves. MedicalEconomics. com magenta cyan yellow black IF STAFF MEMBERS DO NOT ASSOCIATE MEETINGS WITH CONCRETE POSITIVE CHANGES, THEIR ENTHUSIASM FOR THE MEETINGS WILL QUICKLY WANE, AS WILL YOURS. Also, if staf members do not associate the meetings with concrete positive changes, their enthusiasm for the meetings will quickly wane, as will yours. Take Time 6Allotted Normally to Patient Care to Have the Meeting Regarding this tip, administrators and bean-counters may raise an eyebrow. But if you want your staf to take participation in these meetings as a serious part of their job, treat it as equally serious as the patient-care part of their job. If the meeting is scheduled too early, too late or at a time your staf would otherwise not be caring for patients in one way or another, you will likely lose the time you save wrestling with how to get your employees engaged in this “extra” obligation. In case you were wondering, my compensation is tied in part to the fnancial performance of the entire practice. Do you know how I see this supposed “lost revenue?” As a bargain that more than pays for itself. Use Positive 7Liberally Feedback These meetings are the perfect forum to congratulate someone on a job well done and reinforce the performance you like. Have a low threshold to say “thanks” MORE ONLINE Managing staf performance with reviews and raises during the meeting, and morale will trend accordingly. In closing, one more general philosophical thought: You cannot have a team that never convenes in real time as a group. Therefore, if you choose not to meet with your co-workers, you cannot expect your co-workers to operate like a team. Adapting your medical practice to the demands of healthcare reform http://bit.ly/1wy0AYP http://bit.ly/1z6zPst How to motivate and retain your top employees The role of staf in meeting quality metrics http://bit.ly/1qvonWM http://bit.ly/1uKNwLM Increasing employee satisfaction at your practice Delegating taks to staf enhances team-based care http://bit.ly/1ByCHlb http://bit.ly/1zPhakm David Switzer, MD, is a family practice physician with Luray Family Medicine in Luray, Virginia. This article was an honorable mention in the 2014 Medical Economics Physician’s Writing Contest. Send your practice management questions to medec@ advanstar.com. Medical econoMics ❚ January 10, 2015 ES544401_ME011015_041.pgs 12.16.2014 22:26 41 ADV LegaL advi c e f r o m th e e x p e rts Legally Speaking HOw an EmplOyEE manual can HElp cOntrOl risk and cOntain cOst by An d r ew L. Zwe r Li ng, J d Contributing author The questions of whether your medical practice should have an employee handbook and what should be covered in the document are important for any physician practice owner to answer. This manual will impact every aspect of the practice on a daily basis. It Is fundamental that a medical practice have an employee handbook, because a properly drafted handbook can be a critical tool for risk management, communication and cost containment. An employee handbook informs employees and supervisors of the workplace rules and policies in a uniform manner, and serves many functions, including: ❚ providing clarity regarding expectations and the standards that must be followed; ❚ informing employees about workplace policies designed to enhance an entity’s operational viability and efciency, such as overtime issues; ❚ informing employees of their rights and benefts in a clear, consistent manner; ❚ notifying employees 42 about appropriate grievance and complaint procedures; and ❚ explaining an employee’s at-will status and that the employee did not have an implied or express contract An employee handbook can reduce the risks of litigation or provide a defense in a litigation by, for example, demonstrating the employer’s intended consistent treatment of its employees, and showing a plaintif/employee’s violation of the workplace rules and/or that a plaintif/ employee’s claim for benefts is baseless given the express language of the handbook. Although there are costs (attorney’s fees) associated with drafting an employee handbook, those are fairly minimal, and are more than ofset by the risks and potential costs to a practice Medical econoMics ❚ January 10, 2015 magenta cyan yellow black that does not have one. Certain fundamental concepts must be addressed in a handbook. It should include a highly visible disclaimer stating expressly that the handbook does not constitute a contract between the employer and the employee or alter “at will” employment relationships. The handbook should make clear the employer’s authority and right to amend the handbook. The employer should regularly audit and update the handbook, preferably at least once a year, to ensure that it is consistent with current law and the practices in the workplace. An outdated handbook may be a detriment in litigation. It’s also important for the employer to collect and maintain signed acknowledgements from all employees that they received, read and understand the handbook, that it supersedes prior handbooks and acknowledge they will comply with its terms. Keep these acknowledgements in each employee’s fle, because they may prove helpful in a litigation if an employee claims ignorance of workplace policies. An employer should not promise too much or be too rigid in delineating its policies. Failure to heed this admonition may lead to a limitation on the employer’s ability to act. Use language that endows the employer with appropriate discretion when acting. Finally, ensure that the handbook is consistent with the culture and practices of the workplace and that management is on board with its terms. Consult with frontline supervisors to ensure consistency between policies and actual practices and to ensure that the policies included in the handbook can actually be enforced. Andrew L. Zwerling, JD, is a partner-director at Garfunkel Wild, P.C. in Great Neck, New York. Send your legal questions to [email protected]. MedicalEconomics. com ES543981_ME011015_042.pgs 12.15.2014 22:12 ADV In Depth The defensive medicine balancing act Ordering tests and diagnostic procedures can be a dilemma for physicians, who must navigate issues of patient care, liability and cost by J u dy Packe r-Tu r s man Contributing author HIGHLIGHTS 01 For practicing physicians, preventing defensive medicine in their practices boils down to good communication with patients. 02 Tort reforms may be needed to persuade physicians to change practice patterns as part of a larger transformation to healthcare delivery and payment systems. MedicalEconomics. com magenta cyan yellow black Te common assumption among healthcare experts is that physicians practice defensive medicine out of an abundance of caution amid worries of being sued for malpractice. But recent studies reveal that defensive medicine many not be as straightforward as many physicians believe and the impact on healthcare spending remains an open question. Despite broaD consensus that defensive medicine exists, it remains difcult to defne the term, much less measure its impact on U.S. healthcare spending. Typically, defensive medicine means physicians ordering tests and procedures, making referrals or taking other treatment steps to help protect themselves from liability rather than to beneft their patients’ care. Some researchers label it as unnecessary care of marginal value at best. Others de- scribe it as overuse of medical services that afords more economic—and even psychological—beneft to physicians than to their patients. “You’ve got America as a ‘can do’ country, wanting tests that may not in any way be useful,” says Henry Aaron, PhD, a health policy expert at the Brookings Institution. “Tat said, it is in the interest of the provider to provide it, and in the interest of the patient to get it,” especially 45 Medical econoMics ❚ January 10, 2015 ES544420_ME011015_043.pgs 12.16.2014 23:18 43 ADV Defensive medicine Does malpractice reform affect defensive medicine practices? Study looks at physician behavior in emergency departments before and after reform legislation By Jeffrey Bendix, MA Senior Editor hysicians and health policy experts have long assumed that doctors are driven to practice defensive medicine because they fear being sued for malpractice. But a recent study of what happened in states that made it more difficult to sue some physicians casts doubt on that assumption. The researchers looked at the numbers of computed tomography (CT) and magnetic resonance imaging (MRI) procedures and inpatient admissions ED physicians ordered for a random sample of Medicare fee-for-service patients in the three states between 1997 and 2011. They focused on the imaging procedures because ED physicians frequently self-report them as examples of defensive medicine practices. Researchers also studied pervisit charges as a proxy for the intensity 44 Medical econoMics ❚ January 10, 2015 magenta cyan yellow black Getty Images/Digital Vision/Michael Grimm The study examines the impact of changes in the behavior of emergency department (ED) physicians following the reform of malpractice laws in in three states: Texas, which in 2003 changed its malpractice standard for emergency care to “willful and wanton negligence;” and Georgia and South Carolina, which changed their standards to “gross negligence” in 2005.“From a legal standpoint, these two standards are considered synonymous and are widely considered to be a very high bar for plaintiffs,” the study’s authors write. MedicalEconomics. com ES544421_ME011015_044.pgs 12.16.2014 23:18 ADV Defensive medicine of the level of services provided to the patients. The authors then compared patientlevel outcomes before and after passage of malpractice reform both among the three reform states and in surrounding states, with the goal of isolating the specific impact of the reform legislation from other trends and from patient characteristics. The goal was to arrive at what the authors term “policy-attributable changes” in ED physician behavior. After subjecting the data to regression analysis, the researchers found no decrease in rates of CT or MRI use or hospital admission in any of the three reform states, and no reduction in per-visit charges in Texas or South Carolina. Georgia experienced a 3.6% reduction in per-visit charges. The authors note that ED physicians frequently cite the use of advanced imaging as example of a defensive medicine practice. “Our results challenge the validity of these assertions, or at least suggest that the use of emergency department imaging is unlikely to be affected by malpractice reform alone,” they write. Although the study focused on ED physicians, the results have wider implications for the debate over shielding doctors from malpractice suits would reduce defensive medicine practices, and thereby reduce the nation’s overall medical costs, says Daniel Waxman, MD, PhD, the lead author and an adjunct natural scientist at the RAND Corporation. “People have said over and over that malpractice reform is an important way to save money, and I think the interesting part of this study suggests that’s a blind alley,” Waxman says. The study, “The Effect of Malpractice Reform on Emergency Department Care,” appears in the October 16 issue of the New England Journal of Medicine. MedicalEconomics. com magenta cyan yellow black 43 when out-of-pocket cost-sharing is low, he says. In a 2014 study led by the Cleveland Clinic and published in JAMA Internal Medicine, researchers asked a few dozen physicians in three hospital medicine services to estimate the defensiveness of their own orders. Fully 28% of 4,200-plus orders were reported by physicians as being at least partially defensive, but only 2.9% were seen as completely defensive in nature. Te Cleveland Clinic study cited a national cost estimate of $46 billion related to defensive medicine, but noted that such costs have been measured only indirectly. Other studies, along with the American Medical Association, put the cost impact much higher. Moreover, researchers said, physicians’ attitudes about defensive medicine failed to correlate with cost, suggesting that only a small portion of costs might be reduced by tort reform. Defensive medicine is viewed by many as a deep-seated dilemma. Vikas Saini, MD, president of the Lown Institute, says the nonproft Boston think tank launched a grassroots initiative of physicians, patients and community organizations in 2013 called the RightCare Alliance to change behaviors “primarily because we view the problem of unnecessary care and use as a deep cultural problem, I can sum it up as more is not always better, but that is the cultural bias,” he says. Saini puts the issue in the context of a demanding profession. “Tere’s a lot of borderline. Tere’s a lot of uncertainty, guessing. It is not purely defensive. Tere’s — VIkaS SaInI, MD, preSIDenT, Lown InSTITuTe also profound concern for your patient and concern for your reputation all wrapped together,” he says. “For us, the deeper issue is [that] modern medicine has become driven a lot by technology, a lot by money—and we need to free decisions to be driven by patients’ needs.” At times there can be poor communication and lack of trust between physicians and their patients and tort reform “isn’t going to fx the habits of defensive medicine,” Saini says. Research suggests that physicians’ per- The deeper issue is: Modern medicine has become driven a lot by technology, a lot by money— and we need to free decisions to be driven by patients’ needs.” Medical econoMics ❚ January 10, 2015 ES544419_ME011015_045.pgs 12.16.2014 23:18 45 ADV Defensive medicine If you want to fix defensive medicine, develop trusted therapeutic relationships using effective communication skills and be available to patients. period.” —rIcHarD roberTS, MD, JD, proFeSSor oF FaMILy MeDIcIne, unIVerSITy oF wISconSIn ceptions are a key driver. A 2013 study published in Health Afairs linked physicians’ survey responses on their levels of malpractice concern to claims of Medicare patients treated in their ofces. It found that physicians reporting a high level of malpractice concern were most likely to engage in practices that would be considered defensive ( for example, more aggressive diagnostic testing) when diagnosing patients with new complaints of chest pain, headache, or lower back pain. “It’s a multidimensional problem. You’ve got patient expectations for care. You’ve got conficting recommendations for care, and then you have local practice patterns that also drive physicians to order certain diagnostic tests and treatments,” says David A. Katz, MD, associate professor in the department of internal medicine at the University of Iowa and one of the study’s coauthors. “One thing that was striking from the data is state malpractice policies really had much less of an impact on [physicians’] fear of malpractice than what we had expected,” adds Katz. “Having said that, the [physician] perceptions were a big driver, particularly on the use of imaging...and we saw a higher likelihood of referral to the emergency department” among doctors more fearful of malpractice, especially for patients with chest pain. Katz, who also practices in the Veterans Afairs Iowa City Health Care System, says when there is uncertainty about a test’s value, he tries to explain to patients about conficting data on its benefts “and that a cascade of tests may result downstream after a positive screening test. Sometimes insurance or a third-party payer may encourage a procedure and be willing to pay for it, but it may not be in the best interests of the patient.” “Sometimes it defes rational discussion, and many physicians will give in to the patient,” he concedes. Patients getting too much care Primary care physicians are regarded as key to helping reduce waste in the system. Yet, according to a 2011 study in the Archives of Internal Medicine, 42% of family and general internal medicine physicians in the U.S. thought their patients were getting too much medical care; only 6% thought patients were receiving too little care. Brenda Sirovich, MD, MS, associate pro- 46 Medical econoMics ❚ January 10, 2015 magenta cyan yellow black fessor of medicine at Dartmouth University’s Geisel School of Medicine and the study’s lead author, explains that researchers’ interest “wasn’t specifcally in malpractice, but in drivers of healthcare practice patterns” and gaining understanding that clinical indications are not the only things that infuence physician decision-making. Yet Sirovich says it is hard to determine what other factors infuence decisions, in part because surveys are standardized instruments with fnite responses—and perhaps also because physicians might not know the factors themselves. “I think most would say defensive medicine is practiced with the primary aim of minimizing litigation,” Sirovich says. “But a number of studies came out with the conclusion that defensive medicine plays a tiny role in explaining rising costs and practice patterns.” Sirovich’s belief, while not based on specifc evidence, is that this conclusion is fawed because defensive medicine is diffcult to understand and “malpractice is a very feared thing, a completely destructive experience,” she says. trained to ‘find the zebra’ Recently, physicians confrmed their ongoing worries about the fnancial impact of defensive medicine. In the 2014 Survey of America’s Physicians, 20,000-plus physicians were asked to identify the factors most likely to contribute to rising healthcare costs. Six in 10 physicians cited defensive medicine, putting it at the top of the list; an aging population came in a distant second at 37.4%. Primary care physicians and specialists cited defensive medicine to the same degree, but relatively more—nearly seven in 10—physicians aged 45 or younger cited defensive medicine as a contributor. Kisha Davis, MD, a family physician in practice for seven years, says part of the reason for practicing defensive medicine is that medical schools train students to look for, and rewards them for, fnding “the zebra.” In other words, the idea that “maybe this is the one [case] that doesn’t ft the textbook,” Davis says. Davis, the medical director of Casey Health Institute, an integrative primary care practice in Gaithersburg, Maryland, says she maintains a good relationship with her patients and doesn’t think much about malpractice or being sued. But she does think MedicalEconomics. com ES544417_ME011015_046.pgs 12.16.2014 23:18 ADV Defensive medicine about patient outcomes. “I don’t want to be the one who missed cancer,” she says. As a younger doctor, Davis says she may feel more comfortable than some physicians in telling her patients not to worry if she doesn’t order a slew of the most sophisticated, costly testing. But clinical experiences can change practice patterns. Davis recalls sending for referral a patient who came to her with suspicious abdominal bloating. Ovarian cancer was diagnosed. Tis led her to worry more about the next few patients who came in with similar symptoms, despite less-suspicious exam results, because she didn’t want to delay diagnosis. “You worry more [under such circumstances],” Davis says. “I, in general, tend to be a provider who doesn’t order lots of tests, [and] don’t jump to the MRI. But I might have ordered blood work [and] tests because more suspicion creeps into your mind. It’s not always about malpractice. Tere is also an element of uncertainty.” Patient education “has a huge part to play” in avoiding defensive medicine, adds Davis. She says a patient with a headache came into her ofce in November telling her a head scan was needed. “Sometimes it takes a lot of convincing” to sway patients from such desires, and much of her time is spent in doing so, she says. In the Washington, D.C. area where she practices, she says patients tend to see many specialists, so she must explain to patients why they don’t need a cardiologist for hypertension. Davis says she worked previously for four years at a community health center in Columbia, Maryland, where many patients didn’t have other care options. “I handled it all,” she says. “Now, it’s diferent trying to get people to understand the benefts of primary care and how care coordination can work. “People come in wanting antibiotics, wanting studies, wanting to see the specialists,” she adds. “I have time in my practice to explain what primary care can do [and why such steps aren’t necessary], but I understand why my colleagues in busy practices may not have the time to have more in-depth conversations as much as they should. You really have to make it a priority.” aiming to imProve care In a broad efort to improve quality and safety of care, the American Board of Internal MedicalEconomics. com magenta cyan yellow black % 13 Approximate percentage of costs incurred by hospitals that can be attributed to the practice of defensive medicine, according to JAMA Internal Medicine. $46 bILLIon Estimated annual cost of defensive medicine to the U.S. healthcare system. % 61 of physicians older than age 55 that have been sued for medical malpractice, according to a study in Policy Research Perspectives. $3.7 bILLIon The amount of medical malpractice payouts in 2013, according to the Washington Post. Medicine (ABIM) Foundation launched the Choosing Wisely campaign. Te national initiative aims to help providers and patients discuss overuse of tests and procedures and support eforts to help patients make what the foundation describes as “smart, efective care choices.” Its frst recommendations were rolled out in 2012, followed by more in 2013 and 2014. “Choosing Wisely helps recognize there are times when we try to manage uncertainty by overtesting, but overtesting itself can do harm,” says Richard J. Baron, MD, the ABIM Foundation’s president and chief executive ofcer. “Choosing Wisely isn’t about rationing or withholding [care]. It’s about doing what’s right, not less.” Baron says that holding “evidence-based conversations” about appropriateness of care with patients “is a better way to go than just assuming if you do another test you’re somehow reducing your liability profle,” he says. To date, 69 medical societies, and groups representing nurses and physical therapists have joined the Choosing Wisely initiative, along with 21 Robert Wood Johnson Foundation grantees for implementation eforts and more than 24 consumer organizations, including Consumers Union. As the U.S. healthcare market shifts toward use of more high-deductible health plans, patients bearing more of the cost are going to ask doctors when and if they really need certain tests or procedures, Baron says. And physicians in large organizations increasingly are working under global budgets, trying to improve quality of care and decrease costs at the same time, he adds. Cedars-Sinai Medical Center is putting Choosing Wisely recommendations into patients’ electronic health records, he notes. Katz says he and other staf doctors working as salaried employees at the University of Iowa Medical Center are looking at overused practices identifed by the Choosing Wisely campaign and examining the evidence behind the recommendations as part of an internal efort to create more awareness about marginally efective treatments. “What’s driving that is macro-economics,” Katz says. “Te University of Iowa Medical Center is working to create an accountable care organization (ACO), and the idea is we have to be more accountable and discriminating in our use of treatments.” But some physicians will need convinc- Medical econoMics ❚ January 10, 2015 ES544416_ME011015_047.pgs 12.16.2014 23:19 47 ADV Defensive medicine ing to embrace the evidence-based model promoted by Choosing Wisely. In a 2014 online exchange about Choosing Wisely, a physician criticized the initiative, asserting he was involved in saving a patient’s life by not following a Choosing Wisely recommendation related to cardiac screening. Another physician replied that surgeons must individualize patient care based on risk assessment from a careful history and physical exam. Routine duplex scanning for carotid artery disease “is not indicated in the absence of symptoms or specifc risk factors, as there is not evidence that this screening results in improvements in patient outcomes,” he wrote. Who Will be in the driver’s seat? Te real question is who’s going to be in the driver’s seat with respect to defensive medicine, says Laura Hermer, JD, associate professor at Hamline University School of Law. “I ask doctors at CME talks: ‘Do you want it to be you or state legislatures?’ ” Te medical profession must mandate its own practice and ethical standards, Hermer says. “If you’re simply upping the ante at every turn because you’re worried you might be sued—and, by the way, you’ll get paid for it anyway—you’re not taking the right stand,” she says. As for Choosing Wisely, Hermer asserts the issue is whether it is “something that will translate to the courtroom.” Hermer coauthored a 2010 study on defensive medicine, cost containment and reform that concluded that traditional medical malpractice reforms won’t allay various pressures leading doctors to overprescribe and overtreat. But researchers said such reforms may be needed to persuade physicians to change practice patterns as part of a larger transformation to healthcare delivery and payment systems needed to curb costs. Hermer points to a 2014 RAND study published in Te New England Journal of Medicine that found defensive medicine is still prevalent in three states, including Texas, despite laws raising the legal threshold for malpractice in emergency settings. “In Texas, you have a state that implemented strong tort reform and you don’t see a reduction in defensive medicine as a result of that,” she says. “Te answer is physicians are going to continue to fear be- 48 Medical econoMics ❚ January 10, 2015 magenta cyan yellow black ing sued, notwithstanding tort reform, and probably notwithstanding strong eforts like Choosing Wisely.” good Patient communication is key For practicing physicians, preventing defensive medicine in their practices boils down to good communication with patients, says Richard Roberts, MD, JD, Professor of Family Medicine at the University of Wisconsin. “Te best we do is basically ask people, is this defensive or not? Would you be comfortable stopping at 95% certainty, and not doing three more tests for 98% certainty?” he says. “I think Choosing Wisely is a great idea, looking at the evidence and expert opinion, and letting people know you don’t have to do x, y and z, because there’s no beneft to the patient. Tere may be harm.” Roberts illustrates the idea that communication with patients is key: “Imagine I’ve been your family doctor for years, helped you, your kids, your husband. We’ve had this relationship over time, and one of your kids comes in with an ankle sprain. I say, ‘I don’t think [your child] needs an X-ray right now.’ I say, ‘I’m here tomorrow, you have my cell phone.’ My patients know we’ll be closely connected until the situation is resolved, even if they don’t get every test.” Roberts says when he is taking care of patients one-on-one, he doesn’t want his thinking clouded or his decisions skewed by worries about legal issues that he is unable to predict or control. “If you want to fx defensive medicine, develop trusted therapeutic relationships using efective communication skills and be available to patients, period,” Roberts says. “And then practice medicine using the best science available. Tat to me is about as good as it can get for a doctor. You can’t consistently look at the lawyer behind you or you’ll run into the wall.” More online Malpractice liability caps don’t reduce defensive medicine costs http://bit.ly/1AqLgKX Can ‘safe harbor’ laws stop the practice of defensive medicine? http://bit.ly/1zHrLQ9 Defensive medicine is now a part of physician training (commentary) http://bit.ly/1uvb045 MedicalEconomics. com ES544424_ME011015_048.pgs 12.16.2014 23:19 ADV Go to: products.modernmedicine.com Products & Services SHOWCASE ELECTRONIC HEALTH RECORDS Wonder what these are? Go to products.modernmedicine.com and enter names of companies with products and services you need. Search for the company name you see in each of the ads in this section for FREE INFORMATION! 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There is a lot of variation in how and when physicians seek specialist intervention—physician training and expertise, as well as the severity of the patient’s illness and their expectations for care, all factor into referral decisions. Yet when physicians make the call to send a patient to a specialist, there is no standard practice for evaluating the ft between the patient and the referred physician. Niteesh K. Choudhry, MD, PhD, and Joshua M. Liao, MD, both of Brigham and Women’s Hospital and Harvard Medical School in Boston; and Allan S. Detsky, MD, PhD of the University of Toronto, Mount Sinai Hospital and University Health Network made the case in a recent issue of the MedicalEconomics. com magenta cyan yellow black Journal of the American Medical Association (JAMA) for standardizing the referral process. “Physicians must often base their referral recommendations on little or no objective information,” the authors write. “Physicians have few mechanisms for personal performance feedback and little or no training in how to evaluate the quality of care that their peers provide.” Standardization could afect both the cost and quality of care, they argue, due to the fact that there is currently little consistency across the profession, with a variation of up to fve-fold. The issue is even more apparent in the inpatient setting, when everchanging on-call specialists are used. Even in ambulatory settings, the authors argue that patients are often referred to generic clinics or departments, with little consideration made by the referring physician as to which particular specialist would best suit the needs of the patient. Of course, authors note, there is a another end of the spectrum where physicians practice much more control over the referral process, but often availability of appointments, who works within certain networks, geographic locations, and the patients’ ability to pay are key factors in the referral process as well. In terms of patient preference, physicians may be apt to refer patients who value thoroughness to specialists who are “liberal” with diagnostic testing, or to those who have similar cultural beliefs as the patient. The authors suggest that some of the metrics currently reported for various industry initiatives, such as pay- for-performance or other federal programs, could also be used to help physicians select specialists for their patients. But that system would still have drawbacks, the authors note. “Although acquiring more granular and detailed data about physician performance maybe helpful, it alone will be insufcient for improving crucial aspects of the referral and recommendation process,” they write. “Knowing that a consultant’s patients generally achieve good glycemic control also does not indicate how easy it is for patients to have their blood drawn, how efectively results are communicated to patients, or how collegial or collaborative consultants and their staf are in comanagement along with referring physicians.” With this in mind, patient satisfaction scores may be a useful tool in making referrals. But the key to fnding a better method for the referral process will likely be a combination of clinical metrics and patient feedback, the authors conclude. Medical econoMics ❚ January 10, 2015 ES543976_ME011015_053.pgs 12.15.2014 22:11 53 ADV You know the drill: faxes, forms, phone calls, web portals, and the long wait before you get the prescription approved. No more. Simplify the whole process with CompletEPA®, a real-time, end-to-end electronic prior authorization solution that’s integrated within your EHR. As the solution for a majority of health plans, only CompletEPA delivers approved prescriptions before your patient even leaves the ofce. Ask your EHR to get CompletEPA For more information, visit Surescripts.com/CompletEPA Prior Authorization without the Frustration Copyright © 2014 by Surescripts, LLC. All rights reserved. magenta cyan yellow black ES543200_ME011015_CV4_FP.pgs 12.12.2014 02:01 ADV
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