Physician News

Use EHRs to avoid unnecessary care

Marla Durben Hirsch - Contributing Editor — Wed, 01 Feb 2012 11:29:26 -0500

Electronic health records can do more than identify which patients should be receiving preventive care and other additional services. They also can help providers pinpoint who shouldn't receive care, according to a recent study published in the Journal of the American Medical Informatics Association. The researchers studied EHR data from clinics affiliated with Northwestern University to see if the data could flag and measure whether certain patients were receiving pap smears too frequently, FierceEMR reported. The study found that EHR data was sufficiently precise to better identify which women are at low risk for cervical center. --Read the full article from FierceEMR

ACOs must be ready to manage populations with tech, staff

Debra Beaulieu — Wed, 01 Feb 2012 10:53:32 -0500

For accountable care organizations (ACO) to succeed in their goal of providing improved care at reduced cost, participants are being asked to use data to more effectively manage populations of patients. This means not only a shift in mindset for involved practices but also likely enhancements in technology and staffing to help make that happen.

For starters, practices that want to take part in ACOs should optimize their use of electronic health records to be much more than a repository of data, according to Physicians Practice. Practices that already have become accredited patient-centered medical homes will have an edge in this respect because they're already using EHRs to track, analyze and improve the health of patient populations, said family physician Dick Salmon, Cigna's national medical director who oversees its ACO program. Their EHR usage goes "beyond just documenting what happened with the patient visit," he added.

And using such data effectively will require additional patient outreach and monitoring, noted Richard Lopez, internist and chief medical officer at Atrius Health, an ACO in Massachusetts. Doing so could entail adding tasks for existing staff members, as well as hiring new employees. However, practices might want to consider hiring people without healthcare degrees to handle some phone follow-up, Salmon said.

Finally, meeting ACO cost and quality targets rely hugely on patients following their health providers' recommendations, such as to exercise or take their medication. To boost patient engagement, Lopes suggested ACO providers implement a patient portal in which patients can request prescriptions and appointments and view lab results and related material.

To learn more:
- read the article in Physicians Practice

Selling practices to hospitals can hurt profits

Debra Beaulieu — Wed, 01 Feb 2012 08:38:54 -0500

Despite the trend, selling your practice to a hospital isn't a surefire way to increase profits. To the contrary, physicians who give up control to hospitals may see their incomes drop, especially if their practice was well-run to begin with, according to an article in Medscape Today.

There are several possible reasons to back up the recent finding from the Medical Group Management Association that hospital-owned practices are 25 percent less productive than those that are privately owned:

Centralized billing. Within independent practices, a symbiotic relationship between the front-desk and billing staff drive both sides to do an effective job. When centralized billing staff take over, removing that connection, the accountability and communication needed to help both groups succeed may diminish.
Lack of physician control. When physicians lose control over their billing, they tend to loosen oversight over their practices, according to consultants. The authors also note that billing and collections are more optimal when physicians do their own billing and coding. A third-party coder, who didn't actually provide the services, suffer an obvious disadvantage in documenting and coding encounters correctly.
Lack of performance incentives. When physicians feel more like employees, they can also feel less responsibility for the practice's financial performance. But it is possible for hospitals to recapture some of the employee and physician engagement that may be lost when a practice is no longer independent. Practices that have seen revenue dip after being acquired may want to ask hospitals to set up incentive systems to promote financial performance. It also could be worthwhile to bring billing staff back to the office, where they'll feel more involved and motivated than at a remote location.

To learn more:
- read the article from Medscape Today (registration required)

Docs practicing outside specialties stir controversy

Debra Beaulieu — Wed, 01 Feb 2012 07:47:06 -0500

With insurance reimbursements flagging, a growing number of physicians are looking to create new revenue streams by offering patient-paid cosmetic procedures. The criticism: Many of the physicians newly offering face-lifts and breast augmentations are board certified in specialties other than plastic surgery.

"The public needs to be protected from doctors who are not upfront about what board certifications they have," Malcolm Z. Roth, chief of plastic surgery at the Albany Medical Center in Albany and president of the American Society of Plastic Surgeons, told The New York Times.

In turn, the society's rival, the American Academy of Cosmetic Surgery (AACS), composed primarily of doctors who are not board-certified plastic surgeons, says traditional plastic surgeons simply don't like having competition. "For a certain group to wage a turf battle and say for financial reasons that they are the only ones who can safely perform cosmetic procedures is hypocritical and grossly untrue," AACS President Angelo Cuzalina told the newspaper.

While certification by the American Board of Plastic Surgery, one of 24 boards endorsed by the American Board of Medical Specialties (ABMS), requires a minimum three-year residency in the chosen area of concentration, plus extensive oral and written exams, physicians receiving training from many sound-alike boards not recognized by the ABMS may take a mere weekend course aboard a cruise ship before giving Botox injections or performing liposuction on patients.

There are no laws in the United States that require doctors to practice only within the specialty fields in which they were trained, noted NYT. Only Texas, California, Louisiana and Florida mandate that doctors specify in their advertising which specialty board certifications they have; elsewhere, they may say only that they are "board-certified."

To learn more:
- read the article in The New York Times

Medicare opt-out data still elusive

Debra Beaulieu — Wed, 01 Feb 2012 05:03:39 -0500

Despite anecdotal reports that increasing numbers of physicians are dropping out of the Medicare program, the Office of Inspector General has been unable to fulfill its goal of getting at the real numbers and reasons behind the trend. According to a Jan. 26 memo sent to Marilyn Tavenner, acting administrator of the Centers for Medicare & Medicaid Services, the OIG simply doesn't have access to enough data to conduct a meaningful investigation, Healthcare Finance News reported.

Although CMS provided the OIG with 7,900 providers ranging from 1998 to March 2011, only one out of 10 Medicare Administrative Contractors and one of six legacy carriers provided OIG with all data elements required by CMS. Thus, the OIG said it couldn't sample opted-out physicians to interview, Business Insider reported.

Based on the limited data available, however, the OIG reports that the number of physicians opting out of Medicare appears to have increased each year from 2006 to 2010. The agency warned that if Congress does resolve the sustainable growth rate cuts to Medicare physician payment, more doctors may opt out in the near future.

"Although the percentage of physicians who choose to opt out may be small (perhaps less than 1 percent), monitoring the number of opted-out physicians and their specialties is important to ensure that Medicare beneficiaries have sufficient access to providers, including specialized providers," the OIG stated in its letter to Tavenner. "Additionally, having appropriate data on opted-out physicians is essential to ensuring that such physicians are not inappropriately receiving Medicare payments."

To learn more:
- read the article from Healthcare Finance News
- see the post from Business Insider
- read the memo released by HHS (.pdf)

Patients email docs about conditions, complaints

Debra Beaulieu — Wed, 01 Feb 2012 04:04:08 -0500

Despite the years-long debate over the pros and cons of physician-patient email, there's been little insight available to doctors about what kinds of messages to expect from patients or vice versa. But in a new study entitled, "You've Got Mail: Exploring Patient-Provider Email Communication in a Primary Care Setting," researchers dug into the content of 527 unique, de-identified email messages from three general practitioners collected over 90 days.

Through their analysis, University of Kansas researchers Mugur V. Geana, assistant professor of journalism, and K. Allen Greiner, associate professor of family medicine at the KU Medical Center, both former physicians, identified some characteristics of the electronic messages.

Doctors took an average of 23 hours to reply to a patient's email, compared to five hours for patients. The longer it took physicians to respond, the lengthier their responses tended to be. Patients did not appear to be dissatisfied with physicians' response time.

Seventy percent of physician emails were in response to a patient's message, while the rest were emails providing test results, appointment reminders or other similar items. Treatments and lab tests were the most common topics of discussion for both patients and providers.

Regarding patient emails, about 18 percent of patients' email messages included complaints of some sort. Among the emails with complaints, 9 percent were about the doctor, 13 percent about other medical personnel, 17 percent about their treatment, 61 percent about the evolution of their disease, and 26 percent about other issues.

Twenty-three percent of them were about medical problems of a family member or friend they were caring for. About a fourth of patients' emails included updates on their condition, most commonly when it had gotten worse.

The researchers hope to expand their preliminary findings to get more in-depth answers about how physicians and patients use email and why.

To learn more:
- read the press release from the University of Kansas

5 low-cost ways to boost employee competence and confidence

Debra Beaulieu — Wed, 25 Jan 2012 11:21:58 -0500

Deb Beaulieu

One memory sticks out from the day I started my first "real" after-school job. It was a warning from my mom, just as I was leaving the car, to expect a moment when I felt that I'd have to quit immediately. No matter what triggered it, she said, the impulse to run for the door would be almost overwhelming. The feeling would pass, she reassured, if I managed to persevere. But it would be back--without warning--at some moment during every job I would hold for the rest of my life.

And I'll be darned, Mom was right.

When I retell the story to my own children, I'll add this: At the root of each of those terrifying, fight-or-flight moments was the feeling that I simply wasn't competent to do what was being asked--whether the task was as menial as opening a box when no sharp objects presented themselves or having to jab another human being with a decidedly sharp syringe--it was a lack of confidence that caused the panic.

When medical practice employees quit, or, more subtly, continually avoid doing something in their job descriptions, they might not admit to feeling overwhelmed or unsure of what to do. But while it's been long advised that a major key to reducing staff turnover is providing adequate training, strained budgets can make it difficult to ensure education is adequate.

Fortunately, however, there are ways to weave meaningful training into your practice's work flow without adding much cost. Consider the following:

Ask all employees to, perhaps anonymously, share one thing they struggled to figure out during their first week on the job. It could be unjamming the photo copier, working the switchboard or handling an angry patient. Keep track of these items over time, look for patterns and pay special attention to helping new employees overcome these common pitfalls.
Assign mentors. Mentorship can be an invaluable asset for physicians, and there's no reason it can't work for employees too. But sending a new hire out to lunch with a seasoned "buddy" on his or her first day isn't going to cut it. Pair up individuals you think will complement each other and give them ideas for activities to do together on a regular basis. Sometime during the first week, for example, the mentor could give the trainee a tour of all of the office supplies and equipment they'll be using, giving them a heads up as to any quirks. Perhaps a month later, they could practice role-playing ways to handle sticky situations with patients or even coworkers. Incentivize employees to serve as mentors by giving them first pick of summer vacation days, entering all mentors into a raffle to win a prize or offering some other perk that won't cost much or disrupt the harmony of the practice.
Hire interns. By hiring a low-cost of free intern, you not only get work done at a reduced rate but potentially create a future employee who knows your practice inside and out. So, when working with interns, make sure you encourage them to stretch and learn as much as possible from their experience. By challenging them, without putting on too much pressure, these individuals can develop a comfort level and loyalty to your office, making them perfect full-timers down the line.
Swap jobs. Developing a schedule for employees from different nonclinical departments to swap jobs for a day (or even a few hours) serves a variety of purposes. First, it helps cross-train employees, giving you a contingency plan for days you might be understaffed. Next, it allows employees to have a better appreciation for what their coworkers do, as well as a better understanding of how their own work makes or breaks the other's success, such as with front-office employees taking accurate demographic information for the back office. Finally, moving employees around occasionally allows them to connect with other employees. Whether employees learn new things from each other incidentally or simply builds each other's network of support, the exercise stands to benefit the practice in surprising ways.
Praise problem-solving. While most practice administrators and managers I've talked to recommend an open-door policy in which employees feel comfortable asking questions, they also want to hold people accountable to figure some things out themselves. You can create a more collaborative, free-thinking culture at your practice by simply asking patients for feedback on problems or decisions. Encourage employees to present ideas for how things could be done better, more quickly or with less confusion, and be open to testing whether they work. And when you notice an employee doing a good job of addressing a problem--or helping a coworker overcome one--be sure to commend that person publicly.

In many ways, building employee confidence comes down to building their trust--among coworkers, with managers and in themselves. The better employees feel about their own skill sets and the resources around them, the less likely they are to flee from challenges. - Deb @PracticeMgt

Experts debate merits of physician-patient email

Debra Beaulieu — Wed, 25 Jan 2012 09:41:14 -0500

This month's Wall Street Journal's "Big Issues" feature focuses on healthcare, including a debate-style article with two expert views on physician-patient email conversations, FierceHealthIT reported. Arguing in favor of physician-patient emails, Joseph Kvedar, founder and director of the Center for Connected Health in Boston, says the practice helps build better relationships and is good for business. And, he adds, privacy concerns are overblown. Meanwhile, Sam Bierstock, founder and president of Champions in Healthcare, a healthcare IT consulting group in Delray Beach, Fla., argues that email should be limited to basic patient-doctor communications, such as appointment scheduling and prescription refills, as email does not allow physicians to watch patients' important reactions to information or ensure that the information exchanged is accurate and understood. The FierceHealthIT report also includes an overview of the arguments for and against unique patient identifiers. --Read the full FierceHealthIT article

State invests $1M in medical home training

Debra Beaulieu — Wed, 25 Jan 2012 09:00:37 -0500

Most people are familiar with the proverb, "Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime." A new initiative in Ohio seeks to apply that philosophy to expand the use of the patient-centered medical home model for primary care.

In particular, the state will invest $1 million from the state's newly created Office of Health Transformation to train 1,000 to 1,500 doctors, nurses and other professionals to better handle electronic medical records, create disease registries, schedule patients efficiently and manage new channels of communicating with patients, the Associated Press reported.

With a recent report revealing that the medical-home transition is indeed a stressful endeavor for employees, the support should come as a welcome gift to the 50 Ohio facilities that the investment will reach.

State Sen. Peggy Lehner, who sponsored the law when she was in the Ohio House, told the AP that she recognized the time, stress and money involved in changing a well-established, over-worked practice into a technology-driven, team-oriented medical home. "It made a lot more sense to train medical students, residents and nurse practitioners in this model from the very beginning," she added.

The funds are intended to benefit not only employees of the 50 sites but also to offer scholarships to medical and nursing students to experience hands-on training for how to deliver care under the model.

A state law signed in 2010 helped pave the way for 44 sites without money to support the practices' transition to medical homes. The new program fully funds training at those sites and opens up the door for six more medical homes, all of which provide care to underserved or minority populations in the state.

To learn more:
- read the Associated Press article on CBS Moneywatch

Doc groups push SGR repeal to be funded by war savings

Debra Beaulieu — Wed, 25 Jan 2012 07:58:53 -0500

Congress should use money allocated for Overseas Contingency Operations (OCO), a budget line no longer needed for the Iraq and Afghanistan wars, to help fund a permanent fix to the sustainable growth rate (SGR) formula, urged more than 100 medical societies and physician groups, including the American Medical Association (AMA), Medscape Medical News reported.

Although political parties agree on the SGR, which currently calls for a 27.4% cut to Medicare reimbursements March 1, Congress has been unable to agree on how to pay for the solution. The Congressional Budget Office estimates it to be $290 billion if rates are frozen for 10 years.

In a Jan. 18 blog post, however, AMA President Peter Carmel wrote: "There is also now a clear pathway to offsetting the cost to repeal the SGR. Both the president's budget and the House-passed budget produced substantial savings--more than $1 trillion--by reducing future allocations for overseas contingency funding."

Organized medicine followed up the appeal Monday with a letter to Rep. Dave Camp (R-Migh.), chair of the House Ways and Means Committee, signed by 110 medical societies throughout the country. "Using the OCO baseline as an offset for the accumulated SGR bad debt amounts to 'cleaning the books' by eliminating one flawed budget gimmick with another," they wrote.

The idea's supporters, including medical societies representing every state except Alaska, Indiana, Louisiana and Utah, also encourage Congress to move swiftly, as the cost of SGR repeal escalates over time.

"An SGR patch of two years will cost $39 billion in 2012, increase the cost of repeal to $346 billion, and increase the size of the next scheduled cut to physician payments to 36%," they wrote. "Pushing off this problem continues this reckless pattern of spending billions of dollars only to make future cuts deeper and more expensive to solve."

To learn more:
- read the article from Medscape Medical News (registration required)
- see physician groups' letter to Congress
- see the press release from the AMA
- read this post from the AMA's On the Road with Dr. Carmel

Specialist referrals doubled over decade

Debra Beaulieu — Wed, 25 Jan 2012 07:02:16 -0500

Physician referrals to specialists have roughly doubled during the past decade, reveals a study published in the Jan. 23 issue of the Archives of Internal Medicine. Although the increase in referrals made by both primary care and specialist physicians is clear, the research itself does not point to definitive reasons behind the surge, Medscape Today reported.

But the lack of causation data hasn't prevented the authors and other health experts from taking a crack at solving the puzzle. One theory proposed by the authors and backed by Sarah Kliff, blogger at The Washington Post's Wonkblog, is that financial incentives lead physicians with an ownership stake in their practices to be more than 50 percent more likely to refer a patient to a specialist. Although Kliff argues that referrals "would increase the total revenue generated by a given patient," internist and blogger Kevin Pho counters that, stating that very few physicians have any financial incentive to make referrals, and that the point becomes even less relevant as more doctors enter salaried hospital positions.

The next hypothesis is that the increasing complexity of healthcare combined with "the tyranny of the 15-minute office visit" leads doctors to refer out more cases. Bloggers, for the most part, indicated this theory was plausible.

Finally, Pho argues that "failure to refer" is the leading reason why physicians are sued; it essentially represents another form of defensive medicine.

Nonetheless, Mitchell H. Katz from the Los Angeles County Department of Health Services in California points out in an editorial accompanying the study that it is unclear from current medical literature what might be the right frequency of referral. Despite the possible reasons driving referrals, we still don't know whether physicians are "referring too often, too infrequently or (most likely) both," he said.

To learn more:
- read the article from Medscape Today (registration required)
- see the post from The New York Times' Prescriptions blog
- see the post from The Washington Post's Wonkblog
- see the post from KevinMD.com
- see the study abstract from the Archives of Internal Medicine

Pressure for health price transparency mounts with new bills

Debra Beaulieu — Wed, 25 Jan 2012 05:56:35 -0500

Less than a year after a Florida law made it voluntary for doctors to post price lists in their offices resulted in very few having done so, a new pair of bills up for hearings Wednesday would require many physicians to disclose their prices to patients, the South Florida Sun-Sentinel reported.

Under one bill, doctors' offices would have to post signs, showing prices for their 50 most common procedures. Both bills would require doctors to give each patient a price sheet at every visit. In addition, the legislation would force hospital-owned urgent care centers to post whether they charge emergency room prices and give a price break to patients who can't give permission for treatment by a health provider that's not part of their insurance network.

The bills, H.B. 1329, sponsored by Rep. Richard Corcoran (R-Trinity), and S.B. 7186, sponsored by the Senate Health Regulation Committee, chaired by Sen. Rene Garcia (R-Hialeah), have drawn opposition from healthcare lobbyists who argue the rules are punitive and take money from physicians, according to the newspaper.

As for posting prices, some medical groups claim it isn't sharing the information they object to, but having to pay for the signs that also would clutter up their waiting rooms. The argument against the other part of the legislation, which waives extra fees for patients who have no control over where they are treated--such as when taken to an out-of-network emergency room while unconscious--is that insurers would be excused from paying the fees, as well. Thus, the legislation essentially takes money out of providers' pockets, according to the Florida Medical Association. In turn, doctors may cease seeing out-of-network patients if the bills pass, according to the Association.

A recent Bloomberg Business News column by Peter Orszag, vice chairman of global banking at Citigroup Inc. and a former director of the Office of Management and Budget in the Obama administration, contends that few government price-transparency efforts, thus far, have resulted in patients becoming smarter consumers. A better approach, he wrote, may be found in the example of Castlight Health Inc., which provides individual, private information to employers about their employees' out-of-pocket health costs. By keeping the data unavailable to the public, the Castlight approach also may reduce the likelihood that greater price transparency would lead to collusion among providers, he said.

To learn more:
- read the article from the South Florida Sun-Sentinel
- see the column from Bloomberg Business News

Business loans surge for struggling doctors

Debra Beaulieu — Wed, 25 Jan 2012 03:27:26 -0500

As further evidence that physicians are struggling to keep their practices afloat, government-backed Small Business Administration (SBA) loans issued to physicians have dramatically risen from less than $60 million in 2000 to $675 million in 2011.

While some physicians say they've applied for SBA loans just to meet payroll amid falling insurance reimbursements and ever-changing regulations, others have invested the money into transitioning to concierge or direct-pay business models, CNNMoney reported.

According to CNN, doctors tend to favor SBA loans, which are government-guaranteed bank loans, because they are easier to get and have lower interest rates than regular loans.

Meanwhile, with banks still suffering from the real estate crisis, many are eager to meet growing demand in healthcare, the Las Vegas Review-Journal reported.

In Nevada, for example, Plaza Bank, City National Bank and Bank of Nevada all report to have enhanced their services to doctors, clinics and medical specialty groups looking to meet growing local demand. And with competition heating up for loan business in the healthcare sector, some banks are rolling out new products specifically with physicians' needs in mind.

According to Ali Rizvi, chief banking officer with Plaza Bank, in response to numerous physician requests for a simplified loan application and revolving lines of credit of as much as $100,000, the bank introduced its HealthPro product, which includes those features plus access to payroll service, online banking, courier service and a single point of contact with a manager assigned to the client.

For banks, medical business also is attractive because physicians tend to have a lower default rate than other clients, the newspaper noted.

To learn more:
- read the article from CNNMoney
- read the article from the Las Vegas Review-Journal

Retail labs let patients bypass physicians

Debra Beaulieu — Wed, 18 Jan 2012 09:52:21 -0500

With the pressure mounting on physicians to reduce unnecessary testing and services, a new retail niche is opening for companies that allow patients to order their own tests, NPR reported.

At Any Lab Test Now, for example, which has 100 stores nationwide, patients can go to a storefront and order, off of a "menu," tests from an HIV screening to a "fatigue" panel. According to company co-owner Anthony Richey, the service is appealing to patients because it's convenient, fast and confidential. Although a company physician reviews the results before releasing them to patients, he or she provides no medical advice other than to follow up with one's own physician.

Even though some states such as New York and Rhode Island prohibit what's called direct access testing, experts expect testing franchises to prosper in a market where insurance companies pass along more lab costs to consumers.

But despite its potential to empower patients, critics say the trend comes with risks. For example, Michael Wilkes, professor of medicine at the University of California, Davis, noted that inevitable false-positive results will not only cause patients anxiety but also lead to an array of unnecessary repeat and additional tests when patients follow up with their physicians, ultimately driving up health costs. Moreover, experts such as Rodney Forsman, president of the Clinical Laboratory Management Association, said they worry about the motives of those turning lab tests into a commodity.

To learn more:
- read the post from National Public Radio's Shots blog

Medical home employees satisfied but risk burnout

Debra Beaulieu — Wed, 18 Jan 2012 09:46:43 -0500

Providers and staff at patient-centered medical homes have high levels of morale and job satisfaction, but they also have a risk of burnout, according to a new study published Thursday in the Archives of Internal Medicine. More than half of survey respondents (53.7 percent) said they were satisfied with their jobs and about a third (32.8 percent) graded their morale as good. Less than half (49.5 percent) said, "occasionally I am under stress at work, but I don't feel burned out," FierceHealthcare reported. While the industry looks at the medical home approach to coordinate and improve quality care, the study offers insight into how front-line staff are reacting to the model. --Read the full report from FierceHealthcare