From day one of his administration, President Donald J. Trump has pledged to repeal and replace the Affordable Care Act, an effort that gained and lost steam repeatedly. Efforts to chip away parts of the law continue both inside and outside of Congress. The Medicare Access and CHIP Reauthorization Act (MACRA), moved from acronym to reality as physicians began reporting data in hopes of avoiding reimbursement cuts, or receiving financial bonuses in 2019. And that’s what happened just in Washington, D.C.
On the front lines of healthcare, physicians continued to find themselves stuck in the middle. They are torn between patients and paperwork for their time. They are caught in between payers and patient requests. And with their career, many want to remain dedicated to medicine while fighting against the forces that further divide their time and attention.
POPULAR ONLINE: Shining a mirror on gripes
For the fifth consecutive year, Medical Economics reveals its list of obstacles physicians say they face next year and, more importantly, how to overcome them. As we’ve done before, we asked readers to tell us what challenges they face each day and where they needed solutions.
Here are their responses, starting with the biggest challenge of the coming year.
1. Avoiding burnout/remaining dedicated to medicine
For primary care physician Dan Diamond, MD, the signs of his looming burnout were evident.
“I was waking up as tired as when I went to bed and I was going to bed incredibly tired,” he says. “I had intense physical and emotional exhaustion and doubted whether I was actually making a difference in medicine for such incredible sacrifices.”
But something happened to Diamond after Hurricane Katrina in 2005. He served as director of the mass casualty triage unit at the New Orleans Convention Center. Surrounded by disease and death, he had a personal and professional epiphany.
“What got my attention were the people that in spite of losing everything, did not become victims,” he says. “Instead they became unstoppable and I wanted to become unstoppable myself.”
Today, Diamond deploys to sites of international disasters with Medical Teams International and consults with healthcare professionals on how to overcome burnout, build stronger teams and transform their organizations.
He is the first to acknowledge that the medical environment in the U.S. is “brutal” right now, between increasing regulations, physicians being tethered to their electronic health records and payers bringing productivity to a halt with prior authorizations and other requirements. Over time, those who went into medicine wanting to give back can get weighed down and this leads directly to burnout.
“I don’t think we can change whole organizations and cultures, without starting on individual mindset,” Diamond says.
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He encourages physicians to remember their passion for medicine and not let the challenges of the day—from a busy waiting room to cranky patients to dealing with payer rules—slowly drag them down.
Instead, he wants physicians to become “empowered givers,” focusing not on themselves, but rather their medical practice team and their patients first. By shifting attention to the team and its performance, the work becomes more manageable and care improves.
“As empowered givers, physicians can work to make the members of their team successful,” he says. “And then rally the team to look at the teams around them in [their medical] sphere of influence and do what we can to make the other team successful. I don’t see how we can go forward as a profession any other way.”
For more on physician burnout, visit bit.ly/18-burnout
2. The time demands of EHR data entry
Health information technology tools such as electronic health records (EHRs) have the potential to significantly improve care delivery and patient outcomes. However, physicians who have adopted EHRs continue to struggle to effectively use these systems because of the difficulty of dividing their time between the patient and the computer.
The average physician spends 30% to 50% of a patient encounter looking directly at the EHR, with the majority of that time spent typing in an office layout that does not allow the patient to remain engaged through screen sharing, according to 2013 research from the Journal of General Practice.
Thus the question has become: How can physicians find a balance between EHRs and satisfactory patient engagement? One solution is to use scribes, as Jerry Hizon, MD, told Medical Economics earlier this year.
“The key to a good EHR is the minimal touching of keys,” says Hizon, the owner of Motion Sports MD, a primary care practice in Murrieta, California.
Hizon says the scribe’s responsibilities are to update the patient’s medical records since his or her last encounter and determine the purpose for the patient’s visit.
After presenting the information to the physician, the scribe transcribes the physician-patient encounter through a combination of free typing and completion of pre-made templates. The scribe also documents all procedures performed in the office, new imaging and/or laboratory results and any notes from outside physicians.
Melissa Lucarelli, MD, a solo primary care physician in Randolph, Wisconsin and Medical Economics Editorial Advisory Board member Medical Economics Editorial Advisory Board member says that before entering the exam room she:
Studies the patient’s data and history to make sure she has the basic knowledge she needs to avoid relying on the computer;
Copies and pastes the patient’s history in her EHR to get a head start on the note before seeing the patient; and
Uses laptops on carts, which lets her position herself to look the patient in the eye regardless of the layout of the exam room.
“Ideally, your EHR would become invisible, but what I’ve set for myself as the sort of gold standard for the computer in the room, is to make it as unobtrusive as a paper chart,” says Lucarelli.
For more on overcoming EHR-related issues, visit bit.ly/18-EHRs
3. The growing number of uncompensated tasks
Doctors are spending too much time during their day on uncompensated tasks. As much as 20% of the workday is spent grinding through tasks such as prior authorizations, EHR data entry and non-clinical paperwork. This busywork costs physicians at least $50,000 in lost revenue annually, says Joseph Valenti, MD, a board member of the Physicians Foundation, a nonprofit group that advocates for practicing physicians.
It’s impossible to entirely eliminate uncompensated tasks from the daily schedule, but practices can minimize the disruptions they cause and redirect physician efforts toward revenue-generating work. Consider these solutions to common problems related to uncompensated care.
Problem: Non-clinical tasks
Solution: Physicians should avoid tasks that do not require a medical license. Physicians who find themselves performing non-clinical tasks, such as answering phones, should delegate these to non-clinical staff members. “What we’ve found is that physicians who are better at delegating unlicensed tasks to others are the ones who tend to have the highest net incomes,” says Keith C. Borglum, CHBC, a healthcare consultant.
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Problem: EHR documentation
Solution: Nitin Damle, MD, an internist at a small practice in Rhode Island, takes notes on a paper form during a patient encounter. Staff members enter the notes in the EHR afterwards. This adds to overhead costs as it requires additional staff, but Borglum argues that it can increase revenue by freeing up physicians to see more patients.
Problem: Family conferences
Solution: Physicians often spend uncompensated time addressing requests and questions from family members. Jeffrey Kagan, MD, an internal medicine physician and member of the Medical Economics Editorial Advisory Board, says it’s important to do this, but taking phone calls and responding to emails may not be the most efficient method. At his Newington, Connecticut-based practice, he asks families to accompany the patient to appointments. When the patient is present, he can bill for the time he spends talking with family members.
For more solutions on reducing uncompensated time, visit bit.ly/18-uncompensated-time
4. Third-party payer interference in patient care
David Belk, MD, who runs a solo internal medicine practice in the San Francisco Bay area, understands the frustration many doctors feel when insurance companies telling them how to practice medicine and require prior authorizations.
When a patient shows symptoms of diverticulitis, for example, he wants to order a CT scan, but it requires a prior authorization. “I don’t get paid extra for the scan, so why does a nurse from an insurance company have to sign off on that? How is that about saving money?” he told Medical Economics earlier this year.
Physicians are increasingly baffled by payers’ use of prior authorizations for what they say are often routine, low-cost treatments or for drugs that have already proven effective for years at treating a patient.
FURTHER READING: Payers becoming extreme headache for physicians
Interference from insurance companies costs practices time and money. Here are five ways to be more efficient when dealing with prior auths.
1. Document the details
Brief practice staff members on the importance of thorough documenting of symptoms and prior treatment measures. Payers need to see everything that’s been done for a patient and details of all the symptoms. The more they know, the less likely they are to challenge a doctor’s decision—or waste time by asking for details they should already have.
2. Know prior auth medications
Create a list of medications that commonly trigger prior authorizations, either in the EHR or on paper. Note which medications are on a payer’s formulary and keep that list updated. If physicians check the list before prescribing, many prior auths can be avoided.
3. Loop in the staff
Physicians are often focused solely on delivering the best care and not what payers are pushing back against. Encourage nurses and practice staff to keep all providers informed when prior authorization issues arise and to point out any tests or medications that continually create difficulties with payers.
4. Work with payers
Many prior authorizations may be unavoidable, but practices can still save time by finding out how payers prefer prior authorization communication and what details they are looking for.
Track the types of care for which payments are being denied. Are there recurring administrative errors that can be corrected? When a prior auth goes well, have the staff note how the information was delivered and to whom and use that same approach for future requests. Is one staffer getting approval for a particular treatment that gets denied when others request it? Examine the differences between approvals and denials for the same treatment.
5. Share the criteria
Once the payer criteria for prior authorizations is known, keep it handy so physicians in the practice know what kind of information to include in the request to better the chances of success. If possible, assign a staffer to particular payers so they are familiar with the requests and the rules for prior authorizations. These connections can lead to smoother approvals in the future.
For more solutions on reducing uncompensated time, visit bit.ly/18-uncompensated-time
5. Managing quality measure incentives / disincentives
The Centers for Medicare & Medicaid Services (CMS) recently released its final rule governing its Medicare Quality Payment Program in 2018.
While the final rule did not deviate significantly from the proposed rule released in June, there was a major change for those eligible for participation in the Merit-based Incentive Payment System (MIPS)—beginning in 2018 the cost category, based on claims data, becomes 10% of eligible physicians’ final MIPS score.
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This represents a major change from the proposed rule, which kept it at 0% next year. CMS will calculate cost through Medicare Spending per Beneficiary (MSPB) and total per capita cost measures for 2018—carryovers from the Value Modifier program.
The change will affect physicians—who already report struggling with managing quality measures and the incentives and disincentives that come with it—in a major way.
“Physicians are supplying data, but it stops there,” Owen Dahl, MBA, FACHE, a practice consultant, tells Medical Economics. Getting little direction from CMS “is a universal frustration for all offices I talk with.”
So, what can physicians do to make quality measure reporting easier?
Focus on what you do well
Because physicians and practices are allowed to pick the measures used to evaluate them, they should examine the menu and figure out where they might do well, says Cristina Boccuti, MA, MPP, associate director of the program on Medicare policy at the Kaiser Family Foundation.
Consider areas of improvement
Eric Schneider, MD, FACP, formerly a practicing internist and now a senior vice president for policy and research at The Commonwealth Fund, advises physicians to think about the selection of measures where there is room for improvement over time.
Think about type of clinical care
By selecting measures that accurately reflect the types of clinical care they most commonly provide, physicians will have sample sizes large enough to be statistically significant, Schneider says.
Range of quality measures does matter
According to Harold Miller, president and chief executive officer of the Center for Healthcare Quality and Payment Reform, physicians should ensure that the range of quality measures they choose is broad. The proposed list of quality measures “doesn’t even come close to being able to address the various types of patient conditions and the different needs of patients,” he says. “You wind up with a lot of those measures being designed for patients with only one health problem and don’t work well for those with multiple health problems.”
To better understand the Medicare Quality Payment Program, visit bit.ly/18-MACRA
6. Costs as barriers to patient adherence
Getting patients to adhere to a medication regimen has been a long-standing challenge for doctors. But the ever-rising costs of prescription drugs, combined with the greater share of those costs falling on patients in the forms of deductibles and copays, are making the task even harder.
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The reasons for the increases in prescription drug prices, whether brand-name or generic, are a matter of debate. But the impact on patients is not. Studies from a wide variety of governmental, professional and non-profit organizations all point to the conclusion that adherence is closely tied to the cost of drugs, and what patients must pay out-of-pocket to obtain them.
“All patients care about the cost [of prescriptions], even patients who are wealthy,” says Damon Raskin, MD, an internist and addiction medicine specialist in Pacific Palisades, California. “Especially older patients who are on multiple medications it’s a big chunk each month depending on what they’re taking.”
Doctors who have confronted the problem and experts recommend the following:
Address the issue head-on
“If adherence is detected to be a problem for a patient, one of the questions that’s often asked now is, ‘Are you having trouble affording your medications?’” says former practicing internist Eric Schneider, MD, FACP, now with The Commonwealth Fund.
Prescribe generics whenever possible
While prices for generic drugs have also been rising, in most cases they’re still substantially below their brand-name equivalents. So except in cases where a generic is ineffective or contraindicated, they are powerful tools for overcoming financial barriers to adherence.
Help patients find financial assistance
Provide information about the financial assistance programs most major pharmaceutical companies now offer. Patients who meet the income criteria can get free or deeply discounted copays. Nonprofit and government organizations in many communities also provide help to patients who can’t afford needed medications.
Turn to technology
Make sure patients know about the numerous apps and websites, such as GoodRx and OneRx,that enable comparison shopping for copays and/or provide access to discounts for certain medications.
Partner with pharmacists
As the professionals actually dispensing the medications doctors prescribe, pharmacists can help battle high drug costs. Some large, multi-specialty practices employ their own pharmacists who work directly with patients to find the most cost-effective medications for treating their diseases or conditions. Joe Moose, Pharm D., co-owner of a North Carolina-based chain of independent pharmacies, notes that the typical patient in that state sees a pharmacist 10 times more often than a primary care provider in the course of a year. “That means we have 10 times more opportunities to reinforce the care plan. That’s the real way you save on drug costs,” Moose says. He suggests making pharmacists part of the care team by sharing patient treatment plans with them whenever possible.
For more strategies on increasing patient adherence, visit bit.ly/18-adherence
7. The rapidly changing reimbursement landscape
After years of discussion, the shift from rewarding volume to value took formative steps this year, but there is uncertainty that it is moving at the pace set by federal officials.
In 2015, the U.S. Department of Health and Human Services (HHS), announced that it would tie 30% of all Medicare fee-for-service payments to quality or value through alternative payment models (APMs) by 2016 and 50% by 2018. These APMs include accountable care organizations and bundled payment arrangements among physicians.
Furthermore, HHS said it would tie 85% of all Medicare fee-for-service payments to quality or value by 2016 and 90% by 2018. A Centers for Medicare & Medicaid Services (CMS) spokesperson told Medical Economics via email it could tie 31.2% of fee-for-service payments to APMs in 2016 based on reconciled claims data. This result would be updated with quarterly data from 2016 as part of the next CMS budget in 2019, the spokesperson said, so it will still not have final data for some time.
Regarding the 85% projection, however, CMS says it would not comment on that goal at this time.
The spokesperson says that under a value-based system it is not CMS who should define value.
“CMS should equip patients with the information they need so they can choose the providers that they feel deliver high value,” the email states. “Patients must have the tools and incentives to seek value and quality as they shop for services—the competitive pressure that results will drive the system towards efficiency.”
The statement also says that “getting the move to value-based care right” requires giving clinicians flexibility on process and then holding them accountable for a small set of meaningful outcome measures. This ties to CMS’ recent “meaningful measures” initiative, its pledge to physicians to streamline quality measures and reduce regulatory burden.
CMS says the new approach to quality measurement will assess only core challenges to providing high-quality care and improving patient outcomes. It will achieve this primarily through a re-focused CMS Innovation Center, which will lead efforts to promote greater flexibility and patient engagement.
To keep up with the latest changes in physician reimbursement, visit bit.ly/18-reimbursement
8. Growing patient disrespect toward physicians
The doctor-patient relationship has changed in recent years. Whereas patients used to follow their doctor’s advice without question, thanks to the internet and social media patients today often come to the examining room convinced they know what ails them and what should be done about it. Meanwhile, doctors are able to spend less time with patients and thus can’t get to know them as well as they used to.
Gail Gazelle, MD, FACP, an executive coach for physicians and physician leaders and author of “How to Build Your Resilient Self,” discusses how these trends erode patient respect for physicians and the medical profession, and how doctors can respond.
Medical Economics: Do patients respect doctors as much as they used to?
Gail Gazelle: I think a lot has changed. We can all get vast amounts of information about anything. So that divide between physicians and patients has really shifted. There’s an attitude of, ‘How do you know you’re right, doctor?’ People can doubt the wisdom of the medical field.
In addition, society has changed. With all our electronic devices, we don’t relate to one another with the same compassion that we might have in the past. And with the corporatization of medicine, doctors have much less time with patients than they used to and many more distractions.
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ME: How does all this play out in the context of the one-on-one encounter between the patient and the doctor?
GG: What doctors talk about is the erosion of respect. Part of that’s on the patient’s side, but I think a great deal of it is doctors don’t feel respected by their employer. The doctor in private practice had a lot of autonomy. Now the doctor has become just another employee, and they’re not used to that. So the doctor enters the exam room feeling kind of resentful of all the pressures and not valued.
ME: Anger can sometimes be the product of discovering how much of a bill you owe. That’s different than no longer taking the doctor’s word as gospel, or respect. Is there anything doctors can do about those?
GG: I think what’s critical for both the doctor and the patient is basic human respect and compassion. So it behooves the doctor who encounters a hostile patient to realize it’s nothing personal. They need to check that personal reaction and ask, ‘What’s actually going on with this individual that they’re reacting to me in this way?’ Because when we do that, we come to a more compassionate place and have more clarity about what’s going on, what we have to accomplish in the medical encounter.
ME: Which can be hard to do sometimes, when it’s late in the day, and the doctor has had to deal with lots of other hassles?
GG: Of course it’s hard to do, but at the end of that long day the doctor will feel a lot better about herself or himself if they have responded this way than if they’ve gotten irritable. What’s going to make you hold your head a little higher at the end of the day? Aligning actions with our personal values, which for most doctors is caring for patients.
I’m a believer in the power of awareness and shared humanity of any endeavor. And the more we align with that I think we actually build pathways to mutual respect. We all want to be acknowledged and valued and have our basic human dignity appreciated. The more we can treat one another from that perspective I think a lot of these problems will resolve themselves.
Find more resources to improve physician-patient communication by visiting bit.ly/18-patient-relations
9. Remaining independent in a time of value-based care initiatives
The ranks of independent primary care practices continue to dwindle. A report from the American Medical Association shows that the percentage of physicians with an ownership stake in their practice declined from 53% in 2012 to 47% in 2016. The rising cost of compliance with government reporting and changing reimbursement models has forced many doctors to either join larger physician groups or sell their practice to a hospital.
Here are three strategies experts recommend to help physicians remain independent.
1. Change the practice model
If insurance reimbursements are declining and compliance costs are up, do away with both problems by contracting directly with patients via a direct primary care (DPC) model. Patients pay a flat monthly fee to the doctor in exchange for expedited access. By eliminating much of the documentation, billing and coding, doctors are able to spend more time with patients.
2. Join an ACO or become a PCMH
ACOs and patient-centered medical homes (PCMHs) are models that take a team approach to coordinating care across providers. The benefit to the physician is that patients receive better care, while many of the costs of compliance are shared across the group. Both ACOs and PCMHs may be eligible for additional payment bonuses from government and private payers, depending on their structure.
For Lerla Joseph, MD, a primary care physician in Richmond, Virginia, participating in an accountable care organization (ACO) was a way to stay independent and handle increasing government regulations. “As a small practice, we’ve been challenged by many things in terms of electronic health records (EHRs), regulations and managing quality metrics,” Joseph told Medical Economics earlier this year. Although doctors in her area were increasingly deciding to become employees of hospitals or large groups, she had no interest in leaving private practice, because she felt she could better serve her community by remaining independent.
3. Add ancillary services
If reimbursement from standard medical care isn’t providing enough revenue to survive, consider adding ancillary services to boost the bottom line.
In-house labs, echocardiography, X-rays, mammography, aesthetics and dietary assistance are all potential moneymakers, but experts warn to study the numbers carefully before making a commitment. Insurance reimbursement may not cover the full cost to provide a service, and patient demand may not be as high as projected.
But if the patient population is right and the service is carefully studied before buying anything, ancillary services can add much-needed revenue that allows a practice to remain independent.
To learn more best practices from private practices, visit bit.ly/18-independence
10. The ever-changing healthcare insurance marketplace
The year 2017 was one of great uncertainty in healthcare policy, and next year appears murky as well. President Donald Trump and Republicans in Congress made multiple efforts to “repeal and replace” the Affordable Care Act (ACA), failing each time. Meanwhile, Republican leaders have discussed Medicare and Medicaid reform, including per capita limits and block grants to the states, which if enacted could have significant ramifications for physicians and patients.
Medical Economics spoke with Robert Berenson, MD, an internist and fellow at the Urban Institute, about the coming healthcare policy challenges for physicians. Here is his advice for physicians.
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Physicians should not dwell too much on ACA exchange turbulence.
Physicians who see patients with insurance bought on the exchanges must be vigilant in monitoring changes to the ACA. Yet Berenson cautions physicians not to get overwhelmed by that and to focus on other areas, such as Medicare and Medicaid.
Only 4% to 5% of patients insured in America have coverage through the exchanges, Berenson says. “The Republicans have a major stake in exaggerating the problems of Obamacare,” he says. “They imply that it’s affecting all healthcare when it’s not. Now, if you are a doctor caring for marketplace patients it is going to affect you. I’m not minimizing it, but I just think the politics of it overwhelm the reality of it.”
Required to participate in MACRA?
If not, don’t worry too much about it.
As many as 134,000 physicians and 926,000 providers will be exempt from the Merit-based Incentive Payment System (MIPS), according to the final MACRA rule released in November. Since the exemptions exclude most small practices, this will leave almost exclusively large groups in the program, who will have to decide whether they want to attempt to earn a financial bonus through MIPS or shift to the Alternative Payment Model (APM) track, Berenson says.
“MIPS may not be applying to anyone anymore,” he says. “I’ve argued for three years that it was bad legislation. CMS is working very hard, correctly, to nullify the impact of MIPS.”
Physicians should find out now whether they are eligible for MIPS exemption. Physicians or groups with $90,000 or less in Medicare Part B charges or 200 or fewer Part B patients will not be required to participate in quality metric reporting.
Medicare and Medicaid reform attempts are coming.
The 2018 budget resolution passed by Congress to pave the road for Republican tax cut efforts included roughly $1.5 trillion worth of cuts to Medicare and Medicaid. Berenson says physicians tracking healthcare policy should watch for efforts to introduce premium support concepts into Medicare and block-granting and per-capita caps in Medicaid.
These programs are vital to patients, Berenson says. While he believes Republicans would be politically foolish to attempt these reforms, all indications are that House Speaker Paul Ryan and Republican congressional leadership plan to explore this, and that President Trump won’t stop them despite his assurances to protect the entitlement programs.
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“I think that’s alive and will be part of this going forward,” Berenson says. “How do you cut $1 trillion from Medicaid without moving to fundamental restructuring? That’s the same issue with cutting $500 billion from Medicare.”
Market consolidation isn’t going away—and many physicians want it.
The past year featured two failed mergers by four major payers in an attempt to gain market dominance. News in November that CVS wants to purchase Aetna shows that the payer market is still ripe for a shakeup.
Meanwhile, providers continue to integrate into larger groups, even while data suggest that smaller independent practices provide better care and value, Berenson says. “We are going to have more and more vertical integration, less because they are going to be more efficient and lower costs and more because physicians want to be employed,” Berenson says. “They want shift work.”
This trend is discouraging for national healthcare outcomes because there’s growing evidence that small practices provide better care, Berenson says. “Docs in small practices know their patients and they don’t have all these barriers to communicating with them. And so they have better performance, yet that’s who we’re putting out of business.”
For more information on changes with payers and how they affect practices, visit bit.ly/18-payers