Keith L. Martin

	It’s no medical breakthrough that different patients respond to the same medication differently.

	But it is now becoming more obvious that different patients will also respond to the same treatment plan differently due to external conditions.

	Those non-medical factors–ranging from access to transportation to income to simply where they reside–are commonly referred to as social determinants of health. And according to the American College of Physicians, the medical society representing internal medicine physicians, it’s time to acknowledge these determinants are major influencers in a patient’s road to wellness.

	“This is about your zip code, not your gene code,” ACP President Jack Ende, MD, said during the society’s annual conference, held this year in New Orleans. “Where a person is born and what the social determinants of health are for them can have very, very significant outcomes on health.”

 by the ACP, featuring nine policy recommendations to address social determinants of health. They include the organization’s
	• support for increased efforts to evaluate and implement public policy interventions;
	• support for adequate and efficient state, federal, tribal and local funding to address social issues;
	• recommendation to adjust quality payment models and performance measures to reflect the increased risk of caring for disadvantaged patients; and
	• promotion of social determinants of health lessons into medical education.

	“We need to teach people how to do this,” said Sarah Candler, MD, MPH, chair-elect of the ACP’s Council of Resident/Fellow Members. “We need to acknowledge social determinants and know that not everyone has the same opportunities, but also have policies to teach [physicians] how to look for them and policies to address them.”

	Entering his third decade of medical practice, Ende noted he learned nothing about social determinants of health in medical school. This resulted in him, and many of his peers, “missing the big picture” for their patients.

	Candler practices at the Michael E. DeBakey VA Medical Center and talked about the challenges she faces everyday with her patients in improving well-being, but also taking social factors into account before, during, and after a visit.

	“As a primary care doc, I tell my patients all the time that my job is to keep them as healthy as they want to be for as long as they want to be that way,” she said. “Unfortunately, it’s disappointing to know that sometimes my patients can’t get there because of some of these social determinants of health.”

	Candler discussed the “homework” she gives patients and tasks they can perform to keep them healthy between visits, but also acknowledged she has some extra learning to do as well. That can range from asking a recently diagnosed diabetic how taking insulin will fit into their job functions or asking about transportation to ensure critical prescriptions are filled and taken.

	“It’s my job as a doctor to make sure my patients’ voices are heard when they don’t have those things,” she said.  “I think it is my job, as a doctor, to look for those reasons my patients may not be able to have the same opportunities for health.”

	Former acting assistant secretary for HHS and National Coordinator of Health Information Technology, Karen DeSalvo, MD, MPH, put the need to address social factors bluntly.

	“It’s the right thing to do to understand social challenges … and work with our community partners,” DeSalvo said. “Yes, there is also a business case, but it’s what we should do.”

 that the ACP’s work means a lot to her given her time as health commissioner for New Orleans following Hurricane Katrina as well as in her newest role, as president-elect of the Society of General Internal Medicine, an organization dedicated to internal medicine research and teaching.

	“I want to see that we just don’t care about it, that we take action around social determinants,” she said. “That means coming up with strategies that make sense in the clinical environment and building partnerships and that we change policy. … And I want physicians to be educated and be sure we keep the humanity in what we do as doctors. I want it to be a priority.”

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Internists urge focus on non-medical factors to truly drive patient improvement, promote health equity

Addressing social determinants ‘the right thing to do’

	Year one of the Medicare Quality Payment Program’s Merit-based Incentive Payment System (MIPS) is in the books. As physicians anxiously await reimbursement implications for 2019, they cannot let up on year two initiatives.

	While CMS enacted a “pick your pace” approach in 2017, allowing physicians to essentially dip their toes into the value-based pool, this year requires more data, a larger reporting period and therefore, more focus on how their practices are promoting quality care.

	“In our first year, we focused on maximizing participation,” said David Nilasena, MD, MSPH, chief medical officer for CMS Region VI, based in Dallas, Texas. “We emphasized that and had some success there last year.”

	Nilasena, who spoke at this year’s American College of Physicians annual conference in New Orleans, added that CMS continues to find ways to make the program “continually easier” for physicians to participate in.

	But for many private practices, tracking and collecting data on their patient panel and simply understanding the program is the main obstacle. Others remain hopeful that the Trump administration will simply repeal the program, so they are hesitant to participate past the minimum requirements for fear of spending time and energy on a temporary effort.

	In 2018, under MIPS, physicians must no longer simply score three points to avoid a decrease in payment, but instead score at least a 15 on the program’s four categories: quality (comprising 50 percent their score); cost (10 percent); clinical improvement activities (15 percent); and advancing care information (25 percent).

	Ryan Mire, MD, FACP, of Nashville-based multi-specialty practice Heritage Medical Associates, said this is an important number for all physicians participating in the Medicare program.

	“QPP is a program we need to understand to get paid,” he said. “The bottom line is that we all want to make more money, but we definitely do not want to lose money. So you want to make sure to at least get the minimum score of 15 to at least meet our current payment rate from CMS. The better you do, the more incentive.”

	Mire, who helped oversee MIPS at his 140-physician private practice, told 

 that physicians “have to take this seriously” as the value-based environment is here and looks to be around for a while.

	The key for his practice, Mire said, was changing the culture in team-based care, requiring buy-in from everyone from the primary care and specialty physicians to medical assistants, nurses, and other non-physician providers.
	 

Traditionally, we’ve worked in silos as the physician and the head of the team, taking care of the patient,” he said. “But now we are in a more team-based environment, with physician extenders that can do a lot of this work, such as contact patients after discharge, do their medication reconciliation, which once again, minimizes cost because it decreases [hospitalization]. So physicians need to get to a point of team-based culture.”

	During the session, Mire detailed several best practices for private practices to survive and potentially even thrive under MIPS, including:

Become recognized as a patient-centered medical home.

 “A lot of the same concepts for PCMH translate into results in MIPS from quality improvement and using an EHR to just clinical improvements,” he said. Under MIPS, such recognition gives practices full credit for the clinical improvement activities category, “and that’s one less pillar [in MIPS] to worry about,” he told 

 Utilizing the Healthcare Effectiveness Data and Information Set (HEDIS) at a practice to measure performance on care standards can go a long way, he said. Several HEDIS measures align with MIPS criteria.

Getting educated on the QPP is critical, he said. This includes utilizing tools from the ACP, CMS, and other professional organizations that are geared toward helping small practices with finding the best measures for them to report on.

One physician offers advice to peers to make value-based care work at private practices, and perhaps even see financial gains.

Surviving and succeeding in MIPS as a private practice

	Technology has the power to connect, but also the power to divide, as physicians well know.

	One of the biggest barriers now in the physician-patient relationship lies in doctors’ constant typing, clicking, and touching screens to get every detail of a visit documented. Many bemoan their lot as glorified EHR data-entry clerks, wasting their medical knowledge.

This article appears in the 4/10/18 issue of Medical Economics.

	And then there’s telemedicine, a technology that promotes well-being by connecting physicians with patients even though they are in different locations. Some would call it “good” screen time vs. the EHR-fueled distraction that exists in an exam room. 

	Telemedicine is a tremendous tool to increase access to much-needed medical advice and intervention for rural patients, those with transportation issues, or any patient confronting a geographical obstacle to getting in front of a healthcare professional.

	But I also worry about its misuse. I worry that telemedicine used as a tool to increase the quantity of patient visits will lead to the detriment of the quality of visits. I worry that in a hurry to meet millennials where they live-in their phones-practices and physicians will rush into the decision to implement e-visits whenever and wherever a patient wants in order to keep up with the times. 

	Today’s tech-enabled world gives us the power to demand immediacy and for things to revolve around our schedules: from food delivery to when we watch certain television shows. But patients shouldn’t dictate the process of a thorough examination for medical treatment due to their desires or convenience.

	Telemedicine isn’t right for all practices either. Like any other evolving tech tool, jumping in too quickly can be costly for both the physician and practice.

Physicians face punishment for speaking out against non-physician care

	In this issue, you’ll find information on how to set up a telemedicine program the right way-taking into account the long-term goals of your practice vs. just implementing it because other practices are doing so. We put this information together to help you separate the sales pitches from the true value of telemedicine. 

	In an era of tech-enabled patients and sometimes tech-encumbered physicians, there has to be a balance. Physicians know when a problem can be diagnosed on a hand-held screen and when something requires the physical touch and interaction with a physician in an office. 

	In the right hands, telemedicine can complement a physician’s mission to improve well-being. In the wrong circumstances, it can actually put lives in danger. So before using technology to improve patient connectivity, be cautious. 

 is editorial director for Medical Economics. Do you see telemedicine as more of a benefit or a detriment to healthcare? Tell us at medec@ubm.com. 

Technology has the power to connect, but also the power to divide, as physicians well know.

Adding more ‘screen time’ for  physicians must come with caution

	Last year, Cleveland Clinic announced it was expanding its telemedicine program to 24 states outside its Ohio headquarters, signifying a growing trend. More hospitals and health systems are expanding their online patient visits into other markets.

	But experts note that just because a patient living outside Ohio can see a physician from the Cleveland Clinic, doesn’t mean they will. Rather than presenting a challenge to small medical practices, it can present an opportunity.

	“I, personally, would prefer to see my own primary care physician via telemedicine rather than meeting a new physician and working with them via telemedicine,” says Kristi Fahy, manager of informatics, information governance and standards at the American Health Information Management Association.“Fostering ongoing patient loyalty can be seen as a driver to encourage small physician groups to consider implementing telemedicine.”

	Fahy adds that telemedicine extends to connecting patients  with specialists. Some patients may have to travel long distances for a referral or don’t have the option of choosing preferred specialists based on where they live. Through their primary care provider’s telemedicine connection, however, they can visit a familiar, nearby office and have a customized telemedicine consultation encounter with a specialist of choice and with their trusted primary care doctor in the room.

	“That small practice physician continues to stay involved in the patient care path through telemedicine,” she says. “These patients can more easily keep up with follow-up visits and hopefully keep up with their medication needs through the physician they are loyal to already.”

	Providing telehealth access not only makes a smaller practice more competitive, Fahy says, it can also increase revenue. This can include seeing more patients online and in the practice as well as taking advantage of numerous reimbursement opportunities from government and private payers. This year, Fahy notes, Medicare has 96 codes for telehealth-related payments.

	However, like any technological tool available to practices, telehealth must have a focus for the medical practice before implementation, including identifying ways to integrate its use into the practice. 

	Neha Sachdeva, a director at consultancy KPMG’s advisory healthcare and life sciences practice, says physicians need to first “identify the ‘why’” when implementing telehealth services. This includes the purposes for adoption, asking if it makes sense for the business, and how it can benefit both patients and the practice.

	A thorough analysis of how telehealth will keep the practice competitive is critical. This includes taking a hard look at costs to implement the program and what reimbursement opportunities it opens up. 

	“Telemedicine isn’t a silver bullet to solve all physician problems,” Sachdeva says. “It shouldn’t be the only option to help remediate all the challenges to [patient] access or financial challenges.”

	Like Fahy, Sachdeva sees a well-implemented telehealth program as a competitive edge for small practices. As regulatory and reimbursement challenges are reduced, telemedicine will have the opportunity to become more of the norm than the exception in care delivery.

	“You also have an evolving patient population, used to doing everything on a smart device or online in all other aspects of their day-to-day activities,” she says. “Patients will start to shop around … so I think telemedicine helps organizations remain competitive and provides a service to help them not only retain patients, but acquire new patients as well.” 

Rather than presenting a challenge to small medical practices, telemedicine can present an opportunity.

Author | Keith L. Martin

Articles

Addressing social determinants ‘the right thing to do’

Surviving and succeeding in MIPS as a private practice

Adding more ‘screen time’ for physicians must come with caution

Telehealth as a competitive edge, not a competitor's advantage