Mary Pratt

The Centers for Medicare & Medicaid Services (CMS) wants physicians to use 2015-certified EHRs,  an upgrade that CMS officials believe will help providers more easily share patient information.

Requiring the use of these up-to-date EHRs comes after CMS redesigned its incentives under the Merit-based Incentive Payment System (MIPS), which is part of Medicare’s value-based-pay program affecting many physician practices.

Yet CMS and health IT experts estimate that thousands of physicians have yet to switch to 2015-certified EHRs. This scenario could leave those physicians scrambling in the coming months to make potentially costly and complex EHR upgrades. The alternative is to risk lower MIPS scores for 2019, which could mean lower Medicare reimbursements.

As a result, some health IT experts see the government’s push for physicians to update their systems as unduly burdensome.
“There’s a big group of physicians who haven’t made a switch to the new software, and those who aren’t on the 2015-certified EHRs are usually the small and independent practices,” says Robert Tennant, MA, director of health IT policy for the Medical Group Management Association, headquartered in Englewood, Colo. “We don’t want to impose such a hardship on these practices just to get them on some arbitrary standards with their EHRs that may not even produce higher quality of patient care.”





MIPS mandates physicians to use EHRs certified to have specific features and functions established under the federal government’s 2015 Edition Health IT Certification Criteria.

After months of discussion, CMS is finalizing its 2019 Medicare Quality Payment Program rules and is expected to approve the requirement for physicians to use 2015-certified electronic health records (EHR) systems in order to be eligible to receive the maximum MIPS score.
Many vendors have their 2015-certified EHR updates ready for physicians to implement, according to healthcare IT experts. And many medical facilities and physician practices already have implemented these updated systems.

In fact, the Office of the National Coordinator for Health Information Technology reports that 80 percent of clinicians have access to 2015-certified EHRs, with experts explaining that many EHR vendors don’t yet  have certified EHRs ready for the physicians using their technology.
But access to 2015-certified EHRs is not the same as having those upgraded systems implemented and in everyday use, says Jeff Coughlin, MPP, senior director of federal and state affairs at the Healthcare Information and Management Systems Society (HIMSS), a nonprofit health IT advocacy organization.

Indeed, the estimated number of upgraded EHRs actually implemented is lower: ONC earlier this year reported that at least 66 percent of clinicians eligible to participate in MIPS have 2015-certified EHRs.

Heath IT leaders say that’s a healthy track record of adoption, but they stress that the ONC figure means that one-third of the roughly 750,000 physicians in the United States don’t have the updated EHRs they’d need to meet these new CMS requirements.

Health IT experts say that physicians with EHR vendors who have yet to receive certification for their products (mostly the smaller and niche companies) and small practices without strong IT support services will be more likely to face such struggles than practices using EHRs from the bigger vendors and/or those practices affiliated with medical centers with IT departments handling the work.

Interoperability behind push for new certification



Physicians will still be able to practice without the 2015-certified EHRs; in fact, CMS is expected to require physicians use the updated version for only a 90-consecutive- day reporting period in 2019, which CMS officials say gives physicians time to implement the upgrades.

But Tennant says physicians will be hard-pressed to meet some of the anticipated reporting requirements for 2019 without a 2015-certified EHR in place and they will not be able to optimize their MIPS scores without having the upgraded version in place and fully utilized for at least one quarter of the upcoming year.

He says physicians could miss out on meeting requirements under Promoting Interoperability-one of four categories that make up the MIPS score-by not having a 2015-certified EHR in place. Moreover, physicians also might not be able to meet all the requirements under the Quality category without an updated EHR in place for the entire year.

Tennant says CMS should recognize that requiring this EHR upgrade is a hardship for many practices, pointing out that some physicians can’t afford the costs associated with implementing updated software while those whose vendors have yet to release a 2015-certified version are struggling to decide whether to wait or go the more costly route of finding  a new EHR vendor. He says his organization suggests CMS continue encouraging practices to move to 2015-certified EHRs while still allowing physicians to use their current versions without risking lower MIPS scores.

Still, many health IT leaders say they support the goals of the 2015 certification. “We’re big boosters of the 2015-CEHRT,” Coughlin says. “We talk about interoperability, and the steps and benefits included with the 2015 changes really promote greater data exchange.”



Physicians should anticipate a lot of work and potential extra costs associated with that work.

“An upgrade always takes longer than anyone anticipates, because there’s never anything seamless about something like this. And this is a major upgrade,” says Mari Rose Savickis, MPA, vice president of federal affairs with the College of Healthcare Information Management Executives (CHIME).

Tennant says the work involved in an upgrade varies based on numerous factors. Physicians with an EHR using an on-site server will likely need their vendor to come on-site to update the systems, while vendors offering cloud-based EHRs will be able to remotely upgrade the systems of their physician customers.

Physicians also will find that whether, and how much, a vendor charges for its 2015-certified EHR updates can vary, depending on their contracts, whether they’re on the most current version of their vendor’s EHR software or have skipped previous upgrades, and other factors, Tennant adds. They should expect moving to 2015-certified EHRs possibly to require re-working certain processes or adjusting to new user interfaces.  

As a result, physicians need to build in time to train themselves and their staff on their upgraded EHRs,  which could mean everything from learning how to navigate new screens to tweaking workflows, says Brooke Rockwern, MPH, an associate of health IT policy at the American College of Physicians.

Experts advise that physicians also plan for a reduced number of patients following implementation as they get accustomed to their new systems in addition to the downtime scheduled for actual training.



Physicians who don’t yet have a 2015-certified EHR in place need to determine if their existing EHR vendor has one available, Savickis says, noting that the government provides an online list of certified health IT products at https://chpl.healthit.gov/#/search.

If a vendor doesn’t yet offer a 2015-certified EHR, the physician needs to find out whether it will soon have one available. If the vendor doesn’t, the physician will need to find a different vendor and plan to take out the existing EHR and replace with a new one-a significant undertaking, Savickis says.

Some physicians might find, for example, that they need to upgrade some hardware; they might need new servers if they’re using server-based EHRs, or they might need new computers powerful enough to handle the upgraded software.

Savickis says physicians need to ensure their 2015-certified EHRs are fully tested to ensure everything works properly and securely. This process could reveal that the EHR doesn’t work well with other software systems, a glitch that will require additional technical work and testing to solve.

Additionally, physicians should anticipate a possible time lag in implementing the upgraded version of their EHRs, Rockwern says. Even if a physician or practice is ready to implement upgrades, the vendors, IT consultants and technical workers it needs might have a backlog of work as other providers get ready for the new CMS requirements

However, health IT experts say they expect CMS to provide hardship exemptions for physicians who aren’t ready in time.

Still, Tennant, Rockwern and others say that despite physicians’ frustrations over the years about their EHRs and government mandates around the use of technology, they believe the requirements for 2015 certification will bring improvements through improved interoperability capabilities, increased security features, a greater ability to incorporate patient-generated health information and more capacity to analyze patient demographic data to identify trends.

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Physicians whose EHR vendors have yet to receive certification for their products and small practices without strong IT support services will be the ones most likely to face upgrade struggles.

EHR certification: Is the latest standard attainable?

Patients are more likely today than in the past to seek care from multiple sources: their primary care physician, the local urgent care center, retail clinics, and even online. They’re also generating more healthcare data on their own, through fitness trackers or at-home devices like glucometers and blood pressure cuffs.

As a result, patients want technology that consolidates all that information and allows them to access and share what they need, when they need it. Patients will look for physicians who provide them with the online experiences that they’re used to and expect in other aspects of their lives.

“Over time, the customer is going to gravitate to providers based on convenience,” says Don Rucker, MD, national coordinator for health IT with the Office of the National Coordinator (ONC) for Health Information Technology.

Patient portals-intended to provide that improved engagement and outcomes-have yet to deliver on the promise. But that’s expected to change within the coming decade as portals become more patient-centered.

In the years ahead, experts expect portals will move beyond the limited functionality they have today and transform into a user-friendly technology that put a patient’s whole health history into one easy-to-navigate online portal.

“We’re going to see a highly personalized portal, one that aggregates data from multiple sources, that can contextualize the data, run analytics on it, and that can empower patients as they navigate their health journey,” says Mark Gilbert, MBA, director of research at Gartner Inc., a Stamford, Conn.-based IT research and advisory firm. “And I think 10 years out, we’ll find these tools will become a critically important part of a precision health model.”



Even though today’s portals typically have limited functionality, physicians still say they see them as the primary tool for engaging patients, says Adam Cherrington, MBA, research director of patient engagement at KLAS Research in Orem, Utah.

“[Physicians] call it the highway to the patient,” he says, “but they also tell us that adoption is still low. It’s still a challenge to get patients to log in.”

Cherrington says that the vast majority of healthcare providers (both systems and individual practices) have implemented patient portals, yet studies show less than 20 percent of patients on average log in and use them. And those patients who do use portals generally do so only to check appointment times, send or receive messages, or check lab results and healthcare records-even though some portals already offer more advanced functions such as online scheduling and even telemedicine options.

Health IT leaders point to a poor user experience as a significant reason for the low rates of use by patients.

“It’s a pain point we hear a lot from patients,” says Margeaux Akazawa, a public health analyst at ONC. “We can see patient portals as a success in getting patients access to their data, but they’re very limited. Not only are they very static, but they’re not designed with the user in mind.”

Cherrington predicts technology vendors will develop portals that are easier for patients and physicians to use, which he says should spur higher levels of adoption.

Similarly, health IT experts say technology vendors will increasingly optimize portals for mobile device use, because studies show people overwhelmingly use smartphones and tablets to access online information.

“What we know is mobile is the dominant platform for consumers today, so that has to be the predominant platform [for portals],” says Walter Jin, CEO of Pager, a New York City-based company that sells a mobile app to insurance companies to help guide their members through the healthcare system.

Making the user experience smoother and optimizing it for mobile use are critical steps that will help increase adoption rates, experts say. However, those steps are just the start of the improvements in portal applications expected in coming years.



EHR vendors are not the only ones developing patient-centered technologies.

Software companies outside the healthcare industry are introducing portal-like products, too, with experts pointing to the January 2018 announcement from Apple Inc. about its Health Records app as an example.

As these software makers create new features, physicians and patients can expect future portals to:

Deliver more information and support more interaction between patient and provider.

 Health IT leaders say portals will be the main tool physicians use to remind patients about upcoming visits, the protocols they need to follow between appointments, and other critical healthcare recommendations. Likewise, they see portals making it easier for patients to send emails, search information, schedule appointments online, and even securely exchange text (the preferred method of communication for many younger patients). Experts note that portals typically have these functions now; however, they’re not widely used nor are they always easy for patients and physicians to navigate. 

Organize and summarize patient data from multiple EHRs and consumer devices such as fitness trackers

. This will be done in a way that the average person can understand, and provide details and insights on what the patient’s healthcare data means for them. For example, portals will provide action plans from the patient’s physicians and links to appropriate guidelines or follow-up treatment guides. Portals will also use artificial intelligence-enabled self-management and self-diagnostic tools. “There is the potential for healthcare that’s happening in the doctor’s office to move back to the patient,” says Edward Yu, MD, a primary care physician and medical director of quality at Palo Alto Medical Foundation. 

 Patients will be able to initiate and conduct a virtual visit with a simple click from the portal. In turn, portals will make it easier for patients to provide relevant information in advance of both virtual and in-office visits via automated questionnaires contained within the portal, says Stephen Dart, MBA, senior director of product management with AdvancedMD, a South Jordan, Utah-based vendor of cloud software for independent medical practices. 

Offer more resources, including connections to support groups or communities focused on their specific health conditions or wellness concerns. 

“Portals will become richer as they’re able to incorporate other capabilities that patients want,” says Peter Kilbridge, MD, senior director for research at The Advisory Board Co., a healthcare research and consulting firm headquartered in Washington, D.C. For example, physicians could use portals to connect patients to nutrition programs or deliver ongoing content that helps motivate patients with chronic conditions to stay on track with their care programs. Taken all together, “the future of the portal is about getting the right data to the patient in an understandable format to help them engage and improve their ability to follow a healthcare plan,” says Ripley Hollister, MD, a board member with the Physicians Foundation and a primary care practitioner in Colorado Springs, Colo.

CHALLENGES TO IMPLEMENTING BETTER PORTALS



Such a future state isn’t that far off , according to health IT experts. Some portals already have advanced capabilities, such as telemedicine functions, online scheduling options, and the ability to access physicians’ notes. But those are the exceptions. Moreover, the technologies that will enable future features already exist.

Application programming interfaces, or APIs, and the Fast Healthcare Interoperable Resource (FHIR) standard already enable interoperability between systems. AI is being used to help physicians make diagnoses and plan the best courses of care. And many patient portals can be accessed by smartphones, even if they’re not all existing portals are yet optimized for mobile devices. Still, there are challenges to creating the more advanced features described above and achieving widespread adoption of them, health IT leaders say.

For starters, EHRs can’t yet easily share data with other EHRs. Similarly, many EHRs can’t readily accept or share data with patient-owned apps. Additionally, some providers don’t want to share all their notes directly with patients. Many others don’t want to open up their schedules for patients to set up appointments online without staff screening to determine the urgency of the patient’s needs.

Questions about how and how much physicians will be reimbursed for services offered via patient portals-such as telemedicine visits or text exchanges-could slow adoption of anticipated future features, Hollister says. “There’s a cost to this technology and the maintenance of it. Who will pay for those costs? Will the physician be reimbursed?” Hollister asks.

Physicians will also need time to incorporate the advanced patient portal capabilities into their practices, Hollister says, explaining that physicians will have to establish for themselves and their patients what types of information is appropriate to share via the enhanced portals of the future and what communication will remain best done via in-office visits.

Cherrington acknowledges that these challenges could stymie the patient portals of the future, with a lot of developments having to come together in order to see the high level of patient portal adoption that can then impact healthcare outcomes. However, he says, his research shows that optimism regarding future improvements is high in light of Apple’s entry into this market and other advancements.

Physicians and other healthcare providers see a future where this technology can help with interoperability by providing a conduit for sharing data as well as making data more accessible and thereby allowing patients to really take charge of their healthcare. “Providers want to not only have a vehicle to connect with their patients, but they want their patients to participate in their care by making it easier to navigate it,” Cherrington says.

And patients want this too, he adds, in the form of a tool that makes their experience smooth and easy when seeing their healthcare team. “That’s what has to happen, Cherrington says. “And whether we call it a portal or patient guidance tool or something diff erent, I don’t know. But it’s going to have to be something significantly useful for the patient and as that happens the value alone will keep patients coming back to it.”

In the years ahead, experts expect portals will move beyond the limited functionality they have today and transform into a user-friendly technology that put a patient’s whole health history into one easy-to-navigate online portal.

The future of patient portals

Physicians have good reasons to change EHRs. They switch systems to one that better meets their needs or integrates more easily with other healthcare practices in their region and hospital system. Sometimes they’re making the move because they want a better user interface or more robust features.

In fact, 62 percent of respondents to the Medical Economics 2017 EHR Report had already switched systems at some point in their careers.
Experts say the payoffs for making the switch can be positive, with gains coming from increased efficiencies and productivity gains. But they also warn that the costs of moving from one EHR to another can be significant-and usually much higher than most practices anticipate. From costs for new software and hardware to per-record transfer fees, charges can quickly add up.

Indeed, experts say, the costs of switching EHRs start well before the system is even implemented.
 



Russell Libby, MD, president of Virginia Pediatric Group, saw the bills start as soon as he decided it was time to switch to a new EHR.
At first, the costs were just in his own time as he worked with the other physicians in the practice to get their support for moving forward and as he researched different EHRs to decide which one would work best for his practice.

Then, as the project progressed, Libby involved others from his staff, asking them to review and test EHRs that he identified as contenders. They had to commit more time to review contracts and plan for the switchover project once the EHR was selected, too.

“That time is inestimable,” says Libby, also co-founder of American Pediatric Consultants Inc. and a board member of the Physicians Foundation. “You shut down the practice for an afternoon to see how you operate, compare it to how the system operates, and you may do this for two or three or four EHRs. And you need your whole staff sitting in the room and working with a representative from the vendor.”

Some practices could incur even higher costs, experts say, as many also travel to other practices to see prospective EHRs in action, a move that’s recommended but can mean hours away from seeing patients plus travel expenses.






There are many fees to watch for in EHR contracts, experts say.

“There are maintenance fees, software subscription fees, support fees. And you might have other fees, like signing up for a database that’s required to run the system or a fee for a coding system,” says Lydon Neumann, vice president at Impact Advisors, a healthcare information technology consulting firm based in Naperville, Ill.

EHR contracts also specify whether and by how much those fees can increase each year, a point well worth watching because typical annual increases of 5 percent or so can add up quickly over the life of a contract, says Kathy Downing, director of practice excellence at the American Health Information Management Association in Chicago.

Moreover, EHRs now bundle functions that were previously in other software, meaning a practice could be paying for capabilities such as scheduling, billing or secure messaging in its new EHR even though the practice may already own those capabilities in other applications, Neumann says.

Although buying all the functions through a single EHR vendor helps ensure those functions work together, physicians should still examine and compare costs and certainly shouldn’t pay for the same functions twice. Experts recommend a cost analysis to know whether taking the bundled features with the new EHR is better than keeping the existing functions with other vendors.



Software upgrades can require upgrades in hardware, too, Neumann says. Older printers, monitors, tablets and PCs might not work well with a new EHR, while older servers and networking equipment might not support the higher-intensity computing requirements of some modern applications.

Some practices that implement new EHRs, particularly if they’re moving from a system that ran on office-based servers to a cloud-based version, may also find that they don’t have the internet bandwidth to support the new software-thereby adding additional dollars to the total cost of implementation.

Vendors generally advise practices on hardware and networking requirements, and can sometimes even offer deals on those items, Downing says. “They’re not huge costs compared to other parts of the implementation, but it’s something to understand upfront,” she adds.

Practices also should anticipate the costs of integrating their new EHR with other systems, such as coding and insurance verification applications. These interface fees vary depending on what other systems need to interface with the new EHR and the complexity of the practice’s overall IT environment. For example, a typical office might face costs for integrating its new EHR with a secure messaging application (if not part of the new system) as well as potentially additional integration costs for tying the new EHR in with more specialized equipment, such as the software on an X-ray machine.

The cost and complexity of this work is often lower when the new EHR vendor has experience building interfaces to other applications from specific vendors, Neumann says. Given that, a practice might consider switching some of its other systems to products made by those vendors. That may be a smart move if the contracts for those other systems are nearing their end; however, it’s probably not cheaper or easier to do if that’s not the case or if the practice prefers its existing ancillary systems for any variety of possible reasons.

“A lot of times it takes some custom interfaces, and you might have to pay vendors on both sides [of the project] to make sure it works. And it’s worth having the conversation on whether it’s going to be an ongoing cost and what it’s going to cost to maintain them,” Downing explains.



Some practices hire consultants to help right from the start with the assessment of a new EHR. Libby says he did, noting that it cost him about $2,500 just for this early-stage advice.

For many practices, that’s just the start of the fees they’ll pay to the consultants they’ll hire to help with the EHR switch.
Of course, not all practices want or need multiple consultants, and they may actually find having too many involved can complicate the implementation, Downing says.

Libby, for instance, says he only used a consultant to help with the area where he felt he needed the most help: negotiating the contract. On the other hand, many physician practices, particularly larger ones with more complicated IT systems, use consultants throughout the entire process, from choosing the new EHR to getting the most benefits from it, experts say.

Downing says practices, particularly smaller ones without complicated IT needs, may find that the consulting services that usually come as part of the new EHR contract are adequate and more affordable.

Experts say physicians must decide whether they will need consultants to help them switch to a new EHR and, if so, what consulting services they will need and whether a single consultant or a single consulting firm can handle all of their needs which could range from customization and configuration requirements to staff training and software testing.

Some physician groups also hire project managers to help coordinate all the work, timeline, and personnel involved to ensure that deadlines are met and the implementation stays on track. “All that can get expensive very fast,” says Peter Winkelstein, MD, MS, MBA, executive director of the University at Buffalo Institute for Healthcare Informatics.

Practices frequently have consultants on site the day the new EHR goes live, and even during the first few weeks to get physicians and staff used to the new system and to help with any unexpected glitches.

“You need to provide that support at the point of go-live,” Stephanie Newkirchen, principal in life sciences and health care practice for Deloitte Consulting, says. While the cost can be unpredictable, because practices don’t always know how fast their physicians and staff will learn the new systems, she says practices commonly underfund this line item.

“The cost of that change management is always underestimated,” she warns.
 



Another frequently underestimated cost of switching EHRs is the price tag that comes with moving data out of the old application, experts say. Downing says she has seen costs run into the tens of thousands of dollars for physician groups.

This process may involve fees to both the previous EHR vendor as well as the new one. Costs vary depending on how contracts are structured. Experts say many existing EHR contracts between vendors and physicians don’t directly address how data will be transferred when the contract expires nor how much it will cost, leaving physicians to negotiate when they’re trying to switch. (That’s why experts advise physicians to address data-transfer fees when they’re negotiating initial contracts with vendors.)

There could also be fees for consultants or technical staff brought in to help with the data-transfer process. Then there are fees associated with archiving data that’s not transferred into the new EHR but still needs to be kept for regulatory or business requirements.

“You might have to pay for [your previous EHR] system to stay online just to meet your record retention requirements. That’s one bucket of cost that people just don’t think about and it can surprise them,” Downing says.

Transferring records from the previous EHR to paper files or discs is a cheaper option, Winkelstein says, but he notes that creating and storing those files to regulatory standards still have costs.
 



Productivity will almost certainly suffer when switching EHRs, and experts say that the dip in productivity could last months.
“The costs there are really human [resources] costs,” Libby says. “The time and effort within a workplace to prepare and convert and then to work in a new routine with the EHR is never, never made up by future visits or payments.”

Neumann says he advises a 10 percent to 20 percent reduction in scheduled patient visits during at least the first few weeks following the switch to accommodate the demands of learning the new system, creating workflows within the system, and tweaking interfaces to personal and office needs, although some physicians and staff members will learn the new system faster than others and will be able to return to full schedules more quickly.

Other experts warn that it’s difficult for an office to accurately gauge exactly how long it could take the practice to be back to full capacity.
“It could take at least a month and up to six months before you’re up to full productivity,” Winkelstein, who is also chief medical informatics officer of UBMD Physicians’ Group and chief medical informatics officer of healthcare provider Kaleida Health, says. “We usually recommend cutting the patient load down by 50 percent in those first few weeks because there’s a real productivity hit there.”

Underestimated and unanticipated expenses



Like any project, switching EHRs can result in unanticipated costs no matter how well a practice thought through an implementation plan. Missed deadlines can increase consulting costs or result in longer downtimes. Integrating the new EHR with other systems could be more challenging than expected. Productivity could dip more or for longer than anticipated.

Despite all his research, Libby says he encountered some unexpected costs for messaging patients shortly after he implemented his new EHR. “I didn’t realize [in advance] there was going to be that cost per message. There might be costs not there in the beginning but they’re going to show up. That’s something you have to be aware of,” he says, noting that his experience underscores the need to thoroughly review an EHR’s features and how fees for those are structured.

Neumann advises setting aside an additional 20 percent of the total implementation budget for unanticipated expenses or underestimated costs. “And once you’re into the implementation, that 20 percent should not be erased,” he says. “Think of it as a checkbook that you can draw on as needed, and if it’s not needed, it’s a bonus.”

The costs of moving from one EHR to another can be significant-and usually much higher than most practices anticipate.

The true cost of switching EHRs

	2016 was a challenging year on many fronts for healthcare providers.

	Physicians have just started to digest the 

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA

) and its changes to physician reimbursement. A long presidential election finally reached its conclusion, but the consequences of a Republican Congress and President-elect Donald J. Trump for U.S. doctors and patients remain unclear. And running a private practice did not get any easier. Balancing the need to deal with patients who won’t listen or won’t pay while also seeking positive patient satisfaction scores remains a daily struggle for many. 

	These were just some of the challenges physician readers told 

 they experienced this year and anticipate continuing for the foreseeable future. 

 reveals its list of obstacles physicians will face in the coming year and, more importantly, how to overcome them. For this latest presentation, 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.

	“MACRA is the biggest thing that’s hit healthcare payments in a generation,” says John Goodson, MD, an internist at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School. “This is going to be transformative.”

	And even though MACRA begins taking effect January 1, many physicians still don’t know what they need to do to comply. 

	“Each practice needs a Paul Revere to ride through shouting, ‘MACRA is here, change is here,’” says L. Patrick James, MD, chief clinical officer, health plans and policy and medical affairs for Quest Diagnostics, a healthcare technology provider. “Physicians need to get together and accept it. If you haven’t already started, you need to get started ASAP.”

	Accept reality. Healthcare reimbursements are migrating from volume to value. MACRA will most likely serve as the road map for other payers, so get used to the reporting requirements, says James. “Physicians have gotten a lot better over the years with electronic health records (EHRs), but it’s going to be even more important that physicians aren’t just ‘doing’ but documenting,” says James. Documenting and reporting every treatment through a certified EHR or other approved method is the only way physicians can get paid for services.

	Get educated. The law directs physicians to choose one of two reimbursement paths-advanced alternative payment models (APMs) or the Merit-based Incentive Payment System (MIPS). Most small practices probably will opt for MIPS, which measures quality, advancing care information (meaningful use) and clinical practice improvements to start (resource use will be included later.) 

	“Figure out what you are already doing that you can get credit for under MIPS that you haven’t declared,” says John Squire, president and chief operating officer of Amazing Charts, an EHR vendor. “Many are based on treating diseases to improve outcomes and using prevention screening-most physicians are doing that today.” 

	Understanding these gaps between what you already do and what MACRA requires is key to a successful transformation. “Take a deep breath and don’t panic,” Squire says. “It can be daunting when you look at your to-do list, but you don’t have to do it all at once.”

	Develop a plan. MACRA compliance isn’t going to happen without a commitment to change management, says James. “Create a vision, get your practice together and develop a plan,” he says.

	This includes making sure all services are billed properly, says Goodson. Ensure that every diagnosis is part of the billing for that patient, and that all ICD-10 codes are attached to the bill. With the focus on patient wellness, make sure the plan includes scheduling annual wellness visits and transitional care management (TCM) visits, when appropriate.

	“For TCM visits, there are few documentation requirements and they are quite reasonable,” says Goodson. “These visits benefit both the patient and the physician.” 

	The increased contact also helps enhance overall engagement, which makes for happier patients and better outcomes, he says. “The better the relationship between doctors and patients, the better the doctor can manage resource allocations for those patients,” Goodson adds.

	This is one area small practices may have an advantage over their larger competitors, because physicians may know their patients better and know where they can influence behavior and where they can’t, Squire says. 

	When planning for MIPS, remember that some easy points are available just by following good practice procedures, says Squire. As an example, he cites the practice improvement category, which accounts for 15% of the total MIPS performance score. The category offers easy wins for those who plan and document for steps such as reserving time for same-day appointments, performing medication reconciliation and communicating with patients via a portal or messaging. 

	Under MACRA, in addition to the 15% for improvement activities, quality accounts for 60% and advancing care information is 25%. (Cost won’t be counted until 2018.) This composite score is used to calculate financial bonuses and penalties. “Make sure you know the components of the MIPS scores and plan for them,” Squire says.

	And remember, the healthcare industry will be developing products and services that support MACRA, so talk to vendors to find out how they can help. Squire suggests starting by seeing what technology your EHR vendor can deliver to assist with the changes, and branch out from there. For example, talk to lab vendors to find out what they can do with lab results or digital images to help with the advancing care information score.

	Don’t procrastinate. MACRA was originally supposed to take effect at the start of 2017, but the Centers for Medicare & Medicaid Services (CMS) has delayed full implementation until January 1, 2018, allowing practices to submit partial information or participate only for part of 2017. “Have a plan for 2017, but be ready to go in 2018,” says Squire. “The delay was a reprieve, but CMS is not rescinding the rule. Don’t ignore it.”

 requirements have increased steadily in recent years, and the growth trend shows no signs of abating in 2017.  

	That’s the bad news. The good news is the growing array of products and services available to medical practices that are designed to speed up the prior auth process. There is also the possibility that value-based payment models could reduce the number of drugs and procedures that need approval before payers will cover them. 

	In the meantime, prior auths remain an unpleasant-and increasingly common-fact of life in healthcare. For example, a 2015 Kaiser Family Foundation analysis of Medicare data found that 23% of drugs in private drug plans covered by Medicare Part D required prior authorizations, up from 8% in 2007. During the same period, the percentage of drugs carrying some type of utilization management restriction more than doubled, from 18% to 39%.

	The proliferation of prior auths is largely a function of cost, says Jack Hoadley, Ph.D., a health policy analyst at Georgetown University’s McCourt School of Public Policy and the lead author of the Kaiser study. 

	“As drugs get more expensive, especially drugs where the use is complicated or has questions about appropriateness, then we see plans and PBMs [pharmacy benefit managers] increase their use of prior authorizations,” he says.

	The nation’s changing demographic profile is also playing a role, notes Randy Vogenberg, Ph.D., principal of the Institute for Integrated Healthcare in Greenville, South Carolina. As more people become eligible for coverage under Medicare Part D, he says, drug costs rise, and plan administrators turn to prior auths as a way to control costs.

	Physicians see the increase in prior auth requirements in their practices. George G. Ellis Jr., MD, an internist in Youngstown, Ohio, and 

’ chief medical adviser says his practice spends about 32 hours per week handling prior authorizations, up from 25 hours two years ago. Kevin de Regnier, DO, a solo primary care provider in rural Winterset, Iowa, says his practice’s weekly authorization requests are up between 40% and 50% compared with 2014. 

	While there isn’t much that individual providers can do to stem the rising tide of prior auths, technology may help minimize the amount of practice time they consume. The e-prescribing company Surescripts, for example, has developed a software that integrates with electronic health record systems to streamline the prior auth process. 

	Looking longer term, Vogenberg predicts that the growth of value-based payment models will limit the growth of prior auths, or possibly end the need for them entirely. Prior auths are a process, he says, but the healthcare system is moving toward rewarding outcomes.

	“So while it’s true you’ve still got a lot of prior auth activity going on, I think we’ll soon see the rigidity of the prior authorization system being loosened, and at some point it’s just going to be incorporated into your outcomes measures,” he says.

	De Regnier expresses a similar desire. “I do hope that as we move into more quality-based payment methodologies, especially those involving downside financial risk for physicians, insurance companies will understand that with physicians having real skin in the game, they can get out of our way a little,” he says. 

	As payers move to consolidate, physicians find themselves facing the prospect of 

declining reimbursement and narrowing provider networks

. Many doctors lament that payers now come to the table with a “take it or leave it” approach, 

 to one-sided contracts to maintain their patient head count. 

	But while the ability to negotiate remains a challenge, and varies to some extent by region and payer, it remains possible. One key: physicians should focus on the value they provide to patients, their successes and why the payer needs them.

	“The payers need you to take care of their beneficiaries,” says Elizabeth Woodcock, MBA, FACME, a healthcare consultant and author with Woodcock & Associates. “One of the things I recommend is to create a fact sheet, a pitch, for your practice. Here is your pitch, here is your value in the community. You want that one sheet in your back pocket when payers start talking about quality and narrow networks."

	One physician finding success with these techniques is Melissa Lucarelli, MD, a solo physician in Randolph, Wisconsin, and member of the 

 editorial advisory board. She enlists the help of her staff to build payer negotiations considerations into her weekly workflow processes so that she can be prepared when it’s time to negotiate. It starts with a spreadsheet containing all of the practice’s payer contracts and some key information for each, including termination clauses, how quickly they pay and reimbursement rates for commonly-used codes.

	As the time for contract negotiations approaches, Lucarelli meets with her clinic manager to review some of the problems the practice encounters when working with the payer and discuss potential opportunities for enhancing the practice’s value to that payer, such as quality data and star ratings assigned by payers.

	“I always try to figure out for this company, what are they valuing and monitoring, and how are we measuring up?” Lucarelli says. And it’s not the time to be timid: If the practice is doing well at taking care of the payer’s patients, “It’s not unreasonable to ask to be rewarded more,” she says. 

	Woodcock acknowledges that it’s not always possible for physicians to negotiate significant reimbursement increases. Furthermore, too many physicians focus on that goal and ignore other crucial areas. For example, physicians should pay attention to claim filing deadlines and “take-back” provisions-essentially how long after a claim is filed that the payer can revoke payment because of a mistake. All of those items are negotiable, Woodcock says.

	Even physicians attempting to negotiate in markets with heavy payer concentration,  still have some strategies they can use. Woodcock suggests going bold: Find the large employers in the markets and talk to their benefit managers, share data about the practice’s successes in taking care of their employees and the focus on quality.

	“Sometimes employers call payers and say, ‘You need Dr. Smith,’” Woodcock says. “I can’t say it will always work, but it will turn heads.”

	And don’t rely on e-mail and other impersonal communication methods. Get on the phone and talk. Remember, negotiations occur between people, and building a relationship between the physician and the negotiators for the payers can only help strengthen the doctor’s position, Lucarelli says.

	“I can make a human connection,” Lucarelli says. “That’s what doctors are good at, so move this uncomfortable business stuff into our playing field.”

	Challenge 4: Staying motivated to practice medicine

	Like everyone else, doctors want to enjoy their work, but they are finding it harder to do so.

 has been steadily growing in recent years, driven by increasing workloads and frustration at being unable to spend sufficient time with patients. 

	While the larger forces driving physician unhappiness aren’t likely to change soon, experts say there are steps doctors can take on the practice and individual levels to combat burnout and maintain their enthusiasm for practicing medicine.   

	In the most comprehensive study of physician dissatisfaction to-date, published in the December 2015 issue of Mayo Clinic Proceedings, 54% of the physicians surveyed reported at least one symptom of burnout in 2014, compared with 46% in 2011. The percentage of respondents reporting satisfaction with their work-life balance declined from 49% to 41%.

	In contrast, the study found minimal changes in rates of burnout or dissatisfaction with work-life balance among other working adults in the U.S. 

	By now the causes of physician unhappiness are well known, says Christine Sinsky, MD, FACP, an internist and vice president of professional satisfaction for the American Medical Association (AMA), who coauthored the study. They include ever-increasing amounts of time spent on administrative tasks and documentation, frustration with the demands imposed by electronic health records and the feeling they are having to cede control of their practices to government regulators and third-party payers.

	“It’s a cumulative effect of well-intended efforts adding up to a burden of work that no one anticipated,” says Sinsky. “Physicians feel they’re spending their days doing the wrong work, and that leads to burnout.”

	To address the problem, the AMA has created a series of online tutorials-which Sinsky calls “transformation toolkits”-designed to help practices operate more efficiently and enable physicians to gain more control over their workday. Many of the tutorials focus on ways doctors and practices can save time, such as renewing all of a patient’s medications once a year, or spreading documentation and data entry among members of a care team.

	“By doing some of this reengineering, within the constraints imposed by EHRs and regulations, doctors can create a lot more room in their day for enjoyment,” she says. 

	Along with making changes in their work environment, doctors can combat burnout by employing stress reduction techniques, such as mindfulness-the state of “living in the present moment, in a compassionate way, without judgment,” says Gail Gazelle, MD, FACP, an internist and executive coach for physicians.

	Gazelle cites the example of a doctor starting his day knowing he faces a full schedule that includes difficult patients and frustrating tasks, such as dealing with prior authorizations. That leads to fears of getting home late, having to stay up late finishing the day’s work and memories of being unhappy when that’s happened before.

	“Worries about the future, ruminations about the past, all these things pull us away from the present,” Gazelle says. “When we can pay attention to what’s actually in front of us, without the overlay of what might happen or what should happen, it often isn’t that bad.” 

	Meditation, the practice of keeping one’s attention focused on one thing-such as breathing-can help people achieve mindfulness, Gazelle says. And while the common perception is that meditation requires setting aside large blocks of time, in reality it can be practiced while performing everyday activities, such as paying attention to the feelings in your feet as they lift off of and touch the ground while walking.

	By developing the habit of focusing on the here and now, Gazelle says, “doctors become more resourceful for their patients and their staffs, and can be a little kinder and gentler to themselves.”

	Challenge 5: Maintenance of certification

For the fourth consecutive year, Medical Economics reveals its list of obstacles physicians will face in the coming year and, more importantly, how to overcome them.

Author | Mary Pratt

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