Physicians often struggle to help patients with chronic obstructive pulmonary disease (COPD) make and maintain the lifestyle changes and medication regimes necessary to manage it. No single approach is sufficient, so experts recommend a multi-pronged strategy to manage this complicated disease.
	
	COPD is shorthand for a group of diseases that cause airflow blockage and breathing problems. While its most common cause is smoking, for a small number of people, the cause is genetic. It affects more than 15 million people, and poses a significant burden to the U.S. healthcare system. The Centers for Disease Control and Prevention (CDC) estimates the annual costs of COPD were $32.1 billion in 2010 with a projected increase to $49 billion by 2020.
	
	


	
	COPD patients often present with symptoms including chronic cough, shortness of breath during regular daily activities, wheezing, excess mucus, and fatigue.
	
	As a result, COPD and asthma are often used interchangeably, to the detriment of COPD patients, when they are not the same disease process, according to Keith Robinson, MD, an associate pulmonologist with Pulmonary Physicians of South Florida in Ft. Lauderdale.  “I spend a good chunk of my time actually erasing diagnoses and giving patients the right term for what they have,” Robinson says.
	
	Before discussing treatment options, it’s important to confirm the diagnosis with spirometry, the primary diagnostic tool for COPD. When patients who truly do have COPD receive a diagnosis it’s also often extra motivation to make the lifestyle changes to keep their disease from progressing, Robinson says.
	
	The test is also important because even smokers who are symptomatic may still have normal lung function that doesn’t qualify as COPD. Those patients will still need education and intervention to prevent COPD from developing, but the treatment process may be different.
	
	Once a diagnosis has been made, the next step is to get patients to stop smoking, says Philip Diaz, MD, a professor of medicine in the pulmonary, critical care, and sleep medicine division at Ohio State University Wexner Medical Center in Columbus.
	
	“Getting off smoking is the best way to prevent the disease from progressing,” Diaz says.
	
	Diaz relies upon a combination of pharmacotherapy-Chantix and Wellbutrin as key medications-and counseling to help patients quit. He finds it more effective to get patients to commit to a single quit date than to titrate slowly off.
	
	Some people’s disease process can still progress even after quitting, but usually more slowly than if they continued.
	
	Robinson also encourages physicians to prioritize the patients who are at the mild and moderate stages of the disease, because they can have the most impact on those patients’ disease process.
	
	


	
	COPD, like many chronic illnesses, isn’t one that physicians can manage alone, says Ken Thorpe, Ph.D., a professor of health policy at Emory University in Atlanta. He says patients are better served when they have a care team that can make sure that none of the elements of their care are not overlooked.
	
	He says that while physicians may do a good job creating treatment plans, things often fall apart in the execution. “A care team is really important. These patients are going to be in a physician’s office infrequently for a short period of time and the key is, what happens when they leave?” Thorpe says.
	
	In addition to the physician, a care team might consist of a pharmacist and a nurse practitioner to manage medications, and possibly a care coordinator to help with transitions in and out of the hospital if the patient is acute. “Care teams are generally very diverse, because people with these chronic diseases often have other chronic diseases,” Thorpe says.
	
	Thorpe also recommends a program created by the CDC known as the National Diabetes Prevention Program. The name is misleading, he says, because it’s really just a useful lifestyle program that offers education, exercise, nutrition, and behavioral advice for anyone with a chronic disease.
	
	“It focuses on reducing the number of diabetics from pre-diabetics by generating weight loss behavior change but it has impact on a whole host of conditions,” he says. “Many physicians don’t know the benefit exists.”
	
	

Behavioral approaches to lifestyle changes


	
	Once a diagnosis is confirmed, quitting smoking is only the first lifestyle change that COPD patients need to make to stay as healthy as possible. Exercise is especially important for COPD patients to manage their symptoms, Robinson says. It may seem counter-intuitive to recommend exercise to patients who are short of breath, but it is effective, he says.
	
	This can be a challenge for many physicians, since patients often are reluctant to begin exercising. “If our patients weren’t really physically active as young adults, they’re not all that inclined to become active after they get a diagnosis of COPD,” Robinson says.
	
	To encourage this behavioral change, his practice treats COPD patients as if they are struggling with an addiction, that addiction being a sedentary life. “We’re learning that COPD is a behavioral disease as much as an obstructive lung process,” Robinson says.
	
	To overcome patients’ resistance, physicians in Robinson’s practice rely on motivational interviewing rather than just telling people what they should do differently. “We have patients reflect back on the activity or the lack of activity and ask them about what benefited them or what potentially might be the harm of not trying to change that behavior,” he says.
	
	They also ask patients to reflect on what they have missed out on in life due to fear of shortness of breath or the embarrassment of being seen with an oxygen tank. They’ve also drawn upon scientific research that has found milder forms of exercise such as Tai Chi, yoga, and Pilates meet the same level of activity improvements as getting patients up on a treadmill for twenty minutes.
	
	“More importantly, the mindfulness that they get out of [these exercises] and the awareness of their breathing becomes a foundation for those activities,” Robinson says.
	
	Meditative breathing techniques can also help COPD patients, says Siobhan Bulfin, founder and CEO of Melon Health, a San Francisco-based healthcare consulting company that helps clinicians enable patients to self-manage chronic illnesses.
	
	“With COPD we’ve focused on breathing techniques because we know that shortness of breath causes people with COPD a lot of anxiety,” Bulfin says. They teach physicians and nurses to walk patients through basic breathing techniques that can calm anxiety and restore breathing to a manageable state.
	
	


	
	Along with its physical symptoms, COPD carries a lot of stigma, says Diaz. “I think some patients feel that they’re met with this idea that ‘you smoked, and you’ve done it to yourself,’” he explains.
	
	Patients’ shame over their behavior and stigmas around smoking can prevent patients from getting treatment, which is unfortunate, Diaz says. “I tend to look at it more positively, that there’s always something that can be done. You can keep them out of the hospital, try to improve their quality of life, look into more advanced therapies.”
	
	He does recommend setting realistic goals with patients, however. A person with COPD probably won’t run a marathon, but they might be able to play their favorite sport or get to the gym regularly.
	
	Bulfin says they help patients create intrinsic rewards and make incremental changes. “An intrinsic reward is, ‘Oh I just did something I couldn’t do before,’ or ‘I just walked three times in a week,’” she says.
	
	She says that for COPD patients with acute symptoms, improvement may be slow. With treatment, a patient may be able to walk to the end of their driveway every morning to pick up a newspaper, or maintain some basic mobility. But however small, every bit of progress is important.
	Additionally, Robinson says, it can be productive when physicians show their human side with their patients by discussing their own failures. “In pulmonary rehab, we have a chance to [talk about our failures] often, by saying, ‘I failed you by choosing the wrong inhaler, let’s try a different delivery,’” Robinson says. “Or ‘maybe this class of medication isn’t making you feel well, let’s try a different class.’”
	
	


	
	Another crucial, and often overlooked, area of patient support is for physicians to help patients meet with other COPD patients.
	
	Belfin says her company has helped physicians be successful in getting COPD patients to engage in better medication adherence and lifestyle changes by connecting them to their peers. Melon Health does it through a HIPAA-compliant, online community where people with COPD can communicate with each other. It is overseen by a community manager nurse who can also advise and offer resources.
	
	“Changing behavior and managing chronic illness is really hard, but it’s easier to do if you know that you’ve got other people to do it with,” Belfin says.
	
	Whatever strategies a physician employs, Diaz emphasizes offering patients hope. “I think navigating these patients through their illness can really help them. Even though COPD is not something that can be cured, you can help them manage it.”

Articles

Why treatment requires a multi-pronged approach

Managing COPD patients

Judd Hollander, MD, holds a medical license in Pennsylvania, where he practices, but to ensure that he could legally treat his patients virtually, even when they’re traveling out of state, he sought out medical licenses in an additional 18 states.
	
	Hollander obtained those credentials after surveying 3,500 of his patients and asking about their travel showed that obtaining licenses in those 18 states, along with Pennsylvania, would allow him to see his patients nearly any time they needed him.
	
	Hollander, who in addition to practicing is a senior vice president of Healthcare Delivery Innovation at Jefferson Health, a regional healthcare system based in Philadelphia, says this step allows him treat his patients without worrying about whether he is legally out of bounds.
	
	Hollander says that it takes time and effort to manage the requirements associated with all those licenses. “It’s a half-time job keeping up with them,” he jokes, but he says physicians need to take such steps if they want to offer telemedicine services and be compliant with administrative rules and legal regulations.
	
	Patients are increasingly seeking out virtual medical care, while more physicians are working toward providing increased telemedicine services.
	
	However, as physicians add such services to their practices, experts say they need to consider legal and compliance issues around providing such care, from telemedicine-specific regulations to state licensure requirements and even malpractice-related questions.
	
	“You do have to be careful. You can be successful if you’re meticulous, use good resources, have risk managers looking at policies and procedures, and have good technology selection, appropriate documentation and training around telemedicine,” says Neal Sikka, MD, chief of the innovative practice and telemedicine section at the George Washington University Medical Faculty Associates.
	
	

Multiple state licenses might be required


	
	Technology now enables physicians to deliver a range of medical services virtually. Experts group these services into two categories: telemedicine, which is when the physician delivers care via telecommunications to a patient located at another site, and telehealth, which includes technology-enabled health services such as remote patient monitoring.
	
	A leading consideration when implementing telemedicine is state licensure, experts say. Telemedicine adds a complication to licensure needs, because the technology enables physicians to see patients who are located in a state where the doctor is not
	licensed to practice.
	
	As such, physicians and other clinicians will likely need a license to practice in multiple states if they want to treat their patients virtually.
	Experts advise physicians to examine their patient panel to determine if they have patients living out of state-for example, in a neighboring state if their practice is near a state line. Physicians may want to determine if they have a significant number of patients who re-locate for part of the year-such as retirees who head to warmer climates during the winter-or if a large percentage of their patients travel extensively.
	Thus, a physician seeing a patient via video link needs to know where that patient is located at the time of the visit-known as the “originating site”-and understand that state’s  licensure requirements.
	
	Some states are making it easier for physicians to practice in other states. The Interstate Medical Licensure Compact,  which encompasses 28 states and the territory of Guam and their 38 medical and osteopathic boards, offers an “expedited pathway to licensure for qualified physicians” seeking to practice in multiple states.
	
	It also offers reciprocity, with the members recognizing each other’s licensing requirements so physicians don’t have to review and meet each state’s requirements to obtain a license, says Steven E. Waldren, MD, MS, vice president and chief medical informatics officer for the American Academy of Family Physicians.
	
	Waldren notes that although physicians  still need to apply and pay license fees for each member state where they want to practice, the IMLC offers a more efficient way for physicians to obtain additional state licenses.
	
	However, physicians seeking licenses in states that aren’t part of the compact will have to meet the requirements of each of those, Sikka says.
	
	


	
	Physicians also need to understand the differences in state regulations governing telemedicine, experts say.
	
	Some require physicians to see patients in person before offering any type of telemedicine service, while some have additional regulations that could apply to physicians billing patients located in those states. Some states have restrictions on asynchronous visits-interactions where the clinician and patient do not interact in real time-while others allow both synchronous and asynchronous visits as well as a  broader range of telemedicine services.
	
	States vary in their regulations in other ways, says Rachel Dixon, a consultant and telemedicine expert with the Medical Group Management Association (MGMA). For example, some states allow physicians to prescribe certain controlled substances via telemedicine visits under certain circumstances. Such rules, she says, require physicians to understand such regulatory differences if any of their patients are out of state.
	
	Furthermore, she says, states generally require physicians to obtain consent from patients before treating them, but some states have specific requirements around  consent that others do not.
	
	California, for instance, requires the originating site provider to obtain and document patient consent, according to the Center for Connected Health Policy, while Kentucky says the treating physician who delivers or facilitates the telemedicine services is responsible for obtaining consent.
	
	Jitendra Barmecha, MD, MPH, FACP,  who chairs the American College of Physicians’ newly formed Digital Health Advisory Group, says physicians should seek to ensure compliance with the varying state rules and regulations by building them into their telemedicine workflows.
	For example, he says, just as most practices have front-office workers automatically obtain consent as part of the check-in process, the telemedicine application can include the appropriate consent documents based on the state rules where the patient is located at the time of the visit.
	
	Medicare rules add another layer of complexity for physicians expanding into telemedicine, says Mollie Gelburd, JD, associate director of government affairs at MGMA.
	
	For example, Gelburd explains, both the originating site and the physician providing the service are expected to submit documentation of the visit. Failure to meet that extra requirement would mean noncompliance with the federal rules.
	
	


	
	Telemedicine must also meet all HIPAA requirements. “The rules are no different for telemedicine than for [in-person visits],” says Ronald Weinstein, MD, founding director of the Arizona Telemedicine Program.
	
	This means physicians need to ensure they’re in a location where no one can overhear the virtual visits, which would violate HIPAA’s privacy and confidentiality requirements. Additionally, physicians must use technology that’s compliant with HIPAA rules. The technology should have fully encrypted data transmission and provide secure connections. Experts stress that consumer videoconferencing platforms, such as Apple’s FaceTime application, do not offer those features.
	
	Physicians that opt to work with another business or a technology provider to offer telemedicine services to patients must ensure that those partners are compliant with HIPAA regulations, too, Weinstein says.
	
	“You should have contractual assurances that third parties will follow all the rules around HIPAA,” he adds.
	
	


	
	Experts say physicians offering virtual services don’t face new malpractice rules or risks.
	
	“Telemedicine isn’t really high risk, but you do want to make sure you’re practicing under the board of medicine for the state where the patient is located, and practicing under the terms of your licensure and the standards of care for the conditions and for your practice focus,” Sikka says.
	
	Physicians who comply with licensing rules, who document appropriately and who follow the same standards of care they would for in-person treatments don’t create additional malpractice risks just because they’re offering their services virtually.
	
	Still, there are risks if physicians don’t diligently adhere to the rules. For example, Waldren says, physicians could face a loss of malpractice insurance coverage if they treat a patient located in a state where they aren’t licensed to practice-even if that error was inadvertent.
	
	As a result of the potential for such situations, Waldren advises physicians to consult with their attorney as well as with their malpractice insurance company before starting to offer telemedicine services.
	
	


	
	Technology can help physicians adhere to the various regulations and laws that govern telemedicine services.
	
	Some telemedicine applications, for example, allow physicians to incorporate into their telemedicine workflows the appropriate consent forms and checks on patient locations thereby helping them follow the rules applicable to their practice.
	
	Additionally, experts advise physicians to seek out training in delivering telemedicine services to ensure that they’re not only following the applicable rules, but also so they’re delivering the best possible care in this new setting. Institutions that offer training in telemedicine services for physicians include the American Telemedicine Association, the American Medical Association, the Arizona Telemedicine Program and Thomas Jefferson University.
	
	Experts say physicians shouldn’t let complicated regulations over licensure, rules and regulations stymie their adoption of telemedicine, because patients will increasingly seek out virtual visits and other technology-enabled care.
	
	At the very least, Hollander says, physicians should offer telemedicine service to their existing in-state patients if they want to remain relevant in healthcare. “You have to figure out how to do it.”

As physicians add telehealth services to their practices, they need to consider legal and compliance issues around providing such care, from telemedicine-specific regulations to state licensure requirements and even malpractice-related questions.

How to avoid the legal risks of telemedicine

Originally heralded as a tool that would make healthcare more efficient and effective, EHRs have revealed themselves to be a mixed blessing.
	In addition to frustrations over badly designed interfaces and interoperability issues, physicians are coming to realize that the software they rely on to manage their practices can be putting their patients at risk of medical error and themselves in danger of medical liability.
	
	The problems were highlighted in a recent joint Kaiser Health News and Fortune investigation that showed that EHRs are not living up to their promise, but they have been blamed for everything from incorrect prescriptions to patient deaths and serious injuries. 
	
	And while many practices have come to working terms with their EHRs, they might be unaware of the malpractice dangers they can pose. “It’s definitely on our radar,” says Robert Hanscom, JD, vice president, business analytics at Coverys, a medical liability insurer. “We are urging [physicians] to pay more attention.”
	
	Three years ago Coverys created a code to flag EHR-related malpractice claims.The number of cases rose from 21 in 2013 to 63 in 2017 and continues to climb, Hanscom says.
	
	In the Medical Economics 2018 EHR Scorecard, dozens of practicing physicians commented on how their EHR systems made them more prone to errors.
	
	“I make more prescription errors with the EHR than I ever did with paper charts,” said one respondent.
	
	


	
	Many of the problems stem from the fact that EHRs were forced into widespread adoption after the passage of the HITECH Act in 2009. Rather than mandating a universal standard based on design research, best practices and user experience, the government allowed competing vendors to develop their own EHRs. The result is a hodgepodge of systems that creates unnecessary risk, says Hanscom.
	
	User difficulties and risks are compounded for doctors who work on multiple EHR systems, each with its own user interface, quirks and design flaws. “There are components that can come back and bite physicians if they’re not handled correctly,” Hanscom says.
	Another insurance executive says he has seen malpractice cases stemming from EHR-related errors that led to incorrect medication doses and even removal of a wrong kidney.
	
	“Even though the frequency is small, the potential for harm can be catastrophic,” says Darrell Ranum, JD, vice president of patient safety and risk management, The Doctors Company.
	
	EHRs are not going away and the patchwork of competing systems, many of which still don’t work well together, is not going to be replaced anytime soon by a universal, interoperable network. So what can doctors do to prevent errors and subsequent liability?
	
	


	
	No matter how long they’ve used a particular system or how satisfied they are with its performance, practices should test their EHR’s capabilities, says Lorraine Possanza, DPM, JD, MBE, director of the Partnership for Health IT at ECRI Institute, an independent nonprofit authority on the safety of medical practices and products.
	
	Double check to make sure the system is doing everything it should, such as prescribing the correct amount of drugs, delivering prescriptions to pharmacies and sending orders to labs, she says. “The objective is you don’t want to make a mistake you shouldn’t have made. And you don’t want a system that makes it easier to make a mistake,” she says.
	
	Physicians often have no idea how frequently EHRs can make mistakes, says Zach Hettinger, MD, MS, medical director and director of cognitive informatics, MedStar Health National Center for Human Factors in Healthcare. The center tests EHRs and one recent evaluation of a common system revealed a 40 percent error rate in writing prescriptions, Hettinger says.
	
	The center offers free tools that allow practices to test their EHRs. Its “EHR See What We Mean” program explains many common problems with electronic records and how their designers could avoid errors.
	
	In one example, a physician treating an adult male wants to prescribe Tylenol 500mg and, upon entering “Tylenol”, is confronted by more than 80 options, many of which are not relevant to the patient, such as children’s Tylenol. An attempt to narrow the search by adding “500” after Tylenol fails to turn up anything because the EHR search engine, unlike public search engines, does not recognize near matches and requires exact wording. The doctor returns to the original screen of 80 possible matches and scrolls through to find 500mg, which is the 68th option.
	
	A better system would have screened out options irrelevant because of the patient’s age, gender or other factors and presented Tylenol 500mg, the most common adult dosage, as an easily selected choice.
	
	Possanza also recommends creating backups and contingencies in case an EHR does fail. Common measures include security measures to prevent hacking, data backup and retrieval tools and more.
	
	


	
	While some EHRs allow users to modify them, most improvements must be made by the vendor, either through regular upgrades or specific fixes.
	
	And a vendor can’t fix a problem if it doesn’t know it exists, says Possanza, so she urges users who notice a persistent or dangerous problem with EHRs to document and report it to the manufacturer. Though not always as responsive as users would like, vendors do want to make their products more reliable and user friendly and eliminate errors, she says.
	
	ECRI formed a patient safety organization, where clinicians and healthcare organizations can report, aggregate and analyze data related to patient safety, including EHR faults. Problems also can be reported to the Office of the National Coordinator for Health Information Technology at the Department of Health and Human Services. 
	
	“This is a really complex system we’ve implemented and we need to have a multidisciplinary approach to solving the problems,” says Hettinger. “Sharing and collaborating on the information is the only way the system is going to get better.”
	
	However, even if an EHR is fully or partially responsible for a medical error, physicians should not think that blaming the software will get them off the malpractice hook.
	
	“It’s never not the physician’s fault,” says Hanscom, adding that many EHR vendor contracts include “hold harmless” provisions that protect the manufacturer. And while some patients have successfully sued EHR vendors in addition to the healthcare providers, the resulting settlements are usually not disclosed.
	
	


	
	Practices should ban copying and pasting information from one form or page to another, says Ranum. This simple function saves time for users in a rush, but it’s one of the worst dangers posed by EHRs.
	
	Copying and pasting on a chart can propagate incorrect or outdated information, Ranum says, a harmful error that can easily spread like a virus as other users do the same. “We want physicians to be extremely careful with copying and pasting. It’s often better to type it in yourself to make sure it’s the most recent,” he says.
	
	Ironically, an EHR feature designed to prevent mistakes is proving to be one of the biggest problems. Systems come with alerts and alarms that appear when a potential problem is indicated by the information entered, such as a drug allergy or incorrect dosage.
	
	However, some users complain that there are so many alerts-many of which are irrelevant-that they are ignored, which can sometimes cause errors. Hanscom cautions users who do ignore or deactivate alarms to document it and explain why in order to protect themselves in the event of litigation.
	
	Some practices employ medical scribes in order to allow physicians to focus on patients during visits. That can avoid data entry mistakes caused by divided attention and reduce the number of users of the EHR system, which could lead to fewer mistakes.
	
	


	
	Most practices have been working with their EHR systems long enough to have uncovered many of their weaknesses, quirks and blind spots. However, that level of knowledge can vary among users in a practice, depending on their jobs and experience with the system.
	
	Consequently, it’s important that all users in a practice share best practices about the system and know its dangers, says Possanza. Likewise, any workarounds or steps that can prevent errors should be implemented as practice policy, she says, adding that any fixes must be shared among users, as well.
	
	It’s important that new employees be brought up to speed, particularly if they’re used to a different system.

How to protect yourself from EHR technology-related legal danger

Risks of EHRs

If patients are complaining that they’re paying more for their healthcare than in the past, it’s because they probably are. Between 2006 and 2016, employees paid 8.2 percent more than their salary increase for employer-sponsored insurance, and their out-of-pocket costs rose by 53.5 percent, according to the Economic Policy Institute.
	
	Whether or not patients share cost concerns with physicians, financial issues are a growing part of healthcare decision-making. Many patients would like to talk with physicians about those costs.
	
	Until recently, physicians have been wary about these discussions. But the landscape has shifted in the last decade as health plans have steadily raised deductibles and cost-sharing requirements. In 2013, The New England Journal of Medicine published a physician-authored essay that called costs a “side effect” and urged physicians to “disclose the financial consequences of treatment alternatives just as they inform patients about treatments’ side effects.”
	
	Linda Oberstein, MD, an internist in Burlingame, Calif., has been practicing medicine for more than 20 years, and has noticed patients’ growing reluctance in the last five to seven years to undergo a test before finding out what their insurance would cover.
	
	“I’m getting more and more questions about how much tests will cost,” she says. “Patients come back to me and say they had to pay $300 for a blood test, and they have insurance and don’t know why it wasn’t covered,” she says.
	
	As a result, Oberstein now weaves cost into her discussions more frequently, even though that can be uncomfortable at times.
	
	The problem is that not all physicians are engaging their patients on cost the way Oberstein does. While 76 percent of
	patients surveyed by Avalere Health felt it was important to discuss the costs of their care with their physician, 21 percent said they received some, little, or no such information during a doctor visit.
	
	The place to start when talking about cost of care with patients is to consider the discussion fair game with every patient. Physicians should not make assumptions about which patients may want to have financial discussions, says Emmy Ganos, Ph.D., a program officer at the Robert Wood Johnson Foundation.
	
	“It’s not just about finding patients who can’t afford to pay their co-pay or for prescribed medications,” says Ganos, a participant in the recently-published Cost Conversation projects. “It’s also for people who want to plan for what’s coming down the road.”
	
	


	
	Experts cite a variety of reasons why doctors are reluctant to discuss care costs with their patents. Among them:


	
	Most healthcare services don’t come with a set menu of prices. Moreover, the patient’s portion can depend on their insurance plan, deductible, and billing code. So rather than seeking the exact cost of each treatment option, says Ganos, find out the relative cost of the most-frequently prescribed medications or services, and places with potentially lower pricing.
	
	While Oberstein doesn’t always know which lab charges preferred rates for which insurance plan, patients sometimes know which labs or imaging centers their insurance company prefers. Or she’ll tell them that there may be a cost for the service, and suggest that the patient find out what lab the insurance company recommends.
	
	She may ask the patient to find out if their insurer will cover a blood test as preventive lab, and if not, she sometimes can order it using a different code, like noting a strong family history of the disease.


	
	Doctors think cost discussions with patients are more time-consuming than they  are, since data show that the amount of time they actually take is quite short. A study in the Journal of Oncology Practice showed that cost conversations took a median 33 seconds in a 12-minute appointment. Moreover, cost conversations can potentially save time in the long run, as the doctor may be able to avoid subsequent calls from the pharmacy for an alternative prescription, or not have to identify potential adherence issues at future visits, says Ganos.


	
	“I think that physicians often experience stress asking [patients] about cost because they’re not always aware of resources to help patients,” says Syed Yousuf Zafar, MD, a cost-of-care researcher  and medical oncologist at Duke University, in Durham, N.C. “Primary care physicians have more alternatives than oncologists, in that there are often generic medications, which might be less expensive,” he says.
	
	Primary care doctors can also refer patients to pharmaceutical companies’ financial assistance programs or use apps such as GoodRx, which can sometimes provide discounts on prescription drugs.
	
	While some medical treatments and diagnostic tests are unavoidable, others can be spread out to help with budgeting. This may give the patients the option to choose between different treatment pathways, or delay a test or procedure the patient ultimately decides is not worth the cost.
	
	Oberstein sometimes delays ordering tests for patients who are clinically stable so they won’t have to pay for tests they might not need. She says that while she talks with patients about the costs of outside treatment, she is uncomfortable bringing up the cost of her own visits, especially follow-ups.
	
	“I want them to come back, to see how they’re doing. I sometimes will say to follow up with me in six weeks, or if that’s difficult, to email me and let me know how you’re doing” through the secure portal. She offers that option for issues such as blood pressure monitoring, if she is confident their equipment is accurate.


	
	Even if doctors bring up cost issues, patients may be reluctant to discuss them,  out of concern that they won’t be offered all care options in the future, or that they’ll receive lower quality care, says Ganos. So after determining that finances are an issue, Ganos recommends that doctors reassure patients that they’ll make all medical decisions together, and that the patient will be presented with all options, regardless of cost.
	
	Oberstein, though, has seen patients share less with her during the annual physical or wellness visit, since the session may not be fully covered by the payer if additional health issues are discussed. The receptionist gives patients coming for their Medicare annual wellness visit or private payer check-up information alerting them that there may be some charges for an office visit instead.
	
	For the insurance-covered wellness visit, “I can’t talk about anything but what’s covered in the annual visit, by strict guidelines,” she says. “If we talk about your blood pressure and it’s high and I change your prescription, I have to charge for it.” Oberstein says this puts her at odds with her patients, who come expecting a free annual visit. Some tell her they have other medical issues but won’t share them because it means they’ll have to pay for the visit.
	
	


	
	It’s important for the physician to bring up cost of care, because patients don’t always know they can ask about it.
	
	“It’s clearly something that patients worry about, and we’ve seen in our research the stress that the financial impact of medical care puts on people at a vulnerable time,” Ganos says.
	
	Some patients feel ashamed and don’t want to raise the issue. To create a welcoming environment, physicians can use language like “a lot of my patients have trouble affording medications. Has that been an issue for you?” Ganos says. People don’t want assumptions made about their financial situation, so physicians can say that it’s something they ask all patients. “The universal approach makes people feel more comfortable,” Ganos says.
	
	Zafar frames cost as a side effect patients should expect. “We’re careful to inform our patients about the side effects they might experience from treatment, and cost is one of the side effects,” he says. Even if he can’t give an exact amount, he tells patients if they will face expenses not covered by insurance as a result of the treatment he’s prescribing.
	
	Zafar prefers to talk about affordability rather than cost. “If I tell the patient I want to make sure they can afford the treatment, that helps align my interest with theirs,” he says. He’ll say, “I want to make sure you get the best treatment possible and that you can afford that treatment. Let me know if you have problems paying for your care.”
	
	The physician is often the best person to initiate the cost discussion, says Zafar, because they are responsible for the treatment plan. But other team members can sometimes help as well. If the office uses a nurse or medical assistant for medication reconciliation, that person can include a question about the affordability of medications during the intake.
	
	A practice’s financial navigator can take this on as well. Smaller practices that don’t have a financial navigator can train someone for this role. Zafar suggests meeting with practice staff to find out what patient questions they’re getting about cost, and who gets which questions. They they can  share resources, such as which facilities offer less expensive imaging, procedures or medical supplies.
	
	


	
	One outcome of RWJF and Avalere’s Cost Conversation projects is a series of practice briefs available to physicians on America’s Essential Hospitals website. It includes examples of conversation starters, such as “Have you ever had trouble going to your appointments due to things like travel or childcare?” or “Do any of these medications/treatment plans represent a significant financial burden for you? If so, which ones?” or “How about if we take another look at your medications/care plan and see if there are any less expensive alternatives?”
	
	The practice briefs also include resources on medication discount programs, how to integrate cost conversations into the workflow, and examples of flyers practices can post to make patients more comfortable asking about cost issues.
	
	Care costs can also include transportation, child care and lost wages. “Oftentimes physicians and care providers have strategies they can share, or resources that make a difference, but you don’t know if someone will need that help unless you ask,” Ganos says.
	
	While a solution may not exist for every cost issue a patient faces, physicians are better able to help their patients if they know the patient’s challenges. “Not talking about it isn’t working,” Ganos says.

Whether or not patients share cost concerns with physicians, financial issues are a growing part of healthcare decision-making. Many patients would like to talk with physicians about those costs.

Discussing costs of care with patients

Despite the fact that there is little or no evidence showing cost savings or improved patient outcomes with various value based quality programs and pay-for-performance schemes, CMS and many insurers seem dedicated to expanding these programs and the endless number of acronyms used to describe them.
	
	Many primary care physicians cite such programs and the administrative burden that they impose as a leading cause of burnout and job dissatisfaction. The specifics behind this include tedious data entry, unfair, unrealistic or uncertain performance measures.
	
	Even though it seems obvious that holding someone responsible for things over which they have no control is wrong, these programs are almost entirely predicated on just that. And even though it seems clear that requiring physicians to spend a large percentage of their time doing tedious data entry is counterproductive, wastes patient care time, diminishes access to care and leads to burnout, that is yet another hallmark of such programs.
	
	As such programs become increasingly ungainly and transition from pay-for performance to punishment-for-compliance-failure it seems the time is right for a primary care bill of rights. I think it should look something like this:

It is not and will never be the duty of a physician to force, coerce, intimidate, enforce, order or command a patient into compliance with recommended medical practices, preventive care, medications or procedures. Any payment model or compulsion for physicians to assume such a role is unethical.
		 

In many if not most circumstances, primary care outcomes depend on patient compliance. It is unethical and unreasonable to hold physicians fully accountable for outcomes that are primarily dependent on the patient.
		 

Inasmuch as the two statements above are true and reasonable, no quality metric or credit for such metric shall ever be based on any measure that is primarily dependent on patient compliance.
		 

Likewise, it is also unreasonable and unethical to hold a physician accountable for outcomes or metrics for which another physician is responsible. In other words, if the patient of an internist sees an endocrinologist for the management of diabetes, the internist cannot be held responsible for any metric, quality measure or outcome related to the patient’s diabetes.
		 

Data collection and tabulation of quality metrics will be the full responsibility of the collecting agency. No physician will be required to document such metrics solely in the format demanded by the collecting agency. As long as documentation of those metrics has been entered into the patient’s chart in any form of widely acceptable medical record, including written, dictated and transcribed notes, they will be acceptable. It will be the responsibility of the collecting agency to gather and format that data in whichever format they prefer.
		 

No physician will be held accountable for meeting quality care standards based on fluid, debated or unclear guidelines. More research into chronic disease management and prevention indicate that care and screening should be tailored to individual patient needs. No concrete metrics in these cases is acceptable.
		 

The idea that quality is more important than volume drives many quality programs. It must be acknowledged that this is a false dichotomy since it is patently and intuitively true that volume also equates to access to care. It must be understood and acknowledged that without access to care, quality of care is meaningless.

Physicians must embrace these simple, common sense concepts and use them to inform employers, patients,payers and the government how cumbersome, unfair and ineffective such  programs have become.

0710, 2019 edition

Managing COPD patients

How to avoid the legal risks of telemedicine

Risks of EHRs

Discussing costs of care with patients

Your voice: A pay-for-performance bill of rights for primary care physicians

Medical Economics cartoon: The anti-vax bubble