In 2017, Black Book’s "Revenue Cycle Management" report revealed that the average patient was expected to pay 

 a year for insurance deductibles and other out-of-pocket costs. That’s almost 30 percent higher than average consumer healthcare costs in 2015. It’s also a harbinger of the shift toward consumerism that the healthcare industry needs to embrace.

The report also noted that 82 percent of providers and 92 percent of hospitals struggled with traditional collection methods. Millions of dollars in unreconciled medical bills were left on the table. Rather than spending millions more paying third-party agencies to chase those payments, providers are closing the gap by changing their methods to cater to consumers.

That means more than providing excellent healthcare and service - it also means making everything, including admissions, billing, and coding, more transparent and convenient. When patients understand their out-of-pocket costs and the bills they receive are exactly what they expected, they’re more likely to pay them consistently and on time.

They’re also more likely to share their positive experiences online, which is the surest way for organizations to stand out from competitors. About 

 of internet users in a study by Pew Research Center's Internet and American Life Project said they search for health information online. Among that group, 21 percent said they looked up reviews about particular doctors and hospitals before making a choice.

Appealing to consumers has traditionally been more of a retail strategy. Stores need consumers to choose them. In healthcare, patients' choices have been restricted by limitations in their insurance, Medicare, or Medicaid coverage, which means organizations have had a largely predetermined supply of patients.

As more costs for care and treatment shift to patients, they're becoming more discerning about where they go to receive care. That is new territory for healthcare providers, which aren't used to having to compete for business by appealing to savvy consumers.

Without the experience of retail marketing, hospitals and providers have found it difficult to attract and keep patients within the new healthcare economy. In an Experian Health consumer study, researchers found that the most significant pain points for patients lie in the 

To create the type of experiences your patients will enjoy and tell the world about, you'll need to address these pain points in a way that puts their needs first. Here are three pain points healthcare providers should address:

1. Patients receive inaccurate estimates about the cost of care. 

Healthcare billing is complicated by nature, especially as insurance policies, medical suppliers, and partnering organizations constantly evolve. It’s easier for hospitals to speculate what a patient might have to pay than to break down exactly what will factor into those costs. But it’s extremely frustrating for patients to receive bills much higher than they expected.

The discrepancy between the bill and the expectation leads to sinking customer satisfaction and more unpaid bills. Healthcare providers need to set more accurate expectations by taking the time to provide transparent price estimates, including how much the patient's insurance company will cover and how much the patient will pay.

2. Patients are unable to compare prices among providers. 

As organizations make pricing easier to understand, patients will use this information to 

 of local hospitals and providers. Organizations will need to keep their consumer-centric focus to stay relevant. If you ignore transparency or if the costs you project are difficult to understand, you could be left out of the comparison altogether.

Instead, make those comparisons a part of the conversation. If a trusted clinic offers MRIs for thousands of dollars less, work with the patient to ensure the imaging is high-quality enough instead of shunning the idea. Focusing on patients as consumers means taking every aspect of their well-being into account, including what’s financially best for them.

3. Patients are not allowed to make payment choices. 

Having the freedom to choose and the information necessary to do so wisely notably enhances patient satisfaction. It also makes it easier for patients to understand their bills from the very beginning, which is critical in appealing to their needs as consumers. No matter how high-quality their care was, patients still report negative experiences if they’re frustrated about their bills.

Being transparent helps clarify the bill, and patient-facing technologies, such as online patient portals, make it more convenient for them to pay. There’s no confusion about where to send the payments, and billing through a portal can be consolidated into a single payment or payment plan that patients can access almost anywhere.

Online portals can also incorporate credit data into the patient billing process. Credit data offers insight into each patient’s propensity to pay and financial disposition. This information allows organizations to identify the best financial pathway (payment plans, assistance, deposits, etc.) for the patient at the time of service - or even before.

Patient self-service products anticipate how to best help each patient by creating a proactive and compassionate mobile-first experience that empowers people to apply for financial assistance, activate payment plans, review insurance benefits, and estimate the cost of care.

Now that consumers are paying more for their healthcare out of their own pockets, they’re not willing to accept pain points from healthcare providers. Stand apart by being exactly what patients expect: an organization that caters to them as though their business matters.

, vice president of product development at 

, is responsible for creating and designing patient portal solutions. He pioneered the patient-friendly billing movement in 1991 at RUSH University Medical Center in Chicago, and his efforts led to the launch of a human-centered approach to patient communications at premier health systems like Cedars-Sinai, Stanford Medical Center, and Northwestern Memorial Hospital. In 2001, Paul developed the industry’s first self-service online business office for patients, which is used by more than 500 U.S. hospitals. Paul is a passionate visionary devoted to developing technology to improve the patient experience.

Articles

If physicians address these three pain points in a way that puts patients' needs first, they should be able to create the type of experiences patients will enjoy and tell the world about.

Ease patients' financial pain points through billing transparency

An overwhelming number of new medical technologies promises to improve diagnostics and increase efficiencies in healthcare-and we’ll start to see these improvements as soon as 2019. Patients are advocating for themselves more vocally as the standard of care shifts toward a more person-centered model and the expectations of convenience and access to information is more critical than ever. Changes in medical (or insurance) coverage and legislation have pressed physicians to be more strategic about how they can provide optimal care. This is not the time for fighting change, but it is an opportunity for clinicians to implement these changes in a way that will benefit, not burden, both themselves and their patients.

Unlike science fiction, artificial intelligence (AI) technologies should give us great hope for the near future. The technology will enhance, not replace, human efforts. AI promises to alleviate repetitive burdens and provide more accurate tools, so that the medical community can offer better care. Its explosion onto the funding/startup scene is both indicative of its potential and the reason less tech-savvy people feel overwhelmed. 

Growth in the AI health market is expected to reach 

. While early adoption can be an advantage, we as clinicians must educate ourselves to truly leverage AI’s potential. On a day-to-day basis, look to AI tools for automating routine processes and providing more intuitive interfaces for your EHRs and other online tasks. At a higher level, AI algorithms can analyze that EHR data to 

 and recommend targeted treatments. Pathology results-relied upon for 70 percent of healthcare decisions-can be more precise under the guidance of AI. That same level of accuracy will be used for earlier 

 and more efficient pharmaceutical discoveries. For due diligence, look beyond the jargon and ask, “How will we see the benefits of this technology today?”

Healthcare mergers and acquisitions are on the rise, with an increase of  and a reported 

 of 2018. The reasons behind this trend are key to understanding whether and how it could impact your practice. According to 

 of the Brookings Institute, “It is becoming an increasingly challenging environment to be a small hospital or medical practice. The system is going through a challenging [digital] transition, which is expensive and requires specialized expertise to avoid pitfalls.” 

We are also seeing small practices being acquired by larger organizations in an effort to provide the economies of scale needed to keep up with the times, and spread out the burden of supply chain, IT, and other back office functions. However, this increased efficiency comes at a price. Medical costs will 

 as these acquired organizations may adopt the fee schedule of the larger organizations, resulting in higher prices. These consolidated systems will occupy an increasingly large share of the healthcare market, giving them the power to 

Changes in healthcare legislation and patient philosophies have resulted in both a greater supply of and demand for care on a 24/7 basis. 

We can see how legislation influenced access to care when the Affordable Care Act began to 

. The revenue generated by these additional patients enabled clinicians to serve them by extending hours, hiring more staff, opening more facilities, and adopting support technology. This increased access to care challenges the convention of office hours being for in-person appointments and after-hours being for emergencies. 

The patient-first approach means that physicians must adopt new, more flexible models of care to accommodate patients. For example, seniors are demanding more in-home care and busy adults want fewer interruptions to their own work days, be it for their appointments or their children’s. Nonetheless, this trend also has resulted in 

, as patients turn to retail clinics and boutique providers for the convenient, accessible care they prefer. With a new reality of care delivery, how can practices satisfy their patients’ accessibility and continuity of care expectations while maintaining, or better yet, increasing, the standard of care offered by physicians?

Telehealth solutions have not been compelling enough to warrant mass adoption due to either needless complexity or the lack of value-add to patients and physicians. But the same philosophies that have governed the patient-first approach to care have now been applied to technology design, resulting in an infinite number of possibilities for connecting patients and clinicians remotely. These virtual visits (

) best serve level 1-3 patients and those requiring refills and follow-ups, freeing up office time for patients with different/urgent needs. The rise of video calls means doctors can spend more time providing face-to-face care instead of playing phone tag. A 

 for “Brief Communication Technology-Based Service” will reimburse doctors for virtual care, which opens the door for new revenue while reducing time wasted on administrative tasks. Now as accessible as any consumer app, telehealth will enable doctors to maximize their billable time and offer better continuity of care. 

We’re poised for a 2019 that showcases a drive for better, more personal access to care and the embracing of technology to deliver it through consolidated databases. It’s an exciting time to be a physician-and to reconnect with our roots. Why did you become a physician?  Likely so that you can help people -and a return to more personal care-leveraging technology will help you do just that.  

Samant Virk, MD, is the CEO and founder of MediSprout.

An overwhelming number of new medical technologies promises to improve diagnostics and increase efficiencies in healthcare-and we’ll start to see these improvements soon.

Top 4 healthcare trends for 2019

Welcome to Medical Economics' blog section

 which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.

There’s a quiet revolution taking place in healthcare. The dramatic swing of the pendulum over the last 20 years-away from private independent physicians, towards being employees of big corporate healthcare organizations-has not, by any means, been a smooth transition for the nation’s physicians. A quick glance at any healthcare news site will show the growing unease among practicing doctors. They are increasingly looking for ways off of the corporate treadmill, frustrated by the dramatic loss of autonomy and control that they have experienced.

Two examples of healthcare models that are rapidly gaining popularity are direct primary care (DPC) and concierge medicine. Both eliminate the need for insurance and the regulatory middle man and significantly reducing bureaucratic burdens. Watch that space. 

Physicians also are moving away from corporate medicine by taking advantage of the supply-demand mismatch that exists in most medical specialties, and independently contracting with healthcare facilities to provide services. 

Traditionally, this type of work was done under temporary or “locum” contracts and mostly by doctors at the end of their careers, as a way of “cutting back” on clinical work. But with the surge in healthcare demand over the last few years, savvy physicians can arrange this work on a regular basis for themselves (in many parts of the country and very close to home, too), and are doing much earlier their medical careers.

After only one or two years into practice post residency, an avalanche of physicians are realizing that long-term job satisfaction is almost impossible with the inevitable constant administrative clashes involved in a corporate-type healthcare environment. They are also being bombarded with job opportunities and new career options. So why only be tied to one institution and be reliant on a sole employer for income? Why suffer all the administrative headaches if you don’t need to? 

There’s no need to ever feel stuck in a suboptimal situation. Every healthcare facility has pros and cons-but doctors who choose to spread their wings can make sure to get the best possible deal. They can get a variety of inpatient and outpatient experiences, perform well-paid clinical (or even non-clinical) work, and decide on their own ideal mix of work (many are now doing "side" entrepreneurial ventures). But most importantly, doctors can create their own schedule and experience a degree of autonomy and independence again. Is it any surprise then that physicians are jumping on board with this as soon as they can?

Suneel Dhand, MD, is an internal medicine physician, author and speaker. He is the cofounder of 

, a service that helps physicians find local moonlighting and per diem opportunities, bypassing the expensive middleman. He can be reached at

Physicians are thinking outside the box early in their careers.

Getting off the corporate treadmill

I am a proponent of direct primary care (DPC). OK … maybe I’m a fan-boy.  It has changed my life so dramatically that it is hard to explain it without sounding like I’m giving a sales pitch. My practice, the quality of my care, and my life have all improved since making the change six years ago. But with such enthusiasm comes a danger: being blinded to the negatives, the risks, and the potential problems of the model, both in the present and future. 

recently caught my eye. The author was a primary care doctor who had read my articles on DPC.  While interested in the practice model, he pointed out the potential negatives:

…there is a dark side to the conversion that nobody in the DPC camp ever seems to talk about. While the new practice model might be great for the select group of patients who agree to stay on and pay their monthly fees, what about everyone else? Dr. Lamberts wrote that he averages 8 to 11 patients per day. I wonder how many he was seeing before he made the switch. In my practice, I was routinely seeing 25 to 30 patients per day. Had I jumped on the DPC bandwagon, that would have meant that about 20 patients per day would have been displaced and forced to find a new family doctor.

He goes on to spell out the obvious concern based on this real observation:

I just can’t help but wonder where the thousands of patients who get displaced are supposed to go for care once their family doctors can no longer see them. Urgent Care picks up a lot of the slack for acute care needs (I still see 25 to 30 patients per day) but they don’t handle chronic conditions. Especially as the population ages, there is an ever-growing need for better primary care access. It seems to me that a growing DPC movement will make the access situation even worse.

This is a very valid point that those at the head of the DPC movement need to address and answer up front. Yes, I did consider this when I left my old practice, and it was the largest source of hesitation I had in making the leap.  

Beyond this, there are other even larger concerns that could swallow up the DPC movement and shunt it from being a potential salvation for our system to a flash in the pan. This article will explain the problems that direct care may cause and point toward a potential solution. I do realize that my foresight in this arena is limited, so I may be missing the real problems we will face in the future. But the best chance for this practice model, which has made my life and my care so much better, is to succeed in the long run.

This is what the letter to the editor was saying: I and my DPC colleagues were abandoning patients, leaving care to be picked up by those who hadn’t made the switch.  While I don’t think the number of office visits makes the case strongly, I do think this is a valid concern.  

In truth, the lower number of office visits is a good thing. The reason I see less patients per day is not just because I have lower overall census, but because I don’t limit care to office visits.  While I see between 8-12 patients per day, I actually give care to 20-50 patients each day via text messaging and phone calls. I found that only about 25 percent of my visits in my old practice 

an office visit. I don’t have to worry about lost income in my new practice, so I can handle most problems without an office visit.

I actually think that the average primary care doctor’s schedule of 25-35 patients per day is a major indictment of our system. It is not possible to see that many patients (especially with the huge time burden of insurance compliance and unfriendly medical record systems) and still give high-quality care. This is what drove me to burn out: the knowledge that there was no way I could give the care my patients deserved when seeing so many people each day. 

A more serious number, however, is the fact that I reduced my entire patient census from 2000-3000 to 800. How can this work if adopted by all doctors? What will happen to all of the patients if DPC becomes widely adopted? I think the answer will not be as simple as many DPC proponents say. It will likely cause a crisis of access, which I hope will be met by an increased workforce of primary care doctors who no longer see the profession as a booby prize. Primary care has become the domain of the idealist-those willing to give up significant income to do good for people. DPC raises the possibility that primary care won’t be relegated to the realm of self-sacrifice and social good, but turned back into the most fulfilling and important job in the entire system.

The other, more subtle risk of DPC comes from the blatantly independent nature of most doctors who adopt the practice model.  

This seems like apostacy within a “movement” in medicine that is defined by its libertarian leanings. I am, by definition, anti-insurance company and anti-government in my practice. I accept no payment from either, which is part of what makes the model so great. But while I am dedicated to giving excellent evidence-based care to my patients, what keeps other doctors from wearing the “noble” DPC mantle and not being so dedicated?  

I have seen much discussion about approaches to care within DPC practices that are far from mainline. DPC groups (such as the DPC alliance, of which I am a founding member) are regularly approached by naturopaths for membership. Within our membership are doctors who engage in medical practices I do not endorse, and I’m sure that some of my approaches to care wouldn’t be endorsed by all of my colleagues.

There is nothing keeping a medical provider, regardless of training or practice, from claiming to be DPC. Left to chance, this could dilute the current goodwill enjoyed by the direct care community at this time.  It seems to me that the only real solution to the lack of regulation is a set of criteria and certification by a medical body/society.

Can the DPC movement police itself?  Can a group of vigilantes who are largely defined by what they 

become a cohesive and influential mover in our system? These are real questions that the DPC leadership must address, and ones that will be met with much resistance from some of the current members (and leaders) of the DPC movement.  

I certainly hope that DPC is here to stay. But we in the early stages of this movement must look ahead to what our biggest challenges will be. We can’t deny there are negatives, because doing so will play into the hands of those with a vested interest in seeing this movement fail.  

I think that DPC is the best model we have at this time. I believe I give better care than most other doctors out there, and it’s not because I am smarter or more talented; I think it’s because the model encourages me to give good care, not bad (as is the case with regular fee-for-service medicine).  We in leadership need to assure that this good care will be available to everyone in the future. 

is a board-certified internist and pediatrician who runs Dr. Rob Lamberts, LLC, a direct primary care practice in Augusta, Ga. He also recently gave a 

 on the DPC model. Have questions about DPC? Email 

There are concerns that could swallow up the direct primary care movement and shunt it from being a potential salvation for our system to a flash in the pan.

The risk of direct care

In his 24 years of practice, family physician Rob Danoff, DO, has noticed a significant change in the way patients approach their medical care. 

Early in his career, patients viewed him as their main source of information about their health problems and how to treat them. Now that’s no longer the case. 

“I have multiple patients using internet resources to find out about their medical care, insurance co-pays, what is involved in procedures, what is involved in rehabilitation after procedures, the quality of the doctor, and the hospital facilities,” he says.  

Danoff, the director of the family residency program at Jefferson Health’s Sidney Kimmel College of Medicine in suburban Philadelphia, is hardly unique when it comes to patients who’ve done extensive homework about their health problems and how they might be treated. Doctors and healthcare experts say growing numbers of patients are becoming empowered-a term the World Health Organization defines as “a process through which people gain greater control over decisions and actions affecting their health.” 

On an everyday level, an empowered patient is one who searches for health and wellness information on their own rather than waiting to get it from their doctor, then partners with their doctor in deciding the care they need, who should provide it, and where, explains Jan Oldenburg, a patient engagement consultant, blogger, and author of 

Participatory Healthcare: A Person-Centered Approach to Healthcare Transformation.

 “Empowered patients are very clear that they have the ultimate responsibility for their own health and that the ultimate decision-making is in their hands,” Oldenburg explains. “They view doctors as advisers and resources rather than all-knowing authority figures.”

Experts point to a variety of factors coming together in the last few years to foster the empowerment trend, starting with the ready availability of health and medical information via the internet, but also including the popularity of social media and ubiquity direct-to-consumer pharmaceutical advertising.

“We’ve seen a real explosion in the kind of information that ordinary people can get access to about their own health and from sources like medical journals and results of clinical trials,” Oldenburg says. “That means patients today can go pretty deep into their health issues and quickly get to a position where they’re at least asking questions that might lead their doctors to do additional research.”

Oldenburg cites the example of a patient profiled in her book, who suffers from lupus. “She told me, ‘my doctors may have an MD degree but I’ve got a PhD in lupus. I’ve lived with this condition and understand it in a deep way that can inform how we think about treatments.”

In addition, the internet has made it easier for people to find advice and support from people with similar health challenges through message boards, groups on social media, and organizations such as PatientsLikeMe and the Society for Participatory Medicine. 

“Whereas traditionally patients turned to big organizations like the American Heart Association for information, now there are a lot more informal ways to connect with other patients and learn from them,” notes Emmy Ganos, PhD, a program officer with the Robert Wood Johnson Foundation.  

Such networks can be especially helpful to people with rare diseases and conditions. “Those patients often know a lot about their medical issues and can teach each other things that their doctors may not know, like a home remedy or type of exercise that works well,” Ganos says.

Growing numbers of patients are also using the internet to research and comment on the quality of individual doctors, practices and hospitals. A study published in the March 2019 issue of 

 found that in 2015, 27 percent of respondents to a longitudinal survey consulted online rankings or reviews of doctors, compared with 17 percent who did so in 2012. 

Another development fueling patient empowerment, experts say, is financial: as a result of rising copays and deductibles, and the growing popularity of high-deductible insurance plans, patients often face substantial payments even for routine tests and procedures and generic medications. 

“It used to be that if you got really sick, you could be on the hook for huge amounts,” Ganos says. “Now it’s common to find that even if you’re relatively healthy or have a pretty well-controlled chronic condition, you could still be paying thousands of dollars out of your own pocket.”

 The upshot is that patients are far more attentive to costs than they used to be. “You find more people are willing to ask, ‘is this [procedure or test] really necessary?’ or, ‘maybe I can find an alternative that works better for my budget,‘” she says. 

Danoff says cost concerns drive many of his retired patients, who often live on fixed incomes, to do their own research before coming to see him--despite having grown up at a time when unquestioning acceptance of doctors’ recommendations was the norm.   

“They’re looking at different costs of care and options for different medications based on their copays and overall household budgets, as well as things like a facility’s location and ease of access,” he says. “That’s a big change even from five or 10 years ago.”

Along with money and access to information, Ganos says, patient empowerment is consistent with other trends in American society. Among them is distrust of authority, an attitude that first took root among baby boomers and has continued with younger generations. Tied in with that is a growing desire among Americans of all ages to take charge of all facets of their lives, including healthcare. 

“The idea of a paternalistic medical culture doesn’t fit as well with people’s views of their lives as it did in the past,” Ganos says. “Patients understand that they know things that doctors don’t know about their lives and their health and have an expectation that they need to take an active role in their own healthcare.” 

The fact that patients now have access to much of the same medical information as their doctors, and that more of them regard their doctors as partners rather than all-knowing authority figures has been difficult for some doctors to accept.

“When you have patients asking whether what you’re recommending is really the best treatment, bringing in their own information, it can feel threatening,” Oldenburg says. 

Paul Wicks, PhD, vice president for innovation at PatientsLikeMe.com, a website geared to patients with rare and/or chronic diseases, says he hears anecdotal reports of doctors offended by patients using medical terminology, asking to try alternative medications to those their doctor has prescribed, or otherwise questioning the doctor’s advice. “A small number of physicians have been rude, or in rare cases fired the patient for attempting to use Dr. Google,” he says. 

Most doctors, however, say they welcome patients taking a more active approach to their healthcare. “I have long believed that knowledge is power, and people should be learning as much as they can about their current conditions and health generally,” says Leonard Reeves, MD, FAAFP, a family physician and associate dean of the Northwest Campus of the Medical College of Georgia in Rome, Ga. 

Reeves left private practice about five years ago, but continues to see patients at a free clinic in Rome. He encourages those he treats to learn all they can about their health problems because it can spark a conversation that yields meaningful information.

“There’s only so much you can learn from lab tests and blood draws” he says. “At some point you’ve got to listen to the patient’s fears and concerns because it may be something totally different from their chief complaint,” he says.

Administrators and physicians at The Permanente Medical Group, the country’s largest medical group, see patient empowerment as vital to shared decision-making, which in turn leads to better outcomes, says Patricia Conolly, MD, executive vice president of information technology and an associate executive director of Permanente. 

“Often there’s more than one way to address an issue or problem a patient is experiencing, and there’s mounting evidence that if the patient is part of making the decision, their adherence to whatever the recommendation is will be greater,” Conolly says.

Damon Raskin, MD, an internist in Pacific Palisades, Calif., has seen that dynamic play out in his practice. Patients who inform themselves about their health are more likely to adhere to a medication regimen and follow his advice, he says, particularly when it comes to treating chronic diseases such as diabetes or conditions like high cholesterol.

 “I have some patients who don’t believe that lowering cholesterol is going to reduce their risk of heart disease, so if they become informed about it, that can help with adherence to taking a statin,” he says.

The drawback of patients taking more responsibility for their care is that the information they find on their own sometimes is misleading, incomplete, or simply wrong.

“Sometimes a patient will come in saying, ‘I need this test,’ or ‘I want to be on such-and-such antibiotic,’ and I have to say, ’but that antibiotic isn’t good for your particular condition,’ or ‘did you know it will interact negatively with one of your other medications?’” Danoff says. He urges patients who research online to look only at sites with a .edu or .gov in their web address, where the information is generally evidence-based and up-to-date. 

Similarly, Danoff urges caution when patients say they don’t want to be treated by a certain specialist or admitted to a particular hospital because of a negative rating or comment on the web.

“I have to remind them that they’re reading one website or one comment and it may not be representative, the person may have had an ax to grind, so they should try to get information from different sources for a more accurate picture,” he says.  

Raskin, too, is skeptical about the value of provider and facility ratings. “If patients don’t want to see me because they saw a negative comment online about my billing department, that’s their choice. But those patients who meet me and we develop a relationship, they’re usually quite satisfied with me and my office,” he says. 

For Reeves, a danger of patients seeking out information online is that what they find may turn out to be a sales pitch disguised as objective information. “You can usually ferret out some of these more questionable websites simply by seeing what they have to sell,” he says. “I tell my patients, ‘if it claims to cure more than three things stay away from it, because it’s not going to do that.’” 

In those cases, doctors have to spend already-scarce appointment time explaining why the patient’s information is wrong or inappropriate, thereby exacerbating the enormous time pressures they already face. The response many doctors adopt is to rigorously prioritize, says Wicks. 

“When a patient comes in with hundreds of pages of internet printouts saying, ‘I found this miracle cure, what do you think?’ [these] doctors will say, ‘We don’t have time to go through all of this, what can I do for you at this appointment?’ Wicks explains, adding that it’s important to do so in a respectful way, such as offering to look at the information if the patient will send links to the websites where they found it. 

Still, many doctors prefer a patient who come in even with bad information to one who is entirely passive in the relationship. “My view is the more information the patient has, the better,” says Kaiser Permanente’s Conolly. “It makes it easier to have a conversation, but more importantly, it tells us they’ve been thinking about their problem, and that’s a big part of eliciting a thorough and appropriate history. My nightmare is the patient who responds to questions with one-syllable answers.”

Ultimately, doctors say, harnessing patient empowerment in a way that helps the patient requires the classic traits of good doctor-patient relationships: trust, communication, and patience. 

“It’s about taking the time to explain to patients that I’m suggesting a treatment or medication based on my years of schooling and my 23 years in practice,” says Raskin. “That’s what develops the sense of trust you need in the doctor-patient relationship.”

Conolly acknowledges that winning the trust of an empowered patient sometimes requires extra effort on the doctor’s part, but says that few doctors will object to the effort if it results in better patient care. “And after these conversations lots of patients will say ‘thank you,’ and that feels pretty good. It’s why we became doctors.” 

Doug Lindsay may well be the ultimate example of an empowered patient. 

Twenty years ago Lindsay, a resident of St. Louis, found his life turned upside down when he began experiencing a series of debilitating conditions including tachycardia, painful muscle cramps, and vertigo. He was forced to drop out of college, and wound up spending the next 11 years essentially bedridden for all but a couple of hours each day.

None of the doctors he consulted could explain his condition or how to cure it. So Lindsay decided to take matters into his own hands. “I realized if I just kept asking doctors what was wrong I might never get an answer,” he says. “So I pivoted and began tackling my problem as a scientist. I decided I would partner with the doctors, but take the lead in finding answers.”

Lindsay immersed himself in texts on physiology, endocrinology, and general medicine. Through his studies, he theorized the existence of a class of disorders involving dysfunction of the autonomic nervous system, which controls functions such as breathing and heart rate. He discussed his findings with his doctors, who were highly skeptical at first. “They said problems like this don’t exist,” he recalls. 

Undaunted, Lindsay continued his research. He bought his first computer, enabling him to access articles through Medline and explore websites such as the National Organization for Rare Disorders for additional information. He presented a paper outlining his theory at an international medical conference, and found a collaborator who ran an academic laboratory researching autonomic dysfunction.

“Once he’d run the testing [on me] and had objective data, it was much harder for people to dismiss,” he says. And while it took 14 years and two surgeries, today he leads something close to a normal life, having developed a career as a lecturer, blogger, and what he calls “personal medical consultant” to people with rare or complex diseases and conditions.

“I have some limitations, but I’m no longer homebound,” he says. “I can travel and give speeches and go to the grocery store any time I want, which feels pretty good.” 

While Lindsay’s experience is unusual, he thinks it holds lessons for doctors dealing with patients who are seeking greater control over their healthcare-starting with a willingness to treat the patient as a partner.

 “If the doctor has a sign saying something like ‘your Google search is not the same as my medical degree’ they should take it down,” he says. “I think doctors need to regard empowered patients with the mindset that they have someone they can partner with.”

Even a patient who comes to an appointment with wrong information represents an opportunity if the doctor takes the time to listen carefully, Lindsay says. “The chance is there for the doctor to put aside the patient’s incorrect explanation of their symptom and say ‘tell me more about that sore on your leg,’” he says. “When we get back to things where the patient is the expert, which is making observations about their own body or feelings, it gives the doctor a chance to start from some place solid.”

Still, Lindsay says, the chance that a patient will misdiagnose their problem is outweighed by the benefits of shrinking what he terms “the knowledge gap” between doctors and patients. 

“The existence of the Googles and the WebMDs represents a special opportunity for both sides because patients have access to more information and doctors can guide them through it,” he says. “You have two people working together instead of one being in the hands of the other. That can lead to much better outcomes than we ever had before.” 

How physicians can adapt to the patient empowerment trend 

Patients take charge: How physician-patient relationships are changing

Is the patient-physician relationship evolving or eroding?

The dynamic between patient and physician is in the midst of massive transformation, shifting as rapidly as the health systems surrounding it. This surpasses generational expectations, and is as much sociologic as it is ideologic and systematic. 

New pathways to care, including telemedicine, urgent and retail clinics, impact how patients view their personal connection with any one given physician. Increasing sub-specialty care and advancing complexity of illness has led to a perceptible increase in the number of healthcare providers involved in a patient’s care across a lifetime. 

Expansion of healthcare teams to include social workers, care coordinators and others alters the one-on-one dynamic and obscures the days of the solo family doctor or heroic surgeon. With the exception of areas of innovation such as direct primary care, it is yet to be discerned what number of different team members that a patient will accept before the sanctity of the individual relationship is lost.

Healthcare systems have done a poor job of communicating expectations and rationale for new pathways to care. The role of technology within the patient-physicians dynamic remains in flux, ill-defined, and inconsistent. Both patients and physicians are left with underlying confusion and uncertainty as they attempt to apply antiquated frameworks to navigate the modern healthcare environment.

Technology has revolutionized how patients interact with their own health as well as the structure of individual episodes of care. Clinicians access up-to-date resources at the click of a mouse. Computers and cell phones distract eyes and ears, often making listening a luxury for both parties. I am astounded by the number of patients who express guilt and sheepish admissions that they have researched their symptoms online. 

I regularly encourage my patients to explore and understand their own health. I believe the past role of the physician as sole purveyor of knowledge is outmoded. Patients hold more information in the palms of their hands than I could ever hope to encapsulate in years of study. 

My role as physician is now much more about intuitively and creatively interpreting and applying shared information and experience. Patients, literally armed with wearable devices and access to a limitless internet, can and should be empowered to fundamentally alter the nature and exchange within the relationship. 

Physicians must be purposeful about how they initiate and maintain relationships. Expectation setting as well as clearly defined teams and roles are essential. Health systems and insurers must be more proactive in guiding appropriate pathways towards care and articulating the rationale for cost and decision-making, allowing physicians to focus more on the care they deliver. 

Systemic frustration should not be triangulated in ways that directly harm the patient-physician relationship, as is now common. 

Ultimately, I refuse to accept that the patient-physician relationship is on life support. Rather, it is possible to reframe the core structural elements of trust, access and continuity that allow the relationship to be successful and meaningful. For example, to many, the notion of continuity means seeing a given physician at every visit and that they be omnipresent in care delivery. A modern notion of continuity speaks to a cohesive team that delivers comprehensive care under the leadership of a physician. Access must be reconsidered within the contexts of telemedicine and the potentials of artificial intelligence to augment encounters with the healthcare team.

I still carry my uncle’s black leather handbag from the 1950s as I make my own modern house calls, though I now have the benefit of filling the bag with a point-of-care ultrasound, digital stethoscope and iPad. Perhaps this is an ideal image for how we should approach the modern patient-physician relationship, honoring the roots of the profession, while employing the benefit of new technologies and methods for team-based delivery of care. 

It is the responsibility of both health delivery systems and physicians to share transparently a coherent vision of evolving practice and relationships, and to assure that this new vision achieves quality patient care. The physician-patient relationship must still provide the cohesion necessary for the patient to maintain trust, access and continuity that form the bedrock of the best patient- and physician-experience. 

Aaron George, DO, is a family physician practicing in his hometown of Chambersburg, Penn. He was an Andlinger fellow in health policy with the Center for Public Health in Vienna, Austria, and has been awarded both the Bristol-Myers Squibb award for excellence in graduate medical education, as well as recently named one of the 40 under 40 physicians by the Pennsylvania Medical Society.

The physician-patient relationship has changed

Q: Can an ICD-10-CM body mass index (BMI) code be used as a stand-alone code? If not, what does the documentation need to include to justify the use of a BMI code?

A: The 2019 ICD-10-CM Official Guidelines state that you cannot use a BMI code alone (these are found in ICD-10-CM code category Z68.-). BMI codes should only be assigned when the associated diagnosis (such as overweight or obesity) meets the definition of a reportable diagnosis.

Keep in mind that that BMI codes were never intended to be used as standalone codes; they were always meant to be accompanied by a corresponding diagnosis code.  In previous years, the guidelines read, “As with all other secondary diagnosis codes, the BMI codes should only be assigned when they meet the definition of a reportable diagnosis.” However, there was a long-standing issue of Coding Clinic published in 2011 that stated:

“Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented.”

This 2011 direction appears to no longer be valid. The Coding Clinic published in the fourth quarter of 2018 specifically states that the provider must provide documentation of a clinical condition such as obesity or overweight to justify the reporting of a code for BMI.

So this begs the question of what diagnoses, such as sleep apnea, diabetes, or hypertension, could make the use of a BMI code relevant. The same Coding Clinic article does not identify the conditions that can be considered associated with a BMI. So my best advice to show that BMI is clinically relevant is to ensure that the documentation clearly links the condition to BMI. 

For patients with provider documentation identifying “morbid” obesity, the code E66.01 (morbid [severe] obesity due to excess calories) can be assigned even if the BMI is not greater than 40, per the Coding Clinic.  This guidance is important since there are some situations where a patient can have severe or morbid obesity with a BMI of 35-39.9 due to co-existing comorbid conditions.  

As noted in the 2019 ICD-10-CM Official Guidelines, Section I.A.19, “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” 

Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Ind. Send your billing and coding questions to medec@ubm.com.

Can an ICD-10-CM body mass index (BMI) code be used as a stand-alone code?

New 2019 regulations for BMI coding

They track caloric intake, sleep, and daily steps. They educate patients about their conditions and medications. They coach patients to self-manage their anxiety, depression, diabetes, and pain … and so much more. We’re talking about the thousands of consumer health apps available on app stores today. 

Experts agree that these apps foster consumer empowerment that may even translate to better outcomes and lower costs, both of which can help physicians gain points under the Merit-based Incentive Payment System (MIPS). Some apps-those that capture physiologic data-may also help physicians generate revenue for reviewing the data that’s captured.

Another reason to keep these apps on the radar? Consumers want them. A September 2018 

 found that 54 percent of surveyed consumers would be open to trying an FDA-approved digital app or online tool to treat their medical condition.

This raises an important question: Should physicians recommend these apps to their patients, particularly in an era of value-based reimbursement? 

 co-founder and president of Redox, a healthcare data standardization company in Madison, Wisc. “Providers need to be the ones saying that one app is better for patients than another in the same way they’d say one medication is better than another,” he adds. “They need to think about apps as therapeutic interventions.”

Frederic S. Goldstein, president and founder of Accountable Health, LLC, a population health management company in Jacksonville, Fla. agrees. “The time between office visits is where the action happens,” he says, adding that many consumer health and wellness apps help fill these gaps using reminders, prompts, and coaching. “These are all intervention efforts to potentially correct a behavior before it gets bad enough to require treatment.”

Consumer health and wellness apps are also important because they enable data-informed conversations between patients and physicians, says Jan Oldenburg, principal at Participatory Health, a patient engagement consulting company in Richmond, Va. “This data can help physicians and patients make more of an impact during the limited time they have during face-to-face visits,” she adds.

Given the benefits, are physicians starting to recommend these apps at the point of care? Yes, according to the PwC report. Fifty-six percent of physicians said they’ve initiated discussion about an app or digital program during a conversation with a patient. Twenty-six percent said a patient initiated the discussion.

More physicians don’t initiate these conversations because the quality of the apps varies tremendously, says Yauheni Solad, MD, internist and medical director of digital health and telemedicine at Yale New Haven Health System in New Haven, Conn. “We want to make sure that when clinicians recommend these apps during the clinical encounter, they have a clear understanding of the app’s effectiveness,” he says. “Physicians should avoid apps with low-quality content and inappropriate data handling, and we need to guide them in making this choice,” he adds. 

Yale New Haven pays for access to a digital platform that allows physicians to prescribe apps that have been clinically validated and assessed for their value to the patient. Patients receive a text message with a URL link to download the app. The platform also includes a physician-facing dashboard that aggregates data from all apps into a single view for each patient, making it easier to manage individuals using different apps to manage multiple chronic conditions.

However, this type of platform may be cost-prohibitive for small independent practices, meaning these physicians often must sort through the endless sea of apps on their own trying to identify which ones are clinically effective and worthwhile. There are also other challenges, most notably that many apps are not integrated with EHRs, meaning it may be difficult to glean useful information from the data that’s collected.

Using and recommending consumer health apps

Fortunately, there are several steps physicians can take to make the task of selecting, recommending, and using apps at the point of care less daunting. Consider these seven steps.

 Experts share these questions to consider:

What behavior do you want to change? Are there any apps that can help? For example, do you have a lot of patients with diabetes who need help managing their diet, exercise, or medications? There are many apps available to help patients with each of these tasks, one of which is provided by the American Diabetes Association. Other associations may provide similar apps targeting a chronic condition.

What information do you typically ask patients to track and share? Is there an app that captures this information digitally?

What MIPS quality measures do you report? What quality metrics are included in your value-based payer contracts? What apps are available to target these conditions?

What apps are your colleagues and larger health systems using? Have any of these apps helped patients achieve better outcomes?

Did the app developer solicit physician input, and can you rely on the accuracy of the content? Physicians should download the app first to get a sense of whether it’s clinically sound and something patients will use, says Ashish Atreja, MD, MPH, FACP, chief strategy officer at Rx.Health, a platform for prescribing curated apps and digital therapeutics. Is it easy to set up an account? And read user feedback and reviews. Do patients find the app valuable, and does it help them improve their health?  

“A lot of these app developers are small companies looking to gain traction,” says Skievaski. “They’re very approachable. Email them or call them, and ask them to convince you that it’s going to work for your patients.” He also suggests that physicians look to see whether any medical journals have published clinical studies about the app, he adds.

Studies published in medical journals hold more weight than those published by the app developers themselves, says Atreja. That’s because developer-sponsored studies rarely use randomized controlled trials, and tend to focus on small sample sizes of individuals who are already healthy, he says. A January 2019 study  published in 

Determine whether the app will integrate with your EHR.

Integration allows providers to make use of continuous monitoring and predictive analytics, says Solad. Although EHR vendors are increasingly working with app developers to enable interfaces that allow for seamless data transmission, the majority of apps currently do not integrate, he adds. However, if a physician is passionate about using a particular app, Solad suggests asking the developer whether it would consider working with the EHR vendor to enable integration. Developers may be willing to do so if it means they can expand their user base, Soldad says. 

Integration may also present revenue opportunities for certain apps-particularly those that measure physiologic data and are FDA-approved. When using these apps, providers may be able to report CPT code 99091, for which Medicare pays approximately $59. However, providers should find out whether their local Medicare and Medicaid administrative contractors and commercial payers will pay this code for the review of consumer app-derived physiologic data before they try to bill it, says Michael Warner, DO, CPC, a national advisory board member of AAPC, a training and credentialing organization for the business of healthcare in Salt Lake City, Utah. CPT code 99091 is reportable once per patient every 30 days provided that the physician reviews appropriate data every 30 days and spends at least 30 minutes reviewing, interpreting, and responding to the data, says Warner.

Even if the app doesn’t have an interface with your EHR, it may have a dashboard that aggregates and presents the data in a meaningful way-and this may be as useful as integration in some cases, says Oldenburg. “In fact, it’s really important that the app aggregates information and presents trends visually because it helps both patients and physicians see trends and harvest learnings,” she adds.

Physicians should also keep in mind that not every app may be well-suited for integration, says Steven E. Waldren, MD, MS, vice president and chief medical informatics officer at the American Academy of Family Physicians. For example, physicians may want to integrate an app that’s tied to an FDA-approved glucometer but not necessarily one that simply tracks exercise. Glucometer readings can inform medical decision-making when tied to specific alerts for data that falls outside of set parameters, he adds. Exercise data, on the other hand, wouldn’t necessarily trigger a clinical intervention.

Determine whether there’s a cost for using the app. 

Keep in mind that patient adoption may be lower for apps that aren’t free to use, says Atreja.

April 10, 2019 edition

Ease patients' financial pain points through billing transparency

Top 4 healthcare trends for 2019

Getting off the corporate treadmill

The risk of direct care

Patients take charge: How physician-patient relationships are changing

The physician-patient relationship has changed

New 2019 regulations for BMI coding

How to integrate health apps at the point of care

Six tips to getting paid for CPT modifiers

The rising price of insulin

IT services at your practice: In-house or outsourced?

Your voice: Primary care is dying because burdens are too great