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.

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The physician-patient relationship has changed

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.

Review the developer’s data handling policy. 

Does it even have a policy? “There are unfortunately malicious entities out there who are putting applications together just to collect name, date of birth, and other information,” says Waldren. “These details are pretty valuable on the black market.” Look for answers to these questions: What data can the app access after patients download it? Some apps may be able to access phone and email contacts, call logs, calendar data, data about the device’s location, and more. What will the developer do with that data? This information can often be found in the “app permissions” under the details, or in the apps privacy policies.

Oldenburg suggests starting with a handful of patients who already use apps. “Tell them, ‘I’m using this app, and I’d love to see what you think of it. I’d like you to send me a note in a couple of weeks to let me know how it’s going,’” she says. As these individuals see positive results, share their stories with other patients to motivate them, she adds.

Ask medical assistants to help patients download the app while they’re still in the care setting, says Skievaski. This helps ensure follow through, and it demonstrates that the physician values the app because they’re willing to devote resources to help ensure patients’ success.

Integrate the app into the clinical workflow. 

There are several ways in which physicians can integrate a consumer health app into their workflow. If the app doesn’t already integrate with the EHR, consider asking patients to simply open the app on their mobile device at the time of the visit, says Solad. A nurse or medical assistant can review the most recent data (or look at the dashboard if the app includes one) before the physician enters the exam room and then enter that data into the EHR, says Atreja. Another idea is to review the data when care coordinators contact patients receiving chronic care management services. 

Although validation is important, it shouldn’t necessarily preclude physicians from trying the app with their patients to achieve better outcomes, she adds. “You don’t need to be super scientific,” she says. Start recommending an app, and then track the results of the people who are using the app versus those who aren’t. Are you starting to see some results?”

patients. Do patients like the app? Do they use it consistently? Does it help them manage their condition? “The app development community is very iterative,” says Skievaski. “It releases something and then relies on feedback from users and providers. This is where physicians can actually make a difference so these products provide value back to patients.”

What physicians can do to harness patient-collected data.

How to integrate health apps at the point of care

Insulin, the life-saving medication that the more than 30.3 million Americans with diabetes require to live, is getting dramatically more expensive every year. 

According to a report from a working group at the American Diabetes Association (ADA), the list price of insulin has nearly tripled since 2002 and the average price of insulin has increased by 64 percent since January 2014.

Some patients have to make hard choices between paying for their medicine or other basic life necessities, such as food and electricity, or are even rationing their insulin, a dangerous practice that can lead to death. 

What is driving this exorbitant spike in cost for a drug that has remained largely unchanged since its discovery in the early 1920s? And what can physicians do to help their patients obtain the insulin they need?

Deane Waldman, MD, MBA, distinguished senior fellow in healthcare at the Texas Public Policy Foundation in Austin, Texas, says simply caring for patients is muddled by third-party entities, including the government, health insurers and pharmacy benefits mangers (PBMs). 

This works against physicians being able to offer their patients the best care possible, because physicians are forced to prescribe from what are often limited medications available through a patient’s insurers and pharmacies.

“This whole third party in between the doctor and the patient is not only jacking up the prices [of medications] astronomically, we can’t really do what we think is best for our patient and give the patients the option to choose,” Waldman says.

Consumers perceive that their insurance plans pay for their prescription drugs, and the consumer simply pays the remaining co-pay. However, “[Insurance companies] haven’t paid for a prescription probably since the 70s,” says Aaron Heilaman, PharmD, owner of Tradition Drug in Ada, Okla.

Indeed, the supply chain for insulin is described as “complex” by an ADA working group organized to address insulin’s affordability problem. The working group writes that, due to the numerous stakeholders including manufacturers, PBMs, pharmacies, health plans, and employers, “There is no one agreed-upon price for any insulin formulation. The price ultimately paid by the person with diabetes at the point of sale results from the prices, rebates, and fees negotiated among the stakeholders.” 

Health insurers farm prescriptions out to PBMs, typically to the top three: CVS/Caremark, Express Scripts, and OptumRx, which between then manage about 70 percent of the market, according to the ADA.

PBMs negotiate lower prices directly with the pharmaceutical companies, getting discounts on different medications. 

“PBMs came along and said, ‘We can be Visa for you. We can streamline the process from the point of sale at the pharmacy back to the insurance company,’ ” Heilaman explains.

Therefore, in many cases, PBMs decide which drugs they’ll carry in their formulary and can add or remove a drug at their whim. The pharmaceutical companies then have to offer steeper discounts or “rebates” in order to have their drug included in a PBM’s formulary. 

When PBMs manage the pharmacy benefit portion of a health plan, the ADA working group points out, they are beholden to their clients, health insurers and employers, not patients. 

Though the three insulin manufacturers-Sanofi of France, Novo Nordisk of Denmark, and Eli Lilly and Co.-all make similar insulin, whichever company is willing to give the largest rebate is the one that gets put on the formulary, Heilaman explains.

“The United States healthcare game is not an open, free, fair market. It’s captive by big corporations that call all the shots,” he says.

Another driver of higher cost, Waldman says, is that pharmaceutical companies have figured out ways to tweak drugs that are about to go off patent, enabling the manufacturer to extend the patent on the drugs or obtain new ones. This process prevents generic drug manufacturers from producing cheaper versions of the drugs. 

“A drug company can take a known drug that is about to go off patent and simply combine it with another drug that never was on patent in the first place, and get a new patent,” Waldman says.

The pharmaceutical companies have come under fire for such practices but are not prevented from doing so.

Other than lobbying for legislative checks and greater transparency for PBMs and pharmaceutical companies, where does this leave physicians who just want to make sure their patients can get the insulin they need?

There are a variety of programs to which physicians can direct patients in need of financial help. Eli Lilly, Sanofi, and Novo Nordisk all offer patient assistance programs, but these are generally reserved for people whose income is less than $36,000 per year and who do not have health insurance. 

Blink Health and Inside Rx are programs that may offer discounts of up to 40 percent on insulin compared to pharmacy prices.

According to the Juvenile Diabetes Research Foundation, several nonprofit patient and insulin assistance programs are available to help with the costs of Type 1
	diabetes medication. They include:

 which is sponsored by pharmaceutical companies, doctors, patient advocacy organizations, and civic groups. It helps low-income, uninsured patients get free or low-cost brand-name medications.

 maintains a free, extensive database of patient assistance programs, state assistance, medication discount programs, and free or low-cost medical care. The site also includes information on programs geared to help consumers through the application process.

is an online database of pharmaceutical company programs that provide free or affordable medicines and co-pay assistance. 

 is an online resource patients can search for an assistance program according to the type of medication. It also helps with the application process.

 is a nonprofit mail-order pharmacy for uninsured or underinsured people.

The National Institute of Diabetes and Digestive and Kidney Diseases

 (NIDDIK) publishes a resource called “Financial Help for Diabetes Care,” containing information about resources that may help with medical expenses of a person with diabetes. You can view this publication online or order copies from the National Diabetes Information Clearinghouse at 1-800-860-8747.

The JDRF also recommends that physicians with low-income, uninsured patients in immediate need of insulin seek out an older formulation of insulin that may be sold over the counter at Walmart or Sam’s Club. This insulin is typically sold under the name
	ReliOn. 

However, it does work differently than newer insulins, so physicians will need to be sure they help patients dose it correctly.

Oral medications and lifestyle changes for Type 2 diabetes

For patients with Type 2 diabetes who are taking insulin, lifestyle changes might be a way to reduce the amount of insulin they’re taking, or eliminate the need for it altogether, according to Megan Williams, MD, who is board certified in family and obesity medicine and owner of Elemental Weight Loss and Wellness Clinic in San Antonio, Texas.

“Physician to physician, don’t forget that there are lifestyle interventions that can be very powerful,” Williams says. “A major cost-reduction technique would be to try to move more, eat less, lower sugar and carb intake, and lose weight.”

Also, for Type 2 diabetes patients, she always looks for an oral insulin alternative that might be more affordable. “I’m a firm believer in evidence-based medicines over jumping straight to the most expensive thing, when the patient may not even be able to afford it,” she says. 

Williams emphasizes the importance of physicians discussing cost with their patients before making any diabetes treatment plan, since it won’t do any good if the patient can’t afford it.  

“I always make sure that patients that are having struggles [financially] contact the manufacturer directly because usually they’ll offer some type of discount,” she says.

In the wake of massive negative media attention to the plight of people who are unable to afford their lifesaving insulin, drug maker Eli Lilly has announced that they will begin to sell a cheaper insulin. 

The new version will be an “authorized generic” of Humalog 100, according to the New York Times, and will sell for $137.35 per vial, which is a 50 percent discount from the list price. 

The new drug, though identical to Humalog, will be called Insulin Lispro. Eli Lilly will continue to sell Humalog 100 at its regular price to insurers and employers.

Affordable insulin advocates hope this move pushes other drug companies to follow suit.

The rising price of insulin

CPT modifiers help payers understand all of the distinct services and procedures physicians perform. As the scope of practice for today’s internists continues to expand, these modifiers are also increasingly required to ensure accurate payment, says Toni Elhoms, CCS, CRC, CPC, director of coding and compliance at RT Welter & Associates Inc., a healthcare consulting company in Arvada, Colo. 

For example, say an internist performs an annual wellness exam and addresses a skin lesion during the same visit. If the physician doesn’t append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the evaluation and management (E/M) service for the lesion, most payers will disregard the E/M service and only pay for the annual wellness exam, says Elhoms. 

Appending a modifier when it isn’t warranted can also be costly. For example, an internist owns their own radiology equipment. If they append modifier -26 (professional component only) to each radiology service, they actually miss out on revenue, depending on the service, says Elhoms. For example, when appending modifier -26 to the CPT code for chest x-ray, single view (71045), physicians could lose approximately $13 for every test performed.

Elhoms cites the case of an internal medicine practice with its own radiology equipment that saw an immediate 60 percent increase in reimbursement simply by removing this modifier from the radiology CPT codes it reported. 

On the other hand, when a physician incorrectly appends a modifier and subsequently receives payment, they could be subject to a post-payment audit. “I’ve seen so many recoupments regarding inappropriate use of modifier -25 that have put private practice physicians out of business,” says Elhoms. “There’s a false sense of security when it’s paid. Recoupment requests can come out of nowhere.”

Elhoms knows of one family medicine practice that couldn’t recover from a $250,000 recoupment after a payer audited the practice’s use of modifier -25 on E/M office visit codes when providers rendered osteopathic manipulation treatment (OMT) during the same encounter.

The payer alleged that the documentation didn’t support a significant and separately identifiable service, and the payer felt the OMT was part of the typical work associated with the E/M code and shouldn’t have been paid separately, she says. 

Is there anything physicians can do to collect the payment they deserve while also avoiding compliance risk? Here are six tips experts recommend:

Just because one payer accepts a modifier doesn’t mean all will, says Michael Miscoe,   JD, founding partner of Miscoe Health Law LLC in Central City, Pa. For example, one payer might accept modifier -25 in all instances consistent with the CPT definition of “significant, separately identifiable” while another might not permit it at all for certain services (e.g. when a physician reports an E/M code in addition to a code for a pain management injection). 

Take the time to identify the modifiers each payer does-and doesn’t-recognize. “Check each payer’s medical policies for service-specific as well as general policies regarding separate reporting,” says Miscoe. 

“Ideally, you would have at least one person in-house who can assist with modifiers and be proactive about monitoring denials and providing education,” says Elhoms. Another option: Keep a trusted compliance consultant on stand-by as questions arise, she adds.

For example, when physicians report modifier -25, their documentation must support the history, exam, and medical decision-making for two separate services, says Elhoms. 

Think of each service as a separate encounter even though they’re rendered during the same visit, she adds. For modifier -59 (distinct procedural service), documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.  

Take a closer look at your billing system. 

Does your vendor incorporate National Correct Coding Initiative (NCCI) edits and update these edits quarterly? If so, are you certain that each payer has adopted those edits in its reimbursement policies? Do templates or billing automation encourage modifiers when they aren’t warranted or omit modifiers that are required? 

Append each modifier to the correct code. 

For example, modifier -59 should accompany a procedure or service code but not an office visit E/M code. Always refer to the NCCI procedure-to-procedure edits or specific payer bundling rules when determining what procedure or service code should include this modifier.

Example: When reporting an excisional biopsy and lesion destruction, append modifier -59 to the code for the lesion destruction. When removing an intrauterine device  and inserting a Nexplanon during an office visit, append modifier -59 to the code for the IU removal. Modifier -25, on the other hand, is always appended to an E/M office visit code when supported by the circumstances of the encounter, says Elhoms. 

Know what to do if you run into payment problems. 

While most payer contracts don’t permit this, a physician who is not under contract with a commercial payer may have the option to do so if all other state statutory advance notice requirements are met. Physicians are not permitted to balance bill patients with Medicare, and some states are enacting statutes to limit exposure of patients to either non-covered service costs or disallowed amounts for services that are covered, says Miscoe. 

If the payer hasn’t published a policy on modifier usage, physicians may be able to successfully appeal the denial by citing standard industry guidance (e.g., CPT definitions of various modifiers, the NCCI Policy Manual for Medicare Services, or even medical policies of other major commercial payers), says Miscoe.

Ask payers to accept modifiers in all or certain circumstances, says Elhoms. 

Taking proactive steps to ensure compliant use of modifiers pays dividends in the long run, says Elhoms.

What physicians can do to collect the payment they deserve while also avoiding compliance risk.

Six tips to getting paid for CPT modifiers

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

Small medical practices must perform many IT functions-among others, EHR system management, cybersecurity, imaging, billing, and controlling and keeping tabs on infrastructure operations-to achieve the clinical and financial outcomes necessary for their success. While most such offices don’t have in-house IT staff, some do, whether they train existing personnel to perform these functions or hire dedicated staff who already have these skills. 

This article looks at both approaches, examining the pros and cons of each, and when, or if, it can make sense to combine the two.

Before a practice decides who will handle its IT, it must know what IT functions are essential to clinical and financial success. EHRs are a given, but so is a practice management system whose patient data can be integrated with the health records and that creates a workflow that expedites patient appointments. 

To accomplish this, the EHR must have an API (Application Programming Interface) that has easy back-and-forth communication with the management system, and both components must be HIPAA-compliant. In addition, while it isn’t mandatory, it’s certainly desirable to have a patient portal that lets patients access their appointment schedules and records online. 

The major trade off with hiring IT staff versus outsourcing the function is that a practice has greater operational control with staff, but assumes higher costs and risks. says Graham Caparulo, principal consultant with Diligex, a New York City-based provider of IT services to small and medium-sized medical practices. 

“On the risk side, if you have your own staff and a data breach, there’s no one to point the finger at except yourself,” Caparulo says. (Under the HIPAA Omnibus Rule, if the contractor has signed a HIPAA Business Associate agreement with the practice to comply with HIPAA privacy, security and breach notification requirements, it is liable for any HIPAA infractions it commits.)

Contracting out IT lets a practice focus on its core business of providing healthcare. Moreover, the practice may get a broad base of contract employees with a wide variety of technical competencies, and it’s not left exposed if the in-house IT staffer gets sick, goes on vacation, or leaves the practice. 

“The average tenure of an IT person is about two or three years,” says Caparulo, “so do you want to go through this every couple of years or shift that over to somebody else?”

Before hiring outside contractors, the practice needs to conduct a thorough internal inventory to determine what the staff members and doctors already know about the existing IT system, identify their IT product and service needs, and then develop a Request for Proposals based on those precise needs.

“For instance, do you need to select a system?” says Ken Hertz, FACMPE, a principal with MGMA Health Care Consulting Group, in Englewood, Colo. “Is it hardware you need? Is it networking? Is it EHR selection? There’s so many services that external vendors offer that you need to be very clear about what it is that you want to get.”

At some point, however, it makes sense for a small practice to hire some in-house IT staff, for what Caparulo calls “level one or front-end triage issues,” such as if a front-desk staffer can’t log in to the EHR, access e-mail, or print out a medical record. In those instances, it’s better to have a technically adept practice employee on hand to solve the problem. 

“They’ll likely get things resolved quicker than if they go through an outsourced provider,” says Caparulo.

Alternatively, a practice might train its own employees-even if they have little or no IT experience-instead of hiring new personnel. While this certainly costs much less than hiring a full-time IT staffer, the questions become: is it worth the time to train a tech neophyte on the practice’s staff, and will the growth in size and complexity of an IT structure make it too difficult for that staffer to manage in the future? It might be easier to choose this path if the practice’s IT vendor makes training and system support part of the technology purchase cost.

On the other hand, Hertz posits that many workers today are comfortable with sophisticated digital technology. These staffers can use their familiarity to learn the workings of the EHR and perform certain IT functions in a practice, potentially removing the need for a full-time IT staff person. These “super-users” can be and “are highly trained in software, and in understanding and problem-solving with the EHR or practice management software. A vendor can furnish that training.”

However, “they’re not going to solve your network problems and things like that,” Hertz cautions. Even so, he notes, super-users who develop more experience handling software can sometimes help with networking and hardware problems. One caveat, though: super-users have other jobs in the practice that they could neglect if called upon to spend hours diagnosing and fixing an IT problem.

Thus the more complex services, such as interoperability and telemedicine, ought to be left to contract experts, Hertz says. “You want somebody who knows all about HIPAA issues, cybersecurity issues, encoding messages and so forth, so that’s where you’re going to use outsourced vendors.” Specifically, Hertz recommends that a practice should have “one really good external, outsourced IT support” vendor it can rely upon for  guidance in these areas. 

For some small practices-like that of Karen Smith, MD, a family physician in rural Raeford, N.C.-hiring new or training existing in-house staff isn’t an option. First, the cost is prohibitive-about $30,000 per year, according to practice administrator Michael Hendricks. That would be an operations budget-buster for Smith, who also has a practice manager, registered medical assistant, part-time nurse practitioner, and billing coordinator on staff.

Second, it’s more practical to use a sub-contractor from nearby Fort Bragg to provide IT support, just as he does in his full-time position on the base. (This sub-contractor’s predecessor, another Ft. Bragg IT specialist, originally set up Smith’s IT systems and made the practice completely paperless.) 

“Even if we had an IT specialist to come in and train us it’s out of our purview because we would literally have to study that technology and know what the upgrades are,” explains Smith, adding that it’s “far more cost-effective” to leave that up to her sub-contractor, who does this every day for the U.S. Army.

Moreover, each service the practice installs, like the patient portal Smith is about to install for opioid addiction treatment, or the telepsychiatry functionality her practice has had for some time (to offset the dearth of pediatric psychiatrists in the state), always comes with training costs. Here, too, it’s much better having an IT-savvy sub like Moore learn this, “because we just don’t have the knowledge base for it,” Smith admits.

A look at both approaches, examining the pros and cons of each, and when, or if, it can make sense to combine the two.

April 10, 2019 edition

The physician-patient relationship has changed

How to integrate health apps at the point of care

The rising price of insulin

Six tips to getting paid for CPT modifiers

Patients take charge: How physician-patient relationships are changing

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

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

New 2019 regulations for BMI coding

The risk of direct care

Getting off the corporate treadmill

Top 4 healthcare trends for 2019

Ease patients' financial pain points through billing transparency