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.

Medicaid was founded in 1965 to provide care for our most vulnerable. The program is funded by federal and state governments, administered by the states. However, because of dramatic increases in the population covered-2 percent at inception to today’s 22 percent (>74 million participants)-and ever-increasing expenditures per patient, there is agreement that with huge increases in cost, it cannot survive in its present form. According to CMS, total Medicaid spending as of 2016 was 

 and under current law projected to be 

Presently, state expenditures for Medicaid 

that for primary and secondary education. This is disturbing because adequate education is the means by which the young can avoid needing Medicaid in their future. Budget limitations have created lower reimbursement rates for physicians and hospitals. This limits physician access (varying by state), resulting in continued use of expensive emergency departments for otherwise routine care. Low reimbursements have led hospitals to cover losses by negotiating higher reimbursements from private insurance. In many poorer rural areas this has not been possible, leading to hospital closures. 

This “cost-shifting” causes higher premiums for employer-sponsored and other insurances, contributing in part to stagnation of salaries for many workers. In effect, this is a hidden tax to subsidize the program. Many studies have consistently demonstrated a lack of health outcome benefit for Medicaid patients. Recently, the Government Accountability Office claimed 

not enough is being done to eliminate fraud

. Faced with unsustainable costs, many states are applying for federal waivers to explore a variety of options, such as Medicaid managed care, work requirements (

), direct primary care, health savings accounts, and premium assistance 

Solutions are difficult as evidenced by recent attempts to save funds, in this case paying hospitals a yearly amount caring for Medicare/Medicaid patients, irrespective of usage, called global capitation. This has had the unintended consequence of seriously curtailing and endangering pediatric care. As a price-fixed, third-party program, individuals are removed from any cost signals. Despite these many criticisms, a few states that initially refused to expand their Medicaid program via the ACA expansion are now doing so, perhaps to capture the federal funds that are going to nearby states funded, in part, by their taxpayers. These states’ hospital associations are strong advocates to expand Medicaid, seen as a money stream in addition to already covering their costs by “cost shifting.” There is also the belief that insurance should be available to as many as possible. Others argue that insurance is not synonymous with care especially with Medicaid because of the findings of 

improvement in outcomes and its huge state and federal costs.

With deep philosophical differences between our two political parties, is there a solution to saving Medicaid? Yes. There is a uniquely American solution. Let individuals decide between the present Medicaid and a proven successful plan that provides better care at far less cost.  This alternative could be modeled after 

Indiana’s successful Medicaid pilot program

 (2007-2012). The idea behind this plan was relatively simple: with the proper financial arrangements the poor would wisely manage the money and develop healthy behaviors. A health account was set up for each participant, a $1,100 deposit (would need adjustment) into the individual’s account paying for routine care, coupled with nationally available insurance solely for bigger ticket items. Contributions by federal/state governments and the individual would be on a means-tested sliding scale, thus avoiding a “welfare cliff.” This insurance would be in the individual’s name, thus immune from cancellation due to developing a chronic illness. Funding for hospital care would be at private insurance levels greatly helping rural institutions. For the recipients to receive funding for the following year they had to obtain preventative care. This plan avoids “middle men” between patients and care. The results were impressive:  96 percent had positive feelings about this plan. It was proven that Medicaid recipients managed their healthcare dollars in a proper manner, their use of EDs significantly declined, as did their medical costs. They reported improved health.

Medicaid now is spending more than $7,000 per person; this alternative would cost significantly less, conserve government funds, and allow for personal choice. This should appeal to conservatives. It would also improve care of our most vulnerable and be available to more Americans. This should appeal to liberals. Importantly more resources could then be devoted to the future of our nation by putting more emphasis on educating our young, which should appeal to everyone.

Kenneth A. Fisher, MD, is an internist/nephrologist, teacher, author ("Understanding Healthcare: A Historical Perspective" and "In Defiance of Death: Exposing the Real Costs of End-of-Life Care"), and co-founder of Michigan Chapter of the Free Market Medicine Association.

Articles

Despite deep philosophical differences between our two political parties, there is a uniquely American solution to saving Medicaid.

We must save Medicaid through a bipartisan effort 

Internist Ann Cordum, MD, belongs to a seemingly endangered species of primary care doctors-those who enjoy their work and look forward to coming to the office every day.

It hasn’t always been that way for Cordum. She spent the first quarter century of her career in clinical and administrative positions with large healthcare systems, where she found herself growing increasingly frustrated with bureaucracy, too-short patient visits, and answering to managers who were MBAs rather than MDs.

So in 2015, Cordum decided to strike out on her own. She and another internist opened a direct primary care practice in Boise, Idaho, with the goal, she says, of “having no intermediary between myself and the patient.” The result has been exactly what she hoped for in terms of her approach to practicing medicine. “Now it really is joyful,” she says. “I like going to work and even when I’m not at work, I’m always available. I feel like it’s my pleasure to help the patients with their needs.”

Doctors’ use of terms like “joyful” and “pleasure” when talking about medical practice has grown increasingly rare in the last decade or so. Studies and surveys consistently show rising levels of burnout and alienation within the medical profession. For example, in the Physicians Foundation’s 2016 Survey of American Physicians, 54 percent of respondents rated their morale as “somewhat or very negative,” and 49 percent said they “often or always experience feelings of burnout.” Only 37 percent said they harbored positive feelings about the future of the medical profession.
The reasons behind these feelings have been well documented. They range from frustration with EHRs and time spent obtaining prior authorizations to anger over government mandates and payers’ “take it or leave it” attitude in contract negotiations.

And yet, in spite of all the obstacles, it is still possible for doctors to enjoy their work. The key, according to practice consultants, psychologists, and physicians, is spending more time doing what doctors are trained to do and gives them pleasure: treating patients.

While that sounds obvious, the challenge lies in finding the time for it. To start with, many doctors-particularly those working for hospitals and hospital systems-usually have little control over their schedule or working conditions and often must wrestle with the system’s bureaucracy to get patients the care they need.

But even doctors in independent practice often find it difficult to carve out more time for patients, given the range of administrative tasks and quantity of paperwork pulling them away from the exam room.

“A lot of what’s driving doctor unhappiness is that more and more is being expected of them than in the past, and this has compressed the amount of time they have to spend with patients, while the documentation burden has gone up,” says Cynthia “Daisy” Smith, MD, FACP, vice president of clinical programs for the American College of Physicians and part of the ACP’s Physician Well-being and Professional Satisfaction initiative.

Smith cites a 2016 study in Annals of Internal Medicine that found that for every hour doctors spend in face-to-face clinical time with patients, they spend nearly two hours on “EHR and desk work in the office,” according to the authors, and another one to two hours of personal time on computer and clerical work.

Rethinking approaches to medical practice

But the barriers to finding, or rediscovering, joy in medicine aren’t all external, experts say. Sometimes it requires physicians to rethink how they approach their work, says Gail Gazelle, MD, FACP, a former hospice physician who now coaches doctors on issues of professional satisfaction and work-life balance.

Gazelle notes, for example, that many physicians are perfectionists, a personality attribute that is important for success in medical education and training but can contribute to frustration and anxiety as a practitioner. “If you spend hours [on patient notes] perfect because you believe that every note has to be, but you only have so many hours in a day, you can see how the math doesn’t add up, and helps to explain why so many physicians struggle to keep up with documentation demands,” Gazelle says.

That drive for perfectionism, Gazelle adds, goes hand-in-hand with how many doctors learn to deal with problems they encounter in their practice: by working harder. “Many of us were taught that to be a good doctor you just power through, and don’t pay attention to your own needs,” she says. “And we know, given the high levels of burnout in front-line specialties, that is not an effective strategy in the long run.”

Another impediment to professional satisfaction doctors sometimes face-especially older physicians-lies in the attitude of supreme authority instilled during their education. “When I was in medical school 40 years ago, there wasn’t a lot of emphasis on team care,” says Louis Snitkoff, MD, FACP, chief medical officer of Community Care Physicians, a multi-specialty practice in the Albany, N.Y. region. “You were trained that everything the patient needs, or happens to the patient, is your responsibility, and it’s a tremendous burden.”

So how can doctors find more time to spend with patients, and thereby find-or rediscover-the joy of practicing medicine? For Cordum and her partner, the solution has been to remove as many barriers as possible between themselves and their patients, starting with insurance companies, which is why they have chosen the direct primary care model for their practice.

“If you are on an insurance panel, your contract is with the insurance company, not with the patient, and that’s a conflict of interest for me. It goes against my oath to work for the patient and not someone else,” she says. Besides, she adds, “I get intimidated with all the third parties and contracts and 1-800 numbers, and it takes away from having meaningful time with my patients.”

Not accepting third-party payments has brought the additional benefit of not being required to use an EHR. Instead, Cordum uses a Microsoft Word-based system to record her notes and other pertinent information. “It’s perfectly adequate [and] costs me nothing so I can keep costs down,” she says.

Using the DPC model also allows her to keep her patient panel between 400 and 500 patients. “We know our patients, and we know what’s important to each of them, their goals and their values,” Cordum says. “Also, we don’t have intermediaries and barriers to patients’ ability to reach us and spend time with us. When the patient calls our office, we call them back ourselves.”

Cordum notes that the DPC model hasn’t freed her entirely from the administrative hassles of medical practice. Some of her patients have health insurance, which means she must still get prior authorizations for some drugs she prescribes and prepare bills for these patients to submit for reimbursement. But the amount of work and time required for these tasks is far less than what her colleagues with insurance contracts contend with.

“When I decided on this model, it was for simplicity and removing anything onerous or complex and bringing it back to the patient and the doctor,” she says. “And I’m having fun with medicine again. I get to do house calls, I get to do walking visits with my patients. And if something isn’t working, I don’t have to go through three committees. I just change it and make it better.”

Of course, most independent practices have payer contracts and thus operate under more constraints than Cordum. But even under those circumstances, doctors can take steps to increase their patient time and reduce their frustration level, experts say. Among these are: streamlining practice workflow, strengthening collaboration among practice staff, and reassigning tasks not requiring an MD to other providers or staff members.

The ACP’s Smith recommends that practices hold regular staff huddles, establish protocols and standing orders wherever appropriate, and utilize pre-visit planning. “Have someone from the staff look at the patient’s chart and anticipate what needs and questions that patient is going to have,” she says. “Some practices even go so far as to order labs ahead of time so all the administrative needs are addressed before the patient comes in and the doctor can focus all his attention on the patient.”

At Community Care Physicians, improving physician satisfaction took the form of negotiating an agreement with one of the practice’s major payers, with whom it is in a shared-savings arrangement, to eliminate prior authorizations for complex imaging procedures. “Even though it’s not all our payers, it’s still a huge thing for morale, and has really helped reduce the burden on our physicians and staff,” says Snitkoff. 

Allowing doctors some say in patient scheduling can also help to increase their satisfaction, particularly when it comes to who they see at the beginning and end of the day. “We’ve found the bookends of the day can be some of the most stressful for physicians, particularly those who are juggling competing demands at home and at work,” Smith says. For example, a parent needing to pick up a child at daycare will feel less stress knowing the last appointment of the day is for something minor and straightforward, like a urinary tract infection.

“If you can give clinicians some flexibility over that first and last slot of the day, that really seems to ease anxiety and makes people feel like they have more control,” she says.

Allowing primary care doctors more flexibility in their schedules and time with patients was the goal of an experimental program at Virginia Mason Medical Center, a Seattle, Wash.-based hospital system. Launched in 2016, the program increased patient appointment lengths for some physicians and nurse practitioners in outpatient settings to a uniform 30 minutes, rather than Virginia Mason’s standard 15- or 20-minute allotments.

“Some of that [the reason for the pilot] was to try and give us back time with our patients,” explains Carrie Horwitch, MD, FACP, who oversaw the pilot program. “It also simplified our scheduling, so that the provider didn’t have to figure out if that patient needed a longer or shorter appointment.

Part of what enabled Virginia Mason to free up time for longer visits, Horwitch explains, is its long-standing emphasis on team-based care and handing off tasks that don’t require a physician to other staff members. For example, patients who come in for opioid prescriptions first meet with a pharmacist, who provides information about the medication, ascertains that the patient is using it correctly, and checks the patient’s record in the state’s prescription monitoring program database.

“That sets up the appointment for the clinician so that we can really spend time with the patient, answer their questions, and see how they’re doing,” she says.

Horwitch notes that the program led to greater feelings of satisfaction among the participating clinicians, leading Virginia Mason to expand the option of uniform 30-miniute appointments to all its primary care providers. Its success, she adds, confirms her belief that much of what makes doctors unhappy is due to not having the time necessary to provide quality care to their patients.

“It’s why we’re in this profession and we stay in it,” she says. “To be healers and helpers of people."

Patient input helps physician design joyful practice

Like many primary care doctors, Pamela Wible, MD, was unhappy with the “assembly line” style of medicine she was practicing early in her career. She bounced among jobs at large clinics and hospital systems, where patient visits were short and long-term relationships were few. What’s more, she knew that patients were dissatisfied as well.

But while Wible’s feelings about the care she was providing were hardly unique, her response was: before starting her own practice, she convened a series of townhall-style meetings in and around her hometown of Eugene Ore., in which she asked people what their ideal medical practice would look like.

“I pretty much told them I would try to do whatever they wanted me to as long as it was legal,” Wible recalls. What she heard was not surprising. “People wanted a human-scale experience. “They wanted me to be on-time for appointments and in a good mood. They wanted me to address their medical problems and not rush them. They wanted me to be able to refer them to someone nearby to help them if I couldn’t.”

Armed with this feedback, the practice she opened in 2005 was one in which she was-and remains-not just the sole provider, but the only employee. “Solo in the truest sense,” she says.

Wible’s office space consists of 280 square feet that she rents in a wellness center. Since she doesn’t employ a receptionist, she greets patients herself and escorts them to the exam room. Appointments run either 30 or 60 minutes. “That allows us to cover a lot more territory” than in standard 15-minute appointments, she says.

Wible does her own billing of insurance companies, she adds, and generally is paid within two weeks. Thanks to her minimal overhead, she keeps about 90% of what she bills. “It’s a very easy, simple process,” she says. “The patient goes home happy and I’m able to live the life of a joyful doctor.”

Wible believes the process of inviting lay people’s help in designing a practice is one that can, and should, be adopted elsewhere. “It’s very empowering for a patient to walk into a facility they helped design,” Wible adds. “In the current medical model patients and physician feel they’re held hostage by a process that was designed with neither of them in mind, but is what I would call administration-centric. It’s built around what’s convenient for people at the top, whereas my practice was designed to be patient-centric. I’m working for my patients and not for other people, and that’s what brings me joy.”

Since opening her own practice Wible has spread her gospel of joyful medicine via blogs, seminars, and retreats for physicians. In addition, she has sought to draw attention to the alarming upsurge in physician suicides, which led her to being named a Medical Economics 2018 ChangeMaker in Medicine.

While acknowledging that most physicians don’t enjoy her degree of autonomy, Wible maintains there are steps doctors in larger practices, or those employed by hospital systems, can take to find joy in their work.

“They should read their statement from when they applied to medical school about why they wanted to be a doctor,” she says. “Or spend some time thinking about what brings them pleasure in their work.”

In addition, she notes, many doctors develop an affinity for treating certain diseases and/or classes of patients. “You can orient your practice no matter where you work to attract the subset of patients you really enjoy,” she says. “If you like working with women over 40 with fibromyalgia, you’ll have a lot more fun than if you spend your time treating men with bronchitis.

Wible thinks doctors can feel more positive about themselves, and their work, by looking for pleasurable incidents, however small, that occur during the course of a day.

“No matter how bad your day is there are usually moments of joy that sneak through that make you laugh or say ‘wow,’” she says. “We need to pause once in a while to think about those moments because even though we talk a lot about what we hate in our jobs, there are always things we love, too.”

Some physicians are pushing back against the stress of medicine by simplifying their practices to remove barriers between them and their patients.

Restoring the joy in medical practice 

It is a common refrain I heard at a national internal medicine conference addressing the stress today’s physicians face:

“You can’t yoga your way out of burnout.”

I agree. Yoga, meditation, and mindfulness are helpful, but more is required to restore the joy of practicing medicine. These are just some of the ways. There are many more.

The fact is, there is no one-size- fits-all answer to an issue as large as physician burnout. As the stressors vary-from time in front of an EHR vs. face-to-face with a patient to battling payers over the best treatment-so do the means to relieve that tension. But that doesn’t mean it is too much to overcome.

Physicians have numerous allies in this battle, most importantly, their peers. Find strength in their path and their advice.

In this issue, you’ll find examples of numerous doctors who are overcoming and/or preventing burnout from interrupting their core mission of treating patients. And we’d be foolish to believe that readers use this as a handbook, following step-by-step the path of another doctor and expecting the same outcome. But, what we believe we’ve provided are sound strategies to piece together the initial path to improving physician wellness and truly restoring the joy of medicine.

And the other thing we hope becomes clear after reading about peers is that it is OK to ask for help. The stigma around physician burnout-that it is “part of the job” or only happens to weaker individuals-is one of the biggest obstacles to improvement.

Ask for help. Ask a peer how they get back to the heart of treating patients without added, and unnecessary, obstacles. Learn from and listen to one another.

Use this issue as a starting point, as a small step toward taking back a little more of each day to help those who truly need you-whether patients or family and friends. Fight back.

Relief could come in the form of opening a direct primary care practice. Perhaps some simple workflow adjustments free up additional time. It might even be reaching out for some peer-to-peer support and guidance. The solutions are out there, and they are numerous.

And yes, you might even consider a little yoga as well.

The war against physician burnout starts with a strong plan of attack

What is the correct way to code for venipuncture? Does the billing change if the procedure is performed by a medical assistant (MA) instead of a physician?

If your physician has seen the patient prior to the MA performing the venipuncture (on the same day or a previous date) and instructs the MA to perform the venipuncture, the billing is the same regardless of whether the physician or MA actually performs the service, based on incident-to guidelines. Just make sure that the physician’s order and the performance of the venipuncture are documented.

1. Select the right code. Venipuncture coding is described using CPT 36415 (collection of venous blood by venipuncture).

2. Don’t append modifier -63. Modifier -63 describes a procedure performed on an infant less than 4 kg. CPT instructs us that use of modifier -63 with 36415 is inappropriate.

3. Report a single unit of 36415, per episode of care, regardless of how many times venipuncture is performed. This instruction comes from the 2018 National Correct Coding Initiative (NCCI) Policy Manual, Chapter V: Respiratory, Cardiovascular, Hemic and Lymphatic Systems CPT Codes 30000-39999. The Policy Manual stipulates:

CPT code 36415 describes collection of venous blood by venipuncture. Each unit of service (UOS) of this code includes all collections of venous blood by venipuncture during a single episode of care regardless of the number of times venipuncture is performed to collect venous blood specimens. Two or more collections of venous blood by venipuncture during the same episode of care are not reportable as additional UOS [Units of Service].

Per the Policy Manual, “An episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.”

Medicare will not reimburse for routine venipuncture, and neither will many private payers.

CPT includes codes to report venipuncture requiring a physician’s skill, which are chosen according to the patient’s age and, for those patients younger than 3 years old, by the vein accessed:

36400  Venipuncture, younger than age 3 years, necessitating physician skill, not to be used for routine venipuncture; femoral or jugular vein

36410  Venipuncture, age 3 years or older, necessitating physician skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)

Medicare will separately reimburse for 36400-36410, but only if documentation supports medical necessity. Documentation should describe the circumstances requiring physician skill.

Keep these tips in mind when documenting and billing for venipuncture.

How to properly document and bill for venipuncture 

C. Nicole Swiner, MD, has worked hard to create a better work-life balance for herself. She transitioned from a hospital-owned clinic to private practice eight years ago and now is one of two physicians at Durham Family Medicine in Durham, N.C. She knows that devising best practices and strategies before they’re needed can go a long way toward keeping the “flow” in “workflow.” 

Here’s how to strengthen organizational workflow within a practice to make sure everything isn’t always the physician’s responsibility-a surefire set-up for burnout.

The best thing she’s done to improve her sanity is to hire someone who functions like a scribe, says Swiner. “I should have done it sooner. Now I focus less on note-taking and finishing and more on being able to listen to my patients instead of staring at the computer.”

She knows time is money. “Now it takes me 15 minutes to do 15 to 20 notes,” she says. “Paying a premed or grad student to scribe gives me time to see two to three extra patients in a day. They gain knowledge by working with me, and we both win.”

Ideally, everyone works to maximal capabilities and training, says Swiner, who also works with her LPNs and medical assistants so they understand her organizational structure and can support her at “full capacity,” meaning they can rise to the ever-changing list of tasks that occur in the practice every day.”The fewer phone calls and less paperwork I have, the better my life is,” she says.

Leading contributors to the pervasive problem include increasing administrative and documentation burdens, and the pressure to do more with fewer resources, says Nisha Mehta, MD, a radiologist based in Charlotte, N.C., who writes and speaks about physician burnout.

“To address this, practices need to take a sincere look at workflow, identify areas where other members of the healthcare team or staff can help, and then devote resources and training to make this possible,” Mehta says.

“The first thing physicians sometimes need to understand is how to ask for help,” says Kenneth T. Hertz, FACMPE, principal consultant for the Medical Group Management Association Health Care Consulting Group. “Remember, too, that there isn’t always one solution, i.e., ‘If you do this, everything will be fine.’”

Enter the practice manager, who can help build teams “to pull people together to solve problems,” says Hertz. “This requires collaborative effort, knowing you can’t solve everything by yourself. Practice managers really can help when we’re able to analyze things from the outside, without being in the middle of them.”

Make work performance expectations very clear, up front, Hertz says. “For example, say to your trusted nurse, ‘When I come into the exam room, please have this and this laid out for me. And check the chart to make sure lab and X-ray results are back.’”

In addition to the nurse, the receptionist is just one staff member who may see patients before the physician and should process them quickly, says Hertz. Checking them in and obtaining their medical files, confirming current insurance, address, phone, and emergency contact efficiently prepares them for the next steps.

“Then [the patient is] ready to be seen so the doctor can walk into the exam room and do his or her job. Everyone needs to accept responsibility for their little piece and to know that everyone succeeds or fails as a team,” he says.

Remember to recognize good work, says Hertz. “You can do this when you praise your staff. It’s especially powerful from the doctor, who might say, ‘Thank you, it was a great day today.’ The employee on the receiving end walks on air for the next two weeks and now wants to continue to rise to the occasion on the job.”

Be patient with staff, since sometimes, practices can be quick to let valued staff members go for reasons that aren’t so well thought out, says Mehta. She suggests that maybe it’s ultimately beneficial not to focus on the “small stuff,” but to appreciate the broader contributions a seasoned staff member makes to the practice workflow.

“Focus on the retention and satisfaction of valuable, well-trained staff so that you’re not wasting time, money, and effort on recruitment and training of new members,” Mehta says. Think about creating efficiency in the practice-then preserving it.”

Acknowledge that just as the physician has a life away from work, so do staff members, says Hertz. Try to be empathetic and flexible when the biller, who may also have a husband and two children, reports that one child is really sick and asks for time-off consideration.

Workflow is also better without problematic patients, so don’t hesitate to make necessary changes, says Swiner.
“Taking that action is appropriate when patients are late, cancelling or no-showing, not taking medications correctly, or being belligerent with staff. You have every right to ask them to find someone who suits them better,” she says.
This tactic can result in immediate benefits, says Swiner, for both doctor and patient.

“I’m much less stressed when I look at the schedule and don’t see as many patients that give me heartburn. And it may be healthier for both of you,” she says.

Learn to delegate responsibly to help ease pressure on physicians.

Manage practice workflow to reduce burnout

Physicians could have new assistants in the future: artificial intelligence (AI). AI could be capable of screening patients, offering diagnoses, and suggesting optimal treatments as well as triaging patient inquiries and processing patient claims.

AI is a technology that mimics human thought processes by finding patterns, then using what it finds to make decisions. AI is also defined by its ability to learn as it processes more data over time.

AI, in fact, promises to impact nearly every aspect of primary care, according to health IT experts.

Those knowledgeable about the technology say AI-enabled computer applications will collect and synthesize disparate patient data and present it to physicians alongside insights into the patient’s medical needs.

It will help physicians better identify patients who need more attention and provide personalized recommendations on what protocols would work best for each individual. And AI will even help diagnose patients by analyzing quantities of information that would be too difficult for any human to assess.

“There are very high hopes for AI to improve the lives of physicians as well as the lives of their patients,” says Anil Jain, MD, FACP, an internist who is vice president and chief health information officer for Watson Health at IBM in Armonk, N.Y. “As a primary care doctor, I’m encouraged by this because it could make my life easier.”

Several factors have come together recently to support the quickening pace of AI developments for healthcare and, more specifically, for primary care.

Leading the way is the amount of healthcare data collected in recent years. The high level of computing power now available to process large data sets, the ubiquity of computer systems and EHRs, and overall advances in computer technologies also have fueled AI’s advancements in medicine, according to experts.

Still, AI in healthcare is in its early stages, says Teresa Zayas CabÃ¡n, Ph.D., chief scientist at the Office of the National Coordinator for Health Information, which funded the 2017 report “Artificial Intelligence for Health and Health Care.”
Zayas CabÃ¡n says technology vendors, medical institutions, and other health organizations are working to identify the tasks that would be suitable for AI to ­handle and bring together the right data needed to ­develop, or “train,” AI to handle those tasks.

Even though AI is in its early stages, experts say it’s poised to impact both clinical care and administrative tasks in primary care practices and thereby allow more physicians to practice to the top of their license, says Erik Louie, MD, chief medical officer at HealthBox, a healthcare innovation consulting and fund management services firm in Chicago, Ill.

Louie and others envision a variety of different uses. AI could screen patient data from physician notes, tests results, and other data sources and combine that with information from protocols, clinical studies, and recommendations to identify a patient’s condition, which follow-up tests are needed, and which medicines work best. In other words, AI will be significantly more sophisticated versions of today’s clinical decision tools.

Meanwhile, AI could collect and analyze patient data as it is generated from multiple sources, including fitness trackers and at-home monitors, thus aiding physicians as they monitor patients’ health in ways that time and resources without AI don’t allow. “AI lets us look at data and help think about the patient’s total picture. In the future, it will help [physicians] to get insights, rather than just data,” Jain says.

Moreover, AI is expected to enable primary care physicians to engage in precision medicine, where care protocols culled from large-scale studies are tailored to the individual patient based on analysis of his or her own conditions, genetic makeup, and even social circumstances. It’s a level of analysis that no human could do, Jain says.

Experts predict physicians will use AI to help them more accurately identify patients who need specialty care. They also expect physicians will use it to better manage patients by directing those who need higher-level care to specialists while being able to more accurately monitor at-risk patients in their own practice-a critical benefit as the U.S. healthcare system moves more patients to value-based care models.

As an example, Louie points to an AI application to screen for diabetic retinopathy as a tool for primary care physicians. The federal Food and Drug Administration in April approved IDx, a diagnostic system that uses AI to detect diabetic retinopathy. IDx does not require a specialist to interpret the images or results, making it the first such system cleared for use by the FDA.

Physicians and their care teams, even those not normally involved in eye care, can use the technology to screen their patients for the condition during routine office visits.

In addition, physicians soon could have AI take their notes, analyze their discussions with patients, and enter required information directly into their EHR systems. Physicians might even use AI to analyze indicators that they can’t, such as patients’ voices to detect anxiety or depression.

IT forecasters predict that this emerging technology will also improve many front- and back-office functions. For example, AI will guide patients through intake forms that it tailors based on responses, and AI will analyze patient records to determine how to most accurately submit claims for timely reimbursements with less chance of denials.

AI has the potential to positively impact healthcare in several ways, all delivering real returns, health IT leaders say. Consider, for instance, that research shows that clinicians have an average of 15 minutes with each patient but spend nine of those minutes entering data in their EHRs, says R “Ray” Wang, MPH, principal analyst and founder of Constellation Research Inc. of Monta Vista, Calif. Imagine, he says, how much more a clinician can discuss with the patient if AI takes over those mundane data-entry tasks.

Wang also notes that AI can access and learn new research at a volume and speed impossible for any human to match. That means a physician using AI can expand his or her breadth of knowledge and ensure his or her decisions draw on the latest research as well.

“AI will be going through information-the patient’s genome, history, current medications, all the things the physician doesn’t have the time to be on top of and information that might not even be accessible [to him or her],” says John Huffman, chief scientific officer of data science and AI at Philips, a Dutch company whose portfolio of integrated health tech products includes AI-enabled platforms.


Numerous initiatives and technology vendors are introducing more AI products into a variety of healthcare disciplines, including primary care.

One example of AI at work in primary healthcare is the nonprofit Human Diagnosis Project, or Human Dx, which uses machine learning algorithms to analyze patient conditions.

This is how it works: a physician inputs his or her patient’s background and medical findings into the Human Dx system, which then invites other physicians to review the case and enter their recommended tests and diagnosis. The system uses AI to combine and analyze the information from the contributing physicians along with the patient’s medical records; it also factors in what it has learned from other cases analyzed on the Human Dx system.

In the future, Human Dx will also incorporate genomics, epigenomics, proteomics, published medical research, and health outcomes data. Already, though, thousands of physicians around the world are using Human Dx to gain insight on their patient cases, according to a spokesperson with Human Dx.

Robin Healthcare, a Berkeley, Calif.-based technology company, has developed a voice-enabled AI device that drafts clinical notes for clinicians as they speak and enters them directly into their EHRs. A spokesman says the company is currently serving only orthopedists but plans to expand to other outpatient specialists and eventually primary care physicians.

IBM Watson Health also uses AI to help physicians and researchers derive insights from vast data sets to support cancer care in more than 230 hospitals and health organizations worldwide, according to IBM.

Healthcare organizations, particularly some of the larger institutions, also have implemented AI for administrative needs, such as using chatbots to answer and direct patient inquiries and to handle financial tasks, says Kaveh Safavi, MD, JD, senior managing director for the global health practice at Accenture, a global management consulting firm.
Safavi says EHR vendors and technology giants like Apple and Google as well as numerous startups around the globe are exploring ways that they can develop AI-powered products for the healthcare industry.

Patients seem comfortable interacting with a computer instead of a doctor. Global consulting firm PwC, in its 2017 report, “What doctor? Why AI and robotics will ­define new health,” found that 54 percent of the 12,003 respondents in Europe, the ­Middle East, and Africa said they’re willing to engage with AI and robotics for their healthcare needs, while 38 percent said they’re unwilling to do so. (Some 7 percent said they were neither willing nor unwilling.)

EHRs and other computerized medical systems have created vast quantities of data over the past few decades, but not all that data is ready to be used to teach AI systems, Zayas CabÃ¡n says.

For AI to work, the data and the algorithms that process it need to be perfect, with no “biases,” meaning algorithms producing skewed results due to either ­being trained with faulty data or developed in ways that ­incorporate the developers’ own human misconceptions. She says technology vendors, medical institutions, and other health organizations are still working to “train” AI applications to handle certain tasks by “feeding” systems the large data sets they’ve gathered in recent years.

That work takes time, so health IT experts say physicians shouldn’t expect a plethora of additional AI applications to arrive soon.

Moreover, they predict that AI will work its way into EHRs and other applications gradually, with vendors building AI into existing systems or offering AI functions as add-on components one or two functions at a time. “You won’t go to the AI system; there isn’t going to be an AI product. AI will always be embedded in some operational system,” Huffman says.

Even if AI functions are embedded in EHRs and other applications that physicians already use, health IT leaders say that’s no guarantee physicians will quickly adopt them. They say vendors will have to develop AI applications that integrate well into physicians’ workflow and that are easy to use.

More important, AI vendors will have to demonstrate to physicians and even to their patients-who may eventually interact with the AI applications directly-that the systems are based on solid science and produce consistently accurate results.

Regulators and medical leaders will want to test AI functions and ensure they’re safe, secure, and reliable–requirements that could slow AI’s move into the exam room. “The algorithms have to be transparent, and they have to be explainable,” Wang says.

Furthermore, given how most physicians struggled for many years with EHRs and other health IT components without seeing real benefits, physicians will need to know that AI will help them be better, more efficient clinicians and not become another mundane computer function that they feel obligated to use, says Scott Shipman, MD, MPH, director of primary care initiatives and workforce analysis at the Association of American Medical Colleges.

Artificial intelligence vs. augmented intelligence

Already, however, examples exist of AI stepping into the role of primary care physician.

London-based Your.MD offers a free service that employs AI to help users find health information. Ada Health of Berlin, Germany, similarly uses AI alongside physicians for its app that helps consumers manage their health, an application that also includes some diagnostic capabilities.

Still, health IT experts see a future that involves physicians leveraging AI for clinical and administrative tasks but not one where physicians are actually replaced by AI. As such, Jain says AI should be thought of as augmented intelligence.
Safavi has similar thoughts, saying that AI won’t ever get good enough to replace a physician’s capabilities for higher-level decision-making-even as it starts to help the clinician with his or her job.

“We never thought an AI agent would get good enough to replace the judgment of a well-trained physician,” he adds. “What I would say is we expect the technology to take the simpler and more routine tasks away.”

The evolution of cognitive technology has the potential to transform the way physicians work.

Artificial intelligence in primary care 

Changes to the way many Americans select insurance-and the plans they ultimately choose- have introduced a number of new factors to the payment equation making the issue of bad debt ever more pervasive for medical practices. In an 

, over 90 percent of hospital chief financial officers report selling debt to multiple collection agencies, recouping only a portion of what is rightfully owed to them.

More Americans are turning to high-deductible healthcare plans through both employer-provided and Affordable Care Act coverage. 

 purchased low-premium, high-deductible plans through ACA exchanges in 2016; and a study from administrative software developer Benefitfocus found 

 purchase high-deductible plans from employers when given the choice.

This means more healthcare costs fall directly on patients-and this is happening on a significant scale across the country. Of the financial executives AArete surveyed, only one-tenth said patients feel they have coverage that can meet their health needs, while nearly half reported patients still have to pay out of pocket for the majority of their services. For physicians, that kind of shift means a new patient population, the under-insured, is now accumulating additional bad debt. This is a situation that must be addressed head-on to avoid serious financial pitfalls.

Given the right tools and institutional mindset, practices can adopt a strategy and goals to move past the current back-end-focused approach to bad debt, and more reliably collect the money they are owed. While acquiring the technology-tools to establish payment plans, financially clear patients, and perform other tasks-is relatively straightforward, creating the necessary organization-wide cultural shift in attitude toward bad debt isn't. It's critical for practice leaders to understand why this attitudinal change is so vital, and what benefits it can bring.

As Medicare moves to a value-based care reimbursement model where payments are tied to patient satisfaction, a positive patient experience has a direct impact on physicians’ bottom line. Executive teams are investing heavily in improving the patient experience to both protect their branding strategies and meet the challenges of patients as consumers.

And since a patient’s final interaction with the clinician will be the financial settlement of what they owe, their entire perception of the quality of care, and their experience will be largely influenced by the aftercare settlement. We have found that engaging up front with the patient, in an honest and transparent manner that avoids financial surprises, is one successful strategy to shape a positive patient experience.

This potentially difficult conversation should occur when patients are following up with their primary care physician and specialists, scheduling elective procedures, or even as soon as they are stable in the emergency department.

Only one-fifth of surveyed hospital executives report that financial clearance-a practice that ensures patients’ ability to pay before they arrive for an exam or procedure-is part of their facility’s operations. This process guarantees patients have access to funds, sometimes beyond insurance and direct payment, to compensate the hospital. Financial clearance can mean having your facility's financial counselors work with patients to find alternative resources such as charity and community sponsorships, low- or no-interest loan options from the facility, or simply setting up a payment plan.

For independent medical practices, it can mean developing programmatic or manual processes to screen for a patient’s ability to pay, and verify insurance prior to scheduling visits and rendering care. Proactive bad debt avoidance is especially critical here as it likely be more difficult to track bad debt as an expense for the medical practices. Financial clearance is thus focused on ensuring that the right payment information and resources are presented in a way that helps both the facility and the patient-an attitudinal shift that moves beyond collection to education.

While adopting this financial clearance process won’t mean that 100 percent of what's owed is paid as soon as care as provided, it goes a long way toward helping facilities recoup payment, and not letting their debt turn bad or get old. Historically, there have always been patients who regularly avoid payment, and choose facilities based on the strength (or weakness) of their collection efforts. Considering this, facilities that make a strategic change in their approach to payments also benefit by keeping a financially risking group of patients at bay.

Making a cultural shift in terms of patient payments and bad debt isn't easy. Many staff members have strong opinions and established methods for dealing with this concern. However, from a top-down perspective, a change than ensures a significantly higher degree of revenue capture while still giving patients options is better for everyone involved, facility, patient, and individual staff member alike.

Bad debt is an unfortunate constant for healthcare providers. All practices, large and small, constantly contend with patients who won't or simply can't settle their bills. The issue of bad debt will never go away in the current U.S. healthcare model, but that by no means indicates there aren't strategies and tactics to tackle bad debt head on, reduce the financial liability, better connect with patients, and realize better outcomes.

John Marchisin is a managing director, and Ravi Kumrah is a director in the healthcare practice of AArete, a global consultancy specializing in data-informed performance improvement. They can be reached respectively at 

Making a cultural shift in terms of patient payments and bad debt isn’t easy, but it helps both those giving and receiving care. 

Take a proactive approach to bad debt

There is no question physician burnout is high as some estimates put it at more than 50 percent of the current practicing population in the United States.

This is troubling as burned-out physicians retire early, reduce the time they devote to clinical work, or leave medicine entirely. As a result, patients have longer waits to see their doctor or, worse yet, are losing their trusted physician forever.

Additionally, burnout can lead to serious emotional and physical health consequences for physicians themselves.

Here are some programs that enable physicians to help themselves and their peers overcome burnout.

American Medical Association’s STEPS Forward

The AMA’s immediate past president, David O. Barbe, MD, MHA, says “an energized, engaged, and resilient physician workforce is essential to achieving national health goals. Yet burnout is more common among physicians than other U.S. workers, and that gap is widening as the bureaucracy of modern medicine inflicts a mounting toll on physicians.”

As part of AMA’s commitment to help physicians, it has created STEPS Forward, an interactive practice transformation series that provides proven, physician-developed strategies for confronting common challenges in busy medical practices, allowing physicians to devote more time to caring for patients.

Barbe says the AMA is striving to help physicians navigate and succeed in a continually evolving healthcare environment and it is imperative to promote engagement and combat the issues leading to burnout.

“Evidence suggests that improvement is possible, investment is justified, and return on investment measureable,” he says.

This training program promotes peer-to-peer burnout solutions through seven components. These include establishing wellness as a quality indicator for the practice; organizing a wellness committee; distributing a yearly wellness survey; holding regular meetings with practice leaders or staff to talk about data and interventions to promote wellness; initiating selected interventions; repeating the survey over the course of the year to evaluate progress; and looking for answers within the data, refining the interventions, and working to continually make improvements.

“Analysis has shown that engagement levels with STEPS Forward’s practice transformation modules have been high, with 86 percent of participants indicating their likeliness to implement their learnings,” Barbe says. “What’s even more encouraging is the feedback we’re getting from physicians saying they can finally get back to spending time with their patients, and how good that feels.”

The executive and physician leadership at Centura Health Physician Group, which includes more than 900 providers and 6,000 physician partners in Colorado and Kansas, has recognized the need to develop a comprehensive program to address physician well-being. The program is being developed with the goal of a system-wide comprehensive approach for its members to prevent burnout.

“Our goal is to address as many areas as possible which contribute to decreased physician well-being,” says Lief Sorensen, MD, specialty medical director with Centura Health. “As our program progresses, we hope to offer support groups, mentoring options for new physicians, a provider-specific onboarding process, options for collaboration and socializing with other physicians, and more.”

Moreover, the fact that such a high percentage of physicians are experiencing symptoms of burnout has begun to shift the focus on how this issue is being addressed among the entire healthcare population. Previous efforts focused mostly on resiliency and coping strategies. While these efforts continue to be very valuable, Sorensen notes there is now increasing attention toward addressing the environments where physicians are working.

“Physicians understand the pressures other physicians are under better than anyone,” he says. “Historically, physicians are very poor at admitting we are having concerns. We often just internalize our stresses and fears and are scared to discuss with others. One of the most valuable things I see happening ,as more physicians are aware of these issues and start talking about them, is simply the understanding that we are not alone.”

North Carolina Physicians Health Program (NCPHP)

The NCPHP, based in Raleigh, N.C., assists more than 3,000 physicians and other licensees of the North Carolina Medical Board with burnout and other problems that may affect their ability to deliver high-quality care and services to their patients.

Clark Gaither, MD, medical director of the NCPHP, notes the program was created to assist physicians with issues that would put their own health or the safety of their patients at risk. “Over the years, in addition to alcoholism, drug addiction, and mental health issues, we have seen a rise in the number of participants with job-related burnout,” he says. A full third of the health issues the NCPHP sees can be directly tied to burnout and another third is indirectly associated with burnout.

The program is designed to give providers a compassionate, caring, and confidential pathway to get the help they need. If needed, it facilitates professional assessments, therapies, treatment, and ongoing follow-up. Sometimes monitoring is also employed to give physicians the support they need early in their recovery.

The fact that such a high percentage of physicians are experiencing symptoms of burnout has begun to shift the focus on how this issue is being addressed.

How physicians are assisting peers to overcome burnout

“So, how’s life in your concierge practice?”

I didn’t correct him; people don’t know the difference. Five years ago, I left “normal” fee-for-service medicine to start a direct primary care practice. Most people have no idea what that means, and my colleague, who was calling me for a recommendation on a nurse practitioner student I’d precepted, obviously didn’t know either.

“Great,” I said honestly. “Life is really so much better, and the care I give is so much better than it used to be. I’ve got time with people.” I normally try not to get too enthusiastic when talking to colleagues, as it sounds either too good to be true or like I’m rubbing in how good my life is now. But for some reason I added, “Even after five years I’m not busy; I saw just two patients this morning.”

There was a brief silence on the other end of the line. “Two patients?” He asked, sounding stunned. Then he added quietly, as if talking to himself, “I just can’t imagine that.” Feeling a bit guilty (I was taught to never brag), I changed the subject and talked about the nurse practitioner, asked about his life, his family, and ended the call. 

I was struck by just what a gulf lay between my life and his, and between my life now and the one I had just five years ago. I had been in my old practice for 18 years when a disagreement with the other doctors led to my departure. I had loved being a primary care doctor and had built a thriving (and very busy) practice. But over the last few years, my joy in practice had been hacked away by the increasing requirements of the government, computerized records, data submission, insurance harassment, and shrinking time with each person. By my last year I was becoming increasingly aware of my ineffectiveness as a doctor. I didn’t feel like I was able to give truly good care to anyone.

DPC is not only best for doctors and patients, but perhaps an idea that could rescue a system that is dying at the hands of others.

August 10, 2018 edition

We must save Medicaid through a bipartisan effort

Restoring the joy in medical practice

The war against physician burnout starts with a strong plan of attack

How to properly document and bill for venipuncture

Manage practice workflow to reduce burnout

Artificial intelligence in primary care

Take a proactive approach to bad debt

How physicians are assisting peers to overcome burnout

How my life changed: transitioning to direct primary care

Funny Bone: Work-life balance

Getting to the guts of physician burnout: A resident’s perspective

Physician burnout led to my retirement