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.

The troubling trend of healthcare consolidation is gaining momentum, and Americans are paying a heavy price. Not only is this merger mania destroying our nation’s healthcare system, but it’s also decimating our middle class. However, if consolidation is healthcare’s cancer, consumers are the cure.

Every week, we hear reports of hospitals buying up doctor’s practices and merging with other hospitals. For example: Advocate Health Care and Aurora Health Care finalized their $11 billion deal last April to form the nation’s 10

 largest tax-exempt health system; Dignity Health and Catholic Health Initiatives are marching toward a $28 billion deal.

More recently, we’ve heard about insurers merging with health providers and retail pharmacies: UnitedHealth’s subsidiary Optum is buying DaVita Medical Group, a group of several hundred independent doctors and clinics, for nearly $5 billion. In April, Medicare insurance giant Humana bought 22-clinic Family Physicians Group in Central Florida. Now rumor has it Walmart might buy Humana. And, of course, CVS Health Corp. and Aetna continue to move toward their $69 billion union.

Many, many smaller deals go through weekly.

Mergers were up 13 percent last year, setting a record for the most healthcare mergers and acquisitions in recent history, according to a Kaufman Hall 

. The first quarter of 2018 was the busiest start for healthcare mergers in over a decade, according to 

Regardless of what the merging parties say about streamlining care and greater efficiencies, when healthcare entities merge, costs only go one way: up, way up. Ask those trying to convince you of the benefits to point to one study that shows costs go down after a merger, or that quality goes up. They can’t.

 from the nonprofit Physicians Advocacy Institute reported that hospitals buying up doctors was the leading driver in soaring Medicare costs. Between 2012 and 2015, Medicare costs rose $3.1 billion due primarily to the 49 percent uptick in hospital-employed doctors that occurred over the same period. And that study only looked at four procedures. Imagine the tally if all procedures were accounted for.

When hospitals merge, price increases on the order of 20 percent to 30 percent are common, and can exceed 50 percent, said Carnegie Mellon economist Martin Gaynor in a 

. What’s more, he added, many studies have found that patient health outcomes are substantially worse at hospitals in concentrated markets where there is less competition.

The only parties who benefit when healthcare entities merge are the executives at the top.

Meanwhile, consumers foot the bill in the way of higher premiums and more tax dollars going to pay for healthcare.

No wonder healthcare bills are the number one reason Americans declare bankruptcy, and healthcare costs consume 20 percent of the average family’s budget.

Yet health entities continue to merge, grow, gain market share, and increase their bargaining power with payers. The bigger they are, the more they get. So the mergers continue. Until someone does something.

 They lobbied hard to get the system here, and they’re profiting handsomely. Every time they merge, they profit more.

They have no incentive to bring premiums down, especially since under the Affordable Care Act’s “

” rule, which states that insurers can keep only 20 percent of every healthcare dollar, and put at least 80 percent must go toward claims, or rebate the rest. Though presumably well-intentioned, the government’s plan backfired. Insurers quickly figured that 20 percent of a higher premium is more than 20 percent of lower one, so guess which way premiums have gone?

. An eye-opening visit to opensecrets.com will tell you how much money your representative gets in campaign funding from hospitals and insurance companies. The American Hospital Association alone 

That leaves the rest of us. Educated consumers and brave physicians are the cure for consolidation cancer.

As physicians, we can start to change the market by remaining or becoming independent, by referring only to other independent doctors and free-standing outpatient centers, and by educating patients about why they, too, must only go to independent doctors. We also must push for transparency in healthcare pricing, so consumers can shop for healthcare based on price and value, and-most important-we must just say no when slick-talking executives come to town serving up pitchers of “consolidation Kool-Aid.”

If we don’t, we can expect a lot more of our money to pour directly into health executives’ pockets, covering the cost for their skyboxes.

Marni Jameson Carey is the executive director of the 

. Prior to joining AID, she was a senior health reporter for Tribune Media, writing for the 

. A nationally syndicated columnist, she is also the author of four books. Jameson Carey can be reached at 

Articles

Don’t be fooled. When mergers occur, patients and physicians lose; executives at the top are the only ones who truly win.

Don’t drink the healthcare consolidation Kool-Aid 

The rules of other consumer commerce sectors somehow do not apply to medical billing. Stop and think about that for a moment. It’s easier to make sense of how much we spend for goods and services such as groceries, clothing, and gasoline because we know how much it costs up front. No smoke and mirrors. No hidden expenses we are billed for days, weeks, or even months later. Imagine buying gasoline and two weeks later receiving a bill from the station owner because he didn’t include the excise tax on the pump price – would you pay that?

Yet that kind of scenario is exactly what healthcare consumers have learned to expect when it comes to their medical bills.  Medical billing and collection is a broken system with far-reaching negative consequences-it’s about time we got down to fixing it. 

Lack of timely payment or no payment at all is leading to a crisis in healthcare. The simple fact is that in comparison to other products and services, people do not understand how much healthcare costs. In fact, a recent report by the research company West stated that 

75 percent of patients don’t know what they’ll owe until they see a bill

. 75 percent! Imagine if you went to the store and purchased a gallon of milk but had no idea what it cost until a bill came later. Oh, and add to that the fact that the price of milk would vary wildly from store to store. In all likelihood, people would stop purchasing a product with such an unpredictable cost structure. Perhaps we’re onto something here…if people know prices upfront, they are more likely to pay them.

The need for clear and understandable statements

How many times have you tried in vain to decipher an Explanation of Benefits (EOB) from your insurance company? Sometimes it seems these things are written in some kind of code, seemingly with the intent to obscure benefit information from patients. It’s no surprise to many that trying to understand the healthcare billing system, how benefits are applied, and what balance patients are ultimately responsible for paying has traditionally been as confounding as trying to understand a garbled voicemail-if the message is unclear, it is impossible to take the appropriate action. No wonder so many patients struggle to meet their medical financial responsibilities.   

Lack of price transparency killing private practice

As the proportion of patient financial responsibility grows with the rise in high deductible health plans (HDHP), profit risks are pushed higher for independent practices. Small practitioners are seeing larger write-offs, higher costs to collect, and longer revenue collection cycles. We seem to be amid a healthcare payment system crisis that is squeezing these small practitioners the most, forcing them out of independent practice. 

33 percent of physicians reported as independent

In 2016 20 percent of doctors worked in groups of 100+ compared to 12 percent in 2012

73 percent of those in independent practice

 would remain so if they could maintain stability and profitability, but 44 percent expect to sell their practice in the next 10 years

 that small practices deliver better care, especially in areas where high-quality primary care makes a difference: lower hospital readmission rates, better outcomes for patients with diabetes, etc. 

These statistics paint a distressing picture-one that shows an eroding of independent practice that ultimately leads to poorer overall health outcomes for everyone. 

The solution to this problem is taking a price transparency cue from the retail sector to help patients more clearly understand the why and what of payment responsibility so they can make smarter decisions about healthcare consumption and budget accordingly. 

Here are additional suggestions for medical providers to move toward more effective solutions to the pressing issue of poor revenue cycle management:

Have frank discussions with patients about ability to pay before care is delivered (only a quarter of healthcare providers do this now)

Embrace patient revenue cycle technology solutions that make it easier for patients to understand and make payments upfront and on-time. This will lead to greater rates of patient engagement, participation, and bill payment:

77 percent of healthcare consumers say it’s important or very important to know costs before treatment

Just one in five (20 percent) physicians currently send reminders about payments on or near due dates

Join an independent physician association (IPA) or similar organization to enjoy some of the benefits of being part of a larger group of physicians without sacrificing independence, allowing the opportunity to:

Enjoy bulk rates on malpractice insurance

Leverage billing companies to ensure timely and accurate notifications of patient payment responsibilities (most practices 

fail to bill for about 12 percent of the work they do

More broadly, the healthcare industry needs sounder infrastructure to support independent physicians and, in turn, medical practices must be more proactive to research and adopt innovative technology tools that can successfully simplify and streamline both time-of-service and residual balance patient payments. We already know the demand is there-

 expect they will have to develop innovative billing and payment models to stay independent. 

Healthcare price transparency and payment convenience pays dividends

One of the core faults of our healthcare pricing system is that patients aren’t required to pay for healthcare in any consistent way. As a result, one of the most pressing needs is to implement technology solutions that push healthcare providers to think less like an institution and more like a small business. The simple fact is, if you make the payment process clearer and convenient, more patients will fulfill their financial obligations. Medical providers must tailor billing and payment process to patient needs and desires, implementing tools and resources the modern healthcare consumer has come to expect-such as the ability to pay online or via a smart phone app. Providers should seek to create more of a convenient patient “experience” than an unpleasant episode.

By implementing patient revenue cycle solutions that promote price transparency and offer payment convenience, patients will experience higher levels of satisfaction, peace of mind, and trust. After all, the next generation of healthcare consumers are watching you more closely than ever, are eager to share their experiences via social media and review sites and have a virtual global peer-to-peer network right at their fingertips. 

If we don’t proactively tackle the growing fiscal problems that are essentially forcing many smaller medical practitioners to fold their tents, we can’t realistically expect our healthcare system to evolve into a leaner entity with better outcomes.  

Lance Goudzwaard is president of the Center for Transformative Coaching (CTCi) and has more than 20 years of experience as a healthcare operations and financial management professional. 

Medical billing and collection is a broken system with far-reaching negative consequences-it’s about time we got down to fixing it.

Cracking the code behind the patient revenue cycle

Let’s face it-today’s patients are flighty. They’re significantly more likely to switch practices than patients of just a few decades ago. In fact, experts 

 that one in three medical patients will leave their current provider within the next couple of years. A surprisingly large number of these are not switching due to insurance change or a household move, but because of unmet expectations. Driven by the experiences they’ve had in other industries, patients are looking for innovations and advances in their patient experience. Unfortunately, many providers are failing to meet these expectations. 

Practices that ignore the needs of today’s patients will quickly lose them. These losses are extremely costly, with research showing that losing a patient due to dissatisfaction results in the loss of over 

 in income over the lifetime of a practice. Multiply that by the “one in three” patients who expect to switch practices and you can quickly see just how much those patient relationships are actually worth.  

Technology helps practices retain patients 

To build strong relationships with your patients, you have to meet their expectations. One of the main things they are looking for? Technology. 

 say they won’t stay with a practice that doesn’t provide the digital experience they want. And 

 of those looking for a new provider say they’re hunting for one that offers the latest in digital technology. 

The PwC Health Research Institute recently conducted a widespread study to look at the defining issues of the healthcare industry in 2018 and the years to come. This 

 advised, “Organizations need to educate both patients and clinicians how to use available tools and integrate them into care.” 

Adding technology to your practice will strengthen your patient relationships and improve patient retention, ultimately increasing your bottom line. Including funds in your budget dedicated to technological investments that improve the patient experience will be worth it in the long run. 

The following are the most popular technologies patients are seeking. 

 shows that 77 percent of patients want to book their own appointments. Online self-scheduling tools allow patients to view the physician’s availability and select an appointment time that best suits their schedules at their convenience.  This minimizes the need for rescheduling, eliminates phone calls, and reduces frustration for patients and staff members

Patients are looking for digital options when it comes to both billing and payment. Around 

 of patients say they want to pay their healthcare bills online. Unfortunately, 90 percent of surveyed providers still use paper patient statements and as a result only 20 percent of patient make any online healthcare payments. 

. Patients are looking for digital access to their doctors’ offices and want to remove the need for a phone call. They want to be able to request a prescription refill or ask a health question in a more convenient manner. A 

 found that 59 percent of insured patients and 70 percent of millennials would choose a primary care provider who offered mobile options over one who did not. Enabling practice texting (especially two-way texting) is an easy way to meet this demand. 

Easy access to medical records is one of the top requests of today’s patients. While health information is now available electronically more than ever before, over half of patients (

) say that they have little to no access to or control over their medical information. If you haven’t given your patients’ electronic access to their medical records, now is the time to do so. If you choose to make the switch to online patient medical records, be sure to educate your patients how to access these records, because there is a good chance your patients will not know how to access their records without initial instruction.

Running a business successfully, regardless of industry, is all about creating strong, long-term relationships by meeting the demands of your market. And the healthcare market is demanding additional technology. So as you create your budget for the upcoming year, take an assessment of your practice. Are you offering the digital experience today’s patients demand? If not, see where you can make some changes. A small investment in those patient relationships now can lead to great dividends in the future. 

Josh Weiner is the chief operating officer at Solutionreach. As an operator and investor, Weiner has deep experience helping healthcare and technology companies scale operations and access new markets. Before joining Solutionreach, he served as vice president at Summit Partners, a leading global growth equity firm, and advised a wide range of healthcare and technology companies. Prior to that he was a consultant with McKinsey & Company. He has been recognized by Utah Business Magazine as CXO of the Year and 40 Under 40. Weiner is a graduate of Stanford University. He writes and speaks extensively on patient relationship management.

Including funds in your budget dedicated to technological investments that improve the patient experience will be worth it in the long run.

Can you put a price on patient relationships?

There are two big differences between a traditional and a direct primary care (DPC) practice:

The doctor is paid directly by patients, not insurance (or other third-parties)

The patient doesn’t pay for office visits, instead paying a low monthly fee (typically about $50 per month).

The monthly payment is enabled by the freedom from insurance billing and codes, so the two changes are tied closely together. This article will focus on the ways in which the monthly payment changes the experience for doctors and patients.  

First, I want to address certain hybrid practice models and their use of monthly fees. Many “concierge” practices (and even some who label themselves DPC) use the monthly fee in addition to traditional insurance billing. This practice can only legally be done if the monthly fees are for “uncovered services,” those not covered by third party billing codes. While this does give the opportunity for significantly increased revenue, it also increases the risk of double-billing for a single service, which has especially bad repercussions if Medicare or Medicaid are the payer. For those who are considering this approach, I recommend doing so with great care and close counsel from experts. people/companies with significant experience doing this.

The “ideal” patient for a subscription-based practice is one that doesn’t use your services frequently, but also sees value in paying your monthly fee. This is why I set my fees based on age, starting at $30 per month for children, and increasing incrementally by age to a maximum of $75 per month for seniors. 

Any practice is much more likely to have frequent visits from a 70-year-old than a 30-year-old. Furthermore, if you set your prices too high for the younger patients, you select against the very patients you are seeking-generally healthy people who need you on occasion. I’ve been satisfied with the income I can generate from my practice with our current fee schedule and with the level of medical need of my patient population. I’ve been able to grow my practice above 750 patients and still not feel overwhelmed, and I have very little loss of patients on a monthly basis.

Financially, one of the greatest benefits of having a practice based on monthly fees is the predictability of revenue. Not only is overall income predictable, but the flow of revenue is steady throughout the month, making cash-flow easy to navigate. While there is no such thing as a “big month” in a subscription practice, neither are there “slow months,” which is a trade I am happy to make. Plus, I’ve twice adjusted my price up by $5 per month, which caused very little loss in patient numbers but generated a substantial gain in revenue (which is nice with kids in college). 

Before leaving my old practice, I tallied the reasons for office visits to see what percentage of patients 

needed to be seen for their care. I looked at the data and thought: “Could this care be done via phone call or text message?” The actual portion of patients who needed to be seen was stunning: it was less than 25 percent.  Many of the visits were to touch base about medication changes, many were for minor acute problems (URI’s, stomach bugs, etc.), patients needing work/school excuses, or problems that could easily be handled remotely (Otitis Externa, conjunctivitis, etc.). In truth, the main reason they were coming to the office was financial: I didn’t want to work for free. The monthly payment removes that pressure, and so lets us care for people in the way that makes most sense.  

I give much of my care via secure text messaging. There are many questions people have about smaller health problems. There are simple things (like rashes, acute illnesses) that can be communicated easier by this means. I also follow-up by sending a quick message asking how they are doing. My patients 

this.  They love the fact that they don’t have to wait forever and get passed around the phone system to contact a human. They reach out to me or my staff and quickly get the help they need. This takes a huge burden off of our phones, so the wait for those who do choose to call is much shorter.

Having a greatly decreased volume of unnecessary visits opens up the schedule. There is no benefit to being fully booked. in fact, you are more rewarded for having a relatively open schedule at the start of the day. This took me some time to get used to, finding myself worried when my office was quiet, and even getting bored when nothing was happening. But two facts kept me from freaking out when things slowed down: First, I am paid just as much on a slow day as a busy one and, second, my patients are paying me monthly so they get access to my care, not necessarily for the care itself. The second point was harder to wrap my brain around. One of the big universal complaints about doctors is that they are difficult to get any time with. Appointments are hard to get, and are often too short. With an open schedule, patients easily get same-day appointments. My busiest schedule in the past 5+ years was 15 patients, and my average day is between 8 and 11 patients. 

I mentioned this earlier, but it needs to be emphasized, as it is a huge benefit. New patients get 60 minutes of my time, and established patients get 30 minutes per visit. This means I have time to explain, education, listen, and think about things. I don’t have to limit the patient to “just one problem” (as many doctors do).  And, most importantly, I can be careful and give better care. Now, I don’t spend 30 minutes on a strep throat or ear ache, but I can check preventive care on these while they are here, making sure I am giving the best care possible. Overall, patients love the fact that they aren’t rushed and that they get my full attention in their office visits.

 In the more than 5 years I’ve been in business, the longest I’ve made someone wait for a visit is 20 minutes (aside from when they come early for appointments). Most patients go immediately to the exam room and I see them within 5 minutes of them showing up.  

Again, the reason I have this freedom is because I am no longer tied to the office visit as the only profitable means to give care. Healthy patients are no less profitable to my business, in fact they are beneficial in that they leave the schedule more open than do sick patients.  

So what keeps me from “cherry picking” healthy patients (as some have suggested occurs with DPC)?  

First, I don’t have a good means of determining ahead of time which patients will be “easy” and which will be more complex. Second, and more importantly, with my schedule free I have time to give good care for complex patients, eventually turning them into “easy” patients, as their problems are finally under control. I enjoy taking care of complex and difficult patients if I have the time to do so. The time demanded by government regulations and insurance compliance is now given back to the patient so I can give quality care.

And that is the main benefit: I get to be a 

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

 on the DPC model. Have questions about DPC? Email 

The monthly fee changes the experience for doctors and patients for the better. 

The value of the direct pay monthly fee to physicians and patients

Your article (“The value of nurse practitioners to medical practices”, August 8th) correctly cited the number of nurse practitioners (NPs) is on the rise. While more patients are choosing NPs as their provider, conducting over a billion visits annually, the article misses the mark on a handful of key points.
	
	NPs have been providing primary, acute and specialty care to patients of all ages and walks of life for nearly half a century. NPs’ abilities to assess patients, order and interpret diagnostic tests, make diagnoses, and initiate and manage treatment plans, including prescribing medications, make us neither mid-level nor an extension of our physician colleagues, rather a critical provider of patient-centered care.
	
	Second, the assertion that NPs merely exist to free up time for doctors undermines the value that NPs bring to health care cost management. Numerous studies have documented that patients seen by NPs have lower readmission rates and are more likely to adhere to plans of care - two important factors in bending the cost curve and improving the quality of life for patients.
	
	Lastly, there was no mention of the prevailing trend of states which have modernized their scope of practice laws to allow NPs to practice to the fullest extent of their licensure and training. As evidenced in recent analysis, nine of the top 10 best states for health care (as measured by outcomes, costs, and accessibility) have enacted such laws, known as full practice authority (FPA). Interestingly, nine of the bottom 10 still limit patient access to NPs by keeping collaborative agreements and other restrictive measures in place.
	
	While we appreciate the interest in gaining perspective on the value of NPs to medical practices, it is these facts which matter most to your audience and patients alike-especially when considering choosing an NP for primary care.

, Ph.D., C-FNP, APRN, FAANP
	President, American Association of Nurse Practitioners

Physicians, not payers, should control prior authorizations


	
	Since when did physicians allow insurance companies to decide what medicines a patient can have? Insurance companies are playing with patients’ lives.

The idea of a “prior authorization” is demeaning, and intensely frustrating. This is why doctors are burned out. I want our medical associations to reverse this so that an insurance company needs MY prior authorization to change any medicine that I prescribed. Let them ask me if it’s OK to give the diabetic patient Trident instead of Januvia. My prescription order should mean something after the years I went to medical school to earn the privilege to write it!

Our readers share their opinions and feedback.

Your voice: Nurse practitioners are critical providers of patient care

When doctors talk about the biggest challenges facing the profession, they generally focus on topics such as burnout, the shortcomings of EHRs, and the transition to value-based care.
	
	Often overlooked, however, is the rapid consolidation taking place throughout the healthcare industry, a trend with profound implications for the availability and affordability of medical care.
	
	Whether it’s hospitals buying up independent medical practices, hospital systems swallowing one another, or insurance companies merging with pharmacy chains, the prevailing attitude now is that bigger is better.
	
	Among providers, that sentiment results in part from the uncertainty created by shifting payment models and competition from new entrants in the industry, says Anthony LoSasso, PhD, professor in health policy and administration at the University of Illinois-Chicago and executive director of the American Society of Health Economists.
	
	“The feeling is that size will protect them [hospitals and doctors] in the face of new initiatives, be they market-driven or government-instituted policies,” LoSasso says. “Essentially, they’re trying to buy a seat at the table.”


	
	While consolidation hasn’t received as much attention as, say, the price of prescription drugs, it’s far from a new phenomenon.
	
	A 2014 study for the National Bureau of Economics Research, for example, noted that more than 1,000 hospital mergers had taken place since 1994. In 2015 Congressional testimony Leemore S. Dafny, PhD, now a professor of business administration at the Harvard Business School, showed that in 2006 the four largest commercial insurers already controlled 74 percent of the healthcare insurance market. (By 2014 it was 83 percent.)
	
	That said, the pace of consolidation has increased dramatically in the last few years. Consider that in 2018 alone:

Texas-based hospital systems Baylor Scott & White Health and Memorial Hermann Health announced plans to merge, creating a 68-hospital system with annual revenue of more than $14 billion.

Philadelphia-based Jefferson University said it would acquire Einstein Healthcare Network, creating an 18-hospital system in and around Philadelphia.

Cincinnati-based Mercy Health completed an $8 billion merger with Maryland-based Bon Secours Health System to form the nation’s fifth-largest Catholic health system, with 43 hospitals and more than 2,100 physicians.

Summa Health, headquartered in Akron, Ohio, revealed it was seeking to merge or partner with another healthcare system

Drugstore chain CVS received government approval to buy Aetna, the country’s third-largest health insurance company, for $69 billion.

Health insurance giant Cigna and pharmacy benefit manager Express Scripts received the government’s OK for their $52-billion merger.

All this activity follows a year that saw 967 merger and acquisition deals among healthcare payers and providers, according to the PwC Health Research Institute.


	
	Experts cite a variety of motivations for the accelerating pace of mergers and acquisitions among healthcare providers, most of which involve the drive to grow revenue and profits.
	
	That leads hospital systems, for example, to acquire primary care practices to increase the size of their patient base, ensure that patients are referred to specialists within their system, and take advantage of lucrative facility fees-the charges tacked on to services and procedures performed at a medical practice when it becomes part of a hospital system. 
	
	“The idea is, ‘let’s capture as much of the patient dollar and as much of the patient services as we can, and let’s keep it under one organizational umbrella,” explains Timothy Hoff, PhD, professor of healthcare systems and healthcare policy in the D’Amore-McKim School of Business at Northeastern University in Boston.
	
	The movement toward value-based reimbursements is another catalyst for hospitals to buy independent primary care practices, Hoff says, in that it causes hospitals to broaden their focus beyond inpatient care and expensive surgical procedures.
	
	“Essentially they [hospitals] are looking to reinvent themselves, and that involves placing more emphasis on services like primary care and population health,” Hoff says. That process, in turn, spurs hospital systems to acquire primary care practices and even establish new primary care “access points,” such as urgent care centers.
	
	The result, Hoff says, is that even under value-based payment models, “consolidation will keep moving along because there are rewards for getting ahold of a patient population and providing them with a range of services, from prevention to primary care to acute care. And big hospital systems think that with more primary care access points they can be one-stop shops for all those kinds or services.”
	
	Bringing more patients under a single corporate umbrella also gives hospital systems more leverage when negotiating with insurance companies, notes J.B. Silvers, PhD, professor of healthcare finance at Case Western Reserve University’s Weatherhead School of Management in Cleveland.

A payer can refuse to include an individual hospital in its network unless the hospital agrees to substantially discount its fees. “You had a pushback sentiment that said, ‘the reason you’re able to get away with that is I’m sitting out here by myself. But if I become part of a larger entity, then it shifts market power from the payer back to the provider,’” Silvers explains.

The providers’ growth, in turn, motivates payers to get bigger so as to recapture some of their negotiating leverage, and to join forces with pharmacies and pharmacy benefit managers to try and bring prescription drug costs-a large and rapidly-growing expense-under control.
	Meanwhile, independent practices-faced with the expense of EHRs and the staffing and data requirements of value-based care-often find they have little choice but to become part of a hospital system or merge with other practices.
	
	A study commissioned by the Physicians Advocacy Institute released earlier this year found that hospitals acquired 5,000 independent practices between July of 2015 and 2016, and that 42 percent of the nation’s doctors were hospital-employed by July 2016. In 2012 it was 25 percent.


	
	What’s good for the bottom line of healthcare providers, however, may not always be good for their patients.
	
	“Consolidation [among hospital systems] is always pitched as a positive thing, that it will lead to lower costs and more investment in the things that bring higher quality care,” says Hoff. “But when you look at the research, the opposite of those things can often occur. In highly consolidated markets, patient choice of providers and services is often reduced, and quality can improve but in some cases has been shown either to stay the same or even go down.”
	
	Hoff notes that another effect of consolidation among hospitals is to limit patient choice. He cites the Boston region, which is dominated by the Beth Israel Deaconess and Partners HealthCare systems. “If you don’t want to go to one of these systems to get care, the options become very limited,” he says.
	
	And while growth sometimes enables hospital systems to reduce their operating costs through economies of scale, those reductions don’t always result in lower prices for insurance companies or patients, Hoff says.
	
	The same dynamic occurs among insurance companies, according to Eric Schneider, MD, FACP, senior vice president for policy and research at The Commonwealth Fund, a healthcare policy research foundation.
	
	Although their growth often enables them to negotiate price discounts with providers, “there’s very little evidence that they are passing those savings along to consumers in the form of lower premiums or copays,” he says.
	
	Along with higher costs, an additional-and often overlooked-impact of consolidation among providers is the transportation problems it causes patients, says Caitlin Donovan, a spokeswoman for the Patient Advocacy Foundation.
	
	“If your doctor’s office closes you have to find a new site of care, and especially for people in rural areas or the elderly, it can be a really big problem, especially if there’s no public transportation,” Donovan says.


	
	But if consolidation, broadly speaking, is not benefiting patients, its impact on doctors appears to be more mixed, and often determined by individual circumstances.
	
	For Howard Mandel, MD, an independent ob/gyn physician practicing in Los Angeles, it has meant a nearly two-thirds decline in annual income since the mid-1990s. That’s largely because most of the independent primary care doctors who used to be his main source of referrals have joined Cedars Sinai Medical Center, a regional hospital system, and refer their patients to Cedars Sinai-affiliated specialists.
	Mandel notes that although the Stark Law forbids hospital systems from requiring their doctors to refer patients to others in the system, they can offer other incentives, such as tying financial bonuses to how much revenue the doctor generates for the system, including through referrals to specialists.
	
	Sometimes the penalties for not being part of a hospital system can take subtler forms, such as getting less desirable surgery times or having surgery privileges linked to the number of procedures the doctor performs.

“If you work for a hospital system, that’s really easy because they’re constantly feeding you patients,” Mandel says. “I’m someone who wants to only operate when necessary, so what do I do now? Either I change my practice style and start doing surgeries more liberally, or I lose my privileges for doing certain types of surgeries.”


	In contrast, Fred Nichols, DO, is expecting a substantial bump in income as a result of consolidation. He is affiliating his Hamburg, New Jersey-based ob/gyn practice with Atlantic Health Partners (AHP), a network of specialty practices operated by Atlantic Health System, which owns six hospitals in the northwest corner of the state.
	
	Nichols will continue to run the practice, but bill at the higher reimbursement rates AHP has been able to negotiate with payers because of its size. Had he been part of AHP for 2018, he would have been reimbursed an additional $265,000. “Obviously I can’t ignore that type of difference,” he says.
	
	In addition, AHP will take over the practice’s billings and collections and provide IT support, for which Nichols will pay an amount equal to 12 percent of his collections, compared to the 16 percent he now pays for those services.
	
	A further benefit comes from implementing Atlantic Health System’s EHR. “If I send a referral to one of their affiliated physicians, I can look up their consult, look up the results, really get that seamlessness of information they [EHR manufacturers] talk about. I see that as a plus,” he says.
	
	As to whether being part of AHP will limit the choice of nearby doctors to whom he can refer patients, Nichols says, “In theory that’s true, but in practice Atlantic Health’s penetration in this area is around 90 percent, so most of the doctors I’m referring to are already part of the system.” Moreover, the nearest hospital not part of Atlantic is 40 miles away. “That distance is prohibitive for most people around here,” he says.
	
	


	
	Are there limits to how far consolidation in healthcare can go?
	
	One possibility is the federal government stepping in to block mergers or acquisitions on anti-trust grounds.
	
	“I think the main countervailing trend is just regulatory oversight,” says Christopher Whaley, PhD, an associate policy researcher at the RAND Corporation. “We see the Federal Trade Commission taking a bit more active role in thinking about hospital and physician mergers and the Department of Justice has been pretty active in looking at insurance mergers.”
	
	Regarding the latter, Whaley cites the Justice Department’s role in blocking the   proposed mergers between insurance giants Aetna and Humana and Cigna and Anthem.
	
	Over the long term, however, a more powerful constraint-among hospital systems, at least-may be the unwieldiness and diminished efficiency that often results from getting too large.
	
	“Just because you’re big doesn’t mean you’ll figure out how to do things in a way that will keep you successful,” says Hoff. “Over time, it gets really difficult to manage a multi-layered organization. And in some ways it’s even worse with a hospital system because they are highly siloed organizations and you can only integrate so much across the different care delivery streams.”
	
	In addition, Hoff says, large consolidated hospital systems could face pushback from patients who don’t want care from what they perceive as a faceless, bureaucratic institution.
	
	Instead, he says, “I think we’re going to see some pullback to a model that’s not as big, where patients get more of a personal touch and are able to interact more humanely with their providers.”

Why one hospital system is seeking a partner

In early 2018 Summa Health, based in Akron, Ohio, announced it would begin looking for another health system for a partnership or merger. With four hospitals, 10 health centers, and about 7,000 employees spread over two counties, Summa has faced mounting financial challenges in recent years, culminating in a $28 million operating loss in 2017 and an announced plan to eliminate 300 jobs.

In its announcement, Summa acknowledged that changes in the healthcare industry “have put pressure on hospitals and healthcare systems to expand access to care while minimizing costs,” and that Summa would need a partner to achieve those objectives.

Summa’s experience is a useful lens through which to view the financial and economic forces behind hospital consolidation. Summa President and CEO Cliff Deveny, MD, explains that a major catalyst for its decision to seek out a merger or affiliation partner is the reimbursement cuts it is facing from government payers: a half percent from Medicare, and five percent from Medicaid. 

The latter program, he adds, covers 22 percent of the system’s patient population. Reimbursements from commercial payers and private employers are expected to be no better than flat. 

“Meanwhile, we know we have expenses that will continue to go up, whether it’s pharmaceuticals or medical supplies or making sure our people get appropriate salary increases,” he says. Summa has responded by cutting expenses over the last five years or so, while adding or expanding some clinical services. 

As a result of these efforts, Deveny says, the system expects to end 2018 in the black. “Now we’re at a point of strength and we want to see if there’s an opportunity to kind of super-charge our success and bring certain services and more access points and all kinds of other things we need to invest in,” he says. 

At the same time, Summa faces growing competition for patients and revenue. In 2015 the Cleveland Clinic, one of the nation’s largest healthcare systems, purchased nearby Akron General Hospital. More recently Portage Medical Center, another Akron-area hospital, was acquired by University Hospitals Health System, which is based in the same neighboring county as the Cleveland Clinic. 

“We had essentially been the tertiary health system for Portage, but since University took it over, we’ve seen a 70 percent reduction in transfers from them. Now they’re all being sent to Cleveland,” Deveny says. 

Meanwhile commercial payers, faced with resistance to spiraling health insurance premiums, are growing increasingly hard-nosed in their contract negotiations with providers, including Summa.

So another benefit of merging or partnering, Deveny says, is enhanced ability to attain what he terms “appropriate reimbursement” from insurance companies and self-insured employers.

Responding to concerns that Summa’s decision could lead to facilities being closed and/or patients having fewer choices among providers, Deveny predicts that, if anything, the opposite will occur.

“In fact, what we want to do is expand and grow. We feel like there’s a significant amount of demand for our services, especially in the ambulatory area,” he says, citing services such as such as women’s healthcare, behavioral health and treating opioid addiction.

“Those things aren’t sexy, or as profitable as some other services, but we want to make sure we continue focusing on services that are important to our charter as a community hospital,” he says.

Asked what lessons Summa’s experience might hold for other health systems, Deveny says, “You’ve got to embrace change, and know that you’ve got to continue to find avenues to grow.”

The forces driving the latest wave of consolidation in healthcare and what it means for doctors and their patients.

Surviving merger mania

Before physicians decide to join a practice or a hospital, they should know if doing so aligns with their professional and personal goals. This is an important decision, and before they take it, doctors should do the necessary research to determine if their prospective new employer is right for them. 

Understanding the culture of a large practice


	
	Doctors should get a feel for the culture of the new employer-i.e., its internal dynamics, how people relate to one another, how personalities mesh, and if there is life after office hours.
	
	“You’re looking at whether or not you like the individual physicians in the group,” says Russell Still, CVA, CHBC, executive vice president of Medical Management Associates, a healthcare consulting firm in Atlanta that provides management resources and counsel for physicians in private practice. “You want to find out if they’ve had other employed physicians and, if they’re not there anymore, you want to talk to them to find out why they left.” 
	
	The new doctor also should understand the work ethic is of the physicians who lead the organization. “If you’re looking for balance in your life, do they have balance in theirs?” asks Still. “Are they just working all the time?”
	
	How decisions are made, and by whom, and how much autonomy and decision-making power doctors have is a critical cultural issue.
	“Ask if decisions are made by physicians or by business people in the boardroom,” says Robert M. McLean, MD, FACP, president-elect of the American College of Physicians and medical director of clinical quality for the Northeast Medical Group, in New Haven, Conn.
	
	While McLean thinks that non-physicians may be qualified to make those decisions at times, he nevertheless says that “frequently, doctors have more trust in physicians making the big management decisions. That often is a major cultural factor.”
	
	If doctors want to be part of the management structure, they should say that up front.
	
	“You should be very clear that you want to be more participatory and exercise some leadership,” says Scott Joy, MD, MBA, FACP, medical director of Colorado Care Partners and chief medical officer of the Continental Division of the HCA Physician Services Group in Denver.
	
	“During the negotiation, ask what committees you can serve on-such as EHR or quality improvement,” Joy says. “You’re going to have better opportunities to be on committees by making that part of the contract that you negotiate.”
	
	Doctors should ask the practice leaders why they want to hire a new member. “You’d be surprised, but sometimes people don’t ask why they’re looking,” says Wanda Parker, a principal with the HealthField Alliance, in Danbury, Conn.
	
	Parker also suggests doctors ask prospective employers about their expectations for a new employee or associate-i.e., what duties do they want the new doctor to assume? How many and what types of patients do they want the doctor to see? What are their long-term goals for the doctor? What are the quality metrics they want the doctor to satisfy? How will the doctor mesh with the other physicians and non-physician members of the staff?
	
	Culture also includes what doctors are allowed to do aside from seeing patients. Can they teach or do research or donate their services elsewhere?
	
	“Sometimes they don’t want people to do outside activities because they feel it detracts from their commitment to the practice,” says Parker. “In other cases, the practice will be absolutely thrilled if the doctor volunteers for the local football team to be their sports medicine doctor.”


	
	Investigating the organization’s culture also should help doctors detect any problems that might dissuade them from signing on. A huge warning sign is any vagueness or reluctance about spelling out the precise conditions, and costs, of becoming a partner in the future.
	
	“The big red flag for me is when they won’t talk about the ultimate buy-in to the practice,” says Still. Doctors who get nothing more than a general promise of partnership someday may never attain that status and end up feeling like victims of a bait-and-switch ploy.
	
	If doctors have particular expectations about when and under what circumstances they would become partners, they must protect themselves by getting those expectations spelled out in the contract.
	
	Another potential problem is that the fee a physician ordinarily must pay to become a partner could be prohibitively expensive, where a doctor might have to borrow money to do it. “Doctors should always know up front what the buy-in’s going to be and how it’s going to be calculated,” Parker says. “And what happens when one of those partners leaves? Will they have to buy that person out?”
	
	Frequent turnover, either among staff, the leadership or physicians, is another worrisome indicator, according to Joy.
	
	“If your average tenure of a doctor is a year and a half, that’s not good,” he says.
	
	Average tenures can vary, where doctors leave for personal reasons, differences with the practice leaders, or, increasingly, the desire to remain independent instead of staying with groups that affiliate with hospitals/health systems. There really isn’t a set average tenure for group practices, though Still suggests a new doctor may be with the practice for two to four years before becoming a partner.
	
	“Doctors should ask about how long the practice manager’s been there and what the average staff and physician turnover are.”
	
	A parallel concern is when a practice that may be financially pressed skimps on staff to save money and thereby makes it harder for physicians to do their work.
	
	“If you don’t have enough care coordinators or medical assistants to do some of the data management legwork, it’s going to be really hard to meet some of the quality metrics,” says McLean. The best way to find out about staffing levels is to ask and, if given a tour of the office, request a tour during work hours, be aware of how many staff are present, take notes and ask about staff functional responsibilities. Focus particularly on the front desk and clinical assistants – the staffers who are essential to the patient’s office visit.


	
	Not only should doctors know what their pay will be and how it’s determined, they should understand exactly what their contract means, and what issues the practice is willing to negotiate up front.
	
	Still says it’s possible to find out the local pay rates for physicians who do similar work, and advises hiring a consultant who has access to survey data or works in physician hiring not only in your specialty but in the local market. That information might also be available online from sources such as the American Medical Group Association or a compensation and benefits analysis firm such as Sullivan & Cotter, or at a local library.
	
	Moreover, doctors should know what formula a prospective employer uses to determine salary and other benefits. “How much of the formula is balancing productivity expectations versus other things-around quality and value, data, oversight and management-that take time and energy?” McLean says.
	
	Also, is some of the compensation formula based on quality bonus payments and shared savings contracts? In that regard, McLean offers a hypothetical example: If the insured savings that totaled 70 percent of a practice’s shared savings in a given year are completely gone the following year, would the practice try to compensate for that loss by cutting back or eliminating quality bonuses.
	
	Determining the compensation isn’t always as simple as quoting a flat-rate salary.
	
	“Sometimes, if you have a higher guarantee, you’ll be paid at a lower RVU rate,” says Joy. “If you want a higher RVU rate, you get a lesser guarantee. You also want to ask about signing bonuses and CME bonuses that are available.”
	
	Flat-rate salaries sometimes are offered, but many practices offer additional pay based on collections in excess of a threshold-- usually the new physician’s direct costs divided by the income rate.
	
	Contract stipulations such as restrictive covenants (i.e, contract provisions restricting the future conduct of the doctor, such as competing with the practice for a certain period after leaving it, or soliciting or engaging with patients of that practice after leaving it) and non-compete clauses might seem problematic, but Still says doctors should expect them, and not sign an agreement if they intend to break it later on.
	
	“If you don’t think it’s fair, then don’t sign,” he says. “Work it out or go somewhere else.” And not all such covenants and clauses carry the same legal weight. “Are they really enforceable in your state based upon precedent?” McLean asks.
	
	To find that out, doctors should consult attorneys with specific experience litigating that type of contractual language. Also, enforceability can depend upon factors such as the practice specialty and location, the specific circumstances of a doctor’s termination, and if a court feels that a non-compete clause  is unreasonable (e.g., preventing a doctor from practicing in a territory that’s much larger than the area from which a practice derives most of its patients).
	
	Termination clauses can be deceptive, as when doctors negotiate multi-year contracts that they think keep them safely employed for that period.
	
	“What they don’t realize is the contract is only as long as their termination clause, so if the termination clause is 90 days, then your contract is really a 90-day contract,” Parker says. “And then what happens if bonuses are due and the person is terminated?”
	
	While a no-cause notice provision might seem to undermine the value of having a contract, there are ­other aspects of the relationship that require contract protections for both parties, such as designated responsibilities and salaries. “With no contract, doctors could be fired at any moment,” Parker cautions.
	
	Both no-cause and for-cause termination clauses can be tricky. Doctors should particularly beware of broad statements like “failure to follow the policies of the practice,” because they might be unaware that they’ve done anything wrong. Ideally, those policies should be spelled out.
	Still advises that if there is a vague, unclear or confusing contract clause that could create a misunderstand, where a doctor could unwittingly violate a policy, the doctor should seek contract language to clarify the meaning of the clause. Otherwise, the doctor is subject to the practice’s interpretation of the provision in question.
	
	To sidestep these potential contractual minefields, doctors should hire a healthcare attorney who is steeped in healthcare law to review the contract and assist with the negotiations, says McLean.


	
	In some ways, working for a hospital can be like working for a medical practice, but in other ways it can be quite different. In weighing the relative merits of joining a private practice or a hospital, doctors should take those differences into account.
	
	A hospital might be less accommodating than a group practice in the way it treats a doctor. “You go to work for a hospital and it’s all about business decisions and profitability, and if things aren’t working, they’re more likely to fire you than a practice would,” says Still.
	
	As with a medical practice, it’s important to know if physicians or non-physicians are calling the shots at the hospital. McLean implies that hospitals headed by non-physicians may be lower in quality.
	
	“Are enough physicians making decisions to have a medical perspective on healthcare delivery?” asks McLean, who notes that studies show that most of the top 100 healthcare systems are led by physicians. “Having physicians in charge might make doctors more comfortable.”
	
	Contract terms likely are less negotiable with hospitals. “In a hospital situation, where you might have 50 employed doctors, you’re going to get a cookie-cutter contract which says you’ve got four weeks of vacation and one week of CME and here’s your salary,” says Parker.
	
	Sometimes, doctors can have the best of both worlds by joining a private practice that has close relations with a hospital by virtue of having its offices on the hospital campus. These can include perks like preferred parking, free meals in the physician dining room and CME classes, as well as opportunities for personal growth.
	
	Joy, who works on a medical center campus, says doctors in larger and specialty-based practices with that kind of proximity to a hospital can develop productive relationships with the hospital leadership.
	
	While this wouldn’t necessarily involve admitting patients, doctors instead could get to know hospital leaders through service on committees and participate in the leadership’s outreach into the community. In that way, physicians could make themselves known in that community.

Before physicians decide to join a practice or a hospital, they should know if doing so aligns with their professional and personal goals.

Physician employment: How to find the right fit

I could tell he is loved by many. I could tell he is a good man. His smile is kind and it has a quality that I cannot identify. He is thin with a full head of salt-and-pepper hair. He has a gentle and serene aura about him as he lays in his bed. As I talk to him, I realize that the serenity about him also comes from his stillness.  It is subtle, his lack of motion-and also deceiving. Looking at him, he does not look “toxic” as we tend to call the really sick ones.

It is a random day, much like many before it, busy and demanding. By the time I get to Mr. T, it is evening and his family members have made their way to his hospital room, the young the old, the millennials and the baby boomers. I introduce myself as the hospitalist who will be the main doctor on his team. There is a hum of worry, dimly present behind the jovial hellos and the small talk.

It is the usual, community-acquired pneumonia that has failed outpatient treatment. His primary care doctor had tried a few antibiotics but nothing seemed to have worked; that was a clue to which I turn a blind eye. I simply do not see it.

So, I give them hope. He should be out of here in the next few days I say. We are giving him stronger antibiotics I explain, “the big guns,” and they nod their heads. As I leave the room, I make a joke, and they all laugh. I am pleased because my jokes are usually off and rarely do I get a perfect setup where the joke is funny and there is a room full of people who get it and laugh. My biggest worry as I leave the room is that on the subsequent days when I see him during my daily rounds, they will realize that my jokes are really awkward and poorly timed and not that funny at all.

The days come and they go. Mr. T, who has been getting out of bed to his chair, now prefers to stay in his bed mostly. He tells me some days that he feels good, maybe even better, but lately he says he has been having rough nights. He is so short of breath, the only thing he seems to be able to do without losing his breath is think. His daughter, who happens to be a nurse, often tells me that until the time he started having the cough he was fit and that he played volleyball with his grandchildren on summer vacations.

The infectious disease specialist, Dr. P, a petite woman with probing eyes and one who does not sugarcoat things is the first to voice her concerns that the patient might have cancer. It takes my breath away. When I go into the room, I see Mr. T with yet another one of his many children. I cannot say the word and where I cannot give hope there is no replacement. I leave the room quickly.

Having mainly done the admission part of patient care for many years, I rarely have had the chance to make a claim on a patient the way I claimed this patient on the third floor of our small hospital. I had made a prediction that he would be well and I had worked every day towards that goal which had initially seemed attainable.

It has been over a week since I first met Mr. T and his family.  I approach his wife as she stands outside his room with a nurse and the infectious disease consultant. All of a sudden, Mrs. T wails and puts her hand over her mouth.  I assume that the biopsy result is back and that Dr. P has just given her the news before breaking it to Mr. T. The nurse hugs Mrs. T.

I hover, trying to give my support or answer questions. Nobody notices. The nurse is wrapped up in the moment, wrapping her arms around the wife’s shoulders and Dr. P is looking at them with those eyes, bracing herself for the consequences of her words.
Instead of hanging around them I step into Mr. T’s room. He is lying in the same position. He is weaker today than he was yesterday and weaker at this moment because he has just heard his wife’s anguish and he knows. His son who also now knows is holding his hand. Tears well up in my eyes and I have to leave right away.

Later I sit on the couch in our office and I tell our office manager, who also at times doubles as my unofficial therapist, about it all and my tears seem to surprise her. In the past my tears have come from telling her how my ten-month-old fell down the entire flight of stairs at my house. There was also the time when I announced my third pregnancy that had occurred a little too soon after my second pregnancy and I fretted about how I could be the breadwinner of my family and leave two babies  at home while I work full time.

However, this time I cry not just because despite my armamentarium of medications and knowledge, death will win more times than I would care for it to but also because I had unintentionally crossed an invisible line.  Over the years, I had put myself at a distance, given patients labels like “toxic” and did my best to make them feel better.  When I walked into Mr. T’s world however, I had allowed myself to hope with the rest of his family, then after that, I had allowed myself to feel, to be caught up in the sadness and later on in the acceptance of the end. Caring for Mr. T has made me realize I still have room to feel for strangers what I feel for my family, that I was still fighting the good fight with more passion than I knew I had.



Editor’s note: The names of patients have been changed to preserve privacy.

2018 Physician Writing Contest runner-up.

Mirrors & mirages

By focusing on asthma management, physicians not only improve patient outcomes and reduce healthcare spending, they also earn more money. Asthma is a condition targeted under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the federal law that seeks to reform Medicare payments while improving population health and cutting costs.
	
	Beginning in 2019, physicians in the Merit-based Incentive Payment System (MIPS), one of two participation tracks under MACRA, will be penalized if their costs exceed anticipated amounts or rewarded for keeping costs under the projected amounts. By helping patients control their asthma and thereby preventing costly hospitalizations and ED visits, physicians choosing to report on related MIPS measures may boost their quality scores and receive a financial bonus.
	
	“The last thing you want is for a patient to be hospitalized because it’s such a high-cost place to receive care,” says Timothy Brundage, MD, medical director at Brundage Medical Group LLC in Tampa, Fla., a consulting company that helps physicians improve their clinical documentation. “Keeping the patient well and the asthma under control are the best ways to care for patients and reduce costs.”
	
	Rex Mahnensmith, MD, an internist at Docs of CT in Milford, Conn., agrees. “The motivation behind value-based payments is keeping people well and safe, especially when they have asthma-a condition that can quickly become life-threatening."


	
	Assessing asthma severity helps physicians identify the proper course of treatment to ensure good outcomes, says Steven Kagen, MD, an allergy and immunology specialist in Appleton, Wisc. Kagen suggests asking patients these questions:

Have you had problems with coughing, wheezing, shortness of breath, or chest tightness during the day?

Do you wake up during the night due to coughing, wheezing, or other symptoms that don’t improve within 15 minutes of using the rescue inhaler?

Do you have symptoms of asthma while exercising or playing?

Physicians can get credit under MIPS by using one of the following assessment tools:

Asthma Therapy Assessment Questionnaire (ATAQ)

Physicians can also ask patients diagnosed with asthma to record their peak expiratory flow rate daily and bring these measurements to their appointments, says Mahnensmith. “This is meaningful information, and it’s a good gauge of whether their inhaler is working,” he adds.


	
	Prescribing a rescue inhaler may be sufficient for patients with mild intermittent asthma; However, those with more severe forms of asthma-those who use their rescue inhaler more than once a day two times per week-may also require a controller medication to continuously relax and dilate their airways, says Mahnensmith. Physicians may overlook adding the controller medication if they aren’t aware of the severity of the patient’s symptoms. This happens either because they don’t ask detailed questions or because patients don’t provide the information, for example if they forget or if they simply dismiss their own symptoms, he adds.
	
	Pharmacists can provide insight into how often patients use their rescue inhaler so physicians know when a controller medication may be necessary, says Mahnensmith. For example, when prescribing an inhaler, physicians should consider starting with one refill only. They may also include a note to the pharmacist asking them to call the physician’s office when the patient requests the refill. Each inhaler typically includes 120 inhalations and should last for at least three months. If the patient refills the script in one month, that means they’re using the inhaler four times a day and require a controller medication immediately, he adds.


	
	Raising patient awareness of the environmental factors that trigger their asthma is critical because, in some cases, they may be able to avoid the triggers entirely (e.g., by staying inside on days when pollen counts are high), says Kagen. Physicians should ask patients to record when and where asthma attacks occur as well as the symptoms they experience, he adds.
	
	There are also a variety of mobile apps available that can help patients log their symptoms. Kagen created one that correlates self-reported symptoms-wheezing lungs, itchy eyes, cough, and runny nose-with various weather elements, helping patients identify the environmental triggers that make them feel worse. Patients can also use the app to predict symptoms based on a four-day weather forecast. In addition, the app locates the closest board-certified asthma and allergy specialist so patients can seek help immediately.
	
	Allergy testing using a simple skin test is another option to identify asthma triggers. The test takes fewer than 10 minutes, and it identifies approximately 60 airborne allergens, says Mahnensmith. Once patients are aware of the allergens that trigger their asthma, they can receive allergy desensitization therapy that weakens allergic reactions by exposing them to gradually increasing doses of allergens, he adds.


	
	Cost is one of the most common barriers to medication adherence, and physicians can overcome it by simply asking patients whether they can afford their inhalers, says Brian Boyce, CEO of ionHealthcare LLC in Richmond, Va., a healthcare consulting company that specializes in risk adjustment. Provide sample inhalers, look into the cost reduction programs offered by many pharmaceutical companies, and prescribe generic medications when possible, he adds. There are also high-tech, low-cost inhalers available with global positioning systems that measure location-specific air quality.
	
	Helping patients adhere to their medications also requires frequent patient monitoring (i.e., every three months), says Mahnensmith. “If I’m really concerned about someone, I’ll tell them [all patients at risk of an exacerbation] I want to see them next week so I can see how they’re doing, listen to their lungs, and do a peak expiratory flow ratio,” he adds.
	
	Patients with uncontrolled asthma should return to the office every two to four weeks for repeat education and ongoing monitoring, says Kagen.
	
	Kagen provides a demonstration and then asks a nurse to reiterate the same information to patients. “Each inhaler may be different in terms of the technique that’s required, and each patient may have different skills,” he says. For example, a patient with rheumatoid arthritis can’t generally use an inhaler that requires them to squeeze the device, but they can use one that employs a “click and inhale” technique.
	
	Physicians must observe patients using the inhaler, says Mahnensmith, adding that coordination, timing, and direction of the spray is often incorrect. For example, do patients pump and inhale into the lungs, or do they pump onto the tongue and upper palate with no inhalation? If the patient is unable to inhale into the lungs due to lack of coordination, do they need a spacer to guide the medication directly into the lungs?
	
	Physicians should consider providing patients with written instructions on how to use the inhaler properly. The CDC also provides a video that instructs patients on proper inhaler use (bit.ly/CDC-inhaler).
	
	“Every patient is unique,” Kagen says, “and every patient must be managed according to their own needs, immune system, autonomic nerve system, home and work environments, and underlying inflammatory pathways.”

Manage asthma

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

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

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

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





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

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

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

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

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

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

Interoperability behind push for new certification



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

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

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

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

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



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

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

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

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

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

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



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

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

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

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

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

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

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

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

December 10, 2018 edition