Editor's note: This article on implicit bias in health care was first published in late 2019, but due to recent attention on racial disparities in the United States, we have decided to re-feature it. 

James Ellzy, MD, FAAFP, is a board-certified family physician, an assistant professor at the Uniformed Services University of the Health Sciences and served for 22 years in the U.S. Navy, where he attained the rank of captain.
	
	In spite of his sterling credentials, Ellzy, who is also a board member of the American Academy of Family Physicians (AAFP), says he frequently encounters double-takes the first time he meets with patients at his clinical practice at the Fort Belvoir Family Medicine Residency in Virginia. In part, he says, the response is due to looking younger than his 49 years. But mostly it’s because he is African-American, while many of his patients are white.
	
	It’s not that these patients are overtly racist or even aware of holding any biases against African-Americans. Still, he adds, “I notice the look on their face when I first meet them that says, ‘this isn’t who I was expecting to see.’”
	
	The “this isn’t who I was expecting to see” reaction is an example of what psychologists and others who study human behavior call “implicit bias”: the unconscious, usually negative assumptions humans make about others they perceive as being in some way different from themselves.
	
	While implicit (or “unintended”) bias affects nearly everyone, its consequences are especially significant in medicine. Since the majority of physicians are white and male, the unconscious assumptions they may hold about patients who are neither white nor male can lead to inappropriate treatment decisions, and on a larger scale, worsen disparities in health outcomes. 
	
	The good news is that as understanding of implicit bias grows, so do techniques for combating it. Increasing numbers of healthcare institutions, physicians organizations, and medical schools are developing training programs to help doctors recognize unintended bias and prevent it from affecting their medical decision-making.


	
	By itself, experts say, implicit bias is neither good nor bad. Rather, it is a result of the brain performing one of its primary evolutionary functions-absorbing and organizing the information constantly bombarding it and guiding our actions based on that information.
	
	“It’s our brains trying to function at maximum capacity by finding patterns among information or events or groups of individuals as a way of enabling us to make decisions without really thinking about it,” explains Kierra S. Barnett, MPH, a doctoral candidate in public health at the Kirwan Institute for the study of Race and Ethnicity at Ohio State University in Columbus.  
	
	While this form of information processing is highly efficient-and indeed vital to humans’ ability to function on a day-to-day level-psychologists note that it comes with a significant drawback: some of the information it takes in produces, or reinforces, negative stereotypes about others based on attributes such as their race, gender, ethnicity, and sexual orientation.
	
	Michelle van Ryn, Ph.D., MPH, a professor at the Oregon Health and Sciences University School of Nursing who has studied and written extensively about stereotypes and implicit bias, cites the example of an experiment where two groups of white people  were given an account of the same crime, except that in one account the criminal had a name usually associated with African-Americans.
	
	The people in the group reading that account were more likely to recall the violent aspects of the crime than was the group who assumed the criminal was white, which in turn reflects the pervasive images of African-Americans as violent criminals in the news and entertainment media, she says.
	
	“So implicit biases are basically this [learning] system applying whatever information it’s learned, even if it’s negative and inaccurate, to whole groups of people,” she explains. Moreover, unless the process is interrupted, the brain will engage in confirmation bias by focusing on events or actions affirming what we think we already know about those groups, van Ryn says.
	
	


	
	The impact of unintended bias, both in individual physician-patient encounters and outcome disparities, has been well-documented in research studies, most notably in an influential 2003 Institute of Medicine report on racial and ethnic disparities in healthcare.
	
	The report found evidence that “stereotyping, biases and uncertainty on the part of healthcare providers can all contribute to unequal treatment.” Moreover, even white clinicians who don’t believe they are prejudiced “typically demonstrate unconscious implicit negative racial attitudes and stereotypes.”
	
	More recently, a 2016 study published in the Journal of Clinical Oncology examined interactions between black patients and white oncologists who had been administered a test for their levels of implicit bias. (See sidebar, “Measuring Implicit Bias”).
	
	It found that oncologists who rated higher in implicit racial bias had shorter interactions with their patients, and their patients rated the interactions as “less patient-centered and supportive” than those with less implicit bias.
	
	The study also found links between a physician’s bias level and their patients’ confidence in recommended treatments, and more perceived difficulty in completing them.
	
	Louis Penner, Ph.D., professor emeritus in the oncology department at Wayne State University School of Medicine in Detroit and lead author of the study, notes that the results highlight another harmful result of implicit bias: patients are able to recognize their physician’s attitude and, as a result, become less likely to adhere to treatment recommendations.
	
	“One of the effects we and other researchers have demonstrated in a variety of medical contexts is that if the doctor is high in implicit bias, the patient leaves the interaction with the feeling the doctor doesn’t really care about them, they don’t trust the doctor, and the treatment may not work,” he says.
	
	In the case of cancer treatment, with its expense and unpleasant side effects, the result may be high rates of non-adherence or sometimes stopping treatment entirely-outcomes which can, in turn, shape doctors’ treatment decisions.
	
	“What happens in a lot of cases is, black patients are underdosed and the rationale many physicians give is, ‘the patient’s probably not going to do the treatment anyway, so why should I make him that sick?’” Penner explains.


	
	While many people have difficulty acknowledging that their actions are influenced by unconscious biases, the concept is particularly troubling for doctors, who have been trained to view-and treat-patients equally, and the vast majority of whom sincerely believe that they do.
	
	“Doctors have been molded throughout medical school and all our training to be non-prejudiced when it comes to treating patients,” says James Allen, MD, a pulmonologist and medical director of University Hospital East, part of Ohio State University’s Wexner Medical Center. “It’s not only asked of us, it’s demanded of us, so many physicians would like to think they have no biases. But it’s not true. All human beings have biases.”
	
	“Among physicians, there’s a stigma attached to any suggestion of racial bias,” adds Penner. “And were a person to be identified that way, there could be very severe consequences in terms of their career prospects or even maintaining their license.”
	
	Ironically, as Penner and others point out, the conditions under which most doctors practice today-high levels of stress, frequent distractions, and brief visits that allow little time to get to know patients--are the ones most likely to heighten their vulnerability to unintentional biases.
	
	“A doctor under time pressure from a backlog of overdue charting and whatever else they’re dealing with will have a harder time treating all patients with the same level of empathy and concern,” van Ryn says.
	
	


	
	So what can physicians and healthcare organizations do to address these biases? Since the process that produces them is “hardwired,” eliminating them is next to impossible, experts say. Instead, the focus should be on reducing their impact on doctor-patient interactions and medical decision-making. And that process begins by just recognizing that they exist, says Preshuslee Thompson, a training and development specialist at the Kirwan Institute.
	
	“Once you become aware of your biases, you can kind of bring them to your conscious mind and be able to say, ‘I know I have this bias, so I’ll keep it in mind while I’m working with this patient, or I know that some circumstances make me more susceptible to my implicit biases so I’ll try to avoid those when I’m making decisions about my patients,” she says.
	
	Conversely, according to Barnett, “If you’re not going to acknowledge those biases, then you’re going to continue to allow your brain to work on autopilot and be influenced by them.”
	
	Equally important is finding each patient’s unique qualities or features, thereby making it easier to see them as an individual rather than part of a faceless group. Penner cites the example of a white physician’s initial encounter with a patient who’s African-American.
	
	“If that doctor views the patient simply as a black woman, the possibility that the doctor’s implicit bias will be activated is much greater than if she’s seen as Mrs. Brown, a retired school teacher and mother of four children. So he’s not looking at a social category, he’s looking at an individual,” Penner says.


	
	People who have conducted training in identifying and addressing implicit bias also find it helpful to emphasize its pervasiveness. “No one is immune to this, even those of us with the most egalitarian goals of fairness and equality,” says Danielle Jones, MPH, manager of the AAFP’s Center for Diversity and Health Equity. “When you frame it from that perspective, I think it makes people a lot less defensive and more open to having a conversation around, ‘what are my biases, and what can I do to address them’”?
	
	That was true for Ohio State’s Allen, who earlier this year participated in a university-sponsored training session on implicit bias, an event he approached with some trepidation.
	
	“I had this fear there were these dark sides of me that I was not aware of and that the training would make me discover that I’m a bad person without realizing it,” he recalls. So he was pleasantly surprised to find that wasn’t the goal of the training, but rather to explore different forms of bias and how to overcome them.
	
	Allen attended the training to learn how to work better with his colleagues, who hail from a wide variety of ethnic, national, and religious backgrounds. But he  found that it also changed how he relates to patients.
	
	“I think it has resulted in my taking more of a shared decision-making approach in caring for my patients, rather than paternalistically dictating what the patient has to do,” he says. “Now, I’m more sensitive to personalizing care plans depending on whether the patient wants to be more aggressive or less in their treatment.”
	
	Another useful technique for lessening the impact of unintentional bias is by undermining stereotypes. For example, in her group training sessions, Jones might present a case study about an African-American patient who’s frequently late to appointments and ask participants to discuss factors that might account for the patient’s behavior, such as difficulty finding reliable transportation.
	
	“The goal is to find additional information or context to minimize that immediate reaction of assuming that the stereotype is true,” Jones says.
	Similarly, Jones encourages doctors to practice mindfulness as a way of counteracting the bias that can result from not being able to spend much time with patients. The situation may unwittingly lead to assumptions- what Jones calls “mental shortcuts”-about patients.
	
	“These mental shortcuts are where bias kind of sneaks in,” she explains. “So when we talk about mindfulness we’re trying to make doctors aware this could be happening, and get them to maybe consider alternatives in their clinical decision-making and patient interactions.” Doing so, she adds, can also help physicians develop empathy for, and build relationships with, their patients.
	
	While not attributing it to mindfulness, Allen says that as a result of his training he now makes a point of chatting with patients about what’s going on in their lives, such as what they did on vacation or how their children are doing. Such conversations usually add no more than a minute or two the visit, and Allen feels it is time well spent.
	
	“It allows me to build those ties that come from showing my interest in them as unique people,” he says. “And hopefully it lets them see that I care about them as a person and not a bunch of skin and bones that happens to have a disease.”

Articles

As understanding of implicit bias grows, so do techniques for combating it.

How implicit bias harms patient care

Sound accounts receivable (A/R) management is integral to the financial health of a medical practice. The ability to maximize collections and profitability depends on it. Thus, it’s important that practices know what processes they can implement to ensure a smooth-running AR operation.
	
	David Norris, MD, MBA, an anesthesiologist in Wichita, Kan. and author of The Financially Intelligent Physician: What They Didn’t Teach You in Medical School, pays his practice’s employees every two weeks, but has an average A.R. cycle of 45 days, meaning it takes about three pay periods for him to earn what he’s already paid out to his staff. So having an efficient A/R process makes possible the cash flow that, in turn, lets him pay his employees on time. “You want a system that is very accurate and gets as much of the money into the practice as quickly as possible,” he says.
	
	


	
	Obtaining and verifying current insurance information, including any recent changes in coverage-preferably before the patient arrives-is essential to that accuracy and efficient income stream. So is properly coding patient visits, entering the correct data into the billing system, billing insurance on that basis and posting and adjusting the resulting payment.
	
	“So let’s say the bill was $100, your contract with the insurance company says you take $80, and there’s a coverage for 80 percent, where the remainder has to be charged to the patient,” says Jeffrey Kagan, MD, who operates an internal medicine practice in Newington, Conn. and is a Medical Economics editorial adviser. “If you can know all that information up front you can tell the patient they owe you $16 before they get out of the office.”
	
	But Kagan says that might not be the end of it. If the patient has Medicare coverage and  supplemental insurance, and the latter gets billed for that 20 percent not covered by Medicare, the practice has to verify that the secondary insurer has received the bill from Medicare, that the secondary insurer’s data is correct, and if the supplemental coverage is still in force.
	
	Finally, after the practice gets a list of excluded items that didn’t get paid by Medicare or an insurer, the staff must review and resubmit them if. Only then, after the practice has exhausted all those efforts to get money from the insurance company, can it go back to the patient to collect what hasn’t been covered by their deductible, says Kagan.
	
	A practice doesn’t want to go through all of that a second time because somebody made even a minor error along the way. “The most important function of the A/R process is to get that claim out right the first time,” says Margo Williams, MHA, CMPE, a senior associate in the medical practice department at the American College of Physicians.
	
	


	
	Getting revenue cycle management right depends, in large part, on making sure patients understand what they owe to their insurance company and to the practice and holding them accountable for those obligations.
	
	“That’s where the breakdown happens, because providers don’t invest the time up front to make sure the patient knows what their responsibilities are,” says David Zetter, CHBC, founder of Zetter Healthcare, a healthcare practice management consulting firm in Mechanicsburg, Pa. “And that’s why they’ve been chasing money for years.”
	
	To prevent that breakdown, the practice should verbally inform all its patients what their payment expectations are, have them sign an agreement containing that information, and ensure that back-office staff know about and support that agreement. This is a financial policy that clearly spells out what’s expected of both patients and staff.
	
	To minimize the possibility of any misunderstandings, the staff should discuss the policy’s main points with the patients.  As well, the policy must be enforced uniformly (e.g., the practice will collect a copay at the time of service; it will request some kind of payment if a high-deductible plan applies.)
	
	“The biggest challenge there, if you have more than one owner, is making sure the owners buy into their own process,” says Zetter, alluding to practices where doctors waive copays for friends-a behavior that, if repeated, means the practice has breached its contract with its commercial insurers and likely violated Federal law (because it’s probably seeing Medicare and/or Medicaid patients). If it bills the insurance company while waiving the copay, the practice has committed fraud.
	
	Unfortunately, few practices have what Zetter insists must be in that policy: a clear-cut assignment of benefits that gives practices the right to bill and be paid by patients’ insurance. Indeed, Zetter estimates that “probably 90 percent” of practices “do not have a legally binding, worded contract of assignment of benefits that their patients are signing.
	
	“If an auditor sees that an assignment of benefits is worded incorrectly, and truly doesn’t provide them the right to bill, then the payer can ask for every single dime back,” he says.
	
	Zetter is adamant that sending out patient statements and doing follow-up calls to retrieve tardy payments doesn’t work any longer. “It’s an archaic process that’s been going on since the days of Marcus Welby,” he says, adding that it’s better to establish processes to guarantee the money up front, including keeping a credit or debit card on file. Then, when the balance falls to the patient account, the practice already has approval from the patient because it has communicated this information, and it can start billing that balance and get paid immediately.
	
	


	
	Monitoring and managing your payers to see how much they have in the A/R pipeline is a vital task, according to Norris. His practice’s staff generates a monthly report, broken into 30-, 60-, 90- and 120-day A/R cycles, showing who owes them how much money, how many of those dollars are still uncollected, and if that number is rising. Then he tracks denials –what’s being denied and, just as important, why.
	
	“Are they playing games? Is it something on our end like we’re not coding things right? Are people making certain the claim is ready to be submitted as a clean claim or are we just trying to get as many bills out the door as fast as possible, where we’re just missing things that wind up costing us money as we try to reprocess that claim?” he says.
	
	With denials, spotting trends is crucial in discovering where the problem lies. “Are claims being denied for certain things for which they haven’t been denied before?” asks Norris. “If you see that, I would get on the phone with that carrier to see if I could come to a resolution.”
	
	Practices can’t afford to leave money on the table or be slow in collecting it. For Williams, staff training is essential in preventing that. “Process breakdowns could be any number of things, including that staff, when they’re working on insurance and patient balances, may be writing off things that are collectible,” she says. “And they need to know at what point do you escalate problems with insurance companies that aren’t paying properly.”
	
	It’s A/R staff’s responsibility to identify any breakdowns that delay payments, including technical problems such as computer or clearinghouse glitches. “But if you’ve got an astute staff that are running regular reports and know what they should be looking for, then they should be able to stay on top of collections,” says Williams.
	
	Patients sometimes dread talking with A/R departments, which is why adopting a payments policy that’s consistently applied, and coupling it with a flexibility to work with patients on a payment plan can make that conversation easier on both ends. So it helps if A/R can tell patients with a financial hardship upfront that the practice is willing to work out an installment plan with them. Kagan suggests what a hypothetical deal might look like: “If you’ve got a deductible of $3,000 and you owe me $800, I’d be thrilled if you gave me $100 a month,” he says.
	
	“Having a smooth patient portal where you can store credit card information can help you engage with the patient, too,” says Norris. So can having a human touch, which the practice can encourage by training staff members how to politely but firmly ask for payment on the day of the visit.
	
	Finally, practices must ensure that their statements are more patient-friendly than the typical physician’s handwritten prescription in the pre-digital days. Otherwise, the patient may be forced to call the billing staff and ask them to interpret something that makes no sense to them– something nobody enjoys doing.
	
	“It’s often necessary to work with your process vendor to make sure that the statements are easily understood,” says Williams.
	
	Ultimately, successful A/R is about two basic, but not necessarily simple, tasks: keeping close tabs on the accounts, every day, and getting timely payments. “Those are going to be your main challenges: figuring out who owes you and then when you can collect it,” Norris says.

The ability to maximize collections and profitability is vital for medical practices.

How to manage accounts receivable


	
	What has gotten done, what is still in process, and which high priority projects would you like to complete by the end of 2019? Review your calendar and your to-do lists and ask the staff involved in the discussion to do the same.
	
	Consider that, although you’ve got a few months to address priority items before year-end, the holidays will be here soon, and that productivity may wane a bit given employee time off and schedule. Be realistic about what you can achieve by December 31; some projects may need to be moved to next year.
	
	


	
	A good plan starts with a vision of what you want from your practice. What do you want for your practice in the next one to three years? For example, do you want to improve physician time flexibility by transitioning to a concierge model or adding telemedicine services? Add new services by opening a physical therapy department or recruiting a subspecialty partner? Increase revenue by partnering with the hospital in a new surgery center? Get your ideas out on the table, and refine them into a list of no more than three objectives. More than that can splinter your focus. Put the finalized list in writing.
	
	


	
	Do you have old technologies that need updating? Is the practice experiencing growth that requires additional managers or staff? Are the days in A/R through the roof? These are examples of business problems that could be solved next year. Walk through each area of the practice and discuss which problems need to be addressed. For instance:


	List the issues in each area and identify the highest 1-2 priorities in each. Set goals for how you will address and achieve them. If you can, add a few details - such as a likely project lead for technology selection and implementation, or the type of roles you’ll need to hire for if say, you are planning to develop and open a second office site.
	
	


	
	If done well, planning discussions should foster rigorous discussion and questions about the direction of the practice. Don’t see disagreement as negative but rather as a way to get to a better quality result.
	
	For the goals and objectives in the plan you might ask the team:

“What do we have to make sure we do right in order to achieve this goal?”

“What tools/staff need to be in place to get this project done?”

“If we choose to pursue this goal in 2020, what are we going to have to decide not to do?”


	
	Putting the plan in writing makes it real. It does not have to be lengthy or complicated. Several pages or a short slide deck will do. Document your vision for 2020, the three objectives you chose, and the specific goals for solving key business problems. Distribute it to your team so everyone knows what to expect.

Don’t leave the management and growth of your practice up to chance. Now is the right time to think about what you want to achieve in 2020. Here’s how to prepare.

Get your practice  ready for 2020


	
	Insurance is complex and is getting more so. Patients could use a bit of schooling. Copays, deductibles, and other medical billing terminology can be a bit of a mystery to most people.
	
	Consider printing a simple flyer that explains billing basics that can apply to any insurance plan. Direct patients toward the customer service number on the back of their insurance cards for more detailed questions.
	
	Educating patients on where to get more information can also help improve patient relationships. Patients often blame the doctor when billing problems are really between patients and their insurance provider.
	
	

2. Talk to your patients in an effective way.


	
	Make sure your staff knows how to communicate with patients about their bills. Never ask patients whether they want to pay their bill now.
	Instead, offer a choice of two options for paying. Assume that they’re going to pay and ask them if they prefer to pay by check or credit card.
	
	


	
	This is one of the most important things you can do to improve your bottom line.
	
	File claims on time, daily if possible, and have a routine system for checking open claims.
	
	Be sure to file amended claims when necessary and never miss a resubmission deadline.
	
	


	
	Do this on the phone before and at every patient visit.
	
	When you verify insurance, be sure to also confirm the patient’s contact information. People change jobs, switch email accounts, ditch landlines and move across town but don’t always remember to notify their physicians.
	
	Regardless of how you send bills, be sure to avoid sending statements to the wrong address.
	
	Be sure you have a way to follow-up if patients don’t pay to avoid payment delays.
	
	


	
	Take a little time at the first of the year to review your contracts with payers.
	
	Make sure you are aware of any changes from the prior year, especially if those changes require a change in workflow, process or staff (re)training.
	Note all filing deadlines for the year ahead.
	
	This is also a good time to make a chart of when your contracts come due, so you can plan ahead for any renegotiations.
	
	


	
	Make sure you have one person on your staff who is thoroughly trained and experienced in all things billing.
	
	Refer any staff and patient questions or issues to this person.
	
	Spend the time and money training your go-to person, too, as your revenue depends on her capabilities. It’s also wise to cross-train in case your billing pro has to miss work for a lengthy period.

If your practice is like most other practices, then one area where you could use some work is billing and collections.
	Here are six resolutions that can improve your billing and collections in 2020.

6 tips to boost billing and collections

I met Mr. AR for the first time in September of my intern year. He was a 70-year-old gentleman admitted to the hospital with nausea, vomiting, and abdominal pain. CT scans revealed an obstructing mass in the head of his pancreas. The rest of the workup yielded a frightening diagnosis of pancreatic cancer, prompting his primary medical team to consult us-the surgical oncology service. Although another resident had already seen him the day before, the patient’s daughter had only just arrived today, having traveled over 300 miles to be with her father. Mr. AR knew only that he needed to have surgery, so his daughter asked the nurse to page the surgery team, asking for someone to explain the proposed procedure.
	
	I felt my heart pounding as I listened to the nurse relaying the request. I was barely three months out from graduating medical school, but my senior residents were operating (and so was the attending physician), so there was no one but me to walk to the north wing of the hospital, frantically studying diagrams on my phone as I made my way over. I made silent promises to myself that it would be okay to say, “I don’t know,” because I truly didn’t know. How long would he have to stay postoperatively? When could he eat normal food? What activity could he do afterward? Would he be cured? Would he still need chemotherapy? These were questions I’d ask if I were the patient, and yet I had none of the answers.
	
	Up until that day, I had decided that I hated surgical oncology. The patients were ill to begin with, having spent some time fighting a malignancy prior to presentation, then some of them would be weakened by neoadjuvant chemotherapy, sustaining neither nourishment nor exercise, and then we would throw them into the gauntlet of a major surgical resection. Much of a surgical intern’s time is spent on the inpatient floor following postoperative patients, and I felt a crushing gloom entering the ward every day looking in on how sickly the patients seemed to be. Watching them die was even worse. The promise of more time to live, however long, didn’t seem worth it, and I struggled to care about these patients when everything seemed so futile to me.
	
	Despondent, I knocked gently and pushed the door open, peering in. Mr. AR and his daughter looked up from their conversation, smiling brightly and asking if I was the surgery person. I stumbled over my greeting, taken aback by the sunny atmosphere. They were so glad that someone had come. He looked nothing like my patients: no temporal wasting, no ribs showing through his side, no exhaustion in his eyes. I drew pictures of the anatomy that would be altered during the procedure in order to remove the cancer. I apologized where I had no answer and reassured them that the attending surgeon would be by to fill in the gaps.
	
	I also found out that he and his daughter came from my hometown, and by the time we were done chatting about more than just his diagnosis, an hour of my afternoon had drifted by. They thanked me for the information that I could give, and as I left the room, I couldn’t hide my own smile at having shared a positive connection with another human being.
	
	The next time I saw him, Mr. AR had undergone his surgery and relocated to our surgical postoperative floor. His recovery was not without complications. He endured a prolonged course of ileus, a string of electrolyte derangements, fluid collections requiring percutaneous drains, and an infection requiring antibiotics. Despite that, he greeted me cheerily every morning, even if I came to bother him at five or six o’clock. When I caught him pushing a rolling walker in the halls, he wanted to show off his dance moves, weak as he was. The optimistic attitude he and his daughter shared was contagious, and it motivated me to continue working hard to get him better after every setback. By the time he left the hospital, he looked more like the cancer patients I was used to seeing, frail and thin, but he didn’t stop smiling.
	
	Months later, a stranger tapped me on the shoulder. I almost didn’t recognize him. He was a far cry from the last I’d seen him: normal clothing, filled out cheekbones, standing on his own. Apparently he was there following up with his oncologist and was doing very well on his adjuvant chemotherapy. He thanked me for the care he had received and expressed that I must continue doing so for others. I left that encounter with a renewed sense of purpose: the care I was providing no longer seemed futile.
	
	Though progress was slow, I began to see how Mr. AR had changed me. As an intern, I had focused on the nitty-gritty details: the diagnosis, the pathophysiology, the workup, the treatment, the answers to difficult questions from the attending, the right orders to input into the computer. As a second-year resident, I found that the knowledge and workflow were now second nature, and I began to really see the patients for who they were. I saw new patients, anxious about their symptoms, fearful of the “c” word.
	
	I saw survivors, racking up years free of cancer, eating well and living normal lives. I saw beyond the details of the treatments and began realizing the principles and patterns guiding the care of cancer patients. I assisted in surgeries big and small, where some patients were cured with a small excision and others like Mr. AR had to face the gauntlet. For these latter patients, I could now picture where they would be a few months following their surgery, strolling down to the hospital cafeteria for a snack after their infusion.
	
	But they wouldn’t get there on their own. Motivated by their stories, I challenged myself to take ownership of their care, to read as much as I could, to be able to answer their questions where I couldn’t answer before. I presented patients I had seen at the multidisciplinary tumor board. I took notes on my clinic patients the night before so that I could spend more time with them in person and less with the computer. I stayed past shift changes to struggle through difficult cases with my attending. So imagine the surprise when third year rolled around, and I said with certainty, “I want to go into surgical oncology.”
	
	Mr. AR is still alive today, and the lesson I learned from our shared experience is still with me as well. He showed me a different perspective of caring for cancer patients. Where I had once viewed it as a process of dying and merely delaying the inevitable, now I view it through his lens, as a process of living for the hope of living better, no matter what length of time we can give them. He had the strength to face every day with joy and positivity, and now I can do the same for my patients who don’t have that strength themselves. This is what has helped me become a better doctor.

Scarlett Hao, MD, is an Asian-American resident physician in general surgery at the East Carolina Brody School of Medicine. She received her medical degree from the University of Maryland School of Medicine and speaks multiple languages, including Spanish and Mandarin. She is happily married and enjoys board games, Marvel movies, and trying new restaurants. Her hope is to become an academic surgeon in the field of surgical oncology.

The second-place entry in this year's Physician Writing Contest

2019 Physician Writing Contest: The hope of living better

Physicians understand the connection between mental and physical health, yet many don’t feel equipped to address patients’ behavioral health problems. They also don’t have the time, says Bonnie T. Jortberg, Ph.D., RD, associate professor of the department of family medicine at the University of Colorado School of Medicine. “Severe depression and anxiety isn’t something you can address effectively during a 15-minute visit,” she adds.
	
	Yet talking about behavioral health is critical-particularly when physicians are increasingly held accountable for patient outcomes under value-based care models. For example, screening for depression, evaluating risk of opioid misuse, and screening for unhealthy alcohol use-all of which are billable-can help physicians increase reimbursement under the Merit-based Incentive Payment System.
	
	Providing behavioral health-related services can also help providers hit quality benchmarks, bill for new and/or higher-level services, and even address social determinants of health such as food insecurity, housing instability, and health literacy.
	
	Behavioral health integration care management, another billable service that focuses on care coordination between a care manager and behavioral health specialist, pays approximately $49 for 20 minutes of services each calendar month.
	
	Aside from the revenue implications, incorporating behavioral health into a primary care practice also can help patients achieve better outcomes-both physical and mental.
	
	“This isn’t just about someone’s mood-it’s about addressing physiologic problems that affect patients’ health,” says Allen Y. Tien, MD, MHS, president and chief science officer at mdlogix, a software company that develops cloud-based solutions to help practices streamline behavioral health screening, care coordination, and outcomes reporting.
	
	In some cases, a mental health problem is the root cause of the physical ailment, says Tien. Depression fueling diabetes is one example. If physicians don’t treat the depression, they likely won’t improve the diabetes, he adds.
	
	

Creating a one-stop shop for addressing patients’ needs


	
	Experts agree that embedding a behavioral health specialist in the practice can potentially boost revenue and take pressure off physicians by serving as a resource for patients. Doing so makes sense because primary care physicians already have a rapport with patients, making it more likely that patients will follow through with behavioral health referrals, says Coley Bennett, CMM, CHA, practice manager at A Plus Medical, P.C., an independent primary care practice in Tacoma Park, Md.
	
	Earlier this year, A Plus Medical hired a certified registered nurse practitioner  to focus on billable mental health services such as smoking cessation counseling and intensive behavioral therapy. As in many communities, there’s a growing need for these services because many providers don’t accept Medicaid, and there aren’t enough outpatient mental health centers to accommodate timely appointments.
	
	In addition, Takoma Park is a culturally diverse city with many undocumented immigrants. Trust plays a large role in whether patients ultimately decide to seek any kind of treatment and particularly behavioral health services for which there continues to be a stigma, says Bennett. Once they find a provider they trust, they tend to want to stay within the practice for as many services as possible, she adds.
	
	Last year, Matthews-Vu Medical Group, a multi-specialty group in Colorado Springs, Colo. integrated an adult psychiatrist, a pediatric psychiatrist, and five licensed clinical social workers (LCSWs)after physicians had difficulty finding providers who would accept Medicaid patients, says Debbie Chandler, MBA, CMPE, chief executive officer at the practice. Even with these providers, Chandler says, there’s frequently a waiting list for patients requesting services.
	
	


	
	Despite the benefits of behavioral health integration, experts agree that hiring a specialist requires a financial risk that isn’t easy for small independent practices to take.
	
	“The model that typically works best is the primary care physician employs an LCSW or team of LCSWs that internally handle the majority of behavioral health care and then contracts with a psychiatric consultant for services that require advanced expertise,” says Toni M. Elhoms, CCS, CPC, consultant at Alpha Coding Experts LLC in Orlando, Fla. “LCSWs are a lot more affordable than psychologists and psychiatrists.”
	
	According to Payscale.com, the average national salary for an LCSW is approximately $57,000, whereas a psychologist earns about $76,000, and a psychiatrist earns approximately $202,000. Local and regional salaries may vary.
	
	Physicians need to determine what services the behavioral health specialist will perform and whether revenue from those services will pay for that provider’s salary, says Chandler.
	
	For example, if physicians don’t routinely screen for anxiety and depression, these should be among the most common services the behavioral health professional renders, says Tien. Many of these screenings can be completed electronically on a tablet while patients wait to see the physician in a fraction of the time it takes administer them face-to-face, he adds.
	
	However, specialists can also focus on more intensive therapies (e.g., for obesity) and generally spend more time with patients discussing advanced care planning, smoking cessation, and other mental health concerns.
	
	A behavioral health specialist can also perform and bill for general behavioral health integration care management for patients with a behavioral health condition (including substance abuse) who require at least 20 minutes of face-to-face or non-face-to face services each calendar month, says Elhoms. This service is appropriate for patients who require ongoing care coordination similar to chronic care management, though the documentation requirements are not nearly as onerous, she adds.
	
	Behavioral health specialists can also bill for this service during the same calendar month as the patient receives chronic care management, creating more revenue for the practice while helping patients with chronic conditions obtain the added layer of behavioral health services when needed, she says.
	
	Another consideration is how much additional revenue the primary care physician can generate as a result of increased productivity. For example, a planned 10-minute visit could easily become a 45-minute encounter when a physician tries to manage the patient’s anxiety or depression.
	
	By saving 35 minutes, physicians could potentially see an additional three patients. The SAMHSA-HRSA Center for Integrated Health Solutions has published a guide, The Business Case for Behavioral Health Care, that can help physicians calculate a more specific return on investment.
	If employing a full-time specialist isn’t realistic, another option is to hire one on a contractual basis with a financial split. The CRNP at A Plus Medical, for example, is a contractor who receives a percentage of each fee-for-service amount billed.
	
	Under this model, there’s less financial risk for the practice because the specialist is paid based only on the revenue she generates, says Bennett.
	However, “Bringing the behavioral health specialist on as an employee changes the financial game,” she adds. “It means their schedule must be full, and you’re also going to need to actively market those behavioral health services as if you’re building a business from the ground up.”
	
	If neither of these are feasible, practices could consider co-locating a behavioral health specialist in the practice, says Chandler. The primary care physician could refer patients to the specialist, who  rents space within the office-but there are no financial ties or formal care coordination.
	This arrangement gives physicians an option when behavioral health issues arise, but it doesn’t offer the full suite of benefits that comes with truly integrated care, including the ability to bill for their services, she adds.
	
	


	
	Consider these six tips to ensure a successful integration of behavioral health and primary care:
	
	


	
	At A Plus Medical, for example, patients complete relevant screenings, then, depending on the results, there’s a “warm handoff” between the physician and CRNP. During these handoffs, Bennett says, physicians tell patients they reviewed the screening and feel the patient could benefit from talking with someone else in the practice to get the help they need. Then they introduce the patient to the CRNP, who schedules the patient to come back for an appointment.
	
	Matthews-Vu follows a similar workflow; however, it also has a process in place for crisis management. If a patient presents in crisis, or a crisis develops during a medical appointment, a behavioral health specialist is always available to speak with that individual.
	
	Practices may want to consider using a daily huddle to identify patients who might benefit from behavioral health services, says Jortberg. For example, have any patients been on depression medication long-term? Do any patients have a history of substance abuse? Flag these patients in the EHR for a warm handoff to the specialist for a brief check-in after meeting with the physician, she adds.
	
	

2. Hire a behavioral health specialist with diverse experience.


	
	Depression and anxiety are common; however, behavioral health providers may have varying degrees of experience with trauma, post-traumatic stress disorder, eating disorders, substance abuse, post-partum depression, and pain management, says Chandler. Identify specific needs within the population, and hire someone who can address those needs, she adds.
	
	

3. Develop a plan to address coding, billing challenges.


	
	Practices may need more specialized administrative support when hiring a behavioral health specialist, says Chandler. Matthews-Vu, for example, hired a certified medical coder with behavioral health experience to address coding and billing challenges.
	
	Alternatively, a practice could pay for existing staff to obtain training in this field. A Plus Medical trained staff on how to obtain prior authorizations for initial assessments and subsequent visits, though Bennett says there are ongoing challenges. For example, some payers will approve psychotherapy for depression but not for anxiety.
	
	

4. Make sure your EHR vendor can accommodate documentation requirements.


	
	The SOAP note works well for primary care; however, behavioral health providers must also perform a mental status examination that should be included in an EHR template, says Bennett. To provide effective care, these providers also need access to comprehensive assessment tools that go beyond the standard Patient Health Questionnaire (PQH)-2 and PQH-9, she adds.
	
	


	
	A module that integrates the state’s Prescription Drug Monitoring Program (PDPM) database into the EHR streamlines the process of prescribing controlled substances, says Bennett. In Maryland, providers prescribing these medications are required to check the state’s PDPM before prescribing because many mental health drugs are controlled substances. Forty-one states have this type of mandate, though the specific requirements vary.
	
	

6. Require the specialist to sign a business associate agreement (BAA).


	
	This only applies if the practice intends to provide access to protected health information without employing the behavioral health specialist directly, says Tien.

Physicians understand the connection between mental and physical health, yet many don’t feel equipped to address patients’ behavioral health problems.

How to generate revenue, improve patient care

Maintaining a positive online presence is vital to the success of any medical practice.
	
	A recent survey from Doctor.com revealed that as many as 63 percent of respondents would choose one provider over another because of a strong online presence. Similarly, 60 percent of respondents have chosen one provider over another based on a positive online reputation.
	
	As patients increasingly rely on the internet to determine which provider is best for them, online reviews play a critical role in the success-or failure-of modern medical practices. Unfortunately, it is often impossible for a potential patient to differentiate truthful and accurate reviews from fraudulent ones. Worse, a single disgruntled patient may leave many reviews across a number of platforms, inflicting untold harm with a few keystrokes. Thus, defamatory reviews can quickly destroy a thriving practice.
	
	The risks posed by online reviews are especially dangerous for healthcare practices since health complications can arise or worsen even if providers have done everything properly, and reviewers may be completely misinformed regarding the standard of practice applicable to their situation.
	
	Doctors have a right to defend their reputations and livelihoods against reviewers who spread false and damaging claims. Fortunately, there are a variety of legal options available to combat defamatory online reviews.
	
	


	
	Defamation laws vary from state to state but, generally, a person may be liable for defamation when he or she posts a review that contains demonstrably false assertions of fact (as opposed to opinion), that are damaging to the subject of the review.
	
	This means that patients are entitled to post reviews that are statements of opinion, such as “I didn’t care for the doctor’s bedside manner” or “The office was poorly decorated.” While a provider may disagree with a patient’s opinion, those disagreements are not proper bases for legal action because opinion is generally protected by the First Amendment.
	
	Patients can also provide reviews that contain statements of fact, so long as those assertions are accurate. Like statements of opinion, truthful statements of fact are protected free speech under the First Amendment.
	
	However, if a review contains a false assertion of fact, the reviewer may be liable for defamation. This may include statements such as “I was billed for procedures that were not performed” or “The doctor botched the procedure.”
	
	


	
	Unlike many other industries, healthcare providers operate in a highly-regulated environment. Providers should be extremely careful when confronting defamatory reviews, as they must not violate any of the ethical, legal, or regulatory guidelines, e.g., HIPAA, that govern doctor-patient relationships.
	
	In addition to regulatory concerns, healthcare practices should keep the following steps in mind when considering whether or how to address negative online reviews:

 Consult a lawyer with experience handling defamation matters for healthcare providers. These matters are fraught with potential peril if not handled properly, so you need to work with a qualified and effective advocate. After all, your business and reputation are on the line not only because of the defamatory review but in how you respond to it.

Determine if the review qualifies as purported fact

. Work with your lawyer to determine whether the statements in the negative online review qualify as statements of purported fact. To do this, you may need to parse the language carefully to determine exactly what the reviewer was communicating. Often times, statements may initially appear to be factual but after a deeper look may constitute opinion, or vice versa.

 If the review contains only statements of opinion, consider alternative methods for addressing it, such as pursuing any takedown procedures or other features the review platform provides to help business owners address negative reviews.

 Make a sustained effort to increase the number of positive reviews. Asking satisfied patients to post truthful online reviews can increase a provider’s overall rating and may dilute the effect of one older negative comment compared to more recent positive reviews.

 If you believe that the review is indeed defamatory, ask your lawyer about whether you have a viable legal claim. When determining whether to pursue legal action, keep in mind that:

If a review is posted anonymously, you may be able to obtain a court order compelling the internet service provider to disclose the identity of the wrongdoer so that he or she may be taken to court.

To prevail in court, you will need to prove that the statements in question are false. There are many different ways of establishing the falsity of the reviewer’s claims, including through the testimony of witnesses (such as office personnel), records, or other evidence.


	Ask yourself if legal action is worthwhile. Consider the severity of the harm inflicted when determining whether to pursue legal action. A widespread defamatory review can lead to the loss of patients as well as significant-and often permanent-reputational harm. Pursuit of a legitimate defamation claim can result in both removal of the offending review and an award of damages to the provider to compensate for the harm suffered.
	
	On the other hand, in cases of very minor misstatements, it may not be worth investing the time and resources required to pursue legal action, even if you may have a valid claim.
	
	


	
	Some proactive healthcare practices have begun fighting back against defamatory online reviews. Although many such cases settle outside of court, providers have been increasingly seeking court intervention where the damages are significant or when the reviewers will not cooperate.
	
	Online reviews play a critical role in virtually all modern businesses, and healthcare providers are no exception. Although physicians operate in a highly-regulated environment, they have the right to defend their reputations and businesses when they are defamed.
	
	If this happens, physicians should consult experienced lawyers to ensure they take appropriate legal measures that comply with HIPAA and other regulations while effectively addressing damaging and defamatory reviews.

December 10, 2019 Edition

How implicit bias harms patient care

How to manage accounts receivable

Get your practice ready for 2020

6 tips to boost billing and collections

2019 Physician Writing Contest: The hope of living better

How to generate revenue, improve patient care

Defending against defamatory online reviews

Medical Economics cartoon: Litigation strategies