At first blush, the shift from volume to value appears progressive, thoughtful and even prescriptive for a healthcare system burdened with treating too many patients in too little time at too high a cost. But appearances can be deceiving, and you don’t need to dig too deeply to uncover the drawbacks of mandated value-based care, and why real value may be found in a much simpler way.
	
	The original intent was sound, aimed at fulfilling the quadruple aim of healthcare and rewarding physicians with incentive payments for quality of care versus quantity of services.
	
	However, the nature of many value-based care models appears to be more about value to the insurer, the employer and the hospital. The physician and patient, who rightfully should be at the forefront, may be at the very end of this line.
	
	The term “value” itself has different meanings to all involved in healthcare, naturally viewed through each individual lens. Patients value compassionate care that decreases suffering and pain and is available at their convenience with minimal out-of-pocket expenses, while payers define value as overall population health at the lowest cost possible. Agreeing on a common value proposition for healthcare becomes almost impossible to achieve, given the diverse goals-quality, service, cost, outcomes, access-of its main stakeholders.
	
	Even the question of who bears primary responsibility for a patient’s health improving is one without consensus as shown in the recent Value in Health Care Survey: physicians overwhelmingly assigned themselves responsibility, patients assigned responsibility equally to themselves and physicians, while employers split accountability among patients, physicians, health system, insurers, and themselves. Value, it seems, is in the eye of the beholder.
	
	So it’s not surprising that the push toward value-based care has met with mixed results. A recent study from the Healthcare Financial Management Association showed value-based payment models had no impact on cost or clinical outcome reduction in their early years.
	
	Half of physicians surveyed for a 2018 Future of Healthcare report felt that value-based care and reimbursement will have a negative impact on overall patient care, and 61% said it will also negatively affect their practice, with concerns expressed about decreasing reimbursement rates and resources needed for additional documentation and data collection.
	
	Concierge medicine offers an exceptionally viable solution, simultaneously simplifying and transforming the physician’s practice. Independent physicians remain that way, unfettered by the need for tedious documentation to prove value and achieve financial sustainability. This type of personalized care drives down the need for urgent care and ED visits, and improving outcomes for patients. 
	
	Most importantly, physicians are able to fulfill their personal vision for patient care. As one of our clients eloquently sums up: “All those things that we’re not compensated for in traditional primary care medicine are the most essential things.” That’s the real meaning of value-based care.

Terry Bauer is CEO of Specialdocs, a concierge practice transition and management company established in 2002.

Articles

You don’t need to dig too deeply to uncover the drawbacks of mandated value-based care, and why real value may be found in a much simpler way.

Defining value: What does this term really mean?

When it comes to motivating employees, money isn’t everything. Sure, people have to make enough money to pay their bills. But when getting them to put in additional effort for the team, it takes more than a good paycheck.
	
	Fortunately, the best motivators often are relatively easy, inexpensive, and can be a whole lot of fun. Try a few of these ideas at your practice, and see if your team is more willing to go the extra mile.

It might seem obvious, but many leaders miss it: Know everyone’s name.
	
	“One of the best ways to have a motivated team is when the doctor knows everyone’s name, and says thank you,” says Elizabeth Woodcock, president of Woodcock and Associates, an Atlanta-based physician practice consulting firm.
	
	


	
	“Make sure your team is aware of the mission,” says Cristy Good, CMPE, Senior Industry Advisor at MGMA. “When I worked in a pediatric organization, everyone was dedicated to the mission: making kids better.”
	
	When your team is aware of the larger goal that their work is a part of, they’ll feel an investment in the organization and have a reason to work hard to achieve that organization’s goals.
	
	


	
	When your employees do a good job, make sure they know that you know. “In my experience,” says Good, “nurses, front desk, staff, and back office staff really respond well  to being recognized.” You can acknowledge the work of a team or point out individuals who’ve gone above and beyond. Just make sure the message gets through. Don’t assume they know you value them.
	
	


	Acknowledging a job well done is most effective when the acknowledgment is specific.
	
	“I spoke with a doctor recently,” Woodcock recalls, “who went to his scheduler and said, ‘Mr. Jones (not his real name), because you were able to get this patient in today, he will not have to go to the hospital. You helped give excellent care.’” This not only recognized the employee for his work, it recognized his role in the organization and its mission. “This is very powerful,” says Woodcock.
	
	


	
	It’s great to be recognized by the boss, but Good points out that the practice shouldn’t stop at the top. “Encourage employees to recognize, thank, and support each other,” she says. “Build that culture of support and kindness.”
	
	


	
	“Work culture is important,” says Woodcock. “People want to work at a place that’s fun.” It’s easier than you might think to make your practice a fun place to work. Good suggests offering simple amenities, such as free snacks and pleasant break rooms. Holiday parties are also a great way to build a welcoming office culture, Good says.
	
	Woodcock suggests things like participating in charity events as an office, having a crazy sweater day, or a dinner swap. “I love this one,” says Woodcock. “Everyone brings a favorite covered dish to trade with another employee. Everyone takes home a ready-made dinner-that someone else cooked for them.” If you try, you can probably think of dozens of fun ideas to boost office culture. “It’s a good idea,” Good says, “to let employees take the lead on this; let them develop their own culture.”

When it comes to motivating employees, money isn’t everything. Sure, people have to make enough money to pay their bills. But when getting them to put in additional effort for the team, it takes more than a good paycheck.

6 ways to motivate your practice team

Regarding the brief article titled “Study: PCPs deficient in recognizing prediabetes” [Medical Economics, October 25 issue]. The summary of this survey tells us that John Hopkins researchers found that primary care physicians lack overall knowledge of risk factors, diagnostic criteria, and recommended prevention practices for prediabetes.
	
	While this is disturbing news, why do I get the feeling that similar findings of primary care physicians’ ignorance would be found in surveys about countless other conditions? Wouldn’t it be refreshing to report that primary care physicians are doing a remarkable job in at least something or other? 
	
	Let’s be honest. Medical journals and pharmaceutical advertisers have a common interest not just in keeping physicians reading the articles and the advertisements, but also-for better or worse, in reinforcing doctors’ insecurity in thinking they might not know enough as their peers, do enough for their patients, or prescribe enough of the latest pharmaceutical breakthroughs. As a former full-time editor of peer-reviewed medical journals (The Medical Journal of Australia and The New York State Journal of Medicine), I have long been aware that all medical journals do this to some extent. I myself have also served as a co-author of articles about physicians’ lack of knowledge of the cost of common laboratory tests and medications.
	
	We’d all like to think that keeping doctors on their toes is a main reason for conducting and publishing such research. But perhaps the nation’s health would be better off were the CDC and other government health agencies to divert some of the funding for surveys with predictably disturbing results to the purchase of mass media space aimed at better educating the public in disease prevention.

Dr. Dominika Jegen is right to suggest that in urban areas where a good supply of specialists exists, family doctors may have a limited scope of practice compared to hers-practicing as she does in an underserved area: (“Family physicians manage complex patients every day”, November 10, 2019).
	
	She has my sincere apologies if my comments that family practitioners are limited to treating common illnesses and coordinating care with specialists (“Expanding the roles of NPs and PAs will make primary care more desirable”, September 10, 2019) have offended her.
	
	Treating patients as she does, in the clinic, in the hospital, in nursing homes and veteran homes; treating newborns and octogenarians; and treating patients with gynecologic, pediatric, and mental health problems as well as providing palliative care is truly a Herculean task and deserving of all physicians’ admiration.

Your voice: Too much focus on what doctors don't do well

Insight into a doctor's New Year's resolutions...

Medical Economics comic: What's your resolution?

Q: How do we bill situations when a patient comes in for a preventive visit and, once in the exam room, informs the physician of additional issues?  Does it matter if the conditions are stable?  Also, when can we bill an E/M when these types of issues are presented in addition to a procedure performed at that visit?

Many times a patient’s “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit or a minor office surgery into something more. We always need to keep in mind the patient’s expectations for the visit.  According to CPT®, separate, significant physician evaluation and management (E/M) work that goes above and beyond the physician work normally associated with a preventive medicine service or a minor surgical procedure is additionally billable. The code that tells the insurer you should be paid for both services is modifier -25.
	
	Used correctly, it can generate extra revenue.
	
	The key is recognizing when your extra work is “significant” and, therefore, additionally billable. While CPT® does not define “significant,” asking yourself the following questions should help lead you to the answer:

Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?

Could the complaint or problem stand alone as a billable service?

Is there a different diagnosis for this portion of the visit?  Or, if the diagnosis is the same, did you perform extra physician work that went above and beyond the typical pre- or post-operative work associated with the procedure code?

If your answers to each of these questions is yes, then you should report the appropriate E/M code with modifier -25 attached as well as the preventive medicine service code or minor procedure code. You can increase the likelihood that the insurer will pay for both services by organizing your note so that documentation for the problem-oriented E/M service is separate from documentation for the preventive service or procedure. You may even want to use headers or a phrase such as “A significant, separate E/M service was performed to evaluate …”
	
	

Preventive medicine service with E/M service


	
	The following examples might help clarify the difference between “significant” and “insignificant” services performed in addition to a preventive medicine visit.
	
	A 44-year-old established patient presents for her annual well-woman exam. A complete review of systems is obtained, and an interval past, family and social history is reviewed and updated. A neck-to-groin exam is performed, including a pelvic exam, and a Pap smear is taken. Counseling is given on diet and exercise. Appropriate labs are ordered.
	
	The following situations would not be significant enough to warrant billing a separate E/M service:

The patient also complains of vaginal dryness, and her prescriptions for oral contraception and chronic allergy medication are renewed. This additional work would be considered part of the preventive service, and the prescription renewal would not be considered significant.

The patient also requests advice on hormone replacement therapy. She is anticipating menopause but is currently asymptomatic. This would not be considered significant because the patient is asymptomatic and preventive medicine services include counseling or guidance on issues common to the patient’s age group.

The following situations would be considered significant enough to warrant billing a separate E/M service:

The patient also complains of night sweats, hot flashes and lighter, irregular menses. After a discussion of treatment options, risks and benefits, a prescription for estrogen replacement is given. Because the patient is symptomatic and additional history is taken, along with medical decision making, this could be considered significant. The diagnosis code for menopause would be linked to the E/M code.

The patient also complains of fatigue, hair loss, feeling cold and lighter menses. On exam, mild hair thinning and areflexia are noted. The physician orders a complete blood count and thyroid stimulating hormone test with the intention of writing a prescription after reviewing the test results. Because symptoms are present and the physician documents extra work in all three E/M key components, this could be considered significant. Diagnosis codes for the symptoms would be linked to the E/M code.

The patient also complains of bilateral knee pain in the morning. Tenderness and swelling are found on exam. The patient is given a nonsteroidal anti-inflammatory drug prescription. The extra physician work that is documented for all three E/M key components makes this significant. The diagnosis code for knee pain would be linked to the E/M code.

The patient also states that home monitoring has shown fasting blood sugars of 120 mg/dL to 180 mg/dL and some random sugars over 300 mg/ dL. This is a significant problem that needs to be addressed, and extra physician work is performed and documented for all three E/M key components. The diagnosis code for uncontrolled diabetes mellitus would be linked to the E/M code. The status of previously diagnosed stable conditions would be considered part of the preventive medicine service and not separately billable.

Minor surgical procedure with E/M service


	
	CPT code reimbursement for minor surgical procedures includes pre-operative evaluation services such as evaluating the site or problem, explaining the procedure and risks and benefits, and obtaining the patient’s consent. Also, the Centers for Medicare & Medicaid Services (CMS) has clarified that the initial evaluation is included in the reimbursement for a minor surgical procedure and is not separately billable.
	
	However, when you perform an “Oh, by the way” E/M service at the same visit as a procedure and the E/M service requires physician work above and beyond the physician work usually associated with the procedure, the E/M service may be billed in addition to the procedure, with modifier 25 attached to signal to the payer that both services should be paid.
	
	The following examples might help clarify what constitutes “significant” and “above and beyond.”
	
	In the following situation, you should bill the minor surgical procedure code only:

The patient complains of a troublesome lesion; you evaluate the lesion and you remove it at that visit. The surgical code includes the evaluation services necessary before the performance of the procedure, so no E/M code should be billed.

For the following scenarios, an E/M service could be billed in addition to the minor surgical procedure:

At a follow-up visit for the patient’s stable diabetes and osteoarthritis, the patient also complains of a worrisome skin lesion that you remove at that same encounter. These services are separate and significant and not part of the preoperative services for the lesion removal. The code for the lesion removal would be linked to the appropriate lesion diagnosis code, and an E/M service, linked to diabetes and osteoarthritis diagnosis codes, should be submitted as well, with the 25 modifier attached to the E/M code.

The patient presents with a head laceration, and you also examine the patient for neurological damage before repairing the laceration. It would be appropriate to bill both an E/M service and a laceration repair code because your work was above and beyond what is typically associated with a routine preoperative assessment of the laceration. Separate diagnoses are not necessary.


	
	Unfortunately, not all insurers will pay you for the separate E/M service even if you code in compliance with CPT rules. Be sure to have your staff appeal any denied or bundled claims. A review of your documentation by the insurer may result in payment for your provider’s work.

Many times a patient’s “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit or a minor office surgery into something more.

Oh, by the way: How to  bill for additional issues

Physician burnout is an epidemic that’s rattling the healthcare field as much as any illness, leaving many physicians wondering how they can continue to practice medicine. Practice transformation to a direct pay or concierge model is one solution physicians are taking to deal with burnout, declining revenue and payer hassles.
	
	Direct pay practices charge patients a membership fee to pay for all costs of practicing. Concierge practices also charge a membership fee but bill some services to the patient’s insurance, as well. In both models, physicians tend to have smaller patient panels so they can give more time and attention to their patients.
	
	For the physician with little or no experience in either model, getting started can be daunting, but experts who have already forged the path offer reassurance that transitioning to these models is a realistic goal, though it means learning to practice medicine in a new way.
	
	


	
	The biggest hurdle in the transition to direct pay practice may just be getting started, says Matthew Mintz, MD, FACP, a clinical associate professor at George Washington School of Medicine in Bethesda, Md. Mintz left a hospital two years ago to start his own direct pay practice after he ran the numbers and determined that he would need only 200 to 300 patients (of a panel of over 2,000) to follow him to be able to afford to make the leap.
	“A good rule of thumb is that about ten percent of patients will follow you,” he says, and that was true for him.
	
	By the time a physician is thinking of starting a direct pay practice, Mintz says, there’s very little point in waiting from a psychological standpoint. “It’s not worth it to stick around for another few years and be miserable trying to save up a few pennies. You’re better off making a clean break and taking out a loan, investing in yourself, essentially.”
	
	He acknowledges that making such a choice is a leap of faith for many physicians, and that the comfort of a solid paycheck often leads people to stay in a traditional fee-for-service, insurance-based practice, even when they are miserable.
	
	“The systems that we work for tend to de-value physicians, and the physicians then internalize that and de-value themselves. The one piece of advice I have is for physicians to know they are of value, and that people are going to be willing to pay for those services even without insurance,” Mintz says.
	
	He charges his patients an annual membership fee that they can pay all at once, monthly or quarterly. It covers basic primary care services such as physicals, EKGs, and blood draws. For services beyond basic care, patients can bill their insurance, but he does not bill any insurance directly.
	
	Erin Jackson, JD, a healthcare lawyer with Jackson LLP in Chicago, who helps physicians make the transition to concierge care, urges physicians to be aware of their patient demographics before the practice transition, and to plan about six to nine months in advance. “Not only do you need to determine if there are patients there to support your practice, but can your patients afford a direct pay model?”
	
	An additional $50 to $100 per month may be more than some patients can afford, she cautions. Alternatively, a physician may be aware of a need or gap in healthcare in their community that they can fill for patients who are already paying high deductibles and often have to wait months to see their physicians.
	
	Jackson also encourages physicians to evaluate their personal motivation for setting up a direct pay practice. “I start the conversation about what you are hoping your life’s going to look like,” she says. She helps her clients make sure that they are getting into concierge/direct pay for the right reasons-usually to focus more on patient care and to spend less time on paperwork. 
	
	


	
	Starting a direct pay practice can mean leaving behind much of the staff of a traditional practice, including medical assistants, scribes, billers and coders, Dan Wohgelernter, MD, a cardiologist in Santa Monica, Calif., did not try to go it entirely alone. He contracted with a third-party organization called Concierge Choice Physicians that helps set up the administrative aspects and address any legal concerns. “Just like I think patients shouldn’t be their own doctors, doctors shouldn’t be their own lawyers,” Wohgelernter says.
	
	Under this arrangement, Concierge Choice takes a fee. They were especially useful helping him transition away from a hybrid model, where he charged an annual fee, but still billed patients’ insurance, which eventually met with limitations, to a completely direct pay model.
	
	His hybrid model recruited those patients he treats frequently, or ongoing, who had greater need for intervention into the concierge side, where they would pay an annual membership fee and gain access to him 24/7, with few exceptions. “This entitled patients to have this type of enhanced relationship with me.” For hospital visits, procedures and diagnostic tests, he still billed their insurance. 
	
	But eventually, the hybrid model began to fail. “The disadvantage of the hybrid model is that you are creating an exit ramp for patients who might otherwise want to stay with you,” Wohgelernter says. “And the patients who were paying the extra fee often resented me seeing other patients who weren’t signed up.”
	
	He soon made the decision to get rid of insurance and go completely direct pay. While it was hard to say goodbye to some patients, the new model has changed his life and how he practices. He spends between 30 and 60 minutes with each patient instead of 10 to 15. “You are really able to fulfill the requirements of the art of medicine,” he says. “Patients love it, and I feel that I’m fulfilling what I always envisioned in my role as a doctor.”
	
	Jackson also favors a direct pay or concierge model over hybrid because it’s more streamlined and easier to navigate from a legal and financial standpoint. “Hybrid models raise more red flags. And traipsing through the regulations can be extremely tedious. There’s a lot more opportunity for messing up if you’re taking insurance,” Jackson says.
	
	She reminds physicians that there are legal gray areas in matters such as marketing and fundraising that it’s useful to engage a lawyer on, no matter whether they enter a hybrid or complete direct pay model, “So long as you practice medicine you cannot escape the legal restrictions upon your license,” Jackson says.
	
	Unlike Wohgelernter, who relies upon the support of a third-party organization, Daniel Paul, MD, an orthopedic surgeon and founder of Easy Orthopedics in Colorado Springs, Colo. found that setting up a concierge practice did not require much outside expertise and allowed him to simplify processes because he does not have to seek reimbursement from insurance companies. He uses a HIPAA-compliant Google Drive in place of an EHR and acts as his own receptionist. “You save so much time in administrative junk,” Paul says. “My notes are basically just a narrative. You don’t have to pre-authorize or anything.”
	
	Moreover, changing to concierge is not so much about administrative functions, as it is personal ones. “You can’t just take your existing practice and strip out all the insurance and expect it to work, because it won’t. A concierge practice is relationship-based medicine, which means spending more time with people,” Paul says.
	
	Paul also points out that the transition might involve rethinking finances and lifestyle altogether. “If you’ve got a super expensive house and car and all your kids are in private school, you might have locked yourself into your job. The first step is downsizing yourself to prepare for this period of not making a lot of money.”
	
	However, he says that these sorts of life changes are worth the results. “I will bet you money that [physicians who transition to concierge] will be happier than they were before.”
	
	

How to talk to patients about the transition


	
	Perhaps the scariest part of the transition to direct pay is letting patients know and hoping they will follow. “It takes convincing patients at first,” Paul says. “But if you have established relationships with these patients you can explain, ‘Now I can practice how I want, and provide you with better patient care.’”
	
	Erin Jackson says that physicians who want to thrive in this model need to educate their patients on the benefits. Since overhead costs will go down, physicians should budget more money for reaching out to patients to discuss the value of the model.
	
	“Patients feel like they’re paying cash anyway with these massive deductibles. So they get to cut through all of the red tape and have access to a physician 24/7. I think it allows the patient to feel much more content with their relationship with their physician,” Jackson says.
	
	Wohgelernter agrees that patients benefit as much as physicians. “There are so many aspects of the concierge relationship that not only improve the quality of patient care but also actually reduce costs for the patient and the system,” he says.

Practice transformation to a direct pay or concierge model is one solution physicians are taking to deal with burnout, declining revenue and payer hassles.

Getting started with a direct pay practice

Physicians must navigate a host of obstacles every day, ranging from payment hassles to burnout, and each December, Medical Economics compiles its list of the top challenges facing physicians in the year ahead.Here are the top 10 challenges physicians will contend with in 2020, and some possible solutions.

Slideshows

Here are the major challenges physicians will contend with in 2020, and some possible solutions.

The top 10 challenges facing physicians in 2020

There is a point of tension unearthed in the care of a critically ill infant. A visceral, know-it-when-you-see it feeling that medicine has crossed a line. Textbooks speak of finding balance between fighting diseases to prolong meaningful life and promoting human suffering to preserve the sanctity of life. Within this teeter-totter is the nuanced beauty of neonatology, the raw honesty with which we counsel families. One of the hardest lessons in medicine is that you never can know how things will work out. We don’t always agree: every doctor feels the weight of this ethical seesaw differently. Even harder is learning, really learning, that your own ethical balance, your own vision of humanity, must fall into stride with the beliefs and desires of the parents you counsel.
	
	I remember my first stint in the NICU. A universe where we examined stomach juice in syringes and mucous-tinged, stool-stained diapers by flashlight in the night. There, mixed in between the growing and the gaining, was a baby who lived to have needles jabbed through the muscles between her ribs daily, draining pockets of murky fluid. Chronically high settings on her ventilator hammered the air in to her chest. The pain of every procedure, every day, took its toll on the team. Nurses begged not to care for her. Senior residents pushed the attending to let nature win out.
	
	The daily burden of her life felt cruel to me.
	
	This baby’s mother was alone, her husband in Afghanistan or Iraq. The distinction was important at the time but now, all these years later, I only remember that he was at war. She was a brand-new mother, fighting on behalf of her daughter. She drove an hour to visit, often coming at night to avoid the data of daytime. I remember how the attending would sit beside her, chairs nestled alongside the incubator, and emphasize the graphic and painful details of the daily needle sticks.
	
	I remember my internal compass pushing for this mother to just understand her daughter’s reality as I saw it. Each time an attending brought up taking a different, more compassionate path forward, the mother shut it down. She was taking her baby home, she would say. Concretely. And she’d unlatch the flaps that covered the portholes into the incubator and put a hand on her daughter’s head, gently stroking it. I imagine her singing in my memory but cannot say whether or not she did. She taught me, then, about hope.
	
	The baby grew, although she did not improve. Each needle left space to inhale. Her father took a brief leave from his service to meet her and we forced him to face a different type of war. The war in our NICU was about the pain of surviving; how much can one tiny baby endure. The pain of needles seemed farcical compared with the pain of severed limbs and shrapnel removal. He was a father; his daughter was a fighter.
	
	I learned that the point of my own compass had to yield to the directions of this infant’s parents. I watched as the team shifted rhetoric to fight with them, to fight for her. We championed the sanctity of life, of family, of survival. We moved her from one hospital to the other. She went from a room with five other babies who all, eventually, went home bottle feeding, to her own hospital room. We cut a hole in her neck once we stopped piercing holes in her sides. Her mother moved from the military base to that room, her days measured by suctioning secretions and pausing alarms. She had no family nearby. No friends came. The ebb and flow of her day, her journey, defined by the rhythm of beeps, the careful measurements of medications, the silent crying specific to a tracheostomy.
	
	Unlike so many cases that haunt me, this baby did not die. At least, not then. Almost a year after her birth, weaned from needle sticks, with a machine pumping life through a tube in her neck, she went home. She could not smile. She could not sit. Her eyes disorganized in their movements. Child life specialists hung balloons of pink foil from her crib. Her father had come home from war. We had done everything to send this child home, to form a family. Everything. And I had learned the discomfort that comes without paternalism.
	
	Many years later, this time as the attending, I met with a woman several months after the death of her son to review his autopsy. I’d done this only a few times before. His mother arrived disheveled, teeth and hair chronically un-brushed. She had gone to his birth hospital just that morning looking for a blue bear she remembered from his time there. It had long been thrown out. She let out a slow trickle of tears. She wanted an answer. Not about his cause of death, but about why this had all befallen her.
	
	This woman taught me about life after the death of a child. The odor of mildew and sweat; she showed me the pervasive despair of waking up every day knowing that you have outlived your offspring. The lost promise of fresh powder-scented diapers and curdled milk and the soft snuggle of heavy head against chest rocking in the grey shadow of night.
	
	We went through his autopsy, and the story of his life. We talked about his heart. The problem, cardiomyopathy, is often genetic. We drew pictures. I implored her to see a geneticist, to have testing done on herself, to learn if this could happen to another one of her children, should she have more. Wallowing in her grief, however, made her feel close to her son. An end to grieving perhaps meant that he was really gone.
	
	I left after the autopsy review thinking of the military mother from years prior, whose daughter would have been a teenager by then if she were still alive. With her life we abated the ache of a loss that never heals. I left this meeting understanding, truly, for the first time how women whose children die will wake up in the middle of the night, pining over the loss of their children, forever. Some parents go home to an empty nursery with crisp paint on the walls, stuffed bears along the window sill, perhaps a lamp with moons hand-painted on the shade.
	
	Compassion is taught to medical students in concrete actions. Sit down, eye contact, talk less, pause, recap. Touch a hand. Cry if you need to. As if these boxes can be checked off, one by one, toward reward. Gravitating toward death, toward social suffering, is a choice. Inserting yourself in the vacuum of need. Listening, truly listening, to find the balance between the meaning and the suffering. And accepting that the teeter-totter may not always tip your way: these are lessons never conquered, but I am learning, daily, how to listen.

2019 Physician Writing Contest: Learning how to listen

By embracing two-way texting as a communication channel for patient engagement, practices can achieve significant improvements throughout their operations.
	
	Here are seven ways that practices can benefit immediately from two-way texting.

1. Generate inbound calls.
	
	Not every outbound phone call staff members make is answered, but almost every inbound call to a practice during hours of operation is answered. Texting is a great way to inform patients that they need to call the practice. The text can even put the practice’s phone number at their fingertips.
	For example, you can send a text to patients letting them know that their insurance has been verified and that they may have a copay, then ask them to call the practice if they need more information.
	
	2. Provide education and support.
	
	Two-way texting is an easy way to put relevant information in patients’ hands before or after appointments. Many patients will lose or discard printed information given or mailed to them, but they will likely read and engage with a text.
	Remember, smart phones have access to the internet. If you want patients to look at an online video, read appointment- related instructions or go to a portal to view lab results, just include the link in the text.
	
	3. Increase compliance.
	
	Two-way texting also is a great way to ask patients if they are complying with medication and/or care protocols. Consider sending the following reminder tasks:

“Are you taking your medication as instructed?”

“Have you completed your knee exercise for 15 minutes today?”

“Have you scheduled your follow-up appointment with us?”

If patients reply via text that they are not in compliance with your instructions, staff can reach out and re-engage the patient.
	
	4. Improve online reputation management.
	
	Two-way texting is a very effective way to gauge patient satisfaction following an appointment and steer satisfied patients to leave positive reviews about your practice online.
	
	Furthermore, by asking a patient to text back to share their level of satisfaction with an appointment experience, the practice can receive immediate feedback from the patient and can intervene quickly if an experience was unsatisfactory for any reason.
	
	5. Increase top-line revenue.
	
	Using texting for appointment-related messages reduces cancellations and no-shows. Not only can you more effectively identify which patients plan to keep their appointment, but staff also can identify patients who need to cancel or reschedule. That gives staff a chance to fill that appointment slot with other patients.
	
	For practices that provide annual visits, texting is a great way to recall patients or remind them about available services, such as annual wellness visits.
	
	6. Improve payment-related communication.
	
	Before mailing out letters to patients regarding overdue payments, you can send a polite text reminding them that payment is due. Include a link to an online bill pay website if you offer such a payment mechanism. This approach to securing payment is familiar to most people, since many other industries already use texting for payment prompts, including most major credit cards and many banks.
	
	7. Provide updates concerning local weather-related and other schedule changes.
	
	Texting is a fast and efficient way to update patients about relevant changes to their appointment due to a local weather event, power outage, or physician illness. Sending a text to a group of patients letting them know their appointment needs to be delayed or cancelled and asking them to call the practice to reschedule is much easier than picking up the phone and calling every patient on the schedule for that day or multiple days.

By embracing two-way texting as a communication channel for patient engagement, practices can achieve significant improvements throughout their operations.

December 25, 2019 edition