As physicians look for new ways to increase productivity, they might consider the benefits of employing physician assistants (PAs) and nurse practitioners (NPs). Trends indicate these types of advanced practice providers (APPs) are filling gaps in patient care and helping to extend the doctor’s reach. 

Work with varying degrees of autonomy, increasing access and freeing up the doctor’s schedule for more complex patients.

Spend extra time with patients, improving satisfaction scores.

Monitor wellness, improving the practice’s quality metrics.

Provide billable services, boosting practice revenue.

There are some practical distinctions between PAs and NPs. Essentially, PAs follow a medical model of training and focus on pathology, diagnosis, and treatment, while NPs follow a nursing model and concentrate on wellness and the impact of the diagnosis and treatment on the patient. 

Joseph E. Scherger, MD, MPH, vice president for primary care at Eisenhower Medicine Center in Rancho Mirage, Calif., and a Medical Economics editorial advisor, says in a busy primary care office, the typical model is one in which the doctor and APP “co-practice.” 

Under this model, patients are stratified according to complexity, and the physician delegates care for the less complex cases to the APP. Additionally, the APP might provide follow-up care for a complex patient the physician has already seen. 

“Think of the APP as an extension of the doctor-that’s why doctors hire them-to meet the added demand,” Scherger says. 

By taking on a variety of care delivery tasks, APPs can help reduce physician burnout, he says. However, new NPs and PAs shouldn’t be expected to start seeing patients on day one, he says. Practices should allow at least a month’s time for integration, during which APPs should shadow the doctor and become familiar with the practice, the workflow, and the patient population.

According to the American Association of Nurse Practitioners (AANP), there are more than 248,000 NPs licensed in the United States, and 86.6 percent are certified in primary care. There are 123,000 PAs , and about 25 percent are practicing in primary care, according to the National Commission on Certification of Physician Assistants.

Each state’s scope-of-practice regulations define how PAs or NPs may deliver care. The broadest scope allows NPs to see patients, diagnose, order tests, deliver treatment, and prescribe medications for routine patient visits without physician oversight. PAs ­require supervision established through “collaborative agreements” with physicians-written documents that define the practice’s model for care delivery and how or when the physician should be involved in the patient’s care. AANP offers a state-by-state online resource citing regulations for NPs, and American Academy of Physician Assistants (AAPA) offers similar information for PAs in a guidebook for members.

Generally, a PA is subject to a state’s board of medicine regulations, while an NP will be governed by a state’s board of nursing regulations, says Kevin Ryan, JD, a member of the law firm Epstein Becker Green.

“Even though the professional acts of the physician assistant and the nurse practitioner may be very similar, the supervision and collaboration requirements, if any, may be very different between the two,” Ryan says.

In 22 states and the District of Columbia, NPs have full practice authority, according to Joyce Knestrick, PhD, APRN, president of AANP. Among states that have restrictions, the degree of supervision varies widely. For example, nine states limit the number of NPs a physician can supervise. 

“We think removing these practice barriers would be helpful to all of us in healthcare,” Knestrick says. She believes full practice authority for NPs increases access for patients while also helping practices improve quality metrics tied to value-based payment because NPs are able to spend extra time with patients.

Jonathan Sobel, DMSc, MBA, president of the AAPA, says the organization is similarly advocating for more independent practice authority for its members. “We want to see that relationship maximized without the administrative oversight regulated or legislated,” Sobel says. “We want physicians to be able to define what’s right for their practice.”

Generally speaking, scope-of-practice regulations are leaning toward greater independence for APPs as a direct response to nationwide provider shortages, but the specific provisions are ever-evolving, says Kim Hoppe, clinical risk management and patient safety specialist for Coverys, a medical professional liability insurer.

“Sometimes the physicians themselves depend too much on the NPs and PAs without understanding the full scope of their ability to practice,” says Hoppe. “I’ve also seen NPs and PAs get very comfortable with their good relationship with the patient, resulting in ‘scope creep.’ They may be practicing above their scope of practice, certification, or education, and the physician may not be astutely aware of that.”

In states where NPs can practice independently, the physician wouldn’t have liability for the NP’s actions. However, a PA is almost always required to have a collaborative agreement with a physician, according to Ryan. 

“In states that require oversight and collaboration agreements, the risk to the physician will depend on whether the physician met the statutory obligations for oversight as well as the requirements in the collaboration agreement,” he says.

If the physician is required to audit 10 percent of the PA’s charts on a regular basis, for example, liability would be related to whether the physician fulfilled the obligation. Ryan says risk for supervising physicians is minimal when they meet their contractual and state requirements.

Consequences for noncompliance on the part of the overseeing physician could include licensure action by the state board of medicine. Additionally, he says, the physician could be named in a malpractice case if he or she failed to provide the required supervision and if the APP acted beyond the allowed scope of practice and caused harm to the patient.

Hoppe says it’s best for practices to create written agreements between the physician and the APP. The content of the agreements should include details such as prescribing authority when permitted by the state, how often the physician and APP will interact, and how the physician will be involved in patient care when needed. Providers also should outline a contingency plan for instances when the supervising physician isn’t available, she says.

Some medical boards require that the practice file the written agreement with the state, while others allow the agreement to be a living document, kept at the practice level and updated as needed.

But physicians must be realistic about how much time and attention is necessary when using APPs. For example, when a chronic condition is not under control, a PA would likely hand off the patient to the doctor, according to AAPA.

Full-time PAs and NPs earned a median annual salary around $105,000 in 2017, according to both AAPA and AANP. Scherger says with APP compensation equaling about half that of a physician, “they usually more than pay for themselves.”

Billing guidelines (Section 4112.1 and 4112.2) from the Centers for Medicare and Medicaid Services detail how and when an APP can bill for services for Medicare patients. Commercial plans often follow the lead of Medicare, but practices should verify any additional requirements, Hoppe says.

She cautions that improper billing of services can result in rejected claims, lost reimbursement, or even fraud investigations. “It’s muddy water,” Hoppe says, “and it can be hard to understand those rules.”

Medicare reimburses PAs 15 percent less than a physician for the same services, according to AAPA’s Sobel. However, he believes, adding a PA to the practice who can work independently and bill independently-even at the lower rate-produces a net gain in reimbursement.

“That 15 percent is offset big time,” he says. “You just have to do the math to figure out how many patients the PAs can see, if they are seeing new patients, and how they are expanding access to care for the overall practice.”

Articles

By taking on a number of care delivery tasks, nurse practitioners and physician assistants can help reduce physician burnout.

Working with non-physician providers

Steve Maron, MD, read an article in his local newspaper about nurse practitioners (NPs) providing care independent of a physician’s supervision and worried the public might confuse the two professions. As a result, he penned an op-ed for his local newspaper, the 

 in Green Valley Ariz., in January 2018 highlighting the differences in training between a doctor and a nurse practitioner. 

Maron, a pediatrician who worked at a Federally Qualified Health Center in Green Valley, was informed a few days later by the facility’s leadership that they were terminating his employment because his opinion was counter to the organization’s principle of mutual respect. 

Stunned by the decision, he offered to apologize for any offense he caused in what he saw as nothing more than a comparison of training levels to help educate the public about the different types of providers. 

“They said it was too late for that,” says Maron, who adds that the whole incident was outrageous and traumatic, and something he still isn’t completely over. He had planned on working at the clinic for at least five more years, but the firing forced him into quasi-retirement. Maron now works as a locum tenens for the Indian Health Service while he searches for a permanent position. 

“The nurse practitioners I’ve encountered are very intelligent, motivated, and for the most part, have good interpersonal skills and do very well with patients,” says Maron, adding that they are especially good at working with patients who have chronic conditions. 

But he objects to the idea that NPs should be allowed to practice independently. “I think we are on a slippery slope where the nurse practitioner organizations are pushing the idea-and the public is accepting-that they are pretty good at what doctors do. Where nurse practitioners fall short isn’t because they aren’t smart enough, but because they haven’t had the training and background. They are dismissing the value of medical school residency and fellowship.”

Maron is not alone in his concern about the growing influence of nurse practitioners and other non-physician providers in primary care. Readers of 

 ranked “replacing primary care physicians with NPs/PAs” fifth in the magazine’s “What’s ruining medicine?” poll. And a group advocating for patient care led by physicians, Physicians for Patient Protection, launched late last year in response to the growing movement favoring independent practice rights for non-physicians.

NPs now have independent practice rights in 22 states and the District of Columbia. While physician assistants (PAs) still require a formal agreement with a supervising physician, the American Academy of Physician Assistants is advocating that a collaborative agreement with a physician no longer be necessary to practice. And while the organization says it still expects its members to maintain such relationships, it wants to eliminate the legal formality of a the agreement.

The American Osteopathic Association (AOA) issued a news release in October voicing its objection to non-physician providers being granted independent practice rights (known legally as full practice authority) and the effect that will have on patient care. It also called for greater transparency to patients about the qualifications of who is providing their care.

“Ultimately, we want to make sure patients have the information to make informed decisions about their care,” says David Pugach, JD, senior vice president of public policy for the AOA. “There are highly trained, qualified providers across all professions, but the fact is, given the educational requirements and variations, you don’t know what level of training the provider has if the person you are seeing is not a physician.”

While Pugach says that physicians value the skills NPs and PAs bring to patient care, the AOA believes they should be part of a physician-led team. “When part of a physician-led team, there is additional assurance that the physician plays a role in the diagnostic and treatment decision-making process, which is important for high-quality care,” says Pugach. 

According to the AOA, physicians average more than 12,000 patient-care training hours, while NPs average more than 500 and PAs over 2,000. 

“Even the best NP is not trained or prepared to function fully independently like a physician,” says Richard Thacker, DO, FACOI, an internist and assistant professor of internal medicine at the Alabama College of Osteopathic Medicine. 

In addition to the concerns over training hours are questions regarding how and where some NPs are being instructed. “Some of the programs for NPs are almost exclusively online,” says Thacker. “That’s just crazy.”

Joyce Knestrick, PhD, FAANP, president of the board of directors for the American Association of Nurse Practitioners (AANP), says that how a nurse practitioner receives his or her education is irrelevant. “There is no evidence that shows that nurse practitioners who complete their coursework online versus a standard brick-and-mortar school are less qualified,” says Nestrick. “We do have standards the schools have to pass regardless of modality as well as clinical requirements. Regardless of where a student takes their courses, they still have to pass a test.”

Thacker says that a test is only one measure of competency, and that NPs who don’t have any nursing experience but practice independently are a concern to him. “Nothing substitutes for actual experience and managing patients at a bedside,” he says. “I’m board certified and have taken several high-stakes tests. I don’t like it, but it’s only one small aspect of demonstrating to the public that I’m qualified.”

Rebekah Bernard, MD, a family physician in Fort Myers, Fla., thinks NPs should not be allowed to practice independently. “They are told constantly in training and by their political organizations that they are just as good as doctors and can do everything a doctor can do,” says Bernard. “It may not be what they want to hear, but they don’t realize what they don’t know.”

Roy Stoller, DO, an otolaryngologist in New York City and board member of Physicians for Patient Protection, says his recently launched organization already has 10,000 physician members. He attributes its rapid growth to concern over non-physician providers providing care once reserved for doctors, and doctors’ fears about voicing objections to it. 

“I have a bunch of friends who can’t speak out because they’ll lose their jobs,” says Stoller. “They are seeing ridiculous workups from unsupervised NPs, and do not want to stay silent. I’m not sure how someone with a master’s degree, who has not had the benefit of eight years of schooling and three years minimum of residency, can see themselves as just as qualified as a doctor.”

One of the arguments for granting NPs more independent practice rights is that they help alleviate the primary care physician shortage.

“We are seeing a drastic decline in the number of physicians in primary care, particularly in rural and underserved areas,” says Knestrick of the AANP, who notes that about 80 percent of NPs focus on primary care. “We are able to go in and close those gaps.” 

Not everyone agrees. Henry Travers, MD, a retired pathologist in Sioux Falls, S.D., who is now the historian for the state medical association and studies trends in medicine, say non-physician providers aren’t helping rural areas. 

“The evidence of expanded practice for midlevels in areas with a physician shortage is that they are having no impact at all,” Travers says. “Data suggests that midlevels are distributed about the same way as physicians, at least in South Dakota.”

Thacker says the same trend is evident in rural Florida. “NPs don’t go to rural areas any more than anyone else,” he says. “If you look at where they practice, they are concentrated in the same metro areas. The places that are underserved are still underserved, and they have not filled any gaps.”

Pugach of the AOA says that even if NPs provide care in underserved areas, he questions whether that care meets the highest standards. “The goal shouldn’t be ‘some care’ instead of ‘no care,’” says Pugach. “The goal should be, how do we ensure every American has access to optimal care?” Instead of expecting NPs to fill areas devoid of physicians, he says a better solution is to create policies and programs that can solve the physician shortage, so that everyone has access to a physician-led team of providers. 

“The best way is to increase education and training in those underserved areas and then incentivize physicians to make it financially feasible to practice in that area,” says Pugach.

But experts acknowledge that consumers are driving much of the decision-making in medicine. With fewer physicians, the only way to better serve a society that wants on-demand care is to get patients in front of a provider, even if that provider isn’t a physician. Even consumers who have had positive experiences with non-physicians providers may not readily understand the difference-all they know is that they received a convenient appointment and believe their needs were addressed.

Doctors who have studied the topic also say that physicians are partly to blame for the expansion of independent practice rights for non-physicians by not always being strict in their oversight. 

Lax supervision has given credence to the idea that non-physician providers can work on their own, says Thacker. “There has to be a dedication and commitment on the doctor’s end to work with the midlevels,” he says. “Once you hire them, you have to give them the training and supervision they need.” 

NPs say studies show they provide care that is as good as or better than doctors, in many cases. Physicians say the studies are limited in scope and that the evidence doesn’t support that conclusion.

But Travers says fear is driving much of the opposition. Fear of revenue loss is one aspect, but a loss of identity is really the key motivation. “The concept of their professionalism is being challenged by a group of people that have less training, less experience, and perhaps less ability, and who are holding themselves out to the public to do all the things a physician can, and that’s scary,” says Travers. 

Randy Wexler, MD, MPH, an associate professor of family medicine at Ohio State University and a practicing physician in Columbus, Ohio, says that primary care physicians have several things working in their favor and thus shouldn’t worry about being replaced. 

First, as medicine continues to move toward value-based care, primary care physicians have proven that they are most effective at containing costs through prevention and disease management, says Wexler. One study published in 

 in 2008 by RC Bowman, MD, of the AT Still School of Osteopathic Medicine in Mesa, Ariz., showed that over the course of a 30-year career, it took 10 NPs or 4.8 PAs to provide the same amount of care as one family physician. “So even if a health system has more non-physician providers, they are providing less care,” he adds. 

But the biggest protection for primary care doctors is simply demographics, says Wexler. The population continues to age, creating more patients in need of care. “If you took all the primary care physicians, and the NPs and PAs who practice in primary care, there are not enough of them combined to manage all the patients moving forward,” Wexler says. “Primary care is the most sought-after specialty by search firms, and I would submit that is a strong indicator of future value.”

Although some health systems or institutions may opt for non-physician providers in lieu of physicians depending on the market, Wexler says research shows they tend to order more diagnostic studies and labs than physicians, which can eliminate the savings gained from their lower salaries.

“In a value-based world, what you need are individuals who can manage large populations with comorbid diseases-and manage them in a beneficial manner without extra lab studies. The only provider group that has shown they can do that is the primary care doc,” he says.

Travers says the paradigm in medicine is shifting, and the old model, where physicians are the apex of the pyramid and all other healthcare workers fall under them, is not sustainable. Quality-of-care arguments can be made, but he says there is probably no reversing independent practice rights in the 22 states that already have them. If anything, he expects more states to permit them. 

Instead of fighting the trend, physicians should look for opportunities to cooperate with non-physician providers to make a difference in caring for patients, such as fighting for affordable drugs or eliminating prior authorizations, Travers says.

“The health of patients is our only goal,” he says. “That is what is most important, and that is what the system should be designed to do. Anything that doesn’t place the patient first has to be changed, but we can’t do it alone.” 

A look at the competition for the future of primary care 

Replacing doctors 

President Donald Trump has proposed lowering drug prices by basing them on other countries’ costs, a monumental change that could save Medicare beneficiaries-as well as the government-millions of dollars. 

But many Republicans oppose the plan because it promotes importing price controls from other countries, while Democrats feel it doesn’t go far enough. Numerous physician groups and provider advocacy organizations have already spoken out against the proposal.

Conservative groups are fighting it as well. Last month, FreedomWorks, a Washington-based advocacy group, and Americans for Tax Reform, an anti-tax organization, wrote a joint letter to HHS Secretary Alex Azar criticizing the proposal and demanding that it be withdrawn.

Trump released the outline of his plan shortly after the October publication of a government report showinig that Medicare was paying as much as 80 percent more than other advanced industrial countries, such as France and Germany, for some of the most expensive physician-administered medicines.

Additionally, the report showed that the costs charged by drug manufacturers to U.S.-based wholesalers and distributors were 1.8 times greater than in other countries for the most prescribed drugs. 

Under the administration’s proposal, CMS would reduce the Medicare payment amount for some Medicare Part B drugs to make them more comparable to international prices by benchmarking them against 16 other European and Asian nations.

Additionally, it would allow private-sector vendors to negotiate drug prices and compete for physician and pharmacy business, and would increase the 4.3 percent drug add-on payment to 6 percent of historical drug costs. The proposal also would pay physicians a flat fee for prescribing medicines, independent of pricing.

HHS estimates this new payment model would save $17 billion over five years.

Edward Halperin, MD, chancellor and CEO of New York Medical College, says the proposal only addresses about 5 percent of the drug market, focusing on drugs administered by physicians in their offices, adding that Trump’s action is a slow motion, minimalist attempt to deal with a small proportion of pharmaceutical companies’ price gouging.

“It has nothing to do with the vast majority of the purchases of drugs: people filling prescriptions at either their brick-and-mortar or online pharmacies,” he says. “For a self-proclaimed economic nationalist, President Trump seems perfectly happy to outsource negotiating lower drug prices to European national health systems rather than do the right thing for most Americans: empower Medicare to directly negotiate lower drug prices for Medicare Part D with pharmaceutical companies.”

Lindsay Bealor Greenleaf, director at ADVI Health, which counsels healthcare companies on government affairs, says the Trump administration has enacted several promising reforms to align incentives across the supply chain and reward innovation, but the latest proposal to implement international reference pricing for Medicare Part B drugs is troubling.

She says the proposal poses significant access issues for seniors suffering from some of the most devastating and complex conditions, such as cancer, rheumatoid arthritis, and other autoimmune diseases. 

“Compared to the rest of the world, the U.S. places a high value on access to therapies, which is why Americans currently enjoy access to cancer treatments about two years earlier than other developed countries,” she says. “If the government chooses to swap today’s payment design for a model that links to foreign countries’ socialist payment designs, then the speedy access to innovative therapies that we enjoy today is at risk.”

She argues that this IPI (International Pricing Index) model would hinder access to current and future drugs, and would restrict access to patients’ preferred physicians as many of today’s independent practices would be compelled to sell their practice to large hospital systems to absorb the uncertainty and financial risk associated with the proposal.

Independent practices already face pressure to sell themselves to hospital systems, she says, due to the significant reimbursement disparities between hospital outpatient departments (HOPDs) and physician offices, and due to the 340B drug discounts afforded to HOPDs and not physician offices. If finalized, this proposal would add to that pressure by creating significant reimbursement uncertainty for independent practices.   

“The cures on the market today are the result of an environment that encourages and rewards innovation,” she says. “Going forward, if the U.S. reimbursement system is tied to socialist countries that do not reward innovation, manufacturers will lack the incentive to invest in the costly research and development that is required to produce these treatments.”

Although the proposed index is likely to save money in the short term, it will have an adverse effect on patient health in the long run, says Jason Shafrin, PhD, senior director of policy & economics for Precision Health Economics. 

“Linking U.S. pharmaceutical prices to those in other countries to drive down cost means that the overall revenue for innovators will also fall,” he says. “Academic research clearly indicates lower revenues lead to pharmaceutical firms reducing their investments on research and development, leading to lower levels of future innovation.”

If only certain drug classes were affected, innovation could be expected to fall for just those specific therapeutic areas, he says. For instance, pharmaceutical firms could shift towards R&D for treatments that affect a larger number of working age adults. 

“One item to note is that overall innovation may not be affected if the result of the plan is that pharmaceutical firms raise prices in Europe and Asia,” he says. “In that case, U.S. prices would fall, European and Asian prices would rise, and overall innovation may not change for these products.”

In the short run, however, it may be difficult to change prices abroad if these contracts are already negotiated.

Precision Health’s research shows that cancer mortality reductions were highest in countries that spent the most on cancer treatment. Therefore, Shafrin believes, while the Trump plan would produce short-term cost savings, it would risk worsening American’s long-term health prospects due to lowered rates of innovation.

The logic chain is whether more innovation results in more novel treatments, which then results in better patient outcomes. The study Shafrin cites does not link reimbursement to levels of innovation, but rather  that more innovation/quicker adoption of innovation leads to better outcomes.

“The Trump plan will benefit patients’ wallets as lower drug costs likely would mean either lower patient out-of-pocket costs or lower premiums,” he says. “However, patient health is likely to suffer as there will be fewer new and effective treatments available, unless pharmaceutical firms are able to raise their prices in Europe and Asia.”

While costs may not be cut only from R&D, additional belt-tightening not affecting the bottom line assumes that pharma is  inefficiently run and includes a lot of waste to wring out. Shafrin says if that were the case, pharma companies could already make more profits by cutting non-R&D costs.  

“At a more basic level, pharma firms will consider whether to invest R&D dollars in a risky clinical area,” he says. “If there is additional belt tightening, that likely means return from that investment will be lower.  Lower returns likely will reduce the number of treatments pharma will try to pursue.”

For instance, if a drug had a 5 percent chance of coming to market, with lower subsequent profits, perhaps pharma would only invest R&D funds in treatments that have a 10 percent chance of approval. The numbers are hypothetical, but they demonstrate how expected reimbursement and profits will affect the likelihood of individuals (or in this case companies) investing in the first place. 

John Driscoll, CEO of home health coordination company CareCentrix, explains that physicians currently are paid a percentage of the price of the drug that they administer. They lose income when they prescribe a less expensive medication, even though they are saving Medicare money, and they gain when they prescribe something more expensive and when prices increase. Under Trump’s plan, physicians would receive a flat fee, which is a more logical approach that aligns the interests of doctors and patients.

If office-based infusion becomes less financially attractive, he adds, in some cases physicians may refer their patients to far more expensive hospital outpatient facilities, driving system costs up. Ideally, Medicare would provide coverage for home-based infusion, which is more convenient, less expensive, and safe.

Shafrin says a drawback to flat rate reimbursement is that it could limit patient access to breakthrough treatments, as some physician-administered medications may cost tens or even hundreds of thousands of dollars per year and physician outlays on inventory for these treatments can be substantial. 

“Flat physician payments do not take into account physician’s cost of capital needed to hold these treatments in inventory over an extended period of time,” he says. “Thus, physicians may begin refusing to stock highly effective, though expensive, treatments if the administration costs more than this new flat rate reimbursement level.”

For example: Drug A is more expensive than drug B, but expected survival for patients on drug A is 10 years compared with only one year on drug B. Most people would want patients to get the more effective drug A. But under the proposed plan, physicians may not be able to afford the capital cost of holding drug A in inventory. 

Halperin says that by creating a flat fee for physicians to buy and sell drugs administered in their offices, rather than paying them as a percentage of the price of the drug, there will be no financial incentive for physicians to choose high-cost drugs over equally effective and cheaper alternatives.

“Physicians try to justify reasons to select expensive and complex treatments when simpler and less expensive options are just as effective,” he says. “To the extent that this proposal cuts the legs out from the profit motive that influences drug selection by physicians giving drugs in their offices, it will be to the benefit of patients-at least those in the 50 percent of the country affected by the proposal over the proposed five-year roll-out.”

In many European countries, there is a social contract that the government holds down the cost of treatment and assumes most of the cost, and patients are willing to wait longer for innovative treatment. 

“Historically, in the United States, people do not want the government dictating prices centrally and do not want delayed access to potentially life-saving treatments,” Shafrin says. “The key question is: Are Americans willing to reduce innovation in the future in order to gain more affordability in the short run?” 

Experts analyze a proposed Medicare change that could impact the way physicians prescribe pharmaceuticals.

Trump's drug price plan 

More Americans are choosing high-deductible health plans for their lower monthly premiums, though this results in steeper out-of-pocket costs for care. According to the Centers for Disease Control and Prevention (CDC), in 2017 42.3 percent of insured patients were enrolled in high-deductible health plans, up from 39.4 percent in 2016. This leaves some physicians scrambling to collect payments and manage shrinking cash flow. 

What can physicians do to improve their cash flow in this new landscape? Experts suggest that successful practices will review and establish new financial policies, do a better job of educating patients, and consider cash-pay services.

Many physician practices erroneously assume their patients know and understand their financial obligations and insurance details, according to David Zetter, CHBC, a healthcare business consultant in Mechanicsburg, Pa.

“Most practices don’t have patients sign a financial policy, so most patients have no clue what the practice expects,” Zetter says.

Physicians need to set policies on getting money up front, he says. He usually recommends a practice rewrite their financial policies to include steps such as: charging a late or no-show fee; requiring all patients to have a credit or debit card on file; or always taking a flat deposit upon booking an appointment, that can later be credited back to the copay once the patient’s percentage is determined. 

“If the business isn’t taken care of first, you’re not going to be able to take care of patients, because you won’t be able to afford it,” Zetter says. He also recommends that every patient be required to have a phone meeting with a patient financial counselor,  which can be an office staff person, who reviews the practice’s financial policies and gets the patient to sign the practice’s agreement to the financial policies.

“I’ve got clients that won’t even accept patients if they don’t have a debit or credit card. They don’t have an accounts receivable problem,” Zetter explains. Other practices he’s consulted with have strict policies where patients can’t be seen until they catch up on outstanding payments.

Tisha Rowe, MD, a primary care physician in private practice in Houston, Texas, says that it’s up to the practice to help patients understand their financial responsibility. 

“Whether that’s highlighting that portion of their [explanation of benefits] in writing or maybe creating a short video that spells it out, you want to make sure patients know their deductible and what a visit costs them,” Rowe says.

She’s had many incidents where patients were upset with her for being charged around $100 for something as simple as a medication refill where they had to come in office. However, the cost of the visit is related to what percentage of the deductible the patient has to pay. “I can’t change the price because [the patient] hasn’t met their deductible,” she says. “So we have to educate our patients.”

Rowe creates simple videos she uploads to a YouTube channel on topics such as telemedicine and wellness tips, each no longer than a couple of minutes. “You’re going to repeat that same information twenty times per day. Just put it out there, and make it accessible, and you can have partners share it,” she says, adding that even if a physician is not tech savvy or doesn’t have the time, it’s not complicated to get help creating them.

With deductibles increasing to all-time highs, Rowe says people who are not managing a significant illness or expecting surgery are unlikely to ever meet their health plan’s  deductibles. Her practice has a hybrid concierge plan for these patients. 

If she sees a patient for a physical and labs, they may end up paying $1,000, she says. However, she says, if a patient signs up for her concierge plan for $100 per month,  the patient knows exactly what services they’re getting, and get better access, as well.

She says that physicians shy away unnecessarily from concierge or self-pay plans because they believe that only wealthy people can afford them. In her practice, she says, most of her concierge patients are working-class people.

Rowe contends that people who use a high deductible health plan can afford a concierge doctor because they’re unlikely to ever meet their deductible anyway. “I guarantee you’re not going to see that much in medical care most years,” she says.

Paula Muto, MD, FACS, a vascular surgeon in Lawrence, Mass., and the founder of UberDoc, which helps patients find specialists, agrees that doctors should have some form of self-pay offering because it works in both the physician’s and the patient’s favor. “It is usually cheaper for a patient with a high deductible to pay cash for a procedure. You’re never going to reach your deductible anyway.” 

Physicians get paid immediately without going through the hassles of billing, coding, or denials, she points out. Muto suggests cash pay also creates greater transparency. She says that bringing it back to cash leads the physician talk to the patient honestly not just about their care itself but about the cost of their care. “If deductibles are here to stay, we must be transparent,” she says.

Take a deposit and/or get a credit card on file

Another way to increase the likelihood of getting paid is to request a flat rate deposit on all appointments. Destiny Biggs, RN, practice manager for MedNow Urgent Care in Augusta, Ga, says that her practice requires a $75 deposit and a credit card on file for all patients with a high-deductible plan.

Additionally, if a patient comes in and has an outstanding balance, the balance is due at the time of service. “They don’t get to say, ‘I’ll pay it next week,’” Biggs says.

Just having a credit card on file has made a tremendous difference in their collections. Whatever the patient owes beyond the $75 deposit is charged at the time of service, and the patient is alerted at the same time. “With credit cards on file, we collected [an additional] 15 percent of our patient balances last year or this current year,” Biggs says.

This puts a greater responsibility on front desk staff to be assertive in obtaining patient credit card information every time, so she says practices should be thoughtful when hiring for these positions or consider training them in this approach. At MedNow, the front desk staff sells the idea by reminding patients that putting a credit card on file means they won’t have to receive bills in the mail and/or make payments later.

For James Wilk, MD, an internist who works for the University of Colorado in Denver, high-deductible plans have changed the way he orders diagnostic tests.

He admits that he didn’t know the cost of some of the tests he orders until patients complained about financial hardship, or worse, refused to get the tests, leading to worsening or untreated conditions. “So this person is walking around with probable but undiagnosed asthma because the cost of the test is so high that they couldn’t get it,” Wilk explains. 

“I think twice about how necessary some diagnostic workups are. Instead of doing a bunch of tests, sometimes I’ll just plan a three- or four-step kind of thing. That way, if we make the diagnosis, we don’t have to test for twelve things, which would cost a fortune.”

He makes sure to inform his patients that he is ordering tests in the most cost-effective way possible. “They usually thank me for being conscientious of that,” Wilk says.

While this is not his ideal way of practicing medicine, he understands that patients are facing increasing financial pressure and encourages patients to work with financial counselors so that they don’t put off necessary treatment or tests.

Use big data and AI to determine propensity to pay

High deductibles may not be the only reason that patients are struggling to pay their doctor bills, according to Florian Otto, MD, co-founder of Cedar, a healthcare technology consulting business based in New York City.

He says that simply ranking patients by their propensity to pay may not be very effective because there may be multiple reasons ranging from:

The bill is incorrect/ not what they expected and patients don’t know how to get a corrected bill

He recommends that practices use artificial intelligence-based programs that draw from basic demographic information and user data to assess more accurately why patients aren’t paying. For example, he says, if a patient received their bill digitally and clicked on it three times but never paid, it might warrant sending a text asking if they are having trouble understanding the bill, and then connects them to a live chat function. 

Additionally, he says, physicians should automate the billing process to make it easier for patients to pay. “We strongly believe that it shouldn’t take longer than 20 to 30 seconds to pay your bill, similar to the Amazon Prime experience,” Otto says. 

Patients just want an easy, convenient and quick way to pay, he says, and it’s up to physicians to offer these.

“Reducing friction makes happier patients, and also increases cash flow,” Otto says. 

Successful practices will review and establish new financial policies, do a better job of educating patients, and consider cash-pay services.

How to survive high-deductible health plans

During each of the past three years, covered entities paid more than $20 million in HIPAA fines. While a handful of major breaches made headlines-most notably Anthem’s $16 million mistake-small practices can’t afford to be complacent about security.

The more negligent a healthcare organization is found to be at the time of a HIPAA violation, the higher the penalty. According to the U.S. Department of Health and Human Services, fines can range from $100 to $50,000 per violation or record, with a maximum penalty of $1.5 million per year for each violation.

For physician practices, even minor penalties can take a major financial toll. And that’s where the trouble just begins.

“More importantly for practices, a breach could impact their business continuity,” says Robert Tennant, director of health information technology (HIT) policy for the Medical Group Management Association. The loss of one month’s worth of claims data, for example, could cause significant disruption and potential loss of revenue, he notes.

Another significant risk to medical practices is damage to their reputations, says Matthew Fisher, JD, a partner with Mirick, O’Connell, DeMallie & Lougee LLP, in Massachusetts. Once you’ve had a HIPAA breach, the name of your practice is listed permanently on the Office for Civil Rights’ Wall of Shame-including the offense, date, and number of individuals affected. “It does have an impact in terms of patients wanting to continue with the provider,” Fisher says.

There’s also the ongoing cost of providing credit monitoring to affected patients for at least a year, as required by HIPAA, as well as the mental anguish of having to respond to a government investigation, whether a fine is issued or not, adds Fisher. 

As a result, preventing breaches of protected health information should be viewed by practices as a business imperative, says Tennant, adding that security depends on continually asking the question, “What if?” 

The list of scenarios to consider is nearly infinite: a phishing attack, sending a fax to the wrong number, losing an unencrypted thumb drive, as well as threats that have yet to evolve.

The best way to identify a practice’s key vulnerabilities is by conducting a baseline risk assessment, which has been required of practices since the HIPAA Security Rule went into effect. HHS is vague as to when and how often covered entities must conduct risk assessments-they recommend it be done ‘regularly’-but experts suggest performing this assessment at least annually.

“The risk analysis is going to give you a pretty comprehensive overview of your weaknesses, and is really going to help frame out how you’re going to implement all the different security policies,” says Fisher. Nonetheless, it’s a step practices often  skip. “For incidents that result in a settlement of monetary fine, almost every time, there’s either a missing risk assessment or an inadequate risk analysis,” he says.

For practices that don’t have the necessary in-house technical expertise, it can be worth the cost to outsource at least part of the project, experts say. A third party may also give a more accurate assessment by looking at a practice’s systems with true objectivity, notes Fisher. He recommends getting an outside perspective every three to four years.

And if a breach does occur,  a thorough risk assessment as well as written policies and procedures will help the practice defend itself against penalties, Fisher says.

While major cyberattacks involving ransomware or other external hacks draw headlines, many breaches result from mistakes made within the practice.

“The human component is the most difficult to secure,” says Michael Yamamoto, chief information security officer for Beth Israel Deaconess Medical Center in Boston. “We have 23,000 employees. If a hacker asked everybody what their passwords are, then there’s probably somebody who’s going to tell them.”

Yamamoto recommends that healthcare organizations of all sizes focus cybersecurity training around the basics of everyday work life. “Fundamentally, a lot of security comes down to people’s passwords,” he says. “If somebody gets that password, they’re in.”

To keep hackers at bay, he recommends using long passwords with at least 12 characters, and different passwords for every place a user logs in. To keep track of them all, he advises using a password manager, which  is a software application that stores and manages a user’s passwords for all their various online accounts and security features. This tool stores the passwords in an encrypted format, which the user accesses with a master password.

Fisher also recommends that practices require multi-factor authentication, such as a password and a fingerprint, whenever possible.

Another best practice is to instruct individuals not to access medical records they don’t need to perform their job. “People probably don’t realize they’re perpetuating data breaches when they enter a record that they really have no clinical reason to be in. We tell people they can’t look in their own medical records or those of family members outside of the due course of their jobs,” Fisher says. 

Finally, physicians must take cybersecurity training seriously and keep their knowledge up to date by really listening to the education their employers provide, says Rebecca Grochow Mishuris, MD, MPH, associate chief medical information officer for Boston Medical Center and an assistant professor of medicine at Boston University School of Medicine.

“There are new threats coming out all the time that we have to address,” she says. “It’s not enough to say you learned it three years ago. Three years ago, things were very different than they are now from a data security standpoint.”

For example, phishing attacks have become much more sophisticated in recent years. “It’s not like the email from the prince in Nigeria anymore. It’s an email that looks like it came from your institution,” says Mishuris, a general internist at Boston Medical Center. So anyone using the practice’s email system needs to be aware that the practice will never ask for a password over email, or a link that requires the user to sign in, without verbal warning.

A strong spam filter will catch most  emails falsely claiming to be from the practice or other trusted entities, but it’s critical that all users learn to recognize a potentially dangerous email and what to do about it.

Practices must make it clear to all clinicians and staff that if they click on a bad link, open a suspicious attachment, or make another security-related mistake that they will not be disciplined-and that reporting incidents is crucial, Mishuris says. 

The sooner a potential breach is discovered, the sooner an organization can take steps to stop or minimize the damage, such as securing the employee’s password and sending a blast email to describe the threat to the rest of the staff and instruct them on what to do if they receive it. To that end, individuals must be trained in reporting procedures, which typically involve notifying IT via a dedicated email address of phone number, she explains.

“It’s important that the practice culture not penalize reporting, but promote behaviors that help find gaps and make improvements,” Mishuris says. Early detection that allows time to intervene in a breach is essential to limiting a practice’s liability when security incidents occur, she says.

Security and privacy officials at Beth Israel Deaconess employ several tactics to instill good security habits throughout the organization, but a common thread is an effort to make messaging memorable, says Yamamoto.

For example, the organization has distributed bags of Swedish Fish candy with accompanying information about phishing, he says. Yamamoto has also been filmed holding a fishing pole in an educational video about the same topic.

“We try to use a story-based approach, using funny or [silly] things that will help people stop for a moment and think about what they’re doing,” he says. “When you’re so busy pushing things out, it’s really easy to perpetuate a major problem.

Finally, HIT systems themselves need regular attention to operate securely, using outside help if necessary, says Yamamoto. It is especially important to install software updates when they are released and make sure antivirus software is adequate and up-to-date. 

“Keep those things up with some tender loving care, and you’ll be in pretty good shape,” he says.

While newsmaking cyberattacks often involve external hacks, many breaches result from mistakes made within the practice.

A physician’s guide to preventing data breaches

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.

Over the past twenty years, the practice of healthcare has been overtaken by secondary entities. Time spent in physician-patient interactions, the core of any medical practice, is now being governed by insurance companies and complex billing and payment systems, federal and legal mandates, the pharmaceutical industry, and technology that was intended to improve the business of care. As physicians, we have given up control and lost the ability to do the job we were trained to do. Our focus has turned instead to serving needs that have become more demanding than those of our patients.

It is estimated that doctors today spend just 27 percent of their time interacting with patients, according to a study in the 

. The remaining time-far exceeding our billable hours-is whittled away on administrative duties, often serving documentation required by law. The frustration it leaves is real, not just on patients who wind up receiving fragmented care, but on physicians as well. Numerous global studies show that doctors are overburdened and burned out. The catalysts for choosing to pursue a medical career- helping people and making a difference-are buried in the mundane paper shuffling required of the medical field today. Climbing physician suicide rates are likely examples of the most extreme consequences of this problem. We’re struggling to understand how we, as healthcare providers, can provide quality medical care when we are rapidly losing control of our profession. 

In many ways, we gave it away. We relinquished authority to peripheral entities instead of taking it upon ourselves to determine how to best serve our nation’s healthcare needs. We can continue to let others lay obstacles and mandates that impede care and tell us how to do our jobs-because they most certainly will-or we can take the lead by creating and leveraging technologies that safeguard personal interaction and create better, as well as more efficient, options for patients to access care. The choice is ours.

One of the major factors that contributed to our loss of control is when Health IT entered the exam room. Congress passed the stimulus (the American Reinvestment and Recovery Act of 2009) that included a requirement to convert to electronic health records (EHR) or face Medicare reimbursement penalties.  With the passage of this directive, instead of a systematic conversion to electronic records, we scrambled to digitize massive files of patient records and train ourselves and our staff to change our workflow to accommodate new systems and accompanying challenges. It was then that we began to lose eye contact with our patients as our attention turned instead to entering government or insurance required data that often has little or nothing to do with the chief complaint of the patient in front of us. While managing records digitally offers numerous benefits, it must be done in a more thoughtful way. 

Technologies, like the use of EHRs, are often aimed at providing convenience, yet they have a way of road-blocking care. They are often outdated, time-consuming, and too complex to weave into regular practice. The rise in on-demand medical services, websites and retail clinics make it clear that patients are seeking more convenient care options to accommodate their increasingly demanding lives. Better access to care is necessary, yet many of the new models miss the boat by sacrificing continuity and personal connection for convenience, with care being provided by physicians who are unfamiliar with the patient’s they’re seeing. 

Patient-driven technology builds stronger connections

 that asked healthcare consumers what matters most shows that patients want to be known and understood by their provider in order to get the personalized care they desire.  They want to feel connected and understood by providers who know their personal stories-the unique factors that contribute to overall wellness and its breakdown. Without knowing those stories, we can’t provide good healthcare. It boils down to a personal connection.

Yet, with so little time allotted to face-to-face patient interaction, how can we build compassionate, therapeutic relationships that lead to better patient outcomes? It doesn’t have to take tremendous time. It’s here that technology can be used to enhance and even accelerate the process. 

Machine learning and artificial intelligence (AI), for instance, can be leveraged to track and analyze complex, valuable data and empower us to better know our patients. It can process information beyond human capability, such as massive sets of lab test results, family history, socio-economic factors and clinical trial data, to help us monitor our patients’ well-being and assess their risks based on their own history and others like them. These powerful technologies can help to flag signs of preventable, chronic diseases-including diabetes, heart disease, and even cancer that attribute to 86 percent of our nation’s healthcare 

 and are responsible for nearly 70 percent of 

 each year-and provide us with clinical insights to aid in our planning and providing of care, leading to more accurate, personalized treatment. 

There is also the not yet measurable data we get when we look at our patients, hear what they say and understand their personal situations, that technology can help us address. For example, telemedicine, the use of video-conferencing to communicate eye-to-eye with patients and provide healthcare without barriers of distance, allows us to leverage technology to add value to the most important part of a medical practice-seeing patients. It improves care and enables practitioners to see more patients by offering virtual care for level 1-3 visits-for instance, helping a patient manage diabetes or back pain before it reaches crisis level. Televisits-conducted with a few clicks on a personal computer-promote continuity of care by keeping patients connected with their own doctors, and maximize billable time through a built-in mechanism that monetizes after-hours care and communications like calls backs and follow-ups, helping us operate more profitable practices

By leveraging technologies truly aimed at helping us serve our patients, we can free ourselves to do the job we were trained to do. It’s time to take the lead-speaking out about the role we want technology to help us fill-or continue to be victimized by insurance companies and government mandates that want to take over our exam rooms and tell us how best to do our job.

As physicians, we have given up control and lost the ability to do the job we were trained to do. Our focus has turned instead to serving needs that have become more demanding than those of our patients.

February 10, 2019 edition

Working with non-physician providers

Replacing doctors

Trump's drug price plan

How to survive high-deductible health plans

A physician’s guide to preventing data breaches

Who will own your exam room?

U.S. Rep. Phil Roe, MD: Healthcare issues the new Congress needs to address