As many as six million people in the United States have atrial fibrillation (Afib), a quivering or irregular heartbeat, and this number continues to increase with an aging population, according to the Centers for Disease Control and Prevention (CDC). 

There’s another driver of Afib patients: Health and fitness wearables, most notably the newest Apple Watch Series 4 set to include an FDA-approved built-in EKG sensor.

“There’s a tsunami of Afib patients coming,” says Jim Collins, CPC, physician educator and chart auditor with Cardiologycoder.com Inc. in Saratoga Springs, N.Y. “We’ll be more aware of patients with Afib who are completely asymptomatic. These are individuals who would have never sought medical therapy if it weren’t for their smart watch telling them to contact their physician.”

James Allred, MD, a cardiologist and CEO of CV Remote Solutions, a remote monitoring consulting company in Greensboro, N.C., agrees. “I think we’ll see an explosion in the detection of patients with atrial fibrillation over the next few years, and there’s a huge opportunity for internal medicine,” he says. 

Rising numbers of Afib present primary care physicians, many of whom make the initial diagnosis, with opportunities to prescribe heart rate-controlling and/or anti-coagulant medication as quickly as possible to prevent costly ED visits and hospitalizations. Doing so not only improves outcomes, but can also boost payments under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the federal law that seeks to reform Medicare payments while improving outcomes and reducing costs.

Beginning in 2019, physicians in the Merit-based Incentive Payment System (MIPS), one of two participation tracks under MACRA, will be penalized if their costs exceed anticipated amounts or rewarded for keeping costs under the projected amounts.

By prescribing warfarin or another FDA-approved anti-coagulant medication for certain patients with non-valvular Afib or atrial flutter, physicians choosing to report on related MIPS measures may boost their quality scores and receive a financial bonus. 

With MIPS, reducing costs is critical, says Collins. Medical costs for individuals with Afib are more than $8,000 higher per year than for individuals without it. Afib causes more than 750,000 hospitalizations each year and costs the United States approximately $6 billion annually, according to the CDC.

“Everybody will hit that button saying they prescribed warfarin or another anti-coagulant. That’s basic medicine,” says Collins. However, he adds, to win under MIPS, physicians also need to reduce costs, meaning they must ensure that their patients cost less to treat, on average, when compared with other providers in their specialty

Physicians gain points under MIPS when they use the CHA2 DS2-VASc assessment to determine risk for patients with non-valvular Afib or atrial flutter. This assessment addresses certain risk factors, including congestive heart failure, hypertension, age (65 or older), diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque), and sex (female). Patients with a risk score greater than one are included in the MIPS measure.

Novel anti-coagulants should be the first line of defense for patients with non-valvular Afib who have normal kidney function, says Allred. “Warfarin has a higher risk for intracranial bleeding, and there are more drug interactions and food interactions with warfarin than the newer drugs,” he says. “You also need to monitor warfarin frequently.” 

However, one challenge is that newer anti-coagulants are expensive, says Nitin Damle, MD, an internist at South County Internal Medicine in Wakefield, R.I. and past president of the American College of Physicians.  He frequently refers patients to drug manufacturer coupons and rebate programs. 

“If the drug companies would price these medications appropriately to begin with, we wouldn’t need to jump through all of these hoops to help patients get discounts,” he adds.

Warfarin costs as little as $4 while Xarelto, a newer anticoagulant, is at least $424.69, according to GoodRx.com. 

Even though warfarin requires frequent INR monitoring, Melissa Lucarelli, MD, FAAFP, a primary care physician in Randolph, Wisc., uses a fingerstick INR machine so she can check patients’ levels at the point of care and receive immediate results. 

“We have standing orders saying that if patients are between two and three, they stay on their same dose for four weeks,” Lucarelli says. “If they’re outside of that range, then someone contacts me while the patient is still in the office so I can address the dosing.”

Some of Lucarelli’s patients-particularly those that are immobile-also use a home INR monitoring machine. She’s able to bill for setting up this service using CPT code 93792 (patient/caregiver training for initiation of home INR monitoring) that pays $55.08 on average. She reports anticoagulation management every four weeks using CPT code 93793 that pays approximately $12.24 on average. 

For patients with symptomatic Afib, best practice is to involve a cardiologist as soon as possible, says Allred. “Our ability to achieve and maintain normal rhythm decreases the longer the patient is in a-fib,” he adds.

Damle consults with cardiologists ­frequently to identify the optimal course of treatment-chemical or electrical cardioversion versus ablation therapy. Cardiologists also help him determine whether warfarin, coumadin, or a new anticoagulant is the best option given the patient’s other comorbidities. 

“We want to try and discourage internists from practicing in a silo and taking care of these Afib patients on their own,” says Allred. “By partnering with a cardiologist, they’ll also see a bigger savings because patients will be in normal heart rhythm, feeling well, and not in the ED or hospital.”

Another way to reduce costs is to create an Afib clinic in which patients have immediate access to a dedicated provider. This is often a nurse practitioner or physician assistant who can advise patients when they start to experience symptoms of the condition, says Allred, who runs a dedicated clinic in his own cardiology practice and provides consulting services around creating similar care models. 

Allred’s clinic, which is staffed by a nurse practitioner who sees 15-30 patients daily, resulted in an 8% reduction in ED visits over the course of one year.

“I’ve seen a dramatic decrease in ED visits and hospitalizations when patients are managed in an Afib clinic,” says Allred.

“These clinics are a fairly new concept, but they can really help you win the MIPS game,” says Collins. Here’s how: Even though frequent outpatient visits and labs may add several hundred dollars on the ambulatory side, they reduce costs on the inpatient side-costs that often exceed $10,000 for a single Afib-related hospital admission or $100,000 or more for a stroke-related admission, he adds.

Afib clinics also make it easier to focus more aggressively on lifestyle modification that can reduce the impact of the condition, such as weight management, sleep apnea management, and tobacco and alcohol cessation counseling, says Allred.

Having a dedicated Afib clinic may also make it easier to bill for services such as transitional care management and chronic care management, says Collins.

Remote monitoring cardiac devices (e.g., pacemakers, defibrillators, and implantable loop recorders) can also reduce costs, improve outcomes, and generate additional revenue, says Collins. In particular, physicians can report CPT code 99091, which denotes the collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional requiring a minimum of 30 minutes. This code pays an average of $58.68.

Setting patient expectations about Afib management is an important part of cost savings. “Afib is a lifelong disease state, but it’s not life threatening unless you have a stroke,” says Allred. “We need to give patients a plan for the next time they have Afib-as-needed medicines and what to do when symptoms arise. It’s about helping patients learn to live with their disease.” 

Medication adherence can also reduce costs, says Damle. South County Internal Medicine is part of an accountable care organization that has hired a part-time (two days per week) pharmacist who checks in with patients every few months. “They report back to us so we can make sure the patient is on the right medication and dosage and is taking that medication appropriately,”  Damle explains. “This prevents additional ED visits and hospitalizations.” 

Jim Collins, CPC, physician educator and chart auditor with Cardiologycoder.com Inc. in Saratoga Springs, N.Y., says physicians can ensure accurate payment for treating patients with Afib by including the following five elements in their documentation: 

This list must include warfarin or another FDA-approved anticoagulant drug.

To ensure specificity, document the following:

Type of Afib (i.e., paroxysmal, persistent, chronic, or unspecified)

Type of atrial flutter (i.e., typical, atypical, or unspecified)

Patients with low risk of a thromboembolic event (i.e., those with a CHA2 DS2-VASc risk score of 0 or 1) are excluded from the MIPS measure. Physicians must document either the numeric score or all of the individual risk factors assessed to support an assessment of the CHA2 DS2-VASc score.

Obesity, sleep apnea, and hypertension frequently contribute to Afib and atrial flutter and may generate higher payments in some risk-adjusted payment models.

Document any of the following, when applicable:

Comfort care (i.e., those receiving hospice, palliative, and supportive treatment for a terminal illness or who have refused life-sustaining treatment)

Transient or reversible cause of Afib (e.g., pneumonia, hyperthyroidism, pregnancy, or cardiac surgery)

Medical reason for not prescribing warfarin or another FDA-approved anticoagulant (e.g., atrial appendage device in place)

Patient reason for not prescribing warfarin or another FDA-approved anticoagulant 

System reason for not prescribing warfarin or another FDA-approved anticoagulant (e.g., patient is currently enrolled in a clinical trial for treatment of Afib or atrial flutter)

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Manage patients with atrial fibrillation to boost payments under MIPS.

Managing atrial fibrillation 

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Relationship counseling 

Seventy-year-old William Keimig, MD, doesn’t like to think about what’s coming.

“I’ll feel really old when I retire-really old,” says the internist with the Henry Ford Health System in Detroit.

Keimig is past the average retirement age for physicians, but he’s still working 55-hour weeks and hasn’t set a date for when he will stop practicing. Maybe 2020, he says, adding that he doesn’t like to contemplate life as a retiree. “One of the most satisfying and cool things you can do is to be a physician,” he says. “I know I’ll really miss it.”

The popular stereotype of older workers is that everyone is counting the days until they can retire, but that’s not the case for many physicians, who have a more complicated relationship with retirement than do many other professionals. 

And as the country’s physician workforce ages, it’s an issue with which more doctors will have to grapple. According to the 2016 U.S. Census, 30 percent of physicians are 60 or older, up from 26 percent in 2010. And the average age of active licensed doctors is 51.

In a 2017 survey of physicians age 50 and older by healthcare staffing firm CompHealth, respondents, on average, said they intend to retire at age 68. By comparison, the average retirement age for all Americans is 63. 

If physicians, on average, work longer than other people, it’s partly because they started their careers later.

Four years of medical school and three years or more of residency mean many physicians do not begin earning substantial incomes until they’re 30 or older, well after their peers who pursued most other professions.

That means fewer years in which to accumulate enough savings for retirement while simultaneously paying expenses such as mortgages and children’s college educations. For doctors who combine an expensive lifestyle and a lack of financial acumen, that can mean working past the age at which they’d like to retire, says Joel Greenwald, MD, CFP, a Minnesota financial planner who works primarily with physicians.

That’s not the case with Keimig, who says he can afford to retire now, but likes still having an income. “It is nice to have that paycheck coming in on a regular basis,” he says.

Keimig, who has been with Henry Ford Health System his entire career, says the support of its administrative and medical staffs has made it easier for him to keep practicing by allowing him to focus on providing medical care rather than performing ancillary tasks.  

For some doctors, it’s hard to say goodbye to a career they’ve loved and one which has formed a large part of their identity. In the CompHealth survey, physicians identified losing social interactions at work, a loss of purpose and boredom/loneliness/depression as their top concerns about retirement.  

Cardiologist David Mokotoff, MD, says his decision to retire in 2015 at age 67 provoked something of an identity crisis.

Being a physician was at the core of who he was and he worried how he would feel without the work and the status that accompanied it. On the other hand, he says, he wanted to retire while he was still healthy and able to enjoy physical activities. When a good friend and fellow physician contracted Parkinson’s disease and died, that convinced Mokotoff it was time to retire. 

“For me, time is something you can’t save up and you can’t replace,” he says. “It’s always a gamble. No one has a crystal ball.”

Three years into retirement, the Florida resident is an avid fisherman and has become a tai chi instructor. He also blogs. He says he misses interacting with patients, but not EHRs and government mandates. “If I miss it too much, all I have to do is talk to my colleagues or go visit the doctor and they tell me how much worse it’s gotten,” he says.

He advises physicians considering retirement to realize there is life and purpose after medicine. “The trap is when you assume that all you are is a doctor, because you can lose your identity,” he says.

Alfred Narraway, DO, still dreams about making rounds and working in the catheterization lab. But the cardiologist has no regrets about retiring in 2015 after 40 years of practice.

Retirement was a gradual process for him. He reduced his workload at an Idaho hospital over 18 months before retiring, then returned for three stints as a locum tenens doctor before stopping work for good and moving to Ohio to be near his grandchildren.

In retirement, Narraway is doing a lot of reading about basic science, learning Spanish online and tending to his three acres of property. “I’m very busy and I can’t find enough time to do everything I want to do,” he says, adding that he did not keep his medical license current. 

“You’re either in or you’re out,” he says. “To be halfway in is no way to go.”

It’s uncommon for physicians to retire well before the traditional age, but that’s what Valerie Jones, MD, did in 2016. At age 37, the Maryland resident walked away from her practice as an ob/gyn, only seven years after completing her residency.

“That was never the plan. I had intended to practice indefinitely,” she says. However, a health scare and a growing dissatisfaction with the state of medicine caused her to reassess her plans and retire.

“(Medicine) had morphed into something I really wasn’t interested in anymore,” she says, citing the loss of autonomy, lack of time to form deep relationships with her patients and an ever-growing emphasis on productivity. The mother of three says she and her husband have lived frugally and invested well and that has allowed her to avoid having to get another job.

Jones says she had a hard time adjusting to the new reality: “It was very strange at the beginning. So much of my identity was wrapped up in this, I didn’t have time to develop outside interests.” However, she hasn’t left medicine behind entirely. She keeps her license current, writes the blog OB Doctor Mom, and is considering volunteering, teaching, and writing a book about her decision to retire.

At the other end of the age spectrum from Jones is James Hutchinson, MD, a 95-year-old family physician practicing in San
	Mateo, Calif. The solo practitioner graduated from medical school in 1950 and opened his practice in 1953. 

Now in his 65th year of practice, he still sees patients four days a week, including some great-grandchildren of patients he saw when he began practicing. Hutchinson, who until recently walked 10 miles a day to stay fit, has a ready answer for those who ask when he will retire. 

“I’ll practice until the river rises,” he says, noting with a laugh that there are no rivers in San Mateo. “What else can I do? I’ve done this all my life and I live in a one-horse town-there’s nothing else to do.” 

Having outlived his wife and eldest child, Hutchinson says spending whatever time he has left as a retiree holds no appeal: “I love what I’m doing. I enjoy people and I enjoy helping them. I’m not missing out on anything; I’ve had a full life.”

For many people, retirement is attractive because it means no longer working at jobs they don’t like or find rewarding, but that doesn’t seem to be the case with most physicians.

When respondents in the CompHealth survey were asked what they most looked forward to after retiring, traveling more, pursuing other interests, and spending more time on hobbies topped the list. Only 32 percent said they looked forward to no longer working while 48 percent said they intended to work part-time or volunteer.

When he finally retires, Keimig says he might volunteer, teach an English as a second language class or even earn a master’s degree in literature, but none of those prospects is as alluring as continuing to practice medicine.

“General MacArthur said old soldiers never die, they just fade away. I think it’s the same way with doctors,” he says.

When Patricia Kloser, MD, MPH, FACP, retired from her professorship at Rutgers New Jersey Medical School in 2013, she wasn’t ready to stop practicing medicine.

Instead, the internist and infectious disease specialist has taken her practice on the road. Kloser, who is in her 70s, has been working as a locum tenens physician since retiring. Based in New York City, she has taken assignments in Georgia, Florida, Wyoming, and Alaska, among other states. “I absolutely love it. I can’t imagine doing anything else,” she says.

Locum tenens assignments are one option for physicians who’ve retired, but there are many alternatives to the traditional retirement of leisure, hobbies and travel. Retired doctors who still want to use their medical skills can volunteer, teach, consult and even go back to work part-time.

Kloser says she wasn’t ready to stop practicing medicine and locum assignments let her control where, when, and how much she works. A typical assignment is six to 12 months, and she takes breaks between jobs to enjoy her hobbies of hiking, travel and photography. When she’s home, she still sees some long-time patients.

Locum work is not for everyone, she says, and requires flexibility as well as a tolerance for living in hotels and adjusting to unfamiliar surroundings. “I’ve done some really wonderful things,” she says. “The only downside is I’ve met some wonderful people and it’s hard to say goodbye, but I know there is an adventure down the road.”

Like Kloser, George Meyer, MD, knew he would not spend his retirement on the couch. Since retiring from Kaiser Permanente in 2013, the 77-year-old gastroenterologist from Sacramento has been a medical volunteer through Health Volunteers Overseas, a U.S.-based nonprofit that trains healthcare workers in underserved countries.

He has been to Mexico, Costa Rica, Uganda, Bhutan, Nicaragua and elsewhere. He also finds time to volunteer with The Flying Samaritans, which provides free healthcare in Baja California, Mexico, and he teaches a medical course in Japan each year.

“It allows you to maintain your skills. It allows you to meet wonderful people while helping the countries develop medically,” Meyer says. “I get more out of it than I give. It truly is an absolutely wonderful experience.”

An increasingly popular option for retirees is to become a telemedicine provider, which usually can be done from home on a part-time basis, does not require in-person interaction with patients, and largely deals with simple cases.

The ideal retirement means something different for every physician, depending on their individual circumstances, desires, health and other factors. However, it’s clear that the valuable skills they spend their careers developing afford physicians the opportunity to continue to contribute even after they retire.

For some doctors, it’s hard to say goodbye to a career they’ve loved and one which has formed a large part of their identity.

Physician retirement: Why it's hard for doctors to retire

There was a time when doctors looked forward to retiring after a successful career, looking to vacation, play golf and spend more time with their families. But these days, it seems more physicians are halting retirement plans. 

A 2017 study from CompHealth examined late-career physicians’ sentiments toward retirement and revealed that many aren’t looking to hang up their scrubs and stethoscopes anytime soon.

According to the study, social interaction topped the list of retirement concerns, while 91 percent of doctors still feel they can provide a useful service to patients. It’s no wonder that many physicians are holding off on retiring for as long as they can.

Larry Good, MD, a gastroenterologist in Lynbrook, N.Y., has been in practice nearly 40 years in a wide range of settings, including academic, director of a clinical department, lecturer, researcher and presenter at national and international medical meetings.  

“I have not thought about retirement. I am involved in many projects, including a pharmaceutical development project. I deeply believe that I provide a very valuable service to my patients and profession,” he says. “Being active allows me to be more effective clinically in areas of research and pharmaceutical consulting.”

In the study, 51 percent of respondents said that working occasionally or part-time is part of their ideal retirement plans.

Murray Grossan, MD, part of a five-person ENT group at Cedars Sinai Center in Los Angeles, California, says there is evidence that being creative slows aging, so despite being in his 90s, he still works four half-days a week. 

“I’ve certainly thought about retiring, but when you consider what gives you energy, it turns out to be doing medicine and solving medical problems,” he says.

He compares the field of medicine to the music industry, where many musicians continue to tour well into their post-retirement-age years.

“They are most energized when they do music; similarly, doctors went into medicine for the love of medicine, and they feel fulfilled, just like the musician,” Grossan says. “Social interaction is also a factor-I’ve seen too many examples of a person retiring and expiring.”

Joe Heider, president of Cirrus Wealth Management, has more than 30 years’ experience working in retirement, estate, tax and business planning with a focus on the financial concerns of medical professionals.  

“When it comes to retirement and physicians, although a large percent of physicians do not want to retire, there is a substantial percent that do,” he says. “Just like other professions, the burnout happens over time due to stress and work hours as well as increasing government intrusion into their practice. The physicians that do not want to retire have found a way to focus on what they love to do, which is working and treating patients.”

Heider says physicians should establish a financial plan early on so that they have the freedom to pursue what they want to do upon reaching retirement age without having to worry about money issues.

While some older doctors might slow down in their later years, it doesn’t mean that their skills can’t be put to good use. After all, as Grossan notes, “We’ve seen a thing or two.”

“A huge amount of experience in the senior doctor can be of value,” he says. “The senior doctor comes from where you palpated muscles, listened to the heart, and made pretty good diagnoses without $3,000 lab tests. We see today’s doctors who barely touch a patient and they can’t get to feel the abdomen because all those sensors cover it.”

Many seniors would love to continue practicing, but Grossan says EHRs and expensive recertification costs force them out of practice.

Physicians tend to be very busy and very involved in their work, and Good says many haven’t developed a lot of outside hobbies or other interests throughout the course of their career. 

“I think my generation of physician believe that medicine is a calling,” Good says. “Many of us would be kind of lost without medicine. There is an old psychology 101 test where you are asked to describe yourself-man, woman, son, daughter, etc. Most physicians say doctor first and then everything else, which admittedly is a little psychologically flawed.”

He agrees with the CompHealth study that the loss of social interaction is a concern for physicians considering retirement.

“Physicians spend all day talking to patients,” Good says. “My friends who have retired do report loneliness and isolation and those considering [retirement] note it is a concern.”

Still, 76 percent of respondents indicated that they would like to travel more in full retirement, and while making the decision to call it a career is hard, it’s something that many could look forward to one day. 

There was a time when doctors looked forward to retiring after a successful career, looking to vacation, play golf and spend more time with their families. But these days, it seems more physicians are halting retirement plans.

Why more physicians are postponing retirement

Around 125,000 people die per year in the U.S. due to failure to properly take medication, and 50 to 60 percent of those taking medications for chronic disease don’t take them as prescribed, according to the National Council on Patient Information and Education. 

Convincing patients to improve their health requires a mindset shift and changing from a transactional relationship to a partnership. 

“They have a need, and you have a need,” says Ellen L. Singer, MD, an internist with Northwest Permanente in Portland, Ore. The key, Singer says, is drawing out the patient’s story. Some of her best techniques were learned through an improv coach, including how to move the story along and connecting with a patient to keep the door open, instead of closing it.

Recognizing non-adherence is the first step in helping the patient stick with a plan. If noting that a patient’s blood pressure isn’t getting better, the physician should ask an open-ended question like “how is everything going with your medications?” instead of a closed-ended one with a yes or no answer, like “have you taken the medication?” 

The patient is more likely to answer a closed-ended question untruthfully, not wanting to disappoint the doctor, says Douglas Drossman, MD, an internist and gastroenterologist and president of the Drossman Center for the Education and Practice of Biopsychosocial Care in Durham, N.C.  

If a patient says they have not taken their medication, Drossman would avoid making a judgmental response, like “why not?” Instead he would tell the patient that sometimes there are challenges to taking a medication, and asking what the patient sees as pros and cons of taking it. The physician can then help address the reasons why the patient didn’t take it.

Some patients are averse to pills because they remind them they have a medical condition, they’re a nuisance to take, or they’re too expensive, says Wayne Weston, MD, a board member of the Institute for Healthcare Communication and co-author of 

Patient-Centered Medicine: Transforming the Clinical Method.

 He may ask a patient, “what do you think about taking medications for the rest of your life?” It’s a big change for patients who had a heart attack and need four different pills daily, for example. 

Whether accurate or not, patients have their own health explanatory models, where their understanding of their illness or condition is influenced by prior experiences, social or cultural contexts, and this helps them make decisions. If they believe a medication is harming them, they won’t take it.

If a hypertension medication causes erectile dysfunction, they may not take it. They may view it as treating one condition that doesn’t cause pain, but negatively impacting another part of life. Asking an open-ended question lets patients share their reasoning, allowing the doctor to find a different medication or approach, or challenge their view.

A non-judgmental approach that aims to listen to what the patient says can help make the patient feel more comfortable sharing, and not feel they have to please their doctor with the answer.

Offering medical advice without getting the patient’s permission, however, isn’t advisable, says Auguste Fortin, MD, MPH, a New Haven, Conn. internist and past president of the Academy of Communication in Healthcare. Asking permission empowers patients and puts them in the driver’s seat, he says, allowing them to feel in charge. By granting permission, a patient is more open to receiving the information. 

This has an added benefit to doctors, who may feel exhausted trying to get patients on the right path. Fortin recommends that doctors think of themselves as coaches or advisers, offering suggestions and encouragement. “It’s up to the patient, not us, to do the work,” he says. “Sometimes we hold ourselves to a higher position than we should.”

Weston recommends focusing on three things for a successful patient interview during a visit: what the doctor thinks the problem is, what the patient thinks the problem is, and each of their goals. The problems and goals may not be the same, he says. The doctor may realize that the patient’s problem is not going away, so the patient should find a way to comfortably live with it. Ultimately, if the patient doesn’t feel heard, they may not follow the doctor’s suggestions.

A patient will feel heard if the doctor uses reflective listening, reflecting back what the patient said and asking to hear more about it. Showing empathy-sharing the patient’s concerns-is next. 

“The patient needs to know that you really do understand what it’s like for them and that you care for them, even if you totally disagree with them,” Weston says.

Using motivational interviewing techniques, the physician can elicit what would encourage the patient to stick to a plan. Motivational interviewing helps encourage people to make positive adjustments by asking nonjudgmental questions to draw out a person’s reasons for wanting for to change. 

“The patient may be motivated by wanting to fit into a dress, or wanting to look good at the beach,” Fortin says, rather than being motivated by their hemoglobin A1C level. He’ll say to the patient: “that sounds like a good reason to make some changes. What might you be able to do?”

Even if he thinks their proposed changes are inadequate, Fortin supports them fully. “If they’re successful with that, they may want to do something else,” he says. He helps them set a SMART (specific, measurable, actionable, relevant, and time-limited) goal, asking them about contingency plans and when they want to start. 

He also asks how confident they are on a scale from one to 10 that they can carry out the plan. Instead of trying to get them to a higher number, he asks why that number so high and what makes them feel they can make the change. Research shows that if they get to seven or higher, their likelihood of making the change increases, he says.

If they’re under seven, he may ask what it would take for them to increase their confidence level. In addition, he asks how important the patient feels it is to make this change, using the same scale and the same follow-up questions about their choice.

After discussing the patient’s proposed plan and how they’ll deal with contingencies, he asks them to repeat back the plan. “When you say something out loud, you’re much more likely to do it,” Fortin says.

Recognizing where the patient is in their journey is important, too. Patients will only make a change if they’re at the right stage, says Weston. The four stages include pre-contemplation, contemplation, action, and maintenance and identification. In pre-contemplation, the patient hasn’t thought about changing, or decided not to. 

The next is contemplation; the patient thinks it’s a good idea, but recognizes the difficulty. “People can stay in that ambivalent stage for years,” Weston says. In the action stage, the patient develops a plan and begins, though they are vulnerable to slipping back. Next is maintenance and identification, where a patient identifies with the  change. If they stopped smoking, they identify as a nonsmoker, for example.

“It’s important to tailor what you do to the stage,” Weston says. If they’re in the pre-contemplation stage, there’s no point in sharing strategies to quit smoking. Instead you can explain why you’re concerned.

The contemplation stage is the best time to develop strategies. Assessing confidence and interest are good strategies at this point, using the techniques of having the person rate his or her confidence and interest on a scale of one to 10. If a person is confident he or she could quit smoking but doesn’t want to, the discussion could focus on why it’s important.

Sometimes a person doesn’t adhere to treatment because the problem is overwhelming. 

If someone with diabetes has out-of-control blood sugar and lipids, Singer may let the patient choose their biggest concern, or she’ll suggest just one change. She might say, “I’d like to think about starting you on a statin. Are you okay talking about that, or do you want to wait two weeks?” A patient may shut down and not be able to process a lot of information at one office visit.

Singer helps the patient understand the risks in not taking care of themselves. “With diabetes, I’ll say, ‘When your blood sugar is high, you’ll be tired, and your body is inflamed. These are strategies to make you feel better,’” Singer says. 

She tells them if they take their pills once a day and are willing to exercise, they’ll feel better in 4-6 weeks. She may suggest a follow-up visit or phone call. “I don’t care about the interval-I’ll let them have some control about the time,” Singer says.

Another approach is: “I’ve seen people in your condition and they’ve really struggled with this. Then something bad happens like a stroke, and they find a new way of doing things. I’d love to prevent that,” Singer says, and then asks if they think they could commit to a specified plan of action. 

Another negative technique is to try and frighten the patient into changing, by saying “if you don’t stop smoking, you’ll die of lung cancer,” or “your kids will get asthma and it will be all your fault,” Weston says. 

Learning new communication skills isn’t easy. “There’s a sense that I should know how to do this,” Singer says. Organizations like the Foundation for Medical Excellence, the Institute for Healthcare Communication and the Academy of Communication in Healthcare offer courses in communication.

Focus on three things for a successful patient interview during a visit: what the doctor thinks the problem is, what the patient thinks the problem is, and each of their goals.

Communication tips for dealing with non-adherent patients

It’s been a long day. You managed to squeeze in three extra patients-and the only thing between you and the door is a few chart updates. Just as you finish, you are alerted to a new email from what looks like a well-known insurance company, complete with a recognizable logo. You recall your office manager mentioning that this company had recently declined several reimbursement claims. The email refers to you and your office manager by name-and informs you that you can clear up your reimbursement issues if you just click a link and provide some extra information. What do you do?

Many healthcare professionals would click without a second thought-and, in doing so, they might very well be inviting a hacker into their networks via a sophisticated electronic communications scam called spearphishing. These personalized attacks are on the rise in healthcare and can have serious consequences for organizations of all shapes and sizes.

“In today’s day and age, hackers are going after people instead of the technology directly,” says Anahi Santiago, CISM, chief information security officer at Christiana Care Health System in Wilmington, Del. “And the breaches that happen as the result of these attacks not only give hackers access to protected patient data but also the ability to disable networks which, essentially, can disable providers and organizations from being able to effectively care for their patients.”

As noted in Verizon’s 2018 Breach Investigations Report, phishing, a form of cybercrime that uses emails purportedly from a known organization to persuade individuals to provide sensitive data, including passwords or financial information, is linked to more than 90 percent of data breaches-making it the most common attack method for hackers. Parham Eftekhari, executive director of the Institute for Critical Infrastructure Technology, a cybersecurity think tank, says that spearphishing is a more sophisticated form of phishing, targeting a specific organization or individual. 

“With phishing, the hacker doesn’t necessarily care who clicks, he or she is casting a wide net in hopes of getting someone to do so,” he says. “But spearphishing uses a tailored lure-a spear, so to speak-to make the email with those links more appealing to a specific victim.”

In a recent American Medical Association (AMA) survey, 4 out of 5 survey respondents said they had been the target of a cyberattack, with more than half of those stating the attack was the result of a phishing lure. Eftekhari says that is not a surprise-and that providers often are an easy mark for hackers because the healthcare environment is so fast-paced. 

“Physicians are busy and their focus is on helping patients. There’s more and more technology in practices, and that technology can often be frustrating for them,” he says. “So if they do get an email, and it looks somewhat legit, it’s not surprising they might click and download and execute a malicious payload.”

Few medical schools discuss the ins and outs of cybersecurity, even though medical practice has become more technology-intensive-and hacks can affect both patient safety and patient satisfaction. James Kaplan, MBA, a partner specializing in information technology (IT) infrastructure and cybersecurity for the management consulting firm McKinsey & Company, says that providers should be concerned about the consequences. Those consequences may include the theft of protected health data-and the consequent fines from the U.S. Department of Health and Human Services’ Office for Civil Rights-as well as the loss of the practice’s financial data.

But more concerning is the possibility of being locked out of EHRs or medical devices and IT systems that play a critical role in providing patient care. The AMA survey reported that the majority of physicians who had been hacked suffered  up to four hours of downtime, with many reporting they were unable to provide care for an entire day. 

Protect your organization, protect your patients

Leslie Saxon, MD, a cardiologist and executive director at the University of Southern California Center for Body Computing, says that protecting an organization from spearphishing and other cyberattacks starts with education about “cyber hygiene,” or common practices individuals and organizations can undertake to help improve network security.

“It’s hard to create awareness, especially since cybersecurity really is a shared responsibility between providers, clinical and office staff, and even patients,” she says. “That’s why the right education is so important. It’s like handwashing or any other hygienic practice. You have to teach the basics throughout the system in order to be successful.”

The AMA has published specific cybersecurity guidelines for physicians on its website to promote proper cyber hygiene. It also recommends that physicians familiarize themselves with cybersecurity recommendations offered by the Department of Homeland Security. Eftekhari says that provider practices can also benefit from contacting IT organizations that likely have local chapters in their area, like the Healthcare Information and Management Systems Society (HIMSS) or the International Information System Security Certification Consortium (ISC2).

“Cybersecurity can be a challenge for smaller organizations-but that’s no excuse not to practice good cyber hygiene,” he says. He explains that organizations like HIMSS or ISC2 have education materials available that can help educate physicians and their staff, and often hold meetings or seminars to help raise awareness of different cyber threats and how to best deal with them. He says they may also be able to connect your practice with a local expert who can train your staff about appropriate cyber hygiene for a fee.

But Santiago says that practices can adopt cyber hygiene basics before any formal training. She says that provider practices should make sure to keep all network systems patched and updated to help protect them from any potential attacks. Some systems can be set to do so automatically. And she says that maintaining good password hygiene is also critical to success.

“With so many technologies in use, I understand why people want to use one password for a bunch of different systems or keep passwords written on a post-it note somewhere,” she says. “But don’t do it.”

Cybersecurity experts recommend that passwords be difficult to guess-no children’s names or birthdays-and at least eight characters long. Santiago recommends using passphrases so they are easy for physicians to remember but difficult for hackers to crack.  

“For an electronic health record system, your password could be a phrase like ‘I love to care for patients,’” she says. 

But most importantly, Santiago recommends that physicians and clinical staff always slow down and think before they click. “All it takes is one person to click on the wrong link to result in a breach,” she says. 

Kaplan says there are several indicators that an email or social media message may be a spearphishing attack in disguise. He says that emails telling recipients they need to click immediately, or have return email addresses or web links with O’s replaced with zeros or L’s with ones mean that recipients are likely clicking at their peril. If it is unclear whether the message is legitimate, Santiago recommends logging in to the company’s website or to pick up the phone instead of clicking.

She adds that physicians also need to understand that cybersecurity attacks don’t happen just on laptop and desktop computers. Personal and professional mobile devices can also put their networks-and their patients-at risk.  

“Mobile devices are no different than computers. They can be hacked and they can have viruses-many people don’t realize that,” she says. Today, she says, mobile devices often hold more information than desktop computers-and that requires physicians and clinical staff to be vigilant about how they use their tablets and phones. The same guidelines regarding passwords and links apply.

“You really need to guard your phone,” she says. “I like to say ‘treat your phone the same way that you would treat your wallet.’”

What about outsourcing cybersecurity efforts to protect from spearphishing attacks? While many vendors offer cybersecurity solutions, Kaplan says there is often a “security poverty line,” with smaller organizations lacking the resources to hire dedicated information security staff or procure good IT software to support cybersecurity efforts. But with that said, he says that organizations can get some degree of security investment by utilizing cloud-based services.

“When you procure cloud-based services, even if it’s just for your email and calendar, you are also investing in the security infrastructure of the vendor you choose,” he says. “While it doesn’t absolve your organization of responsibility, it does make being more secure less resource intensive.”

There is no one-size-fits-all approach to cybersecurity, but experts agree that good cybersecurity is a community effort. Providers need to make a point of educating and training staff about proper cyber hygiene practices. And as more individuals use their personal devices to interact with EHRs or provide medical information, share those practices with patients, too. 

“This is about changing the culture in your practice to promote cyber hygiene and integrate cybersecurity as part of your values,” says Eftekhari. “This goes beyond talking the talk-physicians need to walk the walk to protect their networks and, ultimately, their patients from spearphishing attacks.”

Hackers are increasingly using targeted attacks that resemble legitimate electronic communications.

Spearphishing: A new cyber threat to prepare for

Transitioning the U.S. healthcare system from one driven by volume to one driven by value could take another 15 to 20 years, experts say. For the independent physician, there is ample opportunity to consider a leadership role in the evolution by joining an accountable care organization (ACO). 

Federally regulated, fee-for-service Medicare ACOs are setting the standards for value-based payment structures nationwide, and participation remains voluntary. In Medicaid programs, 12 states are actively pursuing ACOs, with another 10 states pursuing the option. In the commercial market, all the large payers have their own versions of accountable care with a variety of benchmarks and reimbursement details. About half of all ACO contracts cover commercial populations, according to consulting firm Leavitt Partners.

David Muhlestein, PhD, JD, chief research officer for the consulting firm Leavitt Partners, says there are approximately 1,000 ACOs in existence, with the majority organized around partnerships between hospitals and physician groups. 

Among Medicare ACOs, 30 percent are physician-led, according to the Centers for Medicare and Medicaid Services (CMS). Their collective results indicate quality improvements and notable savings, but value-based models are still evolving. “ACOs are neither super successful nor a disaster,” says Muhlestein.

He says a successful ACO needs three key ingredients:

Acceptance among staff and clinicians with an acknowledgement that the value-driven delivery model requires significant process changes

An understanding of the needs of the population served and the necessary interventions to improve outcomes; and

The ability to track, communicate, and share information across the organization-typically through technology interfaces.

Even though pockets of experimentation exist, by and large, providers are still functioning in a fee-for-service structure, Muhlestein says. It’s not so much an indicator of resistance to the ACO concept, but more a reflection of how they’re getting paid.

Here are pros and cons for primary care providers to consider regarding ACO participation.

In 2017, CMS distributed $780 million in performance payments to ACOs under the Medicare Shared Savings Program (MSSP).In 2016 providers earned $700 million, according to CMS. But ACO participation by itself doesn’t guarantee a bonus.

Muhlestein says about 20 percent of ACOs achieve enough savings to qualify for the extra payments in their first year. Among those in existence for five years or more, about half are sharing savings. 

Practices can earn bonus payments from commercial payers as well, but each payer has its own unique model, he says. The population served, care needs, and even geography can factor into how a commercial accountable care contract might be structured. 

Cigna, for example, reports that its accountable care program generated $424 million in savings from 2008 through 2016, and participating providers have seen a return on investment of 2-to-1.

Linda F. Delo, DO, owner of Delo Medical Associates in Port St. Lucie, Fla., says her practice is a patient-centered medical home and has earned $22,000 in bonus payments from a Blue Cross plan with a 50 percent shared savings model.

She’s also earning shared savings through participation in Palm Beach ACO (PBACO), which ranks as Medicare’s top performer, based on savings. In 2017, PBACO saved the  program $63 million and earned more than $28 million in performance payments. Physician-led, the ACO includes 275 primary care providers and 175 specialists. 

ACOs bring practices closer to patient-centered care delivery.

Performance data for the MSSP from 2012 through 2016 show that providers are achieving average quality scores of 91 percent, according to CMS. Virtually all ACOs have demonstrated continuous quality improvement, says Elias Matsakis, JD, senior partner of law firm Holland & Knight in Chicago. 

And there’s a spillover effect: Practices meeting Medicare’s ACO benchmarks will likely improve care for patients not covered by Medicare. According to Muhlestein, experienced ACOs have been able to change delivery practices, and as they do so, they’re taking on additional value-based contracts. 

“Yes, those bonus payments are great, but if you’re doing it just because you think you’re going to get paid, that’s probably not a reason to join an ACO,” Muhlestein says. “You should be doing it because you believe it will actually lead to better care and a better delivery system.”

Physicians should weigh the pros and cons of participating in accountable care organizations.