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.

Hearing about moonlighting and per-diem opportunities may frequently conjure up images of traveling long distances to go to work. You could be driving to some remote part of your state. You could be hopping on a plane to some far-flung part of the country to cover a hospital or clinic for a few days. That’s how it works, right? Wrong.

How about getting in your car and driving 20 minutes down the road? Or if you live in a big city, walking to work? Yes, it’s very possible to moonlight closer to home if that’s what you want. The great thing about working in this way, is that it’s very much all on you. Currently, there’s a massive physician shortage across the country, especially in the generalist specialties. This is only getting worse with each passing year, and the shortfall is estimated to be over 100,000 doctors in the next decade. That’s a staggering number and obviously has huge implications for physicians’ work choices. Healthcare institutions really need you. So if you are a smart about it, there are a multitude of options to take advantage of this supply-demand mismatch. 

The benefits for physicians are immense. The healthcare landscape and practice environment for doctors is changing at a breathtaking pace, and this is unfortunately reflected in soaring burnout and job dissatisfaction statistics (topping 50 percent overall and climbing for all physicians, according to various reports). Breaking free from the administrative and bureaucratic headaches of regular full-time employment with a sole employer is one way to break the cycle and regain a bit of control and autonomy over your schedule.

I have found that traveling far away and having “mini-adventures” was something that initially tended to suit doctors at the beginning or end of their careers. In other words, those without family commitments, or those who’ve completed those responsibilities. This has, however, changed over the last couple of years, and now doctors at all stages of their career are taking the leap.

For those desiring to work closer to home, if you live in or near a big urban area, you will likely have your pick of the bunch within a small radius. Will you have to be a bit flexible? Of course. Will you perhaps sacrifice a small amount of pay by working in a non-rural area? Probably. But it’s important to remember that setting yourself free by not being beholden to only one place is always worth it, if you do this in a way that returns freedom and independence to your work life.

If you do decide that you can handle long-distance travel, most hospitals and clinics will reimburse you for all travel and accommodation costs. That’s something that should always be worked into your contract negotiations, assuming you make the choice to not go through a locums agency or third-party recruiter.

When you are weighing up your options, always consider the pros and cons of every opportunity, and how your work life will pan out logistically and practically. This will depend on a number of individual factors.

I always advise doctors to be as flexible as possible when making any travel decision, because great lucrative offers can be a game-changer. But the ultimate choice on how far you want to voyage is always yours. 

Suneel Dhand, MD, is an internal medicine physician, author and speaker. He is the cofounder at DocsDox (www.DocsDox.com), a service that helps physicians find local moonlighting and per diem opportunities, bypassing the middleman. Hear him talking about these issues in 

Articles

Many doctors think leaving full-time employment equates to arduous travel, but that doesn’t necessarily need to be the case.

Physician moonlighting doesn’t mean major travel burdens

Navigating the reimbursement landscape can be confusing for physicians because of the number of entities that exert influence on payments. For example, CMS uses the Medicare Physician Fee Schedule (PFS) to adjust Medicare payments, and sometimes these changes can have dramatic effects on doctor pay. Coding changes reward some types of care while de-emphasizing others through how much reimbursement is allowed for each. In addition, the MIPS program is pushing Medicare into value-based care, distributing bonuses and penalties to doctors depending on how well they meet various quality measures. 

Many private payers also use quality metrics, but often, these are somewhat different from those that CMS uses and from each other’s. 

And to top it all off, all these rules can change each year. So what reimbursement trends can physicians expect in 2019? 

For physicians using the “ignore it and hope it goes away” strategy for MIPS, 2019 might provide a rude awakening as bonuses and penalties based on 2017 claims data go into effect. “The concept of MIPS will not go away, and even if it did, it would just be replaced by something similar,” says Anders Gilberg, MGA, senior vice president, government affairs, for the Medical Group Management Association. “It is one of the few bipartisan-supported concepts in healthcare today.” 

The payment adjustments for this year are relatively small-2 percent is the maximum bonus and 4 percent the maximum penalty, depending on how a physician did on the performance measures in 2017. While that might not have much effect on a practice’s financial situation this year, those adjustments are scheduled to increase to 7 percent in 2021 and 9 percent in 2022 and beyond. “Practices have the opportunity to receive a higher increase in 2021 than previous years based on what they do in 2019,” says Gilberg. “But they could also see a significant penalty.” 

CMS reported that 93 percent of MIPS-eligible clinicians earned a payment bonus for 2019, but 2017 was a “pick your pace” year to introduce physicians to the program. As performance measures change-and cost containment becomes a bigger component of the score-fewer physicians are likely to qualify for a bonus, especially those not actively monitoring their progress.

“Practices should try to get good advice on how MIPS is going to affect them,” says Mark Friedberg, MD, MPP, senior physician policy researcher for the RAND Corporation. “It is a very complicated and changing payment model.”

Private payers and physicians are always haggling over reimbursement rates, and 2019 will be no different. But as the market on both sides continues to consolidate, smaller practices may find it more difficult to negotiate for the rates they desire.

From an insurer standpoint, the overall pie to pay physicians, hospitals, and other providers is fixed, says Mark Dietrich, CPA, member of the National Society of Healthcare Business Consultants. “The largest portion of the pie goes to provider entities that have the greatest amount of negotiating leverage. Smaller practices get what’s left.” 

Larger entities can not only negotiate better fee-for-service rates, but also more lucrative quality incentives for value-based care contracts, he adds. Physicians should expect the reimbursement challenges for small practices to continue. “Government policy is really designed to loosen the regulatory restriction on providers coming together,” says Dietrich. “The whole idea is that if they get more integrated provider groups along the continuum of care, they will get better data, better clinical options, and better outcomes.”

The result is that larger practices or those affiliated with health systems can extract significantly higher rates than small, independent practices, according to Dietrich. “It’s all about who has the biggest piece of the pie,” he says. “Like on the savanna, the big lion gets the most and the hyena gets what’s left.”

Small practices can help themselves in negotiations by having strong data that proves they are improving outcomes for patients, as ultimately, this lowers a payer’s costs. Experts agree that practices can expect to see more demands for data from CMS and private payers as the march to value-based care continues.

“Carriers are doing deals that generally reward physicians in value-based contracts, but minimize reimbursement increases if they are not involved in value-based benefits,” says Ken Goulet, former executive vice president of Anthem Inc. and current board member at OODA Health, which focuses on streamlining interactions between payers and providers. While he says fee-for-service won’t be completely eliminated, doctors can expect to see diminishing reimbursements in 2019 and in the future.

“Fee-for-service is going to last for a while, but it’s becoming less preferred by carriers,” says Goulet. “In 15 years, it will probably still be here, but there will be significantly higher levels of contracts in value-based care. Anyone still doing fee-for-service will find reimbursement not increasing much, so it will be less and less beneficial to be in those contracts.”

The challenge for primary care providers is that every payer has its own version of what value-based care looks like, with different measures for evaluating quality, outcomes, interaction with other physicians treating the same patient, and efficiency, says Goulet, adding that one model insurers favor is the Patient-Centered Medical Home (PCMH).  

“It’s fair to say that a primary care physician or primary care practice can increase earnings by 25 percent in bonus payments if actively engaged in PCMH,” says Goulet. “It allows them to increase quality, improve outcomes, and lower costs, therefore triggering bonus payments.”

The appeal to insurers is to identify patients with chronic conditions and pull them back into primary care practices, which can help them manage their conditions, says Goulet, who notes that it isn’t uncommon for insurers to have patients who visit the emergency department 35 or more times a year. The PCMH model was put in place not only to drive better outcomes, but provide smaller primary care practices a way to thrive in a value-based care market, so he says to expect continued emphasis on this and similar business models. 

While government policy may encourage provider consolidation, private payers don’t necessarily favor it, especially if small practices can work with them to improve outcomes. “Payers do prefer independent practices, and feel that working with them can keep costs down,” says Goulet.

Reimbursement in 2019 and beyond will require an increasing reliance on data from primary care practices proving to payers that they are meeting performance measures. “Reimbursement models will become more complex and also involve more and more measures,” says Friedberg. 

CMS created quite a stir in 2018 when it proposed consolidating E/M levels 2 through 5 into one payment rate. After listening to concerns from medical associations and others, the merging of payment levels has been delayed to 2021, and as currently proposed, will collapse levels 2-4 into a single payment rate, while retaining level 5 as a separate rate. 

“If equating a level 2 visit with a level 5, it could create a disparity in reimbursement for those with multiple chronic conditions,” says Gilberg. Part of the reason behind the delay was the short timeline between the final rule announcement and when it would have to be implemented.

 “It would be nearly impossible for all the software systems and EHR and payment vendors to get this up and running,” says Gilberg. So for now, E/M reimbursement levels remain unchanged, but expect to see further debate on what collapsing levels 2-4 would mean to physicians, says Gilberg.

Another significant PFS change for this year is the addition of codes for virtual check-ins, allowing physicians to bill for some evaluations done over the internet or phone. “It’s a little wonky in the sense that they don’t call it telehealth, but it is telehealth,” says Gilberg. “If physicians can now bill for the time spent talking to patients on the phone or internet, that will help alleviate the time taken away from other patients. From a financial standpoint, it allows reimbursement for common communications with patients.”

Nancy Enos, FACMPE, a professional coder, says physicians need to find out if their private payers will reimburse for these new codes. “Having the codes added to Medicare is a good first step, but it remains to be seen what private payers will cover them,” says Enos.

CMS may be adding new codes for remote consults, but Enos points out that physicians will miss out on many 2019 reimbursement opportunities if they don’t focus on the codes already in place, such as those for transitional care management (TCM) and chronic care management (CCM).

“Some docs use them, but don’t use them well,” says Enos, noting that common mistakes include not documenting patient discharge dates or noting phone calls within the required 24-hours of discharge. “If you are not using these TCM and CCM codes, you are really missing the boat on getting good reimbursement for time when you are not face-to-face with the patient.”

Another frequently-lost opportunity is the Medicare annual wellness visit. Enos says doctors often can bill for both the wellness checkup and for dealing with a chronic issue in the same visit provided they document it properly. “For some doctors, these extra codes are seen as either too much work, they don’t understand the details, or they think it’s only for a few extra dollars,” says Enos. “But those dollars add up.”

Enos says successfully capturing all the reimbursement a physician is eligible for requires a commitment by the entire office staff. “Assign a nurse to look at the patients who are due for physicals and coordinate screenings and the annual Medicare wellness check,” she says. “Call those that are overdue for appointments. Another person should be in charge of tracking patients that are in and out of the hospital and documenting what’s necessary for the care management codes.”

She advises starting with one code and working it into the office workflow. “If you say you are suddenly going to start tracking everything on Monday, by the end of the month, it’s all going to fall by the wayside,” says Enos. “You need some sort of reasonable, planned deployment to succeed.”

As Medicare moves toward value-based care and private payers add more incentives focused on outcomes, data becomes increasingly important for a practice’s reimbursement outlook.

Physicians in the MIPS program must track and submit data on a dizzying array of measures, and many private payer contracts have similar metrics that require data as the proof point. If a practice does not have the data to prove patients are achieving desired outcomes, reimbursement can take a substantial hit-up to 9 percent from MIPS alone by 2022. Combine this with private payer contracts that continue to incentivize value-based outcomes, and a substantial part of practice reimbursement could be endangered by a lack of performance data, experts say.

Accumulating and analyzing this data can be expensive, notes Ken Goulet, former president of Anthem Inc. and current board member at OODA Health. Consequently, Goulet says, doctors can expect to see more companies helping independent practices navigate the changing reimbursement landscape for negotiation and technology-support purposes, and  insurers investing more in helping practices acquire and evaluate their data.

Goulet adds that another change practices may see as early as this year is more customized arrangements for primary care, based on region or even ZIP code. “Carriers are all going to more cloud-based capability and moving away from significant legacy software systems to pay claims,” he says. Once implemented, these systems will allow for flexibility in value-based contracts, faster payments, and easier interaction between providers and insurers.

Here are the reimbursement trends physicians can expect in 2019.

Getting paid in 2019 

Lowering the cost of a medical education 

Few would disagree that the cost of medical school is high as Aaron George, DO, explains in “We must address the rising cost of medical school” (The Last Word, November 10, 2018 issue).

But, as an alternative, why not combine medical school and college into a five-year program instead of the traditional eight? After all, much of what is learned in college is of questionable value for practicing physicians, especially those in primary care.

I remember sitting in my organic chemistry class and wondering what organic chemistry had to do with being a doctor. Not to mention calculus and physics; and trying to understand the Krebs Citric Acid cycle.

While browsing in a bookstore ­recently, I pulled an MCAT prep book off the shelves and paged through it. The questions about osmosis, semipermeable membranes, osmolality and the Krebs Citric Acid Cycle were still there.

Now after 43 years of practicing primary care I wonder even more.

In 1910 the Carnegie Institute commissioned Abraham Flexner to investigate medical school education. He was appalled at the lack of full time teachers with any scientific knowledge.

His report sparked a revolution in medical education. The result was an over-emphasis on basic science and full-time professors. But, years later Flexner lamented that medical schools had gone too far in their focus on science. Which may explain the why so many students take residencies in specialties and so few in primary care.

If the costs of medical education are worrisome, the overemphasis on science is just as worrisome. It’s not a matter of education, it’s a matter of common sense.

Nurse practitioners are critical providers of patient care

Your article (“The value of nurse practitioners to medical practices”, August 8th) correctly cited the number of nurse practitioners (NPs) is on the rise. While more patients are choosing NPs as their provider, conducting over a billion visits annually, the article misses the mark on a handful of key points.

NPs have been providing primary, acute and specialty care to patients of all ages and walks of life for nearly half a century. NPs’ abilities to assess patients, order and interpret diagnostic tests, make diagnoses, and initiate and manage treatment plans, including prescribing medications, make us neither mid-level nor an extension of our physician colleagues, rather a critical provider of patient-centered care.

Second, the assertion that NPs merely exist to free up time for doctors undermines the value that NPs bring to health care cost management. Numerous studies have documented that patients seen by NPs have lower readmission rates and are more likely to adhere to plans of care-two important factors in bending the cost curve and improving the quality of life for patients.

Lastly, there was no mention of the prevailing trend of states which have modernized their scope of practice laws to allow NPs to practice to the fullest extent of their licensure and training. As evidenced in recent analysis, nine of the top 10 best states for health care (as measured by outcomes, costs, and accessibility) have enacted such laws, known as full practice authority (FPA). Interestingly, nine of the bottom 10 still limit patient access to NPs by keeping collaborative agreements and other restrictive measures in place.

While we appreciate the interest in gaining perspective on the value of NPs to medical practices, it is these facts which matter most to your audience and patients alike-especially when considering choosing an NP for primary care. 

Joyce M. Knestrick, Ph.D., C-FNP, APRN, FAANP

President, American Association of Nurse Practitioners

Editor’s note: This was first published in the December 10, 2018, issue of 

 It contained errors and this is the corrected version.

Your voice: Lowering the cost of a medical education

Russell Libby, MD, selected his EHR system because it has the features and functions that best fit the needs of his practice.

He worries, though, that the features that make this EHR work so well for him and his practice colleagues could be eliminated if his EHR vendor merges with another-as so many other vendors have done.

“Not enough doctors pay attention to what’s happening with healthcare technology. But there are some who are worried, and they’re worried because they’re aware of the ramifications,” says Libby, president of the Virginia Pediatric Group and a board member of the Physicians Foundation.

Libby’s concerns are well-placed. The number of EHR vendors has dwindled in recent years following numerous mergers and acquisitions, dropping from 1,000-plus 10 years ago to approximately 400 now, according to KLAS Research, an Orem, Utah-based health IT review firm.

Libby and others say they expect more vendor consolidation in the future, a fact that could leave physicians with a host of problems, such as reduced levels of tech support, increased fees, and the need to migrate to a new system.

Health IT experts say physicians should keep an eye on EHR industry news and take steps to safeguard themselves to ensure practice continuity should their vendor merge with another.

“There’s only so much a practice can do about vendor consolidations, but physicians can be vigilant and make sure they do all they can to protect themselves and their practice. What they don’t want as a practice is to be unprepared and not know what their options are,” says Robert Tennant, MA, director of health information technology policy at the Medical Group Management Association.

The EHR market expanded rapidly in the past 20 years, with technology advances and government incentives spurring physicians and healthcare institutions to move from paper-based to electronic records. The percentage of physicians using EHRs jumped from 18 percent in 2001 to 57 percent in 2011 to 87 percent in 2015, according to the Office of the National Coordinator for Health Information Technology (ONC).

ONC figures from 2017 show that most physicians – or 64% -- use one of seven major vendors; Epic Systems Corp. and Allscripts lead the way with about 33% of the physicians as customers. 

But tens of thousands of physicians use EHRs from other vendors, from well-known makers such as Practice Fusion and eMDs to dozens of niche companies that cater to the unique needs of medical specialists or small independent practices.

However, consolidations in recent years have shaken up the market, as various vendors bought up others to gain market share, break into specialty practice areas or bolster their financial prospects, says Aaron Gleave, director of research for the ambulatory market at KLAS Research.

Much of the acquisition activity has involved small EHR vendors being bought up, but plenty of mid-size and larger vendors were acquired as well. For example, health IT vendor eMDs bought several tech assets, including EHRs, from McKesson Business Performance Services in 2016. And in 2018 Allscripts acquired Practice Fusion for $100 million.

Joel White, executive director of Health IT Now, a nonprofit group promoting the use of information technology in healthcare, predicts more consolidation in the future. He says EHR vendors are seeing fewer customers needing new implementations, as most physicians and healthcare institutions have EHRs by this point.

As a result, vendors are looking for other ways to grow their customer base and revenue streams while positioning themselves to compete. White says vendors are looking at acquisitions as one strategy to reach those objectives.

Gleave, White and others say small EHR vendors and those servicing niche markets are most likely to be targeted for acquisition, as they typically are weaker financially than the larger players in this market. But industry experts say even major EHR vendors could be bought by even larger companies within the health IT space as well as by large companies outside it.

“Everyone is making acquisitions of some kind, whether they’re adding additional EHR players to their portfolios or acquiring companies that would be considered ancillary products as a complement,” Gleave adds, explaining that an EHR vendor may see a strategic advantage to buying a company that makes patient outreach systems or a revenue management software vendor may want to buy an EHR vendor as a way to grow marketshare.

Many physicians are nervous about these market dynamics because they fear that consolidations could negatively impact their practice.

Physicians could see changes to the monthly fees charged by their vendors and tech support levels, Gleave says. Worse, they could see their EHR system phased out, forcing them  to migrate to another product.

Libby says some physicians worry that the functions they like in their existing EHR could change and that the niche offerings within their existing EHR might disappear. “That could really impact [the practice] and create some significant long-term problems,” he says.

Gleave says mergers among EHR vendors do not always lead to problems for the physicians using those systems; he says many vendors work hard to take care of their customers before, during and after the consolidations. However, he adds, even if a transition between vendors goes smoothly for a physician, such mergers still generally result in some changes to the EHRs, service level agreements, and fees.

Although physicians can’t stop consolidations, they can take steps to limit the potential for negative impacts to their own practices.

Gleave says physicians should have a good handle on their data –where it is and how to transfer it. “Make sure your data is ready to grab and go. Know very specifically what the process is to migrate your data from your existing vendor to another-what’s the timeframe for the work, what’s the cost, and what format is the database in,” he says, noting that each vendor has its own procedure and associated costs for transferring the data.

He says EHR vendor contracts typically spell out this information, so physicians should start by reviewing their contracts (on their own or with a lawyer) and then discuss with their vendor any details that remain unclear.

White says the federal 21st Century Cures Act, passed in 2016, could provide some help. He says the law incents vendors to make it as easy as possible for physicians to export their data out of the vendors’ systems-although other health IT experts say they’re not sure this new law will do much to reduce the challenges or costs of transferring data.

Gleave says physicians should have a list of a few vendors with products that could fit their needs so they can move quickly if they must find a replacement.

Meanwhile, physicians who find themselves with a vendor being bought by or merging with another should contact their vendor immediately to ask several key questions, Tennant says. These include how the merger will proceed, the timeline for consolidation, and what support the vendor will provide during any transition from one EHR version to another.

In addition, they should ask how fees, service and support will change as well as what features, functions, templates and other user interfaces could change and when. And physicians should work with their existing and new vendor representatives to determine whether changes resulting from the merger would impact any of the new EHR’s integration with other systems.

White says mergers among EHR makers could bring many positives to physicians. “When I think about vendor consolidation, I’m thinking about products becoming more usable, more functional and more customer friendly,” he says.

He says the consolidations could yield economies of scale for vendors, giving them more capital to invest in developing innovative capabilities. He predicts vendors will want to focus more on developing additional functions and more user-friendly features to better compete in the marketplace moving ahead.

“The vendors will need to compete in delivering value,” he adds, noting that as EHR vendors have seen a drop in the number of new customers implementing EHRs for the first time they now must compete on better usability to retain and attract customers.

Libby, too, says market consolidation could yield benefits such as increased interoperability among physician office systems as there will be fewer systems with unique integration requirements. 

But Libby says consolidations could bring challenges for physicians. Physicians who have to switch to a new EHR as a result of a consolidation may face unexpected costs as well as lost productivity as they learn to navigate a new system-both of which are particularly hard blows to small practices struggling to survive financially. And physicians could lose the strong relationships that they built with their vendors, should they be acquired by bigger companies. 

Those negative impacts could hurt practices, Libby says. “Those ripples [from EHR consolidation] can become waves that overwhelm practices,” he adds.

Gleave likewise says market consolidation could hurt practices, as acquiring EHR vendors could raise fees, change service levels and eliminate features that individual physicians rely on.

“Support is a big concern, particularly for small practices. They don’t have deep pockets and they feel vulnerable in the marketspace,” he says.

Libby also says there’s the possibility that market consolidation could lead to near monopolies, which have traditionally meant lower levels of innovations and higher rates charged to customers.

“That’s a fear that many of us have,” he says.White, too, says he sees potential for consolidations to create difficulties for physicians, such as when their EHRs are discontinued following mergers. White says the government entities should oversee consolidations to ensure such scenarios are kept in check and to ensure a near monopoly doesn’t emerge in the EHR market.

“There’s no guarantee that this will all be positive; I think there’s risk of harm to the consumer with consolidation. That’s why we need oversight,” White says. “But my expectation is we’ll see a lot more innovation as a result and that’s good for doctors and, more importantly, it’s good for patients.” 

What does the shrinking market mean for physicians?

EHR market consolidation and the impact on physicians 

Obesity, whether it’s on the list of medical concerns or a stand-alone appointment, is difficult for physicians to treat during the 15 minutes or so allotted for primary care visits.

Even with time constraints, it’s possible for primary care physicians to compassionately and effectively guide patients in decreasing their weight. Weight loss experts say obesity should have a treatment pathway in primary care settings like what was developed for smoking cessation and depression. Given the multi-factorial treatment approach, the key is individualizing care. 

An estimated 39.8 percent of U.S. adults over age 20 have obesity, with another 31.8 percent considered overweight, according to the 2015-2016 National Health and Nutrition Examination Survey. Obesity increases the risk for many medical issues, including hypertension, diabetes, sleep apnea, cardiac disease, arthritis, hyperlipidemia, and certain cancers. The U.S. spends approximately $190 billion annually, or 21 percent of healthcare dollars, on obesity and related conditions. 

“We need to start treating the largest disease in our country, as all other health issues go along with it,” says Craig Primack, MD, board certified in internal medicine and obesity medicine, and co-founder of the Scottsdale Weight Loss Center in Arizona. 

The first step is combatting two major false assumptions that many physicians and patients often have. They are that weight loss is a matter of “calories in, calories out” and that obesity is only due to patient behaviors, says Rekha Kumar, MD, assistant professor of medicine and attending endocrinologist at the Weill Cornell Medical College in New York City. 

The American Medical Association declared obesity a disease in 2013, but many doctors still don’t appreciate that and rely on stereotypes that patients with obesity are lazy or lack self control. 

Decreasing weight is more than just changing diet and exercise routines. While there may be a behavioral component, Kumar says “there are things that go wrong in the body that perpetuate weight problems. There is significant appetite dysregulation with hormones and neurotransmitters.” 

There’s no room for judgment when it comes to treating obesity, Primack says. “I take care of people who go to the gym five or six times a week and run marathons, and still have weight problems,” says Primack. “You don’t say a person with cancer is cancerous. A woman has obesity, she is not obese,” Primack says. 

Understanding obesity genetics is important for understanding how those with obesity issues may differ from those without. Hormone levels involved in body regulation signal if a person should be full or hungry, and these may not function properly in patients with obesity. Primack notes a landmark 2011 

 study measuring hormones related to weight. In the study, diet-induced weight loss changed the levels of hormones regulating weight. In the year after losing the weight, the subjects’ bodies used less energy and their appetites increased, resulting in weight gain. 

Genetics also affect the body’s ease in losing weight. Since human bodies are programmed for survival, Kumar says, the brain’s setpoint remembers a person’s highest weight. When the person loses weight or burns too many calories, the brain perceives intense hunger and stores fat to survive.

“The human body is not engineered to lose weight,” says Angela Fitch, MD, board certified in internal medicine and obesity medicine, and associate medical director of the Massachusetts General Hospital Weight Center in Boston. “If you’re trying to lose weight, you’re trying to be abnormal. It’s normal to gain weight.”

Primary care physicians don’t have to know everything about body regulation, says Kumar, but they should bring up obesity without blaming the patient. When approaching patients, experts recommend applying the five A’s used for smoking cessation to obesity: ask, advise, assess, assist, and arrange. This gives physicians a framework to work from.

Start by asking the patient if obesity is something they are interested in talking about. Even if the patient isn’t interested, it plants the seed for the future. The doctor can advise the patient on how much weight they recommend that the patient loses, and on the importance of exercise and diet. They can then assess whether the patient is interested in losing weight. The doctor can assist the patient by asking if they want to see a nutritionist or schedule time to come back to talk in more depth, and arrange follow-up with the primary care office or with a referral.

Some physicians are concerned about upsetting their patients, Fitch says. But “people want us to ask about it,” she says. “We just don’t, because we think they’ll be offended.”

After calculating the patient’s BMI, physicians can tell patients if it’s in a range that could contribute to their medical problems. She also brings up genetic and hormone connection to weight gain, and tries to find an appropriate balance between presenting medical information and addressing lifestyle factors. 

Fitch encourages primary care clinics to come up with a treatment model that can be individualized to each patient. The patient chart should contain an action plan, showing what the patient will do to increase physical activity. The doctor can provide a handout with nutrition options, which can include meal replacement plans using information from the Look AHEAD study, or recommend a commercial plan like Weight Watchers. The physician can also prescribe anti-obesity medication. “If every primary care practice had that at a basic level-a handout, medication, and follow-up-that would produce significant results,” Fitch says. “There are 2,500 board certified obesity medicine physicians, and 98 million Americans with obesity. Each one of us would have to care for 32,000 people. Some of the care has to be delivered at a different level.”

A primary care physician likely won’t provide all nutritional counseling and behavior support for obesity, but can track height, weight, and BMI, and encourage patients to maintain a healthy weight. It’s appropriate to suggest a three month trial of lifestyle interventions, says Kumar. Treatment can and should involve healthcare extenders, as the physician likely won’t have time to offer the needed education, accountability, and program structure. Referrals to a specialist are an option as well. 

Treating obesity is like treating other chronic diseases. Different treatments are used until the right one works. Starting treatment with a primary care physician, and then escalating treatment to a specialist is appropriate, just as is done with diabetes, depression, and cardiac health. Obesity is something that should be addressed at every visit, but doctors should schedule separate appointments for treatment and follow-up if more time is required. 

“We need to eat differently,” says Tom Campbell, MD, board certified in family medicine and the medical director of the Weight Management and Lifestyle Center at the University of Rochester Medical Center’s Highland Hospital. 

He advises patients that food is essential to their health, and if they eat the standard American diet, they will not lose weight, as the food is calorie dense, and eating less of it will not be filling enough. “The idea of eating less has been overplayed. We need to eat different foods, whole natural foods.” As long as the patient sticks to mostly whole, unprocessed foods, it doesn’t matter which specific diet a patient chooses, be it Atkins, low-carb, Paleo, or vegan. “There’s a lot more consensus in nutrition than people realize. The guidelines from established organizations are to eat more fruit and vegetables and less processed foods,” says Campbell. Weight loss diets fall along the spectrum, from processed American foods at one end, and plant-based foods at the other end. Other diets are all gradations along the spectrum.

Though he says a plant-based diet is best, he recognizes that some people have life-long eating habits that are socially and emotionally related. The nutritional plan should meet people where they are, or patients are less likely to change.  

“The key is not which diet works. All diets work. It’s which works for [the patient], that’s the clincher,” says Fitch.  

Exercise does not produce weight loss, Fitch says. It is important, though, and should be enjoyable, as the patient should maintain some form of physical activity during and after losing weight. Doctors can suggest different types of exercise that might appeal to the patient, whether it’s walking, a group fitness class or swimming, for example. A patient may find motivation using a fitness tracker, counting steps, or by enrolling in a race and training for it.

Activity only accounts for up to 20 percent of weight loss, says Primack, with dietary changes accounting for the rest. Once the weight is gone, however, the metabolism slows down, so continuing to exercise is an important part of weight maintenance. Primack says that lack of exercise accounts for half of weight regained. The Look AHEAD study, which followed 8,000 subjects for eight years during and after initial weight loss, shows that those who successfully maintained a 10 percent weight loss reported “significantly more” physical activity than those who regained weight.

Learning a person’s triggers for eating too much or eating the wrong foods is another element in tackling weight loss. People feel bad if they don’t have the willpower to avoid food, like the contents in a bowl full of candy, says Fitch. “It’s normal not to be able to avoid it. That’s why controlling the environment is important for people trying to lose weight,” she says. The Look AHEAD study demonstrates that by providing more structure, patients can lose more weight and maintain it. That can include meal and snack replacements, as studies show that using them helps provide structure, so patients can sustain longer term weight loss. Otherwise they underestimate the number of calories in their food, and making food choices is difficult. The study also recommends providing the patient with a shopping list and detailed menu plan, which adds structure to help control their environment. Regular group and individual meetings with a lifestyle counselor provide structure, as did weekly physical activity goals, to exercise a certain number of minutes per week. Patients were also advised to record their daily food intake and exercise time. Physician can help their patients set up structures like these to help them stay on track.

Behavioral-based interventions were shown to significantly improve weight levels and type 2 diabetes in a September 2018 report by the U.S. Preventative Service Task Force, compared to the control group. Combining behavioral interventions with anti-obesity medications, however, yielded greater weight loss and maintenance over 12-18 months than just behavioral interventions.

Medications are indicated when a person’s BMI is 30 or higher, or 27 or more with related comorbidities, such as high blood pressure or diabetes. The medications can help patients lose 5 percent to10 percent of total body weight in most cases, says Kumar. “Most Americans that have obesity need to lose more than that,” Kumar says, which is one reason the drugs are not frequently prescribed. 

With medications alone, 60 percent of patients will lose more than five percent of their body weight, says Fitch. Adding them to the treatment paradigm with behavioral actions further improves weight loss.

Prescribing anti-obesity medications is appropriate for primary care physicians, but data doesn’t show they’re comfortable doing so, Kumar says, noting barriers like lack of medication education, high cost and lack of insurance coverage, and doctor and patient assumptions that medications are unsafe or a crutch.

The idea that medications are a crutch is an antiquated way of thinking, considering the science behind them, says Kumar. Pharmacotherapy is not a cure for obesity, but an ongoing treatment for a chronic condition. Once the patient stops taking the medication, their appetite will return.

Less than 1 percent of eligible patients are prescribed anti-obesity medications. Insurance typically does not cover them as a standard treatment and only 30 percent of employer health plans cover these medications, Fitch says.

Bariatric surgery is reserved as the last stage in the weight loss journey. It’s been shown to have a dramatic benefit in weight reduction, quickly resolve diabetes, and also reduce cancer risk. “It’s pretty effective for weight loss and related chronic diseases. There’s absolutely a place for surgery for people who can’t or won’t change diet and lifestyle,” Campbell says.

Even with time constraints, it’s possible for primary care physicians to compassionately and effectively guide patients in decreasing their weight.

Treating obesity: How to individualize care 

The new year brings new health plans, often with higher deductibles, and old bills that patients may be struggling to pay. According to 2018 data compiled by MedData, 83 percent of physician practices with fewer than five practitioners reported that their top collection challenge was slow payment among high-deductible plan patients.

In this landscape, physicians may have to get creative in order to increase their revenue. Experts suggest that the more payment options physicians offer their patients, the better the chance that bills will get paid. 

Patients are growing accustomed to an Amazon-like consumer experience, where they can click on a link and pay in an instant, ideally from their mobile phones, according to Deirdre Ruttle, vice president of strategy, for InstaMed, a healthcare payments network in Philadelphia, Pa. 

“We live in an always connected world. According to research, 75 percent of adults are online daily, and one in four adults report being connected all the time,” she says. 

Technology has made paying for goods and services incredibly convenient, Ruttle says, with options such as digital wallets, e-statements, and text reminders to pay balances owed, but it’s also increasing consumer demand for a variety of payment options.

The MedData study also found that 68 percent of consumers would prefer to pay their medical bills electronically, and 92 percent want to know what their patient responsibility is in advance of service.

As a result, Ruttle says, “Physicians should give patients multiple options with payment channels and payment methods so that you can really meet patients where they already are.” 

Assess your patients’ financial health

In order to determine what options to offer, physicians should adopt some tools for assessing their patients’ fiscal health, according to Kevin Fleming, CEO of Loyale Healthcare, a healthcare technology company in Lafayette, Calif.

Fleming breaks this assessment down into a series of measures:

“When patients aren’t paying, they’re already communicating strongly to you, in very real terms, that there’s a problem.”

And rather than treating that problem as a hassle, Fleming encourages physicians to work with the patient, because this can lead to a greater likelihood of receiving payments and a better patient experience. “The patients’ financial experience should be as good as, or even better than the clinical experience.”  

To streamline the process as much as possible, David Shelton, CEO of PatientMatters, a patient collections company in Orlando, Fla., recommends that all payment solutions be standardized and consistent. He recommends scripting conversations in advance so that front desk staff can engage easily with patients, and employing some sort of analytics or measurements on payment methods to see which ones are working best.

“It can all be incorporated into one presentation and the patient will have full satisfaction with the overall experience, not just the clinical side,” Shelton says.

When determining which payment methods to offer, physicians should consider that affording healthcare costs is not just a problem for the low-income, says Mark Spinner, president and CEO of AccessOne, a patient finance company based in Charlotte, N.C. “The majority of the country has a [healthcare] affordability problem now. People with jobs, with families, with mortgages and auto loans, people who are credit worthy.”

AccessOne is among many companies that offer “co-branded, personalized financing,” much like a store brand charge account that a person might get at Home Depot or Nordstrom. 

These accounts work much like a credit card, so physicians see their revenue, and the patients can pay down their balance in the ways that work best for them. 

There are multiple kinds of accounts, too within this framework. “Some accounts are built as part of deductible plans, some are built for catastrophic balances, some are built for partial charity or partial financial assistance recipients. Those different programs help the provider deliver a positive payment alternative for every patient that walks through their doors.” Patients can even obtain plans that offer zero interest for a set rate of time and the option to pay off their balances as needed.

Many physician practices offer standard payment plans, which Fleming says are only moderately successful in obtaining revenue.

He has seen physicians be successful with a prompt-payment discount for paying within a certain time frame. “You’d be amazed at what a simple discount of 10 to 20 percent will do to the psychology of the whole transaction,” Fleming says. “The patient is getting additional cash back in their wallet.”

A more common model is to break a bill down into monthly payments over a time period, such as a year, but there is still a financial risk to the physician.  He says that sometimes physicians have to be willing to increase the length of payment time. “When the patient just can’t afford say $200 per month, they might need three-year financing on something like an emergency room visit or cancer [treatment].” 

Additionally, he says, allowing patients to set the payment parameters can lead to better results, within reason. “When patients self-construct plans, selecting an amount and the period that works for them, they’re able to keep up their end of the bargain and pay.”

Another option is to pre-pay before a large and planned medical cost, such as childbirth or a big equipment purchase like hearing aids, according to Leonard Wenyon, BSBA, vice president of IKS Health, a practice management consulting company in Newark, Del.

Then, when the baby is born, or the equipment comes in, the patient doesn’t owe anything. 

If none of those options bring in prompt payment, Wenyon says, physicians can consider outsourcing to a collection agency.

When the patient’s deductible is extremely high, or if they don’t have insurance, Wenyon recommends physicians consider offering some basic services at a flat rate. “You tell the patient ‘this is the rate we expect at time of service.’”

He took advantage of such an opportunity while on vacation in Hawaii, when his daughter became sick and the local hospital did not take his insurance, but did offer a flat rate. The advantage is that the patient knows what they’re paying up front, and once it’s paid, there’s no bill to collect on. Sometimes, he says, commercial insurance or Medicare will cover it retroactively.

No matter what payment options a physician offers, front desk staff will play a crucial role in making them work, Ruttle says. “There is a great opportunity for providers to bring those financial conversations up at the beginning of the encounter, not the end,” she says.

She says taking the taboo out of talking about money up front helps to eliminate some of the fear and confusion that is so prevalent in healthcare payments today.

This requires training front desk staff to become comfortable talking about money and getting some form of payment at the point of service. It doesn’t have to be awkward, Ruttle says, comparing it to the experience of checking into a hotel, where the consumer knows in advance that they’ll have to provide a credit card upon arrival, but will only be charged for specific things. 

Fleming says patients want to feel cared for not just from a clinical aspect but from a financial aspect, too. Having these conversations when the patient checks in, he says, allows the patient relief from the financial stress or burden, and helps them focus on their clinical care they’re seeking. 

Shelton says that just asking patients about obstacles to paying has led to his clients’ point-of-service collections increasing by as much as 20 percent. 

“Our experience is that most people truly want to pay their bill,” Shelton says. “The challenge has always been whether the healthcare provider will have the conversation with them at the very beginning, taking into account their financial challenges or opportunities.”

If physicians are worried about the costs of adding any of these payment options to their EHRs or practice management software, Ruttle points out, “The overall cost is a very small percentage of what bad debt looks like. The return on investment (ROI) is very strong.” She recommends that physicians who feel overwhelmed by choices start with an online payment portal and e-statements and phase in other options over time.

Patients use smartphones for so many purchases it only makes sense that they want to pay for their healthcare that way. Now that patients are also shouldering a greater burden of their healthcare costs, the pressure is mounting on physicians to offer mobile and online payment options. 

Probably the easiest method for most practices is to create a payment portal to the practice management system, either accessible via the web or through a patient’s mobile device, says Craig Cooper, product manager for AdvanceMD, a medical practice management and EHR company out of South Jordan, Utah.

“This gives them the opportunity to receive a text saying they have a balance due and go make that payment.”

“When we offer more convenience to a patient, the more the patient will participate,” says Paul Gordon, manager of business development for Micro Office Systems in Cleveland, Ohio.

Gordon recommends that physicians take advantage of some form of online payment service, whether an app or a patient portal. “Whatever you use-the Square app, PayPal, or a bank’s basic shopping cart function, use it. You have to have a 24-hour, 365 day availability to take a payment in this day and age.”

However, the kind of mobile app or payment portal should be thoughtfully considered, Gordon cautions. “We recommend a tight integration between your payment app and your practice management system.”

Saya Nagori, MD, an opthalmologist in private practice in Bowie, Md. and CEO of Simple Health, a telemedicine platform for vision exams and birth control evaluations, sees the lure of cash payment apps. “The pro is their ease of use. We’re on our phones all the time, and the app interfaces are easy.”

However, she also cautions against tacking them on without thought. “Offices are complicated. There’s a billing system, an EMR, a scheduling system. A payment app like VenMo or Paypal [can’t be] integrated into those systems.”

Additionally, many cash apps don’t secure patient information like a payment portal does. Simon Greenberg, MS, product manager for MedManage, a medication management and pharmacist consult app, warns that they can also cause HIPAA violations, as some of them show the address of the physician’s office where a payment was made. 

Nagori’s practice offers patients the ability to pay online by embedding links into texts and emails. While for now that’s the only online payment she offers, she hopes that mobile solutions will become more integrative in the future. “Anything I can do to make the [payment] process easier and give the patient more options, I’m all for it.”

Another low-cost way to make payments convenient for patients that is not mobile, Gordon says, is to combine a credit card swiper in-office, with a “tokenization” process-a service that allows the practice to store the person’s credit card data securely for future use. A patient could then authorize payment over the phone using the stored data.

“The more convenience you can offer the patient, the more ease, the more info, the more likely they are to pay,” Gordon says. 

Strategies to increase your collection rate in 2019

The benefit of flexible patient payment options

Opioid use has become a top priority, and, as part of that, CMS emphasizes that review of a patient’s opioid use should be a standard element of the Initial Preventative Physical Exam (IPPE) also known as “welcome to Medicare”, and the initial and subsequent Annual Wellness Visit (AWV).

Medicare has included the following languarge as part of the review of the patient’s medical history for IPPE visits and AWVs: “Medicare would like to emphasize that review of opioid use is a routine component of this element, including Opioid Use Disorder (OUD). If a patient is using opioids, assess the benefit from other, non-opioid pain therapies instead, even if the patient does not have OUD but is possibly at risk.”

The IPPE is covered for all Medicare beneficiaries once during their first year of becoming a beneficiary of Part B coverage, and the elements of the IPPE include:

Review the patient’s medical and social history

Review potential risk factors for depression and other mood disorders 

Review functional ability and level of safety 

Measurement of height, weight, body mass index (BMI), and visual acuity screening 

End-of-life planning (upon agreement of the individual) 

Education, counseling and referral based on the review of previous 5 components 

Physicians should update templates to include info on patients who are at risk or are using opioids.

January 10, 2019 edition

Physician moonlighting doesn’t mean major travel burdens

Getting paid in 2019

Your voice: Lowering the cost of a medical education

EHR market consolidation and the impact on physicians

Treating obesity: How to individualize care

The benefit of flexible patient payment options

Asking about opioid use now part of Medicare welcome and annual visits

Eliminate claim denials for medical necessity

What primary care physicians can do about rising rates of obesity