Articles

Burnout risks

Pediatrician Karen Ailsworth, MD, began her career with a multi-specialty practice in Baraboo, Wisc. She enjoyed the job at first, but a couple of years after she started an HMO bought the practice, and soon afterward conditions began to change for the worse.

“They wanted us to be more and more productive, like we had to see a patient every 15 minutes,” she recalls. It wasn’t long before she began experiencing a common symptom of burnout: anger at her patients. “I started feeling like, ‘don’t tell me your problems, I don’t have the time. Just make my life easy.’ And that wasn’t the way I wanted to practice.” 

Ailsworth stuck it out for 16 years, finally quitting in 2010 and pursuing locum tenens work before landing a less stressful position at an Indian Health Center. 

“It felt like the bean counters were in charge, and it wasn’t about patient care any longer,” she says of her former practice. “I didn’t feel like we got recognized for what we did. It wasn’t like I wanted an award, but more like recognizing not every patient fits into a 15-minute slot, and doctors aren’t just widgets in a factory.”

Ailsworth’s story would no doubt be familiar to many physicians, both for the feelings of burnout she experienced and the reasons behind them. Like her, doctors are reacting not just to the ordinary frustrations of workaday life but to obstacles produced by the healthcare system itself. These include, among others, the mounds of paperwork they must contend with, unhappiness over loss of professional autonomy and the ongoing decline in long-term relationships with patients. 

“What we hear from doctors repeatedly is, ‘I went into healthcare to help people, but I spend my day typing into a computer or on the phone doing prior authorizations and I feel like my time is being wasted on all of these things instead of focusing on taking care of my patients,’ ” says Clif Knight, MD, FAAFP, a board member of the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, a group fighting burnout in healthcare. “And over time doctors lose that connection of why they went into medicine and start wanting to do something else because they feel like they’re just wasting their time.”

Whatever its source, there’s little doubt that feelings of burnout-which the AMA defines as “a stress reaction marked by depersonalization, emotional exhaustion, a feeling of decreased personal achievement and a lack of empathy for patients”-are widespread and growing. In the Physicians Foundation’s “2018 Survey of America’s Physicians: Practice Patterns and Perspectives,” 77.8 percent of respondents reported having feelings of professional burnout either sometimes, often or always-up from 74 percent in 2016.

Similarly, a 2016 study of the prevalence of burnout, published in the Mayo Clinic 

, found that 54.4 percent of the physicians surveyed reported at least one symptom of burnout in 2014 compared with 45.5 percent in 2011.

The fact that so many doctors express similar feelings of frustration and alienation  is itself evidence of deep-seated dysfunction in the nation’s healthcare system, according to many experts. “We feel caught between doing the work our patients need and the work we feel is mandatory in our environment,” says Christine Sinsky, MD, an internist and vice president of professional satisfaction for the AMA. “And when those competing demands are not aligned, it creates a situation that is simply unmanageable for many physicians and other health professionals.”

Some who have studied the problem believe “burnout” doesn’t accurately capture doctors’ reactions to the hurdles they face in trying to care for their patients. They describe it instead as “moral injury,” a term first coined to describe soldiers’ responses to the dilemmas they frequently face during wars. (See sidebar on page 23.) 

Not surprisingly, a major culprit in creating unmanageable situations for many physicians are electronic health records. The technology’s shortcomings-lack of interoperability, poor user interface and interference with face-to-face patient care, among others-are well known by now, and a frequently cited cause of burnout. But their impact on doctors’ morale can extend beyond frustration with the technology itself by surfacing organizational dysfunction in hospitals and healthcare systems, says Mark Friedberg, MD, MPP, senior physician policy researcher with the RAND Corporation. 

Friedberg notes that in large organizations, non-clinician executives often are the ones deciding which EHR system to purchase and how it will be configured with little input from the doctors who will be using it. That means patient care may not be an important part of the decision.  

“If you’re a physician in a hospital telling management that this technology you use every day is inadequate, and you’re being told that [the EHR] isn’t for you but is for billing and complying with Medicare, that kind of response is a surefire path to burnout,” he says.

A second underlying source of burnout for many doctors, experts say, is loss of autonomy, as more physicians leave independent practice for employment with hospitals and health systems. While this relieves them of the administrative responsibilities that come with owning a practice, it also means they have less control over working conditions, says Robert McLean, MD, FACP, president-elect of the American College of Physicians. 

“When you become part of a large system, you’re no longer a self-employed person who can determine their own work or call schedule,” he says. “A lot of those little decisions you used to make [as a practice owner] while they could become headaches, they also contribute to the feeling that you’re a self-actualized person, and that gets lost as an employee.” 

But even doctors in independent practice no longer enjoy the degree of autonomy they once had in caring for patients, McLean notes, thanks to the proliferation of payer-imposed requirements such as prior authorizations and quality metrics. Meeting these requirements is not only time-consuming but runs counter to the emphasis on decision-making doctors receive during their training.

“Now a lot of those decisions can’t proceed the way the doctor thinks they should because there’s the ever-present middleman who’s following the golden rule, meaning he or she with the gold makes the rules,” he says. “So when someone else is paying the bill, to some extent they’re going to insert themselves in the process by determining how much they’re going to pay for treatment.”

Another underlying factor leading to feelings of burnout among doctors is the decline in long-term relationships with patients, according to the AMA’s Sinsky. 

“I think we have come to conceptualize healthcare as a series of independent transactions that can be distributed among providers willy-nilly, so that we have lost sight of the value that’s derived from relationships,” she says. That value comes both from the emotional satisfaction doctors derive from their relationships with patients, and the quality of care they are able to provide.

“I can help guide my patients and make better diagnoses if I know them better,” she says. “And not every bit of knowing a patient is captured in the EHR or can be transferred from one physician to another.” 

An additional cause of burnout has been an erosion in the belief that everyone in the  healthcare industry is acting in the best interest of patients, rather than their own bottom line. 

Knight cites the example of the extensive documentation that now accompanies evaluation and management codes, a widespread source of frustration among primary care doctors who are the main users of the codes. 

“The coding documentations don’t really result in improved value from a clinical standpoint,” he says. “I think it boils down to a lack of trust that physicians won’t overbill.” The same logic applies to payers who require step therapy and prior authorizations before agreeing to pay for expensive treatments and medications. 

“I think all these strategies have some degree of validity to them, but they’ve resulted in stealing time from physicians that they’d rather spend focusing on the clinical aspects of taking care of their patients,” he says. 

At the root of these and many other sources of physician burnout is the tension resulting from the drive to hold down costs while improving patient outcomes and efficiency, says Bryan Bohman, MD, founder and former director of the Stanford Medicine WellMD Center, and chief medical officer for University HealthCare Alliance, a network of medical practices affiliated with Stanford University. 

“Because of the increasing share of GDP we (healthcare) chew up, we’re under tremendous pressure to cut costs at the same time we’re trying to become more reliable, to provide better patient experiences, to show that quality processes are being implemented,” he says. 

“It’s a confluence of forces that stresses the whole industry and doctors tend to blame ourselves for the fact that the system is inefficient and it creates a cycle of stress, overwork and negative self-judgment. And I think that’s a big part of what’s producing burnout.”

Despite the seeming intractability of the problems behind burnout, there are signs that healthcare institutions and policymakers are beginning to address them. 

Among these are CMS’ “Patients Over Paperwork” initiative and the AMA’s STEPS Forward program, and the detailed recommendations for combatting burnout contained in the Institute for Healthcare Improvement’s “Framework for Improving Joy in Work” and the ACP’s “Putting Patients First By Reducing Administrative Tasks in Health Care” papers. 

Along with these is a growing recognition of the responsibility hospital systems and other healthcare institutions have in alleviating burnout, since they now employ a large percentage of the nation’s healthcare providers.

Experts say that role extends beyond just offering wellness classes or helping doctors become more resilient. The ACP’s McLean notes that while such initiatives have a role in combatting burnout, they don’t get at the underlying causes.

“When docs have been experiencing death by a thousand cuts, we can’t just give them a bandage, we have to try to remove the knife,” he says. “You can’t yoga yourself out of burnout.”

Moreover, offering wellness programs without acknowledging the systemic causes of burnout can wind up being counterproductive, says Bohman. “Often the doctor’s attitude is, ‘you’re telling me one more thing I have to do. When am I going to exercise or meditate when I’m already doing medical records for three hours at home every night?’” 

Instead, Bohman says, hospital systems need to focus more on getting input from “frontline workers”-clinicians-in
	decisions and policies that affect how they do their jobs. He cites the example of how University HealthCare Alliance sought to come up with a universal set of quality metrics for its primary care providers. 

“There are hundreds of different things you can measure to assess quality,” says Bohman. “So we asked our physicians, ‘what do you think are the things that have the most impact on patients, that improve clinical outcomes the most?’” 

UHA is starting with 11 quality metrics that include common ones such as smoking cessation, depression screening and blood pressure control. 

“It’s a small number of the ones that we need to ultimately take care of but we’re building the systems and the processes to do that in a way that doesn’t rely on doctors putting sticky notes on their computers to remember things,” Bohman says. 

In addition, he says, institutions can reduce burnout by focusing on physician engagement, which requires developing a culture of trust and mutual respect. 

“Assuming good intent on the part of every clinician is the key to improving engagement and wellness overall,” he says. “I’ve been an administrator for 10 years and I can’t remember getting burned by assuming a physician is trying to take good care of a patient. People don’t go into medicine with any other intent.” 

“Burnout” is the word most commonly used to define the feelings of exhaustion, frustration and cynicism prevalent among growing numbers of American doctors. But some experts who have studied burnout think the term doesn’t accurately capture these doctors’ emotions or the situations from which they arise, preferring instead the term “moral injury.”

Wendy Dean, MD, formerly a psychiatrist and now senior medical officer at the Henry M. Jackson Foundation for the Advancement of Military Medicine, says moral injury occurs when doctors feel they are impeded from doing what is best for their patients. Impediments can take a variety of forms, such as an insurer’s unwillingness to pay for a medication or procedure, limits on appointment times set by the doctor’s employer, or the need to score highly on patient satisfaction surveys.

“How do you answer to all those masters and do what you pledged under the Hippocratic oath, which is always to work in the best interests of the patient?” Dean asks. “With every patient encounter you’re in a bind and not able to do what you were trained to do. You can tolerate that if it’s an occasional event, but when it happens every day it becomes a crushing burden.”

Moreover, she says, labeling a doctor burned out implies a condition that it’s the doctor’s responsibility to fix, rather than the result of a systemic failure. “The way I think of it is that physicians are very, very eager to take care of their patients. But sometimes we can’t do it. We’re not allowed.” 

Adam Schwarz, MD, an internist in Hanover, N.H., spends a great deal of time talking with unhappy physicians in his role as a “well-being champion,” part of the American College of Physicians’ Physician Well-being and Professional Satisfaction” initiative, designed to combat burnout among ACP members. But the majority of doctors he encounters “identify more with the moral injury mindset than they do burnout,” he says.

The difference, he says, is that burnout implies feelings of being  overwhelmed by the demands of being a physician, whereas “moral injury speaks to the sense that they have fallen below what they think standards should be or they’re cutting corners due to productivity requirements in ways that make them feel uncomfortable.

“It’s not that these docs aren’t working really hard. It’s that they’re having to make decisions that go against their core beliefs” he says. “It’s that alteration of the moral compass that makes docs feel like they’re betraying their patients.”

Dean believes the growing popularity of direct primary care models stems in part from doctors’ desire to avoid feelings of moral injury. She cites her own decision to adopt the DPC model when she was in practice. “The only way you could make a living taking insurance was to run people through at 12 an hour,” she recalls. “And I wasn’t going to do that because it’s not good patient care.” 

“What physicians are saying is, ‘take the insurer out from between us and the patient,’” she adds. “Take the EHR out. Allow us the time to get to know who my patient is and what they want.”

How the system works against you -and what to do about it.

The real reason docs burn out 

Doctors often have opportunities to gain insider knowledge about new drugs, devices, and other healthcare innovations being developed by publicly traded companies. A doctor may acquire such information by sitting on a firm’s board of directors, serving as an expert consultant, or helping to run clinical trials whose outcomes can affect the value of a company’s stock. 

Insider trading occurs when an individual possessing such information makes investment decisions based on it, explains Michael S. Sinha, MD, JD, a research fellow in therapeutic science at the Harvard-MIT Center for Regulatory Science at Harvard Medical School. It’s important to know how to avoid it.   

Physicians need to proceed with care when they acquire inside intelligence, that is, material information that could alter a healthcare company’s share price and that is not publicly available. The law prohibits a clinician with access to such inside information from buying or selling stock based on such information and keep it strictly to themselves.

Importantly, the law considers consultants who gain access to inside information during a temporary position with a company, such as clinical researchers, to be insiders, according to a recent 

article whose lead author is Aaron S. Kesselheim, MD, JD, an associate professor of medicine at Harvard Medical School and director of the Program on Regulation, Therapeutics, and Law at Brigham and Women’s Hospital. “Temporary insiders are subject to the same rules as company management and full-time employees,” the authors note. 

There are two basic traps that people fall into with insider trading, explains Steven W. Schuster, JD, a partner at McLaughlin & Stearn, a New York-based law firm. 

The first trap consists of an officer, director, or employee of a company taking advantage of knowledge they have obtained through their position with the firm. For example, a physician might observe that a new drug they have been given to test is either a great success or an utter failure. 

These results amount to material inside information and trading on it would be illegal, says Schuster. Or a doctor might know that a certain drug or device is about to be approved or disapproved by the FDA. These kinds of situations are what people traditionally think of as inside trading, Schuster explains.

The second trap involves a person with inside information tipping off somebody else who then trades in the shares, says Schuster. 

In some cases, the person receiving inside information will share their monetary gains with the person providing the tip. However, such sharing of the illegal profits does not have to occur for insider trading to have taken place, says Schuster. 

Insider trading can result in both civil and criminal charges. Often, people convicted of insider trading are required to return any profits accrued in the 12 months prior to their prosecution, wrote Kesselheim’s team. The penalties depend upon the extent of the transgression and the amount of illegal gains, and can also include imprisonment, Sinha explains. 

What’s more, a person need not actually profit from insider trading in order to be guilty of committing securities fraud, and to be liable to prosecution, according to Kesselheim. 

As described above, physicians often engage with publicly traded companies in various ways, such as serving on boards or as expert advisers. “In these cases, the physician is almost always asked to sign confidentiality or nondisclosure agreements before serving in such roles. Carefully read and then reread the terms of such agreements before you sign them,” says Sinha.

If you don’t understand aspects of the agreements, seek immediate clarification from a representative of the company asking you to sign, Sinha adds. 

Before buying or selling stock, consider the source of the information prompting the trade 

When a doctor receives information about a public company through their professional activities, they have an obligation to consider the source of the information and whether it has already been made public before trading on it, says Sinha. 

“There is a big difference between, ‘I read it in 

’ and ‘I heard it during a company board meeting,’” he says. When in doubt, he advises, do not trade in a stock, even if the information came to you from family or friends.  

Schuster gives this example: A doctor might socialize with an old friend who works for Disney, and the friend might mention that visitors to the theme parks are up 30 percent for the current year. 

The doctor must determine if that information has already been made public or not.  If the information is not yet widely available, the friend may expect the doctor to refrain from trading on the basis of it. 

If the doctor did buy or sell Disney stock after that conversation, both the doctor and the friend may have broken the law. 

“Information received in a social setting is a gray area, but when in doubt, don’t trade on it,” says Schuster. The friend may not be guilty if he expected the visiting physician to keep the comments on attendance confidential. 

Do trade freely on insights and ideas you develop yourself 

A physician may have extensive knowledge of a particular illness or a certain type of surgery. He or she may then read that a certain company is about to invest heavily in an approach that the doctor thinks  is going to work or is not going to work, says Schuster. In that case, the physician is free to trade and to advise others to trade in the stock, he says. “You’re using your knowledge and public information. There’s no expectation of confidentiality.” 

A doctor would also have the green light to trade, he says, based on clinical observations, insights and intuitions. “Say you’re using a device and it’s just not working well. Or maybe you observe how patients react to a new medication. Trade on it. Tell people about it,” says Schuster. “You’re not getting those ideas from anyone at the company.”   

But if a doctor learns about the underperforming device or the fantastic new drug from someone who has a relationship with the company making the device or drug, he or she must not trade on that information or reveal it to anyone else, says Schuster.

Physicians engaging with publicly traded companies, such as serving on boards or as expert advisers, should pay particular attention to the rules around their agreements.

Insider trading: What it is and how to avoid it

2018 may well go down as the year of telemedicine expansion.  

Telemedicine, or healthcare facilitated by means of video, phone, or other telecommunications technology, has been around for decades. 

Yet last year, major players across the healthcare industry  made significant investments in it. Pharmacy giant CVS introduced virtual care offerings to its MinuteClinics. The Cleveland Clinic announced that telemedicine would be a major component of future care across the health system. And telemedicine vendor TelaDoc announced a new global initiative supporting remote care in more than 20 languages. And those are only a few of the telemedicine-related plans announced over the past 12 months. 

These initiatives beg an important question: As corporate telemedicine offerings continue to expand, what will be the impact on physicians outside of major health systems?

“There is currently pressure on physicians to consider alternate shared services delivery models that telemedicine solutions can offer,” says Neha Sachdeva, MS, a director at KPMG’s Healthcare & Life Sciences practice, referencing new ways provider organizations can extend their services using virtual care delivery methods. “But there is no one-size-fits-all strategy for telemedicine use.”  

She argues that, with telemedicine platforms ranging from a few thousand to tens of thousands of dollars, physicians need to think beyond the cool factor of recent telemedicine advances and consider how such systems will improve patient health and solve business needs.

Telemedicine, despite not being a new technology, remains a buzz word across the healthcare industry. And for good reason: Instead of costly and time-consuming in-person encounters, physicians can rely on video visits, smartphone photos or other means to assess, treat, and manage patients with medical problems. 

Ana MarÃ­a LÃ³pez, MD, FACP, president of the American College of Physicians, says that a renewed focus on value-based care has brought telemedicine into the spotlight.

“Telemedicine offers opportunities for significant savings. There is a strong case to be made for its use to expand patient access to care and to reduce medical costs,” she says. “So it’s not surprising that we are seeing more solutions out there.”

Take video conferencing in an ambulance, she says. EMTs can send information, including images or other important clinical data to the trauma team waiting at the emergency department. That can result in streamlining care and significant savings in time and treatment costs.  

Sachdeva agrees. “There are a lot of  pressures, certainly, to adopt this kind of solution,” she says. “But there are also internal drivers-to reduce wait times to see a particular provider, to offer patients, who are looking for more consumer-centric healthcare, more options about how to receive care, and to help streamline workflows for the providers themselves.”

William Morris, MD, MBA, Cleveland Clinic’s associate chief information officer, says its foray into telemedicine is due to a combination of all of those factors. “First, it’s the right thing for patients, when appropriate, to see them where they are and create a high-touch experience at their convenience,” he says. “But telemedicine also offers a lot of operational efficiency.” 

Morris argues that when physicians can answer questions and review tests remotely, it is more efficient for the provider, the practice, and the patient. “We’re trying to change the way we think about practice-because there’s not just one way to provide care. You should be able to get our clinical expertise without having to deal with our parking,” he says.

Daniel Barchi, MS, chief information officer at New York-Presbyterian Hospital, believes that telemedicine is poised to fundamentally change the way medical care is provided-in practices of all shapes and sizes. New York-Presbyterian currently uses  telemedicine for emergency department triage as well as for peer-to-peer physician communication-and Barchi says the hospital plans to expand its offerings.

“If we are not investing in this area and providing great care and service to our patients through it, we are not going to be prepared for the way medicine is delivered in the future,” he says.  

But despite these motivations, as well as multiple studies suggesting that telemedicine provide outcomes equivalent to traditional in-person visits, some physicians remain skeptical about how the technology can benefit their practices.  

A recent Healthcare Information and Management Systems Society analytics survey reveals that 55 percent of hospital respondents were not sure they would invest in telemedicine in the next two years. A 2017 

 survey looking at telemedicine adoption in smaller practices found that less than 20 percent offered such services.

In both studies, providers acknowledged the value of implementing such platforms to promote efficiency. But they said the return on investment was not clear. Between the price tags on current telemedicine platforms and the unknowns regarding costs of liability insurance and payer reimbursements, many providers feel, at this point, the investment is too risky. 

Contrast those findings with a 2018 survey by Software Advice, a consultancy that helps organizations select the right software, including telemedicine options, showing that 77 percent of consumers would be more likely to select medical providers that offer telemedicine services-and that the majority of patients who use telemedicine appreciate its convenience.

The findings suggest physicians may be underestimating consumer interest in telemedicine options-both now and in the future.

Sachdeva says that as no two physician practices are the same, no telemedicine strategies should be either. Before considering adoption, physicians should determine where, when, and how a particular option can benefit the practice and its patients. She suggests providers look at their current patient base and see in which situations telemedicine may be appropriate. 

Developing inclusion and exclusion criteria by looking at specific cases-perhaps a remote visit for a regular check-in with a diabetic patient, but an in-person appointment for the same patient if he is complaining of neuropathy-like symptoms–lets practices  better determine whether a remote care delivery model is right for them.

Providers may benefit from building or leveraging relationships with other organizations to make the most of telemedicine platforms. For smaller practices, aligning with a hospital or partnering with other practices may help alleviate some of the cost burden. Such relationships can also provide guidance about how to best deploy telemedicine programs.

Sachdeva says creating successful remote offerings won’t be as simple as following in the exact footsteps of bigger organizations but smaller providers can learn what to do, and perhaps more importantly, what not to do.  It’s important for finding the right telemedicine vendor, she says-one who can work with the practice to set up a system that meets its specific needs.  

“It really all goes back to, ‘Why am I doing this? What case studies makes the most sense here? Who am I trying to target? How will it help improve care and lower costs?’” says Sachdeva.

Providers who take the time upfront to answer those questions-and look closely at the factors that are driving them to consider telemedicine-will be at an advantage.  They can then look to other healthcare organizations with similar drivers, or vendor partners who specialize in those areas, to help them find the way forward.

But it’s important, Barchi adds, that such analyses should be physician-led. “Where we’ve been most successful is letting our physicians tell us what issues they are facing and how telemedicine might help them better manage those issues-whether it’s reducing wait times in the emergency room or having an expert assist you on a complex surgery from 1,500 miles away,” says Barchi. 

What can physicians outside large health systems do to counter corporate telemedicine expansion? To start: their homework. That means investigating where, when, and how remote care delivery models can help them treat patients, and the specific business cases practices hope to address through their use, Sachdeva says. 

But it continues with knowing how telemedicine will link up with electronic health record (EHR) systems. 

“Think about what kind of telemedicine solution you might use and what kind of documentation needs to be [in the EHR] to support the care delivery you’re providing-and your reimbursements,” she says.

Sachdeva adds that physicians need to consider medical liability when adding telemedicine services. A practice’s malpractice insurance plan may need to change to cover remote care delivery. While many physicians may assume telemedicine will raise liability, that is not always the case. Doctors should discuss their options with their insurance provider, including what type of coverage makes the most sense for the platform they are implementing.  

Product liability is a concern:  if the technology isn’t reliable, care can and will suffer. And practices need to review their insurance contracts, Sachdeva says. Telemedicine reimbursements can vary greatly from payer to payer-and providers may have to renegotiate some terms if they take on a telemedicine care model. “There are lots of pieces and parts to think about before deploying a system,” Sachdeva says.

Morris agrees. “I think any successful telemedicine program starts with a physician evangelist who uses facts and data to bring others along. Telemedicine isn’t something that can be done to physicians. It needs to be done with physicians,” he says.

He adds that practices need to carefully consider payment parity, or how much a physician is paid for services rendered in person versus remotely, when discussing any telemedicine deployment.  

“You need to align incentives-for the patient and the physician,” he says. “But you also need to think about reimbursement. It’s important that any telemedicine solution reflects the work of the ­physician.”

He maintains that just because doctors are seeing patients virtually does not mean less work is involved than an in-person visit. “These visits still take time and are still leveraging a physician’s intellectual capital in terms of practice and ­expertise,” he notes. 

Telemedicine’s impact on medical practices

Telemedicine holds a lot of promise to help medical practices promote efficiency, reduce costs, and increase patient satisfaction.  But Lopez cautions that it is just another tool in a clinician’s care delivery toolbox, not a healthcare panacea.

“As with any tool used to care for patients, it’s important to use it appropriately,” she says. “It’s important for physicians to take a long view, assess where it can appropriately answer the diagnostic questions at hand, and make sure they are doing the right clinical thing for each and every patient.”

Morris says that telemedicine scales well-from large health systems like Cleveland Clinic to smaller rural practices. By taking the time to plan, looking at everything from the financials to changes in practice workflows, even smaller practices can reap the benefits.

But consumer expectations will drive even the smallest providers to find ways to affiliate with organizations who can help them implement at least some telemedicine options. With the technology continuing to expand across the globe, patients will increasingly expect access via telemedicine.

 “Instead of calling a pager or service, the patient is going to expect a quick video visit. I think we’ll see adoption being less physician-driven and more consumer-driven as time goes on,” he says.

 Morris cautions that no two practices are the same-and there are a multitude of experiences that telemedicine may augment at the provider level.

”Telemedicine can help with many different cases in a way that benefit the patient, the provider, and the financial systems without the burden of overhead involved with an in-person visit,” says Morris. “It’s a time where we can really reimagine the way we want to experience healthcare, as patients and as providers.” 

Telemedicine holds promise, but it is just another tool in a clinician’s care delivery toolbox.

How telemedicine expansion will affect physician practices

It’s not something you hear every day at work, but that’s what we recently heard from Chris Robben, MD, Houston Methodist’s ACO’s medical director, while he was building a new quality metric dashboard. 

We suspect, though, that the true driver of his excitement was something more than mere metric making. He shared with us that he feels buoyed by a sense of progress, team autonomy and ownership of the work taking place within the ACO. We couldn’t be happier to hear those words, and to hear similar remarks from some of our providers.

It has certainly been a journey to get there-one that has been worthwhile, with many hurdles and contributors working hard to make sure physicians love their jobs and have an active role in making that a reality.

Physician burnout is closely linked to low self-compassion; not just the workload and work conditions, but the physician’s perception of their ability to deliver well on that workload within those conditions. Physicians hold themselves to high standards and become stressed when they can’t live up to them. This situation is exacerbated when they don’t have a voice, must work with inefficient systems, and face non-stop changes in their day-to-day.

So how do you reduce physician burnout and increase physicians’ sense of self-compassion and joy? From our experience, it goes far beyond getting physicians to buy in to a new initiative by focusing on changing their daily workflows. Instead, it’s about making sure physicians ultimately feel a sense of team autonomy and ownership. 

Robert Phillips, MD, PhD, our system chief medical officer, established the Physician Engagement Resiliency Taskforce (PERT). The goal of the task force is to bring primary care physicians, specialists, residents, surgeons, process engineers, residency directors, and analysts together to share their perspectives on how to improve physician satisfaction. PERT meets quarterly to determine what practical action items and programs make sense to pursue as a cross-functional team. Those decisions are informed by our physician engagement survey. Subgroups are working on programs to address specific issues the survey identified by finding fixes to inefficient workflows and promoting physician well-being. For example, one of our subgroups worked on enabling oncologists to work at the top of their license by removing administrative burdens.

Employment cannot be seen as an easy path to physician engagement because that strategy won’t carry you across all initiatives. While many of our primary care doctors are employed, most of our hospital and ED doctors are independent. At the end of the day, it’s all about the patients. We need expertise from physicians, whether they’re employed or are one of our independent partners. 

It’s essential to listen to everyone’s perspectives. We asked our providers: What feedback or data do you need? How can we build our infrastructure to better support you and your patients?

We began to see positive signs that we were moving beyond engagement and into partnership. One sign: Our hospitalists are not just coming to our meetings. They’re raising their hands and volunteering to partner with us and own their role in the process. We bring data to hospitalists, cardiologists, and many others to find ways to reduce readmissions and proactively avoid and manage chronic conditions.

At the system level, it’s wonderful to be able to congratulate these clinicians on their strong partnership and focus on the patient. For every clinician who feels like they have the support of a team and can own their next steps, our ACO gains a smart resource ready to take an opportunity and run.

We recognize that each primary care doctor has a unique communication style and preference. As we have expanded our integrated network, we began by soliciting feedback on how each doctor prefers to both receive and convey patient information-by secure emails or texts, faxes or EHR messages. We have worked tirelessly to communicate in the most meaningful and efficient manner indicated by the physician.

Ask any primary care physician or specialist what provides the greatest satisfaction and you will almost always universally hear “making a difference for my patients.” In an effort to improve care for our patients with diabetes, we began by sharing outcomes with a select team of primary care providers, pharmacists, and endocrinologists. We elected to use a multi-disciplinary team to pursue diabetic patients who were not adherent to scheduled visits to better understand barriers to care they encounter. The physicians recognized that this strategy holds the promise of averting worsening diabetic complications while improving patients’ quality of life.

It’s essential to take a look and be honest with yourself to see where you are in the physician engagement process. We’re trying to find ways to improve processes and partnerships every day, and even have some fun along the way. 

 is vice president for population health and primary care and president and CEO for Houston Methodist Coordinated Care (HMCC). 

, is vice president of clinical transformation for management consulting firm Evolent Health.

How one ACO took on burnout

Developing a coding and compliance infrastructure that is both appropriately sized and equipped can be tricky for many independent and hospital-based physician groups. The tug-of-war that occurs when trying to maximize revenue without compromising compliance with professional fee billing can be daunting, especially when placing equal focus on productivity and performance. 

In some cases, just bringing this topic to the forefront of discussions with clinical and management teams can be problematic, as coding and compliance specialists may be viewed as impediments to productivity. However, with the preponderance of recovery audit contractor (RAC) audits, complexity of ICD-10 coding, and changes in payer reimbursement policies, many organizations are now realizing the importance of enhancing their coding infrastructure to ensure success.

The coding process is no easy task-there are more than 8,000 CPT codes and 69,000 ICD-10 diagnosis codes to choose from, as well as a litany of complex payer and regulatory guidelines to follow, in order to code accurately. Moreover, organizations utilize a wide array of resources and workflows to complete the coding process. Some require providers to select codes via an EHR or encounter form, while others utilize support staff to abstract directly from the medical record, and each approach has its own benefits and drawbacks. 

The challenges associated with billing and collections are not new, as inadequate attention to coding has always had the potential for high-cost repercussions (e.g., increased billing lag, unnecessary denials, increased cost to collect). In addition, the Office of the Inspector General’s ongoing focus on RAC audits for evaluation and management (E/M) coding signals increasing scrutiny on physician billing in the ambulatory setting, adding high audit and recoupment costs (or worse) to the list of challenges. For an organization to successfully manage the tug-of-war between cost and benefit for its coding and compliance program, it must first recognize the importance of the functions provided by its revenue cycle teams.

High-performing organizations maintain coding and compliance programs that appropriately balance revenue maximization, coding compliance, and costs to ensure each visit is coded for optimal reimbursement. All of the coding and compliance functions detailed in the tables below play an active role in fostering an organization’s overall success, and should be evaluated to see if there are opportunities for improvement within your own organization. Each activity is equally important builds upon the others to drive consistent professional fee coding.

The first set of activities to consider are pre-bill coding activities.

Next, organizations should review audit and compliance activities.

Finally, coding education and feedback loops should be reviewed.

Please note, while education is listed last in this series of functions, it is by no means least important. Creating something of a “chicken-or-egg” scenario, provider education needs to be informed by policy and audit, but also influences the ability to effectively perform.

For most organizations it is infeasible to have certified coders abstract and/or review every professional encounter. To that end, the ideal operational structure is a function-based model, where coders are deployed to support critical activities based on their skill sets and expertise, while providers maintain a high degree of responsibility in the coding process for more routine encounters. In this model, illustrated below, the production team (responsible for abstraction, edits, and coding denials) and the audit team (responsible for compliance audits) provide trends/feedback to the education team, which in turn acts as a resource for providers by communicating issues and opportunities for improvement.

Given that each team is responsible for defined tasks, the best practice model enables consistency and quality and allows management to easily measure/monitor results. Work standards and performance expectations should also be established to confirm adherence to policies and protocols and ensure proper management of work volumes and backlogs.

Additionally, it should be noted that the audit team reports to a separate authority from the production team. This reporting structure helps guarantee that chart reviews are focused solely on compliance and are not influenced by cash opportunity.

That said, despite the segregation of duties, it is important that all members of the infrastructure adhere to a common set of policies and that teams are led by qualified individuals with deep coding expertise. Finally, while the model above describes distinct teams, there may be instances where qualified coders would be responsible for multiple functions (e.g., audit and education)-functional duties should be driven by size/necessity of the coding or compliance work.

While system tools and automation should be used where possible, the final step in establishing a successful coding and compliance program is to review the staffing model to ensure:

1. The appropriate number of resources are working in unison to complete the coding and compliance activities required; and

2. The work is segmented and structured in a way that allows for a streamlined and consistent approach to the workday. 

Figure 2 provides a summary of the process organizations should follow to estimate necessary staffing levels.

In short, reviewing your organization’s coding and compliance infrastructure and implementing best practices can ultimately protect your organization from compliance-related risks and increase your organization’s reimbursement in a cost-effective manner. An examination of the activities highlighted above will ensure the charge submission process is efficient, claims are billed and adjudicated appropriately, and risk and subsequent expenses are mitigated.

With more than 1,600 providers across Utah and Idaho, Intermountain Healthcare is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery.

Intermountain Health developed a model that prioritizes provider audit and education over coder abstraction. Generally speaking, under the model, providers are responsible for their own coding and charge entry; however, approximately 50 coding-certified consultants meet with the providers regularly to discuss areas of opportunity identified from audits and denials. It is important to note that given the complexity of select areas, coders are utilized to support procedural coding for orthopedics, cardiology, and neurosciences.

The rationale for Intermountain’s model is based upon the notion that educated providers need to clearly understand their role in the revenue cycle, as well as their exposure to risk. As Adam Freebairn, director of professional documentation and coding at Intermountain, put it, “when you disconnect doctors from billing, their documentation tends to suffer. They also tend to forget that they are ultimately accountable for the accuracy and compliance of their coding, regardless of whether a coder abstracted from the record.” In addition, the model is described as being a reaction to the expense and challenges associated with recruiting. According to Adam, “our research has found that coders are no more accurate than physicians that have received coding education and have the right tools in place. On top of that, it is hard to find great coders.”

Ben Colton is a principal and Chris Gaspard a senior consultant with ECG Management Consultants, a national consulting firm working exclusively with healthcare providers.

Ensure compliance while maximizing reimbursement and staffing levels at your organization.

January 25, 2019 edition

Burnout risks

The real reason docs burn out

Insider trading: What it is and how to avoid it

How telemedicine expansion will affect physician practices

How one ACO took on burnout

Avoiding a compliance and coding tug-of-war at your practice