 A family conference is one of the first services that we provide for our patients who have dementia and need additional help with activities of daily living, finances, driving, medications, and other services. Should we capture this service with a time-based E/M code, or is there another code that would work?

With our ever-growing geriatric population, it is important to note that the Center for Medicare and Medicaid Services (CMS) is adding new services to help manage their care. One of those services was just added January 1, 2018, and specifically focuses on the assessment of and care planning for patients with cognitive impairment.

It sounds as though this code might better describe the services that you are offering your patients. I’ve detailed the code below, a listing of the requirements included in the code descriptor, along with some additional information that you might find useful.

Medicare national reimbursement for CPT code 99483 is $178.92 for facility and $241.92 for non-facility. This is higher reimbursement than even that of 99205, which is $172.08 for facility and $210.60 for non-facility.

This shows that Medicare understands the importance of this type of service. Here are the elements required for this code:


Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements:
â Cognition-focused evaluation including a pertinent history and examination. While no specific elements are required for this code, the stipulation is that the focus is on the patient’s cognitive ability. So this should not be equated to E/M elements.
â Medical decision making of moderate or high complexity. These levels of medical decision making should equate to those levels spelled out in the E/M coding guidelines. This will be determined by the patient’s dementia severity and treatment and would also include depression, lack of functional ability and any co-morbidities.
â Functional assessment (e.g., basic and instrumental activities of daily living), including decision-making capacity.
â Use of standardized instruments for staging of dementia (e.g., functional assessment staging test [FAST], clinical dementia rating [CDR]).
â Medication reconciliation and review for high-risk medications.
â Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s).
â Evaluation of safety (e.g., home), including motor vehicle operation.
â Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks.
â Development, updating or revision, or review of an Advance Care Plan. Advanced care planning has been a recent focus for Medicare, so your patients could well have a plan already in place.
â Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neuro-cognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/ or caregiver with initial education and support.
â Typically, 50 minutes are spent face-to face with the patient and/or family or caregiver. This service does not differentiate between new or established patient status.

Seen today for a follow-up family conference regarding memory loss, mood, and lab results. Patient is accompanied by his wife, who provides additional information with patient’s permission.

Patient and family goals: He wants more independence.
Memory: Wife describes patient’s memory as variable. Wife first started to notice changes in patient’s memory about 4-5 months ago. Patient does repeat questions and stories, but he does not forget recent events or conversations. No word-finding issues reported. Patient takes 10 mg Aricept daily since November 2017.
Living environment: Patient lives with wife in a one-story home.
Support: Wife; patient’s 3 children are not involved in patient’s care. Patient’s wife is experiencing caregiver stress.
ADLs: Patient is independent in bathing, dressing, grooming, feeding, toileting, and ambulation.
Physical ambulation: Patient has a walker for home use, but does not use it consistently. A wheelchair is used away from home. Wife reported that patient had three falls.
Toileting: Patient has urinary incontinence and utilizes Depends for support. Takes Colace daily.
IADLs:
Finances: Wife manages money.
Meals: Wife prepares meals. Patient denies difficulty eating 2-3 meals/day. Some difficulty swallowing.
Medications: Patient’s wife has managed his medications since October 2017.
Driving: Patient stopped driving in October 2017.
Mood: Patient’s mood is described as labile and can go from pretty good to angry, irritable and being agitated. Patient’s recent office visit with PCP did mention anxiety and depression. Patient is taking Cymbalta 60, Klonopin 0.5 mg, 1/2- 1 tablet TID, and Remeron 7.5 mg at night.
Activities: Patient enjoys spending time with his wife. Patient likes to walk for exercise.
Sleep: Patient’s sleep is described as restless. Patient has sleep apnea, but does not use a CPAP, per wife. He declined a sleep study.
Appetite/weight: No overt concerns.
Vision: Patient uses reading glasses. Last exam March 2018.
Dentition: Has full set of dentures but does not use them. Last dental exam is unknown.
Hearing: Patient has some hearing loss. No hearing aids.
Pain: Bilateral shoulder pain which have both been replaced. On Cymbalata and uses OTC Ibuprofen for pain management. Will refer to PT.
Smoking: Quit 35 years ago.
Alcohol Intake: Denies current use.
Caffeine Intake: One cup of coffee per day.
Other chronic conditions: Arthritis; cancer; chronic kidney disease, stage 3, GFR 30-59 ml/min; COPD; Coronary artery disease; type 2 diabetes; GERD; hyperlipidemia; hypertension; lung disease.
Family history: Cancer in his maternal grandfather; Heart disease in his father and mother.
Review of systems:
General: Denies fevers, chills, weight stable with 4 pounds weight gain since the last visit
Cardiovascular: Denies chest pain, shortness of breath, edema
Pulmonary: Denies cough, difficulty breathing
Gastrointestinal: Denies abdominal pain, nausea, vomiting, black or tarry stool
Skin: Denies dryness, sores, other lesions
Psych: Denies depression, anxiety, hallucinations
Diagnostics: Mild neurocognitive disorder. Suggest using preset testing as baseline and that he be re-examined in 12-18 months.
PHQ-9 Test results show mild depression.

Articles

Should a family conference be captured with a time-based E/M code?

New codes for care planning of cognitive-impaired patients

Patients are more likely today than in the past to seek care from multiple sources: their primary care physician, the local urgent care center, retail clinics, and even online. They’re also generating more healthcare data on their own, through fitness trackers or at-home devices like glucometers and blood pressure cuffs.

As a result, patients want technology that consolidates all that information and allows them to access and share what they need, when they need it. Patients will look for physicians who provide them with the online experiences that they’re used to and expect in other aspects of their lives.

“Over time, the customer is going to gravitate to providers based on convenience,” says Don Rucker, MD, national coordinator for health IT with the Office of the National Coordinator (ONC) for Health Information Technology.

Patient portals-intended to provide that improved engagement and outcomes-have yet to deliver on the promise. But that’s expected to change within the coming decade as portals become more patient-centered.

In the years ahead, experts expect portals will move beyond the limited functionality they have today and transform into a user-friendly technology that put a patient’s whole health history into one easy-to-navigate online portal.

“We’re going to see a highly personalized portal, one that aggregates data from multiple sources, that can contextualize the data, run analytics on it, and that can empower patients as they navigate their health journey,” says Mark Gilbert, MBA, director of research at Gartner Inc., a Stamford, Conn.-based IT research and advisory firm. “And I think 10 years out, we’ll find these tools will become a critically important part of a precision health model.”



Even though today’s portals typically have limited functionality, physicians still say they see them as the primary tool for engaging patients, says Adam Cherrington, MBA, research director of patient engagement at KLAS Research in Orem, Utah.

“[Physicians] call it the highway to the patient,” he says, “but they also tell us that adoption is still low. It’s still a challenge to get patients to log in.”

Cherrington says that the vast majority of healthcare providers (both systems and individual practices) have implemented patient portals, yet studies show less than 20 percent of patients on average log in and use them. And those patients who do use portals generally do so only to check appointment times, send or receive messages, or check lab results and healthcare records-even though some portals already offer more advanced functions such as online scheduling and even telemedicine options.

Health IT leaders point to a poor user experience as a significant reason for the low rates of use by patients.

“It’s a pain point we hear a lot from patients,” says Margeaux Akazawa, a public health analyst at ONC. “We can see patient portals as a success in getting patients access to their data, but they’re very limited. Not only are they very static, but they’re not designed with the user in mind.”

Cherrington predicts technology vendors will develop portals that are easier for patients and physicians to use, which he says should spur higher levels of adoption.

Similarly, health IT experts say technology vendors will increasingly optimize portals for mobile device use, because studies show people overwhelmingly use smartphones and tablets to access online information.

“What we know is mobile is the dominant platform for consumers today, so that has to be the predominant platform [for portals],” says Walter Jin, CEO of Pager, a New York City-based company that sells a mobile app to insurance companies to help guide their members through the healthcare system.

Making the user experience smoother and optimizing it for mobile use are critical steps that will help increase adoption rates, experts say. However, those steps are just the start of the improvements in portal applications expected in coming years.



EHR vendors are not the only ones developing patient-centered technologies.

Software companies outside the healthcare industry are introducing portal-like products, too, with experts pointing to the January 2018 announcement from Apple Inc. about its Health Records app as an example.

As these software makers create new features, physicians and patients can expect future portals to:

Deliver more information and support more interaction between patient and provider.

 Health IT leaders say portals will be the main tool physicians use to remind patients about upcoming visits, the protocols they need to follow between appointments, and other critical healthcare recommendations. Likewise, they see portals making it easier for patients to send emails, search information, schedule appointments online, and even securely exchange text (the preferred method of communication for many younger patients). Experts note that portals typically have these functions now; however, they’re not widely used nor are they always easy for patients and physicians to navigate. 

Organize and summarize patient data from multiple EHRs and consumer devices such as fitness trackers

. This will be done in a way that the average person can understand, and provide details and insights on what the patient’s healthcare data means for them. For example, portals will provide action plans from the patient’s physicians and links to appropriate guidelines or follow-up treatment guides. Portals will also use artificial intelligence-enabled self-management and self-diagnostic tools. “There is the potential for healthcare that’s happening in the doctor’s office to move back to the patient,” says Edward Yu, MD, a primary care physician and medical director of quality at Palo Alto Medical Foundation. 

 Patients will be able to initiate and conduct a virtual visit with a simple click from the portal. In turn, portals will make it easier for patients to provide relevant information in advance of both virtual and in-office visits via automated questionnaires contained within the portal, says Stephen Dart, MBA, senior director of product management with AdvancedMD, a South Jordan, Utah-based vendor of cloud software for independent medical practices. 

Offer more resources, including connections to support groups or communities focused on their specific health conditions or wellness concerns. 

“Portals will become richer as they’re able to incorporate other capabilities that patients want,” says Peter Kilbridge, MD, senior director for research at The Advisory Board Co., a healthcare research and consulting firm headquartered in Washington, D.C. For example, physicians could use portals to connect patients to nutrition programs or deliver ongoing content that helps motivate patients with chronic conditions to stay on track with their care programs. Taken all together, “the future of the portal is about getting the right data to the patient in an understandable format to help them engage and improve their ability to follow a healthcare plan,” says Ripley Hollister, MD, a board member with the Physicians Foundation and a primary care practitioner in Colorado Springs, Colo.

CHALLENGES TO IMPLEMENTING BETTER PORTALS



Such a future state isn’t that far off , according to health IT experts. Some portals already have advanced capabilities, such as telemedicine functions, online scheduling options, and the ability to access physicians’ notes. But those are the exceptions. Moreover, the technologies that will enable future features already exist.

Application programming interfaces, or APIs, and the Fast Healthcare Interoperable Resource (FHIR) standard already enable interoperability between systems. AI is being used to help physicians make diagnoses and plan the best courses of care. And many patient portals can be accessed by smartphones, even if they’re not all existing portals are yet optimized for mobile devices. Still, there are challenges to creating the more advanced features described above and achieving widespread adoption of them, health IT leaders say.

For starters, EHRs can’t yet easily share data with other EHRs. Similarly, many EHRs can’t readily accept or share data with patient-owned apps. Additionally, some providers don’t want to share all their notes directly with patients. Many others don’t want to open up their schedules for patients to set up appointments online without staff screening to determine the urgency of the patient’s needs.

Questions about how and how much physicians will be reimbursed for services offered via patient portals-such as telemedicine visits or text exchanges-could slow adoption of anticipated future features, Hollister says. “There’s a cost to this technology and the maintenance of it. Who will pay for those costs? Will the physician be reimbursed?” Hollister asks.

Physicians will also need time to incorporate the advanced patient portal capabilities into their practices, Hollister says, explaining that physicians will have to establish for themselves and their patients what types of information is appropriate to share via the enhanced portals of the future and what communication will remain best done via in-office visits.

Cherrington acknowledges that these challenges could stymie the patient portals of the future, with a lot of developments having to come together in order to see the high level of patient portal adoption that can then impact healthcare outcomes. However, he says, his research shows that optimism regarding future improvements is high in light of Apple’s entry into this market and other advancements.

Physicians and other healthcare providers see a future where this technology can help with interoperability by providing a conduit for sharing data as well as making data more accessible and thereby allowing patients to really take charge of their healthcare. “Providers want to not only have a vehicle to connect with their patients, but they want their patients to participate in their care by making it easier to navigate it,” Cherrington says.

And patients want this too, he adds, in the form of a tool that makes their experience smooth and easy when seeing their healthcare team. “That’s what has to happen, Cherrington says. “And whether we call it a portal or patient guidance tool or something diff erent, I don’t know. But it’s going to have to be something significantly useful for the patient and as that happens the value alone will keep patients coming back to it.”

In the years ahead, experts expect portals will move beyond the limited functionality they have today and transform into a user-friendly technology that put a patient’s whole health history into one easy-to-navigate online portal.

The future of patient portals

In advising doctors on how to optimally build and protect their wealth, financial specialists like me often make use of highly targeted “off-label” strategies for trusts, IRAs, 529 plans, health savings account and other vehicles with the objective of enhancing the effectiveness of these tools.

The following five strategies can be particularly advantageous in helping doctors preserve what they earn, bolster tax savings and better plan for the future.


Simply put, cash balance plans offer physicians the opportunity to take larger tax deductions and accelerate their retirement savings. Cash balance plans are actually a type of defined benefit plan, but instead of requiring complex calculations that provide vague projections of retirement benefits, cash balance plans are more predictable and easier to understand.
These plans can be used by smaller practices, including sole proprietors, as long as the cash flow needed to cover the funding requirements remains fairly consistent each year. Combined with more commonly used 401(k) plans, the two together can allow for generous pre-tax contributions of $150,000-$250,000, resulting in significant tax savings. Executing these combined plan design will require third-party administration by a licensed actuary.


Since they were created in 1997, Roth IRAs have been the darling of retirement savers due to their tax-free treatment of both growth and distributions. Roth IRAs’ income eligibility limits, however, disqualify most physicians from taking advantage of them. However, a backdoor Roth IRA provides a workaround.
Using this method, you can make a non-deductible regular IRA contribution (non-deductible because of income limits)-and the following day convert those assets to a Roth IRA. This will allow tax-sheltered growth on those assets, plus no tax on withdrawals. 
With these benefits come several requirements. Among them: You must hold the Roth account for at least five years and be at least 59.5 before you can tap the earnings tax-free and penalty-free. The good news is that, unlike traditional IRAs, there are no mandatory withdrawals or required minimum distributions at age 70.5.

3/ Trusts and Family Limited Partnerships


The value of complete peace of mind can’t be understated. Trusts provide the ability to shelter assets from creditors above and beyond tort reform’s protections.
Family limited partnerships are an alternative to trusts that are favored by many physicians. Along with protecting assets, these partnerships are useful in estate planning, as they provide a discounted valuation of the assets contributed. These discounted valuations can be particularly beneficial for gifting strategies, effectively allowing you to contribute approximately $20,000 per beneficiary, rather than $15,000-without having to file a gift tax return.


For those of you with children, college savings plans are a great vehicle for saving money for their education. With the new tax law, they can also be used to pay for K-12 private school tuition (up to $10,000 per year). These accounts are funded with after-tax contributions, with no additional taxation on the growth of the assets if used for qualified educational expenses. 

The annual maximum contribution that can be made to a 529 without filing a gift tax return is the annual gift exclusion amount ($15,000 in 2018). But you can contribute five years’ worth of gifts at one time ($15,000 x 5= $75,000). Unused funds can also be transferred to your other children’s 529 accounts. Finally, although the assets you deposit into a 529 account aren’t included in your estate, they don’t leave your control for estate-planning purposes.


Those enrolled in a high-deductible health plan can establish a health savings account (HSA), which permits annual tax-free contributions of $3,450 for individuals or $6,900 for families (with an additional $1,000 contribution for those age 55 or older)-with no taxes incurred when withdrawn for payment of qualified medical expenses. Most HSA custodians will allow account holders to invest their HSA funds in excess of certain account minimums. These accounts possess the “holy trinity” of tax benefits: tax-free contributions, tax-free growth, and tax-free distributions if used for qualified medical expenses. While working, you can pay medical expenses out of pocket, watch the assets grow, and use them to pay for this spending post-retirement.

Craig W. Eissler, MBA, CFP, is a wealth adviser with Halbert Hargrove based in Houston.

Preserve earnings, bolster tax savings and better plan for the future.

Five ways physicians can build wealth

Sohan Dua, MD, got the bad news in a phone call one morning in February 2017: His practice had been hacked.

The EHR system shared by Dua and his wife, Kiran Dua, MD, had been breached and hackers were holding their patient data for ransom. That attack sent the couple, who practice in Northridge, Calif., on a months-long ordeal that cost their separate practices time, money, and service interruption.

Dua, a nephrologist, never thought he and his wife, a primary care physician, would join the ranks of healthcare providers and organizations that have suffered crippling cyber attacks. Luckily, their losses were at least partially covered by the combined $100,000 cyber coverage they had through their medical malpractice insurance. The insurer also provided them with experts to help recover from the attack.

However, even with that assistance, their practices were forced to shut down for several months while they dealt with the attack. “We still don’t know how much money we lost,” Dua says. “We lost patients, too.”

The growing threat of being hacked has more primary care physicians buying cyber insurance, according to experts. But what those policies cover, how they work, and how much they cost are mysteries to many healthcare providers, most of whom are only familiar with malpractice and business insurance.



Cyber insurance covers losses and damages resulting from patient data being stolen, exposed, held for ransom, or improperly shared. It covers deliberate actions, such as hacking or ransomware, as well as accidents, such as a lost laptop containing unencrypted patient information or a coding error that accidentally exposes patient data.

A comprehensive policy will cover paper records as well, since so much information is still stored in physical files. 
Cyber insurance helps providers deal with the consequences of data breaches, which can range from relatively minor to catastrophic. The assistance provided can include:

compensating for loss of income from downtime or lost patients;

hiring IT experts to find and fix the breach;

hiring a call center to handle inquiries from patients;

hiring a public relations firm to deal with unwelcome publicity;

hiring attorneys to represent the practice in any lawsuits filed by patients (as well as any damages awarded); and

In short, it covers almost any loss or expense that can be attributed to the data breach.

For example, the Duas’ coverage helped them when they were forced to write off tens of thousands of dollars in uncollected billing due to unrecovered patient payment records, a loss that Dua estimates at $40,000 to $50,000.

Coverage typically applies only to the data itself and not the computer hardware a practice uses, such as laptops, smartphones, tablets, or servers, which often are covered under a general business insurance policy.

A complete policy includes first-party and third-party coverage, says Marcin Weryk, vice president of XL Catlin, a seller of cyber insurance. First-party coverage pays for damages suffered by the policy holder, such as lost revenue, business interruption, IT forensics and data restoration. Third-party coverage compensates for damages caused to others by the data breach, such as the legal costs incurred from lawsuits filed by affected patients.

Practices that haven’t bought cyber insurance often have some coverage through their malpractice or general business policies, but it’s usually limited to about $30,000 in damages and contains exemptions, says Brandon Clarke, co-founder of Affenix, a brokerage specializing in cyber insurance.

Before deciding whether to purchase additional cyber insurance, physicians should know what coverage they already have, Clarke says. Though the Duas have separate practices, they were able to combine their separate $50,000 cyber insurance coverage in their malpractice policies to help compensate for the joint attack.



The cost of a cyber insurance policy varies, depending on the carrier, the size of the practice, and the extent and amount of the coverage, experts say. The larger the practice, the greater the risk and the more it can expect to pay.

The good news is that cyber insurance is less expensive than malpractice and liability insurance. A typical five-physician primary care practice should have at least a $1 million umbrella cyber policy, Clarke says. That coverage would cost anywhere from $1,200 to $5,000 a year, he estimates.

Christine Marciano, a certified information privacy professional (CIPP-US) and president of Cyber Data Risk Managers, a cyber insurance broker, recommends $1 million to $5 million in coverage for that same practice and says it would cost $1,500 to $8,000 a year. Coverage can be purchased from general insurers or companies that specialize in cyber insurance.

Some insurers will assess a practice’s cyber security practices before deciding whether to write a policy and recommend ways to decrease risk, such as encoding laptops and improving passwords.



When shopping for cyber insurance, practices should investigate exactly what help they will receive in case of a breach. Unlike a fire, managing a data breach often requires the help of a team of experts, not just a check to cover damages. Depending on the nature and size of the breach, that team can include lawyers, forensic accountants, IT experts, publicists and call center operators, among others.

Besides the coverage itself, the real benefit of cyber insurance is being able to turn over management of the crisis to a carrier with experience in data breaches. Most practices do not have the time or resources to handle it themselves, says Clarke. Once an insurer is notified by a policyholder of a breach, it assesses the situation and decides which corrective actions need to be taken to prevent further damage and deal with the aftermath. The insurer hires vendors and contractors to provide the necessary services.

For example, a lawyer will handle HIPAA notification, while IT specialists locate and fi x the breach and a PR firm writes the notification to patients whose data has been affected. The decision whether to pay ransomware is up to the practice, but the insurer typically recommends a course of action and handles any payment, if one is made.

For example, XL Catlin has vendors with Bitcoin wallets, since that is the cryptocurrency usually demanded by ransomware hackers, Weryk says. In the Duas’ case, their insurance provider, The Doctors Company, employed a computer forensics company to determine the extent of the breach and a law firm that specializes in privacy issues to determine if HIPAA notification was required. “They were a lot of help,” Dua says. “We did not know how to handle everything that needed to be done.”

Patient data is exchanged between practices, insurers, hospitals, and labs every day. The more places data is stored, the more vulnerable it is to attack and accidental disclosure. Even a practice that is not targeted directly can be liable for data lost by a partner or vendor. For example, in April, the state of New Jersey levied a fine of nearly $418,000 against Virtua Medical Group, a physician network, after a vendor error left the records of more than 1,650 patients visible online.

Many data breaches are going to involve EHR systems, and while the electronic records providers usually work with IT experts to find and fix the breach, it does not mean the vendors are legally or financially responsible, experts say. “Many practices expect their EHR system to handle breaches or pay for damages and that’s not always the case,” Clarke says.

Practices should investigate what sort of cyber protection and coverage their partners and vendors have, with an eye toward working together to keep data safe, says Lee Kim, JD, CIPP-US, director of privacy and security at the Healthcare Information and Management Systems Society. “It’s really a shared responsibility between you and your vendors,” she says, “and you each have a responsibility to keep it secure.”

Healthcare data breaches are rampant. In a 2017 survey by the AMA and Accenture, 83 percent of physicians reported experiencing some sort of cyber attack, though not all resulted in breaches. Cyber criminals target healthcare organizations because their data contain patient names, birthdates, addresses, social security numbers, credit card numbers, and health insurance information.

Whether the hackers use the information themselves or sell it to others on the black market, that’s all that’s needed to steal identities and commit fraud. That’s why healthcare data is more valuable even than credit card records.

Physicians in small primary care practices who think they would not be a worthwhile target for hackers should look at the U.S. Department of Health and Human Services (HHS) list of reported breaches of healthcare information.

There, among the giant health insurers, government agencies, and large hospital systems, are medical practices that found out the hard way that they, too, can be targeted: an 11-doctor cardiology practice in Knoxville, Tenn.; a solo primary care physician in Weston, Fla.; a solo internist in Scottsdale, Ariz.; and many more.

In fact, a practice might be targeted specifically because it is small, says Christine Marciano, a certified information privacy professional (CIPP-US) and president of Cyber Data Risk Managers, a cyber insurance broker in the United States and Australia.

“I think it’s the smaller offices that are much more vulnerable,” she says. “They’re focused on treating patients, not on (encrypting) their laptops, and making sure they have the latest security measures.” Lee Kim, JD, CIPP-US, director of privacy and security at the Healthcare Information and Management Systems Society, says attacks on small practices were uncommon five years ago, but no longer.

In fact, some hackers will test and refine their methods on small practices before going on to attack larger targets, such as healthcare systems. She is seeing more of a new kind of attack, which isn’t after a practice’s data or patient information, but its computing power to earn digital currency.

Attackers have hijacked practice servers to mine for pseudocurrencies, like Bitcoin. Users might be unaware that the reason their computers are operating so slowly is that they’re running the complex calculations to reap the currency.

“Even though you’re a small practice, the motivation to attack is still there. People who say they haven’t been targeted simply haven’t been targeted yet,” Kim says.

The growing threat of being hacked has more primary care physicians buying cyber insurance.

What physicians need to know about cyber insurance

No one expects physicians to become blockchain experts. Instead, blockchain could be viewed in a similar manner to one’s internet connection: Most users don’t have a deep understanding of exactly how it works, yet they can benefit from the tech. In the same way, blockchain works in the background to make complex processes more efficient.




Due to a reliance on manual steps and third parties such as clearinghouses, claims processing can require months to complete. Given blockchain’s ability to reconcile transactions in near real-time, incorporation of the technology into billing systems could lead to much prompter payment for physician practices.


Exchange of patient data is notoriously hampered by interoperability problems between separate information systems. It has been virtually impossible to create a system in which multiple providers can view and share patient data while still maintaining an authoritative and up-to-date record. Blockchain allows the participants to maintain their own systems yet share the patient records in a permissioned manner while tracking this process in an end-to-end manner. So, this provides for proof of work as well as a time-stamped audit of the transactions.




This process is often performed through an inefficient, time-consuming series of paper, phone, and unencrypted email-based communications that result in lost time for staff and excessive costs for practices. However, automating the process through blockchain enables easy data sharing among payers, providers, and care team members, removing the need for many manual tasks. Blockchain-enabled smart contracts codify business rules associated with referrals, such as whether certain payers or practices require specific forms to execute referrals, which streamlines communication among participants.


It’s important to note that blockchain is not the solution to every healthcare problem under the sun. Blockchain works best for solving problems that involve sharing data among multiple, disparate entities-a scenario quickly becoming the norm under value-based care models, which focus on care coordination and outcomes throughout.

Rahul Sharma is chief executive officer of HSBlox, a team of blockchain healthcare, financial technology, and digital supply chain management professionals.

Digital ledger holds the potential to improve practice processes, but don’t get blinded by hype.

Blockchain can simplify physicians’ lives

Payers fracturing physician-patient relationship



It isn’t so much that patients don’t trust their doctors, but more that the respect for them is diminished. When I was in medical school, I was told that we were not just doctors but scientists who should strive to make healthcare better.
Now we are called providers that follow algorithms and everyone has a doctoral degree. Thus, the term doctor to the patient is not as meaningful as it used to be. Patients also see the money aspect more today. In the past, you paid the doctor either cash or your deductible and that was all. Today the system nickel-and-dimes people with constant copays and extra fees that the doctor has to collect which makes the patient think we only care about the money. Due to reduced reimbursement, patients also see doctors selling them braces, vitamins, stem cells, Botox, and anything else that is cash. That is why the trust is gone.
Patients wonder if they get a good deal for their dollar when they are badgered about money at the front window and then the doctor walks in and abruptly walks out or tries to sell them something not covered by their insurance. The unfortunate flip side of this is that people want medicine to be like the airlines: cheap, on time, and with no errors. I believe that we have gone down a road that has no turns and where it ends is probably not good.

When cost trumps care, doctors lose respect



n response to “Waning trust in physicians,” (April 10), the lack of trust in physicians by our patients can be laid squarely at the feet of the health insurance industry. They collect the premiums, decide whether or not to pay for the care decided upon by patient and physician, and then make statements such as “investigational,” “experimental,” or the most oxymoronic, “we are not against the treatment but we will not pay for it.”
As the middleman that muddies the waters and profits the most by doing so, we would see a tremendous improvement in the appropriate care of patients if health insurers were required to pay for all healthcare deemed medically necessary and beneficial to our patients. The level of customer (patient) satisfaction would be unprecedented.
Until this scenario occurs, we will just continue to treat the symptoms of the health insurance “cancer” rather than getting to the root of the problem.

Solo practice ‘in their death throes’



Unlike Keith L. Martin in “No matter the pressure applied, independent physicians will survive” (First Take, April 25), I do not share the optimism of the 80-year-old family doctor mentioned in the article who said that independent physicians will survive.
Perhaps large independent groups of say five or six doctors will survive if they have the help of nurse practitioners and physician assistants and if they use EHRs, and if they have staff that is adept at coding they may just make it.
But not the solo practices. Many are already in their death throes.
Solo practitioners in general practice except in some rural areas will soon become a thing of the past.
Despite the optimism expressed by the veteran solo practitioner (I liked his attitude), the combination of the physical and emotional stress that goes along with seeing patients, complying with insurers’ rules and regulations, and trying to survive financially in solo practice have already begun turning young doctors away from solo practice.

Your voice: Payers fracturing physician-patient relationship

Estate planning may not be the first item on the to-do list once physicians complete residency and start practicing, but it should be.

Physicians have similar concerns and needs when it comes to estate planning as non-doctors do, but they accumulate wealth to a greater degree and more quickly than most people, says Kara Rademacher, JD, an estate planning and administration attorney with New York City-based law firm Douglass, Rademacher and Brown. Furthermore, physicians work in a profession with a high likelihood of getting sued, hence the more urgent need for estate planning that protects assets and puts in place direction for transitioning or unwinding a medical practice.

But one of the main obstacles in conducting due diligence in estate planning is contemplating death, a task no physician enjoys, says Lori Anne Douglass, JD, an estate planning attorney and colleague of Rademacher at the law firm. So she suggests that her clients to reframe their perception of estate planning.

It is, she says, about protecting assets for future use before death as much as it is for leaving a legacy. “People think of estate planning as planning for your death, but it’s really planning for your own future.”

To ensure effective protection, physicians must put in place basic estate planning documents and consider going above and beyond those with some asset protection strategies.

Core estate planning documents, dictating what happens to a person’s assets after death or incapacitation, include a last will and testament, a financial power of attorney, and a medical power of attorney.

There are do-it-yourself services for creating a will, but a physician’s estate is complicated enough to warrant hiring an attorney, says Rademacher. “Physicians should look for an attorney who has expertise not only in estate planning, but in asset protection and business succession planning as well,” says Rademacher.

One way to find a reputable estate planning attorney is to ask for a referral from another attorney, such as a real estate attorney. Attorneys, Rademacher says, tend to be well connected with each other across practice areas and often have a good sense of expertise and quality. Financial advisers or other service professionals, such as accountants, could also be resources for a referral.

Other sources for finding an estate attorney include the local bar association and a lawyers’ rating service called the Super Lawyers directory for the geographic area where the physician lives or works.

Physicians should identify two or three potential estate attorneys and call each to learn what their services cost, how the bill is calculated, and when payment is expected, says W. Ben Utley, CFA, president of Physician Family Financial Advisors in Eugene, Ore. Utley often gets estate planning conversations started with his clients and then connects them to estate planning resources.

After selecting an attorney, physicians should make two key appointments at the same time: the first to discuss what should be in the will and the second to execute what was discussed in the first appointment, he says.

To save money, there are steps physicians should take before meeting with the attorney, Utley says, such as deciding who will be named guardians of any children or what happens to assets in the event of the death or incapacitation of all beneficiaries named in the will. Physicians should also make lists of all assets, all debts, any life insurance documents, and beneficiaries (such as for 401(k) plans).

“It’s better to do this thinking when you’re at home than when you’re sitting in front of an attorney at $300 an hour,” he says.

The will is the centerpiece of an estate plan. It dictates how and to whom assets are distributed after death. It also designates an executor-the person who will administer the estate.

An effective will not only sets forth the wishes of the testator (the person making the will) but also provides for contingencies, says Rademacher.

For example, if, at the time the testator signs the will, he or she is married without children and has assets below the federal and state estate tax exemption amounts, the will should set forth how the estate should be administered if a spouse survives or predeceases him or her and what to do if there are surviving children.  

A will also should designate someone to manage digital assets, Rademacher says. That person will have the authority to close social media profiles, shut down blogs, or transfer them to someone else. Without legal designation in the will-or in a financial power of attorney in case of incapacitation-online accounts often can’t be touched, she says.

Some states have regulations about digital asset management after death or incapacity. If a physician only takes one estate planning action, the last will and testament is the way to go because it ensures the testator’s wishes dictate what happens rather than the state being in control and it will save the surviving family a lot of hassle.

Thomas Leitner, MD, JD, a Wisconsin-based attorney specializing in estate planning, was about a decade into his career in internal medicine when his father, living in New York, died unexpectedly. While his father was in his early 80s and had “reasonable” financial resources, he hadn’t set up a will. A concentration camp survivor, Leitner’s father was intensely private and reluctant to discuss personal matters-even with his family-and distrusted lawyers intensely. Without a will, his estate went into probate. “It was an eye-opening experience to say the least,” Leitner says.

It took over 18 months and $30,000 in legal fees to resolve his father’s estate. Having an estate plan in place is important, he says, “… because if you don’t and you pass away early, you will introduce unwanted complications for your family for a process that should be fairly smooth.”

The second core estate planning document is a financial power of attorney. An effective one grants an assigned person the authority to manage the finances of an individual who is alive but incapacitated.

Upon death, this document (and the medical power of attorney) becomes null and the will takes precedent. A financial power of attorney is particularly important for physician practice-owners, says Douglass, because the designated person will be able to guide what happens with the practice-for example, whether to keep it operating if there is a short-term incapacity or unwind it if it’s permanent.

As with the will, someone familiar with the practice should be selected as financial power of attorney due to the particularities of running a medical practice, for instance, knowing how to handle HIPAA-regulated patient files. The third core document is a medical power of attorney. It designates someone to make healthcare decisions, Douglass says, and that applies to any health-related situation, not just end-of-life.

So, for example, if someone is in surgery and a surgeon needs permission to do more extensive surgery than originally planned or someone has become mentally incompetent and needs someone to direct medical treatment for ongoing care. A medical power of attorney appoints someone who knows and is willing to carry out the medical and end-of-life wishes of the principal.

In addition to those three core documents, physicians may want to consider other estate planning strategies that help protect their assets. One of the simplest strategies is titling of assets, says Rademacher. Assets are put in the name of the physician and that of another person or entity, such as a trust, and those assets will be protected from creditors.

A trust is also a popular option for protecting assets, she says. There are a number of different trust types, and a thorough conversation with an estate lawyer will help determine which is best. There are pros and cons to trusts, says Laura Johnson, JD, who specializes in estate planning at Baltimore, Md.-based law firm Gordon Feinblatt.

On the con side, they can be cumbersome because they have trustees and are separate tax-paying entities that require separate tax returns. On the pro side, they offer a measure of protection from creditors and some control in difficult or unusual family situations. For example, if a child has a disability and is eligible for governmental assistance for that disability, a trust can set up a support system that wouldn’t circumvent or disqualify the child from receiving those benefits. No matter what protective measures are put in place, it’s best to set up that protection before getting sued, she says. Physicians don’t want to be accused of fraudulent conveyance-where assets are transferred solely to avoid a creditor

Initial estate planning is only the beginning, says Rademacher. “Physicians keep their estate planning documents relevant by keeping the asset protection features up-to-date,” she says.

For example, if a doctor establishes a family limited partnership to transfer wealth to the next generation but fails to properly maintain it, those funds, or some of those funds, may be accessible to creditors.

As a general rule, Rademacher says, physicians should review their estate planning documents whenever there is a significant change in circumstances, such as marriage, divorce, the birth of a child, or meaningful change in wealth, or, if there are no significant changes, every five years.

Given their salaries and chances of getting sued, physicians should strongly consider estate planning after residency.

Estate protection: Plan early, plan often

Physician reimbursement is being increasingly impacted by patient satisfaction scores. Once, this was something only hospitals had to worry about, but now it’s affecting practices of all sizes. If you are participating in Medicare payment reform, known as MACRA, it may impact you even more.

But for those who are exempt, value-based reimbursement is the trend, and patient satisfaction will affect revenue, if it isn’t already. Unfortunately, getting those good scores is becoming harder. Patients are comparing their healthcare experience against their experiences in retail and the service sector. And, let’s face it, healthcare hasn’t been known for providing modern, super engaging, seamless experiences.

Still, one study showed that about half of patients expect the same customer service experience in healthcare that they get in retail. From the way patients find a provider-through online reviews-to the way they communicate before and after visits-via text-patients do want a more seamless digital experience.

And they are showing their frustration with a poor experience and communication by walking out. One in 10 patients left their primary care physician last year and one in three say they may leave in the next two years, according to Solutionreach’s Patient-Provider survey. Nearly 40 percent of those who already left said it was entirely about experience.

This trend shows it’s more important than ever to be able to track and monitor patient satisfaction and take steps to make improvements to meet the changing expectations of patients. To effectively gauge what patients think and identify areas for improvement, here are four best practices to follow:

Keep it simple: You can’t do anything about preset CAHPS surveys, but you can control the length and complexity of a patient survey you send out. It shouldn’t take more than five minutes to complete and should focus on a single topic, like their recent visit or changes you’ve made like new technology or services. Don’t do it all in one survey.

Be timely: For a post-visit patient survey, send it out within 24 to 48 hours. The sooner the better. You want to strike while patients remember their experience.

Get hard data: Avoid creating open-ended survey questions. It’s appropriate to have a spot at the end for additional comments, but you want to be able to easily analyze the data. Use multiple choice and “yes” or “no” questions. For example, don’t use, “Tell us what you thought of the wait time.” Instead, ask, “Was the wait time reasonable, yes or no?”

Go digital: Create and send your surveys electronically. People prefer online survey 30 times more than paper ones. Using a digital platform also allows you to automate the sending of surveys, personalize them to the patient, and easily see the results.

If you aren’t currently conducting patient surveys, then your priority should be to get one in place and start gathering data about your patients’ experiences.

This baseline information is what you can use to make improvements. There are many solutions you can use to generate electronic surveys, but one designed for healthcare will provide some preset questions that you can customize to your practice.

Also, consider editing or adding some questions to help you gauge how you are doing in addressing patients’ top frustrations. The Solutionreach Patient-Provider Relationship Study identified a few key areas of poor experience from the patients who had left their provider in the last year.

These included:
• Poor experience with office staff
• Feeling more like a number than a person
• Difficulty scheduling (both wait times and availability of methods for scheduling)

Take the opportunity to ask if staff were friendly, if patients found it easy to schedule an appointment, and if they received communications from the practice through their preferred method (i.e., text or email). If scores are low for friendliness, then you know this is an area for improvement. If lots of patients say they’d like to get communication via text and you aren’t offering that, then you know that is something to change.

Take this simple feedback and make a list of areas to work on. Then you can begin to tackle improvements. Some tips to make that process more successful include:

• Group potential improvements into small changes and big changes. A small change might be something like temperature control and a big change might be service training with staff.

• Tackle bigger changes one at a time. The little things like adding a coffee station to the waiting room can quickly be ticked off the list.

• Get as much buy-in on the big changes as possible. Share the feedback from patients and ask for input on how to improve. Get the staff involved and engaged.

• Be open to changes or upgrades in technology and processes to help address problems.



Finally, make sure that as you implement changes and settle into new ways of doing things that you follow up to see what patients think. Surveys should not be static. If you’ve made changes, then change your post-visit survey or send out a single survey specifically about those changes. Following up shows patients you are committed to improving their experience and continues to engage them in the process. These types of ongoing interactions and engagement are a key way to build loyalty at a time when patients are more likely than ever to go elsewhere when they are dissatisfied.

Patients are comparing their healthcare experience against their experiences in retail and the service sector. And, let’s face it, healthcare hasn’t been known for providing modern, super engaging, seamless experiences.

5 best practices to improve practice performance and patient satisfaction scores

Patient portals once were seen as a solution to overworked staff and lack of patient engagement. But even though they’ve been available for decades, portals have yet to meet those lofty expectations, a situation for which both patients and doctors share the blame, experts say.

Portals enable patients to view their health records and lab results online, share the information with other providers, and exchange secure messages with their doctor and practice staff. CMS thought portals were sufficiently important to require them for EHRs seeking meaningful use certification, and then include them as part of the Merit-based Incentive Payment System.



Patients’ reluctance to use portals is documented in a 2017 Government Accountability Office (GAO) report. It found that, as of 2015, only 30 percent of outpatient Medicare beneficiaries were using them, even though 87 percent of Medicare-eligible practices made portals available to their patients.

But the fact that most practices now have portal capability doesn’t mean providers are using the technology to its full capacity, says Michael McCoy, MD, the first chief health information officer at the Office of the National Coordinator for Health Information Technology. “Most physicians haven’t really embraced using it in a way that shifts workload, which is one of the things online access was meant to do,” he explains. For example, many practices don’t use portal features, such as allowing patients to schedule visits or check-in online, that would save time and streamline practice operations.

The GAO report found that portal use is lowest among patients at practices in rural or high-poverty areas, areas with a higher-than-average percentage of residents over age 65, and practices with 10 or fewer providers. In other words, age, poverty, and lack of access to broadband often are impediments to widespread use of portals.

Those findings are reflected in physicians’ experiences with getting patients to use portals. Charles Cutler, MD, an internist in the Philadelphia suburb of Norristown, Pa., says his practice began signing up patients for its portal a little over a year ago, but thus far, not many have used it to communicate with him. “I have a practice that is largely geriatric and blue collar,” he says. “They still prefer to contact me by telephone. There just hasn’t been that much interest in e-mail.”

A few of Cutler’s patients have been using the portal to view results of their lab tests, a fact that he usually discovers when the patient comes in for something else. “I’ll say, ‘I see you had blood tests a few months ago and we haven’t discussed those results,’ and they’ll tell me ‘I looked at the results online and they were all normal, so I didn’t think I needed to call you,’” he says.

Gordon Jones, MD, a primary care practitioner in a multi-specialty group based in Sikeston, Mo., says he and his colleagues began signing up patients for its portal about five years ago, but “We have a great deal of difficulty persuading people to get on it,” he says. He estimates that about 10 percent of his patients are using it.

Part of the problem, he says, lies in Sikeston’s location, a rural area 150 miles from St. Louis and Memphis. And though most of his patients have internet access, few have high-speed broadband in their homes, making portal use more difficult.

The challenge is compounded, he says, by older patients’ discomfort with computers. “But there’s also the problem that if you go to multiple doctors, they each have their own portal that you have to remember passwords and sign-in codes and everything else, so it becomes just one more thing to be hassled with.”



McCoy, who is now CEO of Physician Technology Services Inc., attributes providers’ unwillingness to fully utilize portal features to the fact that they could lead to changes in practice workflows and/or make some staff members redundant-neither of which are easy topics for practices to address. “Who wants to talk about staff reductions? They’d rather tick along as they are than make some of those hard decisions,” he says.

Moreover, features such as scheduling appointments online now are routine among other types of service providers, and the fact that they’re often not available in healthcare adds to patients’ frustrations with portals, McCoy notes. “If you can go online to buy an airplane ticket, select a seat, and check in for your flight without ever talking to a human, what’s so difficult about being able to schedule a routine physical exam?”



Still, with all their shortcomings, many physicians feel portals benefit them and their patients in a variety of ways. “From a doctor’s standpoint, one of the nicest parts is the ability to communicate more easily with patients,” says Betsy Greenleaf, DO, an OB/GYN in a Rumson, N.J., group practice that’s been using portals for about five years.

Greenleaf frequently uses the portal to communicate lab results to patients. “For tests with normal results, it’s an easy way to send messages because there’s usually not much discussion involved,” she says. “And it’s great from a business standpoint because you don’t spend as much time tracking people down and dealing with telephone tag.”

Patients also appreciate the ease of communication, along with features such as the ability to request prescription refills at any time. “If you realize at midnight you need a refill, you can’t call a doctor, but you can send a message through the portal,” she says.


Greenleaf also likes that portals provide opportunities to communicate with and educate patients beyond face-to-face visits, such as e-mailing summaries of visits or links to websites where patients can find additional information on a topic.

“I’m a medical professional and even I will sometimes leave a doctor’s appointment and think, ‘What did he just say?’ So it’s nice to be able to go back and look at what I’m supposed to do for a follow-up. I think care gets delivered a little better because of that,” Greenleaf says.

Along the same lines, the fact that patients can access their doctors’ notes becomes an incentive for doctors to ensure their notes are clear and accurate, says Robert Rowley, MD, a health IT consultant and primary care practitioner in Hayward, Calif. “It requires you to be more transparent and accountable for what you write, because the audience is no longer just you,” he says. “That’s a good thing, in my opinion.”
Andrew Carroll, MD, owner of a two-physician primary care practice in Chandler, Ariz., says the portal has become a valuable marketing tool. He attributes that in part to his making an “easy-to-use, robust” portal a priority when he purchased his EHR in 2014. In addition, he strives to respond quickly to messages he receives via the portal, and to personalize the responses.

For example, he says, when he sends a patient their lab results, “I’ll create a secure message along the lines of, ‘Your labs are really great, that change we made in your meds seems to be working. Stick with it and I’ll see you in a few months.’ “Patients want an experience through the portal that they find easy to use and where you the doctor, not somebody who is your proxy, communicates back to the patient,” he says.

Carroll estimates between 15 and 20 percent of his patients use the portal, although they’re striving to grow that number by requiring new patients to register electronically, including demographic information, health history, and insurance information. “From day one, we’re trying to show patients that we are a practice using a lot of tech tools to help our patients engage in their healthcare,” he explains.
 



Probably the biggest complaint physicians voice regarding portals is how patients often respond to viewing their lab results: with unnecessary worry or by self-diagnosing with the aid of web searches. Cutler says he will sometimes get panicked phone calls from patients due to an abnormality as minor as a slightly elevated electrolyte level.

“You really need a doctor to interpret test results,” he says. “You can’t do it with Google.” Greenleaf agrees. “I don’t always like patients having full access to their test results, because then they consult Dr. Google and the next thing you know, they think they have a deadly disease and we’re getting panicked phone calls,” she says. “Sometimes too much information is not good.” Even viewing lab results can be frustrating for patients, McCoy says, despite the fact that it’s among the most common reasons they use portals. “Not all portals display the results well, show the highs and lows, and where the patient fits in that range, so the patient winds up getting more raw data than usable information,” he says.

Rowley, too, has had to talk down panicked patients, but sees it as part of the transformation of the physician’s responsibility brought about by portals and other forms of doctor-patient communication. “The role of physicians is evolving from being the keeper of all the facts, which we dole out to the patient, to being one of the facts are there for everyone to see ... For me, that’s the most rewarding position for a physician to be in.”

Even though they’ve been available for decades, portals have yet to meet their lofty expectations, a situation for which both patients and doctors share the blame.

Patient portals showing mixed results

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 below are that of the author and not of UBM / Medical Economics.

I frequently hear the lament that when a primary care physician converts to direct primary care (DPC)/retainer-based/concierge care models,  a lot of patients get left out, equating to patient abandonment. Some go so far as to suggest that it is unethical for the physician to downsize. I find this a false argument.

Consider first that the 2,500+ patients in a PCPs panel today are not getting the best possible care because the doctor is on a never-ending treadmill. It is a production line approach akin to the famous “

 where Lucy and Ethyl are wrapping chocolates on a conveyor line. They could not keep up but tried very hard. Then the supervisor said they were doing so well that the line was set even faster.

 by Joel Bessemer, MD, a DPC internist in Omaha, Neb.” 

“To those who say concierge doctors are hurting the system by diminishing the number of patients we can care for, my reply is: If you keep doing the same thing year after year, you are going to get the same results. If we don’t focus on salvaging the doctor-patient relationship and allowing the appropriate time for each patient’s care and follow-up, patients will begin to feel their primary care is a waste of time.” 

Yes, if lots of PCPs in one community converted all at once there could be a serious shortage. But that is not likely to happen. More likely is a gradual conversion process by those who wish to do so. It is not so unlike the PCP who quits his or her practice and seeks employment elsewhere. The affected patients will be cared for by other doctors in the community that still do “production line medicine.” If it is a rural or other area without additional physicians, then it is time to recruit more providers including nurse practitioners and physician assistants.

DPC, retainer, or concierge care need not be expensive. Once it becomes clear that people can get better care at a reasonable cost, the general public will be the ones who will pressure their PCPs to make the conversion. It is supply and demand. If the demand is there, the supply will increase; but only if the system is fixed. DPC is one way to fix the system.

The alternative is to wait and let the doctor totally burn out and close his or her practice; then no one gets the benefit of that physician. The current high visit number is a direct consequence of a reimbursement system that has paid too little for too long. If that had never happened, there would never have been the pressure to see too many patients or have too large a panel size. The need today is to get back to a reasonable number of visits per day. Using better technology and team functions, that number can be somewhat greater today than it was years ago but it still needs to be a reasonable number that the PCP can interact with appropriately.

One other point: Doctors today spend an inordinate time on nonclinical paperwork. DPC gives that 20 percent of time back. That dramatically lessens the PCP shortage.

And as medical students begin to observe that it is possible to be a high quality PCP giving superior care in a satisfying setting, then more and more will once again choose primary care.

Perhaps an analogy told me by primary care physician Josh Umbehr, MD of AtlasMD would be helpful. Think of PCPs as 60-watt light bulbs, he said. If you overload them, they burn out. Right now the bulbs (PCPs) are burning out from overload. DPC is like setting the bulb to 60 watts and keeping it there. It can function well for a very long time. A longer burn and more net light is equivalent to a long productive career with all patients getting expanded primary care. And since it is comfortable to burn at 60 watts, we are likely to see more light bulbs produced-more medical students choosing primary care again.

There is one other very important advantage: Total costs go down with many fewer referrals to specialists, fewer ED visits, and fewer hospitalizations. Given this reduction in total costs yet with greatly improved care and satisfaction, it behooves insurers (including government-sponsored Medicare and Medicaid) and employers to work with these models. They can benefit from the lower costs, the greater patient satisfaction, and improved health outcomes.

Primary care need not be expensive. Paradoxically the insurance methodology has made it so. In all these direct pay, concierge, and retainer/membership models, the physician and the patient break the bonds with the insurer and replace it with a direct contractual relationship with each other. The result is better care, greater satisfaction by the patient and by the doctor and reduced overall healthcare costs. That is certainly not patient abandonment.

Stephen C Schimpff, MD, MACP, is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and author of 

Longevity Decoded – The 7 Keys to Healthy Aging

While some claim it is unethical for physicians to go the direct-pay route, it actually provides better care to patients.

July 10, 2018 edition