Articles

Price transparency is one thing, but this is ridiculous.

Medical Economics cartoon: Are your costs too transparent?

An inevitable occurrence in any physician’s practice is the death of a patient. But in family medicine, deaths are an unfortunate part of the territory. They happen all the time.
	
	I think an important question to ask yourself is: “How do I as a physician respond to the death of one of my patients?” It’s a pertinent question because you have become a valued, respected member, yet peripherally, of the family. You have taken care of most of the family for years delivering their babies, giving them shots, treating their strep throats, pneumonia, broken wrist, caring for Grandma’s fractured hip, and holding their hands through chemotherapy. Now one of them has passed on. How do you respond to the family’s grief? How do you express sympathy for their loss?
	
	It’s possible you were there when your patient died, but if you weren’t, I think there are three ways you can show how much you share in their family’s loss. These are things I did while in practice and have continued to do after retirement.
	
	One, call the family on the phone and personally express your condolences, answer any pressing questions, offer prayers if requested, and offer emotional and physical support.
	
	Two, I no longer live where I practiced so each day I scan the obituaries of my old town’s newspaper for familiar names and make a point to send the family a hand-written note expressing my sympathy and sharing in their grief.
	
	Three, if the deceased has a funeral calling, make a visit and speak to as many family members as possible. Attending the funeral is an even better gesture. I have never had a family react negatively to my presence, and most express sincere appreciation and introduce me to family members who live elsewhere.
	
	Of course, each of us has his/her own way of expressing sympathy to grieving families. But I think calling, writing, or being there are important ways you can express your concern and help a family deal with the death of a loved one. Cynically, one might say I’m “grandstanding.” I completely disagree with that insinuation. Families hold their physician in high regard, and practicing the courtesies I mentioned are always met with thanks and endless praise.
	
	Showing kindness and concern almost never has negative consequences. Giving of yourself can only help and is very much appreciated by those on the receiving end.

William M. Gilkison, MD
	Cave Creek, Ariz.

Jenifer Frank, MD, in “How we can defeat burnout” (The Last Word, May 25, 2019, issue) mentions the main culprits behind burnout: long hours, poor remuneration, electronic heath records, EHR, quality metrics, and tort law.
	
	Until we doctors can find the courage to unite and confront the many forces aligned against us (which may be many years from now, if ever), the best remedy for burnout is to simply work fewer hours.
	
	Of course working fewer hours may be an economic impossibility for most. Putting APRNs and PAs into the health system may be the only solution.

Your voice: Dealing with the death of a patient

The federal government is pushing forward with regulatory action that it hopes will end data blocking and promote more sharing of patient information.
	
	The latest move on this front came in February, when the Office of the National Coordinator for Health Information Technology issued its proposals for implementing the provisions against information blocking that were laid out in the 21st Century Cures Act.More specifically, ONC is defining what does and does not constitute information blocking by detailing the seven specific scenarios it believes are legitimate reasons for clinicians withholding electronic health information (EHI).
	
	Experts say they see ONC’s move as signaling clinicians to more readily share EHI in all circumstances except for theseven exceptions it is outlining-a message that experts believe has the potential to greatly improve the free flow of patient data needed to ensure the best quality of care.
	
	“This is a big deal for providers, because you can’t be successful in the world of value-based care if you don’t have good information,” says Joel White, executive director of the Health Innovation Alliance (formerly Health IT Now), a nonprofit group promoting the use of information technology in healthcare.
	
	


	
	The Cures Act, passed in December 2016, seeks to encourage freer flow of EHI. To do that, the act tasked the U.S. Department of Health and Human Services, of which ONC is a part, with establishing the limited scenarios under which clinicians could withhold sharing of EHI.
	
	ONC in March published the details of the seven activities that it says should not be considered information blocking. HHS is accepting public comments on this proposal through June 30 before finalizing the regulations.
	
	ONC proposes that clinicians are not engaged in information blocking if they are

responding to requests that are infeasible

licensing of interoperability elements on reasonable and nondiscriminatory terms

maintaining and improving health IT performance.

ONC also established the conditions clinicians would have to meet under each of those seven scenarios to show that they’re not engaged in information blocking.
	
	


	
	Information blocking (sometimes also called data blocking) happens for various reasons related to policy decisions, business practices, and technical challenges, says ­Jeffery Smith, M.P.P., vice president of public policy with the American Medical Informatics Association.
	
	In some cases, clinicians aren’t sharing information because their computer systems cannot exchange patient data with other systemsbecause of technology barriers. This represents a lack of interoperability, which experts say remains one of the most common reasons why information isn’t freely flowing. Moreover many clinicians, especially in small, independent practices, find that the costs of implementing the technologies needed to create interoperability are prohibitively high.
	
	In other cases, clinicians are not sharing patient data because they incorrectly believe that the Health Insurance Portability and Accountability Act (HIPAA) prohibits them from doing so. Similarly, some clinicians may not be sharing patient data because doing so could violate other government privacy policies. For example, Smith says, some states require clinicians to get a patient’s consent before they can share information about the patient’s HIV/AIDS status.
	
	Meanwhile, business policies can block the exchange of patient data, White says. Some clinicians may not readily share-or share at all-any patient information with clinicians outside their healthcare system in order to keep patients within their own institution.
	
	Vendor policies can also block information sharing, experts say, as some clinicians find that when they want to switch electronic health record (EHR) vendors they have to pay steep fees to their former vendor to have the patient data transferred.
	
	Information blocking is not a new problem, he adds. White recalls working with clinicians in an emergency department in 2011 that couldn’t get needed EHI from a radiology department within its own healthcare system even though both were using the same EHR system. The reason? The radiologists had closed its application programming interface (API), a software tool that allows information to flow from one source to another.
	
	


	
	The proposed ONC rule outlining the seven allowable reasons for not sharing data could go into effect in some form later this year, after ONC reviews the comments it receives and makes any changes.
	
	Although health IT advocates say the government efforts could indeed promote more sharing of patient data, some also worry that the rules could be confusing, cumbersome, or costly-and possibly all three-for physicians.  “These may create new challenges and overhead costs for healthcare providers. It could create new burdens,” White says.
	
	As a result, the Health Innovation Alliance has cautioned ONC against implementing its proposal. In a March 25 statement, White said: “Patients and taxpayers have waited years for regulators to act to end information blocking because it threatens patient safety, raises health costs, and adds to provider burden and burnout. ONC’s own numbers show that we could save more than $3 billion in provider hours by getting this right, so we must not settle for weak rules that add to the regulatory headache facing doctors without delivering on their promises.”
	
	However, White further stated that while ONC is making progress in fulfilling the promise of increased data sharing as envisioned by the 21st Century Cures Act, the organization believes the proposed rules do not do enough to counteract information blocking.
	
	Meanwhile, the AMA and several industry organizations successfully lobbied for ONC to extend its comment period from early May to the end of June. An AMA spokesman said the organization has concerns over other areas that impact the flow of data. The AMA has specifically cited excessive fees to connect EHRs to each other and with other health IT; the technical limitations vendors use to limit data made available by their APIs, and EHR vendor contractual roadblocks that restrict physicians from freely choosing which software or service to use.
	
	Similarly, Robert Tennant, MA, director of health IT policy for the Medical Group Management Association, says it’s unclear to what extent the ONC proposal will enable more data sharing among physicians and others. For example, Tennant points to the exception regarding “reasonable fees” and wonders if it will mean that many physicians will continue to face prohibitively high costs from vendors.
	
	“ONC uses the term ‘reasonable fee,’ but reasonable isn’t a technical term. And while ONC might have some oversight over the term ‘reasonable,’ I think physician practices at the end of the day will be the ones who are going to pay for this,” he says. “I think the cost is going to continue to be a barrier, particularly for primary care physicians who don’t have a lot of extra money to spend on technology.”
	
	


	
	Tennant recommends physicians review their practice policies and procedures to make sure there’s nothing in them that unnecessarily blocks the transfer of patient data.
	
	He also advises physicians to talk to their EHR vendors about when their products will be 2015-certified – if they’re not already – according to the standards set by CMS, as 2015 certification requires APIs to promote interoperability.
	
	Physicians should also talk to other physicians as well as representatives from professional associations and Health Infromation Exchanges (HIEs) to ensure they’re keeping pace with best practices and technology innovations that promote information sharing.
	
	“If physicians can get the right technology in place and fit it into their workflow so that they can share information,” Tennant says, “it could mean a lot of better data in the hands of the physician-and that means better healthcare for their patients.”

The federal government is pushing forward with regulatory action that it hopes will end data blocking and promote more sharing of patient information.

What’s being done to stop EHR data blocking?

Chronic care management (CCM) has an overarching clinical goal-improving the health of Medicare patients with multiple chronic conditions.
	
	Besides knowing the service parameters, pay rates and usage requirements for CCM codes, physicians must understand how to effectively bill for CCM in order to profitably achieve that goal. 
	
	


	
	Medicare pays for CCM (typically, non-face-to-face) services to patients with multiple chronic conditions that are expected to last at least one year and present a significant risk of death, acute worsening of those conditions or functional decline. Three primary codes define this type of billable care:

 – Patients receive CCM services through at least 20 minutes of clinical staff time each month. The provider must also create a dynamic comprehensive health plan – i.e., an electronic care plan that assesses patient factors (physical, mental, cognitive, psychosocial, functional and environmental) and inventories all available care resources. The vast majority of Medicare claims are billed under this code.
	
	

– Similar to the first code, except that the patient receives complex CCM services, minimum monthly clinical staff time is 60 minutes, and the necessary medical decisions are moderately or highly complex. (Complex and non-complex CCM services differ in the amount of clinical staff time, care planning, and billing practitioner work.)
	
	

 – This covers each additional 30 minutes of clinical staff time each month and also applies to complex services.

Primary CPT code rates run from $42.17 for 20 minutes (CPT 99490) to $92.95 for 60 minutes (CPT 99487), with the rate for the extra 30 minutes under CPT99489 being $46.49.
	
	Providers ordinarily can bill for CCM services under only one code per month, though services for both complex codes can be billed if the practice meets each code’s reporting time requirement. CCM can’t be billed in a month when the patient receives home health or hospice care supervision or services involving certain end-stage renal care, transitional care management or prolonged evaluation and management services.
	
	Before billing for CCM services, providers must satisfy these basic preconditions: Patients must give verbal or written consent and pay 20 percent for coinsurance; the billing practitioner must make an initial visit with the patient within 12 months of the first CCM claim; provide 24/7 access to care; use a certified EHR to aggregate all patient health information; and establish continuity through a designated care team member who works with the patient to implement a dynamic plan that spells out the patient’s key prevention and treatment goals and strategies.
	
	


	
	By billing for CCM, practices can cut expenses and boost revenues. A Mathematica Policy Research Group study found that providing CCM services reduced growth in total monthly expenditures by $74 per patient over 18 months while averaging revenues of $18 whenever a patient received healthcare services for a specific condition within a month. CCM program savings were $95 per beneficiary per month when beneficiaries received healthcare services more than once in that month.
	
	The report, which tracked costs for patients enrolled in CCM programs vs. costs for non-CCM beneficiaries between 2014 and 2016, also suggests that practices adopting CCM will score very well in the cost category of the Merit-based Incentive Payment System’s performance scores.
	
	These results largely flow from the improved care that CCM has delivered by increasing patients’ connections with their primary care provider and decreasing hospital and emergency department visits, and, per the Mathematica study, from an approximately tenfold increase under CCM in the rates at which patients establish advance care directives with their providers.
	
	Yet Martie Ross, JD, a founding partner in the healthcare management consulting practice PYA, in Overland Park, Kan., says the formula for Medicare reimbursement rates-adding physician work effort and practice expenses-makes it tough for most practices to offset the infrastructure investment needed to make CCM work.
	
	Practices that have discovered how to make CCM profitable “have some things in common-most importantly, the primary care provider directly introduces the services by engaging the patient in an initial conversation about CCM” instead of handing out a descriptive form or recruiting patients by phone, she says.
	
	Membership in an ACO can ease that infrastructure cost burden, because the ACO can efficiently provide CCM services through a hub serving multiple practices. For instance, an ACO that PYA advises has provided 30,000 CCM services through a team of health coaches across 30 rural Kansas counties through a centralized team of care managers under the supervision of a physician who also handles all CCM billing.
	
	“In this model, the peer managers all have access to the practice’s EHR, so they can see the electronic health record of the patient for whom they’re providing CCM and also enter data and maintain the care plan within the patient’s EHR,” Ross explains. Moreover, ACOs can give multiple providers access to the data analytics required to manage patients in a value-based contract.
	
	


	
	Fee-for-service (FFS) billing is still used by most practices.  But if practices are to cope with CCM’s administrative, clinical, documentation and billing requirements, they must change their FFS mindset, says William Mills, MD, ABIM, founder of Chronic Care Management, Inc., a Solon, Ohio consulting firm that helps providers implement CCM technology and services.
	
	“The groups that do the best with CCM have buy-in from their leadership team to start taking a population health management (PPM) approach to their chronically ill patients and also are interested in a new per-patient, per-month revenue stream,” Mills says. In his view, an individual physician or practice with anywhere from 500 to 2,000 or more patients could develop a very significant gross revenue stream by billing 42 to 90 or so dollars per patient per month.
	
	Effectively furnished and profitably billed CCM also requires an advanced technology platform to enable CCM workflows. It needs to use evidenced-based tools to assess risks such as emerging functional, social or psychological complications, acute care utilization, and the concurrent usage of multiple drugs to treat a condition. It also should generate a comprehensive care plan and an audit trail to ensure compliance with CMS rules.
	
	


	
	If a practice’s CCM program is big enough, it can even contribute to CCM enrollment among healthcare professionals outside of the practice. CareMount Health Solutions, the physician-owned Medicare coordination subsidiary of CareMount Medical, a multi-specialty practice in six New York counties, is doing just that.
	
	While CareMount has targeted up to 10 percent of its own 25,000 Medicare beneficiaries for CCM services delivered by its own primary care providers, “We’re also starting to branch out and educate our specialists, who may not be following patients who have primary care physicians within our group, but are still following patients who are quite ill and eligible for CCM services,” says Lisa Bardack, MD, chair of CareMount’s department of internal medicine. “Those specialists are now interested in utilizing the CCM platform we developed.”
	
	At the same time, CareMount’s scale and CCM platform sophistication have positioned them to help practices-at a competitive cost-that can’t do CCM on their own. “We’re looking at capturing smaller medical groups or individual providers outside of our organization who may want our assistance in participating in a program like this,” adds Bardack. Clinical care coordination, quality improvement, population health and data analytics are among the services CareMount may offer in this regard.
	
	


	
	Given the administrative challenges of CCM billing and the expertise needed to aggregate and analyze data available with an advanced EHR platform, it may be that most practices don’t have the bandwidth or experience to operate CCM themselves, says Mills. Going in-house might seem economical, yet it’s expensive to recruit, train and equip qualified people who can manage the care and provide full, accurate documentation and billing. But Mills cautions that “a disadvantage of outsourcing can be that unless there is a good bilateral agreement between the practice and the CCM enabler (vendor), the identified patient risks and care gaps are difficult to address.”
	
	According to Mills, it’s up to the practice to close any such gap that the vendor identifies, but since the vendor doesn’t practice medicine, developing a workflow that effectively addresses those gaps “depends upon good collaborative communication and workflow setup.”
	
	Failure to detect and eliminate those risks and care shortfalls can delay the interventions necessary to prevent a hospitalization or other care crisis and keep patients from accessing support services that complement their medical care. To make certain that both parties are on the same page, the practice may want a services agreement that commits the vendor to furnishing services that establish round-the-clock care coordination, such as conducting monthly reviews to refresh the care plan; ensuring that patients receive all of their recommended preventative care; operating an online care management portal to inform and answer questions from the patients and their families; reminding patients about upcoming visits and therapy through texts and phone calls; and facilitating the delivery of community resources when necessary.
	
	Beware of third-party vendors who promise significant revenue from CCM, warns Ross. “Instead, what makes sense is finding a third party partner who helps you more effectively reach and manage patients that demand a lot of your resources and staff time-and who can help you cut your CCM management costs.”
	
	Nor should practices equate outsource value with how many of their patients the vendor can call every month. When River Bend Medical Associates, a family practice in Sacramento, Calif., began its CCM program in 2015, it started small, targeting about 100 of its sickest, highest-need patients, and sought an outside vendor that aligned with that approach and would assist, rather than run, its program.
	
	But most of the companies the practice approached wanted to take over the program, take 50 percent of River Bend’s CCM reimbursements “and just hit as many of our patients each month as possible,” recalls Francisco Garcia, MD, the practice’s leader. Instead, River Bend hired a vendor who charges much less and risk-stratified patients by acuity levels, with highest-acuity patients getting at least one call each month and those with lowest acuity getting quarterly calls.
	
	That, and a relationship-based strategy assigning a care coordinator to each CCM patient has resulted in high patient satisfaction, minimal disenrollment and a sustainable operation.
	
	Taking a value-based approach to CCM that combines robust enrollment, the aggressive and correct documentation of billable activities, and the efficient, needs-based delivery of services to patients can give practices a CCM program that reduces the total cost and increases the overall quality of patient care.

Besides knowing the service parameters, pay rates and usage requirements for CCM codes, physicians must understand how to effectively bill for CCM in order to profitably achieve that goal.

How to deliver effective and profitable chronic care management

When  physicians think about buying insurance they tend to focus on medical liability coverage, and understandably so: It’s probably the largest premium they’ll pay and it applies to the risk that usually worries them the most.
	
	But doctors may overlook other types of insurance that can be just as crucial to protecting their assets and livelihood-coverage for everything from fire and hacking to employee theft. In some states, certain forms of coverage are required by law, a mandate of which practices might be unaware.
	
	“I find coverage holes all the time,” says Richard Weston, CIC, a senior account executive at Physicians Insurance Agency of Massachusetts. “Practices don’t know what’s required or what they need until it’s too late.”
	
	Insurance needs vary among practices  and not every practice needs every type of coverage, but here is a guide to some of the common forms, beginning with two often required by law:
	
	


	
	Regulations vary from state to state, but many require small businesses with more than a certain number of employees to provide workers’ compensation coverage. This covers medical expenses and a portion of lost wages for employees who become ill or injured on the job. Coverage can also include employee rehabilitation and death benefits.
	
	This type of coverage is relatively inexpensive, says Weston, who estimates the annual cost at 28 cents per $100 of payroll.
	
	


	
	The Employment Retirement Income Security Act sets rules and standards for private sector employee benefit plans, such as 401(k)s, and the people that manage and invest their assets. ERISA requires fund managers to be covered by a fidelity bond to protect the plan from losses due to fraud or dishonesty. The coverage is specific to a practice’s retirement plan with the amount of required coverage at the lesser of $500,000 or 10 percent of plan assets. A bond typically lasts three years and can cost less than $500, Weston says.
	
	


	
	This protects against claims for bodily injury and property damage arising out of operations, premises, and products. These policies are often required by landlords as a condition of leasing.
	
	


	
	This covers damages to buildings, so a practice would obtain this type of insurance if it owns its own building. But even if a practice leases space, it needs this insurance to protect against loss of medical and office equipment, fixtures, and furniture due to theft, fire, water damage caused by broken pipes, etc.
	
	Property insurance often is bundled with general liability in a business owners policy (BOP), says Patrick Lawn, owner of Physicians Insurance Consultants, an independent brokerage in Pennsylvania. A BOP also can be expanded to include worker’s compensation, cyber, and other forms of coverage, he adds.
	
	Premiums depend on a variety of factors, including the size, age, and condition of the building; value of the contents; whether the building has fire sprinklers etc. A typical policy for a small practice might cost about $2,000 a year, Lawn says.
	
	


	
	This is a relatively new form of insurance, but it’s becoming a necessity, even for practices that might think they’re too small to attract hackers. It covers losses and damages resulting from patient data being stolen, exposed, improperly shared, or held for ransom. 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 exposes patient data.
	
	A comprehensive policy will cover paper records as well, since so much information is still stored in physical files. It also should include first-party and third-party coverage. First-party coverage pays for damages suffered by the policy holder, while third-party coverage compensates for damages caused to others by the data breach, such as legal costs incurred from lawsuits filed by affected patients.
	
	Malpractice and general insurance policies often include some cyber coverage, but usually not enough, Lawn says.
	
	When shopping for cyber insurance, be sure the carrier is required to provide a comprehensive range of assistance in event of a breach, such as paying regulatory penalties, hiring IT experts to find and fix the breach, hiring attorneys to defend patient lawsuits, and paying ransom to free hijacked data.
	
	


	
	This provides income in the event that a practice cannot function or bring in revenue  because of an event such as a fire or natural disaster. It differs from property insurance in that it covers lost income.
	
	


	
	No practice likes to imagine misconduct from an employee, but it happens, says Kenneth Hertz, FACMPE, principal consultant with Medical Group Management Association. He advises practices to have every employee who handles money, whether cash or credit card payments, be bonded because “you never know when theft is going to raise its ugly head.” 
	
	


	
	This policy protects a practice if it’s sued for reasons such as discrimination and sexual harassment. Coverage protects the physician owners as well as claims against the staff, such as an HR manager. A 10-person practice might pay $1,500 a year for a $1 million policy, Weston estimates.
	
	


	
	This coverage comes into play if a physician or other significant revenue generator is disabled and unable to bring in revenue. In that case, the policy replaces that income. This is particularly important for smaller and solo practices where the loss of one physician could threaten its existence.
	
	Any policy should define disability as a physician no longer being able to work as a physician, rather than as complete disability, says Lawn. That is to prevent an insurer from denying a disability claim if a physician could perform a different job.
	
	


	
	This provides medical, disability and, sometimes, life insurance for employees and owners. While these types of coverage are not always required by law it is difficult, if not impossible, to attract employees without offering them as benefits.
	
	


	
	If an owner or employee uses company or personal vehicles to perform any sort of task related to the practice, such as making bank deposits, delivering lab samples, or picking up supplies, the practice could be held liable in the event of an accident. A commercial auto insurance policy can protect the practice. One way to avoid needing this coverage is by using couriers, taxis, or ride-share services, says Hertz.
	
	


	
	It might seem with all these policies that a practice wouldn’t need any additional coverage, but experts recommend a policy to guard against catastrophic awards that exceed the limits of other coverage.
	
	These umbrella policies, so called for the way they shelter everything beneath them, typically provide an additional $1 million in coverage. They can be written to cover a range of claims and cost roughly $500 a year for $1 million of coverage, according to Weston.
	
	


	
	Does a typical independent practice need every policy listed above? Not necessarily, says Hertz, who warns against buying so much coverage that a practice becomes “insurance poor.”
	
	Some forms of coverage, such as worker’s compensation and ERISA, are required by law while others, such as general liability, employee health, and property are fundamental to a practice’s ability to operate.
	
	Every practice must decide what other coverage it requires based on its exposure, tolerance of risk and ability to pay, Hertz says. He advises physicians seeking guidance to talk to colleagues about their coverage and experiences.
	
	


	
	Shopping for so many different types of insurance can be daunting and time-consuming. Many insurers offer most or all types of policies and it can be easier to go with as few vendors as possible. Insurers also sometimes offer discounts for bundling multiple policies.
	
	Weston recommends using an independent insurance broker who specializes in medical practice coverage. “A lot of generalists aren’t as well versed in the risks presented by a medical practice,” he says.
	
	But research the broker, adds Lawn: “There is a comfort level in using the same broker for all of your policies; however, is the broker contracted with the right companies? Your broker may not be able to provide you with the best priced carrier as they may not be contracted to represent them.”
	
	Don’t be afraid to ask for discounts and use comparison quotes to negotiate a better deal, says Hertz, who adds, “You don’t get what you don’t ask for.”
	
	And buying policies doesn’t require staying with the same carriers forever, adds Lawn, who recommends comparison shopping every few years to ensure the best pricing and adequate coverage.

Doctors may overlook insurance options that can be just as crucial to protecting their assets and livelihood as malpractice coverage. In some states, certain forms of coverage are required by law, a mandate of which practices might be unaware.

The other types of insurance doctors need

Amid a resurgence of measles across the country, many physicians aren’t sure how to talk with patients whose confidence in vaccines has wavered as a result of the anti-vaccination movement.
	
	Today, patients’ concerns about vaccinations fall along a spectrum, with some refusing all vaccines while others are more hesitant about specific immunizations like the MMR vaccine or receiving several vaccines at once.
	
	As vaccines have eradicated illnesses, some patients no longer view these diseases as threats. They may believe that real or perceived adverse events from vaccinations are a bigger threat than the illnesses themselves, says Saad Omer, MBBS, MPH, Ph.D., director of the Yale Institute for Global Health in New Haven, Conn., and a vaccination researcher.
	
	Mistrust of government, drug companies, and healthcare providers as well as misinformation about vaccines spread by anti-vaccine advocates are also factors fueling vaccine hesitancy. Along with access and insurance issues, they could be contributing to a downward trend in vaccination rates.
	
	CDC data show the percentage of unvaccinated children is rising, with 1.3 percent of children born in 2015 not receiving any recommended vaccinations, compared with 0.9 percent of children born in 2011.
	
	


	
	Douglas DeLong, MD, FACP, chair of ACP’s Board of Regents and chief of general internal medicine at Bassett Medical Center in Cooperstown, N.Y., says his general internal medicine practice has not been affected by the anti-vaccination trend to the extent that many pediatric or family medicine practices have.
	
	Still, he has sensed increasing reluctance among some of his patients to receive immunizations, particularly the influenza vaccine, which some erroneously believe causes the flu.
	
	Like many practices aiming to boost immunization rates, DeLong’s office sends patient reminders when vaccinations are due, as well as recall notices when patients are overdue for their shots. When he encounters a patient who is reluctant to receive an immunization, he tries to discuss the science behind vaccines but says this strategy often fails to change minds.
	
	


	
	So which techniques can improve physicians’ chances of getting their patients vaccinated? One is by making a presumptive statement that assumes the patient will be vaccinated.
	
	For example, rather than asking parents if they are ready for their child to get a shot, a physician might say, ‘It’s time for Johnny to get vaccinated.’ Such an approach doesn’t take away the parents’ choice to say no, says Yale’s Omer. “What it is doing is framing it as a routine procedure, which it is, based on its safety profile.”
	
	Some studies have shown this technique can improve vaccine uptake.
	
	Of course, presumptive announcements are not a solution for every patient. “You won’t get absolute vaccine refusers with this approach, but you will get a lot of parents who are on the fence,” says Sean O’Leary, MD, associate professor of pediatrics and infectious diseases at the University of Colorado Anschutz Medical Campus in Aurora, Colo. “By taking that presumptive approach, you’re emphasizing vaccination as the social norm.”
	
	


	
	If presumptive announcements fail, physicians can try motivational interviewing, in which they try to elicit the reasons why patients are refusing vaccines and then ask permission to share facts.
	
	O’Leary explains how it works: The physician might ask an open-ended question such as, ‘What concerns do you have about the vaccine?’ After parents share why they are hesitant to vaccinate their child, the physician rephrases their concerns, then might say, ‘I’ve looked into this a great deal. Would it be OK with you if I shared what I’ve come to find out?’
	
	“Simply asking that question makes people more receptive to the information that you are then going to impart,” O’Leary says.
	
	In randomized trial results published in 2018 in JAMA Pediatrics, O’Leary and colleagues found that motivational interviewing helped improve HPV vaccine series initiation by 9.5 percent among parents who were resistant to vaccinating their teens.
	
	Currently, O’Leary is collaborating on an NIH-funded study to investigate combining presumptive announcements and motivational interviewing to improve uptake of the infant series of vaccines.
	
	


	
	O’Leary cautions that physicians should be careful when seeking to debunk vaccine myths because this strategy can backfire. In fact, talking too much about a myth can have the opposite effect of reinforcing the misinformation, experts say.
	
	Yale’s Omer adds that when physicians want to counter a myth outright, they should be clear about labeling the myth as such. Then they can explain why it’s not true and offer an alternative explanation.
	
	For example, if a parent believes that the MMR vaccine causes autism, the physician should say this is a myth. Then the physician can reference the wide body of evidence, mention that several genes have been linked to autism, and connect the increasing prevalence of autism to better diagnosis and monitoring of the disorder, Omer says.
	
	Another strategy Omer suggests is for physicians to focus the discussion on the disease the vaccine prevents, not the vaccine itself. This helps build their credibility as disease experts. “If you’re talking about the disease, you’re on stronger ground than if you are going through the nitty-gritty of countering every myth,” he says.
	
	

Closing the doors to ­non-vaccinated patients


	
	For practicality, patient safety or other reasons, some physicians are dismissing existing patients or refusing new ones if parents do not agree to follow the recommended vaccination schedule.
	
	Paul Ehrmann, DO, medical director for the Family Health Care Center, a family practice in Royal Oak, Mich., is upfront with patients about maintaining a traditional immunization practice that requires full vaccinations. As such, the practice does not take new pediatric patients if their parents do not want them vaccinated.
	
	Ehrmann estimates that he has declined fewer than a dozen patients. However, he has not dismissed the handful of patients in his practice who are not immunized and joined the practice more than 30 years ago when the practice did not have specific guidelines.
	
	His practice’s website describes its vaccination philosophy, and office staff are trained to convey it respectfully and without judgment on the phone with prospective patients. “We try to set the tone before we see the patient,” Ehrmann says.
	
	When talking with patients who have concerns about vaccinations, Ehrmann favors a low-key approach that focuses on the benefits of vaccinating based on the research. “I try not to be argumentative or contentious in any way,” he says. However, he wants to make sure that there is no misunderstanding his pro-vaccine position.
	
	When asked, Ehrmann will sometimes stagger shots for children under age two whose parents are reluctant to have them receive several shots at one time. “I respect that and don’t push that, but I try to get the kids caught up as soon as we can,” he says.
	
	In Oakland County, where Ehrmann practices, more than 40 cases of measles had been identified at press time, but none in his practice. Given the threat of future outbreaks, he believes physicians have a responsibility to do what they can to improve immunization rates.
	
	“We respect patients’ feelings, however, we are stewards of not only our patients but also the public health and community at large,” he says.
	
	


	
	Of course, physicians are not the only ones who can reverse the anti-vaccination trend, experts say. Employers could offer on-site flu shots. Payers could start reimbursing providers for vaccine counseling even when a vaccine is not administered. The federal government could withhold health or education funding to states that do not eliminate non-medical vaccine exemptions. Social media platforms could step up their efforts to curtail false information about vaccines.
	
	Although coordinating such efforts will not be easy, Yale’s Omer is optimistic about the outlook in the United States compared with European countries such as Germany, France, Great Britain, and Italy that have had national outbreaks of measles. He credits school-entry vaccine requirements and public health agencies for maintaining immunization rates and quickly responding to measles outbreaks in the United States, as well as professional medical societies for their strong vaccine advocacy.
	
	“There are a lot of things we don’t do well,” Omer says, “but this is one thing we do very well.”

Eliminating non-medical vaccine exemptions


	
	In light of the recent measles outbreaks, it is likely that more states and localities will move to eliminate non-medical vaccination exemptions, says Lawrence Gostin, JD,  professor and director of the O’Neill Institute for National and Global Health Law at Georgetown Law in Washington, D.C.
	
	“The more measles is in the headlines, the more likely the government will be compelled to act,” says Gostin, who responded to questions via email. Oregon, for example, is considering eliminating non-medical exemptions, while cities such as Los Angeles and New York City now require vaccinations on university campuses and in Orthodox Jewish communities, he adds.
	
	But state vaccination mandates will be ineffective if physicians fail to advise their patients to be vaccinated, actively discourage vaccination, or provide misleading information.
	
	“After California eliminated non-medical exemptions, the number of medical exemptions went way up,” Gostin says. “Physicians are clearly not honestly filling in exemption forms and ignoring the overwhelming scientific consensus that vaccines are safe and effective.”
	
	Federal policymakers are also stepping up efforts to combat the anti-vaccination movement. At press time, a bipartisan bill introduced by two physicians in the House of Representatives, Reps. Kim Schrier, MD, (D-Wash.) and Michael Burgess, MD, (R-Texas) would provide federal funding to monitor vaccine hesitancy and educate the public on vaccines. The bill is supported by American College of Physicians, the American Association of Family Physicians, the American Academy of Pediatrics, the American Osteopathic Association, and other groups.
	
	“It is very important that we increase vaccination rates, because vaccines have been arguably the most important public health measure in modern medicine,” says Douglas DeLong, MD, FACP, chair of ACP’s Board of Regents and chief of general internal medicine at Bassett Medical Center in Cooperstown, N.Y. “It is important for us as physician-scientists to make that message loud and clear.”

Today, patients’ concerns about vaccinations fall along a spectrum, with some refusing all vaccines while others are more hesitant about specific immunizations like the MMR vaccine or receiving several vaccines at once.

July 25, 2019 Edition

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