Traditional primary care needs an overhaul

Clearly, nurse practitioners will be playing an important role in providing primary care as pointed out by Joyce M. Knestrick, Ph.D., C-FNP, APRN, FAANP, in “Nurse practitioners are critical providers of patient care” (Your Voice, January 10, 2019).

It’s been reported that only about 18% of American medical students are entering primary care residencies.  Most primary care doctors are seeing too many patients trying to keep up with the demand for their services. They’re spending too little time with them and too much time with paperwork, for medicine and patients’ needs have become complicated and time consuming. More so than ever before.

The future of primary care training will probably be a hybrid that combines the best of traditional physician training and of nurse practitioner training, a hybrid that will provide the practical skills that are needed to provide care in the new world of medicine.

It will talk about 6 years (after high school) to produce the primary care providers of the future. Most to their training will occur in community health centers, which will also be the training sites for all primary care providers.

Primary care providers will see only about 8 patients in a typical day. Their incomes will be greatly reduced.  Some may work in hospital networks or large private organizations; some will be stationed in urgent care centers-some of which will be independent or affiliated with hospitals.

The time has come for primary care to undergo major changes. Traditional primary care training is due for a major overhaul.

Discussions of gender pay gaps seeks to divide physicians

The article published in the November 25, 2019, edition of your journal regarding “gender pay gaps” bothers me.

I am a board certified family physician in my 41st year of practice. I am not aware that disclosure of my gender to insurance payers was necessary to negotiate contractual payments, and that checking off the hypothetical male check box would ensure me higher reimbursements. A 99213 is a 99213 no matter who sees the patient.

I would be interested as to how the content of this article was obtained. Was it derived by a blanket look at demographic information and numbers  which a biased author wanting to push their own narrative used? Was individualization of each physician taken into account (hours worked, amount of patients seen, amount of procedures conducted, etc.)? Are we to automatically assume that whoever is issuing reimbursement rates for insurance companies are misogynists across the board?

Perhaps pay gaps have nothing to do with gender and everything to do with the other factors mentioned. Perhaps I work harder, smarter, or longer caring for my patients than others do-whether they be male or female. Perhaps I carry a larger patient panel and see higher volumes?

When women (or men) work less hours than I do, it would make sense to be paid less. I find the lack of information as to how this author came about the conclusion that payment gaps amongst physicians can come down to gender and gender only troublesome.

I find it problematic that such an article was chosen for publication. Uniting physicians, both male and female, as opposed to drawing controversy would be more beneficial to us a whole profession. Find a clinic in which there are both male and female counterparts practicing the same specialty, with the same degree credentials, under the same office manager, and show me that their payment reimbursements for individual office codes are unbalanced because of their gender. Then we can have this conversation.

Charles P. Bolotte, MD
	Napoleonville, La.

Articles

Your voice: Traditional primary care needs an overhaul 

IT experts talk about interoperability in terms of great progress, new opportunities, and advances in patient care. With doctors, the same topic tends to generate eyerolls, skepticism, and even fear-fear of costs, poor interfaces, and more government interference in their workday. 

The fundamental idea of interoperability is simple-doctors should be able to access all data regarding their patients irrespective of where in the healthcare system the data was generated or what software was used to create it.

But experts say the path to get there requires solving a complicated puzzle of linking competing businesses, state and regional information exchanges, technology-focused nonprofits, and federal regulations. 

“If I’m at a facility using Epic, and I’m getting patients from another Epic facility, then it’s not bad. But if they are on any other EHR, the data is still coming by fax or email and it’s difficult to get the information,” says Darren Sommer, DO, MBA, MPH, who works as a hospitalist in multiple facilities and has broad experience with EHR systems. “In one hospital, I have to cut and paste patient information into a HIPAA-compliant email and send it to myself at another hospital, even though they are both on the same EHR system.”

Sommer says that he’s seen little progress toward interoperability. In some ways, it’s gotten worse as more technology floods into healthcare, adding more data from devices that may not connect with EHRs and other healthcare software.

“Even if we had complete interoperability and access to data, what do we do with it all?” says Sommer. “Ultimately, we are limited in how much time we have. The ability to find information quickly is just as important as access,” he says.

Peter Basch, MD, MACP, senior director for IT quality and safety, research, and national health IT Policy at Columbia, Md.-based MedStar Health, says part of the problem is that what a doctor needs to effectively treat patients is a constantly moving target. “Before there was any interoperable information or fax machines, doctors were satisfied with the information they received via mail or courier,” Basch says. “I believe that as the expectation of what is considered physicians’ work changes, the expectations of whether we are getting what we need will change with it.” 

Even in situations where information systems are connected, the data that doctors need will vary by role, says Basch. For example, what an ED doctor requires to see for a patient complaining of chest pain is different from an internist doing a general checkup. He adds that doctors also need a broader pool of information, including nonclinical data such as insurance coverage and prior authorization requirements. 

Experts say the foundation of today’s interoperability problems started with the Meaningful Use program. It created a situation where many vendors were fighting for market share in the burgeoning EHR field, and doctors often ended up with software that wasn’t adaptable to changing needs and companies that weren’t interested in sharing patient information with competitors, even though that’s what physicians needed. 

When information was shared, it was often of little use. “You hear horror stories of moving from a page or two for a discharge summary to a mandated 50 to 100-page summary that said nothing,” says Basch. “A lot of doctors found it was a waste of time reading it and easier to just ask the patient why they were in the hospital and what their symptoms were.”

EHR purchases made in the early days of Meaningful Use can haunt physicians to this day. “The first requirement to receive incentives in stage one of Meaningful Use was that you had to obtain health IT,” says Amit Trivedi, director of health IT standards for the Health Information and Management Systems Society (HIMSS). “It didn’t matter what you bought or how you used it, just that you bought it. Now, you may be stuck with what you had and hope it evolved or maybe you picked the right one to begin with.”

Sommer says EHR companies aren’t required to share data, and have no incentive to help. “They already sold the technology, and if someone has to pay for access to patient records from other systems, that’s another revenue stream for them.” Switching EHRs is costly and time-consuming, which leaves doctors with few options.

Experts say that nothing stops data from flowing between doctors other than the organizations that house it, and until that changes, interoperability will suffer. “When you are looking at interoperability and why we can’t seamlessly move data, part of it is because we are still in a growth phase,” says Robert Tennant, MA, director, health information technology policy, Medical Group Management Association. 

“There is so much opportunity out there, but it’s going to require some action, and some of that will come in the form of regulations issued by the Office of the National Coordinator for Health IT (ONC),” he says. 

One of the key regulations being crafted as part of the 21st Century Cures Act, passed in December 2016, focuses on stopping data blocking-the willful policy by companies and healthcare organizations of preventing health information from being shared.

“Healthcare providers and technology developers may have powerful economic incentives not to share electronic health information and to slow progress towards greater data liquidity,” Don Rucker, MD, national coordinator for health IT said in a blog post in June. “The Cures Act confronts information blocking by providing a comprehensive response to these concerns. The information-blocking provision addresses actions that can impede the flow of electronic health information, or its use to improve health and the delivery of care.”

ONC is also working on initiatives to make health records accessible via smart phones and creating standards for organizations to safely exchange data, but experts say questions still remain about how interoperability should work to best benefit doctors. For instance, should the information be “pushed” to the physician or “pulled,”- meaning does the doctor have to actively search for the patient’s records or should all that data be automatically delivered to all the patient’s other providers? 

Tennant says there are pros and cons to both approaches. Pushed information may be more convenient, but might result in information overload. “In the push approach, a clinician might come to work Monday and find 200 messages pushed from various entities-discharges notices, lab reports-the physician could spend the entire day going through all the data.” 

The pull approach requires the physicians to spend time searching for the patient’s information, but ensures the physician gets only the specific information they require.

The best solution, says Tennant, may be to combine both approaches, where priority patients, such as those who were in the ED, have their information pushed to their physicians as part of an alert, while data for routine exams is pulled when needed.

“This is not just a problem of getting data, but getting the right data at the right time and prioritizing it, and the industry has a long way to go to get there,” says Tennant. 

Almost all of the issues affecting interoperability are offshoots of its newness, says Jitin Asnaani, MBA, executive director of CommonWell Health Alliance, a nonprofit trade association focused on universal access to health data. CommonWell has more than 45 million patient records available through its network and is adding two million more each month. “We are in an early growth stage that is similar to what the internet was in ’97 or ’98,” says Asnaani. “Every year, health data is becoming a bigger and bigger part of life, which is very similar to internet development.”

But like the early years of the internet, there remain a lot of questions about quality and consistency. “There is a huge body of work and a big body of hype in this space,” says Asnaani. “Today, there is a concerted industry effort to get the data that is produced to be more consistent, complete and of higher quality. In the short term, the data itself still needs to get better.”

He says two recent major events have pushed interoperability closer to the finish line. The first was when CommonWell and Carequality-another industry trade group with similar goals- started working together. 

“This meant that you no longer had two large parties that didn’t talk to each other,” says Asnaani. “Now that we do, we have 15 of the top 20 EHR vendors on the network.” The second event was passage of the 21st Century Cures Act, whose data blocking prevention rules should provide a major boost to interoperability efforts.

In contrast to what many physicians think, Asnaani says, data blocking today originates more with health systems and providers than with EHR vendors. That wasn’t the case five years ago, when most jealously guarded their data. “Over the last five years, I don’t know of any major vendor who looks at the world that way anymore,” he says. “I still see a broad spectrum of information blocking in the provider community-they do not want to participate and do not want to share data.”

He says thin margins and a surplus of hospital beds leave health system leaders looking for every little advantage, limiting their interest in participating in health information exchanges that may give data to competitors. The Cures Act will change that. “That will unlock [health institutions] and force them to participate if they are not already planning to do so,” says Asnaani. “Our intention is to make good data available to both providers and patient.”

Asnaani acknowledges that many obstacles remain, including the fine-tuning of information for each specialty, as Basch noted earlier. But progress will continue this year and beyond, Asnaani says. He compares interoperability progress to highway building. The building of roads is going great, but the type of “vehicle” each doctor needs to navigate the roads effectively have not been built yet.

“Today, all vehicles are clunkers,” Asnaani says. “Over this year and next, we’ll start to see sedans that consistently work well and you’ll know what you are getting, but we still won’t have Ferraris or semis built for specific needs.”

Trivedi says much progress has occurred in the last 10 years, but he understands why physicians may be frustrated. “Progress isn’t the same as satisfaction, so I think it’s safe to say that folks aren’t satisfied with the progress made to date,” he says. He adds that while the government and private sector forces have been driving interoperability to date, a third player may push for significant progress in the coming years: consumers.

“If you look at all the entrants into health IT, they are focused more on consumers,” says Trivedi. Devices like smart watches generate patient data, and new smart phone apps allow consumers to track everything from their exercise to their medication usage. “I think you will see more interoperability based on that demand, because it will not just be government, but consumers demanding more interoperability.”

One reason some doctors have seen little progress is that interoperability advancement efforts are not uniform across the country. “There is a lot of disparity depending on what physicians you talk to, what organizations they are with and where they are located,” says Trivedi. “A lot of times, the industry is focused on enterprise and large academic centers and that’s where you see the advances happen. On the other hand, smaller physician practices may not get to see all the benefits.”

This information divide concerns both health IT experts and physicians. While Basch lives in a city, he knows the challenges doctors face doctors in rural areas where broadband access may not even be available. “Physicians who do not have access to these services may at least potentially land on the wrong side of the information divide,” says Basch, adding that a rural doctor in solo practice should have access to the same information as a doctor in a large city.

“My hope is that we can accommodate that through public policy that encourages affordable broadband and encourages stakeholders in the IT community to make information available,” he says.

Tennant says physicians will have to shoulder some of the cost burden to make interoperability practical. “Patients will benefit from better care, providers will have more robust data and health plans will have fewer claims, but who ultimately is expected to pay for it? Physician practices,” says Tennant. “They have to buy the technology, they are expected to buy the software interface that links to the health information exchange or hospital.”

Jitin expects interoperability to be similar to internet service, where providers understand its value and pay a monthly fee to support it. Trivedi sees everyone paying for it in some fashion. “One way or another, we all pay,” says Trivedi. “Government makes its investment in regulations; vendors in developing products; physicians, clinicians, and hospitals have to purchase them and consumers have to purchase insurance. Those costs, one way or another, get distributed and borne by everyone in the system.”

Experts say the best thing doctors can do now is to assess their EHR’s capability and plans. “Don’t sit back and wait-talk to your EHR vendor,” says Tennant. “Tell them you want the ability to get access to the data, because a lot of times, vendors are saying they aren’t hearing a demand from their customers. Without that demand, it won’t move forward.” He adds that if the EHR vendor is not planning on adding interoperability access, it may be time to look for another one to avoid being left behind.

Basch says doctors need to be involved in developing the rules of the road for interoperability. “Sharing data without rules or understanding isn’t necessarily going to lead to better, safer and more affordable care,” says Basch. “We have to think about how we can better work together. We can get there and we will get there, but we can’t assume a perfect digital information flow will get there on its own.”

Jitin says there are opportunities for physicians to have a say in how interoperability develops, and to check with both vendors and health information exchange websites to learn how to get involved and offer feedback.

“Interoperability is happening now in U.S. healthcare the way the internet happened for consumers in the ‘90s,” says Jitin. “Like the early internet, you can either wait and wait and be at a disadvantage, or participate now and have a say in how it improves and get it into your practice. Ten years from now, doctors won’t know how they lived without it.”

Who will solve interoperability, and when? 

Sharing patient data: The challenges of healthcare interoperability

One of the most infuriating challenges for physicians is obtaining prior authorizations for prescriptions and testing. In the eyes of physicians, prior authorizations are nothing more than insurance companies inserting themselves into the care decision-making process, creating problems for both doctors and patients. 

Most doctors view prior authorizations as an attack on their autonomy, their years of training, and their ability to care for their patients. Plus, there’s the time wasted and revenue lost due to haggling with payers over approval for drugs and tests. In a recent survey, physicians told 

 that prior authorizations were one of the major problems that were “ruining medicine.”

“Prescriptions are expensive and prior authorizations are an easy way for insurance companies to save money,” says Matthew Mintz, MD, FACP, an internist in Bethesda, Md. “The process is made, in my opinion, purposefully burdensome so that the physician or patient will simply give up, and use a cheaper alternative.”

According to a December 2017 study from the American Medical Association, 86 percent of physicians report that prior authorizations have increased during the prior five years and 51 percent report that they have increased significantly.

The health insurance industry says prior authorizations are an important tool adopted by health plans and government-sponsored healthcare programs to help ensure patients receive the best care. 

“It protects patients, ensuring that the treatment is safe, medically necessary and appropriate,” says Cathryn Donaldson, the director of communications for America’s Health Insurance Plans (AHIP), an industry group. “Health insurance providers have a 360-degree view into how patients use their care and coverage, and we are committed to helping people get better when they’re sick and keeping them healthy when they’re well.”

Just as doctors use scientific evidence to determine the safest, most effective treatments, health insurance providers rely on data and evidence to understand what tools, treatments, and technologies best improve patient health, Donaldson says. 

“It takes collaboration between health insurance providers and clinicians and hospitals,” Donaldson says, adding that AHIP agrees that the prior authorization process can be more efficient. That’s why in January 2018, AHIP, in conjunction with the American Medical Association (AMA) and other healthcare organizations, issued a pledge to streamline the prior authorization process. 

But many physicians believe that the true motivator of prior authorizations is the bottom line for payers, not necessarily patient care.

Timothy Cordes, MD, a pediatric cardiologist in Indianapolis, Ind., says he has experienced a rise in prior authorization requests over the last couple of years. “They seem to modify their own internal guidelines regarding when certain testing is indicated, and how frequently these tests should be repeated,” he says. “More often, lately, the insurance guidelines don’t match the medical society recommendations or don’t align with common practice.”

Cordes notes that every discussion with an insurance company’s physicians requires spending time to educate the reviewing MD, who might not be familiar with the specialty.

“Wasting physician and nurse time does not reduce healthcare costs,” he says. “All prior authorization calls by doctors or nurses requires time and resources. The insurance company prior authorization requirement and obstacle impedes timely and efficient provision of care. It also usurps the doctors’ decisions and ultimate responsibility for care, but does not compensate for time spent or assume medical-legal responsibility for patient outcomes.”

The fact that practices bear the burden of requesting the prior authorization is what causes so much frustration among providers, says Johnathan Rhodes, JD, a healthcare attorney at Denver-based Fennemore Craig Rhodes.

“Both individual and institutional healthcare providers must hire people just to manage these prior authorizations and shepherd them through the process,” he says. “Keep in mind that many providers, particularly the large institutional providers, may deal with dozens or even hundreds of different health plans, all with different requirements related to prior authorizations. This leads to a very frustrating and cumbersome process.”

Kevin Gebke, MD, a family practitioner at Indiana University Health, says prior authorizations have long been a challenge for providers and their staff because insurance companies have different requirements for formulary inclusion and prior authorization criteria.

“There certainly are times when prior authorizations are reasonable and limit unnecessary testing or reduce costs of medication therapy,” Gebke says. “Unfortunately, we do recognize that many of these hoops are in place to discourage utilization. This, in turn, feeds into the pessimism.”

By putting the burden of lowering costs on physicians through increasing numbers of prior authorizations, insurance companies are detracting from patient care, Mintz says.

Most physicians agree, according to the AMA survey. More than 90% said that prior authorizations have a negative affect on patient care, either by delaying care or causing patients to abandon treatment.

More than 60% of physicians said they needed to wait at least one business day to complete prior authorizations, while 30% said they have had to wait three business days or longer.

This time lag creates a massive barrier to patients receiving the care they need, says Matthew Hahn, MD, a family physician in Hancock, Md., and author of 

Distracted: How Regulations Are Destroying the Practice of Medicine and Preventing True Health-Care Reform

“The more hoops a doctor or practice has to jump through to obtain care for their patients, the less likely that care will take place,” says “In addition, some meds, tests and referrals are declined in the prior authorization process.”

“The burden created by prior authorizations is extremely taxing to physicians and medical practices, creating minutes to hours of work just to obtain basic care for their patients,” he adds. “This translates into added administrative costs for practices, and incredible distraction from patient care, which is difficult even under optimal circumstances.”

Gebke says the most effective way physicians can lessen the burden on their practices is to standardize in-office processes for handling prior authorizations. 

“Typically, we tend to have a set of standard work for our staff to follow-to prepare prior authorizations for approval or final input from the physician,” Gebke says. “The real challenge is knowing which services will require a prior authorization.”

“We recognize that [prior authorization] is going to be in administrative burden, but if we can approach it as a team so that the providers are not completely overburdened by the task, it makes it seem more manageable,” he adds.

There are also technology tools that can help. Cordes says a strategy physicians can use to help ease the burden is to take advantage of any electronic or automated
	processes a payer may have for receiving requests and returning determinations. 

“Automated prior authorization processes seem to be increasing in number and some states even require an electronic process with respect to prescription drugs,” he says. “Make sure whoever is accountable for the prior authorization process is familiar with that particular payer’s requirements. There may be certain deadlines, documentation, etc., that vary from payer to payer and providers need to be aware of what those are.”

But electronic systems are not perfect. It’s rare that a physician gets an immediate answer, and will often need to check back to provide more information. 

Mintz also likes electronic authorization, and has found it to be his most effective coping strategy. It eliminates the huge pain point of waiting on the telephone, dealing with cumbersome automated phone trees and getting disconnected, Mintz says. That allows staff to focus their efforts on cases that don’t meet the rules for automated approval. 

Physicians need to communicate effectively with patients regarding prior authorizations, and it’s often better to address the matter proactively with patients rather than wait until a treatment has been ­denied.  

Hahn explains to his patients, many of whom are often unaware of the prior authorization process, that insurance coverage for some medications, tests, and referrals is difficult to obtain because the insurance company makes it so difficult for the physician and his or her staff. 

“There’s not much we can do. This is dictated by the insurance,” he says. “As for medications, we often try to encourage patients to use a medication that doesn’t require prior authorization.”

Once it is understood that a prior authorization is required, it’s important for physicians to educate the patient on that process and the possibility that the authorization will be denied. 

“They need to understand, up front, that prior authorizations take time and it could mean a delay in care,” Rhodes says.

Payer interference is increasing. Here's what to do about it. 

The impact of prior authorizations 

Physical medicine may focus on the ills of the body, but behavioral and psychological issues are unavoidable for patients in any physician’s practice. In fact, primary care physicians provide half of all mental health services, and 92 percent in elderly populations, according to the World Health Organization. 

To reduce some of the burdens of tending to both physical and mental health, shared or integrated behavioral health services may be key.

Patrice Whistler, MD, MPH, a pediatrician with Western Colorado Pediatric Associates, part of Primary Care Partners, in Grand Junction, Colo. has found that, “Seventy percent of your day has some psychiatry or psychology mixed into the basic functioning of every visit.”

Whistler has been using shared services in her practice for over 15 years, long before the concept of shared services became mainstream. In the early days, she would drive to the office of a local marriage and family therapist for an integrative visit, and the therapist would reciprocate.

Whistler and her partners tried other variations as well, including having therapists and psychiatrists come to their office to do intakes, but that became a billing challenge. The psychiatrists asked for 50 percent private pay for their Medicare patients, which wasn’t feasible. 

Soon, she joined with several physician groups to create Primary Care Partners, and Young’s mental health care group moved into their building. Then, they applied for funding through an Assertive Community Treatment (ACT) grant, which offered seed money for “creative ways to have integrative visits,” she says.

Eventually, they brought on Raul De Villegas-Decker, PsyD, LCP, director of integrated behavioral services at Western Colorado Pediatric Partners, and one other full-time psychologist. Having De Villegas-Decker has made a huge difference, she says. “You feel you’re not drowning in life-changing psychological crises, which is basically everyday pediatric practice,” Whistler says.

She says that in almost every visit there’s a mental health component. For example, “A kid has a chronic life-threatening illness, or someone gets the HPV shot and can’t stop crying, or you have a postpartum mom who’s too depressed to feed her baby.”

With De Villegas-Decker on board, not only is there extra support for the physicians and other providers, but his presence allows for quick interventions in a crisis. Additionally, they can brainstorm difficult cases together. 

This shared relationship can also improve care coordination, she says. “So if a patient goes into a crisis because they are suicidal, and then goes to the ER because there is no bed at the hospital, we can call our behavioral health folks to strategize what might happen.”

De Villegas-Decker knew when he joined the practice that he didn’t just want to create a behavioral health service but “an integrated culture,” he says. 

Now, when there is evidence of a behavioral health issue at intake, he or the other full-time psychologist join the physician in the room with the patient, so the patient only has to describe what’s going on once, building upon the trust already established between patient and physician.

If the patient is new to the practice, De Villegas-Decker says, they introduce their team-based approach and identify who will participate in the patient’s care.

For patients who come in infrequently and/or have not established trust with their medical team, but would benefit from meeting with a behavioral health professional, De Villegas-Decker says that the nursing staff and/or medical providers engage in education and motivational interviewing to see if the family is open to having one of those individuals join the visit.

“It is very rare that a family will not accept a greet and meet opportunity,” he says. 

The results have been remarkable, he says. “It has enhanced our team-based care, improved staff satisfaction and reduced some of the physician burnout because they had to take on so much previously,” he ­explains. 

They’ve also noticed benefits to the patients. “It promotes health, helps with self-management and increases resiliency,” he says. Moreover, it helps their practice to address behavioral health needs sooner and with less stigma.

Whistler calls integrative behavioral health “transformational,” adding, “There are a billion things you can barely cover in sick and well visits, so it’s helpful to have a partner that can sometimes take over. You can’t do it alone.”

Additionally, she says, physicians tend to want to fix problems, while mental health practitioners understand that for behavioral health, the issues may be more complex and lack straightforward solutions. She gives the example of a father who keeps nagging his teenage son to get to school on time so he can graduate high school. “Raul would say, ‘Let him fail, there’s a point where you have to stop rescuing him.’”

De Villegas-Decker has also seen an unexpected benefit of their integrated approach-physicians have adopted some of the techniques used in behavioral health, such as motivated interviewing and coaching, allowing them to use these skills around such issues as anxiety, insomnia and ­bullying. 

Most helpful to the practice, the psychologists’ presence can take burdens off the physicians. “Every medical condition has a behavioral health component,” De Villegas-Decker explains, “Even something as simple as taking your aspirin every day.” 

Physicians, he says, are good at telling patients what and how to take their medications, but may not be able to determine why a patient isn’t complying. “We know how to figure that out. We can decrease the number of times a patient comes in to see a physician,” he says.

For other physicians looking to begin integrating behavioral health, Whistler recommends they first reach out to community and state based programs to find out what courses of action are possible.

Whistler co-authored a paper on integrating a behavioral health specialist into a physician practice. The authors describe five possible levels of integration:

Collaboration at a distance (referrals and some direct communication),

Close collaboration in a partly integrated system,

Close collaboration in a fully integrated system.

Whistler and her co-authors suggest that the most practical starting point is to create a collaboration where a behavioral health specialist enters into a contract with the practice for space and use of staff.

Every practice will have to find the method that works best for them, she says. If there is a mental health clinic in the same town, she recommends collaboration, perhaps trading clinicians for a few hours every week. However, as her practice has demonstrated, it can be worthwhile to bring in someone who can be physically present all the time. That’s up to the individual practice to decide.

Despite feeling as though they are always struggling to pay for their behavioral health program, Whistler says, “I don’t think I can go back to practicing without behavioral health.”

Primary care physicians can join forces to provide these services. 

Use shared services to provide behavioral health 

What will the doctor of the future look like?

With new advances in the field of artificial intelligence (AI)-as well as the publication of a handful of high-profile studies demonstrating that AI systems can offer diagnostic capabilities surpassing human doctors in specific cases-many believe the next generation of physicians will have their healthcare capabilities enhanced by these special computer algorithms. Experts believe that these systems will help relieve physicians’ burdens, increase interoperability among different information technology systems, expand patient access to specialty care, and improve treatment plans for chronic conditions.  

Vimla Patel, PhD, director of the New York Academy of Medicine’s Center for Cognitive Studies in Medicine and Public Health, says the idea that AI could help solve many of healthcare’s biggest challenges should not come as a surprise. Modern computer programs are very good at sifting through vast quantities of data. And between electronic health records (EHRs), genetic sequencing, and mobile health data, more and more aspects of healthcare, from diagnosis to clinical decision-making, is becoming data-driven.

“Doctors are human beings. Human beings have limited memory and cognitive resources to apply to what can be very complex medical problems,” she says. “And given that we are overburdening physicians with so many other things, having the extra help from computers to take on that complexity can be a very good thing for patients-and for the doctors themselves.”

But despite growing enthusiasm for AI, can the reality live up to the hype?

With a 2017 Mayo Clinic study suggesting that as many as 88 percent of patients may be misdiagnosed during a first clinical encounter, AI algorithms offer the possibility that doctors could better detect medical conditions in their earliest stages-and recommend the right interventions for treating them.  

Joshua Denny, MD, MS, an internist and medical informatician at Vanderbilt University Medical Center, says that AI programs could help free physicians from medical “busy work” by taking on the rote review of medical images and symptoms, allowing physicians to focus on more complex medical decision-making.  

“I don’t know any physicians who suffer from too little work: so being able to reduce some of the volume of run-of-the-mill stuff so they can focus on more challenging cases-focusing on diversity over volume-I think that would be a good thing,” he says. “And something that would likely result in better patient outcomes.”

In addition, Denny says, AI may offer patients improved access to care. It offers the possibility of performing initial scans for disease more easily and affordably, so instead of having to hunt down referrals or book appointments with a specialist who may be out of network (or even out of town), patients can simply check in with their primary care provider. He says he can imagine a future where, for example, a visual scan of the retina for diabetic retinopathy or a skin cancer check could be done by machines housed in a local chain pharmacy or big box store, much like the blood pressure kiosks we see today.

“AI could reduce some of the health disparities we see, with patients unable to get to or afford a specialist,” he says.

Experts also think that AI systems could help manage one of healthcare IT’s greatest plagues: the lack of  interoperability, or the ability for different medical systems to communicate seamlessly with one another.

Such programs could mine EHRs and health information exchanges for structured data, enabling better communication between physicians at different facilities, decreasing the amount of time doctors have to spend filling in missing patient information in their EHRs, and providing the data required to better inform population health initiatives.

Put those possibilities together, and healthcare organizations can realize new opportunities to streamline  care and better inform treatment selection says Isaac Kohane, MD, PhD, chair of biomedical informatics at Harvard Medical School. Currently, two patients may have the same diagnosis, yet often require different treatment regimens.  As AI programs get better at stratifying patients, especially with more genetic data becoming available, they can also help predict who will respond best to a particular treatment regimen and better inform best practices for managing chronic health conditions. Kohane believes both physicians and patients will benefit as a result.

“Primary care physicians can have all these specialty software programs at their fingertips, providing  them the ability to offer patients specialty care in their own office,” he says. AI applications could cut down on unnecessary referrals to specialists, reducing costs and the risk of repeat tests and procedures. It could also help doctors prescribe the right treatment to each patient the first time-without having to rely on trial and error.

“There are algorithms that can tell you whether a patient is taking their medicine or not,” says Kohane. “So many of these programs can help clarify what is really going on, giving physicians the information they need to make good decisions, avoiding unnecessary changes to more expensive drugs that may have worse side effects.” 

These programs also can offer significant financial benefits to healthcare organizations. Administrative tasks are filled with inefficiencies that could be mitigated with AI algorithms.

Kohane says there are many ways AI could be used outside actual medical care, whether it’s doing automatic eligibility checks, identifying errors in the claims process, or helping to optimize revenue cycle management. If these programs have access to the pertinent data, they can offer significant savings, highlighting ways to boost an organization’s bottom line in areas that hospital administrators might not even think to look.

While AI offers the possibility of enhancing physicians’ capabilities and streamline business operations,  there are some important caveats. First and foremost, these algorithms are only as good as the data that go into them.  Kohane cautions that AI programs are often trained on very structured data.

Once they go into more widespread use, any data that isn’t as structured may skew the results, whether it’s an AI system used to mine medical information systems for interoperability purposes, a diagnostic tool analyzing a medical image, or a back-office application sifting through claims. While doctors often bristle at being limited to the structured fields in their EHRs, preferring unstructured data to document cases in more natural language or add notes, by doing so they may inadvertently be impeding the interoperability they seek.

“Once you introduce increased diversity of data, data that’s beyond what the system trained on, it becomes more likely that these programs will be fooled,” he says.  

A second limitation is the data or image features AI systems use to predict specific medical conditions. Sometimes these algorithms pick up on unexpected data points that ultimately invalidate the results. Denny cites the example of a machine learning program he was working on to help diagnose colon cancer from magnetic resonance imaging data. He says the system was doing remarkably well at identifying patients who had cancer using a  training data set of patients who had been previously diagnosed and treated for the condition.  But after taking a closer look at what attributes the algorithm was using, he learned it wasn’t relying on the images to predict cases, but rather the unique way vital signs were recorded at the clinic where confirmed cases were sent for treatment.  As such, the algorithm could not successfully be applied to new cases.  It was an “eye opener.”

“It’s always possible that the system will pick up on something you don’t expect,” he says.  

But even when the algorithms work as advertised, they may still bring unexpected administrative annoyances. While AI enthusiasts talk about how these programs can help improve patient care, they can also be used to justify billing and reimbursements. And because medicine is often filled with “noisy” data, key administrative applications will be easier to develop, vet, and deploy. Kohane predicts insurance companies will likely to be the first to adopt AI programs to take a closer look at where, why, and when healthcare dollars are being used-and physicians may have to debate whether their expertise is superior to a computer program’s.

“One of the most obvious uses for AI is to use a program to predict appropriate billing codes for patients with a particular history,” he says.  “If a doctor is billing for things that are different than what the system predicts, you have to imagine that the insurance company will at least want to start a conversation and understand why he or she did so.”

With widespread adoption of EHRs, and larger quantities of health data within physicians’ reach, experts agree that the potential applications for AI systems are numerous.  But while headlines joke that “the robot will see you now,” most observers think that no one has to worry about AI systems putting doctors out of their jobs. Still, these algorithms are likely to change the way doctors do their jobs.  

“These systems will let doctors work in more of their sweet spots, supporting them as they provide the best quality healthcare and, hopefully, also increasing accessibility to care across the population,” says Denny.

Kohane believes that physician input will be critical to ensuring that AI platforms are able to enhance rather than interfere with their workflows.  

“Now, more than ever, I’m convinced that for AI to succeed, it’s going to have to be a joint effort with doctors,” Kohane says. But he says AI programs, while they may not live up to their hype, can add significant value to medicine. He suggests that physicians, instead of waiting to be financially compelled to adopt AI technologies as they were with EHR systems, can benefit by learning about them now-and, if offered the opportunity, providing their IT departments, or even technology developers, feedback on how, where, and when they’d like AI to augment their abilities, now and in the future.  

“Doctors have some time to be strategic, to think about how these technologies can help better align them with their patients-and make sure they are properly vetted before bringing them into their practices,” he says. “But even though it’s early days, it’s important to understand these systems, the good and the bad.  It’s time for physicians to think about how they can best use AI to help reduce their workload, improve their businesses, and help their patients. Because, like it or not, they are on their way.”

The term “artificial intelligence” was first coined by the English mathematician Alan Turing to describe “the science and engineering of making intelligent machines, especially intelligent computer programs.” Today, AI may be better described as computer programs, trained on massive data sets, that can accomplish tasks that usually require human intelligence, including, problem-solving, and decision-making, says Pedro Domingos, PhD, a computer scientist at the University of Washington and author of The Master Algorithm: How the Quest for the Ultimate Learning Machine Will Remake Our World.

“You often hear terms like AI, machine learning, and big data used interchangeably-they are related but not the same,” he says. “Machine learning is a type of algorithm that learns from large data sets that are often called ‘big data.’ So AI, in some sense, is the goal-but machine learning is how we get there, with the machine learning algorithms fueled by all that big data.”

Such machine learning algorithms, after being trained by data from medical databases, can take in hundreds of thousands of data elements, analyzing the information over time to identify trends and associations that may not be immediately discernible to the human mind.

And such systems have demonstrated significant diagnostic power. Researchers from Google and Stanford University made headlines in 2017 when their machine learning algorithm, trained on imaging data, was able to diagnose melanomas more successfully than veteran dermatologists.  Other studies have shown that AI can outperform physicians in diagnosing diabetic retinopathy, predicting risk of suicide or heart attack, and managing congenital cataracts.

How this technology will change the way physicians practice. 

Artificial intelligence: Looking beyond the hype

A variety of factors-such as market competition, high deductible health plans, and lack of transparency from insurers-is driving more patients to pay for healthcare with cash, says Sean McSweeney, president of Apache Health, a medical billing company based in Santa Monica, Calif.

Cash pay creates its own set of problems that physician practices need to consider in order to maximize revenue and minimize hassles.

McSweeney breaks cash pay into two categories: actual cash, for patients who do not have health insurance, and “effective cash,” where a patient has a plan that doesn’t cover a service or a high deductible that effectively makes them cash pay.

McSweeney urges physicians not to wait until there are problems to solve with cash-pay patients, and instead put together a “comprehensive policy to take into account and plan for both of these situations in advance.”

Practices with cash-pay patients would do well to make prices for top services available to the patients as easily and transparently as possible, McSweeney suggests. “If patients see something posted on a wall, that might eliminate a lot of problems on the back end where patients are complaining ‘I had no idea it would be $1000 for that procedure,’” he says.

McSweeney says that many providers aren’t used to cash-pay patients. Since cash-pay presents issues that may be different from patients who pay with insurance, McSweeney also suggests designating a specific administrative person or team to cash-pay, or ensuring that practice management software has a tool to field the types of questions about price and payment options that come up in cash pay situations.

Often, cash-pay patients may find themselves paying out of pocket for procedures insurers don’t want to pay or deem experimental. “There’s such a massive variation in insurance plans now that you can no longer predict [a service or procedure] will be paid by a plan.”

McSweeney says his company is even seeing cases where some women’s health services are not being covered.

Maintain a database of procedures covered

Providers aren’t used to this new landscape where once-covered procedures may now no longer be covered, he says. “So more work needs to be done up front where providers maintain a database of which procedures are covered by which payers.” If it isn’t feasible to keep track of all procedures, he recommends keeping track of “the top 80 percent procedures for your top plans.”

Doing this, he says, will save time on the back end. “We see all the time where the provider’s chasing the patient after the fact once they realize the plan didn’t pay anything,” he says.

One strategy that can be successful with cash-pay patients, or in situations where coverage is uncertain, is to take deposits from patients on lower cost services. For example, if the patient pays $50 of a potentially $125 service, “It’s not going to make or break the provider if they don’t get that.” Plus, if insurance covers the procedure, patients may get their deposits back. “A deposit is easier to get from a patient than paying all cash up front,” he says.

With more expensive procedures, such as MRIs, surgical procedures or lab tests, it’s important for the practice to be able to know in advance whether the payer is going to cover the service, which is where that payer database can come in handy.

Whether a practice handles billing internally or uses a billing company, it’s still necessary to have the ability to check eligibility in place, McSweeney says.

“The days of not checking that should be over for everyone on every single visit,” he says. “You don’t want to find yourself in a position where you didn’t ask the right question and suddenly find out you’re not going to get paid for something.”

How to deal with patients who pay you directly. 

4 tips for handling cash-pay patients

Phishing is a leading cause of data security incidents, and the healthcare industry is the number one target of scammers.

A phishing attack is when someone is tricked by an email message into providing access credentials to an unauthorized party, visiting a phony website or clicking on a link that installs malware. Scammers use information like Social Security numbers and healthcare identification-private details about illnesses, conditions, etc.-to create false identities and fraudulently bill Medicare, Medicaid, and other payers, says Eric Packel, a partner at Baker Hostetler who specializes in privacy, data security and technology issues.

The cost is quite high: An average forensic investigation into a phishing attack costs more than $84,000, with the largest investigations costing nearly $437,000. The average time between the incident and discovery is 66 days, with three days from discovery to containment, and then another 36 days to complete the forensic investigation and notification process. All 50 states have a data breach notice law, which requires providers to notify patients and vendors whose information may have been compromised, as well as HIPAA rules.

So, how can physicians and their staff protect their practices from being compromised? Packel offers the following tips:

1/ Determine which employees are most at risk for clicking on a phishing email. 

“Some companies send out a fake phishing email to test their employees, and those who consistently respond to any phishing emails can get additional education,” Packel says. “You can target your training to the employees who need it the most.

2/ Institute a multifactor authentication process. 

A multifactor authentication process means that not only do people have to enter in their usernames and passwords, after they click on those, they have to put in an additional code. This code could be sent as a text, to another email address, or it could be a keyfob. “It makes it much more difficult for the attacker to get into the system if you have multifactor authentication,” Packel says.

Work with your informational technology staff or vendor to determine what kind of multifactor authentication process would work best for your practice, and then determine the logistics of installing a system and getting everyone on board. “It’s becoming the de facto standard,” Packel says.  “Here at my law firm, we have multifactor authentication in place, and we’re certainly used to it.”

Expect pushback, especially from higher-level staff, who sometimes feel they don’t have enough time or energy to learn or implement the new system.

There are also costs to installing new technology. “There’s political pushback and financial and technical issues to consider, particularly with larger, more complex organizations,” Packel says. “But certainly the cost of one data security incident could be more than the cost of putting multifactor authentication into place.”

Strategies to make sure your practice does not fall victim. 