I would like to respond to the comments by Edward Volpintesta, MD, in the March 25, 2019, issue. As a primary care physician myself, I would first say that based on his response to Dr. Dinklage and his prior article in the 

 “Primary Care Training Must Change,” Dr. Volpintesta himself appears to have sold out his own profession. He seems to believe that his colleagues in primary care are all practicing as first-aid stations, appeasing our patients until they can see a real physician with adequate training to handle the “life-threatening” problems. 

I myself see patients in the clinic, hospital, nursing home, and emergency room. I practice obstetrics, including operative vaginal deliveries, cesarean deliveries, postpartum tubal ligations, versions, etc. I also do EGDs and colonoscopies. 

Physician training gives us a strong foundation of medical knowledge so that we know our limits, thus allowing us to seek specialty consultation when appropriate, avoiding extraneous, unnecessary and costly labs, imaging, and referrals. Ideally, in the outpatient setting, primary care physicians are preventing the patient from ever getting to the “life-threatening” stage of their disease process.

While there are obvious concerns over primary care shortages, nurse practitioners practicing unsupervised is NOT a safe or wise answer. There are ways to promote quality, physician-led care including changes in payment scales to favor medical decision making and prevention over procedures, promotion of primary care as a career choice (the opposite of what Dr. Volpintesta has been doing with his criticism), and lifting the restrictions placed on residency position numbers in the 1997 Balanced Budget Act. 

The introduction of free market principles such as allowing HSA funds to be used for direct primary care subscriptions, repealing Safe Harbor, and ensuring that patients can ALWAYS choose their own physician are also helpful tools. 

Furthermore, after nurse practitioners are granted the ability to practice without physician supervision (which has happened in 23 states), they do not usually practice under-served primary care. To make the argument that nurse practitioners are suited to practice primary care, you would have to solve the same issues preventing them from entering into primary care that we already face as physicians, and even then, the care provided with less training and medical knowledge will be sub-par.

As physicians, it is essential that we take a leadership role to ensure that our patients receive the safe, timely, and affordable care that they deserve. Nurse practitioners are not in a position to provide that. 

Alisha Scott, MD, Blair, Neb.                                                                                                                  

Deborah Sutcliffe, MD, Red Bluff, Calif.

Jake Pletcher, MD, Mountain View, Calif.

Articles

While there are obvious concerns over primary care shortages, nurse practitioners practicing unsupervised is NOT a safe or wise answer.

Your voice: Stop selling primary care physicians short

Slideshows

A shady inquiry 

Q: We are getting denials when we are billing a simple skin repair code with a lesion excision.  Can you help us figure out why the repair code is being denied in these situations? It’s happening with all insurance carriers, so it’s difficult to know what’s going on without calling each of them.

A: This is a common coding mistake, and there are a couple of things that you can do to remedy it prior to billing.

First, make sure that you check the National Correct Coding Initiative (NCCI) edits when reporting multiple codes. 

The Centers for Medicare & Medicaid Services (CMS) developed the NCCI to help ensure correct coding methods were followed and to avoid inappropriate payments for Medicare Part B claims. These are automated pre-payment edits where the code pairs are compared when billed on the same date of service for the same patient.  The American Medical Association notes, “If there is an NCCI edit, one of the codes is denied.”

Second, confirm that you aren’t unbundling codes. 

Unbundling refers to using multiple CPT codes for parts of a procedure when a single code is available, either due to misunderstanding or in an effort to increase payment. Reviewing the section guidelines for the codes involved is key to determining this.  When there is a single code that captures payment for the component parts of a procedure, this is the code that should be billed.

You billed for a lesion excision and a simple skin repair on the same service date. However, the Current Procedural Terminology (CPT) section coding guidelines for excisions read, “Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed.” So separately coding the repair would be wrong and generate an NCCI edit because you are unbundling the codes.  

In rare instances, the repair could have been performed on a different site from where the lesion was removed, and, in these situations, it is acceptable to bill for both and append a modifier (likely modifier 59) to let the payer know the procedure was indeed separate from the excision. In these situations, make sure that you have reviewed the documentation to ensure the repair was for a different location.

Q: We often hear that the flu vaccines only help protect patients against a percentage of the flu strains that are out there, so I understand why there are new vaccines coming out all the time. Are there any new codes for 2019?

A: Yes, a new influenza vaccine code has been introduced for dates of service in 2019, as follows: 90689 Influenza virus vaccine, quadrivalent (IIV4), inactivated, adjuvanted, preservative-free, 0.25 ml dosage, for intramuscular use

This code can be utilized for all vaccines that fit this description.  The Centers for Medicare and Medicaid Services’ physician fee schedule reimbursement amount for this code has not yet been published.

Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Ind. Send your billing and coding questions to medec@ubm.com.

What physicians can do about these common coding mistakes

Two ways to reduce coding denials

The federal government recently finalized a rule that will allow Medicare Advantage plans to offer telemedicine as a core benefit. As a result, practices of all sizes will have a greater incentive to adopt virtual visits, observers say.

Traditional fee-for-service Medicare provides very limited coverage of telemedicine. For the most part, virtual care is covered only in rural areas, and virtual consultations must be initiated in healthcare facilities.

Providers can’t bill for virtual visits with patients from their homes, with one exception: CMS last fall ruled that physicians can bill traditional Medicare for brief “virtual check-ins,” in which they determine whether a patient should come into the office. Remote evaluation of video recordings and images is also covered. 

The new rule doesn’t expand telemedicine coverage under fee-for-service Medicare. However, it gives Medicare Advantage plans carte blanche to cover any form of telemedicine, wherever it is provided or initiated. Since more than a third of Medicare patients belong to these plans, this could mean a significant change for many physicians.

Some Medicare Advantage plans already cover virtual care as a supplemental benefit for which plan members must pay extra. Now that telemedicine is a core benefit, however, “providers would be more likely to invest in the infrastructure to make this available,” says Jerry Penso, MD, MBA, president and CEO of the American Medical Group Association (AMGA).

Steven Waldren, MD, vice president and chief medical informatics officer of the American Academy of Family Physicians (AAFP), says that when Medicare Advantage plans begin to cover virtual visits with patients’ own physicians, “I think it would convince more doctors to add telemedicine to their practices.”

The telemedicine used today represents the confluence of two forms of the technology: secure online messaging, which has been around since the early 2000s, and virtual visits based on audio-video conferencing.

Until around 2015, video visits were usually conducted between patients and doctors who worked for outside services such as American Well, Doctors on Demand, and Teladoc. But there are inherent limits to this approach, because the outside doctors don’t know the patients who consult them, and they rarely coordinate care with the patients’ regular physicians.

“The critical piece is to make sure the care is coordinated,” Penso notes.

Today, however, the telemedicine medical practices use is likely to connect patients directly to their own physician or his or her colleagues, rather than an outside doctor hired by a service. Secure texting or online messaging is often the first step. Then the patient completes an online form, providing information that may be sufficient for a doctor to diagnose and treat his or her complaint. If the doctor and the patient believe a video visit would help, that might be the next step, or the patient might be asked to come into the office.

Telemedicine is most often used to diagnose and treat minor acute problems like influenza, low back pain, conjunctivitis, and urinary tract infections. Some practices are also using telemedicine for routine follow-ups on chronic conditions.

“Virtual health has been great for my diabetic patients,” says Donnie Aga, MD, medical director of healthcare innovation for Kelsey Seybold, a large multispecialty group in Houston. “I know them really well, and they can go to the lab at any time; fasting is not an issue. For routine follow-ups on diabetes, it’s very well done.”

Kelsey Seybold and Kaiser Permanente also use telemedicine routinely for post-op follow-ups, and other groups plan to follow suit. In such a virtual visit, Aga says, “Our PA will say to patients, ‘take off the bandage so I can look at the wound, let’s look at your mobility and how does it feel,’ etc. Sometimes, post-op patients are taking pain medicine, so they don’t need to be driving to the office.” 

Telemedicine is especially well suited to behavioral health, notes James Korman, Psy.D., chief of behavioral health and physician wellness for the Summit Medical Group, based in Berkeley Heights, N.J. Besides doing teletherapy and medication management with patients who have difficulty getting to the office, Korman notes, Summit has established a virtual therapy program in conjunction with its primary care offices. Primary care physicians can consult with therapists or have patients do video visits with them in the office.

Physician-to-physician virtual consults are an integral part of Kaiser Permanente’s approach, says Richard Isaacs, MD, CEO and executive director of the Permanente Medical Group. For example, a primary care doctor who is seeing a patient with a skin lesion can immediately pull a dermatologist into a virtual video conference, show him the rash and ask him what to do. 

“It’s all about care without delay,” Isaacs notes. “If you connect a primary care doctor [to a specialist] immediately via smartphone technology, that drives a lot of efficiency.”

Some groups use an internal telemedicine platform that incorporates their EHR. Kelsey Seybold, for instance, uses the virtual care platform in its Epic EHR for both video visits and “e-visits” based on online messaging through the EHR’s patient portal. When a physician encounters a patient in a scheduled video visit, the doctor sees the patient on one side of the screen and views and documents in the EHR on the other side. 

The video encounters with primary care physicians can be scheduled within a day; if a patient’s doctor isn’t available, he or she can visit another physician. A dedicated team of rotating physicians handles the e-visit requests, usually within 10 minutes of a call, Aga says.

Austin (Tx.) Regional Clinic’s telemedicine service uses an outside platform from a telemedicine vendor, says Jacob Childers, MD, medical director of the service. The platform allows video, voice and text messaging.

After sending a text about his or her problem, the patient is quickly connected to a doctor. A group of 20 clinic doctors handles these requests 24/7. Some do it on their own time for extra money; others fit video visits between in-person clinic visits.

Intermountain Healthcare, based in Salt Lake City, uses a hybrid technology approach. While the group deploys its own clinicians for scheduled virtual visits, it uses American Well’s telemedicine platform, which is integrated with the scheduling module in Intermountain’s iCentra EHR (a modified form of Cerner’s software). Summit Healthcare also uses an outside platform integrated with its athenahealth EHR.

An important value of telemedicine to large practices is that it supports population health management, says Richard Trembowicz, a principal with ECG Management Consulting. Groups that are taking on financial risk can use telemedicine to increase patient engagement and improve their access to care. Moreover, practices can use it to expand the number of patients their primary care providers see, he adds.

Penso of AMGA says, “If a group is taking financial risk, it’s in their interest to manage the care as effectively and as efficiently as possible-and to meet the patient’s needs, because patients have a choice of whether to stay in your network or program. For those groups, it can be very worthwhile to have telemedicine as another option.”

But most practices still receive a lot of fee-for-service income, and they may be located in areas where telemedicine is not ordinarily covered by insurance. Prevea Health in Green Bay, Wisc., for instance, uses telemedicine mainly for online messaging and video visits with its urgent care centers, says Ashok Rai, MD, president and CEO of the group.

Prevea charges patients $35 per virtual visit because their health plans don’t usually cover it. For the same reason, the group has not yet extended telemedicine to its primary care offices.

Rai hopes the new Medicare Advantage telemedicine option will help change that. “We can do a lot of care virtually if patients don’t need to come into the office and their care is covered as part of the premium. Things would be more efficient and more timely for our chronic care. In the end, it’s good for the patient, it’s good for the physician, and it’s good for reducing costs in the overall healthcare system.”

While fairly few small practices have used telemedicine, they should definitely start considering it, especially now that Medicare Advantage covers virtual visits, says David Zetter, CHBC, a practice management consultant in Mechanicsburg, Pa. For one thing, he says, telemedicine could help practices expand their business.

He cites a solo family physician in a rural area who is using telemedicine to provide after-hours care. For a fee that is automatically applied to their credit card, patients can have a virtual visit whenever the doctor is available. “He’s definitely filled his practice up a bit and increased revenue,” Zetter notes. Many psychiatrists in small practices,  are doing virtual mental health visits, he adds. 

Grace Terrell, MD, a North Carolina internist who founded the Cornerstone Medical Group, now part of Wake Forest Baptist Health, is a big supporter of telemedicine and believes the Medicare Advantage core benefit could prove highly important.

“Telemedicine should open up business models that aren’t based on a patient being in a facility in front of a doctor,” she says. “There are a thousand use cases out there that could redesign medicine in many ways. Over time, it could re-engineer the healthcare system so that expertise is delivered in more convenient ways through technology.”

One new business model that small practices could try, she says, involves providing care to more patients without increasing overhead costs or overburdening physicians. In a typical primary care practice, she notes, providers must see a certain number of patients each day to cover their overhead costs. But if the practice hired additional doctors or midlevel practitioners and they provided virtual visits without patients needing to come into the office, the average overhead per patient would decrease, and profitability would increase. 

“The problem with small practices now is that they want to fill their exam rooms, and that’s why they view virtual visits as one offs on top of that,” she says. “But you can imagine a situation where you have twice the number of doctors for the space you’ve got, and half the doctors are not using the space.”

To participate in telemedicine, Zetter says, practices first must determine which kinds of patients are likely to use the service and which of their payers cover it. If a patient’s insurance doesn’t cover telemedicine, practices must tell them that there’s an out-of-pocket cost.

It’s also important to understand each state’s regulations on telemedicine, including what kinds of services plans must cover and whether they have to cover telemedicine-provided services that are comparable to in-person services, he points out. Thirty-one states and the District of Columbia require full parity, and two other states have partial parity laws. In addition, all 50 states have some Medicaid coverage for telemedicine.

Zetter warns against simply doing video chats with patients on their smartphones because of HIPAA security and privacy considerations. Fortunately, a wide range of secure messaging and videoconferencing software is available, he notes, and some of it is not expensive. 

The AAFP offers a virtual visit platform based on software from Zipnosis. Designed for minor acute issues, the platform includes a questionnaire for patients to fill out. In most cases, a doctor can diagnose their problem and prescribe a medication based on their answers, Waldren says. Patients can also request a video visit and conduct it on the platform. 

The cost of AAFP Virtual Care is $159 per month per authorized user. Patients pay practice-determined fees for the service, but the platform can be linked to a practice’s EHR for billing purposes, he adds. 

Cindy Dunn, RN, FACMPE a consultant with the Medical Group Management Association, is skeptical about the suitability of telemedicine for small practices. She notes that the practice must look at the workflow changes required to accommodate virtual visits. They also have to figure out how to document these encounters. And their billers have to learn which codes to choose for insured telemedicine services.

However, she concedes that telemedicine could work well for post-op visits, which are frequently bundled into surgical fees; as a result, surgeons earn nothing for office follow-up visits. In addition, she says, virtual visits could free up slots for doctors to see patients with more complex conditions in person. And telemedicine could help practices extend their hours.

“In the long term, telehealth will become just as much a part of care as doing routine child checks and those kinds of things,” she says. “We’ll also move from telemedicine’s current acute care focus to chronic disease management and wellness as part of value-based care. Telemedicine is going to become a big component of medicine moving forward.” 

The federal government recently finalized a rule that will allow Medicare Advantage plans to offer telemedicine as a core benefit.

New rule provides telemedicine opportunity 

Melissa Lucarelli, MD, knows what it’s like to run a practice that’s short-staffed.

The family physician in Randolph, Wis., has 12 employees in her office. In the past year, four have gone on maternity leave, including the clinic manager and the claims ­manager.

“We had to be very creative in how we compensated in order to stay open and keep seeing patients,” says Lucarelli, a member of the 

It’s a problem most small- to medium-sized practices face at some point: A staff member quits unexpectedly or goes on leave for a long period of time because of pregnancy, illness, accident, or emergency. How the practice compensates for that staffing shortage can affect its revenues, workloads, staff morale, and even the quality of care patients receive.

In many practices, existing staff must pick up the slack when there is a vacancy.

That requires cross-training in various jobs, says Melissa White, practice administrator at Newton Family Physicians in Newton, N.C. The practice has six physicians and four nurse practitioners supported by a non-clinical staff of 12. “Everyone is cross-trained in at least one job and many in two,” White says. “All of us can do something else or everything else. It’s a condition of being in private practice.”

For example, the practice typically has two people working the front desk, but three others can step in as needed. The single checkout employee has two backups, and so on.

All employees must embrace cross-training as a condition of employment, White says. “We make it very clear that it’s a team effort and if you aren’t willing to be part of the greater good, maybe it’s not a good fit for you,” she says, adding that she once fired a staffer who was good at her primary job, but who wouldn’t train up to the required level in a secondary role. 

It’s a similar story at Associated Physicians, a 20-doctor independent practice in Madison, Wis. Job applicants are informed they’ll be cross-trained and the training begins immediately when the person is hired, says Executive Director Terri Carufel-Wert, RN, MHA.

The practice sends new employees to its EHR provider for training and pairs new workers with veteran employees. Staff members also have monthly online training in their own specialty and others, and employees are asked to share their knowledge with each other.

The practice also solicits employee input on such things as the best ways to learn and what skills are required, says Business Operations Manager Margaret Wilkinson, CMC. 

Detailed written descriptions of office procedures and policies are invaluable for training new staff members and getting temps up to speed quickly, adds Lucarelli. 

Many practices turn to staffing agencies to fill vacancies. This can be a fast and easy way to find a credentialed temp, but has drawbacks, such as the expense and work restrictions.

Lucarelli has hired temporary workers from agencies to fill vacancies, but prefers not to. Her quarrel is not with the quality of their work, but the extra cost and the restrictions on their duties. Office temps cost 50 percent more than regular staff once the agency fee is included, which is more expensive than paying overtime to an existing employee, she says.

She also doesn’t like that temps work under a contract that can limit their hours and duties. While an employee might stay late to get a job done or help out, temps tend to stop working as soon as their shift ends, she says. And she once had a temp skip a day because her contract did not require her to come to work if it was snowing. “And this is in Wisconsin,” she says.      

“They’re not beholden to your employee handbook; they’re beholden to their employer’s contract,” she says.

However, using temps can save staff from overwork and burnout while keeping the office functioning at a high level, says Nick Fabrizio, PhD, FACMPE, a principal with the Medical Group Management Association Health Care Consulting Group.

He recommends asking other practices for recommendations for reliable staffing agencies. When using an agency, be explicit about the work the temp will be expected to do and make sure the person they’re sending has the necessary credentials and experience for that job, he says. 

It’s also a good idea to request that the temp be familiar with the EHR system the practice uses because training a temp on an unfamiliar system can be time consuming and place an additional burden on the staff.    

If a practice has to repeatedly use an agency it should request the return of any previous temps who have performed well, proven a good fit with the practice culture and are already familiar with office operations, Fabrizio says. The less time spent bringing a temp up to speed with policies and procedures, the more time they can spend working and the more smoothly the office will run.

Temp agencies can be a good way to scout new employees, says Carufel-Wert, who has hired billers and coders from their ranks. “That’s been nice because you’ve been able to try them before you hire them,” she says.

To avoid the extra expense and uncertainties of a temp agency, some practices rely on their own “float pools” of workers who can fill in for a single shift, a week, or even months. These people often have other jobs, but are looking to earn extra income.

Lucarelli says she is always on the lookout to add to her pool of former staff members, friends they’ve recommended and even
	patients who can fill in short-term. It helps to stay on good terms with former employees so they’re willing to return, she says.

While some staffing shortages are unavoidable, many practices do what they can to reduce turnover and shortages.

A leave doesn’t always mean the employee can’t work at all. While she was on maternity leave, Lucarelli’s clinic manager still managed payroll and other business office functions on a part-time basis.

If a staffer gives notice at Associated Physicians, Carufel-Wert and Wilkinson will talk to the person about their reason for leaving and sometimes make changes to persuade them to stay, such as more flex time or even a raise. That’s easier and less expensive than hiring a replacement, they say. Of course, any accommodation must be reasonable and can’t have a negative effect on the rest of the staff.

“I’m not going to be held hostage by an employee’s demands,” Carufel-Wertz says.

Associated Physicians surveys salaries in its market to make sure its pay is competitive. It also pays for employees’ continuing education programs and sometimes gives raises if an employee acquires an additional skill.

Of course, staffing shortages can happen to the best-prepared practice. In that case, Wilkinson says, “You put your survival mode hat on and do what you can do.”

Many practices turn to staffing agencies to fill vacancies. This can be a fast and easy way to find a credentialed temp, but drawbacks included expenses and work restrictions.

How to survive staff shortages

Let’s say there’s a physician who is aware that some states, including his, have taken initiatives to import medications form Canada. But he can get the identical brand name drugs even cheaper from India. He intends to provide the drugs to his poorer patients at no charge, and his patients are eternally grateful.

One of these patients is so happy that he sends a letter to the local newspaper applauding the efforts of his physician. The article, written by a local reporter, is picked up by the national press and covered in the national news.

Three days later FDA agents show up at the doctor’s door threatening him with both civil and criminal penalties. What is the basis? He was only trying to save his patients money. 

What is clear is that prescription drug expenditures are one of the fastest growing segments of the United States healthcare system. Over the last several decades, prescription drug spending has increased dramatically, whereas other components of the healthcare system, such as hospital care and physician services, have risen less.

Several factors have led to this tremendous increase in expenditures.

First, prescription drug utilization per capita has grown dramatically because of the aging population. In addition, older, less-expensive drugs are being replaced by new, high-priced drugs. Finally, many manufacturers have increased the prices of drugs already on the market. With this increase in the cost of prescription prices, many consumers may be forced to choose between purchasing basic necessities and filling their required treatment prescriptions.

The reason prescription prices in the United States are, at times, more expensive than the prices for identical medications from other countries is clear: Costs in the United States costs remain high because of current patent protection coupled with the unregulated free market system.

The cost for these medications is governed by the laws of supply and demand. Since there is no price ceiling for many of the currently required drugs in the United States, (such as is in place in Canada), prices remain quite high. Thus, there is the inevitable desire to import the drugs from abroad where the cost of such pharmaceuticals may be less.

In all fairness, the pharmaceutical industry maintains that the reasons behind the high prices of American drugs are the cost of the research and development needed for new break-through drugs. In 1993, the pharmaceutical industry spent $12.7 billion on research and development. A decade later this figure more than doubled to over $33.2 billion. It continues to increase.

With all this said, there is still a natural desire to get the same medications available to our patients from a cheaper source. Our doctor turned to India. Other physicians have looked to Canada, Europe and South America. Whatever the source, and despite his admirable intent, Dr. Rash’s actions are illegal.

FDA regulations prohibit the re-importation of exported prescription drugs manufactured in the United States by anyone but the actual U.S. manufacturer. In part, the justification for such laws lies with Congress’ intent to ensure the safety and efficacy of the prescription drugs.

The FDA cannot vouch for the safety of a product once it is sent to another country; it becomes out of the FDA’s control. There are both civil and criminal consequences for our example doctor if he continues this approach. He would be advised to discontinue his actions. 

David J. Goldberg, MD, JD, is a dermatologist and healthcare attorney. Send your legal questions to: medec@ubm.com.

Is it legal for physicians to import medication for poor patients?

Importing prescription drugs for patients

It wasn’t long ago that a primary care practice’s calculation of whether to provide an ancillary service, such as lab work or sleep testing, was relatively simple: would patients use it, would it improve their health, and would it generate additional revenue, or at least break even?

Those are still the main considerations for practices operating under the traditional fee-for-service payment model. But experts say that the growth of value-based models, which reward practices for reducing the overall cost of patient care while maintaining or improving outcomes, adds a new wrinkle to the ancillary service question. 

“In a predominately fee-for-service environment, it’s a fairly straightforward financial calculation, where you look at the volume of patients who need the service, what it costs to provide the service and how much you get reimbursed for it,” says Russell Kohl, MD, FAAFP, a family physician in Stilwell, Kan., and chief medical officer with TMF Health Quality Institute, a Medicare quality improvement organization.  

Under a value-based system, Kohl adds, with its focus on cost of care and outcomes, the financial return for adding a service is harder to calculate. He cites the example of whether to provide pulmonary function testing for patients with COPD. Not only does the practice have to decide if it can provide the service for less than a pulmonologist, it has to weigh whether in-house testing will reduce the number of its patients requiring trips to the emergency department or hospitalization, which would drive up the overall cost of caring for that patient.

“In a value-based world, it becomes a more nebulous calculation than it cost me ‘X’ dollars to do a pulmonary function test and I get paid ‘Y’ dollars for it,” he says.

Whatever their reasons for doing so, many primary care practices continue to offer some form of ancillary service. In the 2018 

 Physician Report, 91 percent of family, and 89 percent of internal medicine practices said they offer at least one of 16 types of ancillary services, with lab services and electrocardiogram being the most common. Among all non-surgical primary care survey respondents, 84 percent said they provide ancillary services.

Moreover, experts say, the growing role of alternative and value-based payment models doesn’t alter the fundamental questions of whether patients will benefit from an ancillary service and whether the practice can make money providing it.

Nick Fabrizio, Ph.D., FACMPE, now a principal with the Medical Group Management Association, previously spent 10 years as practice administrator for a large primary care group. “We had a lot of long, hard discussions around questions like, ‘is this service one that we feel comfortable in providing, can we provide a high level of quality in doing it, and is it more convenient for our patients to have it done by us rather than someone else?’”

The easiest way to determine if patients will use an ancillary service, Fabrizio says, is to ask them-either through a mail or online survey, or face-to-face at the end of an appointment. Another useful technique is to look at the services and procedures for which patients are most frequently referred out. Among the practices he consults with, the most common ancillary procedures include stress tests, ultrasounds, and blood labs. 

A factor practices sometimes overlook when considering ancillary services is any laws and regulations governing who can provide the service and under what circumstances, says Owen Dahl, MBA, FACHE, principal of Owen Dahl Consulting in The Woodlands, Texas. For example, laboratory services have to meet the requirements of the federal Clinical Laboratory Improvement Amendments. “The encouragement there would be to check your state laws and federal regulations to make sure your staff and providers meet the necessary criteria for that service,” he says.

While in the past ancillary services often were seen as a source of additional revenue, under value-based payment models, practices may find they need them just to maintain their current revenue, says Dahl. 

“In a world of fee-for-value, the key is not necessarily to generate revenue, it’s to protect against loss of revenue,” Dahl explains. “That’s because you might wind up getting dinged financially for referring to a very expensive outside provider. So then you’d want to be able to control your expenses by offering that service at a lower cost than referring it out.”

For Lovelace Family Medicine of Prosperity, S.C., being part of an alternative payment model-specifically, an ACO-has provided a bonus to its decision some years ago to acquire a dual-energy X-ray absorptiometry (Dexa) scanner-a device used to measure bone density-a somewhat unusual and costly purchase for a practice in a rural area.

“By virtue of having the Dexa, we’re detecting osteoporosis and preventing women from having hip and spinal compression fractures,” says family physician Oscar Lovelace, MD, the practice’s founder. “That’s allowed us to keep patients out of the hospital for hip fractures and skilled nursing facilities for rehab, which is saving thousands of dollars for our ACO.”

The same dynamic applies to the practice’s hospital-grade chemistry analysis machine that it uses to perform blood counts and metabolic panels. He cites the example of a diabetic patient who comes in with a dangerously high blood sugar level. “If we catch that patient early and can give them intravenous fluid hydration and insulin in our office, we can save a trip to the hospital that would cost Medicare $10,000 easily,” Lovelace says.

Once the decision is made to add a service, the next step is to find out whether, and how much, payers will reimburse for it. The challenge, says Kohl, is that insurance plans differ in their coverage policies and amounts. For practices that contract with a large number of payers, determining how many patients will be covered for the service is often a difficult and time-consuming exercise. 

If an insurer doesn’t cover a service, practices can sometimes persuade them to do so by showing it will reduce costs of care, says Fabrizio. That’s particularly true when it comes to counseling for lifestyle and chronic disease issues, such as smoking cessation, weight management and diabetes education. “Can you keep my patients healthier and prevent their needing more costly services by providing that counseling? If I’m a payer that’s something I’m certainly looking at,” he says.

But even with the complexities of value-based care and differing payer requirements, ancillary services at many practices are still determined by such basic factors as the practice’s location and the needs of its patient population. Lovelace Family Medicine’s decision to acquire sophisticated blood lab technology was driven in part by high rates of diabetes and blood-related diseases among its patients.

“We’re able to manage a lot of things in the office right then during the patient’s visit, rather than having to send them to the hospital, because we have that lab capability,” Lovelace says. 

Other services the practice offers have been added largely because of patient demand, says Lovelace. And even though the demand for some, such as laser hair removal,  is less than in urban areas, “one of the good things about being a part of the community and providing continuous care is it allows you to consider the long haul when you’re making decisions about whether to invest in the technology you need for an ancillary service.”

While financial return is always an important consideration when considering an ancillary service, Lovelace says, “if it allows us to at least break even, if it improves our quality of care and it doesn’t come with too much regulatory hassle, as a rule, we’ll probably do it.”

Fabrizio says that settling for break even on an ancillary service is generally a reasonable approach, given that the service will benefit patients. At the same time, he notes, practices need to consider what other opportunities it may be foregoing by adding the service.

“Adding a service takes “X” number of hours in staff time and physician time. If they didn’t provide that service, how many more of their ‘regular’ patients could they see?”, he says. “And it’s not just the physician time, but also the staff time and the room utilization resource that you also have to figure.” 

Patient demand has also guided the practice Sports Medicine at Chelsea which, despite its name, provides both family and sports-related procedures and services. The New York City-based practice has a patient panel numbering some 40,000 and has undergone several physical expansions since its founding in 2006, according to Naresh Rao, DO, FAOASM, one of its three physicians. 

The practice’s family medicine services are popular among patients of all ages, while sports medicine attracts younger, physically active patients, of which there are many in Manhattan’s Chelsea neighborhood where the practice is located. “Being an osteopathic family practitioner and fellowship-trained in sports medicine opens up a whole bunch of ancillary services we can deliver to our patients,” Rao says. 

Family medicine services the practice offers range from sleep studies to tropical medicine to cryotherapy and wart removal. On the sports medicine side, services include joint and soft tissue injections, musculoskeletal ultrasounds, integrative sports medicine and physical therapy, among others. 

The latter has been responsible for most of the practice’s growth in recent years, says Rao, such that the practice how employs four full-time and one half-time therapist.  “Half the patients that come to our office see a physical therapist, because there’s such a recurrent nature to physical therapy,” he says. 

By and large, Sports Medicine’s commercial payers are “pretty accepting” of its ancillary services, Rao says, in part because the practice belongs to an Independent Practice Association, which negotiates payer contracts on its behalf. If a service is not covered, or requires a prior authorization, the practice makes sure to inform the patient. “We find that when the patient is told upfront what they’ll have to pay for, it tends to produce higher levels of satisfaction,” he says. 

For practices considering ancillary services, Rao says: “The most important thing is to think about what’s comfortable, what’s truest to who you are as a person and a medical professional. I love family medicine, it’s the base of everything we do here, and there’s a lot we can do to build on that base. So if you’re comfortable in a particular realm, then by all means go for it.”

Under value-based pay, practices may find they need ancillary services just to maintain their current revenue.

Ancillary services: A new cost-benefit analysis 

Welcome to Medical Economics' blog section

 which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.

If four jumbo jets filled with passengers crashed every day for a year, killing everyone on board, wouldn’t we mobilize as a community and do something about it? That’s the same amount of people who die annually from heart disease. Over 80 percent of these deaths can be prevented, but despite having the tools to avert this hypothetical crash, our patients continue to board the plane. 

Heart disease is the underlying cause of one in three U.S. deaths and kills more Americans a year than all forms of cancer combined-and yet people still fear cancer more. The healthcare community has made significant strides in raising awareness of heart disease and cholesterol, but a 

 conducted by MDVIP and Ipsos found that Americans still need help digesting the information and understanding their personal risk. 

62 percent of survey respondents failed a 

, proving an overall lack of knowledge about heart disease, risk factors, and prevention.

Only 42 percent have asked their primary care doctors (PCP) for advice on prevention or management.

Only 42 percent have been coached by their PCP on specific lifestyle habits that can help prevent or manage heart disease, such as diet, exercise, and meditation.

So, what can we, as medical professionals, do to support our patients?  

One reason we continue to see cardiovascular events is that we focus on improving our patients’ low-density lipoprotein (LDL) levels, often skimming over other important factors such as saturated fats and inflammation. 

According to the survey, more than half of Americans believe that people with heart disease should eat as little fat as possible-they don’t understand that unsaturated fats that can actually help reduce their risk. In addition, three-quarters of Americansdon’t know that most heart attacks occur in people with normal cholesterol levels, and only 35 percent are aware that inflammation is the trigger for most heart attacks. So, not only do we need to dispel the misconception that cholesterol is the best indicator for heart disease risk, we also need more education about inflammation.

Offering more comprehensive heart screenings and speaking with patients about their personal risk is the first step in heart attack prevention. According to the survey, only 14 percent of Americans had their inflammatory markers checked within the last year, while 54 percent have had their cholesterol levels checked. In addition, doctors should consider ordering a patient’s bloodwork in advance of his or her appointment, so they can review the results face-to-face with the patient and answer questions the patient may have. 

More and more research has found that heart disease can affect anyone at any age. Lifestyle changes, including diet, exercise, sleep, and stress management, can make a significant difference in preventing and even reversing heart disease. Therefore, we need to help our patients create a lifestyle plan for optimizing their heart health-and this includes our younger patients, since the decisions they make in their 20s and 30s will affect them decades later. 

Andrea Klemes, DO, FACE, is chief medical officer for 

, where she also serves as the executive and organizational leader of MDVIP’s Medical Advisory Board that supports quality and innovation in the delivery of the healthcare model drawing expertise from the affiliated physicians. 

Many Americans still need help digesting information about heart disease and understanding their personal risk.

How we can stop America’s silent killer

Here’s the deal: Of course we all want to improve patient outcomes and reduce healthcare costs. These are big challenges the healthcare industry is up against. But the bottom line is really, well, your bottom line. You can’t care for patients if you can’t keep the lights on. At the end of the day, you are running a business. Whether or not practices outright state it, just like any other business, the ultimate goal of providers and healthcare organizations is to have a healthy balance sheet. 

While the strategies may seem simple-attracting new patients and/or getting your current patients to be more consistent in their care-it is often an uphill battle. However, based on your specific revenue goals (as well as your practices’ current strengths and weaknesses), there are a lot of ways to do this, and any practice can be successful with the right balance of techniques and tools. 

This kind of goes without saying, but the more patients you provide care to, the more revenue you bring in to your practice. But what are the most effective ways to increase the number of new patients visiting your practice? 

Ask for referrals. I like to call a patient referral the “golden ticket” of the healthcare world. Referrals from one patient to another are one of the most effective ways to attract new business-and should play a big part in your marketing strategy. Train your staff on how to request referrals from satisfied patients. This could be through word-of-mouth or by sending a link in your online communication. 

Create a strong website. There is nothing more important in today’s business world than having a good online presence. That starts with your website. Make sure you are regularly updating your site. Make it easy to navigate. If possible, include educational pieces (such as common health questions or a regular blog) to position yourself as an expert in the field. Providing valuable content on your site will also improve the chances that your site will rank higher in search engines. 

Encourage online reviews. Just as your website is important to creating an awesome online presence, reviews are also critical. The best way to build your online presence is to ask your satisfied patients to leave reviews. Modern PRM (patient relationship management) systems now let you send quick requests to patients after their appointments asking them to review your practice on a particular site. 

Does it feel like more and more patients are becoming inactive? You’re not just imagining things. Americans are visiting their healthcare providers 19 percent less often than they did in 2000. As your regular patients start to disappear, so does the revenue they bring with them. As regular visits to providers continue to fall, recall efforts have never been more important. Here are a few quick ideas to give your recall program a little jumpstart. 

Automate your efforts. Using automation to reach out to inactive patients is important because it ensures that no patient falls through the cracks. Implement a system where you can automatically send out messages to patients who are due (or overdue!) for care.

Uncover why patients aren’t coming. You can send a survey to all inactive patients to get a feel for why they might have stopped coming. Ask questions honestly…”Are you afraid of visiting?” “Does the cost prevent you from making an appointment?” and so on. Doing so will enable you to address the unique issues your patient base may be facing.

Unleash the power of the internet. From social media to email, there are lots of great ways you can connect with patients online. Doing so will help keep your practice top-of-mind with patients, even between visits.

The average practice sees no-shows rates of 

-and those numbers can be significantly higher depending on your specialty. That’s almost one in every four patients just not showing up! Each one of those lost appointments is expensive (ranging from 

, depending on specialty). Fortunately, there are things you can do to help alleviate no-shows and cancellations.

Consistently remind patients of appointments. The most common reason to miss a doctor’s appointment-

-is that the patient simply forgot. Reminders make a big difference in helping jog those memories. A 

 found that no-show rates fell 26 percent after sending a reminder. Automating these reminders is a key piece to making sure reminders go out at the right time and to the right patients.  

Use the most effective reminder. Sending a reminder via the communication method that patients prefer is one of the best ways of ensuring they actually show up. This means that some reminders will need to go out via text message, some through email, and others with an old-fashioned phone call. On all of your intake forms, in emails, or even in person, be sure to ask each patient how they want to be contacted-and then use that method. 

Actively use a wait list. Experts have found that about 

 scheduled appointments will end up being canceled by patients. These cancellations create headaches for staff and losses on your balance sheet. The best way to tackle last-minute cancellations is to keep an active wait list. Track those patients that would like to be seen earlier and then, when an appointment becomes available, send those patients a quick message seeing if they’d like to fill it. It’s easy and effective. 

As you focus on both increasing the number of new patients and maximizing the appointment attendance of current patients, your practice can expect to see significant improvement in its bottom line. Consider implementing one or two of these methods at a time and then continue to add additional strategies over time. As you do so, you will start to see the improvements in your revenue that you are aiming for. 

Josh Weiner is chief operating officer of Solutionreach.

We all want to improve patient outcomes and reduce healthcare costs, but you can’t care for patients if you can’t keep the lights on.

May 10, 2019 edition