The sad truth is that many physicians are dissatisfied with their careers. They still enjoy helping their patients, but often feel beaten down by many challenges that overwhelm the reason they went into medicine in the first place. Survey results show that a lack of autonomy often is to blame for their frustration. But what does physician autonomy mean in today’s health care world?

 recently interviewed Wendy Dean, M.D., a psychiatrist and president and co-founder of Moral Injury of Healthcare, to discuss what physicians can do to take back control of their careers. This interview was edited for length and clarity.

 One of the things we hear about often from our audience is that they lack an autonomy they feel they should have as physicians. Can you talk a little bit about physician autonomy and what that means to you?

Dean: Physicians are trained from the time they go into medical school, and sometimes even before that, to be independent thinkers, to be critically analytical about the problems that they’re looking at that, that they’re investigating for their patients. And they’re also taught not to blindly follow algorithms because that may get them into trouble. And so, after a decade of that sort of training, to go out to practice and have to follow strict algorithms based on reimbursement policies, rather than on clinical best evidence, really goes against the grain of what we believe is good patient care.

ME: In a previous episode, we talked about moral injury. And I’m just wondering how much you feel there’s a relationship between moral injury and a lack of autonomy?

Dean: From my perspective, there’s quite a lot when we are not allowed, for reasons other than good patient care, to get patients what they need. That really goes against some deeply ingrained beliefs on our part and the promises that we made to our patients when we left medical school and went out into training. And the more we are constrained in what we can do for patients, the more frustrated, the more demoralized we become. So I think the two are linked.

ME: One of the things we often hear from our physician audience is that the solution to these systemic issues is just to get rid of the insurance companies, open a direct pay practice or concierge practice. What do you think about direct pay and concierge for simplifying a practice and are they solutions to physician autonomy concerns?

Dean: I think those are great solutions for some physicians. I’m not sure that it is a viable solution across all of health care in the U.S. I have practiced as a direct patient care psychiatrist, and it really did streamline my practice quite a bit. But ultimately, it wasn’t a solution for all of the patients that I wanted to see. So what I would like to get back to is a practice where we don’t have to make those machinations of direct patient care or not, that every patient comes through and can get the same attention, the same one-on-one care, the same undivided attention from their physician ... can walk out and get the prescription they need, the physical therapy they need, the imaging they need, without either the patient or the physician having to go through contortions to make that happen.

ME: What systemic changes do you think need to happen with health care in our country to allow physicians to have more autonomy to spend more time with their patients?

Dean: The biggest change that needs to happen is for the health care system to change the way it supports physicians. So, right now, when physicians are engaged with a patient, they’re reporting to their chief financial officer about how many patients they’ve seen, and this is all indirect, but they’re expected to make metrics on how many patients they see. They’re reporting to the insurer about what they think this patient needs. They’re making a case for why they need the imaging or why they need the medication. So the physician is actually responsible to report to a lot of different people. And really what would be great is if the administrative side of medicine would instead ask how they can support the physician and the physician-patient relationship and change the dynamic so that the physician is facilitated, and how they can get their patients what they need.

ME: The No. 1 reason physicians tell us they are losing autonomy is prior authorization, the insurance companies telling them how to practice medicine. And I’m just wondering, from your experience, what’s the link between the growth of prior authorization and how physicians feel about their careers?

Dean: I think the growth of prior authorization goes along with a lot of the other regulations that have come in and a lot of the other cost-saving measures that have been implemented in health care. So it’s one of a number but it is the most abrasive. The challenge for physicians is we’ve trained for 10 years or 15 years to know what our patient needs. We’re pretty clear that maybe another type of imaging isn’t going to yield us as much as we’d like. It’s going to cost the patient time, it’s going to cost them a copay. And all of that is a challenge, it’s a struggle. We don’t want to have to inflict those things on our patients. When we’re clear we could go right to a particular test, a particular medication, and to be asked to do that based on reimbursement rather than good care, it goes against the grain of our training. And it also doesn’t feel at times as though we’re talking to an equivalent specialist. We’re talking to a nurse who’s trying their best to do what’s right by their company, but not by the patient. We may be talking to a neurosurgeon, may be talking to an OB/GYN to get authorization. And so it just goes against what we believe is good care.

ME: I’m wondering what changes you think need to happen in medical school in the way physicians are trained, to prepare them for the realities of health care and to participate in changing health care?

Dean: Medical students are so fantastic because they are energetic, they’re idealist, which is great. It’s also a double-edged sword. Because if we don’t prepare them for what they’re coming out into as residents or as attendings, then they may become very disillusioned very quickly. So I would love to see us train medical students in what the economic realities are of medicine, how the money flows, how reimbursement works, how policy gets made, how legislation happens. Really train them to be activists in their own interest and in the interest of their patients, because that’s what’s going to be critical in the next 20 years.

ME: What recommendations do you have for physicians to reclaim autonomy in their own careers? Obviously, there are a lot of systemic issues, but I’m wondering what can physicians do for themselves to carve out a space where they feel they’re practicing medicine the best way?

Dean: The best thing that they can do is learn how the incentives are aligned in their own institution. Understand how reimbursement happens, what the incentives are at their entity. And whether they can negotiate to build bridges with the administration, build bridges with other licensees, so that everyone can work together to start fixing things at the local level.

ME: Even for individuals, what this sounds like is they need to talk to their fellow physicians and their fellow health care providers about how to really put the patients front and center and make this better for everybody.

Dean: Correct. In talking to all their fellow clinicians and other physicians, they’ll start to notice what the patterns are, where the stumbling blocks are. Each separate specialty may have its unique challenges, but there will be commonalities that happen. And as you start to look into that more and more, you can quickly become an expert and can have the tools available to you to change what that problem is.

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Survey results show that a lack of autonomy often is to blame for their frustration. But what does physician autonomy mean in today’s health care world?


How to restore physician autonomy

The last thing I wanted to do was to write an article on racism. Not being an expert on the topic, any time I even contemplated writing something, I was crippled by self-doubt. But even more, I was paralyzed by fear. All I could think of were the buzzwords floating around social media. If I wrote against racism, would I be accused of “virtue signaling?” If I didn’t go far enough in condemning racism, would my words be perceived as insufficient, a mere “dog whistle?” What if I unintentionally wrote something that smacked of “white fragility?” Worse yet, I found myself avoiding the topic because of my own discomfort. What if in researching the issues of systemic racism I found myself unintentionally complicit in hurting people I cared about? How would I face this guilt and shame?

But the universe has a way of forcing us to face the unpleasantness that we dread, and when my editor specifically asked me to write an article for doctors on facing implicit bias in medicine, I knew that I had to answer the call. I’m glad I did. Because after speaking with multiple physician experts, I now have the tools to begin to identify and overcome my own implicit biases, and so can you.

Every one of us has a certain degree of implicit bias, or subconscious automatic thoughts about others that stem from our upbringing and social framing. Having these thoughts does not mean we are inherently bad or evil. But if we fail to identify areas of implicit bias — blind spots in our knowledge and understanding of other groups of people — we risk inadvertently providing them with lower-quality care. Because this is the antithesis of what most doctors strive for, realizing that we have blind spots may be hard for us to admit.

Christina Girgis, M.D., a consultation-liaison psychiatrist in Chicago, Illinois, and founder of the Psychiatry Network, an educational group and advocacy resource for psychiatrists, says that one of the biggest challenges of acknowledging implicit bias is the cognitive dissonance that it creates. “We all want to think that we are good. Recognizing that we have automatic negative thoughts about certain groups of people does not fit with that belief. That’s why it can be so hard to recognize and accept this within ourselves.”

But everyone struggles with bias, including doctors of color. Brian Dixon, M.D., is a Fort Worth, Texas, psychiatrist, author and founder of Together Forward, a nonprofit think-tank focused on improving health and alleviating cultural disparities. Dixon discovered during a test of implicit bias that he, a black person, was biased against black people and in favor of white people. “I already knew it,” says Dixon, who grew up in a predominantly white area and attended medical school and residency with few other black people. “My biases, like those of anyone, are a result of my environment and the societal messaging I have received in my lifetime.”

Wamda Ahmed, M.D., a neurologist in Houston, Texas, with a special interest in racial disparities, agrees. “Even African American physicians face similar bias, because we receive the same messages and social framing that our white colleagues experience.” Ahmed notes that she sometimes even struggles to overcome automatic negative thoughts about herself that stem from her social conditioning. “I have to challenge my ‘imposter syndrome,’ and consciously transform the negative thoughts of ‘I am not good enough’ into ‘I can do better.’”

“Having bias doesn’t make you a bad person,” says Nicole Christian-Brathwaite, M.D., child adolescent and adult psychiatrist and CEO and founder of Well Minds Psychiatry & Consulting in Boston, Massachusetts. “Identifying bias is an opportunity to become aware and act.” To help recognize our inherent bias, psychiatrists like Christian-Brathwaite and Dixon suggest taking the Harvard University’s Implicit Associations test, which, although imperfect, can at least begin to raise our self-awareness. Another good way to avoid blind spots is to focus on patients as individuals. “Ask your patients about their cultural backgrounds. Listen to your patients’ stories. The more you individuate, the less likely you are to stereotype,” says Christian-Brathwaite.

Maiysha Clairborne, M.D., an integrative family physician, physician coach, neurolinguistic programming expert and founder of Stress Free Mom MD, says that one of the keys is to not only listen to patients but to watch their responses carefully when you talk with them. “Don’t dismiss patients’ reactions as sensitivity,” advises Clairborne. “If you see your patient react, ask them about it.” Clairborne uses the technique of emotional mirroring and validation, labeling the response that she sees the patient exhibit and asking for clarification. “Check in with your patient. If I see a patient flinch, I might say, ‘I just observed your face change, what happened there?’” She recommends asking specifically, “Was that a racially insensitive thing I just said? I’m sorry; I’m still learning.” This takes the pressure off and gives the patient space to respond.

One of the reasons that we fail to examine our biases is because of the emotions they can produce. These emotions can be immensely powerful, and without help in processing them, we may develop maladaptive coping mechanisms, including denial or anger. “Trauma begets trauma,” Dixon says. “If we are not careful in dealing with our emotions, we can risk traumatizing others. It becomes a vicious cycle unless we learn to break it.” Dixon believes that this trauma is one of the reasons it has been difficult to have a reasoned discussion about racial issues. “We cannot even begin to have a public debate or discourse about racism when tensions are high, because traumatized people can’t act in an even-keeled manner. When you feel afraid, you have a biological imperative to run away or lash out.”

To help examine your emotions, Dixon recommends finding a guide, usually a psychiatrist or psychologist. Another option is a physician coach, which may be ideal in states where the medical licensing board takes a punitive approach to mental health counseling. “It’s important to find someone to help you interpret areas of implicit bias and to remind you that having automatic thoughts doesn’t make you a racist. You may need help in overcoming the trauma of realizing that you’ve hurt someone. You have to learn to forgive yourself, and that takes work,” Dixon says.

Girgis says that physicians must work to change our thinking from “I’m a bad person” to “How can I change this type of thinking?” We can also transform our feelings from being about us to being about other people. “Reframing is one of the best tools that we can use. We need to see the realization that we are biased as a positive; now we can begin to deal with it,” Girgis says.

“The best way to deal with anxiety or fear is exposure therapy,” says Christian-Braithwaite. She compares the process to what physicians experience to M&M (morbidity and mortality) rounds during training. “We don’t go into medicine to hurt people, so when we do, it’s humiliating. We should discuss racism in medicine in the same way that we do medical errors, as both lead to negative patient outcomes. Although it’s difficult and uncomfortable, this is how we grow,” she says.

Once we have acknowledged that we have hidden bias, the next step is to develop a better understanding of the systemic issues that our patients face. We can do this by reading about social policies that have negatively affected black populations, such as redlining (the denial of mortgage loans in certain areas for people of color), wage inequality and unjust criminal justice policies. We must also research the effects of racism on medical outcomes. For example, Christian-Brathwaite notes that black patients are more likely to be improperly diagnosed with psychosis and schizophrenia and more likely to be restrained in an inpatient psychiatric unit than white patients. Ahmed points out that African American and female patients are less likely to be treated with tissue plasminogen activator for a stroke and more likely to have a stroke misdiagnosed as a psychiatric disorder or drug abuse reaction. African American patients are also less likely to undergo cardiac catheterization or receive a kidney transplant compared with white patients. African American and Latino patients have been found to receive less pain control in the emergency room than white patients.

Resources for learning about racial disparities include the Office of Minority Health’s Knowledge Center and the American Medical Society’s Health Disparities Toolkit. Dixon suggests checking to see if your hospital or university has a diversity officer. “Many organizations are hiring diversity officers who are trained in addressing racial disparities.”

“Physicians have a unique obligation to address racial disparities because our patients are vulnerable and trust us with their lives,” Ahmed says. However, she notes that this is not always easy, and she often must work at maintaining her objectivity. “Sometimes my first impression may be that a patient’s symptoms are psychiatric. But I remind myself to stop and follow my usual protocols for every patient until I have excluded the most serious neurologic causes,” she says.

Once she has confirmed that a patient is not suffering from a neurological condition, she takes the next step to try to determine the root of their problems. “I ask myself: ‘If this is not a stroke, what is it?’ Often, I discover that patients have had a recent traumatic life experience or an underlying socioeconomic cause for their symptoms,” Ahmed says.

Although many physicians worry they won’t have time to address racial disparities or socioeconomic pressures, Ahmed says that even taking a moment to connect with your patients on a human level can make an impact. “Take a few minutes to be kind, give encouragement or a hug, just to show that you care.” She notes that developing emotional connections with patients also has been found to decrease physician burnout.

Christian-Brathwaite, who specializes in helping physicians fight racial disparities, suggests that doctors take time to reflect on the care that we provide. “Consider doing a chart audit to look at your plan and your goals for different patients,” she says. “Ask yourself: ‘Are my treatments consistent?’”

She notes that implicit bias increases when we are tired, rushed or stressed. “Medicine is often not conducive to being unbiased because when we are under stress, we often find ourselves resorting to shortcuts, including stereotyping our patient,” Christian-Brathwaite says.

Developing anti-racist thoughts and behaviors

I hesitated to write this article because I was afraid of saying the wrong thing. I’ve also avoided discussing racial issues on social media for the same reason. Girgis told me that this is a common concern. “Discomfort can be the worst feeling, and most of us try our best to avoid it. Sometimes you just have to acknowledge your fear and just jump in,” she says.

Girgis notes that if we stay silent, our colleagues won’t know about our support. “Most of the time, our efforts are appreciated, even if they are clunky or imperfect.” She recommends using an accountability partner such as a friend or colleague to help us evaluate our objectivity.

One of the things we can all do, Girgis says, is to analyze what advantages and resources we have as physicians to help mitigate racial disparities.

“I may not be able to go out and protest, but I can take steps to make my patients feel more comfortable, to talk with my colleagues and to mentor trainees,” Girgis says. The public pays attention to doctors, and our words and actions carry weight. “We can educate the public by writing and speaking out, or we can just be a good example in our interactions with others outside of work,” she says.

“We have to keep trying,” Ahmed says. “I see the process of developing as a physician to like that of a parent. I’m not going to be perfect every day, but I’m going to keep trying, because the stakes are too high.”

Rebekah Bernard, M.D., is a family physician and author of “Physician Wellness: The Rock Star Doctor’s Guide” and “Change Your Thinking, Improve Your Life.” She can be reached at rebekahbernard.com.

Analyze what advantages and resources we have as physicians to help mitigate racial disparities.

Overcome your bias blind spots to better help patients

Six months into the COVID-19 pandemic, its impact on medical practices is becoming clear: fewer in-person visits, more care provided via telehealth and, for many, lower revenue.

But even as doctors struggle with the day-to-day challenges of practicing under radically new circumstances, some health care policy makers, academics and payers are asking another question: What do the changes brought about by the pandemic mean for accountable care organizations (ACOs) and other value-based care models, under which doctors and practices are rewarded for keeping patients healthy while holding costs down?

The consensus among experts who spoke with 

 is that the pandemic will, in the long run, benefit ACOs and other value-based programs, as practices lessen their dependency on fee-for-service medicine as the sole source of their income.

“If you’re a small practice living on fee-for-service, and suddenly all your patients disappear, you realize how much risk you’re under, as opposed to those who have moved to some sort of capitation or bonus for quality arrangement covering at least part of their patient base,” says J.B. Silvers, Ph.D., a professor of health care finance at Case Western Reserve University’s Weatherhead School of Management in Cleveland, Ohio.

“What many thought was the less risky approach of just practicing fee-for-service turns out to be more risky when you have these unexpected ‘black swan’ events,” he says.

Early in the pandemic, as practices’ patient visits and incomes plummeted, value-based programs seemed anything but appealing, especially if they involved financial risk. A mid-April survey by the National Association of Accountable Care Organizations (NAACOS) found that 56% of ACOs in a two-sided risk program — i.e., one that requires sharing losses as well as gains — said they were “very likely,” “likely” or “somewhat likely” to leave the program due to fear of having to repay losses incurred as a result of treating patients with COVID-19.

Partly as a result of this sentiment, the Centers for Medicare & Medicaid Services (CMS) moved quickly to shore up its main value-based initiative, the Medicare Shared Savings Program (MSSP).

According to Silvers, CMS had little choice but to act quickly to ensure that ACOs remain in the MSSP program. “This [MSSP] is a big bet they’ve made, and if practices start to bail on them, the whole program goes down the tubes,” he says. “Having practices stay in it for the long run is really important, so they want to make it as stable and predictable as they can.”

Allison Brennan, MPP, senior vice president of government affairs for NAACOS, says the steps CMS has taken have helped allay members’ initial fears over the effects of the pandemic.

“The main reason they are taking these actions is to prevent ACOs from unfairly shouldering the burden of a pandemic over which they have no control, and so far it seems to be working,“ she says, adding that “we still have to wait and see what the net effect will be in some of the hardest-hit areas.”

How value-based programs are responding to pandemic

Despite their initial fears, practices in value-based programs appear to be better positioned to survive the COVID-19 crisis, says Keely Macmillan, M.S., senior vice president of policy and solutions management at consulting firm Archway Health, which helps practices shift to bundled payments and other types of value-based models.

“The providers who had put infrastructure in place to achieve success in these models, like care coordination, patient tracking and telehealth, are able to respond more quickly and continue providing high-quality care to patients in the midst of this health emergency,” she says.

That has proven true for CareMount, an ACO based in Mount Kisco, New York, with more than 600 providers in five counties and parts of New York City. It began participating in MSSP in 2013, and since 2018 it has been part of the Next Generation ACO program, where it shares in losses as well as cost savings. It also has performance-based contracts with many of its commercial payers.

Because of its long experience with value-based programs, CareMount understood the importance of population data in improving patient care, says Kevin Conroy, M.S., the group’s chief financial officer and chief population health officer. It had built an in-house data analytics department that performed functions such as alerting doctors when a Medicare patient was due for an annual wellness visit.

Once the severity of the pandemic became apparent, Conroy says, CareMount was able to use the data it had accumulated to quickly identify and contact its most vulnerable patients. “We already had a robust care coordination team, but we became more targeted with it,” he explains. “We looked at things like who was deferring care or missing a screening and who we needed to reach out to telephonically to make sure there’s no deterioration in their condition.”

CareMount also had a telehealth platform, Conroy says, although before the arrival of the pandemic it was rarely used. Beginning in mid-March, however, telehealth visits escalated rapidly, peaking at 1,500 per day, and they have been an important tool in enabling CareMount’s providers to stay in touch with patients and monitor their health.

In addition, Conroy says, CareMount is in the early stages of developing a home health program to augment telehealth visits. The goal is to send medical assistants to patients’ homes for tasks that can’t be done by phone, such as blood pressure screenings and checking on prescription adherence.

Conroy predicts that the pandemic will heighten the appeal of value-based care models such as ACOs. “Groups that are using value models are positioned to create a more predictable revenue flow,” he says.

Another effect of COVID-19 on value-based programs is the increase in telehealth visits. A Commonwealth Fund study released in mid-June found that while telehealth visits were down from their mid-April peak, they were still about 8% higher compared with four months earlier. Meanwhile, numerous surveys have shown high levels of patient satisfaction with telehealth and a desire to continue using it, even post-pandemic.

The growth has been fueled in part by CMS’s decisions to allow Medicare to pay for more types of telehealth visits and raise reimbursements to match what it pays for in-person visits, and Congress’s loosening of restrictions on how and where telehealth visits can take place. And while it’s not known if these changes will be permanent, they will likely remain in effect at least for the duration of the public health emergency, according to Travis Broome, MBA, MPH, senior vice president for policy and economics at Aledade, a consulting firm that helps practices form and join ACOs.

Broome notes that ACOs and other value-based programs are a good environment for testing whether more telehealth visits improve patients’ health, and, if so, under what circumstances. “Under these models, the providers are incentivized to find and do just the parts of telehealth that really add value, because they’re on the hook for the total cost of care,” he says. In other words, practices will incur financial penalties if telehealth leads to more visits without improved outcomes.

Mark Fendrick, M.D., director of the Value-Based Insurance Design Center at the University of Michigan and a professor of health management and policy at the university’s School of Public Health, echoes Broome’s prediction and thinks it will also extend to fee-for-service medicine.

“I’m certain that, across populations, patients seen virtually will have lower rates of unnecessary services than those seen in person,” he says, adding that too many primary care doctors routinely order electrocardiograms, blood work-ups and other tests at every patient visit.

“I’m hopeful [with telemedicine] that the volume of these low-value services will fall and free up funds to invest in the areas where we really need to be spending money,” he says.

Another significant question for practices in value-based models, especially those that are part of the MSSP, is the effect of the steep decline in health care spending due to patients delaying or foregoing care, both elective and necessary. Results of a study from the insurance and consulting firm Milliman, released in April, estimate that health care spending in 2020 will be down by at least $75 billion, and possibly as much as $575 billion, due to deferral or elimination of care related to COVID-19.

The spending drop-off has both short- and long-term implications for ACOs in the MSSP, according to Archway’s Macmillan. In the short term, it has caused CMS to adjust the formulas it uses to set spending benchmarks for some shared savings programs.

Looking ahead, Macmillan says, the big question for ACOs and other value-based programs concerns medically necessary care that has been deferred because of the pandemic. “A lot of patients with chronic conditions haven’t been well managed in the past few months because they’ve stayed home, which means their diseases may have progressed more quickly than normal,” she says. The result would be more severe acuity when these patients do finally venture out, leading to higher costs of care.

“CMS is going to have to figure out how to address that issue fairly, and I don’t think there’s enough data yet to measure the impact this [deferred care] has had,” Macmillan says. “But going forward they have to make sure their benchmarking methodologies reflect the circumstances of COVID-19.”

Fendrick says the changes in care delivery wrought by the pandemic could result in a wholesale rethinking of spending priorities. “Everyone agrees we have enough money in the health care system to take care of everyone, we’ve just been spending it in the wrong things and in the wrong places,” he says. “My hope is that payment reforms, combined with changes to benefit designs, will better align around high-value services and make it harder to use low-value services. I think that outcome would be a win-win.”

If you’re a small practice living on fee-for-service, and suddenly all your patients disappear, you realize how much risk you’re under, as opposed to those who have moved to some sort of capitation or bonus for quality.

What will COVID-19 mean for value-based models?

Exclusive survey: Physicians explain COVID-19 financial impact on practices

The COVID-19 pandemic has proved an unprecedented challenge for physician practices.

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When considering the importance of medication adherence, former U.S. Surgeon General C. Everett Koop said it best: “Drugs don’t work in patients who don’t take them.” That was 35 years ago, and the issue remains a major area of concern for clinicians today.

One-fourth of new prescriptions are never filled — and even when filled, up to 50% of patients with chronic conditions fail to take their medications as prescribed. These statistics reflect the situation before COVID-19 led to social distancing and stay-at-home orders that may be making the situation worse.

Medication nonadherence can lead to serious health consequences and higher medical costs. Each year, medication nonadherence results in approximately 125,000 deaths and up to 25% of hospitalizations, which is estimated to cost the American health care system nearly $300 billion.

As the number of coronavirus cases continues to grow across the U.S., medication adherence has never been more critical, especially for elderly patients and those with chronic conditions who are the most susceptible to complications, including death, from COVID-19, according to the Centers for Disease Control and Prevention. To protect the most vulnerable patients, physicians and pharmacists must work together to identify the underlying reasons patients aren’t taking their medications as prescribed and to provide solutions that improve adherence.

There are three primary reasons why patients don’t fill new prescriptions or take their medications as directed: high cost, lack of symptoms and forgetfulness.

A major contributor to medication nonadherence is high out-of-pocket costs for prescription drugs, as shown by the results of a recent consumer survey. In the survey, 48% of respondents reported not filling a prescription within the last few years because of cost. The survey also found that even a $10 rise in copay increases the likelihood of prescription abandonment by as much as 19%.

 also found a direct correlation between the amount of a patient’s copay and the likelihood of prescription abandonment. Patients with $50 copays were nearly four times more likely to abandon a prescription at a pharmacy than patients paying $10.

Today, millions of Americans have lost their jobs, their health insurance and the incomes they used to pay for out-of-pocket health care costs. One in seven report they would avoid seeking care for potential COVID-19 symptoms because of cost concerns, according to a recent Gallup-West Health poll. Unless patients find some financial relief, medication nonadherence rates surely will rise.

Lack of symptoms and misunderstanding of disease

Patients often do not understand why they need certain medications. It’s not uncommon for a person to say they don’t feel their blood pressure is high or that they don’t have any symptoms from high cholesterol. If they don’t 

sick, people may stop taking their medications, which can have serious consequences over time. This situation often leads to unnecessary visits to the emergency department and, occasionally, hospital admissions that could have been avoided.

During the current health crisis, we have all been encouraged to stay at home, limit trips to the grocery store and pharmacy and postpone nonessential medical care. This means patients may have less interaction with physicians and pharmacists who can educate them about prescribed therapies. Now is the time for care team members to adopt proactive measures to make sure patients understand what their medications are for, how to take them and why doing so as prescribed is important.

Delaying or forgetting to pick up prescriptions

Even in our former everyday lives, it was easy enough to put off a trip to the pharmacy for a prescription. Now, as many of us remain sheltered at home, it’s a challenge to recall what day it is, much less remember to pick up a prescription.

Using reminder tools that notify patients when medications are prescribed and when they are ready for pickup, pharmacists and physicians can help reduce prescription abandonment. Many independent pharmacies and national chains are offering free delivery services for prescriptions, which is particularly beneficial for patients who feel leaving home could compromise their health. Additionally, health plans have eased restrictions on filling prescriptions in larger quantities, reducing trips to the pharmacy.

Improving medication adherence with technology

Care team members can improve medication adherence and health outcomes by leveraging technologies that provide price transparency, offer access to educational materials and send reminders directly to patients’ mobile devices. Technology also can facilitate secure communication between prescribers and pharmacists.

For example, when prescribers see patient-specific drug pricing detail

 at the point of encounter within prescribing workflows, it empowers them to discuss formulary options and out-of-pocket costs with patients and potentially review financial assistance options if cost is a barrier. Real-time price transparency tools let patients know exactly how much their medication will cost before going to the pharmacy. These tools eliminate the “sticker shock” experienced when the pharmacist accesses the patient’s health plan benefits to discover the medication is unaffordable for the patient.

Care providers also can reduce financial barriers with new technology that gives patients direct access to copay assistance options. Emerging solutions may link patients to educational content about prescribed medications, giving them a better understanding of the prescribed therapy.

Better communication between pharmacists and doctors

Physicians and pharmacists can further drive adherence by sending automatic reminders to patients’ smartphones, for example, to notify them when a prescription is sent to the pharmacy or when a prescription is ready. Such tools may allow patients to set reminder notices to pick up their medication. By committing to a specific time, patients are more likely to pick up their prescriptions and more likely to take them.

Sometimes, prescriptions are not filled in a timely manner because the pharmacist needs additional clarification from the physician or the payer. A pharmacist may place a call to the physician and leave a message, which starts a time-delaying game of phone tag. To increase efficiency, improve coordination and ultimately fill prescriptions more quickly, a patient’s care team can communicate directly using secure texting, email or videoconferencing technology.

COVID-19 has affected every aspect of our lives and created tremendous financial and emotional strain for many of the most vulnerable patients. Health care professionals must help patients overcome any hurdles standing in the way of medication adherence, including financial and safety concerns. With the right communication and educational tools, providers can help ensure patients take the medicines they need, especially those managing chronic conditions or at the highest risk of complications.

 is chief strategy officer and chief privacy officer for DrFirst. He is a board-certified cardiologist and internal medicine specialist with more than 40 years of clinical practice and is a past president of the Massachusetts Medical Society. Send your technology questions to medec@mjhlifesciences.com.

One-fourth of new prescriptions are never filled — and even when filled, up to 50% of patients with chronic conditions fail to take their medications as prescribed. 

Improve medication adherence with technology

There’s nothing more frustrating than rendering a service and not being paid. Nuanced coding rules are difficult to understand, and physicians aren’t taught this information in medical school.

Still, health care is a business. As business owners, physicians need to know how they’re paid, including what codes to use, what modifiers to append and what details to document. Brushing up on common coding mistakes helps avoid costly recoupments and denials. We’ve asked several coding experts to provide their best advice on how physicians can maintain compliance and collect all of the revenue to which they’re entitled.

In part 1 of our two-part coding guide, we focused on coding for telehealth and other forms of remote patient care — important codes for physician practices’ short-term survival as the U.S. continues to grapple with the COVID-19 pandemic.

In times of social distancing, telephone services have become a practical way to improve patient access and prevent spread of COVID-19. Telephone services are ideal for straightforward problems (e.g., simple rash, asymptomatic cough, medication refills) that require a minimum of five minutes of medical discussion, says Toni Elhoms, CCS, CPC, chief executive officer of Alpha Coding Experts, LLC, in Orlando, Florida. Consider the following codes that Medicare accepts during the current public health emergency (PHE). Commercial payers may accept these codes, as well. Note that once the PHE has concluded, Medicare may only accept G2012 (virtual check-in) for telephone services.

Elhoms provides these tips to ensure compliance:

Document verbal consent, including patient acknowledgement and acceptance of any copayments or coinsurance amounts due.

Only count time spent on the phone engaging in medical discussion with the patient or caregiver. Do not report these codes for conversations lasting less than five minutes.

Clearly document what was discussed, as well as the outcome of the conversation (e.g., medications prescribed, referrals to specialists, additional steps for the patient to take).

Don’t report these codes when the telephone service ends with a decision to see the patient in 24 hours or the next available appointment.

Don’t report these codes when the telephone service relates to a related E/M service performed within the previous seven days or within the postoperative period of a previously completed procedure.

Only provide 99441-99443 and 98966-98968 for established patients. During the PHE, Medicare permits providers to bill G2012 for new and established patients.

The best way to operationalize these codes is to set up an edit in the practice management system that pends claims for a manual review to determine whether and which services are ultimately billable, Elhoms says.

In the last few months, providers have adopted telehealth to improve patient access and generate revenue during COVID-19. Among the services physicians can render via telehealth to patients with Medicare during the current PHE are Medicare annual wellness visits, new and established patient office visits, prolonged services, smoking and tobacco cessation counseling, annual depression and alcohol screenings, advanced care planning and more. Medicare covers more than 200 services via telehealth, many of which were added for temporary coverage during the current PHE. Commercial payer coverage of these services may vary, and it’s best to check with individual payers, Elhoms says.

Elhoms provides these tips for billing telehealth services:

Pay attention to audio-only vs. audio-visual requirements. Medicare requires the use of audio-visual technology for certain telehealth services and permits audio-only for others. Commercial payers also may have specific requirements. For example, physicians can render a telehealth visit for advanced care planning using audio only, but they must use audio-visual technology for a new patient telehealth office visit.

Don’t render Medicare’s Initial Preventive Physical Exam via telehealth. Medicare does not permit it.

Document verbal consent for telehealth, including patient acceptance of any copayments or coinsurance amounts due.

Use place of service (POS) code 11 and modifier -95 when billing Medicare. Note that commercial payers may require a different POS code (e.g., POS 2 or POS “other”) and modifier.

Document, document, document. Physicians need to prove they met all of the code requirements even when rendering the service via telehealth, Elhoms says. “Don’t pull in a problem list if you didn’t treat or manage all of those problems,” she adds. “Physicians need to link the diagnosis with the assessment and treatment plan. That’s imperative.” One caveat is that during the current PHE, physicians can bill 99201-99215 rendered via telehealth based on time or medical decision-making. “The total time in direct medical discussion with the patient is going to be critical,” Elhoms says.

“The best advice I can give anyone doing telehealth right now is to watch the CMS [Centers for Medicare & Medicaid Services] and commercial payer websites pretty much on a daily basis,” says Rhonda Buckholtz, CPC, CPMA, owner of Coding and Reimbursement Experts in Pittsburgh, Pennsylvania . “The coding of services changes constantly, and practices really need to be careful.”

Though online digital E/M services are relatively new, they also can help practices increase patient access during COVID-19. Here’s how it works: An established patient initiates a conversation through a HIPAA-compliant secure platform (e.g., electronic health record portals, secure email, secure texting). A physician or other qualified health care professional reviews the query, as well as any pertinent data and records. Then they develop a management plan and subsequently communicate that plan to the patient or their caregiver through online, telephone, email or other digitally supported communication.

Elhoms provides these tips to maintain compliance:

Use these codes when physicians or other qualified health care professionals make a clinical decision that would otherwise occur during an office visit. Do not use them for scheduling appointments or nonevaluative communication of test results.

Use these codes only for established patients.

Do not use these codes for fewer than five minutes of E/M services.

Do not report these codes when the online digital E/M service ends with a decision to see the patient in 24 hours or the next available urgent visit appointment.

Do not report these codes when the online digital E/M service relates to a related E/M service performed within the previous seven days or within the postoperative period of a previously completed procedure.

Promoting these services is often the biggest barrier, says Elhoms, who suggests putting up signs letting patients know they can access their provider electronically for nonurgent medical issues.

Remote patient monitoring (RPM) is a relatively easy way for physicians to keep tabs on patients without requiring them to come into the office. Medicare covers RPM for patients with one or more acute or chronic conditions, and commercial payer coverage may vary. During the PHE, physicians can initiate RPM on new and established patients. Normally, Medicare permits it only for established patients.

RPM consists of two forms: monitoring data through either a non-manual or manual data transfer, says Jim Collins, CPC, CCC, consultant at CardiologyCoder.com, Inc. in Saratoga Springs, New York.

For example, physicians can remotely monitor a patient’s pulse oximetry, weight, blood pressure or respiratory flow rate using a device that transmits daily recordings or programmed alerts. Physicians can purchase them directly from manufacturers or patients can purchase the devices themselves. Collins says patients should look for Bluetooth-enabled devices or ones that include a built-in Global System for Mobile Communications (GSM) transmitter. The former requires an Internet connection, and the latter automatically transmits data to an internet cloud service through an encrypted bandwidth. Physicians can bill for the initial setup, cost of the device itself (when applicable) and data monitoring.

Another example is self-measured blood pressure monitoring. When patients supply their own blood pressure device that a physician calibrates, physicians may be able to bill for patient education, device calibration, reviewing the data that the patient provides and communicating a treatment plan to the patient or caregiver.

“Monitoring physiologic data on a regular basis substantially reduces hospitalizations, trips to the emergency room and exacerbations of chronic conditions,” says Collins. “It can also be a huge chunk of revenue.”

Collins provides these tips for compliant RPM billing:

Document patient consent. Patients must opt in for these services.

Document total time spent rendering these services to support time-based requirements.

Know when these codes are appropriate. It’s unclear whether Medicare will pay physicians for monitoring physiologic data derived from internal devices (devices placed within the patient’s body) or data derived from wearable fitness devices.

Only bill 99457 when the provider renders at least 20 minutes of live, interactive communication with the patient or caregiver. “It’s not going to be medically necessary to spend 20 minutes every month on every patient,” Collins says. “Patients could go for several months without physicians needing to do anything for them.”

Telehealth coding guide

Even though the first wave of COVID-19 cases is still happening,health experts warn that once the weather gets cooler in the fall, a second wave of cases is likely to arrive.

And if the wave coincides with the start of flu season, it would put an enormous strain on doctors and their practices. That’s why practices should start preparing now.

With an increase in the number of patients with cough and fever symptoms, the problem lies in how to differentiate illnesses. Doctors will need to correctly and quickly distinguish COVID-19 from the flu, strep throat or other viral illnesses.

Alicia Wright, M.D., a pediatrician for Holston Medical Group in Kingsport, Tennessee, says it’s important to keep patients who have symptoms of COVID-19 separate from those who do not.

“We are continuing to perfect our social distancing and virtual visit protocols so that it becomes second nature for our staff and providers,” Wright says. “This includes masking, temperature screening, call triage, making sure our lobbies are social distanced enough, as well as improving our survey questionnaires at the beginning of every visit. Perfecting these protocols practiced each day puts us and our patients in a safer position so whenever the illness does return, we are really prepared.”

Jeff Bullard, M.D., family medicine specialist at MaxHealth in Colleyville, Texas, notes his practice’s greatest challenge with the initial wave of COVID-19 was lack of preparedness.

“We have had to develop infection-control policies, navigate PPE [personal protective equipment] procurement and learn new way to communicate with patients,” he says. “The most glaring challenge was how to deliver care. [COVID-19] required a rapid shift from brick and mortar to virtual care delivery, which for most of us was a new skill.”

Coordinating PPE procurement was a big obstacle when the coronavirus first started spreading. It’s expected to continue to be a concern, as everyone needs the same equipment at the same time.

“Maintaining relationships with suppliers as well as leaning on the local community are two important factors in making sure practices maintain the appropriate amount of PPE,” Wright says.

For example, she suggests reaching out to the community to ask for donations of homemade face masks, face shields and goggles. Some local manufacturers have shifted their production lines to make hand sanitizer.

Most practices don’t routinely maintain a stockpile of PPE to manage pandemic-level events. Bullard says the lack of PPE greatly affected his ability to see patients in the office early on and also hindered the practice’s ability to be a testing resource for patients.

“To prepare for a second wave, clinics must begin ordering PPE now,” he says. “Most distributors are allocating monthly supplies of PPE to outpatient clinics but only a limited amount with each order. By ordering frequently throughout the summer, you should be able to build a decent stockpile before flu season and what many believe will be the return of [COVID-19].”

For many practices, finding vendors that can sanitize N95 masks has been challenging, and this is where partnerships with state resources and national associations may be helpful in finding solutions.

It’s also vital that physicians prepare for the next wave of COVID-19 by maintaining competencies gained during the first wave.

As the pandemic began and many facilities started closing, proactive physicians were finding alternative ways to care for and communicate with patients. If a second wave comes in the fall, physicians will find themselves once again experiencing closures and shelter-in-place orders. Physicians will need to let patients know what options are available to contact them and spell out circumstances in which they may need an in-person visit versus a virtual encounter.

Telehealth and virtual visits help ensure the continued delivery of health care during times of high COVID-19 activity, which is particularly critical for individuals in high-risk groups.

During the upcoming flu season, doctors will need to leverage telehealth to virtually assess symptomatic patients and conduct drive-through flu and COVID-19 testing.

Practices should be building these protocols now, Bullard says.

“Most doctors are now well down that path of optimizing and integrating this new delivery model,” he says. “At the same time, factors like the fear of a reversal of insurance parity and the need to rightsize the financial strain COVID-19 has placed on practices are tempting doctors to move back to what was comfortable and abandon televisits in favor of in-office visits.”

Excluding appointment reminders and lab follow-up, practice communication historically focused on managing incoming patient requests. The is not a winning strategy in the COVID-19 era.

In recent months, fear of infection and lack of information have left patients uncertain about how to address their health care needs, as shown by the reported 30% to 70% decrease in physician visits around the country, including a survey from the Commonwealth Fund.

Physicians must stay highly engaged with their patients as COVID-19 continues to disrupt health care delivery and traditional access. What may have once felt like overcommunicating should be the goal moving forward.

Now is the time to update social media channels to keep patients informed about safety protocols in place and what to expect during a visit.

“At my clinic, during [COVID-19], we utilized text, email, portal, website and social media messages to educate patients about limiting exposure and staying home safely while simultaneously informing them about available virtual visit, in-person visits, parking lot check-ins and drive-through testing,” Bullard says. “Our patients reported feeling appreciative, connected and supported during a stressful time.”

Placing prominent signage at the practice, especially on doors and in waiting areas, is a great way to keep patients informed about what to expect.

“I think the most important thing is for our staff and patients to know that their safety is our highest priority,” Wright says. “We aim to take measures to ensure that patients and staff are confident that their well-being is being protected.”

Stuart A. Meyers, M.D., an internist in Woodbridge, Va., says that COVID-19 causes a very stressful scenario for those who work on the front line.

“They can be helped by assuring all PPEs are available, even the ones not used for [COVID-19], monitoring their quality so that they can feel as safe as possible,” he says. “Front-line personnel shoulddevelop proper management strategies, including rigid time off and [standard procedures] developed during the first wave.”

A practice’s staff must feel prepared and have the appropriate resources to do their jobs each day, especially when dealing with COVID-19 situations.

“Look for every opportunity to communicate with your staff,” Bullard says. “Along with the ongoing worry about employment sustainability, workers are also concerned about their health and the health of their families. Keep your employees informed about the financial stability of the practice and all you are doing to assure their continued employment.”

Additionally, he says to develop a robust clinic safety plan. It should include work site cleaning, contamination prevention and patient triage protocols, along with infection control policies that will be followed if patients who test positive for COVID-19 receive care at the practice.

“Review the plan details, and the logic behind it, with all your employees,” Bullard says. “Take every opportunity to engage your employees as participants or even as monitors who are responsible for assuring plan adoption and success. This gives everyone an opportunity to hold some control over their environment. Even more, it lets them know that their safety is an important matter that you care about.”

Practices must take these steps to ensure they are ready.

Preparing for a  second wave of COVID-19

Primary care is in the midst of a crisis. Many practices face the possibility of closure as they deal with fallout from the COVID-19 pandemic. So what can physicians do to save their practices and treat their patients effectively? Farzad Mostashari, M.D., says physicians should embrace risk.

And by risk, he means value-based care. Mostashari contends that the fee-for-service system has exacerbated these financial struggles and that the way forward is to accelerate the evolution of how physicians are paid for providing care. In a wide-ranging conversation, we discuss value-based care, telehealth and what the ideal primary care practice of the future should look like.

Mostashari is the former director of the Office of the National Coordinator for Health IT and current CEO of Aledade. Based in Bethesda, Maryland, Aledade assists small practices with transitioning to value-based care models. This interview has been edited for length and clarity.

Medical Economics®: What is the state of primary care right now? What are practices going through and how do we fix primary care so that they can succeed in the future, given the challenges?

Mostashari: Primary care has never been more needed. We have obviously a lot of need for primary care on the front lines of COVID-19. We all hear about hospital workers who are at risk of being infected with COVID-19, but those patients who end up in the hospital first went to their primary care practices. And those primary care doctors aren’t like you and me, who get to stay home and socially distance ourselves. Those primary care practices are exposed to every patient who walks in the door, and they care for them. They close the door, they’re in a room with them, often with inadequate personal protective equipment, because the supply chain for those small practices is broken, they could not order masks.

These primary care heroes have been caring for patients, helping patients stay home and healthy and telling them, “Don’t come in if you don’t need to.”

But that means under their current business model of primary care, they are struggling financially, because the only way they had been getting paid is by doing visits — not by answering phone calls or reaching out to patients. And so, at the very time we need primary care the most, we see more and more practices that were fee-for-service threatened with going out of business.

So it’s not a good time for primary care. They’re worried about themselves. They’re worried about their family members. They’re worried about their staff, and they’re worried about how to make payroll.

ME: What do you think needs to happen to save these practices from financial ruin?

Mostashari: This is quite topical. [Recently] BlueCross BlueShield of North Carolina announced a program that we’ve been working with them on for some time now, where they are leading the way on this issue for any health plans, in terms of thinking of what should be done to save these independent primary care practices. Quite simply, what they’re saying is, we will give you a lump sum payment to make up the loss of revenue that you had this year. There’s no clawback, if they miscalculated; there are no additional reporting requirements.

The one requirement is that you enter into a total cost-of-care accountability contract. Aledade is honored to be the partner helping support those practices and succeeding in these value-based contracts.

And guess what? If you’re in one of those value-based contracts now you’re less dependent on fee for service. Our North Carolina practices, like those in other parts of the country, are getting hundreds of thousands of dollars in payments — not for patients walking in the door, but for patients being healthy and at home and not having to go to the hospital. That is what we should be doing. We should be keeping independent primary care practices whole and using this as an opportunity to move toward value-based care.

How do you see value-based care approaches evolving, given this cataclysmic event?

Mostashari: It’s a cataclysmic event as far as fee for service goes, with hundreds of billions of dollars of bailouts required to compensate hospitals and others for lost revenue from people not walking in the door for fee for service. Value-based care is fine. It hasn’t needed a bailout. The ACO [accountable care organization] models are pretty robust. You have to say, “Can we be better than if we weren’t in an ACO? Can we respond faster to the needs of the patients? Can we educate the patients? Can we take care of their preventive care? Can we deal with care transitions? Can we deal with our medication issues?” All of the things that we are working on with our practices to do a good job on the value-based contract is exactly what you would want to do for your mother at the time of COVID-19. Right? You would want her primary care practice to reach out and let her know she can call us first, we’ll see her on video, we’ll talk to her on the phone. If she has any problems, we’ll send her a 90-day prescription so she doesn’t have to go to the pharmacy in person. It’s all the things that you would want done for her. And if she does end up in the emergency department, we’ll call to see how she’s doing and follow up. That’s what we should be doing anyway. It’s just that the current payment system didn’t support it.

ME: Telehealth utilization has skyrocketed. What is the link between telehealth and value-based care and how can we strengthen that link?

Mostashari: Telehealth has a long history of problems with reimbursement, because the concern on the part of the health plans and Medicare and others is it’s not going to substitute for face-to-face visits, that it’s just going to be additive, it’s going to increase costs, it’s going be harder to trace for fraud and abuse purposes. All of those issues are suspended now, because we can’t get any face-to-face visits, and this is a substitution for the loss of care. But when things go back to normal — and things 

The way forward is to accelerate the evolution of how physicians are paid for providing care

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