This article is sponsored content. Learn more below.

Most physicians have long been frustrated by the number of patients they have to see in a day and the time pressures of those visits. On top of that are the hours devoted to administrative tasks that eat up the time they would rather spend caring for patients. According to studies of time demands on physicians, primary care doctors would need 18 hours a day to fulfill all their responsibilities. It’s a prescription for burn-out.

Much of the problem rests with the traditional fee-for-service (FFS) payment system that forces physicians to do most of their work single-handedly, while pushing the size of patient panels upward. Shuttling patients in and out of exam rooms in 15-minute increments does not make for good care or job satisfaction. In that short time frame, it’s rarely possible to build strong relationships with patients and have in-depth conversations that could reveal the factors at the root of their health problems.

Having spent my medical career practicing in underserved communities, I know that addressing those underlying issues and social determinants of health—such as food and housing insecurity, and emotional health—is essential to improving a patient’s overall health. Under an FFS model, there is neither the time nor the resources to provide that care, which is why I’ve become a proponent of the value-based care model.

I am a practicing physician in Houston and the Texas area medical director for Partners in Primary Care, a company committed to a value-based, care-team practice model throughout its network of senior-focused medical centers. The team approach is critical to providing comprehensive care to our older patients, many of whom have chronic and complex conditions, as well as psychosocial risk factors.

Because others on the team handle much of the paperwork and assist with the non-medical care of patients, our physicians can focus on what we trained and love to do — care for patients. By limiting our patient panels, we have extended time for patient visits — 45 minutes on average—allowing us to establish a true rapport and understand their health goals and needs, and the support systems they have in place or may require. Having a behavioral health specialist and social worker as part of the team also enables us to provide patients with needed mental health and social services.

During the pandemic, the care team has become even more essential for providing care beyond the walls of our medical center, keeping in frequent contact with patients through tele- health and even curbside visits.

To make the value-based care model succeed, the leadership charged with implementing it must fully commit to doing it right. Far too often, the focus becomes about performance metrics, which doesn’t work without the necessary resources in place.

Besides properly staffing and resourcing a care team, other essential ingredients for a successful value-based care team practice include:

Defining each team member’s specific function

Delineating the triggers that require specific members of the team to engage with a patient

Scheduling regular meetings with the entire care team to dis- cuss individual patient cases

Establishing a collaborative work environment and emboldening every member of the team to share their recommendations

Communicating that quality, not quantity, of care determines bonuses for every member of the care team, from receptionist to physician

A true value-based care system will require physicians to be better educated about the model, which should start as early as medical school. Doing so will help ensure that value-based care is implemented as it’s meant to be so that patients and physicians reap its benefits.

, is the Texas Area Medical Director for Partners in Primary Care and is a practicing physician in Houston. She earned her medical degree from the University of Texas Health Science Center, Houston and completed her residency in Internal Medicine and Pediatrics at Baylor College of Medicine. Dr. Hayes chose to pursue her passion for medicine as a way to positively impact the lives of others in her community.

This article is sponsored content. Support provided by Humana. Copyright 2020 and published by MJH Life Sciences. No portion of this program may be reproduced or transmitted in any form, by any means, without the prior written permission of MJH Life Sciences. The views and opinions expressed in this material do not necessarily reflect the views and opinions of MJH Life Sciences, or Medial Economics®.

Articles

To make the value-based care model succeed, the leadership charged with implementing it must fully commit to doing it right.

Why Value-Based Care is a Better Way to Practice Medicine 

Many independent practice owners today are in a difficult bind. By training and temperament, they are fiercely devoted to maintaining their autonomy. But survival in today’s environment requires the financial resources and access to patient data that doctors usually can get only by being part of a hospital system or some other large organization. Moreover, federal antitrust laws prohibit them from working together to obtain more lucrative contracts with payers.

So how can these practices stay in business without sacrificing their independence?

One solution lies in creating, or joining, an independent practice association (IPA) and/or a clinically integrated network (CIN). IPAs provide practices with many of the clinical support services, technological resources and group purchasing advantages enjoyed by hospital systems and large multispecialty practices while allowing their members to remain independent. Approximately 300,000 physicians are in an IPA, according to the Independent Practice Association of America.

In a CIN, participating practices form an “umbrella” corporate structure — usually a limited liability company (LLC) — under which they aggregate quality and cost data with the goal of demonstrating the network’s ability to provide high-value care. The LLC can use that data to negotiate value-based contracts that apply across its member practices.

Practices that aren’t able to maintain their quality levels can be removed from the network.

Quality and accountability are keys to success

Demonstrating and maintaining quality is key to keepinga CIN on the right side of antitrust laws, explains Allen Dobson, M.D., FAAFP, former president and chief executive officer of Community Care of North Carolina and 

® editor-in-chief. “If you’re working to enhance quality and hold each other accountable, then the law says a CIN can sign contracts on behalf of all the members and operate as one.”

Guidelines for how independent practices can legally cooperate were laid out in a 1996 joint statement from the Federal Trade Commission and Department of Justice. For example, the statement designates the percentage of specialists in a geographic area that can be included in a physician network (20% for exclusive networks and 30% for nonexclusive) without drawing government scrutiny.

“The guidelines represented the agencies’ compromise between the need to guard against price fixing and desire to allow independent practices to engage in limited forms of cooperation,” says William Maruca, J.D., a health care attorney with the law firm Fox Rothschild in Pittsburgh.

“As a general rule, the antitrust laws create pretty difficult barriers for independent practices to coordinate any relationships with payers,” Maruca adds. “And that hasn’t changed much since 1996.”

Still, if organized properly, a CIN offers benefits to both payers and physicians, Dobson says. “For the payer it means now they’ve got one signature covering all these small groups and holding them accountable for their costs and quality. And it allows the practices to participate in value-based contracts because now they’ve got scale and technology and support.”

Tom Banning, CEO of the Texas Academy of Family Physicians in Austin, views CINs and IPAs as frameworks within which doctors can work together to prepare for the end of fee-for-service medicine and its replacement by forms of value-based care. He has spent much of the past decade preaching that message, he says, with mixed results.

“Some groups have understood that value-based care was the direction the system was moving and jumped at the opportunity. Others tell me they are waiting for a sign before they pull the trigger. I tell them when they see that sign, it’s an 18-wheeler about to run them over.”

Much of the resistance, he believes, stems from the culture of medicine. “Most doctors have been trained to work in silos, and that’s how they’ve practiced,” he says. “Physicians were expected to be the team leader and do everything, and that sort of thinking hamstrings their ability to think outside of their proverbial box.”

One physician who has embraced Banning’s message wholeheartedly is Christopher Crow, M.D., CEO and co-founder of Catalyst Health Network, a CIN based in Dallas. Crow, who founded a family practice in 2000, had grown alarmed by the growing consolidation of primary care practices under the umbrellas of the region’s two major hospital systems.

“My practice had grown into a level 3 patient-centered medical home (PCMH), and through my PCMH contract I got to see data showing how much less it costs for independent physicians to care for patients compared to a large health system,” he recalls. “If this consolidation continues, it will send health care costs through the roof, so we’ve got to do something about it.”

Crow met with 30 or so like-minded primary care colleagues and developed the framework for the entity that became Catalyst. They were quickly able to recruit several hundred more, enough to enable Catalyst to enter into value-based contracts with national payers on behalf of its members. The contracts pay physicians on a fee-for-service basis but include opportunities for shared savings, along with monthly per-capita care management fees. The latter, Crow explains, is used to pay for business operation and clinical support services the CIN provides to its participating members, such as revenue cycle management, IT support, care coordinators and pharmacy technicians.

“When you layer that support on a value-based incentive program to improve care and lower costs, then you’ve built a structure where independent physicians can thrive and everyone wins,” Crow says. “Our business model is to keep people healthy. That means the physician is being rewarded for providing better care rather than just seeing more patients. The patient wins by being kept healthier, and payers win because costs are lower.”

The network has proven especially useful during the COVID-19 pandemic, Crow says, by helping practices pivot to telehealth, obtain supplies of personal protective equipment, and set up drive-through clinics — actions that few would have been able to accomplish individually. “We were a lifeline for a lot of them,” he says.

Blue Cross and Blue Shield of Texas (BCBSTX), one of the region’s major payers, supports Catalyst’s model of bringing independent practices together to improve value, says Rick Haddock, vice president of network management at BCBSTX. “We saw the value of trying to aggregate independent physicians to manage total cost of care while improving the quality of care by providing data in a nonrisk-based environment,” he says.

Today Catalyst includes about 1,000 primary care doctors, Crow says, adding that rather than having to recruit members, practices now are asking to join. “When we started this, the attitude of some docs was, ‘I don’t want to deal with data, and I don’t need anyone to help with my patients.’ But many of them have come around and now say, ‘This is exactly what I need.’”

Pediatrician George Rogu, M.D., has a story similar to Crow’s but on a smaller scale. The owner of three pediatric practices and a pediatric urgent care center on Long Island,New York, Rogu had watched with dismay as nearby pediatric practices joined hospital systems or closed their doors because they could no longer compete financially.

In response, Rogu began organizing informal meetings with fellow pediatricians to brainstorm ways they could cooperate to strengthen their individual viability without breaking antitrust laws. “We all had the same goals: to practice good medicine and take care of our patients,” he recalls. “But everyone was afraid to even speak to anyone elsebecause we thought it might look like collusion. Also, it meant overcoming the habit of seeing each other as competitors.”

From informal discussions to clinical integration

At first, Rogu’s meetings focused on sharing best practices for dealing with common practice management challenges. But they soon evolved into discussing ways the participants could work together more formally. The result: In 2018 the Independent Pediatric Collaborative of Long Island (IPCLI) was created; the CIN is headed by Rogu and today includes about 50 providers in 10 practices.

A key to the collaborative’s operation, Rogu says, has been the ability to monitor the quality of care provided by its doctors. It does so through use of a “clinical dashboard” — a software program that synthesizes quality data taken from participants’ electronic health record systems and, with some massaging from information technology staff, organizes and presents the data as though they were coming from a single organization.

“The dashboard lets us quickly see how the organization is doing as a whole and breaks the data down by practice and even by individual doctor on a particular measure,” he says. He cites the example of a doctor in the network who was having trouble meeting measles, mumps and rubella vaccination metrics for her patients. “We were able to suggest a few simple tweaks that brought her numbers to where they needed to be,” he says. “Our thing is to provide good clinical care and share resources for the benefit of our patients.”

Using that quality data has enabled the collaborative to sign a value-based contract with a Medicaid program, and it is negotiating similar contracts with two other payers, Rogu adds.

IPCLI has also helped its participating practices lower overhead costs by creating greater bargaining power with vendors. For example, prior to forming the collaborative, each had used the same vendor for medical waste disposal. But the greater size of IPCLI enabled it to contract with a different company and pay substantially less. Disposal costs for Rogu’s practice dropped from $1,500 per month to $150.

“With IPCLI negotiating and managing the contract, everyone benefits,” he says. The collaborative’s group purchasing power has also reduced participating practices’ costs for vaccines, malpractice insurance and some employee benefits.

Asked what advice he’d offer to others thinking of forming a CIN, Rogu says, “It takes a lot of time because docs aren’t used to working together. The mentality used to be, ‘Whoever has the most patients wins.’ Now it’s, ‘If you win, I win.’ But getting to that point is a long, windy road.”

Still, he adds, the time and effort are worthwhile if the only alternative is joining a hospital system. “The hospitals around here are knocking on our door constantly, but I just can’t do it,” he says. As part of a hospital, everything is five levels of bureaucracy. When you’re independent, if it’s a good idea, you just do it.”

How independent practices can survive by working together.

Strength in numbers: How physicians can work together and thrive

Malpractice liability is one of those issues that keeps many physicians awake at night, particularly this past year. Dealing with the effects of the COVID-19 pandemic — and the resulting increase in the virtual and remote care they’re conducting — made it an especially challenge time. Making matters worse, COVID-19 cases are spiking across the country in the middle of flu season.

So how can physicians ensure they’re doing everything possible to minimize their liability?

® sat down with David Feldman, M.D., chief medical officer of The Doctors Company Group, the nation’s largest physician-owned medical malpractice insurer, to discuss strategies for physicians to protect themselves from liability while treating patients during this unprecedented crisis.

The transcript was edited for length and clarity.

® (ME): What are some of liability issues surrounding this pandemic? Are we actually seeing malpractice cases resulting from COVID-19 yet? Or is it still too early in the process for that?

Feldman: We are too early. There have been a handful, a very small number. But we know malpractice is always lagging behind other things. We know that if you’re looking for malpractice as a leading indicator, you’re looking at the wrong thing. It takes years for these things to happen. So right now it’s a little too early to tell.

ME: What are some of the liability risks from COVID-19? What should physicians watch out for?

Feldman: The real answer is misdiagnosis. That’s the one thing we want to be careful about right now. Adding to that, clinicians are stressed, patients are anxious and testing is difficult. All of that just makes it even harder for clinicians to be sure they’re making the right diagnosis.

People are afraid to go to a doctor’s office. So we’re doing virtual visits, which I believe is a great thing. But they’ve got their issues. There have been very few malpractice cases around virtual visits in the past because (physicians didn’t do that many of them). But for the cases we’ve had, a lot of them have been around misdiagnosis.

So misdiagnosis is the one thing we really want to be careful of during this time. One of the resources we have on our end is on our website. If you read our recent article about the flu versus coronavirus, you’ll see this talk about the concept of system thinking. And this is certainly not my idea. It’s way above my cognitive abilities. But the idea is that, as human beings, we think with two different systems. There’s one system that’s sort of our automatic thinking — which I used to commute to Brooklyn every day from New Jersey when I was working at a hospital there. And if you had asked me when I got home how my drive was, I’m not sure I could have even told you, right? Because I was working on system one.

System two is the more cognitive way that our brains work. And if you think about when seeing patients, you want to be careful not to use system one too often, right? Patients come in with something, and you go right to what you think it is. And then you think, “Well, wait a second. Let me take a step back and think because it may actually be something else.”

And that’s a really interesting way of thinking about how we treat patients during this time, with all these other things happening at the same time that can really impede our ability.

ME: What practical steps should physicians do to protect themselves from liability?

Feldman: I oversimplify things by using what I call the three Ps. The first P is preventing adverse events. Patients have diseases. Doctors treat them. Can you make sure that things don’t go wrong? We can’t always do that. We know that in the overall world of patient safety, probably half the things that go wrong can be prevented, and we keep getting better at it. Certain things that we put in place allow us to prevent bad things from happening. But we know we can’t prevent all adverse events.

The second P is: Can we preclude a malpractice case even in the face of an adverse event? The good news about malpractice, if there is such a thing, is that it’s pretty rare. Even when there are adverse events, it’s not typical to have a lawsuit. And most of us believe the way we can avoid a lawsuit, even in the face of an adverse event, is with communication — how we communicate with patients both before and after an adverse event happens.

I used to have a mentor who once said: “When you talk to patients about complications before a procedure, that’s informed consent. When you talk to them about complications afterward, it’s called an excuse.” So there needs to be this continuum of doctors talking to patients and families at the beginning of treatment, during treatment and after treatment. And that’s just a great way to avoid malpractice, even when things go wrong.

And the final P is about prevailing in a lawsuit, and that is about documentation.

So think about the three Ps — prevent adverse events, preclude by improving communication and prevail by improving documentation — in the context of the coronavirus pandemic. How do we protect our patients from adverse events? We’re talking about having the right (personal protective equipment), taking the usual precautions so there isn’t an adverse event and treating them properly. That’s the most important thing. But also we talk about communication and informing patients of risks, right? Talking to them about the things that we hear about all the time: wearing masks, washing your hands, watching your distance with other people. Those are the things that are going to keep people safe before vaccination.

Now we’re starting to talk about vaccinations. It’s very exciting. And I certainly tell the patient to get a flu vaccine. That’s important too. ... And then talk to patients and families about prevention of other illnesses and make sure they’re getting their routine screening, which is really a concern to a lot of people. Mammography, (prostate-specific antigen) testing — all the things that we normally do that we didn’t do for a long period of time, we need to get back to doing those things to make sure we don’t suffer from other illnesses besides COVID-19.

And then it’s documentation. I don’t have to tell your audience about how documenting is critical. I have lawyers tell me that no one reads a patient’s chart when nothing bad happens. Only when there’s a lawsuit do people get really concerned. So especially when patients have problems, when there are issues, you really want to pay attention to what you’re writing in the chart to make sure you’re (including) all the things you did to show that you did everything in the best interest of the patient.

ME: In regard to those important screening tests, how should a physician protect themselves if a patient has not been screened? How should that be handled if this sort of gap in potential care occurs?

Feldman: It’s just writing down in your chart what the communication has been with your patients to let them know they really need to come in and get their preventive testing done. That you’ve called patients to follow up with them, that your office staff has been in touch with them. It’s really documenting everything. You want to be able to look in the chart and see that you did all the right things.

Malpractice liability is one of those issues that keeps many physicians awake at night, particularly this past year. Dealing with the effects of the COVID-19 pandemic — and the resulting increase in the virtual and remote care they’re conducting — made it an especially challenge time.

COVID-19 brings new malpractice risks

Today’s physicians have a lot on their plates, and marketing the practice may not be at the top of their priority list. However, experts say this is the ideal time to connect with new and existing patients, serve as a resource and explain how to access care.

Why is marketing the practice important, particularly during the COVID-19 pandemic? It’s absolutely essential for patient retention, says Stewart Gandolf, MBA, CEO of Healthcare Success, a full-service health care marketing and advertising agency in Irvine, California. “Doctors by and large overestimate the loyalty of their patients,” says Gandolf. “Competition is accelerating with leaps and bounds.”

Independent practices compete with hospital-owned practices, urgent care centers, virtual care providers and pharmacy-based walk-in clinics — all of which have large marketing budgets, notes Gandolf. During COVID-19, patients may be more willing to switch providers if they perceive that those other entities provide safer, more efficient care, he adds.

Marketing also can also help physicians attract new patients, says David Zetter, CHBC, founder and president of Zetter HealthCare, LLC, a full-service practice management consulting firm in Mechanicsburg, Pennsylvania. However, before investing in marketing efforts, physicians need to ask this important question: Are there enough providers and medical assistants to handle an increase in patient volume? “I wouldn’t be marketing if you don’t have your act together,” he adds.

To attract and retain patients, consider the following eight budget-friendly ways to market your practice.

Search advertising (e.g., a Google ad) is a text-based ad that appears at the top of search engine results when a user searches for relevant terms (i.e., internist near me). The service uses a pay-per-click model, and physicians can expect to pay approximately $3 per click for a Google ad, says Rachael Sauceman, head of strategic initiatives and internet marketing at Full Media, a health care digital marketing company. Cost per click is determined largely by the keywords used in the ad, she explains. The more competitive the keywords, the more expensive the ad.

“In our experience, searching advertising is the best lead-generation tool,” says Sauceman. “We don’t recommend other types of advertising unless they have done this first.”

Unlike expensive newspaper, radio or TV ads, Google ads are cost effective and agile, enabling physicians to easily update their message, says Sauceman. For example, did the practice adjust its hours to accommodate patients who are symptomatic for COVID-19? Has the practice taken additional precautions to keep patients safe? Physicians can update a Google ad in seconds to include this new information.

Search advertising is also all about timing. “If you get in front of patients on social media or the newspaper, you might get in front of a lot of people, but they’re not looking for a provider necessarily right at that time,” Sauceman says. “With Google, they are. If you get in front of them at that critical decision-making time, then you have the ability to influence that decision.”

Overexplain the in-office and virtual care experiences, says Sauceman. “It’s easy to forget the amount of confusion that’s out there and the fact that every practice is doing things a little differently.” She suggests including a step-by-step explanation of what patients can expect upon arrival to the practice or when they check in for a telehealth appointment, how they’ll interact with physicians and staff, and what happens after the appointment.

Consider devoting a section of the website to COVID-19-related education, Zetter advises. “There’s a lot of bogus information out there,” he says. “What can you do to unmuddy the waters? What are you going to do so your patients see you as the expert on their care and well-being? You want people to trust you and rely on you for information.”

Another idea is to provide a section devoted to financial resources, says Sauceman. Examples include links to patient assistance programs, a transparent list of costs for common services or contact information for the practice’s billing staff so they can answer questions and clarify invoices.

“Many patients are experiencing financial hardship or a loss of insurance at this time, so if price or the types of insurance you accept are a competitive advantage for you, it’s a good time to make that transparent,” she adds.

If possible, try to obtain backlinks from other reputable sites because this helps with search engine optimization, says Gandolf. For example, if a physician typically donates to a local Little League team, is the team willing to include a link to the practice’s website on its own site?

Most importantly, explain why the office is a safe place during the COVID-19 pandemic. For example, post pictures of staff wearing personal protective equipment, of hand sanitizer stations or of the Plexiglas-protected front desk. Also include a bullet point list of what the practice does to ensure a clean environment (e.g., we thoroughly clean exam rooms after each patient or our medical assistants put a sign on each waiting room chair immediately after someone is called for their appointment so front desk staff know to clean the chair before another patient sits in it).

Physicians can also create a free YouTube video that details what the practice is doing to keep patients safe and then embed that video on their website, Gandolf says. “It doesn’t need to be fantastic production quality. It’s about reassuring patients that it’s safe to come in.”

This free service integrates with most websites and provides physicians with insight into total views, page views and more, says Sauceman. It can also track contact forms or appointment requests made through the practice’s website back to a specific ad or other source. This helps physicians understand whether their marketing efforts are paying off. For example, if they placed a paid ad on social media, they could monitor whether that ad has successfully led patients to schedule an appointment.

Linking Google Analytics to a practice website is easy. Most websites simply require users to input their unique Google Analytics identifier code — a number that can be obtained under the administrative settings of the Google account. The rest happens automatically behind the scenes.

Google My Business is a free tool that enables physicians to promote their business profile and website on Google search and maps. Physicians must verify their business before they can make changes to their listing.

“An up-to-date and thorough listing not only pleases prospective patients, it also pleases Google,” Gandolf says. “Google rewards businesses that take the time to create robust profiles and respond to reviews by increasing their visibility in search results.”

Secure texting complies with federal law restricting release of medical information, enabling practices to text preventive health reminders (e.g., call to schedule your physical or don’t forget to come in for your flu shot), appointment reminders, marketing of new services and other health tips, says Zetter. “There are all kinds of things you can do to keep your name in the forefront of patients’ minds.”

For example, flu shots and COVID-19 tests aren’t big revenue generators, but they’re ways to introduce physicians to new patients, Gandolf notes. Telemedicine is another example. Patients want this service, and practices that don’t offer it will be largely overlooked, he says.

Travis Withers, operations manager at Essence of Health Wellness Clinic, a direct primary care medical practice in Chattanooga, Tennessee, posts two or three updates per week on the practice’s Facebook and Instagram pages, mostly providing helpful health tips and other timely health-related information.

“We have created posts about the importance of handwashing, benefits of a plant-based diet and the importance of flu shots, among many other topics,” he says. “In addition, every Friday we do a 10- to 15-minute Facebook Live on a health topic, (and) we take questions. Several new patients have told us that they followed us on social media for months before joining the practice.”

This is the ideal time to connect with new and existing patients, serve as a resource and explain how to access care.

8 budget-friendly ways to market your practice during COVID-19

, female primary care physicians generate 10.9% less revenue from office visits compared to male physicians, despite spending 2.6% more time in the office with patients. Although female physicians had a lower volume of patient visits, they spent almost 16% more time with each patient. During this additional time, researchers found that female physicians placed more medical orders and discussed more medical diagnoses and preventive care than male physicians.

This begs the question: Why are women not being paid for their additional labor? According to the study, the answer seems to be that male physicians are simply better at billing for their work than female physicians, including billing based on time. Also, female physicians in procedural fields like radiation oncology were less likely to bill for “lucrative procedures” than male physicians.

Here’s the good news: This is one type of gender pay difference that is easy to fix. Female physicians can either opt out of a broken health care system that rewards short visits and high billing codes and enter into a direct primary care (DPC) model, or they can invest some time learning how to work the system to their advantage. As a female family physician, I’ve done it both ways. Although I advocate for the former (DPC has been a life changer for me), I was also able to out-earn many of my male colleagues in traditional practice by learning how to outsmart the system.

What follows are my top tips on how female physicians can close the gender pay gap in a practice using the relative value unit model.

Unlike attorneys, a physician’s billing clock only starts ticking when we have a face-to-face encounter or formal telemedicine session with a patient. Phone calls and emails reviewing lab results are not compensated. Medication refills, prior authorizations, insurance forms, disabled parking passes, jury duty excuses, school medical excuses — physicians are not paid for any of these services, even though they may take a considerable amount of time (family physicians spend nine hours per week on uncompensated labor).

The reality is that in a fee-for-service insurance model, the only way to be fairly compensated for work as a physician is to see patients in the office. So rather than calling or emailing lab results, schedule your patient to return for a visit to review results together. If a patient calls with questions, concerns or clarifications, ask them to schedule an office visit. After all, an office visit is almost always the best way of evaluating your patient and providing the best medical care.

In addition, every time a form appears on your desk to be filled out, forward it to your office scheduler with a note to bring the patient in for an office visit. Doing paperwork while the patient is in the office not only allows you to bill for your work, it also saves you time: The chart is ready for you, the patient can directly answer many of the questions on the form and you have the opportunity to address medical concerns that relate to the paperwork, such as changing a medication or requesting prior authorization for a medication that is medically necessary but not covered by the patient’s insurance.

Don’t miss out on quick, easy visits like urinary tract infections or minor skin infections because you lack schedule availability. With the current system of coding, a minor issue that you can attend to in five minutes is reimbursed just a bit less than a visit that takes you 30 minutes and loads of cognitive effort. The best way to ensure availability is to block several slots per day for urgent, acute care visits. These can be dispersed throughout the day or reserved during certain intervals, such as the last hour of the morning or the end of the day.

It is simply impossible to attend to every single problem that a patient has in one visit, along with addressing preventive care, although it’s clear from the 

study that female physicians certainly try their best! We need to accept that we can’t do it all, and instead, prioritize the most important issues and ask our patients to schedule follow-up visits. This can be difficult, as many of us are “people pleasers” and fear letting down our patients. We also worry about patients’ schedules and causing an additional copay. However, we need to accept that one of the keys to quality health care is developing a long-term relationship with a patient. Having the same physician over time reduces patient mortality by allowing more opportunities for us to explore our patients’ health and intervene in their lives. Remember: You cannot address a lifetime’s worth of problems in a single 15-minute visit, and you must not expect this of yourself.

It’s especially important to schedule frequent follow-ups with patients who have serious chronic health conditions or underlying psychological conditions like anxiety disorder. Some of these patients are prone to showing up without appointments, often in crisis, and can severely impact the day’s schedule. By 

frequent follow-up visits, you eliminate some same-day, “urgent” appointments. Frequent visits are reassuring to patients, many of whom fear abandonment. It also helps to tell your patient how much time you have scheduled for them at their appointment, to help them prioritize what is most important.

When families come into the office together, “surprise” visits can cause a strain. You know the situation. You’re in the exam room seeing a well child when Mom points to a sibling and says: “Can you just check his brother’s throat? He’s been complaining that it hurts.” Or you’re seeing a husband and wife together, but just one is scheduled for an appointment. Inevitably, the conversation turns to a concern about the other spouse’s health.

This creates a dilemma. Although you could ask the “add on” patient to schedule an appointment to discuss their issues, it may be quicker and easier to address the problem directly. However, don’t forget to capture a billing code for your work. Even if you spend minimal time, you are likely to garner enough information to capture at least a level 99212 code for the work you did.

Also don’t forget to ensure that you properly bill for wellness visits and screening codes. The most efficient way to do this is to create a template or form. I also recommend including the dates of your last preventive screening in your problem list, where you can see at a glance what services are due.

Female physicians must take the time to learn how to code accurately to be fairly paid for their work. Often, we underestimate the amount of work we’re doing and undercode. Yes, it seems unnecessarily complicated, but a few steps can make it easier. First, remember that billing codes are driven by the extent of medical decision-making. If a patient has a new problem, requires additional evaluation like blood tests or needs a prescription medication, they are likely going to warrant a higher level of service. If a patient has a life-threatening condition, you need to call 911 or you are going to really worry about the medication you must prescribe, then the level of service increases to the maximum. To ensure that you are checking all the right bullets, consider posting a chart of coding requirements for history, physical and medical decision-making next to your computer.

As a physician, you should never be coding a 99211, which is a nursing code for an evaluation ordered by a physician, like a blood pressure check. If you take a quick look at a patient and make a straightforward recommendation, you have earned at least a 99212.

Don’t forget to use time-based documentation when you spend the bulk of your visit “counseling or coordinating care.” For example, time-based coding will likely come into play with the patient who comes in severely depressed or has a stack of forms for you to fill out. While you don’t have to do lots of documentation for history or physical, you 

have to document the time spent, both total and counseling time, and the details on the counseling/coordination of care activity.

Our current system rewards interventions more highly than cognitive services. Primary care physicians should take advantage of this to serve patients. The key to success is having proficiency in your procedural skills and developing an established protocol for each procedure that you perform in the office.

If you didn’t have the opportunity to practice many procedures in your residency, many courses are offered at continuing medical education conferences. Another way to gain expertise is to find a physician mentor who does procedures in the office. Of course, be sure to know your limitations, and when in doubt, refer the patient to the appropriate specialist.

Before performing a procedure, break it down into individual steps. Create an organized list of supplies and actions required. Be sure that you have all the proper equipment ahead of time, and get the best equipment that you can afford. Develop a plan for follow-up and a patient handout, if necessary, for after the procedure. Using your prepared protocol, your medical assistant should be able to quickly ready the exam room for the procedure. Also make sure that your patients know that you offer office procedures so they can contact you if they need help, rather than visiting an urgent care or specialist.

6 ways physicians can close the gender pay gap

The COVID-19 pandemic is an unprecedented public health crisis that has disrupted millions of lives globally.

This “new normal,” in which people’s homes have become their office, gym, school and more, has impacted everyone differently. Some, perhaps, were already telecommuting to work or home schooling their children; however, for others, this transition has been difficult.

Take patients with migraines, for example. When asked how the COVID-19 pandemic has impacted her migraine patients, says Susan Hutchinson, M.D., a headache specialist, family physician and founder of the Orange County Migraine & Headache Center in Irvine, California, “For about one-third of my migraine patients, their migraines are better, one-third are worse and one-third are about the same.”

Increased stress may be part of the problem

To further understand just how much the pandemic is affecting adults in the United States, the American Psychological Association (APA) adapted its annual Stress in America poll into a monthly analysis of stressors and stress levels. The online survey was conducted from April 24-May 4, 2020, by the Harris Poll on behalf of the APA and included 3,013 U.S. adults ages 18 and older.

The findings showed that the average reported stress level for U.S. adults related to the COVID-19 pandemic was 5.9 on a scale of 1-10 (1 meaning “little or no stress” and 10 meaning “a great deal of stress”). Regarding stress level

, the average reported stress level was 5.4, which marks the first significant increase in average reported stress among U.S. adults since the survey started in 2007, according to the APA.

These rising stress levels are particularly concerning for patients with migraines, for whom stress is a common trigger. According to the American Headache Society, 4 out of 5 patients with migraines report stress as a trigger.

When asked how her migraine patients were managing during the pandemic, says Linda Davis, M.D., a family physician with Kolvita Family Medical Group in Mission Viejo, California.“I do think (COVID-19) had a negative impact and (that) they’re probably suffering from more (migraines) because of the stress.”

One source of stress for patients with migraines could be tension in the household related to home offices and remote learning. Such changes may have forced some adult patients with migraines to telecommute for work and/or home-school their children and younger migraine patients to switch from in-school learning to home schooling.

, an independent news organization that provides comprehensive coverage on K-12 education, tracked pandemic-related U.S. school closures. From March 6-May 15, 2020, school closures impacted as many as 55.1 million students in 124,000 public and private schools nationwide at the pandemic’s peak.

In addition, a significant number of adults switched from working at the office to telecommuting if their job permitted. According to a Gallup poll conducted from March 30-April 2, 2020, 62% of employed Americans said they’ve been working from home during the pandemic (double the number working from home in mid-March).

Although working from home offers some benefits, including increased flexibility and time spent with loved ones, for some, that extra family quality time may be a source of stress. “There’s a lot of tension in some households with kids home, Mom and Dad home,” Hutchinson says.

For example, a 12-year-old migraine patient of Hutchinson’s presented with headaches that had transformed into a refractory pattern. “After further discussion with the mother, she said the husband, because he’s stuck at home all day with the daughter, (is) angry,” explains Hutchinson. “He’s angry at the slow internet speed. He’s just angry at the world, and I think he makes his 12-year-old daughter feel like she’s somewhat responsible.”

The patient was also missing her friends from school, so Hutchinson told the patient’s mother, “I’m going to do what I can with medication, but all the medication in the world isn’t going to be able to get your daughter back to an infrequent episodic pattern.” Hutchinson advised that they look at the family dynamics at home to relieve some of the patient’s stress.

Davis shares a similar example of a patient who was doing well with her maintenance medications for some time, but she developed a migraine recently that would not break and came into the office for an injection.

“We were talking about it, and she said that what’s been hard for her is normally when she gets in these cycles of migraines that she can’t break, there’s a reprieve at home. Home is ... her safe place (where) she can go lie down, she can relax,” says Davis. “But right now, she’s working from home, her husband’s working from home, the kids are being home-schooled. So suddenly, her stress environment is her home.”

Davis adds that the patient had to get in her car and take a drive to find some peace. “It was kind of an eye opener. … I think maybe in the beginning, the migraines (were) a little bit less, but as time goes on, I think this (new normal) is becoming a trigger for (patients with migraines),” she says.

Pandemic impacts women and men differently

Female patients with migraines are a group of particular concern during the pandemic. Women have migraines three times as often as men, and migraine is also one of the leading serious health issues affecting women.

“I think the women probably are faring worse than men because women have children to take care of now who maybe had been going to school,” notes Hutchinson about her female migraine patients. “So all of a sudden, they have the school responsibilities. Many of them also have careers and jobs so they also have work responsibilities.”

A Kaiser Family Foundation Health Tracking Poll conducted March 25-30, 2020, included 1,226 U.S. adults age 18 and older and found a widening gap between men and women in self-reported negative mental health impact from COVID-19. Overall, 53% of women said worry or stress related to the COVID-19 pandemic has had a negative impact on their mental health vs 37% of men, and this gap widened more among parents of children under age 18 — with 57% of mothers vs 32% of fathers reporting their mental health has gotten worse during the pandemic.

“There have been a lot of articles in the medical literature, sort of opinion articles, that (the pandemic) is going to set women back quite a bit in general because what’s going to happen is when the fall comes and their kids are not going back to school, somebody’s going to have to stay home. And usually it ends up being the woman,” says Davis. “It’s going to be a vicious cascade across the board because more of the home responsibilities are already still on the women.”

COVID-19 impact on care for migraine patients

Physician practices across the country have had to change the way they deliver care to ensure patient safety in response to the COVID-19 crisis.

An April 2020 survey of 842 U.S. physicians conducted by the physician search firm Merritt Hawkins, in collaboration with The Physicians Foundation, found that 48% of physicians are treating patients through telemedicine. This is a significant increase since 2018, when only 18% of physicians reported using telemedicine.

Peter McAllister, M.D., medical director at the New England Institute for Neurology and Headache and chief medical officer for the New England Institute for Clinical Research and Ki Clinical Research in Stanford, Connecticut, explains how being near the epicenter of COVID-19 cases drastically changed how he delivered care to his migraine patients. “The short answer is, it’s been profound,” he says. “Clearly with New York City being the epicenter of the number of cases and number of deaths — (and) we are just up the road in Connecticut. There were a lot of people being quite afraid to go out, understandably and quite reasonably.

“We had to make some big decisions at our practice. Some practices, neurological practices, closed their doors completely and have gone to a full telemedicine thing. My perspective was that we could probably thread the needle and do it safely to be at least partially opened.”

As now mandated by the Centers for Disease Control and Prevention for patient safety, McAllister and colleagues call all patients the day before an appointment to complete a questionnaire on potential COVID-19 exposure or infection; the questions are repeated upon arrival at the office, and temperature is checked. Patients and staff are required to wear a mask or other face covering.

McAllister and his staff also get tested for COVID-19 on a weekly basis; half the staff is assigned to work from home, and then they rotate.

“It’s decreased the actual number of people, our footprint of people, here. So it’s actually a bit quiet, but I wasn’t going to stop seeing patients because I felt that wasn’t the right thing to do,” says McAllister.

Hutchinson has made similar changes to care delivery for migraine patients.

“We’re encouraging everyone to do a virtual follow-up,” says Hutchinson. “We do allow people to come in ... if they’re not doing well, and some people come in for a nerve block. ... We also still have patients that come in every 12 weeks for Botox for their chronic migraine.”

Communication with migraine patients is also important in delivering quality care during the pandemic. At Kolvita Family Medical Group, Davis and her staff send out weekly emails with COVID-19 updates to patients.

“We get a nice response when we send out our emails because they’re pretty objective and informative. We’ll get responses saying, ‘Thank you. It’s always so calming to hear from you guys and get some real information,’ even though we’re very clear that we don’t have all of the answers and that the testing is not as accurate as we would hope it would be,” Davis says.

The continued uncertainty around when the pandemic will come to an “end” can be particularly difficult for migraine patients who like structure.

“It’s going to be a process though, right? There’s still going to be a little stress as things open up because you have that uneasiness of, ‘Is it safe?’ It’s the new normal, so I think it’ll be gradual, but yes, some people’s migraines will get better as they feel more comfortable getting back to some degree of normalcy,” says Hutchinson.

Until then, communicating with migraine patients is important. The pandemic continues to evolve, and new information is released nearly every day — but there is also a lot of misinformation that can make it for hard for patients to decipher fact from fiction.

“Our weekly emails have been huge,” says Davis. “Sometimes it’s hard to be super proactive, but that persistent reminder that they need to not disregard other aspects of their health care is very important. The persistent reminder that we’re still here, even if it’s not physically in the office, we have access by phone and technology. That constant ‘Please reach out to us if you have questions and concerns on any of your health care issues’ is hugely important.”

If the only communication to the patient base is telling them about the office’s COVID-19 protocols, patients may get the impression that their physician is only focusing on COVID-19 and not on other important health concerns, including migraine.

Says Davis: “I think (if you have) some method (to communicate) — whether it’s on your website or if you have a social media platform that your patients look at or you have the ability to mass message them — (you) should.”

Patient impact and management tips for physicians

COVID-19 and migraines

There’s nothing like landmark regulation released during a time of great uncertainty.

On May 1, 2020, the clock began ticking for health plans, providers and information technology (IT) developers to implement the Centers for Medicare & Medicaid Services (CMS) Interoperability and Patient Access final rule. For all of us struggling to cope with the COVID-19 “new normal,” there is more at stake with this coming wave of interoperability than may meet the eye. Now is the time to plan and take action.

What is the Interoperability and Patient Access final rule and why does it matter?

Put simply, individuals will have the option to take greater ownership and accountability for a broader and consolidated set of electronic health information (EHI) and, with individual consent, share that information with their health plan and providers. This will be supported by the creation of a system of regionalized data brokers who arbitrate the exchange of electronic health information with and from CMS-regulated health plans, providers and IT developers according to defined patient consent parameters. This new approach — the Trusted Exchange Framework and Common Agreement (TEFCA) — is still being considered by regulators but will likely follow the National Information Exchange Model (NIEM), a proven federal approach for the exchange of data within and across industries, including the Department of Homeland Security. This likely means that in the future:

Data brokers (Qualified Health Information Networks [QHINs]) will arbitrate the parameters for all patient EHI transfer, including B2B from developers to health plans/providers.

Federally certified IT developers will have access to the same core data set as health plans and providers and be focused on creating value for patients through the development of new digital products that will enable more transparency, efficiency and choice.

Individuals will move through the health care ecosystem with their EHI based on tiered levels of consent, with a core data set that is opt out for exchange, but with higher tiers of confidential EHI that patients must opt in for sharing.

Make no mistake, the new rule will create disruption in the health care marketplace. Federal regulators are doubling down on the idea that creating a more open system of exchange to a publicly owned virtual clearinghouse of claims and clinical data will force competition and innovation that is good for health care consumers. When the wave breaks, the health care landscape will look very different from today.

Why is interoperability particularly important to providers?

Historically, health plans and providers have been understandably reluctant to share information both for competitive and regulatory reasons. However, as the new rule is implemented, consumers will exercise increasing control as to how and with whom their EHI is shared. This will usher in unprecedented risk, including risk to privacy, as third-party developers are able to directly access patient data, and risk to monetization of data with the rise of new applications that circumvent traditional regulatory gatekeeping policy. Understandably, the costs to establish, maintain, audit and retain EHI will be borne by health plans, providers and potentially patients.

To stay relevant, health plans will need to embrace this new reality via a consumer-focused strategy and not just check the box

 Survival requires not only getting on board with these newly defined needs but getting in front of them by putting the member at the center of value creation, while transforming how data is tracked and managed. This may take some deep, authentic introspection, and asking questions such as:

How do we seamlessly identify and capture member consent for data exchange so that we can remain viable for members and have the information to support high quality care?

Where do members and their families most often get stuck trying to navigate care and advocate for themselves — both within and outside our clinical network — and how can we help?

How do we safely and securely support the right level of transparency for members to get the right care at the right time?

What customer-experience tools and incentives can we provide members and group plans to help us prioritize and better target our population health programs?

How can we use the new rule to build a relationship with providers that puts the patient at the center and moves us away from being at odds?

At its core, this rule is about transparency and giving individuals the ability to move across health plans and providers and have both their clinical and administrative information move with them and be accessible throughout their journey. Bottom line, certified IT developers will empower individuals to actively engage in their health care in an unprecedented way, through a seemingly limitless set of new use cases, such as these, at the highest level:

Before patients decide where to buy insurance coverage, they can see if their doctor is in a health plan’s clinical network, and they will have a better way of comparing health plans offered by a variety of payers.

Through a single application, patients can access current and historical health insurance data, and clinical data from all visits, regardless of a doctor’s EHR. The patient can see things such as scheduled appointments, lab results, diagnoses, referrals, prescriptions, authorizations, deductibles and copays.

When a patient arrives for a new specialist appointment, they do not need to fill out the same paperwork yet again. Five-plus years of cumulative EHI can be instantly transmitted through an authentication process between their phone and the specialist’s EHR.

Patients, providers and health plans will have better information to navigate the health care system and reduce the risks to the patient that come from incomplete information.

In the near term, the industry will continue to lobby for scaled-back regulatory requirements and a longer implementation timeline​. There will be operational pressure for health plans and providers to comply by adopting new technologies, workflows and governance models​, as well as new investment and rapid growth of third-party developer solutions combined with a race to prototype, test and market these products.

Incremental improvements in patient access to EHI and provider directory data leading to a higher level of discernment in customer product choice.

Higher precision in matching patients to clinical history, medical needs, social determinants of health and physical/digital location; significant data security risks ​and more reliance on strategic partnerships and trusted health information networks/exchanges for reliable sharing of EHI.

Increased market competition stemming from a need for digital products and strategies to attract and retain patients and networks​.

Improved care coordination, continuity and quality of care resulting from a portable, digital patient health record, better data standardization and improved B2B interoperability.

Accelerated adoption of value-based payment models resulting from a growing cumulative patient record and corresponding ability to more accurately measure patient outcomes and risk stratify needs (medical, behavioral and social determinants).

Voluntary commercial insurance adoption of standards and rules.

First, it’s important to understand where you’re at and where you need to go. This includes launching a readiness assessment, governance, program planning and execution. Whether you’re a family practice in a retirement community or a publicly traded insurance carrier with a Medicare Advantage plan, you’ll need to evaluate options, ensure you meet the requirements, and align resources to pivot to take advantage of the changes coming.

Medical Economics February 2021