The COVID-19 pandemic brought telehealth into the mainstream for many physicians and patients. Usage rates have declined from highs in April, but experts say that telehealth will play a much bigger role in health care moving forward and that physicians need to embrace it to succeed.

® spoke with Caroline Brennan, Ph.D., vice president of the health division of Escalent, a health care research firm, to learn more about telehealth strategies and trends. The transcript has been edited for clarity and brevity.

® (ME): How can doctors encourage people to use telehealth for the first time?

Brennan: I believe that it’s about communication at every stage of the interaction between the patient, the office and the doctor. So right away, when a patient calls the doctor’s office looking for an appointment, the office can offer telehealth as an option and provide a little bit of background about how that visit would work. Another way to encourage usage is to have a lot of information on the practice’s website. It should explain how telehealth works, not just the technological aspects of it, but what to expect, how these visits go, what conditions are appropriate for it, what are inappropriate for it. Also, include frequently asked questions or things such as anonymized patient testimonials to help put people at ease and make them more interested in giving it a try.

ME: How much of the reluctance to use telehealth comes from not having a comfort level with the technology? And how can doctors help patients overcome that?

Brennan: What’s interesting is when we started our research on this, we thought that the technology barrier would be significant. And what we found is that not many people expressed concern about technology, about not being tech savvy, or not having some tools at home. But nonetheless, any time any of us goes to a new website, logs in and uses technology for the first time, there’s always some apprehension. Doctors’ offices can provide very detailed login information, explain exactly what needs to be downloaded, give instructions on how it will work, maybe even provide some test runs, so that people can get more comfortable with it before their first telehealth appointment.

ME: What are some best practices doctors should use during a telehealth visit?

Brennan: One thing that we did hear loud and clear, it wasn’t technology … what people were really concerned about was the face-to-face interaction and missing out on that. Anything the doctor can do to re-create it or simulate what an in-person visit would be like would go a long way in putting the patient at ease. So things such as small talk and eye contact with the patient set the expectations of how that visit might go. Doctors also should explain how they will make a diagnosis and acknowledge some of the limitations of telehealth because patients aren’t right there with them. At the same time, assure patients that they can still get a quality diagnosis, that they will still have good quality of care through this telehealth experience.

ME: Why should doctors continue to use telehealth once the pandemic is over, even if many of them are more comfortable with in-person visits?

Brennan: I think everybody is probably more comfortable with in-person visits. But the opportunity to have telehealth continuing after this pandemic … there are a lot of convenience factors here, and it’s also opening up health care to people who might not be as likely to go to the doctor’s office. Maybe they’re very busy, they don’t have reliable transportation to get there, or maybe a doctor’s office is very far away, so it takes a lot of time. Continuing to offer telehealth as a robust alternative to the in-person visit would improve the opportunity for people to get health care that they might not otherwise be accessing.

ME: Telehealth usage rates have dropped from the initial highs in April — how can physicians encourage patients to keep using it when appropriate?

Brennan: I think it all comes down to bringing it up when they’re making the appointment, whether that’s on the phone or even if they’re booking the appointment online, offering that as an option. I think word of mouth is very persuasive, so as people slowly get more experience with it, and they tell their friends and family that, no, it actually wasn’t so bad and they had a good experience, I think that would go a long way in encouraging people to continue using it.

ME: Is there a certain patient demographic that prefers telehealth?

Brennan: We found in our study that people of all walks of life were using telehealth — all ages, all income levels, socioeconomic backgrounds. However, we did see that those who were seniors, or older folks, as well as those with lower incomes, we’re not using it quite at the same rate as others, which is interesting, especially for the seniors. They might be a particular group of people who would really benefit from telehealth not just during COVID-19 to reduce their risk of exposure, but longer term, in terms of mitigating some transportation concerns that they have, or especially if they have a lot of medical appointments.

ME: What does the long-term future of telehealth look like in the United States?

Brennan: Based on what we’re hearing, it certainly is not going to replace in-person visits. But I do think it will remain as a viable option in a lot of cases for a lot of people. At first, it will be for very specific conditions and situations. But I think telehealth is here to stay, and anything that will increase people’s access to health care is a win in my book.

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Virtual visits will remain important part of engaging with patients even after the pandemic.

Keep using telehealth to boost your practice

With stay at home and shelter in place orders, it is safe to assume many practices have seen a significant decline in visits and revenue. It is probably also safe to assume that many practices will suffer a loss this year. While this is undoubtedly an unfortunate event, Congress passed the CARES Act in an attempt to provide relief.

As you can imagine from an 880-page bill, there are many tax and nontax provisions in the bill. This article will focus solely on the changes made to net operating losses (NOL). We will start with defining an NOL, discussing the legislative history of NOLs, and finish up with some examples of the benefits of the new rules.

According to IRS Publication 536, an NOL occurs when deductions exceed income. In 2020, losses are generally caused by deductions from a trade or business, casualty and theft losses from a federally declared disaster, or rental property. Business losses are the most common cause of an NOL. Even though partnerships and S corporations generally cannot use NOLs, partners and shareholders can use their portion of the business’s income and deductions to calculate their own NOL.

Prior to the passage of the Tax Cuts and Jobs Act (TCJA) in late 2017, NOLs could be carried back two years and carried forward 20 years. The TCJA generally disallowed NOLs from being carried back and allowed them to be carried forward indefinitely. There was also an 80% of taxable income limitation placed on NOLs.​

Enter pandemic. Stay at home orders and social distancing guidelines have decimated small businesses. In an effort to blunt the effects, Congress passed the CARES Act. The act now allows losses arising in 2018, 2019, and 2020 to be carried back five years. This means that a 2018 NOL can be carried back to 2013. Taxpayers can, however, elect to forgo the carryback and carry the loss forward, instead. The CARES Act also allows losses carried to 2019 and 2020 to offset 100% of taxable income.

Taxpayers are encouraged to consult their tax preparers to see if carrying back or forward is more beneficial. If one decides to carry back a loss, they can either amend a return or file an application for tentative refund depending on deadlines. If a carryforward is decided upon, taxpayers must file an election to waive the carryback period.

Given the TCJA’s decrease in marginal tax rates, carrying back a loss to years with higher brackets could provide a tax rate arbitrage. For example, a married filing joint taxpayer with $150,000 of taxable income in 2019 would be in the 22% bracket. If the same were true in 2013, they would be in the 28% tax bracket. So, assume this taxpayer had an unusually bad year in 2018 and experienced a $50,000 net operating loss. The taxpayer could carry that back to 2013 to offset their income or carry it forward to offset 2019 income.

Additionally, there could be an even greater tax benefit for higher income earners choosing to carryback an NOL to pre-TCJA years. Some high-income earners were subject to an exemption and itemized deduction phase out due to the Pease limitation before 2018, both of which are currently nonexistent. Lastly, some practitioners could be currently eligible for the new 199A deduction possibly reducing their effective rate even further compared to pre TCJA years with higher marginal rates and no 199A deduction.​

While our current circumstances are dire, the new NOL rules could provide some financial solace. Practitioners should consider how these new rules affect them.

James Enriquez is a partner at Adaptive Tax Planning, LLC. Send your financial questions to medec@mjhlifesciences.com.

Understanding your net operating losses is key to claiming tax benefits for your practice.

Tax benefits of the CARES Act for medical practices

If doctors had to chart their feelings about practicing medicine, many would list “paperwork” as their chief complaint.

In countless surveys and studies, and across specialties, physicians consistently cite the time and energy they must devote to filling out forms and other administrative tasks near or at the top of their list of grievances. The mantra repeatedly heard throughout the profession is, “This isn’t why I went into medicine.”

The problem is worsened by electronic health records (EHR), now used by close to 90% of office-based physicians. Once seen as a way to streamline documentation data sharing, EHRs instead have become enormous time-sucks. A December 2016 study in 

 found that physicians in outpatient settings spent about 27% of their day on direct clinical face time with patients, but 49% on EHRs and desk work. Many also worked up to two hours every evening on EHR-related tasks.

More recently, the proliferation of quality metrics physicians must document, while well-intentioned, has resulted in another layer of time-consuming administrative tasks for doctors and their staffs.

“Payers and CMS with their reporting requirements are trying to do the right thing and reward quality care, but the process and metrics we have today are adding to the burden with little evidence it is helping quality,” David Gans, MHA, senior fellow of industry affairs for the Medical Group Management Association, told 

The growing number of treatments and medications requiring prior authorizations from payers are yet another source of administrative frustration for doctors and their staffs. In a 2020 American Medical Association survey, 86% of respondents described the administrative burden of prior authorizations as “high or extremely high.”

® Physician Report said prior authorizations consumed, on average, more than 16 hours per week of practice time, including 11.6 hours for staff members and 4.6 hours for themselves.

Paperwork and administrative requirements are also linked to the alarming increase in physician burnout rates, especially among primary care doctors. When 

® recently asked doctors what contributed most to their feelings of burnout, 31% cited “paperwork” — more than twice the percentage of the second-leading cause, poor work-life balance.

“The data show that the things that cause burnout are the things that get in the way of why you went into medicine in the first place, such as being able to provide the kind of care you want to provide to your patients,” Jack Resneck, M.D., immediate past chairman of the American Medical Association board of trustees told 

Fortunately, there are steps physicians can take to reduce their administrative burden, starting with the EHR. Gans suggested that doctors and practices work with their EHR vendor on ways to automate data reporting, such as tailoring prompts according to patients’ specific requirements. For patients with diabetes, for example, the EHR might be programmed to provide reminders of the need for foot and eye exams, and report to payers that the patient received the reminder. In addition, some EHRs now offer the option of automatically reporting some quality data to CMS.

Employing scribes can also help to reduce paperwork and other administrative burdens. A 2018 study in

concluded that their use was associated with significant reductions in EHR documentation time and “significant improvements in productivity and job satisfaction.”

Ultimately, however, doctors probably need to accept that paperwork and administrative tasks will be an inescapable part of practicing medicine — particularly with the spread of value-based care models, which usually require detailed tracking and reporting of quality metrics.

“In the long run, value-based reporting is going to be a requirement from all payers,” Gans predicts.

In late 2020, Medical Economics® asked our physician audience what they thought would be the most challenging issues they will face this year. This is what they told us. 

Top Challenges 2021: #1 Administrative burdens and paperwork

Generating enough revenue to keep a practice open requires knowing the intricacies of medical coding to make sure reimbursement is maximized while also recognizing trends that keep patients coming back.

Getting paid is regularly listed as a top challenge facing physicians, according to the 2020 

The good news for physicians who primarily deliver office/outpatient services is that CMS has made significant changes to Evaluation and management (E/M) coding and documentation to make the process simpler.

For 2021, there are three areas physicians need to focus on to make sure they get paid.

E/M codes are now much simpler, according to coding experts. Physicians will not select an E/M code based on total time spent during the encounter or medical decision making, whichever one pays more.

For medical decision making (MDM), gone is the complicated points system derived from the number of treatment options, complexity of data and morbidity risks. The new MDM table includes easy-to-understand requirements and compensates them for complex cases, regardless of time spent, as long as documentation supports medically necessary services.

In addition, physicians now get credit for many tasks, including reviewing and interpreting test results, speaking with family members if a patient cannot provide their own history, and discussing patient management with another health provider or other professional involved in their care.

For time-based billing, physicians can now count the total time on the date of the encounter that may or may not include counseling and care coordination. Doctors may also count, among other tasks, documenting clinical information in the EHR, ordering medications or tests, preparing to see the patient, and referring the patient to and communicating with other health care professionals.

Physicians should contact their payers to verify whether they will adopt Medicare’s changes. Some payers may continue to require code selection based on history, exam and MDM. They may also have requirements for individual codes.

The most important thing is to ensure everything done matches the documentation.

“Remember that if it’s not documented, it didn’t happen,” says Dreama Sloan-Kelly, M.D., CCS, president of Dr. Sloan-Kelly Consulting, a medical coding consulting company.

The COVID-19 pandemic closed many primary care offices throughout the country, forcing physicians to quickly adopt telehealth as the only way to see patients and keep revenue coming into the practice.

To say telehealth was a lifeline for practices is an understatement. According to 

® 2020 Technology Survey, more than 93% of physicians used telehealth to see patients during 2020, and 77% of them were using telehealth for the first time.

The Centers for Medicare & Medicaid Services (CMS) and private payers made a number of emergency exceptions to laws to make telehealth more accessible for both patients and physicians, and reimbursement for virtual visits was added or increased to match payment rates for in-office visits.

But the Medicare changes were made as part of the federal government’s public health emergency declaration, which will end whenever the pandemic has passed. While no one knows for sure when the pandemic will pass, doctors need to be ready for a sudden shift in telehealth reimbursement. In addition, some private payers have already rescinded reimbursement for certain telehealth visits as public confidence for in-office visits has increased.

Experts say physicians must balance keeping telehealth available for patients who are not comfortable coming into the office to capture as much revenue as possible with the fact that at some point in 2021, it’s likely that reimbursement for it may dry up.

Before the pandemic, telehealth reimbursement was extremely limited. Even if reimbursement remains for some services, it may not be at the same level as for an in-office visit, so doctors need to understand the return on their telehealth investment both now and when the public health emergency ends.

Experts say fee for service isn’t going to vanish in 2021, but more contracts will be focused on value-based care, and the lifeblood of any value-based care contract is data. Payers want data to evaluate which physicians are the most effective, and the top performers get the best bonuses.

Participating in the most lucrative forms of value-based care requires that physicians have plenty of data on their outcomes and can show improvement and the ability to keep patients out of the hospital. An investment in software and equipment may be necessary to fully master all the data points within a practice, but without it, doctors will be at a disadvantage to both participate in and excel at value-based care.

“The key is for us to really break the fallacy that fee for service is a good way to pay for primary care,” says Farzad Mostashari, M.D., the former director of the Office of the National Coordinator for Health IT and currently CEO of Aledade, a company that assists small practices with transitioning to value-based care models. “We shouldn’t be basing primary care payments on that — it should be on the value created and we need to move towards more person-based rather than
transactional.”

In late 2020, Medical Economics® asked our physician audience what they thought would be the most challenging issues they will face this year. This is what they told us.  

Top Challenges 2021: #2 Getting paid and seeing enough patients

The perennial issue of physician burnout has only been intensified by the equipment shortages and shutdowns of the COVID-19 pandemic. Despite increased awareness in the health care system the same problem persists.

®Physician Burnout Survey found that burnout is pervasive among physicians, with 91% of doctors saying they have felt burned out from practicing medicine at some point in their career. A further 71% of physicians reported feeling burned out at the time of the survey.

When asked what caused their burnout, 31% of physicians said too much paperwork and government/payer regulations, 15% cited poor work-life balance/work too many hours and 12% said the COVID-19 pandemic.

While little can be done on the ground with regard to increased stressors from pandemic, there are ways health care leaders can reduce the underlying issues.

Howard Baumgarten, LPC, has extensive experience working with physicians who feel burned out. He says there are three categories of burnout physicians should be on the lookout for: physiological, which can take the form of physical symptoms like headaches and high blood pressure; mental/emotional, which can take the form of anxiety and/or depression; and behavioral, which can take the form of increased alcohol use or smoking, overspending and not sleeping.

He says that once a physician starts feeling the symptoms of burnout, they should take steps to fight it. He gave some helpful tips for physicians to prevent feeling the heat of the health care system.

The first strategy is to aim for seven to eight hours of sleep, starting at the same time every night, and to avoid both drinking alcohol and screen time before bed. The next is to get 30 minutes of aerobic exercise four or five times a week with some muscle-building exercises mixed in. Physicians should also avoid sugary and fried foods and do something that makes them feel good, such as a hobby.

The National Academy of Medicine released a report early in 2020 saying personal stress management strategies are insufficient to tackle the burnout problem facing health care. While some of the suggestions the academy gave relate to structural issues, some can be adopted for independent practice leaders.

Address burnout in training and at the early career stage.

Reduce tasks that do not improve patient care.

Improve usability and relevance of health IT.

Reduce stigma and improve burnout recovery services.

® Physician Burnout Survey, 11% of physicians experience burnout due to a lack of autonomy or career control.

Wendy Dean, M.D., a psychiatrist and president and co-founder of Moral Injury of Healthcare, says that following the long period of rigorous training, focusing on independent, critical thinking with strict adherence to algorithms based on reimbursement policies
can be grating.

Beyond the big systemic hurdles that must be crossed to bring this issue under control, Dean recommends that physicians learn how the incentives are aligned at their health care institution.

“Understand how reimbursement happens, what the incentives are at their entity,” she says, “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.”

Dean says that by talking to their fellow physicians they can see what the patterns are and where the stumbling blocks may be.

“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,” Dean says.

Susan T. Hingle, M.D., professor of medicine at Southern Illinois University School of Medicine, says there are burnout resources available on the websites of most major physician organizations, such as the American College of Physicians for internists.

She says many hospital systems also offer support phone lines to help deal with the increased stress from the COVID-19 pandemic.

“I want people to know that those are available and to know that there’s no shame in asking for help,” Hingle says. “That’s how we’re all going to get through this: by helping each other and getting through it together.

In late 2020, Medical Economics® asked our physician audience what they thought would be the most challenging issues they will face this year. This is what they told us.

Top Challenges 2021: #3 Physician burnout and autonomy

A practice is only as good as the people who work there but finding and keeping the right people can seem like an insurmountable task. This can be compounded with the uncertainty and increased scrutiny introduced by the COVID-19 pandemic.

In a recent entry in weekly studies performed by the Larry A. Green Center and the Primary Care Collaborative on how COVID-19 has affected primary care practices, 35% of physicians say hiring new staff is a big obstacle to their practice.

With this perennial problem only getting worse, the question remains for physician leaders on how to hire, motivate and retain clinical staff.

Target the talent by looking for candidates from areas similar to those your practice is in. This familiarity can smooth over some of the wrinkles the staff member may feel starting at a new practice.

Another suggestion is to adjust your pay system to reward hard work or to boost the total compensation package. This can take the form of creating bonuses for staff members who meet productivity goals, giving employees a sense of how they can earn more without leaving the practice.

The practice leader can also consider offering staff members growth opportunities such as enabling them to pursue more education through training. Sometimes the cost of training and giving the employee a raise can be lower than the cost of hiring another employee to handle the same new duties.

Personalized benefits, such as flexible hours or more vacation time, can be a good recruitment tool and a motivator for current staff members. Allowing newly hired physicians the ability to hire their own care teams or set their own office hours can increase their motivation.

All these changes should be documented and formalized so that, even if employment packages are individualized, they do not appear to be capricious.

An often-overlooked source for clinical staff is the newest batch of medical school graduates. While millennials may get a bad reputation in the media, they can be a key part of a health care team.

Andrew Hajde, CMPE, assistant director of association content at Medical Group Management Association in Englewood, Colorado, says the health care system is reaching a point where millennial physicians are becoming the only ones left to pick up the slack of retiring boomers and Generation Xers before Generation Z comes of age.

When hiring millennials it is important to remember that the cohort tends to put a premium on work-life balance and the feeling that their work has purpose.

Natasha Bhuyan, M.D., is a family physician and regional medical director with One Medical in Phoenix and a millennial. She says the members of her cohort no longer base their success on the hours they spend in the office or the number of patients seen.

“They’re measuring success based on fulfillment of purpose, based on developing meaningful relationships with patients and having time to connect with patients, improve their behaviors and see health results and outcomes change,” she says.

Millennial physicians are also aware that they need feedback and mentoring and can see the value in picking a senior employee’s brain to help them in their own work.

Bhuyan says this new emphasis on mentorship is closer to coaching than in years past.

“How do we coach physicians to reach the top of their potential and beyond?” she asks. “How do we push people beyond what they think is their best?”

Top Challenges 2021: #4 Hiring and retaining clinical staff

The latest CDC National Health and Nutrition Examination Survey revealed that 39.6% of adults and 18.5% of children aged 2 to 19 in the U.S. have obesity.

Obesity can impact essentially every organ in the body. It increases the risk for cardiovascular disease, fatty liver disease and cirrhosis, cancer and, of course, diabetes. Type 2 diabetes rates have climbed along with obesity and diabetes represents an urgent public health crisis.

“There is a plethora of medical conditions that arise from unhealthy weight gain and they are categorized by metabolic changes and physical forces,” says Krishna Doniparthi, M.D., director and physician at Functional Medicine of Georgia in Milton, Georgia. “Metabolic changes entail elevated blood glucose, elevated blood pressure, dyslipidemia, cancer and other metabolic diseases.”

Obesity is a chronic condition that requires a strong physician-patient relationship, honest and direct conversation and personalized treatment plans to tackle.

In 2013, obesity was recognized as a disease by the American Medical Association. Since then, the medical world is beginning to view obesity less as a lifestyle choice and more as a multifactorial dysregulation of hunger and satiety hormones.

Lydia C. Alexander, M.D., an internist in San Francisco who has specialized in weight management and obesity treatment, says adipose tissue is not just an inert storage depot for excess energy but is metabolically active.

“When adiposopathy occurs — also known as ‘sick fat’ disease — inflammation in the body predisposes to other diseases such as metabolic syndrome, hypertension and Type 2 diabetes,” she says. “Given what we know about adiposopathy or obesity as a disease, it is not surprising that obesity is recognized as conferring excess risk for severe sickness from COVID-19.”

In fact, on July 17, the CDC added BMI under 30 kg/m2 as a risk factor for severe COVID-19. Untreated obesity predisposes to increased morbidity and mortality from COVID-19, just as it does for many other health conditions.

Alexander notes the best way to address obesity is through a multidisciplinary treatment approach based on the four pillars of obesity treatment: behavioral modification, nutrition, physical activity and pharmacotherapy, with bariatric surgery as an important adjunct modality for a subset of patients.

“Beyond structuring treatment on these foundational elements, taking a ‘partnership’ approach with patients is key,” she says. “This involves asking open-ended questions, listening, summarizing health goals, collaborating on the treatment and informing the treatment with one’s medical expertise.”

“Would you like to talk about your weight?”

This is considered the first step outlined by the Obesity Medicine Association when approaching a patient about the subject of obesity.

“The language should not be offensive or blaming/shaming,” Doniparthi says.

Sarah Hallberg, D.O., M.S., medical director of the medically supervised weight loss department at Indiana University Health Arnett, notes the most important things to have with you when approaching a patient about the issue of obesity are compassion, evidence and no judgment.

“Being nonjudgmental may​ seem easy to many physicians, but I ask them to really have a good look in the mirror when it comes to passing judgment,” she says. “It is very easy for us to think that we are acting nonjudgmental, but if it is really an act instead of something that you truly believe, it is easy for patients to see right through that.”

For that reason, Hallberg says evidence is important to bring to a conversation. It is also important for the physician to review the evidence themselves when questioning if they are truly nonjudgmental when facing a patient struggling with obesity.

“Obesity is a disease, not a choice or lack of willpower,” Hallberg says. “Evidence in a patient conversation needs to be centered on the impact that obesity has on morbidity and mortality.”

After speaking to a patient about evidence that supports acting on the disease of obesity, the next thing to discuss is food.

“I can’t tell you how many patient discussions I have been in on and how many lectures on obesity I have listened to where food is not brought up. This is so frustrating,” Hallberg says. “You have to know what your patient is eating to understand how best to help them.”

Alexander notes that unlike many chronic conditions or diseases, obesity cannot be hidden from others. Patients often come into their physician’s office embarrassed and self-conscious about their weight.

“First and foremost, it is important to begin any conversation about weight by asking permission,” she says. “An example of what this looks like may be, ‘Would it be OK to discuss your weight today during our visit?’ Most patients will welcome the opportunity to talk about their weight concerns with the doctor.”

When discussing weight, Alexander suggests using patient-first language, which makes a distinction between the disease and the individual.

“For example, we would not refer to a patient with stomach carcinoma as cancerous,” she says. “We discuss them in the context of having cancer, a disease. They are not the disease. Similarly, it is important to address obesity and a patient as having obesity rather than being obese. Lastly, I think it is helpful to discuss the science behind obesity.”

Too often, patients feel their inability to successfully address obesity on their own is a personal failing and demonstrates a lack of willpower or character flaw, when this simply is not true.

Physicians who have been able to help patients with obesity often rely on solid motivational interviewing and developing personalized treatment plans.

​For most patients, the key to losing weight is to assess their total carbohydrate consumption. As weight has increased in this country over the last few decades, calorie consumption has increased as well. However, the increased calories have all been in the form of carbohydrates.

“The push to get patients to eat a low-fat diet has had unintended consequences as it has resulted in many low-fat, but highly processed high-carbohydrate/sugar products coming to the marketplace,” Hallberg says. “This can be seen in everything from low-fat yogurt to low-fat crackers. For most people suffering from obesity, it is the carbohydrates that need to be cut and not the fat. In fact, fat is incredibly satiating which can be a big help when trying to lose weight.”

Alexander uses a six-point model of “ask, listen, affirm, summarize, inform and treat” when approaching patients about this sensitive topic.

“I think the most important tenets for motivational interviewing include asking permission, patient-first language and taking a collaborative approach to arrive at a treatment plan to improve obesity and the concomitant chronic conditions associated with it such as sleep apnea, diabetes, high blood pressure, GERD, depression and more,” she says. “As part of motivational interviewing, it is important to address internalized weight bias and educate patients on appetite regulation.”

She starts with an open-ended question such as “Tell me more about what’s been going on for you weightwise?” and listens to their response so she understands the root problems.

A patient may mention: “I’ve gained 25 pounds since COVID began in March because the gym closed and I’m more sedentary working from home. I barely get out of my chair. I’ve also been under a lot of stress taking extra precautions to protect my husband’s mom who is living with us from getting COVID.”

That’s when Alexander goes into affirm mode, responding with something like, “It sounds like you have a lot of stressors right now and feel time-constrained to care for yourself in the way you would like,” moving to summarize the problem to make the patient understand she’s been listening.

Next, she informs the patient of what she knows, stressing that a lot has recently been learned about obesity and how to treat it and asking if they would be interested in hearing about the newest and best understanding of why some will struggle with their weight, how effective treatment now exists and how it works.

“An example of a personalized treatment plan would take into account patient preferences and reality,” Alexander says. She suggests “incorporating NEAT — nonexercise activity time— into daily routine on days when formal exercise isn’t possible, managing work and/or school expectations, meditation to manage stress and anti-obesity medication to modulate appetite signaling.”

When physicians see that their patients are not losing weight, it might not be that they are not listening, but that perhaps the advice they were given was wrong.

“Health care providers have consistently been telling patients that the key to weight loss and improvement for almost every other health condition is a low-fat diet. What we know now through increased research and research review is that there is no evidence to support this advice as a broad recommendation,” Hallberg says. “In many cases, this approach has worsened medical conditions and certainly frustrated people attempting to lose weight.”

Some reliable evidence-based sources that she recommends to patients are the Obesity Medicine Association, Obesity Action Coalition and Virta Health.

For those who are unsure how to begin changing their nutrition, Doniparthi recommends starting by eliminating easily digestible foods such as sweetened sodas, which tend to be a source of sugars for many people.

Furthermore, he notes to respect the patient’s wishes and don’t force change on them; try to guide them toward the decision to make a healthier lifestyle change.

“Sometimes patients are not ready to make a change,” he says. “Consider using the stages of behavior change to determine where a patient lies: precontemplation, contemplation, preparation, action and maintenance.”

Additional material and resources are available from the Obesity Medicine Association, including a free copy of the Obesity Algorithm, a quick reference guide to understanding the four aspects of obesity medicine: behavior, nutrition, pharmacology and physical activity.

How physicians are addressing obesity as a chronic condition and helping patients lose weight.

Tackling obesity

The COVID-19 pandemic is a monumental challenge for the U.S. health care system. But it’s also a once-in-a-lifetime opportunity to shake up the status quo, which relies on a-fee for-service system that is outdated and leaves both physicians and patients wanting more.

What should a post-pandemic health care delivery system look like? And what role should primary care physicians hold in this system?

 sat down recently via Zoom with Mark McClellan, M.D., Ph.D., to discuss that opportunity. McClellan is a former CMS administrator and FDA commissioner, and now serves as director of the Duke-Margolis Center for Health Policy at Duke University. This transcript was edited for length and clarity.

: How would you assess the performance of the health care system during COVID-19?

 I think it’s been mixed. First of all, health professionals in this country have done an incredible job working under often very difficult conditions and a pandemic where we never seem to be able to get to full containment. So it’s continuing to be a heavy burden on health care workers all over the country as we keep seeing recurrent cases and continued heavy burdens on our health care system throughout hospitals and detecting cases and managing patients with COVID-19.

I’ve also been impressed with the progress that we’ve made on therapeutics. I’m glad that Remdesivir seems to be moving beyond a shortage, limited access stage and becoming more broadly available. And we’ve clearly learned a lot about how to manage severe cases. Where it’s been tougher is in just how well prepared and robust our health care systems are. At the beginning of the pandemic, we just weren’t well prepared for this. We faced shortages in everything from diagnostic testing to PPE, and that had big consequences for our ability to contain the spread.

Now, people have commented a lot about the relative weakness of the U.S. public health system. I’ve seen a lot of examples of health care organizations moving upstream and doing more testing and at-risk communities helping integrate with public health. That may be the best path forward for our country for the future, since we just don’t have a well-developed public health system.

And then finally, in terms of the way our health care system has responded, I’ve been particularly impressed with organizations that have already moved away from fee-for-service payments. Some of the organizations that are more advanced in capitated type models, those organizations didn’t have their revenue floor fall out from under them when utilization fell in March and April. They were already engaged in a lot of telehealth and longitudinal data management to monitor their higher risk patients. They had a relatively easy time adapting to what was needed in the pandemic, which was a shift towards early intervention with patients, managing risks, redesigning care to put an emphasis on sites of service that were more community- and home-based.

I hope those features of our health care system, the interaction with public health, the building on population- based, value-based care models are something that we can develop further as we get through the rest of this pandemic and move beyond. It would make for a much more resilient health care system, one that’s much easier on health professionals the next time around.

ME: What should that post COVID-19 health care delivery system look like? And how do we take the next step with value-based care?

McClellan: In Duke Margolis, we’ve been collaborating with a lot of organizations and experts around the country, including six former CMS administrators who have worked from different perspectives, Republican and Democrat, on value-based care and payment reforms, including organizations like Families USA that are very concerned about the well-being of lower- and middle-income families that have really struggled during the pandemic.

And it all comes back to changing the way that we support our health professionals so they have an easier job not only responding to the pandemic but delivering care that reflects the opportunities for keeping people out of the hospital, for early diagnosis, and for dealing with the root causes of health problems much better than we have in the past. You know, people have been talking about value-based care for a while and it I think the evidence confirms that it does supportpaying differently by designing care differently.

Working as teams, using longitudinal data systems, we can do a better job of keeping people out of the hospital, improving patient experience, avoiding complications, and even get some savings at the same time. It’s been slow going, but I’m hoping that this will be a time for some further progress. I think it’s something that health care providers are maybe a bit more open to after seeing their fee-for-service revenues go down.

From a patient standpoint, people really have appreciated not just the ability to set up a telehealth visit, but all these services being reorganized around them and meeting their needs. Things like phone calls to let them know their risk. Or if they do have symptoms or a problem, connecting 24/7 to a nurse practitioner who knows their care and their and their records. It’s just a better way of delivering care. Here in North Carolina, Blue Cross of North Carolina has implemented aprogram where they’re giving some of their primary care groups some additional payments to help them get through the pandemic, who haven’t had as much assistance as some of the hospitals from the CARES Act and other emergency funding.

So they’re getting some financial help right now. And in conjunction with that they’re planning to move into so-called advanced medical home models over the next couple of years. This was a strategic direction that Blue Cross wanted to move in anyway, to get to better care. But it’s a special opportunity to do it now with some of the savings from reduced utilization that we’ve seen over the last few months, channeled directly into strengthening the practices and helping them move into these better models.

And we’re seeing some other examples like that around the country. CMS is starting some new programs that permit some upfront payments to physicians as part of their direct contracting and primary care first models and retooled oncology care model and kidney care model. Many other private insurers are interested in the same kinds of approaches. So it does seem like an opportune time to reflect on what went wrong, and really try to advance some of these value-based care models.

ME: I’m wondering what you think the correct approach is to getting providers to embrace value-based care? There’s the carrot and there’s the stick, and we sort of applied both of them in different ways. I’m wondering what you think is the way to really get physicians and health systems to leap with both feet into value-based care?

McClellan: Yeah, there are carrots and sticks. And from my time at CMS, a lot of providers complained about too much paperwork. So obviously, the more this is carrot-incentive oriented, the better. I actually think that the challenge with MIPS is that it puts a lot of emphasis on some minor adjustments in fee-for-service. You still get paid on a fee-for-service basis. You still have to do all the billing, all the paperwork, and on top of that, you’ve got to make sure you’re reporting on all the measures and things like that. And some of the things that the metrics are intended to do, like avoid readmissions, or improve other aspects of quality, the fee-for- service system doesn’t really pay you that well to support.

So the kinds of reforms I think are more promising, and the ones that in recent CMS reports they’ve shown have led to more savings and bigger measurable improvements in care, are ones that do move a bit more away from fee-for-service. So for a primary care group, giving them a payment per person, as a medical home or direct contract payment, that they get up front, and that they can use to make new kinds of investments, restructuring their practice, moving towards more of a team-based approach to care, investing in new IT capabilities that they can use in collaboration with health plans and other community organizations to augment the scope of services they can provide to keep people healthy.

And it’s those shifts away from the fee-for-service hamster wheel that give providers a chance to take a step back and say, okay, how do I really want to design my practice, that I think can make the most difference. And we’re seeing those kinds of models, not just in primary care, but in oncology, and kidney care. Getting kidney patients out of the dialysis clinics, which are generallynot associated with the best outcomes and instead using modelsthat enable more dialysis at home. That just wasn’t possible under the old here’s-your-payment-for-each-dialysis-service approach. And same thing true for other areas of specialized care and for accountable care organizations, as well.

CMS has tried to take a step in a number of their major Alternative Payment Model programs recently, pushing a bit more towards bigger shifts away from fee-for-service. I get nervous when I hear terms like downside risk, but really the flip side of that is money that you get up front that you can spend on what you think is most important, not just money where you have to ask, “do I have to do this procedure, this visit, and document this MIPS measure in order to get it?”

So it’s those bigger shifts that I think are more promising. And the good news here too, is that there are more supports and more experience available for all types of providers, small and large, primary care and specialty, to understand better how they can succeed in these approaches. It’s something that we work on a lot at Duke Margolis. There are other large collaborations producing more examples of successes. Other programs that really can help providers that are interested in these models look at and understand what they need to do. It is some work but in terms of provider experience—the quality part of the quadruple aim that’s very important for practice sustainability, as well as patient experience and quality of care and outcomes — these really are, it is increasingly clear, better ways of delivering care.

ME: Primary care physicians often feel very undervalued. And they feel like they’re on the hamster wheel, maybe more than a lot of other specialties. What do you see as the ideal role for primary care in the health care system?

McClellan: They need to have a bigger role. That means more support for more enhanced kinds of primary care programs, the kinds of things I’ve just been talking about. They involve primary care physicians not just doing a couple of office visits a year, but really being the coordinators, or the integrators of better care models that include working with a team, a nurse who can help with ongoing chronic care management, a social worker who can help with root causes of patients not taking their medication, or having some kind of issue that keeps them from getting into the office when a checkup is needed. Working with someone in the community who can help them as well as be sort of a trusted voice.

What we’re really talking about is an enhanced primary care model that costs more money. And that’s why I think some of the major payers for value-based care models are trying to get there by really creating significant payments to the enhanced primary care groups that are more than what they would have gotten before. But it’s also not linked to fee-for-service, because all those things I just mentioned are not things that are paid for in fee for service but instead are related to additional capabilities for helping to manage patients more effectively, getting better results, keeping them at home more. And they typically come with some accountability around health outcomes for their population or experience for their population. And getting total cost of care down.

We saw a number of models tried in the 2000s and 2010s, that were kind of additional payments for primary care. And those were helpful, and they made a difference in terms of supporting these kinds of additional capabilities, strengthening the primary care offices. Unfortunately, especially if you count the additional payments to primary care, they didn’t generally show overall health care savings, at least in the first few years after they were implemented.

The models that have shown more of an effect are these kinds of direct contracting or advanced primary care models that are more like physician led ACOs where the physician groups do take on at least some limited accountability for the total cost of care for their patients. It gives them more opportunities for additional revenues when they keep patients out of the hospital, get them into more effective care models, use specialty care more efficiently. Bring costs down as well as improving outcomes.

There are more programs available that physicians can get engaged in, like Aledade Health or Agilon, to provide support for some of these additional capabilities. Or they can work with health plans and Medicare Advantage and the Blue Cross plan that I mentioned earlier. So those kinds of opportunities look very promising as a realistic path available increasingly now to primary care docs to take primary care reimbursement from the really low5% or thereabouts of spending in the US, up to 10% or more. If you count all the integrated services, the coordination with behavioral health, and so forth, it makes for what should be a much stronger, enhanced primary care for the future.

What should a post-pandemic health care delivery system look like? And what role should primary care physicians hold in this system?


Creating a post-COVID health care system

Electronic health record (EHR) systems remain a primary physician frustration. While the vendor market has matured, there is still a massive usability gap between what physicians want their systems to do and what their systems are capable of.

® Technology Survey, about 70% of physicians have used the same EHR for more than five years and 71% say they have no plans to switch EHRs in the next year.

At the same time, physicians still feel EHRs leave them wanting. When asked in the survey about their primary complaints about the systems, 38% said they wanted a system that was easier to use and 33% said they wanted improved customization options.

“Frankly, I’ve never talked to a physician who said, ‘Boy, I just can’t wait to get on my EHR in the morning,’” says Rob Tennant, director of health information technology policy, Medical Group Management Association. “They understand their functionality, their utility, they know how important they are. They know, in some form, the capabilities that these software programs have, but they’re just not intuitive.”

Still, there remain effective ways physicians can reap more benefits from their existing systems, by optimizing them to improve practice efficiency and support physician workflow, says Mary O’Brien, FACHE, national practice director for Patina Solutions, a professional services organization in Chicago.

Here are four tips physicians should keep in mind.

Physician practices and hospitals should appoint what she calls a physician champion whose role is to support improvement in the utilization of the EHR through education, advocacy and training.

“There needs to be physician involvement in the design of workflows, in the design of how clinical decisions can be made,” O’Brien says. “Physicians always have to be talking to their administration about staying up to date on what their EHR’s highest capabilities are.”

This person can advocate for some key strategies to improve physician utilization and satisfaction of their EHR.

The physician champion will want to begin by making sure the EHR’s settings are personalized to the physicians using it.

“It’s very important that physicians can decide on their own what kind of alerts they want, what kind of education can come up next to some documentation or order they’re putting in,” she says.

Ideally, O’Brien says, physicians also have within their practice or hospital what she calls a clinical informaticist, someone whose role it is to make sure the information available in the EHR is actually used by the physician in the care of a patient.As an example she refers to an epidemiologist caring for a patient with diabetes. “The EHR needs to be capable of bringing up a patient’s past glucose level or past clinical visit.”

This is where those personalized settings are especially key.

Not every practice will have such a person on staff, however, so for smaller practices or private practices, she recommends partnering with other physician groups or large hospital systems or health plans to share services.

Next, she says, physicians should learn how to use the automated documentation tools within their EHR, such as text messages and voice-to-text dictation tools for documentation, which can include mobile device documentation tools.

These tools can reduce the amount of time the physician spends facing the computer instead of the patient, limiting the need for a scribe.

Medical Economics January 2021

Keep using telehealth to boost your practice

Tax benefits of the CARES Act for medical practices

Top Challenges 2021: #1 Administrative burdens and paperwork

Top Challenges 2021: #2 Getting paid and seeing enough patients

Top Challenges 2021: #3 Physician burnout and autonomy

Top Challenges 2021: #4 Hiring and retaining clinical staff

Tackling obesity

Creating a post-COVID health care system

Top Challenges 2021: #5 EHR usability

Top Challenges 2021: #6 Increased competition

2021 Physician payment outlook

Top Challenges 2021: #7 Saving for retirement

Top Challenges 2021: #8 Transitioning to value-based care models