Stay in network or out? Accept Medicare or don’t? What’s better for physicians or more appealing to patients?

For physicians changing to a membership medicine model, these are some of the most pivotal questions to consider. Under the membership medicine umbrella, concierge models usually accept insurance while direct primary care (DPC) generally does not. The lines, however, are not solidly drawn, and in certain situations and markets, concierge physicians have launched thriving payer-free practices in an effort to simplify payment arrangements for themselves and their patients.

The majority of physicians in our concierge medicine network 

 choose to participate in both Medicare and remain in-network with commercial insurance, which is a decision fueled by patient preference. From the patient’s perspective, the ability to use Medicare, a program they’ve paid into for decades, is a valued benefit. It’s also important to note that the entire insurance submission process is not as unwieldy or time-intensive for physicians caring for between 300 and 600 members in our concierge model versus nearly 2,000 patients in traditional fee-for-service practices.

But our model is tailored to reflect each doctor’s individual vision while ensuring optimal care and convenience for their patients. We have successfully partnered with doctors who prefer to practice outside of insurance networks and be freed of the need to file or submit claims, enter insurance data into the EHR or comply with insurance oversight and restrictions.”

For Chicago-based internist and endocrinologist Robert Sobel, M.D., who changed to concierge medicine with the help of Specialdocs in 2016, the decision to practice without payers was carefully considered but seemed almost inevitable.

“The direction of reimbursement payments continued to go south over the last two decades, and cost controls and increased regulations for professional services were becoming unmanageable for our practice,” Sobel explains. “In my opinion, more bureaucracy seldom means better care. Our healthcare system is evolving with increasing complexity as more advanced diagnostic and therapeutic tools are introduced, and it’s vital that we use only the best clinical decision-making to incorporate and implement these into our practice.”

Sobel stresses that being out of insurance networks does not eliminate interaction with their systems and processes.

“We are still intimately involved in advocating for our patients’ treatments and medications, and in providing referral entities with essential information,” says Sobel. “However, practicing in this model allows me to focus on making the right clinical decisions for my patients as well as the time and resources to fight through bureaucratic tangles to help them get what they need.”

Family medicine physician Larry Leibowitz, M.D., who hasn’t participated in any type of insurance network since establishing his Connecticut-based Matrix Personalized Medicine practice with Specialdocs’ support in 2017, says he’s never regretted his decision.

“There’s really no advantage to patients by my accepting insurance or Medicare,” he says. “If I were in-network, patients would be responsible for copays and would incur out-of-pocket costs for office visits and other procedures until they met their deductibles, on top of my annual membership fees.In my model, they’re responsible for none of that.”

Once he clarifies for prospective patients that all services beyond the ones he renders will continue to be covered by insurance, patients rarely object to the arrangement. In fact, Leibowitz says he has never had a prospective patient opt to not enroll as a member of his practice because of insurance concerns.

“On a personal and professional level, I couldn’t have anticipated how much more unfettered I feel over the course of the day,” he says. “While I still need to obtain prior authorizations for medications and imaging studies for my patients, I no longer have to please insurance companies or Medicare or meet the proper metrics for reimbursement.”

The decision to stay in-network or remain outside of it is a personal one for physicians, not based on finances, but on their perception of how they can make it easier for their patients to receive care. The concierge medicine model is not sustained by insurance reimbursement but by membership fees. On average, 87% of a concierge physician’s revenues come from members paying an annual fee, while only 13% of revenues are realized through insurance reimbursement.

Leibowitz acknowledges that he’s leaving a relatively small amount of money on the table by not filing for reimbursements, but says the resulting independence is worth every penny.“I’m able to care for patients without the daunting administrative burdens that most participating providers face.And the personal and spiritual freedom I’ve gained in this model has been priceless to me.”

He adds: “I’m also able to modify my fee schedule as I please in order to accommodate a patient who has fallen on hard times. I can simply say ‘I’ve known you for years... so let’s make this work for you’ without concerns about insurance backlash.”

My advice for physicians weighing whether to accept insurance as they make the change to a personalized practice model is keep in mind the potential downside of not accepting insurance in terms of practice growth. Insurance coverage remains the top-ranked factor influencing American consumer decisions about where and with whom to seek medical treatment. Other surveys show that patients typically first evaluate potential providers by posing just one question: Do they take my insurance? And if you do feel strongly that remaining outside of insurance networks is the right choice for you?

Consider your patient panel carefully. Doctors who successfully practice without accepting insurance have exceptionally loyal patients who stay with them because of the value placed on their relationship.

Thoroughly understand your community’s demographics. Price your services in a manner that both sustains your practice and is affordable for current and future patients.

Work with a partner who is flexible in considering your best options when making the change to a concierge medicine practice with or without payers, and has the experience and compassion to support your decision. Our approach has always been to manage the business for our physician clients according to their values and preferences, and enable them to focus solely on the business of caring for their patients.

Terry Bauer is CEO of Specialdocs, a leading concierge medicine transition and practice management company.

Articles

If you are in a membership medicine model, is working with payers the right way to go?

Practicing with, and without, payers

Here are 5 tips to help you buy the right malpractice insurance policy:

Daniel Cavanaugh, vice president of membership development for malpractice insurer Cooperative of American Physicians Inc., says young physicians going into private practice generally search the internet for information and coverage options or ask a colleague for a carrier or broker recommendation. Both of these, he notes, are a good start. Meanwhile, midcareer and older physicians are often more familiar with the insurance market and will gravitate toward carriers that have been in the marketplace for many years

Older physicians are also more likely to seek coverage through an intermediary such as an insurance broker or financial adviser.

Diane Robben, JD, an attorney with Sandberg Phoenix’s medical malpractice group, advises physicians to pay attention to the laws for whatever jurisdiction they practice in. Talking to colleagues can help with this as well.

Bill Fleming, chief operating officer for The Doctors Company, says independent physicians should choose a carrier with an A.M. Best rating in the “A” range and be aware of the class size from I to XV, as the smaller the number, the smaller the company. Even with a rating in the “A” range, if the carrier is very small, a few large losses can have a devastating effect on its financial security.

“You’ll want a carrier with history and experience in your state and specialty,” he says. “Medical professional liability insurance has an industry reputation of producing more volatile results, so you’ll want an insurer that has weathered the cyclical conditions of this market.”

Remember, if it’s too good to be true …

Fleming also advises physicians to be wary of policies that offer numerous one-year discounts, because prices will almost always increase substantially and physicians will often be stuck paying more than what they were first led to believe.

Also, if a practice is multi-state or might become multi-state in the future, it’s important to choose a company that is licensed in the states where a physician might practice, including telemedicine visits.

Before finalizing a policy, a physician should read the entire document, including all addendums and exclusions and be proactive if there is something that is excluded that they thought was covered before it becomes an issue.

“Know the scope of what is not included in the coverage such as HIPAA liability or cyber insurance coverage,” Robben says. “Also pay attention to whether the policy provides coverage for defense of licensure board complaints, or governmental investigations. Having a trusted and experienced lawyer to guide you through those scary and complex proceedings can help ease your fears and anxiety, and knowing there is coverage for the expenses is important.”

A physician who does it the right way compares policies, including commercial carriers and risk retention groups, which are liability insurance companies owned by the people it insures. This will help physicians determine which offer the best protections and provide the ability to consent and/or select counsel of his/her choosing, says Christopher J. Kutner, J.D., MBA, of Rivkin Radler LLP’s Health Services Practice Group.

When buying malpractice insurance, Fleming says, be candid with the underwriter. The more accurate and comprehensive the application is, the better.

“It is best to deal with issues like prior claims, changes in practice locations, negative news or social media, at the beginning,” he says. “That way you have established that you are open and candid in your relationship with the carrier.”


Even if physicians are happy with their malpractice insurance, they shouldn’t ignore it. It should be evaluated yearly and kept up to date.

“Whenever you change in size, add or drop practitioners, or have a significant change in the scope of practice, you should evaluate your medical malpractice insurance needs,” Robben says. “At a minimum, I would recommend calendaring to review your malpractice insurance on an annual basis. You want to be sure there are no gaps in coverage and that you have coverage from term to term.”

And don’t wait until the last minute to make a change. It’s important to leave enough time before the expiration of one term to be able to evaluate other options and test the market.

How to find the right malpractice policy for your situation.

Tips for buying the right malpractice coverage

Twenty-two years ago, the National Institutes of Health published the first ever evidence-based guidelines for identification and treatment of obesity. This 262-page report was an important milestone, but at the time, the authors stated that the “understanding of how and why obesity develops is incomplete.” Today, we know much more. And because of that knowledge, obesity care has changed radically in twenty years.

Today we know that obesity is an altered physiologic state.

Obesity researchers know that obesity results from the effects of environmental triggers on genetically susceptible individuals. These triggers are many but may be grouped into four categories:

 are most cited – the composition of food, its quantity, and its promotion to consumers. Research has identified many dimensions of the food supply that may contribute.

 that makes routine physical exertion less common.

 can act as endocrine disruptors with the effect of promoting obesity.

Perhaps the most important change in understanding the physiology of obesity comes from a 2011 study in the 

. Sumithran et al. demonstrated that weight loss causes changes in metabolic hormones that serve to return the body to its prior level of adiposity. Simply stated, the authors documented how the body acts to protect fat mass in subjects with overweight or obesity.

In other words, they documented that the physiology of obesity makes weight loss, by itself, unlikely to be an effective treatment for the chronic disease of obesity. It requires chronic treatment —just like dyslipidemia, hypertension, or diabetes.

The meaning of these insights for primary care is straightforward. When obesity is a clinical concern, simply advising a patient to lose weight will have a negligible benefit. The physiology of this disease state will make long-term clinical improvement very unlikely – even though many patients might lose weight in the short term.

The emerging standard of care is to use a range of treatments to help a patient reach and maintain a better state of health. These include dietary interventions, physical activity, behavioral therapy, pharmacotherapy, and metabolic surgery. Most often, a combination of these will yield the best outcomes, tailored to the needs of the patient.

A growing number of primary care physicians are seeking certification in obesity medicine to equip themselves to provide such treatment. Others might instead refer to an obesity medicine specialist. Either way, the patient will benefit from evidence-based care for this complex, chronic disease.

Ted Kyle is a pharmacist and health innovator living in Pittsburgh.

What are the implications for primary care?

The physiology of obesity

Physician contracting is becoming extremely important today, as more physicians are working for hospitals, large health systems and multiphysician practices in nonownership roles.

® recently sat down with Richard Roberts, M.D., J.D., a professor emeritus of family medicine at the University of Wisconsin School of Medicine and Public Health. Roberts was an attorney and has counseled numerous young doctors on employment matters and contracts. He believes it is very important for doctors to investigate the core culture of a potential employer before signing a contract with them. The below transcript of this interview was edited for length and clarity.

: Why is it important for doctors to learn about the culture of a particular institution or practice before going to work for them?

Roberts: The typical physician will spend more awake hours at work than with his or her family and friends. …The sense of your feeling welcomed and supported, and the sense of professional growth, those are all the things that make a workplace a good or bad place for you to be. And so, if you don’t get that, it really doesn’t matter what the contract says because you’re going to be miserable.

ME: How can adoctor investigate a potential employer to learn about their culture?

Roberts: Usually it’s about just asking the physician recruiter, that’s typically the first person you’ll be talking with about the job; talking with other physicians, especially in your department; the staff that are there, even those employees sitting out in the reception area; and watching how the receptionist and patients interact. Do the nurses seem to enjoy working with each other? Is there a sense of teamwork and camaraderie? These are all key.

And then you can step away from the practice and ask the community. Ask doctors in the community, ‘What do you think of this group? I’m thinking about joining them.’ The nurses are often, in many ways, the better people to ask because they typically have more interaction with the physicians from the group you’re looking to join. So, it’s that kind of reaching out.

ME: Are there areas of flexibility where doctors can negotiate in a contract, and what are some typical examples?

Roberts: Absolutely, there are all kinds of areas to negotiate. But when hospital people say to me or to a young doc, ‘Well, we try to treat everybody the same,’ my immediate answer is, ‘Does that mean the custodial staff is getting paid the same and has the same benefits as a CEO?’

The reality is, nobody is exactly the same as anybody else, because people have unique needs. You may have a young mom who’s got scheduling needs that don’t match what the typical young male physician may feel is a good schedule for him. If the contract doesn’t reflect that, it has not done a good job of really identifying and addressing the priorities of the individual. It’s in the organization’s best interest to try to make you happy. Yeah, you do take up more of their time. Yeah, you do generate more legal fees for them as these things have to be reviewed by their lawyers. But hey, it’s your life.

In an ideal world, at the end of the day, when both you and the organization are prepared to sign, you can both look at that set of papers and say, ‘This is pretty good. This meets our needs but isn’t perfect.’

Roberts: The example that I’ll often turn to is …the group at Harvard called the Harvard Negotiation Project (cofounded) by professors Roger D. Fisher and William L. Ury. Their book called 

 lays out some basic ideas on what they call “principled negotiation,” because their view is that if a contract …or an agreement unfairly gives one the advantage over the other party, it’s in the end not going to succeed.

I usually say to people to identify two to three things. One thing might be having the ability to do certain kinds of procedures. And if that’s something that’s really, really important to you, put it in the agreement. On the other hand, there may be certain things that you’re being asked to perform, a certain task or service, and you absolutely cannot deal with that or don’t want to do that. So, it should say, basically, in the agreement that you don’t have to do them. But it’s not an infinite list, because then you’ll never manage to get through the contracting process. It’s a list that really highlights the few things both that you must have and that are deal breakers.

Now, the thing to be careful about in all of this is that language is important and the tone that we set is important. I think, as a physician, you always want to be professional, you want to be polite. You want to assume good intentions on the other party’s part. But you also need to ask good, hard questions and not be afraid to push gently but persistently.

ME: Can you provide a stepy-by-step guide for thinking through a job offer?

Roberts: Well, just like planning for a procedure or visit with a patient in the office, I think the first step is (that) you want to think ahead. And that means planning and prioritizing and developing an overall game plan with a pretty clear sense of the things that you really need to have to be a happy, successful physician and the things that you really must avoid or must not have. Now, you may only be able to identify one or two, that’s fine, or you may identify 10. That’s not so good. But you want to make sure that whatever you’ve identified as key issues for you and for those who are important to you in your life are reflected in the document.

Don’t ever be afraid to speak up for yourself. I think many times, we physicians are so used to deferring gratification and putting the needs of others before ourselves that we feel a little embarrassed asking for this or asking for that, especially when you go from kind of minimum wage jobs as a college student to pretty substantial salary offers. When the recruiter or whomever you’re talking with from the organization says to you, ‘Well, this is the same agreement that everybody signs,’ my advice is that your first response should be, ‘I’m not everybody.’ And I tell people, when you get the first draft of the contract –– because it’s always written by the system’s lawyer not by your lawyer –– change something, even if it’s the date, because under the law, the two bargaining parties have equal rights until you sign on the bottom line. Because what you do when you sign a contract is you give away certain rights to the employer. So, you want to be sure that your rights are protected sufficiently around the things that you care the most about.

And the third thing that I would say is you need to always be thinking ahead and reflecting on this whole process as your career plays out, because what you find is that most people today, especially professional people, usually have several careers. And not only in terms of where we might work, but the particular kinds of duties or jobs. And so, as a young physician, I’m going to find myself constantly going through this prioritization and identifying what I must and must not have, in terms of my list, the standard of living that I’m trying to fund, the investments I’m trying to make for my children’s future — all the things that we all have to think about. And always doing that on a regular basis puts you in a better position when something comes up that feels more pressured or all of a sudden.

It’s the planning ahead that keeps you out of trouble.

Doctors need to investigate the core culture of a potential employer before signing a contract with them. 









Physician employment contracts

Medical records, which most patients think are private and protected, are in reality lucrative commodities in a multibillion-dollar industry. As hospitals and health networks assemble these records, they routinely strip away names and other identifiers and sell millions of HIPAA-compliant files to massive aggregator corporations. Aggregators in turn profit from integrating, analyzing and selling access to data on a massive scale. For example, Truven Health Analytics, part of IBM Watson Health, brought 215 million patient records to IBM when it was purchased in 2016, raising IBM’s total to about 300 million records. Access to these records is sold to pharmaceutical companies, insurers, health systems and government entities for research purposes.

Medical data reside with other owners, as well. Since the development of modern pharma, it has been axiomatic that clinical trial data belong to the companies that gather that data. When participants join a clinical trial, they typically agree that, aside from test entries into their medical records, the data they generate become the property of the sponsor. It makes sense: A typical phase 3 clinical trial costs about $40 million, and pharma companies want the sole right to profit from the data they’ve spent millions to collect.

Other collectors of medical data have taken a more consumer-facing route. 23andMe and Ancestry.com have built massive genetic testing databases. They acquire data by selling DNA test kits for genealogy purposes and using that money to cover testing costs. Consumers get a genealogy report, and 23andMe and Ancestry.com then sell access to the identity-stripped analyses of genetic data on millions of people similar to the way large aggregators such as Truven share medical records. An investigator can pay 23andMe to identify 250,000 people distributed across multiple genetic groups, launch an Institutional Review Board-approved voluntary email survey to those people and deliver the research results. This business model is by no means clear to consumers who want to trace their family trees, but it is legal and thriving.More concerning still is that analysts have found ways to break anonymity, marry records from multiple sources (including search engines and social media) and sell these amalgamated records to a variety of for-profit enterprises.

These data owners also sell access to medical and genetic data for many beneficial uses. For example, if investigators want to know the long-term adverse effects of a drug, they can access 10 years of data for 20 million people and check how often adverse effects or dangerous drug interactions occurred.

It’s critical to understand that patients generally do not have exclusive rights to their data. Once a patient shares their data, they have little or no say in how it is used. Most do not even know their data are being sold and never see any direct profit from the sale. But that could change. In an age where consumers know that Facebook, Google, Amazon and others are exploiting their electronic data for profit, the models for medical data ownership soon may be ripe for overhaul. Governments in Europe and elsewhere already are legislating limits on these data uses.

Fueled in part by European Union’s General Data Protection Regulation, which reflects a growing societal consensus that each of us should own the biomedical data we generate, new ideas are taking shape. These new European rules are leading many to ask: Is it possible to create a transparent model where patients own their medical data and share in any profits derived from it? Will the future of data ownership remain exclusively with large corporations who aggregate that data, or will a more patient-centered approach emerge?

One area where one might imagine change in the near term is pharma. Big Pharma has, in recent years, been making its approach to study participants increasingly patient-centric. More broadly, the health care industry has been developing new ways to regulate and share data in interoperable formats. With emerging standards such as the Fast Healthcare Interoperability Resources, a format that makes patient records compatible across platforms, transactions in which data are sold or loaned at the level of individual patients are becoming feasible. Clinical trial data gathered in a drug study could even be transferred back into patients’ medical records.

HIPAA presents another opportunity for change. When Congress passed the Health Insurance Portability and Accountability Act of 1996, medical records were still kept on paper in file rooms. The law has been amended in the past, but it is becoming increasingly clear that, in our fully digital medical landscape, it will need to be revised again. When patients sign a HIPAA form in a hospital waiting room, they authorize providers to strip away 18 pieces of potentially identifying information and then empower their health care provider to sell their data without compensating them. A new HIPAA could not only retain a patient’s right to access their data, it could also give them ownership and even some measure of control.

When patients own their medical data in a more exclusive way, the data’s intrinsic value remains with them. They could opt to keep the data completely private and not sell it to any corporation. But with companies willing to pay for access, the potential for profit exists.

How can patients share their medical data and reap the profits? One possibility is a medical data “bank.” Patients could elect to store and pool their medical records at the bank in exchange for a slice of the profits. Instead of data ownership residing with private companies, medical data would be aggregated in a patient-centered model where drug companies and others gain access for a fee, and patients receive a share of the profits. It would work much like a savings account, where thousands of account holders deposit their money, the bank makes loans at 7% interest and the bank returns 3% interest to the savings accounts. Patients who participate in clinical trials would be making their medical records more valuable and thus earn a larger return. This may sound far-fetched, but many people are advocating for a model such as this on an ethical level, and it is now being explored commercially by several startups.

Led by regulators in the European Union and California, parts of the U.S. government are actively exploring changes to data ownership that could significantly alter the contemporary landscape. As our society develops new positions with regard to data privacy, ownership and profit, patients and consumer organizations are likely to join insightful health care leaders in building a new medical data system with transparency, privacy and patient control.

 is a neuroscientist, psychologist, economist and entrepreneur who holds the Julius Silver Professorship at New York University. At NYU, he is also a professor of neuroscience and physiology, NYU Grossman School of Medicine professor of psychology and economics, and codirector of the Institute for the Study of Decision Making. In addition, Glimcher is chairman and chief science officer of Datacubed Health, developer of new platform-as-a-service (PaaS) technologies for health care and biomedical/behavioral research.

Medical records, which most patients think are private and protected, are in reality lucrative commodities in a multibillion-dollar industry.

Who profits from medical records?

The COVID-19 pandemic has added a wrinkle to my pediatric office’s plans to administer more than one thousand influenza vaccines to our patients and their parents.

In previous years we would put families in an exam room, administer the shot or live nasal vaccine, and send everyone back out through the waiting room packed with other families awaiting their turn. We did this both during regular office hours and also during some after-hours times in the evening and on weekends.

This traditional approach will not work this year for several reasons:

The requirement for social distancing means we can’t have several families waiting in the reception area for their turn in an exam room.

Time between each family would now need to be built in, drastically reducing the number of persons we could vaccinate per hour.

Cleaning all the surfaces in a room between each family’s use — something not required previously — would also add time and expense.

So, here in Raleigh, North Carolina, we have come up with a plan.

We have all seen pictures on TV of long lines of cars with people waiting their turn for a COVID-19 test or picking up some free groceries for the unemployed. Why would this drive-through approach not work for your office in giving vaccines?

If your office is in a commercial building, check with your landlord or fellow tenants to see whether you could commandeer the parking lot for a Sunday morning or afternoon or both. A school parking lot on a weekend morning or a large church’s parking area during the week are also options, but you would need to obtain permission.

You may want to have some tents for your staff and proceed even if it rains. Or, have an alternate date and time. We intend to set our date up on a Saturday afternoon with a plan to move it back 24 hours to Sunday afternoon should it rain.

Tell your patients about your plan for a drive-through vaccination clinic. Social media, your website, your on-hold phone message, signs in your office, and e-mail blasts to all your patients are some options to consider. A press release to your local paper or TV station might lead to some free publicity at the risk of having nonpatients show up on the day of the clinic.

Appointments avoid traffic jams and ensure you have enough supplies on hand on the day. I would suggest one car every five minutes. Some cars will have a single person wanting a vaccine and some may have four or five. For our office I think the average will be between three and four people per car.

We will be offering either the shot or the nasal vaccine. Both take about the same amount of time to administer to a cooperative patient. Children will be left in their car seats. A parent may be required to hold their arms, and car doors may need to be opened.

office staff print out the appointment log

Print it out for next day’s staff the day before the clinic. We plan to have a preprinted sheet for each car with lines for each scheduled patient or parent and a few empty spaces in case of an unexpected extra. As the administration site of the vaccine is supposed to be recorded, four choices for the nurse to circle will be present next to each name — left arm, right arm, left leg and right leg — which cover the four extremity choices in pediatrics. Adult patients require just two, right arm and left arm.

Each preprinted sheet will have the initials of all staff administering the vaccines because that information also must be recorded. Additionally, the sheet must have a list of the vaccines being offered. As we won’t need any vaccines for patients older than age 65, we will simply list the shot or live attenuated influenza vaccine as options for the nurse to circle. The administering provider will circle their initials, the vaccine given, and the location of administration.

You will need PPE for your staff, alcohol wipes, Band-Aids, antiseptic hand gel for use between cars for staff, sharps containers, an emergency medical kit with epinephrine available, tables and chairs for staff, and proper storage gear for the vaccines. We will be using prefilled syringes to save time. A laptop on site will allow you to remotely access electronic medical records if required. The CDC has guidelines for off-site vaccine clinics and proper storage requirements at this link: https://www.cdc.gov/vaccines/hcp/admin/mass-clinic-activities/.

One is for check-in and one for administration, on your clinic day.

, a staff member will confirm who in the car is receiving vaccinations. Your preprinted sheet will have the names already listed, but you will have to expect some no-shows and also be ready to add someone extra. Names of no-shows will be crossed out and an extra person’s name can be added to the sheet, which will eventually be required for billing.

Vaccine Information Statement sheets should be available

 here and offered. If you have standard screening questions, this is the place and time to ask them. When check-in is complete, the staff member will hand the driver the preprinted sheet and direct them to the administration station ahead.

Have the nurse collect the preprinted sheet at the administration station

Ask if any other questions need to be answered, and vaccinate those patients who are on the sheet. If the driver is receiving a vaccine, you may want to suggest they pull over into a parking space for 15 minutes to cover yourself from a medical-legal point of view in case of syncope. Someone from your office will need to monitor those spaces. The vaccine administrator then circles the initials, the vaccine given, and the site and saves the sheet for later when information is entered into the medical record and billing. You may wish to have some preprinted sheets available for those patients requesting a copy of what they received (eg., as proof for an employer).

Our office is planning to do a trial run with 12 cars the week before we have our mass clinic(s). Most likely, we will need to modify some things. In pediatrics, we always have a few resistant, uncooperative school-aged children dragged to the office by their parents. In previous years we would leave such families alone in the exam room for that parent-child discussion that can sometimes take 15 minutes. When this happens this year, we will give the vaccine to everyone willing in the car, then the family will be required to get out of line and go back through the check-in line when they think their child is ready.

COVID-19 has caused a lot of changes in our lives. We have all had to think outside of the box and make changes to long-established routines. Some of those changes may end up being for the better (eg., an elbow bump instead of a handshake).

Hopefully, we will find that this drive-through clinic works out better than our old way of doing things.

Terry Brenneman, MD, is a pediatrician and the founder of Pediatrics Partners in Raleigh, North Carolina.

The best way to issue flu shots might be for patients to never enter your office.

How to set up a drive-thru flu shot clinic

With the ever-changing health care landscape and the increasing competitiveness among physician practices and hospitals, many physicians are looking at acquiring other practices and bringing them into the fold. Unfortunately, I have often seen physicians who would like to jump to the valuations or due diligence of a medical practice without having first established their own strategy as it relates to potential acquisitions.

If your practice doesn’t already have a strategic growth plan, make one. Growing for growth’s sake really doesn’t make sense for you or for the potential target. Instead, think about practices that might be interesting to acquire, geographies that might be important, capacity that might enhance operations, or perhaps even technology that could be transformational.

You should consider what you need before looking at opportunities, because after the acquisition the integration follows, and that can be an extremely difficult process if there was no strategy beforehand. The discipline of articulating a strategy will guide you in finding and assessing acquisition targets.

What is your vision for where you want your practice to go? In developing your acquisition strategy, you should consider your goals (What is it that you want to do?) as well as your experience (What have you already demonstrated the capability to succeed at?). It is imperative that you fully study these two areas and write down your thoughts before you proceed.

As a physician-owner, you need to know what strategic outcomes you ultimately want from engaging in acquisitions and consider the implications to both you, as the buyer, and the practices that may want to sell. Developing an acquisition strategy requires knowing what makes your practice successful now and what a potential acquisition can add to make your business even better in the future. This strategy will help you clearly define the value proposition for both buyer and seller, as well as the value drivers that should guide acquisition decisions. In this instance, the value drivers are essentially capabilities that add worth to the practice.

Practices are continually bought and sold as a result of an opportunity being made available or because of a strategic plan. As the buyer, you are acquiring an established practice that is hopefully making money and has patients and employees already in place. You also know that if you buy a good practice, you have the opportunity to make it a better one. From time to time, things come your way that are more opportunistic. Ask yourself, is the downside (risk) significantly less than the realistic upside (opportunity)? Are the seller’s goals aligned with what you want to do? Look at the fit. Will integration require a fundamental change in either practice? Unfortunately, the answers are rarely black and white, hence the importance of having an underlying acquisition strategy.

When your desires and experience intersect with a good acquisition strategy, you have the foundation for your plan. It is now time to look at opportunities, by first defining the parameters of the practice you want to acquire. What are the characteristics of the medical practice you propose to buy? Items such as practice size, location, price range and patient catchment area are just some of the key areas to initially think about.

What is your plan to grow the new, combined business? You should include both top- and bottom-line growth in your discussion. Are you looking for a troubled practice where you can create value or a practice that is already on a fast-growth trajectory? Do you foresee additional acquisitions? If so, what are the attributes of the prospective add-on practices. What will the new business look like as your plan moves forward?

Once this exercise is complete, you will be in a position to start targeting the right practice. There are two ways of doing this: find a practice already listed for sale, or approach the physician-owner of a practice that is not for sale and make an offer. Some key questions you should keep in the forefront of your mind include the following:

How does the target make you, the buyer, better?

How do you make the target better? Most often, you are buying the producer (the physician), so alignment with his or her personal goals is absolutely critical.

What are the risks that could impact the future success of the business? What is your plan to deal with them?

The process of buying a medical practice can be narrowed down to one very simple question: Is the practice you’re buying actually the 

 that you think you’re buying? Some purchases are more straightforward than others. If you have a thorough understanding of what you are buying, then the process will be smoother. It is extremely important to remember that when you encounter an opportunity that does not align perfectly with your original strategy, return to the key questions that defined it. Local market dynamics may change your own practice and, thus, there may be a need to alter your acquisition strategy. There is nothing wrong with that. In fact, I am a firm believer that strategy should be fluid and ever-evolving. Just make sure that as your acquisition strategy changes over time, the practices you acquire still make your business better and more valuable.

Essentially, your strategy will become the roadmap for your acquisition initiatives and will serve you well at every stage. Thoughtful development of an acquisition strategy should tell you as much about the medical practices you should not pursue as those you should. You can use your refined strategy to help locate medical practices, seek investors and lenders, assess the value of practices, and structure deals. Most importantly, as you get caught up in the heat of the chase, it will help you to assess whether the deal you are working on is really going to be right for you.

The challenge is to stay true to your strategic direction, not allowing yourself to be distracted by acquisitions that don’t keep you on the intended path. Physician-owners often make mistakes here. All the work you do to meet and evaluate practices, only to walk away, is not wasted. It’s part of staying true to the thesis and testing and achieving your long-term vision for your business.

 is the CEO and founder of ABISA,
a consultancy specializing in strategic health care initiatives for physician practices. His firm helps devise and implement strategies that will allow
practices to remain competitive and solvent. Send your financial questions
to medec@mjhlifesciences.com

Strategy checklist for medical practice acquisitions

Good news for physicians tired of counting bullet points to assign an evaluation and management (E/M) level for an outpatient office visit: Per new AMA guidelines, it’s going to be a whole lot simpler. As of January 1, 2021, physicians will select an E/M code based on total time spent on the date of the encounter 

medical decision making (MDM)—whichever is most financially advantageous. An added bonus? Medicare payments for almost every E/M level will increase if proposed payment rates become final.

Today, the three key components of an E/M level are history, exam, and MDM. In 2021, the history and exam must simply be medically appropriate. They aren’t factored directly into the E/M level, nor must they adhere to a specific type (i.e., problem-focused, expanded problem-focused, detailed or comprehensive) says Cheryl Cyrus, RHIT, CPMA

quality assurance auditor at ComforceHealth, a health care business consulting company. This means streamlined documentation, fewer cumbersome requirements to remember and potentially more time spent on direct patient care, she adds.

“We’re shifting back to the patient-provider relationship,” says 

 CEO of Enjoin, a clinical documentation integrity company. These changes also reflect the AMA’s desire to reduce physician burnout, a major component of which is documentation, he adds.

Still, physician documentation must accurately depict what occurred during the encounter, says Dreama Sloan-Kelly, M.D., CCS, president of Dr. Sloan-Kelly Consulting, a medical coding consulting company. “You still need to be covered in the event of a lawsuit or post-payment recoupment,” she adds.

Although January 1 is several months away, experts say physicians must prepare now to ensure they understand precisely what is changing.

Current E/M guidelines require physicians to document one of the following four types of MDM: Straightforward, low complexity, moderate complexity, or high complexity. Each of these types is driven by a complicated point system derived from the number of diagnoses or treatment options, the amount and/or complexity of data reviewed, and the risk of complications and/or morbidity and mortality.

In 2021, these four types and drivers remain; however, physicians will use a “new and improved” MDM table that includes easy-to-understand requirements for each E/M level.

Other good news? Physicians get credit for the following:

Reviewing prior external notes from each unique source.

Reviewing the results of each unique test, including imaging, lab, psychometric or physiologic data.

Performing an assessment requiring an independent historian, defined by the AMA as an individual who supplements information provided by a patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia or psychosis) or because a confirmatory history is deemed necessary. Examples include a parent, guardian, surrogate, spouse or witness.

Independently interpreting a test performed by another physician or other qualified health care professional (QHP). Note that physicians and QHPs can only count this toward the MDM when they cannot report the service using another CPT code.

Discussing patient management or test interpretation with an external physician or other QHP (i.e., someone who is not in the same group or who is in a different specialty or subspecialty, a licensed professional practicing independently, a hospital, nursing facility or home health care agency), or another appropriate source (e.g., lawyer, parole officer, case manager or teacher). It does not include discussion with family or informal caregivers. Note that physicians and QHPs can only count this toward the MDM when they cannot report the service using another CPT code.

Fee provides this example of the new MDM table in action:

An established 69-year-old female patient presents to the office with her daughter. The patient has had stable depression for the last three years and a new onset of mild amnesia. She reports increased frustration in losing objects over the past few months. Her daughter confirms this and also says the patient frequently forgets names and isn’t able to remember certain words during conversations. The patient denies any stressors, headaches, dizziness or problems with sleep or anger. The physician reviews recent TSH, CMP, and B12 labs; orders an MRI scan; and renews her anti-depression medication. The total duration of the visit is 25 minutes. This maps to a 99214 code based on the 2021 MDM table.

Physicians will be happy to hear that the new MDM table compensates them for complex MDM regardless of the time spent, as long as documentation supports medically necessary services, says Joe Rivet, Esq., CEMC

 health care reimbursement attorney and coding compliance and audit expert. Currently, physicians are only compensated for a complex MDM when they also document a higher-level history or exam, he adds.

Current E/M guidelines permit physicians to select an E/M level based on time only when they spend more than 50% of the visit counseling and/or coordinating care. In 2021, this requirement no longer applies. Instead, physicians can count the total time on the date of the encounter that may or may not include counseling and care coordination. Eligible time includes both the face-to-face and non-face-to-face time that the physician personally spends before, during and after the visit on that same day. Specific examples include:

Care coordination (when not separately reportable).

Counseling and educating the patient, family and/or caregiver.

Documenting clinical information in the electronic or other health record.

Independently interpreting results (when not separately reportable) and communicating results to the patient, family and/or caregiver.

Getting and/or reviewing separately obtained history.

Ordering medications, tests or procedures.

Performing a medically appropriate exam and/or evaluation.

Preparing to see the patient (e.g., reviewing tests).

Referring the patient to and communicating with other health care professionals (when not separately reportable).

“My fear is that physicians would forget to count some of this, so they need to make sure they review this list,” says 

 independent coding and reimbursement consultant. For example, physicians will be able to count the time they spend reviewing their state’s prescription drug monitoring program database when prescribing opioids.

Experts provide these seven tips to maintain compliance:

For example, if a physician obtains and reviews medical records, they should document what specific records, from whom, and for which treatment dates, says Jessica Miller, CPC, CPC-P, manager of professional coding at Ciox Health, a coding outsource company.

Simply selecting a diagnosis from a drop-down menu won’t be sufficient, says Huey. To get credit for diagnosis management in the new MDM table, physicians need to link each diagnosis with some type of action—a prescription, test, counseling or some other type of workup. Stating that the diagnosis is managed by another provider doesn’t count.

Physicians aren’t required to itemize their time; however, their documentation must be an accurate depiction of services rendered, says Rivet. “I think itemizing starts to dilute the benefit of these new guidelines.” It could also open physicians up to scrutiny, he adds. For example, an auditor may question why it took 12 minutes to review a complete blood count.

However, be mindful of total time spent, says Rivet. For example, a physician sees 20 patients a day and documents that they spend 35 minutes per patient, totaling approximately 12 hours. This exceeds a typical eight-hour workday and could be a red flag for a payer, says Rivet.

Pay attention to when services are rendered

For example, a physician reviews lab results two days after an encounter. They can’t count this time toward the E/M level for the previous visit to which the labs pertain, says Rivet.

However, they may be able to report CPT codes 99358 and 99359 for prolonged services on a date other than the date of a face-to-face encounter, says Huey. The code description for 99358 states that it requires at least 60 minutes of services; however, per CPT rules, physicians may bill it once they have reached the midpoint (30 minutes). The code description for 99359 is for each additional 30 minutes, but physicians may bill it once they have reached 15 minutes. These codes must pertain to a face-to-face encounter that has occurred or will occur related to ongoing patient treatment, she adds.

There is also a new code that physicians may be able to report when they personally render prolonged services when billing 99205 and 99215 based on time: 99XXX. Physicians can report this code only when they spend at least 15 minutes of additional time on the date of the encounter with or without direct patient contact, says Huey. For 99205, this means more than 75 minutes. For 99215, it means more than 55 minutes.

Don’t count services that are separately reportable

For example, if a physician performs an ECG interpretation and report, they can’t apply that toward the E/M level because separate CPT codes exist (93000, 93005 and 93010), says Rivet.

Focus on social determinants of health (SDOH)

Capturing SDOH via ICD-10-CM diagnosis codes (e.g., Z59.0 for homelessness or Z59.5 for extreme poverty) may help support a more complex MDM and thus a higher-level E/M code, says Huey.

“You’re not going to be able to justify 50 minutes on a patient with strep throat,” says Sloan-Kelly.

Coding based on time or MDM—that is the question

Although optimal code assignment depends on the clinical circumstances of each scenario, Fee provides three important questions to consider when determining whether it is more advantageous to bill based on time or MDM:

Did the physician spend a considerable amount of time collecting the history or performing the exam? If so, it may be more advantageous to bill based on time.

Did the physician order several tests, speak with other physicians, or review complex data? If so, it may be more advantageous to bill based on MDM.

Is the patient medically complex (and do they support a level five E/M) but the physician went beyond the time threshold associated with the code? If so, it may be more advantageous to bill based on time because then the physician can also bill for prolonged services.

Do you want to prepare for the upcoming E/M changes, but are not sure how? Experts provide the following five tips:

Identify someone within the practice (e.g., a coder or practice manager) to champion the education effort, says Courtney Davenport, CCS, CCS-P, lead educator at Aquity Solutions, a coding outsource company. This person can attend webinars or take online courses and provide staff members with need-to-know education.

Ask whether they will adopt Medicare’s changes. Some payers may continue to require code selection based on history, exam and MDM—or they may have specific requirements for individual codes, says Davenport.

Ask what the vendor is doing to incorporate Medicare’s changes. In particular, how will the EHR’s code calculator incorporate time and MDM? How will the algorithm distinguish between outpatient office visits and other types of E/M services to which the 2021 changes don’t apply?

Create an edit in your practice management system for 99XXX

Flag this code for manual review to ensure documentation supports services lasting 75 minutes or longer for new patients and 55 minutes or longer for established patients, says Miller.

Does it support total time spent with patients as well as complex MDM? How does your current documentation map to various E/M levels using the new AMA guidelines? Now is the time to start documentation improvement efforts, if needed, says Huey.

“Remember that if it’s not documented, it didn’t happen,” says Sloan-Kelly. “We went to school for a long time to get paid for what goes on in our minds.”

Is your practice ready for the changes that are coming?

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