Clinicians see the results of patients not following their treatment plan, whether it’s medication adherence, lifestyle recommendations, or attending follow-up visits. But there are often social factors influencing a patient’s lack of adherence. They may struggle with basic survival needs like housing and food, lack transportation, or not understand their health condition and how they can improve it.

About 40 percent of factors contributing to a person’s health are social and economic, according to Health Research and Educational Trust, and only 20 percent are related to clinical care. Healthcare systems around the country are realizing that addressing these social determinants of health can improve patient health, while also sometimes saving the medical system money by reducing treatment costs. Here are three programs to watch, and ways that health systems can implement something similar.



Food is health: program for Patients with diabetes



Physicians at Riverside Family Practice in Columbus, Ohio, rarely asked patients about food insecurity. That is, until the Mid-Ohio Food Bank reached out to them to pilot a food and health initiative. The practice sampled its patient population, which includes many patients with diabetes, to see if food insecurity was an issue. It turned out to be a much larger problem than they expected: 43 percent of patients said they had problems getting healthy foods to eat.

Laurie Hommema, MD, a primary care doctor and program director of Riverside Methodist Hospital family medicine residency, says they were surprised by the results, because any who responded positively have private health insurance, full-time jobs, and own their own homes. The USDA estimates that Ohio has a 16 percent food insecurity rate, compared to a U.S. average of 13.66 percent. In Franklin County, which encompasses Columbus, the rate is 32.2 percent, according to a 2017 study by The Ohio State University.

In May, 2018, the practice started its “Food is Health” program for its patients with diabetes, adding a food bank inside their practice . They give participants fresh produce each week, along with recipes, cutting boards, peelers, and a short nutrition-related class.

Miriam Chan, PharmD, a certified diabetes educator and director of research and evidence-based medicine education at OhioHealth Riverside Methodist Hospital, devised 12 sessions that residents teach, on topics like portion size, eating less sugar, and choosing healthy fats. They introduce produce like butternut squash, explaining how to cut it up and cook it. After the class, patients choose their own produce, though residents often suggest items, encouraging them to take and try more. “Avocados were the big hit,” Hommema says. “A lot of people had never tried an avocado.”

One program goal is to increase the amount of healthful and fresh foods patients and their families have access to, though they also offer foods like whole wheat pasta, canned beans, and canned vegetables. Family members can come to the group education sessions to learn and pick out food. “Seeing the next generation of patients getting that benefit is really rewarding,” Chan says.

Clinicians don’t weigh patients or do testing at these sessions, but at clinic visits they monitor weight, blood pressure, and hemoglobin A1C levels. They want patients to recognize the impact of eating healthier foods on their own. “They see changes in their health,” including lower weight, Chan says.

Food is Health sees 40-50 patients a week, also providing fresh produce for families, which means serving around 110 individuals weekly. When reviewing medical charts from the first four months of the program, 12 patients showed reduced A1C levels after participating, with seven patients experiencing more than a 1 percent reduction, and two patients reducing theirs by 1.5 percent. Anecdotally, Chan says patients enjoy coming to the sessions and have a high attendance rate, but it’s too early to know if the program has reduced hospitalizations or emergency department visits, but they are going to track these trends.

The program costs about $7 per person per week, with a $40,000 yearly budget, which comes from the residency program’s operating budget. The residency program can sustain this amount for now, says Hommema, but their ultimate goal is to get funding from Medicare and Medicaid, as it can save them treatment money. “Insulin is way more expensive,” Hommema says. One of her patients is already on the verge of stopping her oral diabetes medication as a result of the healthier eating. “She’s out of that range now where she needs them. That’s our goal.”

One unanticipated benefit is that the program is increasing physician satisfaction and reducing physician burnout. Residents and medical students appreciate the meaningful interactions with patients. “One resident said, ‘This is why I got into medicine. This is exactly what my heart needed, and I didn’t realize it,’” Hommema says.

Practices who are not able or ready to start their own food bank can still screen patients for food insecurity as part of the intake process, and counsel them on food issues. MedStar Health in the District of Columbia uses the website AuntBertha.com, which has an accurate database of support systems, including food banks, searchable by ZIP code. Of course the problem with food banks is that you don’t always get fresh food and you’re at the mercy of whatever is donated/purchased by them. Not all the food is healthful.

Pete Celano, MBA, director of consumer health initiatives at MedStar Institute for Innovation says that nurses and social workers can quickly access the site, print out resource lists, refer patients to the organizations, and save search results for specific patients in the HIPAA-compliant website. That way they can follow up with patients during subsequent visits and even ascertain whether the patient visited the recommended organization.





OhioHealth Doctors Hospital in Columbus, Ohio also, started the pilot Health Literacy program focusing on patients hospitalized with congestive heart failure (CHF) and COPD. Nationally, 20 percent of patients over age 40 who are hospitalized have a COPD diagnosis, according to the Agency for Healthcare Research and Quality. Of those hospitalized with COPD complications, 20 percent will be readmitted to the hospital within 30 days. The national readmission rate for those with CHF is about 22 percent.

OhioHealth’s program reduced its 30-day readmission rates with participating patients with these diagnoses from 18 percent to 10.3 percent. “This tells me that people aren’t noncompliant, but that we haven’t done a good enough job meeting patients where they’re at. They’re able and willing to adhere to information they can understand,” says Joseph Geskey, DO, an internist and vice president of medical affairs at Doctors Hospital.

Participating patients admitted to Doctors Hospital with a COPD or CHF diagnosis are given the Newest Vital Sign screening. Patients answer six questions about an ice cream nutrition label, requiring them to read the label and sometimes perform basic calculations relating to allergies, fat and daily percentage of calories.

Geskey says that when introducing the screening, his colleagues scored six out of six, while half the patients scored zero or one, showing a high likelihood of impaired health literacy. “That’s incredibly illuminating to the physicians,” he says, and the staff couldn’t predict which patients did poorly. Without understanding a patient’s health literacy level, doctors may not change their communication styles or realize that their patients may be missing necessary information for their care and follow up.

Nationally, only 12 percent of Americans have proficient health literacy, according to the U.S. Department of Health and Human Services, and more than one-third have difficulty with common health tasks like following prescription medication labels.

They also screen patients with PAM13 (patient activation measure), a 13-item tool assessing patients’ self-management skills and knowledge. These screenings have helped clinicians become more empathetic toward hospitalized patients who, for a variety of reasons, are unable to process health information given to them.

Doctors Hospital has admitted 125 ­individuals into the program, who meet the criteria of a COPD or CHF diagnosis, low health literacy and low activation screening scores, and Medicare homebound criteria. The program includes one-hour home visits once a week for four weeks. They ask the patient to pick something they want to do but can’t, due to their illness. A patient might say she wants to attend a grandson’s baseball game. Once the patient reaches the goal, they can see how their actions are positively affecting their health, motivating them to ­continue.

Clinicians use a teach-back method, asking patients what they understand about their disease, and how to take their medications. They may teach the patient how to set up a weekly pill box, or discuss dietary or exercise issues. The last visit focuses on problem solving and how patients can advocate for themselves. The program measures success by whether the patient is readmitted to the hospital in 30 days, and if they’re motivated to take charge of their care.

“Many with lung or heart disease can’t explain their disease, understand what medications are, and how take them, let alone what they need to do when they get sick,” Geskey says. When clinicians write hospital discharge summaries, they overestimate people’s skills and understanding about their chronic disease therapy. “We end up seeing them back in the emergency department or in our clinics, and we label them as noncompliant. That immediately turns off our creative ability to meet patients where they’re at.”

The program is funded completely through philanthropic grants. Geskey attends the initial home visits during the pilot, but they’re generally handled by a health coach or nurse, often one who lives in the community. They’re trained for motivational interviewing and patient education.

Large health systems that treat CHF or COPD patients could potentially see large cost reductions from lower readmission rates, especially if they’re receiving bundled payments from Medicare, says Geskey. The savings can more than pay for the program costs. More than half of healthcare systems pay penalties to Medicare for hospital readmissions, according to JACC.





Healthcare facilities have historically arranged taxi rides for some indigent patients for non-urgent clinical care. What is new is the lower cost, trackability and increased flexibility of doing so through ride hailing companies. Earlier this year, Uber Health and Lyft Concierge rolled out programs with secure, HIPAA-compliant web-based dashboards for healthcare providers to hail rides for their patients.

MedStar Health has seen the Uber Health program help patients keep appointments that otherwise might be missed or rescheduled. “The use of Uber Health for qualifying patients who lack transportation reliably helps enable an appointment that otherwise could not happen, for a minimum cost,” says Pete Celano, MBA, director of consumer health initiatives at MedStar Institute for Innovation.

Since the healthcare organization is principally fee-for-service, Celano says MedStar Health’s cost is balanced by the additional revenue they bring in from keeping those appointments. MedStar determines which indigent patients are habitual cancelers or reschedulers. Using the ride hailing programs, MedStar can still bring patients in whose appointment is within an hour. Patients don’t need a smartphone or ride code.

For practices that already provide rides to indigent patients, instituting one of the ride hailing platforms should be an easy switch, especially since it’s web-based. Confirming appointments by phone is time consuming, but can pay off if there are fewer cancelled appointments that can’t be filled last minute.





In addition to food banks, sites like AuntBertha.com compile resources including housing assistance options, low-cost or free transportation programs, health services, financial resources for low income individuals and families, support for navigating social services and other areas.
Without a stable foundation, these are all areas that impact a person’s ability to care for their own health and their family’s health. Talk to patients about what struggles they have and what stands in the way of them fully focusing on their health. This can be done by a nurse during the intake, or by a physician when discussing a care plan or prescribing a medication. Even telling a patient that if the medication isn’t covered by their insurance or if they have trouble paying for it, to let the physician know. There are community resources and pharmaceutical resources available to help patients with some drug costs.

Programs addressing social determinants of health can be replicated and scaled at other healthcare systems, and don’t have to be a financial drain on the system. Experts say that reaching patients through creative programs such as the ones covered in this article engage patients more in their own health, helping them to attain lifestyle and health goals. Much of the daily work with patients can be done by healthcare extenders and residents whose cost to the healthcare system is lower than physicians, but who are also already intimately involved in patient care.

Articles

There are often social factors influencing a patient’s lack of adherence. They may struggle with basic survival needs like housing and food, lack transportation, or not understand their health condition and how they can improve it.

Addressing social determinants of health 

How was the modern doctor made?

That’s the key question Rajeev Kurapati, MD, MBA, set out to explore in his latest book, “Physician: How Science Transformed the Art of Medicine” not only for himself, a practicing hospitalist for the past decade, but for his fellow physicians.

Kurapati, who practices at St. Elizabeth Medical Center in Northern Kentucky, says you have to start at the beginning-as in 2,000 years ago-to trace how the doctor transformed from a priest and a healer to become today’s technologically driven provider of care. And it’s critical to look at the digitization of medicine not only in the evolution of the profession, but also in terms of what it will mean for the future.

Kurapati recently talked about the book and the state of medicine with Medical Economics. The following are excerpts from that discussion.

Medical Economics: Why is it important to explore the transformation of medicine?

Kurapati

: I thought I would write a book on the history of medicine, looking at where we’ve been and where we’re going and why that matters. I wanted to write something conversational and accessible that gave doctors, healthcare providers, and patients a good overview of the field of medicine-how doctors practice, how they think, and how patients are impacted by advances in medicine. That was the idea behind the book.

In the past, practitioners would look at the whole human being and say, “Okay, you have a stomach pain, but how are you sleeping? How are your family members? What are your relationships like? What do you eat?” That sort of holistic thinking came before the invention of disease-centric medicine, because healers needed all this information to make their assessments.

When we switched to a disease-centric approach, specialists emerged. In many ways this was helpful, but it also meant these doctors started seeing people not as human beings in total but mostly as, “This is my organ of interest, so I’m just going to focus here.”

When that happened, we started losing the human touch with our patients. It became a piecemeal approach to practicing medicine. This was the compromise we doctors had to make. There’s so much of an information overload that the explosion of knowledge, this explosion of information, was so great that at the individual level we couldn’t keep up.

ME: You talk about the current state of technology in the book. How can physicians find more help than harm from their new tech tools?

Kurapati

: We have to endure the growing pains of technology. Even if we don’t embrace technology, it doesn’t mean it’s going to stop-it just means we’ll be imposed upon by industries, profit makers, and governments. Either we embrace it or it moves on without us. The younger physicians-the millennial physicians-they have to take charge of technology and steer it in the direction they see is going to make it the most useful and valuable. And the more experienced physicians have to be ready to go with the flow.

ME: You’ve said you wrote the book “to answer the question of ‘Who am I as a physician?’” What lessons did you learn and what can you share with your peers?

Kurapati

: One of the biggest lessons is to embrace technology. This technological revolution is going to transform and help [physicians]. With that in mind, make sure you first understand its usage. The more you resist, the more monstrous it becomes, because it’s just going to keep advancing.

Then, steer it in the direction that you want it to help you. That’s how you enhance its capabilities to become the most useful.

Second, slow down. Doctors are stuck in a fast-paced lane where salary or compensation is based on the number of patients we see and the number of days we work because the practice of medicine is a fixed service that we provide for a fixed price.

I’d caution my peers not to keep seeing more patients because you want to make more money faster. That’s an easy way to lose track of why you signed up for this job in the first place. You signed up so you could help others alleviate or manage their suffering, and that’s where you derive satisfaction in this field.

Recognize that you can slow down, spend some personal time, carve out moments of silence in your life and reflect upon the previous day.
Ask, “How can I make my life better?” and “How can I make the lives of others better?” This mindfulness improves our ability to care for others.

These questions get to the point of the book. When we introduced the scientific method, we decided we were going to examine only the things that could be measured-blood pressure, blood sugar, heart rate and so on. But this method is incapable of taking into account the human attributes that aren’t measurable. Fears, biases, prejudices, beliefs-these are apprised human attributes, and they’re necessary to help paint a complete patient picture.

In many practices today, a patient comes to a physician’s office and is nothing more than a bunch of numbers in a chart because the scientific method trained us this way.

If we don’t realize there are certain human attributes that are beyond the boundaries of this objective method, then we are losing the human connection, we are losing the reason why we are here in the first place as doctors, which is to yield suffering.

In his latest book, Rajeev Kurapati, MD, explores the history of medicine and what physicians can learn about today’s transformations

How the modern doctor was created

Medical marijuana allows Ajay Suman, MD’s cancer patients a safer alternative to opioids for chronic pain. It can be an effective treatment for his terminally ill patients, says Suman, a New York-based anesthesiologist and a professor of anesthesiology and pain medicine at Weill Cornell Medicine, who is qualified to evaluate patients in New York State who want to use marijuana for medical reasons.
	
	As of April 2018, medical marijuana was legal in 30 states as well as the District of Columbia, Guam, and Puerto Rico, according to the National Conference of State Legislators’ website.
	
	Meanwhile, medical associations such as the American Medical Association and the American College of Physicians are calling for more scientific research and trials regarding how medical marijuana actually benefits patients. Many also believe physicians and patients shouldn’t face federal penalties for its use in states where cannabis use is legal.
	
	For physicians who want to include medical marijuana in their practices, knowing their state laws is crucial. Federal law deems marijuana a Schedule 1 substance under the Controlled Substances Act, putting it in the same category as heroin, LSD, and Ecstasy for its potential for abuse and addiction. This makes it a federal offense to distribute marijuana.
	
	Marijuana is used to treat assorted medical conditions including chronic pain, side effects related to cancer, Alzheimer’s disease, and nausea, among others. Marijuana is not covered by medical insurance so patients pay out of pocket for products, which can include marijuana in different concentrations as well as different forms, including edibles, tinctures, and oils. 
	
	Here’s what doctors need to know if they want to prescribe marijuana to patients.


	
	Unlike a medical practice that offers ancillary services, generally a medical practice cannot partner with or incorporate an on-site marijuana dispensary due to marijuana’s federal classification as a Schedule I drug, says Michael F. Schaff, JD, an attorney with Woodbridge, N.J.-based law firm Wilentz, Goldman & Spitzer.
	
	“As of today, any medical practice relationship with a dispensary puts the physician in a position to risk losing their federal Drug Enforcement Agency (DEA) license,” he says.
	
	Angelo J. Cifaldi, JD, RPh, who co-chairs Wilentz, Goldman & Spitzer’s cannabis law group with Schaff, urges physicians to learn about their state’s marijuana laws, suggesting that physicians look at their state’s medical society and understand how to work with medical marijuana following state and federal laws.
	
	For example, notes Cifaldi, some states follow a corporate practice of medicine, which is a doctrine that may limit the practice of medicine to restrict non-licensed entities from practicing medicine; so a physician cannot be hired by a non-physician. A physician, therefore, needs to know state law if working for a dispensary as a medical director or is hired by a dispensary to train the staff, he says.
	
	Cifaldi also points out that physicians may not agree on making medical marijuana available to treat specific conditions, despite state laws identifying which diagnoses might benefit from its use.
	
	Physicians need to learn the proper terms used in their state. Because of marijuana’s status under federal law, physicians cannot write a prescription for a dose of medical marijuana. Instead, physicians write “recommendations” or “orders” (depending on state terminology, and comparable to writing a prescription while complying with state laws) for a medical marijuana card, which the patient then fills at a marijuana dispensary. “Clarify whether you are writing an order or a recommendation,” says Cifaldi. “If you use the wrong term on the wrong form, you may be violating the law.”
	
	Physicians can earn extra income for evaluating a patient’s eligibility for medical marijuana use by charging a fee for the visit, but “a medical practice should not just be charging for writing marijuana prescriptions to qualified patients,” says Schaff. He notes an evaluation should be conducted to determine a recommendation or order first versus simply for a visit to gain access to medical marijuana.
	
	Other ways physicians can earn income from medical marijuana, Schaff says, include working at a dispensary, if state laws permit it, or consulting with a dispensary or one of the growing number of marijuana-related companies. Physicians who evaluate patients for medical marijuana cards may see patient volume increase as new patients come into the office for evaluations.
	
	There are other things physicians must follow to maintain compliance with state laws. This can include things like checking with the landlord to determine if working with medical marijuana violates the terms of the practice’s lease or speaking to the practice’s medical partners to ensure that one physician’s views regarding marijuana are consistent with others in the same practice, because there may be limitations on the forms of treatment in company documents, says Schaff.
	 


	
	It can be tough for companies that work with medical marijuana to remain compliant with all the financial considerations by and between financial institutions, state licensing agencies, and licensees, particularly as they cross state lines. Since the law varies from state to state, banking options can be challenging, which physicians should keep in mind if they are considering working with marijuana as a way to increase business to an existing medical practice.
	
	Nathaniel Gurien, the founder and CEO of FINCANN, the Cannabis Banking Financial Network, helps businesses in the marijuana industry find banks that are comfortable providing checking accounts and/or MasterCard/Visa credit care processing to marijuana-related businesses.
	Often, Gurien says, banks refuse to open checking accounts or provide merchant processing for marijuana-related businesses because of marijuana’s stigmatized reputation. The few banks that do will charge relatively high fees to cover the additional risk and compliance-related costs of providing service to these customers, he says.
	
	Gurien notes, however, that there are more cannabis-friendly banks around the country today than in prior years and that access to such banks is improving as medical marijuana becomes more mainstream. A bank could potentially notice if a medical practice is now advertising medical marijuana evaluations through the practice’s website, and a bank’s representative may reach out to its physician customer and terminate the banking relationship if the bank has a problem with marijuana-related businesses.
	
	With any kind of marijuana business, even if it’s illegal, the federal government taxes it, says Eric Foster, director of strategy for the Banks & Company Cannabis Practice Group. “The federal government wants to minimize the tax write-offs of being in that business because cannabis is still a Schedule 1 drug.”
	
	As a result, those who grow, process, or sell marijuana products cannot deduct or write off many expenses related to the business, which reduces the potential return of running the business, says Foster. (Expenses related to the cost of cannabis can be written off, he notes.) However, this law doesn’t apply to physicians who are qualified to evaluate patients for medical marijuana cards, as they are an ancillary service for the industry, Foster notes. Physicians should still check with their practice’s tax advisor just to be sure, he adds.
	
	Ultimately, those who believe that medical marijuana is a valid form of treatment can decide how to best get involved with it. Some physicians may restrict their practice to patients with a specific condition. Others may decide to evaluate patients with any of the multiple diagnoses approved by state laws for medical marijuana treatment, despite its current federal legal status. And while some states have approved the use of medical marijuana, that might change in the future.
	
	“I’m prescribing medical marijuana to patients with terminal cancer,” says Suman. If new legislation makes medical marijuana illegal in New York State in the future, Suman says he isn’t worried about prosecution. “In three or four years, if my charts are audited, I have no question that I am covered. I don’t think people will come after someone prescribing it for terminal cancer patients.”

It is crucial for physicians to know how to legally handle what is still considered an illegal substance in some jurisdictions

Understanding the business of medical marijuana

Vaccines are a high-volume service in most primary care practices, but are physicians capturing all of the Medicare revenue they’re entitled to?
	
	Not always, says Yvonne Dailey, CPC, CPC-I, CEO of Dailey Billing Services Inc. in Toms River, N.J. Physicians often don’t report the correct codes, or they forget to report certain codes. During peak flu and pneumonia season, these mistakes can definitely add up, she adds.
	Dailey provides five tips to help practices bill Medicare Part B correctly.
	 


	
	Medicare Part B only covers the following immunizations:

Hepatitis B vaccine (for patients at high or intermediate risk)

Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition (e.g., tetanus, diphtheria, and pertussis [TDAP])

When billing Medicare, physicians frequently omit the code for the administration, says Dailey. This is how practices lose revenue, she explains, adding that the omission of a single administration code could cost the practice approximately $20-$25, depending on the Medicare Administrative Contractor.
	
	“You need to review your denials and make sure the right codes were used before you assume it was a contractual write-off,” Dailey says.
	Another mistake is that physicians report a CPT code for the administration rather than a HCPCS code, Dailey says. If the EHR auto-posts a CPT code for all immunizations, physicians will receive a denial when administering vaccines that would normally be covered for Medicare patients. 
	
	Best practice is to review each administration code manually or create payer-specific rules within the EHR for Medicare versus commercial payers, says Dailey.
	
	The specific drug, dosage, and route of injection will determine the vaccine code that’s reported in addition to the administration code, says Dailey.
	
	Consider the following:

For the influenza vaccine, report one of the following CPT codes: 90630, 90653-90658, 90660-90662, 90672-90674, 90682, 90685-90688, 90756, or Q2034-Q2039. Payment for these codes range from approximately $9 to approximately $55.

For the hepatitis B vaccine, report one of the following CPT codes: 90739-90740, 90743-90744, or 90746-90747. Payment for these codes range from approximately $26 to approximately $131.
	
	For the pneumococcal vaccine, report one of the following CPT codes:

For the TDAP vaccine, report CPT code 90715 (pays approximately $31).

Medicare also posts updated payment information specifically for the influenza vaccine, so be sure to stay up-to-date.

Don’t forget to report ICD-10-CM diagnosis code Z23


	
	If the sole purpose of the encounter is to administer a vaccine, report Z23 with both the administration and vaccine codes, says Dailey.
	However, in many cases, vaccines are given during a visit in which physicians render other services. For example, physicians frequently administer the influenza vaccine (split virus for intramuscular use) during an initial wellness exam.
	
	Report the following codes for this scenario:

Q2034 (for the vaccine) with diagnosis code Z23

G0008 (for the administration) with diagnosis code Z23

G0438 (initial wellness exam) with any other relevant diagnosis codes

Use caution when providing the vaccine for TDAP


	
	Medicare Part B covers the TDAP vaccine only when it’s related to a current injury (e.g., accidental puncture wound), says Dailey.
	
	When a patient with a current injury requires the vaccine, physicians must report a diagnosis code from Chapter 19 of the ICD-10-CM manual for the injury rather than Z23, she adds. The last character in the diagnosis code should be ‘A’ to denote an initial encounter (i.e., current injury) rather than a ‘D’ for subsequent encounter or ‘S’ for sequela.
	
	Also be sure to document the type of injury, how and where it occurred, and the area of the body where the injury was sustained, she adds.
	Also note that unlike other vaccines, TDAP administration requires one or more CPT codes-not a HCPCS code-depending on how many separate vaccines are administered.


	
	For example, some EHRs allow physicians to create rules that prevent them from giving a vaccine before it’s due or remind them when one is due, says Dailey. Rules can also specify that Z23 is automatically reported with every vaccine and administration code, she adds.


	
	If Medicare Part B doesn’t cover a certain vaccine, providers can bill the patient-but only if they have a signed Advanced Beneficiary Notice (ABN) on file, says David Glaser, JD, attorney at Fredrikson & Byron PA, a business law firm in Minneapolis, Minn.
	
	The ABN must describe the specific service that Medicare won’t cover, why it isn’t covered, and the anticipated amount the patient will owe, he adds.
	
	“You basically need to know in advance why you’re going to get a denial,” says Glaser. “You can’t just get a blanket ABN for every vaccine.”
	He provides this example: A Medicare patient presents for a hepatitis B vaccine as a preventive measure. Medicare Part B only covers this vaccine when it relates to a current injury. If the patient insists on receiving the shot even though it’s not covered, the provider should obtain an ABN stating the patient accepts financial responsibility for the vaccine.
	
	The same is true for an influenza vaccine given more than once during the same flu season or a second pneumococcal vaccine given within one year of the initial vaccine.
	
	Something else to keep in mind is that Medicare Advantage plans may cover vaccines not covered under Medicare Part B as long as the vaccine is reasonable and necessary to prevent illness, says Dailey.
	
	For example, a patient with a Medicare Advantage plan requests the hepatitis B vaccine as a preventive measure. Although Part B won’t cover the vaccine in this instance, Part D may.
	
	To learn more about Part D coverage for vaccines, view MLN Fact Sheet ‘Medicare Part D Vaccines and Vaccine Administration’ dated January 2018. To learn whether a specific Part D plan covers a particular vaccine, visit https://www.medicare.gov/find-a-plan/questions/search-by-plan-name-or-plan-id.aspx.

6 tips for getting paid to administer vaccines to Medicare patients

Good morning. Listen up!” All eyes focus on the stocky chief resident as he balances a paper coffee cup on a towering stack of charts. He scans his fresh crop of third-year medical students and quickly targets the weakest among us.

“Sheppard!” Adam Sheppard is a gentle giant who wants to become a pediatrician.

“Yes?”

“Bed 309 is a regular customer. He’s a 70-year-old alcoholic who was re-admitted last night. What do you see?” Overhead we gaze at an X-ray of the abdomen.

Adam answers, “Bowel obstruction?”

“Good guess.” Student, one point. Resident, zero. Game on. General surgery in 1989 is all about toughing it out, proving yourself, and when abruptly called upon, spewing out the right answers. I made sure like everyone else to spew out the right answers.

We stop in front of the next room. “Engel!”

“Yes?”

“This lovely lady in bed 311 was sent to us this morning from our friends downstairs,” he adopts a falsetto, “in Psychiatry.” Then he slaps a chest X-ray up on the light board. “Diagnosis, please.” I have never seen anything like it. Neither has my fellow student, Marvin Engel.

Meticulous, punctual, and always in the front row, Marvin is enthusiastic about forensic pathology. This should be right up his alley. He carefully crafts each word.

“There appear to be multiple radio-opaque foreign ­bodies…”

“Yes, and?”

“They are located in sub-dermal fat.”

“And?”

Marvin has no clue. Resident one point. Student zero.

“Today you will have the opportunity to assist in surgery to remove the sewing needles our patient has imbedded into herself.” We march on.
 
“Carlson!”

“Here.”

“We know you are here, Carlson. Bed 313 is a young woman with ITP. What is ITP?”

“Idiopathic thrombotic pur…”

“Idiopathic thrombocytopenic purpura. Cytopenia. It means not enough cells, specifically platelets. She has been unresponsive to medication. She needs surgery. Can you tell us what surgery?” Everyone in the room feels the scoreboard is about to light up in favor of our resident. My throat clenches. Think.

“Something to do with her spleen?”

“Correct. Please consent her for surgery. You will be assisting in splenectomy tomorrow.”

That afternoon I enter her dimly lit room. An acrid odor of disinfectant hangs in the air. Glancing at the chart, I take in her name, Annabelle Sanders. She is 29. She’s my age? The short dark hair on the back of her neck is already starting to mat against a flat pillow. Her rounded face from chronic steroid use obscures once-delicate features. She stares blankly at the television.

“Hello Miss Sanders, I’m a medical student on your surgical team. We need to go over some paperwork.”

She replies to the television. “I don’t want surgery.”

“It’s OK.” I inch toward her. “Removing your spleen will stabilize your condition.”

“Removing my spleen will kill me.”

For a moment or two neither of us speak.

Stay upbeat. “Oh, I doubt that.” I say, forcing cheerfulness. “The chances of dying from surgery are small.” Deep purple blotches around her fingers make my own hands appear strangely too young. I wonder how much she is already suffering.

“You people can’t cut me up just because you want to!”

“We don’t want to. We, uh…” I pick up the remote and mute her television. She shoots me a menacing glance.

“You don’t get it, do you?”

“Miss Sanders, we want to do what is best for you.”

Annabelle pulls her knees up close to her chest. She searches me for allegiance. Then her voice drops to despair.

“Promise you won’t let me die?”

“Well I can’t, I mean we…” I begin to riffle through the pages of her chart looking for a rope hold, a life ring, any solid ground, but I am confronted only by the blank signature line of her informed consent. All the pride I have earned from pulling high scores on written exams seems instantly outstripped by her life experience. I muster a bit of feigned confidence. “You are in good hands. Don’t worry, you will be just fine.” But something feels wrong. “I’ll tell you what, maybe I’ll come back later?” I take a few steps toward the door. As if bargaining with fate itself, Annabelle pleads,

“Don’t let me die.”

I let the door swing closed.

Back in the doctor’s lounge, our chief resident is not amused. He is certain the patient in bed 313 with ITP simply enjoys creating her own little drama. With a firm grip on the sanctity of surgery, he teaches me how to obtain an informed consent. We return. He impresses upon our patient the importance of her decision. He outlines for her the benefits, the risks, and her futile alternatives. He dutifully notes her concerns, and then he hands her his pen. Thirty-two hours later, after an uncomplicated splenectomy, to everyone’s shock, Annabelle Sanders dies.

Since that day, my hair has greyed, and under my care countless patients have benefited from surgery. I never fully understood why she died, but on the day she died, Annabelle Sanders handed me a precious gift: pay attention. Even when circumstances seem innocuous, pay attention. Even when timing is woefully inconvenient, trust your gut. A successful doctor will fold into the brew of medical decision-making one or two drops of the elixir of intuition.

By example, recently a 9-year-old boy was referred for second opinion. The child inconsistently reported 20/20 vision one minute, and total blindness the next. There were no other symptoms. On physical examination, everything checked out. The eye exam was normal, so I reassured his mother. “Lots of kids pretend. Glasses are cool.” I sent them both home. By the end of my workday a gnawing voice spoke. This mother knows her child. She left unconvinced. Maybe he is not that kind of kid? No, he’s fine. He has no headache. I heeded my intuition and picked up the phone. “Mrs. Gonzales? Sorry to bother you this late, but could you please bring your son back in tomorrow? I’d like to run one additional test.” It was a difficult computerized test requiring prolonged concentration, something not typically performed on young children.

That afternoon the technician called me urgently out of a room. Blind spots, scotomas, had divided the child’s vision down the center. The right halves of both of his eyes could see 20/20. The left halves of both of his eyes were blind from a brain tumor.

In medicine, we cast our gaze through the lens of logic and reason. The keystone upon which we build our knowledge is our ability to prove fact and disprove assumption. The exacting discipline of medicine requires that which is measurable and repeatable. It can be frustrated by the enigmatic or the mystical. Intuition does not fit, and yet it must fit. A scared young woman who died in 1989 taught me this. Embracing intuition allows us to honor the whole of what makes us human. It accesses a kind of understanding that can enhance and enrich. It makes us better doctors.



Editor’s Note: Names have been changed to protect privacy.

A gut feeling

As both public and private payers focus more on value-based care, population health management has become more common as providers take a more proactive approach to caring for patients.

And while definitions vary, experts agree that population health management is about going beyond the walls of the practice to improve patient health, with the ultimate goals of better quality scores for providers and fewer long-term issues for patients, especially those with chronic conditions.

“Population health is about no longer just treating the patients who walked in the door to see you today,” says Christina Taylor, MD, an internist and chief quality officer at The Iowa Clinic in Des Moines, Iowa, where she also serves as director of the population health, quality analytics and care management team. “Whether the patients choose to come to you for care or visit other [primary care] providers, you are responsible for their healthcare and outcomes.”

This requires an approach to managing patients that many primary care physicians are not used to, as well as investments in technology and personnel that smaller practices may struggle with, but  solutions are available.

Data analysis and social determinants become as important as mammograms and diabetic eye exams as value-based care drives demand for more population health analyses to manage costs.

“For folks on the frontlines, population health is an explicit recognition that delivery of care is only 20 percent of the story,” says David Nash, MD, MBA, an internist and dean of the Jefferson College of Population Health. He adds that linking physician income to performance measures at the population level is leaving doctors little choice other than to implement it.

Nash predicts that small practices eventually will be forced to incorporate population health, either because of the elimination of exemptions in the Merit-based Incentive Payment System (MIPS) or the demands of  commercial insurers who also want to pay for healthy outcomes and not just patient volume.

“If CMS doesn’t get you, Aetna and Anthem will,” he says.

While payers see the cost benefits to population health, providers have seen it make a difference in the health of their patients. Anuradha Phadke, MD, an internist and director of population health at Stanford Health Care, says Stanford’s efforts have improved patient care and freed up doctor time to focus on the most serious cases.

“For instance, we’ve been able to identify which patients are poorly controlled diabetics and connect them to resources who reach out and help them bring it under control,” says Phadke. “It makes it easier for us to get the desired action by the patient without the clinician spending their time.”

Taylor says outreach to remind patients of annual physicals, vaccines, and cancer screenings are all examples of how patients benefit. “It’s all about a stronger emphasis on preventative medicine and making sure these appointments happen,” says Taylor. “You have to view it as your responsibility to shepherd patients to make sure they get checkups and preventive care.”

Some doctors have seen population health management in a negative light,  because it requires an emphasis on healthier behaviors. These physicians view that as being beyond their influence.

“As physicians, we can tell people to move more and eat less, but we can’t force them to be healthy,” says Taylor. “That may all be true, but it is still our responsibility to try, and if we continue to try, we will reach some.”

Preventative care and value-based care are closely linked, because without a solid commitment to prevention, most patient problems will only get worse-and more expensive, says Taylor. As a result, she says, population health management will continue to be an integral part of moving the healthcare industry in a value-based direction.

“It’s key to keeping costs down,” she says. “If you do it right, there is less duplication in tests and less waste. You are keeping track of and coordinating a person’s healthcare.”





Experts say the challenges facing a small practice looking to implement population health management are difficult, but not impossible, to overcome.

One of the first challenges is identifying patients with chronic conditions that might benefit from outreach efforts, and the place to start is with the EHR.

Taylor suggests seeing what tools are available within the EHR that can help identify specific groups of patients with chronic diseases, such as diabetes, and then develop a plan to better manage those patients. “It should be team-based care,” she says, adding that much of the work is nonclinical and doesn’t require a doctor’s time.

“Have a nurse take a look twice a year or quarterly, to see who has been in for an appointment and how they are doing. If they haven’t been in to the office in six months, you need to get them in.” This level of commitment does not require advanced analytics or expensive software tools to implement, she adds.

Phadke says to start small and build gradually. For example, is the practice doing a better job of getting all diabetic patients into the office for regular exams? Are patients with high blood pressure getting regular screenings? Are all patients up to date on their vaccinations? Find out who needs what and contact patients to get them into the office, she says.

“Population health can be intimidating at first, but if you start with a smaller scope and a small set of measures, that will make it easier,” Phadke says.

Another entryway to population health management is to consider becoming a patient-centered medical home (PCMH), says Jay Bhatt, DO, MPH, an internist and chief medical officer of the American Hospital Association and president of the Health Research & Educational Trust.

“If you don’t want to go through the whole process to becoming a PCMH, a small practice could still work toward it, allowing them to experiment with managing a population effectively. It’s a great way to build competency.”

Why joining a larger group may be necessary



While population health management can be achieved to some degree by a small practice, if payers start to require physicians to accept some downside risk in their contracts, it may require more resources than the practice can afford.

“For those with risk-based contracts, you have to have a lot more resources and there is a lot of infrastructure that goes into it,” says Taylor. “You have to be able to analyze claims, there are expensive pieces of software you need and you have to pay analysts to turn the data into meaningful information.”

Once patients with chronic conditions are identified, it requires staff time to act on it. “It might require hiring a [nursing assistant] or additional clerical staff, and if you are doing high-risk patient management, hopefully you are doing some health coaching. But that requires a health coach or nurse,” says Taylor.

Larger organizations, like the Stanford clinics where Phadke works, have sophisticated software tools that help identify which patients need extra care as well as message the patients.

“It allows us to do a lot more with fewer personnel,” she says. “But for a small practice, the upfront cost is something they would have to consider.”

Nash doesn’t envision a long-term future for small practices that aren’t affiliated with a larger group, because he sees healthcare marching inexorably toward favoring groups and health systems that can afford high-tech tools and additional staff. 

“That may not be the answer they want, but it will be incredibly hard for practices with one or two doctors to compete in the new world.”



There may be ways for a practice to get the tools and support it needs for population health management that don’t require a complete sacrifice of independence.

Bhatt says to check with local hospitals to see if they have any affiliate programs that share resources and data with local physicians. “Getting into a clinically integrated network can be very helpful for small practices,” he says. “They do not have to give up their independence, but generate economies of scale and get the resources they need.”

“Shared resources are definitely a good idea,” says Phadke, adding that Stanford enables sharing through its United Healthcare Alliance, a group of clinics affiliated with the university to get the tools they need to provide better care.

Joining an Accountable Care Organization may also be an option for practices. “They can share best practices and be able to share the administrative burden of doing things like claims analysis,” says Taylor.

Phadke says the stakes involved in population health management are too high to ignore.

“CMS (via MIPS) added a financial reward or penalty for your Medicare patients,” she says. “For private payers, population health could determine whether they will contract with you, if you are underperforming on quality measures.”

Experts agree that physicians are going to need much more data on their patients to prove they are providing value, and that the demand for this data is only going to increase. It might also provide some surprises when first examined in detail.

“By measuring how you are doing on your performance and benchmarking that to your peers, it can shed light on different opportunities,” says Phadke. “Most physicians think they are performing better than they are, but if they look at population health management as an opportunity to improve, it really does help patient care.”

Regardless of what approach a practice takes to population health management, Nash says there really is no avoiding it.
“You can run, but you can’t hide from it,” he says. “We are heading toward the total accountability for the outcome of care, and with no outcomes, there will be no income for doctors, and that is a sea change.”

How practices can benefit from data-driven patient care.

Succeed at  population health management

Those who fail to learn from history are doomed to repeat it.

Have physicians failed to learn anything from the history of the American Board of Medical Specialties (ABMS)? How it steadily increased its authority over physicians’ lives in ways that physicians never intended at its creation almost a century ago? Would physicians ever have supported the ABMS if they knew that their board certification had an expiration date-that they would have to be recertified?

The ABMS maintenance of certification (MOC) policy is misguided. It undermines the very legitimacy of the ABMS and the credibility of its leadership.

I can think of no greater arguments against MOC.

Like Dr. Sean McNeeley (“What’s behind the growth of urgent care clinics?” September 10, 2018), I first dipped my toes into the urgent care waters for some extra income in April 2016. I had been in full time family practice for nearly 23 years at that point. I was tired of working harder and harder, seeing more and more patients, and making less money. I was also constantly inundated with paperwork like physical forms, FMLA and other disability forms, prior authorizations, DME requests, and the like.

My experience in urgent care was remarkably different. I spent my shifts treating patients, and that was it. No insurance hassles. No pre-certifications. No pharmacy callbacks. And zero paperwork beyond a school or work note excusing someone for the day.

On top of that, I was earning significantly more for my time. Eventually, I transitioned from per diem work to part-time and ultimately to full-time at urgent care, leaving my family practice for good in September 2017.

A year later, I couldn’t be happier with my decision. I’m earning the most I’ve ever made and have the least stress and aggravation I’ve ever had since going into practice 25 years ago. My only regret is that I didn’t do it sooner.

Your voice: Time to fight ABMS power creep

Welcome to Medical Economics' blog section

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

Five years ago, Jim Butler took his car to a garage in Dayton, Ohio, for service. Before the mechanic started working on his car, he gave Butler a written estimate of what everything would cost: parts, labor, disposal fees, all of it. While waiting for his car to get fixed, Butler asked himself, “Why can’t healthcare prices be made this clear up front?” 

So Butler, a U.S. state representative (R-Oakwood) and lawyer, drafted The Ohio Price Transparency Law, a bill that would require health providers, except in the case of emergency, to give patients up-front, good-faith estimates of what their care would cost before they got treatment.

The estimate would have to include all fees: physician, hospital, facility, anesthesia, labs, imaging, everything. The quote would let consumers know not only the total price, but also what portion insurance would cover and their out-of-pocket obligation. 

Everyone loved the idea-well, almost everyone. In fact, the price transparency bill was so refreshing, the Ohio legislature passed it unanimously. That’s right. Because transparency is one aspect of healthcare that both parties agree on, as well as virtually all Americans, lawmakers in both houses on both sides of the aisle were all in favor.

They passed the bill in 2015, and the law was to go into effect on Jan. 1, 2017.

But it didn’t. Those most threatened by the fact that consumers might learn the cost of their over-priced treatments and shop around blocked it. Heaven forbid that competition might enter the market.

The Ohio Hospital Association and seven other state health organizations went to court to oppose the law. Ohio Gov. John Kasich sided with the hospitals and helped stall the law further by not writing the regulations it needed to take effect. Today the law remains mired indefinitely in Ohio’s court system.

While Ohio’s situation is stark, it is not unique. Similar laws are also being blocked or diluted to the point of meaninglessness in other states. All over the country, hospital associations, medical associations and insurers are working double time to keep healthcare pricing impenetrable.

 on the secret deals between hospitals and insurers, which, the journal reported, were the norm. “Dominant hospital systems use an array of secret contract terms to protect their turf and block efforts to curb health-care costs,” the article read. “… Other terms allow hospitals to mask prices from consumers … . In some cases, contract clauses prevent patients from seeing a hospital’s prices by allowing a hospital operator to block the information from online shopping tools that insurers offer.” 

Meanwhile, at the federal level, a bipartisan bill sponsored by Ed Perlmutter, (D-Colo) and Mike Gallagher (R-Wisc) would require hospitals to post their prices. House bill 4808, the Transparent Health Care Pricing Act of 2018, “requires entities that offer or furnish healthcare related products or services to the public to disclose the price for those products and services at the point of purchase and on the Internet,” according to the 

This sounds promising, but when I called one of the lawmaker’s offices to ask about the bill’s chances, the healthcare aid said the bill had a long way to go. “We’re still socializing the idea,” he said, as if we were discussing a puppy and not a needed reform in the law.

Butler, the Ohio state representative, said he fears that the bill is just more window dressing, an effort to make it appear as if lawmakers are taking steps to improve a broken system. 

“Even if it were to pass,” Butler said, “it would not help transparency. Any strategy of posting prices online or somewhere else will never work so long as we have a third-party-payer system.” 

Patients almost never search for healthcare prices online partly because, to get an accurate estimate, they would need CPT codes, the numbers billing departments use to bill payers. These codes are not easy to come by, and even harder to understand. Any one procedure, say a knee replacement, can fall under five or six different codes.

What’s more, a hospital can list the price for a procedure, but not include all the related charges, like the facility fee, physician professional charges, specialist charges, lab charges and more. 

The more you look into our healthcare system and its lack of transparency, the more you appreciate how ingenious it is. If you want to create a business that rains money, that allows you to consistently charge people five to ten times more than is reasonable and get away with it, here’s your model: 

Take the matter out of the consumer’s hand. 

Give the task of negotiating costs and choosing who delivers it to third parties. 

Have the third parties convince consumers that they can spend consumers’ money better than the consumers can, and for that presumed benefit these middlemen can help themselves to a large portion of the consumers’ money. 

Make the pricing structure unnecessarily complicated. Have many cost components (i.e., doctors, networks, facility fees, labs, medications). Create codes. 

Charge absurd retail prices (Chargemaster) to make consumers believe they really are getting a deal.

Keep prices hidden, so consumers cannot know costs, and must purchase products and services on blind faith. 

Only provide the price after the non-refundable services are rendered, then demand payment.

Send those who don’t pay to collections, then threaten to put a lien on their house.

Obstruct any bill or law that threatens the system.

If you’re really clever, call yourself a nonprofit, so you can avoid paying any taxes.

Sadly, as long as special interests continue to line lawmakers’ pockets, this perfect plan will continue.

The best hope for disruption will be for consumers to get informed and then get angry. Complete price transparency is the first step. For patients to be empowered, they need the information. The second step is to break apart the networks that hem patients in and funnel them into the costliest settings. 

Meanwhile, doctors can help by saying no to employment contracts that take pricing out of their hands, by working to opt out of insurance and creating a direct payment practice where feasible and by posting their cash prices the way a car center does.

Until then, special interests will continue shutting down laws that would upset their money train, and keeping patients in the dark, right where hospitals and insurance companies want them.

Marni Jameson Carey is the executive director of the Association of Independent Doctors 

Special interests keep patients in the dark, right where hospitals want them.

Path to transparency isn’t so clear

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

The work of primary care has changed. What was once mostly minor acute care with patients only going to their doctor when they were sick with one problem has become much more complex. Today, primary care physicians are expected to provide comprehensive preventive services, manage a variety of chronic diseases and provide counseling for patients suffering from stress at home or at work. On top of that, the coding and documentation of patient visits now takes up half the time of a busy physician’s schedule.

The problem is that nobody changed the schedule! Primary care doctors are still expected to do their work in brief visits and care for the same large panel of patients as yesteryear. No wonder the burnout rate among primary care physicians is approaching 50 percent, according to various studies, and U.S. medical students are avoiding primary care specialties. 

The fable of the boiling frog is widely known. The premise is that if you put a frog into boiling water it will jump out. If you put a frog in water and you slowly turn up the heat it will just sit there and boil. Most primary care physicians today are boiling frogs. Some commit suicide, many retire early, and brave ones go into new models such as direct primary care.

Primary care is vitally important to any rational healthcare system. Primary care physicians 

manage 75 to 85 percent or more of the reasons a person should see a doctor

. When primary care is used, populations are healthier and have lower overall healthcare costs. For that, in the U.S., 

primary care physicians receive about 8 percent of the healthcare insurance premium dollar

.) Primary care has been in great trouble for some time and needs to change.

There must be a national effort to rethink how primary care is practiced. Quality primary care takes time with patients to do the complex work, even with teams providing the effort, and the panel sizes per physician needs to match the work required. There are new models of primary care emerging such as concierge medicine, direct primary care, and franchise models such as Iora Health. These all provide insights into what works well.

It is time for a revolution throughout primary care voicing the words of Howard Beale played by Peter Finch in the 1976 film 

, “I’m mad as hell and I’m not going to take it anymore.” 

The healthcare system would grind to a halt of primary care physicians stopped and demanded proper working conditions, with appropriate payment from health plans and health systems. Let’s do that before we boil away.

Joseph E. Scherger, MD, MPH, is vice president for primary care and Marie E. Pinizzotto, MD, Chair of Academic Affairs at Eisenhower Medical Center in Rancho Mirage, Calif. He is also a member of the 

Quality primary care takes time with patients, so it’s time for physicians to press for the time needed to truly make needed change.

November 25, 2018 edition