Getting paid has never been so complicated for primary care doctors.

An uncertain policy landscape, ever-changing regulatory requirements, and evolving practice and reimbursement models mean that physicians must constantly stay on top of how they are being paid to ensure they receive what they are owed.

In recent weeks, CMS officials have released a bevy of proposals that will affect how Medicare will pay physicians in 2019. The regulations cover value-based payments, level of care changes that will impact reimbursement rates, and continued efforts to equalize payments between office- and hospital-based doctors.

Physicians should remember these proposals could change after federal officials consider comments from the public and stakeholders. Final determination on all these issues is expected in late 2018.

Here are the proposed changes physicians should monitor:

streamlining the Quality Payment Program (QPP), Medicare’s value-based payment initiative;

restructuring the evaluation and management (E/M) level-of-care coding system as part of the 2019 Medicare Physician Fee Schedule (PFS), which sets out reimbursement rates for fee-for-service payments;

making brief patient check-ins via phone, text message, or video a reimbursable service; and

taking additional steps towards site-neutral payments for outpatient visits.

No. 1: The QPP and value-based care are here to stay

While doctors will find some beneficial changes, physician groups say the QPP needs to become more physician-friendly.

CMS is proposing changes to eligibility requirements, coding, some documentation requirements, and how certain categories are weighted, among others, with goals of streamlining billing and expanding access to care.

“Internists are excited to see that CMS is proposing long overdue improvements in the physician fee schedule and the QPP that will help physicians provide the highest quality care to patients,” says Ana Maria Lopez, MD, MPH, president of the American College of Physicians, in a statement.

The proposed changes to the 2019 rule governing the QPP include:

Expanded exemptions. A third low-volume threshold has been proposed: providing 200 or fewer covered professional services under the PFS. Any doctor who meets this requirement, or one of the previous two-$90,000 or less in Part B charges or caring for 200 or fewer Medicare beneficiaries-would be exempt from program participation.

Ability to opt in to the Merit-based Incentive Payment System (MIPS). Any clinician or group that does not meet the low-volume exemptions could choose to opt in to MIPS. However, the decision to do so is irrevocable.

Changes to general performance category weights used to calculate MIPS scores. Quality would decrease from 50 percent of the total to 45 percent, while cost increases from 10 percent to 15 percent. Promoting interoperability (formerly called advancing care information) and improvement activities remain at 25 percent and 15 percent of the total score, respectively.

Removal of 34 quality measures deemed by CMS to be of low value.

Requiring the use of 2015 Edition Certified EHR Technology in 2019. This was originally proposed for 2018, but CMS backtracked to allow 2014 Edition certification because EHR vendors were not ready.

One notable change from the 2018 QPP rule that physician advocates lobbied for but did not receive was 90-day reporting periods for all four performance categories. Instead, quality and cost will remain 12-month reporting periods, and improvement activities and promoting interoperability will remain 90-day reporting periods.

“Reducing the reporting burden would allow more physicians to participate in MIPS and focus the program on rewarding quality care rather than quality reporting,” Anders Gilberg, senior vice president, government affairs, for the Medical Group Management Association, said in a statement. “Requiring medical groups to submit excessive amounts of data to the government has little impact on the quality of care delivered to Medicare beneficiaries.”

The ACP also continues to argue that a 12-month reporting period for the MIPS performance categories does not offer any more insight to a practice than a 90-day period. “We are advocating for shortening the reporting period to reduce the burden and shorten the feedback loop,” says Suzanne Falk, MPP, senior associate of regulatory affairs for the ACP, adding that a quarterly report with real-time feedback would add more value to the program for physicians.

Complicating the MIPS cost category is that not only is its weight increasing in the overall score, but it will include eight new episode-based measures. For 2018, MIPS is using cost measures that cover the total cost of care during the year or during a hospital stay. Now, CMS is proposing to use new episode-based measures to calculate costs. “Increasing the weight of the category while adding eight new measures is not a smart move,” says Faulk.

Another possible area of concern is the proposal to mandate use of EHRs with 2015 certification. The required upgrade could put an undue burden on smaller practices, says Faulk. She says many vendors do not have a 2015-certified product to offer. Practices also need time to implement the new software, and the 12-month reporting requirement means they would need to be ready January 1. “Vendors need more time and practices need more time to work out the kinks in the systems,” says Faulk.

Small practices required to participate in the QPP are still at a performance disadvantage because of the financial and labor requirements to be successful. “The performance gap between small and large practices is not because small practices aren’t providing good care or thinking about value,” says Faulk. “It comes down to a matter of resources and having people on staff to navigate the program.”

Valinda Rutledge, vice president of federal affairs for America’s Physician Groups (APG), a group which represents physicians practicing capitated, coordinated care, says the changes to QPP look to include “real action to advance the value movement” and indicate that MIPS is “here to stay.”

No. 2: The Medicare PFS may simplify levels of care

A major proposed change in the PFS is to restructure the E/M codes. Currently, office-based physicians code for five different levels of care, with different codes and reimbursement rates for new and established patients based on the complexity of the visit. CMS Administrator Seema Verma pitches the proposal as a bid to simplify and offer more flexibility in documentation requirements, delivering on the agency’s pledge to “put patients over paperwork.”

Under the proposal, E/M levels 2 through 5 would be combined into one payment rate, with add-on codes included to address visits of greater complexity. The potential impact is that office-based physicians who see more patients with less complex health issues (levels 1 through 3) could see reimbursement rates rise, while physicians who deal largely in levels 4 and five 5 complexity, could see reimbursement rates fall.

It’s unclear if the proposal will be approved, as it has received mixed reviews from healthcare observers. Organizations representing primary care physicians have expressed support for the proposal’s simplification and additional flexibility. Organizations that advocate for specialty physicians oppose it.

Jennifer Breuer, JD, vice chair of healthcare group for the law firm Drinker Biddle, says the rules will reallocate money to better reflect how care is provided.

“They will pay more for the kind of visits people are having to better reflect the actual resources involved,” she says. “There’s long been a concern that the reimbursement rates applied to services don’t necessarily reflect the true cost or value of services. This is meant to emphasize with respect to primary care, what a visit means.”

The ACP supports CMS’s efforts, particularly documentation streamlining and the use of add-on codes, which the organization says can reimburse for services provided by internists that “are currently not adequately supported in the traditional E/M structure.”

“We strongly support the proposal to reduce the burden of current E/M documentation requirements, specifically by allowing E/M documentation to focus on medical decision making, as ACP has strongly advocated for in the past,” the ACP statement reads.

Brian Outland, director of regulatory affairs for ACP, told Medical Economics that while the organization appreciates that CMS took some of their suggestions on easing physician burden, the college remains concerned about certain proposals, including the reduction of five E/M codes to two in.

“We want to make sure there is no disadvantage to physicians taking care of complex and frail patients,” he says. “A doctor could have a patient come in that has a cold or some less-sensitive problem and get paid the same as a physician taking care of someone with four or five chronic conditions that require attention and care and much more time.”

Others are skeptical of making these sweeping changes in such a short timeframe. Rutledge, with APG, says the organization is concerned about implementing changes of this magnitude by Jan. 1, 2019, as proposed. “The flattening of the E/M codes from five to two is a massive undertaking and will create winners and losers among physician specialties,” she says.

Terry Fletcher BS, CPC, healthcare coding executive with Terry Fletcher Consulting, says CMS officials seem to have designed the proposal with only primary care physicians in mind. “Paying the same amount, regardless of the patient’s condition, presenting problems or the complexity of services provided, makes absolutely no sense to me.”

Fletcher also believes that if this proposal or any form of it goes through, it is setting up practices to see fewer Medicare patients, and more commercial plans that won’t follow the Medicare model. “I also see this giving a big boost to concierge medicine, as physicians will simply be frustrated that their most consistent payer has now abandoned them for a one-code price,” she says.

Jennifer McLaughlin, senior associate director of government affairs for MGMA, says these broad changes will have trickle-down consequences into almost every aspect of Medicare payment policy and would impact a lot of physician practice workflows.

“Some of our members are cautiously optimistic that it could reduce some of the documentation burden and increase a physician’s ability to spend more time with the patient,” she says. “On the flip side, what we’re hearing is documentation isn’t just driven by coding requirements; a lot of it is driven by clinical needs and external factors.”

No. 3: New payment opportunities for 'technology-based services'

A third major proposed change in the PFS includes streamlining documentation requirements and modernizing payment policies to enable Medicare beneficiaries to take advantage of the latest technologies to provide care.

For the first time, physicians would get reimbursed for services provided with the use of technology, but outside of telemedicine services and in-patient visits. For example, a brief, non-face-to-face check-in with a patient via phone, text messages, e-mail, or video conferencing to evaluate whether the patient needs to be seen in the office could be reimbursed under this proposal.

Furthermore, Medicare is also proposing to pay even when patients initiate the virtual communication, another first, Rutledge says.

Rutledge says that the reimbursement is proposed at $14 per virtual visit as opposed to $90 for an office visit, but it allows for more convenient check-ins and will be more efficient for patients and doctors alike.

No. 4: Changes to site-neutral payment rules

In late July, CMS proposed a rule under which it would pay for most clinic visits under the PFS, rather than the more costly Outpatient Prospective Payment System (OPPS). The change, if approved, would represent another step toward the achieving the agency’s long-sought goal of site-payment neutrality-paying the same amount for a patient visit, regardless of whether it occurs in an independent or hospital-owned practice.

“The bottom line is, patients should not pay more for a service or procedure based on the building it’s done in. That’s the underlying logic here,” says Marni Jameson Carey, executive director of the Association of Independent Doctors, which supports the proposed rule.

CMS estimates that the rule would save it $760 million annually in the form of reduced payments to hospitals and lower Medicare beneficiary copayments. The OPPS is higher because it includes facility fees, charges hospitals add to cover the range of other services they provide, ranging from 24/7 emergency departments to imaging equipment. CMS says clinic visits-which it defines as “check- ups with a clinician”-are the most common type of service billed under the OPPS.

“Part of the reasoning around charging facility fees is to have these services at the ready should they be needed,” says Shari Erickson, MPH, vice president for governmental affairs and medical practice with the American College of Physicians. “But in most cases they aren’t necessary for these types of visits. So having insurers and patients pay more for them really isn’t appropriate.”

The rule would apply only to hospital-owned practices that are not part of a hospital’s main campus. Practices located on hospital campuses would be exempt.

Erickson adds that the proposed rule will likely encounter stiff opposition from hospitals. “The challenge is that many of them have become reliant on facility fees along with other types of funding to pay for many of the things that hospitals do,” she says. “So I recognize there are challenges, but at the same time there needs to be other options to fund the needs of inpatient facilities.”

Articles

Many of the proposals are aimed at reducing the paperwork and compliance burden on physicians. Whether they can achieve this goal remains to be seen.

4 ways doctor reimbursement could change next year

Doctors listed the burden of paperwork / quality metrics as their top concern in the Medical Economics 89th Annual Physician Report. 

Paperwork? I thought medicine was fully electronic? But there is now more administrative work rather than less as the shift to fully digital practices proceeds along the same lines as the shift to value-based care and its data requirements.

Physicians continue to struggle with all being asked of them. One driver of additional administrative work is the demand from the Merit-based Incentive Payment System (MIPS) to gather “essential” data. Another is to keep up with ever-changing demographic and insurance data for the practice.

None of this appears to have a direct benefit for the patient but it is necessary for the operation of the business. This is best tracked and housed in the electronic system(s) accessed daily.

A simple way to address additional administrative tasks is to talk about it at the clinician level. This communication would be built on evidence-based discussions.

Does it benefit the patient or the business?

What is the best way to retain and access it now and in the future?”

Another key question is: What is necessary to improve patient care? That’s a decision both patient- and specialty-specific. It is also related to what is needed for the practice or system, since patient data is expected to be shared with referring physicians.

Further, the business focus must be considered. Is it worth continuing with the MIPS program? Are we gathering demographic and insurance information in a timely manner and reviewing it frequently enough? If staff is too busy doing unnecessary tasks, they are not supporting the patient process as effectively as they should.

Using the “5S” workplace organization methodology in all areas of “paperwork” can help tremendously. The idea is to reduce paperwork or clutter in the work area. Work areas include the exam rooms, nurses’ station, and the clinician office.

If you look around at any of these areas, there are items that distract your attention or get in the way of “finishing” your current task. Following the 5S will start and keep you on the path to an efficient work environment and facilitate the reduction of paperwork. The 5S model is:

Sort: identify what is needed, eliminate everything else

Set in order: determine where needed items go and when

Shine: update the data, removing anything unnecessary

Standardize: approacheach patient in the same fashion with the same data goals in the first three S’s

Given this, we get to time and shuffling or rearranging all of the above to the right person/source at the right time.

If you realistically look at your day, you could deduce that 80 percent of your patient visits, regardless of diagnosis, require the same amount of resources. The other 20 percent would require more or fewer resources. This of course does not consider any new patients or patients that would require an office procedure. This also does not consider the time allocation to hospital rounds made at some time during the day.

Now that it is known that it is difficult at best to accomplish a “complete” patient visit in the time available, what can be done? Consider the following options:

The most efficient physicians are those that complete the process, including appropriate documentation, as the patient leaves the exam room. This may require some significant changes in approach to each day. But consider why you are spending time after the work day completing your patient records.

The necessary data is added to the record by the clinical staff at the triage point. Does the clinician need to ask the same questions or is the data provided sufficient and clear and the only need is for clarification on one or two aspects of care?

Is the outside report-e.g., image study or consultant report-scanned into the system or is it necessary for someone to look for it?

3. Determine the right time to enter or follow-up with the data

There may be time outside of a patient visit that the team can do their work rather than during the patient encounter.

Adequate face-to-face time with the patient ensures attention is paid and given during the visit.

This also includes access to the keyboard and screen. Each room should be designed for the maximum convenience of data entry and face time.

If you consider that a Medicare patient visit is a level 3 visit and you can see two more patients per day, the amount generated will be around $40,000 per year, which in most cases is adequate to justify a scribe.

Aside from the financial side, improved work-life balance and overall reduced stress may justify the addition.

It is not easy to consider the above thoughts when the office is too busy in the first place. But eliminating unnecessary paper or data gathering, shifting work to the right team member, and reducing waste and stress are positive outcomes. The requirement is to stop and take a serious look at what is being done, when, and by whom to answer the questions of what is necessary for the patient and for the business.

, is a nationally recognized medical practice management consultant with over 43 years of experience in consulting and managing medical practices.

Take a serious look at what is being done, when, and by whom, to answer the questions of what is necessary work for patients and for the business.

Getting a handle on healthcare paperwork

The interview lies at the heart of the hiring process. This face-to-face encounter enables physicians and other staff to get to know a candidate in ways that go beyond a resume on a desk and letters of recommendation.

“A critical step when hiring a physician is to do your homework to understand what’s important to your own practice and what is the culture of the medical group,” says Jack Chou, MD, physician-in-charge at Kaiser Permanente Baldwin Park, part of the Southern California Permanente Medical Group in Baldwin Park, Calif.

Once clarified, bring those criteria into the interview, he adds.

Here are five questions that can help a practice ascertain if a physician candidate will indeed meet those criteria.

This open-ended question is an important starting point, although the practice already has information about background, credentials, and experience from the candidate’s resume.

“I like to hear individuals describe their own background to hear how they communicate, since communication skills are a critical part of being a good physician,” says Rick Kellerman, MD, professor and chair for family and community medicine at the Kansas University School of Medicine-Wichita.

Don’t be too specific at the beginning, he advises. A practice will want to know if the person’s self-report matches their resume and how he or she accounts for gaps in employment or other issues that might stand out. Then ask clarifying questions, he says.

“Why did you choose this profession?”

Chou notes that healthcare is a “service industry”and providing service goes beyond “talent and quality.”

Since the reasons for choosing a medical career reflect the candidate’s values and goals, they will highlight the candidate’s ability to provide service that transcends clinical skills. “So you want to find out why your candidate chose this particular profession,” Kellerman advises.

“Why are you interested in our practice?”

Understanding the motivations of a candidate is crucial in determining if he or she is a good fit.

Ask, for example, “Are there geographical motivations, perhaps nearby family?”

Interviewers should inquire how much a prospective candidate knows about the practice, which gives a sense of how much due diligence they have done and how thorough they are.

“Can you recall a disruptive patient?”

One way to ascertain whether a candidate is a good fit is to see how he or she relates to the nonclinical challenges patients often pose.

Chou’s group engages prospective physician associates in behavior interviewing, but their questions do not entail creating hypothetical “what-if” scenarios.

Instead, Chou asks open-ended questions such as, “Can you recall a patient who was disruptive and how you handled it?”

“A red flag would go up in my mind when a candidate is having difficulty coming up with situations that he or she dealt with or is trying to make up hypothetical answers,” he says.

An equally important component of the interview is hearing what questions the candidate asks.

“Candidates who have no questions show a lack of interest in your group,” Kellerman warns.

And the types of questions candidates ask can help ascertain what their real interests. If they ask primarily about the salary and other financial arrangements, he notes that their major interest is monetary.

This face-to-face encounter enables physicians and other staff to get to know a candidate in ways that go beyond a resume on a desk and letters of recommendation.

5 interview questions for your next physician hire

At a time when primary healthcare in the United States is more dependent than ever on foreign-trained doctors, the programs that permit those doctors to practice in this country face an uncertain future under the Trump administration.

Uncertainty, red tape, and anti-immigration policies have some primary care physicians contemplating leaving the U.S. for more welcoming countries, while some international medical graduates are reconsidering whether they want to practice here.

A decline in the number of international medical graduates would worsen the already serious shortage of primary care doctors, particularly because they tend to choose primary care specialties and many of them work in medically underserved areas.

“We are making healthcare more accessible, but we are subject to such uncertainty that some of us are rethinking whether we have a future here,” says Ram Sanjeev Alur, MD, an Indian-born internist in Marion, Ill., who’s thinking of leaving the country. 

The impact of international medical graduates

According to the American Immigration Council (AIC), just over one-quarter of doctors (247,449) in the U.S. were foreign-trained as of 2017, meaning they received their medical degrees from schools outside the country. A small percentage are U.S. citizens who went abroad to medical school, but most are not.

The percentage of these doctors in primary care is even higher. The same study found that nearly a third (31.8 percent) of physicians specializing in family medicine, internal medicine, or pediatrics are foreign-trained.

International medical graduates are more likely to serve in low-income areas, as well. More than half (53.4 percent) of all such doctors work in areas where the population has a per-capita income of $30,000 or less, according to the AIC. In areas where per-capita income is below $15,000 a year, these graduates account for 42.5 percent of all doctors.

In areas where 75 percent or more of the population is non-white, 36 percent of the doctors are trained outside the U.S. They also make up greater shares of all doctors serving populations with lower educational attainment.

With the Association of American Medical Colleges (AAMC) predicting a shortage of primary care physicians of up to 49,300 by 2030, the AIC and other organizations are raising concerns about the future of primary care.

“International medical graduates serve a very important purpose in providing primary healthcare in this country, particularly in light of the physician shortage,” said Ana Maria Lopez, MD, MPH, FACP, president of the American College of Physicians (ACP). The ACP and other healthcare organizations have lobbied Congress and regulators to ease some policies that made it more difficult for internationally trained physicians to practice here.

The difficulties of those policies are well known to Narayanan Krishnamoorthy, MD, and Chitra Mony, MD, a husband and wife practicing in Tallahassee, Fla. They went to medical school in India, then trained in Scotland.

In 2006, Mony matched with Tallahassee Memorial HealthCare’s residency program. A year later, Krishnamoorthy matched with the same hospital and joined his wife in Florida. Mony, who entered on a national interest visa, was required to work for three years in an underserved area. Krishnamoorthy switched from an H-1B visa, which binds him to one employer, to an H4 visa Employment Authorization Document (EAD) work permit, which allows him more flexibility in working as the spouse of an H-1B visa recipient. They have both applied for green cards to become permanent residents but are in a quota-restricted waiting line that could take decades.

In the meantime, the couple fills multiple gaps in primary care in their community. She is a family practitioner at Tallahassee Memorial. He works four-and-a-half days a week as an internist at a large medical practice while also treating his patients who are admitted to the local hospital and rehabilitation center. He also works half a day a week at a wound treatment center and volunteers to train phy- sician assistants and nurse practitioners, as well as medical students.

The couple have a 13-year- old daughter, who was born in Scotland, and an 8-year-old son, who was born in the United States. They say they want to stay in Tallahassee, but, after 12 years here, their future is still unsettled.
As part of its overhaul of immigration, the Trump administration has announced it intends to end the H4 visa EAD program, which allows H-1B visa spouses, like Krishnamoorthy, to work. He had his H4 visa renewed for three years in April and hopes he will be grandfathered in until 2021 if the program is ended. If not, he would have to apply again for an H-1B visa and return to work for the hospital system or another sponsoring employer.

That could put an end to his practice with the medical group, a practice he says he has built up to 2,000 patients, many of them Medicare recipients who turned to him after two other primary care doctors retired. If that happens, the couple is thinking of relocating to another country with a more welcoming immigration policy for doctors, such as Canada, Australia, or the United Kingdom.

“We are deeply rooted in this community, but what do I say to my 2,000 patients [if I leave]]? I want people to know these things are happening,” Krishnamoorthy says. “We have always played by the rules and done everything right, but we might still have to leave.”

Most Americans agree that the country needs more international medical graduates, but their fate is tangled up in the larger debate over immigration. Many enter the country on H-1B visas, the same as other highly skilled foreign professionals, particularly IT workers who have drawn the fire of immigration critics.

Bureaucratic restrictions and backlogs have existed for a long time, but critics say it’s gotten worse under President Trump, who has made reducing immigration-legal and illegal-a centerpiece of his administration. Under the Trump administration, H-1B visa approval rates declined from more than 90 percent in fiscal 2017 to less than 85 percent in the first two months of fiscal 2018.
  
U.S. Citizenship and Immigration Services (USCIS) has become more demanding and less responsive to non-native doctors who want to practice in this country, say Jennifer Minear, JD, and Greg Siskind, JD, immigration attorneys who represent such doctors and the U.S. healthcare organizations that want to hire them.

“This is an administration that has a general hostility to immigration, no matter the occupation,” says Siskind. “The overall goal of the administration, I think, is to make the system as unpleasant as possible and try to reduce the number of applicants. I think that is their tactic.”

Minear says USCIS is making it more difficult and time-consuming to renew work visas through “requests for evidence,” demanding proof of everything from doctors’ salaries to their work schedules. From January to November of 2017, USCIS issued around 40 percent more requests than in all of 2016. Minear says USCIS has even challenged whether physicians meet the H-1B requirement that they be “highly skilled.”

“How anyone can assert that a job as a physician doesn’t require a college degree, I don’t know,” she says. “It’s almost like there’s been some sort of internal decision to deny those claims.”

The delays and increased scrutiny are difficult and expensive for the healthcare systems and practices that want to hire the doctors, Siskind says. Uncertainty over when a visa will be approved makes it hard for employers to know when an international medical graduate can be added to a rotation, he says. While visas are eventually renewed, it’s taking its toll. “There are doctors asking themselves whether the U.S. is a good long-term bet,” he says.

In June, the U.S. Supreme Court upheld the administration’s travel ban, which severely restricts immigration from Iran, Libya, North Korea, Somalia, Syria, Venezuela, and Yemen. This policy could worsen the shortage of doctors.

According to the Immigrant Doctors Project, which opposes the travel ban, there are more than 7,000 doctors from the targeted countries practicing in the U.S. The travel restrictions will make it harder for physicians from those countries to work here and could impose hardships on those already here who will not risk traveling home for fear of not being able to return.

Some states have stopped waiting for the government to act and started their own programs to make it easier to practice within their borders.

The Minnesota Department of Health’s Office of Rural Health and Primary Care in 2015 began its own program to help offset a projected shortage of 2,000 primary care physicians by 2025. So far, the initiative has funded six residency programs for non-native doctors with the requirement that they practice in underserved areas for five years after graduation.

“We really need (international medical graduates) to provide primary care and we need primary care,” says Yende Anderson, JD, head of the program.

Funding two residencies a year isn’t making a dent in the need, Anderson says, so she is trying to raise $3 million to $4 million a year from foundations and corporations to pay for 10 residencies annually.

UCLA has a program specifically for graduates of medical schools in Latin America. It allows qualified graduates who legally reside in the United States to get the same hands-on training with California physicians as UCLA medical school students.

More programs like that are needed to bring in Hispanic physicians, says Elena Rios, MD, MSPH, FACP, president of the National Hispanic Medical Association. Immigrant Hispanic communities are more likely to trust and seek treatment from doctors of similar backgrounds, she says.

“When people get sick, they want to be treated by someone they’re comfortable with, someone who speaks Spanish,” she says.

As the primary care shortage worsens, healthcare organizations are calling for reform, but so far, progress has largely been limited to fighting to keep a faulty system from getting worse. For example, the AAMC, ACP, and other groups in June persuaded USCIS to reverse its decision to no longer accept AAMC resident stipend data for prevailing wage information on H1-B visas. That had resulted in the denials of visa requests from IMGs scheduled to begin work in residency programs July 1.

Some Indian-born physicians have formed Physicians for American Health Care Access to advocate that Congress create a separate path for doctors to obtain green cards. They also want reform of the rule that says no more than 7 percent of H-1B visas may be issued to natives of any one country in a year. That quota is largely responsible for the backlog of physicians from India, which accounts for more applicants than any other country.

One of the group’s founders is Alur, an internist at Marion Veterans Affairs Medical Center in southern Illinois. He has to renew his H-1B visa every three years and faces a decades-long wait for a green card. “I’m 42,” he says. “I can’t be doing this is my fifties and sixties. If things don’t go right then my job is in peril and my life here is in peril.”

Restrictions and backlogs on work visas have existed for a long time, but critics say it’s gotten worse under President Trump, who has made reducing immigration a centerpiece of his administration.

Future uncertain for internationally trained docs

For Sean McNeeley, MD, patient care was what drew him to medicine. But the challenges of running his own private practice, with its growing administrative burden, made it hard to stay there. So he decided to limit his work to urgent care.

“I loved being in private practice, but it was a challenge in family medicine to be able to do it all well and balance time with my family,” says McNeeley, the medical director of University Hospitals Urgent Care Network based in Cleveland. 

Board certified in both family and urgent care medicine, McNeeley ran his private practice from 1999-2004 while also working at an urgent care clinic for extra income. Ultimately, he closed his practice to work solely as an urgent care physician. Today he oversees healthcare providers at ten University Hospitals Urgent Care Network facilities, while still seeing patients every week.

“Working in urgent care gives physicians the ability to balance work and life, which has no on-call schedule, no nights, and limited weekends,” says McNeeley, who is also the president of the board of directors of the Urgent Care Association.

While urgent cares typically are open longer hours than practices, he notes that patients don’t expect to see a particular provider when they seek care at an urgent care clinic, so when a physician is off work, they are truly off. “I can feel good about what I’ve done during the day and I can go home and have some personal time,” McNeeley says.

Interest in, and demand for, urgent care clinics is growing rapidly. The number of clinics has ballooned from 6,946 in 2015 to 8,285 as of June 2018, according to Laurel Stoimenoff, CEO of the Urgent Care Association (UCA) and co-author of “The Essential Role of the Urgent Care Center in Population Health,” a 2018 association report. Behind those figures lies an $18 billion industry ex- perts predict will grow 5.8 percent this year.

Urgent care clinics handle about 89 million patient visits each year, or more than 29 percent of all primary care visits in the country, and nearly 15 percent of all outpatient physician visits, says Stoimenoff.

Urgent care isn’t booming only because of physicians seeking a better work-life balance. Other factors driving the industry’s growth include patient demand, convenience, and costs.

Patients seeking medical care don’t want to wait. Urgent care clinics, with their longer hours and walk-in appointments, fulfill that need in a way traditional physicians’ offices can’t always accomplish.

“This is the age of the patient as a consumer, where fast and convenient is never fast and convenient enough,” says Richard Park, MD, CEO and co-founder of CityMD, a group of urgent care clinics in New Jersey, New York, and Washington state, and president-elect of the UCA.

Urgent care clinics blend retail elements such as ground-floor locations that provide easier access, and the ability to schedule same-day appointments using an online calendar program. A customer-first approach, oriented to service and technology, is fueling growth, says Stoimenoff.

However, urgent care clinics could become victims of their own success, writes Len Schlesinger, DBA, Baker Foundation Professor at Harvard Business School, in a column for athenaInsight: “The tension that I see now is that as these urgent care clinics compete for patients, they might lose the focus that made them successful in the first place.”

Urgent care centers save money compared to emergency departments, where many patients go, even though they are not experiencing a true emergency.

A 2017 Annals of Emergency Medicine study compared the average price-per-visit for Texas-based urgent care clinics, free-standing emergency departments, and hospital-based emergency departments in 2012 and 2015. Researchers found that urgent care clinics charged $168 in 2015.

At hospital-based emergency department visits, the average price per visit in 2015 was $2,259 and $2,199 at a freestanding emergency care clinic. Most of the visits, regardless of facility, were for 20 of the most common diagnoses, and prices for patients with the same diagnosis were, on average, almost 10 times higher at freestanding and hospital-based EDs when compared to similar services received at urgent care centers, the study said.

McNeeley says the cost of an urgent care visit is typically similar to a primary care physician visit, and much less than an ED visit. In addition, urgent care clinics offer more services than most primary care offices. “We can do more, such as run IVs, splint a fracture, or sew wounds,” he says.

Millennials are considered relatively healthy and have only one or two episodic health emergencies a year, says Stoimenoff. This demographic makes up a quarter of all visits to urgent care clinics, according to a 2015 PNC Healthcare consumer survey. “I think it’s very appealing to that generation,” she says.

Other patient groups also report not always turning to a primary care physician for care. A UCA study of patients over age 65 found that 11 percent said they had no primary care physician. A Kaiser study from 2014-2016 reported that, on average, 17 percent of women in the United States didn’t use a primary care provider. For men it was 28 percent.

The growing number of older patients is also a factor, says Park, who oversees more than 100 CityMD clinics. An aging population is taking up the resources of primary care and emergency care departments, according to the same 2015 PNC Healthcare consumer survey. It found that 85 percent of seniors choose to see primary care physicians first. Only 11 percent of that population goes first to an urgent care center. This trend “is making other patients choose to go to urgent care clinics for faster, easier and cheaper service,” Park says.

Rural areas in particular are benefiting from the rise in urgent care clinics. A report by FAIR Health, a nonprofit that studies insurance claims, found that from 2007 to 2017 there was a 2,308 percent increase in insurance claims for procedures done in rural urgent care facilities compared to a 1,675 percent increase in urban areas.

And with more patients paying out-of-pocket for healthcare services, more are turning to urgent care because costs are lower, says Park.

“About 35 percent of employees are on high-deductible health insurance plans, and that number is growing,” he says. Many of those patients pay from $6,000 to $8,000 out-of-pocket before insurance pays anything. About 80 percent of them never meet their deductible, so they are essentially self-paying and want to pay the lowest fees.

“Urgent care is one service that checks both boxes,” says Park. “It is faster, better, and less expensive, and relative to primary care physicians, urgent care centers provide better access and an extended scope of practice.”

What’s behind the growth of urgent care clinics?

Opening an urgent care facility may just be the perfect business opportunity. It fits doctors’ skill sets and can supplement income or provide more independence while tapping into a physician’s entrepreneurial nature. But, according to those who have made the leap, the hours are long, the profits margins are thin, and the financial risks are high. 

“I wish I knew before I opened my urgent care how many hours I would have to put in,” says George G. Ellis, Jr., MD, FACP, chief medical adviser to Medical Economics. Ellis owns the 910 Rapid Care clinic adjacent to his private practice in Youngstown, Ohio. “The private practice and urgent care consume about 90 hours a week for me.”

For a new urgent care to succeed, physician-owners must carefully research all the details about the location under consideration, the services and staffing requirements, and accept the fact that urgent care medicine demands a different mindset than private practice.

But when done right, urgent care can be an opportunity to help meet the medical needs of the community while providing financial rewards for the long hours and risks a physician must take to open the doors.

“There are a lot of people that think of open- ing an urgent care as a construction project, but that’s just 20 percent of what needs to be done and what they need to be thinking about,” says Laurel Stoimenoff, PT, CEO of the Urgent Care Association, which provides accreditation and resources to urgent care facilities. “Like studying for an exam, a lot of work needs to go in upfront before you start.”

The first thing to understand is the financial commitment. Stoimenoff says it will most likely take between $800,000 and $1.2 million to build and open an urgent care, depending on facility size and location.

And experts say location is extremely important.“This is retail medicine,” says Thomas Brown, MD, an internist and founder of Kathy’s Urgent Care, which operates three urgent care centers in the greater Hartford, Conn., area and has leases signed to open two more in the next several months. “The first consideration is what’s a viable location that will be profitable, and that entails a detailed demographic analysis.”

This analysis should include population density in a one-, three-, and five-mile radius around the proposed clinic. To be successful, an urgent care needs at least 30,000 people within five miles, says Stoimenoff. The analysis also should include daily traffic counts on the street where it will be located, ease of getting in and out, number of parking spaces, and nearby competition.

“Find a visible location that is easy to get to,” says John Kulin, DO, an emergency medicine physician who is the founder and CEO of six Urgent Care Now clinics in the Philadelphia area. “Sometimes the most visible spot is not the easiest to get to.” For example, a potential location may be easily seen from a busy road, but doesn’t have direct access, making it inconvenient for the patient.

An average urgent care requires about 3,000 square feet, which usually translates to six exam rooms plus space for a lab and X-ray equipment, says Stoimenoff. But the total square footage will depend on the amount of competition and how many patients are expected to be seen each day. For example, Kulin says that in 2005 when his urgent care was the only one in the area, he built a 5,000-square-foot facility. As competition increased and patient counts decreased, the space requirements shrank. The facility he opened in 2017 required only 2,500 square feet.

With a possible location identified, the next step is to obtain payer contracts. “A lot of insurers are closing or limiting panels,” says Kulin. “I’ve seen urgent cares open up that did not even have the major insurers in the area and suffered the consequences. Even if it takes another three to nine months to get the contracts set up, if you are paying $70,000 a month in payroll, it’s worth it to wait.”

Brown says not getting credentialed early enough with insurance companies can cripple an urgent care’s cash flow in those crucial first few months and create difficult choices. “Should you turn away patients because you aren’t credentialed with the insurance company yet or see them for free and hope that four months from now when you get credentialed that they will retroactively pay for folks?” says Brown.

And while insurance companies understand the value of urgent cares as a means to keep patients out of more costly emergency departments, the increasing number of facilities can make it more difficult to contract with payers. This is why physicians must understand the details of each contract to find out who is going to pay for what before investing money in a new urgent care, says Stoimenoff.

“Knowing and understanding reimbursement is key,” says Ellis. “If you don’t know what you are being paid for, then you are in trouble.”

Doctors need to invest time considering the design of the facility, and understand that urgent care clinics require a more practical and utilitarian space than a private practice to keep building costs down.

“Watch your overhead as a new urgent care provider,” says Kulin. “We function on margins that are not huge, so you don’t want to build the Taj Mahal. The office should be neat and easy to keep up with infection control. You don’t need marble counter tops and other things that don’t make sense in an urgent care setting.”

The design of the space will also depend on what services will be offered. For example, 99 percent of urgent cares have X-ray capabilities, says Stoimenoff, and most provide some level of lab services.

“Before you put any services in place, find out if it will be reimbursed,” says Kulin. “Make sure that any service you are considering offering you have done a [return on investment] study for. Run it like a business and not just on the idea that, ‘It would be nice to have this.’”

Before starting his urgent care, Ellis made a list of equipment he needed and then prioritized it, getting the high-priority items first and adding the lower-ranked items later, he says. A physician must also strike a balance between having the required equipment and materials in every exam room versus wasting time looking for them, which can hurt the efficiency of the operation.

Experts advise carefully considering staffing levels based on the projected number of patients and the services offered.

“Once you are up and running, the biggest expense won’t be overhead, it will be payroll,” says Brown. Start adding up the salaries of any doctors beyond the founder, a mid-level, an X-ray technician, a medical assistant, a biller, and any other personnel needed to provide the services and the financial demands become apparent. “Payroll is the beast you have to pay attention to,” says Brown.

Some payer contracts require a physician to be on-site at all times while others do not, so that’s another reason to have contracts settled before any construction starts. But regardless of the mix of physicians, mid-levels, and technicians, Kulin says everyone has to work to the top of their license and be cross-trained to do anything that is needed, such as turning exam rooms around and helping with splinting or casting. “You have to run as lean as you can without affecting the patient experience,” he says.

And if business declines or falls short of projections, doctors must be willing to make staffing reductions. “When you come into the market, you are the disruptor and the new guy offering something new and different,” says Kulin. “Then others come in and disrupt you. How will you respond? You have to be prepared if patient volume drops down.”

Running an urgent care requires a different mindset than a private practice, experts say. It’s not just about the building and the on their way as quickly as possible, she adds. This allows the physician to see as many patients as possible while also creating a positive patient experience.

“Urgent care is a different kind of care,” says Ellis. “You have to cater to the patient. If you don’t, you won’t see them come back.”

Kulin says that urgent care patients expect a better customer service experience, starting with registration and running through the nurses and physician. This means that to grow the business, physicians have to have methods in place to get feedback from patients.

“We have a mechanism through our EHR where we get reviews back from people and adjust to that, making sure all our staff is informed about anything said, both positive and negative, and looks for opportunities to make a better overall patient experience,” says Kulin.

“The customer is never wrong,” says Brown. “It kills me when a patient comes back and thinks we misdiagnosed something. I can try to explain, but it’s too complicated, so I just say sorry and write off the bill. I can’t imagine that happening in a primary care practice.”

A commitment not just to customer service, but strong operational principles is the only way to succeed. “Running [profit and loss] statements and proformas have to become part of what they understand,” says Kulin. “If it’s not in their wheelhouse, they need to make sure they have someone at the beginning who can help. Realistically, an urgent care is a medical retail business.”

What to consider before investing-and what it takes to win.

September 10, 2018 edition

4 ways doctor reimbursement could change next year

Getting a handle on healthcare paperwork

5 interview questions for your next physician hire

Future uncertain for internationally trained docs

What’s behind the growth of urgent care clinics?

Succeed at urgent care

Coding for mental health issues

How Yelp made me a better doctor

How blockchain could make waves in healthcare

Your voice: Portal problems not extensively outlined

The next big EHR interoperability idea?