A recent AMA study found that in 2018, for the first time, employed doctors outnumbered those that owned, or had an ownership stake in, a practice. For independent practices, this milestone highlights the importance of operating as efficiently as possible. That’s because financial difficulties are among the main reasons practice owners cite in giving up their independence by selling or merging their practice.
	
	The good news, according to practice management experts, is that many independent practices can find ways to grow revenue and reduce overhead costs. And while doing so requires planning and sometimes making difficult changes, for practices that want to continue operating independently the effort often pays off. 
	
	“In some cases even small improvements in revenues and operating efficiencies can make the difference between staying independent and selling or merging a practice,” says Reed Tinsley, CPA, CFP, a medical practice consultant based in Houston, Texas.
	
	


	
	Often, the most direct route to bolstering revenue is by seeing more patients. “In this era of declining reimbursements, you’ve got to add patient volume, and you do that by adding appointment slots,” Tinsley says.
	
	Finding ways to see additional patients often is easier said than done, Tinsley acknowledges. Some doctors work more slowly than others, or want to spend more time with patients. Sometimes nurse practitioners and physician assistants balk at the idea of seeing more patients during the day. Still, says Tinsley, “I tell my clients, ‘I don’t care how you do it, it just needs to get done. Even if it’s two a day per provider, over the course of a year that’s going to add some nice revenue to the bottom line.’”
	
	Two common methods for scheduling additional patients are to extend appointment hours and to double-book appointments with the expectation of no-shows. And while the latter technique carries the risk of some patients having to wait longer if there aren’t any no-shows, “it just takes a very good front desk staff to communicate to patients why the doctor is running behind,” Tinsley says.
	
	Another technique is to take a strategic approach to appointment scheduling. Some appointments may be getting more time than they need, says Laurie Morgan, MBA, a partner in the San Francisco-based medical practice consulting firm Capko & Morgan.
	
	“Look at the schedule over the past six months, and see if you can determine whether certain types of appointments that have always been booked for, say, half an hour, are only taking 20 minutes the vast majority of times. You may be able to recapture some time by doing that type of analysis,” she advises.
	
	Along with seeing more patients, Tinsley emphasizes the value of good customer service. “I often say to my clients, ‘are you a referable medical practice?’” he says. “It’s an intangible way to add revenue, by becoming the kind of practice where patients want to come, and refer their friends and family and coworkers to,” he says.


	
	A second way practices can increase revenue is by ensuring they receive all the money they are owed and to which they are entitled-in other words, by being efficient and up-to-date in their billing, coding, and collections.
	
	“Understanding all the codes available to you and using them appropriately and regularly is extremely important because it improves your reimbursement from payers,” says Ripley Hollister, MD, board member and chair of the research committee of the Physicians Foundation and owner of
	Dynamic Healthcare Team, a family practice in Colorado Springs, Col.
	
	Dynamic Healthcare recently hired a “patient navigator,” whose responsibilities include tracking and following up with patients so that the practice can bill Medicare’s transitional care and chronic care management codes. In addition, Hollister says, the practice’s coder/biller learned that Medicare has codes for time spent discussing advance directives and living wills during annual wellness visits, so he has started billing for those.
	
	The wellness visits serve another important revenue-related function, Hollister says. Reviewing patients’ records prior to their visits sometimes reveals services for which they are due, or overdue. “This lady isn’t getting her mammograms, that patient needs their pneumonia vaccine, this guy hasn’t had a colonoscopy in 11 years, it all pops up,” he says. “They help keep patients healthy and many of them are services we can bill for.”
	
	Along the same lines, Tinsley encourages clients to put in place a recall system for tracking when patients are due for a needed service and notifying them to come in. He recommends starting by printing out a diagnosis frequency report for the practice’s patients, and identifying which diagnoses require regular visits to manage or treat.
	
	The next step, Tinsley says, is to “data-mine your system for every patient you’ve billed one of those diagnoses to and determine whether they need to come back in. Then bombard them with messages reminding them why they need to come in and to make an appointment.
	“It’s low-hanging fruit and it’s just crazy to let it sit there without taking advantage of the revenue opportunity,” Tinsley says.  
	
	Billing and collecting from patients are other areas where practices often can find more revenue with little or no additional investment. For example, Tinsley recommends keeping patients’ credit card numbers on file to ensure that copays and self-pays are collected promptly.
	“Think about the time and money you waste when a bill ends up in the receivables process. It’s a total waste,” he says.
	
	Some practices, he adds, go as far as requiring non-emergent patients to reschedule if they can’t pay what they owe the day of their appointment.


	
	Morgan urges her clients to bill and collect electronically, via a patient portal. “From my perspective, the biggest thing practices can do is to enable patients to receive their statements and pay online,” she says, since that’s how people increasingly are accustomed to-and usually prefer-paying bills. Moreover, having to mail a statement to the patient and wait for the patient to mail payment slows the revenue cycle.
	“Automating those processes is a real win-win because the practice gets paid faster and at lower cost, and the patient is happier,” she says. “We’ve worked with practices where they’ve turned on the payment portal and that night they started getting new payments from patients. It’s a really nice thing to come in in the morning and see that you got money while you were sleeping.”
	
	Effective portal use can also help bolster revenue in less direct ways, by enabling providers and staff members to use their time more efficiently, says Margo Williams, MHA, CMPE, senior associate for practice management at the American College of Physicians.
	
	Practices that encourage patients to use the portal generally see a reduction in phone calls, she says, and spend less time playing phone tag with patients. Also, many of the queries that come via the portal are routine and can be handled by someone other than a physician. “If someone just wants to know their lab results, as long as they’re normal, a nurse can usually respond,” she says.
	
	“The overarching thing to remember is that practice efficiency isn’t rocket science,” she adds. “It’s just a constant process of looking at each step and asking, ‘what can we do to make it better? What can we do to address snags in the system?’”


	
	Turning to the expense side of the equation, the biggest overhead costs most practices incur are in staffing, and here an easy target for savings is overtime pay. The first step in eliminating or reducing overtime is determining why it’s occurring, says Morgan, since that might suggest the solution.
	
	“If it turns out that an entire section of your staff is constantly working overtime, it may not take long before it’s no more costly, and far more efficient, to bring in another body,” she says.
	
	Tinsley agrees. “I think any overtime is a problem,” he says. “It means either you’ve got inefficient employees or not enough employees or a combination of the two.”
	
	Sometimes, investigating overtime can surface an entirely different problem: fraud. Tinsley cites the example of an employee at a client practice who regularly claimed overtime for working over her lunch hour, even though she wasn’t doing any work. When confronted, the employee said she was making up for a raise that had been smaller than she expected. “In the scheme of things it wasn’t that much money, but even small amounts can make a difference,” he notes.
	
	Along with seeking to eliminate overtime, Tinsley advises practices to ensure they really need every employee they have. To do this, he asks them to develop an organizational chart. After spending some time observing the practice’s operations and workflow, he meets with the administrator.
	
	“I’ll take the organizational chart and put an ‘x’ through someone’s name and say, ‘tell me why you need this person? Can their job be absorbed by someone else?’” he says.
	
	Similarly, he suggests that practices require employees to take vacations lasting at least five days, and assign the vacationing employee’s duties to others. “If those people can handle the extra duties with no problem, doesn’t that tell you the person or position may not be needed?” 
	
	


	
	Another area practices can look for savings is in practice-related equipment and services. Here there are no shortcuts; instead, it’s a matter of monitoring  expenses and  looking for ways to trim them without harming productivity, experts say.
	
	A good place to start is with physician societies, some of which offer savings to their members. For example, the American Osteopathic Association provides discounts on medical and office supplies, as well as vaccines, through its group purchasing organization, AOA Purchase Power.
	
	“Vaccines are a significant upfront expense for physicians in private practice” says Matthew Kremke, vice president of the American Osteopathic Information Association. “In busy practices, it isn’t uncommon for our members to incur out-of-pocket costs of $10,000 a month or more.”
	
	Outsourcing vaccine-related services can be another way to reduce their costs, according to Ripley. VaxCare, the company his practice uses, handles all vaccine billing and manages the practice’s inventory. “They know what we have on hand at any given time and send the stuff they know we need. And if it goes out of date, they take it back,” he says.
	
	Ripley recommends that practices regularly shop around for lower prices on services such as telephone and internet, as well as office supplies and equipment. For the latter, he suggests wholesale clubs such as Costco and Sam’s Club. “I’m not above dropping by Sam’s to pick up some c-fold towels or whatever,” he says.
	
	“If it’s something that you absolutely need, then of course you have to make sure you get it,” says Morgan. “But if you can get it at a lower cost then that’s always a good idea.”

Articles

In some cases even small improvements in revenue and operating efficiencies can make the difference between staying independent and selling or merging a practice,

How to rev up  practice productivity

Patients want retail-like convenience, but this might be taking things too far.

Medical Economics cartoon: What to do with patients while they wait?

Senior editor Jeffrey Bendix’s comments in “Non-physician providers can help lower care costs for complex patients” (July 25, 2019 issue) will be met with derision by some primary care doctors.
	
	Why? For two reasons.
	
	First, some primary care physicians feel that their incomes will suffer if nurse practitioners and physician assistants provide primary care services. Second, others consider it demeaning that non-physician providers are considered capable of providing primary care despite their fewer years of training.
	
	But the traditional training of primary care doctors-4 years of pre-med, 4-5 years of med school, and three years of residency-turns out physicians who are over-trained for what is required.
	
	Primary care doctors no longer take care of hospital patients or nursing home patients. They don’t treat patients in the emergency room; and they rarely do gynecology or office surgery.
	
	Most of their work includes treating upper respiratory diseases, hypertension, diabetes and coordinating care with specialists-not to mention the time- consuming, frustrating, administrative work that drains their energy and mental stamina and makes many feel like medical drudges.
	
	One way to solve this predicament is to encourage nurse practitioners and physician assistants to join the primary care work force, and provide the services for which they were trained. This will reduce the workload per provider, reduce burnout, reduce frustration-it may even make a career in primary care desirable.
	
	Although many practice in a collaborative role with physicians, in many states nurse practitioners are licensed to practice independently.
	 
	

Patients demanding convenience means trade-offs

In response to the article “Patients Demand Convenience” (June 25, 2019 cover story):
	
	There is a sign in my nurses’ work area that says the following: “We offer three kinds of services: Good, cheap or fast. But you can choose only two! Choose Wisely!”
	
	Cheap and fast won’t be good. Fast and good won’t be cheap and good and cheap won’t be fast.
	
	I first saw this in a non-medical office 30 years ago. It still applies today, in any business-including medicine.
	 
	Choose wisely, indeed!

Your voice: Expanding the roles of NPs and PAs  will make primary care more desirable

Smart thermostats, home security systems, fitness watches, and other devices that connect with each other and the internet, make up what is called the Internet of Things (IoT). And these devices are ubiquitous these days.
	
	There is another world of internet-connected devices that has not caught on quite so quickly: The Internet of Medical Things (IoMT). Andrew Keller, MD, chief medical officer and chief medical information officer for Western Connecticut Medical Group describes the IoMT as “devices that can collect and exchange data-either with users or other devices-via the internet, and are used to allow doctors to be more aware of a patient’s condition on real-time basis.”
	
	The IoMT could potentially make managing chronic conditions more efficient and more cost-effective. But first physicians have to learn what these devices are and how they can be used safely and effectively.


	
	IoMT technologies cover a wide range of clinical uses. Smart watches and MedicAlert bracelets can detect falls and call emergency medical services. An implantable pulmonary artery catheter can connect to an external device, such as a mobile phone, and notify the doctor when pressure increases.
	
	Another high-tech device on the IoMT is the “smart pill.” These oral medications have ingestible sensors that, when activated by stomach acids, transmit messages to a patch on the patient’s arm, which in turn sends a message to a smartphone app. This allows physicians and family members to make sure dementia patients or patients with mental health problems, for example, are taking their medications as prescribed.
	
	Clinical trials are beginning to prove the benefits of some of these devices. A May 2018 study in JAMA Cardiology found that an Apple watch with an app called Cardiogram could detect abnormal heart rhythms with close to 97 percent accuracy.
	
	“When this data is transmitted via the internet to the doctor-or someone at the monitoring station-the doctor can adjust medicines or take whatever steps he or she feels necessary,” Keller says.
	
	In an interview with Cardiology Today, Jagmeet P. Singh, MD, PhD, Cardiology Today editorial board member and associate chief of the cardiology division at Massachusetts General Hospital, described this technology as a “game changer.”
	
	“Since the sensor and its ability to record ECGs and classify the heart rhythm is FDA-approved, it will begin to find its way into clinical practice and potentially into the electronic health record,” he says.  “It will certainly create a heightened awareness about rhythm disturbances and atrial fibrillation.”  
	
	In a separate editorial, Singh expressed cautious optimism about trends in digital health, writing that “both [artificial intelligence] and digital strategies will make the delivery of care both more patient-centric and cost-effective. The advances in mobile and wearable devices and sensors will help initiate the transition from conventional transactional care to a more continuous form of managing our patients.”


	
	The IoMT could also improve physicians’ bottom line. According to data published in 2017 in the American Journal of Preventive Medicine, 86 percent of healthcare expenditures are for people with chronic conditions, including cardiovascular disease, diabetes, obesity, and dementia.

And these patients are far more likely than others to end up in the emergency department. A 2015 study in American Journal of Managed Care found that patients with the highest care utilization rates, particularly those with multiple chronic conditions, were five times more likely to visit the emergency department than patients with low utilization rates.
	
	Being able to proactively manage these time- and resource-intensive conditions could save money as well as lives. “A device that signals when the patient’s health is changing and alerts the doctor could make it possible to intervene early and reduce hospitalizations and improve patient outcomes,” says Steven Waldren, MD, vice president and chief medical informatics officer at the American Academy of Family Physicians.
	
	“This technology allows you to manage people with chronic conditions more efficiently and effectively without them having to come into the office,” he says. “As folks are moving toward value-based care, being able to manage patients with chronic conditions at home could help practices be more profitable.”
	
	IoMT technologies can also improve patient engagement. According to Accenture’s 2019 Digital Health Survey, 53 percent of patients surveyed would be more likely to choose a primary care provider who uses remote or telemonitoring devices to monitor and record health indicators. That’s up from 39 percent in 2016, and the trend is more noticeable in younger patients. “There’s a lot of push now for this type of care from a subgroup of patients who want to have their health data themselves,” says Waldren.
	
	Payers are pushing for it, too. “If Medicare will pay doctors to use these technologies, then they’re more likely to use them,” says Waldren. And Medicare is doing just that. The CMS 2019 Fee Schedule includes three additional CPT codes for remote patient monitoring devices.
	
	According to the Center for Connected Health Policy 2019 State Telehealth Laws and Reimbursement Policies Report, there has been a slight increase in state Medicare programs that reimburse for at least some remote patient monitoring.
	 
	


	
	This world of increased connectivity does pose challenges, however. Healthcare data is a prime target for hackers, and any internet-connected device poses a risk. “If you’re going to use these devices with your patients, you need to make sure that the devices are HIPAA-compliant and being used in a HIPAA-compliant way, “ says Ron Sterling, a consultant who specializes in health-care IT.
	
	Consumer-oriented devices-fitness trackers, nutritional programs, and so on-are not  necessarily HIPAA compliant, and patients are under no HIPAA obligations. “You must make sure you’re meeting all the HIPAA requirements, but you’re not responsible for what the patient does,” says Sterling. “Devices that you’re prescribing to patients are another matter. You have to stick to the same HIPAA standards and take the same security steps you do with portals, passwords, and so on.”
	
	A physician who is performing due diligence and using FDA-approved devices from trusted vendors should be fine, though. But patients may not be as aware as their doctors of the security risks. When using remote monitoring devices or other IoMT technologies, “the doctor should explain the privacy issue to patients and make sure patients are aware the risks and benefits, and that the benefits do outweigh the risks,” says Keller.
	
	Interoperability and standardization pose additional challenges. As these devices become more widely used, manufacturers and regulators will have to find ways to ensure that devices can communicate easily and securely across a wide range of platforms.
	
	Despite all the potential benefits, it’s important to use these new technologies not only responsibly, but effectively. “Doctors need to understand that just adopting a piece of technology is not that helpful,” says Waldren. “You need to identify a particular problem you have with your patient population and find a solution to address that. Don’t just be enchanted by bright and shiny new tech; make sure it’s something that has clinical value.”
	
	Keller recommends assessing clinical value the same way as any other any treatment. “I would ask the normal questions about sensitivity and specificity,” he says. “There is lots of information available at presentations and sessions at national conventions, and vendors usually have displays set up.”
	
	The IoMT may not be as widespread as the IoT, but it is growing. “The fact of the matter is these devices are here, they’re going to be here, and patients want to use them,” says Sterling. Savvy physicians will be prepared.

The IoMT could potentially make managing chronic conditions more efficient and more cost-effective. But first physicians have to learn what these devices are and how they can be used safely and effectively.

What the internet of medical things means to your practice

Physicians work hard to generate revenue, and with slim operating margins, they don’t want to contend with costly recoupments. Compliant coding and billing helps them avoid the focus of a pre- or post-payment audit.

This article discusses four services that physicians say pose payment challenges along with general tips for coding compliance.

Annual wellness visits vs. physicals: Know Medicare requirements

It’s easy to confuse the AWV and Initial Preventive Physical Exam (IPPE) because both are Medicare-covered services for preventive health. However, there are some notable differences, says Sonal Patel, CPMA, CPC, a coding and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Patel provides these tips for compliant billing:

1. Know what’s included in the AWV visit vs. the IPPE. Visit the CMS website to learn more about specific requirements for the AWV (including subsequent AWV visits) and IPPE. Documentation should reflect each of these services, says Patel.

2. Report the IPPE, otherwise known as the ‘Welcome to Medicare exam,’ only
	once within 12 months of Part B enrollment. The patient is ineligible for this service after 12 months post-enrollment, says Patel.

3. Once the 12 months post-enrollment have elapsed, physicians can bill an AWV once every 11 months thereafter for the patient’s annual AWV. The physician must perform and document all components of the AWV or IPPE, including any updates since the last visit. However, they can’t bill an AWV and IPPE during the same 12 months, says Patel. If the patient needs to be seen after the IPPE but before they’re eligible for the AWV, the physician must bill another appropriate service for which the patient may owe a co-pay or deductible. With the AWV and IPPE, the beneficiary owes nothing.

Telemedicine: Know your codes and modifiers

Telemedicine increases access, convenience and patient satisfaction, but it can cause headaches in terms of getting paid, says Jamie Claypool, CPC, CPMA, practice management consultant at J. Claypool Associates Inc. in Spicewood, Tex. Follow these four tips to avoid denials:

1. Know what codes are acceptable to report as telemedicine. CMS provides a complete list of eligible CPT/HCPCS codes for calendar year 2019 (see pp. 6-9). For example, via telemedicine, physicians can report: 

Payment for services rendered via telemedicine is no different from those rendered in the office setting, says Claypool. She adds that commercial payers may or may not allow physicians to report these same services via telemedicine. 

2. Report place of service (POS) code 02. POS 02 indicates the physician furnished the service as a professional telehealth service from a distant site. Physicians should not report POS 11 (office) when billing these services, says Joette Derricks, healthcare compliance and revenue integrity consultant in Baltimore.

3. Apply modifier -95, when applicable. This modifier indicates the physician rendered telemedicine services through a synchronous interactive communication, and some commercial payers may require it for certain codes, says Claypool. 

4. Don’t confuse telemedicine with virtual check-ins (G2012) and remote evaluations (G2010). Physicians can bill virtual check-ins when they have a direct conversation in real-time with an established patient to determine whether the patient must come into the office to be evaluated. The only caveat is that it’s not billable when the check-in originates from a related E/M service provided within the previous seven days or leads to an E/M service or procedure within the next 24 hours or soonest available appointment. The same caveat is true for remote evaluations during which a physician asynchronously communicates with an established patient (e.g., through the portal) and then speaks with the patient in real time to devise a treatment plan.
	
	CMS doesn’t classify either of these services as telemedicine, which means there are no geographic restrictions, says Derricks. With telemedicine, Medicare will only pay for services when the beneficiary receives the services in an authorized originating site that’s located in a rural Health Professional Shortage Area or a county outside a Metropolitan Statistical Area, she adds. Note that commercial payers don’t accept G2010 and G2012.
	

Chronic care management (CCM): Avoid common denials

Even though physicians have been able to bill CCM since 2015, they still run in to problems in terms of getting paid, says Kim Garner Huey, CPC, owner of KGG Coding and Reimbursement Consulting in Birmingham, Ala. Here are some common reasons for denials and how to avoid them:

Reason for denial: Multiple providers bill CCM for the same patient during the same 30 days.

How to avoid it: Communicate with specialists regarding who will bill for the CCM. “This code was really intended for primary care, but it’s not restricted to primary care,” says Huey. 

Reason for denial: Physician bills CCM more than once every 30 days.

How to avoid it: Set up an alert in the practice management system that prevents physicians from reporting CCM before 30 days have elapsed, says Huey. 

Reason for denial: Insufficient documentation.
	
	How to avoid it: This is a problem that tends to surface during post-payment audits, says Huey. Avoid recoupments by ensuring documentation reflects the intent of the code-that is, to manage all of the patient’s chronic conditions. “CMS intended a very personalized, hands-on type of medical management,” she adds. Documentation such as ‘Patient is taking medications as prescribed’ is not sufficient. Instead, she says to document the following: 

List of all of the patient’s conditions with as much specificity as possible

Why these conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline

Comprehensive care plan-What the physician is doing to manage the diagnoses. If a specialist is managing a condition, the primary care physician should note the specialist’s name, the date of the last appointment, and a brief summary of the visit. 

For more information about CCM, including patient and practitioner eligibility and the service elements included in the code, visit the CMS web site.

Transitional care management (TCM): Track patients, comply with requirements

Physicians can generate revenue by providing TCM, but they must also be prepared to deal with potential denials, says Huey. Here are some common denials and how to avoid them:

Reason for denial: Commercial payer rejects the code.

How to avoid it: Bill as an office visit instead, since most commercial payers don’t pay for TCM, says Huey. 

Reason for denial: Interactive contact (telephone, email, or face to face) with the patient did not take place within two business days of discharge.

How to avoid it: With the rise of hospitalists, very few primary care physicians see their own patients in the hospital, making it difficult to track admissions and discharges, says Huey. She says physicians should tell their patients to notify the practice of any hospitalizations as soon as they occur so the physician can help coordinate care. Then appoint someone in the practice (e.g., a medical assistant or care coordinator) to track the date of discharge and call or email the patient within two business days thereafter.
	
	Even when staff call or email within two business days of discharge, they don’t always document it in the medical record, says Claypool. Best practice is to document the date of discharge, the date of the call, and a very brief summary of the interaction, she adds. If two or more attempts to reach the patient within two business days of discharge are unsuccessful, physicians can bill TCM as long as they meet all of the other requirements. However, staff must document their attempts to reach the patient even after the second business day following discharge and should continue trying until they are successful.

Reason for denial: Documentation doesn’t support high-complexity TCM.

How to avoid it: To report 99496, physicians must perform high-complexity medical decision-making, meaning they must review and document:

An extensive list of possible diagnoses and/or management options,

High risk of significant complications, morbidity, and/or mortality

Physicians may feel as though they’ve rendered complex TCM because they spent a lot of time talking with a patient, for example, but if the documentation doesn’t reflect the elements listed above, it doesn’t meet the criteria for the code, says Claypool.
	
	For more information about TCM, including TCM components and other resources, visit the CMS Web site.

On the horizon: 3 reimbursement trends to monitor

1. Surprise billing protections.
	Twenty-five states have some form of surprise billing protection that prevents physicians from charging patients their out-of-network rates when they go to an in-network hospital or emergency department. President Trump has also vowed to end surprise billing and create more transparency with medical bills. Physicians should keep an eye on this legislation because it could mean they’d take a financial hit for seeing certain patients in the hospital setting, says Tammy Tipton, owner of Appeal Solutions Inc. in Oklahoma City, Okla.
	
	2. Reference-based pricing.
	Some commercial payers are moving away from reasonable and customary rates in favor of paying physicians a multiple of the Medicare rate (usually one or two times that rate). However, Medicare often reimburses at cost, leaving a slim profit margin for physicians. Physicians should review their payer contracts, and may need to make some tough decisions (i.e., part ways with some payers), says Tipton.

3. Social determinants of health.
	The ICD-10-CM Coordination and Maintenance Committee has proposed approximately 20 new diagnosis codes that address problems related to education and literacy, employment status, housing and economic circumstances and social environment. Physicians should monitor journals and professional association newsletters to see whether these codes are finalized, says David Vence, MA, RHIA, CPC, assistant vice president of coding and compliance at First Class Solutions Inc. in Maryland Heights, Missouri. The new codes are part of the calendar year 2020 Hospital Inpatient Prospective Payment System Final Rule and would take effect October 1.

Focus on accurate billing to drive and retain revenue.

Coding for revenue

Natalie King, MD, a family medicine practitioner, trained in Toledo, Ohio, an inner-city environment less than two hours away from the family farm where she grew up. That residency training prepared her to work in under-resourced urban areas. But when she was offered a job at a community health clinic in Jellico, Tennessee-population 2,217-she didn’t hesitate.
	
	“Having grown up in a rural setting, moving to a small town didn’t faze me,” she explains. “As a physician, I was inspired to find ways to engage with more vulnerable populations. And practicing full secondary family medicine, where I could provide real care continuity for my patients, was something I wanted to do.”
	
	Yet, after four years in Jellico, King decided to return to Toledo.
	
	“There are so many different challenges involved with practicing in a rural setting, from lack of insurance to just the distance a patient has to travel to get care,” she says. “I found the work really satisfying, but it was hard, as a single woman, to live in the middle of nowhere. When the hospital where I worked changed hands, and they closed down the obstetrics department, it changed the dynamic for me and I decided to head back north.”
	
	


	
	According to the Centers for Disease Control and Prevention (CDC), more than 46 million Americans, about 15 percent of the entire U.S. population, live in sparsely populated areas with low housing density, often hours from urban centers. Numerous studies have demonstrated a significant gap in health outcomes between individuals who reside in urban areas and those in rural ones.
	
	“Generally, people who live in rural America are sicker, older, and come from a lower socioeconomic level,” says David Schmitz, MD, chair of the Department of Family and Community Medicine at the University of North Dakota and past president of the National Rural Health Association. “They are less well insured and tend to suffer from a lot of chronic diseases. And, by nature of where they are, it’s often difficult for them to access healthcare, even basic primary care.”
	
	While primary care physicians are in short supply everywhere in  the country, the lack of providers in rural settings is more acute. The Health Resources and Services Administration has designated 7,200 regions across the country as Health Professional Shortage Areas. Nearly 60 percent of those shortage areas are located in rural regions. Because healthcare access is widely recognized as a key determinant of health outcomes, these statistics highlight a large and growing issue.
	
	“Provider shortages, like those seen in rural regions in both the U.S. and Australia, are associated with delayed healthcare seeking, reduced continuity of care, increased travel burdens, higher healthcare costs, poorer prognoses, and poorer adherence to care plans,” says Matthew McGrail, Ph.D., a member of the Rural Clinical School at the University of Queensland in Australia.
	
	Yet the very factors that tend to make rural patients sicker are also those that make it difficult to recruit and retain healthcare providers for those areas, says Amitabh Chandra, director of health policy research at Harvard University’s John F. Kennedy School of Government.
	
	“There are likely a lack of jobs in many of these places, as well as lower quality schools and housing,” he says. “Doctors know better than anyone the importance of good healthcare to a thriving community. Will they be comfortable moving to an area, and raising a family, in a place where you can’t get great hospital care-or perhaps any hospital care at all within a hundred miles?”


	
	The lack of primary care physicians in rural areas has led the healthcare industry  to consider what can be done to better encourage doctors to practice outside of metropolitan areas. While the most straightforward approach may seem like finding ways to make it more lucrative for physicians to practice in a rural area, Chandra says simply throwing money at the problem is not the answer.
	
	“The amount of money that you’d need to try and make up for what these doctors could make in the city would be cost-prohibitive,” he explains. “We aren’t talking about the state or other agencies adding 5 percent in extra wages but more like 40, 50, maybe even 60 percent to make up the difference. Instead of focusing on salary, we need to think more creatively about how we can make rural America more attractive to doctors and their families.”
	
	That said, investments in training and recruitment may bring more progress in addressing the rural physician shortage. Relying on physician assistants and nurse practitioners to do more primary care could help fill some gaps, but even so, the need will remain for physicians to help oversee their work and deal with more complex patient cases.
	
	Shannon Brownlee, MSc, senior vice president of the Lown Institute, a non-profit organization working to create a more equitable healthcare system, says that in an age of mergers and acquisitions, she would like to see more health systems making greater investments in their rural facilities.
	
	Rural hospitals are reducing their services, even shutting down completely, at an unprecedented rate. Such changes were part of the reason why King decided to move back to Toledo.
	
	Beyond investing in those facilities, Brownlee says subsidizing medical school for those willing to go into primary care and practice in rural areas could also be beneficial.
	
	“Some countries in Europe have invested in primary care education because they see physicians as public servants that offer a common good to society,” she says. “We already pay for residency training in the United States. What if we also paid for basic medical education and primary care training for doctors who are willing to stay in the field and work in areas with primary care shortages?”
	
	King, having grown up in a rural area herself, believes that targeted recruitment programs that reach out to students in rural areas as early as high school, should also be  considered. Brownlee agrees.
	
	“Some people who live in these communities are just looking for a way out. But many are looking for ways to stay and serve,” she says. “We can put forth a concerted effort to recruit people from these underserved areas and show them that a career in medicine is not only possible but possible to pursue in their hometowns.”
	
	Changes to medical education are also important. The addition of rural residency programs, where doctors can be trained in rural hospitals or other rural care settings, should be a vital part of this effort, says Schmitz. Doctors who train in these resource-limited environments can gain both the competence and confidence to thrive in a rural environment, making it much more likely that they’ll stay after they complete their programs.
	
	“People go to medical school for all kinds of different reasons,” he says. “But if the reason is to make a real difference, there are very few opportunities that offer as many ways to make a real difference as rural medicine. You just won’t know that until you actually practice it.”
	
	Finally, Chandra says, there is  an opportunity for telehealth technologies to provide additional support and expand healthcare access for underserved rural communities, at least for diagnostic purposes.
	
	“In terms of providing better care to communities, telemedicine is a great idea,” he says. “You can connect someone who lives in rural Maine to one of the best physicians in Boston for evaluation. But, unfortunately, no matter how good a telehealth technology is, it’s just not going to be a solution if a patient needs a basic procedure or hospital care.”
	
	King says telehealth does offer much-needed support for physicians, allowing those who work in rural areas to consult with specialists when needed. But given that access to high-speed internet-and sometimes any internet-can often be spotty in many remote regions, larger urban hospitals sending specialists to rural community health clinics to see patients on a monthly basis could be more effective.
	
	“If we could have gotten a cardiologist to come in every month for a day to see my patients back in Jellico, it would have made a huge difference,” King says. “Something as simple as that can help us manage that distance barrier that keeps patients from getting to those specialty appointments that they so need.”
	
	Chandra says that the rural physician shortage is a complex issue, resulting from many factors. And effectively addressing it will require a multi-pronged approach.  When asked if she can see herself returning to rural practice, King says she’d be glad to. But, if she does, she believes rural Ohio, where she grew up, may be a better fit.
	
	“Rural medicine is very rewarding,” she says. “It’s a lot of hard work, and as a provider, you are going to find yourself wearing many hats, but it feels like you are doing something really meaningful. I wish more people could see that.”
	
	Chandra says that doctors, like King, who  serve rural communities really are the unsung heroes of modern American medicine.
	
	“They’re not publishing papers in the New England Journal of Medicine or developing new innovative medical devices, for the most part,” he says. “But they are providing care to patients who, historically, have been systematically underserved and, for many reasons, are really hurting. These providers are not only doctors, but they are social workers, counselors, and advocates for their patients. They do it all. We don’t praise them enough.”

How can the healthcare industry better encourage doctors to practice in rural settings?

September 10, 2019 edition

How to rev up practice productivity

Medical Economics cartoon: What to do with patients while they wait?

Your voice: Expanding the roles of NPs and PAs will make primary care more desirable

What the internet of medical things means to your practice

Coding for revenue

Dealing with the shortage of rural physicians