Executive orders and family medicine
Amid the furor surrounding other executive orders recently signed by President Donald Trump, family physicians may find one on which they can agree.
On Jan. 30, the administration issued an executive order titled, “Reducing Regulation and Controlling Regulatory Costs.” The order establishes a framework designed to reduce the cost of compliance with federal regulations. First, it provides that federal agencies, when proposing a new regulation, must “identify at least two existing regulations to be repealed.” Second, it requires that the incremental cost of any new regulation be “no greater than zero.”
The stated intention of the executive order is to decrease the cost of running a business (such as a family medicine practice), to the extent that regulations from federal agencies contribute to such costs. The order says that all new regulations must be cost-neutral and that the net impact (new regulation minus the two repealed regulations) cannot increase "incremental costs" on the regulated community. Finally, exceptions will be considered on a case-by-case basis.
The implementation of the order is left to the Office of Management and Budget (OMB). On Feb. 2, OMB issued to all government agencies a memo containing interim guidance and frequently asked questions on how to implement this order. This memo clarifies that:
• The order applies to "significant" regulations. "Significant" is not defined in the guidance, but under a 1993 Executive Order still in effect, a "significant" rule is defined as any that imposes an annual economic cost of $100 million or more.
• Government agencies intending to issue a “significant regulatory action” on or before Sep. 30, must first “identify two existing regulatory actions the agency plans to eliminate or propose for elimination” before the new regulation is issued.
• Agencies must “fully offset total incremental cost” of the new regulation as of Sep. 30.
• The costs of regulations are “measured as the opportunity cost to society,” defined as "the net benefit [a] resource would have provided in the absence of the requirement."
• Waivers exist for regulations that address health, safety or financial emergencies.
Future rules governing Medicare physician payment (such as those
implementing the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA)
could be shaped by this order. Stay tuned!
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
University of Colorado clinic wins 2016 FPM Award for Practice Improvement
The University of Colorado School of Medicine Department of Family Medicine has won this year’s Family Practice Management (FPM) Award for Practice Improvement. The department was presented with the award Friday during the Society of Teachers of Family Medicine Conference on Practice Improvement being held in Newport Beach, Calif.
FPM Editorial Advisory Board member John Bachman, MD, presented the award to the department’s medical director, Corey Lyon, DO.
The program was recognized for its success in implementing a team-based model to address access issues, poor outcomes, and burnout. Implementation included increasing provider support with additional medical assistants and support staff, and expanding their roles.
“Culture will eat strategy for breakfast, lunch, dinner, and a midnight snack,” Lyon said. “We had to move beyond the culture of ‘I can’t do that. That’s not how we do it.’”
After one year, monthly visits increased 25.6 percent. Staff costs per visit were unchanged, but monthly charges increased 20 percent. Additionally, provider self-reported burnout was reduced by half.
Survey shows troublesome practice environment could affect patient access
Negative opinions about the state of medicine has large numbers of physicians planning to change their practices in ways that would decrease access to patients, according to a new study by The Physicians Foundation and Merritt Hawkins.
Almost half of the more than 17,000 physicians surveyed this spring said they planned over the next one to three years to cut back on hours worked, retire, take a non-clinical health care position, switch to a cash-only practice, or take other steps that would ultimate reduce access to patients.
"(The survey) reveals a physician workforce that continues to be dispirited about the current state of the medical profession and apprehensive about its future, due primarily to the large regulatory burden physicians face and the perceived erosion of their clinical autonomy," the researchers said in the report.
Overall, only 52 percent of physicians said they planned to remain working at the same level they are now. That represents a decline from 2014 when 56 percent of physicians surveyed said they didn't plan to change their practice.
The reasons for the negative changes are widespread. Almost 63 percent of respondents said they felt either "very" or "somewhat" pessimistic about the future of medicine, which was an increase from 51.1 percent in 2014. Eighty-one percent of physicians said they were overextended or at full capacity and unable to see more patients.
That said, many physicians aren't ready to abandon medicine entirely. Almost 72 percent of respondents said they would choose medicine as a career again, compared with 71 percent in 2014 and 67 percent in 2012. When asked if they would still recommend medicine as a career to their children or other young people, 51 percent said they would, up slightly from 50 percent in 2014.
Primary care physicians were a little more optimistic than their specialist peers, with 50.5 percent saying they are very or somewhat positive about the current state of medicine and 42.5 percent positive about the future of medicine. By comparison, 43.5 percent of specialists were positive about the present and 33.9 percent were positive about the future of medicine. Almost 73 percent of primary care physicians said they would choose medicine again as a career, compared with 71.4 percent of specialists, and 54 percent of primary care physicians said they would recommend medicine as a career to young people, compared with 50 percent of specialists.
The demographics of those responding to the survey showed the continuing trend of physicians leaving private practice for employed positions. Almost 33 percent characterized themselves as practice owners while about 58 percent said they worked for a hospital or large medical group. By comparison, 35 percent identified as practice owners in 2014 and 53 percent worked for large health groups and hospitals.
Looking at specific pieces of health care reform, only 43 percent said they were paid based on quality or value and 80 percent professed little knowledge of the Medicare Access and CHIP Reauthorization Act (MACRA). Only 11 percent of respondents said electronic health records have improve their interactions with patients, and only between 5 percent and 6 percent said the year-old ICD-10 coding has improved efficiency and revenues.
New insurer database tool could cut back on phone calls to physicians
The Council for Affordable Quality Healthcare (CAQH) has created a centralized way for physicians to update their information in insurance plan directories and reduce the amount of time they spend talking to insurance companies.
The nonprofit alliance of insurers and health care providers has created DirectAssure, a database that coordinates with CAQH’s current ProView tool used by more than 800 health plans for such things as credentialing.
CAQH said it will contact physicians designated by participating health plans at least once a quarter to ask them to review and update their information. Physicians can then log on to the system for free and update their location, contact information, specialty, and group/institution affiliation, as well as whether they’re accepting new patients.
CAQH said the health plans can check the DirectAssure system to make sure their directories are correct, instead of a physician receiving several calls from the plans themselves.
Besides making things easier for physicians, the new system is aimed at meeting new federal and state requirements that health plans do a better job of keeping their provider databases current and accurate and more useful to patients.
Surveyed physicans say burnout is increasing
A new study indicates the ongoing focus on physician burnout is not unwarranted. The number of physicians unhappy in their practices is on the upswing.
Medscape’s Lifestyle Report 2016 found that the burnout rate for physicians in 25 specialties surveyed went up from past studies. Fifty percent or more of respondents from a dozen specialties reported a lack of personal accomplishment, cynicism about their work, and a general lack of joy coming into the office.
Among those were family physicians, 54 percent of whom said they were burned out.
On a scale of one to seven, with seven being the worst, family physicians rated their feelings of burnout at 4.37. This was the seventh-highest severity rating, tied with cardiologists. Critical care physicians reported a slightly higher rating at 4.74. Psychiatrists reported the lowest rating at 3.85.
Female physicians again reported a higher prevalence of burnout (55 percent) than their male counterparts (46 percent), although both genders have seen a steady increase since 2013 (45 percent and 37 percent, respectively).
Respondents identified increased bureaucratic tasks as the leading cause of their burnout, although working too many hours, increasing use of computers, and inadequate income also scored highly.
The survey, which polled almost 16,000 physicians, also asked about potential biases toward specific groups of patients and how likely those biases affected the treatment they provided. It found that overall 40 percent of physicians reported some level of bias, with family physicians reporting the fourth-highest level at 47 percent. The highest was among emergency medicine physicians (62 percent), while the lowest was among pathologists (10 percent), a specialty that rarely deals with patients directly.
In terms of whether bias affected patient treatment, 11 percent of family physicians said it did, the same rate as orthopedists, psychiatrists, and rheumatologists. The highest rates were 14 percent of emergency medicine physicians and 12 percent of plastic surgeons. The survey noted that of those who reported that their biases affected how they treated their patients, 29 percent said the effect was negative, 25 percent said it was positive (e.g., overcompensation and special treatment), and 24 percent said it was a mix of the two.
The survey also suggested there may be a relationship between burnout, which can cause depersonalization, and bias. Forty-three percent of physicians who reported burnout also reported bias, whereas 36 percent of physicians who did not report burnout reported bias.
Five issues to watch in 2015
Family physicians spent much of 2014 wrestling with the seismic changes affecting medicine across the United States and in their practices. That won’t slow down in 2015. “The coming year will again be one of major transition for the U.S. healthcare system,” said Lou Goodman, PhD, president of The Physicians Foundation and chief executive officer of the Texas Medical Association, in a statement announcing the Foundation’s “Physician Watch List for 2013.” The list, based on the Foundation’s own research, policy papers, and physician surveys, identifies the five issues most likely to affect physicians and their patients this year.
1. Accelerating consolidation. Hospitals and health systems are buying up small practices and absorbing solo physicians at a faster pace. Besides affecting local competition, costs, and patient choice, the trend has physicians worried about clinical autonomy. The Foundation’s 2014 Biennial Physician Survey found that 69 percent of those participating said they had concerns about autonomy and being able to make the best decisions for their patients. It said that as the consolidation isn’t expected to slow down, hospitals and physicians must work together to prevent bureaucracy or other organizational factors from influencing medical decision-making.
2. The physician-patient relationship is stressed. The increased documentation of value-based reimbursement systems and perceived interference of health care employers are considered key external pressures on the relationship between patients and their physicians. In particular, physicians have told the Foundation that these factors are eating into their face-to-face interactions with patients while also limiting their choices of practice types and requiring more time spent negotiating with payers and vendors. These pressures will call for more reliance on practice support staff to help the physician retain as much focus on the patients as possible.
3. ICD-10 finally arrives. Physicians were given a one-year reprieve when the Centers for Medicare & Medicaid Services (CMS) postponed the implementation date for the new ICD-10 coding structure to Oct. 1, 2015. But the extra time likely won’t improve many physicians’ outlook or support. According to the Foundation’s survey, half of respondents expected ICD-10 to cause severe administrative problems in their practices and three-quarters said it will unnecessarily complicate coding. Still, it’s highly unlikely CMS will delay ICD-10 again, so practices need to make the necessary investment of time and money to be ready for the change.
4. Patients demanding the true cost of care. Medical costs were once a hidden algebra to the public, deciphered only by payers and health care administrators. But media focus in recent years on the lack of transparency in billing practices, as well as higher out-of-pocket costs for patients, has the public much more frustrated. The seeming arbitrariness of what certain procedures actually cost stands to make it harder for physicians to make the best clinical decisions and calls for policymakers, providers, and payers to build a more straightforward cost of care structure.
5. Patient access to care. As more people are gaining access to health insurance through the Affordable Care Act and demanding health care services, the overall number of physicians is declining or reducing the amount of time available to see patients. According to the Foundation, 44 percent of respondents in its survey said they were planning to reduce access to their services, such as shrinking their panels, retiring, going to part-time work, or taking non-clinical jobs. This could reduce patient access to care by tens of thousands of full-time equivalents (FTEs) in the future. The Foundation, along with the University of North Carolina-Chapel Hill, has developed a tool to help analysts and lawmakers to better gauge future shortages of physicians.
Goodman said the list shows the continued threat to small medical practices and that policymakers must “bring physicians into the fold to ensure the policies they implement are designed to advance the quality of care for America’s patients in 2015 and beyond.”
SGR, ICD-10 not the only targets of adopted legislation
Last week's SGR legislation didn't just push back Medicare cuts and delay ICD-10 implementation.
A new blog post by Betsy Nicoletti notes that the 123-page bill passed by Congress and signed into law by President Obama also requires additional reporting for lab test reimbursements and creates greater scrutiny of CT scans.
Health reform, regulations remain top issues to watch in 2014
Expect the continued rollout of the Affordable Care Act (ACA) and the ongoing changes in the health care landscape to dominate the minds of physicians and practices next year. That's according to The Physicians Foundation, which this week released its annual "Physician Watch List for 2014." The Foundation said it worried that the continued consolidation and regulatory requirements being applied to practices won't likely benefit health care in the long run. "While the promise of a better future for health care remains, the current path is leading us towards a more monopolistic, bureaucratic, and costly health care system," Lou Goodman, PhD, president of The Physicians Foundation and chief executive officer of the Texas Medical Association, said in a news release accompanying the 2014 list. The list, based on the Foundation's research and surveys, details five issues it expects to most affect patients and physicians in the coming 12 months.
1. Move to monopolies. The march of hospitals and large health groups gobbling up smaller practices continued in 2013 as it has for several years. The Foundation warned that as these growing entities begin to dominate their markets, they will hurt competition by driving patients away from independent physicians and toward more expensive hospital-based care. Consolidation is also affecting the insurer market, and physicians will find it harder to negotiate terms from a smaller pool of payers.
2. More bureaucracy. Physicians are already spending a significant amount of their time dealing with non-clinical paperwork – 22 percent, according to the Foundation's 2012 Biennial Physician Survey – and that will only get worse as practices must begin implementing the more documentation-intensive ICD-10 coding changes next October. They'll also need to stay on top of the next round of HIPAA changes, which focus on securing electronic transactions.
3. Navigating confusing new waters. As the ACA becomes reality next month, its implementation is confusing both to health care consumers and physicians. For instance, practices are unclear whether they'll see an ungovernable surge of new patients gaining coverage through the federal and state health insurance exchanges, despite enrollment glitches, or if they'll actually lose patients because of coverage changes. Also, they wonder if the exchanges will lead to lower reimbursement rates and how to deal with patients who may have never paid co-payments or deductibles – contributing to collection problems. A Kaiser Family Foundation study has said uninsured patients often have higher medical expenditures but fewer resources to pay for those services.
4. Information technology shortfalls. Much of health care reform is based on a greater use of technology. While many practices have adopted electronic health records, the various systems are hamstrung by not being able to communicate with each other, preventing them from providing additional efficiency and better care. Physicians are also on the lookout for as-yet unreleased regulations governing patient record security and privacy.
5. Lack of health care solutions. Physicians believe Washington, D.C., is not properly dealing with many of the key issues facing health care, such as finding a permanent solution to the Medicare Sustainable Growth Rate, implementing tort reform, and addressing "defensive medicine." Also, this fall's government shutdown had the potential to disrupt Medicare and Medicaid payments, and future shutdowns could foster additional mistrust and make potential students rethink medical school.
While these issues are thorny and complex, the Foundation said physicians can still play an important part in finding solutions because of their daily experience providing patient care. It said physicians' involvement in these discussions is "critical" and that policymakers should focus on increasing it.
Quality care linked to physician satisfaction
A new study suggests that physicians are most satisfied with their jobs when they believe they are providing high-quality care. Researchers said obstacles to such care can diminish physicians' satisfaction and point to hidden problems in the health care system.
The RAND Corp. survey also found that physicians are eagerly awaiting improvements in the operation of electronic health record (EHR) systems, saying that while they support the promise this technology has to improve clinical care, the inherent problems with user interface, data entry, and reduction of face-to-face interaction with patients represent significant obstacles to professional satisfaction.
The study, sponsored by the American Medical Association and released this week, surveyed 447 physicians in six states. While acknowledging that it was a relatively small sample size and not designed to represent practices on a national basis, the researchers said it did include voices from a wide number of practice types.
The study found that physicians generally have accepted the clinical and professional benefits of EHRs in their practices, with only one in five expressing an interest in staying with or returning to paper-only practices. But they continue to have serious misgivings about the current limitations of many EHRs. For instance, they complained that EHRs are frequently difficult to use, require too much time commitment for entering data, often don't share information with other EHR products, and result in less useful clinical documentation. Also, some practices continue to find the price tag for switching to an EHRs prohibitive.
While waiting for improvements, practices are trying to fix some of those problems themselves, including employing new or existing non-physician staff for data entry or to interact with the EHR while the physician focuses on direct patient care. The researchers recommended that federal authorities include improved usability as a key requirement for EHR certification.
Other findings included respondents saying that health care reform in general hasn't yet affected physician professional satisfaction in either direction, other than producing uncertainty. Several practices said they've responded to the economic uncertainty by joining a hospital or other large delivery system or, at least, are considering it.
Some other recent regulations, however, are having an effect, most notably the meaningful-use rules tied to EHR implementation. Respondents said the rules require too much time and paperwork for compliance.
As for primary care physicians in particular, the survey found some respondents complaining of physicians in other specialties treating them or their staff as inferior. They also said that their level of job satisfaction suffered when the pressure to provide more services to more people limited the amount of time and attention they could spend with individual patients. They also found that physicians of all kinds tend to get more satisfaction when they enjoy greater autonomy and control over the pace and content of their clinical work.
Respondents across the spectrum of health care also said they expected primary care physicians to see an increase in relative income in the future at the expense of sub-specialists.
Health insurance exchanges officially open
The online insurance marketplaces envisioned in the Affordable Care Act are now up and (mostly) running, which means a slew of new patients for family physicians may not be far behind.
Tuesday was the start of a six-month open enrollment period for people to buy health coverage through health insurance exchanges set up by the federal government or by individual states. The crush of visitors logging in to sign up caused delays for many state and federal exchanges, at least initially. Most people in the United States will be required to have health insurance or pay a tax penalty beginning early next year.
The Obama administration has said it hopes the exchanges (and an expansion of Medicaid) help reduce a significant portion of the millions of U.S. residents who lack health insurance. Those additional patients are expected to tax the current health care system, especially the number of family physicians and other primary care providers.
For more details on the exchanges, and the health reform law in general, visit the American Academy of Family Physicians' ACA website.
Physicians' ability to provide DOT physicals gets added twists and turns
If you're one of the thousands of family physicians who provide commercial truck and bus driver patients with their Department of Transportation-mandated physical examinations, change is coming.
New regulations going into effect May 21, 2014, will, for the first time, require that all medical professionals who provide these examinations be certified and registered by the Federal Motor Carrier Safety Administration (FMCSA).
Medical professionals have long performed the examinations to ensure drivers are physically qualified to operate a commercial motor vehicle. Typically, examiners had to be licensed, certified, and registered only according to laws in their respective states.
But the National Transportation Safety Board recommended creating a National Registry of Certified Medical Examiners to unify medical oversight of commercial drivers and ensure examiners understand and are trained on FMCSA physical qualifications and standards.
Officials said some examiners were certifying drivers with serious medical conditions that should have disqualified them from commercial driving, and some of those drivers were involved in fatal wrecks or crashes causing serious injury.
The new rule states that, in order to issue a DOT medical certificate, a medical professional must be either a doctor of medicine, doctor of osteopathy, doctor of chiropractic, physician assistant, advanced practice nurse, or any other medical professional authorized by the particular state's law to perform physical examinations. In addition, the individual must pass an examination of the FMCSA to become certified. Once certified and registered, a medical examiner must be recertified every 10 years and must complete periodic refresher training every five years.
The final rule establishing the national registry went into effect on May 21, 2012, and medical examiners have two years to become compliant.
For more information regarding this new rule and to find training opportunity locations, see the FMCSA's FAQ page.
– Renae Moch, MBA, CMPE, Practice Management Strategist for the American Academy of Family Physicians
Time running out for PQRS and eRx incentives
It's not too late to participate in a pair of federal incentive programs targeting clinical quality and computerized prescriptions. But you need to move fast.
The Centers for Medicare and Medicaid Services (CMS) this week hosted a national call to discuss how physicians and other eligible health care professionals can submit 2012 program year data for the Physician Quality Reporting System (PQRS) and the Electronic Prescribing (eRx) Incentive Program.
In case you missed it, below are some of the highlights.
For individual eligible professionals, you still have time to participate in the 2012 PQRS if you report your information either through a qualified registry or through a qualified electronic health record (EHR). The EHR option can communicate either directly or through a data submission vendor.
Registry vendors can submit data between Feb. 1 and March 31. EHR users can already submit their data, but they only have until Feb. 28. No submissions after the end dates will be allowed.
You may potentially qualify to receive a full-year incentive payment. But even if you don't, it's good experience in reporting PQRS measures before tackling 2013, which is the reporting period CMS will use in determining PQRS penalties in 2015.
The same options and dates apply with respect to the eRx Incentive Program. As with the PQRS, you may potentially qualify to receive a full-year incentive payment, and you may potentially qualify to avoid the 2014 eRx penalty. However, to avoid a penalty this year, you had to have complied with the program by June 30, 2012.
For more information on the programs, you can find the presentation from the national call online.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
New rule would let more family physicians treat veterans
While many family physicians want to treat the military veterans in their communities, the Department of Veterans Affairs (VA) hasn't always made that easy. Thankfully, the VA recently began taking steps to loosen its regulations in such a way that family physicians could have greater ability to serve veterans and get paid by the VA for doing so.
Under current law, private physicians can provide certain hospital care and medical services to eligible veterans when VA facilities either are not accessible or aren't able to provide the necessary care. These services are provided under the Non-VA Care program. However, the program allows that non-VA care only if the veteran initially received treatment during a period of hospitalization.
Last month, the VA published a proposed revision to this regulation in the Federal Register. The change would enlarge the list of eligible providers where the veteran initially received care to include nursing homes, domiciliary care, or other medical services. The VA could authorize non-VA treatment under the program for up to 12 months, with the option of additional reauthorizations as needed.
The American Academy of Family Physicians (AAFP) enthusiastically supports this step since it improves health care access for veterans and will allow the VA to better utilize community resources. Separate from this proposed regulation, the AAFP is encouraging the VA to identify and remove additional barriers that inhibit the way community-based family physicians are able treat their patients who also happen to be veterans. Specifically, the AAFP is urging the VA to reexamine a burdensome regulatory requirement that in order for a veteran to obtain a prescription at the VA's discounted price it has to be written by a VA-affiliated provider. Instead, AAFP believes the VA should recognize the validity of a community-based physician's prescription.
The VA’s recent proposal won’t eliminate all of the barriers that community family physicians face in trying to serve veterans. However, it appears to be a step in the right direction for both veterans and their family physicians.
–Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Comprehensive Primary Care Initiative resources
To help practices in the seven Comprehensive Primary Care Initiative (CPCI) markets announced this week, the American Academy of Family Physicians and TransforMED will offer a free webinar at 1 p.m. CDT on May 10, 2012. Bruce Bagley, MD, will present "CPCI Selected Markets: Preparing Your Practice for Participation." A webinar from Feb. 1, 2012, is also available for viewing – "The Comprehensive Primary Care Initiative: Qualification Requirements and How You Can Benefit." For more information about CPCI and these resources, visit http://www.aafp.org/cpci.
Comprehensive Primary Care Initiative: Coming soon to a market near you?
The Center for Medicare & Medicaid Innovation (CMMI) has identified the markets where it will test its Comprehensive Primary Care Initiative (CPCI), according to information posted yesterday on the CMMI website. CPCI, which was announced last fall, will test a payment model that offers physicians a monthly care management fee for each Medicare fee-for-service patient in their care as well as a share of any savings that the initiative generates. The following markets were chosen based on applications from payers:
- New Jersey,
- New York (Capital District/Hudson Valley Region),
- Ohio (Cincinnati/Dayton region),
- Oklahoma (Greater Tulsa region),
Approximately 75 practices in each market will be chosen to participate. CMMI will solicit applications from practices as soon as final agreements are signed with the participating payers, which include private health plans, state Medicaid agencies, and employers, as well as Medicare.
CPCI is a four-year initiative with a planned launch date this summer. If it is shown to improve quality of care and lower costs, CMMI has the authority to roll out the initiative nationwide. Read more about the initiative in Family Practice Management.
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