Choosing wisely: Five services that merit extra scrutiny

As part of a national campaign called Choosing Wisely, the American Academy of Family Physicians this week released a list of five tests and treatments that family physicians should think twice before performing, ordering, or prescribing:

• Don't do imaging for low back pain within the first six weeks unless red flags are present.

• Don't routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for 7 or more days OR symptoms worsen after initial clinical improvement.

• Don't use DEXA screening for osteoporosis in women under age 65 or men under 70 with no risk factors.

• Don't order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

• Don't perform Pap smears for women under the age of 21 or those who have had a hysterectomy for non-cancer disease.

The AAFP is one of nine specialty societies taking part in the Choosing Wisely initiative, which the American Board of Internal Medicine Foundation spearheaded. The purpose of the initiative is to encourage and facilitate discussions between physicians and patients about the potential for overuse or misuse of health care resources. Learn more about the AAFP's involvement in the Choosing Wisely campaign in AAFP News Now.

Posted at 09:09AM Apr 06, 2012 by Leigh Ann Backer  |  Comments[0]

Are you satisfied with your EHR system?

The adoption of electronic health records (EHRs) is on the rise, thanks in part to federal incentives for meaningful use of certified EHR technology. However, increased use does not necessarily mean that EHR systems are living up to users' expectations.

A recent FPM online reader poll asked, "Are you satisfied with the EHR system your practice uses?" Most respondents (44 percent) said they are not satisfied with their EHR system, while 35 percent said they are satisfied and 21 percent indicated that they do not use an EHR.

To view satisfaction ratings for individual EHR systems, based on a separate survey, read the recent FPM article "The 2011 EHR User Satisfaction Survey: Responses From 2,719 Family Physicians."

The online reader poll was conducted between July 12 and Nov. 14 and included 544 responses. Poll results are not scientific and reflect the opinions of only those users who chose to participate.

To take the latest reader poll, visit the FPM web site.

Posted at 08:36AM Dec 02, 2011 by Brandi White  |  Comments[0]

Blended payment model initiative values primary care

Amidst the doom and gloom of the 27.4 percent fee cut called for in the 2012 Medicare Physician Fee Schedule and the all-too-familiar uncertainty about whether Congress will once again intervene at the 11th hour to patch the flawed formula that gives rise to this annual crisis, there is a hopeful sign, and we want to make sure you don’t miss it. A new demonstration project announced by the Center for Medicare and Medicaid Innovation (CMMI) last month will pay participating primary care physicians a care coordination fee in addition to fee-for-service – the blended payment model that has long been at the center of the AAFP’s payment reform advocacy efforts. 

The fee, which will range from $8 to $40 ($20 on average) per patient per month for Medicare and Medicaid patients and for patients who are enrolled in participating private-sector plans, is designed to compensate physicians for the administrative costs associated with patient-centered medical home services. Practices must meet several criteria to qualify for the project, known as the Comprehensive Primary Care Initiative (CPCI), including use of an electronic health record system and other criteria characteristic of patient-centered medical homes. The blended payment model also includes the potential for physicians to share in savings resulting from the initiative.

The project will be rolled out in five to seven health care markets next summer, each with about 75 primary care practices participating. Physicians will apply to participate next spring, after the markets have been identified. If the project demonstrates improved quality and lower costs, the Centers for Medicare & Medicaid Services has the authority to expand the initiative across the country.

Look for more details about the CPCI in the January/February issue of FPM.

Posted at 01:24PM Nov 11, 2011 by Leigh Ann Backer  |  Comments[0]

Health care professionals increasingly recommend flu vaccine, but more work to be done

Forty-three percent of the U.S. population received the influenza vaccine last season, a steady increase over the last several years, according to a new survey from the National Foundation for Infectious Diseases (NFID). While the rate is trending upward -- thanks to an ample supply of flu vaccine, more vaccination options and venues, and an increase in recommendations by health care professionals -- more steps need to be taken to educate patients about the importance of vaccination, says the NFID.

In particular, healthy adults need to get the message that they too need a flu shot. According to the survey, only 63 percent of respondents believe influenza vaccination is now recommended for all Americans over 6 months of age, even though universal vaccination was adopted last year.

The good news is that health care professionals are increasingly recommending influenza vaccination. The proportion of adults who reported that a health care provider recommended the vaccine is up to 68 percent, a 10-percent increase from 2010. And 60 percent of those vaccinated say they did so as a result of a recommendation from a health care professional, up from 44 percent in 2010.

Nearly two-thirds of adults reported that they intend to get vaccinated this year. Those who do not intend to get vaccinated say the following factors could change their mind:

• The belief that if they don't get vaccinated they might infect others with the flu who could become seriously ill (54 percent),
• The experience of watching a family member or friend become very sick with the flu (37 percent),
• A recommendation from a health care provider (34 percent),
• Reassurance of vaccine safety (31percent),
• Greater convenience (24 percent),
• Lower cost/free (24 percent),
• A recommendation from an employer (21 percent),
• Less pain/no needles (18 percent).

In addition, some patients still have misconceptions about influenza and vaccination, such as “Hand washing alone works just as well, or better, than vaccination as a means of influenza prevention” (26 percent) and “Influenza vaccine protects against just one type of flu – or strain – each year” (43 percent). Health care professionals can play an important part in correcting these misconceptions.

The survey was based on telephone interviews conducted in August with 1,006 adults. The margin of error is ±3 percent.

Posted at 11:50AM Sep 22, 2011 by Brandi White  |  Comments[0]

Time to get rewarded for your practice improvements

If you’re like most family physicians, the term quality improvement may have at least as many negative associations as positive ones. It may conjure up memories of endless meetings, laborious PDSA cycles and “improvements” that never seem quite worth the time and effort involved. For some people, too, the term seems to refer to improvements in the quality of patient care only, as if the quality of your business operations, the quality of your relations with staff and the quality of numerous other dimensions of your practice – not to mention the quality of your professional life – were of no import.

As you know, FPM takes a broader view of quality; anything you can do to make your practice work better is to the good, whether you’re improving collections or A1C levels, exam-room stocking or immunization rates. The whole purpose of FPM is to help make improvement easier, and now, for the second year, we’re offering an incentive, in the form of the FPM Award for Practice Improvement.

If, in the past three years, your practice has made improvements you’re proud of, whether they’re improvements in clinical outcomes, clinical process improvement, patient satisfaction, staff satisfaction, physician satisfaction or practice efficiency and productivity, your practice could win a cash award of $500, a framed certificate and two registrations to the Conference on Practice Improvement, Dec. 1-4 in Newport Beach, Calif.

The catch? It’s just that the deadline for applications is almost upon us. Your entry must be submitted by Sept. 1, 2011, to be considered for this year’s award. Still, it’s not hard to apply; see http://www.aafp.org/fpm/award for details.

Posted at 10:00AM Aug 10, 2011 by Bob Edsall  |  Comments[0]

Hospitals looking to add primary care physicians to their staffs

As a first step to prepare for accountable care organizations (ACOs), hospitals are attempting to lure primary care physicians away from their private practices and into salaried employee positions, reports The Washington Post.

In 2008, hospitals owned about half of private physician practices, according to the article. Last fall, a HealthLeaders survey found that 74 percent of hospital leaders say they plan to hire more physicians – mostly primary care physicians – in the next one to three years.

The movement is causing many physicians to reconsider the way they practice medicine. They are having to decide whether the security of an employed position is worth the trade-off of losing some freedom in how they care for their patients. The Post quoted one family physician who rejected a hospital's offer as saying, "It's like the local coffee shop versus Starbucks."

It is unclear how this shift will affect patients. Some believe patients will benefit from one-stop medical shopping with primary care physicians and specialists working under the same corporate roof. Others believe that the economics of ACOs could put added pressure on salaried physicians to meet the bottom line, which could hurt the patient-physician relationship.

Stay tuned
If you're considering a change from private practice to employed practice, look for an article on this subject in the July/August issue of FPM. And look for an overview of ACOs coming this fall.

Posted at 12:31PM Jun 29, 2011 by Lynn Hofeldt  |  Comments[0]

One month left to avoid e-prescribing penalty

Posted at 04:00PM Jun 02, 2011 by Brandi White  |  Comments[0]

Five ways to improve quality and reduce costs in primary care

Physicians are often told that they should improve quality and reduce costs in their practices, but they aren't often told what specific steps they can take to accomplish this. A group of researchers from the National Physicians Alliance is trying to change that. They have developed a report listing the top five ways primary care physicians can improve quality while reducing costs.

The report, published in the Archives of Internal Medicine, offers separate recommendations for each of the primary care specialties -- family medicine, internal medicine and pediatrics. The evidence-based recommendations compiled by the researchers were field tested by 255 physicians to verify their relevance and validity.

For family medicine, the five recommendations are:

1. Avoid doing imaging of the lumbar spine within the first six weeks of symptoms unless the patient has certain risk fractures, such as prolonged exposure to corticosteroids.

2. Avoid routinely prescribing antibiotics for patients with acute mild to moderate sinusitis unless their symptoms have lasted for at least seven days or have worsened after initially improving.

3. Avoid ordering annual ECGs or other cardiac screenings on patients with low risk and no symptoms of coronary heart disease.

4. Avoid performing Pap tests on patients younger than 21 years or those who have had a hysterectomy for a benign disease.

5. Avoid the use of DEXA screening for osteoporosis in younger, low-risk patients (e.g., women under the age of 65 or men under the age of 70).

Researchers acknowledged that physicians could have difficulty avoiding unnecessary tests and treatments if patients aren't on board. They underscored the importance of acknowledging the patient's concerns, clearly explaining the rationale for a selected course of action and offering a back-up plan should the patient's problem continue.

Posted at 11:37AM May 27, 2011 by Brandi White  |  Comments[0]

Physician groups demand that Congress repeal the SGR

Last week, the nation's largest physician groups -- the AAFP, the AMA and the American College of Surgeons -- asked Congress to repeal Medicare's sustainable growth rate (SGR) formula, which threatens to cut physicians' Medicare payments each year. The groups proposed a five-year transition period for testing different payment models and finding one that works.

AMA President Cecil Wilson said in a written testimony, "The only way to start on a path to permanently reform the physician payment system is to repeal the SGR." He went on, "Replacing the SGR ... should not be another one-size-fits-all formula. Rather, a new system should involve transitioning to a new generation of payment models that reward physicians and hospitals for keeping patients healthy, managing chronic conditions in a way that avoids hospitalizations, and, when acute-care episodes occur, delivering high-quality care with efficient use of resources. We envision physicians choosing from a menu of payment models, selecting ones that best address their patients' needs, specialty, practice type, capabilities and community."

AAFP President Roland Goertz requested that primary care physicians get at least a 2 percent higher payment update than others during the transition period. He testified, "Fee-for-service recognizes medical care as a series of things physicians do. ... But what the formula cannot do is pay for thought, analysis, deduction, discussion and persuasion and for the value that comes from managing the care of the whole person, as well as the value that comes from avoiding unnecessary care."

Lawmakers have promised to repeal the SGR formula this year, but doing so would cost nearly $300 billion. If Congress doesn't act in time, physicians would face a 29.5-percent cut in Medicare payments on Jan. 1, 2012.

Posted at 05:09PM May 09, 2011 by Lynn Hofeldt  |  Comments[0]

Have you gotten your primary care bonus payment yet?

Most family physicians should be receiving their first quarterly bonus payment from Medicare this month under the Primary Care Incentive Program (PCIP).

The PCIP, established under the Patient Protection and Affordable Care Act, allows primary care physicians to receive bonuses equal to 10 percent of the amount Medicare paid them for primary care services (CPT codes 99201-99215 and 99304-99350) if at least 60 percent of their total Medicare allowed charges are for primary care services. Physicians were not required to take action to receive the bonuses; instead, the Centers for Medicare & Medicaid Services (CMS) has furnished Medicare administrative contractors with a list of eligible providers. (For more information, see "The secret to getting a 10 percent Medicare bonus in 2011.")

The AAFP estimates that 80 percent of family physicians qualify for the bonuses, which are scheduled to continue through 2015.

Some Medicare administrative contractors (MACs), such as Cahaba Government Benefit Administrators, have set up an online PCIP look-up tool to help physicians find out if they are eligible for the bonus program. And at least one MAC, Highmark Medicare Services, has formally announced that it has begun issuing these payments to eligible physicians.

For physicians who qualify, the PCIP payments will arrive on the same check as other Medicare bonuses, such as the health professional shortage area (HPSA) payments, if applicable. They will be labeled "special incentive remittance" to help physicians identify them. Payments will be assigned to the practice unless the physician is listed as a solo physician in CMS' records.

We want to hear from you!
If you've received your bonus, let us know. Was it less than you expected? More? Or, if you're still waiting for your check, we'd like to hear that as well.

Posted at 10:42AM Apr 26, 2011 by Brandi White  |  Comments[2]

ACO proposed rule outlines risks and rewards for doctors and hospitals

Yesterday, the Department of Health and Human Services (HHS) released the much-anticipated proposed rule for accountable care organizations (ACOs) under the Medicare Shared Savings Program. ACOs are a model of care in which doctors, hospitals and other institutions work across settings to coordinate and improve care for a population of patients and take part in any cost-savings achieved. ACOs were a key part of the Affordable Care Act, which specified that they be operational as early as January 2012.

The proposed rule offers two options for developing ACOs:

1) ACOs willing to take on more risk could pocket bonuses of up to 60 percent of any savings they achieve for the Medicare program. If they fail to achieve the minimum savings rate and fail to meet specified performance standards, they would have to repay Medicare up to 10 percent of what their patients would have cost if they weren't in an ACO.

2) ACOs that are more risk adverse could opt for a smaller share (up to 50 percent) of any savings they achieve (after a two-percent threshold is met, with exceptions for small ACOs in rural or underserved communities), but they would assume no risk for the first two years. In year three, a penalty of up to 7.5 percent would apply if the ACO failed to meet performance standards or achieve the targeted savings.

The proposed rule includes 65 performance measures related to patient experience of care, care coordination, patient safety, preventive health and at-risk population/frail elderly health. In year one, ACOs must simply report the quality measures. The measures are aligned with those used in other Medicare programs such as the Physician Quality Reporting System (PQRS). ACOs that successfully report the quality measures would be eligible for the PQRS bonus as well.

The proposed rule provides flexibility in the structure and participants of an ACO; however, it states that ACOs must include "primary care ACO professionals that are sufficient for the number of Medicare fee-for-service beneficiaries assigned to the ACO." In addition, the ACO must take responsibility for a minimum of 5,000 Medicare beneficiaries, and its governing body must include primarily health care providers who belong to the ACO as well as representatives of the community and Medicare patients being served.

"Whatever form ACOs eventually take, one thing is certain: the era of fragmented care delivery should draw to a close," wrote Don Berwick, MD, CMS Administrator, in the New England Journal of Medicine.

The proposed rule also includes a provision to relax antitrust laws that currently prevent close collaboration between physicians and hospitals. Rural providers and new ACOs with less than 30-percent market share would be given leniency. For larger proposed ACOs, the Federal Trade Commission would have 90 days to determine whether the new entity would violate antitrust laws.

The AAFP and AMA have raised concerns that the large capital investments required for startup and the requirement that an ACO have at least 5,000 Medicare patients could prevent physicians in small practices from participating.

CMS will accept comments on the proposed rule until June 6 before issuing a final rule later this year.

Related reading:

The ACO Model – A Three-Year Financial Loss? NEJM. March 23, 2011.

Case Study of a Primary Care-Based Accountable Care System Approach to Medical Home Transformation. J Amb Care Manag. January/March 2011.

Don't Think the ACO Model Works Within Primary Care? Think Again. AAFP News Now. March 16, 2011.

Launching Accountable Care Organizations – The Proposed Rule for the Medicare Shared Savings Program. NEJM. March 31, 2011.

Posted at 04:28PM Apr 01, 2011 by Brandi White  |  Comments[2]

Flat-rate medicine: The future of health care?

A new model of health care, called flat-rate medicine, is popping up around the country in primary care offices. In these practices, which are similar to concierge practices but generally more affordable, patients pay a monthly fee -- usually ranging from $50 to $150 -- for unlimited, 24/7 primary care that includes everything from preventive care to chronic disease management.

This model is said to save money because the patients have fewer emergency department (ED) visits and hospitalizations, and it cuts the middle men -- insurance companies -- out of the equation, letting doctors spend more time with fewer patients with less overhead.

One practice example is Qliance, a Seattle-based primary care practice that compares its setup to a health club membership, but for health care. According to NPR's health blog, the setup is working. In 2010, Qliance patients had 65 percent fewer ED visits and 35 percent fewer hospitalizations, when compared to benchmarks for its region.

To learn more, watch this video on NBC Nightly News with Brian Williams.

Posted at 01:29PM Mar 23, 2011 by Lynn Hofeldt  |  Comments[1]

Family medicine attracts more students in 2011 residency match

For the second year in a row, family medicine residency training programs have attracted more students in the National Residency Matching Program. According to early results, 1,317 U.S. medical school seniors matched with family medicine – an 11-percent increase over 2010. The total number of medical school seniors choosing family medicine was 2,576 – a 7-percent increase over 2010. The overall fill rate for family medicine for 2011 was a record 94.4 percent.

Family medicine Match data, 1997-2011

"Primary care has become much more visible as a result of the discussion about improving our health care system," said AAFP President Roland Goertz, MD, MBA. "More people understand that if we're to have high-quality care at a controllable cost, we need to rebalance our system on a foundation of primary medical care.

"Add in the heightened awareness through activities of the Family Medicine Interest Groups, and students began to understand that family physicians will be able to practice the kind of medicine they envisioned when they decided to become a doctor.”

Among the other primary care specialties, pediatrics saw a 3-percent increase and internal medicine saw an 8-percent increase in the number of U.S. medical school seniors who matched with their residency programs. Emergency medicine, anesthesiology and neurology also saw healthy increases.

Posted at 01:25PM Mar 18, 2011 by Brandi White  |  Comments[0]

The "Flow" blog – for getting your head back in the game

If you haven't yet encountered FPM's newest blog, "Flow: Family Medicine in the Zone," I'd recommend a visit. The author, Kim Leatham, MD, who practices family medicine on Bainbridge Island in Puget Sound, is one of the leaders of the effort to transform primary care at Virginia Mason Medical Center. Her aim is to achieve the quality of practice you can get only when you are wholly absorbed in your work, focused, "in the moment," or, as the blog title has it, "in the zone." What she has learned – and continues to learn – in the process of transforming her practice and helping others in Virginia Mason transform theirs, can help you do the same in your practice.

Leatham's first two "Flow" entries set the tone. Her introduction defines flow and outlines the scope of the blog, and her second entry gets down to business, explaining why patients think her MA is wonderful – whoever happens to be working as her MA – and how you can get the same reaction from your patients. Clearly, it's a blog that's well worth watching.

Posted at 03:37PM Mar 16, 2011 by Bob Edsall  |  Comments[0]

Study: Physician use of Twitter

A physician-led study suggests that some physicians may need education and accountability to ensure that their use of social media sites like Twitter does not negatively affect the ethical or professional standards of their practice of medicine.

The study, led by Washington-D.C. physician Katherine Chretien, MD, found 260 self-identified physicians on Twitter and analyzed their 20 most recent tweets. Out of the 5,156 total messages, the content broke down like this:

• 49 percent (2,543) were health or medical related,
• 21 percent (1,082) were personal communications,
• 14 percent (703) were retweets (i.e., another user's tweets were resent),
  
• 12 percent (634) were self-promotional,
• 1 percent (73) recommended a medical product or service,
  
• 1 percent (31) were related to medical education.
  

In addition, nearly 3 percent of the physicians' tweets were considered unprofessional -- 0.7 percent represented potential patient privacy violations, 0.6 percent contained profanity, 0.3 percent included sexually explicit material, 0.1 percent included discriminatory statements and 1 percent were coded as "other unprofessional." This included tweets promoting specific health products the physicians were selling and medical treatments not supported by existing medical knowledge.

To read more on this topic, see "The Doctor Will Tweet You Now" on NPR's health blog.

You can follow FPM on Twitter at www.twitter.com/fpmjournal.

Posted at 09:15AM Mar 02, 2011 by Lynn Hofeldt  |  Comments[0]