Medical schools taking additional steps to highlight primary care
U.S. medical schools are taking steps to get more of their students interested in primary care as student enrollment is expected to increase in coming years.
In a recent survey by the Association of American Medical Colleges' (AAMC) Center for Workforce Studies, 76 percent of medical school deans reported that they had or were planning at least one initiative aimed at generating more student interest in primary care. These included changing admissions criteria and curriculum, adding extracurricular opportunities, expanding faculty training, or offering reduced tuition and other financial incentives. The survey pointed out that these plans don't always become reality. Of the 46 schools that said in 2010 that they planned to establish primary care initiatives within two years, only a third had followed through by 2012.
Overall, the medical school deans surveyed estimated that first-year medical school enrollment would reach 21,434 by 2017. That's a 30 percent increase from AAMC's baseline school year of 2002.
More than three-quarters of medical school deans expressed concerns that there wouldn't be enough clinical training sites for their students, and 82 percent worried about the number of qualified primary care preceptors available to satisfy growing enrollment.
Forty-two percent also said they had "major concerns" about enrollment outpacing growth in the number of residency positions available nationally, although only 14 percent said they had "major concerns" over their students being able to find a residency position of their choice after graduation.
Regardless, the AAMC used the survey results to call for Congress to allocate more funding for residency positions; the AAFP and other medical organizations have expressed similar concerns.
Shortage concerns driving up first-year compensation for primary care
Competition for primary care physicians is leading practices to offer bigger initial paychecks and bonuses.
According to a survey released last week by MGMA-ACMPE, the median first-year guaranteed compensation for primary care physicians last year was $180,000, up from $175,000 in 2011.
Internists received the highest first-year median at $180,000, which didn't change from 2011. The median for family physicians (not including obstetrics) grew more than 4 percent to $170,000, while the median for pediatricians/adolescent medicine increased almost 7 percent to $160,000.
The MGMA Physician Placement Starting Salary Survey: 2013 Report Based on 2012 Data included responses from 5,225 providers in 629 medical organizations.
The researchers attributed the gains to growing concern that there won't be enough primary care physicians available when hundreds of thousands of new patients begin seeking care either because of age or new access to insurance under federal health care reform.
The report said practices are trying to attract brand new and experienced doctors with signing bonuses, paid relocation expenses, loan forgiveness, paid vacations, or continuing medical education.
The survey also measured doctor mobility and found that the Midwest saw the most movement of physicians away from the region last year, while the least movement occurred in the West.
FPM wins gold award for EHR user satisfaction survey
Family Practice Management (FPM) has been recognized for excellent content by the American Society of Healthcare Publication Editors (ASHPE).
ASHPE awarded FPM the Gold Award: Best Original Research for the article "The 2012 EHR User Satisfaction Survey: Responses From 3,088 Family Physicians." In the article, authors Robert L. Edsall, former FPM editor-in-chief, and Kenneth G. Adler, MD, MMM, FPM medical editor, described the performance of 31 commonly used electronic health record (EHR) systems across 19 dimensions of user satisfaction, such as vendor support, ease of learning, and the EHR's effect on productivity.
The article included the following findings:
• A majority of respondents (75 percent) said they considered themselves average or above average but not expert users of their EHR system,
• Thirty-eight percent said they are highly satisfied with their EHR system,
• Less than 20 percent said their EHR system helps them be more productive,
• Fifteen percent said they have switched EHR systems at least once because of unhappiness with a prior system,
• The EHR systems most commonly reported by physicians in small practices tended to rank highest in user satisfaction, perhaps because physicians in small practices are more involved in the selection process.
FPM has conducted the EHR user-satisfaction survey four times in the past eight years.
ASHPE's annual awards competition recognizes editorial excellence and achievement in the field of health care publishing.
Does knowing the cost of tests change physicians' decisions?
If you don't know how much the ribeye costs at the restaurant, are you still likely to order it?
Health care advocates are continuing to push for greater "transparency" in how consumers make decisions on their care, such as knowing how much certain procedures cost at various outpatient clinics or hospitals.
But what about doctors? Often, they don't know the prices either. They may order expensive tests due to clinical preference, medical defensiveness, or because past test results aren't easily available.
A group of researchers at The Johns Hopkins University School of Medicine decided to see whether physician ordering behavior would change if physicians actually saw the cost of certain lab tests before ordering them.
In a study published online this week in JAMA Internal Medicine, the group said it saw a 9.1 percent decrease in orders over six months for an "active" group of 30 lab tests for which physicians could see the Medicare allowable charge in the hospital's computer ordering system.
Orders for a "control" group of 31 tests, which lacked pricing information, rose 5.1 percent during the study period.
The smaller number of tests in the "active" group represented a $436,115 decrease in hospital charges.
"Although the overall financial impact is modest, our study offers evidence that presenting providers with associated test fees as they order is a simple and unobtrusive way to alter behavior," the authors said, noting also the study involved no other educational intervention or incentives.
They added that it's unclear how order reductions and savings would play out over multiple years, whether doctors would eventually ignore the prices and those changes would disappear, or whether the quality of patient care declined because of the lower testing.
But they said it was a promising area of future study considering that imaging and diagnostic testing increased 85 percent between 2000 and 2009 and multiple studies and public information efforts have identified reducing waste as one of the best ways to corral U.S. health care spending.
Pay for Performance still in minority of health care dollars
While "pay for performance" is at the center of many discussions about the future of American health care, a recent study of employer-provided insurance shows it still makes up a small – but growing – piece of the market.
Catalyst for Payment Reform (CPR), a group representing large employers and other major purchasers of health care, last month released its first National Scorecard on Payment Reform.
The survey of 57 commercial insurance plans, representing about half of all commercially insured lives, found that only about 11 percent of health care spending is currently tied to how well hospitals and physicians provide care or improve quality and reduce waste.
A little more than 89 percent of payments is still traditional fee-for-service.
The group said just 6 percent of payments to outpatient primary care physicians is value-oriented, identical to the amount for outpatient specialists. Hospitals were a little better, with 11 percent of payments tied to quality.
CPR said the market is moving in the right direction, estimating that 3 percent or less of payments were tied to value when the group formed in 2010. It also expressed interest in seeing more payments going to primary care, noting that 75 percent of outpatient payments were going to specialists.
CPR has set a goal of 20 percent of commercial payments being value-oriented by 2020.
Insurance plans that are targeting value are using a wide range of approaches, the study found, including adding shared savings to fee-for-service; bundled payments; full capitation; and shared risk. Overall, 57 percent of value-based payments penalized providers for missing quality or cost goals, as opposed to the 43 percent that provided bonuses or other incentives.
To learn more about pay for performance, read this article from the FPM archives: What Family Physicians Need to Know About Pay for Performance.
Medical Home Summit takes the temperature of the PCMH
Last week, the Fifth Annual Medical Home Summit was held in Philadelphia, attracting more than 300 physicians, practice managers and other industry members to discuss the current state of practices moving to the patient-centered medical home (PCMH) model.
The model is no longer an experiment, with conference co-chair Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, saying that more than 4,600 sites and 8,300 clinicians were recognized as medical homes in 2012 by the National Committee for Quality Assurance (NCQA), up from just 28 sites and 214 clinicians in 2008.
Much of the discussion was on the many paths organizations across the country are taking to become medical homes and use that structure to improve patient care and patient experience and control health care costs.
Here are five key themes that emerged during the four-day conference:
1. Patients and their families are a key resource in designing how your medical home is built and how to measure its success. Several speakers recommended establishing patient advisory panels so you can make sure that how you provide care and outreach services matches what patients actually want. Also, asking patients' families how they evaluate their health care experience is helpful instead of relying on purely clinical data or process information. Said one presenter, "We often ask things they don't care about."
2. Going hand-in-hand with that involvement is the need to make patients more responsible for their own care, presenters said. That doesn't mean giving up your clinical expertise but instead truly making them part of the team and helping them realize they're not just consumers of health care but "experts" on their own health care needs. Presenters said this involves finding ways to give patients a "voice" in their care that they didn't know they had, but it also will require retraining physicians, nurses, and other providers who were likely not taught non-medical collaboration skills in school.
3. Technology is both an accelerant and a damper on the true opportunity of a medical home. Electronic health records (EHRs), with the ability to help physicians parse their patient panel and identify the sickest individuals or those needing better care coordination, could help make medical homes far more targeted and effective in reducing unnecessary care and cost. But several physicians also complained that many EHRs simply aren't flexible enough to support the wide variety of operational and financial quirks physicians can build into their medical homes and that EHRs lack the interoperability to adequately share data between providers. More technology advancement is needed, they said.
4. Medical homes will continue to rely a great deal on non-physician providers. In fact, several speakers said that how doctors include registered nurses, licensed vocational nurses, physician assistants, medical assistants, and a patchwork of "community care teams," "patient navigators," and "pre-visit planners" in their medical homes' operation will determine if their efforts are successful. That's because medical homes are supposed to create efficiency, they said, letting the physician focus on the sickest patients and letting the rest of the team handle the day-to-day care coordination that will ultimately keep patients out of the doctor's office or hospital. For more information on the roles of medical assistants in medical homes, see this recent Family Practice Management article.
One of the meeting's bigger moments was during a presentation by Camden, N.J., physician Jeffrey Brenner, MD, who suggested that health care groups that don't do a better job of coordinating routine care through their physician offices could find themselves upended and put out of business by nurse practitioners doing many of those preventive procedures themselves. In fact, he compared nurses with the advent of Netflix and other "disruptive" market forces that ultimately reshaped entire industries.
5. Everything still hinges on getting paid. As speakers discussed their own practice designs, complexity of patient panels, and relative success in improving patient outcomes, many returned to the question of when commercial payers or their state Medicaid programs might recognize and pay for the medical home approach. The National Academy of State Health Policy saying that 28 states now have some form of PCMH payment, and the consensus was that most major insurance companies are increasing their interest in the potential benefits of the medical home approach and that "shared savings" – where the provider and the insurer split any savings on the cost of care – is an emerging payment model. Presenters said creating payment schemes where physicians aren't in danger of making less than a certain amount per patient because of "shared risk" (although still able to receive bonuses for improved quality) provides the best chance of motivating physicians to form a medical home.
Osteopathic match program shows some gain for family medicine
Family medicine continued to attract the highest number of specialty residents in this year's American Osteopathic Association match program, increasing 9 percent over the previous year.
According to statistics provided by National Matching Services Inc., 472 students received positions for family medicine programs this year, compared with 433 in 2012.
The next closest specialty was internal medicine, which saw the number of matched residents rise 8.9 percent from 369 to 402.
A total of 1,891 osteopathic medical school students participated in this year's matching program, up 7 percent from last year.
The much larger National Resident Matching Program, which primarily deals with allopathic medical school students, will release its results the week of March 11th.
In 2012, family medicine saw an increase in the number of positions filled in the match, but the majority of matched positions were in non-primary-care subspecialties.
Five (more) services you should avoid
The American Academy of Family Physicians (AAFP) has released a second list of tests and procedures that tend to be overused and merit scrutiny on the part of family physicians and patients. The five recommendations are part of a national campaign called Choosing Wisely, and they include the following:
1. Don't schedule elective, nonmedically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.
2. Avoid elective, nonmedically indicated inductions of labor between 39 weeks, 0 days and 41 weeks, 0 days unless the cervix is deemed favorable.
3. Don't screen for carotid artery stenosis in asymptomatic adult patients.
4. Don't screen women older than 65 years of age for cervical cancer if they have had adequate prior screening and are not otherwise at high risk for cervical cancer.
5. Don't screen women younger than 30 years of age for cervical cancer with HPV testing, alone or in combination with cytology.
The AAFP has provided a downloadable resource that lists the rationale and literature supporting each of these recommendations. It also includes the initial list of recommendations, which addressed imaging for back pain within the first six weeks, antibiotics for mild to moderate sinusitis, annual EKGs for low-risk patients, DEXA screening in younger patients, and Pap smears in young women who have had a hysterectomy.
The AAFP is one of nine specialty societies taking part in the Choosing Wisely campaign spearheaded by the American Board of Internal Medicine Foundation to identify over-utilized services and encourage discussions between physicians and patients.
John Bachman, MD, joins FPM Editorial Advisory Board
Minnesota family physician John W. Bachman, MD, was recently named to the Family Practice Management Editorial Advisory Board.
Bachman is vice chairman of education for the Mayo Clinic's Department of Family Medicine in Rochester, Minn. He also serves as a consultant to the department and as professor of family medicine for the clinic's College of Medicine.
He was appointed to FPM's six-member board in January following the appointment of former board member Kenneth G. Alder, MD, MMM, to medical editor.
The board is an independent advisory body of physicians who help FPM's editors ensure the journal meets the needs of its readers.
CMS finally sets start date for reporting physician gifts under Sunshine Act
Starting Aug. 1, drug and device manufacturers that receive government reimbursements must begin collecting data on gifts and payments they provide to physicians and teaching hospitals, according to the long-delayed final rule of the Physician Payment Sunshine Act, known officially as the National Physician Payment Transparency Program: Open Payments.
The final rule requires companies to submit 2013 data to the Centers for Medicare & Medicaid Services (CMS) by March 31, 2014. Physicians will have 45 days to review and dispute their data before it becomes public, no later than Sept. 30, 2014.
The rule also requires manufacturers and group-purchasing organizations to disclose physician ownership or investment interests. Companies that fail to do so could face fines of up to $1 million.
Passed as part of the Affordable Care Act, the Sunshine Act is intended to increase transparency and reduce conflicts of interest that could influence clinical research, education, and decision making, such as prescribing behavior.
Numerous items are exempt from the Sunshine Act reporting requirements, including the following:
- Over-the-counter drugs and class I and II medical devices, such as elastic bandages and suture materials.
- Gifts or payments valued at less than $10 (unless the aggregate amount paid to the physician exceeds $100 annually).
- Incidental items worth less than $10 (e.g., pens and note pads) as well as general food and drinks offered offered to all participants at conferences or large-scale events.
- Educational materials and items intended for use by or with patients.
- Discounts and rebates from a manufacturer.
- Samples intended for patient use, including coupons and vouchers for obtaining samples.
- Payments for speaking at accredited or certified CME programs, which are already governed by rules designed to reduce industry influence, as long as the manufacturer does not select the speaker or pay him or her directly.
- Certain indirect payments transferred by a third party if the manufacturer does not know the identity of the recipient.
- Payments or other transfers of value to residents.
The Sunshine Act's final rule was supposed to have been issued by the end of 2012 but was delayed, in part because CMS received more than 300 responses during the comment period. The AAFP was among them, warning that the reporting requirements would create "significant complexities."
CMS has estimated the rule will cost health care companies and providers $224 million in the first year and over $163 million annually thereafter to comply.
Additional reading: Physician Payment Sunshine Act: Final Rule Top 50 Things to Know.
What's the cost of prior authorizations for practices?
When primary care providers have to take time out of their day to issue prior authorization for their patients' tests, medications and other clinical procedures, those minutes and hours add up financially.
A pair of new studies reported in this month's Journal of the American Board of Family Medicine looked at prior authorization activity at a dozen practices in the northeastern United States for a four-week period and determined an average annual loss of between $2,162 and $3,430 per full-time equivalent employee.
The annual per-physician losses for individual practices ranged from $926 to $6,067, although researchers said clerical staff handle most of the prior authorization duties.
Those averages are far below earlier estimated losses of up to $85,000 per physician, the researchers said, but they still show that the barrage of insurer requests has a significant effect on practice finances.
The previous and new loss averages "should be viewed as bookend estimates, with the true costs lying somewhere in between (especially when accounting for opportunity and efficiency costs)," the researchers wrote.
They added that the study didn't weigh those costs against any health care savings prior authorization activity gained those health care systems.
Worries about the effect of PA activity on physicians has led the American Medical Association to call for standardization of prior authorizations.
Long-awaited HIPAA changes coming soon to a practice near you
Just when you thought you had a good handle on the patient security and privacy rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), here comes some new ones.
The U.S. Department of Health and Human Services on Jan. 17 announced a final “omnibus” rule that it said would strengthen patient privacy protections, give patients greater control over their health records, and beef up the government’s ability to enforce the regulations.
The new rules go into effect March 26. Practices and others governed by HIPAA must comply with the regulations by Sept. 23.
While experts continue to parse through the new rules – the entry in the Federal Register is 563 pages long – here are some immediate takeaways for family medicine practices:
• Requirements of privacy and security will now extend to a practice’s business associates, such as contractors and sub-contractors, making them directly liable for violations. So practices that have business associates working on their behalf need to have contracts or other arrangements to ensure they’re following the Privacy Rule and Security Rule in regards to protected health information.
• Notification requirements have been strengthened to clarify when security breaches must be reported.
• Patients can now ask for a copy of their medical record in an electronic format. Practices should develop new policies and prepare their staff to accommodate patients requesting these electronic copies.
• If a patient pays in cash, they can request that their provider not share information about their treatment with their health insurer. Practices will need to prepare their registration and billing staff to handle patient requests for this.
• There are new rules limiting how a provider can use patient information for marketing and fundraising efforts. Practices that use patient information for these activities will need to make sure they’re compliant before proceeding.
• Patients will face a much more streamlined process for authorizing the use of their information for research purposes. This makes it easier for parents and guardians to give permission to share proof of a child’s immunization with schools.
For a refresher on HIPAA and how practices should comply with the law, here’s a collection of Family Practice Management articles on the subject: http://www.aafp.org/fpm/hipaa.
– Renae Moch, MBA, CMPE, practice management strategist for the AAFP, contributed to this story.
Introducing FPM's new medical editor: Ken Adler, MD, MMM
Our first issue of 2013 is now published, and you'll notice a new face in its pages, although his name may be familiar to you. Kenneth G. Adler, MD, MMM, has joined FPM in the role of medical editor. The position was created as part of a restructuring that occurred following the retirement of FPM's long-time editor-in-chief, Robert L. Edsall last fall. Ken has co-authored, with Bob, the EHR user satisfaction survey reports that FPM has published in recent years, and he has written several other FPM articles on technology topics. Ken was a member of the FPM Editorial Advisory Board until he became medical editor. Ken and I are both interested in your feedback and ideas as our editorial team begins FPM's 20th year of publication. Comment below or email us at firstname.lastname@example.org.
Only a third of U.S. physician assistants working in primary care
It seems the physician assistant (PA) community is having the same problems getting and keeping new graduates committed to primary care as medical schools are having.
But those similarities could also map a route to improving the numbers.
A new study published this month in Annals of Family Medicine found that of more than 18,000 physician assistants surveyed in 2009, only a third said they were in primary care and that percentage declined for each graduate year through 2003.
PAs graduating between 2004 and 2008 reported a slight increase in the number going into primary care, although the researchers cautioned that study limitations made it difficult to determine whether this reflected the whole PA population.
The survey also found that female, Hispanic, and older PAs showed a slightly greater tendency to work in primary care – a trend similar to what is found among physicians.
Researchers said this suggests that the two communities should move in parallel paths to deal with the anticipated future shortage of primary care physicians.
“The PA profession,” the
authors wrote, “should therefore continue to support workforce policy measures
that successfully increase the number of primary care clinicians, including
loan repayment, improved levels of reimbursement for primary care physicians,
and expansion of Title VII” (funding that aims to increase the primary care workforce).
Health IT was supposed to save money. What happened?
You may have noticed that health care costs have continued to rise even as more physicians and hospitals are using technology designed to bring those costs down.
According to a new analysis by the RAND Corporation, annual U.S. health care expenditures are up $800 billion from seven years ago. It was in 2005 that RAND researchers predicted that health information technology (IT) would save the country $81 billion a year.
So what went wrong?
In the analysis, published in this month's Health Affairs, researchers say a lack of standardization and poor incorporation of health IT into the health care process has stymied many of its strengths.
"In our view, health IT's failure to quickly deliver on its promise is not due to its lack of potential but to shortcomings in the design and implementation of health IT systems," researchers Arthur L. Kellermann and Spencer S. Jones wrote.
The biggest problems facing health IT, the duo say, are the lack of interoperability between systems, essentially isolating patient records from outside providers that need them; the continued sluggish adoption of IT; poor user interfaces that end up hurting physician productivity; and an economic model still favoring inefficient fee-for-service reimbursement.
The fact that patients aren't the ultimate controllers of health care information doesn't help, either.
"The current generation of electronic health records functions less as 'ATM cards,' allowing a patient or provider to access needed health information anywhere at any time, than as 'frequent flier cards' intended to enforce brand loyalty to a particular health care system," the researchers wrote.
RAND said technology companies need to work with providers to make their systems easier to use and embrace attempts by the government and others to create standards that would allow different systems to communicate easily. Also, the systems need to give patients the ability to personally control their information and who it goes to.
But the researchers said that is only the beginning.
"Ultimately, there is only so much that the government and vendors can do," they wrote. "Providers must do their part by reengineering existing processes of care to take full advantage of the efficiencies offered by health IT. This revamping of health care delivery is unlikely to happen before payment models are realigned to favor value over volume."