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."
Five issues to watch out for in 2013
If you think the health care system has changed a lot over the last couple of years, just wait until 2013. It will be "a watershed year for the U.S. health care 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." Based on research studies and policy papers issued by the Foundation, the list identifies five issues that are likely to have a major impact on patients and physicians in the coming year.
1. Ongoing uncertainty about health care reform. Although the Supreme Court upheld the Affordable Care Act (ACA) in June, key parts of the act have yet to be fully defined or fully implemented, including accountable care organizations, health insurance exchanges, and the Independent Payment Advisory Board for reducing Medicare spending. According to the Foundation's "2012 Biennial Physician Survey," uncertainty about health reform was a key reason that 77 percent of physicians reported pessimism about the future of medicine.
2. Ongoing consolidation. Hospitals and large groups are acquiring small private practices at a steady rate by offering physicians income security and relief from administrative burdens, according to the Foundation report "The Future of Medical Practice: Creating Options for Practicing Physicians to Control Their Professional Destiny." While consolidation can yield benefits, such as improved communication between providers, it can also create monopolistic behavior, raise the cost of care, and reduce the viability and competitiveness of solo or small private practices, cautions the Foundation.
3. Patient access challenges. More than 30 million individuals are expected to gain health insurance in 2014 under the ACA. This will likely create challenges for patients trying to access care because the current physician supply is not adequate to meet this demand. In fact, according to the "2012 Biennial Physician Survey," physicians are working fewer hours, and if this trend continues, the health care system could lose the equivalent of more than 47,000 full-time-physicians in the next four years.
4. Eroding physician autonomy. Doctors' ability to exercise independent medical judgment is markedly deteriorating, says the Foundation, because of threats to their reimbursements, liability pressures, and an increasingly burdensome regulatory environment. Increased consolidation may also play a part.
5. Growing administrative burden. One of the chief contributors to physician discontentment, according to the "2012 Biennial Physician Survey," is the increased burden physicians carry because of administrative and regulatory tasks. "The Future of Medical Practice" report calls for the creation of a new federal commission for administrative simplification to evaluate cumbersome physician reporting requirements and eliminate those that do not save money or improve quality.
The Foundation hopes this watch list will serve as "a pragmatic resource that will help policy makers, physicians, and health care providers formulate smart policy decisions that are beneficial to America's patients and doctors," said Walker Ray, MD, vice president of The Physicians Foundation and chair of the Research Committee.
Eliminating higher-paying consultation codes leads to Medicare cost increase
Two years ago, Medicare authorities sought to steer more money toward primary care physicians, who have historically been underpaid, while keeping the program's overall expenses level. One of the approaches they took was to eliminate the relatively higher payments for consultations, most often used by specialists, in favor of raising the reimbursement rates for office visits, more commonly used by primary care physicians.
A new study shows the move did increase revenue for primary care doctors in its first year. But, despite the government's goal of budget-neutrality, the change actually led to a 6.5 percent overall increase in outpatient visit costs to the system.
The increased reimbursement rates for office visits obviously contributed to some of that growth, as the volume of patient encounters did not change significantly. But the researchers also found greater use of higher-complexity office visit codes among both specialists and primary care physicians.
The study was published in the Archives of Internal Medicine.
Using Medicare data from 2007 through 2010, the study found spending on all physician encounters increased $10.20 per Medicare beneficiary per quarter after the policy change went into effect in January 2010. The researchers estimated two-thirds of the increase came from the higher office visit fees while the remaining third reflected the increased complexity codes.
Primary care doctors received more than half of the new revenue, reducing the gap between themselves and specialists. However, the researchers stressed that they only considered office encounters and didn't know whether overall Medicare reimbursement levels changed between the two groups.
They also said the increase in complexity may not represent inappropriate "upcoding" but instead reflects the flexibility inherent in medical coding. For example, they said a physician who previously may have billed for a level-3 consultation (40 minutes) may have determined a suitable replacement was a level-4 new patient office visit (45 minutes) and not a level-3 new patient office visit (30 minutes).
The researchers said the study results highlight the dangers of trying to achieve budget savings through fee changes only.
Announcing the 2012 FPM Practice Improvement Award winner
Terry Reilly Health Services was the winner of this year's Family Practice Management Practice Improvement Award, which I presented today at the American Academy of Family Physicians and Society of Teachers of Family Medicine Conference on Practice Improvement in Greenville, S.C., to Bethany Gadzinski, medical operations manager and leader of the group's patient-centered medical home initiative, and Donald Morrison, RN, nursing manager. Terry Reilly Health Services is a safety net provider serving approximately 30,000 patients each year, two-thirds of whom are at or below the federal poverty level. Seventy-two percent of the patients served have multiple chronic diseases.
Although the field of entries for this year's award contained several strong contenders, Terry Reilly Health Services emerged as the winner. So what did they achieve? In four years, they have replaced their executive director; implemented an electronic health record system, patient portal, and registries; built two new clinics; and achieved recognition as a level-3 patient-centered medical home, all while making significant improvements in quality of care.
Their award application featured an impressive data set. As I looked at the graphs displayed in a poster presentation here at the conference, the improvements in patient outcomes, patient satisfaction, and other measures were so numerous and steady that one significant decrease stood out. That was a decrease in staff satisfaction between years one and two of the initiative. This struck me as more of a reminder than a lesson, because it needs little explanation: Change is hard. This has been a persistent theme in the lectures I've attended here. But as an especially wise family physician once told me, "Chaos is a necessary transition state." With strong leadership and a deep commitment to the many low-income and homeless patients they serve, the physicians, providers, and staff of Terry Reilly Health Services stayed focused on their goal of practice transformation, haven't looked back, and have meaningful improvements to show for it. Congratulations to them.
Six things family physicians can be thankful for
Yes, the health care system is inefficient. Yes, it frustrates physicians and patients alike. And, yes, it often rewards the wrong things. But at this time of the year, it seems appropriate to reflect on a few bright spots, particularly for family physicians:
1. A 10-percent, quarterly Medicare bonus for certain primary care services through 2015.
3. A 7-percent pay increase for primary care services via the 2013 Medicare Physician Fee Schedule (assuming, of course, that the 27-percent pay cut due to the SGR is avoided again).
4. More payers offering improved primary care payments, including care-management fees. Wellpoint is one of the latest examples.
6. A delay in ICD-10!
What would you add to the list?
Researchers find e-visits provide care similar to office visits
But how does the treatment compare between so-called e-visits and normal face-to-face meetings? Are physicians at a disadvantage when the patient is an email address?
Researchers at the University of Pittsburgh Medical Center, in a study published this month in the Archives of Internal Medicine, looked at both types of visits conducted by four primary care practices in the university health system. All visits involved patients complaining of sinusitis and urinary tract infections (UTIs).
They reported that there was no difference in the number of patients needing to come back for more treatment.
"Follow-up rates are a rough proxy for misdiagnosis or treatment failure, and the lack of difference will therefore be reassuring to patients and physicians," the researchers wrote.
On the flip side, the study found that physicians, perhaps to be safe, were more likely to prescribe antibiotics for e-visits in both types of cases. They were also less likely to order preventive care.
The study also found that doctors should expect lower reimbursement for virtual visits, with UTI e-visits paying about $29 less than an in-office appointment.
Penalties increase for lack of participation in Medicare incentive programs
Physicians who do not participate in Medicare’s quality reporting and e-prescribing programs will forfeit potential bonuses and face steeper financial penalties in 2013 and beyond.
The majority of physicians likely fall into this category, according to data from the Centers for Medicare & Medicaid Services (CMS). Of 623,077 physicians eligible to participate in the quality reporting system in 2010, only 181,542 participated and 128,942 qualified for the bonuses. Of 471,684 physicians eligible to participate in the e-prescribing program in 2010, only 90,174 participated and 56,050 qualified for the bonuses. (See "2010 Reporting Experience, Including Trends (2007-2011): Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program.")
Under the e-prescribing program, the 2013 bonus payment is 0.5 percent of physicians' Medicare allowed charges and the penalty is 1.5 percent. For 2014, bonuses cease, and the payment reduction increases to 2 percent. To avoid the penalties, physicians must report at least 10 eligible e-prescribing transactions for Medicare patients by June 30 of the prior year (25 transactions are required for the bonus), or they must request an exemption. CMS recently extended the deadline to Jan. 31, 2013, for physicians filing an exemption for reporting 2012 data. For more information, or to apply for an exemption, visit the CMS e-prescribing exemption reporting website.
Under the physician quality reporting system (PQRS), the 2013 and 2014 bonus for successful participation is 0.5 percent. A 1.5 percent penalty won’t be assessed until 2015, but it will be based on quality measures reported in 2013.
Also in 2015, Medicare rates will be reduced by 1 percent for those who do not achieve meaningful use of an electronic health record system (rising to 3 percent by 2017), and CMS will begin to adjust physician pay using value-based payment modifiers. These modifiers will increase pay for those who provide higher quality and more efficient care than their peers and will decrease pay for others. Initially, only doctors in groups of 100 or more will be subjected to the value-based payment modifiers.
Successful participation in the PQRS in 2013 will prevent groups from being penalized under the value-based payment modifier in 2015.
Physician groups have urged CMS to align these programs, and CMS has made some adjustments. Earlier this month, CMS announced that physicians who successfully report e-prescribing under the meaningful use program will be protected from penalties under the Medicare e-prescribing program. In addition, physicians who use the EHR reporting option for the PQRS will satisfy the clinical-quality-measure-reporting component of meaningful use. For more information on the alignments, see "Physicians Benefit from CMS’ Harmonization of Program Rules."
Survey: Practice execs see little payer momentum on "innovative" payment models
It's still early in the evolution of health care reimbursement from fee-for-service to more performance-based models.
But most practice executives don't like what they're seeing.
In its most recent survey of medical practice executives' satisfaction with payers, the Medical Group Management Association-American College of Medical Practice Executives (MGMA-ACMPE) said the majority of its members reported an unwillingness by major payers to offer what it called "innovative" payment models or new contracts based on such ideas as accountable care, shared savings, medical homes, or payment bundling.
Of the seven large payers included in the survey, Medicare Part B received the highest average rating, although even it didn't quite score high enough to be considered "moderately unwilling."
In cases where a payer was willing to offer innovative payment models, most respondents said they didn't believe the options were favorable to their practice.
Dr. Susan Turney, president and CEO of MGMA, said in a released statement that she understood that a financial revolution for health care providers would not be immediate.
"We welcome opportunities to engage with payers on new payment models and understand that the industry is still developing these options," Turney said. "It’s important for our members not to rush into new models if they aren’t beneficial for their patients and practices. Aligning the incentives for practices, patients, and payers will be key for these types of arrangements to be successful moving forward."
AMA adopts principles for physician employment
With so many U.S. physicians either entering employment with hospitals and other health care providers or thinking about it, the American Medical Association is developing a road map.
The AMA on Monday adopted a series of principles for physician employment. The six principles deal with topics ranging from how to deal with conflicts of interest and patient advocacy to peer review and how employed physicians are paid.
In particular the AMA guidelines say patient care must remain the chief priority of any employment agreement and physicians and not non-medical hospital administrators must retain final authority and responsibility for patient care decisions.
An entire section deals with the type of contracts physicians sign when entering employment. The AMA's top concerns are that employers clearly explain how doctors will be compensated and protect the doctor's right to due process in termination cases. The guidelines also advise against automatically canceling a terminated physician's clinical privileges or relationship with existing patients.
It also discourages physicians from entering employment agreements that contain noncompete provisions or other restrictions on future employment. (For more information on noncompete provisions and other aspects of physician employment agreements, see "Evaluating Employment Agreements," FPM, July/August 2012.)
The guidelines also stress that as billing decisions will likely no longer involve the physician, he or she should be held legally harmless for any violation or breach of contract that was not his or her fault. Conversely, he or she should be aware of and included in discussions governing professional fees, capitation or global billing, or shared savings.
"The principles for physician employment provide a broad framework to help guide physicians and their employers as they collaborate to provide safe, high-quality, and cost-effective patient care," AMA board member Joseph P. Annis, MD, said in a news release.
The American Hospital Association this past January estimated physician employment by hospitals has grown 32 percent in the past decade.
Study suggests doctors share "anti-fat bias"
The overweight and obese certainly face discrimination and unfriendly attitudes in their daily lives. But does that extend to their doctor?
A new study suggests that indeed physicians are just as likely as other members of the general public to be biased against overweight and obese individuals.
Researchers had more than 359,000 people access a web site that measured their implicit and explicit attitudes toward overweight and thin people through a series of pictures and positive and negative descriptions. They also were asked to identify their highest level of education, with 2,284 test-takers saying they had an MD.
The results showed a strong "anti-fat bias" among both the total population and the MDs, although male doctors seemed to have a stronger bias than female doctors. This strong bias continued even when test-takers were directly asked to what degree they preferred overweight or thin people.
"Strong explicit attitudes suggest that individuals, including medical doctors, may feel that it is socially acceptable to express negative attitudes about overweight people," the researchers wrote.
While public disapproval of the overweight and obese isn't news, the fact that so many doctors apparently share that view would suggest it may extend to their practice. The researchers said they're concerned that that could actually persuade overweight patients against seeking checkups and other health care services. They recommended future study of how these provider attitudes may be affecting the quality of health care the overweight and obese receive.
Considering the growing percentage of the U.S. population struggling with weight, those attitudes could have major implications for the health care system down the road.
For an alternative approach, here's a 2002 article from Family Practice Management dealing with how to better care for obese patients.
Tips on rebuilding practice after Sandy
As residents along the East Coast continue to clear away the debris left behind by Hurricane Sandy, many physicians in those communities are having to repair or even rebuild their practices.
Family Practice Management dealt with the challenges of recovering from natural disasters in an article in its May/June 2012 issue.
Among the key preparations discussed was maintaining off-site backup copies of your electronic health records so you don’t have to rebuild your patient records from scratch.
Once the storm has passed, however, the authors said the most important thing is to focus on reorganizing your own life first as that sense of normalcy will make it easier to deal with the business recovery.
As for the practice itself, doctors and/or practice managers should be prepared to work out of temporary quarters for some time, organize after-hours and weekend cleanup efforts, and deal with a crunch on collections as patients also affected by the storm may be slow to pay their bills.
For more tips on what a family medicine practice should do after a disaster, visit this American Academy of Family Physicians checklist: Actions to Take After a Disaster.
New higher Medicaid rates on the way
Family medicine physicians can look forward to higher reimbursement checks next year when they take care of Medicaid patients.
The Centers for Medicare and Medicaid Services (CMS) on Nov. 1 announced final rules that will require that physicians providing certain primary care services to Medicaid patients get paid at the same rate as they do for treating Medicare patients beginning Jan. 1 and extending to the end of 2014. Medicaid, overseen by the individual states, typically reimburses at a lower rate than the federally operated Medicare program.
The change affects physicians in family medicine, general internal medicine, pediatricians, and related subspecialists, such as pediatric cardiologists. Certain other practitioners, such as nurse practitioners, may also receive the higher reimbursements if working under the direct supervision of a qualifying physician.
The higher payments apply only to evaluation and management services, not specific procedures or diagnostic testing. CMS officials said they will work with the states on the details of implementing the higher payments.
The provision was included in the Affordable Care Act of 2010. The federal government will reimburse states for the difference in cost based on their Medicaid rates as of July 1, 2009.
Other final rules released Thursday included changes in the Value-Based Payment Modifier Program, which will assign bonuses and penalties for physicians based on the quality and cost of care provided. The program will be phased in between 2015 and 2017 with the rules initially applying only to practices with 100 or more eligible professionals.
The original proposal was to start with physician practices of 25 or more professionals. In any event, the government still plans to apply the payment modifiers to all physicians by 2017.
Should you offer extended office hours?
A recent study published in the Annals of Family Medicine suggests that offering extended office hours, such as evening and weekend hours, reduces health care expenditures without adverse effects on mortality.
Researchers analyzed data from more than 30,000 individuals responding to the 2000-2008 Medical Expenditure Panel Surveys, an annual national survey of health care use and costs, who had reported access or no access to extended hours through their usual source of care in two consecutive years. Total expenditures were 10.4 percent lower among patients reporting access to extended hours in both years versus neither year. After adjusting for year-two prescription drug expenditures and office-visit-related expenditures (e.g., diagnostic testing), researchers found that the decrease in health care expenditures was 5.7 percent and 4.3 percent, respectively. This finding supports the notion that physicians' clinical choices, such as choosing less expensive or generic medications over more expensive ones or choosing to forgo discretionary testing, also have a great influence on expenditures.
Advice from the real world
Extended office hours may offer additional benefits as well, according to an article in the FPM archives written by members of Primary Care Partners, a group of 23 family physicians and pediatricians in Grand Junction, Colo. After establishing an after-hours clinic in 1998, the group saw increases in practice revenue, patient satisfaction, and physician satisfaction. "The after-hours clinic has been the most successful innovation in primary care delivery in our community in recent memory. Patients love it. Office staff love it. Physicians love it. Insurance companies love it. Hospitals can’t compete with it. And family physicians can do it really well," said the authors. They offered the following pointers to other practices considering an after-hours clinic.
1. Calculate how many patients you need to see in order to break even. The physicians of Primary Care Partners needed to see 12 patients per evening and 31 patients per weekend day. Early on, their patient volume was lower than that, but it gradually grew to more than 50 patients on week nights and 60 to 100 on weekend days.
2. Expect patient volume to vary by day of the week and season of the year. For example, the practice averaged 123 patients on Saturdays during winter flu season, compared with 73 patients on Saturday during the summer.
3. Set up your after-hours fee schedule using a slightly higher conversion factor than for your regular fee schedule. Primary Care Partners was able to negotiate a facility fee with its major insurers by showing that their after-hours clinic reduced ER utilization rates.
4. Ensure adequate staffing. For Primary Care Partners, after-hours staffing initially consisted of two receptionists, one CNA/nurse, one X-ray/laboratory technician, and one physician. The practice also hired a nurse administrator to run the clinic and to work shifts when staffing was difficult. One of the practice owner-physicians served as medical director. Staffing grew with the revenue stream.
5. Market the after-hours clinic within your practice and with other local physicians to help it grow quickly. Local insurers may encourage members to use your facility or even help with some start-up costs if they view it as a less expensive alternative to the emergency room. Primary Care Partners also set up an emergency room “dysutilization” program, under which a staff person contacts patients who have gone to the emergency room for problems that could easily be managed in the clinic and informs them of the practice's after-hours service. The practice received a case management fee from some insurers for this service.
For more information, see Quackenbush J, Shenkel R, Schatzel V. Creating a successful after-hours clinic. Fam Pract Manag. January 2004:39-42.
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.
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.
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