Readers Write: Five Predictions for Virtual Care in 2017

Five Predictions for Virtual Care in 2017
By Ralph Derrickson

The New Year is upon us, as is a soon-to-be new administration, a move from fee-for-service to fee-for-value, and increased patient interest in healthcare convenience – all of which could make 2017 a very interesting year for the healthcare industry. What exactly can we expect? There are few certainties, but we have enough information, looking at existing trends, to make some predictions for the coming year.

Consumers Assume Greater Costs and Greater Responsibility

There is little doubt that health plans will become more expensive for patients, as they are asked to take on higher deductibles, accelerating the consumerization of healthcare. Assuming ever greater responsibility for their own healthcare, consumers will seek additional care options and compare related costs. More consumers are becoming increasingly active in their education and healthcare decision-making. It’s essential that physicians prepare for this changing landscape by providing support for cost-conscious patients including strategic pricing options, convenience, and ease of access.

A recent American Telemedicine Association survey of active healthcare consumers revealed that convenience remains the top motivator behind their demand for telehealth services. I predict that greater telemedicine access in 2017 will shift patient thinking to recognizing telemedicine as a cost-conscious option – not just one of convenience.

Value-based Care Will Shape Virtual Care

This year will be the first in a giant shift to value-based payment models through MACRA, which will in turn highlight the need for cost-effective measures focused on quality metrics. At the same time, MACRA will drive physicians to look for solutions to expand practice access. MACRA encourages physicians to focus on the whole patient, providing new guidance on health records tracking and improving population health management. MACRA will also mean pushing the envelope on innovation and new care delivery models. In this new value-based care landscape, integrated telemedicine will offer a new care delivery model that addresses access issues. Configurable EHR integration and population health management will make telemedicine a natural and agile response to MACRA requirements.

Retail Clinics Create Stiffer Competition and Greater Fragmentation

Physicians will face greater competition as more retail and non-health system organizations look to attract patients through direct-to-consumer advertising. A consumer walking into a familiar pharmacy will bring routine retail habits to their interaction with affiliated clinics. This will make them likely to use a convenient option operating in affiliation with a comfortable retail brand, without thought of how that option impacts their larger relationship with their physician.

The retail clinic market will continue to make services even more convenient for consumers, leading to greater competition in local markets; but it will also lead to greater care fragmentation. To compete, physicians will need to adopt and promote integrated telemedicine services that provide 24-7, on-demand access. Digital marketing, value differentiation, and healthcare brand affinity will be increasingly important as physicians compete to keep current patients and attract new patients looking for greater ease of access.

New Legislation Drives Increased Telehealth Reimbursement

The number of states with telemedicine-reimbursing parity laws has almost doubled in the last three years, reflecting legislative understanding of the coverage barrier to telemedicine. With many state medical boards across the country enacting or considering increased requirements for virtual care, legislation on virtual care reimbursement will become more commonplace. As new rules and legislation are considered, telemedicine providers must work with state medical boards to ensure that patients receive the highest quality of care.

Greater Employer-based Health Plan Coverage for Telemedicine

In 2017, the National Business Group on Health estimates that 90 percent of employers will make telemedicine services available to employees in states that allow it. This is a significant increase over the 70 percent of employers who currently offer virtual care to their employees. This is further evidence that employers are ready to throw their weight behind patient preference for convenient healthcare options. Employers realize virtual care is central to meeting this demand while improving outcomes, managing costs, and minimizing the wait time burden of in-person visits.

I expect that increased health plan coverage for telemedicine in 2017 will increase national rates of telemedicine utilization as more patients gain access. I also foresee greater demand for virtual-care training for providers who are entering the digital clinic space.

At the end of 2017, we can be certain that innovation in healthcare will be driven by the needs of patients, that care quality will always be paramount to technology – virtual or otherwise, and that, like its predecessor, the year will be one of continued changes in healthcare.

Ralph C. Derrickson is president and CEO of Carena in Seattle.

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Readers Write: Survey Says – Independence Trumps Hospital Employment

Survey Says: Independence Trumps Hospital Employment
By Lea Chatham

There has probably never been as much uncertainty about the future of healthcare as there is right now. On the heels of the release of the MACRA final rule came the unexpected results of the presidential election. The President-elect has made it clear that he will make changes to the Affordable Care Act, which has been the law of the land for nearly eight years. And MACRA solidifies the industry shift away from fee-for-service to value-based care.

It might seem like with all these challenges, independent physicians would be looking to shift to employment, but the opposite seems to be true. There actually appears to be a slowdown in employment as physicians look for ways to stay in independent practices.

According to the AMA, only 33 percent of physicians currently work in hospitals or hospital-owned practices. The other 67 percent are in private practice, with 60 percent in practices of 10 physicians or less. Half of the physicians in private practices are owners or co-owners of the practice. While that means the other 50 percent are employed, they are working in private, independent practices, and they do find that more satisfying than hospital employment. A recent survey from MedData Group showed that 80 percent of physician owners and 61 percent of employed physicians strongly or somewhat agree that private practices offer satisfying career opportunities.

That same study also showed that 20 percent of employed physicians are considering owning their own practice in the future. This makes a lot of sense when you consider that self-employed doctors have higher satisfaction then employed doctors, according to Medscape. The same survey also showed that 71 percent of doctors said their work satisfaction improved when they left employment.

And it turns out that the physicians who are already owners or co-owners are loathe to sell out or close. Seventy-three percent of practice owners said they would prefer not to sell their practice. Seventy-two percent of practice owners said they envision a significant number of physicians who have been employed returning to independent practice.

“We have seen this trend firsthand,” says Kareo CMIO Tom Giannulli, MD. “In 2015, 15 percent of our new customers were starting new independent practices, and that has remained steady.” He adds that a recent survey of customers about MACRA showed that 85 percent are planning to participate to the best of their ability and only 2 percent are planning to speed up retirement or close or sell their practice. “What this tells me is that they are willing to tackle the challenges to stay in private practice,” he explains.

Giannulli has also been watching a growing trend of independent practices testing alternate payment models, which he attributes to their ability to be more agile and flexible in the way they practice. The 2016 Practice Models Perspectives survey, sponsored by the American Academy of Private Physicians, showed that 25 percent of physicians are already using some form of concierge, direct pay, or membership model in their practice; and another 35 percent are interested in trying something like that as well. The most striking finding of the survey was that most practices testing these models are not making a complete change. Only 30 percent are using a direct pay or membership model with all of their patients. The majority are using these models with only a portion of their patient population.

“They are trying out these options to see how they work and if they help reduce health plan and government program challenges,” says Giannulli. “The survey also showed these practices were more likely to be trying telemedicine and looking to potentially increase virtual visits.”

The nature of smaller independent practices makes it easier to try new payment models, test out new technologies, and either keep moving if it works or try something else if it doesn’t. Considering this and looking at all the latest trends, we may actually begin to see the slowdown turn into a reversal with more physicians choosing independent, private practices over hospital employment in the coming years.

Lea Chatham is an editor at Kareo in Irvine, CA. 

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CMIO Rant with … Dr. Andy

CMIO Rant with … gives CMIOs a place to air their thoughts or gripes. Yours are welcome.

The Great Prescription Pad Race
By Andy Spooner, MD

Which is more usable: a prescription pad or a computer?

That’s a no-brainer. For writing a prescription, the pad wins, hands down. Consider its features:

• Instant-on. No booting up. Just reach in your pocket and you are ready to go.
• Compact, lightweight. Did I mention your pocket?
• Self-documenting. No need to print a summary describing the prescription.
• No irritating pop-ups with irrelevant alerts.
• Patient-centered. The pharmacist can fill in missing information (liquid or tablet or capsule? brand or generic?) based on patient preferences.
• Flexible. Can be taken to any pharmacy. No need to route it to a specific place, or even to ask the patient about a preferred pharmacy.
• Streamlined. No need to worry about pharmacy benefit management rules. The pharmacist can sort all that stuff out.
• Information-persistent. If the family has a question about an apparently erroneous prescription, they can read the details right off the prescription when talking to the after-hours nurse.
• No record-keeping clutter. Patients can just tell us about their prescriptions next time we see them. They could just bring in the bottle or something.

With all of these advantages, surely only the geekiest of pencil-necked CMIOs would advocate an electronic method of prescribing, right?

Of course not.

The prescription pad is easier only if we define the work as the minimum possible activity that a doctor can do to get a prescription into a patient’s hands. The truth is, we are not done with the task of prescribing when we hand the slip of paper to the patient. If we think we are, then the pad seems far easier to use—more usable—than any electronic health record or e-prescribing system.

The above competition is absurd, of course, in an era when, according to the CDC’s National Ambulatory Medical Care Survey, over 80 percent of office-based physicians in 2013 used electronic prescribing. That rate rose from less than 60 percent over the past three years. E-prescribing is here to stay.

But we still hear about how unusable electronic medical record systems are. In The Atlantic this month, we read that a doctor who sees 14 patients a day spends “1-3 hours” each day entering orders. Assuming that each patient needs some orders for health maintenance (screening lab work), prescription renewals, and maybe a few diagnostic tests and referrals, it’s hard to take that statistic seriously. It’s clear that the writer is irritated at his EMR, and there may be some legitimate design or implementation issues with it. But 1-3 hours of ordering per day? C’mon.

Somewhere between the slapdash paper prescription and the three hours of daily ordering is the truth. Managing clinical information takes some amount of time, and some of it should be done directly by physicians. Some of this activity serves a “compliance” goal that you may not like, but all of it is a part of building a system of healthcare that serves a worthy goal.

If we insist that all clicks are wasted time, then we can’t have a conversation about usability, because under the prescription pad scenario, the only usable computer is one you don’t have to use at all.

On the other hand, if we insist that our current systems are bad because of hyperbolic, data-free assertions about how the EMR is making our lives miserable, we are similarly blocked from making productive plans to improve usability because, well, it’s just too darn much fun to complain.

My thesis, then, is that EMR usability is not as much about design as about expectations. Variations in what these expectations ought to be between different perspectives will lead to unproductive conversations (or no conversations at all) about what it means to have an EMR that’s easy to use.

All I know for sure as a CMIO is that physicians want all of this stuff to be easier to use. We also want these systems to read our minds, but that’s at least a couple of versions away, if I am understanding the vendor presentations at HIMSS correctly.

Andy Spooner, MD, MS, FAAP is CMIO at Cincinnati Children’s Hospital Medical Center. A general pediatrician, he practices hospital medicine when he’s not enjoying the work involved in keeping the integrated electronic health record system useful for the pediatric specialists, primary care providers, and other child health professionals in Cincy.

From the Consultant’s Corner 4/4/14

Three Factors for Success in Using Informatics

As the healthcare industry continues to experience a growing demand for reporting and analytics, organizations will be required to focus on healthcare informatics. Defined as the science of how to use data, information and knowledge to improve human health and delivery of healthcare services, informatics is more than just data reporting. It encompasses business intelligence, data analysis, and analytics as well.

Historically, data reporting was a lesser priority because healthcare organizations did not know how best to leverage data across business and clinical applications. Now, as healthcare leaders begin to understand how to use data and reports to drive performance and outcomes, informatics is moving to the top of the chart with both clinical and business implications. For example, instead of just identifying patients with diabetes, informatics determines whether specific services have been provided and pinpoints care gaps. On the business side, rather than looking at schedule availability, informatics reviews provider productivity expectations and identifies opportunities to standardize and consolidate visit types and provider schedules.

Why focus on informatics

As healthcare leaders define ROI for large investments in new technology, informatics should be at the center. In my experience, although expanding EHR installations and capabilities provides access to more information, the focus has been on implementing technology rather than using the information. The only way to obtain true ROI is to use the captured data for proactively managing patient care and financial operations.

Government regulations also steer the focus to informatics. While Meaningful Use Stages 1 and 2 require technology to be implemented, they also demand that physicians and hospitals become meaningful users. The ICD-10 conversion requires reporting and capturing clinical data in a discreet fashion and understanding what it means from coding, billing and downstream reimbursement perspectives. To comply with these regulations, organizations must understand and respond to the data.

Value-based reimbursement methodologies are another driver for informatics, as accountable care measures of both quality and cost impact how the organization is paid. For instance, organizations no longer are paid to see a patient 10 times with no health improvement; instead, they are reimbursed for keeping him or her healthy. These opportunities require the organization to marry financial and clinical information in a fully integrated manner.

Three factors for success

Leveraging informatics effectively across an organization requires more than EHR technology; it comes down to strategic decisions made by key executives during and beyond implementation. I believe these three factors help organizations realize the true potential of the data and use it to improve operational performance and patient outcomes.

1. Clearly define success metrics.

Without clear goals, no organization can improve performance, regardless of how many reports are run. It’s important to use leader-defined metrics to create reports and deliverables that measure progress and performance against certain key indicators, keeping in mind that information should be published with an operational rather than technical focus. Additionally, leadership should communicate the overall goal of educating and informing end users on what to do with the data, knowledge, and information provided by informatics.

2. Create a customer service culture.

This operational focus for informatics requires a cultural shift in ownership, moving informatics from IT to operational units, such as the revenue cycle or clinical informatics group. Design the informatics effort based on operational requirements, ensuring information is delivered when and where it is needed in the workflow. As a liaison between the technical focus and those using the information, operationally-driven informatics teams should partner with clinical and business managers to understand needs. In my opinion, organizations that allow IT to drive informatics projects will struggle.

3. Set expectations for report development and dissemination.

Resources are not always sufficient to support the increasing reporting demands in healthcare. One way to mitigate this is by implementing service level agreements to prioritize report requests and establish turnaround times. Define the escalation path when resources are not sufficient to meet the organization’s reporting needs.

Moving beyond technology

EHR use alone will not improve care. Rather, the collective knowledge and data captured in the EHR will impact quality and outcomes through informatics. Beyond simply generating reports, informatics supports clinical and business goals by providing the necessary information to the right decision maker in a manner he or she can understand and use to promote health and improve delivery of healthcare services.

Brad Boyd is vice president of sales and marketing for Culbert Healthcare Solutions.

From the Consultant’s Corner 2/21/14

Dusting off Your Physician Compensation Plan: 5 Steps to Creating a Value-based Strategy

For most practices, I suspect physician compensation is not something you are frantically trying to change. However, the sense of urgency may grow as healthcare reform continues to evolve.

As we all know, reform is shifting the focus of compensation from physician productivity (volume) to care quality (value), and payers are beginning to include patient satisfaction and quality as part of various payment reimbursement methodologies. As a result, practices may want to consider aligning their compensation plans with the shift toward value in order to remain viable.

Before we discuss how to align, let us take a closer look at how value-based payment is changing physician compensation. In the past, physicians were paid a percentage of charges or cash collected. More recently, the industry standard shifted to wRVUs (work relative value units) to incent performance. This model uses a point system for services rendered, with the accumulated points converted to a monetary value at the end of each quarter or year.

The wRVU method is almost counterintuitive to healthcare reform as the new emphasis on value disrupts the traditional mindset of “the more services provided, the more providers get paid.” The new thinking rewards quality and efficiency, not performing more surgeries or sending patients for expensive MRIs. In fact, payers see the focus on volume as inconsistent with protocols for quality care.

As you can see, it is a good time to review your compensation plan and ensure it is aligned with healthcare reform. Below are five steps to guide the alignment effort.

1. Find a physician champion. Strong physician leadership can support a smoother alignment process as this individual can address and overcome any physician reservations. Simply put, administrators cannot do this work on their own. A good choice for physician champion might be the head of the practice or a department chair.

2. Form a multidisciplinary compensation committee. If your practice includes several different specialties, you may want to create a committee to review compensation, which includes respected leaders in the practice and representatives of each specialty. This group can communicate to the rest of the practice frequently and transparently.

3. Conduct research and educate the committee. Look for and share information about current payers offering incentives or bonuses based on quality. Good sources of information might be the Healthcare Financial Management Association (HFMA) and the Medical Group Management Association (MGMA) or anecdotal information from other practices in the market.

4. Determine incentive goals and measures. Goals must be fair, measurable, obtainable and lucrative enough to get physicians’ attention. Ideally, you should balance base salary, productivity, quality, satisfaction and other measures. In my opinion, it is best to employ one compensation methodology across the group while the actual measures and goals within the group can vary by specialty. If the practice is already measuring quality for meaningful use (MU), use one or two of those agreed upon measures per specialty. If you are currently measuring patient satisfaction, use a score that reflects how patients feel about the physicians. Regardless of the measures, review incentive amounts to ensure they are meaningful to the physician and specialty.

5. Before launching a new plan, verify your practice can fund it. Make sure you do the math to check that the highest payout scenario is affordable. You also may want to phase the plan in to ensure the goals are captured in the EMR and the plan is doable. Most importantly, design the plan to be adaptable, so it can evolve when you review it annually.

We all know physician compensation plans are a challenge regardless of external influences, such as healthcare reform and value-based reimbursement. While there is no need to rush in and dramatically change your approach, it is definitely time to assess the current landscape and begin planning for the future. Remember, this cannot be done overnight or in a vacuum, especially with all the other priorities such as MU and ICD-10. In my view, the practices that are proactive in aligning their compensation plans will be the most successful going forward.

Johanna Epstein is vice president of management consulting services at Culbert Healthcare Solutions,