Posts Tagged patient

Patient Satisfaction: What Is It Really Worth?

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Patient Satisfaction: What Is It Really Worth?

In previous years, patient satisfaction discussions pertained only to patient surveys and results. Some managers believe surveys are utilized by specialties, such as plastic surgery practices that primarily operate on a cash basis. However, consumerism is here to stay! Cost and quality will create a level playing field in health care and increase the importance of patient satisfaction. When working with a practice, I love to sit in the waiting room to see operations from the patient’s point of view. I also search the specialty online to review the competition and the effectiveness of the practice’s website. During my research, I may also see online reviews, which speak directly to the patient experience.

Every business is a function of its people. Choosing the right people, training them continually and providing ongoing communication is essential to creating an exceptional patient experience. A successful practice has an established culture through a mission statement that is expressed each day through the actions of the physicians, managers and staff. Loyalty and profitability follow when an organization makes a promise to a customer and delivers on the promise over, and over again.

As an administrator, I begin with a good job description and then hire the person with the desired behaviors and skills to perform the task or job. A consistent training program is a key to success, it is not simply assigning a new staff to another employee for training. The staff training should occur through various methods with a supervisor or mentor. Once training is complete, the employee’s performance is validated before they are released to perform the task unsupervised.

Patient satisfaction surveys focus on each aspect of the patient’s visit to assure each person is delivering great service and managing their responsibilities to complete the assigned tasks. Medical staff may be highly trained on a specific clinical task, but a customer service attitude is essential when dealing with patients. Defining a plan to act quickly on feedback from a patient survey is essential to mitigate a problem.

You cannot prevent all problems, but the way you handle a problem can salvage a relationship. Establish key behaviors for staff to protect the patient relationship. If you hired people with a genuine heart for service in a medical practice, a problem may arise but the commitment to patient satisfaction should preserve the patient relationship.

Technology is rapidly improving. We have the tools to measure every activity in our practice to ensure the patient experience is exceptional. Phone systems have the capability to measure abandoned calls, length of time on hold, and the number of calls going to voicemail. Our practice management systems include reports and options to monitor first available appointments, percent of patients utilizing the patient portal and patient flow.

There are many tools to promote better patient engagement, including online registration to eliminate paperwork or automated appointment reminders using text, email or call. The patient portal, if promoted and correctly utilized, can reduce phone calls and improve the patient experience. The portal allows for ongoing communication, as opposed to hours waiting by the phone only to miss the call, which increases the call volume. The portal gives the patient access to information to share with other providers.

The development of defined processes and policies is essential to effective training. If the policies are ineffective, or if management does not enforce the policies, then the patient experience is affected. Patients who have an exceptional experience will tell a few people. If they have a poor experience, they may tell the story over and over again.

If your practice relies on referrals from other physician practices, do not underestimate the power of the referring office. The referring provider can send patients elsewhere if the patient is not satisfied with your practice. You should be able to identify the top 20 referring physicians and track the volume of referrals to assure it is consistent. The manager should contact the manager of the referring practice to assure needs are being met and the feedback is good.

It is important to know what makes your practice thrive. It is comprised of multiple factors, including good physicians and loyal employees, which lead to strong referring relationships. A medical practice exists for the patients, so what is patient satisfaction worth? EVERYTHING!

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official partner with the Medical Association.

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Can I Get a Witness? Do You Use Chaperones in the Exam Room?

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Can I Get a Witness? Do You Use Chaperones in the Exam Room?

In 2018, the world of sports was rocked with the revelation that Larry Nassar, a physician for USA Gymnastics, used medical examinations as a pretext to molest nearly three hundred female gymnasts over a twenty-year period. Many of these young athletes were abused while their parents were in the examination room. News coverage of the scandal caused many physicians to reexamine the professional safeguards that exist to protect a patient during one of his or her most intimate and vulnerable experiences, the physical examination.

In fact, the medical community addressed this concern long before the Larry Nassar scandal brought the issue into the public consciousness. The American Medical Association promotes the use of chaperones to provide a comfortable and considerate atmosphere for the patient and physician to respect a patient’s dignity.  Am. Med. Ass’n Code of Med. Ethics, Op. 1.2.4 (1998). While Alabama has yet to act legislatively to require the use of chaperones during a physical examination, many states have. For instance, Georgia’s Composite Medical Board defines “unprofessional conduct” to include “conducting a physical examination of the breast and/or genitalia of a patient of the opposite sex without a chaperone present.” Ga. Comp. R. & Regs. 360-3-.02(12). While adopting a chaperone policy in your practice is not yet obligatory in Alabama, there are many reasons why doing so is in the physician’s best interest.

First, the presence of a chaperone during a sensitive examination can help put the patient at ease. Patients who have had very few interactions with a physician may not yet fully trust the physician. Offering the patient a chaperone may ease any patient anxiety arising from unfamiliarity with the physician and helps demonstrate the physician’s respect for cultural or personal sensitivities.

Second, a chaperone may serve as a deterrent to improper patient behavior. The presence of a disinterested third party can help prevent false claims of sexual assault by the patient. In some cases, boundary violations may be initiated by patients. For example, patients may initiate boundary violations in order to gain an advantage over the physician. The manipulative patient may use the threat of a medical board complaint or a lawsuit to demand controlled substances or other special treatment. Thus, having a chaperone present can help protect the physician and other medical staff by discouraging abusive patient behavior.

Third, a chaperone serves as a witness to events occurring during the patient interaction. As a defendant in a malpractice suit, the physician will benefit from an additional witness to the physician-patient exchange. The chaperone can serve to corroborate the physician’s testimony, rendering the physician’s version of events more believable to a jury.

Before undertaking any sensitive examination or procedure, the physician should explain the specific components of the physical exam, and offer the patient the option of having a trained chaperone of the gender of the patient’s choice present. Document clearly in the patient’s chart whether the patient consented to the examination, and whether he or she elected to have a chaperone present. Write a note in the chart identifying all individuals present during the exam. Ideally, a practice should train at least one male and one female staff member to serve as a chaperone; however, patients often decline a chaperone when the physician and patient are of the same gender. As the Nassar scandal revealed, lay chaperones such as family members are not trained to observe the examination in a way that best protects the physician and the patient. Additionally, it may be awkward and uncomfortable for a patient to have a family member present during a physical exam. Thus, the presence of a trained, uninterested observer is the most effective means of ensuring a safe and respectful physical examination.

Occasionally, it will not be possible to accommodate a patient’s desire to have a chaperone present. If your practice does not have a chaperone available on the date of the examination, consider rescheduling the patient’s routine physical examination for a date when a chaperone will be available. If your practice lacks the capability to accommodate the patient’s chaperone request, discuss transferring the patient’s care to a physician better suited to make those accommodations.

Physician boundary violations portrayed in the media are increasing calls for mandatory use of chaperones. Rather than viewing this procedure as an unnecessary regulatory response to a few bad actors, physicians should embrace the protections provided by a chaperone policy. An effectively implemented chaperone policy helps physicians to become more responsive to patients’ sensitivities, ultimately strengthening the physician-patient relationship.

Article by William T. Ashley, III, JD, Risk Resource Advisor, ProAssurance. ProAssurance is an official partner of the Medical Association.

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President Signs Bills Lifting Pharmacist ‘Gag Clauses’ on Drug Prices

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President Signs Bills Lifting Pharmacist ‘Gag Clauses’ on Drug Prices

Earlier this week, President Trump signed two bipartisan bills into law that will allow pharmacists to tell patients they can save money on drugs by paying cash or trying a lower-cost alternative. At issue was the “broken” drug pricing system in the U.S. that was forcing patients to make decisions, which could have negatively impacted their health.

The bills, the Patient Right to Know Act and the Know the Lowest Price Act, prohibit health insurers and pharmacy benefit managers from using “gag clauses” that prevent pharmacists from sharing with patients the lower-cost options when they are purchasing medically necessary medication. In addition, the legislation ensures the Federal Trade Commission will have the necessary authorities to combat anti-competitive pay-for-delay settlement agreements between manufacturers of biological reference products and follow-on biologicals. The Patient Right to Know Act would apply similar “gag clause” protections to Medicare and MA plans.

Under the new legislation, pharmacists will be allowed, though not required, to tell patients about lower-cost options. If pharmacists don’t tell, then patients will have to ask about the cost of the medication. However, some pharmaceutical industry experts say although eliminating the gag clause is a step toward consumer transparency, it doesn’t address the issue of lowering actual drug costs, making it unclear how much of a tangible effect the legislation will have.

According to research published in JAMA in March, people with Medicare Part D drug insurance overpaid for prescriptions by $135 million in 2013. Copayments in those plans were higher than the cash price for nearly 1 in 4 drugs purchased in 2013. For 12 of the 20 most commonly prescribed drugs, patients overpaid by more than 33 percent.

Yet some critics say eliminating gag orders doesn’t address the causes of high drug prices. “As a country, we’re spending about $450 billion on prescription drugs annually,” said Steven Knievel, who works on drug price issues for Public Citizen, a consumer advocacy group. The modest savings gained by paying the cash price “is far short of what needs to happen to actually deliver the relief people need.”

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CMS Updates LCD Determination Process

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CMS Updates LCD Determination Process

On Oct. 3, 2018, the Centers for Medicare and Medicaid Services announced updates to Chapter 13 of the Medicare Program Integrity Manual, which deals with Local Coverage Determinations. According to CMS, the updates are intended to “increase transparency and patient engagement.”[1]  These changes call for informal meetings with interested parties before a formal request is submitted to the Medicare Administrative Contractor.  Educational meetings can be held in local jurisdictions and can be either in-person, teleconference or web-based.  Additionally, the changes to the manual set forth a roadmap for how the MAC issues an LCD.

LCDs are issued by MACs when there is no national determination on whether an item or service is covered. The idea is that the regional MACs will take into account local variations in the practice of medicine when issuing the LCD. For example, Palmetto GBA, Alabama’s MAC for Medicare Part A and B has issued an LCD on allergy testing (L33417).

According to a Medicare Learning Network publication[2], CMS’s updates were a result of feedback from providers and healthcare associations who were concerned that beneficiaries were not receiving necessary products and procedures due to deficiencies in the LCD process, such as notification of revisions to and drafting of LCDs. The new LCD process is intended to allow for more interaction with stakeholders before and during LCD development.

The “Roadmap”

1)         Requests for LCD

MACs will consider requests from beneficiaries residing or receiving care in the MAC’s jurisdiction, health care professionals doing business in the MAC’s jurisdiction or any interested party doing business.

A request is deemed complete if the request:

  • Is in writing and is sent to the MAC via e-mail, facsimile or written letter.
  • Clearly identifies the statutorily-defined Medicare benefit category to which the item or service applies.
  • Identifies the language the requestor wants in an LCD.
  • Includes justification supported by peer-reviewed evidence. Full copies of the published evidence must be included.
  • Addresses relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service.
  • Fully explains the design, purpose, and/or method as appropriate of using the item or service for which the request is made.

2)         Consideration of the LCD

The new guidelines suggest that MACs supplement the requests or proposed LCDs with clinical guidelines, consultation with experts, medical associations or other health care professionals.  This information is to be summarized prior to drafting or finalizing the LCD.

3)         Publication

A proposed LCD will be published on the Medicare Coverage Database (MCD) website at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Once published, MACs will allow 45 days for public comment.  There are some exceptions to the publication requirement.

4)         Contractor Advisory Committee (CAC)

A CAC will be established from each state and will be composed of healthcare professionals, beneficiary representatives and representatives of medical organizations.  The purpose of the CAC is to assist in the evaluation of the evidence in developing LCDs and communicate between the MACs and healthcare community.  This is an advisory committee with the ultimate authority residing with the MACs.

5)         Open Meetings

After the LCD publication, the MAC will hold an open meeting to discuss the rationale and evidence supporting the LCD.  Interested parties can also make presentations at these meetings.  The date and location of the meetings must be publicized by the MAC.

6)         Publication of Final Determination

After the close of the comment period and the required public meeting, the final LCD and Response to Public Comment will be published on the MCD (see link above).  MACs must respond to all comments received during the comment period.

7)         Notice Period

The date the final LCD is published on the MCD marks the beginning of the required notice period of at least 45 days before the LCD can go into effect.  If the notice period is not extended by the MAC beyond the 45 days, the LCD is effective on the 46th calendar day.

Additional changes include the retirement (or expiration) of all proposed polices if not finalized within one year after the original posting date and a removal of all ICD and CPT codes from LCDs.

For more information on the changes to Chapter 13, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf.

[1] CMS Accelerates Innovation and Promotes Patient Access to Medical Technology, https://www.cms.gov/newsroom/press-releases/cms-accelerates-innovation-and-promotes-patient-access-medical-technology

[2] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

Angie Cameron Smith is an attorney at Burr & Forman LLP practicing within the firm’s Health Care Industry Group. Burr & Forman LLP is a partner with the Medical Association.

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Study: Doctors Reduced Opioid Prescriptions after Learning a Patient Overdosed

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Study: Doctors Reduced Opioid Prescriptions after Learning a Patient Overdosed

Will clinicians become more careful in prescribing opioids if they are made of aware of the risks of these drugs first-hand? That was one of the core questions researchers set out to explore in a new study published in the August 2018 issue of Science. In doing so, they found that many clinicians do not learn of the deaths of those patients who overdose as they just disappear from their practice, outcomes unknown.

This disconnect from the personal experience of losing a patient due to fatal overdose, related to a prescription for opioids to relieve pain, makes the problem of the nation’s opioid crisis seem remote – statistics happening elsewhere. While the epidemic continues to exert its outsized impact, opioid prescription-writing levels have not responded with adequate risk-benefit analysis by prescribers tasked with caring for patients with complaints around pain.

“Clinicians may never know a patient they prescribed opioids to suffered a fatal overdose,” explained lead author Jason Doctor. “What we wanted to evaluate is whether closing that information gap will make them more judicious prescribers.” Doctor is the Director of Health Informatics at the USC Schaeffer Center for Health Policy & Economics and Associate Professor at the Price School of Public Policy.

The study leverages behavioral insights and psychology to give prescribers personal experience with the risk associated with opioids and finds that when a clinician learns one of their patients had suffered a fatal overdose they reduced the number of opioids prescribed by almost 10 percent in the following three months.

Doctor and his colleagues conducted a randomized trial between July 2015 and June 2016 of 861 clinicians who had prescribed to 170 patients who subsequently suffered a fatal overdose involving prescription opioids. Half the clinicians, who all practiced in San Diego County, were randomly selected to receive a letter from the county medical examiner notifying them that a patient they had prescribed opioids to in the past twelve months had a fatal overdose. The letter, which was supportive in tone, also provided information from the Centers for Disease Control and Prevention on safe prescribing guidelines, nudging clinicians toward better prescribing habits.

In the three months after receiving the letter, prescribing decreased by 9.7 percent compared to the control group who didn’t receive a letter. Furthermore, clinicians who received the letter were 7 percent less likely to start a new patient on opioids and less likely to prescribe higher doses.

The results are particularly exciting given that numerous, more traditional state regulations which often involve mandated limits on opioids have not been shown to have much impact. The authors point to numerous reasons why this study showed more promising results including its simplicity, that the letters still allows clinicians to decide when they will prescribe opioid analgesics and that it provides an important missing piece of clinical information to them.

This intervention is easily scalable nationwide as existing state and national resources already track the information necessary around overdose deaths associated with prescription and illicit drugs.

“Interventions that use behavioral insights to nudge clinicians to correct course are powerful, low-cost tools because they maintain the autonomy of the physician to ultimately decide the best course of care for their patient,” said Doctor. “In this case, we know opioids, though beneficial to some patients with certain conditions, come with high risks that the doctor may not fully grasp when observing patients in the clinic. Providing information about the harm that would otherwise go unseen by them gives physicians a clearer picture.”

###

Co-authors include Andy Nguyen, Roneet Lev, Jonathan Lucas, Tara Knight, Henu Zhao, and Michael Menchine. Funding for the study was provided by the California Health Care Foundation and the National Institute on Aging at the National Institutes of Health (R21-AG057395-01).

The Leonard D. Schaeffer Center for Health Policy & Economics, one of the nation’s leading health policy centers, aims to measurably improve value in health through evidence-based policy solutions, research and educational excellence, and private and public sector engagement. The Center is a unique collaboration between the USC School of Pharmacy and the Sol Price School of Public Policy at the University of Southern California (USC).

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Front Office Transformation – First Impressions

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Front Office Transformation – First Impressions

I recently visited a specialty practice at a major health system. As I approached the registration desk, a posted sign directed me to a standing kiosk to sign in. The family member I accompanied to the appointment was unable to stand at the kiosk, so I provided the needed information and signed her in. Although it was a quick and seamless process, I was concerned because if I needed assistance, there were no employees to ask.

Many practices have implemented kiosk sign-ins and have someone to assist a patient with the process if needed. Practice administrators have made the decision to implement a kiosk to assure verification of the current insurance policy and to prompt the patient to pay any out-of-pocket expense before they see the doctor. Many of the kiosk solutions allow a pre-registration via email permitting the patient to populate data and upload information from their own device at their convenience.

Benefits of Kiosk Sign-in include:

  • reduction in the staffing at the front desk
  • decrease in patient wait time
  • and most impressively, the increase of time of service collections.

You may not be ready for a kiosk at your registration desk, but you should review key areas for process improvements to assure you are preparing your practice for success at the front line. The MGMA Connection magazine reported an increase in the patient out-of-pocket expense by 30 percent in the last two years. Previous reports had already noted significant increases in patient deductibles and co-pays outside of the office co-pay. Failure to educate your front office staff, evaluate workflows, review software for accurate verification of benefits, and the lack of consistent financial policies could cost you at the end of the revenue cycle, and hurt your practice in the long-run.

All this to say, first impressions are vital to a practice. A second experience I had is when I walked into a practice, the first thing I saw was each of the front desk staff members was on the phone and did not acknowledge the patients walking in until they hung up. They were scheduling tests, getting pre-certifications and poorly collecting information and money. The staff had so many tasks that they were unable to perform any of them well and with intention.

Focus your front office staff on key functions: greet the patient, collect data, verify data, and collect money. Setting goals and seeing improvement will engage your staff in the big picture and train your patients to expect quality and consistent service and furthermore, be willing to pay for it.

The changes in health care have caused us to focus on efficiency and high-quality services at a reduced cost. As administrators, physicians, and/or staff members, you rarely enter the office from the front door so you may fail to see your operations from the patient’s perspective. Understanding how patients view your practice can put your practice at the next level.

Paper registration is a hassle to update and likely skipped if the phones are ringing off the hook. Patient satisfaction is vital in any medical practice and patients are learning technology can enhance their experience. The primary goal of the front desk should always be to provide great customer service because it is easier to collect from a happy patient.

Once you assure education, define processes, and establish best practices for the front office, it is time to set goals. Track performance (such as co-pay collection rate), reward success, monitor compliance, and watch your practice grow!

 

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

 

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Changes in Patient Access

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Changes in Patient Access

Physicians have struggled with the impact of the Affordable Care Act since its passage in 2010, but there is a new, more powerful and insidious change underway which will have dramatic impact on all medical practices. The free enterprise system together with an emergence of the Millennial generation has begun to break medicine of some traditional bad habits. Historically, a medical practice could take patient phone calls when it had time, book patient visits at the convenience of the physician and permit patients to sit in the waiting room well after the scheduled appointment time, before seeing the physician.

The Millennial generation population, which now exceeds the Baby Boomers in our population, has not been raised to wait patiently for service providers. They reply to texts while waiting for their name to be called for a customized coffee order. When the texts are handled, they are ready to move to the next multi-tasking activity. The prospect of sitting for two hours in a physician waiting room is not acceptable to them. Our nation’s capitalist system is eager to respond to this high value placed on personal time by the Millennials. Several developments signal the opening of care access alternatives.

The appearance of urgent care facilities was the initial sign of changing times. These care delivery offices are now in many cities, and are as near to each other as fast food sources in some locations. Urgent care facilities are a way to avoid the cost of a parking deck, eliminate the need to navigate a physician office building and avoid waiting long past a scheduled appointment time to be seen. Patients expect to pay out of pocket for the ability to obtain quick care and return to their busy schedules. Traditional office-based physicians might be surprised to know how many of their longstanding patients are seeking more convenient help at urgent care facilities.

Patients who want greater convenience can be seen in the comfort of their own home. Several states have this “Uber” healthcare service, as it was called in a recent Wall Street Journal article. The health care service commits to have a physician or mid-level provider to the home within a short period of time. In Colorado, a home health provider is also dispatched in response to some 911 calls. If the situation can be treated in the home, insurance pays the $300 cost per call rather than incurring the $3,000 ambulance transport cost. Certainly, the $100 fee for these normal house calls is affordable by only the more affluent families, but these are exactly the families a medical practice most needs to retain because they can pay for their care out of pocket.

Telemedicine is the next game-changing element in the provision of care. Hospitals are offering telemedicine consultations for certain specialties rather than paying M.D.s to be on call weekends and nights. Insurance providers offer telemedicine consultations for $10 per consult and this service is available 24 hours a day, every day of the week. These consults may be limited to the more simple medical issues, but these matters enable physicians to generate the incremental patient volume which produces year-end profit and bonuses. When this group can receive their prescriptions via a telemedicine visit at night, physician practices are left with the more complex patient problems and limited ability to bill more for the increased time to treat.

What do these easier points of patient access mean to medical practices? If you want to keep your entire patient base, it is time to make certain that care at your practice is eagerly being offered to your patients. Phones should be answered within three rings. Call your main office line from another number, and see how many rings your patients hear before an answer. Listen for the tone with which the phone is answered. Is it tired and bothered, or happy to take the call? Once a call is answered, how soon can the patient be seen? A sick patient might accept an appointment 10 days out, but they will likely heal or see an urgent care facility before the 10 days passes. That means you will find out in 10 days that you have another no-show on your schedule. When a patient wins the appointment lottery and gets an appointment tomorrow, how long do they have to wait past your promised time to see them? Be careful about long wait times. Most of our population are multi-taskers and have something on their schedule after their office visit. Some will even leave before being seen. Most will say nothing about their displeasure and simply not come back.

In short, the growing medical practices are treating patients like they are being served by a luxury hotel. Your practice is either growing or suffering atrophy. Look at your new patient numbers by month for the last 24 months, and see into which category you fall. If you know your group needs to improve, contact one of our healthcare team members for ways to become a survivor in the new world of patient access.

Article contributed by Warren Averett CPAs and Advisors, official Gold Partner with the Medical Association

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Study: Range of Opioid Prescribers Play Important Role in Epidemic

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Study: Range of Opioid Prescribers Play Important Role in Epidemic

A cross-section of opioid prescribers that typically do not prescribe large volumes of opioids, including primary care physicians, surgeons and non-physician health care providers, frequently prescribe opioids to high-risk patients, according to a new study by researchers at the Johns Hopkins Bloomberg School of Public Health. The findings suggest high-volume prescribers, including “pill mill” doctors, should not be the sole focus of public health efforts to curb the opioid abuse epidemic. The study also found “opioid shoppers,” patients who obtain prescriptions from multiple doctors and pharmacies, are much less common than other high-risk patient groups, suggesting why policy solutions focused on these patients have not yielded larger reductions in opioid overdoses.

“This crisis has been misconstrued as one involving just a small subset of doctors and patients,” said senior author G. Caleb Alexander, M.D., associate professor in the Department of Epidemiology at the Bloomberg School and founding co-Director of the Johns Hopkins Center for Drug Safety and Effectiveness. “Our results underscore the need for targeted interventions aimed at all opioid prescribers, not just high-volume prescribers alone.”

The study, which published on Nov. 29 in Addiction, comes as America’s opioid crisis continues to worsen. Opioids include not only the recreational, poppy-derived drug heroin but also many newer and much more potent synthetic painkillers available by prescription, such as fentanyl and oxycodone. Opioids tend to be highly addictive and when overdosed can stop a user from breathing. Drug overdose deaths in the U.S., which now mostly involve opioids, surged from about 52,000 in 2015 to more than 64,000 in 2016.

Alexander and colleagues have found in previous, smaller-scale studies that a small minority of doctors can account for an inordinately high proportion of opioid prescriptions: just 4 percent of opioid prescribers in Florida, for example, accounted for 40 percent of all opioid prescriptions in that state in 2010.

For this study, he and his team, including first author Hsien-Yen Chang, PhD, an assistant scientist in the Bloomberg School’s Department of Health Policy and Management, examined the relationship between high-volume prescribers and high-risk patients more closely. “While we and others have demonstrated that opioid prescribing tends to be concentrated among a relatively small group of providers, in the current study, we wanted to examine how commonly high-risk patients are prescribed opioids by low-volume prescribers,” Chang said. “We were also interested in whether we could identify systematic differences in the doses and durations prescribed by different groups of doctors caring for the same patients.”

The study covered more than 24 million opioid prescriptions in 2015 by more than 4 million residents of California, Florida, Georgia, Maryland, or Washington, as recorded in a nationwide pharmacy database, QuintilesIMS’ LifeLink LRx.

A key finding was that the high-volume prescribers – those who stayed in the top 5 percent, in terms of total opioid volume, during every quarter of 2015 – were far from being the only prescribers for high-risk patients. Across the five states studied, the remaining, low-volume prescribers accounted for 18 to 56 percent of all opioid prescriptions to high-risk patients, depending on how such patients were defined.

“The point here is that ordinary, low-volume prescribers are routinely coming into contact with high-risk patients, which should be a wake-up call for these prescribers,” Alexander said. “We need to build systems to help prescribers better identify these patients, screen them for opioid use disorders, and improve the quality of their pain management.”

The analysis also revealed “opioid shoppers,” the patient group most commonly thought of as being at high-risk for non-medical use, represent only a small fraction of all opioid users. The researchers defined opioid-shoppers in the study as those receiving prescriptions from more than three prescribers and three pharmacies during any 90-day period. They found this group made up just 0.1 percent of the 4 million patients covered in the study.

“The public health impact of ‘opioid-shoppers’ pales in comparison to that of other high-risk groups we examined,” Alexander said.

The first of these groups, “concomitant users,” were defined as people filling prescriptions for more than 30 days of opioids plus benzodiazepines, a class of tranquilizing drugs that includes Valium and Xanax. Like opioids, benzodiazepines can suppress the nerve signals that sustain breathing. “These two classes of drug interact and enhance each other–they make a dangerous combination,” Alexander said. Nearly one in 10 (9.3 percent) of the opioid prescription users covered in the study were concomitant users.

Chronic high-dose opioid users, comprising 3.7 percent of the total, were another high-risk group that dwarfed the opioid-shopper group. Chronic high-dose users were defined as those filling prescriptions for three months or more for opioids with daily doses equivalent in potency to more than 100 mg of morphine.

The researchers also analyzed prescribers’ prescription patterns and found that, for a group of patients seeing both high- and low-volume prescribers, high-volume prescribers on average prescribed larger doses compared to low-volume prescribers (61 vs. 53 mg morphine equivalents per prescription). Prescriptions from high-volume prescribers also provided about 40 percent more days of supply (22.1 vs. 15.6 days). “Even when the same patients were receiving prescriptions from both low-volume and high-volume prescribers, there was a clear tendency for the high-volume prescribers to provide higher doses for more days of use,” Chang said.

“Our study suggests systematic differences among prescribers. How many opioids you are prescribed, and for how long, appears to depend not only on who you are, but who you see,” Alexander said.

In late October of this year, the Bloomberg School of Public Health and the Clinton Foundation released a comprehensive report, “The Opioid Epidemic: From Evidence to Impact,” that provides evidence-based recommendations to reverse the rising tide of injuries and deaths from prescription opioids. Among its recommendations, the report emphasizes the important role that prescribing guidelines play in improving the safe use of prescription opioids by reducing high-risk use. It also underscores the role of Prescription Drug Monitoring Programs in helping to improve the ability for clinicians to deliver high-quality care for those with pain while reducing the risks associated with unsafe opioid use.

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How to Make HIPAA Disclosures During Mass Tragedies

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How to Make HIPAA Disclosures During Mass Tragedies

In light of the recent incident in Las Vegas, the Office of Civil Rights, the government entity responsible for HIPAA Compliance, issued clarification guidance on the ability of a health care provider to share patient information during such situations. While such incidents are taxing on health care providers in terms of treating capacity and ability, it is important that providers keep in mind the requirements of HIPAA regarding the disclosure of certain information to the public. A summary of OCR’s recent clarification is provided below, as it serves as a good reminder regarding what information can be shared under HIPAA in these types of mass-casualty, disaster scenarios.

Disclosures to Family, Friends and Others Involved in an Individual’s Care and for Notification.

You may share health information with a patient’s family members, relatives, friends, or other persons identified by the patient as involved in the patient’s care. You may also share information about a patient as necessary to identify, locate and notify family members, guardians, or anyone else responsible for the patient’s care, of the patient’s location, general condition, or death. This may include, where necessary to notify family members and others, the police, the press, or the public at large.

  • You should get verbal permission from the patient when feasible or otherwise be able to reasonably infer that the patient does not object to the disclosure. If the individual is incapacitated or not available, you may share information for these purposes if, in your professional judgment, doing so is in the patient’s best interest.
  • In addition, you may share protected health information with disaster relief organizations that are authorized by law or by their charters to assist in disaster relief efforts (g., American Red Cross), for the purpose of coordinating the notification of family members or other persons involved in the patient’s care, of the patient’s location, general condition, or death. It is unnecessary to obtain a patient’s permission to share the information in this situation if doing so would interfere with the organization’s ability to respond to the emergency.

Disclosures to the Media or Others Not Involved in the Care of the Patient/Notification.

Upon request for information about a particular patient by name, you may release limited facility directory information to acknowledge that an individual is a patient at the facility and provide basic information about the patient’s condition in general terms (g., critical or stable, deceased, or treated and released) if the patient has not objected to or restricted the release of such information or, if the patient is incapacitated, if the disclosure is believed to be in the best interest of the patient and is consistent with any prior expressed preferences of the patient. In general, affirmative reporting to the media or the public at large about an identifiable patient, or the disclosure to the public or media of specific information about the treatment of an identifiable patient, such as specific tests, test results or details of a patient’s illness, may not be done without the patient’s written authorization (or that of his/her personal representative).

Kelli Fleming is a Partner with Burr & Forman LLP practicing in the firm’s Health Care Industry Group. Burr & Forman LLP is a partner with the Medical Association.

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