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Can We Fix Alabama’s Rural Physician Shortage?

Posted by admin on June 20, 2019

It takes up to 10 years to train a physician. That decade of training is just one contributing factor for the reason the United States is facing a serious shortage of physicians. Other factors include the growth and aging of the population and the impending retirements of older physicians. While medical schools have increased enrollment by nearly 30 percent since 2002, the 1997 cap on Medicare support for graduate medical education has stymied increases in the number of residency training positions, which are necessary to address the projected shortage of physicians.

A 2019 study conducted for the Association of American Medical Colleges by IHS Markit predicts the United States will face a shortage of between 46,900 and 121,900 physicians by 2032. There will be shortages in both primary and specialty care, and specialty shortages will be particularly large.

Unfortunately, the State of Alabama is already experiencing a physician shortage, most notably in rural areas, and to make matters worse Alabama ranks in the last five of 50 states in health status categories.

Even with Alabama’s medical schools working to educate and nurture a future crop of physicians, there’s no guarantee these medical school graduates will remain here through their residencies or return to Alabama to practice medicine should they complete residencies outside of the state.

In 2018, the Pickens County Medical Society introduced a resolution at the Medical Association’s Annual Business Session to create a planning task force to develop and restore adequate health care manpower with a specific focus on Alabama’s rural areas. The resolution stands as a reminder that while primary care medicine is effective in raising health status, supporting hospitals and improving the economic status of disadvantaged communities, the state’s aging population is also causing an escalation in need for primary care physicians.

“The task force has brought together physicians from across the state with various practice situations to work with the many entities that comprise our health care system,” said Beverly Jordan, M.D., a family and sports medicine physician from Enterprise, Ala., who chairs the task force. “Both long
and short-term goals are being developed, and we look forward to expanding our work to non-physician groups that play an essential role in the development and sustainability of physicians in rural Alabama. A variety of barriers to physician practice in rural Alabama have already been identified, as well as several amazing programs that address those barriers and ideas for innovative solutions.”

Members of the task force met in person for the first time in August 2018 and discussed a number of issues but focused on the importance of fully funding the Board of Medical Scholarship Awards, scope of practice, physician pipeline programs, education and the possibility of GME expansion, recruitment and retention of physicians through meaningful tax credits and rural community support, and start-up business models.

Medicaid Commissioner Stephanie Azar and Dave White from the Governor’s Office joined the meeting to hear the concerns of the task force and take their report back to Gov. Kay Ivey.

“Because this was the first face-to-face meeting of the task force, we had a lot of ground to cover,” said Executive Director Mark Jackson. “Naturally there are a lot of concerns about health care shortages in rural areas, but our goal is a long-term solution. The members of the task force realize this isn’t an easy fix, which is why they were willing to express their concerns openly and honestly to the Governor’s staff.”

This year during the Annual Business Meeting the task force offered a report of its first year’s work including a number of initiatives to improve the rural primary care workforce, new and proposed initiatives, and future recommendations.

What Are We Doing NOW to Improve the Rural Alabama Primary Care Physician Network?

There are already a number of initiatives in place designed to improve the rural physician workforce in Alabama. These have proven successful in the past, yet given the growth trends in population and fewer physicians are choosing to locate to rural settings, these initiatives will not be enough to sustain adequate access to care for our residents living in rural areas:

Alabama Board of Medical Scholarship Awards Amended in 1994, this legislative program was funded at about $1.4 million in 2018. Funding currently allows about nine recipients a year (full cost of medical school attendance), with a significant waiting list. As a result, 96 percent of recipients practice in Alabama; 98 percent in primary care (78 percent family medicine); 90 percent in rural Alabama; 73 percent continue in their original communities after completing the scholarship obligation.

Physician Tax Credit Act The State of Alabama allows a state income tax credit of $5,000 for up to five years for a physician or dentist in rural practice. Legislation is currently being considered to enhance the tax credit. The Medical Association staff will report on any changes to this legislation as the Regular Session of the Alabama Legislature continues.

Rural Medical Scholar Program (RMSP) Since 1996 this program has enjoyed statewide and national acclaim as a successful model for rural college students through medical school. On average, 11 students are admitted to this highly selective five-year medical education program of The University of Alabama and the University of Alabama School of Medicine. The Rural Medical Scholars Program includes a year of study, after students receive their undergraduate degree, that leads to a master’s degree in Rural Community Health and early admission to the School of Medicine. Undergraduates may qualify after their junior year if they have met most of the requirements for their undergraduate major. In the year prior to entry into medical school, students take courses related to rural health and the practice of primary care in rural areas, and participate in special seminars, field trips and community service programs. Since its founding in 1996, more than 200 students have participated in the program, and of the graduates, 81.8 percent practice in Alabama while 62 percent practice in rural Alabama.

Rural Medical Program (RMP) The Rural Medical Program began in 2005 and is modeled after the RMSP. This five-year medical school curriculum’s sole purpose is the training of physicians to serve in the areas of greatest necessity. RMP is a jointly sponsored program by the Auburn University College of Sciences and Mathematics and UAB School of Medicine Huntsville Regional Campus. The RMP curriculum promotes family medicine by providing for students to attend the annual meetings of the Alabama Academy of Family Practice and the National Student American Academy of Family Practice. Students also participate in the Medical Association’s Governmental Affairs Conference in Washington, D.C. The program has 79 percent of graduates that are family physicians, 90 percent are in primary care practice, and 74 percent are rural.

Early Medical and Other Health Professions Pipeline Programs Rural Health Scholars, Rural Minority Scholars and others have sought to provide high school and community college student recruitment and guidance. Tuscaloosa’s Rural Minority Health Scholars has had 200 members and 15 have gone to medical school. Of the 650 Rural Health Scholars from 1993-2018, 56 have gone to medical school. These programs are aimed at all health care occupations and serve to raise awareness of medical opportunities for hundreds.

Huntsville Rural Premedical Internship (HRPI) Since 2004, by bringing college students with rural backgrounds to the UAB Huntsville medical campus for a summer experience including clinic shadowing, didactic sessions, field trips, and medical skill workshops. With 74 percent of available graduates being accepted to medical school (125/169); 67 percent of participants having completed medical school and residency are in primary care; 67 percent are in Alabama with 46 percent rural. Of those in HRPI and a rural track such as RMP or RMSP, 75 percent are rural Alabama family physicians.

Alabama Area Health Education Centers (AHEC) Started in 2012, five centers across Alabama focus on improving access and workforce in rural and underserved communities. AHEC engages in student recruitment and support and physician education and retention activities, partnering with medical and other health professions schools to link students to positive clinical rotations in underserved areas. Revised HRSA funding directions have decreased support for this level of activity by AHEC, through its centers continue to address these goals through other support. Improved networking, information and digital resources may provide leverage for these important but challenging activities.

Medical School Admissions Committees Important factors include student recruitment, school policies and priorities for recruiting rural and underserved students, and committee membership (particularly rural and family physicians). The Medical Association can provide opportunities for expanded dialogue with our medical schools about how to increase the number of rural medical students, utilizing successful models from our own state and others. Using these current programs and initiatives as benchmarks, the task force began to work outward searching for changes and new models to reinforce what was already working and expand opportunities for new physicians in rural areas.

“The most important fact about this rural task force is that the Medical Association is stepping up to the plate to address the wide range of problems and challenges facing rural health in our state. That’s a highly responsible and even courageous act. The last time our Association did this was more than 20 years ago, and the outcome was the modern version of the Medical Scholarship Act and our current collaborative model for advanced practice providers such as nurse practitioners and physician assistants,” said Bill Curry, M.D., Dean of Rural Programs for University of Alabama Birmingham School of Medicine and one of the chairs of the Manpower Shortage Task Force. “This time, Dr. Jordan and the Board have taken a comprehensive and long term approach. We’re looking at everything from the physician workforce pipeline – reaching from rural schools through college, medical school, residency, and practice recruitment and retention – to the plight of rural hospitals to the responsibilities of our medical schools and state agencies to partner with communities and professional societies across all that’s involved in rural health. It’s a very full plate, and it’s important to identify initiatives with impact and to set priorities.”

The Next Step

Fact: During the last five years nationwide, applications to and enrollment in medical schools have increased.

Fact: While there is a projected shortage of primary care physicians, there is also a projected shortage of specialists.

Fact: Fixing the physician shortage requires a multipronged approach including innovations in team-based care and better use of technology to make care more effective and efficient.

Facing the facts of a physician shortage is the first part of the battle. The members of the Manpower Shortage Task Force had the opportunity to define new initiatives to begin to create a path to move the state forward and away from a deficit of physicians in rural areas.

Practice Incubator Models Multiple partnerships involving existing or new practices, health systems and local governments, with or without initial support through the Alabama Board of Medical Scholarship Awards, the National Health Service Corps, or other scholarship programs. The incubator process involves recruitment of mentee doctors (frequently just out of training) to rural practices established by mentors. The mentee then learns private practice and is subsequently enabled to move to another rural location by the mentor or the mentee may simply buy into the existing practice if sufficient growth has occurred. The benefit to the mentor is a return on investment of satellite practices or income realized above the salary of the mentee.

Improved Workforce Database Traditional sources of information about the Alabama physician workforce include the Alabama Board of Medical Examiners, the American Medical Association physician database, the American Academy of Family Physicians, the National Rural Health Association, County Health Rankings, the Center for Medicare and Medicaid Services, and information from the Alabama Department of Industrial Relations. Recently the UASOM Huntsville Office for Family Health, Education and Research (OFHER) has combined, analyzed and displayed data from various sources into more usable and interactive formats, and the Alabama Rural Health Association has collaborated in this effort also.

Improve and Standardize the Designation of Primary Care Shortage Areas for Alabama HRSA has established a work directive for all state Offices of Primary Care (PCOs) to establish a state network of rational service areas for identifying local and/or regional shortages and developing rational and reasonable solutions to eliminate identified shortages. The Alabama medical community must be a major player in the development of Alabama’s Rational Service Areas (RSAs). There is a major concern if the Medical Association and the medical community are not involved in the formation of state RSAs, then private practice primary care providers and physician mental health providers and rural hospitals will be left out.

Scholarships Graduate medical education programs in primary care need more scholarships. Some scholarships expect recipients to enter primary care while others require rural service. Currently, the BMSA is the most successful program in the state, and possibly the nation, for providing physicians to rural areas. The scholarship is repaid by rural service of four to six years depending upon the size of the underserved town.
Changes in Undergraduate Medical Education Students most likely to enter rural practice are those from rural areas. Selecting students from rural Alabama, expanding rural premedical programs, and expanding the rural tracks will provide a larger pool of applicants to the state’s family medicine residencies. Other options include allowing early admission as college juniors providing they achieve predetermined academic and MCAT standards; and placing third-year students with primary care physicians, which serve to increase student familiarity and comfort with the practice.

Changes in Graduate Medical Education Data shows the physician most likely to practice in Alabama is one who is from Alabama and who attends medical school and residency here. Also, the person who is from a rural area in the state is the most likely to return to a rural area. The most important mission is to fill the current family medicine slots with the Alabamians most likely to enter rural practice. New residency programs are also an option. These programs are beginning to pop up across the state from Madison County to Baldwin County in a variety of specialties.

Transition from Residency to Practice The final chapter of the process is moving from a residency to a medical practice. The expansion of the BMSA is the surest and fastest method of attracting physicians (which has solid, objective data proving its worth). Out-of-state physicians may be attracted to rural Alabama because of the advantages in cost of living and professional satisfaction. Physicians may move from states ranked as the worst in which to practice medicine (IL, CA, MD, OR, MA, DC, NY, RI, NM and NJ) to Alabama, which was ranked the third best in the U.S. behind NC and TX. (Medscape Physician Survey, 2016).

Targeting the Black Belt Communities According to the Black Belt Solutions/Community Engagement Subcommittee’s Co-chair John Wheat, M.D., engagement and partnerships among communities and resource agencies for this area will be the lynchpin for its success.

“This population and region desire doctors and other health professionals who understand their life, identify with them, and want to live and practice among them,” Dr. Wheat explained. “It is apparent such physicians are far more likely to be from the Black Belt than elsewhere, their course through medical education must be supported in many ways, that practice facilities must be on par with urban counterparts, that social and professional contexts must be prepared for them, and patients must be able to afford to come to them. Our first and continuing task is to engage the knowledge, trust and commitment of multiple groups with varying perspectives and influences for making changes required to succeed in these efforts.”

Dr. Wheat and co-chair Brittney Anderson, M.D., are originally from Alabama’s Black Belt and have begun reaching into the community to contact local ministers, county commissioners, physicians who grew up in the region, and other community activists with strong commitments to the region for opinions and ideas about how to better serve the area.

“We have been well received and encouraged to continue toward setting up a planning structure that will be inclusive and unify multiple groups and agencies. We look forward to having a planning group that will receive enthusiastic invitations from various Black Belt communities asking us to partner with them in producing and maintaining the health care professionals in their community,” Dr. Wheat said.

The Long Road Ahead…

The Medical Association and the members of the Manpower Shortage Task Force realize there is a long road ahead to finding the best solutions to Alabama’s physician shortage in our rural areas, but we are working toward solutions…and there will be many solutions and many partners to take part in the process.

“We recognized that without a viable rural health system – which has to include either a hospital or a freestanding facility with after-hours and emergency coverage – it’s difficult or impossible to have effective primary care and other services in a rural community,” Dr. Curry said. “The Association’s reaching out to the Alabama Hospital Association and other partners is a huge step, and I hope the regulatory or other changes needed will happen soon.”

Dr. Jordan agreed, adding that help from established physicians is always welcome.

“Our work has just begun, and we look forward to continued efforts to both develop and sustain excellent health care communities in rural Alabama,” Dr. Jordan said. “As we expand our workgroups to include educational, business, political and religious leaders in our state, we welcome the involvement of our physician members. Please don’t hesitate to contact us if you are willing to help – we need you!”

If you would like to be involved with the task force, have questions, or would like to contribute an idea, please email Association Executive Director Mark Jackson.

Tags: care, manpower, physician, primary, rural, shortage

Posted in: Advocacy

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E/M Code Changes: A Deeper Dive at What Could be Coming for 2021

Posted by admin on December 12, 2018

This is the second in a series of articles reviewing notable changes in the 2019 Physician Fee Schedule Final Rule and provides a deeper discussion of the potential changes to the E/M Coding regime scheduled to take effect in 2021. For the original article, please see Evaluating and Managing the E/M Codes for 2019 and Beyond.

Brief Recap

The Centers for Medicare and Medicaid Services proposed some major changes to the way Evaluation and Management services are reimbursed in the 2019 Physician Fee Schedule Proposed Rule. The PFS Final Rule[1] adopted some of the proposed changes but scheduled them to take effect in 2021. The commentary on these proposals and CMS’s responses in the PFS Final Rule provide some valuable insight into what CMS is trying to accomplish with the E/M reimbursement changes and what these changes might ultimately look like when made effective in 2021.

Proposals for 2021

Collapsing Reimbursement for Levels 2-4. CMS has proposed to collapse the reimbursement for E/M level 2 through level 4[2] codes into a single reimbursement amount for office/outpatient settings. To come up with this combined payment rate, CMS is taking the average of the current inputs for determining E/M reimbursement (work RVUs, direct PE inputs, time, and specialty mix) for level 2 through 4 E/M codes, weighted by the frequency with which each code is currently billed (based on the most recent five years of utilization data). For an example of what this new reimbursement structure might look like, see Table 19 and Table 20 below (excerpted from the Final Rule), which compare the 2021 E/M reimbursement methodology to the current methodology for both new and established patients in terms of 2018 dollars:

As you might expect, this new reimbursement structure will likely result in a reduction in overall reimbursement for many physicians who ordinarily bill higher level E/M codes. Fortunately, CMS is proposing new add-on codes (to be billed only with the combined level 2 through 4 visits) with additional reimbursement which should mitigate some of the effects of the new E/M reimbursement structure.

Add-On Codes. CMS finalized its proposal for new add-on codes to account for primary care and particularly complex visits, as well as extended visits associated with E/M services. CMS indicated that there should not be any additional documentation requirements for these add-on codes (for the most part)[3] and that information already captured on the claim form should suffice to show that the E/M service provided was for primary care.

Primary Care Add-On Code. CMS proposed an add-on code (GPC1X) to be appended to claims for primary care E/M services. Notably, the add-on code only applies to face-to-face time with patients[4], and it cannot be appended to a global procedure code that encompasses E/M services. CMS expects this add-on code to be used predominantly by primary care practitioners (e.g., family medicine, internal medicine, pediatrics, and geriatrics), and in fact, indicated that this add-on code would likely be billed for almost all office/outpatient-based E/M services provided by these practitioners. However, CMS also noted that some specialists also function as primary care practitioners (e.g., OB/GYN or cardiologist) and may be able to utilize this add-on code.

Add-On Code for Specialty Professionals with Large E/M Volume. CMS also proposed an add-on code (GCG0X) for certain specialties which perform mostly high-level (4 or 5) E/M services (rather than procedures) involving “non-procedural approaches to complex conditions that are intrinsically diffuse to multi-organ or neurologic diseases.” CMS originally included certain specialties[5] in the descriptor for this add-on code but has noted that several appropriate specialties[6] were omitted and that the appropriate reporting of this add-on code “should be apparent based on the nature of the clinical issues addressed at the E/M visit, and not limited by the practitioner’s specialty.” CMS also noted that there may be some rare instances where both the primary care add-on code and the specialty professional add-on code could be billed for the same service (provided all the requirements for both codes are met in a single E/M visit).[7]

Extended Visit Add-On Code. There is also an add-on code (GPRO1) to account for additional resources utilized when physicians have extended visits with patients. This code may be billed if the practitioner spends between 34 and 69 minutes (for established patients) or 38 and 89 minutes (for new patients) of face-to-face time with the patient, regardless of which level (2, 3, or 4) E/M code was reported. Providers will have to note the amount of time spent face-to-face with the patient in order to bill for the extended visit code.

Choice of Documentation Method. The current (1995 or 1997) E/M documentation guidelines[8] are based on three factors (all of which must be documented): History or Present Illness, Physical Examination, and Medical Decision Making (MDM). Starting in 2021, practitioners will have the option to document E/M services using any one of the following documentation methods: (1) the current (1995 or 1997) guidelines; (2) MDM only; or (3) time only. If practitioners decide to use the existing guidelines or the MDM-only documentation approach, they would only need documentation consistent with the current level 2 E/M service in order to be reimbursed the combined amount for level 2 through 4 E/M services,[9] or consistent with the level 5 documentation requirements where a level 5 E/M code is billed. For practitioners using time as the documentation method, the practitioner must document face-to-face time personally spent with the patient at least equal to the typical time associated with the applicable level of E/M Code.[10]

Regardless of which documentation method practitioners choose, they must still be diligent in documenting medical necessity, as CMS noted several times in the Final Rule that medical necessity would have to be documented in the record regardless of the documentation method the provider chooses. Based on CMS’s comments in the Final Rule, practitioners may expect additional opportunities to comment on the allowable documentation methods in the coming years before the policy is finalized in 2021.

Conclusion

If these proposals move forward over the next several years, it appears there will be substantial disruption not only in how E/M services are reimbursed, but in how they are documented and billed. It is unclear whether these proposals will achieve CMS’s goal of reducing the administrative burden on practitioners, as the proposals simplify E/M coding in some respects and complicate it in others. Either way, practitioners should have the opportunity over the next two years to continue to comment on these proposals in an effort to have CMS modify or refine them before they go into effect in 2021.

Article contributed by Christopher L. Richard with Gilpin Givhan, PC. Gilpin Givhan, PC, is an official partner with the Medical Association.

[1] CMS-1693-F, available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

[2] CMS originally proposed to collapse the reimbursement for E/M level 2 through 5 services into a single reimbursement amount but for now has decided to keep a separate reimbursement amount for level 5 E/M services to “better account for the care and needs of particularly complex patients.”

[3] For instances where the billing of the appropriate add-on code is not as readily apparent based on the information on the claim form, practitioners should consider additional documentation in the medical record to support the billing of the add-on codes.

[4] There are already add-on codes for non-face-to-face time, such as CCM and BHI codes.

[5] Endocrinology, rheumatology, hematology/oncology, urology, neurology, OB/GYN, allergy/immunology, otolaryngology, cardiology, or interventional pain management.

[6] Nephrology, psychiatry, pulmonology, infectious disease, and hospice and palliative care medicine.

[7] CMS provides an example of a cardiologist in a rural area who provides care for complex cardiac conditions as well as primary care in his or her clinical practice. If the cardiologist provided both primary care services and specialty cardiology services in a given E/M visit, both GPC1X and GCG0X could be billed for the visit.

[8] 1995 Documentation Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf; 1997 Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

[9] For example, under the current guidelines, the practitioner must document: (1) a problem-focused history that does not include a review of systems or a past family or social history; (2) a limited examination of the affected body area or organ system; and (3) a straightforward MDM measured by minimal problems, data review, and risk (two of these three). By contrast, a practitioner using the MDM-only method would only have to document straightforward MDM measured by minimal problems, data review and risk (two of these three).

[10] This approach is consistent with the current policy guidelines that time can only be used as the applicable documentation method for E/M codes where counseling and/or coordination of care accounts for more than 50% of the face-to-face time between physician and patient. The typical time associated with a service or procedure is maintained in the AMA CPT codebook.

Tags: care, CMS, code, e/m, fee, primary, reimburse, schedule

Posted in: CMS

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HHS Seeks Comments on Easing Stark Law Burdens

Posted by admin on September 7, 2018

The Centers for Medicare & Medicaid Services has requested public input on how the physician self-referral law, or Stark Law, may be interfering with care coordination. To help accelerate the transformation to a value-based system that includes care coordination, HHS has launched a Regulatory Sprint to Coordinated Care. The Regulatory Sprint is focused on identifying regulatory requirements or prohibitions that may act as barriers to coordinated care, assessing whether those regulatory provisions are unnecessary obstacles to coordinated care, and issuing guidance or revising regulations to address such obstacles and, as appropriate, encouraging and incentivizing coordinated care.

On June 25, 2018, HHS published in the Federal Register a Request for Information seeking comments on the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements and the need to revise or expand exceptions to the Stark Law. CMS states “CMS is aware of the effect the physician self-referral law may have on parties participating or considering participation in integrated delivery models, alternative payment models, and arrangements to incent improvements in outcomes and reductions in cost.” CMS has also engaged stakeholders through comment solicitations in several recent rulemakings. In 2017, through the annual payment rules, CMS asked for comments on improvements that can be made to the health care delivery system that reduce unnecessary burdens for clinicians, other providers, and patients and their families.

CMS is interested in the public’s thoughts on issues that include the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law. Specifically, CMS requested stakeholders’ thoughts on important definitions and/or concepts such as defining “commercial reasonableness,” “fair market value” and “take into account the volume or value of referrals” by a physician.

While the Request for Information does not mean HHS will make any changes to Stark, it is encouraging that CMS recognizes the many roadblocks Stark causes to legitimate arrangements involving physicians.

The Request of Information is available online at https://federalregister.gov/d/2018-13529.

Jim Hoover is a partner at Burr & Forman LLP practicing exclusively in the firm’s Health Care Industry Group. Burr & Forman LLP is a partner with the Medical Association.

Tags: care, CMS, coordinated, guidance, HHS, regulatory, sprint, stark

Posted in: Legal Watch

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Patients, Doctors Dissatisfied with Electronic Health Records

Posted by admin on August 17, 2018

Electronic Health Records are intended to streamline and improve access to information — and have been shown to improve quality of care — but a new study shows they also leave both doctors and patients unsatisfied, even after full implementation.

The study, by researchers at Lehigh University and the Lehigh Valley Health Network, surveyed physicians, mid-level providers and non-clinical staff at ob-gyn practices where EHRs were installed and analyzed survey answers given by patients. While there have been studies looking at how EHR implementation affects provider and patient satisfaction, this is the first study of how the integration of outpatient and hospital EHR systems affects provider and patient satisfaction.

Published in the August print issues Journal of the American Medical Informatics Association, the study tracked two ob-gyn practices and a regional hospital from 2009 to 2013, during the implementation of an EHR system and its subsequent integration with the hospital system. The EHR was installed in 2009 and information began flowing from the hospital to the ob-gyn practices in mid-2011. Full two-way exchange of clinical information was achieved a year later.

Ob-gyn practices posed a good opportunity for study because typically a woman will see physicians at her ob-gyn practice multiple times during the pregnancy before being admitted for labor (often seeing different doctors), and on average will have at least one pregnancy-related hospital visit prior to giving birth at a hospital, co-author Chad Meyerhoefer, professor of economics at Lehigh University, said.

Previous to the integrated EHR — digital versions of patient medical records were accessible through computers for some patients and paper records were sent by courier to the hospital for others — transmission of such records often was not made between hospitals and outpatient practices in a timely manner. This meant physicians at the practices might not know about visits to the hospital or test results ordered there and hospital doctors would not have access to the woman’s prior clinical data from outpatient OB-GYN appointments during visits to the hospital’s perinatal triage unit.

“We wanted to study how the EHR affected information flow between hospitals and practices and we chose pregnancy and obstetrics because it is a well-defined period — the prenatal care, birth and post-natal care all occur in a time frame we can capture,” said Meyerhoefer, who co-authored the paper with Susan A. Sherer, Mary E. Deily, Shin-Yi Chou and Jie Chen of Lehigh University and Michael Sheinberg and Donald Levick of Lehigh Valley Health Network. “In pregnancy, information is very important, having information about the patient’s prenatal experience can help to avert adverse events during the birth.”

Surprising Results

Researchers discovered both unsurprising and surprising results.

In theory, while it is understandable that implementation of an EHR would be seen as disruptive initially, by the time the EHR was in regular use, one would expect patients and doctors to report improvements in communication and coordination of care. However, the study showed that even after the EHR was established, both doctors and patients expressed dissatisfaction.

In the early stages, doctors and staff expressed frustration at learning a new system and the time it took to enter information. By the end of the study, staff appreciated ease with retrieving information and doctors felt communication and care were improved. Doctors, however, were also less satisfied by the system overall, citing the time it took to enter data, changes to workflow and decreased productivity.

“It was more of an adjustment for physicians, as it required them to do additional documentation they didn’t have to do before, and it had a bigger impact on their workflow,” Meyerhoefer said.

Patients felt the disruption at the beginning, and continued to feel less satisfied with their experiences after the EHR was fully implemented and was being used.

“Our thought was after the system was implemented and some time had passed and all these new capabilities are added to the system, the patients would see the benefits of that and feel better about their visits,” Meyerhoefer said. “But that didn’t happen.”

Why? Researchers aren’t sure, but one aspect may be that patients would likely have been unaware of improvements to their care and outcomes as a result of the EHR and may not have considered that when describing satisfaction levels, Meyerhoefer said. A previous study by the researchers, which looked at data flow from outpatient ob-gyns to the hospital and back and which information mattered, showed that implementation of an EHR decreased adverse birth events and had a positive effect on birth outcomes.

Changes in administrative practices, documentation, staffing, staff work roles and stress, and doctors’ concerns about productivity goals related to the implementation may also have changed the patient experience, or a patient’s perception of the care experience, in ways patients didn’t like.

“It could also be the case that having the computer documentation be a bigger part of patient interactions may be a negative thing for patients,” Meyerhoefer said. “The need for documentation sometimes takes the focus away from having a personal relationship with the patient.”

Training for Doctors

“The takeaway message is that during these implementations or after you have the system in place, you have to really think about how this is going to affect patients and maybe do training on patient interactions with electronic medical records to head off some of these negative effects,” Meyerhoefer said. This might include training for doctors in how to maintain verbal and nonverbal communication with patients during visits while also collecting or inputting information into a computer.

Also, since the brunt of documentation impact falls to physicians and impacts productivity, adjustments should be made to productivity targets that take that into consideration, researchers said.

In addition to patient experiences, the impacts are important to study and consider because installation of an EHR generally changes the way doctors and staff record and report information, as well as work processes and staffing related to documentation. “It can be a big change, and can be very disruptive,” Meyerhoefer said. Acquiring EHR software is typically a large financial investment for a hospital or health system as well. And even after a system is acquired and used, replacing it with a new system would engender similar adoption issues.

“These findings are specific to OB-GYN patients, but I think these results on satisfaction would carry over to many other types of care, where physicians and other clinical providers will not really see the benefit of a system until the information flow is improved, and there can be persistent negative effects on patient satisfaction,” Meyerhoefer said.

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The work was funded by a grant from the Agency for Healthcare Research and Quality, an agency of the U.S. Department of Health and Human Services, and by a Lehigh University Faculty Innovation Grant.

Tags: access, care, EHR, hospital, informatics, integration, outpatient, quality, satisfaction, system, transmission

Posted in: Research

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Association’s New Task Force to Address Health Care Manpower Shortage

Posted by admin on July 13, 2018

In response to a resolution passed by the House of Delegates during the 2018 Annual Meeting in Montgomery in April, the Board of Censors formed a new task force to develop and restore adequate health care manpower in all geographic areas in order to provide quality local health care for all Alabama citizens.

The resolution, submitted by the Pickens County Medical Society, stands as a reminder that Alabama ranks in the last five of 50 states in health status categories, and while primary care medicine is effective in raising health status, supporting hospitals and improving the economic status of disadvantaged communities, the state’s aging population is causing an escalation in need for primary care physicians.

The task force had its first meeting the week of July 23 and will meet again on Aug. 14. We will post details as they become available.

Tags: care, force, health, manpower, shortage, task

Posted in: Advocacy

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President Trump Signs VA Mission Act

Posted by admin on June 8, 2018

UPDATE JUNE 6, 2018: President Trump signed the VA Mission Act designed to increase veterans’ access to timely and private health care. The new VA law aims to combine and expand existing community care programs during the next year with intentions to roll out one centralized community care program next May.

Building off the positive changes enacted by the Choice Program, which was created in 2014 after two veterans died waiting for appointments, the Mission Act broadens the circumstances for which veterans can receive non-VA health care. Presently, veterans can seek third-party medical care if they live more than 40 miles away from a VA facility or if they must wait over 30 days for an appointment. The Mission Act will also allow veterans access to non-VA health care if they are in need of a service the VA does not offer or if their doctor thinks it is in the best interest of the patient.

With access to non-VA health care becoming more accessible, some lawmakers became fearful the new law would undermine the VA. The Mission Act recognizes this potential and includes incentives and funding to ensure the Act does not drive veterans away from the VA. The order will boost funding to allow the VA to hire more health care professionals in addition to offering scholarships to medical students willing to work for the VA.

Additionally, the new measure will help pre-9/11 veterans by giving them benefits to help cover the cost of in-home caregivers. Post-9/11 veterans already have access to such benefits. These benefits offer an alternative to institutionalized health care and will help take some of the cost of local governments.

While the Mission Act passed overwhelmingly in both the House and Senate with bi-partisan support in May 2018, there is a debate on exactly how the measure will be funded after May 2019. Sen. Richard Shelby (R-Ala.), head of the Senate Appropriations Committee, is working across party lines in both the Senate Appropriations Committee and the Veteran’s Affairs Committee to help establish the best possible funding plan for the VA Mission Act.

Tags: 9/11, affair, care, health, mission, shelby, veteran

Posted in: Advocacy

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Demand for Non-Physician Providers Rose to Make Up for Physician Shortage

Posted by admin on May 23, 2018

The Medical Group Management Association has released its 2018 MGMA DataDive Provider Compensation Survey revealing primary care physicians’ compensation rose by more than 10 percent over the past five years. This increase, which is nearly double that of specialty physicians’ compensation over the same period, is further evidence of the worsening primary care physician shortage in the American health care system.

A closer look at this data shows this rise in compensation is not necessarily tied to an increase in productivity. When broken down by primary care focus, family medicine physicians saw a 12 percent rise in total compensation over the past five years, while their median number of work relative value units (wRVUs) remained flat, increasing by less than one percent. Practices offered more benefits to attract and retain physicians, including higher signing bonuses, continuing medical education stipends, and relocation expense reimbursements.

“MGMA’s latest survey has put strong data behind a concerning trend we’ve seen in the American healthcare system for some time—we are experiencing a real shortage of primary care physicians,” said Dr. Halee Fischer-Wright, President and Chief Executive Officer at MGMA. “Many factors contribute to this problem, chief among them being an increasingly aging population that’s outpacing the supply of chronic care they require. And with a nearly two-fold rise in median compensation for primary care physicians over their specialist counterparts and increased additional incentives, we can now see the premium organizations are placing on primary care physicians’ skills to combat this shortage.”

Further supporting this trend, the new survey identified meaningful growth in compensation for non-physician providers over the past 10 years. Nurse practitioners saw the largest increase over this period with almost 30 percent growth in total compensation. Primary care physician assistants saw the second-largest median rise in total compensation with a 25 percent increase.

“In many communities that we visit, nurse practitioners and other advanced practice providers provide immediate care and same day access. These providers play an important role in today’s health care system. It’s more efficient and less expensive than visiting the emergency room,” said Nick Fabrizio, Principal Consultant at MGMA.

Based on comparative data from over 136,000 providers in over 5,800 organizations, the 2018 MGMA DataDive Provider Compensation is the most comprehensive sample of any physician compensation survey in the United States. The survey represents a variety of practice types including physician-owned, hospital-owned, academic practices, as well as providers from across the nation at small and large practices.

Other highlights from the survey include:

Over the past five years, rises in median compensation varied greatly by state. In two states, median total compensation actually decreased for primary care physicians: Alabama (-9 percent) and New York (-3 percent). Many states saw much larger increases in median total compensation compared to the national rate, the top five being Wyoming (41 percent), Maryland (29 percent), Louisiana (27 percent), Missouri (24 percent) and Mississippi (21 percent).
Current median total compensation for primary care physicians also varies greatly by state. The District of Columbia is the lowest paying with $205,776 in median total compensation. Nevada is the highest paying state with $309,431 in median total compensation.
Over the last five years, looking beyond just nurse practitioners, overall non-physician provider compensation has increased at a rate of 8 percent. Looking at the changes over the past 10 years, that rate has doubled to 17 percent. As non-physician providers have increasingly become patients’ primary care providers over the past 10 years, combined with a subsequent shortage of non-physician providers, compensation rates continue to grow for nurse practitioners and primary care physician assistants.
The difference in compensation between the highest-paid state compared to the lowest ranges between $100,000 and almost $270,000 for physicians depending on specialties, and $65,000 for non-physician providers.

The 2018 MGMA DataDive Provider Compensation is the most trusted compensation survey in the U.S., undergoing a rigorous evaluation and inspection. Learn more at www.mgma.com/data.

Tags: care, nurse, physician, practitioner, primary, provider

Posted in: Advocacy

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Physicians Spend More Than Half of Work Day on Electronic Health Records

Posted by admin on September 20, 2017

Primary-care physicians spend more than half of their workday on electronic health records during and after clinic hours, a University of Wisconsin School of Medicine and Public Health and American Medical Association study has found. The study, published online in the Annals of Family Medicine, shows physicians spent 5.9 hours of an 11.4 hour work day on electronic health records.

“While physician burnout happens for a number of reasons, spending a good deal of the work day and beyond on electronic health records is one of the things that leads to burnout,” said Dr. Brian Arndt, associate professor of family medicine and community health.

Arndt said 142 family-medicine physicians in the UW Health system were part of the study and all EHR interactions were tracked over a three-year period from 2013 to 2016 for both direct patient care and non-face-to-face activities.

He found that clinicians spent 4.5 hours during clinic each day on electronic health records. Another 1.4 hours before or after clinic were used for electronic health records documentation for a total of 5.9 hours each day.

That means that primary-care physicians spent nearly two hours on electronic health records per hour of direct patient care.

“When you factor in the non-electronic health records duties, it adds up to a workday of 11.4 hours, representing a significant intrusion on physicians’ personal and family lives,” said Arndt.

Order entry, billing and coding, and system security accounted for nearly half of the total electronic health records time (2.6 hours). Clerical duties like medication refills, interpretation of lab and imaging results, letters to patients, responding by e-mail to questions about medications and incoming and outgoing phone calls accounted for another 1.4 hours of every work day.

“It is imperative to find ways to reduce documentation burden on physicians,” said Arndt. “There are a couple of things to consider. Having clinical staff enter verbal or handwritten notes (based on a standardized checklist) could save time and allow physicians to focus more on the patient. In addition, documentation support by staff and additional training in documentation optimization should be available for interested physicians.”

Arndt said the electronic health records event logs used in the study can identify areas of electronic health records-related work that could be delegated to reduce workload, improve professional satisfaction and reduce burnout.

UW Health Chief Medical Information Officer and Senior Vice President Dr. Shannon Dean said the health system leadership supports and appreciates the work of Dr. Arndt and his colleagues in identifying areas of concern and supports reducing any undue burdens on physicians by proactively looking for ways to make the electronic health records system more efficient and distributing appropriate work amongst the clinical care team. Electronic health records systems do offer major benefits to patient care, so preserving their value is also a key goal.

Dean said initiatives include the recent deployment of single sign-on technology that addresses the time spent simply logging in and out of the system and the rollout of advanced voice-recognition software to allow providers to “dictate” directly into the system rather than type.

“UW Health acknowledges that the electronic health records and increased documentation requirements are contributing factors to physician burnout and has invested significant resources in education, optimization and support teams to ensure providers have ‘at the elbow’ support for doing their work,” said Dean. “Our support teams are currently meeting one-on-one with every provider to review their use of the electronic health records and provide them with tips and tricks to improve efficiency.”

Tags: burnout, care, dictate, documentation, EHR, hassle, record, workload

Posted in: Management

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Alabama Medicaid Seeks Public Comments

Posted by admin on September 14, 2017

Alabama Medicaid is seeking public comment on an amendment to the Alabama Home and Community-Based Intellectual Disabilities Waiver.

Medicaid Intellectual Disabilities Waiver Amendment | Comments Submitted by October 8, 2017

The Alabama Medicaid Agency is seeking public comment on its proposal to amend the Alabama Home and Community-Based Intellectual Disabilities Waiver (ID Waiver).

The waiver supports Alabama citizens who have a diagnosis of Intellectual Disabilities and who would otherwise require the level of care offered in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) institution to remain in the community. The waiver provides services such as day services and in-home supports. The amendment proposes changes to the sections pertaining to Individual Directed Goods and Services and self-directed services.

A copy of the proposed application can be found on the Alabama Medicaid Agency website. Click here to view waiver documents.

The comment period is open until October 8, 2017. Written comment regarding the proposed waiver amendment are welcome and should be mailed to Samantha McLeod, Associate Director via mail to: Alabama Medicaid Agency, Long Term Care Division, P.O. Box 5624, Montgomery, AL 36103-5624 or via email to samantha.mcleod@medicaid.alabama.gov.

Tags: care, disabilities, integrate, intellectual, Medicaid, network, waiver

Posted in: Medicaid

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CMS Proposes 2018 Payment and Policy Updates for the Physician Fee Schedule

Posted by admin on July 14, 2017

The Centers for Medicare & Medicaid Services issued a proposed rule that would update Medicare payment and policies for doctors and other clinicians who treat Medicare patients in the calendar year 2018. The proposed rule is one of several Medicare payment rules for CY 2018 that reflect a broader strategy to relieve regulatory burdens for providers; support the patient-doctor relationship in health care; and promote transparency, flexibility, and innovation in the delivery of care.

The Physician Fee Schedule is updated annually to include changes to payment policies, payment rates, and quality provisions for services furnished to Medicare beneficiaries. In addition to physicians, a variety of medical professionals, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities, are paid under the Physician Fee Schedule.

This proposed rule would provide greater potential for payment system modernization and seeks public comment on reducing administrative burdens for providing patient care, including visits, care management, and telehealth services. The rule takes steps to better align incentives and provide clinicians with a smoother transition to the new Merit-based Incentive Payment System under the Quality Payment Program (QPP). The rule encourages fairer competition between hospitals and physician practices by promoting greater payment alignment, and it would improve the payment for office-based behavioral health services that are often the therapy and counseling services used to treat opioid addiction and other substance use disorders. In addition, the proposed rule makes additional proposals to implement the Center for Medicare and Medicaid Innovation’s Medicare Diabetes Prevention Program expanded model starting in 2018.

These updates would help reduce regulatory burdens and allow practitioners to improve outcomes based on the unique needs of their patients. In addition to the proposed rule, CMS is releasing a Request for Information to welcome continued feedback on the Medicare program. CMS is committed to maintaining flexibility and efficiency throughout Medicare. Through transparency, flexibility, program simplification, and innovation, CMS aims to transform the Medicare program and promote the availability of high-value and efficiently-provided care for its beneficiaries. This will inform the discussion on future regulatory action related to the Physician Fee Schedule.