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How New Jersey Public Policy Fails Primary-Care Physicians

How New Jersey Public Policy Fails Primary-Care Physicians | Healthcare and Technology news | Scoop.it

We live in a very exciting time in the healthcare industry. Regardless of how you feel or think about decisions that are made on the government level, healthcare is in a period of controlled chaos right now.


With the potential merger of Anthem and Cigna and Aetna and Humana, or Assurant closing its doors on its health insurance business, things are about to get really interesting for medical practices. Arming yourself with as much information as possible is key to not just surviving financially, but thriving in this new environment.

Let's take Assurant, for example. They've decided that doing business in the healthcare arena and competing against the dominant healthcare insurance companies was far more expensive than expected. What does this mean for your practice? If you have patients that use Assurant as their medical insurance, it's a great idea to step in and take control of those accounts, now. Create a waiver for Assurant patients that explains what is going on, what to expect from their plan, and how they can still see you with a new insurance plan. The waiver should also state that in the event Assurant does not pay the medical claim, patients will be responsible for the allowed amount, and they will have to pay out of pocket if it is a PPO Plan. If the plan is an HMO, and Assurant does not pay, the practice is not allowed to place a PR (patient responsibility) to the patient and will lose that money.


Aetna and Assurant have similar fee schedules, so suggest to your patients to look into individual Aetna plans, to ensure that you will retain those patients and not lose revenue if you are contracted with Aetna. You will also need to really follow up with those claims and make sure that Assurant is paying you. I have seen them use a delaying tactic of denying a claim with the code CO95 (plan procedures not followed), which basically means they are sending your claim to a different claim address than what was provided to you at the time of benefit verification.  


As far as the pending mergers, I really love it when this happens. I'm particularly fond of the companies that have been courting each other lately. With the possible Aetna/Humana merger, Aetna will be able to add a lot more patients to their network. It will position them as a real player and earn them much needed respect within the market. I still have some overall issues with both Aetna and Humana, but merging them together should ease some of those issues.


The Anthem/Cigna cat-and-mouse game going on is particularly interesting. Cigna claims they're worth more than $184/share, and said no to Anthem's last purchase attempt. But Anthem is not giving up. Cigna used to be a premium plan until they teamed up with American Specialty Health. They have basically cut reimbursements to providers in half (if you signed up under their new network, otherwise you are seeing Cigna patients out of network), and implemented a time-consuming authorization process that eats away at whatever profit your practice may have left over from the reimbursement cuts. They implemented this over the course of the last year, or so. Working with Anthem is pretty cut and dried: What you see is what you get, with no hidden agendas. Anthem requires few to no pre-authorizations, allowing you to see your patient and maybe make a few bucks.


Just taking a few moments and reading up on what is going on in the healthcare industry today is really key to insuring your practice is not caught off guard. Always be learning, always be aware. There are multiple newsletters you can sign up for that will drop a daily or weekly e-mail into your inbox that will help you keep up.

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Primary care: No system can replace human effort and commitment

Primary care: No system can replace human effort and commitment | Healthcare and Technology news | Scoop.it

It’s been thirty years since Dr. Pete shook my hand on graduation day and slapped my back, his gravelly voice mumbling a wisecrack that couldn’t quite hide his emotions. I was the first foreign medical school graduate in our small residency program and he had trusted me, just as I had trusted him, through three years of hard work and many challenges.


Our residency program was only a few years old, and my specialty was only twelve when I started. Family practice had begun with the realization in the 1950s that fewer and fewer medical school graduates chose to enter general practice after their internship year, but instead went on to specialize. With the knowledge explosion of the twentieth century, the need for well-trained generalists gained acceptance and the void left by retiring GPs was filled by the graduates of three-year family practice residencies focusing on 1) first-contact care; 2) continuous care; 3) comprehensive care; 4) personal care (caritas); 5) family care; and, 6) competency in scientific general medicine.

Medicine has changed a lot, and America is not the same as when I first came here. Primary care is more complex, with more demands from forces outside the physician-patient-family constellation we thought and talked so much about thirty years ago.

In the early 1980s CT scanning had just been introduced, but there were no MRIs in our state yet. We didn’t have EMRs, there were no prior authorizations, no direct-to-consumer drug advertising; we didn’t even have the Internet.

What we did have when I started out was a generation of young doctors with a shared passion for clinical, albeit low-tech medicine, and for taking care of patients and families in their small communities.

My generation had sit-ins over minor injustices in high school. We wore bell bottoms and sang songs about love, peace and justice. We wanted to make the world a better place. Those of us who wanted to become doctors watched Marcus Welby, MD – I did, as an exchange student, on a large console TV in my Massachusetts host family’s suburban living room. My determination from a year of illness in early childhood to become a doctor gelled right then, in 1971, into a vision of what I have been fortunate to actually be doing for the last thirty years.

I have better tools now than Marcus Welby had, and the technical standard of care has made huge leaps since my residency days. But something has gone missing. The idealism and passion of physicians has become worn and frayed as a result of the paradigm shift toward the manufacturing view of health care. Health care is now becoming impersonal. It is organized, delivered and measured like industrial output in automobile plants. It is mass produced and valued by its consistency and conformity, even though no two patients are exactly alike.

Most of our patients still come to us looking for personalized care, but they feel the pinch of our newly imposed agendas in their fifteen minutes with us. We are more and more put in the role of public health officials, collecting data for government and insurance companies and promoting their population-based agendas.

But when we really engage with our patients we can see the power of the traditional doctor-patient relationship that many others in health care have tried to negate.

The passion and commitment of doctors have been devalued as we are instead building entire systems to do what Marcus Welby and his nurse did, day in and day out, when they practiced their professions and held themselves to their standards and ideals.

But no system can replace human effort and commitment. Doctors, nurses and everybody else in health care need to be at the center, side by side and face to face with their patients and the “system” needs to capture, rekindle and support their passion, not suppress and replace it.

Family physicians were trained to be capable in areas where our ability to keep up is now challenged, just like the general practitioners’ sixty years ago. Fewer and fewer primary care doctors now set fractures, deliver babies or perform even minor surgeries and procedures.

Increasingly, we are instead taking on the role that the journal Canadian Family Physician calls “broker of choices.” With the Internet and all the media exposure about medical issues, we are no longer patients’ primary source of medical information, but we are the ones that are best suited to help them sort out information and compare alternatives.

This actually builds on our specialty’s founding principles. We are still the glue that holds the parts together, even when other specialties are involved. We provide the first contact, the continuity, the personal focus and the family view of the patient and their support system; it requires our solid competency in general scientific medicine; and it is comprehensive in the ancient meaning of the word as it derives from “comprehendere” — to grasp mentally — we help our patients with the big picture while we attend to their everyday medical needs.


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Primary care is broken: Here are ways to fix it

Primary care is broken: Here are ways to fix it | Healthcare and Technology news | Scoop.it

Can primary care survive? At a time when the services of a well trained, well-supported primary care physician are needed more than ever before to help patients negotiate through the confusing health care maze, the specialty is under siege.

We are overwhelmed. Those of us in primary care are overwhelmed by the growing weight of medical, legal, financial, and clerical responsibilities placed on our shoulders. The quality of care we can provide, the level of patient and physician satisfaction we can achieve, as well as the future viability of primary care depends on our ability to successfully address this issue.


The forces which threaten to dismantle primary care, including the growing complexity of patient care, increasing non-physician work responsibilities placed on physicians, mounting pressures to fragment care and inequitable and perverse reimbursement, are identified. Patient-centered, physician-sensitive, deliverable recommendations are developed.

Consider the example of a yearly exam for a common patient in primary care, a patient with diabetes, heart disease, hypertension, osteoarthritis, and a new complaint of fatigue. The workload is substantial; let’s look at its component parts.

First the medical issues: This patient requires three distinct services:  prevention, chronic disease management, and acute symptom evaluation. Provision of any one of these services separately would constitute a significant office visit. Taken collectively, such simultaneous care represents an organizational and intellectual challenge for the physician, integrated care for the patient, and a bargain for the third party payer.

Next the clerical responsibilities: The dictation will be composed for good future care of this patient, but also as a defense toward auditors, lawyers, and insurance representatives. The physician must count bullet points for the history, bullet points for the physical exam, determine the level of complexity, and then integrate each component into a final grid to choose the correct current procedural terminology (CPT) service code, a clerical task estimated by our in-house auditors to require ten to fifteen minutes per encounter.

Finally the bureaucratic responsibilities: Medicare and others have increasingly burdened physicians with unmanageable paperwork for everything from canes and commodes to hearing aid batteries and Meals on Wheels; from a three-page authorization for a motorized scooter to a 29-question family medical leave application. Complex insurance regulations require duplicate copies of prescriptions, systems for formulary compliance, and gatekeeper authorizations. The cost of such unreimbursed work falls disproportionately on the primary care physician.

The primary care physician is allocating resources to maintain the profitability of other organizations. Should physicians continue to be the unpaid workforce of private for-profit companies, such as health insurance companies, suppliers of durable medical equipment, mail order pharmacies, commercial screening ventures (such as mobile vascular labs) and home health agencies? Does every institution and business entity have the right to create additional paperwork with the expectation that the physician will assume responsibility for its completion? How much longer can physicians remain the unfunded agents of the Department of Transportation and the Office of Inspector General?

Given the accumulating burdens placed on primary care physicians, is it any surprise that the number of medical students applying for primary care residencies is steadily declining? Or that job satisfaction among primary care physicians is low?

How can this situation be addressed? We need to affirm that doctors should spend most of their time doing the things both patients and physicians find most important (listening, thinking, talking) and a much smaller amount of time performing clerical, bureaucratic, and defensive tasks. Every element of practice, every technological implementation, every new responsibility should be evaluated in this light.

Specific recommendations

Develop community-based primary care research initiatives. Most medical research is done at academic centers, often from the perspective of a single disease entity, yet most health care is delivered as the complex integration of multiple medical problems over time, usually in a community setting. This disconnect has created a gap between research and reality. Practical clinical trials, and collaboration between academic and community physicians could frame research questions to maximize applicability to clinical practice.

Analyze optimal strategies for structuring an outpatient primary care practice. Apply a systems analysis approach to the microenvironment of the physician’s office to facilitate comprehensive, efficient, and quality care.

Quantify the workload in primary care. Expand on the study that estimated that full compliance with U.S. Preventive Task Force-recommended prevention issues alone would require 7.5 hours per day per primary care physician. Quantify the number of patient care issues addressed at an average office visit in primary care; the number of guidelines that apply to an average patient visit; the time required to address each of these guidelines; and the amount of unreimbursed work in primary care for paperwork, phone care, coordination of care, and services for which reimbursement has simply been eliminated.

Such data will help to clarify the extent of the workload, can provide perspective when additional responsibilities are proposed for primary care, and may point to ways to improve care.

Acknowledge that reimbursement matters. Adequate reimbursement is necessary to support quality care. Take a hard look at the reimbursement in primary care. Is it sufficient to support the services required, and does it represent an equitable distribution of health care resources?

As an example: Using literature estimates for time and regional third party reimbursement rates for payment, I have estimated that procedural preventive services (screening colonoscopy) are reimbursed at about 4 times the rate of cognitive preventive services (annual preventive medicine exam).

Reimbursement for primary care must be adjusted to reflect the scope of services provided and to fund the type of support systems necessary to provide quality care.

Establish the link between workload, reimbursement, and quality. The cumulative effect of the demands on primary care has an inevitable impact on quality. Americans are getting only half of the recommended care for a series of common ailments. Compliance with published guidelines was highest for conditions cared for as single entities (cataracts, prenatal care, breast cancer), and lowest for conditions typically cared for in the context of multiple medical problems, and at an overall lower rate of reimbursement, (headache, diabetes, depression, atrial fibrillation, hyperlipidemia).

Develop a conceptual and computational framework to analyze multiple services provided at a single visit. Primary care specialists provide preventive care, chronic disease management, and acute symptom evaluation services within a single office visit. There is currently no satisfactory mechanism for equitable reimbursement of these distinct services.

Recognize that integrated care is better than fragmented care. Integrated care is what we do in primary care. The patient described above could be cared for in a single visit by a well-trained primary care physician or receive the same care by five separate visits to five separate clinics:  cardiology, endocrinology, rheumatology, hypertension, and preventive medicine. What would be the financial and social costs of the patient’s care if it were fragmented into single organ system clinics? What would be the overall quality, coordination, and contextualization of that care? What would be the patient acceptance and compliance?

Realize that technology can serve or enslave. The details matter. Technology must be scrutinized to assure that it assists in the overall care of the patient. If a new technology adds transcriptionist, receptionist, and pharmacist duties to the primary care physician’s already full slate of responsibilities, then its adoption may be premature. Computerized physician order entry (CPOE) and decision support technologies need to be further refined to efficiently accommodate the simultaneous management of multiple complex conditions.

Evaluate practice guidelines from a primary care perspective. Guidelines should be developed in a collaborative approach which includes the perspective of practicing primary care internists.

Primary care involves the complex integration of multiple medical problems over time. Simultaneous care of multiple chronic illnesses, acute symptom evaluation, and preventive medicine is a difficult but worthy task. Added to this has been an insupportable layer of clerical and bureaucratic duties.

I believe that most physicians are trying to meet these challenges. But none of us can shoulder all of the increasing burdens that suck the life out of our practice and still maintain the intellectual and emotional reserves to deliver quality and compassionate care. None of us can do ten hours of work in eight for the price of one.

Primary care is at the breaking point. Something is giving; we are just not measuring it.  We aren’t measuring it because we aren’t even talking about it. That is the elephant in the middle of the room.


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Our health care system makes no sense. But what if it did?

Our health care system makes no sense. But what if it did? | Healthcare and Technology news | Scoop.it

The conversation was almost comical, until I thought more deeply about it later.  Apparently I was on “the list.”  Insurers make such lists for customers who are  searching for a doctor who accepts their coverage.  Every so often my name comes up on these lists, and I get a smattering of phone calls from perspective patients. Maybe a few times a year.


This particular call came around three-thirty in the afternoon.  My personal assistant had already signed over the phone to me, so my office number came right to the mobile.  I answered quickly expecting one of the nursing homes.  The voice on the other end was hesitant.  He was looking for Dr. Grumet’s office, but quickly realized he had the doctor himself on the phone.  This felt odd for a guy switching physicians because the next appointment at his current practice was two weeks away.  But his toe was hurting something fierce and he was desperate.

So he searched his insurance web site for a list of available providers.  He quickly crossed off any physician that belonged to his current practice or the hospital based medical group because he knew from experience that those doctors rarely had openings.  They almost never returned phone calls.  Although I do not accept his insurance, I somehow had landed upon the sacred list he was scrawling through anxiously.

He told me that I was the tenth phone call he made.  He came up empty with the first nine doctors.  Many claimed that they were closed to his insurance because they were too busy to take on new patients.  One was retiring in a few months.  Another was leaving medicine to work for a pharmaceutical company.  A third was transitioning into a hospitalist position.

I regrettably informed him that I would be happy to bill his insurance but also charged a yearly fee for non-covered services.  He paused for a moment.  I could feel the wheels spinning in is head.  He hated to pay extra, but was dumbfounded to find that he was actually talking to the doctor himself without jumping over any roadblocks or scaling any walls.  His foot ached.  And I knew that it would probably take little mental effort to assess and treat his problem.  Whether stress fracture or gout, infection or inflammation, I felt certain that I could help.

We talked a little longer.  Not about his medical problem in detail but more what was happening to our health care system.  It was a pleasant unhurried conversation.  He eventually decided that he would try his luck with the rest of the names listed in front of him  He thanked me profusely for my time and hung up with a sigh of resignation.

I hope he found the care he needed.  I doubt I will ever hear from him again.  These types of calls rarely end in the signing up of a new patient.

I wonder if he marveled, for just a moment, about how easy it could be.

What if you could talk to your physician whenever you needed to?

What if doctors and patients had time to form strong mutually respectful bonds?

What if our health care system made sense?



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