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O E
S T LIN ICE
TIP AM ACT
RE PR E 33
ST UR PAG
YO
Medical Economics
JAN UARY 10, 2015
PAYM E NT OUTLOOK FOR 2015
JANUARY 10, 2015
VOL. 92 NO. 1
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TH E PROM ISE OF E LECTRON IC PR IOR AUTHOR IZATIONS
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ICD-10: Will it be
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Evaluation and
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Fixing the referral
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PAYMENT
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Your guide to solutions to help
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ES544312_ME011015_cv1.pgs 12.16.2014 21:17
ADV
NEW
7.5 mcg/hour Now Available
Butrans — 7 Days of
Buprenorphine Delivery
Butrans is a Schedule III extended-release opioid analgesic
WARNING: ADDICTION, ABUSE and MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL EXPOSURE; and
NEONATAL OPIOID WITHDRAWAL SYNDROME
Addiction, Abuse, and Misuse
Butrans exposes patients and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death.
Assess each patient’s risk prior to prescribing Butrans, and monitor all patients regularly for the development of these behaviors or
conditions [see Warnings and Precautions (5.1) and Overdosage (10)].
Life-Threatening Respiratory Depression
Serious, life-threatening, or fatal respiratory depression may occur with use of Butrans. Monitor for respiratory depression, especially
during initiation of Butrans or following a dose increase. Misuse or abuse of Butrans by chewing, swallowing, snorting or injecting
buprenorphine extracted from the transdermal system will result in the uncontrolled delivery of buprenorphine and pose a significant
risk of overdose and death [see Warnings and Precautions (5.2)].
Accidental Exposure
Accidental exposure to even one dose of Butrans, especially by children, can result in a fatal overdose of buprenorphine [see Warnings
and Precautions (5.2)].
Neonatal Opioid Withdrawal Syndrome
Prolonged use of Butrans during pregnancy can result in neonatal opioid withdrawal syndrome, which may be life-threatening if not
recognized and treated, and requires management according to protocols developed by neonatology experts. If opioid use is required
for a prolonged period in a pregnant woman, advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure that
appropriate treatment will be available [see Warnings and Precautions (5.3)].
Parentheses refer to sections in the Full Prescribing Information.
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ES543218_ME011015_CV2_FP.pgs 12.12.2014 02:01
ADV
Butrans® (buprenorphine) Transdermal System is indicated for the management of pain severe
enough to require daily, around-the-clock, long-term opioid treatment and for which alternative
treatment options are inadequate.
Limitations of Use: Because of the risks of addiction, abuse and misuse with opioids, even at
recommended doses, and because of the greater risk of overdose and death with extended-release
opioid formulations, reserve Butrans for use in patients for whom alternative treatment options
(eg, non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be
otherwise inadequate to provide sufficient management of pain. Butrans is not indicated as an
as-needed (prn) analgesic.
CONTRAINDICATIONS
Butrans is contraindicated in patients with:
significant respiratory depression; acute or severe
bronchial asthma in an unmonitored setting or in
the absence of resuscitative equipment; known or
suspected paralytic ileus; hypersensitivity (eg,
anaphylaxis) to buprenorphine
■
WARNINGS AND PRECAUTIONS
Addiction, Abuse, and Misuse
■ Butrans contains buprenorphine, a Schedule III
controlled substance. Butrans exposes users to
the risks of opioid addiction, abuse, and misuse.
As modified-release products such as Butrans
deliver the opioid over an extended period of
time, there is a greater risk for overdose and
death, due to the larger amount of buprenorphine
present. Addiction can occur at recommended
doses and if the drug is misused or abused.
Assess each patient’s risk for opioid addiction,
abuse, or misuse prior to prescribing Butrans, and
monitor all patients during therapy for the
development of these behaviors or conditions.
Abuse or misuse of Butrans by placing it in the
mouth, chewing it, swallowing it, or using it in
ways other than indicated may cause choking,
overdose and death
Life-Threatening Respiratory Depression
■ Serious, life-threatening, or fatal respiratory
depression has been reported with modifiedrelease opioids, even when used as
recommended, and if not immediately recognized
and treated, may lead to respiratory arrest and
death. The risk of respiratory depression is
greatest during the initiation of therapy or
following a dose increase; therefore, closely
monitor patients for respiratory depression.
Proper dosing and titration of Butrans are
essential. Overestimating the Butrans dose when
converting patients from another opioid product
can result in fatal overdose with the first dose.
Accidental exposure to Butrans, especially in
children, can result in respiratory depression and
death due to an overdose of buprenorphine
Neonatal Opioid Withdrawal Syndrome
■ Prolonged use of Butrans during pregnancy can
result in neonatal opioid withdrawal syndrome
which may be life-threatening to the neonate if
not recognized and treated, and requires
management according to protocols developed
by neonatology experts
Interactions with Central Nervous System
Depressants
■ Hypotension, profound sedation, coma,
respiratory depression, or death may result if
Butrans is used concomitantly with other CNS
depressants, including alcohol or illicit drugs that
can cause CNS depression. Start with Butrans 5
mcg/hour patch, monitor patients for signs of
sedation and respiratory depression, and
consider using a lower dose of the concomitant
CNS depressant
Use in Elderly, Cachectic, and Debilitated
Patients and Patients with Chronic
Pulmonary Disease
■ Closely monitor elderly, cachectic, and debilitated
patients, and patients with chronic obstructive
pulmonary disease because of the increased risk
of life-threatening respiratory depression.
Consider the use of alternative non-opioid
analgesics in patients with chronic obstructive
pulmonary disease if possible
QTc Prolongation
■ Avoid in patients with Long QT Syndrome, family
history of Long QT Syndrome, or those taking
Class IA or Class III antiarrhythmic medications
Hypotensive Effects
■ Butrans may cause severe hypotension, including
orthostatic hypotension and syncope in
ambulatory patients. Monitor patients during
dose initiation or titration
Use in Patients with Head Injury or
Increased Intracranial Pressure
■ Monitor patients taking Butrans who may be
susceptible to the intracranial effects of CO2
retention for signs of sedation and respiratory
depression. Avoid the use of Butrans in patients
with impaired consciousness or coma
Please read Brief Summary of Full Prescribing Information on the following pages.
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Application Site Skin Reactions
■ In rare cases, severe application site skin reactions
with signs of marked inflammation including
“burn,” “discharge,” and “vesicles” have occurred
Anaphylactic/Allergic Reactions
■ Cases of acute and chronic hypersensitivity to
buprenorphine have been reported both in
clinical trials and in the post-marketing experience
Application of External Heat
■ Avoid exposing the Butrans application site and
surrounding area to direct external heat sources.
There is a potential for temperature-dependent
increases in buprenorphine released from the
system resulting in possible overdose and death
Use in Patients with Gastrointestinal Conditions
■ Avoid the use of Butrans in patients with paralytic
ileus and other GI obstructions. Monitor patients
with biliary tract disease, including acute
pancreatitis, for worsening symptoms
■
ADVERSE REACTIONS
Most common adverse reactions (≥5%) reported
by patients treated with Butrans in the clinical
trials were nausea, headache, application site
pruritus, dizziness, constipation, somnolence,
vomiting, application site erythema, dry mouth,
and application site rash
Visit
Butrans.com
for more information
or to print the Butrans
Trial Offer and Butrans
Savings Cards
The first transdermal system to
deliver 7 days of buprenorphine
©2014 Purdue Pharma L.P.
Stamford, CT 06901-3431
J8365-A 8/14
ES543217_ME011015_001_FP.pgs 12.12.2014 02:01
ADV
for transdermal administration
BRIEF SUMMARY OF PRESCRIBING INFORMATION
(For complete details please see the Full Prescribing Information and
Medication Guide.)
WARNING: ADDICTION, ABUSE and MISUSE; LIFE-THREATENING
RESPIRATORY DEPRESSION; ACCIDENTAL EXPOSURE; and NEONATAL
OPIOID WITHDRAWAL SYNDROME
Addiction, Abuse, and Misuse
BUTRANS® exposes patients and other users to the risks of opioid
addiction, abuse, and misuse, which can lead to overdose and death.
Assess each patient’s risk prior to prescribing BUTRANS, and monitor all patients regularly for the development of these behaviors or
conditions [see Warnings and Precautions (5.1) and Overdosage (10)].
Life-Threatening Respiratory Depression
Serious, life-threatening, or fatal respiratory depression may occur
with use of BUTRANS. Monitor for respiratory depression, especially
during initiation of BUTRANS or following a dose increase. Misuse
or abuse of BUTRANS by chewing, swallowing, snorting or injecting
buprenorphine extracted from the transdermal system will result in
the uncontrolled delivery of buprenorphine and pose a significant
risk of overdose and death [see Warnings and Precautions (5.2)].
Accidental Exposure
Accidental exposure to even one dose of BUTRANS, especially by
children, can result in a fatal overdose of buprenorphine [see Warnings
and Precautions (5.2)].
Neonatal Opioid Withdrawal Syndrome
Prolonged use of BUTRANS during pregnancy can result in neonatal
opioid withdrawal syndrome, which may be life-threatening if not
recognized and treated, and requires management according to
protocols developed by neonatology experts. If opioid use is required
for a prolonged period in a pregnant woman, advise the patient of the
risk of neonatal opioid withdrawal syndrome and ensure that appropriate treatment will be available [see Warnings and Precautions (5.3)].
4 CONTRAINDICATIONS BUTRANS is contraindicated in patients with:
• Significant respiratory depression • Acute or severe bronchial asthma in an
unmonitored setting or in the absence of resuscitative equipment • Known or
suspected paralytic ileus • Hypersensitivity (e.g., anaphylaxis) to buprenorphine
[see Warnings and Precautions (5.12) and Adverse Reactions (6)]
5 WARNINGS AND PRECAUTIONS 5.1 Addiction, Abuse, and Misuse
BUTRANS contains buprenorphine, a Schedule III controlled substance. As an
opioid, BUTRANS exposes users to the risks of addiction, abuse, and misuse.
As modified-release products such as BUTRANS deliver the opioid over an
extended period of time, there is a greater risk for overdose and death, due
to the larger amount of buprenorphine present. Although the risk of addiction
in any individual is unknown, it can occur in patients appropriately prescribed
BUTRANS and in those who obtain the drug illicitly. Addiction can occur at
recommended doses and if the drug is misused or abused [see Drug Abuse
and Dependence (9)]. Assess each patient’s risk for opioid addiction, abuse,
or misuse prior to prescribing BUTRANS, and monitor all patients receiving
BUTRANS for the development of these behaviors or conditions. Risks are
increased in patients with a personal or family history of substance abuse
(including drug or alcohol abuse or addiction) or mental illness (e.g., major
depression). The potential for these risks should not, however, prevent the
proper management of pain in any given patient. Patients at increased risk
may be prescribed modified-release opioid formulations such as BUTRANS,
but use in such patients necessitates intensive counseling about the risks and
proper use of BUTRANS, along with intensive monitoring for signs of addiction,
abuse, or misuse. Abuse or misuse of BUTRANS by placing it in the mouth,
chewing it, swallowing it, or using it in ways other than indicated may cause
choking, overdose and death [see Overdosage (10)]. Opioid agonists such as
BUTRANS are sought by drug abusers and people with addiction disorders
and are subject to criminal diversion. Consider these risks when prescribing
or dispensing BUTRANS. Strategies to reduce these risks include prescribing
the drug in the smallest appropriate quantity and advising the patient on the
proper disposal of unused drug [see Patient Counseling Information (17)].
Contact local state professional licensing board or state controlled substances
authority for information on how to prevent and detect abuse or diversion of
this product. 5.2 Life-Threatening Respiratory Depression Serious, lifethreatening, or fatal respiratory depression has been reported with the use of
modified-release opioids, even when used as recommended. Respiratory
depression, from opioid use, if not immediately recognized and treated, may
lead to respiratory arrest and death. Management of respiratory depression
may include close observation, supportive measures, and use of opioid
antagonists, depending on the patient’s clinical status [see Overdosage (10)].
Carbon dioxide (CO2) retention from opioid-induced respiratory depression
can exacerbate the sedating effects of opioids. While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of
BUTRANS, the risk is greatest during the initiation of therapy or following a
dose increase. Closely monitor patients for respiratory depression when initiating therapy with BUTRANS and following dose increases. To reduce the
risk of respiratory depression, proper dosing and titration of BUTRANS are
essential [see Dosage and Administration (2)]. Overestimating the BUTRANS
dose when converting patients from another opioid product can result in fatal
overdose with the first dose. Accidental exposure to BUTRANS, especially in
children, can result in respiratory depression and death due to an overdose
of buprenorphine. 5.3 Neonatal Opioid Withdrawal Syndrome Prolonged
use of BUTRANS during pregnancy can result in withdrawal signs in the
neonate. Neonatal opioid withdrawal syndrome, unlike opioid withdrawal
syndrome in adults, may be life-threatening if not recognized and treated,
and requires management according to protocols developed by neonatology
experts. If opioid use is required for a prolonged period in a pregnant woman,
advise the patient of the risk of neonatal opioid withdrawal syndrome and
ensure that appropriate treatment will be available. Neonatal opioid withdrawal
syndrome presents as irritability, hyperactivity and abnormal sleep pattern,
high pitched cry, tremor, vomiting, diarrhea and failure to gain weight. The
onset, duration, and severity of neonatal opioid withdrawal syndrome vary
based on the specific opioid used, duration of use, timing and amount of last
maternal use, and rate of elimination of the drug by the newborn. 5.4
Interactions with Central Nervous System Depressants Hypotension,
black
profound sedation, coma, respiratory depression, and death may result if
BUTRANS is used concomitantly with alcohol or other (CNS) depressants
(e.g., sedatives, anxiolytics, hypnotics, neuroleptics, other opioids). When
considering the use of BUTRANS in a patient taking a CNS depressant, assess
the duration of use of the CNS depressant and the patient’s response,
including the degree of tolerance that has developed to CNS depression.
Additionally, evaluate the patient’s use of alcohol or illicit drugs that cause
CNS depression. If the decision to begin BUTRANS therapy is made, start
with BUTRANS 5 mcg/hour patch, monitor patients for signs of sedation and
respiratory depression and consider using a lower dose of the concomitant
CNS depressant [see Drug Interactions (7.2)]. 5.5 Use in Elderly, Cachectic,
and Debilitated Patients Life-threatening respiratory depression is more
likely to occur in elderly, cachectic, or debilitated patients as they may have
altered pharmacokinetics or altered clearance compared to younger,
healthier patients. Monitor such patients closely, particularly when initiating
and titrating BUTRANS and when BUTRANS is given concomitantly with other
drugs that depress respiration [see Warnings and Precautions (5.2)]. 5.6 Use
in Patients with Chronic Pulmonary Disease Monitor patients with
significant chronic obstructive pulmonary disease or cor pulmonale, and
patients having a substantially decreased respiratory reserve, hypoxia,
hypercapnia, or pre-existing respiratory depression for respiratory depression,
particularly when initiating therapy and titrating with BUTRANS, as in these
patients, even usual therapeutic doses of BUTRANS may decrease respiratory
drive to the point of apnea [see Warnings and Precautions (5.2)]. Consider the
use of alternative non-opioid analgesics in these patients if possible. 5.7
QTc Prolongation A positive-controlled study of the effects of BUTRANS on
the QTc interval in healthy subjects demonstrated no clinically meaningful
effect at a BUTRANS dose of 10 mcg/hour; however, a BUTRANS dose of 40
mcg/hour (given as two BUTRANS 20 mcg/hour Transdermal Systems) was
observed to prolong the QTc interval [see Dosage and Administration (2.2) and
Clinical Pharmacology (12.2)]. Consider these observations in clinical decisions
when prescribing BUTRANS to patients with hypokalemia or clinically
unstable cardiac disease, including: unstable atrial fibrillation, symptomatic
bradycardia, unstable congestive heart failure, or active myocardial ischemia.
Avoid the use of BUTRANS in patients with a history of Long QT Syndrome
or an immediate family member with this condition, or those taking Class IA
antiarrhythmic medications (e.g., quinidine, procainamide, disopyramide) or
Class III antiarrhythmic medications (e.g., sotalol, amiodarone, dofetilide).
5.8 Hypotensive Effects BUTRANS may cause severe hypotension including
orthostatic hypotension and syncope in ambulatory patients. There is an
increased risk in patients whose ability to maintain blood pressure has already
been compromised by a reduced blood volume or concurrent administration
of certain CNS depressant drugs (e.g., phenothiazines or general anesthetics)
[see Drug Interactions (7.2)]. Monitor these patients for signs of hypotension
after initiating or titrating the dose of BUTRANS. 5.9 Use in Patients with
Head Injury or Increased Intracranial Pressure Monitor patients taking
BUTRANS who may be susceptible to the intracranial effects of CO2 retention
(e.g., those with evidence of increased intracranial pressure or brain tumors)
for signs of sedation and respiratory depression, particularly when initiating
therapy with BUTRANS. BUTRANS may reduce respiratory drive, and the
resultant CO2 retention can further increase intracranial pressure. Opioids
may also obscure the clinical course in a patient with a head injury. Avoid
the use of BUTRANS in patients with impaired consciousness or coma. 5.10
Hepatotoxicity Although not observed in BUTRANS chronic pain clinical
trials, cases of cytolytic hepatitis and hepatitis with jaundice have been
observed in individuals receiving sublingual buprenorphine for the treatment
of opioid dependence, both in clinical trials and in post-marketing adverse
event reports. The spectrum of abnormalities ranges from transient
asymptomatic elevations in hepatic transaminases to case reports of hepatic
failure, hepatic necrosis, hepatorenal syndrome, and hepatic encephalopathy.
In many cases, the presence of pre-existing liver enzyme abnormalities,
infection with hepatitis B or hepatitis C virus, concomitant usage of other
potentially hepatotoxic drugs, and ongoing injection drug abuse may have
played a causative or contributory role. For patients at increased risk of
hepatotoxicity (e.g., patients with a history of excessive alcohol intake,
intravenous drug abuse or liver disease), obtain baseline liver enzyme levels
and monitor periodically and during treatment with BUTRANS. 5.11
Application Site Skin Reactions In rare cases, severe application site skin
reactions with signs of marked inflammation including “burn,” “discharge,”
and “vesicles” have occurred. Time of onset varies, ranging from days to
months following the initiation of BUTRANS treatment. Instruct patients to
promptly report the development of severe application site reactions and
discontinue therapy. 5.12 Anaphylactic/Allergic Reactions Cases of acute
and chronic hypersensitivity to buprenorphine have been reported both in
clinical trials and in the post-marketing experience. The most common signs
and symptoms include rashes, hives, and pruritus. Cases of bronchospasm,
angioneurotic edema, and anaphylactic shock have been reported. A history
of hypersensitivity to buprenorphine is a contraindication to the use of
BUTRANS. 5.13 Application of External Heat Advise patients and their
caregivers to avoid exposing the BUTRANS application site and surrounding
area to direct external heat sources, such as heating pads or electric blankets,
heat or tanning lamps, saunas, hot tubs, and heated water beds while wearing
the system because an increase in absorption of buprenorphine may occur
[see Clinical Pharmacology (12.3)]. Advise patients against exposure of the
BUTRANS application site and surrounding area to hot water or prolonged
exposure to direct sunlight. There is a potential for temperature-dependent
increases in buprenorphine released from the system resulting in possible
overdose and death. 5.14 Patients with Fever Monitor patients wearing
BUTRANS systems who develop fever or increased core body temperature
due to strenuous exertion for opioid side effects and adjust the BUTRANS
dose if signs of respiratory or central nervous system depression occur.
5.15 Use in Patients with Gastrointestinal Conditions BUTRANS is
contraindicated in patients with paralytic ileus. Avoid the use of BUTRANS in
patients with other GI obstruction. The buprenorphine in BUTRANS may cause
spasm of the sphincter of Oddi. Monitor patients with biliary tract disease,
including acute pancreatitis, for worsening symptoms. Opioids may cause
increases in the serum amylase. 5.16 Use in Patients with Convulsive or
Seizure Disorders The buprenorphine in BUTRANS may aggravate convulsions in patients with convulsive disorders, and may induce or aggravate
seizures in some clinical settings. Monitor patients with a history of seizure
disorders for worsened seizure control during BUTRANS therapy. 5.17
Driving and Operating Machinery BUTRANS may impair the mental and
physical abilities needed to perform potentially hazardous activities such as
driving a car or operating machinery. Warn patients not to drive or operate
dangerous machinery unless they are tolerant to the effects of BUTRANS and
know how they will react to the medication. 5.18 Use in Addiction Treatment
BUTRANS has not been studied and is not approved for use in the management of addictive disorders. 6 ADVERSE REACTIONS The following
serious adverse reactions are described elsewhere in the labeling:
• Addiction, Abuse, and Misuse [see Warnings and Precautions (5.1)]
• Life-Threatening Respiratory Depression [see Warnings and
Precautions (5.2)] • QTc Prolongation [see Warnings and Precautions
(5.7)] • Neonatal Opioid Withdrawal Syndrome [see Warnings and
Precautions (5.3)] • Hypotensive Effects [see Warnings and Precautions
(5.8)] • Interactions with Other CNS Depressants [see Warnings and
Precautions (5.4)] • Application Site Skin Reactions [see Warnings and
Precautions (5.11)] • Anaphylactic/Allergic Reactions [see Warnings
and Precautions (5.12)] • Gastrointestinal Effects [see Warnings and
Precautions (5.15)] • Seizures [see Warnings and Precautions (5.16)]
6.1 Clinical Trial Experience Because clinical trials are conducted under
widely varying conditions, adverse reaction rates observed in the clinical
trials of a drug cannot be directly compared to rates in the clinical trials of
another drug and may not reflect the rates observed in practice. A total of
5,415 patients were treated with BUTRANS in controlled and open-label
chronic pain clinical trials. Nine hundred twenty-four subjects were treated for
approximately six months and 183 subjects were treated for approximately
one year. The clinical trial population consisted of patients with persistent
moderate to severe pain. The most common serious adverse drug reactions
(all <0.1%) occurring during clinical trials with BUTRANS were: chest pain,
abdominal pain, vomiting, dehydration, and hypertension/blood pressure
increased. The most common adverse events (≥2%) leading to discontinuation were: nausea, dizziness, vomiting, headache, and somnolence. The
most common adverse reactions (≥5%) reported by patients in clinical
trials comparing BUTRANS 10 or 20 mcg/hour to placebo are shown in
Table 2, and comparing BUTRANS 20 mcg/hour to BUTRANS 5 mcg/hour
are shown in Table 3 below:
Table 2: Adverse Reactions Reported in ≥5% of Patients during the
Open-Label Titration Period and Double-Blind Treatment Period:
Opioid-Naïve Patients
Open-Label
Double-Blind
Titration Period
Treatment Period
BUTRANS
BUTRANS
Placebo
MedDRA
(N = 1024)
(N = 256)
(N = 283)
Preferred Term
Nausea
23%
13%
10%
Dizziness
10%
4%
1%
Headache
9%
5%
5%
Application site
8%
4%
7%
pruritus
Somnolence
8%
2%
2%
Vomiting
7%
4%
1%
Constipation
6%
4%
1%
Table 3: Adverse Reactions Reported in ≥5% of Patients during the
Open-Label Titration Period and Double-Blind Treatment Period:
Opioid-Experienced Patients
Open-Label
Double-Blind
Titration Period
Treatment Period
BUTRANS
BUTRANS 20 BUTRANS 5
MedDRA
(N = 1160)
(N = 219) (N = 221)
Preferred Term
Nausea
14%
11%
6%
Application site
9%
13%
5%
pruritus
Headache
9%
8%
3%
Somnolence
6%
4%
2%
Dizziness
5%
4%
2%
Constipation
4%
6%
3%
Application site
3%
10%
5%
erythema
Application
3%
8%
6%
site rash
Application
2%
6%
2%
site irritation
The following table lists adverse reactions that were reported in at least
2.0% of patients in four placebo/active-controlled titration-to-effect trials.
Table 4: Adverse Reactions Reported in Titration-to-Effect Placebo/
Active-Controlled Clinical Trials with Incidence ≥2%
MedDRA Preferred Term BUTRANS (N = 392) Placebo (N = 261)
Nausea
Application site pruritus
Dizziness
Headache
Somnolence
Constipation
Vomiting
Application site erythema
Application site rash
Dry mouth
Fatigue
Hyperhidrosis
Peripheral edema
Pruritus
Stomach discomfort
21%
15%
15%
14%
13%
13%
9%
7%
6%
6%
5%
4%
3%
3%
2%
6%
12%
7%
9%
4%
5%
1%
2%
6%
2%
1%
1%
1%
0%
0%
The adverse reactions seen in controlled and open-label studies are presented
below in the following manner: most common (≥5%), common (≥1% to
<5%), and less common (<1%). The most common adverse reactions
(≥5%) reported by patients treated with BUTRANS in the clinical trials were
nausea, headache, application site pruritus, dizziness, constipation, somnolence, vomiting, application site erythema, dry mouth, and application
site rash. The common (≥1% to <5%) adverse reactions reported by patients
treated with BUTRANS in the clinical trials organized by MedDRA (Medical
Dictionary for Regulatory Activities) System Organ Class were: Gastrointestinal
disorders: diarrhea, dyspepsia, and upper abdominal pain General disorders
and administration site conditions: fatigue, peripheral edema, application
ES543184_ME011015_002_FP.pgs 12.12.2014 02:00
ADV
site irritation, pain, pyrexia, chest pain, and asthenia Infections and infestations: urinary tract infection, upper respiratory tract infection, nasopharyngitis, influenza, sinusitis, and bronchitis Injury, poisoning and procedural
complications: fall Metabolism and nutrition disorders: anorexia Musculoskeletal
and connective tissue disorders: back pain, arthralgia, pain in extremity,
muscle spasms, musculoskeletal pain, joint swelling, neck pain, and
myalgia Nervous system disorders: hypoesthesia, tremor, migraine, and
paresthesia Psychiatric disorders: insomnia, anxiety, and depression
Respiratory, thoracic and mediastinal disorders: dyspnea, pharyngolaryngeal
pain, and cough Skin and subcutaneous tissue disorders: pruritus, hyperhidrosis, rash, and generalized pruritus Vascular disorders: hypertension Other
less common adverse reactions, including those known to occur with opioid
treatment, that were seen in <1% of the patients in the BUTRANS trials
include the following in alphabetical order: Abdominal distention, abdominal
pain, accidental injury, affect lability, agitation, alanine aminotransferase
increased, angina pectoris, angioedema, apathy, application site dermatitis,
asthma aggravated, bradycardia, chills, confusional state, contact dermatitis, coordination abnormal, dehydration, depersonalization, depressed level
of consciousness, depressed mood, disorientation, disturbance in attention,
diverticulitis, drug hypersensitivity, drug withdrawal syndrome, dry eye, dry
skin, dysarthria, dysgeusia, dysphagia, euphoric mood, face edema, flatulence,
flushing, gait disturbance, hallucination, hiccups, hot flush, hyperventilation,
hypotension, hypoventilation, ileus, insomnia, libido decreased, loss of
consciousness, malaise, memory impairment, mental impairment, mental
status changes, miosis, muscle weakness, nervousness, nightmare, orthostatic hypotension, palpitations, psychotic disorder, respiration abnormal,
respiratory depression, respiratory distress, respiratory failure, restlessness,
rhinitis, sedation, sexual dysfunction, syncope, tachycardia, tinnitus, urinary
hesitation, urinary incontinence, urinary retention, urticaria, vasodilatation,
vertigo, vision blurred, visual disturbance, weight decreased, and wheezing.
7 DRUG INTERACTIONS 7.1 Benzodiazepines There have been a number
of reports regarding coma and death associated with the misuse and abuse
of the combination of buprenorphine and benzodiazepines. In many, but not
all of these cases, buprenorphine was misused by self-injection of crushed
buprenorphine tablets. Preclinical studies have shown that the combination
of benzodiazepines and buprenorphine altered the usual ceiling effect on
buprenorphine-induced respiratory depression, making the respiratory effects
of buprenorphine appear similar to those of full opioid agonists. Closely
monitor patients with concurrent use of BUTRANS and benzodiazepines. Warn
patients that it is extremely dangerous to self-administer benzodiazepines
while taking BUTRANS, and warn patients to use benzodiazepines concurrently
with BUTRANS only as directed by their physician. 7.2 CNS Depressants
The concomitant use of BUTRANS with other CNS depressants including
sedatives, hypnotics, tranquilizers, general anesthetics, phenothiazines, other
opioids, and alcohol can increase the risk of respiratory depression, profound
sedation, coma and death. Monitor patients receiving CNS depressants and
BUTRANS for signs of respiratory depression, sedation, and hypotension.
When combined therapy with any of the above medications is considered,
the dose of one or both agents should be reduced [see Dosage and
Administration (2.2) and Warnings and Precautions (5.4)]. 7.3 Drugs Affecting
Cytochrome P450 Isoenzymes Inhibitors of CYP3A4 and 2D6 Because
the CYP3A4 isoenzyme plays a major role in the metabolism of
buprenorphine, drugs that inhibit CYP3A4 activity may cause decreased
clearance of buprenorphine which could lead to an increase in
buprenorphine plasma concentrations and result in increased or prolonged
opioid effects. These effects could be more pronounced with concomitant
use of CYP2D6 and 3A4 inhibitors. If co-administration with BUTRANS is
necessary, monitor patients for respiratory depression and sedation at
frequent intervals and consider dose adjustments until stable drug effects
are achieved [see Clinical Pharmacology (12.3)]. Inducers of CYP3A4
CYP450 3A4 inducers may induce the metabolism of buprenorphine and,
therefore, may cause increased clearance of the drug which could lead
to a decrease in buprenorphine plasma concentrations, lack of efficacy
or, possibly, development of an abstinence syndrome in a patient who
had developed physical dependence to buprenorphine. After stopping the
treatment of a CYP3A4 inducer, as the effects of the inducer decline, the
buprenorphine plasma concentration will increase which could increase
or prolong both the therapeutic and adverse effects, and may cause
serious respiratory depression. If co-administration or discontinuation of
a CYP3A4 inducer with BUTRANS is necessary, monitor for signs of opioid
withdrawal and consider dose adjustments until stable drug effects are
achieved [see Clinical Pharmacology (12.3)]. 7.4 Muscle Relaxants
Buprenorphine may enhance the neuromuscular blocking action of skeletal
muscle relaxants and produce an increased degree of respiratory depression.
Monitor patients receiving muscle relaxants and BUTRANS for signs of
respiratory depression that may be greater than otherwise expected. 7.5
Anticholinergics Anticholinergics or other drugs with anticholinergic activity
when used concurrently with opioid analgesics may result in increased risk
of urinary retention and/or severe constipation, which may lead to paralytic
ileus. Monitor patients for signs of urinary retention or reduced gastric motility when BUTRANS is used concurrently with anticholinergic drugs. 8 USE
IN SPECIFIC POPULATIONS 8.1 Pregnancy Clinical Considerations
Fetal/neonatal adverse reactions Prolonged use of opioid analgesics during
pregnancy for medical or nonmedical purposes can result in physical dependence in the neonate and neonatal opioid withdrawal syndrome shortly after
birth. Observe newborns for symptoms of neonatal opioid withdrawal syndrome,
such as poor feeding, diarrhea, irritability, tremor, rigidity, and seizures, and
manage accordingly [see Warnings and Precautions (5.3)]. Teratogenic Effects
- Pregnancy Category C There are no adequate and well-controlled studies
in pregnant women. BUTRANS should be used during pregnancy only if the
potential benefit justifies the potential risk to the fetus. In animal studies,
buprenorphine caused an increase in the number of stillborn offspring, reduced
litter size, and reduced offspring growth in rats at maternal exposure levels
that were approximately 10 times that of human subjects who received one
BUTRANS 20 mcg/hour, the maximum recommended human dose (MRHD).
Studies in rats and rabbits demonstrated no evidence of teratogenicity following BUTRANS or subcutaneous (SC) administration of buprenorphine
during the period of major organogenesis. Rats were administered up to one
BUTRANS 20 mcg/hour every 3 days (gestation days 6, 9, 12, & 15) or received
daily SC buprenorphine up to 5 mg/kg (gestation days 6-17). Rabbits were
administered four BUTRANS 20 mcg/hour every 3 days (gestation days 6, 9,
12, 15, 18, & 19) or received daily SC buprenorphine up to 5 mg/kg (gestation days 6-19). No teratogenicity was observed at any dose. AUC values for
buprenorphine with BUTRANS application and SC injection were approximately
110 and 140 times, respectively, that of human subjects who received the
MRHD of one BUTRANS 20 mcg/hour. Non-Teratogenic Effects In a peri- and
post-natal study conducted in pregnant and lactating rats, administration of
buprenorphine either as BUTRANS or SC buprenorphine was associated with
toxicity to offspring. Buprenorphine was present in maternal milk. Pregnant
black
rats were administered 1/4 of one BUTRANS 5 mcg/hour every 3 days or
received daily SC buprenorphine at doses of 0.05, 0.5, or 5 mg/kg from
gestation day 6 to lactation day 21 (weaning). Administration of BUTRANS or
SC buprenorphine at 0.5 or 5 mg/kg caused maternal toxicity and an increase
in the number of stillborns, reduced litter size, and reduced offspring growth
at maternal exposure levels that were approximately 10 times that of human
subjects who received the MRHD of one BUTRANS 20 mcg/hour. Maternal
toxicity was also observed at the no observed adverse effect level (NOAEL)
for offspring. 8.2 Labor and Delivery Opioids cross the placenta and may
produce respiratory depression in neonates. BUTRANS is not for use in women
during and immediately prior to labor, when shorter acting analgesics or other
analgesic techniques are more appropriate. Opioid analgesics can prolong
labor through actions that temporarily reduce the strength, duration, and
frequency of uterine contractions. However this effect is not consistent and
may be offset by an increased rate of cervical dilatation, which tends to shorten
labor. 8.3 Nursing Mothers Buprenorphine is excreted in breast milk. The
amount of buprenorphine received by the infant varies depending on the
maternal plasma concentration, the amount of milk ingested by the infant,
and the extent of first pass metabolism. Withdrawal symptoms can occur in
breast-feeding infants when maternal administration of buprenorphine is
stopped. Because of the potential for adverse reactions in nursing infants
from BUTRANS, a decision should be made whether to discontinue nursing
or discontinue the drug, taking into account the importance of the drug to the
mother. 8.4 Pediatric Use The safety and efficacy of BUTRANS in patients
under 18 years of age has not been established. 8.5 Geriatric Use Of the
total number of subjects in the clinical trials (5,415), BUTRANS was administered to 1,377 patients aged 65 years and older. Of those, 457 patients
were 75 years of age and older. In the clinical program, the incidences of
selected BUTRANS-related AEs were higher in older subjects. The incidences
of application site AEs were slightly higher among subjects <65 years of age
than those ≥65 years of age for both BUTRANS and placebo treatment groups.
In a single-dose study of healthy elderly and healthy young subjects treated
with BUTRANS 10 mcg/hour, the pharmacokinetics were similar. In a separate
dose-escalation safety study, the pharmacokinetics in the healthy elderly and
hypertensive elderly subjects taking thiazide diuretics were similar to those
in the healthy young adults. In the elderly groups evaluated, adverse event
rates were similar to or lower than rates in healthy young adult subjects,
except for constipation and urinary retention, which were more common in
the elderly. Although specific dose adjustments on the basis of advanced age
are not required for pharmacokinetic reasons, use caution in the elderly
population to ensure safe use [see Clinical Pharmacology (12.3)]. 8.6 Hepatic
Impairment In a study utilizing intravenous buprenorphine, peak plasma
levels (Cmax) and exposure (AUC) of buprenorphine in patients with mild and
moderate hepatic impairment did not increase as compared to those observed
in subjects with normal hepatic function. BUTRANS has not been evaluated
in patients with severe hepatic impairment. As BUTRANS is intended for
7-day dosing, consider the use of alternate analgesic therapy in patients with
severe hepatic impairment [see Dosage and Administration (2.4) and Clinical
Pharmacology (12.3)]. 9 DRUG ABUSE AND DEPENDENCE 9.1 Controlled
Substance BUTRANS contains buprenorphine, a Schedule III controlled
substance with an abuse potential similar to other Schedule III opioids.
BUTRANS can be abused and is subject to misuse, addiction and criminal
diversion [see Warnings and Precautions (5.1)]. 9.2 Abuse All patients treated
with opioids require careful monitoring for signs of abuse and addiction, since
use of opioid analgesic products carries the risk of addiction even under
appropriate medical use. Drug abuse is the intentional non-therapeutic use
of an over-the-counter or prescription drug, even once, for its rewarding
psychological or physiological effects. Drug abuse includes, but is not limited
to the following examples: the use of a prescription or over-the-counter drug
to get “high”, or the use of steroids for performance enhancement and
muscle build up. Drug addiction is a cluster of behavioral, cognitive, and
physiological phenomena that develop after repeated substance use and
includes: a strong desire to take the drug, difficulties in controlling its use,
persisting in its use despite harmful consequences, a higher priority given to
drug use than to other activities and obligations, increased tolerance, and
sometimes a physical withdrawal. “Drug-seeking” behavior is very common
to addicts and drug abusers. Drug-seeking tactics include emergency calls
or visits near the end of office hours, refusal to undergo appropriate examination, testing or referral, repeated claims of loss of prescriptions, tampering
with prescriptions and reluctance to provide prior medical records or contact
information for other treating physician(s). “Doctor shopping” (visiting multiple
prescribers) to obtain additional prescriptions is common among drug abusers and people suffering from untreated addiction. Preoccupation with
achieving adequate pain relief can be appropriate behavior in a patient with
poor pain control. Abuse and addiction are separate and distinct from
physical dependence and tolerance. Physicians should be aware that addiction may not be accompanied by concurrent tolerance and symptoms of
physical dependence in all addicts. In addition, abuse of opioids can occur in
the absence of true addiction. BUTRANS, like other opioids, can be diverted
for non-medical use into illicit channels of distribution. Careful recordkeeping of prescribing information, including quantity, frequency, and renewal
requests, as required by state law, is strongly advised. Proper assessment
of the patient, proper prescribing practices, periodic re-evaluation of therapy,
and proper dispensing and storage are appropriate measures that help to
reduce abuse of opioid drugs. Risks Specific to the Abuse of BUTRANS
BUTRANS is intended for transdermal use only. Abuse of BUTRANS poses a
risk of overdose and death. This risk is increased with concurrent abuse of
BUTRANS with alcohol and other substances including other opioids and
benzodiazepines [see Warnings and Precautions (5.4) and Drug Interactions
(7.2)]. Intentional compromise of the transdermal delivery system will result
in the uncontrolled delivery of buprenorphine and pose a significant risk to
the abuser that could result in overdose and death [see Warnings and
Precautions (5.1)]. Abuse may occur by applying the transdermal system in
the absence of legitimate purpose, or by swallowing, snorting, or injecting
buprenorphine extracted from the transdermal system. 9.3 Dependence
Both tolerance and physical dependence can develop during chronic opioid
therapy. Tolerance is the need for increasing doses of opioids to maintain a
defined effect such as analgesia (in the absence of disease progression or
other external factors). Tolerance may occur to both the desired and undesired
effects of drugs, and may develop at different rates for different effects.
Physical dependence results in withdrawal symptoms after abrupt discontinuation or a significant dose reduction of a drug. Withdrawal also may be
precipitated through the administration of drugs with opioid antagonist
activity, e.g., naloxone, nalmefene, or mixed agonist/antagonist analgesics
(pentazocine, butorphanol, nalbuphine). Physical dependence may not occur
to a clinically significant degree until after several days to weeks of continued
opioid usage. BUTRANS should not be abruptly discontinued [see Dosage
and Administration (2.3)]. If BUTRANS is abruptly discontinued in a physicallydependent patient, an abstinence syndrome may occur. Some or all of the
following can characterize this syndrome: restlessness, lacrimation, rhinorrhea,
yawning, perspiration, chills, myalgia, and mydriasis. Other signs and
symptoms also may develop, including: irritability, anxiety, backache, joint
pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting,
diarrhea, or increased blood pressure, respiratory rate, or heart rate. Infants
born to mothers physically dependent on opioids will also be physically
dependent and may exhibit respiratory difficulties and withdrawal symptoms
[see Use in Specific Populations (8.1)]. 10 OVERDOSAGE Clinical Presentation
Acute overdosage with BUTRANS is manifested by respiratory depression,
somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold
and clammy skin, constricted pupils, bradycardia, hypotension, partial or
complete airway obstruction, atypical snoring and death. Marked mydriasis
rather than miosis may be seen due to severe hypoxia in overdose situations.
Treatment of Overdose In case of overdose, priorities are the re-establishment of a patent and protected airway and institution of assisted or controlled
ventilation if needed. Employ other supportive measures (including oxygen,
vasopressors) in the management of circulatory shock and pulmonary edema
as indicated. Cardiac arrest or arrhythmias will require advanced life support
techniques. Naloxone may not be effective in reversing any respiratory
depression produced by buprenorphine. High doses of naloxone, 10-35 mg/70
kg, may be of limited value in the management of buprenorphine overdose.
The onset of naloxone effect may be delayed by 30 minutes or more. Doxapram
hydrochloride (a respiratory stimulant) has also been used. Remove BUTRANS
immediately. Because the duration of reversal would be expected to be less
than the duration of action of buprenorphine from BUTRANS, carefully
monitor the patient until spontaneous respiration is reliably re-established.
Even in the face of improvement, continued medical monitoring is required
because of the possibility of extended effects as buprenorphine continues to
be absorbed from the skin. After removal of BUTRANS, the mean buprenorphine
concentrations decrease approximately 50% in 12 hours (range 10-24 hours)
with an apparent terminal half-life of approximately 26 hours. Due to this long
apparent terminal half-life, patients may require monitoring and treatment for
at least 24 hours. In an individual physically dependent on opioids, administration of an opioid receptor antagonist may precipitate an acute withdrawal.
The severity of the withdrawal produced will depend on the degree of physical dependence and the dose of the antagonist administered. If a decision is
made to treat serious respiratory depression in the physically dependent
patient with an opioid antagonist, administration of the antagonist should be
begun with care and by titration with smaller than usual doses of the
antagonist. 17 PATIENT COUNSELING INFORMATION Advise the patient to
read the FDA-approved patient labeling (Medication Guide and Instructions
for Use). Addiction, Abuse, and Misuse Inform patients that the use of BUTRANS,
even when taken as recommended, can result in addiction, abuse, and
misuse, which could lead to overdose and death [see Warnings and Precautions
(5.1)]. Instruct patients not to share BUTRANS with others and to take steps
to protect BUTRANS from theft or misuse. Life-Threatening Respiratory
Depression Inform patients of the risk of life-threatening respiratory depression,
including information that the risk is greatest when starting BUTRANS or when
the dose is increased, and that it can occur even at recommended doses [see
Warnings and Precautions (5.2)]. Advise patients how to recognize respiratory
depression and to seek medical attention if breathing difficulties develop.
Accidental Exposure Inform patients that accidental exposure, especially in
children, may result in respiratory depression or death [see Warnings and
Precautions (5.2)]. Instruct patients to take steps to store BUTRANS securely
and to dispose of unused BUTRANS by folding the patch in half and flushing
it down the toilet. Neonatal Opioid Withdrawal Syndrome Inform female patients
of reproductive potential that prolonged use of BUTRANS during pregnancy
can result in neonatal opioid withdrawal syndrome, which may be lifethreatening if not recognized and treated [see Warnings and Precautions (5.3)].
Interaction with Alcohol and other CNS Depressants Inform patients that
potentially serious additive effects may occur if BUTRANS is used with alcohol
or other CNS depressants, and not to use such drugs unless supervised by
a health care provider. Important Administration Instructions Instruct patients
how to properly use BUTRANS, including the following: 1. To carefully follow
instructions for the application, removal, and disposal of BUTRANS. Each
week, apply BUTRANS to a different site based on the 8 described skin sites,
with a minimum of 3 weeks between applications to a previously used site.
2. To apply BUTRANS to a hairless or nearly hairless skin site. If none are
available, instruct patients to clip the hair at the site and not to shave the area.
Instruct patients not to apply to irritated skin. If the application site must be
cleaned, use clear water only. Soaps, alcohol, oils, lotions, or abrasive devices
should not be used. Allow the skin to dry before applying BUTRANS. Hypotension
Inform patients that BUTRANS may cause orthostatic hypotension and syncope.
Instruct patients how to recognize symptoms of low blood pressure and how
to reduce the risk of serious consequences should hypotension occur (e.g.,
sit or lie down, carefully rise from a sitting or lying position). Driving or Operating
Heavy Machinery Inform patients that BUTRANS may impair the ability to
perform potentially hazardous activities such as driving a car or operating
heavy machinery. Advise patients not to perform such tasks until they know
how they will react to the medication. Constipation Advise patients of the
potential for severe constipation, including management instructions and
when to seek medical attention. Anaphylaxis Inform patients that anaphylaxis
has been reported with ingredients contained in BUTRANS. Advise patients
how to recognize such a reaction and when to seek medical attention.
Pregnancy Advise female patients that BUTRANS can cause fetal harm and
to inform the prescriber if they are pregnant or plan to become pregnant.
Disposal Instruct patients to refer to the Instructions for Use for proper disposal
of BUTRANS. Patients can dispose of used or unused BUTRANS patches in
the trash by sealing them in the Patch-Disposal Unit, following the instructions
on the unit. Alternatively, instruct patients to dispose of used patches by
folding the adhesive side of the patch to itself, then flushing the patch down
the toilet immediately upon removal. Unused patches should be removed from
their pouches, the protective liners removed, the patches folded so that the
adhesive side of the patch adheres to itself, and immediately flushed down
the toilet. Instruct patients to dispose of any patches remaining from a prescription as soon as they are no longer needed.
Healthcare professionals can telephone Purdue Pharma’s Medical Services
Department (1-888-726-7535) for information on this product.
Distributed by: Purdue Pharma L.P., Stamford, CT 06901-3431
Manufactured by: LTS Lohmann Therapy Systems Corp., West Caldwell,
NJ 07006
U.S. Patent Numbers 5681413; 5804215; 6264980; 6315854; 6344211;
RE41408; RE41489; RE41571.
© 2014, Purdue Pharma L.P.
This brief summary is based on BUTRANS Prescribing Information
303385-0A, Revised 06/2014 (A)
ES543186_ME011015_003_FP.pgs 12.12.2014 02:00
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MEDICAL ECONOMICS ❚ JANUARY 10, 2015
ES544316_ME011015_005.pgs 12.16.2014 21:37
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Referenced in MedLine®
Volume 92
Issue 01
JANUARY 10, 2015
IN DEPTH
24 PROACTIVE PAYER
CONTRACT NEGOTIATION
Why it’s important to analyze and
efectively negotiate payer contracts
to sustain revenue.
26 ELECTRONIC PRIOR
AUTHORIZATIONS
PAYMENT
OUTLOOK
FOR 2015
STARTS
ON PAGE
18
COLUMNS
PA G E
38
CODING
I N S I G HTS
Renee Dowling
Preparing for 2015 coding
changes
PA G E
40
The promise of electronic prior
authorizations, and whether they
can help the process become more
efcient for physicians.
P R A C TI C A L
M AT TE R S
David Switzer,
MD
How to fne-tune the operations of
your front desk, clinical area and
admistrative ofce.
38 CODING FOR 2015
Preparing your practice for changes
to evaluation and management
codes this year.
40 THE IMPORTANCE OF
STAFF MEETINGS
Why in-person, efciently run staf
meetings are key to practice success.
42 EMPLOYEE HANDBOOKS
How an employee manual can help
mitigate risks and save money.
C O V E R STO R Y | M O N EY
Your guide to solutions to help
your practice thrive.
starts on page 18
Bolster your revenue with:
43 THE DEFENSIVE
MEDICINE DILEMMA
How physicians can navigate the
decisions of when and when not to
recommend tests and procedures.
Chronic care management
❚ Telemedicine
❚ Quality metrics
❚
53 REFERRAL PROCESS
NEEDS OVERHAUL
Primary care physicians make
millions of referrals to specialists
each year, yet there is little protocol
to follow.
6
EDITORIAL BOARD
FROM THE TRENCHES
ME ONLINE
VITALS
ADVERTISER INDEX
THE LAST WORD
Primary care physicians make
millions of referrals to specialists
each year, yet there is little protocol
to follow.
M I S S I O N STATE M E NT
Medical Economics is the leading business
resource for ofce-based physicians,
providing the expert advice and shared
experiences doctors need to successfully meet
today’s challenges in practice management,
patient relations, malpractice, electronic
health records, career, and personal fnance.
Medical Economics provides the nonclinical
education doctors didn’t get in medical
school.
MEDICAL ECONOMICS (USPS 337-480) (Print ISSN: 0025-7206, Digital ISSN: 2150-7155) is published semimonthly (24 times a year) by Advanstar Communications
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53
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The importance of efﬁcient
meetings
33 TIPS TO STREAMLINE
YOUR PRACTICE
MedicalEconomics. com
ES544408_ME011015_006.pgs 12.16.2014 22:30
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You’ve gotYquestions
about the Affordable
ou've got technology
questions. Care Act.
as well as topics such as Patient-Centered Medical Homes, accountable
We’ve
got answers.
answers.
We've got
care organizations, and our EHR Best Practices Study at the above link.
from the
Trenches
I have never heard that any other software needs continuous
certifcations and of users paying a penalty for not using such
software. Do any other small private businesses excluding
medical practices pay a penalty for not using software? If current
practices remain in effect, it will certainly ruin small practices.
Smiljka Stojanovic, MD, Americus, GeorGiA
ehR RequiRementS will
Ruin Small pRacticeS
Editor’s note: Te following is excerpted from
a letter the writer sent to the Centers for Medicare and Medicaid Services and is reprinted
with the permission of the writer.
I work in private solo practice as an internist in an underserved area. Five other internists left this area recently, and currently I
am the only internist here.
EMR [electronic medical record] software
slows down my work. Tis is bad for patients
and for my practice. Perhaps it can be useful for statistical purposes that you need for
practice evaluation.
I have asked many other physicians about
EMR software and none of them recommend
using any software available at this time. On
the other hand, if you consider EMR to improve medical practice, why do you penalize
[physicians] for not using it? Maybe it is just
your excuse to cut reimbursement.
Each health professional would like to be
maximally efcient, but available EMR software does not serve that purpose.
It is clear that all health professionals are
forced to use EMR, but you should reconsider having some exception with small practices in underserved area, where investment
in EMR is not cost- efective. For example,
all private businesses with less than 50 employees are not required to ofer health insurance, but every medical practice is required
8
Medical econoMics ❚ January 10, 2015
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to show meaningful use of EMR or will be
penalized.
My husband is a software developer and
can make highly efcient EMR for my practice. Tis is not cost-efective either, since
EMR needs to be certifed.
I have never heard that any other software needs continuous certifcations and
of users paying a penalty for not using such
software. Does any bank or insurance company pay a penalty for not using software?
Do any other small private businesses excluding medical practices pay a penalty for
not using software?
If current law remains in efect, it will certainly ruin small practices. I hope you will seriously reconsider the possibility of hardship
exceptions for small practices.
Smiljka Stojanovic, MD
Americus, GeorGiA
Some Still chooSe family
medicine
I just read the article on physician families in the November 25 issue of Medical
Economics. (“When medicine runs in the
family,” November 25, 2014.”) I am a family
physician in a small community in Northern Wisconsin and have practiced here for
the past 40-plus years. I did everything from
delivering babies, newborn care to nursing
home care.
MedicalEconomics. com
ES544412_ME011015_008.pgs 12.16.2014 22:37
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from the Trenches
Doctors have conditioned themselves to
practice defensive medicine for at least
the past two decades and the result is
that for many of them defensive medicine
has become so habitual that many consider it
good medicine. Unfortunately, this bad habit
will take a long time to break regardless of
the...malpractice reforms put into place.
Edward Volpintesta, MD, BeTHeL, coNNecTicuT
Our two children, a son and daughter, saw
the lifestyle and the time commitment needed, both as a member of a clinic group and as
a solo practitioner. Tey spent time in the offce, came to the emergency department, and
came on rounds with me. Our son was committed to medicine from grade school on and
went on to medical school, residency in family medicine and is in practice in Washington
state.
Our daughter started college with plans to
teach high school math. At the end of her freshman year she announced that she was changing
her major to chemistry and biology and was going to medical school. She spent a year in graduate school in pharmacology and then on to
medical school and a residency in family medicine. She now is in family medicine in Duluth,
Minnesota.
Both love working with their patients but
are frustrated with the regulation and the
workings of the large healthcare systems.
My wife and I put no pressure on them to
go into medicine, or family practice. Tey
obviously liked what they saw and made their
own choices.
William E. Raduege, MD, ABFM
WooDruFF, WiscoNsiN
malpRactice Study’S
ReSultS aRe flawed
I disagree with the conclusions reached in
MedicalEconomics. com
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“Study: Weak Link Between Malpractice
Fears And Defensive Medicine” (Medical
Economics, November 25, 2014.)
Tey are misleading because the study
did not take into account that doctors have
conditioned themselves to practice defensive
medicine for at least the past two decades
and the result is that for many of them defensive medicine has become so habitual that
many consider it good medicine.
Unfortunately, this bad habit will take
a long time to break regardless of the type
and number of malpractice reforms put into
place.
Moreover, the time span of the study
(1997-2011) is much too short to draw any
valid conclusions from it. And it did not mention whether the magnetic resonance imaging and computerized tomography scans that
were not done in the emergency department
were performed later as outpatients by their
primary care doctors or whether the intensity
(and cost) of the visits were lessened because
the patients were referred to specialists or to
their primary care physicians to complete
their evaluations.
Much more study needs to be done before
it can be said that malpractice reform has not
been as efective as expected.
Clearly, malpractice continues to be the “X
Factor” that drives the cost of health care.
TELL US
medec@advanstar.com
Or mail to:
Letters Editor,
Medical Economics,
24950 Country Club
Boulevard, Suite 200, North
Olmsted, Ohio 44070.
Include your address and
daytime phone number.
Letters may be edited for length and
style. Unless you specify otherwise, we’ll
assume your letter is for publication.
Submission of a letter or e-mail
constitutes permission for Medical
Economics, its licensees, and its assignees
to use it in the journal’s various print and
electronic publications and in collections,
revisions, and any other form of media.
Edward Volpintesta, MD
BeTHeL, coNNecTicuT
Medical econoMics ❚ January 10, 2015
ES544321_ME011015_009.pgs 12.16.2014 21:39
9
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online
MedicaleconoMics.coM
Smarter BuSineSS. Better Patient Care.
exCluSive online Content and newS.
o n li n e exc lu s ive
online PHYSiCiAn rAting
SiteS gAin in imPortAnCe
About 60% of patients say online physician
reviews are “very” or “somewhat” important
factors in their choice of a primary care physician,
according to a survey published recently in the
Journal of the American Medical Association.
In another survey, from practice management
consultants Software Advice, 44% of respondents
were willing to go out of network to see a doctor
who had gotten positive reviews online. See more
details at bit.ly/1vcwh7I
Twitter Talk
Follow us on Twitter
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and participate in the
discussion.
challenges for 2015
View our list of the top 15 challenges facing
physicians in 2015 ow.ly/FUAzf
medicaid
#Medicaid is growing, but patients are
having problems ﬁnding doctors to treat
them ow.ly/FUyBt
practice management
Top Headlines
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#CMS proposes more two-sided risk #ACO
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A proposed government rule
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having to share in downside financial
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#3 medical societies slam
congress over sgr inaction
AAFP, ACP, AOA want formula
repealed. More at bit.ly/1IXiLKN
Risk of #stroke doubles for every
successive decade over the age of 55 years.
ow.ly/FJjt1
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employment offers ow.ly/FJcYw
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Medical econoMics ❚ January 10, 2015
accountable care organizations
Medical societies want
Congress to postpone the
October 1 start date. Find out more
at bit.ly/1Aec01k
pa r t o f th e
10
More practices will offer digital selfscheduling in the next ﬁve years
ow.ly/FJeCY
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ES544184_ME011015_010.pgs 12.16.2014 19:23
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resource centers related to our Business of Health series
You’ve gotYquestions
about the Affordable
ou've got technology
questions. Care Act.
as well as topics such as Patient-Centered Medical Homes, accountable
We’ve
got answers.
answers.
We've got
care organizations, and our EHR Best Practices Study at the above link.
theVitals
ICD-10
supporters
rally to
prevent
another
Delay
The American Health
Information Management
Association (AHIMA)
rallied supporters to
tweet members of
Congress asking them
not to delay ICD-10
implementation any
further. Using the hashtag
#ICD10Matters, more than
5,000 tweets were sent.
AHIMA launched
the campaign after
the American Medical
Association (AMA) and
other regional medical
societies started a
letter writing campaign
to Congress asking
legislators to include a
fourth ICD-10 delay in the
current lame-duck session
legislation. Though
there has yet to be ICD-10
delay language in any
legislation, AMA could
lobby for a delay as part
of any legislation next
year concerning Medicare
sustainable growth rate
legislation.
Supporters who
want to keep the ICD-10
implementation date
at October 2015 noted
how the current ICD-9
coding system does meet
the needs of today’s
healthcare system and the
costs that another delay
would bring.
16
Government report
StateS Lack payer
competition
In at least 37 states, the three largest insures account
for 80% of total health plan enrollment, according to
a new study by the U.S. Government Accountability
Offce (GAO).
as payers leverage rates down.
GAO analyzed enrollment data
from 2010 to 2013 that was reported to
the National Association of Insurance
Commissioners (NAIC) and the Centers
for Medicare and Medicaid Services
(CMS). Te agency provided the report
to the U.S. Health and Human Services
Department (HHS), but didn’t make
any recommendations or comments.
In ten states, a single insurer had
more than half of all enrollees, and
in fve states, one insurer had at least
90% of either the individual, small
group or large group enrollee segment,
according to the report.
A highly concentrated market,
where a small number of insurers enroll
a signifcant portion of the population,
can impact physician’s reimbursement
Payer comPetition
states with least
payer competition
NH
WA
OR
MT
ID
NV
CA
ND
WY
UT
AZ
VT
MN
WI
SD
IA
NE
CO
IL
KS
OK
NM
AR
NY
MI
IN
OH
KY
MO
MS AL
GA
HI
Source: Government Accountability Ofce
RI
VA
NC
DE
SC
NJ
MD
DC
FL
AK
MA
CT
WV
TN
ME
PA
LA
TX
Medical econoMics ❚ January 10, 2015
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Examining the News Affecting
the Business of Medicine
Alabama
Vermont
Rhode Island
North Dakota
states with greatest
payer competition
California
New York
Michigan
Pennsylvania
Wisconsin
MedicalEconomics. com
ES544080_ME011015_016.pgs 12.16.2014 04:17
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theVitals
American elderly still lag
in many healthcare metrics

Despite the
universal healthcare
coverage Medicare
provides, America’s elderly
still lag on many—but by
no means all—measures
of health and care access
compared with other
industrialized nations, a
new survey fnds.
Te authors of the 2014
Commonwealth Fund
International Health Policy
Survey of Older Adults
note that while Medicare
ofers better coverage
than most other health
insurance in the United
States, “it is still clearly
less protective than the
universal coverage ofered
in the health systems of
Te authors note
that none of the 11
nations surveyed—
Australia, Canada,
France, Germany, the
Netherlands, New
Zealand, Norway,
Sweden, Switzerland, the
United Kingdom and the
United States—are able
to ofer their older adults
accessible, coordinated,
and patient-centered care
on a consistent basis.
Nevertheless, the
fact that elderly U.S.
residents are sicker than
the elderly in comparable
nations “will pose critical
challenges for U.S.
policymakers in years to
come,” the authors write.
other countries surveyed.”
Its shortcomings most
likely refect “limitations
in Medicare coverage,
including substantial
deductibles and
copayments, especially
for pharmaceuticals.”
Lack of limitations on
catastrophic expenses and
long-term care coverage
also contribute.
America had the lowest
percentage of respondents
reporting that a healthcare
professional had not
reviewed their prescription
medications in the past
year (14%) or experienced
gaps in their hospital
discharge planning in the
previous two years (28%.)
AmericAn heAlthcAre
the good
❚ Wait times of four weeks or
less to see a specialist (86% of
respondents).
❚ Having a treatment plan for their
condition that they could carry out in
their daily life (83%).
❚ Having a healthcare professional
whom they could easily contact with
questions or for advice (84%).
❚ Having a discussion with someone
regarding healthcare treatment they
want if they become very ill and can’t
make decisions for themselves (78%).
MedicalEconomics. com
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the bad
❚ American seniors are the most likely
(87%) to have a chronic condition.
❚ The most likely (19%) to have costrelated problems in obtaining medical
care.
❚ The most likely (23%) to report
that their medical records and/or
test results were not available at a
scheduled appointment or that tests
were duplicated.
❚ The most likely, along with Canadians
(39%) to have obtained care in an
emergency department during the
past two years.
Study: diabeteS
patientS aren’t
learning
Self care
New diabetes patients
aren’t participating in
education and training
programs that can help
them control the chronic
condition, according to
the Centers for Disease
Control and Prevention.
Fewer than 7%
of newly diagnosed
diabetes patients
take part in diabetes
self-management and
education training
(DSMT) that teaches
them how to monitor
diet, exercise and
glucose levels, according
to data from the
Marketscan database,
which collects private
insurance claim
information. Analysis
of Medicare patients’
claims found that only
4% of those newly
diagnosed with diabetes
participate in DSMT
programs.
The study, which
looked at data from more
than 95,000 patients,
found that almost 26%
of newly-diagnosed
diabetes patients are not
prescribed medications,
so lifestyle monitoring
is even more important
to deter any further
complications. The
Academy of Nutrition
and Dietetics suggests
using both DSMT and
medical nutrition
therapy to complement
diabetes care, as they
provide diferent
techniques to patients.
Medical econoMics ❚ January 10, 2015
ES544081_ME011015_017.pgs 12.16.2014 04:17
17
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PAYER NEGOTIATIONS
IN DEPTH
How to get the most leverage you can [24]
Cover Story
PAYMENT
OUTLOOK
FOR 2015
Your guide to solutions to help
your practice thrive
by J E FFR EY B E N D IX, MA Senior Editor
and E LAI N E POFE LDT Contributing author
HIGHLIGHTS
01 Current Procedural
Terminology code 99490
allows practices to bill for
time spent developing a
plan for, and managing the
care of, patients with two or
more chronic, potentially lifethreatening conditions.
18
 WHAT CHANGES will 2015 bring for your
practice’s reimbursements? Like so much
else in business and medicine, the answer is,
it depends.
If, for example, your practice includes
many patients with multiple chronic diseases, or has remote treatment capabilities,
you have the opportunity to boost your revenues.
On the other hand, if you’re not participating in the government’s Physician Quality Reporting System (PQRS) or meaningful
use program, 2015 will be the year you start
feeling fnancial fallout from that decision.
Medical econoMics ❚ January 10, 2015
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And regardless of what else you do or
don’t do in your practice, you could be facing a 21% cut in your Medicare reimbursements, unless Congress acts to fx the sustainable growth rate (SGR) formula.
In this article, Medical Economics explores some of the major payment changes
and potential hurdles that physicians face in
2015, in order to help readers better understand the opportunities and challenges they
will confront in the next year, and beyond.
1/ Chronic care management
Apart from the ever-present possibility of an
Getty Images/iStock/Getty Image Plus/pxhidalgo (binoculars);
Getty Images/E+/malerapaso (currency); Getty Images/E+/blackred (currency)
Despite the reimbursement
challenges primary care
physicians will continue to face
in 2015, new initiatives will provide
primary care physicians with opportunities to grow and better
manage patient health.
MedicalEconomics. com
ES544476_ME011015_018.pgs 12.17.2014 00:27
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2015 payment outlook
SGR-related cut, probably the biggest story
of 2015 is the inclusion of a code for chronic
care management (CCM) in the 2015 Medicare Physician Fee Schedule.
Current Procedural Terminology (CPT)
code 99490 allows practices to bill for time
spent developing a plan for, and managing
the care of, patients with two or more chronic, potentially life-threatening conditions.
Te decision to begin paying for CCM
services is part of the government’s longterm strategy to encourage a greater focus
on quality of care and patient outcomes,
rather than the volume of services provided,
says Raemarie Jimenez, CPC, CPB, vice president for member and certifcation development with the American Academy of Professional Coders.
“From the provider’s perspective, it takes
a lot of work to be proactive and get their patients the diferent kinds of care they need to
stay healthy. Tis [code] gives them a reportable way to do that,” says Jimenez.
CPT code 99490 pays $42.60 for 20 minutes of staf time, and can be billed once per
month per patient. Its use, however, comes
with numerous scope-of-service and billing
requirements, some of which may require
changes in practices’ workfow. (See “Getting paid for chronic care” in the December
25, 2014 issue of Medical Economics for a
complete description of the CCM code.)
2/ Telemedicine opportunities
Another opportunity to grow revenue may
come from the addition of new codes for
telehealth services in the 2015 fee schedule.
Medicare began paying for some telehealth services for eligible benefciaries living in rural health shortage areas or outside
Metropolitan Statistical Areas in 2000, and
has been expanding the range of covered
services since then. Te newest services include:
❚ Psychoanalysis (CPT codes 90485, 90846 and
90847),
❚ Prolonged evaluation and management
services requiring direct patient contact (CPT
codes 99354), and
❚ Annual wellness visit (HCPCS codes G0438 and
GO439)
3/ Misvalued codes
Te Afordable Care Act mandates that the
Centers for Medicare and Medicaid Services
MedicalEconomics. com
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Codes you may have overlooked
Primary care physicians (PCPs) often are unaware of
services they commonly provide for which they can bill
separately. Below is a list of new or frequently-overlooked
codes for use by PCPs:
CPT 99490 chronic care management:
New for 2015 in the Medicare
physician fee schedule, this code is for
time spent developing a plan of care
and managing care for patients with
two or more chronic, life-threatening
diseases. The code pays $42.60 for
20 minutes of time and can be billed
once per month per patient.
CPT 99091 collection and
interpretation of physiologic data:
Digitally stored and/or transmitted
by the patient and/or caregiver to
the physician or other qualifed
health care professional, qualifed
by education, training, licensure/
regulation (when applicable),
requiring a minimum of 30 minutes of
time. The code pays $56.92.
CPT 90845 Psychotherapy
CPT 90846 Family psychotherapy
without the patient present
CPT 90847 Family psychotherapy,
conjoint psychotherapy with the
patient present
G0439 subsequent AWV: This code is
used in years following submission of
the G0438 code, even if the patient
has a new doctor. (Note: Medicare
pays for only one initial AWV per
benefciary lifetime. All subsequent
wellness visits must be billed using
code G0439.)
CPT 99495 Transition Care
Management: Billing requirements
include a face-to-face visit with
patient within 14 days of discharge
from an inpatient facility, medical
decision-making of at least moderate
complexity, and communication
(phone call, email exchange, or
face-to-face) with patient or caregiver
within two business days of discharge.
CPT 99496 Transition Care
Management: Billing requirements
include a face-to-face visit within
seven days of discharge from an
inpatient facility, medical decisionmaking of high complexity, and
communication with patient
or caregiver within two days of
discharge.
CPT 99354 prolonged service in the
ofce or other outpatient setting
requiring direct patient contact
beyond the usual service; frst hour
(List separately in addition to code for
ofce or other outpatient EM service)
CPT 99355 prolonged service in the ofce
or other outpatient setting requiring
direct patient contact beyond the
usual service; each additional 30
minutes (List separately in addition
to code for ofce or other outpatient
EM service)
G0402 Initial preventive physical
examination (IPPE): Also known
as the “welcome to Medicare” visit
code, it is for use only when the
services are provided during the frst
12 months the patient is enrolled in
Medicare Part B. The deductible and
coinsurance are waived.
G0438 annual wellness visit (AWV):
For use after the benefciary’s frst 12
months of Medicare Part B coverage
and if the benefciary has not already
received an AWV or IPPE during the
previous 12 months.
CPT 99497 End-of-life directives:
First 30 minutes of explaining and
discussing advance directives with
the patient, a family member, or
designated surrogate.
CPT 99498 End-of-life directives:
Subsequent 30 minutes of explaining
and discussing advance directives
with the patient, a family member, or
designated surrogate.
Medical econoMics ❚ January 10, 2015
ES544475_ME011015_019.pgs 12.17.2014 00:27
19
ADV
2015 payment outlook
PQRS
nancial incentives are turning into penalties,”
Medical Economics, September 25, 2014.)
While it’s too late to avoid penalties for
this year and next, practices can avoid having their 2017 Medicare reimbursements
docked by participating in PQRS in 2015.
CMS has changed some of the participation
and reporting rules, however. For example, it
has eliminated 50 of the measures practices
can report on, but added 20 new ones and
two measures groups.
In addition, avoiding 2017 fnancial penalties requires:
Beginning this year, practices that had not
reported PQRS data in 2013 will be docked
in their Medicare reimbursements.
1%**
.5%*
.5%
2013
2014
2015
2016
* if no MOC ** if MOC
† if no successful reporting for 2013
1.5%†
2%
Source: American Academy of Family Physicians
(CMS) periodically identify, review, and adjust values for potentially misvalued codes.
Te latest review produced code decisions
in fve areas, including:
❚
❚
❚
❚
❚
hip and knee replacements,
radiation therapy and gastroenterology,
radiation therapy,
epidural pain injections, and
flm to digital substitution.
In the latter, which is probably of greatest
interest to primary care providers, CMS updated the practice expense inputs for X-ray
services to refect the fact that X-rays now
are performed digitally, rather than with
analog flm.
4/ PQRS
Te PQRS program paid bonuses to medical practices in 2013 and 2014 for reporting
quality data. Starting this year, however, that
carrot becomes a stick, in the form of a 1.5%
penalty for practices that did not report 2013
data. Te penalty rises to 2% in 2016. (For
more detailed information, see “Time’s up! Fi-
20
Medical econoMics ❚ January 10, 2015
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❚ eligible professionals (EPs) and group practices
that use claims or registries to report, and who
see at least one Medicare patient in a faceto-face encounter to report on at least one
measure from a newly cross-cutting measures
set, in addition to any other measures that the
EP is required to report,
❚ all group practices of 25 or more EPs using the
Group Practice Reporting Option (GPRO) web
interface to report measures on a benefciary
sample of 248 patients, and
❚ group practices of 100 or more EPs that are
registered for the GPRO to report on the
Consumer Assessment of Healthcare Provider
and Systems Survey for PQRS, regardless of the
reporting mechanism the practice uses.
5/ Medicaid
Although not part of the Medicare physician
fee schedule, developments in the Medicaid program will afect reimbursements for
many physicians in 2015.
Te legislation that raised Medicaid reimbursements to Medicare levels for two
years was set to expire at the end of 2014. Absent any last-minute Congressional action
to extend it, Medicaid reimbursements will
return to their 2012 levels—which in most
states are well below those paid by Medicare
and commercial insurers.
On the other hand, the number of states
expanding Medicaid eligibility—a provision
of the Afordable Care Act rendered optional
in a 2012 U.S. Supreme Court decision—has
been slowly growing. By the end of 2014 27
states and Washington, D.C., had done so, and
several more states were either considering
doing so or exploring other ways of expanding
healthcare coverage to their residents. Consequently, doctors in these states may start receiving at least some reimbursement for care
they had been providing for free.
MedicalEconomics. com
ES544472_ME011015_020.pgs 12.17.2014 00:27
ADV
2015 payment outlook
6/ Medicare Shared Savings
Program changes
One of the most important developments to
watch in 2015 is the fact that there are now
both hospital- and physician-owned Accountable Care Organizations (ACOs) in the
third year of the Medicare Shared Savings
Program, says Brian Croegaert, chief executive oﬃcer of Sage Technologies in Rockford,
Illinois, a consulting frm which provides
managed services involved with Afordable
Care Act implementation to clients including large integrated health systems, ACOs,
and independent practice associations.
Tis program aims to encourage coordination among providers to improve the
quality of care for Medicare fee-for-service
benefciaries and reduce unneeded costs.
Medicare shares the savings with the ACOs
as an incentive and allows the ACOs the
chance to receive a bigger payment provided they are willing to take on a greater risk if
their performance is not up to snuf.
CMS reported in November that the
current participants found $417 million
in savings. Tese early participants in the
program received $460 million in sharedsavings payments.
“At the end of the third year under
status, they will be required to decide whether or not they want to move forward into
`full risk’ or risk sharing,” Croegaert says.
Te physician fee schedule makes
changes to ACO reporting requirements in
2015, allowing ACOs to earn bonus points
by demonstrating year-to-year improvements in quality. CMS’s changes to the
shared savings program for 2015 in order
to “refect up-to-date clinical guidelines
and practice, reduce duplicative measures,
increase focus on claims-based outcomes
measures, and reduce ACO reporting burden,” reads an American Academy of Family Physicians summary of the fnal fee
schedule.
Te earlier proposed fee schedule would
have changed the quality measures ACOs
report by adding new measures and removing some existing ones. Tat proposal was
scrapped in the fnal fee schedule released
in late October, and the reportable quality measures will remain at 33. However,
CMS has increased the number of quality
measures calculated through fled claims
and lowered the number of metrics that
ACOs must report through CMS’ web inter-
MedicalEconomics. com
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Chronic care management services
BILLING REQUIREMENTS
Te billing requirements for CPT code 99490 include:
Informing the
benefciary about
the availability of the
CCM services from the
practitioner, including
the benefciary’s
authorization for
the electronic
communication of
the patient’s medical
information with other
treating providers as
part of care coordination,
providing the benefciary
a written or electronic
copy of the care plan
and documenting in
the electronic health
record that the care plan
was provided to the
benefciary,
informing the
benefciary of the
right to stop the CCM
services at any time
(effective at the end of a
calendar month) and the
effect of a revocation of
the agreement to receive
CCM services, and
documenting in the
benefciary’s medical
record that all elements
of the CCM service were
explained and offered
to the benefciary, and
noting the benefciary’s
decision to accept or
decline the service,
informing the
benefciary that only one
practitioner can furnish
and be paid for these
services during the
calendar month service
period.
Source: CMS
face. New measures that will be evaluated
based on claims include:
❚ avoidable hospital readmissions for patients
with multiple chronic conditions, heart failure
and diabetes,
❚ depression remission,
❚ readmissions to skilled nursing facilities,
❚ documentation of current medication at every
visit, and
❚ stewardship of patient resources through
the care team’s discussions of prescription
medicine costs with patients.
Medical econoMics ❚ January 10, 2015
ES544474_ME011015_021.pgs 12.17.2014 00:27
21
ADV
2015 payment outlook
Telemedicine and private payers:
A state overview
While Medicare has been making it easier for physicians to get paid for
telemedicine services, what about private payers? The map below shows which states
have legislation that mandates some private payer coverage of telemedicine.
NH
WA
MT
OR
ID
WY
NV
CA
UT
AZ
VT
ND
MA
WI
SD
IA
NE
CO
ME
MN
IL
KS
MI
IN
RI
PA
CT
VA
NC
DE
WV
TN
AR
MS AL
TX
OH
KY
MO
OK
NM
NY
NJ
MD
SC
GA
DC
LA
FL
AK
HI
Some private reimbursement
Proposal pending
No private reimbursement
Source: American Telemedicine Association, as of November 21, 2014
7/ Private payer trends
As changes sweep government insurance
programs, the shift from fee-for-service to
value-based care is shaking up the commercial insurance landscape as well. Commercial payers have been paying close attention
to the Medicare Shared Savings Program.
“More and more physicians will see insurance companies coming to them with
contracts that will ask them to join a formal accountable care organization or they
will receive a contract from their insurance
company saying you can enhance your earning power by doing these quality things for
us,” Croegaert says. “I see a lot of those contracts.”
For many smaller practices, negotiating
with private insurers is likely to remain a
challenge. Pamela Carrington-Tribble, DO,
a private practitioner in Half Moon Bay,
California, says that scanning through her
existing contracts with private payers shows
“how much they don’t value my services.
Tey are paying me less than it costs me to
22
Medical econoMics ❚ January 10, 2015
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buy a vaccine for a patient,” she says.
Like many independent physicians, Carrington-Tribble is trying to remain in private
practice. “If at some point it gets to the point
I can’t pay my staf, I’ll have to totally think
about changing things,” she says. “Somehow,
I’m staying afoat.”
7/ SGR showdown coming
A year ago, it had become conventional wisdom among healthcare analysts and legislators that Congress would repeal the SGR
formula, thereby removing the ever-present
threat of drastic reductions—currently
21.6%—in physicians’ Medicare reimbursements. And while bipartisan legislation repealing SGR passed in both houses of Congress a year ago, the legislation foundered at
the last minute over the issue of how to pay
for SGR repeal.
In its place, Congress passed—for the
17th consecutive time—a one-year “patch”
that raised Medicare reimbursements by
.5%, and left the question of a permanent fx
unresolved.
At the close of 2014 the fate of SGR repeal
remained uncertain. Many observers believe
Congress will try to arrive at a long-term solution again this year. “Te bipartisan, bicameral doc fx that was introduced in early
2014 will likely form the starting point for
what they work up in 2015,” predicts Scott
Gottlieb, MD, a member of the U.S. Department of Health and Human Services’ health
information technology advisory committee and a resident fellow at the American
Enterprise Institute.
Repeal eforts may have gotten a boost
from the Congressional Budget Oﬃce,
which recently lowered its estimate of the
cost of SGR repeal through 2024 to $119 billion, or $5 billion less than its previous estimate. Nevertheless, as last year’s experience
showed, predictions of SGR’s demise are
usually premature.
Stay tuned.
MORE ONLINE
Code with confdence
http://bit.ly/1AetqLl
The role of staﬀ in meeting quality metrics
http://bitly.com/1uKNwLN
MedicalEconomics. com
ES544473_ME011015_022.pgs 12.17.2014 00:27
ADV
Call for SubmiSSionS
2015 AnnuAl PhysiciAn Writing contest
t hi S y e a r ’S t op ic:
“Connecting Care”
We are seeking your real-life stories
that can move, teach, and inspire other physicians.
Your StorY Could Win $5,000…
Maybe in providing care you connected with a patient in a unique and meaningful way.
Maybe you actively engaged a patient in their own care and/or successfully involved their family.
Maybe you efectively coordinated care across settings or collaborated as a care team with powerful results.
Share your story of how you or others on your care team provided a more connected care experience for your patients.
First Prize
$5,000 gift card
second Prize
$2,500 gift card
third Prize
$1,000 gift card
Winning entries will also be published in the March 25th, 2015 issue of Medical Economics and featured on the Modern Medicine Network.
Here are some suggested story ideas to get the creative juices fowing
(but don’t let these limit your thinking). Consider a time when you:
Connected with a patient as a provider in a unique
and meaningful way
Incorporated successful health team strategies
for providing seamlessly coordinated care
Efectively integrated your patient portal
Used communication methods or skills
Leveraged technology for a more connected care experience
Involved a family in patient care
How to Enter
Send us your story in 800 to 1,200 words
Submissions must include name, contact email, address, and telephone number
Submissions can be sent to MedEc@ Advanstar.com or by mail to:
Medical Economics Writing Contest
24950 Country Club Blvd.
North Olmsted, OH 44070
Deadline for Submissions
All entries must be received by January 31st, 2015 for consideration.
S u ppo rte d by
Medical Economics Writing Contest Ofcial Rules
(NO PURCHASE IS NECESSARY TO ENTER OR WIN)
The Medical Economics Writing Contest (the “Contest”) starts on December 18, 2014 at 12:00 a.m. Eastern Time (“ET”) and ends on January 31, 2015 at 11:59
p.m. ET (“Contest Period”).
ELIGIBILITY: The Contest is open to licensed physicians who are legal residents of the ffty (50) United States or the District of Columbia, of legal age of
majority in their jurisdictions of residence (and at least 18). Employees, temporary workers, freelancers and independent contractors, and their immediate
families (spouse and parents, children, siblings and their respective spouses, regardless of where they reside) and those persons living in their same
households, whether or not related, of Medical Economics (“Sponsor”) and athenahealth (“Supporter”) and their respective parents, afliates, subsidiaries,
participating vendors, promotion or advertising agencies are ineligible to enter or win the Contest. By participating, entrants agree to be bound by these
Ofcial Rules and the decisions of the judges and/or Sponsor, which are binding and fnal on matters relating to this Contest. Void where prohibited by law.
Contest is subject to all applicable federal, state and local laws.
HOW TO ENTER: During the Contest Period, write an 800 to 1,200 word essay that shares your successful strategies, approaches, and/or experiences to
providing a more connected health care experience for patients and/or actively involving patients in their own care and send to medec@advanstar.com or
Medical Economics Writing Contest, 24950 Country Club Blvd., North Olmsted, OH 44070, along with your full name, contact email address, mailing address
and telephone number (collectively, an “Entry”). All Entries must be received on or before January 31, 2015. Limit one (1) Entry per person. Entries received in
excess of the stated limitation will be void. If handwritten, Entries must be legible. All Entries become the sole property of the Sponsor and will not be returned.
Entry must (i) be your own original work, (ii) be in English, (iii) cannot be previously published or submitted in connection with any other contest, (iv) be in
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defame or invade publicity rights or privacy of any person, living or deceased, or otherwise infringe upon any person’s personal or property rights or any other
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JUDGING: All eligible Entries received by the Sponsor will be judged by a panel of qualifed judges based equally on the following criteria: practicality of
solutions ofered, clarity and quality of writing, and level of detail to enable other physicians to apply your solution to their practices. The three (3) Entries with
the highest scores, as determined by the Sponsor in its sole discretion, will be deemed the frst, second, and third place potential winners. In the event of a tie,
an additional, “tie-breaking” judge will determine the winner(s) based on the criteria listed herein. Sponsor reserves the right not to award all prizes if, in its
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WINNER NOTIFICATION: Potential winners will be notifed by telephone, mail and/or email on or about February 15, 2015 and may be required to complete
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PRIZES: One (1) First prize of a $5,000 VISA Gift Card (the “First Prize”), one (1) Second prize of a $2,500 VISA Gift Card (“Second Prize”), and one (1) Third
Prize of a $1,000 VISA Gift Card (“Third Prize”). First Prize, Second Prize and Third Prize winners shall also receive publication of their respective Entry essays
in a future edition of Medical Economics Magazine, MedicalEconomics.com, the Modern Medicine Network, and/or afliated publications with attribution
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conditions specifed thereon. All prize details, including publication decisions, are at Sponsor’s sole discretion. Sponsor may substitute a prize of comparable or
greater value at Sponsor’s sole discretion. Prizes are non-transferable with no substitutions or cash redemptions except at Sponsor’s sole discretion. Additional
restrictions may apply, subject to gift card terms and conditions available on the back of the gift card and in included literature. Winners are responsible for all
applicable federal, state and local taxes, if any. Limit one (1) prize per person. In the event that Sponsor is unable to publish a winning essay, that part of prize
will be forfeited and winner will receive a Visa Gift Card only. Sponsor makes no guarantee as to date of publication of each winning Essay.
GENERAL: By participating, each entrant agrees: (a) to abide by these rules and decisions of Sponsor and Judges, which shall be fnal in all respects relating
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ANY ATTEMPT TO DELIBERATELY UNDERMINE THE LEGITIMATE OPERATION OF THE CONTEST MAY BE IN VIOLATION OF CRIMINAL AND CIVIL LAWS AND
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REQUEST FOR WINNERS LIST: For the names of the Winners (available after March 2015), send a self-addressed, stamped, envelope to: Attn: David A. DePinho,
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ES544520_ME011015_023.pgs 12.17.2014 02:20
ADV
F i nan c ial advi c e F r o m th e e x p e rts
Financial Strategies
StrategieS for proactive
payer contract negotiationS
by Raj u Ku R u nthottical, Do Contributing author
In order to sustain viable revenue, it is prudent to
analyze and effectively negotiate healthcare payer
contracts. Cost analysis should be performed in an
organized way to establish dollar value on tangible
and intangible items. You need to have a clear
understanding of business principles, current market
trends, and the cost of delivering quality healthcare.
HealtHcare contracts are
legal documents and need
to be reviewed carefully.
Many physicians sign
payer contracts without
negotiating.
Often the payer will say,
“This is what we are
paying in your market.
Take it or leave it.” We
must understand that the
terms in the contract are
not immutable. We have
to create and demonstrate
value in terms of data,
quality of care and costefective, long-term goals
that beneft the team as a
whole.
Even if the practice is
run efciently, with low
overhead, if the payer
contracts are not properly
negotiated or worded, it
can result in a loss in net
revenue.
There is a beneft in
24
numbers, the larger the
organization, the greater
the leverage.
The organization can
do SWOT analysis, which
is assessment of strength,
weakness, opportunities
and threats to the practice.
For example, internal
strengths can be analyzed
by reviewing: the number
of new patients enrolled
in the plan, utilization of
revenue and expenses with
quality measurements,
patient satisfaction reports,
benchmarking quality and
efciency, providing service
that is unique and new in
the current market and
networking with peers at
state and national levels.
In looking at weaknesses,
we need to analyze the
fee schedule, which is a
percentage of the current
Medicare fee.
Medical econoMics ❚ January 10, 2015
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To help reveal the rates
and overcome payment
inequities, we can create a
utilization report to capture
and review data. Using a
spreadsheet, determine
the frequency of a current
procedural terminology
code and the number of
times it was billed to that
payer. Multiply that by the
current payment amount.
Determine the break
even point. This is done
by adding overhead and
physician compensation by
total frequency of all codes
for that payer. The results
are weighted average cost.
Compare the weighted
average cost to weighted
average reimbursement.
Threats are when
contract start and end
dates are not monitored.
We need to know how
much notice is required
to make any changes. It
may be advisable to start
discussions with the payer
representative 150 days
before the contract term
ends. It helps tremendously
when the communication
is channeled through one
individual from the health
plan with whom a business
relationship has been built.
In preparation for
negotiations, we need to
set a bargaining range that
includes optimum and
minimal target goals. The
optimum goal is where
the terms are ideal. The
minimum goal is the point
which absolutely has to be
met. The target is the point
where you would like to be
at the end of negotiation.
It would be advisable
to meet face-to-face with
the payer representative
and present clear data
and requests for change,
and to listen to what the
representative has to say.
The person who has the
most experience with
complex negotiations
should do this.
It would also help to
know the issues of concern
to the payer. For example,
if the payer’s concern is
with high use of ancillary
services, it would help to
point out how efectively
MedicalEconomics. com
ES544385_ME011015_024.pgs 12.16.2014 22:00
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F i nan c ial advi c e F r o m th e e x p e rts
Severing a payer contract
you manage the use of
these services. You can
show cost control and
forecast the predictable
costs. Share practice data
that shows compliance and
improved outcomes.
Demonstrate the
efciencies that reduce
costs, and that the goal of
this business relationship
is to provide cost-efective
healthcare. This can be
done by showing the
payer how many of their
members avoided hospital
re-admissions because
of the efective, quality
healthcare you provided.
There are other items to
negotiate in the contract.
The prior authorization
process can be made
easier. The period for
submitting a claim may be
extended. Improvement
and ease of the appeal
process is helpful. Timely
payment and interest on
late payments need to be
clarifed.
When presented with
a well-documented and
organized data analysis,
the payer may be able
to recognize the value
your practice brings to its
members. This, in turn, will
help increase the revenue
generated, anywhere from
a 3% to 10% increase in
reimbursements.
In conclusion, it is
essential that payer
contracts are carefully
reviewed for their fee
schedules and the
provisions that can alter
MedicalEconomics. com
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1
Review your contract
Contract termination is governed by the
terms of your participation agreement with
the health plan and by applicable law. You
must always carefully review the terms of the
participation agreement and all subsequent
amendments, as well as any relevant
statutory or regulatory requirements.
3
Find out when
you can cancel
All contracts require a reasonable notice
period prior to the efective date of a
termination. Many may limit your ability to
get out of the agreement to one date per
year. If you miss the notice period, you could
be stuck in the agreement for another year.
4
Additional
termination rights
Many agreements may contain one or
more provisions triggering an additional
right to terminate. For example, a contract
may provide that a regulatory change or
a unilateral amendment to the provider’s
participation agreement that has an adverse
efect on the provider may give rise to an
additional right to terminate the agreement.
5
2
Avoid mistakes
Having an appropriate basis for terminating
or not renewing an agreement means little
if you get the mechanics wrong, so also
make sure you consult the terms of your
agreement that govern the provision of
“notices.” Make sure that notices are sent
to the right contact and address and by the
proper method of delivery.
Breach of contract
All contracts will have a provision
permitting you to terminate the agreement
if you believe the health plan has breached
a material term of the contract, and the
health plan fails to cure the breach within a
specifed period of time.
6 Terminating
one line of business
In some cases, the agreement may permit
the provider to terminate participation with
one or more of the health plan’s lines of
business, while remaining a participant in
all other lines.
Source: Robert Schiller, JD
the net revenue a practice
generates. Research shows
that larger corporations
have an added advantage
in using volume of
providers that service their
clients.
If there are clauses
in the contract that the
insurance companies
won’t negotiate that afect
your break even point,
a letter of intention to
discontinue the contract
should be sent. Ultimately,
the payer may come to
realize that a large portion
of its members would not
have care providers and
would thus reconsider
their position.
Raju Kurunthottical, DO is a family
physician who practices in Round Rock,
Texas. This essay was an honorable
mention in the 2014 Medical Economics
writing contest.
Medical econoMics ❚ January 10, 2015
ES544456_ME011015_025.pgs 12.16.2014 23:22
25
ADV
In Depth
Electronic prior authorization
The solution to physicians’
headaches?
Efforts are underway to ﬁnd technology solutions to the efﬁciency
problems physicians experience with prior authorizations
by Ke n Te r ry Contributing editor
HIGHLIGHTS
01 For electronic prior
authorization to become
viable, it must be available
within electronic health
record systems as part of the
clinical workﬂow.
02 Electronic prior
authorizations may improve
patient outcomes because
patients will be more likely to
get their prescriptions ﬁlled
if they’re pre-approved.
26
Are you tired of dealing with health plans’
prior authorization requirements for certain
prescription drugs? If so, you have a lot of
company. But you and your colleagues may
soon have the opportunity to reduce this
burden on your practices and increase patient
satisfaction at the same time.
 It’s not that health insurers have
suddenly decided they don’t need to pre-approve coverage of these medications. What
has happened is that two technology companies, Surescripts and DrFirst, have begun
rolling out solutions that embed electronic
prior authorization (ePA) in the e-prescribing process. According to the companies,
this approach will allow physicians and their
stafs to request approval from pharmacy
beneft managers (PBMs) and health plans
Medical econoMics ❚ January 10, 2015
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inside their electronic health records. Surescripts says that practices may receive electronic responses within minutes in many
cases.
Consultants and physicians say this approach not only could reduce the work and
cost involved in prior authorizations, but
should also make patients happier. Instead
of being forced to wait a day or two for a
pre-authorization to arrive, usually after
an unsuccessful trip to the pharmacy, pa-
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Prior authorizations
tients may be able to get a prescription approved leaving the physician’s ofce. At the
least, notes Miami gastroenterologist James
Leavitt, MD, physicians will be able to fnd
out which drugs require prior authorization
and inform patients about that in advance.
Going to the pharmacy and discovering
that a medication needs pre-approval, he
says, “is a huge patient dis-satisfer. So from
the patient’s point of view, this will be much
better. It will set their expectations, because
they’ll know what’s going on.”
David Boles, DO, a family physician in
Clarksville, Tenn., likes the idea of having
prescriptions approved while the patient is
still in the ofce. “Tat would be awesome,”
he says, adding that it’s about time. “It’s
amazing how long this has taken.”
Dueling SolutionS
Two distinct ePA solutions have been developed by companies that are well known in
healthcare.
Surescripts, the frm that connects physician ofces online to pharmacies for e-prescribing, is ofering an end-to-end electronic
service, CompletEPA, that links practices to
four PBMs, including CVS/Caremark and Express Scripts. According to Surescripts, these
four PBMs have contracts from health insurers to administer the drug benefts for 210
million people. All of these health plan members would potentially be eligible for ePA.
Surescripts is using a new ePA standard
from the National Council for Prescription
Drug Programs (NCPDP). In the year since
it was adopted, says David Yakimischak, executive vice president/general manager of
medication services for Surescripts, “We’ve
gotten commitments from both PBMs and
physician EMR [electronic medical record]
vendors to use the NCPDP standard.”
Cameron Deemers, president and chief
executive ofcer of DrFirst, which sells e-prescribing software and has imbedded its solutions in nearly 300 diferent EHRs, applauds
Surescripts’ all-electronic initiative. But he
points out that many health plan and PBM
information systems are not yet ready to accept NCPDP-based prior auth transactions.
“We’re trying to provide a universal solution so a doctor doesn’t have to go through
two or three diferent workfows, doing
some prior auths electronically, some by fax,
and some by phone. We’re trying to get away
from that and provide a consistent user ex-
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5 beneﬁts of new electronic prior
authorization standards
1
2
3
4
5
Leverages eligibility and formulary data to notify
providers of medication prior authorization
requirements before e-prescribing.
Instead of forms, speciﬁc prior authorization questions
are sent to the electronic health record system, based
on patient, health plan and medication.
Pre-population of required patient information adds
efﬁciency and accuracy to administrative tasks.
Real-time communications with pharmacy beneﬁt
managers to complete prior authorization review
before sending e-prescription.
Pre-approved e-prescriptions routed to pharmacy and
won’t be subject to prior authorization block.
Sources: HIMSS, NCPDP, Surescripts
perience for prior authorization.”
DrFirst’s EPA solution, Patient Advisor
ePA +, uses the hybrid service of CoverMyMeds to connect practices with payers.
CoverMyMeds allows physicians to submit prior auth requests electronically, then
sends those requests to payers in whatever
form is acceptable to them, including by
fax and online using the NCPDP standard.
DrFirst is also integrating other ePA services, including Surescripts’ CompletEPA, and
it will connect practices directly with some
health plans and PBMs.
“Surescripts has a piece of the market,
and CoverMyMeds has some kind of connection to every payer in the country,” notes
Deemers. “We want to give the doctor the
ability to do electronic prior auth no matter
what, and that means we have to have multiple sources available.”
getting eHR venDoRS on boaRD
For ePA to become viable, it must be available in electronic health records (EHRs) as
part of the clinical workfow.
DrFirst is including Patient
31
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27
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Prior authorizations
27
Advisor ePA + in the EHRs of
all its vendor customers, which
include Greenway, GE Centricity, LSS (part of
Meditech), and Healthland, as well as several
smaller companies. It upgraded about half of
these products in October and will add the
ePA solution to the other EHRs later, Deemers says. DrFirst is also including Patient
Advisor ePA+ in its standalone e-prescribing
programs.
Surescripts scored a big win recently
when Epic Systems, the largest EHR vendor, agreed to incorporate CompletEPA in
its EHR. An Epic spokesman tells Medical
Economics that this will happen in the frst
quarter of the year. Surescripts also has
signed deals with several small vendors, and
Yakimischak forecasts that other leading
vendors will soon follow Epic’s lead.
Other observers agree that ePA, if it works
as advertised, is likely to sweep the industry
because practices will demand it. In fact, ePA
is the top priority of physicians in regard to
e-prescribing, according to Yakimischak.
Currently, some PBMs allow practices
to use their websites to make prior auth requests. But that’s outside the EHR workfow
and is a manual process requiring completion
of prior auth forms online, notes Cindy Dunn,
RN, FACMPE, a health IT consultant for the
Medical Group Management Association
(MGMA).
ePA, in contrast, takes place in the EHR
and is partly automated. As described by
Surescripts, the ePA software can pull data
from the EHR to pre-populate patient demographic information on the prior auth form.
Te PBMs, via Surescripts’ benefts and formulary feature, can supply the patient’s drug
coverage and the plan’s prior auth requirements. And the NCPDP standard automatically tailors the questions on each prior auth
form to the patient’s demographics, skipping the irrelevant ones.
All of this speeds up the request process,
says Yakimischak. In a pilot of ePA with CVS
prior to the NCPDP standard being adopted,
he adds, it took only about fve minutes, on
average, for practices to fll out prior auth
forms.
Rosemarie Nelson, an MGMA consultant in Syracuse, New York and a Medical
Economics editorial consultant, questions
how practices would adapt their workfow
to ePA. She wonders whether some physicians would choose to wait for a response
MedicalEconomics. com
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StateS that require Some form of
electRonic PRioR autHoRizationS
NH
WA
OR
MT
ID
NV
CA
ND
WY
UT
AZ
VT
MN
WI
SD
IA
NE
CO
IL
KS
NM
TX
MI
IN
AR
OH
KY
MO
OK
NY
PA
WV
TN
MS AL
GA
VA
NC
SC
ME
MA
RI
CT
NJ
DE
MD
DC
LA
FL
AK
HI
to an online prior auth request, lengthening
the patient visit. But she notes that if the approval didn’t come right away, physicians
could wrap up the exam and delegate the
task to their nurses. She and Dunn predict
that practices will welcome ePA, regardless.
benefitS of ePa
Currently, practices spend a lot of time and
money on prior authorization of all kinds,
including the pre-approval of prescriptions.
According to a 2009 study, prior auth takes
up an average of 1.1 hours per week for primary care physicians, 0.8 hours per week for
medical specialists, and 0.7 hours per week
for surgeons. And that doesn’t include the
amount of time they devote to formularies,
which are intertwined with prior auth.
Primary care nurses spend an average of
13.1 hours per physician per week on prior
auths and 3.8 hours per week on formularies,
the study found. Nelson points out that ePA
would allow these clinicians to convert most
of the prior auth time to patient care duties.
Noting that 90% of prior auth requests
require a phone call or a fax, Surescripts estimates the cost of completing these requests
at between $2,000 and $14,000 per physician
per year. Yakimischak adds that prior auths
are required for 2% to 4% of prescriptions.
Considering that billions of prescriptions are
Medical econoMics ❚ January 10, 2015
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Prior authorizations
[PrIor auTH] IS a HuGE PaTIEnT dIS-SaTISFIEr. So
From THE PaTIEnT’S PoInT oF vIEw, [ELEcTronIc
PrIor auTH] wILL bE mucH bETTEr. IT wILL SET THEIr
ExPEcTaTIonS, bEcauSE THEy’LL know wHaT’S GoInG on.”
— JamES LEavITT, md, GaSTroEnTEroLoGIST, mIamI, FLorIda
ordered every year, that adds up to a great
deal of extra work.
Leavitt says he gets half a dozen requests
for prior auth each week. He turns them over
to his secretary, just adding a bit of clinical
information and signing the forms after she
completes them. “But it’s still a pain in the
butt,” he says.
Boles says prior auth is a “big deal” in
his practice. He tries to avoid the problem
whenever possible by prescribing generics,
he says, and his nurse is very adept at flling
out prior auth forms when necessary. But
some of his younger colleagues spend a lot
of time on this task, he says.
ePa
coStS
ePA can to reduce the amount of time that
practices spend on prior auths by 70%, according to CoverMyMeds, but it is not without its own costs.
Surescripts is charging EHR vendors a
monthly fee that it expects they will pass on
to physicians, Deemers says. Yakimischak
acknowledges this, but declines to specify
how much these fees are.
DrFirst opposes charging physicians
for ePA, Deemers says, because “doctors
shouldn’t be charged for doing something
they don’t want to do in the frst place.” Nevertheless, DrFirst is ofering Surescripts’ ePA
product alongside its own free solution to
see how the market will respond to the combination of price and service.
Boles thinks his EHR vendor won’t give
him a choice of ePA solutions. But he says
he’d rather not pay anything for ePA, because he’s already being asked to pay extra
for many other EHR features, such as his formulary checker.
Leavitt, by contrast, says that he’ll compare how well the two solutions work if he
has access to both of them. “If one is functionally better, and the price is minimal, I
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don’t care [about the cost],” he says.
effect on outcomeS?
Today, because physicians don’t usually
know what requires pre-authorization, the
process is “retrospective,” Yakimischak says.
Tis means that pharmacies return prescriptions requiring a prior auth to the prescribing
physician.
Surescripts’ and DrFirst’s solutions are
set up to handle that scenario, but they also
allow “prospective” prior auth requests. In
that model, physicians are informed in their
e-prescribing workfow that a medication
requires prior auth and can act accordingly.
Tis might improve patient outcomes,
Yakimischak notes, because patients will be
more likely to get their prescriptions flled if
they’re pre-approved. “Tere’s a high abandon rate for prescriptions that have prior authorization at pharmacy. We want to nip that
in the bud and improve the efciency of the
prior authorization and speed up the time
to approval, so patients get the medicine in
their hands quickly,” he says.
Dunn agrees that ePA will increase the
chance that a patient will fll a prescription.
“In many cases, when they have to wait for
preauth and it doesn’t come quickly, they
lose their desire to take the medication.
What also happens is that it never gets approved. So what happens to the patient?
Tey don’t get their medication.”
Leavitt feels that patients would beneft if
he could tell them which drugs required prior auth at the point of care. But the main issue for his practice, he says, is that payers are
“narrowing down dramatically” the prescriptions that they’ll cover without pre-approval.
“We have no way of knowing what requires pre-auth,” he says. “And there’s more
and more of this. Tis is a really critical problem for us, so electronic prior authorization
is a welcome solution, for sure.”
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In Depth
Coding in 2015
EffiCiEnt mEEtings
Risk managEmEnt
Evaluation and
management changes [38]
Conducting productive
staf meetings [40]
How an employee manual
can help avoid liability [42]
Streamlining your practice
Why upgrading the workﬂows of your front desk,
clinical practice and administrative functions are
necessary to improve efﬁciency and gain time
by E li zab Eth W. Woodcock, M ba, FacM PE, cPc and
d E borah WalkE r kE Egan, Ph d, FacM PE Contributing authors
HIGHLIGHTS
01 Put in writing all of the
steps you would like taken
before your ofﬁce opens
each day.
02 Assign a member of
the clinical team to carefully
review the records of
upcoming patients, noting
any tests, consultations or
other orders placed at the
patient’s previous visit.
03 Make sure you monitor
your key billing metrics,
to include the percentage
of accounts greater than
90 days in receivables
outstanding, net collection
rate, claim denial rate, and
bad debt rate.
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Efcient workfow isn’t natural. It’s earned.
With so much riding on a well-tuned ofce—
from the most efective use of your time to
creating the best patient experience—now is
an opportune time to focus on streamlining
the business operations of your practice.
BEfoRE dElving into specifc work functions, let’s focus on some key management
principles of a successful medical practice.
First, it is important to recognize that
your time is your practice’s greatest asset.
Terefore, make sure the infrastructure of
the practice is geared toward optimizing it.
Second, your prime directive is to care for patients. Terefore, each work function must be
patient-centric and support this imperative.
Here are some key dos and don’ts to transform your front ofce, mid-ofce and back
ofce into a successful medical practice.
1/ The front offce: Directors
of frst impressions
Recruit well. Start by taking a deliberate approach to new employee orientation. Pay
close attention to the quality of the training
you provide to front ofce employees, just
as you do for clinical staf. Te front ofce
plays a critical role in how your practice is
perceived by your patients.
Provide resources. Don’t tolerate slow
computers, inadequate workspaces or
haphazard foor plans. Give employees the
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Streamline your practice
Keep a pulse on the practice. Te sched-
Key principleS of
practice streamlining
Standardize your practice’s work processes, but recognize that every
day will be a bit diferent since you cannot predict all of the events that need to be addressed.
Healthcare is complex and the needs of patients often fall outside of routine processes.
Make your expectations for performance crystal clear to
employees, and hold your team accountable for results. Share outcomes with the team so
they learn of their successes as well as opportunities for improvement.
never tolerate a “virus.” The team member who gossips or tears down others’ eforts
destroys everyone’s morale in the long run, reducing productivity and service. Everyone in a
medical practice has an important role to play but no one should be considered indispensable,
particularly those employees who are not team players.
ule is dynamic, but it can’t be flled without
good communication between all employees. Put a process in place so that if a patient
cancels his or her appointment or the triage
nurse sends a patient who has a scheduled
appointment to the emergency department,
the front ofce team is alerted to fll that
patient’s appointment slot from a list of patients seeking a walk-in or “earliest opportunity” visit. Track wait times for appointments
to ensure you are accommodating patients
within your targeted timelines. Te supervisor in this sector of the practice should create a daily action plan and share it via your
intranet or a white board so that the entire
team understands the nuances of the day.
Ask patients to prepare for their visit. To
Prepare for each day. In other words: if you can predict it, you can manage it. Create a
process map of what’s done every day, from opening the ofce doors in the morning to shutting
computers of in the evening. This clarifes the work that needs to be performed, while serving as
a checklist to ensure completion.
don’t give up. Expect that at least a quarter of each day will involve the unexpected, but
don’t relinquish managing the remainder. Controlling the majority of each day is a great goal
that typically can be achieved.
adjust expectations. Perfection is not possible, regardless of how much we want it.
What’s important is to meet and exceed standards. Always remember that your practice is a
service business where a measure of fexibility ensures that the needs of the practice–and your
patients –are met. Mistakes will be made; if they’re not, you’re not trying hard enough to be
better every day.
the front ofﬁce truly sets the tone. These key team members are the face of your
practice. If they are discourteous, your practice is perceived as rude. Don’t leave the front ofce to
chance; give these frontline workers clear expectations and the tools they need to do their jobs
and do them well.
resources they need to get the job done efciently. Install computers with high processing speed and dual monitors to facilitate
efcient access to systems, and install topnotch workstations. At least once a quarter,
ask each employee the question, “What is
the one thing I can get you so that you can
do your job better?”
Develop a start-of-day checklist. Put in
writing all of the steps you would like taken
before your ofce opens each day. Requesting employees to “turn on your computer”
and “switch the phone of of the service” may
seem trite, but stumbling over these basics
is where problems start.
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prevent delays at the front ofce, put information requests into the registration packet.
Transmitting these requests to patients before they arrive produces a faster and more
complete patient registration and intake
process. It pays of with fewer delays and, potentially, the snags that cause claim denials
Focus on accuracy. Mistakes happen, but
often they are the result of poor training or
lack of understanding regarding the importance of the work. Recognize that investing
in your front ofce means saving money
later on. If your business ofce is busy correcting errors made by your front ofce
employees related to patient demographic
and insurance information, you are spending a lot of money on rework—and delaying
your reimbursements. Avoid claim denials
and delays caused by messy or incomplete
patient information by providing education
to your front ofce team and tracking and
monitoring the quality of their work.
Receive the patient in the scheduling
system. With the advent of electronic
health records (EHRs), the root word of
receptionist—to receive—seems to be lost.
Teach the front ofce team how to appropriately greet patients and ensure that each
patient gets due attention, without overlooking important business processes, such
as collecting patient balances and copayments, verifying coverage and other details.
Te front ofce is truly the director of frst
impressions.
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Streamline your practice
2/ The mid-offce:
7 steps
masters of effciency
to process improvement
1/ Pick a process
Look for something that has a clear
beginning, middle and end. Reducing days in accounts receivable is
not a work process; submitting each day’s claims by 5 pm is.
2/ Break it down
Separate the process into discrete steps
that report everything that requires an action by your employees or
the technology they use.
3/ Get input
Don’t rely on the manager; ask everyone in
the workfow chain how to improve the efciency of the process.
Eliminating even one step — just one piece of paper — is a victory.
4/ Focus on processes, not people
The idea is to
improve process efciency, so lay out the current process and then
brainstorm a new, improved process. Next, identify staf roles for
the new process.
5/ Implement Start with the most obvious and easiest
workfow improvements, then work your way up to the more
difcult, time-consuming items. Deciding to wait for three months
to improve a billing process while a new practice management
system is selected and implemented is a lost quarter. Many other
processes can be identifed for improvement that do not rely on the
new system.
6/ Monitor
Make sure the improvement idea becomes a
reality. If it isn’t working, make adjustments or, if that fails, put it on
hold until you can develop a more successful solution.
7/ Repeat
Return to step one and select another process.
Be sure to engage your employees for suggestions, because they
conduct the work process day-in and day-out and have insights to
improvement. Every wasteful process you eliminate is another step
to a more efcient practice. Every tedious process you replace with
something faster and more engaging improves morale as well as
your practice’s bottom line.
Once the patient is seated in the reception
area, focus on streamlining the workfow
that takes place around the clinical team’s
eforts to get ready for the patient. Preparedness is the overriding principle of efective
patient fow.
Preview charts. Streamlining patient fow
actually starts the day before the patient’s
arrival. Assign a member of the clinical team
to review the records of the following day’s
patients, noting any tests, consultations
or other orders placed during the patient’s
previous visit. Tis serves as an early warning for any missing results. Assess any clinical alerts—an overdue screening exam, for
example—and make notes, pull together
forms, patient education materials or other
paperwork that may be needed in connection with the visit.
Huddle. Gather your team each morning for
a brief, stand-up meeting. Peruse the schedule, noting any necessary preparations (an
interpreter is needed for Ms. Smith at 2:30,
for example), predictable no-shows (Mr.
Jones was admitted last night), and opportunities for add-ons. Always conclude the
huddle with a quick review of the previous
day’s mistakes—and how to avoid them in
the future. Tese brief overviews will help instill the spirit of performance improvement
that, over time, should become embedded
throughout your practice.
Develop a standard intake process. Put
the rooming criteria in writing, including
patient gowning and vital signs, based on
reason for the visit. Create standing orders
based on patient complaint ( for example,
request urine sample if the patient complains of frequent urination). If deployed
efectively, these standing orders can save
precious time for you, your employees, and
your patients.
Standardize exam rooms. Ensure that every exam room is set up in a uniform manner, with supplies, forms, and equipment
in the same place in all rooms. Stock exam
rooms before the morning starts; assess
their status at mid-day as well.
Create a flow station. Popping into your
ofce between patients consumes a lot of
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Streamline your practice
time. Instead, develop a fow station that
has access to your EHR, as well as a telephone. Te fow station may be an anchored
workstation or it could be a workstation on
wheels or computer on wheels. Route messages via your EHR’s task function, noting
that time-sensitive ones should be printed
and tucked into a designated red folder on
your workstation, or another such alert
system. Stop by this area when between patients and encourage your employees to use
it to communicate with you. Tis permits
work to be conducted in an asynchronous
fashion rather than requiring a face-to-face
interaction with your nurse or medical assistant, thereby improving productivity.
By executing an efective patient fow
strategy, the mid-ofce can successfully
achieve the status of masters of efciency.
3/ The back offce:
administrators
of working smartly
What’s the use of streamlining workfow and
patient fow if you don’t get paid? Apply the
same principles of efciency you’ve brought
to your front ofce and mid-stream areas to
the back ofce so you can get paid what you
deserve.
Leverage technology. Determine every
opportunity to leverage technology. For example, turn manual lists into an online database that can be sorted and accessed by
multiple users. Use online access to payers
in lieu of phone calls to streamline the work.
Share important resources and tools rather
than require each employee to reinvent the
wheel. For example, retain appeal letters and
other documents in an organized, shared
intranet-based “library” for employees to use
repeatedly. Meet with employees to look for
ways to better harness your system. From
replacing manual payment postings with
automated remittances to using automated
work queues in lieu of manual accounts receivables, there are many functions in which
technology can be deployed successfully.
Track key billing metrics. Make sure you
monitor your key billing metrics to include
the percentage of accounts greater than 90
days in receivables outstanding, net collection rate, claim denial rate, and bad debt
rate. Create specifc targets, and track and
trend these metrics over time.
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Time is your practice’s greatest
asset. Therefore, make sure
the infrastructure of the practice
is geared toward optimizing it.
Revise work processes due to healthcare
reform. Even though the majority of your
patients may have insurance, many today
also have a high deductible health plan. Tis
means that they are truly “self pay” until they
have met their deductible. Revise your work
processes to determine the patient’s unmet
deductible and either attempt to capture
that at the time of service (provided your
contracts permit) or shorten your patient
collections cycle to ensure timely revenue.
Optimizing patient payments is now “mission critical” for medical practices.
Deliver feedback. Don’t let employees
work in the dark. Share performance data
with them to include revenue, aged trial
balance and days in receivables outstanding, for example. Hold regular discussions
of key performance indicators. If employees
know what you expect, they are more apt to
deliver the “work smart” performance that
ensures you get paid what you deserve.
Remember, streamlining strategies presents routes to greater efciency throughout
the practice. Improving workfow takes time
and efort, but the pay of is well worth it.
Elizabeth Woodcock, MBA,
FACMPE, CPC, (top left)is a
consultant, speaker, trainer
and author with Woodcock &
Associates in Atlanta, Georgia.
Deborah Walker Keegan, PhD,
FACMPE, (bottom left) is a
healthcare consultant and
president of Medical Practice
Dimensions, Inc., in Asheville,
North Carolina.
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C o d i n g an d b i lli n g advi C e f r o m th e e x p e rts
Coding Insights
PreParing for 2015 evaluation
and management code changes
Q
What are the 2015 Current
Procedural Terminology (CPT)
updates that will affect our primary
care practice next year?
A: With an estimated
264 new codes, 143 deleted
codes, and 134 revised
codes in 2015, now is the
time to prepare.
Thankfully, most of
the changes do not afect
primary care physicians.
However, the Evaluation
and Management (E/M)
section does include
signifcant changes in
advance care planning,
E/M prenatal visit guidance
and care management
services. So let’s take a look
at each of these in more
detail.
Advanced care
planning
The two new advanced care
planning codes (99497 and
99498) are used to report the
face-to-face service between
a physician or other qualifed
healthcare professional
(QHCP) and a patient, family
member, or surrogate in
counseling and discussing
advance directives, with or
38
without completing relevant
legal forms.
As you can see, a faceto-face visit is required but
doesn’t have to include the
patient.
The CPT manual defnes
an advanced directive as,
“A document appointing
an agent and/or recording
the wishes of a patient
pertaining to his/her
medical treatment at a
future time should he/she
lack decisional capacity at
that time.”
Some examples of
advance directives include:
❚ health Care Proxy,
❚ durable power of
attorney for healthcare,
❚ living will, and
❚ Medical Orders for LifeSustaining Treatment
(MOLST).
These are time-based
codes, with 99497 to
be billed for the frst 30
minutes, and 99498 for
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each additional 30 minutes.
Because the purpose of
the visit is the discussion,
no active management of
the patient’s problem(s) is
performed during the time
of these visits.
Additionally, these
code(s) can be billed in for
the following E/M services:
❚ new and established
patient ofce visits
(99201-99215),
❚ observation initial,
subsequent and
discharge care codes
(99217-99220, 9922499226),
❚ initial, subsequent and
discharge hospital service
codes (99221-99233,
99238-99239),
❚ observation or inpatient
admit and discharge on
the same date (9923499236),
❚ outpatient and inpatient
consultations (9924199255),
❚ emergency department
❚
❚
❚
❚
❚
❚
visit codes (9928199285),
initial, subsequent and
discharge nursing facility
care codes (9930499316),
annual nursing facility
assessment code (99318),
new, established and
discharge domiciliary
or rest home visit codes
(99234-99337),
new and established
patient home visit codes
(99341-99350),
initial and periodic
preventive medicine
codes (99381-99397), and
Transitional Care
Management Service
codes (99495-99496)
However, these codes
cannot be billed with:
❚ critical care codes (99291,
99292),
❚ inpatient neonatal and
pediatric critical care
codes (99468-99476), or
❚ initial and continuing
intensive care services
(99477-99480).
Be careful: Medicare has
indicated that it will NOT
pay for codes 99497 or
99498 in 2015. Check with
your commercial payers to
see if they are reimbursing
for these codes.
MedicalEconomics. com
ES544384_ME011015_038.pgs 12.16.2014 22:00
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C o d i n g an d b i ll advi C e f r o m th e e x p e rts
E/M prenatal
visit guidance
The maternity care and
delivery guidelines were
revised to specify the
following:
❚ pregnancy confrmation
during a problemoriented or preventive
visit is not considered
a part of antepartum
care. Report using the
appropriate E/M code for
that visit.
❚ Antepartum care includes
the initial prenatal
history and physical
examination.
Care management
services
The section title of
“Complex Chronic
Care Coordination” has
been changed to “Care
Management Services”
with an addition of a new
subsection, “Chronic Care
Management Services”
to better refect the
management services
described by new code
99490.
The new code requires
chronic care management
services that take at least
20 minutes of clinical
staf time directed by a
physician or other qualifed
healthcare professional,
per calendar month, with
the following required
elements:
❚ multiple (two or more)
chronic conditions
expected to last at least
MedicalEconomics. com
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MEDICARE HAS
INDICATED
THAT THEY
WILL NOT
PAY FOR
CODES 99497
OR 99498 IN
2015. CHECK
WITH YOUR
COMMERCIAL
PAYERS TO SEE
IF THEY ARE
REIMBURSING
FOR THESE
CODES NEXT
YEAR.
12 months, or until the
death of the patient,
❚ chronic conditions that
place the patient at
signifcant risk of death,
acute exacerbation/
decompensation, or
functional decline, and
❚ comprehensive care
plan established,
implemented, revised, or
monitored.
Medicare has
announced that it will
reimburse for 99490
instead of the initiallyproposed G-code, and the
Work Relative Value Unit
(wRVU) is 0.61.
Keep in mind that
chronic care management
services of less than 20
minutes in a calendar
month are not reported
separately. The 20 minutes
is in contrast to at least
60 minutes of complex
chronic care management
service that would be
reported by a code 99487.
Also, the add-on
code 99489 should not
be reported for service
of less than 30 minutes
in addition to the frst
60 minutes of complex
chronic care management
services during a calendar
month.
According to the
American Medical
Association, in addition to
the above criteria for care
management services, the
requirements for complex
care management services
include:
❚ establishment or
substantial revision of a
comprehensive care plan,
❚ moderate or high
complexity of medical
decision-making, and
❚ 60 minutes of clinical
staﬀ time directed by a
physician or QHCP per
calendar month.
Patients may be identifed
by practice-specifc or other
published algorithms that
recognize:
❚ multiple illnesses,
❚ multiple medication use
(and potential for drug
interactions),
❚ inability to perform
activities of daily living,
❚ requirement for a
caregiver, and/or
❚ repeat admissions or
Emergency Department
(ED) visits.
MORE ONLINE
New modifers physicians
need to know for 2015
http://bit.ly/1wd5yrT
Evaluation and management
codes under scrutiny
http://bit.ly/1B867nl
How physicians can avoid
denials using modifer 25
http://bit.ly/1vOwQ87
Understanding proper use
of time-based coding
and billing
http://bit.ly/1yyyBZ1
Incident-to billing:
Physician coding
questions answered
http://bit.ly/1qv0Q8a
The answer to the reader’s question was provided by Renee
Dowling, a billing and coding consultant with VEI Consulting,
in Indianapolis, Indiana. Send your coding and billing questions
to medec@advanstar.com.
Medical econoMics ❚ January 10, 2015
ES544386_ME011015_039.pgs 12.16.2014 22:01
39
ADV
P r acti c e manag e m e nt advi c e f r o m th e e x P e rts
Practical Matters
The imporTance of in-person
sTaff meeTings
it. Corollary Tip 1(a) –Don’t
cancel the meeting except
under extreme duress.
The importance of the
meeting and its content for
everyone else will in part
follow from the importance
they perceive it has for
you. There is no better
way to diminish sense a
of importance than by
frequent cancellations.
clerical resolution, and
combining the minds of
everyone is crucial when
difculties arise.
By the way, do you know
who always has the critical
insight needed to resolve
an issue? The person who
is not at the meeting. Any
idea who is not going to
buy into and therefore
undermine the solution to
a problem? The person who
is not at the meeting.
I know that in larger
practices with ambiguous
team delineation, complete
inclusion is particularly
challenging. Of course,
quitting smoking is pretty
challenging, too, but if
you’re a smoker, you should
still work as hard as you can
to make it happen.
Include
2Involved
Everyone
in the
3for Prepare
an Agenda
Yourself
Major Processes
Take a page from the book
of our patients: Write out
the list of things you wish
to discuss ahead of time
and check them of as you
cover them. You don’t have
to distribute it. It is merely
a personal tool to keep you
on track.
The point is that these
meetings should be
treated like the valuable
opportunities that they
by Davi D Switz e r, m D Contributing author
Ever wonder why itÕs taking forever to get your patientsÕ
vital signs? Or why your no-show rate is so high? The
answers to these and other questions may be found by
talking to your staff. I have found no better way to sit
down and talk to my staff than to sit down and talk to
my staff. Yes, IÕm talking about meetings.
If no provIder in your
practice is leading regular
meetings with your
colleagues and your staf,
you should start now.
Although all of us have
been tortured throughout
our professional lives
with painful, pointless
meetings, I have found this
to be vitally important.
You will be amazed at
how the most vexing and
perplexing conundra melt
into pools of simplicity
when you ask hard-hitting
group questions such as:
“Was there a problem with
our phones in the last few
days?”
Epiphanies abound
when the clerical and the
clinical congregate. (We’ve
never assigned ultimate
responsibility for ordering
the rapid strep tests? No
wonder we always run
out!).
Much like the 30
40
minutes of aerobic
exercise fve times per
week we recommend
to all of our overweight
patients, I know that not
all of my suggestions will
be logistically easy. But
following these tips, based
on years of my experience
as a physician, will
ultimately be gratifying as
you watch your staf come
together and become a
better care team.
It Every
1 Have
Week
Do you know what the
diference is between a
minor glitch and a major
crisis? About four weeks.
If you want to have your
best chance at catching
a practice management
problem while it is still
a smoldering ember
rather than a catastrophic
confagration, give yourself
more opportunities to fnd
Medical econoMics ❚ January 10, 2015
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Moving patients and their
communications from the
clerical (check-in, phone
answering) to the clinical
(nursing, provider) realm
and back out again is a
complex endeavor with
numerous opportunities to
go awry.
Consequently, many
problems do not have a
purely clinical or purely
MedicalEconomics. com
ES544400_ME011015_040.pgs 12.16.2014 22:26
ADV
P r acti c e manag e m e nt advi c e f r o m th e e x P e rts
are. Exerting the efort to
make them happen and not
realizing their full potential
is almost tragic.
Too Short,
4 Not
Not Too Long
You need enough time to
cover your personal agenda
and let everyone speak to
any additional topics that
concern them.
I am sure the
requirement varies across
practices, but I have
found that no less than 20
minutes, but no more than
30 minutes, works well for
me. This will also be easier
to accomplish if you follow
Tip 1.
The longer you go
between meetings, the
longer the meeting will
be, and the greater the
likelihood that issues
or problems will go
unaddressed.
Record Action
5Yourself
Items for
Gathering as a group
is indeed productive.
Listening to the
perspectives of others is
educational for you, and
a chance to be heard is
generally appreciated by
your co-workers.
However, if you do not
record for future reference
the specifc actions
required to resolve the
problems covered, you are
likely to prolong or even fail
to execute the resolutions
themselves.
MedicalEconomics. com
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IF STAFF MEMBERS DO NOT ASSOCIATE
MEETINGS WITH CONCRETE POSITIVE CHANGES,
THEIR ENTHUSIASM FOR THE MEETINGS WILL
QUICKLY WANE, AS WILL YOURS.
Also, if staf members do
not associate the meetings
with concrete positive
changes, their enthusiasm
for the meetings will
quickly wane, as will yours.
Take Time
6Allotted
Normally
to Patient
Care to Have the
Meeting
Regarding this tip,
administrators and
bean-counters may raise
an eyebrow. But if you
want your staf to take
participation in these
meetings as a serious
part of their job, treat
it as equally serious as
the patient-care part of
their job. If the meeting is
scheduled too early, too
late or at a time your staf
would otherwise not be
caring for patients in one
way or another, you will
likely lose the time you save
wrestling with how to get
your employees engaged in
this “extra” obligation.
In case you were
wondering, my
compensation is tied
in part to the fnancial
performance of the entire
practice. Do you know how
I see this supposed “lost
revenue?” As a bargain that
more than pays for itself.
Use Positive
7Liberally
Feedback
These meetings are
the perfect forum to
congratulate someone
on a job well done and
reinforce the performance
you like. Have a low
threshold to say “thanks”
MORE ONLINE
Managing staf performance
with reviews and raises
during the meeting,
and morale will trend
accordingly.
In closing, one more
general philosophical
thought: You cannot
have a team that never
convenes in real time
as a group. Therefore, if
you choose not to meet
with your co-workers,
you cannot expect your
co-workers to operate like
a team.
Adapting your medical
practice to the demands of
healthcare reform
http://bit.ly/1wy0AYP
http://bit.ly/1z6zPst
How to motivate and retain
your top employees
The role of staf in meeting
quality metrics
http://bit.ly/1qvonWM
http://bit.ly/1uKNwLM
Increasing employee
satisfaction at your practice
Delegating taks to staf
enhances team-based care
http://bit.ly/1ByCHlb
http://bit.ly/1zPhakm
David Switzer, MD, is a family practice physician with Luray
Family Medicine in Luray, Virginia. This article was an honorable
mention in the 2014 Medical Economics Physician’s Writing
Contest. Send your practice management questions to medec@
advanstar.com.
Medical econoMics ❚ January 10, 2015
ES544401_ME011015_041.pgs 12.16.2014 22:26
41
ADV
LegaL advi c e f r o m th e e x p e rts
Legally Speaking
HOw an EmplOyEE manual can HElp
cOntrOl risk and cOntain cOst
by An d r ew L. Zwe r Li ng, J d Contributing author
The questions of whether your medical practice should
have an employee handbook and what should be
covered in the document are important for any physician
practice owner to answer. This manual will impact every
aspect of the practice on a daily basis.
It Is fundamental that
a medical practice have
an employee handbook,
because a properly drafted
handbook can be a critical
tool for risk management,
communication and cost
containment.
An employee handbook
informs employees
and supervisors of the
workplace rules and policies
in a uniform manner, and
serves many functions,
including:
❚ providing clarity
regarding expectations
and the standards that
must be followed;
❚ informing employees
about workplace policies
designed to enhance
an entity’s operational
viability and efciency,
such as overtime issues;
❚ informing employees of
their rights and benefts
in a clear, consistent
manner;
❚ notifying employees
42
about appropriate
grievance and complaint
procedures; and
❚ explaining an employee’s
at-will status and that the
employee did not have
an implied or express
contract
An employee handbook
can reduce the risks of
litigation or provide a
defense in a litigation by,
for example, demonstrating
the employer’s intended
consistent treatment of its
employees, and showing
a plaintif/employee’s
violation of the workplace
rules and/or that a plaintif/
employee’s claim for
benefts is baseless given
the express language of the
handbook.
Although there are costs
(attorney’s fees) associated
with drafting an employee
handbook, those are fairly
minimal, and are more
than ofset by the risks and
potential costs to a practice
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that does not have one.
Certain fundamental
concepts must be addressed
in a handbook. It should
include a highly visible
disclaimer stating expressly
that the handbook does
not constitute a contract
between the employer
and the employee or alter
“at will” employment
relationships.
The handbook should
make clear the employer’s
authority and right to
amend the handbook.
The employer should
regularly audit and update
the handbook, preferably
at least once a year, to
ensure that it is consistent
with current law and the
practices in the workplace.
An outdated handbook
may be a detriment in
litigation.
It’s also important for
the employer to collect
and maintain signed
acknowledgements
from all employees that
they received, read and
understand the handbook,
that it supersedes
prior handbooks and
acknowledge they will
comply with its terms.
Keep these
acknowledgements in each
employee’s fle, because
they may prove helpful in
a litigation if an employee
claims ignorance of
workplace policies.
An employer should not
promise too much or be
too rigid in delineating its
policies. Failure to heed this
admonition may lead to a
limitation on the employer’s
ability to act. Use language
that endows the employer
with appropriate discretion
when acting.
Finally, ensure that the
handbook is consistent with
the culture and practices
of the workplace and that
management is on board
with its terms. Consult
with frontline supervisors
to ensure consistency
between policies and actual
practices and to ensure that
the policies included in the
handbook can actually be
enforced.
Andrew L. Zwerling, JD, is a
partner-director at Garfunkel Wild, P.C.
in Great Neck, New York. Send your legal
questions to medec@advanstar.com.
MedicalEconomics. com
ES543981_ME011015_042.pgs 12.15.2014 22:12
ADV
In Depth
The defensive medicine
balancing act
Ordering tests and diagnostic procedures can be a
dilemma for physicians, who must navigate issues of
patient care, liability and cost
by J u dy Packe r-Tu r s man Contributing author
HIGHLIGHTS
01 For practicing
physicians, preventing
defensive medicine in their
practices boils down to good
communication with patients.
02 Tort reforms may
be needed to persuade
physicians to change
practice patterns as part
of a larger transformation
to healthcare delivery and
payment systems.
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Te common assumption among healthcare experts
is that physicians practice defensive medicine out
of an abundance of caution amid worries of being
sued for malpractice. But recent studies reveal that
defensive medicine many not be as straightforward as
many physicians believe and the impact on healthcare
spending remains an open question. 

Despite broaD consensus that defensive medicine exists, it remains difcult to
defne the term, much less measure its impact on U.S. healthcare spending.
Typically, defensive medicine means
physicians ordering tests and procedures,
making referrals or taking other treatment
steps to help protect themselves from liability rather than to beneft their patients’ care.
Some researchers label it as unnecessary
care of marginal value at best. Others de-
scribe it as overuse of medical services that
afords more economic—and even psychological—beneft to physicians than to their
patients.
“You’ve got America as a ‘can do’ country, wanting tests that may not in any way
be useful,” says Henry Aaron, PhD, a health
policy expert at the Brookings Institution.
“Tat said, it is in the interest of the provider
to provide it, and in the interest
of the patient to get it,” especially
45
Medical econoMics ❚ January 10, 2015
ES544420_ME011015_043.pgs 12.16.2014 23:18
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ADV
Defensive medicine
Does malpractice reform
affect defensive medicine practices?
Study looks at physician
behavior in emergency
departments before and
after reform legislation
By Jeffrey Bendix, MA Senior Editor
hysicians and health policy
experts have long assumed
that doctors are driven to
practice defensive medicine
because they fear being
sued for malpractice. But
a recent study of what
happened in states that
made it more difﬁcult to sue
some physicians casts doubt on that
assumption.
The researchers looked at the numbers of
computed tomography (CT) and magnetic
resonance imaging (MRI) procedures
and inpatient admissions ED physicians
ordered for a random sample of Medicare
fee-for-service patients in the three states
between 1997 and 2011. They focused
on the imaging procedures because ED
physicians frequently self-report them
as examples of defensive medicine
practices. Researchers also studied pervisit charges as a proxy for the intensity
44
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Getty Images/Digital Vision/Michael Grimm
The study examines the impact of
changes in the behavior of emergency
department (ED) physicians following
the reform of malpractice laws in in
three states: Texas, which in 2003
changed its malpractice standard for
emergency care to “willful and wanton
negligence;” and Georgia and South
Carolina, which changed their standards
to “gross negligence” in 2005.“From a
legal standpoint, these two standards are
considered synonymous and are widely
considered to be a very high bar for
plaintiffs,” the study’s authors write.
MedicalEconomics. com
ES544421_ME011015_044.pgs 12.16.2014 23:18
ADV
Defensive medicine
of the level of services provided to
the patients.
The authors then compared patientlevel outcomes before and after
passage of malpractice reform both
among the three reform states and
in surrounding states, with the goal
of isolating the speciﬁc impact of the
reform legislation from other trends
and from patient characteristics. The
goal was to arrive at what the authors
term “policy-attributable changes” in
ED physician behavior.
After subjecting the data to regression
analysis, the researchers found no
decrease in rates of CT or MRI use
or hospital admission in any of the
three reform states, and no reduction
in per-visit charges in Texas or South
Carolina. Georgia experienced a 3.6%
reduction in per-visit charges.
The authors note that ED physicians
frequently cite the use of advanced
imaging as example of a defensive
medicine practice. “Our results
challenge the validity of these
assertions, or at least suggest that
the use of emergency department
imaging is unlikely to be affected by
malpractice reform alone,” they write.
Although the study focused on ED
physicians, the results have wider
implications for the debate over
shielding doctors from malpractice
suits would reduce defensive
medicine practices, and thereby
reduce the nation’s overall medical
costs, says Daniel Waxman, MD, PhD,
the lead author and an adjunct natural
scientist at the RAND Corporation.
“People have said over and over that
malpractice reform is an important
way to save money, and I think the
interesting part of this study suggests
that’s a blind alley,” Waxman says.
The study, “The Effect of Malpractice
Reform on Emergency Department
Care,” appears in the October 16
issue of the New England Journal of
Medicine.
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43
when out-of-pocket cost-sharing is low, he says.
In a 2014 study led by the Cleveland Clinic and published in JAMA Internal Medicine,
researchers asked a few dozen physicians in
three hospital medicine services to estimate
the defensiveness of their own orders. Fully
28% of 4,200-plus orders were reported by
physicians as being at least partially defensive, but only 2.9% were seen as completely
defensive in nature.
Te Cleveland Clinic study cited a national cost estimate of $46 billion related to defensive medicine, but noted that such costs
have been measured only indirectly. Other
studies, along with the American Medical Association, put the cost impact much higher.
Moreover, researchers said, physicians’
attitudes about defensive medicine failed
to correlate with cost, suggesting that only
a small portion of costs might be reduced by
tort reform.
Defensive medicine is viewed by many as a
deep-seated dilemma. Vikas Saini, MD, president of the Lown Institute, says the nonproft
Boston think tank launched a grassroots initiative of physicians, patients and community
organizations in 2013 called the RightCare
Alliance to change behaviors
“primarily because we view
the problem of unnecessary
care and use as a deep cultural problem, I can sum it up
as more is not always better,
but that is the cultural bias,”
he says.
Saini puts the issue in
the context of a demanding
profession. “Tere’s a lot of
borderline. Tere’s a lot of
uncertainty, guessing. It is
not purely defensive. Tere’s
— VIkaS SaInI, MD, preSIDenT, Lown InSTITuTe
also profound concern for
your patient and concern for
your reputation all wrapped
together,” he says. “For us, the deeper issue is
[that] modern medicine has become driven
a lot by technology, a lot by money—and we
need to free decisions to be driven by patients’ needs.”
At times there can be poor communication and lack of trust between physicians
and their patients and tort reform “isn’t going to fx the habits of defensive medicine,”
Saini says.
Research suggests that physicians’ per-
The deeper issue is:
Modern medicine
has become driven a lot by
technology, a lot by money—
and we need to free
decisions to be driven
by patients’ needs.”
Medical econoMics ❚ January 10, 2015
ES544419_ME011015_045.pgs 12.16.2014 23:18
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ADV
Defensive medicine
If you want
to ﬁx defensive
medicine,
develop trusted
therapeutic
relationships
using effective
communication
skills and be
available to
patients.
period.”
—rIcHarD roberTS, MD,
JD, proFeSSor oF FaMILy
MeDIcIne, unIVerSITy
oF wISconSIn
ceptions are a key driver. A 2013 study published in Health Afairs linked physicians’
survey responses on their levels of malpractice concern to claims of Medicare patients
treated in their ofces. It found that physicians reporting a high level of malpractice
concern were most likely to engage in practices that would be considered defensive
( for example, more aggressive diagnostic
testing) when diagnosing patients with new
complaints of chest pain, headache, or lower
back pain.
“It’s a multidimensional problem. You’ve
got patient expectations for care. You’ve got
conficting recommendations for care, and
then you have local practice patterns that
also drive physicians to order certain diagnostic tests and treatments,” says David A.
Katz, MD, associate professor in the department of internal medicine at the University
of Iowa and one of the study’s coauthors.
“One thing that was striking from the
data is state malpractice policies really had
much less of an impact on [physicians’]
fear of malpractice than what we had expected,” adds Katz. “Having said that, the
[physician] perceptions were a big driver,
particularly on the use of imaging...and we
saw a higher likelihood of referral to the
emergency department” among doctors
more fearful of malpractice, especially for
patients with chest pain.
Katz, who also practices in the Veterans
Afairs Iowa City Health Care System, says
when there is uncertainty about a test’s value,
he tries to explain to patients about conficting data on its benefts “and that a cascade
of tests may result downstream after a positive screening test. Sometimes insurance or a
third-party payer may encourage a procedure
and be willing to pay for it, but it may not be
in the best interests of the patient.”
“Sometimes it defes rational discussion, and many physicians will give in to the
patient,” he concedes.
Patients getting too much care
Primary care physicians are regarded as key
to helping reduce waste in the system. Yet,
according to a 2011 study in the Archives of
Internal Medicine, 42% of family and general internal medicine physicians in the
U.S. thought their patients were getting too
much medical care; only 6% thought patients were receiving too little care.
Brenda Sirovich, MD, MS, associate pro-
46
Medical econoMics ❚ January 10, 2015
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fessor of medicine at Dartmouth University’s
Geisel School of Medicine and the study’s
lead author, explains that researchers’ interest “wasn’t specifcally in malpractice, but in
drivers of healthcare practice patterns” and
gaining understanding that clinical indications are not the only things that infuence
physician decision-making.
Yet Sirovich says it is hard to determine
what other factors infuence decisions,
in part because surveys are standardized
instruments with fnite responses—and
perhaps also because physicians might not
know the factors themselves.
“I think most would say defensive medicine is practiced with the primary aim of
minimizing litigation,” Sirovich says. “But a
number of studies came out with the conclusion that defensive medicine plays a tiny role in
explaining rising costs and practice patterns.”
Sirovich’s belief, while not based on specifc evidence, is that this conclusion is
fawed because defensive medicine is diffcult to understand and “malpractice is a
very feared thing, a completely destructive
experience,” she says.
trained to ‘find the zebra’
Recently, physicians confrmed their ongoing
worries about the fnancial impact of defensive medicine. In the 2014 Survey of America’s Physicians, 20,000-plus physicians were
asked to identify the factors most likely to
contribute to rising healthcare costs. Six in 10
physicians cited defensive medicine, putting
it at the top of the list; an aging population
came in a distant second at 37.4%.
Primary care physicians and specialists
cited defensive medicine to the same degree, but relatively more—nearly seven in
10—physicians aged 45 or younger cited defensive medicine as a contributor.
Kisha Davis, MD, a family physician in
practice for seven years, says part of the reason for practicing defensive medicine is that
medical schools train students to look for,
and rewards them for, fnding “the zebra.”
In other words, the idea that “maybe this is
the one [case] that doesn’t ft the textbook,”
Davis says.
Davis, the medical director of Casey
Health Institute, an integrative primary care
practice in Gaithersburg, Maryland, says
she maintains a good relationship with her
patients and doesn’t think much about malpractice or being sued. But she does think
MedicalEconomics. com
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Defensive medicine
about patient outcomes. “I don’t want to be
the one who missed cancer,” she says.
As a younger doctor, Davis says she may
feel more comfortable than some physicians
in telling her patients not to worry if she
doesn’t order a slew of the most sophisticated, costly testing.
But clinical experiences can change
practice patterns. Davis recalls sending for
referral a patient who came to her with suspicious abdominal bloating. Ovarian cancer
was diagnosed. Tis led her to worry more
about the next few patients who came in
with similar symptoms, despite less-suspicious exam results, because she didn’t want
to delay diagnosis.
“You worry more [under such circumstances],” Davis says. “I, in general, tend to
be a provider who doesn’t order lots of tests,
[and] don’t jump to the MRI. But I might
have ordered blood work [and] tests because
more suspicion creeps into your mind. It’s
not always about malpractice. Tere is also
an element of uncertainty.”
Patient education “has a huge part to
play” in avoiding defensive medicine, adds
Davis. She says a patient with a headache
came into her ofce in November telling her
a head scan was needed.
“Sometimes it takes a lot of convincing” to
sway patients from such desires, and much of
her time is spent in doing so, she says. In the
Washington, D.C. area where she practices,
she says patients tend to see many specialists, so she must explain to patients why they
don’t need a cardiologist for hypertension.
Davis says she worked previously for
four years at a community health center in
Columbia, Maryland, where many patients
didn’t have other care options. “I handled it
all,” she says. “Now, it’s diferent trying to get
people to understand the benefts of primary care and how care coordination can work.
“People come in wanting antibiotics,
wanting studies, wanting to see the specialists,” she adds. “I have time in my practice to
explain what primary care can do [and why
such steps aren’t necessary], but I understand why my colleagues in busy practices
may not have the time to have more in-depth
conversations as much as they should. You
really have to make it a priority.”
aiming to imProve care
In a broad efort to improve quality and safety of care, the American Board of Internal
MedicalEconomics. com
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%
13
Approximate
percentage of costs
incurred by hospitals
that can be attributed
to the practice of
defensive medicine,
according to JAMA
Internal Medicine.
$46
bILLIon
Estimated annual
cost of defensive
medicine to the U.S.
healthcare system.
%
61
of physicians
older than age 55
that have been
sued for medical
malpractice,
according to a study
in Policy Research
Perspectives.
$3.7
bILLIon
The amount of
medical malpractice
payouts in 2013,
according to the
Washington Post.
Medicine (ABIM) Foundation launched the
Choosing Wisely campaign.
Te national initiative aims to help providers and patients discuss overuse of tests
and procedures and support eforts to help
patients make what the foundation describes as “smart, efective care choices.” Its
frst recommendations were rolled out in
2012, followed by more in 2013 and 2014.
“Choosing Wisely helps recognize there
are times when we try to manage uncertainty by overtesting, but overtesting itself
can do harm,” says Richard J. Baron, MD, the
ABIM Foundation’s president and chief executive ofcer. “Choosing Wisely isn’t about
rationing or withholding [care]. It’s about
doing what’s right, not less.”
Baron says that holding “evidence-based
conversations” about appropriateness of care
with patients “is a better way to go than just
assuming if you do another test you’re somehow reducing your liability profle,” he says.
To date, 69 medical societies, and groups
representing nurses and physical therapists
have joined the Choosing Wisely initiative,
along with 21 Robert Wood Johnson Foundation grantees for implementation eforts
and more than 24 consumer organizations,
including Consumers Union.
As the U.S. healthcare market shifts toward use of more high-deductible health
plans, patients bearing more of the cost are
going to ask doctors when and if they really need certain tests or procedures, Baron
says. And physicians in large organizations
increasingly are working under global budgets, trying to improve quality of care and
decrease costs at the same time, he adds.
Cedars-Sinai Medical Center is putting
Choosing Wisely recommendations into
patients’ electronic health records, he notes.
Katz says he and other staf doctors working as salaried employees at the University of
Iowa Medical Center are looking at overused
practices identifed by the Choosing Wisely
campaign and examining the evidence behind the recommendations as part of an internal efort to create more awareness about
marginally efective treatments.
“What’s driving that is macro-economics,” Katz says. “Te University of Iowa Medical Center is working to create an accountable care organization (ACO), and the idea
is we have to be more accountable and discriminating in our use of treatments.”
But some physicians will need convinc-
Medical econoMics ❚ January 10, 2015
ES544416_ME011015_047.pgs 12.16.2014 23:19
47
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Defensive medicine
ing to embrace the evidence-based model
promoted by Choosing Wisely. In a 2014
online exchange about Choosing Wisely, a
physician criticized the initiative, asserting
he was involved in saving a patient’s life by
not following a Choosing Wisely recommendation related to cardiac screening.
Another physician replied that surgeons
must individualize patient care based on
risk assessment from a careful history and
physical exam. Routine duplex scanning
for carotid artery disease “is not indicated
in the absence of symptoms or specifc risk
factors, as there is not evidence that this
screening results in improvements in patient outcomes,” he wrote.
Who Will be
in the driver’s seat?
Te real question is who’s going to be in the
driver’s seat with respect to defensive medicine, says Laura Hermer, JD, associate professor at Hamline University School of Law.
“I ask doctors at CME talks: ‘Do you want it
to be you or state legislatures?’ ”
Te medical profession must mandate its
own practice and ethical standards, Hermer
says. “If you’re simply upping the ante at
every turn because you’re worried you might
be sued—and, by the way, you’ll get paid for
it anyway—you’re not taking the right stand,”
she says. As for Choosing Wisely, Hermer asserts the issue is whether it is “something
that will translate to the courtroom.”
Hermer coauthored a 2010 study on defensive medicine, cost containment and reform that concluded that traditional medical malpractice reforms won’t allay various
pressures leading doctors to overprescribe
and overtreat.
But researchers said such reforms may
be needed to persuade physicians to change
practice patterns as part of a larger transformation to healthcare delivery and payment
systems needed to curb costs.
Hermer points to a 2014 RAND study
published in Te New England Journal of
Medicine that found defensive medicine is
still prevalent in three states, including Texas, despite laws raising the legal threshold
for malpractice in emergency settings.
“In Texas, you have a state that implemented strong tort reform and you don’t
see a reduction in defensive medicine as
a result of that,” she says. “Te answer is
physicians are going to continue to fear be-
48
Medical econoMics ❚ January 10, 2015
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ing sued, notwithstanding tort reform, and
probably notwithstanding strong eforts like
Choosing Wisely.”
good Patient communication
is key
For practicing physicians, preventing defensive medicine in their practices boils down
to good communication with patients, says
Richard Roberts, MD, JD, Professor of Family
Medicine at the University of Wisconsin.
“Te best we do is basically ask people,
is this defensive or not? Would you be comfortable stopping at 95% certainty, and not
doing three more tests for 98% certainty?”
he says. “I think Choosing Wisely is a great
idea, looking at the evidence and expert
opinion, and letting people know you don’t
have to do x, y and z, because there’s no beneft to the patient. Tere may be harm.”
Roberts illustrates the idea that communication with patients is key: “Imagine I’ve
been your family doctor for years, helped
you, your kids, your husband. We’ve had this
relationship over time, and one of your kids
comes in with an ankle sprain. I say, ‘I don’t
think [your child] needs an X-ray right now.’
I say, ‘I’m here tomorrow, you have my cell
phone.’ My patients know we’ll be closely
connected until the situation is resolved,
even if they don’t get every test.”
Roberts says when he is taking care of
patients one-on-one, he doesn’t want his
thinking clouded or his decisions skewed by
worries about legal issues that he is unable
to predict or control.
“If you want to fx defensive medicine,
develop trusted therapeutic relationships
using efective communication skills and
be available to patients, period,” Roberts
says. “And then practice medicine using the
best science available. Tat to me is about
as good as it can get for a doctor. You can’t
consistently look at the lawyer behind you
or you’ll run into the wall.”
More online
Malpractice liability caps don’t reduce
defensive medicine costs http://bit.ly/1AqLgKX
Can ‘safe harbor’ laws stop the practice of
defensive medicine? http://bit.ly/1zHrLQ9
Defensive medicine is now a part of physician
training (commentary) http://bit.ly/1uvb045
MedicalEconomics. com
ES544424_ME011015_048.pgs 12.16.2014 23:19
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MedicalEconomics. com
Th e b r i d g e b eTwe e n po li cy an d h ealTh car e d e live ry
The Last Word
Study: RefeRRal pRoceSS needS
pRotocolS, StandaRdization
by Rachae l Z i m lich Contributing author
Primary care physicians make millions of referrals to
specialists each year, yet there is little protocol to follow
and few tools to rely on when determining who will take
their patient’s care to the next level.
in 2009, there were more
than 100 million referrals
made during ambulatory
visits—that’s roughly 1
in 10 visits resulting in
referrals. There is a lot of
variation in how and when
physicians seek specialist
intervention—physician
training and expertise, as
well as the severity of the
patient’s illness and their
expectations for care, all
factor into referral decisions.
Yet when physicians
make the call to send a
patient to a specialist, there
is no standard practice for
evaluating the ft between
the patient and the referred
physician.
Niteesh K. Choudhry,
MD, PhD, and Joshua M.
Liao, MD, both of Brigham
and Women’s Hospital and
Harvard Medical School in
Boston; and Allan S. Detsky,
MD, PhD of the University
of Toronto, Mount Sinai
Hospital and University
Health Network made the
case in a recent issue of the
MedicalEconomics. com
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Journal of the American
Medical Association (JAMA)
for standardizing the referral
process.
“Physicians must
often base their referral
recommendations on
little or no objective
information,” the authors
write. “Physicians have few
mechanisms for personal
performance feedback
and little or no training in
how to evaluate the quality
of care that their peers
provide.”
Standardization could
afect both the cost and
quality of care, they argue,
due to the fact that there is
currently little consistency
across the profession, with a
variation of up to fve-fold.
The issue is even more
apparent in the inpatient
setting, when everchanging on-call specialists
are used.
Even in ambulatory
settings, the authors argue
that patients are often
referred to generic clinics
or departments, with little
consideration made by
the referring physician
as to which particular
specialist would best suit
the needs of the patient.
Of course, authors note,
there is a another end of the
spectrum where physicians
practice much more control
over the referral process,
but often availability of
appointments, who works
within certain networks,
geographic locations, and
the patients’ ability to
pay are key factors in the
referral process as well. In
terms of patient preference,
physicians may be apt to
refer patients who value
thoroughness to specialists
who are “liberal” with
diagnostic testing, or to
those who have similar
cultural beliefs as the
patient.
The authors suggest
that some of the metrics
currently reported
for various industry
initiatives, such as pay-
for-performance or other
federal programs, could also
be used to help physicians
select specialists for their
patients.
But that system would
still have drawbacks, the
authors note.
“Although acquiring
more granular and
detailed data about
physician performance
maybe helpful, it alone
will be insufcient for
improving crucial aspects
of the referral and
recommendation process,”
they write. “Knowing that
a consultant’s patients
generally achieve good
glycemic control also
does not indicate how
easy it is for patients to
have their blood drawn,
how efectively results are
communicated to patients,
or how collegial or
collaborative consultants
and their staf are in comanagement along with
referring physicians.”
With this in mind, patient
satisfaction scores may
be a useful tool in making
referrals. But the key to
fnding a better method
for the referral process will
likely be a combination of
clinical metrics and patient
feedback, the authors
conclude.
Medical econoMics ❚ January 10, 2015
ES543976_ME011015_053.pgs 12.15.2014 22:11
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