Richard Payerchin is associate editor of Medical Economics.

 has overturned the landmark Roe v. Wade case that legalized abortion in 1973.

The ruling means states will govern abortion rules, which could lead to abortion being outlawed in half the country, according to one organization that advocates for reproductive rights.

On June 24, the Supreme Court issued 213 pages with its ruling and opinions in the case known as Dobbs v. Jackson Women’s Health Organization, which the court heard on Dec. 1, 2021. The Supreme Court considered the state of Mississippi’s appeal of a lower court ruling that struck down as unconstitutional the state’s law banning abortion after 15 weeks of pregnancy, according to the 

A summary in the ruling syllabus stated: “The Constitution does not confer a right to abortion; Roe and Casey are overruled; and the authority to regulate abortion is returned to the people and their elected representatives.”

The ruling also referred to the 1992 case Planned Parenthood of Southeastern Pa. v. Casey, another landmark case in U.S. abortion law.

“We hold that Roe and Casey must be overruled,” the ruling said. “The Constitution makes no reference to abortion, and no such right is implicitly protected by any constitutional provision, including the one on which the defenders of Roe and Casey now chiefly rely—the Due Process Clause of the Fourteenth Amendment.”

Citing case law, the draft ruling said the Due Process Clause “has been held to guarantee some rights that are not mentioned in the Constitution, but any such right must be ‘deeply rooted in this Nation’s history and tradition’ and ‘implicit in the concept of ordered liberty.’

“The right to abortion does not fall within this category,” the draft ruling said.

A 98-page draft by Justice Samuel Alito circulated to fellow justices on Feb. 10. That document was leaked to the news site Politico, which published the ruling on May 2, sparking a firestorm of reaction and demonstrations from abortion supporters and opponents.

Based on the ruling, at least half the 50 states are poised to ban abortion, according to CRR.

That organization called Dobbs v. Jackson Women’s Health “the most consequential abortion rights case in generations” and analyzed the various state laws that regulate abortion in the study, 

CRR categorized the states, the District of Columbia and the five most populous U.S. territories in four ways, based on analysis of current laws in a post-Roe legal environment:

Nine states are considered in the “expanded access” category, with abortion protected by state laws or constitutions, with other laws and policies for additional access to abortion care: California, Connecticut, Hawaii, Illinois, New Jersey, New York, Oregon, Vermont, and Washington

12 states and Washington, D.C., were considered “protected,” with abortion protected by state law, with limits on access to care: Alaska, Colorado, Delaware, the District of Columbia, Florida, Kansas, Maine, Maryland, Massachusetts, Minnesota, Montana, Nevada, and Rhode Island

Three states and two territories are “not protected,” meaning abortion may continue to be accessible but would not be protected by state and district law: New Hampshire, New Mexico, Puerto Rico, U.S. Virgin Islands, and Virginia

26 states and three territories are “hostile,” meaning they could immediately ban abortion: Alabama, American Samoa, Arizona, Arkansas, Georgia, Guam, Idaho, Indiana, Iowa, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Nebraska, North Carolina, North Dakota, the Northern Mariana Islands, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin, and Wyoming

In 2020, there were 930,160 abortions in the United States, an 8% increase from 862,320 abortions in 2017, according to The Guttmacher Institute, which conducts three-year surveys of abortion providers.

That group said the figures showed a reversal of a long-term decline in U.S. abortions that began about 1990, but noted trends varied across states from 2017 to 2020 with “no clear patterns to explain why some had increases or decreases.”

The Guttmacher Institute map of states that will or are likely to ban abortion generally matched that of the Center for Reproductive Rights.

Since the May 2 publication of the draft ruling, physicians groups have lined up in support of abortion rights, publishing statements and member advisories.

In its annual meeting June 10-15, before the Supreme Court ruling, the American Medical Association AMA members adopted a 

 “recognizing that it is a violation of human rights when government intrudes into medicine and impedes access to safe, evidence-based reproductive health services, including abortion and contraception.”

“A growing number of current and pending laws insert government into the patient-physician relationship by dictating limits or bans on reproductive health services and while also aiming to criminally punish patients for their health decisions,” AMA President 

, said in a published statement. “The new policy also calls for AMA to seek legal protections for patients who cross state lines to receive reproductive health services, as well as legal protections for physicians and others who support or provide reproductive health services or referrals to patients who cross state lines.”

This month, outgoing AMA President Gerald E. Harmon did not mention the Supreme Court, but noted “increased government interference in the patient-physician relationship and the practice of medicine,” in his address to AMA’s annual meeting.

“Whether the issue is women’s reproductive health, care for transgender persons, or appropriate treatments for COVID … the AMA demands that politicians get out of the exam room,” Harmon said in his speech.

Articles

Abortion bans are expected to take effect in more than half of states.

Breaking: Supreme Court overturns Roe v Wade abortion ruling

Editor's note: Our partners at Medical Economics are hosting a free Summer Bootcamp: Beyond the Classroom Business Training for Physicians, June 30, from 3-7 p.m. as part of their series of informational webinars for physicians and practice managers. You can sign up for the upcoming bootcamp 

. The story below is the information shared in a session at a bootcamp earlier this year.

To see the entire video presentation, go 

For primary care practices, earning enough revenue to meet overhead expenses and provide quality care has always been a challenge. But practices often make the challenge even greater through sloppy coding and billing, leading to delayed or incorrect reimbursements from payers. The Centers for Medicare & Medicaid Services estimates that in fiscal year 2021, Medicare made $6.25 billion in fee-for-service payments that were improper under its coverage, coding and billing rules.

Fortunately, there are steps doctors and practice administrators can take to ensure they receive all they are owed in a timely fashion. But it requires forethought, training, and commitment from everyone in the practice.

Identify the most common reasons for denials and how to handle them differently to improve practice revenue.

Audit your practice’s coding program and identify areas for improvement.

Learn coding best practices and what changes may be in store.


Independent Consultant
MGMA Health Care Consulting Group

“I didn’t go to medical school to become a medical coder or biller” is a common refrain among doctors unhappy with the time and resources those tasks require. Nevertheless, coding and billing are inescapable parts of practicing medicine, and doing them poorly can have severe financial consequences, either from frequent claims denials or overbillings that the practice must then repay.

Longtime coding consultant Nancy Enos, FACMPE, CPC, CPMA, says claims denials often are the result of errors in billing. Consequently, reducing denials requires identifying the source of the mistakes and providing feedback to staff on how to avoid them. “Without that feedback loop there’s no education and no stemming the tide,” she says.

Enos advises practices to focus on three areas for reducing billing errors and claims denials: front office, clinical staff and back office. Common front office-related reasons for denials include the following:

Lack of coordination of patient benefits.

Expenses not covered by a patient’s insurance.

Expenses incurred prior to the patient’s coverage date.

Lack of required precertification/authorization for an expense.

“The front office is where the revenue cycle begins,” Enos says. That means staff members need to verify eligibility up front so patients know their financial responsibilities and agree to meet them.

Clinicians can minimize claims denials by making sure their notes are concise, detailed and specific, Enos says. “’Diagnosis lacking specificity is one of the biggest reasons for denials. Putting in the clinical details such as the problem’s severity and whether it’s chronic or acute will get you to the most specific diagnosis code and get your claim paid faster,” she explains.

Other problems she frequently sees in clinical notes include:

The date of service doesn’t meet frequency limits.

Time spent with the patient for time-based services is not documented.

The billing provider’s and service provider’s names don’t match.

The note doesn’t support the CPT codes reported for it.


In some ways, back office staff face the biggest challenges in the effort to reduce claims denials because many of the issues they deal with are ambiguous, Enos says. She cites the example of erroneous unbundling. “It’s difficult to completely prevent it because you don’t always know which payers will pay for lesser procedures at the same time as more comprehensive ones,” she says.

Other issues back offices frequently deal with include the following:

CPT codes are inconsistent with the place of service.

The patient has reached the benefit maximum for the time period.

Procedure/modification combinations are incompatible.

When such mistakes occur, “it’s the back office’s responsibility to rectify them as quickly as possible, then share the feedback with the source of the errors,” Enos says.

The possibility of having to repay thousands of dollars following a payer audit is another reason for closely monitoring billing and coding procedures, Enos notes.

“Plan to be audited at some point, and don’t assume everything’s OK as long as you’re getting paid,” she advises. The best way for practices to prepare, especially individual and small group ones, is to follow the compliance program developed by the U.S. Department of Health and Human Service’s Office of Inspector General. Its recommendations include the following:

Conduct internal monitoring and periodic audits.

Implement compliance and practice standards by developing written standards and procedures.

Designate a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards.

Conduct training and education on the standards and procedures.

Investigate violations or allegations of violations and disclose any incidents to the appropriate government entity.

Develop open lines of communication such as staff meetings on how to avoid erroneous or fraudulent conduct.

Enos recommends doing “benchmark” audits of five to 10 records per provider, followed by a minimum sample of 10 to 20 of the provider’s claims submissions, either retrospective or prospective. Departments or individuals of particular concern should undergo focused audits using at least 50 charts.

“Don’t look at auditing and monitoring as a form of punitive obligation, but as a way to ensure that you’re billing and coding properly,” Enos says. She says internal monitoring has the additional benefit of identifying and correcting undercoding, a problem common to most of the practices she works with.

After completing an audit, it’s critical to share the results throughout the practice. “It makes sense for a patient to see their doctor after getting an MRI, so why wouldn’t you want to provide feedback after an audit?” she says. Then she urges using the results to develop further training and education.

“Use that audit feedback to learn, to protect your practice and make sure that you’re optimizing your reimbursement and reducing your risk,” Enos says.

Front office staff can help minimize claims denials by verifying patient insurance coverage and eligibility before the appointment.

Clinician notes should be as detailed and specific as possible in order to obtain the correct billing code(s).

Billing and coding errors should be corrected immediately and feedback provided to the source of the error.

Practices should conduct periodic internal audits of their billing and coding and share the results with clinicians and staff members.

Don’t treat internal audits as an onerous task but rather as a method of self-protection and a tool to prevent undercoding.

For primary care practices, earning enough revenue to meet overhead expenses and provide quality care has always been a challenge. But practices often make the challenge even greater through sloppy coding and billing, leading to delayed or incorrect reimbursements from payers.

Bootcamp 2022: Preventing coding and billing errors can reduce claims denials

Keith Algozzine is co-founder and CEO of 

. A board-certified Physician Assistant, he was formerly the Chief PA of Emergency Medicine for St. Mary’s Hospital in Troy, NY, where he witnessed firsthand the challenges of the modern healthcare system. Keith was also part of the national ER startup management team for Pegasus Emergency Medicine. He represents UCM Digital Health on the American Telemedicine Association Accreditation Advisory Board and serves as an advisor to the Clinical Practice Guidelines Committees dealing with telemedicine considerations for urgent and emergency care.

As COVID-19 descended upon unsuspecting communities, businesses, schools, all non-essential services closed down and sought sanctuary. Most surgeries, medical procedures, and appointments were halted and indefinitely delayed or even closed. Options became extremely limited—at times nonexistent—and many were left with no recourse on where to find answers to health concerns.

Once the quarantine cover was lifted, life began its slow crawl to the slightest sense of normalcy. An unexpected consequence was the cumbersome and lengthy wait times felt in clinics and doctor’s offices. Not only were patients faced with the threat of a global pandemic, but they also had to deal with the fact that the protracted time needed to schedule and secure medical care was an added obstacle. To add, the health care worker shortage continued, overworked staff and stretched-thin resources carried on past the pandemic and burdened physicians and all related medical staff.

Regardless of whether a patient's needs are considered essential or non-essential, access to health information—timely and accurate—is something everyone seeking medical care should have access to.

6 Benefits of Digital Front Doors

Slideshows

As patient volumes grow, digital front doors can be a boon to your practice.

Tired of administrative burdens bogging you down? Are you feeling burned out and need a career reset? Does remote patient monitoring sound interesting but you don’t know where to start? And have you gotten your financials in order to minimize your taxes this year?

These are questions that many physicians ponder, but at 

Beyond the Classroom Business Training for Physicians

Reducing administrative burdens at your practice through clinical-first technology

Physician burnout tipping point: How membership-based primary care could be your career reset

Top 10 tax planning ideas in 2022 for physicians

Register now for this important free online event 

Also, be sure to check out our most recent 

 from the spring, where we touched on the following topics:

Addressing patient needs with a membership-based model

All the content is available online for you to review at any time. Take a moment to learn more about these important topics and don’t forget to register for the summer event. See you there!

Join us to master strategies that will take your practice to the next level.

Summer Boot Camp: Business lessons for doctors

Trevor Cabrera is a California-born, Southern-trained pediatrician with an interest in pediatric oncology, intensive care, neonatology, and hospital medicine working as a 

Although most in the healthcare industry have heard of travel nursing, especially during the COVID-19 pandemic, a lesser known field of medicine is the world of locum tenens. Like travel nursing, 

 encompasses physicians, physician assistants, and nurse practitioners who work in temporary assignments around the country. A Latin phrase coined by healthcare staffing agency CHG Healthcare in 1972, “locum tenens” means “to hold in place of” or “one holding a place”; and contrary to popular beliefs, this musty Latin term has the potential to spark a larger cultural shift in how we practice medicine in the future.

It’s never easy navigating the workforce fresh out of residency, and with the advent of the COVID-19 pandemic, many pediatricians were faced with a growing paucity of work. As my peers were seeking out jobs in academia, private practice, and fellowship training, I drew up blueprints to walk an uncommon path toward exclusive work in locum tenens. From my perspective, jumping into the market of locum tenens was akin to entering an underground society of traveling doctors targeted at helping to fill 

While my colleagues were settling into their new careers, I was busy obtaining multiple state licenses and preparing to broaden my experiences through working in myriad healthcare facilities, geographic locations, and various practice settings. To deepen my medical experiences and continue down the path of eternal education, I sought out work in some of the most isolated spots in the country. From the desert of New Mexico, to the greater plains of North Dakota, to the lakes of Central Maine, the more I practiced in these rural areas, it became clear that these are the regions most in need of providers. According to the 

, “Of the more than 7,200 federally designated 

 areas, 3 out of 5 are in rural regions. And while 20% of the U.S. population lives in rural communities, only 11% of physicians practice in such areas.”

As I traveled from job to job, acquiring new skills, new connections, and reaching a level of flexibility that historically doesn’t exist in medicine, it allowed me to appreciate the ever-changing landscape of hospital needs and how I could use my skills to help meet them.

Locum tenens work has given me the ability to create my own schedule. While I could have easily chosen a life of frequent vacations, I instead chose to maximize my work schedule, navigating from one assignment to the next. In February 2020, I sold 80% of my belongings, moved the remainder back to my mother’s house in California, and gave up my “home base” entirely. With no rent or utilities and most expenses reimbursed by my agency, locum tenens has allowed me to pay off medical school loans at five times the speed of my colleagues, all while quenching my growing wanderlust to travel around thecountry. In less than three years after residency graduation, I will be loan free — seven years sooner than had I sought public service loan forgiveness.

In 2021, I traveled a total of 320 days across multiple states and hospitals, covering for facilities awaiting permanent providers, clinicians on maternity leave and vacations, and physicians who are constantly overworked. I quickly learned the art of business negotiations, the variations in hospital contracts, the ins and outs of an organization’s infrastructure — essentially, the parts of medicine that are often not taught in medical training.

Locum tenens is not for everyone, but it does provide a meaningful alternative to traditional workplace settings in medicine that are prone to provider burnout, constant employee turnover, and a loss of focus as to why we went into medicine in the first place. While my peers have found themselves navigating the complexities of a singular job, I have already navigated working in over a dozen hospitals and clinics. I have learned flexibility, fostered exploration, and experienced compounding personal and professional growth. Today, I am proud to call myself 

 and look optimistically toward the future of locum tenens and where it may take me.

Like travel nursing, locum tenens encompasses physicians, physician assistants, and nurse practitioners who work in temporary assignments around the country.

Shifting the mindsight behind how we practice medicine 

Jeff Bendix is the senior editor of Medical Economics.

Doctors and health care organizations know the importance of 

 in determining patients’ health outcomes, but they often are frustrated by their inability to securely exchange this information in 

 and integrate it into patients’ electronic health records.

CyncHealth, which comprises the state health information exchanges (HIEs) for Nebraska and Iowa, began taking steps in 2020 to address that problem. CyncHealth partnered with Unite Us, a technology company that builds networks of health and social service providers, to provide 

 and social health information on the HIEs. 

® sat down recently with Jaime Bland, D.N.P., RN, president and CEO of CyncHealth, to learn more about the program. The following transcript was edited for length and clarity.

How did this initiative get started? What was the impetus behind it?

Jaime Bland: I started my career as (a registered nurse), so I have a background in care coordination. When I came to the HIE I really wanted to incorporate the data that nurses and care coordinators working in the community need to leverage for better patient outcomes. That led me to onboarding various social care strategies, which is where we began to partner with Unite Us, to really facilitate that whole person picture of health.

ME: Why is it important to include social health data in information exchanged among clinicians?

Bland: We’ve long known that the social care category — housing, transportation, food, utilities — has an impact on health care outcomes. Knowing this information about an individual enables us to inform our clinical decisions when patients are ready to leave the hospital or to make recommendations on nutrition or even look at access to care. These components around social determinants influence how we care for patients as clinicians as well as make decisions about how we discharge patients from hospitals.

ME: How’s it going? Is there any evidence that it’s helped individual patients or on a population level?

Bland: A lot of these platforms are immature. The recent entry into the market of social care platforms, vertical integration, brings that data into the EHR; it really just entered into the United States Core Data for Interoperability, which is what codifies those data standards in the EHR. That was just finalized in 2021in the interoperability rules to include those social care components.

As we’re working through the technology and integration components, I would say that we’re early. This is very similar to how we rolled out computerized order entry
20 years ago, and it’s how we began to understand the wor flows and data standards and the need for extracting information once we enter the information.

I think it’s very much still in the early stages of integration into health care. Merging social care with health care is challenging. We know this just from the manual processes we have in place today. The approach to codify the data standards and build out work flows that meet both health care and community needs is a huge task. We’re two years into it. We’ve learned a lot from it, and we’re adapting and modifying. We brought in United Way and 211 as partners in community engagement, and one of the things we’ve taken away is the community convening piece, which I think fits very nicely with HIEs. We’re a neutral convenor. We’re trying to facilitate interoperability as well as building a longitudinal record that follows the person, so it really made sense for us to take a lead role in convening the community, agnostic to health system and agnostic to vendor, and leverage other community data collection points into one work group.

ME: Who identifies the need for addressing a patient’s behavioral or social health needs in the first place? Is it the primary care provider (PCP)?

Bland: It can come from a number of sources. It can be the PCP or the care manager or even the person checking in a patient at the front desk — for instance, the patient mentions they had a difficult time getting to the appointment because they didn’t have transportation. Those are things we don’t think about as relating to the clinical encounter, but they definitely affect whether someone has access to care or can get from the doctor’s office to the pharmacy or back home. Those are things that we’re bringing in as automated ways to create those referrals and then have that closed loop. Knowing that you referred someone for transportation or utility assistance is one step, but if you know that need was met, the next time you see that individual you have a better sense of how they’re managing their health. That’s what really drew us to a closed loop referral system.

I remember being a nurse and somebody identified a patient need at 4 p.m. on a Friday and thinking, “Who am I going to get to answer the phone at 4 p.m. on a Friday to ensure that this need is met over the weekend?” I would have loved to have a system that sent me an alert that the need was met and I didn’t have to track down someone on Monday morning to check.

So I think that’s very appealing to doctors and care coordinators when sending patients back into the community.

ME: It sounds like what you’re describing is compiling a 360-degree picture of a patient, whereas up to now we’ve only been seeing the clinical aspect.

Bland: Absolutely. That’s where the more expanded longitudinal view of health really comes into play by connecting those episodic touchpoints with health entities and bringing in those social care and community aspects. We all know the studies showing 80% of a person’s health outcomes are based on their social determinants. And that’s why we’re trying to connect the (social determinants) piece for a true health picture and connect the health care components to that longitudinal record as well. This will provide a new picture of what health looks like in a digital way, which is the goal of the longitudinal health record and what we felt was our place as the HIE.

ME: I want to talk more about those small practices in rural areas. How do they find out about services their patients may need?

Bland: That’s one way we are democratizing these applications and where we saw our role as an HIE to provide those applications to providers. In those one- and two-doctor practices, being able to use a system such as this is probably not financially feasible. But at scale we’re able to provide these applications at nominal cost, working with our largest health systems and our state partners and payers to bring not only the social care platform but event notifications and other applications that normally wouldn’t be available financially to providers in small practices and organizations.

ME: Many small communities lack the network of services to help these people. What do doctors in those places do?

Bland: One thing about Unite Nebraska is that myriad resources are available in that repository, so they can look outside of their own communities if they’re lacking resources patients could be referred to.

Additionally, it provides us insight as to where those gaps are. If needs are going unmet, those are data points we can now bring to our state legislators and say these are resources that are constantly being referred and where the need goes unmet, and we have a solid data. It’s really where a lot of these conversations started because we know those gaps exist in behavioral health and housing insecurity and food resources. So this is also a way for us to bring those data to light so we can have those policy conversations and have data-driven information to give policy makers and appropriators so they can direct resources to the appropriate places.

ME: Is securing and transmitting social data any different than how you handle clinical data?

Bland: Who needs to know about social care is different than who needs to know about clinical data. How we present that information in our longitudinal record is “a housing referral was made.” Some of the details about the encounter will be stored differently and will be visible differently to a provider than, say, the person who was providing the service. So those two things are differently represented in our system and that’s where it’s important to have some understanding of clinical protections and privacy laws versus social care. The more that comes into data standards, the more we can apply the same levels of protection as HIPAA (Health Insurance Portability and Accountability Act).

Privacy and security are top of mind. We have many points of security, layers of security, as well as governance. In Nebraska we have the HIT board, which is ensuring we’re meeting compliance standards for security, and it’s all open meetings. The other thing is we have broad participation in compliance and governance committees, and the data requests that come to us are made visible to our data suppliers.

I think there’s a robust governance in place that meets industry standards for sharing of information, HIPAA requirements, looking at the changing policy considerations from the 21st Century Cares Act into the interoperability rules. All those things are part of our organization and our mission around governance and transparency.

ME: What’s been the response from providers?

Bland: This is a new technology, so we have typical patterns of adoption — early adopters, intermediate adopters and the laggards. There are some health care systems with robust value-based care programs. They are the early adopters. They want to codify the work flow, bringing those data back from the community, having those alerts and flags for their care managers.

We’ve had some good uptake in rural counties because they do a lot of phone calls, so this is an automated way for them to send out a broad notification that they have an issue that needs to be addressed or referral that needs to be made without tying up a clinical person making 30 phone calls to find a resource to meet a patient’s needs. But for the most part we’re still working on adoption to get those intermediate adopters and laggards onto the platform.

ME: Did you encounter any resistance from clinicians or institutions? If so, how did you overcome that?

Bland: There’s a lot of persuasion that needs to happen. We’re not replacing anything currently in place. This is a technical enabler. But because it’s new, it’s seen as a threat to established turfs. And that’s where the community convening component is important. It’s a lot of meetings and socializations around how we’re trying to link services together.

There’s always comfort in doing things the way they’ve always been done. But I think if we’re going to make data-driven decisions around human services and truly address cost and quality issues from a state-wide perspective, these are the kinds of systems we need to implement.

Most of what we know about referrals and outcomes is anecdotal because many locations don’t have the ability to link the outcome to the individual. Until we do, we have to rely on aggregate information from claims data and we don’t know whether social and human services in the area actually affect outcomes in a data-based way.

When housing, transportation and other nonclinical data are shared electronically, clinicians can better understand their patients’ needs.

Integrating social determinants of health into health data exchanges

Dr. Walt Hadikin is the Director of Clinical Communications at 

, the #1 mobile medical reference app among US physicians. He currently oversees all clinical communications for the company (mobile news, government and specialty society relationships, etc). Dr. Hadikin is also a physician editor trained in both family medicine and clinical pharmacy, with extensive experience in digital medical communications.

, many individuals who contracted COVID-19 are experiencing new or lingering symptoms that have been dubbed long COVID. While many of them are turning to their physicians or other health care providers in search of answers, so much remains unknown about the underlying causes and prognosis of long 

. One significant challenge facing physicians is that the most prominent symptoms of 

 have been traditionally among the most challenging to treat, even pre-pandemic: fatigue, poor concentration, lightheadedness, among others. Seeing such “reasons for visit” on a clinic schedule would incite discomfort and angst in a physician long before SARS-CoV-2 came along. And, they are no easier to effectively manage now in the context of post-COVID-19.

As clinicians navigate the many unknowns of long COVID and try to effectively manage their patients’ symptoms, keeping the following three things in mind can help them achieve more satisfying outcomes for both patients and providers.



1. Validate your patients’ symptoms, concerns, and fears



As physicians, our goal is to provide the best care possible for our patients, and this encompasses showing them compassion. Patients who are living with long COVID are undoubtedly feeling worried and stressed, along with a myriad of other emotions, in addition to the physical or mental symptoms for which they’re seeking care. Even if clinicians don’t have all the answers when it comes to long COVID, we need to ensure that we validate our patients’ symptoms, concerns, and fears every time they step into the exam room or log on to a telehealth visit. According to 

’s interim guidance on long COVID, objective lab results and imaging findings should not be used as the only measure of a patient’s well-being. Furthermore, the agency notes that a lack of lab or imaging abnormalities doesn’t invalidate the severity or existence of a patient’s symptoms. For clinicians who are accustomed to relying on objective test findings to support their diagnoses, this may mean that evaluating and treating patients with long COVID symptoms may well be outside their comfort zone.

2.Be forthcoming with realistic goals to manage patient expectations


Unfortunately, there is currently no magic bullet that will effectively treat every symptom of long COVID. Given our experience with other post-viral syndromes and the nature of the symptoms themselves, we may never have such a magic bullet. Thus, when treating a patient with long COVID, it’s especially important to communicate clearly and effectively to manage their expectations and set achievable goals.

For example, when managing fatigue, consider establishing a more realistic goal of incremental improvements over time, rather than complete symptom resolution. This will help patients avoid disappointment and frustration if their symptoms linger longer than expected. In fact, there is little clarity on how long various symptoms of long COVID are expected to last. Being open and honest with patients about the evolving knowledge of symptom duration and general characteristics of long COVID will strengthen the clinician-physician relationship as you traverse the journey toward recovery together.


Patients will invariably ask, “How long am I going to feel tired (or breathless, or foggy, or whatever the symptom may be)?” While these kinds of questions will be difficult, and in some cases impossible, to answer, a response with equal parts of optimism and realism will serve the patient best. For example: “Many patients report that their fatigue improves after a few months, but some with post-COVID fatigue may experience a slower return to baseline.”

3. Be comfortable not having all the answers and be open to new information, evidence, and guidance



The understanding of post-COVID conditions and clinical guidance will be fluid and everchanging as evidence evolves – and that’s ok. Additionally, as new evidence and consensus guidance becomes available, it’s natural to expect that it will get easier to treat patients with long COVID. However, that isn’t guaranteed because so many of the symptoms are by nature challenging for clinicians to treat definitively. What matters is being open to learning and adapting to the newest information, evidence, and guidelines as they become available. Clinical decision support tools will be pivotal in helping clinicians stay informed on the latest guidance in the era of long COVID.

While post-viral syndrome isn’t unique to COVID-19, it may seem daunting because of the sheer number of individuals being impacted in such a short period of time. Instead of a clinician seeing just one or two patients each year who might present with lingering symptoms following infections like influenza, Epstein-Barr, or even the common cold, clinicians today may see a far greater number of patients with complex symptoms related to COVID-19 infection. Even though answers may be scarce at the moment, remaining compassionate, realistic, and informed will ensure that patients with long COVID get the best care possible. 



This article is intended for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.

One significant challenge facing physicians is that the most prominent symptoms of long COVID have been traditionally among the most challenging to treat.

3 Things physicians should consider when treating long Covid

, JD, has practiced law exclusively in the areas of asset protection, risk management and wealth preservation for the last 16 years. He helps protect a national client base with more than $5 billion in personal assets, including several thousand physicians. He is a contributing author to multiple books for physicians and a frequent medical conference speaker and CME presenter. 

 on the basics of trust law starts our discussion of asset protection trusts for physicians and how they differ from the common estate-planning trusts you should already have in place.

The basics of Asset Protection Trusts (APTs)

There are many different forms of asset protection trusts available to lawyers and qualified clients and the details vary widely and fill entire books. We start here with a simple outline of some key APT law basics every legal consumer should be familiar with.

APTs of any form are only effective and legal if established and funded with the specific assets well in advance of any liability. 

This does not mean, “I haven’t been sued yet so it’s still OK”.

 Any actual or constructive knowledge of a claim, or even a potential future claim or liability based on an event you are aware of, can legally time you out from acting. This makes any transfer of assets from yourself to a trust or any other person or legal entity a potentially “voidable transaction” in furtherance of a “fraudulent conveyance”.

In order for trust property to be outside the scope of your personal and professional lability and the reach of a judgment creditor by law it must go into a vehicle that is granted permanent, 

title. If you, as the “grantor” can easily pull it back at will, it is generally not protected from others either. It must truly be the property of the trust. However, this does not mean that that property can’t be sold, converted into another form, collateralized or used and enjoyed in many conventional ways, 

including by the person creating and funding the trust

You can establish and fund an irrevocable trust for yourself (known as a 

 and this is a common feature of many APTs. This unique construction is specifically legally allowed by statute in many domestic and offshore jurisdictions (which is the subject of our next installment). Planners pick those jurisdictions based on a variety of fact specific issues including local law, costs, where you live, your liquid net worth, the level of protection and predictability you seek, and your estate planning needs, to name just a few.

 Another common construction allows the creation of trusts for any third-party (or parties) you wish. You can gift or sell a wide range of assets to the trust and in some cases, even keep the income.

They must strictly comply with all formational and operational requirements imposed by the trust’s specific jurisdiction. This drafting should also protect the trust’s assets by limiting the trustee’s ability to make any distributions under duress or to a judgment creditor, but should allow enough discretion to allow the trust’s assets to be used for benefit of the beneficiaries, potentially including 

They have 3rd party Trustees appointed to manage the trust and its assets. These trustees are ideally neither 

 and don’t have a personal interest in the trust’s assets.

Assets with formal title, like real estate deeds, should be formally transferred to the to the trust. Depending on the kind of trust and the trust jurisdiction selected, the assets may be required to be located within the jurisdiction and that an approved local agent, trustee or authority is appointed.

Trusts are not secret or “tax free” and 

 comply with gifting limits and exemptions. Taxes may be the responsibility of the Grantor, the Beneficiary or the trust itself, depending on how it is drafted.

If you are already married, and your spouse already has a marital or community property interest in certain joint assets, regardless of how they are currently titled, you cannot effectively use APTs to deprive them of their existing rights and property.

 On the other hand, if you are single (or already married but have a pre-nup or post nup) and are funding a trust with your undisputed, legally 

, an APT can make those separate property assets even more legally distinct, put them in entities that solely benefit you personally, and help protect them from a variety of risks including both 

Part nine of our ongoing series on the basics of trust law starts our discussion of asset protection trusts for physicians.

Trusts 101 part 9 - Asset protection trusts 

Associate Editor for Medical Economics, Physicians Practice

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