Gabriel Perna

Welcome to Practice Rounds, our weekly column exploring what's being covered in the larger world of health care.

Surgeon General Makes Opioid-related Recommendation

The U.S. Surgeon General this week issued an advisory recommending that more Americans carry an opioid reversing drug, naloxone. The drug, sold under the brand name Narcan, can restore normal breathing if someone has overdosed on opioids. Jerome Adams, MD, says knowing how to use naloxone and having it available can save someone's life. "Despite evidence of the effectiveness of naloxone in reducing opioid overdose deaths, awareness of the drug’s benefits and its possession and use among patients, prescribers, community bystanders, and even first responders in some areas remains limited," Adams wrote in 

health venture between JP Morgan, Amazon, and Berkshire Hathaway

 - until now. In a letter to shareholders, JP Morgan CEO Jamie Dimon laid out a few initial plans for the venture. According to 

, Dimon said the group will aim to align incentives among doctors, insurers, and patients; reduce fraud and waste; increase access to telemedicine and better wellness programs for employees; and look into the cost of end-of-life care. Dimon said in the letter the venture will use big data, virtual tech, and customer engagement to achieve these goals. He said the venture will start small and operate on a long timeline.

The Department of Health and Human Services (HHS) and its Office of the National Coordinator for Health IT (ONC) jointly released a new resource for individuals, patients, and caregivers to more easily access their health information. HHS says the resource supports a goal in the 21st Century Cures Act empowering patients and improving patients’ access to their EHR via the 

recently announced MyHealthEData initiative.

 “This guide will help answer some of the questions that patients may have when asking for their health information," National Coordinator for Health IT Don Rucker, MD,  said in a statement.

Direct-to-Consumer Advertising of Medications is Wrong

"Since patients cannot purchase drugs without a prescription, nor do they have the depth of knowledge to understand the process of drug selection, I wish there were no direct to consumer ads for drugs."

Melissa Young, MD, Endocrinologist, Freehold, N.J.

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The U.S. Surgeon General issued an advisory recommending more Americans carry the opioid reversing drug naloxone.

Surgeon General Makes Opioid-Related Recommendation 

After a year of running his own practice, it became clear to Brett Swenson, MD, a primary-care physician, that a traditional outpatient clinic wasn't for him.

"I was seeing 25 patients per day - which is pretty typical for a doctor in a primary-care practice…my visits were down to 15 minutes per patient, [and] half of the time [I was documenting]. I wasn't getting to know patients like [I wanted to]…my practice continued to grow and it was successful based on the definition of a traditional primary-care practice, but it had become factory medicine," Swenson said at the annual Healthcare Information and Management Systems Society (HIMSS) Conference, held recently in Las Vegas. 

Swenson says he hadn't gone to medical school to practice medicine like this. So he set out to open a concierge practice, which would allow him to focus on quality and value-based care.

"Value, for me, was achieved with happy and healthy patients, that's the value I wanted to deliver," he said.

Once he left behind factory medicine for value, he needed to adopt tech solutions that would help him adjust to a patient-focused practice, especially when it came to communication. One of the draws of concierge medicine is constant interaction between practice and patient. That's where chatbot came into play.

"Chatbot is a computer program designed to simulate conversation with human users, especially over the internet. The goal of the chatbot was to meet the criteria set by the patients - responsiveness, communication, and better outcomes. That's what the chatbot could deliver," he said.

Swenson's concierge practice, Swenson Premier Care in Scottsdale, Ariz., rolled out the chatbot technology in three phases. The first phase was patient-initiated communication, whereby they used the technology to schedule appointments and get medication refills. Instead of calling the clinic, patients could securely text through the chatbot system and make those arrangements.

Usage in this phase was low, said Swenson, who noted behavior change can be hard and most patients still called the clinic for those services. Also, because it was not yet integrated with the EHR, there was still manual work to be done in the back end by his staff.

Instead of having patients use the chatbot service on their own, phase two involved the clinic initiating communication with the patient. The clinic focused on patients receiving preventive care, such as a flu vaccine. In this phase, the tech was still not integrated into the EHR and the process of finding patients eligible for the vaccine had to be done manually.

"We had to generate two files….the first was a list of phone numbers for patients who needed flu shots, the second was a file with timeslots available for [them] to get the flu vaccination. Once we compiled those files, we sent out a text [inviting them to get the shot]," he said. While the response rate was much higher, the lack of integration forced a lot of extra work on the staff.

The final phase, which started in February, aims to solve that problem, as Swenson's concierge practice recently rolled out the chatbot with EHR integration. Meaning every appointment made through the technology goes right into the EHR's practice management suite. Moreover, it's easier to identify patients who may need those shots. They've expanded this capability to focus on patients who need their annual physical.

Swenson's advises other practices looking to adopt this tech that EHR integration will make life much easier. Also ensure the process is compliant with HIPAA regulations. On the operations side, he recommends reaching out to patients in manageable chunks, starting with 500 per physician. As health care goes from volume to value, Swenson sees chatbot as a viable way to help practices make this move. 

"The systems we've been using are better designed for factory-designed medicine. They're designed for the convenience of the clinic rather than the patient," he said, noting the failures of portals and phone calls. "That's where chatbot can be beneficial. It gives the patient 24/7 access. They use a text interface, which they use for everything else in life, so why not health care? And it's interactive with the patient. And it can be designed to provide those nudges we need for preventive care."

A concierge doc shares his experiences with using chatbot technology as a way to provide patients more value.

How Chatbots can Aid Value-based Care Initiatives


The Trump administration saw another major shakeup as President Trump relieved David Shulkin, MD, as Secretary of Veterans Affairs (VA), replacing him with White House physician, Rear Adm., Ronny Jackson, MD. In a widespread op-ed to 

, Shulkin said he was fired because he was against the privatization of the VA, a move favored by advocates from the administration. Shulkin, a rare holdover from the Obama administration, entered the VA as Under Secretary of the Veterans Affairs for Health in 2015. In early 2017, Trump nominated him to the top spot at the VA and he was unanimously confirmed shortly after.

Jackson has served the past three administrations as White House physician. While Jackson has a deep background in medicine, 

 reports that he has no experience in management . The VA employs 360,000 people and has a budget of $186 billion. It's tasked with providing care to more than 9 million veterans each year.


The convergence of retail and insurers may continue as Walmart is in early stage talks to buy health insurer, Humana, 

. According to the report, the deal is in preliminary talks and there is no certainty that it will happen  or what form it could take. Analysts suggest Walmart may be interested in Humana for its foothold with senior citizens, the insurer is the second-largest provider of Medicare Advantage plans. Last year, CVS bought Aetna for $69 million in a major case of an insurer and a retail giant coming together. Both Walmart and Humana's stocks traded up upon news of the proposed deal.
 


Apple announced this week that 39 health systems across the U.S. are making patients' medical records available on the iPhone. The list of health systems and academic medical centers participating includes Johns Hopkins Medicine, Geisinger Health System, NYU Langone Health, and Stanford Medicine, among others. Through these systems, patients will be able to automatically access their records through the Health app. Medical record access through the iPhone was previously only available to patients who had signed up to test a pre-release version, 

"Has the joy of medicine been lost? No, it has been drowned out by the sea of systematization. While I may feel some degree of burnout sitting at my desk ticking check boxes, every time I enter an exam room and sit in front of a patient, I remember why I became a doctor. These patients have no one else. If I wasn’t here, they would be swept away in the waves of our dysfunctional system."
Linda Girgis, MD, family medicine physician, South River, N.J.

President Trump relieved David Shulkin, MD, as Secretary of Veterans Affairs (VA), replacing him with White House physician, Rear Adm., Ronny Jackson, MD.

White House Physician Moves into Top VA Role  

Whether you like it or not, the era of value-based contracts is upon us.

While the majority of health care is still fee-for-service based, there is an emergence of value-based care touching every cornerstone of the industry. Major private payers, such as Anthem Blue Cross, reportedly paid out nearly 60 percent of reimbursements in 2017 through value-based contracts. Other major payers are moving in the same direction, including the one that sets the tone for the rest: the Centers for Medicare and Medicaid Services (CMS).

CMS not only has an ambitious goal of 50 percent of payments through value-based contracts by 2018, but it's administering the Quality Payment Program (better known through the acronym that passed it into existence - MACRA). QPP incentivizes reimbursement based on outcomes through either its Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Method (APM) pathways. By early next decade, a practice's Medicare payment will either get boosted or dinged, up to 9 percent in MACRA, partly based on outcomes and other value-based metrics.

Experts say the program also gives practices a good indication of how value-based programs will be set up, as CMS typically influences other payers. "I think MACRA has done a good job establishing a framework for these [value-based] contracts. Many of the ACOs and payers are modeling the fundamental level of the value-based contracts on the MACRA structure," says Winsor, Conn.-based David Williams, consultant at Milliman, an independent actuarial and consulting firm.

Practices seeking to avoid value altogether will be left disappointed. Experts say it's time to shift their thinking and start tackling value-based contracts head on, by negotiating more favorable terms for their practice. 

"As practices think about this transformation, it's critical they a) understand the population they serve; and b) the relationships with they have with payers. They need to start having new conversations about if they are going to take on more care for wellness and prevention and things that keep people away from the health care delivery system," says Austin, N.M-based Tamm Kritzer, principal at CliftonLarsonAllen LLP, a consulting firm.

Experts say there are three specific strategies practices can employ in the transition to value-based contract negotiation as a good starting point.

Among experts there is a universal agreement: The shift to value is predicated on showing payers that practices are collecting and analyzing data. As Williams says, it's hard to measure success without data.  In fact, Milliman's three pillars of a successful value-based contracting strategy (transparency, stability, and control) involve substantial data gathering. Because payers have their own information to gauge and negotiate a value-based contract, practices need to ensure they are tracking the right metrics.

So what exactly are the right metrics? It depends on the practice, says Steve Selbst, CEO of HealthCents, a Salinas, Calif.-based consulting firm. Some can be pretty simple, he notes.

"If practices are using EHRs 100 percent of the time, they can safely agree that's one of the [bases on how] they're going to be measured. Same sort of thing when it comes to generic medications and things of that nature. So the practice needs to assess whether it has the systems in place to meet the goals of the value-based program they're being presented with," he says.

As conversations shift beyond simple data points like EHR usage and medication adherence, Kritzker says that there needs to be an agreement between payer and practice on the metrics which are impactful and can reduce the cost of care.

In any sense, Selbst says data collection comes down to a practice's technology. It must capture the information to demonstrate the outcomes it is achieving, he says. Williams says most of the components of the value-based contract - risk adjustment, attribution, in and out-of-network usage - come from claims data. He says it would be ideal to tie this claims data to the EHR and clinical data. It also should be done independently of the payer.

"There is so much more complexity in a value-based contract than a fee-for-service one; so much more you have to track and improve upon," says Williams.

Independent practices are seeing more options to experience a "power in numbers" philosophy by joining independent physician associations (IPAs), accountable care organizations (ACOs), clinical integrated networks (CINs), and other value-based arrangements. While there are differences between each one, these arrangements typically allow physicians to remain independent, while benefiting from a larger conglomerate for purchasing, infrastructure, and to ease the burden of reporting.

Whether or not joining a group is beneficial as the practice transitions into value is up for debate, experts say. On the pro side, the obvious benefit is that independent practices can leverage strength in terms when negotiating favorable rates in contracts with payers. Furthermore, an IPA will allow them access to better tools. The most obvious being around better technology.

"In addition to infrastructure, in theory they bring population health reporting tools and best practices around team-based care. They should and could help a smaller entity implement these best practices," Kritzer says. CINs are more about geographic alignment more than anything else, she adds.

Not everyone should jump into one of these arrangements though, cautions Selbst. He says that many practices, he has found, will prefer to negotiate its own contracts, rather than go through an IPA. In particular, specialties may find that certain metrics and outcomes are unique to their practice, while a larger organization might not have those tied into the value-based contract.

"It all depends on what they are negotiating power is. If they can join an IPA and can get what they need at higher rates vs. negotiating an individual agreement, the IPA might be better. In general, if you can get the same or better [rates], my experience is most practices would prefer to control the agreement themselves. Things can change at the IPA. They're only going to have an opt in [to the contract], opt out vote," Selbst says.

An important thing to note, experts say, is that on the whole, fee-for-service is still very much the predominant method of reimbursement for practices. According to the 2017 Physicians Practice Compensation Survey, 65 percent of physicians have no compensation tied to value-based care, 16.6 percent have only 1 percent to5 percent of their reimbursement tied to value. While value is coming, it's still not here for many physicians. As such, practices can tiptoe their way into these arrangements while they're still in a fee-for-service world.

A good way to do this, according to Selbst, is through the inclusion a value-based component of a fee-for-service contract. This would mean most of the contract would be typical fee-for-service, but a small percent would be based on qualitative, quantitative, and efficiency-based measures.

Moreover, Kritzer notes that the government is slowly introducing CPT codes through Medicare that include a value-based component. For example, chronic care management (CCM) and transition care management (TCM) both generate revenue for the practice but don't require a face-to-face visit, rather care provided outside the office.

"This is a subtle change, but it's a transformative one. Unless we can create revenue for non-visit work, it's difficult to create incentivizes whereby providers are going to change their patterns," she says.

Selbst says practices need to focus on clearly and squarely on providing value to the payer, in terms of clinical benefit and cost savings. These benefits may be service-, product-, geographic-based, or simply based on the patient population you serve, he says. Either way, it has to make good sense to the payer to give your practice more favorable terms of the value-based contract.

Kritzer says to practices need to understand that switching to value is incredibly hard work and won't be done in one fell swoop.

"We have an entire generation of providers, an entire health care delivery system that was literally formed [around the concept] that our job is to take care of sick people. In the course of the decade, the message is changing and we're now telling people we need to take care of people in a way that they never get sick," she notes.

As more and more payers offer value-based contracts, how can practices negotiate favorable terms in this strange new territory?

Author | Gabriel Perna

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