Matt Dallmann

In consulting for one of my clients, I was introduced to the Practice Fusion EHR.  If you don’t already know, this online EHR is available for any provider to use free of charge.  This is a big deal, considering that most EHRs cost in the tens of thousands to implement, followed by a monthly licensing fee. What’s the catch? Only that the EHR is not completely customizable and there are small banner ads that appear on the bottom of the screen. 

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For some, those minor inconveniences are a small price to pay for free software.  Like television and the Internet, Practice Fusion is selling access to its subscribers, or audience, and the more subscribers, the higher the cost of the access. This business model got me thinking: Could it apply to other areas in healthcare? Hypothetically, yes. 

According to the Nielsen Ratings, the popular sitcom, "The Big Bang Theory," brought in about 13.5 million viewers for live broadcasts of premiere episodes in 2014.  Advertisers paid an average of $320,000 per 30-second commercial spot during those episodes.  Through this example, companies are willing to pay $42,000 to access one million people, of a certain demographic, for 30 seconds. 

According to the CDC, there were a combined 256 million inpatient/outpatient/ER department visits throughout the United States in 2010.  Using the above ratio of $42,000 to 1 million people, the hospital industry could stand to make over $11 trillion per year if they sold access to their patients in the form of strategic commercials, targeted signage, free samples, e-mails, and sponsored literature, to various commercial companies.  Granted, these numbers could radically change based on any number of variables: demographics, repeat visits, media type, etc. But, even if you cut the numbers in half, $5.5 trillion is still a lot of money. 

Obviously, there would be many objections and concerns, the most glaring of which is that corporations might leverage their advertising dollars to control the course or direction of medicine in their favor. However, one could argue that is already the case. Big Pharma and commercial insurance carriers currently have a majority of the control over what research gets funded and which treatments are covered. 

We could take it a step further and engage the patient population in meaningful communication on products via surveys, etc.  The interactive style of new marketing via social media, the Web, etc., could easily be applied to help ensure a return on the advertiser’s investment.  There could be a number of tailored financial arrangements, but if we are asking patients to participate in, essentially, a focus group on goods and services as a part of their treatment, then deductibles, copays and co-insurances should be eliminated. 

Theoretically, this would lower the cost of healthcare via decreased insurance premiums.  There is nothing, however, to prevent healthcare providers and facilities from simply keeping the increased revenue or to force commercial insurance carriers to lower premiums.  On some level, if this pipe dream became a reality, legislation would need to be implemented to ensure that the new revenue stream would indeed translate to lower healthcare costs to the consumer. 
 

Articles

One EHR company is selling access to its subscribers to commercial companies through advertising. Could this business model apply to other areas of healthcare?

Could Commercial Ads Subsidize Your Medical Practice?

Medical professionals in the current healthcare climate are faced with four major challenges affecting their public perception:


While insurance networks provided under the Affordable Care Act (ACA) are created and managed entirely by the third-party payers that offer them, physicians are bearing the brunt of the public discord. Patients who switch, either by choice or through an employer, from an insurance policy provided on the private market to one provided through the health insurance marketplace, are often finding that even though the name of the insurance company hasn’t changed their current providers are no longer in their network. These narrow networks have severed long-established provider-patient relationships and forced new ones.


With a small number of providers saddled with the majority of the newly insured, physician burnout, an already existing phenomenon, has the potential to grow. The current medical education curriculum focuses primarily on the development of a physician’s clinical skills and rarely, if at all, provides any practical education on social development for their own well-being. Their stress, coupled with very limited down time, can lead to burnout, causing more mistakes and a sour bedside manner.

3. Consumers lack of ability to determine “quality” doctors


Oddly, though the Internet has connected more people to more information, consumers still lack the information they need to identify quality doctors. According to a 

 by the Associated Press - NORC Center for Public Affairs Research, fewer people than anticipated trust information from online patient reviews, commercial insurers, ratings sites, and the media. Unexpectedly, the Internet has also devalued the institution, as individuals are less impressed by long-respected hospital networks and are thus less likely to seek their care on reputation alone. Additionally, there is a disconnect between the patient’s definition of quality, which is based on their perception of the amount of time and attention they receive from a provider, and the healthcare community’s definition, which is based on clinical outcomes.

4. Public release of financial and quality data

and the anticipated quality reporting data from the PQRS program may be misleading to the general public. Providers with million dollar receipts from Medicare have been unfairly judged, as much of those receipts are for multiple doctors billed under a single provider. Additionally, PQRS data is reported primarily through a series of G-codes via claim submission, bringing into question the reliability of the data.

These four challenges have the unfortunate ability to largely overshadow professional accomplishments, board certifications and industry accolades.

How then, after spending a decade or more honing their clinical skills, can a healthcare provider effectively establish his or her professional brand? 

According to the poll by the Associated Press - NORC Center for Public Affairs Research, over half of respondents prefer doctor recommendations from good-old-fashioned family, friends, and referrals from their regular primary-care physician.

Until the anticipated transition to reimbursement by quality measures, physicians and other healthcare providers can build upon their network of trusted colleagues and loyal patients.

These four challenges have the unfortunate ability to largely overshadow a physician's professional accomplishments, board certifications, and industry accolades.

Four Major Challenges Harming Physicians' Reputations 

Since the release of Harvard Business Professor Clayton Christensen's "The Innovator's Prescription," healthcare providers and entrepreneurs alike have been trying to develop a "disruptive" solution to the delivery of healthcare. For example, the latest trend is providing a means to effectively monitor any given patient 24 hours a day, seven days a week, to allow physicians to proactively treat patients before their conditions get worse or develop at all.

How is this accomplished? A variety of inventions, coupled with big data, are allowing the impossible to become possible. Many new products, like Fitbit or Jawbone, have already made it onto our wrists, allowing for the monitoring of sleep patterns, exercise habits, calorie consumption, etc. Hoping to capitalize on this trend, Apple recently announced its new app, Health, meant to collect biometric information which can then be sent to providers for analysis and proactive treatment. Samsung is also weighing in on the phenomenon with their new app, S Health. The jury is still out on whether or not these products will deliver on their promise to positively change the healthcare system, or just become glorified pedometers.

There are, however, some companies that are really pushing the envelope. Once such company, Theranos, is attempting to develop a revolutionary lab technology that can analyze blood in a fraction of the time and with a fraction of the amount of blood currently used to analyze a sample. Once in place, this technology will allow providers to monitor levels tested in the blood far more frequently than they currently can, which will allow for a more complete picture of a patient's health throughout time.

Big data companies and their brokers have also entered on to the scene, accumulating data on patient's habits, demographics, and income. The data can potentially identify patients' health risks based on their habits, socioeconomic status, etc. For example a patient of low socioeconomic status may not have a car, so they would not be able to schedule routine checkups. Once at-risk individuals are identified, healthcare professionals can reach out to them to encourage treatment before a condition develops or worsens.

Consciously or not, the healthcare community has determined that the best way to treat is to pre-treat, and near constant surveillance is necessary for this kind of approach. Of course, most people don't want a phone call from their local doctor asking them to come in for treatment because they're drinking too much soda. Privacy and soured doctor-patient relationships will likely slow down this new approach, with the many blurred lines that will need to be re-drawn.

Whether the general public likes it or not, this approach is here to stay. Huge commercial companies are banking on it, and physician pay is transitioning from fee-for-service to quality measures. With these two giant engines behind it, this "Minority Report" style of healthcare will be coming to a hospital near you.

From apps to analyzing big data, the future of healthcare may be about predicting the future of a patient's well-being and having physicians intervene.

Big Data to Guide Physicians in Helping Patients Before They Get Sick

Recently, while many have been banking on the Affordable Care Act's (ACA's) projected ability to lower the cost of healthcare, another cost-saving industry shift has been playing out behind the scenes: Big data. 

The Big data phenomenon has promised the healthcare industry superior clinical results and 

 in savings, according to global management consulting firm McKinsey & Company. 

From meaningful use and the HITECH Act, to the implementation of ICD-10, to venture capitalists pushing the latest EHR product, the digitization of healthcare systems and medical documentation will inevitably become the standard in healthcare. 

So far, most of this data has improved healthcare administration in the form of leaner budgets, less employee idle time, improved revenue cycle management, and better fraud and abuse prevention.  Data is also poised to increase cost transparency - with side-by-side cost comparisons and/or side-by-side comparisons of services and devices and their success rates -and may even replace more traditional methods of clinical research in the future. For example, upon assessing its own data, Kaiser Permanente’s Southern California hospital reported a 26 percent lower mortality rate compared to other hospitals in the region.

While we are counting on data to improve patient outcomes in the years to come, patients today may be paying the price.  Over the last two years, studies funded by the 

Agency for Healthcare Research and Quality

 showed an average of 30 percent to 40 percent of a physician’s time is spent in front of a computer screen. The same studies report that no one looks at 

 of this data. 

Another study conducted by the College of Health Information Management Executives reports that most hospital CIOs recognize the value of big data collection throughout their institutions, but lack the knowledge and resources to effectively analyze it and subsequently develop and implement clinical and cost saving solutions. 

Extracting and analyzing all of this information requires a skill set that healthcare providers do not have, so expensive third-party companies are paid to analyze the data. The National Institutes of Health alone has committed 

 to fund centers that will analyze and interpret collected information, and the industry is expected to grow. 

This begs the question: Are we merely shifting the cost of healthcare to the cost of data analytics?

In addition to cost, there are some other caveats.  This new information, once extrapolated by a third party, can be used in any way the healthcare provider chooses.  For example, favorable stats on a given diagnostic procedure can be touted to the public to increase business, raising the cost of healthcare where it might otherwise be unnecessary. 

Also as with ACA initiatives, physicians may be slow to participate.  Treatment developed from statistics derived from big data may conflict with an individual provider’s current practice, philosophy, or judgment, rendering the process of big data analytics a very expensive exercise in futility. 

In light of these, and other, obstacles, we hope that the effort being put forth now is commensurate with the solutions that big data promises in the future.  Otherwise, we will have inadvertently created a generation of healthcare providers who are also glorified data entry clerks.   

Big data might lead to cost-savings in healthcare, but it is very costly to begin with. 

Big Data in Healthcare Is Promising, But is It Worth the Cost, Effort? 

As the Affordable Care Act (ACA) falls into place, the healthcare industry continues to look for solutions to anticipated problems.  One potential problem is the projected disparity between patients who will use their benefits under the ACA and the limited pool of primary-care doctors who will treat them.  The growing shortage of primary-care doctors, expected to reach 45,000 by 2020, may cause longer wait times or discourage care altogether. 

Retail health clinics, like the CVS Minute Clinics, are gaining momentum as a potential solution.  These clinics attract patients for a variety of reasons.  First, they allow patients to see a clinician immediately rather than wait days, or even weeks, to see their primary-care doctor.  Additionally, the prices are transparent.  For the primary-care doctors who are overloaded with patients, this new practice may be beneficial.  But price transparency, while theoretically a good thing, may make waves in the industry.  

Retail clinics offer a literal “price menu,” which allows patients to know their responsibility up front, and sheds light on the actual cost of healthcare to the consumer.  In a hospital or private practice, the opposite occurs.  Aside from patient copays, coinsurance, or deductibles, payments for services rendered typically fly under the radar - and it’s not because they’re trying to hide something. 

The reimbursement process is complex. Any given claim submitted to a third-party insurance carrier goes through a variety of filters, such as multiple procedure reductions, bundling, prior authorization penalties, referral penalties, procedure specific deductible or co-insurance application - and the list goes on and on.  

To further complicate things, contracted rates between healthcare providers and third-party payers can vary from one payer to the next, and some providers participate in independent physician associations, which typically have a higher contracted rate with third-party payers.  All of these variables have made it difficult for providers to settle on a single rate for any given service.  But retail clinics are subject to the same variables.  So why are they posting their rates while other providers are not?

In a retail setting, prices are listed everywhere.  The very nature of this environment is prices, discounts, and two for one deals. With ads like, “Youth Sports and Camp Physicals only $49,” the patient becomes a consumer, and with that expects quick, anonymous treatment at a good price.  There are no expectations of long standing doctor/patient relationships.  The subliminal message is quantity over quality.   This is, traditionally, not the brand doctors in private practice or hospitals typically wish to project.  But for retail clinics, that brand is the selling point.

Perhaps everything is falling into place as it should.  When more routine care is provided at retail clinics by less expensive providers, providers in private practice and hospitals can devote more time and attention to more complex medical issues.  However, if that is the case, then there is still room for improvement.  For starters, the reimbursement rates need to reflect the difference, and patients must understand that.

Retail-based health clinics can help ensure patient access to care as more gain insurance, but they also raise price transparency and reimbursement issues. 

Retail-based Health Clinics and Patient Care: Nuisance or Necessity

Under the Affordable Care Act, insurance plans now cover preventative care without patient cost sharing, i.e., without co-pays, co-insurance, or deductibles.  However, services that are not classified as preventative care are still subject to cost sharing. It is important for physicians and their staff to be able to differentiate between the two in order to avoid blindsiding patients and avoid experiencing a revenue loss.

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Since the average deductible on plans offered through the state and federal health insurance exchanges is between $1,000 and $6,000, financial responsibility for a non-preventative visit could easily fall on the patient.

To clarify, here are a few examples of preventative care and diagnostic care.


• If an abnormal finding on a preventative mammography screening is later found to be normal, then the future mammography screening is considered preventative. 
• If a polyp is removed during a preventative colonoscopy screening, the removal of the polyp, and any associated lab and facility fees, performed during the same encounter, are considered preventative. 




• If an abnormal finding on a preventative mammography screening is later confirmed to be abnormal, then the future mammography screening is considered diagnostic, and any deductible, co-pay, or co-insurance is applied. 
• If a polyp is removed during a preventative colonoscopy, any future colonoscopies are considered diagnostic, because the time intervals between future scopes are shorter. 

The first step for avoiding confusion between preventative and diagnostic care lies in the hands of the medical coder and biller. Preventative services must be coded with the appropriate CPT codes, diagnosis codes, and modifiers.  Diagnostic services or problem related E&M codes can be reported on the same encounter, with the appropriate modifier and diagnosis, and, depending on the payer’s policies, be paid at 50 percent of the contracted rate.  If coders know the difference between the two, and can code correctly with supporting documents as a backup, they can effectively maximize physician reimbursement. 

However, even if coders report services optimally, physicians will encounter problems. If you are aware of these potential problems, you will be better equipped to handle them.

Here are some examples of problems and outcomes:
1. If you bill for the preventative and diagnostic codes with appropriate modifiers, etc., and bill the patient for any deductible applied on the problem-oriented E&M code, the patient will likely call to complain, stating there should be no out of pocket because the reason for the visit was preventative.  Since most patients currently have little to no comprehension of the intricacies and protocols of correct medical coding, it will be difficult to explain why the visit was billed the way it was, and the patient will most likely refuse to pay and take his business elsewhere.
2. If you spend extra time and effort evaluating and treating a patient for all her complaints and concerns during a preventative visit, and only bill for the preventative portion of the visit, then you are saddled with the entire burden of all the newly insured, without the appropriate compensation.
3. If you bill for both the preventative and diagnostic portion of the visit, and simply waive any deductible, you may open yourself up to frequent billing audits. 

None of these scenarios is ideal, so it is important to determine which is best for you. In any case, it’s a good idea to present a brief, bullet pointed disclaimer to your patients making them aware of the different types of care and what their potential out of pocket costs might be - perhaps even a simple check box with the statement, “I do (or do not) want to receive diagnostic services not covered under my preventative benefits.”  This way there are no surprises, and you may help enhance your professional brand as a trustworthy doctor. 
 

Physicians and medical practice staff must be able to differentiate between preventative and diagnostic services in order to avoid a loss in revenue.  