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Practice tip of the week: 3 digital payment trends that healthcare providers need to know

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, 

Marketing Your Medical Practice-Ethically, Effectively, and Economically,

 which has sold over 225,000 copies and has been translated into Spanish. He contributes a weekly video for 

 on practical ideas to enhance productivity and efficiency in medical practices.  His 5–7-minute videos and short articles provide practical ideas that can be easily implemented and incorporated into any medical practice. Dr. Baum can be reached at 

Recently, a digital artwork sold for $69.3 million.

Healthcare primer on NFTs

Justin Tabone is the originations leader for healthcare vendor equipment finance at TIAA Bank in Parsippany, New Jersey.

Rather than expending all your capital up front to buy the equipment, financing allows you to spread payments over time and free up capital for other business expenses.

Equipment financing for your practice

Trish Rivard is CEO and Principal Consultant with 

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Why providers need to invest more in online scheduling and recommendations on where to start.

Online appointment scheduling: A missed chance to boost patient satisfaction 

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Asset protection attorney and regular Physicians Practice contributor Ike Devji and Anthony Williams, an investment advisor representative and the founder and president of Mosaic Financial Associates, discuss the impact of COVID-19 on high-earner assets and financial planning, impending tax changes, common asset protection and wealth preservation mistakes high earners make, and more. 

Asset Protection and Financial Planning

Physicians Practice® spoke with Fernando Mendoza, MD, FAAP, FACEP, the founder and CEO of Scrivas, LLC, about the rising rates of reported burnout among physicians and how medical scribes might be able to alleviate some pressures from physicians.

Reducing burnout with medical scribes

Physicians Practice® spoke with Dr. Nada Elbuluk, practicing dermatologist and director of clinical impact at VisualDx, about how cognitive biases present themselves in care strategies and how the industry can begin to work to overcome these biases.

Cognitive Biases in Healthcare

Physicians Practice® spoke with Michael Morgan, at the time the CEO of Updox and a contributor to Physicians Practice, to discuss the new technologies that you should consider implementing in your practice and why implementing a virtual care strategy will be so important post COVID. 

The Paperless Practice: Virtual care strategies

Physicians Practice® spoke with John Harrison, CCO of Concord Technologies, about how documentation technologies can improve workflows in practices. 

Document Automation, Data Extraction for Independent Practices

Physicians Practice® spoke with Scott LaRoque, CEO of MPOWERHealth, about why some physicians may be hesitant to adopt value-based care models and how they can overcome these hesitations.

Overcoming Value-Based Care Hesitations

Physicians Practice® spoke with Colin Carr, CEO of Carr Realty, to find out what physicians and practice owners should know about real estate trends in early 2021 and the best practices in making commercial healthcare real estate purchases.

Real Estate Transactions for Physician Practice Owners

 Today we are featuring my conversation with with Rich Miller, chief strategy officer of Qgenda, after his recent presentation at the Medical Group Management Association's virtual Medical Practice Excellence conference.

Here's a brief excerpt from the program summary: As we move through the Recovery stages of the pandemic healthcare organizations and practices are overhauling technology and processes to accommodate COVID-19 safety protocols and return to more typical operating levels. They're having to make quick adjustments. So just balancing a new combination of telemedicine visits and in person visits, or transitioning to touch free workflows. These critical guidelines and policy changes are impacting patient flow without the right technology and visibility. And these changes can negatively impact patient access and throughput.

Prior to his appearance at the conference, Rich also contributed an article to Physicians Practice about how providers and practices as a whole can 

Our conversation centered around clinical capacity which, Rich explains, is very broad in concept but fundamentally refers to brining providers and patients together in the most efficient way possible.

 One of the ways that I think about clinic clinical capacity is sort of like two funnels coming down towards each other. So, the health system, and the patient system is very much like a funnel of in-taking new patients and doing initial diagnosis and triage, etc, etc, and trying to get them to those points and care.

And that sort of happens over and over again as we move people through that system of diagnosis and treatment, as well. The same is true of providers. So whether it's as far out as making sure that providers are onboard and properly in their credential to work in various locations, and all that kind of thing, the kinds of things that big health systems think about, all the way down to just saying, “Well, how many people do we have in this Urgent Care Clinic today, to see patients who, you know, show up for a walk in or, you know, scheduled patients?” So really clinical capacity, in its simplest form, is the marriage of those two things.

At the small scale, it's really very similar between, you know, a large health system and a small private practice with a with an office practice because those large health systems are made up of lots of small units that work just like that. So an orthopedic unit for a major health system, versus orthopedic unit, for a private practice group, really what they're trying to do is they're just trying to make sure that they can take as many patients as possible, while providing a very high degree of care and not burning out those providers while they're doing it.

 Like a lot of other areas of healthcare, the pandemic had a cascading effect on capacity management, according to Rich Miller.

 So, you know, the Coronavirus, the effect was really dramatic, and really just cascaded all throughout the health system.

You know, on the macro level, the effect of COVID-19 had a huge effect on the concentration of patients. So, we went from, you know, ORs being booked up and patients coming in for elective procedures and people coming into ambulatory clinics to, you know, see a specialist about a shoulder that's aching, that's my shoulder aches here sometimes. So, I naturally the point to that. And those things all got just canceled and shut down and all of those resources were then shifted over into our intensivist areas, the ICU, places like that. And suddenly you have, you know, these massive spikes, especially in places early on, like in April, during the surge in New York City and surrounding areas, Massachusetts, you had an incredible surge in these ICS where they were literally, you know, repurposing any possible room that they could in order to take care of these very, very sick patients.

Also, at the macro level, because there was this huge interruption to the kind of regular business of health care, there was a massive, massive interruption to revenue. So typically, in health systems, surgery is about 50% of your revenue. And even if you're an independent private practice provider, and you're a surgeon, surgeons are incredibly important for your revenue. Certainly, ambulatory revenue is still a real part of that. But both ambulatory and surgical revenue were cut way back way back. So there's a huge shortfall in revenues for 2020 that these hospitals are facing at the same time, that they had to spend more on facilities and PBE and all that kind of stuff. So Big macro effects.

On the micro level, the areas where we are providing care really changed dramatically. And a lot of it had to do with making sure for example, that we had the right level of isolation when people were in waiting rooms and things like that, I had an experience. And I'm going to talk about this a little bit at the practice excellence conference of going to my primary care provider for a regular physical. I drive up and there's like a sandwich board sitting in the in the parking lot that says, “Please call this number before you walk in, and I call it at some of the front desk.” So literally triage and people in their cars, like they want you to stay in your car and make a phone call. So people got very creative about how we were going to distance those patients. And immediately they asked, you know, did you take your temperatures, we asked you last night, were you good? Have you had any contact with anyone in the last, you know, blah, blah, blah, etc, etc, and went through and evaluated whether or not I would be safe to enter that space. And to their credit, that process worked incredibly smoothly. And, you know, boom, boom, boom, I was in the exam room and working with my physician. So that was terrific.

Things like the amount of cleaning and turnover that we have to do, every exam room now has to be cleaned after every patient has really added huge pressure on a system that already was pretty pressurized. The last thing I want to say about it is that it changed. It elevated, I should say the importance of different people you see all the time in healthcare, like for instance, the people who do the laundry, and the people who sanitize and turnover rooms and housekeeping and people who transport patients. Now, people who worked in those roles were suddenly critical critical providers of care, and where in the past, you would only schedule maybe you schedule your physicians, and we'll schedule our you know, advanced practice providers or our nurse practitioners and stuff. Now, we saw how systems that went from, you know, 3000, people under that kind of very precise scheduling to 30,000 people, literally housekeeping people, and need to be able to communicate with those people immediately. So suddenly, a lot more people were involved with carrying out the project. And it really is amazing what health systems have done in the way that they adapt. And it's just, it's been incredible seeing clients and friends and what they've done and been through.

 Managing clinical capacity often requires tools that are already at your practice, but new innovations are always on the horizon.

 Typically, what you would find in a small setting is, you know, a paper or Excel spreadsheet, or emails kind of flying around. You know, in some of the best cases, you have a really, really good administrative system, front desk person and scheduler who is just incredibly vigilant about making sure that those schedules really tie off. So, in general, what we see for tools are pretty rudimentary; certainly, there's going to be small EMR and things like that for booking this patient encounters. But oftentimes, there's very little by way of hard information about how things like exam rooms and provider time are being managed.

One of the things that's exciting for me is the way that we're using provider scheduling, to get right down into the nitty gritty of managing the day to day.

So I've actually worked in provider scheduling since 1998, a very long time. I'm dating myself here a little bit. And, you know, originally it was like, you know, who's on call and, and just trying to understand who the kind of go-to person is for care. But over time, there has been a steady march, closer and closer to now that's kind of the way that I like to say. Where in the past, we may have gotten to saying, “Well, this person is working today”, and then gotten to the place of saying, “Well, their first patient is eight and then I expect them to close at their clinic by 4pm today. Now we're even getting into place where we're saying, this physician is working in three these three exam rooms. This is a medical assistant, that's working with us. And those patients are being roomed and set up and ready for an encounter with their provider. So the provider walks in at this stage of set, and they can have a very productive conversation and get right down to take care of their. So, scheduling has really started to evolve to get more real time. And rooms management is certainly a big part of that.

 Ultimately, your ability to effectively manage your clinical capacity can have ripple effects in patient outcomes, provider satisfaction, and even practice revenue.

 I think that, you know, my wife is a provider and so I know a lot about how, you know, she feels about her day when she has crazy clinics that are piled up sky high, and then other days where maybe she's, you know, seeing 60% of patients that she should be able to see, all the time knowing that there's this incredible backlog of people who are waiting to see her.

So, I think that the real central theme of this is: how do we rationalize this process? How can we make sure that we have a really nice steady flow of patients so that providers aren't overwhelmed, they have time to work on their note and make sure that the wrapping of those cases appropriately that they can spend adequate time with each patient and provide the care that they need to, while at the same time identifying where they're underutilized resources.

That's something that is absolutely incredibly common, where providers have, you know, canceled appointments or scheduled as schedules that aren't managed very vigilantly? Maybe the person doing the scheduling that day wasn't doing a particularly good job, but one of the areas that is really, really poorly managed is facilities and rooms. And if you ask a typical provider, you know, do you have enough rooms in your ambulatory clinic, or in your office? They almost universally say, “No, we do not have enough rooms, because I don't have rooms when I want them.” So my perception is that provider is there just aren't enough rooms available in this facility.

Now, we've done lots of studies and actually looked at how those facilities really run. And the fact of the matter is, that rooms are really incredibly underutilized, that lots of rooms sit empty. And the reason that people perceive that rooms aren't available, isn't that rooms aren’t actually available—that there isn't actually physical space—but the spaces are so mismanaged that when they need a room, they can't identify, can I take this room and someone else gonna come and take this room? So there's a tremendous amount of wasted space there.

In the big application, whether you are, you know, a huge Health System, or you are an independent private practice, is you, if you start thinking, well, I guess we need to go out and get more rooms, now you're building facilities or leasing new facilities, that is incredibly expensive. So now we're seeing this change, where health systems and practices are saying, let's really look at how we're using this, let's implement a system that gives us some strong idea of what our utilization looks like, and maybe we can put off, you know, building that new $7 million facility.

 Up next, Rich discusses how some of his clients streamlined their clinical capacity management.

 It's interesting, we had a client who contacted us and said, you know, we have a huge problem with the way that we're managing rooms. This is University of Alabama, actually. And one of the things that they were struggling with is that they really didn't understand how many rooms are being used and whether or not rooms were booked whether patients were booked to those rooms. And so, our service team being a bunch of maniacs decided, hey, you know, let's just take our product as it exists today, and see if we can put something together to help these guys out. And so they kind of configured the product and sort of a weird way to accomplish what they were trying to do. And this happens all the time in software, people like come up with unexpected uses for your software, and you kind of use it in sort of a strange way to try to make that outcome happen. And what was startling is even using what was very rudimentary, we were able to increase the number of patient visits by 7.4%, increase in the clinical session volume by 4.7%. So, these are things that they were really able to, to measure as outcomes from implementing the system.

That was incredibly inspiring for us, it actually kind of set off sort of cascading series of events within the company where people said, this is they're not alone in this, there are lots of clients who are looking for this. And one of the things that's difficult about making rooms work right is that it's not just a room, it's a room with providers, and it's a room with the support staff to run those rooms. And because, you know, we have strong domain in the provider scheduling and management area, we realized, “Oh, this, this is something that we can very easily address.” So, we started developing some terrific new tools really based on those learnings and interviews of other clients and things. And it just really made us realize that the facility, the rooms that you're working in, what kinds of equipment are in those rooms, and the providers who are going to run those rooms, there's so much untapped opportunity to help people stay busy see clients see patients, and move folks along that, that we didn't realize we had to play a role to play and now that's become a big part of our business.

 If you're looking to improve your clinical capacity management, Rich has some tips on your search for programs and processes.

 I think the one of the things that is so important about doing this right, is that you're not just looking for a system to operationalize that—it is absolutely important to be able to say, you know, this person is, is, you know, in these rooms, and these patients are roomed in these spots, and to have that kind of command and control, but the most important thing that you can do is implement an operational system that produces data after the fact that lets you go through and do really terrific analysis to understand how are we actually using this.

For instance, if you were doing this and Excel, for example, spreadsheets can be quite structured. But when you're doing things like managing rooms and appointments in Excel, there's no real structure to the data, your ability to take that data across multiple days, or years or across multiple facilities and bring it together and say, let's do an analysis of our utilization. Or let's do an analysis to figure out “Should we open up a multi-specialty clinic with different specialties, all in the same building, all using rooms that are appropriate, and can work for those different specialties and sharing those, so we're really maximizing that space and gaining those efficiencies.”

Well, you're never gonna be able to do that without a system that can operationalize it and without analysis and tools that look at that data and produce real answers to the questions of how using the space and how efficient you are.

 Finally, Rich offers some advice for practices looking to streamline their clinical capacity management.

 I think that I think that we spent a long time really focus on things like EMR and meaningful use, and really making sure that we understood the patient side of the business. I think we made huge progress. I mean, if you go to a hospital now, and with having a, you know, coronary event or something like that, pretty darn quickly, they're going to be able to pull up your medical records. You know, wherever you are, especially, you know, if there using the same EMR, you know, obviously, there's a lot of ability to instantly transfer records. But even across the similar systems, we've gotten very good at sharing data. And I think we've got a lot better at kind of moving the flow of patients.

But I really think that 2021 is kind of the beginning of the of the year of the provider, I think we really actually need to look at our providers and say, this is a real scarce resource that we have here, we have a dramatic physician shortage, I have lots of Doctor friends who are retiring early, because they're like, this is horrible. My pay has been cut this year, I'm not accruing any vacation. You know, like, I just you know, and I'm working like an animal in order to take care of people and I've totally burned out. And I think that for us to be sustainable, we really need to focus our attention on how we can maximize the productivity of providers, minimize the amount of administrative garbage that they have to get involved with so that they can just really focus on patient care. And really try to make sure that the work that we put before providers is being managed as even and equitably as possible.

I don't know a single provider who doesn't want to come in and who doesn't want to come in on a given day and take care of patients and help people but when you run the person to the red line that's very frustrating or when that person is sitting around for an hour and a half because there were no patients booked or because of cancellations and things. That's a problem too. So I think that I'm hoping that the next revolution that we'll see in healthcare is really a focus on providers, how to support them, how to make them as efficient as possible, so that we can maximize access for patients and really provide the care that we need to provide.

Physicians Practice® spoke with Rich Miller, chief strategy officer of Qgenda, about practices' clinical capacity management during the pandemic and what you can do to optimize your capacity management strategies.

Managing your practice's clinical capacity

 This month at Physicians Practice, some of our contributors are focusing on the topic of burnout among physicians and staff.

Self care is of critical importance for physician and during the pandemic, self-care took on a whole new level of importance for providers, especially those on the frontlines.

Today, you will hear my conversation with Dr. Wayne Jonas, executive director of Samueli Integrative Health Programs, as we discuss the rise of burnout among physicians and staff both during and just prior to the pandemic, and strategies for reducing burnout in these populations.

We began by addressing why burnout remains such an important topic.

 We were already having trouble with burnout before the the bomb was dropped on the world with the COVID pandemic. You know, many of the frontline people, intensivists, emergency room, physicians, primary care physicians, and others were approaching 40% to 50% criteria for burnout. So, we already had a challenge in the system in dealing with burnout. And I think now with the rapid change that's going on—with sort of the implosion of the economy with the decline in, in both revenues and the capability of doing even basic clinical care—that has just exacerbated the change on top of this. So it is extremely important that we up our game in burnout prevention and management. And so you know, your questions are very appropriate for these areas.

I mean, the reasons for avoiding burnout have been very well delineated. The National Academy of Medicine did a major study on it published last year, American Academy of Family Physicians made it their theme over the last year on physician well being. And so the reasons for those are well known.

You know, with burnout, we have reduced empathy and the ability to actually provide care and a part of healthcare. We have less responsiveness to the needs of patients, and we pick up less on what's going on and therefore we're less accurate in our diagnostic and treatment decisions and capabilities. Trust gets eroded, there's an increased chance of error and mistakes and therefore harm in these areas. And now, if you pile on top top of that, the economic stresses that are occurring both for those in practice as well as for our patients, you know, we've got we've got a problem.

 One of the first steps in reducing burnout is to address that there is in fact a problem. However, bringing up these topics might be erroneously perceived to be admitting a weakness—there is a stigma attached to addressing or admitting burnout and fatigue.

Those in the healthcare industry will need to find a way to get around this stigma in order to begin addressing and solving the burnout plague.

 Stigma is a huge thing. I mean, as physicians know, if you cover up an illness that is ongoing, and don't take steps to catch it early, treat it early prevented, it's going to be a much bigger problem later. And that is the situation with burnout—if you if you put a blanket over it if you pretend that it's not there, if you don't address it. And stigma is one of the ways that keeps us from addressing.

I worked a lot with I might a good part of my practice was in the military, I was in the military for over 20 years, I still see patients in the military. There's a lot of parallels between what's going on now, in terms of frontline, crisis related medicine’s huge changes and what was experienced in the military with PTSD and moral injury. The military, I think, in many ways, like physicians, are tough, right? They're there to do a job, they don't want to show weakness. they want don't want to show ignorance, they don't want to show that things are slipping or they can't deal with the situation.

So the first thing is to acknowledge that there's a lot of changes going on. And really everybody is experiencing stress. And whether you can meet some criteria of burnout on a test or not, is irrelevant. The issue is if you're feeling in fact that your ability to function at your optimal is less, then it's likely that you're experiencing this and you need to open up and acknowledge that you need to say, I’m vulnerable here, because I'm a human being, and I need assistance in coping with this type of thing.”

And when leaders in the military came forward and admitted that, generals, for example, said “Hey, I'm experiencing this too”, that helped reduce the stigma. And so, physicians need to be able to also say that so they and their colleagues can address this importantly,

 Up next, Dr. Jonas explains the signs that physicians should be looking out for in themselves and coworkers to more readily identify symptoms of burnout.

 Yeah, well, there's a number of signs and these have been pretty well delineated. Again, I've seen it in military populations, but the National Academy and others have delineated this as well.

They largely fall into four major categories, some objective and subjective ones. The behavioral and objective ones are the ones that are the most telling—things that you can see in others, and if you see them happening in yourself. Things like: lack of sleep or difficulty in sleeping, waking up or difficulty going to sleep, a sense of apathy and finding yourself isolated from your colleagues or your team, not engaging in the normal type of social contact that you would have with others, being reactive, finding that you're more irritable than usual and that you're responding to small things in ways that you would normally just let a roll off, or even crying or actually feeling despondent or isolating yourself in those situations.

There's emotional issues: anxiety, fear, and anger are major signs of that. There are cognitive issues: difficulty concentrating; or in some cases, over analysis of a situation that you would normally be able to solve and wouldn't be a problem for you, but now you're thinking it through and you can't make decisions, et cetra. That can be a sign of burnout, as well as physical symptoms: increased pain, fatigue, just feeling tired, being depressed. Those are all signs that burnout is creeping up on you or has gotten a hold of you and it's time to take action.

 If you notice any of these symptoms in yourself or colleagues, Dr. Jonas says there are a number of ways the reduce burnout. He says that one of the more successful interventions of his team is to model self-care dialogue among team members.

 it's very important that you pay attention and support your colleagues during this period. One of the things we found to be most useful in managing burnout among our team is realizing that you're not alone with this. In essentially communicating when you see these kinds of signs in your colleagues to say, “You know, I'm experiencing this, are you experiencing this?”—that type of ability to dialogue in this area not only opens you up to a dialogue, but it also helps your colleagues in these areas, being in your own huddles with your team, acknowledging that this is happening, and that self-care and the need to address it is there.

So, modeling It is really, really important. I think once that's acknowledged modeling the self-care components, not only acknowledging it, but a number of self-care components that can help blunt mitigate or reverse it are key,.

Physicians tend to feel like they should have all the answers and they should be able to address every problem. And this is one of the major aspects. And you can't do that in times of very rapid change.

So, I just did a whole set of group visits for my chronic pain patients this morning. And man, I did not deal with the technology, okay. And we were having issues there. We had a guest that was coming in to help build skills in their chronic pain management. And so, I'm learning, and I had to acknowledge that right up front— I can't do everything in these areas. And so, my team then becomes really, really important. I have health coach, coaches and health navigators, Behavioral Medicine folks, pharmacologists—I need to bring them into the support structure so that I don't feel like I have to do all. Delegate in these areas. I think a third thing that'd be two things very important to do.

The third thing is that. As we used to say in the military that the best laid plans were the ones that had to be changed as soon as you met the enemy. That doesn't mean you don't do planning, but it means you realize you have to have flexibility because it's not going to go as planned. Okay. And this certainly hasn't gone with plan as we've gone through this particular pandemic. And so, having the flexibility to realize there's going to be changes and its okay, let's adapt to that. It’s really, really important to take breaks, personal breaks, self-care breaks. One of the big challenges my chronic pain patients were having this morning on our group visit was balancing activity with overactivity. If they did too much, they would get pain. If they did too little, they wouldn't actually improve their pain. It's the same thing with our life—you have to be able to take care of yourself, to heal the healer, if you're going to be able to actually take care of others. So, self-care and self-care skills, then, become extremely important. You need to take the breaks and, in those breaks, do things that refresh you and rejuvenate your mind-body practices to reduce stress and relaxation. Exercise is extremely important for managing stress and burnout. Social connectivity, not just social connectivity with your patients, but with your family, with your friends, with your colleagues, things that you enjoy doing, looking for what matters in your life, and making sure you get some of that regularly every day.

I would say that that extremely important thing that is not really understood, is the mindset. So, there's been excellent study showing that the mindset that you go into managing stresses with can make a difference as to whether you come out stronger on the other side, or whether it becomes burdensome research at Stanford and others have shown that if people see stress as a way to grow as a positive thing, then in fact, they will respond in a much more positive way. And it can give them energy, if they see stress as a burden, as something that is just going to weigh them down, then the same stress is going to produce two completely different responses. So, resilience is not about getting back to the way you were we're never going to be back exactly the way we were after this pandemic. But it's about learning adapting and growing. And the mindset that you go into it has is much more powerful than than we in the in the medical sciences are usually willing to acknowledge.

 The additional challenge now, will be how to implement Dr. Jonas' tips into the busy life of a healthcare professional.

 You know, that's an interesting question. What do you do with less time? Well, if you and then the second question is, do we really have less time?

But if you have less time, then it becomes really important that habits that are involved in self-care are built into the little amounts of time that you have. So, mind body practices, mindfulness-like practices, you know, in the old days, you might take a mind body course, and you go to eight weeks, and you would learn how to meditate 20minutes every day, and all that kind of stuff. You can't necessarily do that all the time. But what you can do is you can take some of those kinds of skills, and there are some of these on my website to help you do this in a more in an efficient way. You can take a breath, you can take a perspective, you can create a mindfulness bubble, if you've practiced it, okay? It's very easy to stay fit if you stay fit on small, regular activities, right? It's the same way with mental fitness. If you engage in periodic small, five-minute kind of mindfulness types of things, breathing exercises, that builds up areas in your frontal cortex that make it easier than to do that when you don't have time to try to do that. They've shown for example, in the area of burnout, which this is about that simply taking a few minutes at the end of every day and reflecting back on what has happened today that you are grateful for. What's something that gives you gave you joy that gave you connection, that you said, “You know, I loved this or it was a wonderful connection”, or “This good thing happened to me”, or “I'm alive in those areas.” Simply a five-to-10-minute reflection everyday can have marked impact on burnout if it's done regularly as part of the habit. So, I would say that time issues is embedding it in your habits taking it in small pieces, gratitude Exercise is mindfulness. And then if you have more time take advantage of those of those times to do the kinds of self-care, organizational things that you would do anyway.

 Telemedicine, the popularity of which soared during the pandemic, also poses new risks for physician burnout.

 I think most of the physicians that I'm talking to and teams I'm talking to, and in my own practice I'm experiencing this myself, is it's a very double-edged sword. And until we learn, you know how to take advantage of the advantages in managing challenges, it's going to be anxiety-provoking, I think the biggest problem of the biggest fear on telemedicine is the demand on time. Because now, it's not simply me going to the office and you're scheduled and I see you now—it can happen any time. Patients have access to me, I have to access them, they come to me in my home where I am right now, I go to them in their home. So that is the big worry, that has to be managed.

But the flip side of that is flexibility. Okay, now I can actually schedule my visits in between bathroom breaks, or in between some interaction with the family or doing something else that's in my in my home that I need to do to take care of my life, between exercise and so I actually may have more time to do this. Now suddenly, I'm making home visits and learning a lot more about my patients, instead of having them coming in and telling me this is going on not really knowing that it's actually like in the old days, when I actually used to actually do regular home visits. And I'd see what's happening there and to help them get better with their safety issues with their behavior and lifestyle with their social issues in those areas. Now, suddenly, I'm in their home, you know, we know that the determinants of most health, chronic illness, for example, our underlying lifestyle, the things that impact the bread and butter of what goes on in chronic disease, heart disease, diabetes, obesity, hypertension, etc, 60 to 70% of these have to do with behavior. It's not simply about pills and procedures, or the social determinants of health, the poverty, the stresses that go on, suddenly, we're out of the office in their homes. And so there's an opportunity, if we take the flexibility to actually more thoroughly and more holistically evaluate and care for our patients than we used to. And so, threats by demand on our time, but flexibility on the other hand, and I think where it pans out depends on how we manage it.

 Up next, Dr. Jonas offers some final parting words of advice.

 Well, I think, you know, on my website, I've put together a whole set of tools, my team has to talk about how you manage burnout in these areas, excellent lectures, that we've made freely available from folks from around the country, on how to manage burnout. So, if people want to get into the more details of this, how to protect yourself, how to enhance your immune system in those areas, and how to have a more comprehensive, whole person integrative dialogue with your patients. And I would say, if there's anything that you need to do with this pandemic, once you've gotten through the major changes that it's causing, is take advantage on building your practice in a way that is more comprehensive, more holistic, and is more effective in addressing the underlying determinants of your own health and the health of your patients.

Physicians Practice® spoke with Dr. Wayne Jonas about the rise in reported burnout among physicians, especially during the pandemic, and how the industry can work to overcome stigmas and begin to address these issues. 

Combating burnout in physician practices

 Last year, The American Medical Association released results of their prior authorization survey, which found that physicians were completing an average of 33 prior authorizations per week, waiting an average of two whole business days for approval. The entire approval process had become so burdensome that some respondents reported increasing their staff specifically to deal with the increased burdens of prior authorizations.

We spoke with Paul Joiner, chief operating officer of Availity, to flesh out some of the results from the survey and find out how primary care practices can improve their prior authorization processes.

In case you are new to the concept of prior authorizations, here is a brief explanation from Paul.

 So prior authorization is a process in which providers have to go through on behalf of their patients to get approval from the health plan to provide a service and get paid for it. This process is often reserved for procedures and diagnostics. It's probably the biggest burden in the diagnostic process, just because you're anxious to get to a diagnosis. You'll also hear it referred to as pre certification. And then sometimes there's other confusing topics, like notice of admission sometimes gets called a ‘preauth’, with people technically, because of a common transaction name, but by and large, in general, pre authorization and pre certification is an approval prior to service from the health insurance plan to perform a procedure and get paid for it.

 Paul mentions radiology, but he also said other treatments that typically require prior authorizations are those that require some medical guidelines before administering or performing, including many preventative diagnostic type tests.

Furthermore, they are intertwined with electronic health records, which may present additional hurdles.

 Well, they are because the source of information for supporting the need for the diagnostic test or for that procedure lives within the medical records. So proper documentation and understanding what is needed to attain the authorization is very, very important. It's important from a training perspective. And it's important that this team working on the authorization process is giving that feedback to the physicians, the physician extenders, so the medical assistants, the nurses and the physician assistants, if you will.

 Regarding the report mentioned earlier, Paul says that the average two-day wait time for prior authorization decisions is due to the fact that every health plan handles various authorization types differently.

 Sure, well, every health plan handles various authorization types differently. It takes two days, because one, the sheer volume, and then two, it requires a lot of these requires some type of clinical review and some type of clinical back and forth. And those are limited, expensive, highly skilled, specific resources. And then the back and forth part is, is that many times, there's a level of clinical information that needs to be supplied. And sometimes there's a back and forth conversation that needs to occur before the final disposition of the pre-authorization or the approval or the denial of the authorization can be can be given. And so many times, providers get very frustrated because they're a little confused about the status of the prior authorization, and how plans sometimes struggle to convey that status back to the providers. Obviously the patient's anxious to move on, so it creates a lot of anxiety, but it's a function of resources, the function of the complexity of the process, and in the back and forth conversation sometimes has to occur.

 Also mentioned in the report from the American Medical Association is a reported increase in a sense of burden among respondents. When asked whether or not this burden was perceptual—that it was an incorrect assessment from the physicians—or whether their sense of burden was actually due to requirement changes and increases in complexity, Paul says that it is certainly the latter.

 Requirements are truly been being increased. The level of which, the types of procedures, the variety of procedures, and diagnostic tests that requiring prior authorization is increasing. And then the nature in which these procedures and services are being scrutinized has been ratcheted up.

To the health plans’ credit though, many health plans are trying their best to innovate and improve the process and exchange of clinical information and make it clear to providers on when a prior authorization is required, and information that they need in order to give the prior approval.

You know any recommendation I would give to any provider or any physician especially if they're new to practice or long established, take a second and spend a couple extra moments with your staff and to make sure the process is worked out. And you as a physician know how you can help and how you can provide the proper documentation to facilitate the process or make sure the process is moving. smoothly.

And then the other thing is, is a lot of this misconception going back this 86% of burden increase. There's a lot of misunderstanding between the providers and health plans. And so, if something doesn't make sense, I encourage the providers to reach out to the health plans and have a conversation about it. Because a lot of times, it's a process or a structural issue in terms of how the information is being sent to the health plan, or the way that information is being interpreted creates a lot of confusion, a lot of problem between the providers and health plans, which increases the burden.

I've seen examples where providers have sat down with health plans and worked out and improve the process. And there's always going to be a little friction to the process. But it definitely can be reduced if you just take the time to kind of learn the process, both internally and also engage the health plans.

 Requirements from health plans are not the only way in which requirements, and subsequent physician burden, are increasing. Paul says that there are some legal and regulatory changes that can affect the prior authorization process as well.

 Well, there are in there are different mandates out there trying to improve the process. In fact, I just participated in and testified to Washington organization in relation to the improvement of the process and different operating rules. Core is putting for roles, the AMA is obviously involved. There are other technological advances that will could probably change the authorization process there since the Da Vinci project, which is a clinical information interoperability initiative that's underway. So, there's a lot of pressure from the federal and state governments to improve interoperability to improve the process. Really, where a lot of the technical legal stuff happens is that if you perform a procedure, and the payer denies it, because they don't think proper authorization was in place, that does trigger a formal legal process that does vary from state to state.

 Though some practices said in the American Medical Association report that they were increasing staffing levels to deal with the prior authorization process, Paul says that improvements do not stop at the hiring process.

 Well, yes, staffing. I'm familiar with one practice. You know, a dozen years ago, they had two people working prior authorizations, and now they have eight, it's a practice I'm familiar with. And so, number one thing around when you're increasing staffing is training. So, make sure that you're working hard to evolve your training with the times and staying current corporate policies, and that you're just not perpetuating common myths and workflows that you're constantly improving as you're training your employees.

Number two, invest. Invest in these in these resources that you have in the authorization problem and make sure that are of a high caliber, because there is a valuable payback in terms of them being a sophisticated resource and capable to navigate the system and capital is also capable to, you know, interpret how this process is changing and how the payers are changing.

Next on the process side, you can subdivide the authorization work by payer type, by procedure type, so you can subdivide the work. And that typically helps because then your resources can get more and more specialized and more and more focused in terms of information they're collecting, and who they're communicating with. Because many health plans outsource certain segments of the authorization process to vendors. Radiology benefit managers is a common one, you'll hear where there's an actual health I know speaking with, they're actually speaking a company, who providers provides the UN services or the authorization process to the provider to the health plan. And then providers have to engage the UN vendor. So, from a process perspective, it's about how can you subdivide the work and make sure the work is prioritized and bucket in terms of the most complex the least and make sure the right people working on the right task.

Then from the technology perspective, there's all sorts of opportunity to think through the person trying to attain the authorization and the approval making sure they have all the proper clinical documentation. And then try to understand and engage with that your largest health plans on what tools they have available to you to submit for an authorization or check the status of it. Besides picking up the phone and calling. One thing I want to share that is a common issue that a lot of providers think that they'll go through a solution like you know like Availity has or other vendors have in relation to electronic submission or authorization. I've heard numerous for physician practices say well I also call even if I get an electronic because I want the name and phone number and I want documentation that got called to double check or for an extra level of verification that the authorization is in place because I do not want to denial after treatment. So, despite so what that means is despite electronic channels and technology channels, and integration channels, they're still calling the health plans and trying to write down the name of a call center and the name or name of the time and a reference number for that phone call. So that they have that additional evidence that they did obtain authorization in the event that their claim was denied for that service because prior auth wasn't on file.

Train, hire well, process, constantly review the process, and make sure you're subdividing the work and the technology. Look for all the opportunities you can to pull the practice correct information forward to the process. And that that you're using all the proper available channels to the end of your largest health plans.

 Before we parted, Paul offered some final advice to practices looking to streamline their prior authorization process.

 Well, I hope that they are who are curious, and they go down and try to find the team and staff and they invest a little extra trying time trying to understand how their practice or their facility is managing authorization process and what role they play in that process.

The other thing is that, despite I know, many, many physicians are very frustrated with the authorization process and get upset. And I understand—put those emotions aside and look at it as it is a process it's out there, it's not going away. So with the most open and innovative mine, you can go to the process and see how you can help improve it, or how you can give additional resources or technical resources or integration resources or additional training to make sure your staff is only calling when they have to call and they're using all the best possible tools out there, available to them.

And another thing is, you know, if it is an increasing burden for your organization, keep the Google search up around, you know, authorization tools, because there are some small, innovative companies out there. We're partnering with some and then there are some that we're keeping an eye on that I think are working on trying to come up with little neat little widgets and modules to improve the gathering of the clinical information and the submission of it. And so keep your eyes and ears open because I do think it's a big enough problem that solutions will continue and innovation will continue to evolve the process probably at a more accelerated rate.

Physician's Practice spoke with Paul Joiner, chief operating officer of Availity, to discuss the implications of an American Medical Association survey and find out how you can improve your prior authorization processes.

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