EPtalk by Dr. Jayne 11/3/16

Although many are focused on the Presidential election, it’s important to remember that Congress is responsible for appropriations. Many professional and advocacy organizations are busy at work, encouraging both parties to keep the government funded. The American Academy of Family Physicians continues to ask Congress to continue funding for the Agency for Healthcare Research and Quality (AHRQ) and other programs tied to primary care and public health. One would think that those kinds of efforts would be relative no-brainers for our leaders, but if there’s anything that we’ve learned during this election cycle, it’s that brains are sometimes in short supply.

A recent Advisory Board daily briefing noted that “Most docs are Dems” according to data from Yale University research. Surgeons, anesthesiologists, and urologists are more likely to be registered Republicans, where pediatricians and psychiatrists were more likely to be Democrats. Contributing factors may include salary, age/sex demographics, and specialty culture.

In the “no surprise” department, a recent piece in the September issue of Health Affairs identified a decrease in the number of small practices, defined as those with nine or fewer physicians. Small practices dropped from 40 percent in 2013 to 35 percent in 2015, while the number of large practices (over 100 physicians) increased by a 5 percent margin. Increasing regulatory and administrative burdens will continue to drive physicians to larger groups or employed practice situations.

The meeting season is in high swing, with MGMA just having wrapped up and various vendor user groups including NextGen and Cerner about to take place. The AMIA Annual Symposium starts on the 12th in Chicago. I’m sad that I’m missing AMIA this year due to other responsibilities, but I have a couple of friends going who promised to fill me in. If you’re attending any of the user groups or AMIA, feel free to share your pictures of good times, great shoes, and groovy entertainment.

I’m often overwhelmed by my Twitter feed, but when I see something that is mentioned by both Atul Gawande and Farzad Mostashari, I take note. Both mentioned this Washington Post piece addressing the practice of enrolling non-terminal patients in hospice care. The Office of the Inspector General found that many patients signing up for palliative care weren’t told that it meant giving up curative treatments. Hospice care has grown to a $15 billion industry and patients that require fewer services are more profitable due to the flat fee structure. Hospice care can provide real relief for patients and their families during very difficult times and it’s appalling that shady characters would choose to profit from it.

Speaking of people operating on the fringes, I’m sometimes amazed at the things people say in the course of trying to make a deal. I may be young and my consulting company may be small, but that doesn’t mean I’m clueless. A prospective client that I’ve been meeting with has repeatedly asked me to do some things with my proposal that I’ll call “irregular” for lack of a better description. I’m no stranger to dealing with convoluted corporate accounts payable processes, but if you ask me to do things that require legal fees to determine whether they’re legitimate, we’re unlikely to do business together.

I came across an interesting statistic today that 20 cents of every dollar in consumer spending goes to FDA-regulated products, including many foods, drugs, medical devices, cosmetics, dietary supplements, and tobacco. Being in healthcare IT, we often think about the FDA in regard to device regulation, but may forget everything else they do.

The “Mr. Yuk” award of the week goes to Kareo, whose “premium content” Medical Economics piece completely ignores the volume-to-value transition, admonishing physicians that “if you are not seeing enough patients each day, you will never be able to grow your practice.” Their guide gives “three key ways to increase the number of patient visits and the revenue that comes with them,” including an effective recall program, an online presence, and encouraging referrals. I was surprised to see someone pushing a clearly fee-for-service model without even remotely mentioning value-based care. It does talk about adding ancillary services such as a dietician, but mostly in the context of increasing the physician’s bottom line rather than as a quality maneuver.

I loved their advice to “don’t bring a dietician on payroll until they are at least 80 percent contracted with your payers. You don’t want to be paying that extra salary while they are unable to bill for seeing patients.” It seems they need a better understanding of how providers enter into employment arrangements. I’ve never met a provider who was willing to sit it out unpaid until the often unpredictable credentialing process reaches a certain threshold. Although you may delay a start date to allow for the paperwork to move through, clinicians will often begin delivering services to build their patient base or to start contributing to quality efforts. There are many things that providers do that aren’t about the bottom line, but apparently Kareo doesn’t get that.

They go further to suggest that practices should limit the slots for capitated patients “while leaving same-day and extended hours open for fee-for-service patients.” A couple of pages later they mentioned that providers can encourage referrals by “offering low wait times and great access.” I guess that’s just for the fee-for-service patients, though. Although many of their suggestions may appeal to the business side of our brains, I found the piece generally tacky and hope they’re more in tune with emerging software needs than they are with clinical transformation.

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