ENGAGE PATIENTS IN HEALTH OUTCOMES
B R O U G H T T O Y O U B Y:
ENGAGING PATIENTS TO DECREASE COSTS AND IMPROVE OUTCOMES BY ALEXANDRA B. KIMBALL MD MPH, KRISTEN C. COREY MD, JOSEPH C. KVEDAR MD
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ncreasingly, healthcare providers face insurmountable opposing pressures: To bring down costs, but accomplish more at every patient visit. Today’s physician is responsible for a tremendous medical repertoire, evidenced by the increasing number of diagnoses in our codes. About 13,000 diagnostic codes expanded to 68,000 with adoption of the new ICD-10 system. Physicians also need to meet or consider multiple meaningful use objectives, pay-for- performance measures, quality incentive measures and medical home elements. These include a daunting number of activities ranging from design of IT interfaces to medical assistant time, nursing interventions and physician effort. To complicate the issue, these requirements have emerged in the context of a shortage of pri-
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mary care physicians and certain types of specialists, generating further discrepancies between supply and demand. The demands cannot be met, even with substantial help from ancillary staff. And even if they could be met, the cost to provide such care would be prohibitive. So how do we manage the myriad of initiatives and the impending physician workforce shortage while also reducing cost and improving quality? In healthcare, we continue to insist on human resource-intense solutions. However, the proportion of a provider organization’s cost borne by human resources is 56%, and healthcare workers are generally less productive than those in other sectors. A staff-heavy plan of action is doomed to fail. Other industries, when faced with the quandary of accomplishing more with less, have resorted to customer-
empowerment initiatives. As customers, we now do our own banking, pump our own gas, assemble our own furniture, check ourselves in at the airport and out at the grocery store. These examples allow those providing services to use human resources more efficiently, contributing to increased worker productivity. In most cases, the advent of these strategies was viewed with concern, but now all are almost universally viewed as empowering consumers. Can we follow this model of customer empowerment and create an architecture that allows us to engage patients in their healthcare? Patient self-management is not a new concept and represents an essential element of the chronic care model (CCM), a theoretical framework developed to guide higher-quality chronic illness management in primary care. Evidence has shown that incorporating CCM principles MEDICAL ECONOMICS
into practice results in favorable health outcomes. Patient engagement initiatives have led to reductions in hospital visits, decreased morbidity and mortality and improvements in treatment adherence and quality of life associated with chronic diseases such as heart failure, ulcerative colitis and asthma. Although an overarching goal of patient engagement is to decrease cost, we do not have to sacrifice quality care.
approach with their healthcare provider, an attitude that will aid a patient engagement initiative. Although barriers will exist for individual patients to adopt this system and its associated technologies, we must focus on developing an infrastructure that supports and encourages active patient participation in their healthcare. n Alexandra B. Kimball, MD, MPH,
is senior vice president of practice
improvement at the Mass General Physicians Organization and a professor at Harvard Medical School. Kristen C. Corey, MD, is an internal medicine physician in Boston, Massachusetts. Joseph C. Kvedar, MD, is director of connected health at Partners HealthCare and a professor at Harvard Medical School. This essay was an honorable mention in the 2014 Medical Economics physician writing contest.
TECHNOLOGY TO HELP PHYSICIANS IMPROVE PATIENT ENGAGEMENT
ALTHOUGH AN OVERARCHING GOAL OF PATIENT ENGAGEMENT IS TO DECREASE COST, WE DO NOT HAVE TO SACRIFICE QUALITY CARE. Areas of opportunity for patient engagement include scheduling appointments, managing correspondence, refills and prior authorizations and facilitating communication with the medical team. These tasks require more health literacy and familiarity with technology than we have asked of patients previously. Not all patients will be able or eager to handle this, but many will. Most patients embrace responsibility for managing their health and view this approach as better quality care. A 2010 survey found that 79% of respondents were more likely to select a provider who allows them to conduct healthcare interactions online, on a mobile device or at a self-service kiosk. One study found that many would even pay for such online services. The majority of patients prefer a shared decision-making MEDICAL ECONOMICS
Online appointments. Scheduling appointments represents a major effort by medical personnel. It is often undermined by the fact that 20% of patients cancel or do not arrive for visits within the same day. Many patients would prefer the convenience of scheduling their own appointments online, and studies have shown that advanced access and online scheduling reduce wait times and no-show rates. Pre-visit check in. Several groups are using tablet computers and kiosks to give patients the opportunity to enter pre-visit updates, demographic information, etc., in order to expedite the process of information gathering. Kiosk technology has even led to improved throughput efficiency in the busy emergency department. Online visits. Online communication is not a new concept, but its adoption among physician practices remains low. Only 13% of physicians use email to communicate with their patients. As the burden of chronic illness increases, one of the consequences will be the need to use brick and mortar resources more thoughtfully. Visits to physicians for routine interactions or data collection can be moved into an asynchronous, online environment creating opportunities for increased efficiency. Patient portals allow certain functions traditionally performed by office staff,
such as viewing test results and communicating specific questions to a provider, to be performed by patients. The results are timesavings, patient satisfaction, and desirable patient outcomes. For example, patients with gestational diabetes recieving follow-up and monitoring care via a text message-based telemedicine system achieved similar HbA1c levels, blood pressure values, weight gain, and rates of normal vaginal delivery at greater convenience compared to patients attending conventional office visists. Remote monitoring programs. Increasingly, devices that monitor the physiologic consequences of disease and treatment are able to share their data via wireless connectivity. Capturing this data and moving it to the electronic health record enables patients to realize how lifestyle and treatment choices affect their health, leading to improved compliance and disease management. In one recent study, patients with hypertension were given the opportunity to titrate their own medications based on home blood pressure readings and were able to do so with surprising ease. Patients with diabetes who upload their glucose readings to a centralized repository that allows them to view and contextualize these readings have achieved reliably lower HbA1c readings than their counterparts who do not participate.
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LOOKING INSIDE OUR HEADS: Brain Imaging and Patient Adherence BY DAVID HAGEDORN, PHD, BCN
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he ultimate goal of healthcare professionals is to achieve well-being in patients, which, as a matter of course, usually requires patients’ compliance with prescribed therapies. Despite the best intentions and efforts of healthcare professionals, issue resolution cannot be achieved if patients
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aren’t adherent in following prescribed therapies. Therapeutic adherence includes not only patient compliance with taking medications, but also typically with prescribed changes in diet, exercise and lifestyle. According to a 2004 study published in Health Psychology, patient compliance with healthcare professional prescribed therapies is historically quite low.
The study concluded with these average rates of compliance: • Long-term medication therapies: estimated between 40% and 50% • Short-term therapies: between 70% and 80% • Lifestyle changes: 20% to 30% Non-adherence with prescribed therapies has a variety of undesirable impacts, includMEDICAL ECONOMICS
ing not only urgent care visits, hospitalizations and higher treatment costs, but also greater financial burdens on society in general; not to mention potential negative effects for patients themselves. The empirical evidence of a broken bone is difficult for a patient to challenge, but even then we see that rates of patient adherence with prescribed courses of therapy are low. So, how can doctors achieve patient adherence when addressing health issues that cannot so readily be seen; in situations in which the health issue is one literally in the patient’s own head? When neurological problems or injuries manifest, it can be challenging for healthcare professionals to bring patients around to understanding both the nature of the problem, and the rationale behind proposed courses of therapy. NEUROIMAGING’S BENEFITS
Neurological issues range across concussion, depression, memory and pain, among others. While a patient may be aware of the symptoms of a neurological problem, such as a traumatic brain injury brought on through concussion, the internalized nature of the injury can make it more difficult to achieve adherence. Fortunately, the development of neuroimaging technologies that enable doctors to peer into our brains themselves, mapping brain activity and tracking changes over time, has opened new doors in diagnosing, prescribing for and managing these conditions. In a 2008 study of 60 psychiatrists and psychologists published in the Journal of Psychiatric Research, 85% agreed or strongly agreed that neuroimaging data would be a MEDICAL ECONOMICS
valuable adjunctive diagnostic tool for clinical evaluation. This study was conducted in the context of imagining that brain scans are used to materialize images related to depression; a condition in which it is often particularly difficult to achieve acceptance with patients due to societal stigmatism.
NEUROIMAGING TECHNOLOGIES CAN HELP BRING ABOUT A COLLABORATIVE PROCESS BETWEEN PATIENTS AND DOCTORS, IN WHICH PATIENTS THEMSELVES HAVE THE KNOWLEDGE AND UNDERSTANDING TO PLAY AN INFORMED, ACTIVE AND DECISIONMAKING ROLE IN THEIR MANNER OF THERAPY. Among the 72 patients who participated in the study, 92% responded favorably to the idea of having a brain scan performed to diagnose depression if such a scan were to be made available to them. Perhaps even more notably, 76% of the respondent patients said that a brain scan would help them accept their condition and 66% responded that it would increase their confidence in a provider’s diagnosis. The study concludes, “From responses of 52 providers and 72 patients, we found high receptivity to brain scans for treatment tailoring and choice, for improving understanding of and coping with disease, and for
mitigating the effects of stigma and self-blame. Our results suggest that, once ready, roll out of the fully validated technology has significant potential to reduce social burden associated with highly stigmatized illnesses like depression.” This study lends remarkable support to the notion that helping patients to visualize the nature of their healthcare issues is a critical step in achieving acceptance of a diagnosis, and therefore adherence with an agreed upon course of treatment. And it is easy to extrapolate from these results that neuroimaging promises to be effective in helping patients understand other brain related injuries and illnesses. The capability to not only collect but also share neurological data in a compelling visual form with patients aids healthcare professionals in helping patients to better understand their injuries and illnesses, and motivate them to adhere to agreed upon therapies to cure and/or manage them. Non-invasive neuroimaging is an important medical advancement contributing to an understanding of the brain and also the quality of care that can be achieved. Neuroimaging technologies can help bring about a collaborative process between patients and doctors, in which patients themselves have the knowledge and understanding to play an informed, active and decision-making role in their manner of therapy. n David Hagedorn, PhD, BCN,
is chief executive officer, chief science officer, and founder of Evoke Neuroscience. He is experienced in clinical health psychology and neuropsychology and serves as an international neuroscience and biofeedback research consultant and instructor. BROUGHT TO YOU BY
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ithin many physicians’ practices, there is a relatively untapped resource for optimizing revenue— business operations data. There has never been a better time to dive into this type of data. It can show both areas of strength and opportunities for improvement. As practices move to value-based care, fully understanding and responding to key business data will be essential to realizing success. The first step is identifying the measures that most clearly demonstrate performance. These metrics should show whether a practice is getting paid in a timely fashion for all the care and services it provides. The following indicators are worth watching from a business perspective. ACCOUNTS RECEIVABLE
This measure reveals how quickly a practice turns receivables into cash. Ideally, organizations should be keeping this metric under 30 days to yield nimble cash flow. AGE OF RECEIVABLES
This number shows how long a receivable has been outstanding. The longer a claim remains unpaid, the less likely it will be collectible. Organizations should examine those receivables past due over 90 days and determine whether there are preventable issues that can be addressed to shorten the payment timeframe and prevent similar problems in the future. AVERAGE DAILY CHARGES
Practices should track this metric over time to identify any patterns which could reveal productivity issues or patient volume fluctuations. For example, by monitoring this measure, a practice can pinpoint staff members who are underperforming and provide further training. Similarly, this measure can highlight seasonal patient volume variations that
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Indicators to Optimize Your Practice’s Revenue BY MONTE SANDLER
may represent opportunities to temporarily augment staff to better manage cash flow. COLLECTIONS PERCENTAGE
This statistic compares the payments a practice receives with what it is supposed to receive for the services it provides. Using this measure shows how well the practice optimizes payer contracts and collects balances due from patients. CLEAN CLAIM RATE
Using technology, this number should be high (near 100%) as claims scrubbers and other tools identify “dirty claims” prior to claims submission, allowing the organization to fix them before sending the claim to the payer. A decline may indicate the need to change payment rules and algorithms, improve workflows or train staff. PATIENT COLLECTIONS
With the advent of high-deductible health plans, patients are taking on greater payment responsibility. Whereas providers
used to be haphazard in collecting copayments, deductibles and coinsurance, there is increasing pressure to fine tune this process to prevent large revenue shortfalls. Practices that watch patient collection rates can make sure their front line staff are asking for and collecting payments consistently and reliably. Outliers in this area can point to the need for staff training, patient education and standardized processes for soliciting payment. DENIALS
Practices should keep a close eye on rejections and denials, because they can highlight a wide array of problems, ranging from staff errors to payer rule changes to lack of eligibly verification. Practices that watch for denial trends can catch systemic issues and prevent future rejections. n Monte Sandler is the executive
vice president of RCM services at NextGen Healthcare. MEDICAL ECONOMICS
FIGHTING FOR HIGHER PAYER RATES IS WORTH THE EFFORT BY JAMES F. SWEENEY
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ichael Barron, MD, decided it made more sense to quit than fight. After months of wrangling with UnitedHealthcare over inaccurate payments, the University City, Missouri, family physician did not renew his contract with the insurance company last year. “They would charge me additional amounts and subtract it and add it back in a different way,” Barron says of his long dispute with the payer. “It was absolutely an accounting nightmare. The way they did it really punished me. I’m still not sure they paid me correctly.”
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He feels the same sense of futility when negotiating contracts with other payers. So he accepts their automatic renewals without trying to negotiate higher payments. “That’s been my assumption that I wouldn’t get anywhere, but I don’t know,” Barron says, adding that as a small practice (himself and a nurse practitioner), he doesn’t have the time for lengthy negotiations. That’s the prevailing attitude among members of Ideal Medical Practices, a Washington state-based nonprofit whose members, mostly solo or small practices, exchange practice management tips and discuss better models of care.
Most member practices don’t even try to negotiate, says executive director Jeffrey Huotari, MD. “For them, it feels like running into a brick wall,” he says. “Our members don’t have the time, the money or the legal help to get into negotiations.” He adds that the only increases he saw as a family practitioner were the result of joining a provider organization that negotiated on behalf of all small practices on Michigan’s Upper Peninsula. Because of these real and perceived difficulties, practices can go many years without a payment increase, even as their own expenses rise. The good news is that it is possible, in MEDICAL ECONOMICS
some instances, to negotiate higher fees. The bad news is that it’s quite difficult. DATA AS A WEAPON
Because it involves insurance companies, it should be no surprise that fighting involves a lot of paperwork. Payers don’t respond to emotional appeals, so practices have to arm themselves with data. Before approaching an insurer, a practice should conduct an internal audit, says Melody Irvine, CPC, CPMA, a practice consultant and owner of Career Coders in Loveland, Colorado. That means pulling all current and past contracts as well as years of payment records from insurers. A practice needs to know how much it makes or loses on each contract, how much business it does with each payer, how many patients are covered by each insurer, which CPT codes it bills most often under each contract, the reimbursement for those codes and how the payments have changed over the years, if at all. Putting all that information into spreadsheets should reveal which contracts are the most and least valuable to the practice, which haven’t changed and more. Billers and coders should be involved because they’re likely aware of which payers are the biggest problems, Irvine says. That’s a lot of work, especially for a small practice that may not have a manager who can dive into the numbers. Faced with that much paperwork and months of bargaining to follow, many practices, like Barron’s, decide they simply don’t have the resources for the fight. “They don’t have the time so they just sign (the contract),” Irvine says, adding that practices should never accept an automatic renewal without at least asking for more money. Others find it worthwhile to hire consultants, like Irvine MEDICAL ECONOMICS
and Marcia Brauchler, MPH, FACMPE, president of Physicians’ Ally in Highlands Ranch, Colorado, to do the analysis and negotiating for them. “They [practices] take no for an answer and think they’ve tried. We have the time and personnel to persist through what the payers inevitably turn into an endurance test,” Brauchler says.
“THEY [PRACTICES] TAKE NO FOR AN ANSWER AND THINK THEY’VE TRIED. WE HAVE THE TIME AND PERSONNEL TO PERSIST THROUGH WHAT THE PAYERS INEVITABLY TURN INTO AN ENDURANCE TEST.” Marcia Brauchler, MPH, FACMPE, president, Physicians’ Ally
NEGOTIATING WITH GIANTS
So how does a practice negotiate with a big insurer that isn’t inclined to raise fees and has time and resources on its side? “You have more wiggle room than you might believe,” Irvine says. In cases where fees haven’t been raised in five years or more, it might be enough simply to point that out. But chances are the payer will need more persuading. In that case, prioritize the biggest contracts first, Brauchler advises, and be prepared for the long haul. The insurer’s reflexive reply will almost certainly be “no,” delivered with a “take it or leave it” attitude. This is why it’s important for a practice to know its competitive market and to look for any small edge. For example:
• Is it one of only a handful of similar practices in the area that contracts with the insurer? • Does it provide services the others don’t? • Can it prove it does a superior job at containing costs and providing top-quality care? • Does it see a lot of patients who will be unhappy with their insurer if they’re forced to change doctors? (It’s not unheard of for practices to enlist patients to pressure payers to grant increases.) • Is there a way for the practice and insurer to work together to produce mutually agreeable results? If the negotiations are unsuccessful, the practice will have to decide whether to accept what’s offered or end the contract. Insurers don’t want to lose practices or drive them into joining healthcare systems with more negotiating clout, so it’s usually not in the payer’s best interest to push practices to the brink. THINGS TO WATCH FOR
Even if higher reimbursements are off the table, practices should scrutinize contracts and payment data for harmful aspects that they might be able to eliminate, experts say. This could include insurers’ use of “silent PPOs,”—organizations that access a discounted rate from a practice without its permission, usually after a service is rendered. Another thing to watch for is insurers’ growing use of material change notices to unilaterally alter a contract with 30 days’ notice and without consent of the practice. One thing is clear: practices that don’t at least try for more money won’t get it. Or, as Irvine puts it, “It never hurts to ask.” n James F. Sweeney is a freelance healthcare writer based in Cleveland, Ohio.
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Physicians Should be Driving
BY ANDIS ROBEZNIEKS
VALUE-BASED SOLUTIONS
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ne group is directly responsible for physician pay lagging behind inflation and for medical practices being micromanaged by payers and government regulators: physicians themselves. That’s according to Harold Miller, president and chief executive officer of the Center for Healthcare Quality and Payment
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Reform in Pittsburgh, who delivered this message at the American College of Cardiology’s (ACC’s) 65th annual Scientific Session and Expo in Chicago in April. “[Physicians] haven’t stepped up with solutions and allowed themselves to be seen as drivers of costs,” Miller said. Miller described three possible futures for physicians in the postSustainable Growth Rate Medi-
care payment formula world, made possible by the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). The first involves some mix of pay-for-performance (P4P) and value-based payments, Miller said. He criticized P4P as a poorly executed solution to the problem of paying low-quality doctors the same as high-performing physicians. MEDICAL ECONOMICS
Under pay-for-performance schemes, physicians are required to deliver high-quality care but are not adequately compensated for it and get penalized for factors beyond their control, Miller said. He wasn’t optimistic that the Merit-Based Incentive Payment System (MIPS) created by MACRA would generate better results, dubbing the initiative “pay-forperformance on steroids.”
“UNDER PAY-FORPERFORMANCE SCHEMES, PHYSICIANS ARE REQUIRED TO DELIVER HIGH-QUALITY CARE BUT ARE NOT ADEQUATELY COMPENSATED FOR IT AND GET PENALIZED FOR FACTORS BEYOND THEIR CONTROL.” Harold Miller, CEO
The second possible future involved alternate payment models that seek to correct deficiencies with fee-for-service systems that do not compensate physicians or their staff for time spent discussing care plans with patients or coordinating care with colleagues. While Miller said per-member, per-month fees cover these services in the patient-centered medical home practice model, other methodologies, such as shared savings rewards, don’t provide much benefit for practices that are already providing high-quality, low-cost care. LET PHYSICIANS TAKE THE LEAD
Ultimately, most payment models are designed by payers for the benefit of payers, Miller said. But MEDICAL ECONOMICS
what is needed is a physiciandesigned system that identifies and removes barriers to better care, provides doctors with the resources and flexibility to provide that care and then holds them accountable for doing so. Miller directed his audience to review a guide to seven physician-directed alternate payment plans he developed
“WHAT IS NEEDED IS A PHYSICIAN-DESIGNED SYSTEM THAT IDENTIFIES AND REMOVES BARRIERS TO BETTER CARE, PROVIDES DOCTORS WITH THE RESOURCES AND FLEXIBILITY TO PROVIDE THAT CARE AND THEN HOLDS THEM ACCOUNTABLE FOR DOING SO.” Harold Miller, CEO
with the American Medical Association, but also pointed out to examples of physicians who have already developed their own working models. One was developed by Lawrence Kosinski, MD, a gastroenterologist in Elgin, Illinois, who developed a payment and care model to manage his medical group’s treatment for the 200 most critically ill of their patients with Crohn’s Disease. The model is described as a specialty intensive medical home program and is a collaboration with Blue Cross Blue Shield of Illinois. Miller also told of the “BirthBundle” model developed by Steve Calvin, MD, medical director of the Minnesota Birth Center in Minneapolis, where high-quality
care is provided at 28% lower cost. Larry Sobal, executive vice president for business development for MedAxiom, a cardiovascular practice consultant in Neptune Beach, Florida, also voiced some optimism through programs presented by the Centers for Medicare & Medicaid Services, notably accountable care organizations (ACOs). “I believe we’re starting to see two things from CMS that normally I can’t say exist: flexibility and creativity,” Sobal said, describing how there are now
“I BELIEVE WE’RE STARTING TO SEE TWO THINGS FROM CMS THAT NORMALLY I CAN’T SAY EXIST: FLEXIBILITY AND CREATIVITY,” Larry Sobal, EVP
434 Medicare Shared Savings Program ACOs providing care to 7.7 million beneficiaries. Although CMS is being flexible with ACO risk levels and patient population size, Sobal added that attaining shared savings is still difficult, so both patience and preparation are required. “I will tell you, it’s not easy money,” he said. “You do need to recognize the transformation necessary to become a full ACO is measured in years.” While “there is no clear road map” to become a successful ACO, Sobal did have some advice to provide. “Maximize what you do well,” he said, and decide what good ideas “you shamelessly steal from others.” n Andis Robeznieks is a freelance
healthcare writer based in Chicago, Illinois. BROUGHT TO YOU BY
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How to Get Your Patients on Board with
DISEASE MANAGEMENT BY ELIZABETH PECTOR, MD
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here are three F’s of patient motivation: Fear, finances and feeling better. Fear is a powerful, but temporary, motivator. A patient whose relative just got cancer is very open to screening. Another strong incentive is finances: money matters. Patients eagerly book well exams or adopt better behaviors to earn discounts on insurance premiums. A more encouraging reason for change is feeling better. It’s frustrating when patients don’t follow recommendations. These tips may get them on track. MOTIVATIONAL INTERVIEWING
Inquire about readiness to change. Patients contemplating or preparing for change are receptive to advice. Have patients rate, on a 1 to10 scale, the importance of an intervention, and their confidence to carry it out. Their answers reveal barriers to abolish through creative problem solving. LEAD WITH LIFESTYLE
For new metabolic diagnoses, I offer a three-month to sixmonth trial of diet and exercise before medications. To raise confidence, I discuss the patient’s past successes, similar patients’ achievements, or my personal benefits from healthful habits. We set realistic goals, and involve allied professionals such
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as diabetes educators to explain what to do, and why. COUNTER FALLACIES WITH FACTS
Patients say: “I can do it alone with diet” or “I only want natural remedies.” If they don’t reach goal with healthful habits, I praise their efforts but point out they can’t escape all genetic risks. I’ll consider plausible alternative medicine along with traditional treatment. Education about benefits, risks and guidelines often requires multiple visits. SIMPLIFY
Stop unnecessary prescriptions. Consider affordable generics and once-daily medication doses. Make testing easier with onestop lab and imaging.
nated to all sites. Internist James Lengemann, MD, my group’s medical director, piloted a halfday diabetes clinic when usual care wasn’t budging his worstcontrolled diabetics. He implemented point-of-care testing and brought in diabetes educators. With focused attention, patients achieve better control and the clinic has expanded to two mornings per week with more providers. Nationally, telehealth is becoming popular. Evidence is limited for its effectiveness on adherence, but it’s worth trying with tech-loving patients. PRE-DISMISSAL LETTERS
INNOVATE
When earlier outreach fails, I write a warning letter to express my concern for the patient’s health. I state that their nonadherence is weakening the physician-patient relationship so I can’t effectively help them. I set a clear goal, e.g. labs and a visit within six weeks, and warn that my next regretful step would be dismissal from practice with 30 days of emergency care until they find another doctor. This has brought nearly all my delinquent patients back into the fold. n
Our hospital-owned medical group employs two quality improvement nurses to compile disease management statistics and brainstorm improvement strategies that are dissemi-
Elizabeth Pector, MD, is a family medicine physician based in Naperville, Illinois, and a member of the Medical Economics editorial advisory board.
HARNESS YOUR EHR
Most EHRs have population management tools: disease registries with automated letters, phone or Web messages to patients with care gaps (uncontrolled metrics, overdue tests or appointments). Our practice is re-engaging people previously lost to follow-up through our product.
MEDICAL ECONOMICS
A Clinical Tool to Help Patients with STRESS-RELATED CONDITIONS BY BRITTANY ROTHHAMMER
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umerous studies over the past five years indicate that mental health disorders are on the rise. Why is this important to primary care physicians? Because mental stress as a result of cognitive impairment or a mental disorder strains the physical body and serves as a catalyst for a myriad of chronic illnesses. The World Health Organization released a pamphlet supporting the negative effects of the global financial crisis of 2008 on mental health. The author states, “Substantial research has revealed that people MEDICAL ECONOMICS
who experience unemployment, impoverishment, and family disruptions have a significantly greater risk of mental health problems.” In addition, aging baby boomers are resulting in a mass of the population developing Alzheimer’s disease or other memoryrelated conditions. A study from the Centers for Disease Control and Prevention showed that “approximately one out of every eight baby boomers has experienced increasing issues with their memory in the past year.” According to epidemiologic data in a 2006 study in the American Journal of Psychiatry, over half of U.S. patients receive
mental health care exclusively in the primary care setting. Combined with the prior two factors listed above and a rapidly increasing world population, a growing number of employed Americans feeling overworked and a neglected mental health care system and one might conclude that there is a great need for primary care physicians to provide more in the form of mental health treatment. HOW PCPs CAN HELP
Primary care physicians who can readily detect and manage behavior problems will be better equipped to manage the growing mental healthcare demand. BROUGHT TO YOU BY
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However, existing mental health care tools for primary care physicians are often time consuming, subjective, expensive or don’t have the requisite sensitivity (e.g., mini-mental status exam, blessed dementia cale). When patients present with concerns of needing greater mental effort to perform daily activities, the physician needs a very fast, easy-to-use, low-cost, objective and sensitive test. Neuropsychological tests completed on the computer like ANAM, MicroCog and CNS Vital Signs have certainly helped over the past decade and still have their place; however, these fall short in that they can take well over an hour to complete by a trained technician and, more concerning, they are largely effort-based. A problem with effort-based computer tests is that the degree of motivation, effort and vigilance that the patient puts forth at the time of testing will significantly skew the resulting scores, thereby changing the interpretation. Neuropsychologists are trained to take this into consideration, but technicians and testing software cannot account for this variable. As a result, traditional and dedicated neuropsychological testing is in many respects better when administered by expert neuropsychologists. The problem with this option is that the testing will require several hours to complete, in addition to the time it takes to score, generate and interpret a meaningful report. This is all without mention of the higher economic cost. Additionally, many neuropsychological tests are indeed objective; however, they are not direct measures of actual human physiology (e.g., block design). Efforts to develop blood and cerebral spinal fluid tests are active areas of research, but to date none have ample sensitivity or reliability.
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When searching for non-intrusive and office-based options, this only leaves the objective electrophysiology measures. Electroencephalography (event-related potentials, quantitative EEG analysis) in particular has a long history of strong clinical research, but, due to the expensive and sensitive equipment, has historically been out of reach from practicing doctors. EEG data collection and data interpretation are also difficult and time consuming for physicians.
WITH THE ADVENT OF FASTER COMPUTERS AND NEW ADVANCES IN SOFTWARE, OBJECTIVE ELECTROPHYSIOLOGY ASSESSMENT AND ANALYSIS ARE NOW AVAILABLE OUTSIDE OF BRAIN RESEARCH CENTERS AND UNIVERSITIES. AN OFFICE-BASED SOLUTION
With the advent of faster computers and new advances in software, objective electrophysiology assessment and analysis are now available outside of brain research centers and universities. Evoke Neuroscience, Inc. is the leading medical device company providing low cost nervous system physiology measurement and biofeedback treatment equipment, called an eVox system, designed specifically to suit the needs of medical doctors and their patients. M edical assistants can skillfully offer physician-determined care to patients presenting early symptoms of cognitive dysfunction. The system uses a heart rate monitor and an EEG to record a
patient’s heart rate, brain waves and brain processing speed while the patient performs a series of mental tasks. From these electrophysiology and heart rate variability results, a clinically derived report is administered to the physician. The report provides visual and statistical data including biomarkers, visual processing, auditory processing, and a brain function map. In addition to the eVox report, a second opinion service is included and is performed by a panel of physicians from NeuroRead, which offers treating physicians another perspective on the electrophysiology data when considering report interpretation and clinical applications (including medication, supplements, neurofeedback, etc.). If neurofeedback is suggested as a potential solution, the device can also equipped with the software needed to provide this treatment and can actually be used by a patient with minimal assistance from a medical assistant. Patients appreciate seeing the objective evidence of their conditions, as well as tracking their physiological change longitudinally during different treatments. Physicians appreciate the office-based, low-cost tool yielding sensitive measures to help patients see the value of treatment compliance, additional biomarker information to support differential diagnosis and a more individualized neurofeedback intervention option. Ultimately, it is clinical tools like this one that will help primary care physicians bridge the gaps between psychiatrics and general medical practice as well as physician recommendation and patient compliance. n Brittany Rothhammer is a prominent brain-health blogger based out of southern California. MEDICAL ECONOMICS
Help Patients Achieve Healthier Brain Function
THE eVox® SYSTEM
“eVox helps me help my patients ‘see’ how their brain is functioning and why they may have memory loss. And it helps us both see the effects of the medications, nutrition, or behavioral therapies we are using to treat their memory issues.” — John McGee, M.D., Internal Medicine
Improve patient adherence to treatment, increase practice revenue, and help patients with stressrelated conditions including anxiety, depressed mood, attention issues, forgetfulness, head injury, pain, and sleep issues. The eVox® system uses EEG, ECG, and event-related potentials (ERP) to provide primary care physicians with objective data in an easy-to-read and actionable report.