Story written by By Jeff Bendix, Charlotte Huff, Rose Schneider Krivich, Chris Mazzolini, Mary Pratt, Todd Shryock at Medical Economics
2016 was a challenging year on many fronts for healthcare providers.
Physicians have just started to digest the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its changes to physician reimbursement. A long presidential election finally reached its conclusion, but the consequences of a Republican Congress and President-elect Donald J. Trump for U.S. doctors and patients remain unclear. And running a private practice did not get any easier. Balancing the need to deal with patients who won’t listen or won’t pay while also seeking positive patient satisfaction scores remains a daily struggle for many.
These were just some of the challenges physician readers told Medical Economics they experienced this year and anticipate continuing for the foreseeable future.
For the fourth consecutive year, Medical Economics reveals its list of obstacles physicians will face in the coming year and, more importantly, how to overcome them. For this latest presentation, we asked readers to tell us what challenges they face each day and where they needed solutions.
Here are their responses, starting with the biggest challenge of the coming year.
Challenge 1: MACRA
“MACRA is the biggest thing that’s hit healthcare payments in a generation,” says John Goodson, MD, an internist at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School. “This is going to be transformative.”
And even though MACRA begins taking effect January 1, many physicians still don’t know what they need to do to comply.
“Each practice needs a Paul Revere to ride through shouting, ‘MACRA is here, change is here,’” says L. Patrick James, MD, chief clinical officer, health plans and policy and medical affairs for Quest Diagnostics, a healthcare technology provider. “Physicians need to get together and accept it. If you haven’t already started, you need to get started ASAP.”
Experts recommend the following:
Accept reality. Healthcare reimbursements are migrating from volume to value. MACRA will most likely serve as the road map for other payers, so get used to the reporting requirements, says James. “Physicians have gotten a lot better over the years with electronic health records (EHRs), but it’s going to be even more important that physicians aren’t just ‘doing’ but documenting,” says James. Documenting and reporting every treatment through a certified EHR or other approved method is the only way physicians can get paid for services.
Get educated. The law directs physicians to choose one of two reimbursement paths—advanced alternative payment models (APMs) or the Merit-based Incentive Payment System (MIPS). Most small practices probably will opt for MIPS, which measures quality, advancing care information (meaningful use) and clinical practice improvements to start (resource use will be included later.) 
“Figure out what you are already doing that you can get credit for under MIPS that you haven’t declared,” says John Squire, president and chief operating officer of Amazing Charts, an EHR vendor. “Many are based on treating diseases to improve outcomes and using prevention screening—most physicians are doing that today.”
Understanding these gaps between what you already do and what MACRA requires is key to a successful transformation. “Take a deep breath and don’t panic,” Squire says. “It can be daunting when you look at your to-do list, but you don’t have to do it all at once.”
Develop a plan. MACRA compliance isn’t going to happen without a commitment to change management, says James. “Create a vision, get your practice together and develop a plan,” he says.
This includes making sure all services are billed properly, says Goodson. Ensure that every diagnosis is part of the billing for that patient, and that all ICD-10 codes are attached to the bill. With the focus on patient wellness, make sure the plan includes scheduling annual wellness visits and transitional care management (TCM) visits, when appropriate.
“For TCM visits, there are few documentation requirements and they are quite reasonable,” says Goodson. “These visits benefit both the patient and the physician.”
The increased contact also helps enhance overall engagement, which makes for happier patients and better outcomes, he says. “The better the relationship between doctors and patients, the better the doctor can manage resource allocations for those patients,” Goodson adds.
This is one area small practices may have an advantage over their larger competitors, because physicians may know their patients better and know where they can influence behavior and where they can’t, Squire says.
When planning for MIPS, remember that some easy points are available just by following good practice procedures, says Squire. As an example, he cites the practice improvement category, which accounts for 15% of the total MIPS performance score. The category offers easy wins for those who plan and document for steps such as reserving time for same-day appointments, performing medication reconciliation and communicating with patients via a portal or messaging.
Under MACRA, in addition to the 15% for improvement activities, quality accounts for 60% and advancing care information is 25%. (Cost won’t be counted until 2018.) This composite score is used to calculate financial bonuses and penalties. “Make sure you know the components of the MIPS scores and plan for them,” Squire says.
And remember, the healthcare industry will be developing products and services that support MACRA, so talk to vendors to find out how they can help. Squire suggests starting by seeing what technology your EHR vendor can deliver to assist with the changes, and branch out from there. For example, talk to lab vendors to find out what they can do with lab results or digital images to help with the advancing care information score.
Don’t procrastinate. MACRA was originally supposed to take effect at the start of 2017, but the Centers for Medicare & Medicaid Services (CMS) has delayed full implementation until January 1, 2018, allowing practices to submit partial information or participate only for part of 2017. “Have a plan for 2017, but be ready to go in 2018,” says Squire. “The delay was a reprieve, but CMS is not rescinding the rule. Don’t ignore it.”
Challenge 2: Prior authorizations
Prior authorization requirements have increased steadily in recent years, and the growth trend shows no signs of abating in 2017.
That’s the bad news. The good news is the growing array of products and services available to medical practices that are designed to speed up the prior auth process. There is also the possibility that value-based payment models could reduce the number of drugs and procedures that need approval before payers will cover them.
In the meantime, prior auths remain an unpleasant—and increasingly common—fact of life in healthcare. For example, a 2015 Kaiser Family Foundation analysis of Medicare data found that 23% of drugs in private drug plans covered by Medicare Part D required prior authorizations, up from 8% in 2007. During the same period, the percentage of drugs carrying some type of utilization management restriction more than doubled, from 18% to 39%.
The proliferation of prior auths is largely a function of cost, says Jack Hoadley, Ph.D., a health policy analyst at Georgetown University’s McCourt School of Public Policy and the lead author of the Kaiser study.
“As drugs get more expensive, especially drugs where the use is complicated or has questions about appropriateness, then we see plans and PBMs [pharmacy benefit managers] increase their use of prior authorizations,” he says.
The nation’s changing demographic profile is also playing a role, notes Randy Vogenberg, Ph.D., principal of the Institute for Integrated Healthcare in Greenville, South Carolina. As more people become eligible for coverage under Medicare Part D, he says, drug costs rise, and plan administrators turn to prior auths as a way to control costs.
Physicians see the increase in prior auth requirements in their practices. George G. Ellis Jr., MD, an internist in Youngstown, Ohio, and Medical Economics’ chief medical adviser says his practice spends about 32 hours per week handling prior authorizations, up from 25 hours two years ago. Kevin de Regnier, DO, a solo primary care provider in rural Winterset, Iowa, says his practice’s weekly authorization requests are up between 40% and 50% compared with 2014.
While there isn’t much that individual providers can do to stem the rising tide of prior auths, technology may help minimize the amount of practice time they consume. The e-prescribing company Surescripts, for example, has developed a software that integrates with electronic health record systems to streamline the prior auth process.
Looking longer term, Vogenberg predicts that the growth of value-based payment models will limit the growth of prior auths, or possibly end the need for them entirely. Prior auths are a process, he says, but the healthcare system is moving toward rewarding outcomes.
“So while it’s true you’ve still got a lot of prior auth activity going on, I think we’ll soon see the rigidity of the prior authorization system being loosened, and at some point it’s just going to be incorporated into your outcomes measures,” he says.
De Regnier expresses a similar desire. “I do hope that as we move into more quality-based payment methodologies, especially those involving downside financial risk for physicians, insurance companies will understand that with physicians having real skin in the game, they can get out of our way a little,” he says.
Challenge 3: Negotiating with payers
As payers move to consolidate, physicians find themselves facing the prospect of declining reimbursement and narrowing provider networks. Many doctors lament that payers now come to the table with a “take it or leave it” approach, forcing physicians to agree to one-sided contracts to maintain their patient head count.
But while the ability to negotiate remains a challenge, and varies to some extent by region and payer, it remains possible. One key: physicians should focus on the value they provide to patients, their successes and why the payer needs them.
“The payers need you to take care of their beneficiaries,” says Elizabeth Woodcock, MBA, FACME, a healthcare consultant and author with Woodcock & Associates. “One of the things I recommend is to create a fact sheet, a pitch, for your practice. Here is your pitch, here is your value in the community. You want that one sheet in your back pocket when payers start talking about quality and narrow networks.”
One physician finding success with these techniques is Melissa Lucarelli, MD, a solo physician in Randolph, Wisconsin, and member of the Medical Economics editorial advisory board. She enlists the help of her staff to build payer negotiations considerations into her weekly workflow processes so that she can be prepared when it’s time to negotiate. It starts with a spreadsheet containing all of the practice’s payer contracts and some key information for each, including termination clauses, how quickly they pay and reimbursement rates for commonly-used codes.
As the time for contract negotiations approaches, Lucarelli meets with her clinic manager to review some of the problems the practice encounters when working with the payer and discuss potential opportunities for enhancing the practice’s value to that payer, such as quality data and star ratings assigned by payers.
“I always try to figure out for this company, what are they valuing and monitoring, and how are we measuring up?” Lucarelli says. And it’s not the time to be timid: If the practice is doing well at taking care of the payer’s patients, “It’s not unreasonable to ask to be rewarded more,” she says.
Woodcock acknowledges that it’s not always possible for physicians to negotiate significant reimbursement increases. Furthermore, too many physicians focus on that goal and ignore other crucial areas. For example, physicians should pay attention to claim filing deadlines and “take-back” provisions—essentially how long after a claim is filed that the payer can revoke payment because of a mistake. All of those items are negotiable, Woodcock says.
Even physicians attempting to negotiate in markets with heavy payer concentration, still have some strategies they can use. Woodcock suggests going bold: Find the large employers in the markets and talk to their benefit managers, share data about the practice’s successes in taking care of their employees and the focus on quality.
“Sometimes employers call payers and say, ‘You need Dr. Smith,’” Woodcock says. “I can’t say it will always work, but it will turn heads.”
And don’t rely on e-mail and other impersonal communication methods. Get on the phone and talk. Remember, negotiations occur between people, and building a relationship between the physician and the negotiators for the payers can only help strengthen the doctor’s position, Lucarelli says.
“I can make a human connection,” Lucarelli says. “That’s what doctors are good at, so move this uncomfortable business stuff into our playing field.”
Challenge 4: Staying motivated to practice medicine
Like everyone else, doctors want to enjoy their work, but they are finding it harder to do so.Physician professional dissatisfaction has been steadily growing in recent years, driven by increasing workloads and frustration at being unable to spend sufficient time with patients.
While the larger forces driving physician unhappiness aren’t likely to change soon, experts say there are steps doctors can take on the practice and individual levels to combat burnout and maintain their enthusiasm for practicing medicine. 
In the most comprehensive study of physician dissatisfaction to-date, published in the December 2015 issue of Mayo Clinic Proceedings, 54% of the physicians surveyed reported at least one symptom of burnout in 2014, compared with 46% in 2011. The percentage of respondents reporting satisfaction with their work-life balance declined from 49% to 41%.
In contrast, the study found minimal changes in rates of burnout or dissatisfaction with work-life balance among other working adults in the U.S.
By now the causes of physician unhappiness are well known, says Christine Sinsky, MD, FACP, an internist and vice president of professional satisfaction for the American Medical Association (AMA), who coauthored the study. They include ever-increasing amounts of time spent on administrative tasks and documentation, frustration with the demands imposed by electronic health records and the feeling they are having to cede control of their practices to government regulators and third-party payers.
“It’s a cumulative effect of well-intended efforts adding up to a burden of work that no one anticipated,” says Sinsky. “Physicians feel they’re spending their days doing the wrong work, and that leads to burnout.”
To address the problem, the AMA has created a series of online tutorials—which Sinsky calls “transformation toolkits”—designed to help practices operate more efficiently and enable physicians to gain more control over their workday. Many of the tutorials focus on ways doctors and practices can save time, such as renewing all of a patient’s medications once a year, or spreading documentation and data entry among members of a care team.
“By doing some of this reengineering, within the constraints imposed by EHRs and regulations, doctors can create a lot more room in their day for enjoyment,” she says.
Along with making changes in their work environment, doctors can combat burnout by employing stress reduction techniques, such as mindfulness—the state of “living in the present moment, in a compassionate way, without judgment,” says Gail Gazelle, MD, FACP, an internist and executive coach for physicians.
Gazelle cites the example of a doctor starting his day knowing he faces a full schedule that includes difficult patients and frustrating tasks, such as dealing with prior authorizations. That leads to fears of getting home late, having to stay up late finishing the day’s work and memories of being unhappy when that’s happened before.
“Worries about the future, ruminations about the past, all these things pull us away from the present,” Gazelle says. “When we can pay attention to what’s actually in front of us, without the overlay of what might happen or what should happen, it often isn’t that bad.”
Meditation, the practice of keeping one’s attention focused on one thing—such as breathing—can help people achieve mindfulness, Gazelle says. And while the common perception is that meditation requires setting aside large blocks of time, in reality it can be practiced while performing everyday activities, such as paying attention to the feelings in your feet as they lift off of and touch the ground while walking.
By developing the habit of focusing on the here and now, Gazelle says, “doctors become more resourceful for their patients and their staffs, and can be a little kinder and gentler to themselves.”
Challenge 5: Maintenance of certification
More changes are on the way for physicians certifying in their sub-specialties through the American Board of Internal Medicine’s (ABIM) maintenance of certification (MOC) process.
Richard Baron, MD, ABIM’s president and chief executive officer says the new wave of changes are designed to ease the stress recertification has on physicians.
“The biggest change that doctors need to know about is a partnership with the American Council on Continuing Medical Education (ACCME) through which many, many more CME programs can count for MOC points,” he says. “We’ve heard a lot from physicians that they would like to be able to use some of the activities they’re already doing for credit. We’ve come up with a very streamlined and physician-friendly way for them to do it.”
Once physicians complete a CME program, Baron explains, they will automatically get MOC points because ABIM and ACCME will use the same system to communicate. Now, physicians have to manually confirm completion with both systems, which can cause problems if they forget to check if both systems’ points were counted.
ABIM is also working with several medical societies that are developing tools to help doctors get credit under Medicare’s recent payment reform and have that count for MOC credit as well, Baron adds.
Enhancing the recertification exam itself is another top priority going into 2017, according to Baron. “[We want to] make the content much more relevant,” he says. All of ABIM’s board-certified members were invited to comment on the blueprint of the test, he explains, and the organization is currently examining these results and how to implement the suggestions and views stemming from the results.
But despite Baron’s positive outlook on ABIM’s changes, many physicians continue to have difficulty keeping up with them. “ABIM is saying, ‘Well the reason we’re doing these things is to make better, safer doctors for the public,” says Christopher Unrein, DO, an internist and hospice/palliative care practitioner in Parker, Colorado. “[But] one, they have no data that any of this stuff does any of that, and two, if they keep changing it, how are they ever going to get data that proves this is making patient outcomes better and making better doctors?”
Unrein says the financial burden of recertification adds to the stress physicians already experience from the many requirements of EHRs, Meaningful Use and now MACRA.
W. David Smith, MD, an internist in Cincinnati, Ohio, is frustrated by ABIM’s continual website updates, which he says are very difficult to follow. “I can’t figure out what in the world I have to do,” he says.
Physicians also feel as though a “board certification industrial complex” has been created by ABIM and MOC, Unrein says. “Our profession’s very own medical societies, that we pay significant amounts of membership dues to, turn around that membership to sell us products in order to pass the exams and/or gain MOC points,” he says. “So not only is MOC a busy-work, anxiety-laden process, it is also one of financial opportunism. Physicians preying upon physicians—it disgusts me, as we are supposed to be a profession that cares and looks out for others.”
Regardless of how physicians feel, Unrein says they have no choice but to continue taking the exams or they will see an end to their careers. “I can’t avoid being called board certified if I want to make a living,” he says.
However, Smith says there may be some hope for the future, as pressure mounts from state medical boards and alternative boards for ABIM to abolish MOC, and competition grows from other certifying organizations. In the meantime, he suggests physicians not wait till the end to complete their recertification requirements and study for the exam.
Challenge 6: Lack of EHR interoperability
Yul D. Ejnes, MD, MACP, estimates his practice could save hours of work daily if EHR interoperability were further along.
Ejnes says he can’t yet electronically transfer all the information he needs to share, and even when he can, the process is often cumbersome, requiring him to switch screens, log in to new systems and manually enter data.
“We’re still faxing a lot of things. We still have to manually enter information that comes in from labs. We still get data electronically, but it’s not usable so we have to re-enter it,” says Ejnes, an internist at Coastal Medical Inc. in Cranston, Rhode Island, and past chairman of the American College of Physicians’ Board of Regents.
Ejnes’s experience is typical. Very few physicians have complete interoperability, which the nonprofit advocacy organization Center for Medical Interoperability defines as “the ability to share information across multiple technologies.”
In fact, a study released by KLAS Research in October finds that a mere 6% of healthcare providers can effectively and efficiently share patient data with other clinicians who use an electronic health record (EHR) system different than their own.
While true interoperability is still years away, doctors and information technology experts say clinicians can employ targeted solutions and specific fixes within their practices to exchange data electronically with colleagues and other organizations. “Interoperability can happen on a micro level,” says Robert M. Tennant, director of health information technology policy at the Medical Group Management Association.
IT experts say doctors should start by working with colleagues to ensure they can efficiently move data locally, where there’s usually the greatest volume. As an example, Ejnes cites the work being done by hospital near his practice. The hospital is deploying technology that will allow affiliated doctors to move patient data in and out of their EHR systems with just a few mouse clicks.
Doctors should consider adopting EHRs from the same vendor as area colleagues and local medical institutions to better enable data sharing among providers, says Steven Stack, MD, immediate past president of the American Medical Association (AMA).
Stack says other interoperability options are also available to providers. He cites Carequality, an organization working to develop a common technical framework to enable electronic healthcare data exchanges.
He points also to SMART Health IT, an open, standards-based technology platform that healthcare organizations can use to build applications to share data. The AMA is also pushing for the Office of the National Coordinator for Health Information Technology (ONC) to refocus its certification program on testing the interoperability of EHRs.
Other solutions can help doctors with targeted interoperability, Tennant says. For example, doctors should maximize use of existing portals, such as those created by insurance companies. Likewise, Jon White, MD, deputy national coordinator for health information technology at ONC, suggests doctors maximize the functions they have within their EHRs to better enable data exchange.
Doctors should make electronic data exchange part of their practice workflow by maximizing the use of the functions already included in their existing software systems, White says. Those functions may not meet the full definition of “interoperability” but they can help move close to that goal. They should tap vendors and other IT support services for training to ensure they know how to fully utilize the capabilities embedded in their systems.
“I like to talk about targeted interoperability,” he says. “We don’t need every bit of data to move everywhere. We need the critical information to be given to the right folks at the right time. That it doesn’t now, that’s the frustration for physicians.”
Challge 7: Patient frustration with rising costs
The rapid rise in copays, deductibles and prescription drug prices is causing concern among physicians who see patients skipping care as a result of these increasing healthcare costs.
A study by CEB and DirectPath that looked at the health plans of 750 major employers showed individual plan deductibles rose 40% in 2016 and inpatient copays increased 68%.
Faced with patients not filling prescriptions, or skipping procedures or referrals because of financial concerns, physicians can help by becoming savvy shoppers on their patients’ behalf and providing education about costs.
“Just as we would do appropriate research when buying a new car, we need to do our research when shopping for healthcare—and this applies to medications, lab tests and even radiologic studies and surgeries,” says Carmela Mancini, DO, MPH, FACP, an internist in Marblehead, Massachusetts.
Mancini has a contract with a nationwide laboratory that gives the practice cash pricing on all labs, and passes the savings on to patients. A cholesterol test costs less than $6—if using insurance, the same test would be between $75 and $150 for the patient, she says. An independent radiology company offering cash pricing recently saved one of her patients $2,000.
Similar discounts may be available at hospitals and surgery centers, even if it means sending the patient out of state. For patients with high-deductible plans needing non-urgent surgery, the travel costs may be less than a procedure performed locally, says Mancini.
Peter Ubel, MD, associate director of health sector management at Duke University, says saving money can be a team effort. Physicians should make sure they know about copay assistance programs available from pharmaceutical companies and nonprofits, and to coach patients to speak up if price is an issue. “Patients often don’t know there might be an alternative drug or are embarrassed to discuss problems with costs,” Ubel says.
Physicians also need to keep in mind that under high-deductible plans, a procedure such as an MRI early in the year may have to be paid for entirely by the patient, Ubel says. Encouraging the patient to discuss financial barriers gives doctors the opportunity to work with the patient either to find other treatment options or identify a less-costly service provider. It also prevents a lot of wasted physician time.
“If the patient doesn’t get the tests or medication prescribed because of costs, then the doctor is wasting a lot of time recommending things that aren’t going to happen,” Ubel says. “It’s good to spend a little time to check on costs, if you can.”
Financial education can also come before care is rendered. For example, Anas Daghestani, MD, chief executive officer of Austin Regional Clinic in Austin, Texas, says the practice sends a letter once a year to patients explaining when it’s appropriate to visit an emergency department. Also, when procedures are scheduled, a financial counselor explains the potential out-of-pocket expenses, so there are no last-minute surprises that can lead to cancellations due to inability to pay.
Daghestani says these efforts contribute to better patient understanding and transparency. “When you book an airline, you don’t have to guess the fees—you log in to compare different options,” he says.
And saving money does not mean a patient is getting inferior quality or compromised care, says Mancini. “If you could purchase a new car for $10,000 at car lot A, but you get the same exact car for $8,000 at car lot B, why would you shop at car lot A? We need to apply this same savings mentality to healthcare,” she says.
Challenge 8: The non-adherent patient and “quality” care
Patients who dismiss medical advice are nothing new, but that attitude increasingly threatens to cost doctors as quality metrics become tied to compensation.
Sometimes patients can’t afford healthier food or even their prescribed medications, says George G. Ellis, Jr., MD, a general internist in Youngstown, Ohio and chief medical adviser for Medical Economics. In other cases, he says, they may simply prefer to spend their cash on potato chips or cigarettes. “It’s about priorities,” Ellis says. “But we’re being penalized for their lack of concern for their own well-being.”
In early 2016 CMS, America’s Health Insurance Plans, (the commercial insurers trade association,) and other groups tried to rein in the proliferating number of quality metrics by establishing a set of core measures broken down by specialty. For primary care doctors it includes 20 metrics—ranging from patient compliance with cancer screening recommendations to the frequency of eye and foot checks for patients with diabetes.
But consolidating measures doesn’t address the problem of the disengaged patient. A 2004 meta-analysis of 569 studies published in the journal Medical Care found that one-quarter of patients didn’t adhere to treatment guidance.
A physician’s ability to connect with patients can help improve adherence, at least to some degree, according to another meta-analysis of 106 studies published in Medical Care in 2009. Researchers reported that patients whose physicians communicated well had a 19% higher rate of treatment adherence than those who didn’t.
Some opportunities begin with making sure the patient receives the optimal drug for their symptoms and their personal circumstances, says Trissa Torres, MD chief operations and North America programs officer at the Institute for Healthcare Improvement in Cambridge, Massachusetts. Help patients to succeed, whether that means getting transportation to the pharmacy or discussing ways to incorporate exercises.
To that end, she says, a practice can start collecting information about their patients’ financial, transportation and other barriers to achieving quality care.
Ask questions to determine if a patient is following through, but in an open-ended way that encourages discussion, says Kelly Haskard-Zolnierek, Ph.D., author of the 2009 meta-analysis on physician communication and a health psychologist at Texas State University in San Marcos. “You could say something like: `Many patients forget to take their medication sometimes. How often does this happen to you?’”
Time-pressed doctors shouldn’t shoulder this extra work, says Torres. Instead, ask other team members, from receptionists to nurse practitioners to assume a role.
Don’t give up, stresses Torres, who believes that truly resistant patients “are a very, very small minority.” None of these quality metrics assume that doctors can achieve 100% success, she notes. “So that small percentage [of resistant patients] is actually irrelevant to the overall metric.”
But Ellis disagrees with that “very, very small” estimate, at least in the economically challenged region in which he practices, where daily stressors and long cold winters can reduce patients’ opportunities to stay active and sap their motivation to change, he says.
He sticks with patients who struggle to improve their health despite limited income or other circumstances beyond their control. He tries motivational questioning, brainstorms ways to overcome hurdles and gives out free drug samples to patients on limited incomes.
Still, Ellis says, “I’d say there are probably 20% of my patients that I can’t move the needle on, no matter what I do. I have told patients just to leave.`If you’re not going to be compliant, don’t waste my time, don’t waste your time.’”
While Ellis was willing to discharge patients who wouldn’t help themselves even before metrics became a factor, now he worries that more physicians will resort to that step if noncompliance impacts their bottom line. “And then who is going to care for these people?” he asks.
Challenge 9: Changing patient attitudes
Today’s patients are educating themselves more, presenting both a challenge and an opportunity for primary care physicians. Google searches make it easy for patients to arrive at appointments armed with self-diagnoses, and consumer advertising means they often have questions about the new, brand-name drugs they see on television. Some, newly insured by the Affordable Care Act, may be coming to the doctor for the first time, and have questions and concerns they expect their new physician to answer.
Other patients are angry. A recent
Medical Economics reader poll suggests physicians are seeing that anger manifested during office visits as frustration with the cost of healthcare, from deductibles to surprise charges. Other patients are taking a consumerist approach to healthcare, looking for convenience and quick access.
As healthcare changes so quickly, and becomes a relentless hamster wheel for providers, many physicians are searching for the best way to reach today’s patients. The solution, some physicians believe, is to get back to basics.
“I think it all comes down to establishing trust with your patient,” says Rick Greco, DO, an internist who spent two decades as an office-based physician and now works as a hospitalist. “I think that’s a problem we’ve created. We’ve downplayed the value of that.”
That’s an old-fashioned notion, but one that has grown in importance as patients become more knowledgeable and want a partnership with a physician, says Joseph E. Scherger, MD, a primary care physician in La Quinta, California, and member of the Medical Economics editorial advisory board.
“Patients feel more empowered to take control over their own health and consider the doctor an adviser. Doctors have to adjust from being in an elevated position to more of a coaching and advising role,” Scherger says.
Fortunately, there are strategies that physicians can use to better communicate and connect with patients.
Greco says part of the solution is tone. When patients come in speculating about their condition or asking about homeopathic techniques, physicians should consider the patient’s perspective when they respond.
“I think physicians fall into a trap of saying, ‘You can’t believe everything you read, there’s more to it than you know,’” Greco says. Instead, he suggests physicians acknowledge they have heard of that approach but add, “If the technique doesn’t seem to be working for that patient, perhaps we could try this.”
Greco and Scherger both embrace shared decision-making, a technique that takes this approach. Everything from medication decisions to referrals for testing or procedures can be a collaboration with patients. While many might assume shared decision-making is important when discussing serious medical conditions such as cancer treatment or end-of-life care decisions, it can—and should—also apply in routine care decisions. “I think that doctors need to look into [shared decision-making] and reflect on it and adapt to it, rather than fight it,” Scherger says.
“I think physicians have to really understand there is value to being the doctor, not a technician,” Greco says. “I think you have to put yourself in the patient’s situation, and maybe we need to do a lot more education for physicians about that.”
Challenge 10: Patient satisfaction scores
Patient satisfaction has become an increasingly important factor in how physicians are treated by their employers and insurers, thanks in part to government regulations.
Moreover, many patients now come to their appointments with a laundry list of tests they want done or diagnoses they have made themselves from information they found from web searches, and demand their physician respond to their findings, according to Gerald Maccioli, MD, chief quality officer for Sheridan Healthcare in Fort Lauderdale, Florida,
Dealing with the internet-savvy patient—but also attempting to make a personal connection with them—all while entering the data correctly into the practice’s electronic health record (EHR) system is a daunting but necessary task because of value-based care.
Even if physicians wanted to hide from patient satisfaction scores, websites such as Yelp, RateMDs and Healthgrades.com make doing so difficult because anyone can look up a doctor’s name and see what other patients had to say about their experience.
So it is not surprising physicians are feeling conflicted over how best to handle patient satisfaction scores. “[Prior to EHRs], those were the days when medicine was practiced in a way patient satisfaction wasn’t really an issue,” says Henry Anhalt, DO, a pediatric endocrinologist in private practice in Hackensack, New Jersey. “Patients were drawn to physicians who felt that there was a personal bond.
What’s happening now, he says, is a result of the current payer environment, which has harmed the personal relationship patients used to have with their physicians.
But focusing too much on patient satisfaction scores can also have dire consequences, Maccioli warns. The opioid epidemic has been one of those consequences, he says, as the emphasis on making patients happy led some doctors to over-prescribe the medications.
According to 2013 research by the Ohio State Medical Association (OSMA) in conjunction with the Cleveland Clinic Foundation, more than three-quarters of responding physicians agreed or strongly agreed that the emphasis on patient satisfaction is leading providers to overuse expensive testing. Furthermore, 58% reported that pressure from hospital administrators to improve patient satisfaction regarding the treatment of pain had increased, which has led to prescribing opioids.
Nevertheless, there are several methods physicians can use to help ease the burden of patient satisfaction scores. Asking satisfied patients to post reviews is a great way to boost online scores and stay ahead of value-based payment, says Lee Ann Van Houten-Sauter, DO, a family physician at Pine Street Family Practice in Williamstown, New Jersey.
Putting yourself in the patients’ shoes is another way to ease the anxiety of dealing with Dr. Google-type patients, Maccioli says. “It really comes down to the rule of treating others the way you yourself want to be treated,” he says. “If we approach every interaction with the patient’s perspective in mind [they’ll lead to better outcomes].”
Physicians also need to start accepting the changing world they live in, he says. “This is a change that is here and isn’t going anyway, so we need to embrace it.” he notes.
Anhalt agrees, saying having more empathy truly is key to solving the satisfaction dilemma.
“The power of listening can’t be overstated,” he says. “You must listen to your patients and you must be empathic because how you see their disease is not how they see their disease. Patient satisfaction is truly a reflection of the job that a physician is doing.”
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