Sunday, September 30, 2018

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Tuesday, September 25, 2018

Refresh your medical practice referral building

Years ago, a "good referral" was described using the Three A's of medicine: Availability, Affability, and Ability. A physician striving to build a successful practice was advised to deliver all three.


Managed care contracts and narrow networks temporarily stifled traditional referral building. But the patient rebellion against limited choices pushed the pendulum back to center, and today, high-deductible health plans and out-of-network options have patients once again voting with their feet. Refreshing your referral building activity has never been more important to patient volume or practice revenue.


Here are five ways a modern practice can use the Three A's in its referral building.


1. Capture and track referral data accurately.



This is the baseline of any effective referral building strategy, but it is very often skipped. Here's how to make sure the data is accurate and meaningful:


1) Create detailed referral categories – for example, "Edwina Jones, MD," not, "Doctor." Or, "Vitals," not "Internet."


2) Update the registration form or patient portal registration field to say "Who may we thank for referring you?" It's more effective at getting patients to respond than "Referred by:"


3) Train the staff to verify that patients provide the information and, if they don't, to ask them verbally.


4) Train the staff how to properly enter the information patients provide into the right detailed category.


5) Create a protocol for how new categories are added and who is responsible. If there is no plan for adding new referral categories, busy staff will end up overutilizing "Other," which will skew the data.


6) Generate quarterly reports and review referral sources.


2. Expand availability using technology.



Years ago, we advised specialists to offer a private, direct phone number so referring physicians could quickly reach the practice. Today, the options are more expansive.


For example, you might offer access to secure text messaging or the physician social network Doximity as a way for referrers to connect about patients. We even have some surgical clients that post forms and information about how to refer patients on a special web page designated for referring physicians?


You also can make yourself more available to patients who have urgent needs, or who live out of town, using ZocDoc, to find and schedule an appointment. And of course, your website or patient portal can offer patients online registration and appointment requests, inquiry forms, online payment options, and more.


3. Deliver patient experiences that garner positive feedback.



In the age of online review sites and value-based care arrangements, affability (a.k.a., bedside manner) is more important than ever. The ire of one unhappy patient can spread like wildfire on rating sites, and, make no mistake, patients and potential patients read and act on these reviews. Plus, more and more hospital employment agreements include patient and staff satisfaction in their physician compensation and bonus plans.


Differentiate yourself as a practice that delivers amazing patient experiences and your online reviews and patient referrals will rise.


4. Verify and promote your online clinical quality indicators.



Demonstrating clinical ability is often easier to do with referring physicians because they are trained to and able to discern your "quality." Patients, not so much. With a service as complex as healthcare, they will typically focus more on the experience and convenience.


You can boost this, however, by making sure your scores on Healthgrades, CMS's Physician Compare, and payer sites are accurate. Direct a staff member to organize or print this information for physician review. Take action if information is inaccurate. And use positive scores and reviews in your referral building and social media efforts.


5. Don't let referral relationships lapse.



If physicians are delivering the Three A's but you're still seeing a drop in referral volume, it might be an issue of relationship lapse. Patients and referring physicians are busy. Referring practice staff–maybe the ones who knew you best–leave their roles.


Take time each quarter to cultivate relationships with physicians, patients, and influencers so they don't go stale. Send handwritten thank you notes. Or email referring physicians, announcing a new service or expanded office hours. Host a dinner in the private room of your favorite restaurant for five or six of your best referrers and their spouse or manager. In between casual conversation and "shop talk," ask the group how you and your team can continue to earn their trust and their referrals.

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Saturday, September 22, 2018

How to recover from a verbal blunder

Guest Post
By Sue Jacques



Have you ever said something to a patient or colleague you wish you could take back? I have.


A few years ago, I placed my foot squarely in my mouth as I was in the midst of the forensic medical investigation of a suicide. The decedent had taken his life with a handgun at home. While I was at the scene, the family’s doctor, who was also their friend, arrived to support them and field their calls. He wanted to give me his private phone number, and I needed a moment to get my notebook to write it down. When I was ready I said to him, clearly without thinking, “Okay, shoot.” It took awhile to get over that one.


While not always as dramatic as my example, verbal missteps happen to everyone. Whether it’s referring to someone by the wrong name or unintentionally breaking a confidence, we’ve all said things we wish we hadn’t.


A slip of the tongue doesn’t have to cut like a knife, though. While ignoring the situation may seem like the best solution at the time, it's not. Here’s how to overcome five common phonetic faux pas.


Problem: You inadvertently shared information you didn’t realize was confidential.

Severity: Critical


Solution: This issue requires immediate action. As soon as you become aware of your oversight, contact the person or people whose confidence you breached and offer an explanation and an apology. Take full responsibility for following up with all parties to make sure the privileged information goes no further. To avoid these predicaments in the future, make a habit of asking people during conversation if any of the details of your discussion are private. And let your expectations about confidentiality be known, too.


Problem: You introduced someone by the wrong name or with the wrong credentials.


Severity: Stable


Solution: As awkward as these moments can be, they’re relatively easy to handle. The secret is to be succinct and sincere. If the person you’re introducing corrects you privately, simply say you’re sorry and move on. If it’s brought to your attention that you’ve misintroduced someone publicly—on a stage or at a meeting—address the error as soon as you can by saying something to the group like, “Please pardon me. When I introduced Dr. Shira, I mistakenly referred to her as a plastic surgeon. She is a dermatologist. I apologize, Dr. Shira.”



Problem: You vehemently disagreed with a colleague only to find out he was right.


Severity: Serious

Solution: When this happens, it’s best to admit you were in the wrong. Give the person a call or send a note indicating you recognize that you stand corrected. A three-step template for this includes (1) acknowledging the disagreement, (2) accepting the truth, and (3) honoring the experience. Here’s an example of what to say: Our lively debate the other day inspired me to do more research on the topic. In doing so, I learned that you were correct about the statistics. I respect your expertise on this subject and I thank you for sharing your knowledge with me.


Problem: You talked about somebody behind her back and she found out and confronted you.

Severity: Grave

Solution: Instant damage control is needed in this situation. Is her accusation true? If so, you owe it to her to own up to your indiscretion. If she comes to you in person, stop what you’re doing and sit down to talk things through. If she sends you an e-mail or text, call her to discuss the issue in real time. Whatever you do, don’t turn the conversation into an inquisition by asking questions like, “Who told you?” or, “How did you find out?” Don’t get defensive, either. Instead, offer a heartfelt apology and assure her it won’t happen again. And then make certain it doesn’t. 


Problem: You lashed out at a staff member and now he’s avoiding you.

Severity: Undetermined


Solution: Things can go either way in this circumstance, and it’s all up to you. Whenever you have a problem with someone’s performance, it’s your job as a leader to deal with it appropriately. That means maintaining a considerate and professional demeanor. Berating a co-worker is unacceptable because it’s a disrespectful and juvenile way to communicate. But if you’ve already castigated someone who’s now giving you the cold shoulder, your only choice is to set things straight. Ask to meet with him, be prepared with an apology, and sort out your differences.

While verbal gaffes can feel uncomfortable in the moment, they don’t have to have long-lasting effects. I recovered, and so can you. The bottom line is this: When you mess up, fess up. By owning up to your mistake, apologizing with sincerity, and making amends when necessary, all parties can move on with respect, professionalism, and grace.

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Tuesday, September 18, 2018

The CMS proposed rule: A fool’s bargain

The CMS proposed rule designed to put patients over paperwork has physicians across specialties protesting. Studies showing that physicians spend more time on paperwork than they do on patient care has prompted the search for reduced complexity and volume of documentation. In theory, decreasing the volume of information in a visit note would help address this, particularly if the information cut is not important to the purpose of visit documentation. In reality, decreased documentation requirements combined with an average reimbursement that could be lower for the same care seems like a fool’s bargain.


Notes are long for a number of reasons, many of which will not be assuaged by changes to CMS regulations. Our patients, their medical issues, the number of diagnostic tests, and pharmacologic management of these conditions are increasingly complex. As a result, it can take many words, phrases, and sentences to describe the medications a patient with depression has tried or a couple of paragraphs to outline a patient’s cardiac testing and intervention history. EHRs remain largely set up like a series of discrete events, not as an individual’s health story. Therefore, each discrete event has to pull in and document information readily available in other parts of the chart for the note to tell the whole story related to the visit.


A physician’s good clinical judgment is no longer assumed. It becomes incumbent on the physician to document the how and why of his thinking so that the rationale for a treatment decision or diagnostic assessment is explicitly stated.


Quality care is assessed through clicks and discrete phases that can be mined from notes and visit documentation easily in order to report data. As a result, it is not enough to perform the diabetic foot exam and write “normal.” I must document it with a specific pre-formed phrase that the computer will recognize as satisfying the requirement to do an annual foot exam. In the most extreme derangement of documenting quality metrics, the quality of documentation is greater than the quality of care being provided.


As a result of these issues and others, it becomes increasingly easy to write a long, poor quality note that says a lot without actually saying much of anything. CMS’s attempt to minimize “note bloat” is laudable because the government is recognizing that quantity is not superior to quality, particularly as quantity becomes easier to automate and pre-populate. However, as long as the note’s length and detail are the basis for reimbursement, decreasing documentation requirements leads to decreasing reimbursement for the same amount of clinical work. This will not succeed in driving to value. The ways to manipulate this new formula for documentation and reimbursement are obvious.


With the goal of value over volume and patients over paperwork, the equation must be simpler. What is high-value must be defined. This is not as simple as a length of stay index or an A1C level, which is partially why the necessary transition is so slow. However, it is also not as simple as a long, overly-detailed note equating to high-value or high-complexity care. CMS must go back to the drawing board to reconfigure an approach that incentivizes hysicians to document the important elements of a visit’s history while emphasizing the non-documentation and non-paperwork parts of the critically important clinical work being done.

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Sunday, September 16, 2018

Help minorities get mental health treatment

Guest Post
By Sarah Masri, MMS, PA-C

______________________________________

The stigma associated with psychiatric disorders and psychotropic medications bars many minorities from seeking mental health services.


Minorities in the United States are less likely than whites to seek mental health treatment. Among adults with diagnosis-based need for mental health or substance abuse care, more than 37 percent of whites receive treatment. Only 22 percent of Hispanics and 25 percent of African American receive treatment, according to research published in the U.S. National Library of Medicine.


While all Americans may face wait times because of psychiatric provider shortages, some minorities have added cultural barriers and socioeconomic challenges. Poverty rates among African American and Hispanics are more than double those of whites, increasing their risk for homelessness and substance abuse—all risk factors for poor mental health. Hurdles such as lack of transportation, childcare, insurance, or time off from work can further exacerbate the problem. These hurdles may seem overwhelming, but mental health awareness among minorities is slowly growing, and effective treatments are available.


How can we as providers improve the process? 

Vindicate the patient. Mental illness isn’t shameful, and those with symptoms are not lazy or weak-willed. A little education on the inheritability and pathophysiology of psychiatric disorders can help shift attitudes. 

Destigmatize psychiatric treatment. Many people liken psychiatric care to what they’ve seen in TV and movies, which does not accurately portray modern treatment. I’ve seen too many patients who truly believe that hospitalization means they’ll be held indefinitely and automatically given “shock treatment.” Providers need to give patients an explanation of treatment and medications. Many fear psychotropic medications will change their personality or make them numb to everything. Education can debunk misconceptions, minimize fears, and help patients adhere to a suggested medication regimen. 

Diversify our ranks. Minority mental health providers are underrepresented in psychiatry. Statistics show more than 70 percent of psychiatrists are white. The addition of more minority providers not only increases access to care but can make minority patients feel more comfortable about confiding in their provider.


A growing number of providers can also help ensure more people are seen. As a physician assistant (PA), I am certified to practice medicine by passing an initial national exam, completing ongoing education requirements, and passing recertification assessments every 10 years. I also earned an additional credential specific to mental health, a Certificate of Added Qualifications in Psychiatry, that requires continuing specialty education, a physician attestation, and passing a National Specialty Exam in psychiatry.


Currently, more than 1,300 PAs practice in psychiatry, according to the National Commission on Certification of Physician Assistants (NCCPA).


Through my hospital system, I’m credentialed to complete initial psychiatric evaluations and oversee the plan of care for patients admitted to Partial Hospitalization Programming and Intensive Outpatient Programming. I collaborate with the patient’s care team, fill out a patient’s disability paperwork, and complete peer-to-peer reviews with insurance companies to ensure treatment is covered. If needed, I’ll consult with my collaborating physician regarding a plan of care. Managing these cases independently, from admission to discharge, allows the physicians in my group to carry more reasonable caseloads and have more time to focus on cases of higher acuity.


I also help psychiatrists treat patients who are admitted as inpatients. After a psychiatrist completes a patient’s initial evaluation and initiates medical treatment, I’ll follow up with patients to see how they’re tolerating the newly prescribed psychotropic regimen, adjust medications as necessary, and determine when patients are ready for discharge to a lower level of care.


Our hospital system also has an intake department called the Assessment and Referral Center (ARC), which offers free mental health assessments. The ARC will complete an assessment, determine appropriate level of care, and provide the individual and family with recommendations or available resources based on their insurance plan.


We offer a multitude of services for all patients regardless of their ability to pay, but I know that’s not all that’s needed to dismantle some of the challenges minorities face. We must connect with minority patients on their terms and through culturally-informed care. In my experience, forming an empathetic connection can be a good place to start.


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