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Wednesday, January 29, 2025

Flexible, practice-centric interventions improve behavioral health integration in primary care

Patients with behavioral health conditions frequently seek care in primary care settings rather than with mental health specialists. Notably, 15.9% of patient visits to primary care primarily address mental health concerns. However, many practices struggle to meet these patients’ complex needs adequately, with only 26% to 44% of practices employing onsite behavioral health providers (BHPs), such as psychologists or social workers.

Integrated behavioral health (IBH), the intersection of behavioral health and primary care, is associated with improved patient outcomes and experiences. Yet, implementing effective, evidence-based IBH models can be challenging. To address these difficulties, a large-scale pragmatic clinical trial evaluated the effectiveness of a quality improvement (QI) toolkit designed to enhance IBH integration efforts in primary care practices.

The study, published in The Annals of Family Medicine, involved 42 randomized primary care practices. These participating practices were divided into two groups: Intervention group: Implementing the integrated behavioral health and primary care (IBH-PC) toolkit.

Control group: Continuing with standard IBH services.

Eligible practices already employed colocated BHPs and demonstrated room for improvement in integration, as assessed by the Practice Integration Profile (PIP). The PIP is a validated tool that evaluate various dimensions of IBH, including workflows, communication and patient engagement. The study also included 2,945 patient participants, all of whom had multiple chronic medical and behavioral health conditions.

The IBH-PC toolkit offered structured QI resources tailored to practice needs, including workbooks, online education, a learning community and coaching by QI professionals paired with psychologists. Practices progressed through three key stages:Planning stage:

Practices assessed their current levels of integration using tools like the PIP and identified actionable goals relevant to their unique needs. This stage emphasized aligning practice priorities with patient needs and existing workflows, laying the foundation for subsequent changes.
Workflow redesign stage: Practices developed and piloted new processes to address their goals. Examples included improving patient identification methods, refining the referral process for behavioral health services and integrating behavioral health workflows into primary care. Iterative testing allowed practices to refine these changes for broader application.
Practice changes implementation stage: Redesigned workflows were embedded into daily operations, prioritizing sustainability and cultural integration. Practices established mechanisms for continuous quality improvement to ensure lasting improvements. This stage focused on embedding changes into practice routines and maintaining momentum for ongoing transformation.

Of the 20 practices included in the intervention arm, 65% completed all three stages, while 30% completed two stages.
Integration outcomes:Intervention practices demonstrated significantly higher levels of integration compared to the control group, particularly in workflow, integration methods and patient identification domains.
Each completed intervention stage correlated with measurable improvements in PIP scores.
Patient health outcomes:No significant changes were observed in patient-reported outcomes between the intervention and control groups.
Metrics included physical function, anxiety, depression and other indicators assessed using PROMIS-29, PHQ-9 and GAD-7 scales.
The absence of measurable improvements might reflect limited direct patient engagement with BHPs, or the baseline care already addressing chronic conditions.

Researchers identified the practice-centered approach as a key strength of the intervention. By allowing practices to set their own goals and adapt the toolkit to their workflows, the intervention successfully addressed diverse needs across participating sites. However, achieving measurable patient health outcomes remains a challenge.

Researchers also noted that foundational changes, including improved integration workflows and team-based communication, might require additional time to translate into tangible patient health benefits. The findings underscore the growing importance of IBH, particularly in the wake of the COVID-19 pandemic, which amplified behavioral health needs and disrupted health care delivery.

“Primary care practices face an unprecedented challenge in the high demand for care to address the complex needs of patients with multiple chronic conditions,” the authors of the study wrote. “A practice-centric, flexible intervention aimed at improving the level of IBH in primary care can help practices transform to meet these needs and improve the health of their most complex patients.”

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Monday, January 27, 2025

Making your website compliant for patients with disabilities

Scenario: A Medicare patient using a cane and considered legally blind refuses to pay their co-pay. The patient is seen again and still does not pay the obligation for coinsurance. The office suggests that the patient see another physician. It offers to make their records available and will terminate care in thirty days. The certified letter to the patient explained that waiving the coinsurance was illegal.

The patient threatened to report the doctor and the practice to state and federal agencies for discrimination against people with disabilities because the practice wasn't handicapped accessible, the website violated the guidelines of the American Disability Act (ADA) with a non-ADA-compliant website.

Before this incident, the doctor hired IT to make the practice website ADA-compatible. The doctor's attorney informed the patient that the website was compliant and met the ADA guidelines. The lawyer told the patient that if the patient persists, the doctor will consider legal action against the patient.

With the thought that the patient might be involved in legal action that entails hiring and paying for an attorney, the patient had an "attitude adjustment" and paid the co-pays.

Although the doctor prevailed, it was a source of anxiety, spending time with legal counsel and the expense of the attorney.

Unfortunately, unscrupulous people find money by harassing healthcare providers about their compliance with ADA guidelines. The number of small businesses sued federally for website accessibility in 2018 was 2285 lawsuits—up 181% over 2017, with 814 lawsuits filed. The number has increased since then. The Americans with Disabilities Act (ADA) is a federal civil rights law passed in 1990 that prohibits discrimination against people with disabilities

ADA compliance for medical practice websites must ensure that the website is accessible and used by people with disabilities, including those with visual, auditory, cognitive, or motor impairments.

Why it's necessary to have an ADA-compliant website?

First and foremost, it is a legal requirement under the Americans with Disabilities Act (ADA) of 1990, which prohibits discrimination against individuals with disabilities in all areas of public life, including online. Failure to comply with these regulations can result in costly lawsuits, damage to a practice's reputation, and loss of potential patients. Having an accessible website can provide a practice with a competitive advantage.

A medical website accessible to everyone can attract a broader audience and increase potential patients. Moreover, accessible websites can improve search engine optimization (SEO) and make it easier for potential and existing patients to find and locate a healthcare practice online.

Additionally, having an ADA-compliant website ensures all individuals can access and interact with its content regardless of their abilities. With the increasing reliance on digital platforms for information and services, be sure that everyone can access such information, including those with disabilities.

How to ensure your medical website is ADA-compliant

To check and ensure that your website is ADA-compliant, consider the following:

Start by conducting an accessibility audit. An accessibility audit is a comprehensive review of your website's design and content to identify any issues. You can hire a website accessibility consultant or use automated accessibility testing tools like WAVE, Axe, or Lighthouse to perform an audit.

Next, familiarize yourself with the ADA compliance guidelines and ensure your website adheres to them. The Web Content Accessibility Guidelines (WCAG) 2.1 provide detailed instructions to make websites accessible to people with disabilities.

Consider asking patients with disabilities to test your website and provide feedback on its accessibility. These patients can provide valuable insights into how users with disabilities navigate and use your website.

Look at the font size of your content. About 8.1 million individuals in the U.S. have vision impairments. They may rely on screen readers or magnifiers to access your website's content. To ensure that your site is accessible to those with vision impairments, you can resize the text up to 200% without using assistive technology.

Approximately 15% of Americans, myself included, have some degree of hearing loss. To make your website's video content accessible to patients who have auditory issues, provide closed captions that display the spoken words on your videos. When adding captions, ensure they appear at the bottom of the screen rather than obscure visual features.

For patients with fine motor impairments, navigating a website using a keyboard can be easier than using a mouse. To make your site navigable by keyboard, ensure that users can jump between mouse or keyboard using the Tab, Enter, and Arrow keys.

Bottom Line: Making your website ADA-compliant can be challenging, thought-provoking, and time-consuming. This is not a job for a high school student who builds a templated website or one of the younger associates who is computer savvy. I recommend securing the advice of website design experts specializing in ADA compliance. This is the best way to see that your website is continually up-to-date and complies with the ever-evolving ADA regulations and guidelines.

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Wednesday, January 22, 2025

Lincoln's lessons for physicians on leadership

The United States has been fortunate to have many great leaders—George Washington, Franklin D. Roosevelt, Benjamin Franklin, and Martin Luther King Jr. While many others could be considered “great,” one leader who unarguably ranks at the top is Abraham Lincoln. Though he passed more than 150 years ago, his leadership continues to inspire people across all sectors of society. Interestingly, the lessons Lincoln imparted during his lifetime are still highly relevant to contemporary physicians, especially those in leadership roles. This article explores four key lessons from Lincoln that can be applied to modern healthcare leadership.

1. Be visible

Lincoln understood the importance of being physically present. He frequently left the White House to visit the frontlines, observe battles firsthand, and even come under fire. He was a leader who valued being in touch with his people, and it is said that he often mingled with soldiers, listening to their concerns, and gaining their trust.

One example of this leadership in action occurred when Lincoln relieved a general of his duties for unethical behavior and for being disconnected from the soldiers under his command. Today, we would call this approach "Management by Walking Around" (MBWA)—a concept that applies equally to healthcare leaders.

Physician leaders, like Lincoln, should leave the confines of their offices and actively engage with staff at all levels. Hospital CEOs can speak with housekeeping staff, while physician leaders should hold regular staff meetings, check in on workflow, and address any issues affecting patient care.

Lincoln’s open-door policy, where he made himself accessible to anyone who wished to speak with him, fostered trust and strengthened relationships. Similarly, physician leaders should cultivate an environment where team members feel comfortable offering feedback and know their opinions are valued. An accessible, engaged leader creates a culture of openness and collaboration.

2. Make liberal use of compliments

Lincoln understood the power of recognition. He frequently praised his staff and military leaders, offering sincere compliments that built loyalty and morale. He knew genuine praise could motivate people to work harder, often in challenging circumstances.

In a healthcare setting, physician leaders can benefit from acknowledging the contributions of their teams. A simple "thank you" can go a long way in fostering a positive work environment. In my practice, I introduced the “Thanks a Million” check—a token of appreciation given to staff members who go above and beyond for patients. For example, when a staff member delivered medication samples to a patient’s home, going beyond their job description, I used the check to recognize their exceptional effort. Small acts of appreciation like this help to build a culture of gratitude and mutual respect within a team.

3. Set an example

Effective leaders lead by example. During his presidency, Lincoln was known for his personal sacrifices, including visiting wounded soldiers in hospitals and attending their funerals. This compassion created an atmosphere of loyalty and admiration among his troops.

Setting the right example is just as important for physician leaders. If you expect your team to be punctual, you must model that behavior yourself. A physician leader who arrives late to appointments or meetings cannot expect staff or patients to respect time. For example, if patient appointments start at 9:00 a.m., the physician should aim to arrive at 8:50 a.m., setting a clear example for everyone in the practice. When leaders demonstrate the behavior they expect from others, they foster an environment of trust and accountability.

4. Use new technology

Lincoln was a forward-thinking leader who embraced the technology of his time—the telegraph. The telegraph allowed rapid communication, revolutionizing how information was exchanged during the Civil War. Lincoln’s use of this technology helped him stay informed and make quick decisions that could change the course of history.

Today, physicians can similarly leverage technology to improve communication and decision-making. Just as Lincoln used the telegraph to receive updates from the frontlines, healthcare leaders can use modern communication tools—such as electronic health records (EHRs), messaging systems, and telemedicine—to streamline operations and improve patient care.

Lincoln’s use of the telegraph also exemplified his commitment to transparency. His clear, direct communication helped eliminate confusion and enabled quick action. Modern healthcare leaders can adopt this approach by using technology to monitor operations and engage with staff and patients in meaningful ways. Social media platforms, for instance, can be used to keep patients informed and engaged, just as Lincoln used his telegraphs to stay connected with his military commanders.

Bottom Line: Leading with purpose

Lincoln’s leadership style was hands-on and deeply engaged with the realities of his situations. Many physicians today, burdened by time constraints, argue that they don’t have the luxury of interacting with staff or listening to patients how they would like. However, while we are not engaged in a war, our task is equally vital: saving lives. Like Lincoln, we must lead purposefully, actively engaging with those around us and setting the example for the culture we wish to cultivate.

Physician leaders who adopt these four principles—being visible, offering compliments, setting an example, and embracing new technologies—can improve the workplace environment and patient care. Ultimately, leadership isn’t just about managing processes; it’s about making meaningful connections with people and guiding them toward a shared vision.

_____________________________

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, Marketing Your Medical Practice-Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish.

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Monday, January 20, 2025

Primary care predictions for 2030

In a 2022 report, Bain & Company, a global management consultant firm based in Boston, Massachusetts, released their 2030 market share forecast for the U.S. primary care market. The group predicted the evolution of reimbursement, care and ownership models over the course of the decade, and how their development would impact the primary care market. In their report, they predicted that nontraditional care providers—which include retailers, payers and advanced primary care (APC) providers, among others—would be key players in the transformation of primary care, capturing 30% of the market by 2030.

According to their latest brief, released on December 4, 2024, several of their predictions from two years ago hold true in 2024. Although they’re sticking with their initial predictions, they have made some refinements to their forecast, largely influenced by the strategic repositioning of major retailers and APC providers, the accelerated growth of payer investment through existing primary care delivery capabilities and the rapid growth of enablers.

Their updated forecast expects the share of primary care patients who are served by traditional fee-for-service providers to decrease quicker than they had previously anticipated. Also, while they maintain their expectation that nontraditional providers will serve approximately 30% of primary care patients in 2030, they now project a different mix among those providers. Their latest forecast projects significant growth from payer-owned providers and enabled primary care providers.

Retailer primary care

The report draws attention to specific examples of big-name retailers like Walmart and Walgreens exiting the primary care space within the past few years, indicating that those moves reflect an increased recognition of how difficult it can be to succeed in comprehensive primary care, particularly when balancing different business models. The group expects the retailers that will be successful in primary care are those that focus on three key objectives:Building the right model.
Investing to evolve their brand.

Ensuring that the right health care expertise exists within their organization.

Health care payers

In 2030, payer-owned primary care is projected to account for 20% of the U.S. primary care market. According to the report, payers find themselves well positioned to navigate the challenges of the primary care industry while scaling effectively, largely due to their past investments in care delivery. Well-established payer-owned health service organizations have developed the capabilities to manage complex primary care delivery, network curation and physician practice management capabilities to support successful care delivery.

Advanced primary care (APC)

APC providers are expected to scale, especially among providers catering to seniors, in 2030. However, they will face additional challenges due to tighter economic conditions and evolving regulations. Medicare Advantage plans continue to encounter obstacles including decelerating growth, updates to risk adjustment models by the Centers for Medicare & Medicaid Services (CMS) and star rating changes. For example, the shift from risk assessment model Version 24 to Version 28 is projected to reduce revenues by 2% to 4%, significantly impacting profitability. Success in this environment will depend on APC providers’ ability to decrease total care costs while delivering high-quality outcomes, solidifying competitive advantage.

Traditional and enabled primary care providers

Bain & Company projects that, moving forward, providers who want to remain independent will look to partner with enablers who can help them successfully transition from fee-for-service payment to value-based payment models, following market demands.

Investment in value-based care (VBC) enablers has seen significant growth, and their influence is expected to continue growing, with enabler-supported providers projected to manage 10% of primary care patients by 2030—up from tan estimated 4% two years ago. However, enablers, like APC providers, will face comparable regulatory challenges. According to the report, the impact that risk adjustment model Version 28 will have on enablers will vary, though it could particularly impact enablers and providers serving higher-risk populations.

Projections indicate that VBC-based enablers that consistently demonstrate cost reductions and high-quality health outcomes will see the most success. According to a Jefferies analysis of CMS data referenced in the report, the top performers in the Medicare Shared Savings Program (MSSP) achieved greater than 7% in cost savings in 2022. The ability to successfully leverage primary care as a means to reduce expensive hospital admissions will remain a key success factor, benefiting both enablers and the physicians they support.

Health systems

Traditional health systems are forced to confront increased competition from population-focused disruptors and nontraditional providers. According to the forecast, the challenges health systems face will depend heavily on the competitive pressures in their local markets, driving significant strategic shifts in the years ahead.

In markets with more competition, health systems will likely adopt one of several approaches to retain relevance. One potential strategy involves becoming the preferred specialty and tertiary care partner for risk-taking primary care providers. By prioritizing specialty care that is both cost-effective and high-quality, these systems can secure referral relationships but must also keep specialty care expenses in check. Other potential strategies include innovating primary care delivery or developing direct-to-employer models to take on greater financial risk.

For health systems choosing to transform, the report highlights critical areas for investment, including improved patient experience, the adoption of advanced digital tools, enhanced care management and a multidisciplinary approach to care delivery. The report also points out that health systems can leverage partnerships with VBC enablers to accelerate their adoption of these innovative practices. With that said, the degree of urgency can vary. In markets where health systems maintain a dominant market share, they’re more insulated from otherwise-disruptive pressures, which could potentially allow them to maintain the status quo for a longer duration without significant overhaul.

As primary care continues to evolve, the report emphasizes the need for health systems to thoroughly assess their existing assets and competitive standing. Those prepared to adapt could position themselves to excel in the increasingly value-focused primary care landscape projected for 2030. Bain & Company anticipates that nontraditional providers will capture a substantial market share, population-focused models will excel at managing payment risk despite facing regulatory and reimbursement challenges, and there will be uncertainty about whether retailers can provide comprehensive primary care. Ultimately, primary care will remain a hub of innovation, with its ownership structure continuing to shift.

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