Practice Management Toolbox

Author's note: This is the first of a two-part series. In December 2018, Atlanta Gastroenterology Associates partnered with Frazier Healthcare Partners to form the practice management company United Digestive (UD). Since that time, colleagues across the country have evaluated their own private equity prospects and partnerships, as well as monitored the progress of our transition.

Our guiding principle is to provide a best-in-class operational infrastructure, so independent gastroenterologists can focus on delivering the highest quality patient care. Thus, in the first year, significant efforts and capital have been invested into United Digestive’s scalable platform to promote organic growth, as well as facilitate a smooth transition for other groups and physicians joining the team. So how are things going? Enjoy this two-part article where we reached out to several team members from all levels within the organization and asked them to share their personal experiences – both highlights and challenges – during UD’s first year. Here’s what they had to say.
 

During the COVID-19 crisis, how has UD management responded? How has the UD management services organization model affected partner level physician (PLP) compensation?

Dr. Marc Rosenberg, UD Physician Executive Committee member:

• “Immediately, the entire leadership team recognized the threat of COVID to our community, patients, staff, and business. A multidisciplinary task force including clinical and business leaders utilized our PE partner’s vast resources, local hospital expertise, national societal recommendations and colleagues’ experiences from around the country to focus on protocols and procedures to protect our patients and staff. A few of the team’s timely decisions included: closing the majority of our patient fronting services, transitioning to telehealth, hiring an infection control consultant, allowing physical distancing of our staff with off sight work, instituting symptomatic pathways, donating personal protective gear to local hospitals, covering all benefits as well as provided resources to obtain government benefits to furloughed team members, developing a provider wellness program, and encouraging hospital coverage considerations for high risk providers. I also know the team is focusing on how we re-open at the appropriate time with necessary safety considerations, like investigating testing options and ensuring appropriate PPE is in place. The collaboration between clinical and business leadership has been tremendous through this evolving and challenging period. As for UD physician partner compensation, our model is uniquely organized such that the MSO covers all overhead expenses with partners contributing a fixed percentage of a partner’s collections, while others typically share overhead expenses. During uncertain times, like the COVID-19 crisis, it is reassuring to partners to know that they are not responsible for the cost of infrastructure (i.e. leases, capital equipment, EHR system, consultants, etc.) and staffing, including current and new associates.”

With formation of United Digestive as an MSO, has your day-to-day work life changed or your clinical decision-making been impacted?

Dr. Aja McCutchen, UD Physician Executive Committee Member:

• “With the formation of UD, my daily work life has changed very little; however, with their focus on improving “back-office” functions, my schedule is now fully optimized by reducing gaps from cancellations with same-day/next-day scheduling. In addition, the patient experience has been enhanced with decreased wait times, easier appointment scheduling, and quicker access to support staff. The procurement of business intelligence tools, and, more importantly, the implementation of dashboards, has provided much needed visibility across the organization allowing managerial decisions to be driven by accurate data.

From a clinical decision-making standpoint, Atlanta Gastroenterology was already armed with strong clinical teams and committees. We have been able to build upon our pre-existing committees and optimize their ability to steward best practices and develop clinical pathways. This, in turn, translates to consistency across the organization in the delivery of evidence-based, comprehensive GI care.”
 

Kimberly Orleck, PA-C, Advanced Practice Provider (APP) Supervisor:

• “The formation of UD has not affected my clinical decision-making abilities. In fact, this new platform is dedicated to empowering and establishing APPs as independent clinicians with appropriate physician oversight. As a result, I have welcomed more administrative responsibilities and have become more involved in business meetings and decision making. We have worked together to better utilize APPs using data to match supply with demand.”

Physician compensation improvement is typically a key concern for physicians who work with private equity MSOs. How has United Digestive performed for its partner-level physicians in year one?

Dr. Marc Rosenberg:

• “The MSO has helped to improve physician income – slowly at first and now on a steeper trajectory. We have been ahead of expected income improvement based on models we reviewed when evaluating the formations of an MSO in potential partnership with Frazier Healthcare Partners. United Digestive’s EBIDTA, of which each partner-level physician owns a significant percentage through shares from rollover proceeds, has grown impressively in one year. This has been achieved mostly through significant organic growth and to a lesser degree through mergers and acquisitions. UD has helped to enhance the bottom line through increased reimbursements from payor negotiated contracts, new revenue-generating service lines, and operational efficiencies.”

Dr. Patel and Dr. Sonnenshine are with Atlanta Gastroenterology Associates in Atlanta, which is part of United Digestive. They have no conflicts.

*This story was updated on 6/1/2020.

Author's note: This is the first of a two-part series. In December 2018, Atlanta Gastroenterology Associates partnered with Frazier Healthcare Partners to form the practice management company United Digestive (UD). Since that time, colleagues across the country have evaluated their own private equity prospects and partnerships, as well as monitored the progress of our transition.

Our guiding principle is to provide a best-in-class operational infrastructure, so independent gastroenterologists can focus on delivering the highest quality patient care. Thus, in the first year, significant efforts and capital have been invested into United Digestive’s scalable platform to promote organic growth, as well as facilitate a smooth transition for other groups and physicians joining the team. So how are things going? Enjoy this two-part article where we reached out to several team members from all levels within the organization and asked them to share their personal experiences – both highlights and challenges – during UD’s first year. Here’s what they had to say.
 

During the COVID-19 crisis, how has UD management responded? How has the UD management services organization model affected partner level physician (PLP) compensation?

Dr. Marc Rosenberg, UD Physician Executive Committee member:

• “Immediately, the entire leadership team recognized the threat of COVID to our community, patients, staff, and business. A multidisciplinary task force including clinical and business leaders utilized our PE partner’s vast resources, local hospital expertise, national societal recommendations and colleagues’ experiences from around the country to focus on protocols and procedures to protect our patients and staff. A few of the team’s timely decisions included: closing the majority of our patient fronting services, transitioning to telehealth, hiring an infection control consultant, allowing physical distancing of our staff with off sight work, instituting symptomatic pathways, donating personal protective gear to local hospitals, covering all benefits as well as provided resources to obtain government benefits to furloughed team members, developing a provider wellness program, and encouraging hospital coverage considerations for high risk providers. I also know the team is focusing on how we re-open at the appropriate time with necessary safety considerations, like investigating testing options and ensuring appropriate PPE is in place. The collaboration between clinical and business leadership has been tremendous through this evolving and challenging period. As for UD physician partner compensation, our model is uniquely organized such that the MSO covers all overhead expenses with partners contributing a fixed percentage of a partner’s collections, while others typically share overhead expenses. During uncertain times, like the COVID-19 crisis, it is reassuring to partners to know that they are not responsible for the cost of infrastructure (i.e. leases, capital equipment, EHR system, consultants, etc.) and staffing, including current and new associates.”

With formation of United Digestive as an MSO, has your day-to-day work life changed or your clinical decision-making been impacted?

Dr. Aja McCutchen, UD Physician Executive Committee Member:

• “With the formation of UD, my daily work life has changed very little; however, with their focus on improving “back-office” functions, my schedule is now fully optimized by reducing gaps from cancellations with same-day/next-day scheduling. In addition, the patient experience has been enhanced with decreased wait times, easier appointment scheduling, and quicker access to support staff. The procurement of business intelligence tools, and, more importantly, the implementation of dashboards, has provided much needed visibility across the organization allowing managerial decisions to be driven by accurate data.

From a clinical decision-making standpoint, Atlanta Gastroenterology was already armed with strong clinical teams and committees. We have been able to build upon our pre-existing committees and optimize their ability to steward best practices and develop clinical pathways. This, in turn, translates to consistency across the organization in the delivery of evidence-based, comprehensive GI care.”
 

Kimberly Orleck, PA-C, Advanced Practice Provider (APP) Supervisor:

• “The formation of UD has not affected my clinical decision-making abilities. In fact, this new platform is dedicated to empowering and establishing APPs as independent clinicians with appropriate physician oversight. As a result, I have welcomed more administrative responsibilities and have become more involved in business meetings and decision making. We have worked together to better utilize APPs using data to match supply with demand.”

Physician compensation improvement is typically a key concern for physicians who work with private equity MSOs. How has United Digestive performed for its partner-level physicians in year one?

Dr. Marc Rosenberg:

• “The MSO has helped to improve physician income – slowly at first and now on a steeper trajectory. We have been ahead of expected income improvement based on models we reviewed when evaluating the formations of an MSO in potential partnership with Frazier Healthcare Partners. United Digestive’s EBIDTA, of which each partner-level physician owns a significant percentage through shares from rollover proceeds, has grown impressively in one year. This has been achieved mostly through significant organic growth and to a lesser degree through mergers and acquisitions. UD has helped to enhance the bottom line through increased reimbursements from payor negotiated contracts, new revenue-generating service lines, and operational efficiencies.”

Dr. Patel and Dr. Sonnenshine are with Atlanta Gastroenterology Associates in Atlanta, which is part of United Digestive. They have no conflicts.

*This story was updated on 6/1/2020.

Author's note: This is the first of a two-part series. In December 2018, Atlanta Gastroenterology Associates partnered with Frazier Healthcare Partners to form the practice management company United Digestive (UD). Since that time, colleagues across the country have evaluated their own private equity prospects and partnerships, as well as monitored the progress of our transition.

Our guiding principle is to provide a best-in-class operational infrastructure, so independent gastroenterologists can focus on delivering the highest quality patient care. Thus, in the first year, significant efforts and capital have been invested into United Digestive’s scalable platform to promote organic growth, as well as facilitate a smooth transition for other groups and physicians joining the team. So how are things going? Enjoy this two-part article where we reached out to several team members from all levels within the organization and asked them to share their personal experiences – both highlights and challenges – during UD’s first year. Here’s what they had to say.
 

During the COVID-19 crisis, how has UD management responded? How has the UD management services organization model affected partner level physician (PLP) compensation?

Dr. Marc Rosenberg, UD Physician Executive Committee member:

• “Immediately, the entire leadership team recognized the threat of COVID to our community, patients, staff, and business. A multidisciplinary task force including clinical and business leaders utilized our PE partner’s vast resources, local hospital expertise, national societal recommendations and colleagues’ experiences from around the country to focus on protocols and procedures to protect our patients and staff. A few of the team’s timely decisions included: closing the majority of our patient fronting services, transitioning to telehealth, hiring an infection control consultant, allowing physical distancing of our staff with off sight work, instituting symptomatic pathways, donating personal protective gear to local hospitals, covering all benefits as well as provided resources to obtain government benefits to furloughed team members, developing a provider wellness program, and encouraging hospital coverage considerations for high risk providers. I also know the team is focusing on how we re-open at the appropriate time with necessary safety considerations, like investigating testing options and ensuring appropriate PPE is in place. The collaboration between clinical and business leadership has been tremendous through this evolving and challenging period. As for UD physician partner compensation, our model is uniquely organized such that the MSO covers all overhead expenses with partners contributing a fixed percentage of a partner’s collections, while others typically share overhead expenses. During uncertain times, like the COVID-19 crisis, it is reassuring to partners to know that they are not responsible for the cost of infrastructure (i.e. leases, capital equipment, EHR system, consultants, etc.) and staffing, including current and new associates.”

With formation of United Digestive as an MSO, has your day-to-day work life changed or your clinical decision-making been impacted?

Dr. Aja McCutchen, UD Physician Executive Committee Member:

• “With the formation of UD, my daily work life has changed very little; however, with their focus on improving “back-office” functions, my schedule is now fully optimized by reducing gaps from cancellations with same-day/next-day scheduling. In addition, the patient experience has been enhanced with decreased wait times, easier appointment scheduling, and quicker access to support staff. The procurement of business intelligence tools, and, more importantly, the implementation of dashboards, has provided much needed visibility across the organization allowing managerial decisions to be driven by accurate data.

From a clinical decision-making standpoint, Atlanta Gastroenterology was already armed with strong clinical teams and committees. We have been able to build upon our pre-existing committees and optimize their ability to steward best practices and develop clinical pathways. This, in turn, translates to consistency across the organization in the delivery of evidence-based, comprehensive GI care.”
 

Kimberly Orleck, PA-C, Advanced Practice Provider (APP) Supervisor:

• “The formation of UD has not affected my clinical decision-making abilities. In fact, this new platform is dedicated to empowering and establishing APPs as independent clinicians with appropriate physician oversight. As a result, I have welcomed more administrative responsibilities and have become more involved in business meetings and decision making. We have worked together to better utilize APPs using data to match supply with demand.”

Physician compensation improvement is typically a key concern for physicians who work with private equity MSOs. How has United Digestive performed for its partner-level physicians in year one?

Dr. Marc Rosenberg:

• “The MSO has helped to improve physician income – slowly at first and now on a steeper trajectory. We have been ahead of expected income improvement based on models we reviewed when evaluating the formations of an MSO in potential partnership with Frazier Healthcare Partners. United Digestive’s EBIDTA, of which each partner-level physician owns a significant percentage through shares from rollover proceeds, has grown impressively in one year. This has been achieved mostly through significant organic growth and to a lesser degree through mergers and acquisitions. UD has helped to enhance the bottom line through increased reimbursements from payor negotiated contracts, new revenue-generating service lines, and operational efficiencies.”

Dr. Patel and Dr. Sonnenshine are with Atlanta Gastroenterology Associates in Atlanta, which is part of United Digestive. They have no conflicts.

*This story was updated on 6/1/2020.

Every year, the Centers for Medicare & Medicaid Services (CMS) releases their proposed recommendations for the next performance year and in 2019, the gastroenterology community was surprised that CMS recommended removal of QPP 0343 – Screening Colonoscopy Adenoma Detection Rate from a reportable measure in the Quality Payment Program. So what happened? Why was the measure removed from the QPP? Is there anything that we can do?

Over the next several months we will be publishing a series of articles related to the Adenoma Detection Rate Measure to give every gastroenterologist an inside look at the work that is done on your behalf and steps that you can take in the future to help your fellow gastroenterologists.

This current article explains the joint effort made by all GI societies to try to save the Adenoma Detection Rate measure from removal from the 2020 Quality Payment Program. All societies uniformly submitted a letter to CMS in disapproval of the recommendation and outlined the importance of this measure as follows:
 

Measure 343: Screening Colonoscopy Adenoma Detection Rate

Our societies are disappointed and disagree with CMS’s decision to remove Measure 343: Screening Colonoscopy Adenoma Detection Rate (ADR) from the Quality Payment Program (QPP) beginning with the 2020 performance year.

The ADR plays a central role in quality improvement and colorectal cancer screening. We urge CMS to reconsider this decision and issue a technical correction to reinstate the measure back into the QPP, as it is the only outcome measure specific to endoscopic skills of gastroenterologists currently available for public reporting.

Studies show that high adenoma detection rates are associated with a significant reduction in colorectal cancer risk.¹ Virtually all studies on this subject have demonstrated that there is, in fact, marked variation in adenoma detection rates among physicians. Further, ADR is essential to recommended intervals² between screening and surveillance examinations.^2,3

1. Variables influencing ADR. CMS explained that the measure does not account for variables that may influence the ADR such as geographic location, socioeconomic status of patient population, community compliance of screening, etc. The agency further states that according to the risk factors outlined by the American Cancer Society, African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. “In addition, dietary factors, such as consumption of highly processed meats will contribute to an increased risk of colorectal cancer. This diet is more prevalent in lower socioeconomic areas, which could influence the outcome of the measure. There are other patient factors like education, health literacy, etc. that might also affect things like the adequacy of bowel preparation, which in turn could affect performance.”

The societies advised CMS that this rationale reflects a misunderstanding of the definition of ADR, which includes all average-risk patients in whom the physician finds at least one adenoma. Further, ADR only includes colonoscopies with adequate bowel preparation and complete examinations. Studies demonstrate that ADR is not influenced by socioeconomic status and sex mix of the provider’s patient population, or by the rate of screening in the community.

Socioeconomics, ethnicity, and diet are not relevant factors of ADR. That said, our societies welcome the opportunity to work with CMS on creating age and sex standardized ADRs for the U.S. population, if feasible, in order to capture information that CMS deems important.

2. Failure to detect all adenomas. CMS stated that the measure does not account for MIPS eligible clinicians that fail to detect adenomas but may score higher based on the patient population.

The societies pushed back with CMS explaining that this rationale again reflects a misunderstanding of the definition of ADR, which includes average-risk patients for whom the physician finds at least one adenoma. Colonoscopy is heavily operator dependent. In an average-risk, mixed population, the variability in ADR reflects quality of the provider’s endoscopic skills and pathology recognition, rather than the risk of the underlying population.

3. Incidence measure. CMS concluded that Measure 343: Screening Colonoscopy Adenoma Detection Rate is considered an “incidence measure” that does not assess the quality of the care provided. In essence, according to CMS, the measure is based on happenstance rather than the eligible clinician providing a thorough examination.

The societies strongly disagreed with this characterization of ADR. Measure 343: Screening Colonoscopy Adenoma Detection Rate is the only measure that assess the quality of the exam performed by the physician in an average-risk patient with an adequate bowel preparation. Physicians can improve their adenoma detection rate by paying attention to detail, spending more time looking for adenomas, and learning better techniques.

4. Benchmarking. CMS stated that because of the measure construct, benchmarks calculated from this measure are misrepresented and do not align with the MIPS scoring methodology where 100% indicates better clinical care or control. Guidelines and supplemental literature support a performance target for adenoma detection rate of 25% for a mixed sex population (20% in women and 30% in men). CMS determined that Measure 343: Screening Colonoscopy Adenoma Detection Rate may be appropriate for other programs but does not align with the scoring logic within MIPS. When this measure was introduced, according to the agency, it was under the legacy program, Physician Quality Reporting System (PQRS), a pay-for-reporting program that does not have the same scoring implications as MIPS.

The societies reminded CMS that the 25% is the minimum requirement for performance and is not a benchmark. This minimum requirement continues to increase as well. With 25% being the threshold, for every 1% increase in ADR the risk of fatal interval colon cancer decreases by 3%. In one important study by Corley et al, the lowest quintile of ADR was 19% or lower, and was associated with the highest risk of interval colon cancer.⁴

CMS must begin to move beyond traditional approaches toward benchmarking performance where 100% compliance is expected. It was encouraging to see CMS acknowledge that nuances to evaluating scores are needed based on the ability of a measure to accurately identify and capture performance based on the patient population and measure specifications. For example, these adjustments were finalized for the blood pressure and diabetes HbA_1c measures, where the highest number of points will be achieved for anyone scoring 90% or higher. This modification was based on the knowledge that it is not realistic nor in the interest of patients to assume that clinicians will be able to achieve the desired targeted outcome for every patient. The potential for unintended consequences was factored into an assessment of what performance could be considered achievable.

In our view, ADR is a similar example where 100% performance across a clinician’s population of patients is biologically impossible since not every individual who receives a screening colonoscopy will have an adenoma detected. ADR is the best-established colorectal neoplasia-related quality indicator and research demonstrates that high rates are associated with significant reductions in colorectal cancer risk.

CMS must continue to explore alternative strategies toward benchmarking in MIPS to ensure that achievement is fairly assessed, and top performance scores are determined not solely based on peer performance but also based on clinical evidence balanced with minimizing unintended consequences. The MIPS program and its benchmarking and scoring methodologies must continue to innovate to ensure that physicians provide the best possible care to their patients while also accurately and fairly representing and rewarding clinicians’ performance. Continuing to promote a siloed view toward quality will only reduce the relevance of the MIPS program and lead our members to question the integrity and validity of the program.

References

1. Kaminski MF, Regula J, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-803.

2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.

3. Rubin CE, Haggitt RC, Burmer GC, et al. DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis. Gastroenterology. 1992;103:1611-20.

4. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298-306.

5. Kaminski MF, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017 Jul;153[1]:98-105. doi: 10.1053/j.gastro.2017.04.006. Epub 2017 Apr 17.

6. ASGE practice guideline: Measuring the quality of endoscopy. Gastrointest Endosc. 2006;58:S1-S38.

7. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rate. Gastrointest Endosc. 2000;51:33-6.

8. Barclay RL, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091-8.

9. Shaukat A, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology. 2015 Oct;149[4]:952-7

10. Lee S, et al. Am J Gastroenterol. 2016 Jan;111(1):63-9.

11. Jia H, et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112(4):568-76.

12. ASGE. Endoscopes and devices to improve colon polyp detection. GIE 2015;81:1122-9.

13. Ussui V, et al. Am J Gastroenterol. 2015;110:489-96.

14. Kaminski MF, et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016;65:616-24.

15. Shaukat A, et al. Rates of detection of adenoma, sessile serrated adenoma, and advanced adenoma are stable over time and modifiable. Gastroenterology 2018(Feb);156:816-7.

Dr. Adams is a gastroenterologist and assistant professor at the University of Michigan, Ann Arbor; Dr. Leiman is a gastroenterologist and assistant professor of medicine at Duke Health, Durham, N.C.; Dr. Mathews is a gastroenterologist and leader of Clinical Innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.

Every year, the Centers for Medicare & Medicaid Services (CMS) releases their proposed recommendations for the next performance year and in 2019, the gastroenterology community was surprised that CMS recommended removal of QPP 0343 – Screening Colonoscopy Adenoma Detection Rate from a reportable measure in the Quality Payment Program. So what happened? Why was the measure removed from the QPP? Is there anything that we can do?

Over the next several months we will be publishing a series of articles related to the Adenoma Detection Rate Measure to give every gastroenterologist an inside look at the work that is done on your behalf and steps that you can take in the future to help your fellow gastroenterologists.

This current article explains the joint effort made by all GI societies to try to save the Adenoma Detection Rate measure from removal from the 2020 Quality Payment Program. All societies uniformly submitted a letter to CMS in disapproval of the recommendation and outlined the importance of this measure as follows:
 

Measure 343: Screening Colonoscopy Adenoma Detection Rate

Our societies are disappointed and disagree with CMS’s decision to remove Measure 343: Screening Colonoscopy Adenoma Detection Rate (ADR) from the Quality Payment Program (QPP) beginning with the 2020 performance year.

The ADR plays a central role in quality improvement and colorectal cancer screening. We urge CMS to reconsider this decision and issue a technical correction to reinstate the measure back into the QPP, as it is the only outcome measure specific to endoscopic skills of gastroenterologists currently available for public reporting.

Studies show that high adenoma detection rates are associated with a significant reduction in colorectal cancer risk.¹ Virtually all studies on this subject have demonstrated that there is, in fact, marked variation in adenoma detection rates among physicians. Further, ADR is essential to recommended intervals² between screening and surveillance examinations.^2,3

1. Variables influencing ADR. CMS explained that the measure does not account for variables that may influence the ADR such as geographic location, socioeconomic status of patient population, community compliance of screening, etc. The agency further states that according to the risk factors outlined by the American Cancer Society, African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. “In addition, dietary factors, such as consumption of highly processed meats will contribute to an increased risk of colorectal cancer. This diet is more prevalent in lower socioeconomic areas, which could influence the outcome of the measure. There are other patient factors like education, health literacy, etc. that might also affect things like the adequacy of bowel preparation, which in turn could affect performance.”

The societies advised CMS that this rationale reflects a misunderstanding of the definition of ADR, which includes all average-risk patients in whom the physician finds at least one adenoma. Further, ADR only includes colonoscopies with adequate bowel preparation and complete examinations. Studies demonstrate that ADR is not influenced by socioeconomic status and sex mix of the provider’s patient population, or by the rate of screening in the community.

Socioeconomics, ethnicity, and diet are not relevant factors of ADR. That said, our societies welcome the opportunity to work with CMS on creating age and sex standardized ADRs for the U.S. population, if feasible, in order to capture information that CMS deems important.

2. Failure to detect all adenomas. CMS stated that the measure does not account for MIPS eligible clinicians that fail to detect adenomas but may score higher based on the patient population.

The societies pushed back with CMS explaining that this rationale again reflects a misunderstanding of the definition of ADR, which includes average-risk patients for whom the physician finds at least one adenoma. Colonoscopy is heavily operator dependent. In an average-risk, mixed population, the variability in ADR reflects quality of the provider’s endoscopic skills and pathology recognition, rather than the risk of the underlying population.

3. Incidence measure. CMS concluded that Measure 343: Screening Colonoscopy Adenoma Detection Rate is considered an “incidence measure” that does not assess the quality of the care provided. In essence, according to CMS, the measure is based on happenstance rather than the eligible clinician providing a thorough examination.

The societies strongly disagreed with this characterization of ADR. Measure 343: Screening Colonoscopy Adenoma Detection Rate is the only measure that assess the quality of the exam performed by the physician in an average-risk patient with an adequate bowel preparation. Physicians can improve their adenoma detection rate by paying attention to detail, spending more time looking for adenomas, and learning better techniques.

4. Benchmarking. CMS stated that because of the measure construct, benchmarks calculated from this measure are misrepresented and do not align with the MIPS scoring methodology where 100% indicates better clinical care or control. Guidelines and supplemental literature support a performance target for adenoma detection rate of 25% for a mixed sex population (20% in women and 30% in men). CMS determined that Measure 343: Screening Colonoscopy Adenoma Detection Rate may be appropriate for other programs but does not align with the scoring logic within MIPS. When this measure was introduced, according to the agency, it was under the legacy program, Physician Quality Reporting System (PQRS), a pay-for-reporting program that does not have the same scoring implications as MIPS.

The societies reminded CMS that the 25% is the minimum requirement for performance and is not a benchmark. This minimum requirement continues to increase as well. With 25% being the threshold, for every 1% increase in ADR the risk of fatal interval colon cancer decreases by 3%. In one important study by Corley et al, the lowest quintile of ADR was 19% or lower, and was associated with the highest risk of interval colon cancer.⁴

CMS must begin to move beyond traditional approaches toward benchmarking performance where 100% compliance is expected. It was encouraging to see CMS acknowledge that nuances to evaluating scores are needed based on the ability of a measure to accurately identify and capture performance based on the patient population and measure specifications. For example, these adjustments were finalized for the blood pressure and diabetes HbA_1c measures, where the highest number of points will be achieved for anyone scoring 90% or higher. This modification was based on the knowledge that it is not realistic nor in the interest of patients to assume that clinicians will be able to achieve the desired targeted outcome for every patient. The potential for unintended consequences was factored into an assessment of what performance could be considered achievable.

In our view, ADR is a similar example where 100% performance across a clinician’s population of patients is biologically impossible since not every individual who receives a screening colonoscopy will have an adenoma detected. ADR is the best-established colorectal neoplasia-related quality indicator and research demonstrates that high rates are associated with significant reductions in colorectal cancer risk.

CMS must continue to explore alternative strategies toward benchmarking in MIPS to ensure that achievement is fairly assessed, and top performance scores are determined not solely based on peer performance but also based on clinical evidence balanced with minimizing unintended consequences. The MIPS program and its benchmarking and scoring methodologies must continue to innovate to ensure that physicians provide the best possible care to their patients while also accurately and fairly representing and rewarding clinicians’ performance. Continuing to promote a siloed view toward quality will only reduce the relevance of the MIPS program and lead our members to question the integrity and validity of the program.

References

1. Kaminski MF, Regula J, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-803.

2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.

3. Rubin CE, Haggitt RC, Burmer GC, et al. DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis. Gastroenterology. 1992;103:1611-20.

4. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298-306.

5. Kaminski MF, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017 Jul;153[1]:98-105. doi: 10.1053/j.gastro.2017.04.006. Epub 2017 Apr 17.

6. ASGE practice guideline: Measuring the quality of endoscopy. Gastrointest Endosc. 2006;58:S1-S38.

7. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rate. Gastrointest Endosc. 2000;51:33-6.

8. Barclay RL, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091-8.

9. Shaukat A, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology. 2015 Oct;149[4]:952-7

10. Lee S, et al. Am J Gastroenterol. 2016 Jan;111(1):63-9.

11. Jia H, et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112(4):568-76.

12. ASGE. Endoscopes and devices to improve colon polyp detection. GIE 2015;81:1122-9.

13. Ussui V, et al. Am J Gastroenterol. 2015;110:489-96.

14. Kaminski MF, et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016;65:616-24.

15. Shaukat A, et al. Rates of detection of adenoma, sessile serrated adenoma, and advanced adenoma are stable over time and modifiable. Gastroenterology 2018(Feb);156:816-7.

Dr. Adams is a gastroenterologist and assistant professor at the University of Michigan, Ann Arbor; Dr. Leiman is a gastroenterologist and assistant professor of medicine at Duke Health, Durham, N.C.; Dr. Mathews is a gastroenterologist and leader of Clinical Innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.

Every year, the Centers for Medicare & Medicaid Services (CMS) releases their proposed recommendations for the next performance year and in 2019, the gastroenterology community was surprised that CMS recommended removal of QPP 0343 – Screening Colonoscopy Adenoma Detection Rate from a reportable measure in the Quality Payment Program. So what happened? Why was the measure removed from the QPP? Is there anything that we can do?

Over the next several months we will be publishing a series of articles related to the Adenoma Detection Rate Measure to give every gastroenterologist an inside look at the work that is done on your behalf and steps that you can take in the future to help your fellow gastroenterologists.

This current article explains the joint effort made by all GI societies to try to save the Adenoma Detection Rate measure from removal from the 2020 Quality Payment Program. All societies uniformly submitted a letter to CMS in disapproval of the recommendation and outlined the importance of this measure as follows:
 

Measure 343: Screening Colonoscopy Adenoma Detection Rate

Our societies are disappointed and disagree with CMS’s decision to remove Measure 343: Screening Colonoscopy Adenoma Detection Rate (ADR) from the Quality Payment Program (QPP) beginning with the 2020 performance year.

The ADR plays a central role in quality improvement and colorectal cancer screening. We urge CMS to reconsider this decision and issue a technical correction to reinstate the measure back into the QPP, as it is the only outcome measure specific to endoscopic skills of gastroenterologists currently available for public reporting.

Studies show that high adenoma detection rates are associated with a significant reduction in colorectal cancer risk.¹ Virtually all studies on this subject have demonstrated that there is, in fact, marked variation in adenoma detection rates among physicians. Further, ADR is essential to recommended intervals² between screening and surveillance examinations.^2,3

1. Variables influencing ADR. CMS explained that the measure does not account for variables that may influence the ADR such as geographic location, socioeconomic status of patient population, community compliance of screening, etc. The agency further states that according to the risk factors outlined by the American Cancer Society, African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. “In addition, dietary factors, such as consumption of highly processed meats will contribute to an increased risk of colorectal cancer. This diet is more prevalent in lower socioeconomic areas, which could influence the outcome of the measure. There are other patient factors like education, health literacy, etc. that might also affect things like the adequacy of bowel preparation, which in turn could affect performance.”

The societies advised CMS that this rationale reflects a misunderstanding of the definition of ADR, which includes all average-risk patients in whom the physician finds at least one adenoma. Further, ADR only includes colonoscopies with adequate bowel preparation and complete examinations. Studies demonstrate that ADR is not influenced by socioeconomic status and sex mix of the provider’s patient population, or by the rate of screening in the community.

Socioeconomics, ethnicity, and diet are not relevant factors of ADR. That said, our societies welcome the opportunity to work with CMS on creating age and sex standardized ADRs for the U.S. population, if feasible, in order to capture information that CMS deems important.

2. Failure to detect all adenomas. CMS stated that the measure does not account for MIPS eligible clinicians that fail to detect adenomas but may score higher based on the patient population.

The societies pushed back with CMS explaining that this rationale again reflects a misunderstanding of the definition of ADR, which includes average-risk patients for whom the physician finds at least one adenoma. Colonoscopy is heavily operator dependent. In an average-risk, mixed population, the variability in ADR reflects quality of the provider’s endoscopic skills and pathology recognition, rather than the risk of the underlying population.

3. Incidence measure. CMS concluded that Measure 343: Screening Colonoscopy Adenoma Detection Rate is considered an “incidence measure” that does not assess the quality of the care provided. In essence, according to CMS, the measure is based on happenstance rather than the eligible clinician providing a thorough examination.

The societies strongly disagreed with this characterization of ADR. Measure 343: Screening Colonoscopy Adenoma Detection Rate is the only measure that assess the quality of the exam performed by the physician in an average-risk patient with an adequate bowel preparation. Physicians can improve their adenoma detection rate by paying attention to detail, spending more time looking for adenomas, and learning better techniques.

4. Benchmarking. CMS stated that because of the measure construct, benchmarks calculated from this measure are misrepresented and do not align with the MIPS scoring methodology where 100% indicates better clinical care or control. Guidelines and supplemental literature support a performance target for adenoma detection rate of 25% for a mixed sex population (20% in women and 30% in men). CMS determined that Measure 343: Screening Colonoscopy Adenoma Detection Rate may be appropriate for other programs but does not align with the scoring logic within MIPS. When this measure was introduced, according to the agency, it was under the legacy program, Physician Quality Reporting System (PQRS), a pay-for-reporting program that does not have the same scoring implications as MIPS.

The societies reminded CMS that the 25% is the minimum requirement for performance and is not a benchmark. This minimum requirement continues to increase as well. With 25% being the threshold, for every 1% increase in ADR the risk of fatal interval colon cancer decreases by 3%. In one important study by Corley et al, the lowest quintile of ADR was 19% or lower, and was associated with the highest risk of interval colon cancer.⁴

CMS must begin to move beyond traditional approaches toward benchmarking performance where 100% compliance is expected. It was encouraging to see CMS acknowledge that nuances to evaluating scores are needed based on the ability of a measure to accurately identify and capture performance based on the patient population and measure specifications. For example, these adjustments were finalized for the blood pressure and diabetes HbA_1c measures, where the highest number of points will be achieved for anyone scoring 90% or higher. This modification was based on the knowledge that it is not realistic nor in the interest of patients to assume that clinicians will be able to achieve the desired targeted outcome for every patient. The potential for unintended consequences was factored into an assessment of what performance could be considered achievable.

In our view, ADR is a similar example where 100% performance across a clinician’s population of patients is biologically impossible since not every individual who receives a screening colonoscopy will have an adenoma detected. ADR is the best-established colorectal neoplasia-related quality indicator and research demonstrates that high rates are associated with significant reductions in colorectal cancer risk.

CMS must continue to explore alternative strategies toward benchmarking in MIPS to ensure that achievement is fairly assessed, and top performance scores are determined not solely based on peer performance but also based on clinical evidence balanced with minimizing unintended consequences. The MIPS program and its benchmarking and scoring methodologies must continue to innovate to ensure that physicians provide the best possible care to their patients while also accurately and fairly representing and rewarding clinicians’ performance. Continuing to promote a siloed view toward quality will only reduce the relevance of the MIPS program and lead our members to question the integrity and validity of the program.

References

1. Kaminski MF, Regula J, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-803.

2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.

3. Rubin CE, Haggitt RC, Burmer GC, et al. DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis. Gastroenterology. 1992;103:1611-20.

4. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298-306.

5. Kaminski MF, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017 Jul;153[1]:98-105. doi: 10.1053/j.gastro.2017.04.006. Epub 2017 Apr 17.

6. ASGE practice guideline: Measuring the quality of endoscopy. Gastrointest Endosc. 2006;58:S1-S38.

7. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rate. Gastrointest Endosc. 2000;51:33-6.

8. Barclay RL, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091-8.

9. Shaukat A, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology. 2015 Oct;149[4]:952-7

10. Lee S, et al. Am J Gastroenterol. 2016 Jan;111(1):63-9.

11. Jia H, et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112(4):568-76.

12. ASGE. Endoscopes and devices to improve colon polyp detection. GIE 2015;81:1122-9.

13. Ussui V, et al. Am J Gastroenterol. 2015;110:489-96.

14. Kaminski MF, et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016;65:616-24.

15. Shaukat A, et al. Rates of detection of adenoma, sessile serrated adenoma, and advanced adenoma are stable over time and modifiable. Gastroenterology 2018(Feb);156:816-7.

Dr. Adams is a gastroenterologist and assistant professor at the University of Michigan, Ann Arbor; Dr. Leiman is a gastroenterologist and assistant professor of medicine at Duke Health, Durham, N.C.; Dr. Mathews is a gastroenterologist and leader of Clinical Innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.

Evaluation and Management (E/M) coding and guidelines are about to undergo the most significant changes since their implementation in the 1990s. For now, the changes are limited to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will take place as of Jan. 1, 2021. Changes to all E/M codes are anticipated in the coming years.

The changes to the new and established office/outpatient codes will impact everyone in health care who assigns codes, manages health information, or pays claims including physicians and qualified health professionals, coders, health information managers, payers, health systems, and hospitals. The American Medical Association (AMA) has already released a preview of the CPT 2021 changes as well as free E/M education modules. They are planning to release more educational resources in the near future.
 

Why were changes needed?

The AMA developed the 2021 E/M changes in response to interest from the Centers for Medicare & Medicaid Services (CMS) in reducing physician burden, simplifying documentation requirements, and making changes to payments for the E/M codes. CMS’s initial proposal was to collapse office visit E/M levels 2-5 to a single payment. While the new rates would have provided a modest increase for level 2 and 3 E/M codes, they would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. There was an outcry from the physician community opposing CMS’s proposal, and the agency agreed to get more input from the public before moving forward.

The AMA worked with stakeholders, including the AGA and our sister GI societies, to create E/M guidelines that decrease documentation requirements while also continuing to differentiate payment based on complexity of care. CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients with complex conditions.

In sum, what are the 2021 E/M changes

While there will be many changes to office/outpatient E/M visits, the most significant are deletion of code 99201 (Level 1 new patient visit), addition of a 15-minute prolonged services code that can be reported with 99205 and 99215, and the following restructuring of office visit code selection:

1. Elimination of history and physical as elements for code selection: While obtaining a pertinent history and performing a relevant physical exam are clinically necessary and contribute to both time and medical decision making, these elements will not factor in to code selection. Instead, the code level will be determined solely by medical decision making or time.

2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation:

• MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
• Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service. This redefinition of time allows Medicare to better recognize the work involved in non–face-to-face services like care coordination and record review. Of note, these definitions only apply when code selection is based on time and not MDM.

3. Modification of the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM.

• Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
• Definitions. Defined important terms, such as “independent historian.”
• Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).

CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) add-on code as of Jan. 1, 2021, that can be used to recognize additional resource costs that are inherent in treating complex patients.

• GPCX1 - Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.).

GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).
 

Who do these changes apply to?

The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to all traditional Medicare and Medicare Advantage plans, Medicaid, and all commercial payers. E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only; commercial payers are not required to accept HCPCS codes.

What should you do?

Visit the AMA E/M Microsite; there you will find the AMA’s early release of the 2021 E/M coding and guideline changes, the AMA E/M learning module and future resources on the use of time and MDM that are expected to be released in March.

AMA E/M Microsite: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429

AMA MDM table: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Connect with your coders and/or medical billing company to create a plan for training physicians and staff to ensure a smooth transition on Jan. 1, 2021.

Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.

Run an analysis using the new E/M office/outpatient payment rates recommended by the AMA for 2021 (https://www.ama-assn.org/about/rvs-update-committee-ruc/ruc-recommendations-minutes-voting) for each of your practice’s contracted payers to determine if your practice will benefit from the new rates. While CMS has proposed to accept the AMA recommended rates, this will not be finalized until CMS publishes the 2021 proposed rule in early July 2020.

Once CMS confirms its decision, reach out to your payers to negotiate implementing the new E/M rates starting in 2021.

With changes this big, we encourage you to prepare early. Watch for more information on the 2021 E/M changes in Washington Insider and AGA eDigest.
 

Dr. Kuo is the AGA’s Advisor to the AMA CPT Editorial Panel and a member of the AGA Practice Management and Economics Committee’s (PMEC) Coverage and Reimbursement Subcommittee (CRS) and assistant professor of medicine and gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston; Dr. Losurdo is the AGA’s Alternate Advisor to the AMA CPT Editorial Panel, a member of the AGA PMEC’s CRS, and Managing Partner and medical director of Illinois Gastroenterology Group, Elgin, Ill.; Dr. Mehta is the AGA’s advisor to the AMA RVS Update Committee (RUC), a member of the AGA PMEC’s CRS, and assistant professor of medicine at the University of Pennsylvania, Philadelphia; and Dr. Garcia is the AGA’s Alternate Advisor to the AMA RUC, a member of the AGA PMEC’s CRS, and assistant professor of medicine and gastroenterology at Stanford (Calif.) University. There were no conflicts of interest.

Evaluation and Management (E/M) coding and guidelines are about to undergo the most significant changes since their implementation in the 1990s. For now, the changes are limited to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will take place as of Jan. 1, 2021. Changes to all E/M codes are anticipated in the coming years.

The changes to the new and established office/outpatient codes will impact everyone in health care who assigns codes, manages health information, or pays claims including physicians and qualified health professionals, coders, health information managers, payers, health systems, and hospitals. The American Medical Association (AMA) has already released a preview of the CPT 2021 changes as well as free E/M education modules. They are planning to release more educational resources in the near future.
 

Why were changes needed?

The AMA developed the 2021 E/M changes in response to interest from the Centers for Medicare & Medicaid Services (CMS) in reducing physician burden, simplifying documentation requirements, and making changes to payments for the E/M codes. CMS’s initial proposal was to collapse office visit E/M levels 2-5 to a single payment. While the new rates would have provided a modest increase for level 2 and 3 E/M codes, they would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. There was an outcry from the physician community opposing CMS’s proposal, and the agency agreed to get more input from the public before moving forward.

The AMA worked with stakeholders, including the AGA and our sister GI societies, to create E/M guidelines that decrease documentation requirements while also continuing to differentiate payment based on complexity of care. CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients with complex conditions.

In sum, what are the 2021 E/M changes

While there will be many changes to office/outpatient E/M visits, the most significant are deletion of code 99201 (Level 1 new patient visit), addition of a 15-minute prolonged services code that can be reported with 99205 and 99215, and the following restructuring of office visit code selection:

1. Elimination of history and physical as elements for code selection: While obtaining a pertinent history and performing a relevant physical exam are clinically necessary and contribute to both time and medical decision making, these elements will not factor in to code selection. Instead, the code level will be determined solely by medical decision making or time.

2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation:

• MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
• Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service. This redefinition of time allows Medicare to better recognize the work involved in non–face-to-face services like care coordination and record review. Of note, these definitions only apply when code selection is based on time and not MDM.

3. Modification of the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM.

• Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
• Definitions. Defined important terms, such as “independent historian.”
• Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).

CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) add-on code as of Jan. 1, 2021, that can be used to recognize additional resource costs that are inherent in treating complex patients.

• GPCX1 - Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.).

GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).
 

Who do these changes apply to?

The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to all traditional Medicare and Medicare Advantage plans, Medicaid, and all commercial payers. E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only; commercial payers are not required to accept HCPCS codes.

What should you do?

Visit the AMA E/M Microsite; there you will find the AMA’s early release of the 2021 E/M coding and guideline changes, the AMA E/M learning module and future resources on the use of time and MDM that are expected to be released in March.

AMA E/M Microsite: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429

AMA MDM table: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Connect with your coders and/or medical billing company to create a plan for training physicians and staff to ensure a smooth transition on Jan. 1, 2021.

Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.

Run an analysis using the new E/M office/outpatient payment rates recommended by the AMA for 2021 (https://www.ama-assn.org/about/rvs-update-committee-ruc/ruc-recommendations-minutes-voting) for each of your practice’s contracted payers to determine if your practice will benefit from the new rates. While CMS has proposed to accept the AMA recommended rates, this will not be finalized until CMS publishes the 2021 proposed rule in early July 2020.

Once CMS confirms its decision, reach out to your payers to negotiate implementing the new E/M rates starting in 2021.

With changes this big, we encourage you to prepare early. Watch for more information on the 2021 E/M changes in Washington Insider and AGA eDigest.
 

Dr. Kuo is the AGA’s Advisor to the AMA CPT Editorial Panel and a member of the AGA Practice Management and Economics Committee’s (PMEC) Coverage and Reimbursement Subcommittee (CRS) and assistant professor of medicine and gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston; Dr. Losurdo is the AGA’s Alternate Advisor to the AMA CPT Editorial Panel, a member of the AGA PMEC’s CRS, and Managing Partner and medical director of Illinois Gastroenterology Group, Elgin, Ill.; Dr. Mehta is the AGA’s advisor to the AMA RVS Update Committee (RUC), a member of the AGA PMEC’s CRS, and assistant professor of medicine at the University of Pennsylvania, Philadelphia; and Dr. Garcia is the AGA’s Alternate Advisor to the AMA RUC, a member of the AGA PMEC’s CRS, and assistant professor of medicine and gastroenterology at Stanford (Calif.) University. There were no conflicts of interest.

Evaluation and Management (E/M) coding and guidelines are about to undergo the most significant changes since their implementation in the 1990s. For now, the changes are limited to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will take place as of Jan. 1, 2021. Changes to all E/M codes are anticipated in the coming years.

The changes to the new and established office/outpatient codes will impact everyone in health care who assigns codes, manages health information, or pays claims including physicians and qualified health professionals, coders, health information managers, payers, health systems, and hospitals. The American Medical Association (AMA) has already released a preview of the CPT 2021 changes as well as free E/M education modules. They are planning to release more educational resources in the near future.
 

Why were changes needed?

The AMA developed the 2021 E/M changes in response to interest from the Centers for Medicare & Medicaid Services (CMS) in reducing physician burden, simplifying documentation requirements, and making changes to payments for the E/M codes. CMS’s initial proposal was to collapse office visit E/M levels 2-5 to a single payment. While the new rates would have provided a modest increase for level 2 and 3 E/M codes, they would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. There was an outcry from the physician community opposing CMS’s proposal, and the agency agreed to get more input from the public before moving forward.

The AMA worked with stakeholders, including the AGA and our sister GI societies, to create E/M guidelines that decrease documentation requirements while also continuing to differentiate payment based on complexity of care. CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients with complex conditions.

In sum, what are the 2021 E/M changes

While there will be many changes to office/outpatient E/M visits, the most significant are deletion of code 99201 (Level 1 new patient visit), addition of a 15-minute prolonged services code that can be reported with 99205 and 99215, and the following restructuring of office visit code selection:

1. Elimination of history and physical as elements for code selection: While obtaining a pertinent history and performing a relevant physical exam are clinically necessary and contribute to both time and medical decision making, these elements will not factor in to code selection. Instead, the code level will be determined solely by medical decision making or time.

2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation:

• MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
• Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service. This redefinition of time allows Medicare to better recognize the work involved in non–face-to-face services like care coordination and record review. Of note, these definitions only apply when code selection is based on time and not MDM.

3. Modification of the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM.

• Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
• Definitions. Defined important terms, such as “independent historian.”
• Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).

CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) add-on code as of Jan. 1, 2021, that can be used to recognize additional resource costs that are inherent in treating complex patients.

• GPCX1 - Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.).

GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).
 

Who do these changes apply to?

The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to all traditional Medicare and Medicare Advantage plans, Medicaid, and all commercial payers. E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only; commercial payers are not required to accept HCPCS codes.

What should you do?

Visit the AMA E/M Microsite; there you will find the AMA’s early release of the 2021 E/M coding and guideline changes, the AMA E/M learning module and future resources on the use of time and MDM that are expected to be released in March.

AMA E/M Microsite: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429

AMA MDM table: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Connect with your coders and/or medical billing company to create a plan for training physicians and staff to ensure a smooth transition on Jan. 1, 2021.

Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.

Run an analysis using the new E/M office/outpatient payment rates recommended by the AMA for 2021 (https://www.ama-assn.org/about/rvs-update-committee-ruc/ruc-recommendations-minutes-voting) for each of your practice’s contracted payers to determine if your practice will benefit from the new rates. While CMS has proposed to accept the AMA recommended rates, this will not be finalized until CMS publishes the 2021 proposed rule in early July 2020.

Once CMS confirms its decision, reach out to your payers to negotiate implementing the new E/M rates starting in 2021.

With changes this big, we encourage you to prepare early. Watch for more information on the 2021 E/M changes in Washington Insider and AGA eDigest.
 

Dr. Kuo is the AGA’s Advisor to the AMA CPT Editorial Panel and a member of the AGA Practice Management and Economics Committee’s (PMEC) Coverage and Reimbursement Subcommittee (CRS) and assistant professor of medicine and gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston; Dr. Losurdo is the AGA’s Alternate Advisor to the AMA CPT Editorial Panel, a member of the AGA PMEC’s CRS, and Managing Partner and medical director of Illinois Gastroenterology Group, Elgin, Ill.; Dr. Mehta is the AGA’s advisor to the AMA RVS Update Committee (RUC), a member of the AGA PMEC’s CRS, and assistant professor of medicine at the University of Pennsylvania, Philadelphia; and Dr. Garcia is the AGA’s Alternate Advisor to the AMA RUC, a member of the AGA PMEC’s CRS, and assistant professor of medicine and gastroenterology at Stanford (Calif.) University. There were no conflicts of interest.

2020 has begun and therefore so has a new year of quality reporting requirements. Quality reporting under the Centers for Medicare and Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) may seem like a burden, but it doesn’t need to be. You can likely get credit for the things you are already doing in your practice with little to no augmentation needed.

First, there are a few pieces of information to keep in mind when tracking your data and preparing your staff for their 2020 strategy.

1. Group Participation – For 2020 there is an increase in the MIPS participation threshold for those participating as part of a group. At least 50% of the MIPS eligible clinicians in the reporting group must participate in the same continuous 90-day period to receive credit for a quality improvement activity. That’s a significant increase from 2019 when only one (1) MIPS eligible clinician in a group was required to participate. Connect with your staff now to make sure your group meets the new 50% participation requirement.

2. Improvement Activities for Group Participation – Improvement Activities that are approved for credit by CMS are given a weight based on their requirements. Approved activities are weighted as either medium or high, and this impacts how many activities a practitioner must report on. In 2020, CMS increased the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice for the Improvement Activities category along with other changes such as modifying the definition of rural area to mean a ZIP code designated as rural by the Federal Office of Rural Health Policy using the most recent file available, updating the improvement activities and removing some criteria for Patient-Centered Medical Home designation. Work with your staff now to make sure at least 50% of the MIPS-eligible clinicians in your group are participating in the same Improvement Activities.

3. Quantity of Improvement Activities Required – CMS requires most individuals or groups report on any of the following options during any continuous 90-day period (or as specified in the activity description) in the same performance year, provided that all participating clinicians are reporting on the same activities:
a. 2 high-weighted activities, or
b. 1 high-weighted and 2 medium-weighted activities, or
c. 4 medium-weighted activities

Be sure to pay attention to the weight of the activity you (if you’re reporting as an individual) or your group is reporting so you don’t have any surprises at the end of the reporting period.

There are a variety of options for activities you can report on and some may be a lower lift than you expect.

Does your practice treat Medicaid patients? If so, do you know their average wait time for an initial visit? If that number is 10 days or less, you can report on this activity. If you aren’t quite hitting this benchmark, then consider implementing a scheduling protocol for this population of your patients in the new year.

Engagement of new Medicaid patients and follow-up

Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.
Subcategory name: Achieving Health Equity
Activity weighting: High

Are you responsible for onboarding and training new clinicians to your rural practice? If so, you could report on the next activity. Eligible clinicians would be responsible for training of new clinicians including physicians, advanced practice providers and clinical nursing specialists. These clinicians must practice in small, underserved, or rural areas. What is considered a small, rural, or underserved practice for the purpose of MIPS?

Small practice

• Defined as a practice with 15 or fewer eligible clinicians-based billing under the same TIN

Rural/underserved practice

• Defined as a practice in a zip code included in the most recent set of Health Professional Shortage Areas (HPSAs), as determined by the Health Resources and Services Administration (HRSA).
• HPSAs are designations that indicate health care provider shortages in primary care, dental health or mental health can be geographic population based or facility based.

Provide education opportunities for new clinicians

MIPS-eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.
Subcategory name: Achieving Health Equity
Activity weighting: High
There are also activities you can report on under the beneficiary engagement category that you may already be doing in your practice. First, the collection of patient experience and satisfaction data and the development of an improvement plan as necessary counts as one activity. Second, the engagement of the patient’s support team in the development of a plan of care, which needs to include goals and be documented in the electronic health record.

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.
Subcategory name: Beneficiary Engagement
Activity weighting: High

Engagement of Patients, Family, and Caregivers in Developing a Plan of Care

Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.
Subcategory name: Beneficiary Engagement
Activity weighting: Medium
Another data collection category is patient access to care. If you collect and use patient data on their satisfaction and experience related to access to care and commit to developing an improvement plan as necessary, you can receive credit for this reporting category.

Collection and use of patient experience and satisfaction data on access

Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.
Subcategory name: Expanded Practice Access
Activity weighting: Medium

One of the hallmarks of a medical practice in any specialty is improvement. We are always striving to improve something, whether it be the patient experience, patient outcomes, the bottom line, or the education of clinical staff. You can leverage the practice improvement plans you have put into place for credit.

Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes

Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.
Subcategory name: Patient Safety and Practice Assessment
Activity weighting: Medium

Prescription drug use is a topic on every providers’ radar right now. Proper prescribing and monitoring of patients are crucial to their safety and quality of care. In the field of gastroenterology, step-therapy adds a new level of complication to the use of prescription drugs. Ensuring the proper medication protocols allows you to provide appropriate and timely treatment for your patients.

Annual registration in the Prescription Drug Monitoring Program

Annual registration by eligible clinician or group in the prescription drug–monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS-eligible clinicians and groups must participate for a minimum of 6 months.

Subcategory name: Patient Safety and Practice Assessment
Activity weighting: Medium

As you can see, there are a variety of improvement activities that you can report on for 2020. This article has outlined several of them that you may already be doing in your practice, but many more can be found by visiting https://qpp.cms.gov/mips/improvement-activities?py=2020 along with information on how to report and the necessary forms for submission.

Dr. Shah is associate professor, Mount Sinai Medical Center, New York, member of the AGA Quality Leadership Council. He has no disclosures.

2020 has begun and therefore so has a new year of quality reporting requirements. Quality reporting under the Centers for Medicare and Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) may seem like a burden, but it doesn’t need to be. You can likely get credit for the things you are already doing in your practice with little to no augmentation needed.

First, there are a few pieces of information to keep in mind when tracking your data and preparing your staff for their 2020 strategy.

1. Group Participation – For 2020 there is an increase in the MIPS participation threshold for those participating as part of a group. At least 50% of the MIPS eligible clinicians in the reporting group must participate in the same continuous 90-day period to receive credit for a quality improvement activity. That’s a significant increase from 2019 when only one (1) MIPS eligible clinician in a group was required to participate. Connect with your staff now to make sure your group meets the new 50% participation requirement.

2. Improvement Activities for Group Participation – Improvement Activities that are approved for credit by CMS are given a weight based on their requirements. Approved activities are weighted as either medium or high, and this impacts how many activities a practitioner must report on. In 2020, CMS increased the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice for the Improvement Activities category along with other changes such as modifying the definition of rural area to mean a ZIP code designated as rural by the Federal Office of Rural Health Policy using the most recent file available, updating the improvement activities and removing some criteria for Patient-Centered Medical Home designation. Work with your staff now to make sure at least 50% of the MIPS-eligible clinicians in your group are participating in the same Improvement Activities.

3. Quantity of Improvement Activities Required – CMS requires most individuals or groups report on any of the following options during any continuous 90-day period (or as specified in the activity description) in the same performance year, provided that all participating clinicians are reporting on the same activities:
a. 2 high-weighted activities, or
b. 1 high-weighted and 2 medium-weighted activities, or
c. 4 medium-weighted activities

Be sure to pay attention to the weight of the activity you (if you’re reporting as an individual) or your group is reporting so you don’t have any surprises at the end of the reporting period.

There are a variety of options for activities you can report on and some may be a lower lift than you expect.

Does your practice treat Medicaid patients? If so, do you know their average wait time for an initial visit? If that number is 10 days or less, you can report on this activity. If you aren’t quite hitting this benchmark, then consider implementing a scheduling protocol for this population of your patients in the new year.

Engagement of new Medicaid patients and follow-up

Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.
Subcategory name: Achieving Health Equity
Activity weighting: High

Are you responsible for onboarding and training new clinicians to your rural practice? If so, you could report on the next activity. Eligible clinicians would be responsible for training of new clinicians including physicians, advanced practice providers and clinical nursing specialists. These clinicians must practice in small, underserved, or rural areas. What is considered a small, rural, or underserved practice for the purpose of MIPS?

Small practice

• Defined as a practice with 15 or fewer eligible clinicians-based billing under the same TIN

Rural/underserved practice

• Defined as a practice in a zip code included in the most recent set of Health Professional Shortage Areas (HPSAs), as determined by the Health Resources and Services Administration (HRSA).
• HPSAs are designations that indicate health care provider shortages in primary care, dental health or mental health can be geographic population based or facility based.

Provide education opportunities for new clinicians

MIPS-eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.
Subcategory name: Achieving Health Equity
Activity weighting: High
There are also activities you can report on under the beneficiary engagement category that you may already be doing in your practice. First, the collection of patient experience and satisfaction data and the development of an improvement plan as necessary counts as one activity. Second, the engagement of the patient’s support team in the development of a plan of care, which needs to include goals and be documented in the electronic health record.

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.
Subcategory name: Beneficiary Engagement
Activity weighting: High

Engagement of Patients, Family, and Caregivers in Developing a Plan of Care

Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.
Subcategory name: Beneficiary Engagement
Activity weighting: Medium
Another data collection category is patient access to care. If you collect and use patient data on their satisfaction and experience related to access to care and commit to developing an improvement plan as necessary, you can receive credit for this reporting category.

Collection and use of patient experience and satisfaction data on access

Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.
Subcategory name: Expanded Practice Access
Activity weighting: Medium

One of the hallmarks of a medical practice in any specialty is improvement. We are always striving to improve something, whether it be the patient experience, patient outcomes, the bottom line, or the education of clinical staff. You can leverage the practice improvement plans you have put into place for credit.

Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes

Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.
Subcategory name: Patient Safety and Practice Assessment
Activity weighting: Medium

Prescription drug use is a topic on every providers’ radar right now. Proper prescribing and monitoring of patients are crucial to their safety and quality of care. In the field of gastroenterology, step-therapy adds a new level of complication to the use of prescription drugs. Ensuring the proper medication protocols allows you to provide appropriate and timely treatment for your patients.

Annual registration in the Prescription Drug Monitoring Program

Annual registration by eligible clinician or group in the prescription drug–monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS-eligible clinicians and groups must participate for a minimum of 6 months.

Subcategory name: Patient Safety and Practice Assessment
Activity weighting: Medium

As you can see, there are a variety of improvement activities that you can report on for 2020. This article has outlined several of them that you may already be doing in your practice, but many more can be found by visiting https://qpp.cms.gov/mips/improvement-activities?py=2020 along with information on how to report and the necessary forms for submission.

Dr. Shah is associate professor, Mount Sinai Medical Center, New York, member of the AGA Quality Leadership Council. He has no disclosures.

2020 has begun and therefore so has a new year of quality reporting requirements. Quality reporting under the Centers for Medicare and Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) may seem like a burden, but it doesn’t need to be. You can likely get credit for the things you are already doing in your practice with little to no augmentation needed.

First, there are a few pieces of information to keep in mind when tracking your data and preparing your staff for their 2020 strategy.

1. Group Participation – For 2020 there is an increase in the MIPS participation threshold for those participating as part of a group. At least 50% of the MIPS eligible clinicians in the reporting group must participate in the same continuous 90-day period to receive credit for a quality improvement activity. That’s a significant increase from 2019 when only one (1) MIPS eligible clinician in a group was required to participate. Connect with your staff now to make sure your group meets the new 50% participation requirement.

2. Improvement Activities for Group Participation – Improvement Activities that are approved for credit by CMS are given a weight based on their requirements. Approved activities are weighted as either medium or high, and this impacts how many activities a practitioner must report on. In 2020, CMS increased the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice for the Improvement Activities category along with other changes such as modifying the definition of rural area to mean a ZIP code designated as rural by the Federal Office of Rural Health Policy using the most recent file available, updating the improvement activities and removing some criteria for Patient-Centered Medical Home designation. Work with your staff now to make sure at least 50% of the MIPS-eligible clinicians in your group are participating in the same Improvement Activities.

3. Quantity of Improvement Activities Required – CMS requires most individuals or groups report on any of the following options during any continuous 90-day period (or as specified in the activity description) in the same performance year, provided that all participating clinicians are reporting on the same activities:
a. 2 high-weighted activities, or
b. 1 high-weighted and 2 medium-weighted activities, or
c. 4 medium-weighted activities

Be sure to pay attention to the weight of the activity you (if you’re reporting as an individual) or your group is reporting so you don’t have any surprises at the end of the reporting period.

There are a variety of options for activities you can report on and some may be a lower lift than you expect.

Does your practice treat Medicaid patients? If so, do you know their average wait time for an initial visit? If that number is 10 days or less, you can report on this activity. If you aren’t quite hitting this benchmark, then consider implementing a scheduling protocol for this population of your patients in the new year.

Engagement of new Medicaid patients and follow-up

Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. A timely manner is defined as within 10 business days for this activity.
Subcategory name: Achieving Health Equity
Activity weighting: High

Are you responsible for onboarding and training new clinicians to your rural practice? If so, you could report on the next activity. Eligible clinicians would be responsible for training of new clinicians including physicians, advanced practice providers and clinical nursing specialists. These clinicians must practice in small, underserved, or rural areas. What is considered a small, rural, or underserved practice for the purpose of MIPS?

Small practice

• Defined as a practice with 15 or fewer eligible clinicians-based billing under the same TIN

Rural/underserved practice

• Defined as a practice in a zip code included in the most recent set of Health Professional Shortage Areas (HPSAs), as determined by the Health Resources and Services Administration (HRSA).
• HPSAs are designations that indicate health care provider shortages in primary care, dental health or mental health can be geographic population based or facility based.

Provide education opportunities for new clinicians

MIPS-eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.
Subcategory name: Achieving Health Equity
Activity weighting: High
There are also activities you can report on under the beneficiary engagement category that you may already be doing in your practice. First, the collection of patient experience and satisfaction data and the development of an improvement plan as necessary counts as one activity. Second, the engagement of the patient’s support team in the development of a plan of care, which needs to include goals and be documented in the electronic health record.

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.
Subcategory name: Beneficiary Engagement
Activity weighting: High

Engagement of Patients, Family, and Caregivers in Developing a Plan of Care

Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.
Subcategory name: Beneficiary Engagement
Activity weighting: Medium
Another data collection category is patient access to care. If you collect and use patient data on their satisfaction and experience related to access to care and commit to developing an improvement plan as necessary, you can receive credit for this reporting category.

Collection and use of patient experience and satisfaction data on access

Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.
Subcategory name: Expanded Practice Access
Activity weighting: Medium

One of the hallmarks of a medical practice in any specialty is improvement. We are always striving to improve something, whether it be the patient experience, patient outcomes, the bottom line, or the education of clinical staff. You can leverage the practice improvement plans you have put into place for credit.

Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes

Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.
Subcategory name: Patient Safety and Practice Assessment
Activity weighting: Medium

Prescription drug use is a topic on every providers’ radar right now. Proper prescribing and monitoring of patients are crucial to their safety and quality of care. In the field of gastroenterology, step-therapy adds a new level of complication to the use of prescription drugs. Ensuring the proper medication protocols allows you to provide appropriate and timely treatment for your patients.

Annual registration in the Prescription Drug Monitoring Program

Annual registration by eligible clinician or group in the prescription drug–monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS-eligible clinicians and groups must participate for a minimum of 6 months.

Subcategory name: Patient Safety and Practice Assessment
Activity weighting: Medium

As you can see, there are a variety of improvement activities that you can report on for 2020. This article has outlined several of them that you may already be doing in your practice, but many more can be found by visiting https://qpp.cms.gov/mips/improvement-activities?py=2020 along with information on how to report and the necessary forms for submission.

Dr. Shah is associate professor, Mount Sinai Medical Center, New York, member of the AGA Quality Leadership Council. He has no disclosures.

I know that many have already started the planning process for next year’s business priorities and therefore I remain hopeful that time was taken to reflect on the success stories already achieved to provide the foundation for next year’s business goals.

What is key, is that one recognizes that the planning process must begin this year to kickstart next year’s work soon after the holidays are over. This planning process should lay out the framework from which to assign the work so it’s part of the business operations wherein goals can be established and ultimately achieved.

As we move into a new decade the evolution of medicine and specifically gastroenterology hasn’t stopped. The question is, have you set yourself (and your practice) up for success in 2020? In the ever-changing world of the gastroenterology practice you don’t want to be left behind this year. Here are the top things you need to know for a productive and successful new year!
 

1. Use the new Medicare Beneficiary Identifier (MBI). Starting January 1, 2020, if you want to get paid by Medicare you must use the MBI when billing Medicare regardless of the date of service. Claims submitted without MBIs will be rejected, with some exceptions. The MBI replaces the social security number–based Health Insurance Claim Numbers (HICNs) from Medicare cards and is now used for Medicare transactions like billing, eligibility status, and claim status.

2. Prepare for Evaluation and Management (E/M) changes. Did you know that E/M coding and guidelines are about to undergo the most significant changes since their implementation? The changes to guidelines and coding for new and established office/outpatient visits (CPT codes 99202-99205, 99211-99215) won’t officially take place until January 1, 2021, but they are so significant that the American Medical Association has already released a preview of the CPT 2021 changes. Don’t miss out on the preview – https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. Sit down with your coders or contact your medical billing company and create a plan for training physicians and staff for the changes for a smooth transition on Jan. 1, 2021. With changes this big, you may find you need all of 2020 to prepare.

3. Review your quality reporting under the Merit-Based Incentive System (MIPS). There have been several changes to the weights of quality and cost performance categories under MIPS for the 2020 performance year. These will go into effect January 1st and will impact your 2022 Medicare payments.

4. Evaluate your clinician participation level if you’re reporting under MIPS as a group. During the 2020 performance year, the threshold for clinician participation is increasing. At least 50% of clinicians from the group must participate in or perform an activity for the same continuous 90-day period to earn credit for that improvement activity.

5. Don’t forget to report under MIPS for 2019. Those not in an Advanced Alternative Payment Model (APM), a Medicare Accountable Care Organization (ACO) or other MIPS alternative must report the required data under the program or face payment cuts in 2021. The submission window for your 2019 data opens on January 2, 2020 and closes on March 31st!

January 2020
January 1 - MIPS Performance Year 2019 Begins 
January 2 - Submission Window Opens for MIPS Performance Year 2019

March 2020
March 31 - Submission Window Closes for MIPS Performance Year 2019

July 2020
 • CMS publishes proposed reimbursement values for the E/M codes in the 2021 MPFS proposed rule
• CMS “Targeted Review” opens once CMS makes your MIPS payment adjustment available
• July 1 - MIPS Performance Feedback Available. CMS will provide you with performance feedback based on the data you submitted for Performance Year 2019. You can use this feedback to improve your care and optimize the payments you receive from CMS.

August 2020
August 31 - Targeted Review period closes (appeals process)
 

September 2020
AMA releases CPT 2021 book with new E/M coding guidelines and new coding for new patient office/outpatient visits (99202-99205)

October 2020
October 1, 2020 – Final day to start QPP activities to meet 90-day minimum.

November 2020
CMS finalizes reimbursement values for the E/M codes in the MPFS final rule

December 2020
December 31, 2020 - Quality Payment Program Exception Applications Window Closes
December 31, 2020 – MIPS Performance year 2020 ends

Stress to your team that proper planning is the norm and not the exception, and that seeking improvement in all facets of your medical practice is critical to achieving long-term success. Be sure to write your plans in the future tense and to include timelines in your final work product, as well as delegate accountability to accomplish those goals.

Use the planning process as an opportunity to build your team so that everyone is focused on the future and stress that their participation is important to achieve the success required to remain an independent medical group.
 

Mr. Turner is chief executive officer, Indianapolis Gastroenterology and Hepatology, Indianapolis. jturner@indygastro.com

I know that many have already started the planning process for next year’s business priorities and therefore I remain hopeful that time was taken to reflect on the success stories already achieved to provide the foundation for next year’s business goals.

What is key, is that one recognizes that the planning process must begin this year to kickstart next year’s work soon after the holidays are over. This planning process should lay out the framework from which to assign the work so it’s part of the business operations wherein goals can be established and ultimately achieved.

As we move into a new decade the evolution of medicine and specifically gastroenterology hasn’t stopped. The question is, have you set yourself (and your practice) up for success in 2020? In the ever-changing world of the gastroenterology practice you don’t want to be left behind this year. Here are the top things you need to know for a productive and successful new year!
 

1. Use the new Medicare Beneficiary Identifier (MBI). Starting January 1, 2020, if you want to get paid by Medicare you must use the MBI when billing Medicare regardless of the date of service. Claims submitted without MBIs will be rejected, with some exceptions. The MBI replaces the social security number–based Health Insurance Claim Numbers (HICNs) from Medicare cards and is now used for Medicare transactions like billing, eligibility status, and claim status.

2. Prepare for Evaluation and Management (E/M) changes. Did you know that E/M coding and guidelines are about to undergo the most significant changes since their implementation? The changes to guidelines and coding for new and established office/outpatient visits (CPT codes 99202-99205, 99211-99215) won’t officially take place until January 1, 2021, but they are so significant that the American Medical Association has already released a preview of the CPT 2021 changes. Don’t miss out on the preview – https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. Sit down with your coders or contact your medical billing company and create a plan for training physicians and staff for the changes for a smooth transition on Jan. 1, 2021. With changes this big, you may find you need all of 2020 to prepare.

3. Review your quality reporting under the Merit-Based Incentive System (MIPS). There have been several changes to the weights of quality and cost performance categories under MIPS for the 2020 performance year. These will go into effect January 1st and will impact your 2022 Medicare payments.

4. Evaluate your clinician participation level if you’re reporting under MIPS as a group. During the 2020 performance year, the threshold for clinician participation is increasing. At least 50% of clinicians from the group must participate in or perform an activity for the same continuous 90-day period to earn credit for that improvement activity.

5. Don’t forget to report under MIPS for 2019. Those not in an Advanced Alternative Payment Model (APM), a Medicare Accountable Care Organization (ACO) or other MIPS alternative must report the required data under the program or face payment cuts in 2021. The submission window for your 2019 data opens on January 2, 2020 and closes on March 31st!

January 2020
January 1 - MIPS Performance Year 2019 Begins 
January 2 - Submission Window Opens for MIPS Performance Year 2019

March 2020
March 31 - Submission Window Closes for MIPS Performance Year 2019

July 2020
 • CMS publishes proposed reimbursement values for the E/M codes in the 2021 MPFS proposed rule
• CMS “Targeted Review” opens once CMS makes your MIPS payment adjustment available
• July 1 - MIPS Performance Feedback Available. CMS will provide you with performance feedback based on the data you submitted for Performance Year 2019. You can use this feedback to improve your care and optimize the payments you receive from CMS.

August 2020
August 31 - Targeted Review period closes (appeals process)
 

September 2020
AMA releases CPT 2021 book with new E/M coding guidelines and new coding for new patient office/outpatient visits (99202-99205)

October 2020
October 1, 2020 – Final day to start QPP activities to meet 90-day minimum.

November 2020
CMS finalizes reimbursement values for the E/M codes in the MPFS final rule

December 2020
December 31, 2020 - Quality Payment Program Exception Applications Window Closes
December 31, 2020 – MIPS Performance year 2020 ends

Stress to your team that proper planning is the norm and not the exception, and that seeking improvement in all facets of your medical practice is critical to achieving long-term success. Be sure to write your plans in the future tense and to include timelines in your final work product, as well as delegate accountability to accomplish those goals.

Use the planning process as an opportunity to build your team so that everyone is focused on the future and stress that their participation is important to achieve the success required to remain an independent medical group.
 

Mr. Turner is chief executive officer, Indianapolis Gastroenterology and Hepatology, Indianapolis. jturner@indygastro.com

I know that many have already started the planning process for next year’s business priorities and therefore I remain hopeful that time was taken to reflect on the success stories already achieved to provide the foundation for next year’s business goals.

What is key, is that one recognizes that the planning process must begin this year to kickstart next year’s work soon after the holidays are over. This planning process should lay out the framework from which to assign the work so it’s part of the business operations wherein goals can be established and ultimately achieved.

As we move into a new decade the evolution of medicine and specifically gastroenterology hasn’t stopped. The question is, have you set yourself (and your practice) up for success in 2020? In the ever-changing world of the gastroenterology practice you don’t want to be left behind this year. Here are the top things you need to know for a productive and successful new year!
 

1. Use the new Medicare Beneficiary Identifier (MBI). Starting January 1, 2020, if you want to get paid by Medicare you must use the MBI when billing Medicare regardless of the date of service. Claims submitted without MBIs will be rejected, with some exceptions. The MBI replaces the social security number–based Health Insurance Claim Numbers (HICNs) from Medicare cards and is now used for Medicare transactions like billing, eligibility status, and claim status.

2. Prepare for Evaluation and Management (E/M) changes. Did you know that E/M coding and guidelines are about to undergo the most significant changes since their implementation? The changes to guidelines and coding for new and established office/outpatient visits (CPT codes 99202-99205, 99211-99215) won’t officially take place until January 1, 2021, but they are so significant that the American Medical Association has already released a preview of the CPT 2021 changes. Don’t miss out on the preview – https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. Sit down with your coders or contact your medical billing company and create a plan for training physicians and staff for the changes for a smooth transition on Jan. 1, 2021. With changes this big, you may find you need all of 2020 to prepare.

3. Review your quality reporting under the Merit-Based Incentive System (MIPS). There have been several changes to the weights of quality and cost performance categories under MIPS for the 2020 performance year. These will go into effect January 1st and will impact your 2022 Medicare payments.

4. Evaluate your clinician participation level if you’re reporting under MIPS as a group. During the 2020 performance year, the threshold for clinician participation is increasing. At least 50% of clinicians from the group must participate in or perform an activity for the same continuous 90-day period to earn credit for that improvement activity.

5. Don’t forget to report under MIPS for 2019. Those not in an Advanced Alternative Payment Model (APM), a Medicare Accountable Care Organization (ACO) or other MIPS alternative must report the required data under the program or face payment cuts in 2021. The submission window for your 2019 data opens on January 2, 2020 and closes on March 31st!

January 2020
January 1 - MIPS Performance Year 2019 Begins 
January 2 - Submission Window Opens for MIPS Performance Year 2019

March 2020
March 31 - Submission Window Closes for MIPS Performance Year 2019

July 2020
 • CMS publishes proposed reimbursement values for the E/M codes in the 2021 MPFS proposed rule
• CMS “Targeted Review” opens once CMS makes your MIPS payment adjustment available
• July 1 - MIPS Performance Feedback Available. CMS will provide you with performance feedback based on the data you submitted for Performance Year 2019. You can use this feedback to improve your care and optimize the payments you receive from CMS.

August 2020
August 31 - Targeted Review period closes (appeals process)
 

September 2020
AMA releases CPT 2021 book with new E/M coding guidelines and new coding for new patient office/outpatient visits (99202-99205)

October 2020
October 1, 2020 – Final day to start QPP activities to meet 90-day minimum.

November 2020
CMS finalizes reimbursement values for the E/M codes in the MPFS final rule

December 2020
December 31, 2020 - Quality Payment Program Exception Applications Window Closes
December 31, 2020 – MIPS Performance year 2020 ends

Stress to your team that proper planning is the norm and not the exception, and that seeking improvement in all facets of your medical practice is critical to achieving long-term success. Be sure to write your plans in the future tense and to include timelines in your final work product, as well as delegate accountability to accomplish those goals.

Use the planning process as an opportunity to build your team so that everyone is focused on the future and stress that their participation is important to achieve the success required to remain an independent medical group.
 

Mr. Turner is chief executive officer, Indianapolis Gastroenterology and Hepatology, Indianapolis. jturner@indygastro.com

There has been a great deal of evolving research and writing about physician burnout. Horror stories about long work hours, frustrations with working environments, administrative challenges are everywhere – social media, medical journals, mainstream media. While burnout is not new, the increased attention and consequences in the health care system are exposing not only the importance of physician well-being but also the impact of burnout on patient care.

What is burnout?

Burnout was first identified in the 1970s and further refined by Christina Maslach, PhD, as a syndrome that is due to prolonged exposure to chronic interpersonal stress with three key dimensions that include 1) overwhelming exhaustion, 2) feelings of cynicism and detachment from the job, and 3) a sense of ineffectiveness and lack of accomplishment.

The Maslach Burnout Inventory (MBI), a 22-item questionnaire that was developed in the 1980s has become the standard survey in research settings for the identification of burnout. However, a two-item questionnaire has been utilized with good correlation to the domains of emotional exhaustion and depersonalization and includes: 1) I feel burned out from my work and 2) I have become more callous toward people since I took this job. Responses are graded on a scale from never to everyday with five points in between; the likelihood of burnout is high when responses are once a week or more frequent (i.e., a few times a week or everyday).

Why are we talking about burnout?

Burnout has far-reaching consequences. It not only affects the individual but also that person’s interpersonal relationships with family and friends. Additionally, burnout affects patient care and the overall health care system.

Let’s imagine the scenario in which you arrive at your office on a Monday morning and open your electronic health record (EHR). You tend to arrive at work about 45 minutes prior to your first patient to try to catch up with messages. As you wait for your computer to login (5 minutes? 8 minutes? 12 minutes?) and Citrix to connect, you are eating your breakfast bar and drinking mediocre coffee because you still haven’t had time to fix your coffee machine at home (should you just order a new one on Amazon and contribute to the world’s growing trash problem?). Once you login to your EHR, the first three messages are about missing charges and charts still left open – yes, you haven’t corrected the resident’s note from clinic on Friday afternoon, yet. The next two messages are about insurance denials for a prescription or a procedure or an imaging study. You decide that perhaps you should change gears and check your work email. The first email is a reminder that vacation requests for the next 6 months are due by end of business today and any requests made after today must go through some administrative approval process that seems inefficient and almost punitive (mainly because you forgot to discuss this with your partner and family and you are feeling somewhat guilty but resentful of this arbitrary deadline that was announced last week). Your pager promptly buzzes to announce that the first patient has arrived and is ready for you to consult. As you walk over to the procedure area, you remind yourself to finalize the resident’s note from Friday, file the missing charges, close those charts and find some reasonable evidence to justify the medication/test/procedure so that your patient is not saddled with a large bill. And as you walk up to your first patient of the morning, you are greeted by a nurse who indicates the patient doesn’t have a ride home postprocedure and what do you want to do?

Does any of this sound remotely familiar? In today’s medical practice, there are multiple factors that contribute toward burnout, including excessive clerical burden, inefficient EHR and computer systems, the sense of loss of control and flexibility, along with problems associated with work-life balance.

What does it have to do with you?

According to two surveys administered by the AGA and ACG, burnout occurs in approximately 50% of gastroenterologists. It also appears that burnout starts as early as the fellowship years when there is even less control, long work hours, and similar demands with regards to work-life balance.

Burnout is prevalent amongt gastroenterologists and it can start early. There is evidence to suggest that procedurally based specialties are at higher risk because of the added possibility of complications associated with procedures. It is important for us to recognize signs of burnout not only in ourselves but also in our colleagues and understand what personal and system-related triggers and solutions are present. The consequences of burnout have been reported to include earlier retirement and/or career transitions and are associated with depression, the risk of motor vehicle accidents, substance abuse, and suicide.

At the systems level, changes can be made to mitigate known pressures that contribute to burnout. There are efforts such as improved workflow and specific quality improvement initiatives that can improve physician satisfaction. Ensuring adequate support for physicians with aids such as scribes and appropriate support staff and para–health care workers can significantly decrease the administrative burden on clinicians and improve productivity and patient care.

At a broader level, talking about burnout, recognizing the signs of burnout and also ensuring the appropriate support is available for physicians who are at risk or already experiencing burnout can arise from leadership at both the institutional level but also at the larger organizational level, where there is greater investment into the health and well-being of physicians. For example, societies can have the negotiating power to advocate to simplify tasks unique to gastroenterologists with regard to reimbursement or EHR pathways. Academic centers can incorporate classes and forums for medical students, trainees, and practicing physicians that focus on health and well-being.

At the individual level, we should be able to reach out to our colleagues to ask for help or to see if they need help. We also need to better identify what our triggers are and what are remedies for these triggers. It’s not normal to be in a profession in which you have a constant sensation that you are drowning or barely treading water but I am sure many of us have felt this at some point if not with some regularity. So as a practitioner, what coping mechanisms do you have in place? There has been some work with respect to adaptive and maladaptive coping mechanisms at the individual and organizational levels. Maladaptive mechanisms can result in significant personal health issues including hypertension, substance abuse, and depression; it can also further exacerbate burnout symptoms in the provider and result in patient-related complications, shortened provider career trajectories, and increased strains on provider’s interpersonal relationships. I think it is an important point here to make that there are likely sex differences in maladaptive coping mechanisms and manifestations of burnout with work that suggests that women are more prone to depression, isolation, and suicide compared with male colleagues.

With respect to adaptive coping mechanisms, the most common theme is to not isolate yourself or others. Ask a colleague how s/he is doing – we are all equally busy but sometimes just popping into someone’s office to say hello is enough to help another person (and yourself) connect. Additionally, it’s not too much to ask for professional help. What we do is high stakes and taking care of ourselves usually comes behind the patient and our families. But who takes care of the caregiver? Working on interpersonal relationships can strengthen your resilience and coping techniques to the stressors we face on a daily basis. Ultimately, we are all in this together – burnout affects all of us no matter what hat you want to wear – provider, colleague, patient, or friend.
 

Dr. Mason is a gastroenterologist at the Virginia Mason Medical Center in Seattle.
 

There has been a great deal of evolving research and writing about physician burnout. Horror stories about long work hours, frustrations with working environments, administrative challenges are everywhere – social media, medical journals, mainstream media. While burnout is not new, the increased attention and consequences in the health care system are exposing not only the importance of physician well-being but also the impact of burnout on patient care.

What is burnout?

Burnout was first identified in the 1970s and further refined by Christina Maslach, PhD, as a syndrome that is due to prolonged exposure to chronic interpersonal stress with three key dimensions that include 1) overwhelming exhaustion, 2) feelings of cynicism and detachment from the job, and 3) a sense of ineffectiveness and lack of accomplishment.

The Maslach Burnout Inventory (MBI), a 22-item questionnaire that was developed in the 1980s has become the standard survey in research settings for the identification of burnout. However, a two-item questionnaire has been utilized with good correlation to the domains of emotional exhaustion and depersonalization and includes: 1) I feel burned out from my work and 2) I have become more callous toward people since I took this job. Responses are graded on a scale from never to everyday with five points in between; the likelihood of burnout is high when responses are once a week or more frequent (i.e., a few times a week or everyday).

Why are we talking about burnout?

Burnout has far-reaching consequences. It not only affects the individual but also that person’s interpersonal relationships with family and friends. Additionally, burnout affects patient care and the overall health care system.

Let’s imagine the scenario in which you arrive at your office on a Monday morning and open your electronic health record (EHR). You tend to arrive at work about 45 minutes prior to your first patient to try to catch up with messages. As you wait for your computer to login (5 minutes? 8 minutes? 12 minutes?) and Citrix to connect, you are eating your breakfast bar and drinking mediocre coffee because you still haven’t had time to fix your coffee machine at home (should you just order a new one on Amazon and contribute to the world’s growing trash problem?). Once you login to your EHR, the first three messages are about missing charges and charts still left open – yes, you haven’t corrected the resident’s note from clinic on Friday afternoon, yet. The next two messages are about insurance denials for a prescription or a procedure or an imaging study. You decide that perhaps you should change gears and check your work email. The first email is a reminder that vacation requests for the next 6 months are due by end of business today and any requests made after today must go through some administrative approval process that seems inefficient and almost punitive (mainly because you forgot to discuss this with your partner and family and you are feeling somewhat guilty but resentful of this arbitrary deadline that was announced last week). Your pager promptly buzzes to announce that the first patient has arrived and is ready for you to consult. As you walk over to the procedure area, you remind yourself to finalize the resident’s note from Friday, file the missing charges, close those charts and find some reasonable evidence to justify the medication/test/procedure so that your patient is not saddled with a large bill. And as you walk up to your first patient of the morning, you are greeted by a nurse who indicates the patient doesn’t have a ride home postprocedure and what do you want to do?

Does any of this sound remotely familiar? In today’s medical practice, there are multiple factors that contribute toward burnout, including excessive clerical burden, inefficient EHR and computer systems, the sense of loss of control and flexibility, along with problems associated with work-life balance.

What does it have to do with you?

According to two surveys administered by the AGA and ACG, burnout occurs in approximately 50% of gastroenterologists. It also appears that burnout starts as early as the fellowship years when there is even less control, long work hours, and similar demands with regards to work-life balance.

Burnout is prevalent amongt gastroenterologists and it can start early. There is evidence to suggest that procedurally based specialties are at higher risk because of the added possibility of complications associated with procedures. It is important for us to recognize signs of burnout not only in ourselves but also in our colleagues and understand what personal and system-related triggers and solutions are present. The consequences of burnout have been reported to include earlier retirement and/or career transitions and are associated with depression, the risk of motor vehicle accidents, substance abuse, and suicide.

At the systems level, changes can be made to mitigate known pressures that contribute to burnout. There are efforts such as improved workflow and specific quality improvement initiatives that can improve physician satisfaction. Ensuring adequate support for physicians with aids such as scribes and appropriate support staff and para–health care workers can significantly decrease the administrative burden on clinicians and improve productivity and patient care.

At a broader level, talking about burnout, recognizing the signs of burnout and also ensuring the appropriate support is available for physicians who are at risk or already experiencing burnout can arise from leadership at both the institutional level but also at the larger organizational level, where there is greater investment into the health and well-being of physicians. For example, societies can have the negotiating power to advocate to simplify tasks unique to gastroenterologists with regard to reimbursement or EHR pathways. Academic centers can incorporate classes and forums for medical students, trainees, and practicing physicians that focus on health and well-being.

At the individual level, we should be able to reach out to our colleagues to ask for help or to see if they need help. We also need to better identify what our triggers are and what are remedies for these triggers. It’s not normal to be in a profession in which you have a constant sensation that you are drowning or barely treading water but I am sure many of us have felt this at some point if not with some regularity. So as a practitioner, what coping mechanisms do you have in place? There has been some work with respect to adaptive and maladaptive coping mechanisms at the individual and organizational levels. Maladaptive mechanisms can result in significant personal health issues including hypertension, substance abuse, and depression; it can also further exacerbate burnout symptoms in the provider and result in patient-related complications, shortened provider career trajectories, and increased strains on provider’s interpersonal relationships. I think it is an important point here to make that there are likely sex differences in maladaptive coping mechanisms and manifestations of burnout with work that suggests that women are more prone to depression, isolation, and suicide compared with male colleagues.

With respect to adaptive coping mechanisms, the most common theme is to not isolate yourself or others. Ask a colleague how s/he is doing – we are all equally busy but sometimes just popping into someone’s office to say hello is enough to help another person (and yourself) connect. Additionally, it’s not too much to ask for professional help. What we do is high stakes and taking care of ourselves usually comes behind the patient and our families. But who takes care of the caregiver? Working on interpersonal relationships can strengthen your resilience and coping techniques to the stressors we face on a daily basis. Ultimately, we are all in this together – burnout affects all of us no matter what hat you want to wear – provider, colleague, patient, or friend.
 

Dr. Mason is a gastroenterologist at the Virginia Mason Medical Center in Seattle.
 

There has been a great deal of evolving research and writing about physician burnout. Horror stories about long work hours, frustrations with working environments, administrative challenges are everywhere – social media, medical journals, mainstream media. While burnout is not new, the increased attention and consequences in the health care system are exposing not only the importance of physician well-being but also the impact of burnout on patient care.

What is burnout?

Burnout was first identified in the 1970s and further refined by Christina Maslach, PhD, as a syndrome that is due to prolonged exposure to chronic interpersonal stress with three key dimensions that include 1) overwhelming exhaustion, 2) feelings of cynicism and detachment from the job, and 3) a sense of ineffectiveness and lack of accomplishment.

The Maslach Burnout Inventory (MBI), a 22-item questionnaire that was developed in the 1980s has become the standard survey in research settings for the identification of burnout. However, a two-item questionnaire has been utilized with good correlation to the domains of emotional exhaustion and depersonalization and includes: 1) I feel burned out from my work and 2) I have become more callous toward people since I took this job. Responses are graded on a scale from never to everyday with five points in between; the likelihood of burnout is high when responses are once a week or more frequent (i.e., a few times a week or everyday).

Why are we talking about burnout?

Burnout has far-reaching consequences. It not only affects the individual but also that person’s interpersonal relationships with family and friends. Additionally, burnout affects patient care and the overall health care system.

Let’s imagine the scenario in which you arrive at your office on a Monday morning and open your electronic health record (EHR). You tend to arrive at work about 45 minutes prior to your first patient to try to catch up with messages. As you wait for your computer to login (5 minutes? 8 minutes? 12 minutes?) and Citrix to connect, you are eating your breakfast bar and drinking mediocre coffee because you still haven’t had time to fix your coffee machine at home (should you just order a new one on Amazon and contribute to the world’s growing trash problem?). Once you login to your EHR, the first three messages are about missing charges and charts still left open – yes, you haven’t corrected the resident’s note from clinic on Friday afternoon, yet. The next two messages are about insurance denials for a prescription or a procedure or an imaging study. You decide that perhaps you should change gears and check your work email. The first email is a reminder that vacation requests for the next 6 months are due by end of business today and any requests made after today must go through some administrative approval process that seems inefficient and almost punitive (mainly because you forgot to discuss this with your partner and family and you are feeling somewhat guilty but resentful of this arbitrary deadline that was announced last week). Your pager promptly buzzes to announce that the first patient has arrived and is ready for you to consult. As you walk over to the procedure area, you remind yourself to finalize the resident’s note from Friday, file the missing charges, close those charts and find some reasonable evidence to justify the medication/test/procedure so that your patient is not saddled with a large bill. And as you walk up to your first patient of the morning, you are greeted by a nurse who indicates the patient doesn’t have a ride home postprocedure and what do you want to do?

Does any of this sound remotely familiar? In today’s medical practice, there are multiple factors that contribute toward burnout, including excessive clerical burden, inefficient EHR and computer systems, the sense of loss of control and flexibility, along with problems associated with work-life balance.

What does it have to do with you?

According to two surveys administered by the AGA and ACG, burnout occurs in approximately 50% of gastroenterologists. It also appears that burnout starts as early as the fellowship years when there is even less control, long work hours, and similar demands with regards to work-life balance.

Burnout is prevalent amongt gastroenterologists and it can start early. There is evidence to suggest that procedurally based specialties are at higher risk because of the added possibility of complications associated with procedures. It is important for us to recognize signs of burnout not only in ourselves but also in our colleagues and understand what personal and system-related triggers and solutions are present. The consequences of burnout have been reported to include earlier retirement and/or career transitions and are associated with depression, the risk of motor vehicle accidents, substance abuse, and suicide.

At the systems level, changes can be made to mitigate known pressures that contribute to burnout. There are efforts such as improved workflow and specific quality improvement initiatives that can improve physician satisfaction. Ensuring adequate support for physicians with aids such as scribes and appropriate support staff and para–health care workers can significantly decrease the administrative burden on clinicians and improve productivity and patient care.

At a broader level, talking about burnout, recognizing the signs of burnout and also ensuring the appropriate support is available for physicians who are at risk or already experiencing burnout can arise from leadership at both the institutional level but also at the larger organizational level, where there is greater investment into the health and well-being of physicians. For example, societies can have the negotiating power to advocate to simplify tasks unique to gastroenterologists with regard to reimbursement or EHR pathways. Academic centers can incorporate classes and forums for medical students, trainees, and practicing physicians that focus on health and well-being.

At the individual level, we should be able to reach out to our colleagues to ask for help or to see if they need help. We also need to better identify what our triggers are and what are remedies for these triggers. It’s not normal to be in a profession in which you have a constant sensation that you are drowning or barely treading water but I am sure many of us have felt this at some point if not with some regularity. So as a practitioner, what coping mechanisms do you have in place? There has been some work with respect to adaptive and maladaptive coping mechanisms at the individual and organizational levels. Maladaptive mechanisms can result in significant personal health issues including hypertension, substance abuse, and depression; it can also further exacerbate burnout symptoms in the provider and result in patient-related complications, shortened provider career trajectories, and increased strains on provider’s interpersonal relationships. I think it is an important point here to make that there are likely sex differences in maladaptive coping mechanisms and manifestations of burnout with work that suggests that women are more prone to depression, isolation, and suicide compared with male colleagues.

With respect to adaptive coping mechanisms, the most common theme is to not isolate yourself or others. Ask a colleague how s/he is doing – we are all equally busy but sometimes just popping into someone’s office to say hello is enough to help another person (and yourself) connect. Additionally, it’s not too much to ask for professional help. What we do is high stakes and taking care of ourselves usually comes behind the patient and our families. But who takes care of the caregiver? Working on interpersonal relationships can strengthen your resilience and coping techniques to the stressors we face on a daily basis. Ultimately, we are all in this together – burnout affects all of us no matter what hat you want to wear – provider, colleague, patient, or friend.
 

Dr. Mason is a gastroenterologist at the Virginia Mason Medical Center in Seattle.
 

“Average leaders raise the bar on themselves; good leaders raise the bar for others; great leaders inspire others to raise their own bar.”

– Orrin Woodward

Gastroenterology practices face numerous challenges every day. From addressing reimbursement changes to the development of new service lines to ensuring the highest quality of patient care – the cacophony can drown out the ability of even the most well-meaning groups from attending to the development of internal leadership skills. But thoughtful and intentioned “succession planning” is essential to the long-term success of any practice. At the bedside, we are all leaders – physicians are comfortable in this authoritative leadership role. But most physicians feel less confident assuming a leadership role when it comes to the daily activities of running a busy practice, or more importantly, developing business strategy in a rapidly changing world. Gastroenterology practices and divisions are increasingly challenged with numerous essential nonclinical tasks, including complex practice administration and employee management, intragroup leadership and maintenance of cohesion, and strategy development. Future success in the evolving health care market will depend on the development and execution of new business and service approaches, as well as emerging partnerships and alliances. It will be essential for leaders to effectively shepherd value-added organizational change, not an easy task, and to embrace more participative leadership skills to accomplish goals.

The majority of independent practices are run by a single president; most GI divisions are run by a single chief. A number of factors may inhibit the interest or cultivation of new leaders. There remains a minimum of devoted attention to training more junior physicians to fill leadership roles, and an autocratic practice structure does not naturally promote junior physician engagement in practice leadership. Few physicians receive formal business training through MBA, or other training programs or resources. Physician leaders may be expected to perform many leadership and management duties outside normal clinical activities. This creates stress, risks burn out, and can inhibit succession interest.

With the increasing corporatization of medicine, if physicians sacrifice key leadership roles and duties, they are quickly filled by administrators with priorities that may not align with patient care and physician well-being. In fact, between 1975 and 2010, the number of physicians in the United States grew by 150%. During that same time period, the number of health care administrators grew by 3,200%.¹ Skilled practice administrators are of tremendous value to most practices, but physician involvement and comanagement at the administrative level remains crucial to align practice goals to optimize patient care.

How do we combat these trends and defend the role of physicians in maintaining control of fundamental aspects of their clinical practices? This begins with making the development of leadership skills an active priority, coupled with baseline levels of training in practice administration for gastroenterologists. There needs to be processes that allow junior physicians to determine their aptitude for and interest in leading, and conversely for established leaders to identify talent. Currently a minimum of this type of training happens during fellowship; the majority of physicians learn this after beginning their practice. Just as we must master clinical and endoscopic skills, we must also attend to the development of practical skills like understanding revenue cycle management, communicating effectively, and reading an income statement. Practices should consider supporting administrative education as an integral part of training, as well as time away from clinical duties to learn and participate in practice leadership, management, and mentorship activities. Physicians need the tools to understand how their practices are run. Arming our next generation of physicians with the necessary skills to thrive in corporate medicine is required.

Physician leadership development, however, remains the responsibility of both the individual and the organization. We each have a role to play in elevating our practices and our community. Passion for medicine and our profession necessarily motivates each of us to take on these challenges. But leadership skills also take mentorship and encouragement to grow.

The dividends to a practice attending to leadership development, however, can be exponential. When each physician member of a practice is encouraged to develop natural aptitudes and address practice challenges (within a shared vision), the practice as a whole benefits. Taking the time to foster leadership skill development for more junior colleagues allows a natural and comfortable delegation of duties over time. Just as physicians will need to commit time and efforts in developing themselves, gastroenterology practices need to commit to supporting their growth, and creating avenues for such tracks within incentive-based compensation models that can create barriers. Practically, leadership development in GI practices, both in the community and at academic centers, can be accomplished in a variety of ways. Some groups have formal internal practice leadership structures that allow for the natural development of physician leadership from within. Participation in an Executive Committee that supports the president and practice administrator can be highly educational and a fertile forum to develop junior leaders. Current physician leaders also have the opportunity and obligation to include junior physicians in strategy discussions, negotiations, and collaborations with administrators. Mentorship, whether formal or informal, is essential to leadership and business skill development. Many practices already have formal developmental programs in place to encourage leadership in office managers, in practice administrators, and at the nursing level. Arguably, most have been less structured in cultivating leadership at the physician level.

There are also numerous opportunities for leadership within your local medical community on hospital quality boards, industry partnerships, and community engagement/service groups. On a national level, working within a professional society can be an excellent opportunity for professional growth and leadership development. The AGA has several dedicated positions for young GIs on committees as well as several programs specifically devoted to leadership training such as the AGA Young Leaders program and Women’s Leadership program. All of these represent opportunities to give junior members a seat at the table to develop and hone leadership skills.

When a culture of leadership and ownership is established, increased engagement naturally follows. When we spend the time to encourage our colleagues to attend to not just the highest quality of medical care but also consider and develop the highest level of patient service through strategic practice development, our overall care is elevated. Developing leadership raises the bar for everyone.

With the increasing corporatization of medicine, it is the duty of physician leaders to be prepared to advocate and protect our patients, our practices, and our professions. But without proper cultivation of leadership within our practices and groups, a leadership vacuum will leave us all vulnerable to sacrificing these important roles to those who do not wear the white coat. Across the country, large and thriving gastroenterology groups are providing cutting-edge care for their patients, despite increasing challenges. Let’s remember to take the time to prepare future leaders for these challenges as well – ultimately the success of our practices and our patients depend on it.

Reference

1. Cantlupe J. The rise (and rise) of the healthcare administrator. Athenainsight. https://www.athenahealth.com/insight/expert-forum-rise-and-rise-healthcare-administrator.

Dr. Mathew is a gastroenterologist at South Denver Gastroenterology in Denver. She has no conflicts of interest.

“Average leaders raise the bar on themselves; good leaders raise the bar for others; great leaders inspire others to raise their own bar.”

– Orrin Woodward

Gastroenterology practices face numerous challenges every day. From addressing reimbursement changes to the development of new service lines to ensuring the highest quality of patient care – the cacophony can drown out the ability of even the most well-meaning groups from attending to the development of internal leadership skills. But thoughtful and intentioned “succession planning” is essential to the long-term success of any practice. At the bedside, we are all leaders – physicians are comfortable in this authoritative leadership role. But most physicians feel less confident assuming a leadership role when it comes to the daily activities of running a busy practice, or more importantly, developing business strategy in a rapidly changing world. Gastroenterology practices and divisions are increasingly challenged with numerous essential nonclinical tasks, including complex practice administration and employee management, intragroup leadership and maintenance of cohesion, and strategy development. Future success in the evolving health care market will depend on the development and execution of new business and service approaches, as well as emerging partnerships and alliances. It will be essential for leaders to effectively shepherd value-added organizational change, not an easy task, and to embrace more participative leadership skills to accomplish goals.

The majority of independent practices are run by a single president; most GI divisions are run by a single chief. A number of factors may inhibit the interest or cultivation of new leaders. There remains a minimum of devoted attention to training more junior physicians to fill leadership roles, and an autocratic practice structure does not naturally promote junior physician engagement in practice leadership. Few physicians receive formal business training through MBA, or other training programs or resources. Physician leaders may be expected to perform many leadership and management duties outside normal clinical activities. This creates stress, risks burn out, and can inhibit succession interest.

With the increasing corporatization of medicine, if physicians sacrifice key leadership roles and duties, they are quickly filled by administrators with priorities that may not align with patient care and physician well-being. In fact, between 1975 and 2010, the number of physicians in the United States grew by 150%. During that same time period, the number of health care administrators grew by 3,200%.¹ Skilled practice administrators are of tremendous value to most practices, but physician involvement and comanagement at the administrative level remains crucial to align practice goals to optimize patient care.

How do we combat these trends and defend the role of physicians in maintaining control of fundamental aspects of their clinical practices? This begins with making the development of leadership skills an active priority, coupled with baseline levels of training in practice administration for gastroenterologists. There needs to be processes that allow junior physicians to determine their aptitude for and interest in leading, and conversely for established leaders to identify talent. Currently a minimum of this type of training happens during fellowship; the majority of physicians learn this after beginning their practice. Just as we must master clinical and endoscopic skills, we must also attend to the development of practical skills like understanding revenue cycle management, communicating effectively, and reading an income statement. Practices should consider supporting administrative education as an integral part of training, as well as time away from clinical duties to learn and participate in practice leadership, management, and mentorship activities. Physicians need the tools to understand how their practices are run. Arming our next generation of physicians with the necessary skills to thrive in corporate medicine is required.

Physician leadership development, however, remains the responsibility of both the individual and the organization. We each have a role to play in elevating our practices and our community. Passion for medicine and our profession necessarily motivates each of us to take on these challenges. But leadership skills also take mentorship and encouragement to grow.

The dividends to a practice attending to leadership development, however, can be exponential. When each physician member of a practice is encouraged to develop natural aptitudes and address practice challenges (within a shared vision), the practice as a whole benefits. Taking the time to foster leadership skill development for more junior colleagues allows a natural and comfortable delegation of duties over time. Just as physicians will need to commit time and efforts in developing themselves, gastroenterology practices need to commit to supporting their growth, and creating avenues for such tracks within incentive-based compensation models that can create barriers. Practically, leadership development in GI practices, both in the community and at academic centers, can be accomplished in a variety of ways. Some groups have formal internal practice leadership structures that allow for the natural development of physician leadership from within. Participation in an Executive Committee that supports the president and practice administrator can be highly educational and a fertile forum to develop junior leaders. Current physician leaders also have the opportunity and obligation to include junior physicians in strategy discussions, negotiations, and collaborations with administrators. Mentorship, whether formal or informal, is essential to leadership and business skill development. Many practices already have formal developmental programs in place to encourage leadership in office managers, in practice administrators, and at the nursing level. Arguably, most have been less structured in cultivating leadership at the physician level.

There are also numerous opportunities for leadership within your local medical community on hospital quality boards, industry partnerships, and community engagement/service groups. On a national level, working within a professional society can be an excellent opportunity for professional growth and leadership development. The AGA has several dedicated positions for young GIs on committees as well as several programs specifically devoted to leadership training such as the AGA Young Leaders program and Women’s Leadership program. All of these represent opportunities to give junior members a seat at the table to develop and hone leadership skills.

When a culture of leadership and ownership is established, increased engagement naturally follows. When we spend the time to encourage our colleagues to attend to not just the highest quality of medical care but also consider and develop the highest level of patient service through strategic practice development, our overall care is elevated. Developing leadership raises the bar for everyone.

With the increasing corporatization of medicine, it is the duty of physician leaders to be prepared to advocate and protect our patients, our practices, and our professions. But without proper cultivation of leadership within our practices and groups, a leadership vacuum will leave us all vulnerable to sacrificing these important roles to those who do not wear the white coat. Across the country, large and thriving gastroenterology groups are providing cutting-edge care for their patients, despite increasing challenges. Let’s remember to take the time to prepare future leaders for these challenges as well – ultimately the success of our practices and our patients depend on it.

Reference

1. Cantlupe J. The rise (and rise) of the healthcare administrator. Athenainsight. https://www.athenahealth.com/insight/expert-forum-rise-and-rise-healthcare-administrator.

Dr. Mathew is a gastroenterologist at South Denver Gastroenterology in Denver. She has no conflicts of interest.

“Average leaders raise the bar on themselves; good leaders raise the bar for others; great leaders inspire others to raise their own bar.”

– Orrin Woodward

Gastroenterology practices face numerous challenges every day. From addressing reimbursement changes to the development of new service lines to ensuring the highest quality of patient care – the cacophony can drown out the ability of even the most well-meaning groups from attending to the development of internal leadership skills. But thoughtful and intentioned “succession planning” is essential to the long-term success of any practice. At the bedside, we are all leaders – physicians are comfortable in this authoritative leadership role. But most physicians feel less confident assuming a leadership role when it comes to the daily activities of running a busy practice, or more importantly, developing business strategy in a rapidly changing world. Gastroenterology practices and divisions are increasingly challenged with numerous essential nonclinical tasks, including complex practice administration and employee management, intragroup leadership and maintenance of cohesion, and strategy development. Future success in the evolving health care market will depend on the development and execution of new business and service approaches, as well as emerging partnerships and alliances. It will be essential for leaders to effectively shepherd value-added organizational change, not an easy task, and to embrace more participative leadership skills to accomplish goals.

The majority of independent practices are run by a single president; most GI divisions are run by a single chief. A number of factors may inhibit the interest or cultivation of new leaders. There remains a minimum of devoted attention to training more junior physicians to fill leadership roles, and an autocratic practice structure does not naturally promote junior physician engagement in practice leadership. Few physicians receive formal business training through MBA, or other training programs or resources. Physician leaders may be expected to perform many leadership and management duties outside normal clinical activities. This creates stress, risks burn out, and can inhibit succession interest.

With the increasing corporatization of medicine, if physicians sacrifice key leadership roles and duties, they are quickly filled by administrators with priorities that may not align with patient care and physician well-being. In fact, between 1975 and 2010, the number of physicians in the United States grew by 150%. During that same time period, the number of health care administrators grew by 3,200%.¹ Skilled practice administrators are of tremendous value to most practices, but physician involvement and comanagement at the administrative level remains crucial to align practice goals to optimize patient care.

How do we combat these trends and defend the role of physicians in maintaining control of fundamental aspects of their clinical practices? This begins with making the development of leadership skills an active priority, coupled with baseline levels of training in practice administration for gastroenterologists. There needs to be processes that allow junior physicians to determine their aptitude for and interest in leading, and conversely for established leaders to identify talent. Currently a minimum of this type of training happens during fellowship; the majority of physicians learn this after beginning their practice. Just as we must master clinical and endoscopic skills, we must also attend to the development of practical skills like understanding revenue cycle management, communicating effectively, and reading an income statement. Practices should consider supporting administrative education as an integral part of training, as well as time away from clinical duties to learn and participate in practice leadership, management, and mentorship activities. Physicians need the tools to understand how their practices are run. Arming our next generation of physicians with the necessary skills to thrive in corporate medicine is required.

Physician leadership development, however, remains the responsibility of both the individual and the organization. We each have a role to play in elevating our practices and our community. Passion for medicine and our profession necessarily motivates each of us to take on these challenges. But leadership skills also take mentorship and encouragement to grow.

The dividends to a practice attending to leadership development, however, can be exponential. When each physician member of a practice is encouraged to develop natural aptitudes and address practice challenges (within a shared vision), the practice as a whole benefits. Taking the time to foster leadership skill development for more junior colleagues allows a natural and comfortable delegation of duties over time. Just as physicians will need to commit time and efforts in developing themselves, gastroenterology practices need to commit to supporting their growth, and creating avenues for such tracks within incentive-based compensation models that can create barriers. Practically, leadership development in GI practices, both in the community and at academic centers, can be accomplished in a variety of ways. Some groups have formal internal practice leadership structures that allow for the natural development of physician leadership from within. Participation in an Executive Committee that supports the president and practice administrator can be highly educational and a fertile forum to develop junior leaders. Current physician leaders also have the opportunity and obligation to include junior physicians in strategy discussions, negotiations, and collaborations with administrators. Mentorship, whether formal or informal, is essential to leadership and business skill development. Many practices already have formal developmental programs in place to encourage leadership in office managers, in practice administrators, and at the nursing level. Arguably, most have been less structured in cultivating leadership at the physician level.

There are also numerous opportunities for leadership within your local medical community on hospital quality boards, industry partnerships, and community engagement/service groups. On a national level, working within a professional society can be an excellent opportunity for professional growth and leadership development. The AGA has several dedicated positions for young GIs on committees as well as several programs specifically devoted to leadership training such as the AGA Young Leaders program and Women’s Leadership program. All of these represent opportunities to give junior members a seat at the table to develop and hone leadership skills.

When a culture of leadership and ownership is established, increased engagement naturally follows. When we spend the time to encourage our colleagues to attend to not just the highest quality of medical care but also consider and develop the highest level of patient service through strategic practice development, our overall care is elevated. Developing leadership raises the bar for everyone.

With the increasing corporatization of medicine, it is the duty of physician leaders to be prepared to advocate and protect our patients, our practices, and our professions. But without proper cultivation of leadership within our practices and groups, a leadership vacuum will leave us all vulnerable to sacrificing these important roles to those who do not wear the white coat. Across the country, large and thriving gastroenterology groups are providing cutting-edge care for their patients, despite increasing challenges. Let’s remember to take the time to prepare future leaders for these challenges as well – ultimately the success of our practices and our patients depend on it.

Reference

1. Cantlupe J. The rise (and rise) of the healthcare administrator. Athenainsight. https://www.athenahealth.com/insight/expert-forum-rise-and-rise-healthcare-administrator.

Dr. Mathew is a gastroenterologist at South Denver Gastroenterology in Denver. She has no conflicts of interest.

A few years ago, private equity (PE) firms began to focus on independent gastroenterology practices as a target for investment. The first PE investment transaction closed in March of 2016, and now an additional three such partnerships have occurred. Investment firms believe gastroenterology is ripe for investment and subsequent consolidation for the following reasons:

• Gastroenterology is a highly fragmented specialty with many small and mid-sized groups that could be rolled up into larger practice entities that create favorable scalability.
• There are multiple revenue streams through ancillary services that can be packaged into a comprehensive, high-quality gastroenterology practice that has high value for patients and that are delivered outside of a hospital environment.
• There is a growing need for gastroenterology care with increasing demand for chronic GI disease management (fatty liver disease, inflammatory bowel disease, and obesity management, for example) and increasing demand for colon cancer screening.
• Most independent gastroenterologists have natural entrepreneurial spirit.
• The current financial environment is favorable for investment and other sectors of the health care market are rapidly consolidating.

A PE transaction is not appropriate for every practice nor every physician. Further, not every physician group will be desirable for a PE firm. Nonetheless, the current business climate in the GI sector is generally favorable for accepting the PE capital model.

The following are 10 common questions dealing with a PE transaction:

1. What does a PE deal mean for the independent gastroenterologist? A PE transaction and the resulting formation of a managed services organization (MSO) will be a liquidity event for all current owners in the acquired practice. Financial benefits are typically substantial, especially when considering the funds can then be invested by the individual physician and often the money paid can be taxed as capital gains rather than ordinary income. In exchange for the pay-out, the physician group relinquishes managerial control of nonclinical decisions through a managed services agreement (MSA) with the MSO. The MSO is typically formed by the partnership between the practice and the PE firm and provides all nonclinical services to the physician group.

2. What autonomy will be left after signing a PE deal/MSA? Autonomy after the deal closes is determined largely by terms written into the contract prior to the closing and will differ among the various PE firms. There will be conditions important to the MSO and some important to the practice that can be codified in the contract. These conditions are spelled out in an employment agreement with the continuing physician group. Both the PE group and physicians will want to ensure that practice culture is not negatively impacted through an acquisition. Physicians must feel that they retain complete autonomy when it comes to clinical decisions, and the PE group must avoid interfering in the patient-doctor relationship. The PE group wants to improve nonclinical management of the practice, without interfering with the actual care of a patient. Physicians may influence nonclinical managerial decisions, but providers must understand that all nonclinical managerial decisions ultimately will be made by the MSO and PE firm.

A few years ago, private equity (PE) firms began to focus on independent gastroenterology practices as a target for investment. The first PE investment transaction closed in March of 2016, and now an additional three such partnerships have occurred. Investment firms believe gastroenterology is ripe for investment and subsequent consolidation for the following reasons:

• Gastroenterology is a highly fragmented specialty with many small and mid-sized groups that could be rolled up into larger practice entities that create favorable scalability.
• There are multiple revenue streams through ancillary services that can be packaged into a comprehensive, high-quality gastroenterology practice that has high value for patients and that are delivered outside of a hospital environment.
• There is a growing need for gastroenterology care with increasing demand for chronic GI disease management (fatty liver disease, inflammatory bowel disease, and obesity management, for example) and increasing demand for colon cancer screening.
• Most independent gastroenterologists have natural entrepreneurial spirit.
• The current financial environment is favorable for investment and other sectors of the health care market are rapidly consolidating.

A PE transaction is not appropriate for every practice nor every physician. Further, not every physician group will be desirable for a PE firm. Nonetheless, the current business climate in the GI sector is generally favorable for accepting the PE capital model.

The following are 10 common questions dealing with a PE transaction:

1. What does a PE deal mean for the independent gastroenterologist? A PE transaction and the resulting formation of a managed services organization (MSO) will be a liquidity event for all current owners in the acquired practice. Financial benefits are typically substantial, especially when considering the funds can then be invested by the individual physician and often the money paid can be taxed as capital gains rather than ordinary income. In exchange for the pay-out, the physician group relinquishes managerial control of nonclinical decisions through a managed services agreement (MSA) with the MSO. The MSO is typically formed by the partnership between the practice and the PE firm and provides all nonclinical services to the physician group.

2. What autonomy will be left after signing a PE deal/MSA? Autonomy after the deal closes is determined largely by terms written into the contract prior to the closing and will differ among the various PE firms. There will be conditions important to the MSO and some important to the practice that can be codified in the contract. These conditions are spelled out in an employment agreement with the continuing physician group. Both the PE group and physicians will want to ensure that practice culture is not negatively impacted through an acquisition. Physicians must feel that they retain complete autonomy when it comes to clinical decisions, and the PE group must avoid interfering in the patient-doctor relationship. The PE group wants to improve nonclinical management of the practice, without interfering with the actual care of a patient. Physicians may influence nonclinical managerial decisions, but providers must understand that all nonclinical managerial decisions ultimately will be made by the MSO and PE firm.

A few years ago, private equity (PE) firms began to focus on independent gastroenterology practices as a target for investment. The first PE investment transaction closed in March of 2016, and now an additional three such partnerships have occurred. Investment firms believe gastroenterology is ripe for investment and subsequent consolidation for the following reasons:

• Gastroenterology is a highly fragmented specialty with many small and mid-sized groups that could be rolled up into larger practice entities that create favorable scalability.
• There are multiple revenue streams through ancillary services that can be packaged into a comprehensive, high-quality gastroenterology practice that has high value for patients and that are delivered outside of a hospital environment.
• There is a growing need for gastroenterology care with increasing demand for chronic GI disease management (fatty liver disease, inflammatory bowel disease, and obesity management, for example) and increasing demand for colon cancer screening.
• Most independent gastroenterologists have natural entrepreneurial spirit.
• The current financial environment is favorable for investment and other sectors of the health care market are rapidly consolidating.

A PE transaction is not appropriate for every practice nor every physician. Further, not every physician group will be desirable for a PE firm. Nonetheless, the current business climate in the GI sector is generally favorable for accepting the PE capital model.

The following are 10 common questions dealing with a PE transaction:

1. What does a PE deal mean for the independent gastroenterologist? A PE transaction and the resulting formation of a managed services organization (MSO) will be a liquidity event for all current owners in the acquired practice. Financial benefits are typically substantial, especially when considering the funds can then be invested by the individual physician and often the money paid can be taxed as capital gains rather than ordinary income. In exchange for the pay-out, the physician group relinquishes managerial control of nonclinical decisions through a managed services agreement (MSA) with the MSO. The MSO is typically formed by the partnership between the practice and the PE firm and provides all nonclinical services to the physician group.

2. What autonomy will be left after signing a PE deal/MSA? Autonomy after the deal closes is determined largely by terms written into the contract prior to the closing and will differ among the various PE firms. There will be conditions important to the MSO and some important to the practice that can be codified in the contract. These conditions are spelled out in an employment agreement with the continuing physician group. Both the PE group and physicians will want to ensure that practice culture is not negatively impacted through an acquisition. Physicians must feel that they retain complete autonomy when it comes to clinical decisions, and the PE group must avoid interfering in the patient-doctor relationship. The PE group wants to improve nonclinical management of the practice, without interfering with the actual care of a patient. Physicians may influence nonclinical managerial decisions, but providers must understand that all nonclinical managerial decisions ultimately will be made by the MSO and PE firm.

If you work in health care or manage a medical practice, you are aware of all the radical changes in technology, medicine, social values, and interpersonal relations over the past few years and you probably do not expect the next several years to be less stressful and less uncertain. To ensure your practice and your provider’s success, you may need to adjust how your team interacts with patients – starting with the first area of patient interaction.

Patients who seek care for their health problems are looking for some measure of kindness when they approach the window of your office’s receptionist. Many are already apprehensive about their clinical condition and adding to that problem is their concern about the financial impact of their visit on the family’s budget. The medical group’s unwillingness to rethink how it greets patients as they approach the receptionist sets the stage for the patient to feel mishandled or underappreciated.

This initial patient interaction stage must be evaluated and recognized as an area of improvement. If not handled properly, it will significantly affect how a medical practice or provider is graded as a group in the field of patient experience and managing patient expectations. Every medical office needs to recognize that people hold on to negative experiences and are not likely to change their mind after that negative experience. The best way to avoid negative bias is to prevent it from happening in the first place.

Listed below are the five additional patient experience mistakes that can cost your group, if they are not recognized as being priorities for both your staff and your patients.
 

Mistake #1 - Educated patients are taking control of their health care.

When health care is treated like any other paid service, an unhappy patient will move along to a new facility or doctor if they have a bad interaction – whether it is with the doctor or the support staff. Educating, training, or adjusting staff to make changes needed is required to ensure that your staff understands the value of patient appreciation and providing the patient with a positive experience.

Mistake #2 - Patients are customers, and just like customers, patients have options.

It should be recognized that patients are customers who are concerned about their future and do not want to be in a medical practice requesting help. They feel vulnerable and out of their routine comfort zone. Reminding your staff that a patient is a customer who has multiple health care choices, but chose to come to your practice, will help your staff understand the value of providing your patient with a positive experience.

Mistake #3 – Dr. Google is becoming the patient’s best friend.

Research indicates that many patients arrive at the doctor’s office already with some information on their condition. Various websites already have provided the patient with free access to learn about their health condition. Popular medical sites such as WebMD.com give the patient the preliminary education they are looking for, so they are already armed with medical information even before they see the doctor or their support staff.

Mistake # 4 - Surveys are carrying more weight.

Outside surveys are becoming even more popular and are carrying additional weight when combined with various social media outlets. All types of surveys and reviews are being used to measure not only the care the patient received, but also the interpersonal relationship between the patient and the doctor, and the patient’s experience with the medical practice’s support staff. Some surveys cover all levels in the practice area, down to the cleanliness of the reception area or the patient’s treatment area, and even the adequacy of the parking lot. These surveys are conditioning patients to recall their entire experience. With a patient experience plan in place, excellent service becomes second nature and will be recognized by those surveyed.

Mistake #5 - Patient-centered care is customer service, too.

It’s not just about the obvious. Excellent patient (customer) service extends beyond a pleasant demeanor. The patient experience does not start or end at the doctor’s office. Perception is built by gathering information from multiple channels, whether it is through review sites, office visits, or surveys. It is necessary to consider the importance of those channels when looking to build patient loyalty.

To avoid the mistakes listed above, the more progressive medical practices are training their staff to anticipate the customer service needs of their patients, much like other major service industries. By rolling out a patient/customer experience training program, they can prevent these mistakes from ever happening and affecting their potential revenue. This training should focus on integrating the following strategies into their daily work habits to provide their patients with exceptional customer service while they are guests in their practice.

1) Patients are the lifeline to building the future of their practice.

Patients are comparing their health care services to other companies that routinely provide high-end services to their clients. Whether groups like it or not, their front-line personnel are compared to five-star hotel receptionists, who are expected to greet their customers both pleasantly and professionally after a long day of traveling and required business functions. Every medical group must understand that patients have options when they select a medical practice and they expect to be treated with respect and transparency, and not just another person to be cared for at the end of a long day. The same level of service needs to be delivered in the doctor’s office no matter what time of day it is because for that patient, the personal problems and subsequent disposition of the medical staff is not their problem. All they want is someone to listen and help them take care of their medical problem. Their long-term loyalty to the group will be solely dependent on how well each personal interaction is handled. Remember that the patient is a person first and not just a customer. We must approach each patient with humanity first, and then customer service.

2) Be courteous and respectful.

Remind your staff to be courteous, always polite and to use good manners. By treating a patient how they expect to be treated, you are showing the patient that you respect them and care for not only their health but also their feelings. The health care worker must understand that the patient is viewing their interactions with staff and providers as being symbolic of the overall group’s brand identity. The group’s leadership needs to select and train their workforce to recognize their importance in how patients view their clinical offerings and their interactions with the patient.

3) Never show indifference to patients.

Losing patients before they complete their treatment regimen is a significant liability issue for any medical practice. In an article written by Strive Labs CEO and Co-Founder, Scott Hebert, DPT, wrote: “Patient churn is too big of a problem to ignore, and it can have a profound impact on your clinic’s bottom line.” In addition to the rather obvious missed revenue opportunity, a churning patient represents a practice liability, because an unsatisfied patient is significantly more likely to leave you a negative review online — or turn the experience with your practice into a cautionary tale for friends and family members. Either way, it’s bad for business — and your reputation.

4) Don’t contradict, argue, or match wits.

It’s tough for a health care worker who is continually being bombarded in a high-pressure environment to agree to disagree. When a person feels they are right or that their perception is the only logical one, they can be very stubborn in their understanding, and they will dig in their heels. It takes a strong person to allow others to have their opinion and not be judgmental about it. Any customer or patient relations training program to be deployed in a medical office must include skill training to teach the staff member how to diffuse an argument or disagreement. This situation can be dispersed by training your staff to consider the source of the conflict, respect the patient’s perception, and then teach the staff member to tell the patient that they never thought of it that way and ease away from the discussion. Their absence will help diffuse the situation.

5) Tell patients you appreciate their business.

How you relate to a patient will speak volumes to them about how much you appreciate their loyalty, all because they chose your practice for their health care. All patient and customer training programs should include discussions on making eye contact, shaking with a firm grasp, and always closing a personal encounter on a sincere and positive note. Health care workers need to understand that they are in the service business and that the patients they care for have options and they can easily walk out of the medical practice and share any negative experience on social media. Educating and reminding your staff on how easily a patient can leave your practice or share their experience with others, needs to be recognized and discussed at all the group’s town hall meetings.

6) Use plain terms and simple explanations.

We all want to appear to be super intelligent by trying to use complex terms to describe a situation because it creates leverage with the other parties engaged in the conversation. While some of this may be necessary when educating patients on their condition, any additional complex terms can easily annoy or even confuse the patient who is only there seeking help. Health care workers need to talk in a manner that keeps the patients engaged and helps them understand the topic at hand. The worker needs to use every day vernacular examples, so the patient quickly understands the reason that brought them to the clinic and what they need to do to get some relief from what ails them. The phrase “plain and simple” means precisely that – explain the topic using basic and simple terms, so the listener understands it. Using this method when discussing a patient’s condition isn’t just for the patient’s benefit because many confused patients ultimately call the office later in the day only to ask additional questions, which uses your staff’s time.

7) Good manners will get you everywhere.

Emily Post wrote, “Manners are a sensitive awareness of the feelings of others. If you have that awareness, you have good manners, no matter what fork you use.” Proper manners are behaving in a way that is both aware of and considerate of the people around us. A person with good manners treats everyone with kindness and respect. It is knowing how to get along without causing offense or harm, no matter how much the current interaction is going south – especially when you are engaged in a tough conversation.

8) Keep seeing health care as a calling.

All health care workers need to know that their vocation of caring for sick and injured patients is a calling and not just a job and all training programs designed to teach customer service need to stress this point. Practicing your vocation means that you will work hard to eliminate all barriers that exist between the patient and the health care worker. Too often we underestimate the power of a simple touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring – all of which have the potential to turn a life or a bad interaction into a magical moment for both the patient and the health care worker. One that has meaning and a bit of affirmation of the dignity of both individuals interacting to find some common ground.

9) Stay in touch with patients.

The group needs to find ways to keep in contact with their patients, whether it is by giving them tips on how to remain healthy or the need for proactive and preventive medicine. The use of technology and social media, as well as handing out freebies at health fairs, giving patients informational brochures upon discharge, or even cards telling them how to contact the practice in case of emergencies, is quite helpful. Calling your patients is a significant signal that your group values the health and welfare of your patients. A phone call from either the doctor or their assistant goes further than any advertisement when building brand and doctor loyalty.

10) Keep your promises.

Do what you say you are going to do, should be a commonly shared mantra for the medical practice. While changing your mind from time to time when circumstances prevent you from keeping a promise, is just part of being flexible in life, regularly breaking promises to other people isn’t healthy. Here’s how to keep your promises: Pay close attention to your words – every word you communicate (through speaking or writing), as a patient may take your words as a promise. Study your patterns of making promises. Figure out when you tend to make careless promises and study the situations in which you do, so you can understand why you’re promising what you don’t intend to do. Take time and careful consideration before making a promise to someone. Don’t rush yourself into a promise that you won’t be able to keep. Even when you’re in a hurry, you usually don’t have an immediate sense of urgency about promising to do something. Stop yourself before you make a vow, delaying your decision long enough to think it through carefully. The more careful you become about making promises, the easier it will be to keep them.

The last step of deploying a patient/customer service program is handling the change in management that is required to train the staff. Accepting “No, we are not changing any part of the group to meet the needs of our patients better.” is unacceptable. Usually, you will be introducing this program to employees that have been in a group for a while and so to get them to buy into the new ideas will require constant reinforcement. It may take some time to align the focus of the group from the neutral zone to the notion that there are new deliverables that would better serve your patients. The following rules will be helpful when beginning your training program:

Rule #1 – Be consistent. Every policy, procedure, and list of priorities sends a message – make sure it’s the right message.

Rule #2 – Ensure quick successes. Look for ways to get the group’s employees to buy into the program – early on after its deployment.

Rule# 3 – Symbolize the new identity. Make sure the group’s logos and branding support the new identity of the group and the culture change.

Rule #4 – Celebrate all the group’s successes. Make sure the group’s employees recognize the work efforts involved as well as the success the group will enjoy. Stress the fact that the work completed will significantly enhance the care and service levels to the patients, which should feed the ego of the group to do more and more in the future.

And lastly, do not forget how vital the buy-in is of the clinicians of the group. They must be introduced early to the new patient/customer service program and embrace it so that their employees will recognize that these efforts are focused on providing a high quality of care throughout the enterprise. As the French philosopher Albert Schweitzer once stated, “Example is not the main thing in influencing others, it’s the only thing.”
 

References

1. Peters, T. “The Excellence Dividend: Meeting the Tech Tide with Work that Wows and Jobs that Last.” (New York, Vintage Books, 2018).

2. 10 Strategies to Provide Patients with Superior Customer Service. Becker’s Hospital Review 2010 Dec 20.

3. Shell MA, Buell RW. Why anxious customers prefer human customer service. Harvard Business Review 2019 April 15.

4. Matt Brannon. 13 Ways to improve customer services at your medical practice. Blog post Sept 7, 2018.

5. 5 Reasons Why Customer Service Matters in Healthcare. https://www.pointsgroup.com/5-reasons-why-customer-service-matters-in-healthcare/Feb. 25, 2014

6. Senge P, Kleiner A, Roberts C, et al. “The Dance of Change: A fifth discipline resource.” (New York, Doubleday, 1999).

7. Bridges W. “Managing Transitions: Making the Most of Change.” (Boston, Da Capo Books, 2017)

8. Michelli J. “The New Gold Standard – 5 Leadership Principles for Creating the Legendary Customer Experience Courtesy of the Ritz-Carlton Hotel Company.” (New York, McGraw Hill, 2008).

Mr. Turner is chief executive officer of Indianapolis Gastroenterology and Hepatology.

If you work in health care or manage a medical practice, you are aware of all the radical changes in technology, medicine, social values, and interpersonal relations over the past few years and you probably do not expect the next several years to be less stressful and less uncertain. To ensure your practice and your provider’s success, you may need to adjust how your team interacts with patients – starting with the first area of patient interaction.

Patients who seek care for their health problems are looking for some measure of kindness when they approach the window of your office’s receptionist. Many are already apprehensive about their clinical condition and adding to that problem is their concern about the financial impact of their visit on the family’s budget. The medical group’s unwillingness to rethink how it greets patients as they approach the receptionist sets the stage for the patient to feel mishandled or underappreciated.

This initial patient interaction stage must be evaluated and recognized as an area of improvement. If not handled properly, it will significantly affect how a medical practice or provider is graded as a group in the field of patient experience and managing patient expectations. Every medical office needs to recognize that people hold on to negative experiences and are not likely to change their mind after that negative experience. The best way to avoid negative bias is to prevent it from happening in the first place.

Listed below are the five additional patient experience mistakes that can cost your group, if they are not recognized as being priorities for both your staff and your patients.
 

Mistake #1 - Educated patients are taking control of their health care.

When health care is treated like any other paid service, an unhappy patient will move along to a new facility or doctor if they have a bad interaction – whether it is with the doctor or the support staff. Educating, training, or adjusting staff to make changes needed is required to ensure that your staff understands the value of patient appreciation and providing the patient with a positive experience.

Mistake #2 - Patients are customers, and just like customers, patients have options.

It should be recognized that patients are customers who are concerned about their future and do not want to be in a medical practice requesting help. They feel vulnerable and out of their routine comfort zone. Reminding your staff that a patient is a customer who has multiple health care choices, but chose to come to your practice, will help your staff understand the value of providing your patient with a positive experience.

Mistake #3 – Dr. Google is becoming the patient’s best friend.

Research indicates that many patients arrive at the doctor’s office already with some information on their condition. Various websites already have provided the patient with free access to learn about their health condition. Popular medical sites such as WebMD.com give the patient the preliminary education they are looking for, so they are already armed with medical information even before they see the doctor or their support staff.

Mistake # 4 - Surveys are carrying more weight.

Outside surveys are becoming even more popular and are carrying additional weight when combined with various social media outlets. All types of surveys and reviews are being used to measure not only the care the patient received, but also the interpersonal relationship between the patient and the doctor, and the patient’s experience with the medical practice’s support staff. Some surveys cover all levels in the practice area, down to the cleanliness of the reception area or the patient’s treatment area, and even the adequacy of the parking lot. These surveys are conditioning patients to recall their entire experience. With a patient experience plan in place, excellent service becomes second nature and will be recognized by those surveyed.

Mistake #5 - Patient-centered care is customer service, too.

It’s not just about the obvious. Excellent patient (customer) service extends beyond a pleasant demeanor. The patient experience does not start or end at the doctor’s office. Perception is built by gathering information from multiple channels, whether it is through review sites, office visits, or surveys. It is necessary to consider the importance of those channels when looking to build patient loyalty.

To avoid the mistakes listed above, the more progressive medical practices are training their staff to anticipate the customer service needs of their patients, much like other major service industries. By rolling out a patient/customer experience training program, they can prevent these mistakes from ever happening and affecting their potential revenue. This training should focus on integrating the following strategies into their daily work habits to provide their patients with exceptional customer service while they are guests in their practice.

1) Patients are the lifeline to building the future of their practice.

Patients are comparing their health care services to other companies that routinely provide high-end services to their clients. Whether groups like it or not, their front-line personnel are compared to five-star hotel receptionists, who are expected to greet their customers both pleasantly and professionally after a long day of traveling and required business functions. Every medical group must understand that patients have options when they select a medical practice and they expect to be treated with respect and transparency, and not just another person to be cared for at the end of a long day. The same level of service needs to be delivered in the doctor’s office no matter what time of day it is because for that patient, the personal problems and subsequent disposition of the medical staff is not their problem. All they want is someone to listen and help them take care of their medical problem. Their long-term loyalty to the group will be solely dependent on how well each personal interaction is handled. Remember that the patient is a person first and not just a customer. We must approach each patient with humanity first, and then customer service.

2) Be courteous and respectful.

Remind your staff to be courteous, always polite and to use good manners. By treating a patient how they expect to be treated, you are showing the patient that you respect them and care for not only their health but also their feelings. The health care worker must understand that the patient is viewing their interactions with staff and providers as being symbolic of the overall group’s brand identity. The group’s leadership needs to select and train their workforce to recognize their importance in how patients view their clinical offerings and their interactions with the patient.

3) Never show indifference to patients.

Losing patients before they complete their treatment regimen is a significant liability issue for any medical practice. In an article written by Strive Labs CEO and Co-Founder, Scott Hebert, DPT, wrote: “Patient churn is too big of a problem to ignore, and it can have a profound impact on your clinic’s bottom line.” In addition to the rather obvious missed revenue opportunity, a churning patient represents a practice liability, because an unsatisfied patient is significantly more likely to leave you a negative review online — or turn the experience with your practice into a cautionary tale for friends and family members. Either way, it’s bad for business — and your reputation.

4) Don’t contradict, argue, or match wits.

It’s tough for a health care worker who is continually being bombarded in a high-pressure environment to agree to disagree. When a person feels they are right or that their perception is the only logical one, they can be very stubborn in their understanding, and they will dig in their heels. It takes a strong person to allow others to have their opinion and not be judgmental about it. Any customer or patient relations training program to be deployed in a medical office must include skill training to teach the staff member how to diffuse an argument or disagreement. This situation can be dispersed by training your staff to consider the source of the conflict, respect the patient’s perception, and then teach the staff member to tell the patient that they never thought of it that way and ease away from the discussion. Their absence will help diffuse the situation.

5) Tell patients you appreciate their business.

How you relate to a patient will speak volumes to them about how much you appreciate their loyalty, all because they chose your practice for their health care. All patient and customer training programs should include discussions on making eye contact, shaking with a firm grasp, and always closing a personal encounter on a sincere and positive note. Health care workers need to understand that they are in the service business and that the patients they care for have options and they can easily walk out of the medical practice and share any negative experience on social media. Educating and reminding your staff on how easily a patient can leave your practice or share their experience with others, needs to be recognized and discussed at all the group’s town hall meetings.

6) Use plain terms and simple explanations.

We all want to appear to be super intelligent by trying to use complex terms to describe a situation because it creates leverage with the other parties engaged in the conversation. While some of this may be necessary when educating patients on their condition, any additional complex terms can easily annoy or even confuse the patient who is only there seeking help. Health care workers need to talk in a manner that keeps the patients engaged and helps them understand the topic at hand. The worker needs to use every day vernacular examples, so the patient quickly understands the reason that brought them to the clinic and what they need to do to get some relief from what ails them. The phrase “plain and simple” means precisely that – explain the topic using basic and simple terms, so the listener understands it. Using this method when discussing a patient’s condition isn’t just for the patient’s benefit because many confused patients ultimately call the office later in the day only to ask additional questions, which uses your staff’s time.

7) Good manners will get you everywhere.

Emily Post wrote, “Manners are a sensitive awareness of the feelings of others. If you have that awareness, you have good manners, no matter what fork you use.” Proper manners are behaving in a way that is both aware of and considerate of the people around us. A person with good manners treats everyone with kindness and respect. It is knowing how to get along without causing offense or harm, no matter how much the current interaction is going south – especially when you are engaged in a tough conversation.

8) Keep seeing health care as a calling.

All health care workers need to know that their vocation of caring for sick and injured patients is a calling and not just a job and all training programs designed to teach customer service need to stress this point. Practicing your vocation means that you will work hard to eliminate all barriers that exist between the patient and the health care worker. Too often we underestimate the power of a simple touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring – all of which have the potential to turn a life or a bad interaction into a magical moment for both the patient and the health care worker. One that has meaning and a bit of affirmation of the dignity of both individuals interacting to find some common ground.

9) Stay in touch with patients.

The group needs to find ways to keep in contact with their patients, whether it is by giving them tips on how to remain healthy or the need for proactive and preventive medicine. The use of technology and social media, as well as handing out freebies at health fairs, giving patients informational brochures upon discharge, or even cards telling them how to contact the practice in case of emergencies, is quite helpful. Calling your patients is a significant signal that your group values the health and welfare of your patients. A phone call from either the doctor or their assistant goes further than any advertisement when building brand and doctor loyalty.

10) Keep your promises.

Do what you say you are going to do, should be a commonly shared mantra for the medical practice. While changing your mind from time to time when circumstances prevent you from keeping a promise, is just part of being flexible in life, regularly breaking promises to other people isn’t healthy. Here’s how to keep your promises: Pay close attention to your words – every word you communicate (through speaking or writing), as a patient may take your words as a promise. Study your patterns of making promises. Figure out when you tend to make careless promises and study the situations in which you do, so you can understand why you’re promising what you don’t intend to do. Take time and careful consideration before making a promise to someone. Don’t rush yourself into a promise that you won’t be able to keep. Even when you’re in a hurry, you usually don’t have an immediate sense of urgency about promising to do something. Stop yourself before you make a vow, delaying your decision long enough to think it through carefully. The more careful you become about making promises, the easier it will be to keep them.

The last step of deploying a patient/customer service program is handling the change in management that is required to train the staff. Accepting “No, we are not changing any part of the group to meet the needs of our patients better.” is unacceptable. Usually, you will be introducing this program to employees that have been in a group for a while and so to get them to buy into the new ideas will require constant reinforcement. It may take some time to align the focus of the group from the neutral zone to the notion that there are new deliverables that would better serve your patients. The following rules will be helpful when beginning your training program:

Rule #1 – Be consistent. Every policy, procedure, and list of priorities sends a message – make sure it’s the right message.

Rule #2 – Ensure quick successes. Look for ways to get the group’s employees to buy into the program – early on after its deployment.

Rule# 3 – Symbolize the new identity. Make sure the group’s logos and branding support the new identity of the group and the culture change.

Rule #4 – Celebrate all the group’s successes. Make sure the group’s employees recognize the work efforts involved as well as the success the group will enjoy. Stress the fact that the work completed will significantly enhance the care and service levels to the patients, which should feed the ego of the group to do more and more in the future.

And lastly, do not forget how vital the buy-in is of the clinicians of the group. They must be introduced early to the new patient/customer service program and embrace it so that their employees will recognize that these efforts are focused on providing a high quality of care throughout the enterprise. As the French philosopher Albert Schweitzer once stated, “Example is not the main thing in influencing others, it’s the only thing.”
 

References

1. Peters, T. “The Excellence Dividend: Meeting the Tech Tide with Work that Wows and Jobs that Last.” (New York, Vintage Books, 2018).

2. 10 Strategies to Provide Patients with Superior Customer Service. Becker’s Hospital Review 2010 Dec 20.

3. Shell MA, Buell RW. Why anxious customers prefer human customer service. Harvard Business Review 2019 April 15.

4. Matt Brannon. 13 Ways to improve customer services at your medical practice. Blog post Sept 7, 2018.

5. 5 Reasons Why Customer Service Matters in Healthcare. https://www.pointsgroup.com/5-reasons-why-customer-service-matters-in-healthcare/Feb. 25, 2014

6. Senge P, Kleiner A, Roberts C, et al. “The Dance of Change: A fifth discipline resource.” (New York, Doubleday, 1999).

7. Bridges W. “Managing Transitions: Making the Most of Change.” (Boston, Da Capo Books, 2017)

8. Michelli J. “The New Gold Standard – 5 Leadership Principles for Creating the Legendary Customer Experience Courtesy of the Ritz-Carlton Hotel Company.” (New York, McGraw Hill, 2008).

Mr. Turner is chief executive officer of Indianapolis Gastroenterology and Hepatology.

If you work in health care or manage a medical practice, you are aware of all the radical changes in technology, medicine, social values, and interpersonal relations over the past few years and you probably do not expect the next several years to be less stressful and less uncertain. To ensure your practice and your provider’s success, you may need to adjust how your team interacts with patients – starting with the first area of patient interaction.

Patients who seek care for their health problems are looking for some measure of kindness when they approach the window of your office’s receptionist. Many are already apprehensive about their clinical condition and adding to that problem is their concern about the financial impact of their visit on the family’s budget. The medical group’s unwillingness to rethink how it greets patients as they approach the receptionist sets the stage for the patient to feel mishandled or underappreciated.

This initial patient interaction stage must be evaluated and recognized as an area of improvement. If not handled properly, it will significantly affect how a medical practice or provider is graded as a group in the field of patient experience and managing patient expectations. Every medical office needs to recognize that people hold on to negative experiences and are not likely to change their mind after that negative experience. The best way to avoid negative bias is to prevent it from happening in the first place.

Listed below are the five additional patient experience mistakes that can cost your group, if they are not recognized as being priorities for both your staff and your patients.
 

Mistake #1 - Educated patients are taking control of their health care.

When health care is treated like any other paid service, an unhappy patient will move along to a new facility or doctor if they have a bad interaction – whether it is with the doctor or the support staff. Educating, training, or adjusting staff to make changes needed is required to ensure that your staff understands the value of patient appreciation and providing the patient with a positive experience.

Mistake #2 - Patients are customers, and just like customers, patients have options.

It should be recognized that patients are customers who are concerned about their future and do not want to be in a medical practice requesting help. They feel vulnerable and out of their routine comfort zone. Reminding your staff that a patient is a customer who has multiple health care choices, but chose to come to your practice, will help your staff understand the value of providing your patient with a positive experience.

Mistake #3 – Dr. Google is becoming the patient’s best friend.

Research indicates that many patients arrive at the doctor’s office already with some information on their condition. Various websites already have provided the patient with free access to learn about their health condition. Popular medical sites such as WebMD.com give the patient the preliminary education they are looking for, so they are already armed with medical information even before they see the doctor or their support staff.

Mistake # 4 - Surveys are carrying more weight.

Outside surveys are becoming even more popular and are carrying additional weight when combined with various social media outlets. All types of surveys and reviews are being used to measure not only the care the patient received, but also the interpersonal relationship between the patient and the doctor, and the patient’s experience with the medical practice’s support staff. Some surveys cover all levels in the practice area, down to the cleanliness of the reception area or the patient’s treatment area, and even the adequacy of the parking lot. These surveys are conditioning patients to recall their entire experience. With a patient experience plan in place, excellent service becomes second nature and will be recognized by those surveyed.

Mistake #5 - Patient-centered care is customer service, too.

It’s not just about the obvious. Excellent patient (customer) service extends beyond a pleasant demeanor. The patient experience does not start or end at the doctor’s office. Perception is built by gathering information from multiple channels, whether it is through review sites, office visits, or surveys. It is necessary to consider the importance of those channels when looking to build patient loyalty.

To avoid the mistakes listed above, the more progressive medical practices are training their staff to anticipate the customer service needs of their patients, much like other major service industries. By rolling out a patient/customer experience training program, they can prevent these mistakes from ever happening and affecting their potential revenue. This training should focus on integrating the following strategies into their daily work habits to provide their patients with exceptional customer service while they are guests in their practice.

1) Patients are the lifeline to building the future of their practice.

Patients are comparing their health care services to other companies that routinely provide high-end services to their clients. Whether groups like it or not, their front-line personnel are compared to five-star hotel receptionists, who are expected to greet their customers both pleasantly and professionally after a long day of traveling and required business functions. Every medical group must understand that patients have options when they select a medical practice and they expect to be treated with respect and transparency, and not just another person to be cared for at the end of a long day. The same level of service needs to be delivered in the doctor’s office no matter what time of day it is because for that patient, the personal problems and subsequent disposition of the medical staff is not their problem. All they want is someone to listen and help them take care of their medical problem. Their long-term loyalty to the group will be solely dependent on how well each personal interaction is handled. Remember that the patient is a person first and not just a customer. We must approach each patient with humanity first, and then customer service.

2) Be courteous and respectful.

Remind your staff to be courteous, always polite and to use good manners. By treating a patient how they expect to be treated, you are showing the patient that you respect them and care for not only their health but also their feelings. The health care worker must understand that the patient is viewing their interactions with staff and providers as being symbolic of the overall group’s brand identity. The group’s leadership needs to select and train their workforce to recognize their importance in how patients view their clinical offerings and their interactions with the patient.

3) Never show indifference to patients.

Losing patients before they complete their treatment regimen is a significant liability issue for any medical practice. In an article written by Strive Labs CEO and Co-Founder, Scott Hebert, DPT, wrote: “Patient churn is too big of a problem to ignore, and it can have a profound impact on your clinic’s bottom line.” In addition to the rather obvious missed revenue opportunity, a churning patient represents a practice liability, because an unsatisfied patient is significantly more likely to leave you a negative review online — or turn the experience with your practice into a cautionary tale for friends and family members. Either way, it’s bad for business — and your reputation.

4) Don’t contradict, argue, or match wits.

It’s tough for a health care worker who is continually being bombarded in a high-pressure environment to agree to disagree. When a person feels they are right or that their perception is the only logical one, they can be very stubborn in their understanding, and they will dig in their heels. It takes a strong person to allow others to have their opinion and not be judgmental about it. Any customer or patient relations training program to be deployed in a medical office must include skill training to teach the staff member how to diffuse an argument or disagreement. This situation can be dispersed by training your staff to consider the source of the conflict, respect the patient’s perception, and then teach the staff member to tell the patient that they never thought of it that way and ease away from the discussion. Their absence will help diffuse the situation.

5) Tell patients you appreciate their business.

How you relate to a patient will speak volumes to them about how much you appreciate their loyalty, all because they chose your practice for their health care. All patient and customer training programs should include discussions on making eye contact, shaking with a firm grasp, and always closing a personal encounter on a sincere and positive note. Health care workers need to understand that they are in the service business and that the patients they care for have options and they can easily walk out of the medical practice and share any negative experience on social media. Educating and reminding your staff on how easily a patient can leave your practice or share their experience with others, needs to be recognized and discussed at all the group’s town hall meetings.

6) Use plain terms and simple explanations.

We all want to appear to be super intelligent by trying to use complex terms to describe a situation because it creates leverage with the other parties engaged in the conversation. While some of this may be necessary when educating patients on their condition, any additional complex terms can easily annoy or even confuse the patient who is only there seeking help. Health care workers need to talk in a manner that keeps the patients engaged and helps them understand the topic at hand. The worker needs to use every day vernacular examples, so the patient quickly understands the reason that brought them to the clinic and what they need to do to get some relief from what ails them. The phrase “plain and simple” means precisely that – explain the topic using basic and simple terms, so the listener understands it. Using this method when discussing a patient’s condition isn’t just for the patient’s benefit because many confused patients ultimately call the office later in the day only to ask additional questions, which uses your staff’s time.

7) Good manners will get you everywhere.

Emily Post wrote, “Manners are a sensitive awareness of the feelings of others. If you have that awareness, you have good manners, no matter what fork you use.” Proper manners are behaving in a way that is both aware of and considerate of the people around us. A person with good manners treats everyone with kindness and respect. It is knowing how to get along without causing offense or harm, no matter how much the current interaction is going south – especially when you are engaged in a tough conversation.

8) Keep seeing health care as a calling.

All health care workers need to know that their vocation of caring for sick and injured patients is a calling and not just a job and all training programs designed to teach customer service need to stress this point. Practicing your vocation means that you will work hard to eliminate all barriers that exist between the patient and the health care worker. Too often we underestimate the power of a simple touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring – all of which have the potential to turn a life or a bad interaction into a magical moment for both the patient and the health care worker. One that has meaning and a bit of affirmation of the dignity of both individuals interacting to find some common ground.

9) Stay in touch with patients.

The group needs to find ways to keep in contact with their patients, whether it is by giving them tips on how to remain healthy or the need for proactive and preventive medicine. The use of technology and social media, as well as handing out freebies at health fairs, giving patients informational brochures upon discharge, or even cards telling them how to contact the practice in case of emergencies, is quite helpful. Calling your patients is a significant signal that your group values the health and welfare of your patients. A phone call from either the doctor or their assistant goes further than any advertisement when building brand and doctor loyalty.

10) Keep your promises.

Do what you say you are going to do, should be a commonly shared mantra for the medical practice. While changing your mind from time to time when circumstances prevent you from keeping a promise, is just part of being flexible in life, regularly breaking promises to other people isn’t healthy. Here’s how to keep your promises: Pay close attention to your words – every word you communicate (through speaking or writing), as a patient may take your words as a promise. Study your patterns of making promises. Figure out when you tend to make careless promises and study the situations in which you do, so you can understand why you’re promising what you don’t intend to do. Take time and careful consideration before making a promise to someone. Don’t rush yourself into a promise that you won’t be able to keep. Even when you’re in a hurry, you usually don’t have an immediate sense of urgency about promising to do something. Stop yourself before you make a vow, delaying your decision long enough to think it through carefully. The more careful you become about making promises, the easier it will be to keep them.

The last step of deploying a patient/customer service program is handling the change in management that is required to train the staff. Accepting “No, we are not changing any part of the group to meet the needs of our patients better.” is unacceptable. Usually, you will be introducing this program to employees that have been in a group for a while and so to get them to buy into the new ideas will require constant reinforcement. It may take some time to align the focus of the group from the neutral zone to the notion that there are new deliverables that would better serve your patients. The following rules will be helpful when beginning your training program:

Rule #1 – Be consistent. Every policy, procedure, and list of priorities sends a message – make sure it’s the right message.

Rule #2 – Ensure quick successes. Look for ways to get the group’s employees to buy into the program – early on after its deployment.

Rule# 3 – Symbolize the new identity. Make sure the group’s logos and branding support the new identity of the group and the culture change.

Rule #4 – Celebrate all the group’s successes. Make sure the group’s employees recognize the work efforts involved as well as the success the group will enjoy. Stress the fact that the work completed will significantly enhance the care and service levels to the patients, which should feed the ego of the group to do more and more in the future.

And lastly, do not forget how vital the buy-in is of the clinicians of the group. They must be introduced early to the new patient/customer service program and embrace it so that their employees will recognize that these efforts are focused on providing a high quality of care throughout the enterprise. As the French philosopher Albert Schweitzer once stated, “Example is not the main thing in influencing others, it’s the only thing.”
 

References

1. Peters, T. “The Excellence Dividend: Meeting the Tech Tide with Work that Wows and Jobs that Last.” (New York, Vintage Books, 2018).

2. 10 Strategies to Provide Patients with Superior Customer Service. Becker’s Hospital Review 2010 Dec 20.

3. Shell MA, Buell RW. Why anxious customers prefer human customer service. Harvard Business Review 2019 April 15.

4. Matt Brannon. 13 Ways to improve customer services at your medical practice. Blog post Sept 7, 2018.

5. 5 Reasons Why Customer Service Matters in Healthcare. https://www.pointsgroup.com/5-reasons-why-customer-service-matters-in-healthcare/Feb. 25, 2014

6. Senge P, Kleiner A, Roberts C, et al. “The Dance of Change: A fifth discipline resource.” (New York, Doubleday, 1999).

7. Bridges W. “Managing Transitions: Making the Most of Change.” (Boston, Da Capo Books, 2017)

8. Michelli J. “The New Gold Standard – 5 Leadership Principles for Creating the Legendary Customer Experience Courtesy of the Ritz-Carlton Hotel Company.” (New York, McGraw Hill, 2008).

Mr. Turner is chief executive officer of Indianapolis Gastroenterology and Hepatology.

Have you noticed that you and your staff are spending more time on prior authorization than in the past? Insurance companies are increasing the number of Current Procedural Terminology (CPT®) codes for services and procedures included in their prior authorization programs. More importantly, they are doing so without providing evidence that this approach improves patient safety or decreases unindicated medical procedures. There is also no transparency about how these prior authorization processes are developed, evaluated, or adjusted over time. Physicians and their staff are pushing back on social media, calling prior authorization programs a hassle and citing lengthy waits to speak to a physician reviewer who is often not even in their specialty.

Historically, insurers have used prior authorization to control costs, particularly those related to procedures and tests that may be inappropriately overutilized or no longer the standard of care; however, current activity suggests a much broader, indiscriminate approach. For example, insurers are requiring prior authorization for whole families of services and procedures. Anthem, the second largest insurance company in the United States, recently added the entire family of esophagogastroduodenoscopy (EGD) codes to its list of procedures requiring prior authorization in 10 states including Calif., Conn., Ind, Ohio, Ky., Mo., Nev., N.H., Va., and Wisc. A conversation earlier this year with the Anthem national prior authorization team revealed that they intend to keep adding codes for all specialties to their prior authorization program, portraying the process conducted by AIM Specialty Health® (a wholly-owned subsidiary of Anthem, Inc.), as fast, simple, and easy. However, many physicians and their office staff find the prior authorization process complex, time consuming, and frustrating.

Social media is rife with accounts from physicians who were forced to cancel planned procedures because the prior authorization process took weeks instead of days, received denials, and later found out that procedures were actually approved, or found themselves in peer-to-peer review with nonphysicians. Gastroenterologists have also reported cases of patients having flares of inflammatory bowel disease because of medication delays related to a cumbersome preauthorization process.

Because prior authorization impacts gastroenterologists’ ability to provide timely care to patients, AGA and the entire physician community have been calling for regulatory change related to prior authorization in Medicare Advantage (MA) plans to reduce physician burden and enhance patient safety and care.

Last year, AGA worked with our congressional champions Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) to secure 150 signatures on a letter to the CMS Administrator requesting the agency provide guidance to MA plans to ensure that prior authorization requirements do not create barriers to care.

One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. A recent survey by the American Medical Association found that over 90% of physician respondents felt that the prior authorization process led to delays in care for patients that could negatively impact clinical outcomes. AGA and other physician organizations are advocating for regulatory changes related to how MA plans use prior authorization.

In addition to our regulatory efforts, the AGA is working with members of Congress on legislative solutions to require the MA plans to increase transparency, streamline the prior authorization process, and minimize the impact on Medicare beneficiaries. Reps. Susan DelBene, D-Wash., Mike Kelly, R-Penna., Ami Bera, D-Calif., and Roger Marshall, R-Kans. introduced the Improving Seniors Timely Access to Care Act of 2019, legislation that would streamline the prior authorization process in the Medicare Advantage program to relieve the administrative burdens this poses for physicians and help patients receive quicker access to the medical care they need. Although this legislation only addresses MA plans, we are hopeful that this will be the first step in requiring health plans to streamline this process and ease administrative burden. Please help us increase support for this bill by contacting your legislators and asking that they cosponsor. It will take less than 5 minutes of your time and will have a significant effect, given the opposition we face from insurers. The AGA is working on your behalf to address prior authorization hassles with private payors, but to be effective we need to hear your experiences. We know private payors continue to develop more and more restrictive prior authorization policies covering an increasing number of services and procedures without evidence that these actions provide benefit to patients. Frequently, these policies are put into action without advance warning and your reports are the first signs we have that a change has been made. Reach out to the AGA via the AGA Community or Twitter to let us know what’s happening. We will take your stories directly to the insurance companies and demand that they work with us to reduce physician burden and improve transparency.

You may also consider filing a complaint with the State Insurance Commissioner. State Insurance Commissioners are responsible for regulating the insurance industry in their state and can investigate to make sure the laws in their state are being followed and providers and patients are being treated fairly. While insurance law and regulation are established at the state level, the insurance commissioners are members of the National Association of Insurance Commissioners (NAIC), which allows them to coordinate insurance regulation among the states and territories.

If you decide to file a complaint with your State Insurance Commissioner, first familiarize yourself with your state’s complaint process. Many state insurance commissioners have a standard complaint form you can download or fill out online. Be sure to keep records of all conversations and interactions with the insurance company to document the steps you’ve taken to attempt to resolve the issue. Consider creating a log of the dates, times, and nature of your contact with the insurance company.

Once you have filed a complaint, the commissioner may send a copy to the insurance company and give them a date by which they must respond. If the commissioner believes the response is sufficient, she or he will send a copy of the insurance company’s response to you. If the commissioner feels the insurance company’s response is inadequate, staff from the commissioner’s office will work with you and the insurer to resolve the issue.

While a report of one negative experience with an insurer may not be enough to elicit action, a pattern of delays and difficulties with an insurer’s prior authorization process noted by many physicians is likely to catch an Insurance Commissioner’s attention. The NAIC cannot tell a problem is widespread if providers and patients don’t report it to the State Insurance Commissioners.

Please reach out to AGA with your stories about prior authorization problems, consider reporting insurance companies that employ systems that cause undue burden and delay to your State Insurance Commissioner and help us increase support for the Improving Seniors Timely Access to Care Act of 2019 by contacting your legislators and asking that they cosponsor using this link https://app.govpredict.com/portal/grassroots/campaigns/io77ozaa/take_action. Together, we can pressure insurers, Congress, and Medicare to relieve physician burden and help our patients receive the timely care they need.
 

Dr. Garcia is a member of the AGA Practice Management and Economics Committee’s Coverage And Reimbursement Subcommittee and clinical assistant professor of medicine, gastroenterology & hepatology, Stanford Medicine, Stanford, California. Dr. Mathews is a member of the AGA Government Affairs Committee and leads efforts in clinical innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.

Tihs story was updated on July 29, 2019.
 

ginews@gastro.org

Have you noticed that you and your staff are spending more time on prior authorization than in the past? Insurance companies are increasing the number of Current Procedural Terminology (CPT®) codes for services and procedures included in their prior authorization programs. More importantly, they are doing so without providing evidence that this approach improves patient safety or decreases unindicated medical procedures. There is also no transparency about how these prior authorization processes are developed, evaluated, or adjusted over time. Physicians and their staff are pushing back on social media, calling prior authorization programs a hassle and citing lengthy waits to speak to a physician reviewer who is often not even in their specialty.

Historically, insurers have used prior authorization to control costs, particularly those related to procedures and tests that may be inappropriately overutilized or no longer the standard of care; however, current activity suggests a much broader, indiscriminate approach. For example, insurers are requiring prior authorization for whole families of services and procedures. Anthem, the second largest insurance company in the United States, recently added the entire family of esophagogastroduodenoscopy (EGD) codes to its list of procedures requiring prior authorization in 10 states including Calif., Conn., Ind, Ohio, Ky., Mo., Nev., N.H., Va., and Wisc. A conversation earlier this year with the Anthem national prior authorization team revealed that they intend to keep adding codes for all specialties to their prior authorization program, portraying the process conducted by AIM Specialty Health® (a wholly-owned subsidiary of Anthem, Inc.), as fast, simple, and easy. However, many physicians and their office staff find the prior authorization process complex, time consuming, and frustrating.

Social media is rife with accounts from physicians who were forced to cancel planned procedures because the prior authorization process took weeks instead of days, received denials, and later found out that procedures were actually approved, or found themselves in peer-to-peer review with nonphysicians. Gastroenterologists have also reported cases of patients having flares of inflammatory bowel disease because of medication delays related to a cumbersome preauthorization process.

Because prior authorization impacts gastroenterologists’ ability to provide timely care to patients, AGA and the entire physician community have been calling for regulatory change related to prior authorization in Medicare Advantage (MA) plans to reduce physician burden and enhance patient safety and care.

Last year, AGA worked with our congressional champions Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) to secure 150 signatures on a letter to the CMS Administrator requesting the agency provide guidance to MA plans to ensure that prior authorization requirements do not create barriers to care.

One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. A recent survey by the American Medical Association found that over 90% of physician respondents felt that the prior authorization process led to delays in care for patients that could negatively impact clinical outcomes. AGA and other physician organizations are advocating for regulatory changes related to how MA plans use prior authorization.

In addition to our regulatory efforts, the AGA is working with members of Congress on legislative solutions to require the MA plans to increase transparency, streamline the prior authorization process, and minimize the impact on Medicare beneficiaries. Reps. Susan DelBene, D-Wash., Mike Kelly, R-Penna., Ami Bera, D-Calif., and Roger Marshall, R-Kans. introduced the Improving Seniors Timely Access to Care Act of 2019, legislation that would streamline the prior authorization process in the Medicare Advantage program to relieve the administrative burdens this poses for physicians and help patients receive quicker access to the medical care they need. Although this legislation only addresses MA plans, we are hopeful that this will be the first step in requiring health plans to streamline this process and ease administrative burden. Please help us increase support for this bill by contacting your legislators and asking that they cosponsor. It will take less than 5 minutes of your time and will have a significant effect, given the opposition we face from insurers. The AGA is working on your behalf to address prior authorization hassles with private payors, but to be effective we need to hear your experiences. We know private payors continue to develop more and more restrictive prior authorization policies covering an increasing number of services and procedures without evidence that these actions provide benefit to patients. Frequently, these policies are put into action without advance warning and your reports are the first signs we have that a change has been made. Reach out to the AGA via the AGA Community or Twitter to let us know what’s happening. We will take your stories directly to the insurance companies and demand that they work with us to reduce physician burden and improve transparency.

You may also consider filing a complaint with the State Insurance Commissioner. State Insurance Commissioners are responsible for regulating the insurance industry in their state and can investigate to make sure the laws in their state are being followed and providers and patients are being treated fairly. While insurance law and regulation are established at the state level, the insurance commissioners are members of the National Association of Insurance Commissioners (NAIC), which allows them to coordinate insurance regulation among the states and territories.

If you decide to file a complaint with your State Insurance Commissioner, first familiarize yourself with your state’s complaint process. Many state insurance commissioners have a standard complaint form you can download or fill out online. Be sure to keep records of all conversations and interactions with the insurance company to document the steps you’ve taken to attempt to resolve the issue. Consider creating a log of the dates, times, and nature of your contact with the insurance company.

Once you have filed a complaint, the commissioner may send a copy to the insurance company and give them a date by which they must respond. If the commissioner believes the response is sufficient, she or he will send a copy of the insurance company’s response to you. If the commissioner feels the insurance company’s response is inadequate, staff from the commissioner’s office will work with you and the insurer to resolve the issue.

While a report of one negative experience with an insurer may not be enough to elicit action, a pattern of delays and difficulties with an insurer’s prior authorization process noted by many physicians is likely to catch an Insurance Commissioner’s attention. The NAIC cannot tell a problem is widespread if providers and patients don’t report it to the State Insurance Commissioners.

Please reach out to AGA with your stories about prior authorization problems, consider reporting insurance companies that employ systems that cause undue burden and delay to your State Insurance Commissioner and help us increase support for the Improving Seniors Timely Access to Care Act of 2019 by contacting your legislators and asking that they cosponsor using this link https://app.govpredict.com/portal/grassroots/campaigns/io77ozaa/take_action. Together, we can pressure insurers, Congress, and Medicare to relieve physician burden and help our patients receive the timely care they need.
 

Dr. Garcia is a member of the AGA Practice Management and Economics Committee’s Coverage And Reimbursement Subcommittee and clinical assistant professor of medicine, gastroenterology & hepatology, Stanford Medicine, Stanford, California. Dr. Mathews is a member of the AGA Government Affairs Committee and leads efforts in clinical innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.

Tihs story was updated on July 29, 2019.
 

ginews@gastro.org

Have you noticed that you and your staff are spending more time on prior authorization than in the past? Insurance companies are increasing the number of Current Procedural Terminology (CPT®) codes for services and procedures included in their prior authorization programs. More importantly, they are doing so without providing evidence that this approach improves patient safety or decreases unindicated medical procedures. There is also no transparency about how these prior authorization processes are developed, evaluated, or adjusted over time. Physicians and their staff are pushing back on social media, calling prior authorization programs a hassle and citing lengthy waits to speak to a physician reviewer who is often not even in their specialty.

Historically, insurers have used prior authorization to control costs, particularly those related to procedures and tests that may be inappropriately overutilized or no longer the standard of care; however, current activity suggests a much broader, indiscriminate approach. For example, insurers are requiring prior authorization for whole families of services and procedures. Anthem, the second largest insurance company in the United States, recently added the entire family of esophagogastroduodenoscopy (EGD) codes to its list of procedures requiring prior authorization in 10 states including Calif., Conn., Ind, Ohio, Ky., Mo., Nev., N.H., Va., and Wisc. A conversation earlier this year with the Anthem national prior authorization team revealed that they intend to keep adding codes for all specialties to their prior authorization program, portraying the process conducted by AIM Specialty Health® (a wholly-owned subsidiary of Anthem, Inc.), as fast, simple, and easy. However, many physicians and their office staff find the prior authorization process complex, time consuming, and frustrating.

Social media is rife with accounts from physicians who were forced to cancel planned procedures because the prior authorization process took weeks instead of days, received denials, and later found out that procedures were actually approved, or found themselves in peer-to-peer review with nonphysicians. Gastroenterologists have also reported cases of patients having flares of inflammatory bowel disease because of medication delays related to a cumbersome preauthorization process.

Because prior authorization impacts gastroenterologists’ ability to provide timely care to patients, AGA and the entire physician community have been calling for regulatory change related to prior authorization in Medicare Advantage (MA) plans to reduce physician burden and enhance patient safety and care.

Last year, AGA worked with our congressional champions Reps. Phil Roe, MD, (R-Tenn.) and Ami Bera, MD, (D-Calif.) to secure 150 signatures on a letter to the CMS Administrator requesting the agency provide guidance to MA plans to ensure that prior authorization requirements do not create barriers to care.

One in every three people with Medicare is enrolled in a Medicare Advantage (MA) plan. Under current law, MA plans may not create inappropriate barriers to care that do not already exist within the original Medicare program. A recent survey by the American Medical Association found that over 90% of physician respondents felt that the prior authorization process led to delays in care for patients that could negatively impact clinical outcomes. AGA and other physician organizations are advocating for regulatory changes related to how MA plans use prior authorization.

In addition to our regulatory efforts, the AGA is working with members of Congress on legislative solutions to require the MA plans to increase transparency, streamline the prior authorization process, and minimize the impact on Medicare beneficiaries. Reps. Susan DelBene, D-Wash., Mike Kelly, R-Penna., Ami Bera, D-Calif., and Roger Marshall, R-Kans. introduced the Improving Seniors Timely Access to Care Act of 2019, legislation that would streamline the prior authorization process in the Medicare Advantage program to relieve the administrative burdens this poses for physicians and help patients receive quicker access to the medical care they need. Although this legislation only addresses MA plans, we are hopeful that this will be the first step in requiring health plans to streamline this process and ease administrative burden. Please help us increase support for this bill by contacting your legislators and asking that they cosponsor. It will take less than 5 minutes of your time and will have a significant effect, given the opposition we face from insurers. The AGA is working on your behalf to address prior authorization hassles with private payors, but to be effective we need to hear your experiences. We know private payors continue to develop more and more restrictive prior authorization policies covering an increasing number of services and procedures without evidence that these actions provide benefit to patients. Frequently, these policies are put into action without advance warning and your reports are the first signs we have that a change has been made. Reach out to the AGA via the AGA Community or Twitter to let us know what’s happening. We will take your stories directly to the insurance companies and demand that they work with us to reduce physician burden and improve transparency.

You may also consider filing a complaint with the State Insurance Commissioner. State Insurance Commissioners are responsible for regulating the insurance industry in their state and can investigate to make sure the laws in their state are being followed and providers and patients are being treated fairly. While insurance law and regulation are established at the state level, the insurance commissioners are members of the National Association of Insurance Commissioners (NAIC), which allows them to coordinate insurance regulation among the states and territories.

If you decide to file a complaint with your State Insurance Commissioner, first familiarize yourself with your state’s complaint process. Many state insurance commissioners have a standard complaint form you can download or fill out online. Be sure to keep records of all conversations and interactions with the insurance company to document the steps you’ve taken to attempt to resolve the issue. Consider creating a log of the dates, times, and nature of your contact with the insurance company.

Once you have filed a complaint, the commissioner may send a copy to the insurance company and give them a date by which they must respond. If the commissioner believes the response is sufficient, she or he will send a copy of the insurance company’s response to you. If the commissioner feels the insurance company’s response is inadequate, staff from the commissioner’s office will work with you and the insurer to resolve the issue.

While a report of one negative experience with an insurer may not be enough to elicit action, a pattern of delays and difficulties with an insurer’s prior authorization process noted by many physicians is likely to catch an Insurance Commissioner’s attention. The NAIC cannot tell a problem is widespread if providers and patients don’t report it to the State Insurance Commissioners.

Please reach out to AGA with your stories about prior authorization problems, consider reporting insurance companies that employ systems that cause undue burden and delay to your State Insurance Commissioner and help us increase support for the Improving Seniors Timely Access to Care Act of 2019 by contacting your legislators and asking that they cosponsor using this link https://app.govpredict.com/portal/grassroots/campaigns/io77ozaa/take_action. Together, we can pressure insurers, Congress, and Medicare to relieve physician burden and help our patients receive the timely care they need.
 

Dr. Garcia is a member of the AGA Practice Management and Economics Committee’s Coverage And Reimbursement Subcommittee and clinical assistant professor of medicine, gastroenterology & hepatology, Stanford Medicine, Stanford, California. Dr. Mathews is a member of the AGA Government Affairs Committee and leads efforts in clinical innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.

Tihs story was updated on July 29, 2019.
 

ginews@gastro.org