The Secret to Patient Engagement – More engaging physicians

If you ask people involved in Patient Engagement about how hands-on they are in their own health, the most common reply you will get would be something along the lines of,  “I try to take care of myself by doing X or Y or Z.”

About 82% of US adults have a regular doctor whom they visit at least once a year with the average number of visits being 3 per year, which, in fact, is double the number of visits made by people with chronic conditions.

Obviously, one would think that this level of patient engagement would be immensely beneficial to physicians, administrators, health IT vendors and others involved. But that wouldn’t be correct. Let us see why.

Physicians, administrators, health IT vendors, etc. each, have their own definition of what patient engagement is. Let us see their definitions and how they measure patient engagement.

1.   Physicians/Provider definition of patient engagement:

Maintaining appointments, even though it might be about 6-7 appointments annually, along with abundant self-care, would not count as patient engagement from the physicians’ perspective. Most patients do not do as they are told by their physicians – they are often non-compliant.

As numerous physicians equate patient engagement with patient compliance, the high non-compliance rates (30%-70%) that are seen these days suggest that a large number of patients are far from engaged. What the clinicians fail to realize is that up to 20% of non-compliance is a direct result of poor physician-patient communication and not lack of engagement.

2.   Health IT Professionals and Vendors:

Health IT professionals neither consider “showing up” nor the level of compliance of the patient when it comes to defining or measuring patient engagement. The HIMSS (NeHC) Patient Engagement Framework would have you believe that the true patient engagement is all about the use of health information technology and the achievement of Stage 2 Meaningful Use, which means, as long as the patients use the right health IT tools, they are considered engaged.

What Health IT industry often overlooks is the fact that 85% of patient prefer to meet their doctor face-to-face when they feel the need. They are reluctant to let technology get in between them and their doctor.

The challenge however, the physicians and health IT professionals face, is not how to engage more patients, but actually, it’s about how to be more engaging to the majority of the patients who have already been engaged.

The reality is that health care is about everyone but the patient. Most physicians still relate to their patients using a peculiar communication style where they act as the clinicians knows best, does the most talking and makes almost all decisions for the patient. Patients are encouraged to be passive and compliant rather than being engaged.

Health IT treats patients as unwise and unneeded when it comes to engagement. They ignore the fact that 85% of adults want to be able to interact with their physician face-to-face whenever they want, regardless of their showing willingness to use secure email, patient portals or any other such technology. People are not unwise. They realize that Health IT wants to put technology between themselves and their doctor. A number of patients have stated that laptops and computers in the exam room interfere with the doctor-patient relationship. This is clearly not serving patient engagement.

The only certain technique to improve patient engagement is to be more engaging to the patient. Which means being more patient-centered. The patient-centered attitude should reflect in the things being done for the patient, the way physicians talk and listen to them, the way products and services are designed, and how patient engagement is assessed.

This includes obtaining the patient’s story, paying attention to their health beliefs, fears and concerns, comprehending their health information needs and interests, understanding their previous health experiences, and so on.

The patient has the major stake in their own health. This should never be forgotten. Besides, it’s not like they don’t have brains.

Empowering patients to ensure their physician does not miss-out on opportunities to be a better provider

It is observed that on a normal day in the office, the average physician misses an ample of opportunities to engage with their patients. The reason behind this being their busy schedules. Research indicates that this happens because physicians do not have the proper patient-centered communication skills and awareness.

On a typical visit, patients provide their physicians with a number of verbal and non-verbal cues, indicating their thoughts and feelings. This is done to pose a question or just to show concern. The value of the cue is directly dependent on the physician understanding it.

Let’s break down a typical day in the office to better analyze the opportunities involved. On an average, a physician receives 3-4 Patient complaints, 2-3 requests and there are around 4-5 patient expectations.   Add them together and we have 9-12 opportunities, per visit. This is a substantial amount. Hence, it is of utmost importance that attention needs to be paid to those cues.

The cues may be apparent; like a patient complaining of depression, but more often, those cues are not clearly stated and the doctor needs to observe the patient’s body language, facial expressions, etc. to get the hint. Regardless of how a patient expresses them, these cues are opportunities to engage the patient.

Let us take an example to understand this better. Following is a brief conversation about the patient’s knee, and there are 4 cues that the patient expressed verbally.

Doctor: So, how is your exercise regimen since your last visit?

Patient: I’ve haven’t been feeling so great ever since I slipped on the ice and my knee hasn’t been as cooperative. I’ve been missing the exercise.

Doctor: How about the diet? Are you still sticking to it?

Patient: Yes, but…

Doctor: Well, now that the weather is warmer, you could get back to the jogging that we talked about before.

Patient: How about doing an MRI of the knee to check if I have torn something. A similar thing happened to my friend and she got an MRI. Turns out, she had torn her cartilage.

Doctor: If your knee continues to bother you after a month, come and see me.

The 4 cues actually represent 5 opportunities for the doctor. Those opportunities could be utilized to:

1.   Demonstrate that the doctor was paying attention and listening to the patient.

2.   Show comprehension of the patient’s expectations

3.   Relate and empathize with the patient.

4.   Explain why MRI isn’t a necessary procedure at this point of time.

5.   To integrate a diagnosis and a treatment plan in a way that the patient can buy into it.

The reason for a potential “fall-out” due to the response of the doctor to those cues would be:

·         Feeling of mistrust

·         Feeling that the concerns were dismissed easily

·         Feeling that the whole visit was a waste of time

·         Problem not resolved

Long-term potential outcomes might include:

·         Patient acting against the doctor which could cause the problem to worsen.

·         Dissatisfaction

·         Patient doesn’t share potentially relevant health information in future visits.

·         Patient decides to visit the ER instead of seeing the physician

Let’s estimate that the average patient visit generates around 10 such cues, which is a conservative number. If the physician identifies and addresses 50% of those cues, it would leave 5 missed opportunities per visit. This analysis would add up to a 110 missed opportunities on a typical business day. Which makes 440 missed opportunities a week and a staggering 22,880 opportunities a year for just one physician.

Think about the impact the physicians in your provider network could make if they were made aware about some basic communication skills which would enable them to be mindful of, acknowledge and properly respond to these cues in a way that the patient would appreciate.   Investing in improving these skills would no doubt have a significant impact.

Asking Insurers to Deviate from Medical Necessity Clinical Guidelines

Insurance carriers routinely cite evidence-based clinical guidelines when denying treatment authorization. However, a number of insurance industry resources confirm that insurance medical decision makers must consider the patient’s unique medical condition and should deviate from the clinical guidelines when appropriate.

Requesting deviation from the guidelines will typically require an appeal focusing on the patient’s unique medical needs and why application of the guideline is not appropriate. Some of the specific factors to address in such an appeal include the following:

  • Patient’s previous treatments and discussion of failed treatment attempts and unwanted side effects
  • Patient’s secondary diagnoses which potentially complicate treatment
  • Any anatomical anomalies or age-related factors (pre-natal or geriatric challenges)
  • Ongoing diagnostic assessment for unexplained symptoms/atypical disease/disorder presentation

Further, the guideline itself can be called into question if it does not appear to adhere to current industry quality care standards and incorporate the latest treatment options. Some of the specific questions useful for assessing the quality of the guideline include the following:

  • How frequently the guideline is updated to incorporate recent medical developments
  • Patient demographic used to develop standards, ie, did the guideline development include studies involving a diverse patient population inclusive of prenatal patients, geriatrics and minorities to ensure appropriate application across a diverse population.

A study of medical necessity decisions made by private health plans discusses the widespread adoption of clinical guidelines for use in medical necessity decision making. According to this study entitled “Medical Necessity in Private Health Plans: Implications for Behavioral Health Care“, several insurer medical directors acknowledged that clinical guidelines are simply a decision making tool and should allow for flexible implementation.

“Interviewees stated that guidelines are not mandates or absolute protocols; rather, they are considered ‘guideposts’ to be informed by, and adapted to, individual circumstances and psychosocial needs of patients. Ongoing audits, performance measurement of in-house care managers and contracted providers, and member and provider satisfaction surveys are used to monitor the appropriate use of treatment guidelines in medical necessity decisions and to build in quality improvements at all levels of decision making,” states the study, available online at

Automate to Collect patient balances

Out of sight, out of mind. Applied to healthcare, this age-old saying is not only true, but also incredibly problematic for physician practices. All too frequently we hear from physicians the same story of providing care up-front, and subsequently facing a growing stack of un-paid deductibles, ultimately hurting the bottom line. No one is immune to this – not general practitioners, specialists, psychologists, nor dentists.

With the trend of increasing deductibles, there is only going to be more to collect. For 2014, the internal revenue service has defined high-deductible as $1250 for an individual and $2500 for a family. On top of that, maximum out-of-pocket expenditures are estimated at $6350 for individuals and $12,700 for families. That’s no small change; that’s real money when factoring in the number of patients you see.

Some practices may have an initial reaction of fear or a sense of alarm from these numbers however, these statistics should be the impetus to be proactive and put the right series of steps and technologies into place. Those steps include implementing a hybrid workflow model that starts with using an established eligibility checking system to identify a patient’s expected out-of-pocket costs prior to an appointment will significantly lessen the follow-up collections that are needed. However, when you do need to collect, make sure you are doing it smartly by leveraging the second piece of a hybrid workflow solution, an automated collection system to significantly increase the odds that you will collect more, and also collect it faster.

Recent highlights from the Pew Research Internet Project state that as of January 2014, 58% of adult Americans have a smartphone.  Doesn’t it make sense then that you should have an automated system that includes texting alerts instead of sending outdated hard copy letters? By replacing traditional collection methods with an automated technology platform that smartly uses decision rules to push out text and secure e-mail, and logs a record of all the activity, you can count your profits instead of counting the number of uncollected deductibles.

High deductible plans: Balancing out-of-pocket costs and outcomes

This post was originally posted on Medical Economics.

ME051014_pg 18In 2013, the U.S. Department of Health and Human Services reported that healthcare spending had grown at a record low pace from 2009 to 2011. The slowdown in  growth was attributed to the sluggish economy and was thought unlikely to continue as more Americans gained insurance under the Affordable Care Act (ACA).

An increase in the spending growth rate was considered inevitable—a 6.1% acceleration was predicted for 2014, compared with a 3.9 % increase in 2011. Even so, there was hope that the consumer-driven belt-tightening that occurred during the recession would continue despite more people being insured.

The way policy analysts expected that to happen was through shifting a larger share of spending to consumers.

High-deductible health plans started appearing after legislation was passed in 2003 that required persons opening a health savings account to enroll in a high-deductible plan. They started gaining prominence in recent years as employers watched their own healthcare spending skyrocket, forcing them to look for ways to shift more of the burden to employees, according to Brett Hickman, CPA, partner in PwC’s health industries practice.

A June 2013 PwC report found that 17% of employers were offering high-deductible plans as their only option, a 31% increase over 2012. The percentage that said high-deductible plans would be the only option in 2014 jumped to 44%, according to PwC.

How high deductibles work
Under a high-deductible plan, in exchange for low monthly premiums plan members must meet higher deductibles before their insurance coverage begins.
For 2014, the internal revenue service’s definition of high-deductible is $1,250 for an individual and $2,500 for a family. Maximum out-of-pocket expenditures are $6,350 and $12,700 for individuals and families, respectively. Many, but not all, include preventive care such as annual physicals or immunizations, as a no-cost benefit.

If high-deductible health plans continue to rise and 50% of the people with employer-provided healthcare plans are covered by them, healthcare spending could be reduced by about 4%, or $57 billion, annually, according to a 2012 study in Health Affairs.

The unknown factor is whether reducing  healthcare spending on the front end will cause unintended consequences later. Under the “gatekeeper” model of care in the 1990s, patients would often forego care from specialists who were, unlike capitated primary care providers, reimbursed using the fee-for-service model that required greater out-of-pocket payments from patients, says Hickman. By putting off care from a specialist, many patients’ conditions deteriorated to the point that they required more care than they would have otherwise, thereby leading to higher costs.

There are many similarities between the model of care prevalent in the 1990s and the one emerging today. How successful the current model will be remains open to debate.

“I think any bean counter or actuary will tell you we are on a slippery slope right now,” says Hickman. “We’ve got to get to organized population health where we can use predictive analytics and we can align the incentives across the patients, providers and the health plans … to ensure the patient gets the right care that he or she needs when they need it and it’s not over- or underutilized.”

The impact on physicians
When patients pay more out-of-pocket, they are generally more judicious about when and under what circumstances they see their doctors, and what tests and procedures they are willing to undergo. Consequently, many healthcare experts have concluded that in a fee-for-service world, physician income will drop as visits decline.

What’s not clear is whether physicians will find ways to offset the financial impact of fewer visits—although some believe the increased number of insured patients entering the system through the ACA will help keep office schedules full—and the impact fewer visits will have on overall care quality.

“Any time you see patients responsible for more of the front-end cost, they don’t go to the doctor as much,” says Bill Hannah, principal of healthcare at the accounting firm  Dixon Hughes Goodman, and a member of the National CPA Health Care Advisors Association. Some patients skipping care might have chronic diseases and require  regular check-ups, Hannah says.

More physicians are joining accountable care organizations, which will have the effect of incentivizing physicians to keep their patients healthy—which means, in turn, that physicians will have to be proactive about ensuring that patients are getting the care they need. As a result, practicing population health will become a necessity.

In addition to fewer visits, practices could face other financial hits as a result of more patient responsibility. The American Medical Association’s annual health insurer report card found that in 2013 patients were responsible for nearly one quarter of total medical bills. This is potentially bad news for medical practices, because collecting from patients can be notoriously difficult. And when patients are faced with financial hardships, medical bills usually don’t take priority.

The National Center for Health Statistics published a report in January, 2014 that found one in four families experienced trouble paying medical bills in 2012. One in 10 had bills they were unable to pay at all. At the every least, practices can expect to see the length of time invoices spend in accounts receivable to grow.

What physicians can do
The new reality for physicians is that they will be forced to have more conversations with patients about the cost of care, says Thomas Graf, MD, chief medical officer for population health at Geisinger Health System. And they will be forced to think about the financial implications of every decision they make, adds Graf, who directs the ProvenHealth Navigator, Geisinger’s medical home.

“There are times when we may be, let’s say, overly complete in the evaluation and a more stepwise approach may be more prudent,” Graf says. “So rather than ordering all the tests the first time you see the patient, perhaps you start with the most likely elements and work to the less frequent causes of it in an effort to support the patient in their desire to limit their out-of-pocket expense.”

Patient education also needs to improve. Patients often think that the newest or most expensive treatment is the best option when it actually might be bed rest, says Mark Bogen, chief financial officer and senior vice president of finance at South Nassau Communities Hospital in New York.

“Some physicians aren’t real excited about having to lay out what the cost of everything is,” says Sherri Sellmeyer, vice president of advisory services at Decision Resources Group, a healthcare research and consulting firm in Burlington, Massachusetts “I think it’s probably a healthy thing for the system for people to know what things cost.”

Research presented at the 2013 meeting of the American Society of Clinical Oncology by S. Yousuf Zafar, MD, MHS, a gastrointestinal oncologist at the Duke University Health System in Durham, North Carolina, showed that a majority of cancer patients think it’s important to talk to their physicians about treatment costs. But only a small percentage actually have that conversation because they fear that bringing it up will lead to the doctor prescribing a cheaper option, which in their minds is inferior. But the researchers found that  when the conversation does happen, the cost of care is generally lower.

Now that patients are paying more out-of-pocket, these conversations may become easier. Graf says he has noticed that patients in high-deductible plans are “suddenly much more interested in my explanation about why they don’t need a CT [computerized tomography] scan than they would have been in the old days when in some situations you could talk for 10 to 15 minutes, knowing the chance of the CT scan showing anything real is all but zero. But they were so worried about it that they sort of insisted on getting that done.”

Employers should take the lead when it comes to talking to employees about how their health plans work, Hannah says. “Call it healthcare economics 101,” he says.

“Employers have an obligation to educate employees on costs and how to promote better health.”

Think like a business
In this new environment, practices will also be forced to think more like a business. Because a large portion of the medical bill has traditionally been paid by commercial insurers, Medicare, and other third-party payers, many practices simply aren’t set up to  collect copayments from patients efficiently. Many small practices, for example, still don’t accept credit cards or have an online payment system, says Bogen. Even worse, when the patient tells the practice that he or she will pay next time, practices aren’t following up to ensure that the patient actually does pay.

Many physicians don’t want to discuss payments out of concern that patients will  think it’s all about the money, says Bogen. Physicians can still offer some flexibility while maintaining the attitude that they are entitled to be paid for services rendered, he says. “When you combine the cost shift of these high-deductible plans with the shrinking payments that the commercial insurers and Medicare are already moving toward, you have to collect every nickel you are entitled to,” Bogen advises. “They shouldn’t feel ashamed they are asking to be paid.”

Many studies have found that practices are more likely to be paid if they collect before or at the time of service. This may mean investing in upgraded revenue cycle management systems that can check eligibility, tell the practice whether the deductible has been met, and calculate the patient portion before the appointment.

It’s likely that practices will start issuing refunds as their collection practices change, says Laura Palmer, FACMPE, senior industry analyst for the Medical Group Management Association. It’s not uncommon for practices to run an eligibility check that shows the deductible has not been met. But that situation may change sometime between the appointment and the time the bill is sent. Practices need to establish policies for how the patient will be refunded for an overpayment.

A practice’s billing policy should also include a process addressing the situation of patients who have trouble paying, and a menu of options that can be presented to the patient, says Palmer. Options may include community programs that assist with medical bills, or referrals to facilities that offer free or significantly reduced care costs.  Options may vary depending on the patient’s circumstances, which the practice should make every effort to understand, she says. There’s a difference between someone who is refusing to pay and someone who simply cannot.

The policy should also detail who in the practice will talk to the patient and where that discussion will take place. Palmer says conversations about overdue bills or a patient’s inability to pay should never take place at the front desk. The conversation should be held in private.
If all other efforts to collect from the patient have been exhausted, physicians can terminate their relationship with them, says Graf. But that option should be reserved as an absolute last resort, and it must be handled delicately. Patients should be given ample warning, and they must be referred to another care provider.

This new world of high-deductible heath plans can produce the intended results as long as incentives are aligned for all stakeholders, says Graf. He tells physicians to gain an understanding of their relationship with each insurer, and their patients’ relationships with the insurers. Physicians should try to “set up a system where the patient can win, I can win and the health plan can win,” he says. “If you can find that middle ground, which is often challenging, but if you can find it then you are going to do really well. Probably better than if you are stuck in a situation where in order for you to win, someone else has to lose.”

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Automated Billing: Increase Time with Patients, Practice Profitability

Physician practices are very aware of the growing amount of deductible collection that will be necessary with the huge influx of eligible patients under the Affordable Care Act. But while they are very aware, this doesn’t necessarily mean they have measures set up to best prepare for this influx. If they have set preparatory measures, are those measures helping to simplify processes and work flow, or is there now just more work to be done?

Eligibility All of the physicians I work with go into practice to help and heal people. They didn’t study medicine to then explore the ins and outs of all things payer, billing, and appointment reminders. For those with smaller practices, they and maybe one other clinical staff member are multitasking; handling everything from diagnosis to accounts receivable follow-up, and even eligibility verification. Add back- and front-office operations to that and you’ve got a formula for loss in revenue and harried business operations. Some of the most prevalent and common issues I see physicians’ practices face include:

  •  Increased cost in overall operations
  • Reimbursements and revenues decreasing
  • High deductibles or increased patient deductibles
  • Delays in collection of deductibles and other balances due to billing inaccuracies
  • Employee compensation increases
  • Overall inflation of business operation costs
  • Confusion about healthcare reform specifications for small- to mid-sized practices
  • Failure or lag in communications through traditional phone calls and mailed letters

But there is a better way: Automating billing and collection systems that will maximize profitability and increase time with patients. While undoubtedly there will be skepticism from some physicians after a decade of the failed promises of enhanced productivity and improved care from many EHRs and other systems, automated billing can be done, and at a cost that won’t elicit sticker shock. You can:

  • Streamline collection methods. This can often be a bane for back-office operations to say the least. Manual collections often result in massive amounts of paper records, hard copy mailings, and staff hours following up with patients on balances owed. Your office staff should be welcoming patients and becoming more involved in their care to help keep them with the practice; not manually dialing phone number after phone number so you can get dollars in the door. Additionally, just because you have the staff to do the office work, doesn’t necessarily mean that work is done cost-effectively and successfully.
  • Increase/better target use of communication such as secure text, e-mail, and phone calls. Similar to my above point, free up your back-office operations to do the most important things for your practice. By targeting communication channels specific to your patients’ likes and needs, you streamline your practice operations. You aren’t hard-copy mailing a young patient who only responds to text messages. You aren’t e-mailing a patient who checks e-mail once every month.
  • Report non-responsive debtors to credit bureaus and/or legal departments to take the workload off of the practice staff. By automating processes, your staff isn’t bogged down by work when people don’t pay. There are solutions to freeing up their time and making sure your practice profits.

Here’s an example that might apply to your practice: Take a look at your eligibility verification. If each claim denial costs your practice $25 to $30, and you know your denial rate is above the industry average of 3 percent, the monthly cost for eligibility verification in advance of patient visits shows an outsourcing company with this specialty effectively pays for itself. As a patient, and with friends and family who are patients, I want to know that when I see the doctor that he is able to be clear minded and exclusively focused on my care or the care of my family member. With automated billing solutions in place, physicians can focus on the practice of medicine, freeing their time to focus on patient care, and work with their office staff to maximize profitability. Vishal Gandhi is chief executive officer of ClinicSpectrum, leaders in hybrid work flow solutions consisting of both an innovative software suite and back-office operations. E-mail him here. See more at: