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.

The Ten Commandments Of Patient Engagement In The Doctor’s Office

Here is a list of things that physicians, hospitals, along with concerned stake holder partners, etc. need to do to increase patient engagement:

  1. Regardless of how busy you are, act like you are glad to see them (patients).
  2. Say something to hint that you actually remember who they are – this one is crucial.
  3. Enquire about their health after the last appointment and the reason for them coming today. Remember what they say and come back to it later.
  4. Seek for the patient’s idea related to the reason behind the complaints and ask them what they would like you to do for them.
  5. When the patient describes their problem, avoid interrupting them. Ask questions that would further clarify the problem. Show interest in them. They need to be invited to speak up.
  6. Let the patient know your recommendations about the tests, treatments and new medications. Give the reason behind your recommendation. Make sure to check if the patient is okay with it. If not, ask why.
  7. Pay attention to the cues initiated by the patient. Oft times, they are a call for help.
  8. 8.   Show empathy towards them and try to support the patient as best possible.
  9. Try to figure out their health goals and find out the steps they believe can be taken in order to achieve them.
  10. 10.  Suggest ways by which you and your team can support the patients’ long-term care plans.

Most physicians do not face the challenge of “How to engage patients?” since most patients are already engaged to the extent that:

  • They bothered to call your staff and made the appointment (which seldom is a pleasant experience).
  • Took time off work to come to your office.
  • Waited a while before seeing you.
  • Thought about what they wanted to talk to you and how you are too busy to listen.

Rather, the challenge for the providers is “How to be engaging to the patients?” Healthcare always has been the intensely personal and social interaction between human beings.

Health IT professionals will have you believe that EMRs, web portals and smart phone health apps are the best way to engage patients. Which they are not. People would be more engaged in the care only if the providers were more engaging.

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.

How Measuring Employee Productivity Boosts Revenue

At its core, healthcare is a business. As a healthcare organization administrator or practice owner, you’re well aware of this. You need to make smart business decisions to ensure a profitable bottom line; decisions that promote quality services, compliant documentation and coding, competitive prices, and most importantly, productive employees.

But like any other business owner, you’re not just focused on a profitable bottom line – you also need to constantly increase profits. How? Most businesses focus on 3 core strategies: (1) lower prices, (2) lower operating costs, or (3) measure and increase employee productivity.

I’ve found the third strategy to be very useful to healthcare organizations and medical practices, since there’s often room for improvement. So, let’s talk. How can measuring employee productivity boost your profits?

The importance of productivity

Productivity is important in any setting. However, it’s particularly important in healthcare organizations and medical practices, where the volume of work seems to increase daily.

Coders are increasingly overwhelmed with preparing for ICD-10, capturing all relevant conditions, ensuring clinical validation for diagnoses that are coded, and querying physicians when necessary. Clinical documentation improvement specialists are faced with the daunting task of educating physicians about ICD-10 and providing documentation audits to identify gaps. Physicians, nurses, and other providers are inundated with new patients who have entered the healthcare marketplace thanks to the Affordable Care Act. The influx of new patients into the system also places an increased demand on administrative staff who must answer patient inquiries, promote the practice’s patient portal and other new technology, schedule appointments, and more.

If you’re like most healthcare organizations or practices, you probably don’t necessarily have the financial resources to hire additional full-time equivalents (FTEs) to accommodate for unexpected changes in workflow and other demands. This means you’ll need to increase the productivity of current staff members to remain fully operational.

To do this, you’ll need to have a solid process in place to ensure that all employees perform at predicted productivity levels, particularly as new tasks are added. This process is particularly important as new employees are hired. When you’re unable to closely monitor and enhance productivity, you’ll likely start to see a slow decline in profits that can ultimately lead to the need to cut FTEs during a time when those FTEs are needed most.

Finding the right candidates

Productive employees are those who not only work hard but who also believe in the overall mission of the organization. When recruiting employees, you should take the time to sort through candidates who may be looking for a short-term job vs. those who understand the critical nature of the work they perform and how it fits in with your goals.

How do you do this? Spend extra time crafting the job posting and provide information about the workplace and the organization or practice’s goals. Post the application on online job search sites to maximize exposure.

During the interview, itself, consider asking the following questions to get a sense of candidates’ work ethic:

  • Why is this job important to you?
  • Why do you think this job is important to the organization overall?
  • How would you describe your own work style?
  • Provide an example of how you’ve handled a time when you needed to multi-task and how you handled that.
  • Describe a time when you set a goal at work. Explain how you accomplished that goal.

Performing ongoing productivity analyses

Setting productivity goals and monitoring those goals regularly is an important component of overall success. The specific goals will vary according to function; however, what’s most important is that you take the time to establish these goals and hold all staff accountable for achieving them. This includes tracking employee time management and attendance, both of which are critical to productivity. Revisit these goals throughout each month. When productivity has declined, identify and address the root cause of the problem. When productivity has remained constant or increased, take the time to praise and reward employees for their good work.

Providing training, when necessary

Knowledge is power, and employees remain productive when they have the most updated information they need to perform their jobs. For example, staff performing coding require ongoing ICD-10 training, access to quarterly changes published inCoding Clinic, and more. Patient registration and billing staff members need ongoing training regarding medical necessity and other insurance policy changes. Providers need training regarding the most updated clinical protocols and/or how to use the EMR. Some employees could benefit from refresher training or more specialized education in an area in which they need improvement. Establish a schedule for employee-specific training and then track employee compliance with that schedule.

Thinking ahead

Measuring employee productivity is an important aspect of running a business that no healthcare organization or medical practice can afford to overlook. Employee productivity is important for everyone, and it is particularly important for those roles that are task- and volume-driven. Take the time to establish role-specific productivity standards, educate employees about these standards, and then hold individuals accountable for meeting—and exceeding—these requirements.

Monitoring employee productivity ensures that employees are performing at full capacity, maximizing their time and getting high-quality results. When all employees give 100% effort to ensure productivity, the business benefits. Dedicated employees who strive to improve performance and increase their knowledge may be one of the most important weapons a healthcare organization or medical practice has against the big changes in healthcare and top threats to revenue this year.

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

Denial Management Strategy. Key Points to Consider.

Estimates show denied claims represent over 13% of gross revenue for providers nationwide. Some studies suggest that over 90% of those denials were preventable and nearly 70% could be overturned. An additional 6% of gross revenue was lost to underpayments. These numbers are staggering when you combine lost revenue as a result with the high cost associated with resolving these denials.

To face this challenge, providers must have an effective strategy in place to identify denials, manage their resolution and analyze root cause to facilitate prevention of future denials. Some keys to an effective denial management strategy include:

1) Capturing all remittance information necessary for denial management
A primary source of denial information is the payer remittance advice (RA). Many providers focus on payment posting from the RA and neglect to capture all of the information critical for effective denial management. For denial follow-up, it is important to capture and categorize all payer reason and remark codes.

2) Paying attention to payers who provide hard copy remittance reports 
To maximize collections, providers must manage denials for 100% of their payer mix. Payers who cannot provide electronic remittance advice (ERAs) typically represent around 15% of total revenue, and many providers feel that the cost of capturing denial information from a hard copy remittance report is just too high to chase such a low percentage of revenue. A simple cost/benefit analysis will likely reveal that the cost of capturing denial information from a hard copy remittance report is easily outweighed by the denial recovery opportunity, and the opportunity to identify and prevent future denials.

3) Identifying and managing underpayments
If your denial management process does not identify and manage underpayments, you may be losing up to 6% of your annual gross revenue. Managing underpayments is frequently overlooked as part of a denial management strategy. First, you can qualify partial payment denials from remittances by looking for specific reason codes to identify charge-level denials. Second, it is critical to identify payment variances by comparing remittance paid amount to the expected payment amount. This can be challenging if HIS systems, contract management systems and denial management systems don’t work well together, however, this problem is easily and clearly worth resolving given the amount of revenue at stake.

4) Considering how denied accounts are assigned to follow-up staff
Too often, the focus on resolving EVERY denial results in chasing hundreds of low balance denials while sacrificing valuable resources who could be working on resolving collectible denials. Make sure follow-up assignments are reasonable. If a follow-up work queue has 2,000 denied accounts in it, the likelihood of staff always working on the most important account will be pretty low, and the likelihood of timely follow-up on all 2,000 denied claims is even lower. There are always exceptions that require judgment, however, consider filtering follow-up work queues to include a smaller number of high priority accounts. Also, consider setting a threshold (based on cost to collect or other defined criteria) for automating low-balance write-offs on denials, eliminating those accounts from work queues.

5) Automating or streamlining follow-up activity
Efficiency is the key to maximizing recoveries. Follow-up staff should have tools to save them time, allowing them to work and resolve more accounts. Some examples:

• Payer-specific appeal letter templates that can be auto-filled with account-level information like Patient Name, PCN, MRN, DOS, Denial Reason Codes, etc.
• Write-off authorization tools to streamline the request and approval process
• Canned follow-up actions and notes to prevent staff from wasting valuable time typing the same thing over and over again
• Quick access to view and/or print the EOB and the denied claim
• Automated alerts that notify users when a prior follow-up action has not resolved the denial within the designated period of time.

6) Tracking and analyzing the outcome of denial follow-up
Make sure the outcome of each resolved denial is clearly identified. Analyze outcomes and educate staff to evaluate processes that historically have not been successful overturning denials. If sending the same appeal letter to the same payer for the same denial reason on 100 different claims has not overturned any denials, consider creating a new follow-up plan for that denial reason.

7) Identifying root cause and focusing on prevention
Increasing denial recovery rate is good. Decreasing initial denial rate is better! The key to prevention is in identifying the root cause. When providers understand root cause, they can make business decisions to facilitate prevention. Studies suggest that almost 80% of denials are Patient Access errors, but if the cause is unknown, staff may not be solving the right problem. It is worth the effort to evaluate and assign root cause to denials whichinclude identifying trends and taking steps to prevent future denials.

8) Setting and tracking financial and operational performance goals 
Dashboard-style reporting tools are very helpful to communicate performance metrics throughout the organization and to manage performance. Important denial performance metrics includes : initial denial rate, recoveries on denials and underpayments, rate of appeals overturned, monthly denial trends by payer and error type, denial outcomes by payer and error type.

These tips are some of the keys to a comprehensive and effective denials management strategy.

by Todd Thomas, Director of Provider Product Management (Emdeon)