How Bots Will Change the Doctor-Patient Relationship
With today’s growing technology, there have been so many gains in the medical community. Especially the use of bots and the evolving doctor-patient relationship that will truly transform how patients are cared for, and how these bots can help a patient with enhancing productivity. There are many positives and negatives to these bots and this article goes into more depth on how it will change the medical field.nn
nnIt seems nearly everyone believes U.S. health care needs some transformative change to improve quality, expand access, or lower costs. Many of the contemporary approaches toward that change involve making it easier for patients to see doctors, particularly primary care doctors. While that seems intuitive, we think it is the wrong path.nnImagine it’s 1970 and commercial bank executives are deciding how to help their customers get the banking services they need. One executive remark, “Most of our customers engage with us through our bank tellers–even if they’re later referred to someone behind a desk. To help our customers get the banking services they need, we must make it easier for them to get in front of bank tellers.”nnWhether or not discussions like that really happened, that wasn’t the direction banks took. Instead, banks introduced automated teller machines to improve customer service. As a result of this unshackling of banking from tellers, 25-year-olds today find it unimaginable that their parents contorted their schedule to get cash during the Monday to Friday, 9 a.m. to 3 p.m. window. In the age of Venmo, they can’t imagine the need for cash in the first place.nnAnd yet, fifty years later, health care leaders continue to discuss how to get more patients in front of primary care providers, or in general to make it easier for patients to see doctors. The value-add from the technical knowledge and skills of primary care and specialist clinicians is greater than that from bank tellers, but the principles limiting the value of this strategy are the same. True transformations come from enhancing productivity, and productivity is enhanced by decreasing personnel effort, not increasing it.nnIf we continue to define health care as a service that happens when patients see doctors, we limit our possible productivity gains.nnWriting in The New England Journal of Medicine, we argued that the doctor-patient relationship is health care’s choke point. There’s no technical reason why a variety of common medical conditions—high blood pressure, diabetes, high cholesterol—can’t be managed by a bot and overseen by a nurse with support from a physician only if needed. And as our experience and the supporting evidence increase, more conditions might be directed by guidelines, allowing physicians to direct more of their time to where they’re really needed. Much is made of the comforting aspects of personal relationships between patient and clinician. But do we really need that soft touch to manage hypertension? Maybe sometimes, but certainly not always.nnSo why is it heretical to suggest replacing some of the health care with the facilitated self-service that has transformed the financial, retail, and travel industries? Why was it relatively easy to abandon bank tellers, travel agents, and tax preparers with the introduction of ATMs, travel websites, and tax software, but we get push back when nearly identical approaches are suggested for health care?nn
We think the resistance reflects our social conventions rather than our technical limitations. The technical challenges of safely introducing driverless cars are far more daunting than the technical challenges of introducing bots to manage hypertension and diabetes, yet the prospect of driverless cars seems to be awaited with excitement. We need to solve three problems:nnFirst, the insurance industry—government and commercial—must get better at its job. Because they are ill-equipped to determine whether care was truly needed or appropriately delivered, they use proxy process measures: Was the care face to face? Was the right amount of time spent or the right number of facts documented? Was the right kind of clinician present? Without a measure of what’s good, insurers have found it easier to insist that care be delivered in traditional ways. It’s hard to explore new and potentially better models of care when only old approaches get reimbursed.nnSecond, state-based regulation of insurance and clinician licensure must be replaced by a system that recognizes that health care is not always best delivered locally. Facilitated self-service creates efficiencies across state lines. It’s likely that occasionally some of Wyoming’s 600,000 residents would benefit from care delivered by someone outside the 1,000 physicians practicing in that state—perhaps by a bot with second-line back up from a nurse or a physician elsewhere. State licensure of physicians and insurance regulations reflect federalist principles harder to justify in a connected world.nnThird, we should require the same standards of safety and efficacy for automated approaches to health care that we have come to assume for the safety of pharmaceuticals. Whether that regulation comes from the FDA or elsewhere, it needs to be ramped up to address the volume of potential new approaches. Even if we think a bot can help manage hypertension, it doesn’t mean any bot can do that. The organizations that credential clinicians might find they are well suited to credential robots.nnIf there is a fourth problem, it is our sense of nostalgia. Norman Rockwell’s paintings of what he saw as wholesome and right reflected a time when doctors attended to the whole family, knew some from the cradle and some into the grave, and were paid with a basket of eggs. Facilitated self-service health care doesn’t challenge the appeal of this image, but it does shift it toward those elements of care that can’t as easily be handled by a machine.nnThe health care changes we want, or at least the opportunities to try them, are held back by a combination of technical limitations and social conventions. But our social conventions present greater obstacles. The lesson from other industries is that transformational change requires productivity change. And in health care, that means we must find ways to move past approaches to facilitate care with doctors toward approaches that facilitate care without them.
We continue to see the risk adjustment model being implemented by several large hospital groups and the sooner small practices catch in the better off their business models will be. So why is this so important?nIt’s simple, Centers for Medicare & Medicaid Services (CMS) utilizes this in the analysis of Medicare Advantage patients and that ultimately is a major factor when it comes to your reimbursements. What can your practice do to avoid missed opportunities?nThe first step to the implementation of anything new is education. Make sure your providers are aware of HCC’s and how they play a roll in risk adjustment factor calculations. Welter Healthcare Partners is excited to now offer our clients Risk Adjustment auditing and educations to assist you and your team with the implementation of HCC’s in your documentation, billing, and coding.
One of the models focuses on a more general population, while the second model is for advanced primary care practices that typically provide hospice or palliative care services and want to take responsibility for high-need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination, according to a CMS fact sheet on the models.The model involves a potential downside risk of 10%, and an upside risk or bonus of 50%, depending on patients’ outcomes, and performance would be measured on “risk-adjusted hospitalizations” or “the ability to keep patients healthy at home,” Adam Boehler, director of the Center for Medicare & Medicaid Innovation (CMMI), which developed the models, said at a press briefing. “For example, doctors that earn $200,000 today could earn up to $300,000 if their patients stay healthy.” For 2020, the CMS has identified 26 regions where practices can participate.The CMS says that the model’s monthly per-patient payments will help doctors stop worrying about their monthly revenue cycle. However, as Miller noted in an article, “at the same time that Primary Care First eliminates the current E/M [evaluation and management] payments for face-to-face office visits for attributed patients, it creates a brand-new $50 fee for each face-to-face office visit, which is about half as much as the average amount primary care physicians currently receive from Medicare for office visits.””Based on the current average frequency with which Medicare beneficiaries make primary care office visits, this means that more than 40% of a typical practice’s payments would still be tied to face-to-face visits. As a result, if the practice is able to care for patients effectively with fewer office visits, it will lose revenue and it could be unable to cover its operating costs,” he wrote.nnLACK OF RISK ADJUSTMENTnAnother problem with the program is that a primary care practice would receive the exact same monthly payment for a patient regardless of how sick or healthy they are, Miller said. “Since an individual patient who has higher needs will require more time and resources from the practice than other patients, a practice that is caring for that patient will have to reduce the time and resources it devotes to other patients if the payment is the same.”And in addition to those issues, since Medicare payment programs are expected to be revenue-neutral compared with the current budget, “the payment is intended to be the same as what the practice is currently getting,” although the practice will be expected to provide more services than before, including 24/7 patient access and integrated behavioral healthcare, Miller said.Miller is a member of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which advises the CMS on Medicare alternative payment models. “In general, I think there’s been a lot of concern for a long time about [the] need to provide better support for primary care, and most payers in the country have been trying to do some kind of medical home programs for quite a while,” he said. “Medicare has been fairly slow to the game on that.”In particular, Miller is disappointed that the CMS hasn’t shown much interest in pilot-testing the payment models that PTAC has recommended. “With PTAC, two proposals [were submitted] for primary care, and we reviewed them and recommended they be tested and implemented … It’s been a long time since the recommendations were made, and the surprising thing to me was that the [Primary Care First] model that was announced by [the CMS] really didn’t look at all like the models recommended by PTAC.”nnROOM FOR IMPROVEMENTnThere are ways that Primary Care First can be improved, Miller said. For starters, “rather than creating a whole new set of office visit payments, what primary care practices have asked for is to get all or most of their payments as a flexible monthly payment so it’s not tied to office visits.”In addition, the monthly payments should be higher for patients who require more care. “If you have more diseases and more care challenges, you’re going to require more attention from your primary care physician,” said Miller. “The way that happens today is more office visits … but we don’t want to pay more only if they come to the office.”When asked during a press briefing about the Primary Care First model, CMS administrator Seema Verma said the agency was trying to give physicians a variety of options. “What we tried to do is recognize that providers are in different places in terms of their ability to take on risk,” she told MedPage Today. “What we’ve tried to do in this model is provide different options … Some providers may say ‘I want to take full risk on,’ so we’ve allowed for that option.””What we want to do in primary care is have them focus less on revenue cycle … and actually be able to focus on patients,” she continued. “The requirements around 24/7 [availability] — the idea there is that it’s based on some work we’ve already done in primary care and some of [it is] ‘lessons learned’; we’re looking at what we know works.”Some providers differ with that assessment. “I know it was well intentioned, but [the] CMS seems not to understand the day-to-day mechanisms of [how] primary care practices work,” Jean Antonucci, MD, a family physician in rural Maine and the author of one of the alternative payment model proposals that was recommended by PTAC, said in an email. “It is really virtually impossible to figure out how much revenue a practice will receive.””Supposing that my patients are well taken care of so I am placed in the lowest [payment] category of $24 a month; it’s very difficult to [keep patients] out of the hospital for $24 a month, but I might be put in that category because I did a good job. So no good deed will go unpunished,” she said.In her own proposal, she considers the cost of an hour’s worth of phone calls — 15 minutes, four times a month — from a practice to a particular patient. “A [medical assistant] is $15/hr. easy, but often the doctor must be involved, or an RN, and that is $40-$150 per hour, plus they need the driver’s license form or the forms for oxygen … We end up with whining by doctors about not being paid, while payers and pundits complain we want to nickel-and-dime them to death.”nnOTHER POSSIBLE APPROACHESn
Primary Care First’s early reviews “reveal that longstanding conflicts remain between, on the other hand, budgetary savings and administrative feasibility goals and, on the other hand, more ambitious desires in parts of the medical community redesign care to elevate the role of effective primary care (regardless of the short-term costs),” Tom Miller, JD, resident fellow at the American Enterprise Institute, a right-leaning think tank, said in an email. “Perhaps more medical outcomes per se could be improved by simply paying primary care doctors more, but that assumes away the political food fight it would require to get there.”A more straightforward approach to “subsidize patients more directly to find and receive the care that they could choose to receive would upset providers either benefiting from the current system or imagining that they could be winners in the next round of political reimbursement roulette, labeled ‘value-based,'” he added.Gail Wilensky, PhD, senior fellow at Project HOPE in Bethesda, Maryland, and a former CMS administrator, said in an email that the difficulty with the model “seems to be the amount paid is too small and too unreliable … That is certainly consistent with the ongoing CMS attempts. It is certainly reason to be skeptical although the results will only become clear after it is tried, assuming [the] CMS goes forward with it … It has been discouraging how difficult it has proven to be to affect change in this area.”nnOriginal 
The clock is ticking, and you’re trying to select the right E/M level from a drop-down menu in the EHR. Choose a level that’s too high, and you run the risk of post-payment audits and recoupments. Choose one that’s too low, and you may lose revenue to which you’re entitled. You decide just to trust your instincts and go with a code that feels right so you can move on to the next patient.nnChoosing an E/M code based on a gut feeling is one of the biggest mistakes a physician can make, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making [MDM]—or time spent counseling and coordinating care) for each E/M level.nnIf physicians don’t document these elements adequately—or the elements they document don’t make sense given the patient’s presenting problem (e.g., performing a comprehensive exam for a patient with a sinus infection)—payers and auditors may down-code the service or even conduct a more in-depth audit that could expose additional documentation vulnerabilities, she adds.nnIt’s equally risky to report the same E/M level for all patients with the same diagnoses (e.g., diabetes or congestive heart failure) without first considering medical necessity—a trap into which many physicians fall because they assume all patients with the same diagnoses generally require the same work, says Toni Elhoms, CCS, CPC, director of coding and compliance at Welter Healthcare Partners , a healthcare consulting company in Arvada, Colo. “In reality, every single visit could be a different level based on the documentation and circumstances of the encounter,” she says.nnFocus on quality E/M documentation—and the dollars will follownnKnowing what documentation is required for each E/M level is paramount. For example, the history, exam, and MDM must meet or exceed certain requirements for all new patients. The only exception is when the physician selects the E/M level using time as the controlling factor. In this case, documentation must indicate that the physician spent more than 50 percent of the encounter face-to-face with the patient and/or family providing counseling and/or coordination of care. The physician must also explain the specific services rendered and the reasons for them.nnOnly two of three key components must meet or exceed certain requirements for established patients unless the physician bills based on time. Elhoms provides an E/M scoring guide that includes a visual depiction of documentation requirements for each specific E/M level based on whether the patient is new or established.nnSound confusing? Experts agree that even the most experienced medical coders have difficulty translating physician documentation into an accurate E/M code. They cite several reasons why E/M coding is so difficult for physicians—lack of formal training on E/M guidelines, complex documentation requirements that don’t align with clinical practices, and the subjective nature of the MDM component.nnWe’ve asked our experts to share their best documentation tips to ensure accurate E/M reporting. Here’s what they said.n
Does your practice screen patients for risk factors like smoking, alcohol or drug use? Do you know the correct coding for use patterns? According to section guidelines by the AMA, “…used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.”nnThis is especially helpful when we look at codes 99406-99409 and incorporate this into your telemedicine services menu. Welter Healthcare Partners recently teamed up with CDPHE for a two-part webinar series on the coding and billing for these important codes and how school-based health centers can take advantage of the services they support.nn n