Medical Economics

ENGAGEPATIENTS

IN HEALTHOUTCOMES

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2 MEDICAL ECONOMICSBROUGHT TO YOU BY

ENGAGING PATIENTS TO DECREASE COSTS AND IMPROVE OUTCOMESBY ALEXANDRA B. KIMBALL MD MPH, KRISTEN C. COREY MD, JOSEPH C. KVEDAR MD

ncreasingly, healthcare providers face insur-mountable opposing pressures: To bring down costs, but accom-

plish more at every patient visit.Today’s physician is respon-

sible for a tremendous medical repertoire, evidenced by the increasing number of diagnoses in our codes. About 13,000 diagnostic codes expanded to 68,000 with adoption of the new ICD-10 system.

Physicians also need to meet or consider multiple meaning-ful use objectives, pay-for- per-formance measures, quality incentive measures and medical home elements. These include a daunting number of activi-ties ranging from design of IT interfaces to medical assistant time, nursing interventions and physician effort.

To complicate the issue, these requirements have emerged in the context of a shortage of pri-

mary care physicians and certain types of specialists, generating further discrepancies between supply and demand. The de-mands cannot be met, even with substantial help from ancillary staff. And even if they could be met, the cost to provide such care would be prohibitive.

So how do we manage the myriad of initiatives and the impending physician workforce shortage while also reducing cost and improving quality? In healthcare, we continue to insist on human resource-intense solutions. However, the propor-tion of a provider organization’s cost borne by human resources is 56%, and healthcare work-ers are generally less productive than those in other sectors. A staff-heavy plan of action is doomed to fail.

Other industries, when faced with the quandary of accomplishing more with less, have resorted to customer-

empowerment initiatives. As customers, we now do our own banking, pump our own gas, as-semble our own furniture, check ourselves in at the airport and out at the grocery store. These examples allow those providing services to use human resources more efficiently, contributing to increased worker productivity.

In most cases, the advent of these strategies was viewed with concern, but now all are almost universally viewed as empower-ing consumers. Can we follow this model of customer empow-erment and create an architec-ture that allows us to engage patients in their healthcare?

Patient self-management is not a new concept and repre-sents an essential element of the chronic care model (CCM), a theoretical framework developed to guide higher-quality chronic illness management in primary care. Evidence has shown that incorporating CCM principles

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MEDICAL ECONOMICS 3BROUGHT TO YOU BY

into practice results in favorable health outcomes.

Patient engagement initiatives have led to reductions in hospi-tal visits, decreased morbidity and mortality and improvements in treatment adherence and quality of life associated with chronic diseases such as heart failure, ulcerative colitis and asthma. Although an overarch-ing goal of patient engagement is to decrease cost, we do not have to sacrifice quality care.

Areas of opportunity for pa-tient engagement include sched-uling appointments, managing correspondence, refills and prior authorizations and facilitating communication with the medical team. These tasks require more health literacy and familiarity with technology than we have asked of patients previously. Not all patients will be able or eager to handle this, but many will.

Most patients embrace re-sponsibility for managing their health and view this approach as better quality care. A 2010 sur-vey found that 79% of respon-dents were more likely to select a provider who allows them to conduct healthcare interactions online, on a mobile device or at a self-service kiosk. One study found that many would even pay for such online services.

The majority of patients prefer a shared decision-making

approach with their healthcare provider, an attitude that will aid a patient engagement initiative. Although barriers will exist for individual patients to adopt this system and its associated technol-ogies, we must focus on develop-ing an infrastructure that supports and encourages active patient participation in their healthcare. n

Alexandra B. Kimball, MD, MPH, is senior vice president of practice

improvement at the Mass Gen-eral Physicians Organization and a professor at Harvard Medical School. Kristen C. Corey, MD, is an internal medicine physi-cian in Boston, Massachusetts. Joseph C. Kvedar, MD, is director of connected health at Partners HealthCare and a professor at Harvard Medical School. This essay was an honorable mention in the 2014 Medical Econom-ics physician writing contest.

ALTHOUGH AN OVERARCHING GOAL OF PATIENT ENGAGEMENT IS TO DECREASE COST, WE DO NOT HAVE TO SACRIFICE QUALITY CARE.

TECHNOLOGY TO HELP PHYSICIANS IMPROVE PATIENT ENGAGEMENT

Online appointments.Scheduling appointments repre-sents a major effort by medical personnel. It is often undermined by the fact that 20% of patients cancel or do not arrive for visits within the same day. Many patients would prefer the conve-nience of scheduling their own appointments online, and studies have shown that advanced access and online scheduling reduce wait times and no-show rates.

Pre-visit check in.Several groups are using tablet computers and kiosks to give patients the opportunity to enter pre-visit updates, demographic information, etc., in order to ex-pedite the process of information gathering. Kiosk technology has even led to improved throughput efficiency in the busy emergency department.

Online visits.Online communication is not a new concept, but its adop-tion among physician practices remains low. Only 13% of physi-cians use email to communicate with their patients. As the burden of chronic illness increases, one of the consequences will be the need to use brick and mortar resources more thoughtfully. Visits to physi-cians for routine interactions or data collection can be moved into an asynchronous, online environ-ment creating opportunities for in-creased efficiency. Patient portals allow certain functions tradition-ally performed by office staff,

such as viewing test results and communicating specific questions to a provider, to be performed by patients. The results are time-savings, patient satisfaction, and desirable patient outcomes. For example, patients with gestational diabetes recieving follow-up and monitoring care via a text mes-sage-based telemedicine system achieved similar HbA1c levels, blood pressure values, weight gain, and rates of normal vaginal delivery at greater convenience compared to patients attending conventional office visists.

Remote monitoring programs.Increasingly, devices that monitor the physiologic consequences of disease and treatment are able to share their data via wireless connectivity. Capturing this data and moving it to the electronic health record enables patients to realize how lifestyle and treat-ment choices affect their health, leading to improved compliance and disease management. In one recent study, patients with hyper-tension were given the opportu-nity to titrate their own medi-cations based on home blood pressure readings and were able to do so with surprising ease. Patients with diabetes who up-load their glucose readings to a centralized repository that allows them to view and contextualize these readings have achieved reliably lower HbA1c readings than their counterparts who do not participate.


he ultimate goal of healthcare professionals is to achieve well-being in patients, which, as a matter of

course, usually requires patients’ compliance with prescribed therapies. Despite the best inten-tions and efforts of healthcare professionals, issue resolution cannot be achieved if patients

aren’t adherent in following prescribed therapies. Therapeu-tic adherence includes not only patient compliance with taking medications, but also typically with prescribed changes in diet, exercise and lifestyle.

According to a 2004 study published in Health Psychology, patient compliance with health-care professional prescribed therapies is historically quite low.

The study concluded with these average rates of compliance:

•Long-termmedicationthera-pies: estimated between 40% and 50%

•Short-termtherapies:between70% and 80%

•Lifestylechanges:20%to30%

Non-adherence with pre-scribed therapies has a variety of undesirable impacts, includ-

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Brain Imaging and Patient Adherence

LOOKING INSIDE OUR HEADS:BY DAVID HAGEDORN, PHD, BCN


ing not only urgent care visits, hospitalizations and higher treatment costs, but also greater financial burdens on society in general; not to mention poten-tial negative effects for patients themselves.

The empirical evidence of a broken bone is difficult for a patient to challenge, but even then we see that rates of patient adherence with prescribed courses of therapy are low. So, how can doctors achieve patient adherence when addressing health issues that cannot so readily be seen; in situations in which the health issue is one literally in the patient’s own head? When neurological prob-lems or injuries manifest, it can be challenging for healthcare professionals to bring patients around to understanding both the nature of the problem, and the rationale behind proposed courses of therapy.

NEUROIMAGING’S BENEFITS

Neurological issues range across concussion, depression, memory and pain, among others. While a patient may be aware of the symptoms of a neurological problem, such as a traumatic brain injury brought on through concussion, the internalized nature of the injury can make it more difficult to achieve adher-ence. Fortunately, the develop-ment of neuroimaging technolo-gies that enable doctors to peer into our brains themselves, mapping brain activity and tracking changes over time, has opened new doors in diagnosing, prescribing for and managing these conditions.

In a 2008 study of 60 psy-chiatrists and psychologists published in the Journal of Psychiatric Research, 85% agreed or strongly agreed that neuroimaging data would be a

valuable adjunctive diagnostic tool for clinical evaluation. This study was conducted in the context of imagining that brain scans are used to materialize images related to depression; a condition in which it is often particularly difficult to achieve acceptance with patients due to societal stigmatism.

Among the 72 patients who participated in the study, 92% responded favorably to the idea of having a brain scan performed to diagnose depression if such a scan were to be made avail-able to them. Perhaps even more notably, 76% of the respondent patients said that a brain scan would help them accept their condition and 66% responded that it would increase their confi-dence in a provider’s diagnosis.

The study concludes, “From responses of 52 providers and 72 patients, we found high receptivity to brain scans for treatment tailoring and choice, for improving understanding of and coping with disease, and for

mitigating the effects of stigma and self-blame. Our results sug-gest that, once ready, roll out of the fully validated technol-ogy has significant potential to reduce social burden associated with highly stigmatized illnesses like depression.”

This study lends remarkable support to the notion that help-ing patients to visualize the na-ture of their healthcare issues is a critical step in achieving accep-tance of a diagnosis, and there-fore adherence with an agreed upon course of treatment. And it is easy to extrapolate from these results that neuroimaging prom-ises to be effective in helping patients understand other brain related injuries and illnesses.

The capability to not only col-lect but also share neurological data in a compelling visual form with patients aids healthcare professionals in helping patients to better understand their injuries and illnesses, and motivate them to adhere to agreed upon thera-pies to cure and/or manage them.

Non-invasive neuroimaging is an important medical advance-ment contributing to an under-standing of the brain and also the quality of care that can be achieved. Neuroimaging tech-nologies can help bring about a collaborative process between patients and doctors, in which patients themselves have the knowledge and understanding to play an informed, active and decision-making role in their manner of therapy. n

David Hagedorn, PhD, BCN, is chief executive officer, chief science officer, and founder of Evoke Neuroscience. He is expe-rienced in clinical health psychol-ogy and neuropsychology and serves as an international neuro-science and biofeedback research consultant and instructor.

NEUROIMAGING TECHNOLOGIES CAN

HELP BRING ABOUT A COLLABORATIVE PROCESS

BETWEEN PATIENTS AND DOCTORS, IN WHICH

PATIENTS THEMSELVES HAVE THE KNOWLEDGE AND UNDERSTANDING

TO PLAY AN INFORMED, ACTIVE AND DECISION-MAKING ROLE IN THEIR MANNER OF THERAPY.

Brain Imaging and Patient Adherence


ithin many physicians’ practices, there is a relatively untapped re-

source for optimizing revenue—business operations data. There has never been a better time to dive into this type of data. It can show both areas of strength and opportunities for improvement.

As practices move to value-based care, fully understanding and re-sponding to key business data will be essential to realizing success.

The first step is identifying the measures that most clearly demonstrate performance. These metrics should show whether a practice is getting paid in a timely fashion for all the care and ser-vices it provides. The following indicators are worth watching from a business perspective.

ACCOUNTS RECEIVABLEThis measure reveals how quickly a practice turns receivables into cash. Ideally, organizations should be keeping this metric under 30 days to yield nimble cash flow.

AGE OF RECEIVABLESThis number shows how long a re-ceivable has been outstanding. The longer a claim remains unpaid, the less likely it will be collectible. Organizations should examine those receivables past due over 90 days and determine whether there are preventable issues that can be addressed to shorten the payment timeframe and prevent similar problems in the future.

AVERAGE DAILY CHARGESPractices should track this metric over time to identify any patterns which could reveal productivity issues or patient volume fluctua-tions. For example, by monitor-ing this measure, a practice can pinpoint staff members who are underperforming and provide further training. Similarly, this measure can highlight seasonal patient volume variations that

may represent opportunities to temporarily augment staff to bet-ter manage cash flow.

COLLECTIONS PERCENTAGE This statistic compares the pay-ments a practice receives with what it is supposed to receive for the services it provides. Using this measure shows how well the practice optimizes payer contracts and collects balances due from patients.

CLEAN CLAIM RATE Using technology, this number should be high (near 100%) as claims scrubbers and other tools identify “dirty claims” prior to claims submission, allowing the organization to fix them before sending the claim to the payer. A decline may indicate the need to change payment rules and algorithms, improve workflows or train staff.

PATIENT COLLECTIONS With the advent of high-deduct-ible health plans, patients are taking on greater payment re-sponsibility. Whereas providers

used to be haphazard in collect-ing copayments, deductibles and coinsurance, there is increas-ing pressure to fine tune this process to prevent large revenue shortfalls. Practices that watch patient collection rates can make sure their front line staff are ask-ing for and collecting payments consistently and reliably. Outli-ers in this area can point to the need for staff training, patient education and standardized pro-cesses for soliciting payment.

DENIALS

Practices should keep a close eye on rejections and denials, be-cause they can highlight a wide array of problems, ranging from staff errors to payer rule changes to lack of eligibly verification. Practices that watch for denial trends can catch systemic issues and prevent future rejections. n

Monte Sandler is the executive vice president of RCM services at NextGen Healthcare.

WBY MONTE SANDLER

Indicators7 to Optimize Your Practice’sRevenue


ichael Bar-ron, MD, decided it made more sense to quit than

fight. After months of wrangling with UnitedHealthcare over inac-curate payments, the University City, Missouri, family physician did not renew his contract with the insurance company last year.

“They would charge me ad-ditional amounts and subtract it and add it back in a different way,” Barron says of his long dispute with the payer. “It was absolutely an accounting night-mare. The way they did it really punished me. I’m still not sure they paid me correctly.”

He feels the same sense of futility when negotiating con-tracts with other payers. So he accepts their automatic renew-als without trying to negotiate higher payments. “That’s been my assumption that I wouldn’t get anywhere, but I don’t know,” Barron says, adding that as a small practice (him-self and a nurse practitioner), he doesn’t have the time for lengthy negotiations.

That’s the prevailing atti-tude among members of Ideal Medical Practices, a Washington state-based nonprofit whose members, mostly solo or small practices, exchange practice management tips and discuss better models of care.

Most member practices don’t even try to negotiate, says execu-tive director Jeffrey Huotari, MD. “For them, it feels like run-ning into a brick wall,” he says. “Our members don’t have the time, the money or the legal help to get into negotiations.”

He adds that the only increases he saw as a family practitioner were the result of joining a provider organization that negotiated on behalf of all small practices on Michigan’s Upper Peninsula.

Because of these real and perceived difficulties, practices can go many years without a payment increase, even as their own expenses rise. The good news is that it is possible, in

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FIGHTING FORHIGHER PAYERRATES IS WORTH THE EFFORT

BY JAMES F. SWEENEY


some instances, to negotiate higher fees. The bad news is that it’s quite difficult.

DATA AS A WEAPONBecause it involves insurance companies, it should be no surprise that fighting involves a lot of paperwork. Payers don’t respond to emotional appeals, so practices have to arm themselves with data.

Before approaching an insurer, a practice should conduct an in-ternal audit, says Melody Irvine, CPC, CPMA, a practice consul-tant and owner of Career Coders inLoveland,Colorado.Thatmeans pulling all current and past contracts as well as years of payment records from insurers.

A practice needs to know how much it makes or loses on each contract, how much business it does with each payer, how many patients are covered by each insurer, which CPT codes it bills most often under each contract, the reimbursement for those codes and how the payments have changed over the years, if at all.

Putting all that information into spreadsheets should reveal which contracts are the most and least valuable to the prac-tice, which haven’t changed and more. Billers and coders should be involved because they’re likely aware of which payers are the biggest problems, Irvine says.

That’s a lot of work, especially for a small practice that may not have a manager who can dive into the numbers. Faced with that much paperwork and months of bargaining to follow, many practices, like Barron’s, decide they simply don’t have the resources for the fight.

“They don’t have the time so they just sign (the contract),” Irvine says, adding that practices should never accept an auto-matic renewal without at least asking for more money.

Others find it worthwhile to hire consultants, like Irvine

and Marcia Brauchler, MPH, FACMPE, president of Physi-cians’ Ally in Highlands Ranch, Colorado, to do the analysis and negotiating for them.

“They [practices] take no for an answer and think they’ve tried. We have the time and per-sonnel to persist through what the payers inevitably turn into an endurance test,” Brauchler says.

NEGOTIATING WITH GIANTS

So how does a practice negotiate with a big insurer that isn’t in-clined to raise fees and has time and resources on its side? “You have more wiggle room than you might believe,” Irvine says.

In cases where fees haven’t been raised in five years or more, it might be enough simply to point that out. But chances are the payer will need more per-suading. In that case, prioritize the biggest contracts first, Br-auchler advises, and be prepared for the long haul. The insurer’s reflexive reply will almost cer-tainly be “no,” delivered with a “take it or leave it” attitude.

This is why it’s important for a practice to know its competi-tive market and to look for any small edge. For example:

•Isitoneofonlyahandfulofsimilar practices in the area that contracts with the insurer?

•Doesitprovideservicestheothers don’t?

•Canitproveitdoesasuperiorjob at containing costs and providing top-quality care?

•Doesitseealotofpatientswhowill be unhappy with their in-surer if they’re forced to change doctors? (It’s not unheard of for practices to enlist patients to pressure payers to grant increases.)•Isthereawayforthe practice and insurer to work together to produce mutually agreeable results?

If the negotiations are unsuc-cessful, the practice will have to decide whether to accept what’s offered or end the contract. Insurers don’t want to lose prac-tices or drive them into joining healthcare systems with more negotiating clout, so it’s usually not in the payer’s best interest to push practices to the brink.

THINGS TO WATCH FOR

Even if higher reimbursements are off the table, practices should scrutinize contracts and payment data for harmful as-pects that they might be able to eliminate, experts say.

This could include insurers’ use of “silent PPOs,”—organiza-tions that access a discounted rate from a practice without its permission, usually after a ser-vice is rendered. Another thing to watch for is insurers’ growing use of material change notices to unilaterally alter a contract with 30 days’ notice and without consent of the practice.

One thing is clear: practices that don’t at least try for more money won’t get it. Or, as Irvine puts it, “It never hurts to ask.” n

James F. Sweeney is a freelance healthcare writer based in Cleveland, Ohio.

“THEY [PRACTICES] TAKE NO FOR AN ANSWER

AND THINK THEY’VE TRIED. WE HAVE THE

TIME AND PERSONNEL TO PERSIST THROUGH

WHAT THE PAYERS INEVITABLY TURN INTO AN ENDURANCE TEST.”

Marcia Brauchler, MPH, FACMPE, president, Physicians’ Ally


Should be DrivingVALUE-BASED SOLUTIONS

Physicians

ne group is directly responsible for physician pay lag-ging behind inflation

and for medical practices being micromanaged by payers and government regulators: physi-cians themselves.

That’s according to Harold Miller, president and chief ex-ecutive officer of the Center for Healthcare Quality and Payment

Reform in Pittsburgh, who deliv-ered this message at the American College of Cardiology’s (ACC’s) 65th annual Scientific Session and Expo in Chicago in April.

“[Physicians] haven’t stepped up with solutions and allowed themselves to be seen as drivers of costs,” Miller said.

Miller described three possible futures for physicians in the post-Sustainable Growth Rate Medi-

care payment formula world, made possible by the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).

The first involves some mix of pay-for-performance (P4P) and value-based payments, Miller said. He criticized P4P as a poorly executed solution to the problem of paying low-quality doctors the same as high-per-forming physicians.

BY ANDIS ROBEZNIEKS

O


Under pay-for-performance schemes, physicians are required to deliver high-quality care but are not adequately compensated for it and get penalized for factors beyond their control, Miller said.

He wasn’t optimistic that the Merit-Based Incentive Payment System (MIPS) created by MAC-RA would generate better results, dubbing the initiative “pay-for-performance on steroids.”

The second possible future involved alternate payment models that seek to correct deficiencies with fee-for-service systems that do not compensate physicians or their staff for time spent discussing care plans with patients or coordinating care with colleagues.

While Miller said per-member, per-month fees cover these services in the patient-centered medical home practice model, other methodologies, such as shared savings rewards, don’t provide much benefit for prac-tices that are already providing high-quality, low-cost care.

LET PHYSICIANS TAKE THE LEAD

Ultimately, most payment models are designed by payers for the benefit of payers, Miller said. But

what is needed is a physician-designed system that identifies and removes barriers to bet-ter care, provides doctors with the resources and flexibility to provide that care and then holds them accountable for doing so.

Miller directed his audi-ence to review a guide to seven physician-directed alternate payment plans he developed

with the American Medical Association, but also pointed out to examples of physicians who have already developed their own working models.

One was developedbyLaw-rence Kosinski, MD, a gastro-enterologist in Elgin, Illinois, who developed a payment and care model to manage his medical group’s treatment for the 200 most critically ill of their patients with Crohn’s Disease. The model is described as a specialty intensive medical home program and is a collaboration with Blue Cross Blue Shield of Illinois.

Miller also told of the “Birth-Bundle” model developed by Steve Calvin, MD, medical director of the Minnesota Birth Center in Minneapolis, where high-quality

care is provided at 28% lower cost.LarrySobal,executivevice

president for business develop-ment for MedAxiom, a cardio-vascular practice consultant in Neptune Beach, Florida, also voiced some optimism through programs presented by the Cen-ters for Medicare & Medicaid Services, notably accountable care organizations (ACOs).

“I believe we’re starting to see two things from CMS that nor-mally I can’t say exist: flexibil-ity and creativity,” Sobal said, describing how there are now

434 Medicare Shared Savings Program ACOs providing care to 7.7 million beneficiaries.

Although CMS is being flexible with ACO risk levels and patient population size, Sobal added that attaining shared savings is still difficult, so both patience and preparation are required.

“I will tell you, it’s not easy money,” he said. “You do need to recognize the transformation necessary to become a full ACO is measured in years.”

While “there is no clear road map” to become a successful ACO, Sobal did have some advice to provide.

“Maximize what you do well,” he said, and decide what good ideas “you shamelessly steal from others.” n

Andis Robeznieks is a freelance healthcare writer based in Chicago, Illinois.

“UNDER PAY-FOR- PERFORMANCE SCHEMES,

PHYSICIANS ARE REQUIRED TO DELIVER

HIGH-QUALITY CARE BUT ARE NOT ADEQUATELY COMPENSATED FOR IT AND GET PENALIZED

FOR FACTORS BEYOND THEIR CONTROL.”

Harold Miller, CEO

“WHAT IS NEEDED IS A PHYSICIAN-DESIGNED

SYSTEM THAT IDENTIFIES AND REMOVES BARRIERS

TO BETTER CARE, PROVIDES DOCTORS

WITH THE RESOURCES AND FLEXIBILITY TO PROVIDE THAT CARE

AND THEN HOLDS THEM ACCOUNTABLE

FOR DOING SO.”Harold Miller, CEO

“I BELIEVE WE’RE STARTING TO SEE TWO

THINGS FROM CMS THAT NORMALLY I CAN’T SAY

EXIST: FLEXIBILITY AND CREATIVITY,”

Larry Sobal, EVP


here are three F’s of patient motivation: Fear, finances and feel-ing better.

Fear is a powerful, but tempo-rary, motivator. A patient whose relative just got cancer is very open to screening. Another strong incentive is finances: money mat-ters. Patients eagerly book well exams or adopt better behaviors to earn discounts on insurance premiums. A more encouraging reason for change is feeling better.

It’s frustrating when patients don’t follow recommendations. These tips may get them on track.

MOTIVATIONAL INTERVIEWINGInquire about readiness to change. Patients contemplating or preparing for change are re-ceptive to advice. Have patients rate, on a 1 to10 scale, the importance of an intervention, and their confidence to carry it out. Their answers reveal barri-ers to abolish through creative problem solving.

LEAD WITH LIFESTYLEFor new metabolic diagnoses, I offer a three-month to six-month trial of diet and exercise before medications. To raise confidence, I discuss the patient’s past successes, similar patients’ achievements, or my personal benefits from healthful hab-its. We set realistic goals, and involve allied professionals such

as diabetes educators to explain what to do, and why.

COUNTER FALLACIES WITH FACTS

Patients say: “I can do it alone with diet” or “I only want natural remedies.” If they don’t reach goal with healthful habits, I praise their efforts but point out they can’t escape all genetic risks. I’ll consider plausible alternative medicine along with traditional treatment. Education about ben-efits, risks and guidelines often requires multiple visits.

SIMPLIFY

Stop unnecessary prescriptions. Consider affordable generics and once-daily medication doses. Make testing easier with one-stop lab and imaging.

HARNESS YOUR EHR

Most EHRs have population management tools: disease registries with automated let-ters, phone or Web messages to patients with care gaps (uncon-trolled metrics, overdue tests or appointments). Our practice is re-engaging people previously lost to follow-up through our product.

INNOVATE

Our hospital-owned medical group employs two quality improvement nurses to compile disease management statistics and brainstorm improvement strategies that are dissemi-

nated to all sites. Internist James Lengemann,MD,mygroup’smedical director, piloted a half-day diabetes clinic when usual care wasn’t budging his worst-controlled diabetics. He imple-mented point-of-care testing and brought in diabetes educators. With focused attention, patients achieve better control and the clinic has expanded to two mornings per week with more providers. Nationally, telehealth is becoming popular. Evidence is limited for its effectiveness on adherence, but it’s worth trying with tech-loving patients.

PRE-DISMISSAL LETTERS

When earlier outreach fails, I write a warning letter to express my concern for the patient’s health. I state that their non-adherence is weakening the physician-patient relationship so I can’t effectively help them. I set a clear goal, e.g. labs and a visit within six weeks, and warn that my next regretful step would be dismissal from practice with 30 days of emergency care until they find another doctor. This has brought nearly all my delinquent patients back into the fold. n

Elizabeth Pector, MD, is a family medicine physician based in Na-perville, Illinois, and a member of the Medical Economics edito-rial advisory board.

BY ELIZABETH PECTOR, MD

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How to Get Your Patients on Board withDISEASE MANAGEMENT


umerous stud-ies over the past five years indicate that mental health disorders are

on the rise. Why is this important to primary care physicians? Be-cause mental stress as a result of cognitive impairment or a mental disorder strains the physical body and serves as a catalyst for a myriad of chronic illnesses.

The World Health Orga-nization released a pamphlet supporting the negative effects of the global financial crisis of 2008 on mental health. The author states, “Substantial re-search has revealed that people

who experience unemployment, impoverishment, and family disruptions have a significantly greater risk of mental health problems.”

In addition, aging baby boom-ers are resulting in a mass of the population developing Alzheim-er’s disease or other memory-related conditions. A study from the Centers for Disease Control and Prevention showed that “approximately one out of every eight baby boomers has expe-rienced increasing issues with their memory in the past year.”

According to epidemiologic data in a 2006 study in the American Journal of Psychiatry, over half of U.S. patients receive

mental health care exclusively in the primary care setting. Com-bined with the prior two factors listed above and a rapidly increasing world population, a growing number of employed Americans feeling overworked and a neglected mental health care system and one might conclude that there is a great need for primary care physicians to provide more in the form of mental health treatment.

HOW PCPs CAN HELP

Primary care physicians who can readily detect and manage behavior problems will be better equipped to manage the grow-ing mental healthcare demand.

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A Clinical Tool to Help Patients with STRESS-RELATED CONDITIONS

BY BRITTANY ROTHHAMMER


However, existing mental health care tools for primary care physicians are often time consuming, subjective, expensive or don’t have the requisite sen-sitivity (e.g., mini-mental status exam, blessed dementia cale). When patients present with con-cerns of needing greater mental effort to perform daily activities, the physician needs a very fast, easy-to-use, low-cost, objective and sensitive test.

Neuropsychological tests completed on the computer like ANAM, MicroCog and CNS Vital Signs have certainly helped over the past decade and still have their place; however, these fall short in that they can take well over an hour to complete by a trained technician and, more concerning, they are largely effort-based. A problem with effort-based computer tests is that the degree of motivation, effort and vigilance that the patient puts forth at the time of testing will significantly skew the resulting scores, thereby chang-ing the interpretation. Neu-ropsychologists are trained to take this into consideration, but technicians and testing software cannot account for this variable. As a result, traditional and dedi-cated neuropsychological testing is in many respects better when administered by expert neuro-psychologists. The problem with this option is that the testing will require several hours to complete, in addition to the time it takes to score, generate and interpret a meaningful report. This is all without mention of the higher economic cost.

Additionally, many neuro-psychological tests are indeed objective; however, they are not direct measures of actual human physiology (e.g., block design). Efforts to develop blood and cerebral spinal fluid tests are active areas of research, but to date none have ample sensitivity or reliability.

When searching for non-intrusive and office-based options, this only leaves the objective electrophysiol-ogy measures. Electroencephalog-raphy (event-related potentials, quantitative EEG analysis) in par-ticular has a long history of strong clinical research, but, due to the expensive and sensitive equipment, has historically been out of reach from practicing doctors. EEG data collection and data interpretation are also difficult and time consum-ing for physicians.

AN OFFICE-BASED SOLUTION

With the advent of faster computers and new advances in software, objective electrophysi-ology assessment and analysis are now available outside of brain research centers and universities. Evoke Neurosci-ence, Inc. is the leading medical device company providing low cost nervous system physiology measurement and biofeedback treatment equipment, called an eVox system, designed specifi-cally to suit the needs of medical doctors and their patients. M edical assistants can skillfully of-fer physician-determined care to patients presenting early symp-toms of cognitive dysfunction.

The system uses a heart rate monitor and an EEG to record a

patient’s heart rate, brain waves and brain processing speed while the patient performs a series of mental tasks. From these electrophysiology and heart rate variability results, a clinically derived report is administered to the physician. The report pro-vides visual and statistical data including biomarkers, visual processing, auditory processing, and a brain function map.

In addition to the eVox report, a second opinion service is included and is performed by a panel of physicians from Neuro-Read, which offers treating phy-sicians another perspective on the electrophysiology data when considering report interpretation and clinical applications (includ-ing medication, supplements, neurofeedback, etc.).

If neurofeedback is suggested as a potential solution, the device can also equipped with the soft-ware needed to provide this treat-ment and can actually be used by a patient with minimal assistance from a medical assistant.

Patients appreciate seeing the objective evidence of their conditions, as well as track-ing their physiological change longitudinally during different treatments. Physicians appreci-ate the office-based, low-cost tool yielding sensitive measures to help patients see the value of treatment compliance, addi-tional biomarker information to support differential diagnosis and a more individualized neu-rofeedback intervention option. Ultimately, it is clinical tools like this one that will help primary care physicians bridge the gaps between psychiatrics and gen-eral medical practice as well as physician recommendation and patient compliance. n

Brittany Rothhammer is a promi-nent brain-health blogger based out of southern California.

WITH THE ADVENT OF FASTER COMPUTERS

AND NEW ADVANCES IN SOFTWARE, OBJECTIVE ELECTROPHYSIOLOGY

ASSESSMENT AND ANALY-SIS ARE NOW AVAILABLE

OUTSIDE OF BRAIN RESEARCH CENTERS AND UNIVERSITIES.

“eVoxhelpsmehelpmypatients‘see’howtheirbrainisfunctioningandwhytheymayhavememoryloss.Andithelpsusbothseetheeffectsofthemedications,nutrition,orbehavioraltherapiesweareusingtotreattheirmemoryissues.”—JohnMcGee,M.D.,InternalMedicine

Improvepatientadherencetotreatment,increasepracticerevenue,andhelppatientswithstress-relatedconditionsincludinganxiety,depressedmood,attentionissues,forgetfulness,headinjury,pain,andsleepissues.TheeVox®systemusesEEG,ECG,andevent-relatedpotentials(ERP)toprovideprimarycarephysicianswithobjectivedatainaneasy-to-readandactionablereport.

THEeVox®SYSTEM HelpPatientsAchieveHealthierBrainFunction

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