Medical Economics Magazine PDF

PRACTICE MANAGEMENT PRACTICES IN PERIL
MEDICAL ECONOMICS
How physicians are fighting

for survival amidst
COVID-19
MAY 2020
SMARTER BUSINESS. BETTER PATIENT CARE. MAY 2020 VOL. 97 NO. 9
THE 91ST
THE 2020 PHYSICIAN REPORT
PHYSICIAN
PRACTICES IN PERIL
REPORT
HOW TO PICK A TELEHEALTH VENDOR
Exclusive data on
salary, productivity
and more
MONEY What health care reform
would mean to your bottom line
TECH How to evaluate a telehealth vendor
LEGAL HIPAA changes: What practices need to know
CHRONIC CONDITIONS The importance of care coordination
CAREERS Ethical dilemmas for physicians
during a global pandemic
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2295-2306. 4. Bauersachs J, et al. Hypertension. 2015;65(2):257-263.
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2 MEDICAL ECONOMICS ❚ MAY 2020 MedicalEconomics. com

May 2020 VOLUME 97 ISSUE 9
Referenced in MedLine®
C OV E R STO RY
CAREERS
2020 Physician
Report
The medical
ethics of
COVID-19
We talk with a physician
and expert in medical
ethics about the
Exclusive data on pay and productivity PAGE 12
dilemmas of fighting this
A LS O I N S I D E
pandemic.
PAGE 30
PRACTICE MANAGEMENT
4 Practices in peril
Physicians say how they’re coping
with the downturn.
IN EVERY ISSUE
7 Strategic planning 8
1 Chairman’s How to build a lasting competitive
letter advantage.
2 Interactive
CHRONIC CONDITIONS
34 Funny Bone
8 Care coordination LEGAL
35 Marketplace It takes a team to manage 28 HIPAA and the new rules
patients with chronic conditions. Regulations are changing during
But who should take the lead? COVID-19. Here’s what you need
to know.
MONEY
24 Health care reform TECHNOLOGY
How transforming the health 33 Starting telehealth
insurance system would How to evaluate a vendor and
impact physicians. find the best fit for you.
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Practice Management
Medical practices reel

financially from COVID-19 losses
by KE N TE R RY Contributing author
A
merica’s physician practices face practices are having difficulty ramping up
devastating financial losses due telehealth systems and workflows. Even if
to the COVID-19 pandemic. What they can master this technology quickly,
will happen long term is unclear, most small practices have no more than two
but doctors and observers say the or three months of operating expenses in
actions taken so far by the govern- reserve, notes Medhavi Jogi, M.D., co-owner
ment to support practices are inad- of Houston Thyroid & Endocrine Specialists,
equate and that more needs done. a five-physician group practice. At some
Currently, physician practices are expe- point, unless the crisis ebbs fairly soon,
riencing 30% to 75% decreases in patient many independent practices will have to
volume, says Halee Fischer-Wright, M.D., consider reducing physician compensation
president and CEO of the Medical Group and/or laying off staff to survive.
Management Association (MGMA) head- Some practices may not survive. “Without
quartered in Englewood, Colorado. The immediate governmental action, practices
business of primary care practices is down around the country will fail,” wrote Jeff Living-
40% to 50%, she says. ston, M.D., CEO of MacArthur Medical Center
The situation would be even more dire if in Irving, Texas, in a recent opinion piece.
not for telehealth and the new willingness “The U.S. will be faced with an unprecedented
of the Centers for Medicare & Medicaid Ser- crisis of unemployed physicians right at the
vices (CMS) to cover virtual visits. “Since potential peak of the COVID-19 pandemic.”
CMS changed their regulation of reimburse-
ment, we’ve seen telehealth enthusiastically SYSTEM-OWNED VS. INDEPENDENT
embraced across the country, to the point PRACTICES
Romolo Tavani/Stock.Adobe.com
where it has become an integral part of Physicians employed by health care systems
care delivery just in the [past] three weeks,” are in better financial shape than indepen-
Fischer-Wright says. dent doctors, at least for now. For example,
Nevertheless, many small, independent internist Jeffrey Kagan, M.D., recently joined
ME0520_004-006_PM_Peril.indd 4 4/29/20 3:21 PM

COVID-19 impact Practice Management
Hartford HealthCare, a large system based For people with respiratory complaints, he
in Hartford, Connecticut, after many years manages them virtually if they’re not too ill.
as an independent practitioner. Kagan be- If they’re too sick to manage virtually but not
came part of Hartford on Feb. 3, just weeks ill enough to send to the emergency depart-
after the first confirmed U.S. case of the ment, he refers them to the group’s respira-
COVID-19 virus. tory urgent care clinic.
Kagan is grateful he made the move The group hopes to avoid layoffs, but
when he did. “It couldn’t have happened at private practices generally aren’t bringing
a better time,” he says. “With the decreased in enough revenue to make payroll, Ejnes
volume of patients we’re taking care of, I’m says. Some of his office’s medical assistants
[still] able to get my salary. Otherwise, I don’t are working from home because patients are
know whether I could keep my staff and not coming into the office. Even with virtual
overhead going.” visits, administrative tasks such as manag-
Another advantage: The system imme-
diately got Kagan up on its telehealth plat-
ing lab results and handling correspondence
and forms have decreased significantly.
“Practices
form, enabling him to conduct virtual visits “There are other needs that are new, such should be
with many of his patients. He says he doesn’t as transitioning people from in-person visits
know whether he could have made the tran- to telehealth visits and teaching or guiding reasonable
sition to telehealth as well on his own.
Kagan is still seeing patients with urgent
them [to install the apps],” Ejnes says. “But
the overall result is that there might be a de- about
nonrespiratory issues in person but is taking
care of other patients via the telehealth app
creased need for support staff. And the pos-
sibility of furloughs is definitely an option.” expectations
in the patient portal of Hartford’s electronic
health records. Still, his appointment vol- SMALL PRACTICES FACE THREATS for their
ume is down 50% to 60%. On a typical day
recently, he saw three people in the office
Jogi, the Houston endocrinologist, says his
practice switched completely to telehealth in volume and
and eight via telehealth. late March and sent all of its staff home. But
it’s still unclear how long the practice will be
how long this
PAY CUTS AND LAYOFFS
Yul Ejnes, M.D., is an internist with Coast-
able to survive in its current form, Jogi says.
Unlike many small practices, which have
downturn is
al Medical, the largest primary care group
practice in Rhode Island. Unlike Kagan, he
been reluctant to embrace telehealth, Jogi
and his colleagues have been conducting vir-
going to last.”
can’t count on a fixed salary. As one of the tual visits for the last five years. About 30%
—HALEE FISCHER-WRIGHT, MD,
physician owners in the 125-provider Prov- of Jogi’s visits were virtual even before the
PRESIDENT, MGMA
idence-based practice — which bases com- pandemic. Although virtual visits comprised
pensation on productivity — Ejnes realizes a much smaller percentage of the other doc-
the reduced volume he’s experiencing will tors’ visits before, “they all knew how to do it,
eventually require him to take a pay cut. and the systems were in place,” he says.
Ejnes is still working in his office but The practice has halted in-office proce-
is doing mostly virtual visits. “We’ve con- dures, such as thyroid biopsies and thyroid
verted our regular day schedules to tele- ultrasounds, because Texas banned all pro-
health — either audio-video or telephone,” cedures at least through April — another
he says. “Our organization has been able financial hit for the practice. In addition,
to set up a couple urgent care clinics for Jogi notes, many patients with diabetes and
people who really need to be seen. We’ve other metabolic disorders are afraid to go to
segregated that into respiratory sick visits and Quest Diagnostics or LabCorp for testing.
nonrespiratory sick visits. We haven’t been That has reduced patient volume because
able to reach some patients to tell them there’s not much to talk about with these
their office visits are being turned into tele- patients in the absence of recent lab results.
health visits, and they’ve come in. I saw one The cash flow in Jogi’s practice has not
[in-person] patient this week, and [every- dropped off yet because payments from
one] else has been [seen] remotely.” claims filed weeks ago are still coming in.
Ejnes says he is now seeing two-thirds But he and his two partners (the other doc-
as many patients as he saw before. Of the tors are employees) are keeping a close eye
12 virtual visits he conducted recently, five on their bank statements. “Once we start
were audio-video and seven were via phone. seeing the daily [electronic] check deposits
MedicalEconomics. com MEDICAL ECONOMICS ❚ MAY 2020 5

Practice Management COVID-19 impact
drop, we know we’re going to have to change

some staffing,” he says.
Where can practices

As long as the group can keep telehealth
volume up, he adds, he doesn’t think they’ll
have to let the employed doctors go. “But it
get financial help? will probably tank at some [point], and we’ll
have to ask for concessions. If they’re not
P
willing to concede, there may be layoffs.”
rivate practices that are or think they will soon be in a financial
bind because of the COVID-19 crisis have some options. For LONG-TERM OUTLOOK
starters, they can get a bank line of credit to cover expenses for Observers expect that most independent
a few months. practice leaders will delay layoffs for now.
“Many practices are going to banks to extend their lines of credit, “The sequence is often that practice owners
which have become much more flexible,” says Halee Fischer-Wright, MD, take home less money,” says Joshua Halv-
president and CEO of Medical Group Management Association (MGMA). erson, who holds a master’s in both public
“With the interest rates close to zero, banks want that kind of business.” health and health administration and is a
Under the recently enacted rescue legislation known as the CARES principal at ECG Management Consultants.
Act, businesses with fewer than 500 employees can access $349 billion “I’m not hearing people talk about big lay-
in loans from the U.S. Small Business Administration (SBA). The low-in- offs of clinical staff. There are a lot of peo-
terest loans, available through June 30, are designed to cover up to eight ple still hopeful that this is a temporary —
weeks of payroll costs and can also be used to pay mortgage interest, month or two — situation and [that] people
rent and utilities. can hold off. ...”
An SBA loan can be forgiven if a business uses at least 75% of the Fischer-Wright of MGMA says that lay-
money to cover payroll. Otherwise, the money must be repaid within offs carry costs, which can include an in-
two years. Loan payments are deferred six months. crease in an organization’s unemployment
The CARES Act also authorizes CMS to expand its Accelerated and insurance tax rate. “More often than not, it’s
Advance Payment Program, normally designated for natural disasters. better to keep people furloughed [than to lay
Qualified physician practices can apply to their Medicare Administrative them off],” she says. “It’s probably better in
Contractors (MACs) for an advance payment of up to three months’ the long run, if you have good staff, to fur-
worth of their historical Medicare reimbursement. The payments will be lough the staff.
issued within seven days of the provider’s request, according to CMS. “At the same time, I’m seeing practices
For 120 days after the payments are issued, practices can continue that are using this crisis as an opportunity
to bill Medicare and be reimbursed for their services. At the end of that to separate staff that are less than optimal.”
period, CMS will begin to recoup the advance payments by subtracting Planning how to deal with staff and oth-
them from new Medicare claims until they are repaid. er overhead costs depends on how long the
Some observers are skeptical these actions will be sufficient. crisis lasts and how severe it is in a practice’s
“This is a half-measure, in my opinion,” says Yul Ejnes, MD, an geographic region, Fischer-Wright says.
internist with Coastal Medical in Cranston, Rhode Island. “All this does is MGMA forecasts that the crisis will contin-
defer the financial hit that will result from COVID-19, which will occur at ue for at least another three to four months
the time of recoupment instead of right now.” and possibly longer.
Fischer-Wright agrees. “If you’re trying to make your practice work to- “Practices should be reasonable about
day, if you’re under the gun, the CMS program allows advance payments expectations for their volume and how long
that you can receive in seven days. That’s the tourniquet on the arterial this downturn is going to last,” she says. “If
bleed,” she says, adding that MGMA, the American Medical Association you’re a primary care practice, this is prob-
and the American Hospital Association are lobbying Congress to remove ably a six- to eight-week period in which
the repayment feature of these loans. you can count on volumes being down
Meanwhile, CMS recently made another rule change that should sig- 50% to 60%. Then you can figure another
nificantly help practices that now depend on telehealth revenues. When four to six weeks while that volume builds
CMS allowed Medicare to cover telehealth visits from any location in any up, when your volume is down 20% to 30%.
area of the country during the COVID-19 emergency, it restricted full re- Then you’re going to have to expect your vol-
imbursement to audio-visual visits and kept phone encounters limited to ume to be only 80% to 90% of what it was for
$15 per visit. In late March, however, CMS said it would start paying for the rest of the year. It’s not going to be 100%
telephone (E/M services (CPT codes 99441-99443) as a telehealth ser- because there will be high-risk populations
vice. According to Ejnes, the payments have been set at a level between who shouldn’t be in the office environment
office-based E/M codes and the old telephone rate. until we have an effective vaccine and treat-
ment available.”
6 MEDICAL ECONOMICS ❚ May 2020 MedicalEconomics. com

Practice Management
PRACTICAL MATTERS
Strategic planning: Build a lasting

practice. The focus and
the results will speak from
themselves.
competitive advantage
Before the COVID-19
outbreak, we conducted
many strategy discussions
with physicians onsite.
Recently, we have
Creating a strategic plan and thinking strategically are people to share what’s shifted to doing these
not about doing more. They are about focusing how you going on with them discussions virtually. They
spend your time so that you are more effective in reach- and what they want to key is to have an outsider
ing your goals and getting to where you want to go. see as the future of the facilitate the meetings to
That said, no physician practice has an unlimited organization. It will open avoid confirmation bias.
amount of time, money or resources. Strategic lines of communication Furthermore, the facilitator
planning can help you make the most of the resources and improve teamwork. will be able to ensure your
you have, allowing you to have more enjoyment in meetings stay focused,
your work while you are doing it. 7 Empowerment allow everyone time to
Here are eight reasons for getting your team You’ll empower others share their thoughts, and
together for a strategic planning session. to take on tasks that will ultimately leave you with a
move the practice forward. clear plan on how to
As a physician owner, that move forward.
means less firefighting and Medical practices
1 Vision 4 Identify Challenges more focusing on what which consistently apply
You will create a clear You’ll create an opportunity you do best: patient care, a disciplined approach
vision for what success to talk about key issues leading and executing. to strategic planning are
looks like in the future. facing the business better prepared to evolve
If you don’t know where (competition, changing 8 Values and Culture as the local market chang-
you’re going, how are you trends, etc.). You want to ride You’ll create the culture, es and as the healthcare
going to get there? the waves, not get smashed values, and behaviors that industry undergoes
by them. Being reactive you want to foster within reform. The benefit of the
2 Priorities throws off your plans and your practice. When your discipline that develops
You’ll identify priorities takes your eye off your goals. values are clearly articulated, from the process of stra-
for the short and medium your team will understand tegic planning also leads
term. You can’t do 5 Direction what you expect from to improved communica-
everything at the same You’ll create a clear road them on a day-to-day basis. tion. It facilitates effective
time, so focus on what map for the rest of the Culture and values are the decision-making, better
needs to be done now and organization. Your staff glue that keeps a strategic selection of tactical
then do it well. wants to know where plan together. options, and leads to
the practice is going and Strategic planning a higher probability of
3 Alignment how they can contribute. doesn’t need to take a achieving the physician
You’ll get alignment and An engaged staff is 20% lot of time away from the owners’ goals.
buy-in on direction and more productive than one
strategy. Having these that is neutral (or, worse,
conversations will move disengaged). Your staff
your team from implicitly wants to win and this is
being on the same page how you can help them. Nick Hernandez, MBA, FACHE, is the CEO and founder of ABISA, a
to explicitly being on the consultancy specializing in strategic health care initiatives for physician
same page. The clarity will 6 Open Communication practices. Send your practice management questions to
energize the whole team. You’ll create space for medec@mjhlifesciences.com.

ME0520_007_PracticalMatters.indd 7 4/29/20 3:20 PM
FOR CLINICAL INFORMATION VISIT
Chronic Conditions
Mastering care coordination

It takes a team to care for patients with chronic disease,
but who should take the lead?
by RACHAE L Z I M LICH, B.S.N., R N Contributing author
P
atients with complex conditions such a time limitation. They really can’t spend
require a multidisciplinary effort that extra time with the patient,” she says.
to optimize care and control costs. Rath, who helped develop a weeklong,
Care coordination is the goal, but face-to-face training program on care co-
getting there can be a challenge. ordination for physicians, pharmacists and
What role should primary care phy- other frontline caregivers, says physicians
sicians play in this process, and how should focus on their strengths and let the
can they do it without neglecting care managers and other service provid-
their patients? Experts provide insights below. ers carry on care management work. This
includes following up with patients and
THE PRIMARY CARE PHYSICIAN: managing ongoing lifestyle issues. If physi-
LEADER OR BYSTANDER? cians have an understanding of what care
Care coordination takes a team that in- management is and an understanding of the
volves physicians, case managers and an- topics that it addresses, they will be more
cillary caregivers. Outlining the physician’s inclined to solidify and endorse the referral
role can be difficult, though, as the current system so it falls not just on themselves but
system does not provide physicians with the also on other caregivers, she says.
time or compensation to thoroughly man- A good referral system is a strong founda-
age the ongoing care of patients with com- tion, and it isn’t limited to medical special-
plex chronic diseases. ties. Physicians should make appropriate
Sarahjane Rath, M.P.H., CHES, a trainer referrals to specialists as well as case man-
and curriculum development specialist for agers and social or community service agen-
the health care policy and advocacy firm Pri- cies to help patients meet their goals. If they
mary Care Development Corporation, says instead take on that care themselves, they
while primary care physicians are important take time away from providing medical care,
to the care coordination process, they should and that’s where they are really needed.
not be the process’s point person. “Their role Many physicians say they simply don’t
is never going to be huge because they have have time to address care coordination,
ME0520_008_011_CC_Coordination.indd 8 4/29/20 3:18 PM

Mastering care coordination Chronic Conditions
Rath adds. “This is where face-to-face train- while it’s true that primary care physicians
ing on what care coordination is and who are pressed for time and reimbursement to
takes on what role in the process is ideal. support care coordination, it’s also a critical
Physicians and other caregivers can discuss part of their role.
the process openly and address issues and
(identify) problems in the cycle. A dialogue
is helpful among all the disciplines,” she says.
“They need to understand the process of “Good care coordination can’t be
case management and acknowledge that it
takes a team to address chronic disease. It’s the responsibility of a given doctor.
not just chronic disease management; it’s
the whole picture.” It’s the responsibility of a care team.
A physician is key to diagnosing and de-
veloping a treatment plan, Rath says. It’s all
That’s a concept that is not widely used
the rest that they really can’t, or shouldn’t,
take on. Making sure patients have access
in primary care practice.”
to their medications and glucometers, a
—KATIE COLEMAN, M.S.P.H., DIRECTOR, MACCOLL CENTER FOR HEALTH CARE INNOVATION
ride to appointments, and help with mak-
ing diet and lifestyle changes, improving
health literacy and addressing social deter-
minants of health — these are all time-con- Church, who has been working with the
suming yet very important elements of American Academy of Family Physicians and
chronic disease management. other stakeholders to improve reimburse-
“It really does take a village to look after ment for care coordination efforts at the
a patient, so in turn, it takes a team to look primary care level, disagrees that physicians
after a patient,” Rath says. should take on a secondary role in the care
Physicians have to keep in mind their coordination process. He acknowledges, how-
role in the care coordination cycle, however, ever, the challenges within the system that do
and problems in the cycle should become not allow them to do this easily. The current
the job of them team to resolve. A case man- coding and billing system in the United States
ager or advocate is best served as the point has provided incentive for fragmented care,
person for each patient and can see where he says, adding that many primary care physi-
things fall through and work with the team cians already wear the hat of care coordinator
to address issues. A primary care physician without being compensated for it.
who sees patients returning over and over “I would wholeheartedly agree that coor-
again for the same issues is a sign that the dinating referrals is something for the team
cycle is broken, Rath says. At that point, a to manage rather than the physician. It is
physician should make a referral to social also not uncommon for people to confuse
and case managers to identify the problem case management with care management,”
in the cycle. Church says. “Case management may be
While this may seem like passing the focused on one task, but care management
buck, Rath says, this is where the open dia- explicitly addresses a comprehensive plan of
logue and training come into play. care, something that family physicians are
“The physician needs to just do a referral uniquely qualified for, and in many cases,
here or there. The physician should know (they are) the only providers willing to em-
whom to refer to for the problem or barrier,” brace this responsibility.”
she says. “Having physicians in these face-to- Patients with intentional care coordina-
face training sessions is invaluable because it tion are less likely to end up in the emergen-
helps them to understand their role.” cy department or hospitalized, Church says,
and a good primary care team is essential
A MATTER OF OPINION OR FACT? to helping patients avoid the hospital and
The notion of giving up the role that is the pri- achieve more efficient care. Despite the
mary care physician’s namesake — as the pri- involvement of other caregivers, many pa-
mary clinician — can be difficult to resolve. tients, especially older patients and those in
Samuel “Le” Church, M.D., M.P.H., a rural areas, turn to the primary care physi-
family physician in Gainesville, Ga., says cian when they need something.

Chronic Conditions Mastering care coordination
“It can be beneficial for patients everywhere

to have primary care physicians right in
the middle of that. … the primary care physician knows what is
going on, and care can be less fragmented when the primary care
physician plays an overview role.”
— SAMUEL “LE” CHURCH, M.D., M.P.H., FAMILY PHYSICIAN, GAINESVILLE
“If the patient perceives there is some- sating for time spent, and providing physi-
thing going on with them outside the spe- cians with training on how to make a good,
cialist, they still call me,” Church says, add- comprehensive plan of care, will benefit the
ing that specialists play a crucial role, but process and the patients.
a central team leader often does not exist. “We’re not just your doctor at these vis-
Without someone patients trust to fill this its. We want to encounter you throughout
role, they often begin self-referrals, and this the year, and we want to be your doctor and
can lead to waste. team all the time,” Church says. “We don’t
“In a world of limited resources, how can want you to wait until you need something.
we use these resources for more bang for our Both the patient and the system win when
buck?” Church asks. our care is proactive and intentional.”
Two big pieces of this are addressing Better coding can help move this forward
care management codes and providing and allow physicians to devote the time they
physicians with the reimbursement they need to achieve better outcomes for their
need to devote time to care coordination. patients and the health system as a whole.
Church has been at the forefront of helping “It can be beneficial for patients every-
to improve coding for these activities. Cod- where to have primary care physicians right
ing for chronic care management (CCM) in the middle of that. It’s not the expectation
used to be limited to just 20 minutes, with that they are trying to be a substitute for the
complex care allowing for 60 or 90 minutes. specialist,” Church says. “But the primary
Additional codes now allow for add-ons care physician knows what is going on, and
patpitchaya/Stock.Adobe.com
for more time, Church says, and regulators care can be less fragmented when the pri-
have abandoned a previous requirement mary care physician plays an overview role.
that care plans had to change anytime the The more hands there are, the more there is
complex CCM codes were used. Compen- a need for coordination.”

Mastering care coordination Chronic Conditions
Being able to set a plan and monitor and to do it themselves. It is entirely dependent on
support its progress in every respect is cru- having a functioning team.”
cial for patients with chronic disease, and A good team can help a patient stick to
the primary care physician is uniquely posi- a plan developed by the primary care phy-
tioned to do that, Church says. sician to avoid unnecessary visits, hospital
“I think this is empowering for patients,” stays and complications. This team can also
Church says. “It taps into the unique skill set save that patient stress and the health care
of the primary care physician and improves system money by making sure the entire
efficiency and cost within the system with- care team is involved in the patient’s jour-
out decreasing care quality. It also hits the ney, avoiding duplicate assessments, labs
fourth aim of the Quadruple Aim. The whole and tests, Coleman says.
team is happier when we can be proactive in “The health care system is overly complex
our care and improve outcomes.” and hierarchal when people are sick,” Cole-
man says, adding that duplicated, unneces-
THE CASE FOR A PARADIGM SHIFT sary care is a big issue facing health care and
Katie Coleman, M.S.P.H., director of the one that stems from poor care coordination.
MacColl Center for Health Care Innovation “This is really behind a lot of the value-based
and director of the Learning Health System payment conversations that are happening.”
Program at Kaiser Permanente Washington Practices need to change the way they
in Seattle, has focused her research on best view care coordination and building teams,
practices for care coordination and says a Coleman further explains. New billing
lot of ambiguity exists in this area of health codes to reimburse for care coordination
care. What isn’t up for debate, she says, is help, but health care has a long way to go
that the role of the primary care team is cen- before good care coordination becomes a
tral in clinical care management. standard in practice.
“Repeatedly in the literature about the ben- Brian Austin, who co-founded Kaiser’s
efits of clinical care management, a healing MacColl Center in 1992 and is currently its as-
relationship with the primary care physician sociate director, shared several resources the
is shown to be more cost-effective and satis- center has developed to help the care coordi-
factory than other programs,” Coleman says. nation process. These include an implemen-
The difficulty is that care coordination tation guide and the Improving Primary Care
is a shared activity among the primary care website, which offers three modules address-
physicians, community services and other ing self-management, referral management
clinicians, and navigating reimbursement is and care management. These resources can
a challenge. While Coleman says the central help a team assess its strengths and weak-
role primary care physicians play in the care nesses and create an improvement plan.
coordination process is important, she also “We’ve got to put an emphasis on the
agrees with Rath to some extent that they primary care team, not just the doctor,”
need to be participants — but not necessar- Austin says.
ily leaders — in the process. To move forward in this, Coleman says,
“Good care coordination can’t be the re- primary care practices have to truly be on
sponsibility of a given doctor. It’s the respon- board with integrating care coordination
sibility of a care team,” Coleman says. “That’s and becoming a care team. For this to hap-
a concept that is not widely used in primary pen, payments have to be in their favor, and
care practice.” referral tracking systems need to be in place.
The biggest step involves the physician rec- “We need to organize teams to manage
ognizing the need for care coordination and patients at every level. It’s really thinking of
placing trust in the process, Coleman says. the whole team as owning the care of their
“The key is really about primary care practi- panel of patients,” Coleman says, adding
tioners deciding they want to improve care that this means that different clinical teams
coordination, accepting that accountability have systems set up to communicate about
and moving forward from there,” she explains, patients and share assessment data.
adding that physicians would need more than “It requires a combination of payment
24 hours a day to provide evidence-based care reform and practice changes, but this is a
for a traditional panel of patients. “This is an critical issue, and I think we can get there,”
impossible task if you’re asking the provider Coleman concludes.

Special Report
THE 91ST
PHYSICIAN
REPORT by M E D ICAL ECONOM ICS ® STAFF
WHAT’S INSIDE
13 HOW MEDICAL PRACTICES
ARE FARING IN 2020
16 SALARY DATA
18 PRODUCTIVITY DATA
19 MALPRACTICE RATE DATA
21 PRIOR AUTHORIZATION DATA

peterschreiber.media/Stock.Adobe.com
23 WHO TOOK THE SURVEY
ME0520_012-023_SpecialReport.indd 12 4/30/20 9:02 AM

91st Annual Physician Report Special Report
How medical practices

are faring in 2020
by KE ITH A. R EYNOLD S Associate Editor
A
majority of physicians have the typical physician respondent was to supplement the Affordable Care Act.
seen their practice’s finan- $273,000. For those with an ownership The state of the medical profession
cial state improve or stay stake in the practice, that number seems strong, with 55% of respon-
the same in 2019, according jumped to $289,000, while those dents saying that if they could go back
to the results of the 91st without an ownership stake averaged in time, they would choose the same
Annual Medical Economics® about $258,000. medical specialty and 25% saying they
Physician Report. Within these figures, the gender pay would go into a different specialty.
In all, 23% of respon- gap is still prevalent, with male physi- Only 15% say they would choose a dif-
dents say their practice did better cians making an average of $300,000 ferent profession altogether. Addition-
financially in 2019 compared with a and female physicians earning an ally, 42% of responding physicians say
year prior. A further 55% say their prac- average of $226,000. Although these they would recommend the medical
tice is doing about the same as the year sums are about $6,000 lower than in field to their children or a friend’s
before. These figures saw a modest rise 2018, the disparity remains the same child, while 32% say they would advise
from 2018. Only 22% of respondents say at $74,000. against that career choice.
their practice is doing worse than the Incomes also vary depending on
prior year. The respondents chalk their specialty. The top specialty is cardiolo- MALPRACTICE RATES
improved performance to seeing more gy, with an average income of $381,000, For malpractice insurance, the 2019
patients (52%), pay-for-performance followed by urology, with an average average cost was $17,900, while 31% of
incentives (29%) and changes in their income of $358,000. Internal medi- respondents say they don’t know what
practice models (26%). cine physicians bring in an average of their premiums are. Regarding chang-
Those who say their practices are $243,000, and family medicine practi- es, 59% say their premiums stayed
worse off than a year ago cite as rea- tioners earn $241,000 on average. the same from 2018 to 2019. A further
sons more time spent on uncompen- Physicians’ pay also seems to be tied 23% say it increased, while only 5%
sated tasks (67%), lower reimburse- to geographic region. Physicians in the saw a decrease in premiums. Thirteen
ments from commercial payers (66%) Midwest are the only ones who saw an percent of respondents say they don’t
and higher overhead (60%). increase in income ($2,000) between know whether there was a difference
Compared with five years ago, 34% 2018 and 2019, while the Northeastern, in premiums between the two years.
of respondents say they are doing Southern and Western parts of the The median annual malprac-
better financially, and 38% say they are country saw decreases in income. tice premium for respondents who
doing about the same. Of the respondents, 63% say they see describe themselves as practicing
This year’s survey garnered 1,055 a minimum of 51 patients in their office family medicine is $8,100; for internal
responses across 17 specialties. A ma- in a typical workweek, while 18% see a medicine, $8,500; and for cardiology,
jority of respondents (29%) practice minimum of 26 patients in the hospital. $18,000. Male physicians saw a higher
family medicine, with internal medi- median annual malpractice premium,
cine (20%) coming in a close second. CHALLENGES at $10,300, than female physicians,
The survey was conducted by The biggest challenges facing primary who saw a median premium of $9,300.
HRA®(Healthcare Research & Analytics) care practices are the continued burden To help boost their business, a vast
via email in February 2020, before the of paperwork and quality metrics (74%), majority (82%) of physician respondents
COVID-19 pandemic began to affect the third-party interference (62%) and inad- say their practice offers a minimum of
financial state of practices. Below are equate reimbursements (61%). one ancillary service. The top ancillary
other highlights from this year’s report. Respondents also cite as a challenge services provided by physician practices
the average medical school debt of are electrocardiogram (52%), lab ser-
SALARY $161,000, and 35% cite the need for the vices (48%), spirometry (28%), radiology
The estimated 2019 total income for United States to adopt a public option Continued on page 14

Special Report 91st Annual Physician Report
The 2020
Physician Report
STATE OF PRACTICE
Financial state of my medical practice, one year ago:
60%
About the same
Worse than a
year ago 30%
Better than a
year ago
0%
2016 2017 2018 2019
Continued from page 13 STAFFING

or imaging services (25%) and nutritional
or weight loss counseling (24%).
The average physician respondent
says they employee 4.4 medical ABOUT THE SURVEY
About half of the respondents esti- assistants, 3.4 front desk workers, The 91st Annual Physician
mate that between 1% and 10% of their 2.9 registered nurses, 2.7 nurse
Report was conducted by
2019 revenue was generated by these practitioners or physician aides, 2.5
HRA® (Healthcare Research
ancillary services. billers or coders, 2.5 schedulers, 2.3
office managers or administrators of & Analytics), a full-service
PRIOR AUTHORIZATIONS social services or care coordinators, health care market research
For prior authorizations, a perennial an- 1.6 information technology (IT) staff agency and a brand of MJH
noyance, physicians spend an average of members and one pharmacist. Life Sciences™. Data were
11 hours a week, while office staff spend The majority of respondent prac- collected from physicians
14 hours a week on average on them. tices (63%) currently have no IT staff, who responded to email
Thirty-five percent of respondents cite but that is likely to change in the near invitations to take the survey
this time spent as the biggest frustration future as practices and the Centers during February 2020.
with prior authorizations. Coming in a for Medicare & Medicaid Services are
close second (34%) is the feeling that forced to move toward telehealth solu-
insurers were telling physicians how to do tions because of the ongoing COVID-19
their jobs. pandemic.

Financial state of my medical practice, five years ago:
38%
34% 35% 34%
31% 29%
Better than 5
years ago
About the same
Worse than 5
years ago
2018 2019
Why my finances improved or worsened in 2019:

Top reasons finances improved Top reasons finances worsened
1. More patients seen 1. More time spent on uncompensated tasks
2. Pay-for-performance incentives 2. Lower reimbursement from commercial payers
3. Change in practice model 3. Higher overhead
4. Renegotiation of payer contracts 4. Difficulty collecting from patients
5. Addition of ancillary services 5. Greater technology costs
The top nine issues faced by primary care physicians in 2019:

*Arrow indicates change from previous year.
1 Burden of paperwork/
quality metrics 4 Lower reimbursement for
primary care compared
with specialty care
7 Malpractice/need
for tort reform
2 Third-party inter-
ference (e.g., prior 5 EHRs not working as
well as they need to 8 Growth and compe-
tition of convenient
care/retail clinics
authorizations)
3 Inadequate
reimbursement 6 Recruitment of
young physicians 9 Patients getting
health informa-
tion online

SALARY
AVERAGE INCOME BY PRIMARY CARE SPECIALTY
2016 2017 2018 2019 Difference
(2018 vs. 2019)
Internal medicine $212,000 $230,000 $262,000 $243,000 -$19,000
Family medicine $187,000 $205,000 $242,000 $241,000 -$1,000
Pediatrics $187,000 $205,000 $233,000 $231,000 -$2,000
Cardiology $412,000 $415,000 $405,000 $381,000 -$24,000
OB-GYN $237,000 $271,000 $288,000 $298,000 +$10,000
Average pretax income comparison for both employed physicians and practice owners
AVERAGE INCOME BY GENDER

2013 2014 2016 2017 2018 2019
Male $257,000 $266,000 $270,000 $268,000 $306,000 $300,000
Female $190,000 $191,000 $204,000 $207,000 $232,000 $226,000
Difference $67,000 $75,000 $66,000 $61,000 $74,000 $74,000
$273,000 $74,000
2019 physician average pretax income Difference in pretax income between
male and female physicians in 2019
AVERAGE INCOME BY COMMUNITY

2013 2014 2016 2017 2018 2019
Urban $247,000 $236,000 $254,000 $253,000 $283,000 $260,000
Suburban $235,000 $248,000 $257,000 $249,000 $285,000 $280,000
Rural $223,000 $232,000 $230,000 $230,000 $274,000 $281,000

AVERAGE INCOME BY REGION

2013 2014 2016 2017 2018 2019
Northeast $229,000 $228,000 $262,000 $245,000 $280,000 $263,000
Midwest $237,000 $238,000 $239,000 $249,000 $278,000 $280,000
South $233,000 $252,000 $256,000 $245,000 $285,000 $280,000
West $241,000 $237,000 $237,000 $252,000 $284,000 $269,000
Average income by practice ownership:
Owner
Non-owner
$31,000
$252,000
$241,000
$315,000
$248,000
$289,000
$258,000
The gap in income between practice
owner and non-owner physicians.
2017 2018 2019
AVERAGE INCOME BY AVERAGE INCOME BY

PRACTICE TYPE/EMPLOYER PRACTICE SIZE
2018 2019 2018 2019
Private practice $301,000 $282,000 Solo practice $280,000 $253,000
Hospital-owned practice $288,000 $290,000 Two physicians $261,000 $280,000
Inpatient hospital $278,000 $276,000 Three to 10 physicians $307,500 $282,000
Nonprofit $228,000 $248,000 11 to 50 physicians $283,000 $277,000
Government $206,000 $214,000 More than 50 physicians $283,000 $286,000

PRODUCTIVITY
Average number of patient office visits per week:
Family
89 85 90 87 85 83 85 82
Internal
76 74 76 74
74
Average number of
patient office visits
for all physicians 2013 2014 2016 2017 2018 2019
Average number of patient office visits per week, per practice ownership:
Private
89 91 90
Hospital-owned
practice
80 75 78 77 76
60 66 65
Nonprofit
52
Hospital
2017 2018 2019
Where physicians saw patients in 2019 (average number of patients per week):
74% Office
35%
25%
23%
Hospital
Senior residences/nursing homes
Telehealth
23
Average number of patients
per week physicians saw
using telehealth
17% Patient homes

Average number of hours worked per week:
Family
Internal
51 53 52 54 52 54 52 53
50
51 52 48 51
Average number
of hours for all
physicians 2013 2014 2016 2017 2018 2019
MALPRACTICE RATES
Change in malpractice premiums Change in malpractice premiums
for 2019 compared with 2018: compared with five years ago:
23% Increased 42% Increased
59% Stayed the same 34% Stayed the same
5% Decreased 11% Decreased
13% Don’t know 13% Don’t know
Median annual malpractice premiums Median annual premiums

for primary care physicians, 2019: by gender, 2019:
Family
medicine Women Men
Cardiology $8,100 $9,300 $10,300
$18,000
Internal
medicine
$8,500

Median annual premiums by Median annual malpractice premiums

geographic region, 2019: by practice ownership, 2019:
$11,900 Northeast $12,600 Hospital inpatient
$11,700 Hospital-owned practice

$10,750 South
$9,800 Private practice
$9,000 Midwest
$6,000 Nonprofit
$8,000 West
$3,700 Government
Median annual 11-20 years 21-30 years

premiums by years 31- 40 years
<10 years
in practice, 2019: >40 years
$11,000
$10,700
$8,200
$9,700
ANCILLARY SERVICES $6,900

Most popular ancillary services in internal Percentage of revenue for
medicine/family medicine, 2019: primary care from ancillary
services (average), 2019:
1 E lectrocardiogram: 52% 6 Hmonitoring:
olter
16%
23% Cardiology
2 Lab services: 48% 7 Icontraceptives:

mplantable
15%
13% OB-GYN
3 Spirometry: 28% 8 Pain management: 14% 12% Internal medicine
4 Rimaging
adiology/
services: 25% 9 Stress tests: 13% 12% Family medicine
5 Nweight
utritional counseling/
loss: 24% 10 Amedicine:
ddiction
12% 11% Pediatrics

SECONDARY INCOME
27%
Did you earn income from an employment source
outside your practice?
2014 2016 2017 2018 2019
Yes 30% 33% 30% 32% 30% Physicians who earned
secondary income in
No 69% 66% 69% 68% 70% 2019 did so by providing
consulting services.
No answer 1% 1% 1% 0% 0%
Top 10 sources of secondary income, 2019: Amount of secondary income

(average), 2019:
1 Consulting: 27% 6 Clinical trials/
research: 8%
$42,000 Internal medicine
2 Teaching: 14% 7 Hospice: 7% $41,300 OB-GYN
3 Clinic work:13% 8 Lassignments:

ocum tenens
7% $40,400 Family medicine
4 Nwork:
onmedical
13% 9 Nursing home: 7% $37,600 Cardiology
5 Madministrator:
edical
12% 10 Telemedicine: 3% $36,000 Pediatrics
PRIOR AUTHORIZATIONS
11
Time spent weekly on prior authorizations, 2019:
Average number
62% of hours per week
Physician Practice for physicians
staff
14
31% 32%
23%
15% 10% 11% 12% Average number
of hours per
2% 2% week for staff
>20 16-20 11-15 <10 0

Biggest frustration with prior authorizations?
35% Time spent on authorizations
34% Feeling as though a payer is telling me how to do my job/what’s best for my patients
10% Reasons for denial
7% Lack of clarity on what requires a prior authorization
6% No frustration with prior authorizations
5% Managing the number of outstanding requests
2% Other
MEDICAL LIFESTYLE
If you could go back in time and Would you recommend that your
choose your career again, you child or a friend’s child pursue a
would choose? career in medicine?
55% The same specialty 42% Yes
25% A different specialty 32% No
15% A different career altogether 25% Not sure
5% Prefer not to answer 1% Prefer not to answer

WHO TOOK THE SURVEY

Physician’s age: Physician’s gender: Do you have an ownership
interest in your practice?
< 35
1%
YES NO
35-44 64% 49% 51%
36%
11%
45-54
Practice region: Practice region:
30% 35% Midwest
47% Suburban
55-64
24% Northeast
35% 34% Urban
>65
22% South
23% 19% West 19% Rural
Practice specialty:
Internal medicine
Other specialties
Family medicine
Dermatology
Urgent care
Hospitalist
Cardiology
Pediatrics
specialty
OB-GYN
Surgical
Urology
29% 20% 10% 9% 6% 3% 2% 2% 1% 1% 17%

Practice type: Practice size:
54% Private practice 30% Solo practice
19% Hospital-owned practice 36% 2-10 physicians
10% Hospital 13% 11-25 physicians
7% Other 21% More than 26 physicians

Money
Health care reform: How it
would affect physicians
What doctors need to know about transforming the health care
insurance system — and what it would mean to their practices
by TOD D S H RYOCK Managing Editor
S
ingle payer. Medicare for all. Public burnout? Experts say dissecting the specif-
option. These terms are bandied ics can be challenging because the defini-
about by presidential candidates tion of each concept varies depending on
and health care experts, but what who’s talking, even if they use the same ter-
do they really mean? minology. But if enacted, the broad changes
At face value, they sound good would be significant, including some that
for patients, who would no longer may surprise many physicians.
have to worry about paying for the
care they need. Increased use of primary REIMBURSEMENT CHANGES
care services could help lower overall health One of the advantages of a single-payer sys-
care costs as chronic patients get regular tem for physicians in private practice would
checkups and patients no longer delay care be simplified billing.
due to cost concerns. “Each payer often uses its own standards
For these and other reasons, the Ameri- for submitting a claim, and all have differ-
can College of Physicians (ACP) released its ent payment policies,” says Anders Gilberg,
own guidance endorsing many of the con- MGA, senior vice president of government
cepts of a single-payer system — one where affairs for the Medical Group Management
private health insurance would be replaced Association. This billing complexity often
by the government — or a system where requires the use of a clearinghouse to adju-
people could opt in to Medicare, effectively dicate all the various policies, something
making it a competitor for private insurance, that would not be needed if there were only
which would then be heavily regulated. one payer with one set of rules to follow.
Much has been discussed about the “The administrative burden would be
benefits for patients, but what would a sin- lower compared to having all these dif-
gle-payer system mean for doctors? How ferent systems, but how that plays out
would it affect their reimbursements, their depends on what the final plan would
administrative burden and their level of look like,” says Jodi Liu, Ph.D., a health care
ME0520_024-026_Money_Reform.indd 24 4/29/20 3:17 PM

Health care reform Money
policy researcher for the Rand Corp. “All would be covered by the single-payer sys-
payments would be processed through one tem. This brings up questions about access
fee schedule. There is quite a lot of admin- to care and timeliness.”
istrative staff needed to deal with billing A single-payer system with govern-
and processing, who may no longer be ment-controlled reimbursement rates
needed. For practices seeing patients with may also affect how doctors are trained
private insurance now, they are likely to see and how that training is financed. “If you
decreased payments, so some of this may go to medical school today, you’re likely to
be offset by savings in administration.” come out with excess of $200,000 in debt,”
The possibility of lower reimbursements says Gilberg. “If we went to a single-payer
through either reduced government pay- system and reduced the salaries of phy-
ments or the loss of typically higher-paying sicians, we would also have to reform
commercial insurers is something physi- the entire way physicians are trained in
cians need to consider, says Gary Price, M.D., this country and subsidize that. If they’re
president of The Physicians Foundation. trained in the system, are they required to
“I suspect that because of the program’s stay in the system?”
huge costs, doctors will be under more pres- Price says the effect of a single-payer
sure to see more patients in less time,” Price system on specialty choice by medical stu-
says, adding that he doubts any administra- dents is also unknown, and those special-
tive cost savings will be enough to make up ties requiring a longer commitment will
for falling reimbursements. need to collect increased reimbursement
Robert McLean, M.D., FACP, president of somehow. But McLean says the reim-
the American College of Physicians (ACP), bursement for primary care also needs to
says that switching to a single-payer sys- increase because there is already a short-
tem would also require rethinking the cur- age of primary care physicians — and more
rent Medicare rates to make it work. “Peo- will be needed to help people stay out of the
ple should not be afraid that we are going hospital and to provide more cost-effec-
to switch over and that everyone just gets tive care. “Does that necessarily mean that
stuck with the current Medicare rates — and the specialist needs to get paid less? The
told to suck it up,” says McClean. Physicians answer is no,” says McLean.
should have input on reexamining rates, and
with the reduction of administration across
the entire system — plus the elimination
of insurance company expenses — there
should be more money to pay physicians. How do you think the U.S. should
reform its health insurance system?
“Patients are paying more, but the insur-
ance companies are making a lot of money
off the backs of patients, who have higher
copays and deductibles,” says McLean. “Any
system needs to be fair and reasonable and
avoid all the cost shifting.”
36% Need a public option to supplement the Affordable Care Act
In the current system, doctors in pri-

vate practice can opt out of Medicare and, 20% Should repeal the Affordable Care Act
depending on their financial situation, also
choose not to do business with any com-
mercial payers that are overly burdensome.
19% Should keep the private insurance system but increase regulation
“What remains to be seen is whether doc-

tors would have the opportunity to opt out 18% Need a single-payer health system (i.e., Medicare for All)
of a single-payer system and would they
have any free-market negotiating power,”
says Gilberg. “There is speculation that if 5% Need a national health system where doctors work for the government
physicians were allowed to opt out, you
would create a dual system where the peo-
ple with money would have better access
4% System is fine as it is
to specialists, subspecialists and certain

Source: Medical Economics® 2020 Physician Report
experts in various fields, while the others

Money Health care reform
With insurance companies taking 20% health,” says McLean. For example, a system
to 30% of every health care dollar, he says that addresses the source of bad air in pub-
there is plenty of money that can be allotted lic housing is a lot cheaper than paying for
to decrease costs for patients and appropri- repeated emergency department (ED) visits
ately pay doctors. by asthmatic patients, he says. This also ben-
“The burden is efits doctors.
PATIENT CARE & QUALITY
unnecessary How doctors care for patients may also FEASIBILITY
regulations change under a single-payer system, experts
say. “Would they still be able to determine
Moving the country from its current way of
paying for health care to a single-payer sys-
and silly quality what care they can provide the same way
they do now?” asks Liu. “The two proposals
tem would be complicated and could cre-
ate some additional risks to patients. “You
measures at in Congress now provide comprehensive

care for the services that you would expect,
would have to be really careful because mov-
ing people slowly to a single-payer system
the patient-care but there would need to be some way to
figure out what care patients could receive.
would remove some of the financial viability
of the insurance market,” says Gilberg. Some
level, and it As new therapies and treatments come out,
how would they be covered? ... There are a
companies might go out of business or dras-
tically narrow their networks, he adds.
adds to burnout. lot of cost implications to the system.”
Also unknown is what would happen to
Liu says that any transition is likely to
take up to two years, and politicians would
prior authorizations. A single-payer system have to carefully craft plans to cover any
This is a huge would result in one set of patient treatment
guidelines, which might reduce doctors
gaps for patients who lose their commer-
cial insurance because of disruptions to the
problem area administrative burden, but authorizations
from Medicare may still be required for
insurance market.
The changes that came about from the
already, and some nonstandard treatments or drugs. Affordable Care Act (ACA) offer some insight
Gilberg says that for any system to be into the types of challenges the government
I think single- effective, more money would have to be may face in any switch, ranging from buggy
payer would invested in preventive care, but the system

would also likely include quality metrics
websites to a skeptical public. “I would hope
the government planners would be wise
make it worse.” to measure doctor effectiveness, whether

through something similar to the current
enough to implement it in a way that those
things wouldn’t happen, but I would be
Merit-Based Incentive Payment System shocked if there weren’t a lot of headaches,”
—GARY PRICE, MD, PRESIDENT, (MIPS) program or something new. says Price. “Personally, I think the speed it’s
THE PHYSICIANS FOUNDATION “Most physicians’ gut feelings are that implemented will be determined by the leg-
quality measures would get exponentially islators’ willingness to finance it. The financ-
worse in a single-payer system,” says Price. ing piece is really the limiting factor.”
“The burden is unnecessary regulations With current split control of the U.S. Sen-
and silly quality measures at the patient- ate and House of Representatives, the like-
care level, and it adds to burnout. This is a lihood remains low that any major change
huge problem area already, and I think sin- will take place. And even if Democrats could
gle-payer would make it worse.” gain control of the Senate, any changes they
The ACP plan calls for a revamped system make could be undone by the next change of
of quality measures developed with more power, Gilberg says.
input from physicians. “Yes, quality metrics McLean says any change won’t be easy,
need to be there, but we need to [help] drive but the time is ripe.
that because they are tremendously tricky,” “I think people were enticed by the prom-
says McLean. ise of a better health care system with the
But the ACP also recommends a system ACA, and having that partially take place,
that would more comprehensively address then be subsequently stripped away has a
how social determinants affect a patient’s lot of people really angry and frustrated,”
overall health. “Whether it’s people getting he says. “I think the level of dissatisfaction
food or shelter or whatever it is, we need among the people of this country is higher
to recognize that these play a significant than people might realize. But that needs to
role in our population’s health, which has be reflected up to the legislators for things to
a significant role in our individual patient’s be done, and that’s a tough one.”

Money
BY DAVE FARR
Why the concierge model is resilient

during the COVID-19 pandemic
F or primary care physicians
– already saddled with stu-
dent debt obligations, vol-
membership revenues, between
$1,800 and $2,000 on average, that
provide cushion against a sudden
physicians report high satisfaction
as a result.
ume-based performance demands, cash crunch. Additionally, con- OPERATIONAL BENEFITS

declining reimbursements, increas- cierge patients are reluctant to Operationally, traditional pri-
ing administrative challenges, and leave their physician, which cre- mary care practices are not well
overall burnout – the spread of ates a more consistent patient base positioned to weather crises like
COVID-19 has been a pressure test. — Specialdocs’ average patient COVID-19. Recent surveys show
It has exposed weaknesses in the renewal rate is 96%. that 48% of independent physician
financial, clinical and operational practices have temporarily fur-
aspects of primary care, and left CLINICAL BENEFITS loughed staff, and 22% have perma-
thousands of doctors scrambling to The size of traditional primary care nently laid off staff. Even when the
save their practices. More than 70% patient panels has presented clini- current emergency abates, tradi-
of practices reported a decrease of cal difficulties in the current crisis. tional practice models designed to
50% or more in patient volumes; On average, an Internal Medicine treat 1,600 patients may not fit the
fewer than half feel they have suf- or Family Medicine physician cares new environment.
ficient patient volume or cash-on- for over 1,600 patients. With pan- Concierge practices are lean by
hand to remain open. els this large, doctors have limited design, typically consisting of one
Independent primary care pro- time to manage care, communica- physician who manages up to 600
viders, in particular, find them- tion and outreach. Adding in the patients with two or three staff
selves at a critical point: Do I join number of COVID-19 questions members. Amidst the COVID-19
a health system or large practice, and cases has proven overwhelm- crisis, no Specialdocs physician has
or can I sustain my business as an ing, making efforts to educate implemented staff reductions.
independent practice? patients on procedures for office or The impact of the COVID-19
For physicians committed to telehealth visits challenging. crisis is still unfolding. Systems
their independence, the good news In contrast, a concierge that worked previously can no
is that the same factors that made physician typically has between 250 longer be depended on. Concierge
concierge practices strong enough and 600 patients, making outreach, medicine is an important piece of
to survive dramatic health care communication and care much reshaping the primary care sys-
reform have enabled them to with- more manageable. During the tem by offering more flexibility
stand the current COVID-19 crisis. COVID-19 emergency, Specialdocs and stability, personalized care
concierge physicians promptly and greater satisfaction for physi-
FINANCIAL BENEFITS and effectively utilized digital cians and their patients.
Concierge practices are better communication and telehealth
equipped to weather the cur- to serve patients, especially the Dave Farr is vice president of business
rent environment with more elderly and those with chronic development at Specialdocs, a concierge
reliable cash flows from annual conditions, and both patients and practice transition and management

ME0520_027_Money_Column.indd 27 4/29/20 3:14 PM
Legal
Manage HIPAA risks
in your practice
What physicians need to do about HIPAA, telehealth
and managing billing staff working remotely
V
by AI N E CRYTS Contributing author
ideo chat tools such as FaceTime, with patients, including their clinical findings, med-
Skype and Zoom are now avail- ical decision-making and other necessary variables
able to physician practices that to support the Current Procedural Terminology code
want to treat patients on a reused by the billing department.
mote basis, according to March
17, 2020, guidance from the According to the OCR guidance, platforms
Department of Health and Hu- such as Facebook Live, TikTok and Twitch
man Service’s Office for Civil are examples of public-facing video commu-
Rights (OCR), which enforces the Health In- nications platforms, and providers shouldn’t
surance Portability and Accountability Act use them when providing care to patients.
(HIPAA).
Michele P. Madison, J.D., a health care BILLING FOR TELEHEALTH VISITS
attorney at Morris, Manning & Martin in Elizabeth P. Litten, J.D., a health care attorney
Atalnta, points out that OCR won’t enforce and chief privacy and HIPAA compliance offi-
penalties for physician practices that use cer at Fox Rothschild in Princeton, N.J., points
“non-public-facing video and audio technol- out that practices need to ensure they’ll be
ogy that’s not secure, and they won’t require reimbursed for the care provided using tele-
business associate agreements.” Still, she ad- health. This is determined on a state-by-state
vises that practices take the following steps: basis, she adds. Kelli Carpenter Fleming, J.D.,
❚ Validate that the physician or other clinician is an attorney at Burr & Forman in Birmingham,
licensed to provide care by telemedicine in the state Ala., advises practices to check with health
where they’re providing the service. insurers to make sure they’ll be paid for the
❚ Secure verbal or written confirmation that patients patient visit.
understand that the platform used to receive tele- The Centers for Medicare & Medicaid
health-based care isn’t secure. Services (CMS) has said that Medicare will
❚ Communicate to physicians and clinicians that they reimburse health care providers for treat-
must fully and completely document the interaction ing patients using telehealth for COVID-19
ME0520_028-029_Legal_HIPPA.indd 28 4/29/20 3:12 PM

HIPAA risks Legal
and other medically reasonable purposes ly mean that only essential personnel should
from offices, hospitals and residences such show up physically at their workplaces. In ad-
as homes, nursing homes and assisted liv- dition, OCR issued guidance on April 2 that it
ing facilities. The federal agency noted that won’t impose penalties for violations of some
Medicare Advantage plans may offer addi- provisions of the HIPAA Privacy Rule against
tional telehealth services beyond what was health care providers and their business asso-
included in its approved 2020 benefits. ciates “for good faith uses and disclosures of
States “have broad flexibility to cover protected health information … by business
telehealth through Medicaid, including the associates for public and health and health
methods of communication (such as tele- oversight activities during the COVID-19 na-
phone, video technology commonly avail- tionwide public health emergency.”
able on smartphones and other devices) In a statement, Roger Severino, director
to use,” according to April 2 guidance from of OCR, said, “Granting HIPAA business as-
CMS. In addition, states aren’t required to sociates greater freedom to cooperate and
seek federal approval “to reimburse provid- exchange information with public health
ers for telehealth services in the same man- and oversight agencies can help flatten the
ner or at the same rate that states pay for curve and potentially save lives.”
face-to-face services,” CMS notes. Some clinicians may be able to provide
Fleming highlights that OCR’s March 20 telehealth consults from their home offices,
guidance says that a telehealth-based visit whereas administrative employees who ar-
doesn’t have to be for a COVID-19-related en’t patient facing can work remotely, with
condition. That means, for example, that a the right guidance. Alissa Smith, J.D., an at-
physician can use telehealth to consult with torney at Dorsey & Whitney in Des Moines,
a patient about an earache, she says. Iowa, points out that employees providing
administrative and billing support can work
DISCLOSING PHI from home. Her advice for physician prac-
OCR’s March 24 guidance provided insight into tices with billing employees working from
ways that health care providers can disclose home includes the following:
protected health information (PHI) about a
person who has been infected by or exposed to ❚❚ Keep billing files and other patient records away
the COVID-19 virus. Health care organizations from others in the household.
can disclose PHI, including the name and oth- ❚❚ Use safeguards, such as firewalls, encryption and
er identifying information about the person, a private network, to prevent patient information
under the following four circumstances: from being hacked.
❚❚ When needed to provide treatment Fleming recommends that practices require

❚❚ When required by law remote billing staff to log in to the practice’s
❚❚ When first responders may be at risk for an infection systems using two-factor authentication.
❚❚ When disclosure is necessary to prevent or lessen a That requires a code to be sent to the billing
serious and imminent threat employee’s cellphone for an additional level
of security.
Fleming points out that this allows a call Practices should discourage employees
center employee or an emergency medical from saving any files onto the hard drives
technician to communicate to a physician on their computers at home, says Fleming.
or other clinician that the patient has been In addition, the employee’s computer should
around someone with COVID-19 or has be set up to require an additional login if the
tested positive for the disease. It also allows computer isn’t in use for three minutes or
health care providers to adequately respond even less. Employees should also limit print-
and protect themselves, she explains. But ing of any patient information, she adds.
she points out that this type of communica- Most payers allow providers up to a year
tion has always been permissible between to drop a claim, says Fleming. But waiting to
first responders and health care providers. send claims to health insurers will hurt the
practice’s cash flow.
MANAGING BILLING STAFF Physicians tell her that billing employees
To date, 42 state governors have issued stay- “are essential — they help me keep my doors
at-home orders or advisories, which general- open,” she adds.

ME0520_028-029_Legal_HIPPA.indd 29 4/29/20 3:12 PM
Careers
COVID-19 raises ethical
dilemmas for many physicians
Physicians are confronting shortages of essential resources
to protect themselves and of equipment critical for patient
survival, forcing hard choices in life-or-death situations.
by TOD D S H RYOCK Managing Editor
A
s the COVID-19 pandemic Jeremy Lazarus: The most pressing di-
increases the numbers of critical- lemmas that have emerged to this point
ly ill patients flowing into hospi- are ... shortages of essential resources,
tals, doctors in many areas are especially personal protective equip-
facing an increased shortage of ment (PPE) for frontline clinicians and
vital equipment and supplies. the looming prospect of having to make
In some cases, this can pres- extremely difficult decisions about which
ent ethical dilemmas to physi- patients will, or won’t, have priority claim
cians who must choose between patients on our limited supply of ventilators. Physi-
and their own safety when providing care. cians are facing very difficult choices un-
Medical Economics® spoke with Jeremy der conditions of great uncertainty — we
A. Lazarus, MD, a member of the Council just don’t have good data yet.
on Ethical & Judicial Affairs at the Ameri- Most of us, in the U.S. certainly, have never
can Medical Association (AMA) and former been in situations where what is widely seen
AMA president, about the challenges phy- as optimal care simply may not be feasible.
sicians are confronting and how to handle We can’t practice the way [we’re] used to,
these difficult situations. and that’s very unsettling. But that’s exactly
what we have to do in a pandemic when the
Q: Medical Economics®: During

this pandemic, what kind of ethical
demand suddenly becomes so much greater
than our capacity.
dilemmas are physicians facing, and

what dilemmas do you expect them to
face as the crisis deepens?
Q: ME: How should physicians
approach these decisions?
ME0520_030-032_Careers_Ethics.indd 30 4/29/20 3:09 PM

Ethical dilemmas Careers
JL: Physicians shouldn’t be left to make
these decisions individually. They need
guidance — from their institutions, their
Q: ME: With a shortage of PPE, what
ethical dilemmas do physicians face when it
states or national bodies. Having the incomes to caring for a patient who may be infected
stitution make the call, in a systematic with the COVID-19 virus but lacking the proper
way, about who gets a ventilator and who equipment to safely treat the patient?
doesn’t is far preferable from an ethics
perspective than leaving that to the pa- JL: One of the commitments physicians
tient’s caregiver. Having a designated make [when] entering the profession is to
committee or institutional officer make accept greater-than-usual personal risk
the call based on objective guidelines in times of urgent need, such as [a pan-
helps ensure that decisions are fair and demic]. In the best of all possible worlds,
takes the burden off physicians and other of course we’d provide them with top-of-
clinicians who are providing care for the the-line personal protective equipment
individual patients affected. because we also need to protect the phy-
We know that many institutions and sician workforce to meet ongoing chronic
states have policies that they’re updating health needs. When there’s a shortage of
in light of what we know currently about PPE, physicians may have to be willing to
COVID-19; others are developing them. accept suboptimal, but safe, protection —
The AMA is gathering triage guidelines at least until supplies can be replenished.
from many sources with the goal of post-
ing examples.
“Balancing the professional commitment
Q: ME: How can physicians deal with
the mental stress of making life-or-death
to provide urgently needed care [during]
decisions caused by equipment shortages? a pandemic with responsibility to one’s
JL: Institutional protocols for making
the life-and-death decisions that we’re
family is tough.”
going to face is one of the most effec-
tive ways to help physicians cope with Decisions to allocate PPE are similar to
the uncertainty and the psychological those to allocate ventilators or other sup-
toll of the pandemic. But we’re also see- plies for patient care. And like other alloca-
ing virtual professional communities tion decisions, the institution should have
emerge with physicians sharing infor- a protocol for how to make them. [The]
mation, concerns, ideas — on Twitter personnel [who] have the most urgent
for example. Not just with clinicians in need for PPE because they are exposed
their local institution or community, but to the greatest risk caring for seriously ill
across state lines and even internation- COVID-19 patients have a strong claim to
ally. Having the support of colleagues available protection. There may be other
who are facing the same dilemmas can options for protecting physicians who
be enormously helpful. are personally at high risk because of an
This started out as ad hoc communica- underlying medical condition — if they
tion, but institutions and communities are can be assigned to provide care to non-
beginning to create virtual activities more COVID-19 patients, for example.
systematically. Things like virtual town The institution should also explore
halls can connect physicians to one another options for increasing the supply of PPE or
and bring the public into the conversation determining whether PPE can be adequately
in ways that support everyone. The state sterilized and safely reused until supplies of
medical society in Colorado, where I live, new equipment are available. Or find other
has been holding these virtual town halls creative ways to meet the need.
bringing in state public health experts to
update us on the situation in Colorado and
responding to questions from practicing
and retired physicians.
Q: ME: Many physicians have young
children or elderly parents at home. Is it ethical

Careers Ethical dilemmas
for them to not show up for shifts at a hospital protect the living, including family mem-
where COVID-19 is prevalent? How should bers. Making sure families understand why
physicians keep their families safe while still they can’t see their loved one doesn’t make it
meeting their ethical obligations as a doctor? easier, but does help them accept it.
We must meet our obligation to ensure
JL: I don’t think we know just how many that every patient receives appropriate pal-
physicians have family or household liative and supportive care at the end of life.
members who are at high risk, but we do
know they’re out there. Balancing the pro-
fessional commitment to provide urgent-
ly needed care [during] a pandemic with
Q: ME: If this crisis ends up being
worst-case scenario, do you think there are
responsibility to one’s family is tough. ethical dilemmas coming that no one has even
Physicians need to think carefully about thought about yet?
what a decision not to show up for work
will mean, what burdens it will place on JL: I don’t know that we’ll see new ethical
their patients and [on] colleagues who issues, but I do think the pandemic sharp-
will have to pick up the slack. Following ens our focus on questions we’ve been
strict infection-control measures at home debating ... a long time now without re-
should be a first choice. The risk to the solving them. For example, in the face of
physician would have to be very compel- pressing needs for access to medical care,
ling to justify a decision not to go to work. we’re being challenged to think very con-
cretely about how we organize care, [offer]
health care coverage and how [we] get
“The prospect of patients dying alone more people into care in a timelier way.
We can think about leveraging technolo-
because protecting the well-being of the gies like telemedicine to screen patients for
community means that family members [the] coronavirus or to provide routine pri-
mary care services.
won’t be allowed to see their loved ones is We can think about how we might tap the
wisdom and skills of retired physicians. Not
appalling. ... It can help to remember that in providing direct patient care in high-risk
settings, but in providing care in other areas
we do it to protect the living, including to free [up] physicians to care for COVID-19
patients. It would be terrific to have local or
family members.” regional clearinghouses where retired phy-
sicians in the community could sign up to
volunteer in different roles. Right now, we
But again, this isn’t a decision that an don’t really know who’s out there willing and
individual physician should make, or be able to help. And in parts of the country that
asked to make, on their own. Health care haven’t been hit hard yet, we still have time
institutions have a responsibility to provide to plan for how they might contribute to the
guidance for their staff. overall effort.
Q: ME: What are the ethics around not

allowing end-of-life visits by family members,
Q: ME: Are there ethical resources
doctors should know about?
leaving someone to die alone?
JL: The [AMA] is developing short-use
JL: The prospect of patients dying alone be- cases that apply guidance from the AMA
cause protecting the well-being of the com- Code of Medical Ethics to issues as they
munity means that family members won’t are emerging in the pandemic. [These] are
be allowed to see their loved ones is ap- posted to the AMA’s COVID-19 Resource
palling. No one wants that to happen. But Center as they become available. The full
that’s the reality of a pandemic, when pub- code is available online at https://www.
lic health needs have to take precedence. ama-assn.org/delivering-care/ethics/
It can help to remember that we do it to code-medical-ethics-overvie.

Technology
TECH TALK
8 ways to evaluate a telehealth vendor

by CH R I S MAZ ZOLI N I, M.S. Editorial Director
Many physicians are now looking to hire a telehealth ❚ What are their customization capabilities?
service company to expand access to care for patients ❚ Can patients access their data?
during the COVID-19 pandemic.
Even though practices want to start their telehealth Cybersecurity and privacy
program quickly, do not rush due diligence. To help Does the vendor have a secure system?
physicians evaluate potential vendors, the American ❚ Do they comply with HIPAA rules?
Medical Association (AMA) recently released Tele- ❚ Will they sign a business associate agreement with your practice?
health Implementation Playbook, a guide with key ❚ What is their liability structure for managing security breaches?
tips and updates on telemedicine expansion. In it, they ❚ Do they comply with local regulations, such as state medical
include criteria that physicians should consider when board rules?
selecting a vendor.
System usability
How well does their system work?
Basic business information ❚ How easy is their system for clinicians and patients to use?
What’s the company’s organizational overview? ❚ Does it provide engagement metrics?
❚ How long have they been around? ❚ How well does the dashboard and workflow systems work?
❚ What’s their funding source? Are they financially stable? ❚ How easy is the billing system?
❚ Who are they affiliated with?
❚ Do they have any notable customers? Vendor support services
How is their customer service?
Cost and prices ❚ How much initial training do they provide?
How will this company impact your program’s return ❚ How much support do they provide beyond initial training?
on investment? Patient education? Project management? Data analysis?
❚ How much does the product cost? ❚ What is their technical support process like?
❚ What’s their business model? ❚ Do you have access to existing templates and procedure examples?
❚ What are details on reimbursement rates, risk sharing and more?
❚ What’s the cost, process and timeline associated with Clinical validation
integration and any product updates? Is their system credible clinically?
❚ Do they have documentation that supports improving clinical
Is it a fit? outcomes?
How well do they know you? ❚ Is there any published peer-reviewed research of their system?
❚ Do they have expertise in offering telehealth to your specialty?
❚ Do they have knowledge of federal and private-payer requirements?
❚ Do they know the laws and regulations in your state?
Technology needs
Does their tech match your needs?
❚ Can they integrate with your information technology landscape,
particularly your electronic health record (EHR) platform?
❚ Can their system capture data important to both the care team
How physicians can Watch this video
and others at:
and the patient? get started now bit.ly/MedEcVideo

ME0520_033_TechTalk.indd 33 4/29/20 4:53 PM
FUNNY BONE
“I’m going to prescribe for you to stay away from

the news on TV and all social media!”
COMING How to find the right career

— and negotiate what you want from it
NEXT ISSUE Until recently, finding a satisfying medical position wasn’t a significant
problem for most physicians. Most were self-employed, and thus had the
freedom to shape their job as they wished. But the number of physician
practice owners has dwindled in recent years, and that means doctors
By Jon Carter, cartertoons.com
need to envision what would make them happy in a job — and learn how
to make it happen through careful negotiation.
ME0520_034_FunnyBone.indd 34 4/29/20 3:06 PM

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PRACTICE MANAGEMENT PRACTICES IN PERIL

How physicians are fighting

SMARTER BUSINESS. BETTER PATIENT CARE. MAY 2020 VOL. 97 NO. 9

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INFLAMMATION AND FIBROSIS

METABOLIC DRIVERS HEMODYNAMIC DRIVERS INFLAMMATORY AND

IT’S TIME TO EXPLORE AN UNADDRESSED DRIVER OF CKD IN T2D AT CKD-T2D.COM

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The state of physicians,

PUBLISHING & SALES

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MedicalEconomics. com MEDICAL ECONOMICS ❚ May 2020 1

George G. Ellis, Jr. M.D.

To read all of our ongoing coverage, go to

Joseph E. Scherger, M.D.

How physicians can

Watch this video

and others at:

2 MEDICAL ECONOMICS ❚ MAY 2020 MedicalEconomics. com

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MedicalEconomics. com MEDICAL ECONOMICS ❚ May 2020 3

Medical practices reel

4 MEDICAL ECONOMICS ❚ MAY 2020 MedicalEconomics. com

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MedicalEconomics. com MEDICAL ECONOMICS ❚ MAY 2020 5

drop, we know we’re going to have to change

Where can practices

6 MEDICAL ECONOMICS ❚ May 2020 MedicalEconomics. com

ME0520_004-006_PM_Peril.indd 6 4/29/20 3:21 PM

Strategic planning: Build a lasting

MedicalEconomics. com MEDICAL ECONOMICS ❚ MAY 2020 7

Mastering care coordination

8 MEDICAL ECONOMICS ❚ MAY 2020 MedicalEconomics. com

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MedicalEconomics. com MEDICAL ECONOMICS ❚ May 2020 9

“It can be beneficial for patients everywhere

10 MEDICAL ECONOMICS ❚ May 2020 MedicalEconomics. com

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MedicalEconomics. com MEDICAL ECONOMICS ❚ May 2020 11

19 MALPRACTICE RATE DATA

21 PRIOR AUTHORIZATION DATA

23 WHO TOOK THE SURVEY

12 MEDICAL ECONOMICS ❚ MAY 2020 MedicalEconomics. com

ME0520_012-023_SpecialReport.indd 12 4/30/20 9:02 AM

How medical practices

MedicalEconomics. com MEDICAL ECONOMICS ❚ May 2020 13

About the same

Continued from page 13 STAFFING

14 MEDICAL ECONOMICS ❚ MAY 2020 MedicalEconomics. com

ME0520_012-023_SpecialReport.indd 14 4/30/20 9:02 AM

About the same

Why my finances improved or worsened in 2019:

The top nine issues faced by primary care physicians in 2019:

MedicalEconomics. com MEDICAL ECONOMICS ❚ MAY 2020 15

Family medicine $187,000 $205,000 $242,000 $241,000 -$1,000

Pediatrics $187,000 $205,000 $233,000 $231,000 -$2,000

Cardiology $412,000 $415,000 $405,000 $381,000 -$24,000

OB-GYN $237,000 $271,000 $288,000 $298,000 +$10,000

AVERAGE INCOME BY GENDER

Female $190,000 $191,000 $204,000 $207,000 $232,000 $226,000

Difference $67,000 $75,000 $66,000 $61,000 $74,000 $74,000

AVERAGE INCOME BY COMMUNITY

Suburban $235,000 $248,000 $257,000 $249,000 $285,000 $280,000

2 Lab services: 48% 7 Icontraceptives:

3 Spirometry: 28% 8 Pain management: 14% 12% Internal medicine

2 Teaching: 14% 7 Hospice: 7% $41,300 OB-GYN

3 Clinic work:13% 8 Lassignments: