Business of Medicine

For this month’s column, I wanted to share some frustrations I have had about the current state of primary care. We all find those things that are going on in medicine that seem crazy and we just have to find a way to adapt to them. It is good to be able to share some of these thoughts with a community as distinguished as you readers. I know some of these are issues that you all struggle with and I wanted to give a voice to them. I wish I had answers to fix them.

Faxes from insurance companies

I find faxes from insurance companies immensely annoying. First, it takes time to go through lots of unwanted faxes but these faxes are extremely inaccurate. Today I received a fax telling me I might want to consider starting a statin in my 64-year-old HIV patient who has hypertension. He has been on a statin for 10 years.

Another fax warned me to not combine ACE inhibitors and angiotensin II receptor blockers (ARBs) in a patient who was switched from an ACE inhibitor in July to an ARB because of a cough. The fax that was sent to me has a documented end date for the ACE inhibitor before the start date of the ARB.

We only have so much time in the day and piles of faxes are not helpful.

Speaking of faxes: Why do physical therapy offices and nursing homes fax the same form every day? Physicians do not always work in clinic every single day and it increases the workload and burden when you have to sort through three copies of the same fax. I once worked in a world where these would be sent by mail, and mailed back a week later, which seemed to work just fine.
 

Misinformation

Our patients have many sources of health information. Much of the information they get comes from family, friends, social media posts, and Internet sites. The accuracy of the information is often questionable, and in some cases, they are victims of intentional misinformation.

It is frustrating and time consuming to counter the bogus, unsubstantiated information patients receive. It is especially difficult when patients have done their own research on proven therapies (such as statins) and do not want to use them because of the many websites they have looked at that make unscientific claims about the dangers of the proposed therapy. I share evidence-based websites with my patients for their research; my favorite is medlineplus.gov.
 

Access crisis

The availability of specialty care is extremely limited now. In my health care system, there is up to a 6-month wait for appointments in neurology, cardiology, and endocrinology. This puts the burden on the primary care professional to manage the patient’s health, even when the patient really needs specialty care. It also increases the calls we receive to interpret the echocardiograms, MRIs, or lab tests ordered by specialists who do not share the interpretation of the results with their patients.

What can be done to improve this situation? Automatic consults in the hospital should be limited. Every patient who has a transient ischemic attack with a negative workup does not need neurology follow-up. The same goes for patients who have chest pain but a negative cardiac workup in the hospital – they do not need follow-up by a cardiologist, nor do those who have stable, well-managed coronary disease. We have to find a way to keep our specialists seeing the patients whom they can help the most and available for consultation in a timely fashion.

Please share your pet peeves with me. I will try to give them voice in the future. Hang in there, you are the glue that keeps this flawed system together.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

For this month’s column, I wanted to share some frustrations I have had about the current state of primary care. We all find those things that are going on in medicine that seem crazy and we just have to find a way to adapt to them. It is good to be able to share some of these thoughts with a community as distinguished as you readers. I know some of these are issues that you all struggle with and I wanted to give a voice to them. I wish I had answers to fix them.

Faxes from insurance companies

I find faxes from insurance companies immensely annoying. First, it takes time to go through lots of unwanted faxes but these faxes are extremely inaccurate. Today I received a fax telling me I might want to consider starting a statin in my 64-year-old HIV patient who has hypertension. He has been on a statin for 10 years.

Another fax warned me to not combine ACE inhibitors and angiotensin II receptor blockers (ARBs) in a patient who was switched from an ACE inhibitor in July to an ARB because of a cough. The fax that was sent to me has a documented end date for the ACE inhibitor before the start date of the ARB.

We only have so much time in the day and piles of faxes are not helpful.

Speaking of faxes: Why do physical therapy offices and nursing homes fax the same form every day? Physicians do not always work in clinic every single day and it increases the workload and burden when you have to sort through three copies of the same fax. I once worked in a world where these would be sent by mail, and mailed back a week later, which seemed to work just fine.
 

Misinformation

Our patients have many sources of health information. Much of the information they get comes from family, friends, social media posts, and Internet sites. The accuracy of the information is often questionable, and in some cases, they are victims of intentional misinformation.

It is frustrating and time consuming to counter the bogus, unsubstantiated information patients receive. It is especially difficult when patients have done their own research on proven therapies (such as statins) and do not want to use them because of the many websites they have looked at that make unscientific claims about the dangers of the proposed therapy. I share evidence-based websites with my patients for their research; my favorite is medlineplus.gov.
 

Access crisis

The availability of specialty care is extremely limited now. In my health care system, there is up to a 6-month wait for appointments in neurology, cardiology, and endocrinology. This puts the burden on the primary care professional to manage the patient’s health, even when the patient really needs specialty care. It also increases the calls we receive to interpret the echocardiograms, MRIs, or lab tests ordered by specialists who do not share the interpretation of the results with their patients.

What can be done to improve this situation? Automatic consults in the hospital should be limited. Every patient who has a transient ischemic attack with a negative workup does not need neurology follow-up. The same goes for patients who have chest pain but a negative cardiac workup in the hospital – they do not need follow-up by a cardiologist, nor do those who have stable, well-managed coronary disease. We have to find a way to keep our specialists seeing the patients whom they can help the most and available for consultation in a timely fashion.

Please share your pet peeves with me. I will try to give them voice in the future. Hang in there, you are the glue that keeps this flawed system together.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

For this month’s column, I wanted to share some frustrations I have had about the current state of primary care. We all find those things that are going on in medicine that seem crazy and we just have to find a way to adapt to them. It is good to be able to share some of these thoughts with a community as distinguished as you readers. I know some of these are issues that you all struggle with and I wanted to give a voice to them. I wish I had answers to fix them.

Faxes from insurance companies

I find faxes from insurance companies immensely annoying. First, it takes time to go through lots of unwanted faxes but these faxes are extremely inaccurate. Today I received a fax telling me I might want to consider starting a statin in my 64-year-old HIV patient who has hypertension. He has been on a statin for 10 years.

Another fax warned me to not combine ACE inhibitors and angiotensin II receptor blockers (ARBs) in a patient who was switched from an ACE inhibitor in July to an ARB because of a cough. The fax that was sent to me has a documented end date for the ACE inhibitor before the start date of the ARB.

We only have so much time in the day and piles of faxes are not helpful.

Speaking of faxes: Why do physical therapy offices and nursing homes fax the same form every day? Physicians do not always work in clinic every single day and it increases the workload and burden when you have to sort through three copies of the same fax. I once worked in a world where these would be sent by mail, and mailed back a week later, which seemed to work just fine.
 

Misinformation

Our patients have many sources of health information. Much of the information they get comes from family, friends, social media posts, and Internet sites. The accuracy of the information is often questionable, and in some cases, they are victims of intentional misinformation.

It is frustrating and time consuming to counter the bogus, unsubstantiated information patients receive. It is especially difficult when patients have done their own research on proven therapies (such as statins) and do not want to use them because of the many websites they have looked at that make unscientific claims about the dangers of the proposed therapy. I share evidence-based websites with my patients for their research; my favorite is medlineplus.gov.
 

Access crisis

The availability of specialty care is extremely limited now. In my health care system, there is up to a 6-month wait for appointments in neurology, cardiology, and endocrinology. This puts the burden on the primary care professional to manage the patient’s health, even when the patient really needs specialty care. It also increases the calls we receive to interpret the echocardiograms, MRIs, or lab tests ordered by specialists who do not share the interpretation of the results with their patients.

What can be done to improve this situation? Automatic consults in the hospital should be limited. Every patient who has a transient ischemic attack with a negative workup does not need neurology follow-up. The same goes for patients who have chest pain but a negative cardiac workup in the hospital – they do not need follow-up by a cardiologist, nor do those who have stable, well-managed coronary disease. We have to find a way to keep our specialists seeing the patients whom they can help the most and available for consultation in a timely fashion.

Please share your pet peeves with me. I will try to give them voice in the future. Hang in there, you are the glue that keeps this flawed system together.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

The strike by health care workers at Kaiser Permanente may not involve physicians (yet). But as more doctors in the United States are finding themselves working as salaried employees, physicians can – and probably will – become a powerful force for change in a health care system that has shown itself to be increasingly hostile to employee concerns over issues involving patient care, wages and benefits, safety, and well-being.

Salaried employment has its challenges. Physician-employees may have less autonomy and voice in decision-making that affects patients. They may splinter into fragmented work groups; feel isolated; and have different imperatives based on who they are, what they want, and where they work. They may feel more removed from their patients and struggle to build strong relationships, with their employers in the way.

Yet important opportunities exist for doctors when embracing their employee side. These opportunities can help them and other health care workers fight effectively for their interests and those of patients in a corporatized health care system. Examples of these interests include adequate compensation, wellness, job security, patient and worker safety, health care quality, reasonable workloads and schedules, and fair treatment by employers, including the need to exhibit a strong collective voice in organizational decision-making.

Some believe that physician-employees must be unionized to maximize their rights and power as employees. Many expect physician unionization to take hold more fully over time. Medical residents, the doctors of tomorrow, are already considering unionization in greater numbers. Some are also doing it in the same employment setting alongside other health professionals, such as nurses.

Having studied doctors and their employment situations for years, I am convinced that whether through unionization or another approach, physicians must also change how they think about control; train and learn alongside other health care workers who share similar interests; and elevate at an early career stage their knowledge of the business side of health care.
 

Adopt a more pragmatic definition of autonomy

Doctors must embrace an updated definition of autonomy – one that matches their status as highly paid labor.

When I have spoken to physicians in my research about what autonomy means to them, many seem unable to reconceptualize it from a vague and absolute form of their profession’s strategic control over their economic fates and technical skills toward an individualized control that is situation-specific, one centered on winning the daily fights about workplace bread-and-butter issues such as those mentioned above.

But a more pragmatic definition of autonomy could get doctors focused on influencing important issues of the patient-care day and enhance their negotiating power with employers. It would allow physicians to break out of what often seems a paralysis of inaction – waiting for employers, insurers, or the government to reinstate the profession’s idealized version of control by handing it back the keys to the health care system through major regulatory, structural, and reimbursement-related changes. This fantasy is unlikely to become reality.

Physician-employees I’ve talked to over the years understand their everyday challenges. But when it comes to engaging in localized and sustained action to overcome them, they often perform less well, leading to feelings of helplessness and burnout. Valuing tactical control over their jobs and work setting will yield smaller but more impactful wins as employees intent on making their everyday work lives better.
 

Train alongside other health care professionals

Physicians must accept that how they are trained no longer prepares them for the employee world into which most are dropped. For instance, unless doctors are trained collaboratively alongside other health care professionals – such as nurses – they are less likely to identify closely with these colleagues once in practice. There is strength in numbers, so this mutual identification empowers both groups of employees. Yet, medical education remains largely the same: training young medical students in isolation for the first couple of years, then placing them into clerkships and residencies where true interprofessional care opportunities remain stunted and secondary to the “physician as captain of the team” mantra.

Unfortunately, the “hidden curriculum” of medicine helps convince medical students and residents early in their careers that they are the unquestioned leaders in patient care settings. This hierarchy encourages some doctors to keep their psychological distance from other members of the health care team and to resist sharing power, concerns, or insights with less skilled health care workers. This socialization harms the ability of physicians to act in a unified fashion alongside these other workers. Having physicians learn and train alongside other health professionals yields positive benefits for collective advocacy, including a shared sense of purpose, positive views on collaboration with others in the health setting, and greater development of bonds with nonphysician coworkers.
 

Integrate business with medical training in real time

Medical students and residents generally lack exposure to the everyday business realities of the U.S. health care system. This gap hinders their ability to understand the employee world and push for the types of changes and work conditions that benefit all health care workers. Formal business and management training should be a required part of every U.S. medical school and residency curriculum from day one. If you see it at all in medical schools now, it is mostly by accident, or given separate treatment in the form of standalone MBA or MPH degrees that rarely integrate organically and in real time with actual medical training. Not every doctor needs an MBA or MPH degree. However, all of them require a stronger contextual understanding of how the medicine they wish to practice is shaped by the economic and fiscal circumstances surrounding it – circumstances they do not control.

This is another reason why young doctors are unhappy and burned out. They cannot push for specific changes or properly critique the pros and cons of how their work is structured because they have not been made aware, in real time as they learn clinical practice, how their jobs are shaped by realities such as insurance coverage and reimbursement, the fragmentation of the care delivery system, their employer’s financial health , and the socioeconomic circumstances of their patients. They aren’t given the methods and tools related to process and quality improvement, budgeting, negotiation, risk management, leadership, and talent management that might help them navigate these undermining forces. They also get little advance exposure in their training to important workplace “soft” skills in such areas as how to work in teams, networking, communication and listening, empathy, and problem-solving – all necessary foci for bringing them closer to other health care workers and advocating alongside them effectively with health care employers.

Now is the time for physicians to embrace their identity as employees. Doing so is in their own best interest as professionals. It will help others in the health care workforce as well as patients. Moreover, it provides a needed counterbalance to the powerful corporate ethos now ascendant in U.S. health care.

Timothy Hoff, PhD, is a professor of management and healthcare systems at Northeastern University, Boston, and an associate fellow at the University of Oxford, England. He disclosed no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

The strike by health care workers at Kaiser Permanente may not involve physicians (yet). But as more doctors in the United States are finding themselves working as salaried employees, physicians can – and probably will – become a powerful force for change in a health care system that has shown itself to be increasingly hostile to employee concerns over issues involving patient care, wages and benefits, safety, and well-being.

Salaried employment has its challenges. Physician-employees may have less autonomy and voice in decision-making that affects patients. They may splinter into fragmented work groups; feel isolated; and have different imperatives based on who they are, what they want, and where they work. They may feel more removed from their patients and struggle to build strong relationships, with their employers in the way.

Yet important opportunities exist for doctors when embracing their employee side. These opportunities can help them and other health care workers fight effectively for their interests and those of patients in a corporatized health care system. Examples of these interests include adequate compensation, wellness, job security, patient and worker safety, health care quality, reasonable workloads and schedules, and fair treatment by employers, including the need to exhibit a strong collective voice in organizational decision-making.

Some believe that physician-employees must be unionized to maximize their rights and power as employees. Many expect physician unionization to take hold more fully over time. Medical residents, the doctors of tomorrow, are already considering unionization in greater numbers. Some are also doing it in the same employment setting alongside other health professionals, such as nurses.

Having studied doctors and their employment situations for years, I am convinced that whether through unionization or another approach, physicians must also change how they think about control; train and learn alongside other health care workers who share similar interests; and elevate at an early career stage their knowledge of the business side of health care.
 

Adopt a more pragmatic definition of autonomy

Doctors must embrace an updated definition of autonomy – one that matches their status as highly paid labor.

When I have spoken to physicians in my research about what autonomy means to them, many seem unable to reconceptualize it from a vague and absolute form of their profession’s strategic control over their economic fates and technical skills toward an individualized control that is situation-specific, one centered on winning the daily fights about workplace bread-and-butter issues such as those mentioned above.

But a more pragmatic definition of autonomy could get doctors focused on influencing important issues of the patient-care day and enhance their negotiating power with employers. It would allow physicians to break out of what often seems a paralysis of inaction – waiting for employers, insurers, or the government to reinstate the profession’s idealized version of control by handing it back the keys to the health care system through major regulatory, structural, and reimbursement-related changes. This fantasy is unlikely to become reality.

Physician-employees I’ve talked to over the years understand their everyday challenges. But when it comes to engaging in localized and sustained action to overcome them, they often perform less well, leading to feelings of helplessness and burnout. Valuing tactical control over their jobs and work setting will yield smaller but more impactful wins as employees intent on making their everyday work lives better.
 

Train alongside other health care professionals

Physicians must accept that how they are trained no longer prepares them for the employee world into which most are dropped. For instance, unless doctors are trained collaboratively alongside other health care professionals – such as nurses – they are less likely to identify closely with these colleagues once in practice. There is strength in numbers, so this mutual identification empowers both groups of employees. Yet, medical education remains largely the same: training young medical students in isolation for the first couple of years, then placing them into clerkships and residencies where true interprofessional care opportunities remain stunted and secondary to the “physician as captain of the team” mantra.

Unfortunately, the “hidden curriculum” of medicine helps convince medical students and residents early in their careers that they are the unquestioned leaders in patient care settings. This hierarchy encourages some doctors to keep their psychological distance from other members of the health care team and to resist sharing power, concerns, or insights with less skilled health care workers. This socialization harms the ability of physicians to act in a unified fashion alongside these other workers. Having physicians learn and train alongside other health professionals yields positive benefits for collective advocacy, including a shared sense of purpose, positive views on collaboration with others in the health setting, and greater development of bonds with nonphysician coworkers.
 

Integrate business with medical training in real time

Medical students and residents generally lack exposure to the everyday business realities of the U.S. health care system. This gap hinders their ability to understand the employee world and push for the types of changes and work conditions that benefit all health care workers. Formal business and management training should be a required part of every U.S. medical school and residency curriculum from day one. If you see it at all in medical schools now, it is mostly by accident, or given separate treatment in the form of standalone MBA or MPH degrees that rarely integrate organically and in real time with actual medical training. Not every doctor needs an MBA or MPH degree. However, all of them require a stronger contextual understanding of how the medicine they wish to practice is shaped by the economic and fiscal circumstances surrounding it – circumstances they do not control.

This is another reason why young doctors are unhappy and burned out. They cannot push for specific changes or properly critique the pros and cons of how their work is structured because they have not been made aware, in real time as they learn clinical practice, how their jobs are shaped by realities such as insurance coverage and reimbursement, the fragmentation of the care delivery system, their employer’s financial health , and the socioeconomic circumstances of their patients. They aren’t given the methods and tools related to process and quality improvement, budgeting, negotiation, risk management, leadership, and talent management that might help them navigate these undermining forces. They also get little advance exposure in their training to important workplace “soft” skills in such areas as how to work in teams, networking, communication and listening, empathy, and problem-solving – all necessary foci for bringing them closer to other health care workers and advocating alongside them effectively with health care employers.

Now is the time for physicians to embrace their identity as employees. Doing so is in their own best interest as professionals. It will help others in the health care workforce as well as patients. Moreover, it provides a needed counterbalance to the powerful corporate ethos now ascendant in U.S. health care.

Timothy Hoff, PhD, is a professor of management and healthcare systems at Northeastern University, Boston, and an associate fellow at the University of Oxford, England. He disclosed no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

The strike by health care workers at Kaiser Permanente may not involve physicians (yet). But as more doctors in the United States are finding themselves working as salaried employees, physicians can – and probably will – become a powerful force for change in a health care system that has shown itself to be increasingly hostile to employee concerns over issues involving patient care, wages and benefits, safety, and well-being.

Salaried employment has its challenges. Physician-employees may have less autonomy and voice in decision-making that affects patients. They may splinter into fragmented work groups; feel isolated; and have different imperatives based on who they are, what they want, and where they work. They may feel more removed from their patients and struggle to build strong relationships, with their employers in the way.

Yet important opportunities exist for doctors when embracing their employee side. These opportunities can help them and other health care workers fight effectively for their interests and those of patients in a corporatized health care system. Examples of these interests include adequate compensation, wellness, job security, patient and worker safety, health care quality, reasonable workloads and schedules, and fair treatment by employers, including the need to exhibit a strong collective voice in organizational decision-making.

Some believe that physician-employees must be unionized to maximize their rights and power as employees. Many expect physician unionization to take hold more fully over time. Medical residents, the doctors of tomorrow, are already considering unionization in greater numbers. Some are also doing it in the same employment setting alongside other health professionals, such as nurses.

Having studied doctors and their employment situations for years, I am convinced that whether through unionization or another approach, physicians must also change how they think about control; train and learn alongside other health care workers who share similar interests; and elevate at an early career stage their knowledge of the business side of health care.
 

Adopt a more pragmatic definition of autonomy

Doctors must embrace an updated definition of autonomy – one that matches their status as highly paid labor.

When I have spoken to physicians in my research about what autonomy means to them, many seem unable to reconceptualize it from a vague and absolute form of their profession’s strategic control over their economic fates and technical skills toward an individualized control that is situation-specific, one centered on winning the daily fights about workplace bread-and-butter issues such as those mentioned above.

But a more pragmatic definition of autonomy could get doctors focused on influencing important issues of the patient-care day and enhance their negotiating power with employers. It would allow physicians to break out of what often seems a paralysis of inaction – waiting for employers, insurers, or the government to reinstate the profession’s idealized version of control by handing it back the keys to the health care system through major regulatory, structural, and reimbursement-related changes. This fantasy is unlikely to become reality.

Physician-employees I’ve talked to over the years understand their everyday challenges. But when it comes to engaging in localized and sustained action to overcome them, they often perform less well, leading to feelings of helplessness and burnout. Valuing tactical control over their jobs and work setting will yield smaller but more impactful wins as employees intent on making their everyday work lives better.
 

Train alongside other health care professionals

Physicians must accept that how they are trained no longer prepares them for the employee world into which most are dropped. For instance, unless doctors are trained collaboratively alongside other health care professionals – such as nurses – they are less likely to identify closely with these colleagues once in practice. There is strength in numbers, so this mutual identification empowers both groups of employees. Yet, medical education remains largely the same: training young medical students in isolation for the first couple of years, then placing them into clerkships and residencies where true interprofessional care opportunities remain stunted and secondary to the “physician as captain of the team” mantra.

Unfortunately, the “hidden curriculum” of medicine helps convince medical students and residents early in their careers that they are the unquestioned leaders in patient care settings. This hierarchy encourages some doctors to keep their psychological distance from other members of the health care team and to resist sharing power, concerns, or insights with less skilled health care workers. This socialization harms the ability of physicians to act in a unified fashion alongside these other workers. Having physicians learn and train alongside other health professionals yields positive benefits for collective advocacy, including a shared sense of purpose, positive views on collaboration with others in the health setting, and greater development of bonds with nonphysician coworkers.
 

Integrate business with medical training in real time

Medical students and residents generally lack exposure to the everyday business realities of the U.S. health care system. This gap hinders their ability to understand the employee world and push for the types of changes and work conditions that benefit all health care workers. Formal business and management training should be a required part of every U.S. medical school and residency curriculum from day one. If you see it at all in medical schools now, it is mostly by accident, or given separate treatment in the form of standalone MBA or MPH degrees that rarely integrate organically and in real time with actual medical training. Not every doctor needs an MBA or MPH degree. However, all of them require a stronger contextual understanding of how the medicine they wish to practice is shaped by the economic and fiscal circumstances surrounding it – circumstances they do not control.

This is another reason why young doctors are unhappy and burned out. They cannot push for specific changes or properly critique the pros and cons of how their work is structured because they have not been made aware, in real time as they learn clinical practice, how their jobs are shaped by realities such as insurance coverage and reimbursement, the fragmentation of the care delivery system, their employer’s financial health , and the socioeconomic circumstances of their patients. They aren’t given the methods and tools related to process and quality improvement, budgeting, negotiation, risk management, leadership, and talent management that might help them navigate these undermining forces. They also get little advance exposure in their training to important workplace “soft” skills in such areas as how to work in teams, networking, communication and listening, empathy, and problem-solving – all necessary foci for bringing them closer to other health care workers and advocating alongside them effectively with health care employers.

Now is the time for physicians to embrace their identity as employees. Doing so is in their own best interest as professionals. It will help others in the health care workforce as well as patients. Moreover, it provides a needed counterbalance to the powerful corporate ethos now ascendant in U.S. health care.

Timothy Hoff, PhD, is a professor of management and healthcare systems at Northeastern University, Boston, and an associate fellow at the University of Oxford, England. He disclosed no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

In the year since generative artificial intelligence (AI) software first began to emerge for use, the staggering pace and breadth of development has condensed years of growth and change into months and weeks. Among the settings where these tools may find the greatest straight-line relevance is private medical practice.

Last month’s column on the basics of AI sparked some interesting questions regarding the various generative algorithms and their usefulness to us in medicine. A multitude of generative AI products with potential medical applications are now available, with new ones appearing almost weekly. (As always, I have no financial interest in any product or service mentioned in this column.)

Last month, I discussed ChatGPT, the best-known AI algorithm, and some of its applications in clinical practice, such as generating website, video, and blog content. ChatGPT can also provide rapid and concise answers to general medical questions, like a search engine – but with more natural language processing and contextual understanding. Additionally, the algorithm can draft generic medical documents, including templates for after-visit summaries, postprocedure instructions, referrals, prior authorization appeal letters, and educational handouts.

Another useful feature of ChatGPT is its ability to provide accurate and conversational language translations, thus serving as an interpreter during clinic visits in situations where a human translator is not available. It also has potential uses in clinical research by finding resources, formulating hypotheses, drafting study protocols, and collecting large amounts of data in short periods of time. Other possibilities include survey administration, clinical trial recruitment, and automatic medication monitoring.

GPT-4, the latest version of ChatGPT, is reported to have greater problem-solving abilities and an even broader knowledge base. Among its claimed skills are the ability to find the latest literature in a given area, write a discharge summary for a patient following an uncomplicated surgery, and an image analysis feature to identify objects in photos. GPT-4 has been praised as having “the potential to help drive medical innovation, from aiding with patient discharge notes, summarizing recent clinical trials, providing information on ethical guidelines, and much more.”

Bard, an AI “chat bot” introduced by Google earlier this year, intends to leverage Google’s enormous database to compete with ChatGPT in providing answers to medical questions. Bard also hopes to play a pivotal role in expanding telemedicine and remote care via Google’s secure connections and access to patient records and medical history, and “facilitate seamless communication through appointment scheduling, messaging, and sharing medical images,” according to PackT, a website for IT professionals. The company claims that Bard’s integration of AI and machine learning capabilities will serve to elevate health care efficiency and patient outcomes, PackT says, and “the platform’s AI system quickly and accurately analyzes patient records, identifies patterns and trends, and aids medical professionals in developing effective treatment plans.”

Doximity has introduced an AI engine called DocsGPT, an encrypted, HIPAA-compliant writing assistant that, the company says, can draft any form of professional correspondence, including prior authorization letters, insurance appeals, patient support letters, and patient education materials. The service is available at no charge to all U.S. physicians and medical students through their Doximity accounts.

Microsoft has introduced several AI products. BioGPT is a language model specifically designed for health care. Compared with GPT models that are trained on more general text data, BioGPT is purported to have a deeper understanding of the language used in biomedical research and can generate more accurate and relevant outputs for biomedical tasks, such as drug discovery, disease classification, and clinical decision support. Fabric is another health care–specific data and analytics platform the company described in an announcement in May. It can combine data from sources such as electronic health records, images, lab systems, medical devices, and claims systems so hospitals and offices can standardize it and access it in the same place. Microsoft said the new tools will help eliminate the “time-consuming” process of searching through these sources one by one. Microsoft will also offer a new generative AI chatbot called the Azure Health Bot, which can pull information from a health organization’s own internal data as well as reputable external sources such as the Food and Drug Administration and the National Institutes of Health.

Several other AI products are available for clinicians. Tana served as an administrative aid and a clinical helper during the height of the COVID-19 pandemic, answering frequently asked questions, facilitating appointment management, and gathering preliminary medical information prior to teleconsultations. Dougall GPT is another AI chatbot tailored for health care professionals. It provides clinicians with AI-tuned answers to their queries, augmented by links to relevant, up-to-date, authoritative resources. It also assists in drafting patient instructions, consultation summaries, speeches, and professional correspondence. Wang has created Clinical Camel, an open-source health care–focused chatbot that assembles medical data with a combination of user-shared conversations and synthetic conversations derived from curated clinical articles. The Chinese company Baidu has rolled out Ernie as a potential rival to ChatGPT. You get the idea.

Of course, the inherent drawbacks of AI, such as producing false or biased information, perpetuating harmful stereotypes, and presenting information that has since been proven inaccurate or out-of-date, must always be kept in mind. All AI algorithms have been criticized for giving wrong answers, as their datasets are generally culled from information published in 2021 or earlier. Several of them have been shown to fabricate information – a phenomenon labeled “artificial hallucinations” in one article. “The scientific community must be vigilant in verifying the accuracy and reliability of the information provided by AI tools,” wrote the authors of that paper. “Researchers should use AI as an aid rather than a replacement for critical thinking and fact-checking.”

In the year since generative artificial intelligence (AI) software first began to emerge for use, the staggering pace and breadth of development has condensed years of growth and change into months and weeks. Among the settings where these tools may find the greatest straight-line relevance is private medical practice.

Last month’s column on the basics of AI sparked some interesting questions regarding the various generative algorithms and their usefulness to us in medicine. A multitude of generative AI products with potential medical applications are now available, with new ones appearing almost weekly. (As always, I have no financial interest in any product or service mentioned in this column.)

Last month, I discussed ChatGPT, the best-known AI algorithm, and some of its applications in clinical practice, such as generating website, video, and blog content. ChatGPT can also provide rapid and concise answers to general medical questions, like a search engine – but with more natural language processing and contextual understanding. Additionally, the algorithm can draft generic medical documents, including templates for after-visit summaries, postprocedure instructions, referrals, prior authorization appeal letters, and educational handouts.

Another useful feature of ChatGPT is its ability to provide accurate and conversational language translations, thus serving as an interpreter during clinic visits in situations where a human translator is not available. It also has potential uses in clinical research by finding resources, formulating hypotheses, drafting study protocols, and collecting large amounts of data in short periods of time. Other possibilities include survey administration, clinical trial recruitment, and automatic medication monitoring.

GPT-4, the latest version of ChatGPT, is reported to have greater problem-solving abilities and an even broader knowledge base. Among its claimed skills are the ability to find the latest literature in a given area, write a discharge summary for a patient following an uncomplicated surgery, and an image analysis feature to identify objects in photos. GPT-4 has been praised as having “the potential to help drive medical innovation, from aiding with patient discharge notes, summarizing recent clinical trials, providing information on ethical guidelines, and much more.”

Bard, an AI “chat bot” introduced by Google earlier this year, intends to leverage Google’s enormous database to compete with ChatGPT in providing answers to medical questions. Bard also hopes to play a pivotal role in expanding telemedicine and remote care via Google’s secure connections and access to patient records and medical history, and “facilitate seamless communication through appointment scheduling, messaging, and sharing medical images,” according to PackT, a website for IT professionals. The company claims that Bard’s integration of AI and machine learning capabilities will serve to elevate health care efficiency and patient outcomes, PackT says, and “the platform’s AI system quickly and accurately analyzes patient records, identifies patterns and trends, and aids medical professionals in developing effective treatment plans.”

Doximity has introduced an AI engine called DocsGPT, an encrypted, HIPAA-compliant writing assistant that, the company says, can draft any form of professional correspondence, including prior authorization letters, insurance appeals, patient support letters, and patient education materials. The service is available at no charge to all U.S. physicians and medical students through their Doximity accounts.

Microsoft has introduced several AI products. BioGPT is a language model specifically designed for health care. Compared with GPT models that are trained on more general text data, BioGPT is purported to have a deeper understanding of the language used in biomedical research and can generate more accurate and relevant outputs for biomedical tasks, such as drug discovery, disease classification, and clinical decision support. Fabric is another health care–specific data and analytics platform the company described in an announcement in May. It can combine data from sources such as electronic health records, images, lab systems, medical devices, and claims systems so hospitals and offices can standardize it and access it in the same place. Microsoft said the new tools will help eliminate the “time-consuming” process of searching through these sources one by one. Microsoft will also offer a new generative AI chatbot called the Azure Health Bot, which can pull information from a health organization’s own internal data as well as reputable external sources such as the Food and Drug Administration and the National Institutes of Health.

Several other AI products are available for clinicians. Tana served as an administrative aid and a clinical helper during the height of the COVID-19 pandemic, answering frequently asked questions, facilitating appointment management, and gathering preliminary medical information prior to teleconsultations. Dougall GPT is another AI chatbot tailored for health care professionals. It provides clinicians with AI-tuned answers to their queries, augmented by links to relevant, up-to-date, authoritative resources. It also assists in drafting patient instructions, consultation summaries, speeches, and professional correspondence. Wang has created Clinical Camel, an open-source health care–focused chatbot that assembles medical data with a combination of user-shared conversations and synthetic conversations derived from curated clinical articles. The Chinese company Baidu has rolled out Ernie as a potential rival to ChatGPT. You get the idea.

Of course, the inherent drawbacks of AI, such as producing false or biased information, perpetuating harmful stereotypes, and presenting information that has since been proven inaccurate or out-of-date, must always be kept in mind. All AI algorithms have been criticized for giving wrong answers, as their datasets are generally culled from information published in 2021 or earlier. Several of them have been shown to fabricate information – a phenomenon labeled “artificial hallucinations” in one article. “The scientific community must be vigilant in verifying the accuracy and reliability of the information provided by AI tools,” wrote the authors of that paper. “Researchers should use AI as an aid rather than a replacement for critical thinking and fact-checking.”

In the year since generative artificial intelligence (AI) software first began to emerge for use, the staggering pace and breadth of development has condensed years of growth and change into months and weeks. Among the settings where these tools may find the greatest straight-line relevance is private medical practice.

Last month’s column on the basics of AI sparked some interesting questions regarding the various generative algorithms and their usefulness to us in medicine. A multitude of generative AI products with potential medical applications are now available, with new ones appearing almost weekly. (As always, I have no financial interest in any product or service mentioned in this column.)

Last month, I discussed ChatGPT, the best-known AI algorithm, and some of its applications in clinical practice, such as generating website, video, and blog content. ChatGPT can also provide rapid and concise answers to general medical questions, like a search engine – but with more natural language processing and contextual understanding. Additionally, the algorithm can draft generic medical documents, including templates for after-visit summaries, postprocedure instructions, referrals, prior authorization appeal letters, and educational handouts.

Another useful feature of ChatGPT is its ability to provide accurate and conversational language translations, thus serving as an interpreter during clinic visits in situations where a human translator is not available. It also has potential uses in clinical research by finding resources, formulating hypotheses, drafting study protocols, and collecting large amounts of data in short periods of time. Other possibilities include survey administration, clinical trial recruitment, and automatic medication monitoring.

GPT-4, the latest version of ChatGPT, is reported to have greater problem-solving abilities and an even broader knowledge base. Among its claimed skills are the ability to find the latest literature in a given area, write a discharge summary for a patient following an uncomplicated surgery, and an image analysis feature to identify objects in photos. GPT-4 has been praised as having “the potential to help drive medical innovation, from aiding with patient discharge notes, summarizing recent clinical trials, providing information on ethical guidelines, and much more.”

Bard, an AI “chat bot” introduced by Google earlier this year, intends to leverage Google’s enormous database to compete with ChatGPT in providing answers to medical questions. Bard also hopes to play a pivotal role in expanding telemedicine and remote care via Google’s secure connections and access to patient records and medical history, and “facilitate seamless communication through appointment scheduling, messaging, and sharing medical images,” according to PackT, a website for IT professionals. The company claims that Bard’s integration of AI and machine learning capabilities will serve to elevate health care efficiency and patient outcomes, PackT says, and “the platform’s AI system quickly and accurately analyzes patient records, identifies patterns and trends, and aids medical professionals in developing effective treatment plans.”

Doximity has introduced an AI engine called DocsGPT, an encrypted, HIPAA-compliant writing assistant that, the company says, can draft any form of professional correspondence, including prior authorization letters, insurance appeals, patient support letters, and patient education materials. The service is available at no charge to all U.S. physicians and medical students through their Doximity accounts.

Microsoft has introduced several AI products. BioGPT is a language model specifically designed for health care. Compared with GPT models that are trained on more general text data, BioGPT is purported to have a deeper understanding of the language used in biomedical research and can generate more accurate and relevant outputs for biomedical tasks, such as drug discovery, disease classification, and clinical decision support. Fabric is another health care–specific data and analytics platform the company described in an announcement in May. It can combine data from sources such as electronic health records, images, lab systems, medical devices, and claims systems so hospitals and offices can standardize it and access it in the same place. Microsoft said the new tools will help eliminate the “time-consuming” process of searching through these sources one by one. Microsoft will also offer a new generative AI chatbot called the Azure Health Bot, which can pull information from a health organization’s own internal data as well as reputable external sources such as the Food and Drug Administration and the National Institutes of Health.

Several other AI products are available for clinicians. Tana served as an administrative aid and a clinical helper during the height of the COVID-19 pandemic, answering frequently asked questions, facilitating appointment management, and gathering preliminary medical information prior to teleconsultations. Dougall GPT is another AI chatbot tailored for health care professionals. It provides clinicians with AI-tuned answers to their queries, augmented by links to relevant, up-to-date, authoritative resources. It also assists in drafting patient instructions, consultation summaries, speeches, and professional correspondence. Wang has created Clinical Camel, an open-source health care–focused chatbot that assembles medical data with a combination of user-shared conversations and synthetic conversations derived from curated clinical articles. The Chinese company Baidu has rolled out Ernie as a potential rival to ChatGPT. You get the idea.

Of course, the inherent drawbacks of AI, such as producing false or biased information, perpetuating harmful stereotypes, and presenting information that has since been proven inaccurate or out-of-date, must always be kept in mind. All AI algorithms have been criticized for giving wrong answers, as their datasets are generally culled from information published in 2021 or earlier. Several of them have been shown to fabricate information – a phenomenon labeled “artificial hallucinations” in one article. “The scientific community must be vigilant in verifying the accuracy and reliability of the information provided by AI tools,” wrote the authors of that paper. “Researchers should use AI as an aid rather than a replacement for critical thinking and fact-checking.”

New England Baptist Hospital has been grappling with a serious problem facing health care today: insurers demanding prior authorizations for services ordered by physicians. Meeting payers’ requirements eats up time, delays treatment, and can be a costly drain on doctors’ practices. 

To deal with this problem, the Boston orthopedic hospital has opted to automate submission of prior authorization requests on behalf of more than 100 mostly orthopedic surgeons on staff. 

After 5 years using this system, “we can say that automation definitely works,” said Lidiya Hadzhieva, director of patient access at the hospital. The software has reduced write-offs by 30% and staff costs by 25%. Prior authorization gets approved 3 days after scheduling, compared with 11 days previously, she said.

“This software not only saves staff time, but it can also more accurately predict when prior authorization is needed,” she added.

For practices deluged with required prior authorizations by insurers, automation is emerging as a way for practices to make the process less time-consuming and save money. However, the software can be costly and may not be adoptable to many practices, and many physicians are not even aware it exists.

So far, the software is mainly used at large organizations like hospital systems. But as word gets out and the software becomes easier to use, private practices and other smaller entities may join the automation trend.

There is definitely a need to automate prior authorization. The American Medical Association reports that physicians spend 16 hours per week on prior authorizations. In a recent AMA survey, more than 60% of physicians indicated that it’s difficult to know when prior authorization is needed. And 93% of physicians reported care delays while waiting for authorization, the AMA said.  

Experts estimate that 80% of prior authorization work could be automated, but most practices still use the phone or fax, even as numbers of prior authorizations continue to increase.
 

How it works

Automation software connects directly to the practice’s electronic health record (EHR). “When the doctor places an order in the EHR, the process starts automatically,” Ms. Hadzhieva said. “The doctor may not even notice it.” 

In addition to using an EHR connection, many software products can communicate with the payer through its portal or by fax or phone, while still automating other parts of the process.

The software’s first step is to decide whether prior authorization is needed. This requires having an updated list of the rules that each payer uses for prior authorization. Manually keeping track of payer rules is very time-consuming, but automation uses bots to visit each payer site to look for rules changes. One vendor, Infinitus, uses a voice-based bot called Eva that calls up each payer and speaks with a representative.

“Automatically updating payer rules is not a new technology,” said YiDing Yu, MD, chief product officer at Olive, the automation vendor for New England Baptist. “What is new in the last 5 years is extracting the information needed for the prior authorization out of the clinical notes.”

This is challenging because each doctor has different ways to describe each step of clinical work. To identify this shorthand, Dr. Yu said Olive uses natural language processing, which is a form of artificial intelligence that learns how each doctor describes things.

Dr. Yu asserts that Olive is actually better than a practice’s staff at digging out clinical information. She said staff without much clinical training may miss terms that the software can catch, and they don’t have the time to go back many months into the record to find valuable information. But automation can do that.

In some instances, however, the software may not be able to find the information, in which case it alerts staff through a prompt in the EHR and the information is retrieved manually, Dr. Yu said.

Next, the Olive software puts the information it found into the request form and sends it to the payer. After submission, the software constantly checks on the status of each request, again visiting payer sites with a bot.

At New England Baptist, the software is used mainly by physicians in fairly small private practices who are on staff. They are using the software on the hospital’s dime, but it only works inside the hospital, Ms. Hadzhieva said. For their work outside of the hospital, they would have to purchase the Olive software on their own, she said.
 

Automation hasn’t spread to practices yet

Despite the promising outcomes for products like Olive, automation software is still primarily used by large organizations. Vendors say very few private practices have bought it yet. “The technology works, but it is still in the early-adopter phase,” Dr. Yu said.

For one thing, the software can be expensive. Very few vendors reveal their prices, but Dr. Yu did so. She said Olive normally costs about $50,000 a year for even a small organization. She insisted, however, that the savings from avoiding just one denial each month for a hip surgery would justify the expense.

On the other hand, some automation software is free, such as the Surescripts product for prior authorization of prescriptions. But it is unclear whether Surescripts does as much as Olive. Vendors’ descriptions of their products tend to be vague.

Also, Surescripts and Olive have entirely separate functions. Dr. Yu said Olive is limited to procedures, so it benefits specialties like oncology, neurosurgery, colorectal surgery, vascular surgery, and cardiology. Olive does not cover prescriptions, because they operate on a different technology.

Dr. Yu said another hurdle for adopting the software is the kind of EHR systems that doctors use. At this point, only a few EHR systems – such as Epic, Cerner, and Athena – are compatible with Olive. Large organizations tend to use Epic and Cerner, while many practices often use Athena or a variety of other systems, she said.

Despite stunted demand, there is no shortage of companies offering automation software for medical (that is, non-prescription) prior authorization. One compilation lists 25 such vendors, including companies like Myndshft, Rhyme, Infinitus, Infinx, and Waystar. As with any start-up technology, companies occasionally buy each other out.

In addition to issues like cost, specialty, and EHR compatibility, another hurdle is that few doctors even know the technology exists. Vendors say marketing focuses on larger provider organizations, not smaller practices.

Even many tech-savvy doctors, like Adam Bruggeman, MD, an orthopedist and CEO of Texas Spine Care Center in San Antonio, say they know little about the technology. “There is definitely a need to automate prior authorization,” he said. “But I don’t know of any colleagues who use it.” He has only just begun to explore vendors, he said.

Many medical practice consultants also have not yet explored the technology. “Automation makes a lot of sense, because there are a lot of repetitive tasks in prior authorization,” said Jill Arena, CEO of Portland, Ore.–based Health e Practices. “But I haven’t looked into it yet, and none of my clients has even asked about it.”

“I could see how it could be an easier sell for large organizations,” she added. “They have an IT person and a CFO who can explore the issue. Smaller practices usually don’t have that kind of expertise.”
 

Where does automation go from here?

Until now, clinicians who want to fully automate prior authorizations would have to buy two products – one for medical procedures and one for prescriptions. This has to do with incompatible electronic transmission standards, which are used to digitize information, said Susan Lawson-Dawson, content marketing strategist for the vendor Myndshft Health.

Myndshft has long been selling automation software for medical prior authorizations, but now it is introducing a product for prescriptions, Ms. Lawson-Dawson said. She said Myndshft will then be the only vendor to automate both kinds of prior authorizations.

Ms. Lawson-Dawson said Myndshft has 685 customers to date and is looking for more business. Recently the company entered the Google Cloud Marketplace. Google Cloud customers can now direct their committed spend with Google to purchasing Myndshft, meaning they could get it at a discount.

Software like Olive and Myndshft can operate independently of payers, but a vendor called Rhyme depends on payers for its software to function, said Rhyme CEO Joe Anstine. He said more than 300 payers have agreed to install the Rhyme system, and Rhyme has signed up a number of large health systems to use the product. Initially, he said, clinicians paid for the service, but now Rhyme is beginning to find payers to foot the costs and to let clinicians use it for free, which would open Rhyme up to smaller practices.

EHR companies themselves are beginning to offer automation, too. Epic, for example, has created a tool for prior authorization as part of its Epic Payer Platform. Like Rhyme, it requires payer cooperation, because information goes back and forth between clinician and payer in what is called bi-directional exchange.

The Epic product is still in its pilot phase. Epic reported that several large health systems were using its product in conjunction with a specific payer – for instance, Mayo Clinic with Blue Cross and Blue Shield of Minnesota and Ochsner Health with Humana. According to Epic, the arrangement reduced Mayo’s denials due to additional documentation requests by 63% for professional billing.

Automating with just one payer still means the clinician has to deal with manual processes at other payers, but a large clinician could have sufficient volume with that one payer to make the arrangement useful.
 

Will payers automate prior authorization?

Ultimately, payers may take the automation business away from vendors, offering a free product to all clinicians. But don’t hold your breath. Payers first have to rebuild their electronic systems to accommodate an electronic connection with providers. Even then, some payers might hold back from automating, forcing practices to continue manually processing some prior authorizations.

Efforts are underway, however, to mandate payers to support prior authorization automation. For this to happen, payers would have to revamp their data so that it could be easily read by practices’ EHRs. This would mean adopting a specific interoperability standard called Health Level 7 Fast Healthcare Interoperability Resources (FHIR).

Toward this goal, the Centers for Medicare & Medicaid Services proposes to require payers to adopt FHIR by January 2026. (CMS still has to finalize the rule.) Experts say the two-year ramp-up time is needed because it takes extensive work for payers to translate their data into FHIR.

The only payer so far to switch to FHIR for prior authorization is Regence in Washington state. In a pilot project, it has automated prior authorization with just one provider, MultiCare Connected Care, an accountable care organization (ACO), also in Washington state.

Anna Taylor, associate vice president of population health and value-based care at MultiCare, explained how the arrangement works. “Two separate entities are sharing one operational process,” she told this news organization. “That means they can have a digital conversation back and forth, so it is much easier to resolve prior authorization issues.” 

Unlike many vendor products, the Regence service is free. And while the vendors market only to large organizations, most doctors in the MultiCare arrangement are in independent practices. Ms. Taylor said these doctors have been “enthusiastic” about the arrangement.

The results of the pilot are impressive. Ms. Taylor said automation has resulted in a 233% productivity gain for MultiCare clinicians, and 89% of submissions to Regence get an immediate response.

There is a potential downside, however, to working directly with payers. A direct connection to clinicians allows payers to access the doctor’s clinical notes, which could make many doctors uneasy. But Ms. Taylor said Regence only has access to the “discrete data fields” on MultiCare’s EHR dashboard, not to the notes themselves.

The ultimate goal of the Regence-Multicare project is to include more payers and clinicians. Ms. Taylor said two of the 27 other payers that MultiCare works with are “highly interested,” but it would take a lot of work for them to get connected with practices and other clinicians. 

Ultimately, payers could offer automation and third-party vendors might then fade away. However, physicians may resist working directly with payers if the arrangement requires full access to their medical records.

A version of this article first appeared on Medscape.com.

New England Baptist Hospital has been grappling with a serious problem facing health care today: insurers demanding prior authorizations for services ordered by physicians. Meeting payers’ requirements eats up time, delays treatment, and can be a costly drain on doctors’ practices. 

To deal with this problem, the Boston orthopedic hospital has opted to automate submission of prior authorization requests on behalf of more than 100 mostly orthopedic surgeons on staff. 

After 5 years using this system, “we can say that automation definitely works,” said Lidiya Hadzhieva, director of patient access at the hospital. The software has reduced write-offs by 30% and staff costs by 25%. Prior authorization gets approved 3 days after scheduling, compared with 11 days previously, she said.

“This software not only saves staff time, but it can also more accurately predict when prior authorization is needed,” she added.

For practices deluged with required prior authorizations by insurers, automation is emerging as a way for practices to make the process less time-consuming and save money. However, the software can be costly and may not be adoptable to many practices, and many physicians are not even aware it exists.

So far, the software is mainly used at large organizations like hospital systems. But as word gets out and the software becomes easier to use, private practices and other smaller entities may join the automation trend.

There is definitely a need to automate prior authorization. The American Medical Association reports that physicians spend 16 hours per week on prior authorizations. In a recent AMA survey, more than 60% of physicians indicated that it’s difficult to know when prior authorization is needed. And 93% of physicians reported care delays while waiting for authorization, the AMA said.  

Experts estimate that 80% of prior authorization work could be automated, but most practices still use the phone or fax, even as numbers of prior authorizations continue to increase.
 

How it works

Automation software connects directly to the practice’s electronic health record (EHR). “When the doctor places an order in the EHR, the process starts automatically,” Ms. Hadzhieva said. “The doctor may not even notice it.” 

In addition to using an EHR connection, many software products can communicate with the payer through its portal or by fax or phone, while still automating other parts of the process.

The software’s first step is to decide whether prior authorization is needed. This requires having an updated list of the rules that each payer uses for prior authorization. Manually keeping track of payer rules is very time-consuming, but automation uses bots to visit each payer site to look for rules changes. One vendor, Infinitus, uses a voice-based bot called Eva that calls up each payer and speaks with a representative.

“Automatically updating payer rules is not a new technology,” said YiDing Yu, MD, chief product officer at Olive, the automation vendor for New England Baptist. “What is new in the last 5 years is extracting the information needed for the prior authorization out of the clinical notes.”

This is challenging because each doctor has different ways to describe each step of clinical work. To identify this shorthand, Dr. Yu said Olive uses natural language processing, which is a form of artificial intelligence that learns how each doctor describes things.

Dr. Yu asserts that Olive is actually better than a practice’s staff at digging out clinical information. She said staff without much clinical training may miss terms that the software can catch, and they don’t have the time to go back many months into the record to find valuable information. But automation can do that.

In some instances, however, the software may not be able to find the information, in which case it alerts staff through a prompt in the EHR and the information is retrieved manually, Dr. Yu said.

Next, the Olive software puts the information it found into the request form and sends it to the payer. After submission, the software constantly checks on the status of each request, again visiting payer sites with a bot.

At New England Baptist, the software is used mainly by physicians in fairly small private practices who are on staff. They are using the software on the hospital’s dime, but it only works inside the hospital, Ms. Hadzhieva said. For their work outside of the hospital, they would have to purchase the Olive software on their own, she said.
 

Automation hasn’t spread to practices yet

Despite the promising outcomes for products like Olive, automation software is still primarily used by large organizations. Vendors say very few private practices have bought it yet. “The technology works, but it is still in the early-adopter phase,” Dr. Yu said.

For one thing, the software can be expensive. Very few vendors reveal their prices, but Dr. Yu did so. She said Olive normally costs about $50,000 a year for even a small organization. She insisted, however, that the savings from avoiding just one denial each month for a hip surgery would justify the expense.

On the other hand, some automation software is free, such as the Surescripts product for prior authorization of prescriptions. But it is unclear whether Surescripts does as much as Olive. Vendors’ descriptions of their products tend to be vague.

Also, Surescripts and Olive have entirely separate functions. Dr. Yu said Olive is limited to procedures, so it benefits specialties like oncology, neurosurgery, colorectal surgery, vascular surgery, and cardiology. Olive does not cover prescriptions, because they operate on a different technology.

Dr. Yu said another hurdle for adopting the software is the kind of EHR systems that doctors use. At this point, only a few EHR systems – such as Epic, Cerner, and Athena – are compatible with Olive. Large organizations tend to use Epic and Cerner, while many practices often use Athena or a variety of other systems, she said.

Despite stunted demand, there is no shortage of companies offering automation software for medical (that is, non-prescription) prior authorization. One compilation lists 25 such vendors, including companies like Myndshft, Rhyme, Infinitus, Infinx, and Waystar. As with any start-up technology, companies occasionally buy each other out.

In addition to issues like cost, specialty, and EHR compatibility, another hurdle is that few doctors even know the technology exists. Vendors say marketing focuses on larger provider organizations, not smaller practices.

Even many tech-savvy doctors, like Adam Bruggeman, MD, an orthopedist and CEO of Texas Spine Care Center in San Antonio, say they know little about the technology. “There is definitely a need to automate prior authorization,” he said. “But I don’t know of any colleagues who use it.” He has only just begun to explore vendors, he said.

Many medical practice consultants also have not yet explored the technology. “Automation makes a lot of sense, because there are a lot of repetitive tasks in prior authorization,” said Jill Arena, CEO of Portland, Ore.–based Health e Practices. “But I haven’t looked into it yet, and none of my clients has even asked about it.”

“I could see how it could be an easier sell for large organizations,” she added. “They have an IT person and a CFO who can explore the issue. Smaller practices usually don’t have that kind of expertise.”
 

Where does automation go from here?

Until now, clinicians who want to fully automate prior authorizations would have to buy two products – one for medical procedures and one for prescriptions. This has to do with incompatible electronic transmission standards, which are used to digitize information, said Susan Lawson-Dawson, content marketing strategist for the vendor Myndshft Health.

Myndshft has long been selling automation software for medical prior authorizations, but now it is introducing a product for prescriptions, Ms. Lawson-Dawson said. She said Myndshft will then be the only vendor to automate both kinds of prior authorizations.

Ms. Lawson-Dawson said Myndshft has 685 customers to date and is looking for more business. Recently the company entered the Google Cloud Marketplace. Google Cloud customers can now direct their committed spend with Google to purchasing Myndshft, meaning they could get it at a discount.

Software like Olive and Myndshft can operate independently of payers, but a vendor called Rhyme depends on payers for its software to function, said Rhyme CEO Joe Anstine. He said more than 300 payers have agreed to install the Rhyme system, and Rhyme has signed up a number of large health systems to use the product. Initially, he said, clinicians paid for the service, but now Rhyme is beginning to find payers to foot the costs and to let clinicians use it for free, which would open Rhyme up to smaller practices.

EHR companies themselves are beginning to offer automation, too. Epic, for example, has created a tool for prior authorization as part of its Epic Payer Platform. Like Rhyme, it requires payer cooperation, because information goes back and forth between clinician and payer in what is called bi-directional exchange.

The Epic product is still in its pilot phase. Epic reported that several large health systems were using its product in conjunction with a specific payer – for instance, Mayo Clinic with Blue Cross and Blue Shield of Minnesota and Ochsner Health with Humana. According to Epic, the arrangement reduced Mayo’s denials due to additional documentation requests by 63% for professional billing.

Automating with just one payer still means the clinician has to deal with manual processes at other payers, but a large clinician could have sufficient volume with that one payer to make the arrangement useful.
 

Will payers automate prior authorization?

Ultimately, payers may take the automation business away from vendors, offering a free product to all clinicians. But don’t hold your breath. Payers first have to rebuild their electronic systems to accommodate an electronic connection with providers. Even then, some payers might hold back from automating, forcing practices to continue manually processing some prior authorizations.

Efforts are underway, however, to mandate payers to support prior authorization automation. For this to happen, payers would have to revamp their data so that it could be easily read by practices’ EHRs. This would mean adopting a specific interoperability standard called Health Level 7 Fast Healthcare Interoperability Resources (FHIR).

Toward this goal, the Centers for Medicare & Medicaid Services proposes to require payers to adopt FHIR by January 2026. (CMS still has to finalize the rule.) Experts say the two-year ramp-up time is needed because it takes extensive work for payers to translate their data into FHIR.

The only payer so far to switch to FHIR for prior authorization is Regence in Washington state. In a pilot project, it has automated prior authorization with just one provider, MultiCare Connected Care, an accountable care organization (ACO), also in Washington state.

Anna Taylor, associate vice president of population health and value-based care at MultiCare, explained how the arrangement works. “Two separate entities are sharing one operational process,” she told this news organization. “That means they can have a digital conversation back and forth, so it is much easier to resolve prior authorization issues.” 

Unlike many vendor products, the Regence service is free. And while the vendors market only to large organizations, most doctors in the MultiCare arrangement are in independent practices. Ms. Taylor said these doctors have been “enthusiastic” about the arrangement.

The results of the pilot are impressive. Ms. Taylor said automation has resulted in a 233% productivity gain for MultiCare clinicians, and 89% of submissions to Regence get an immediate response.

There is a potential downside, however, to working directly with payers. A direct connection to clinicians allows payers to access the doctor’s clinical notes, which could make many doctors uneasy. But Ms. Taylor said Regence only has access to the “discrete data fields” on MultiCare’s EHR dashboard, not to the notes themselves.

The ultimate goal of the Regence-Multicare project is to include more payers and clinicians. Ms. Taylor said two of the 27 other payers that MultiCare works with are “highly interested,” but it would take a lot of work for them to get connected with practices and other clinicians. 

Ultimately, payers could offer automation and third-party vendors might then fade away. However, physicians may resist working directly with payers if the arrangement requires full access to their medical records.

A version of this article first appeared on Medscape.com.

New England Baptist Hospital has been grappling with a serious problem facing health care today: insurers demanding prior authorizations for services ordered by physicians. Meeting payers’ requirements eats up time, delays treatment, and can be a costly drain on doctors’ practices. 

To deal with this problem, the Boston orthopedic hospital has opted to automate submission of prior authorization requests on behalf of more than 100 mostly orthopedic surgeons on staff. 

After 5 years using this system, “we can say that automation definitely works,” said Lidiya Hadzhieva, director of patient access at the hospital. The software has reduced write-offs by 30% and staff costs by 25%. Prior authorization gets approved 3 days after scheduling, compared with 11 days previously, she said.

“This software not only saves staff time, but it can also more accurately predict when prior authorization is needed,” she added.

For practices deluged with required prior authorizations by insurers, automation is emerging as a way for practices to make the process less time-consuming and save money. However, the software can be costly and may not be adoptable to many practices, and many physicians are not even aware it exists.

So far, the software is mainly used at large organizations like hospital systems. But as word gets out and the software becomes easier to use, private practices and other smaller entities may join the automation trend.

There is definitely a need to automate prior authorization. The American Medical Association reports that physicians spend 16 hours per week on prior authorizations. In a recent AMA survey, more than 60% of physicians indicated that it’s difficult to know when prior authorization is needed. And 93% of physicians reported care delays while waiting for authorization, the AMA said.  

Experts estimate that 80% of prior authorization work could be automated, but most practices still use the phone or fax, even as numbers of prior authorizations continue to increase.
 

How it works

Automation software connects directly to the practice’s electronic health record (EHR). “When the doctor places an order in the EHR, the process starts automatically,” Ms. Hadzhieva said. “The doctor may not even notice it.” 

In addition to using an EHR connection, many software products can communicate with the payer through its portal or by fax or phone, while still automating other parts of the process.

The software’s first step is to decide whether prior authorization is needed. This requires having an updated list of the rules that each payer uses for prior authorization. Manually keeping track of payer rules is very time-consuming, but automation uses bots to visit each payer site to look for rules changes. One vendor, Infinitus, uses a voice-based bot called Eva that calls up each payer and speaks with a representative.

“Automatically updating payer rules is not a new technology,” said YiDing Yu, MD, chief product officer at Olive, the automation vendor for New England Baptist. “What is new in the last 5 years is extracting the information needed for the prior authorization out of the clinical notes.”

This is challenging because each doctor has different ways to describe each step of clinical work. To identify this shorthand, Dr. Yu said Olive uses natural language processing, which is a form of artificial intelligence that learns how each doctor describes things.

Dr. Yu asserts that Olive is actually better than a practice’s staff at digging out clinical information. She said staff without much clinical training may miss terms that the software can catch, and they don’t have the time to go back many months into the record to find valuable information. But automation can do that.

In some instances, however, the software may not be able to find the information, in which case it alerts staff through a prompt in the EHR and the information is retrieved manually, Dr. Yu said.

Next, the Olive software puts the information it found into the request form and sends it to the payer. After submission, the software constantly checks on the status of each request, again visiting payer sites with a bot.

At New England Baptist, the software is used mainly by physicians in fairly small private practices who are on staff. They are using the software on the hospital’s dime, but it only works inside the hospital, Ms. Hadzhieva said. For their work outside of the hospital, they would have to purchase the Olive software on their own, she said.
 

Automation hasn’t spread to practices yet

Despite the promising outcomes for products like Olive, automation software is still primarily used by large organizations. Vendors say very few private practices have bought it yet. “The technology works, but it is still in the early-adopter phase,” Dr. Yu said.

For one thing, the software can be expensive. Very few vendors reveal their prices, but Dr. Yu did so. She said Olive normally costs about $50,000 a year for even a small organization. She insisted, however, that the savings from avoiding just one denial each month for a hip surgery would justify the expense.

On the other hand, some automation software is free, such as the Surescripts product for prior authorization of prescriptions. But it is unclear whether Surescripts does as much as Olive. Vendors’ descriptions of their products tend to be vague.

Also, Surescripts and Olive have entirely separate functions. Dr. Yu said Olive is limited to procedures, so it benefits specialties like oncology, neurosurgery, colorectal surgery, vascular surgery, and cardiology. Olive does not cover prescriptions, because they operate on a different technology.

Dr. Yu said another hurdle for adopting the software is the kind of EHR systems that doctors use. At this point, only a few EHR systems – such as Epic, Cerner, and Athena – are compatible with Olive. Large organizations tend to use Epic and Cerner, while many practices often use Athena or a variety of other systems, she said.

Despite stunted demand, there is no shortage of companies offering automation software for medical (that is, non-prescription) prior authorization. One compilation lists 25 such vendors, including companies like Myndshft, Rhyme, Infinitus, Infinx, and Waystar. As with any start-up technology, companies occasionally buy each other out.

In addition to issues like cost, specialty, and EHR compatibility, another hurdle is that few doctors even know the technology exists. Vendors say marketing focuses on larger provider organizations, not smaller practices.

Even many tech-savvy doctors, like Adam Bruggeman, MD, an orthopedist and CEO of Texas Spine Care Center in San Antonio, say they know little about the technology. “There is definitely a need to automate prior authorization,” he said. “But I don’t know of any colleagues who use it.” He has only just begun to explore vendors, he said.

Many medical practice consultants also have not yet explored the technology. “Automation makes a lot of sense, because there are a lot of repetitive tasks in prior authorization,” said Jill Arena, CEO of Portland, Ore.–based Health e Practices. “But I haven’t looked into it yet, and none of my clients has even asked about it.”

“I could see how it could be an easier sell for large organizations,” she added. “They have an IT person and a CFO who can explore the issue. Smaller practices usually don’t have that kind of expertise.”
 

Where does automation go from here?

Until now, clinicians who want to fully automate prior authorizations would have to buy two products – one for medical procedures and one for prescriptions. This has to do with incompatible electronic transmission standards, which are used to digitize information, said Susan Lawson-Dawson, content marketing strategist for the vendor Myndshft Health.

Myndshft has long been selling automation software for medical prior authorizations, but now it is introducing a product for prescriptions, Ms. Lawson-Dawson said. She said Myndshft will then be the only vendor to automate both kinds of prior authorizations.

Ms. Lawson-Dawson said Myndshft has 685 customers to date and is looking for more business. Recently the company entered the Google Cloud Marketplace. Google Cloud customers can now direct their committed spend with Google to purchasing Myndshft, meaning they could get it at a discount.

Software like Olive and Myndshft can operate independently of payers, but a vendor called Rhyme depends on payers for its software to function, said Rhyme CEO Joe Anstine. He said more than 300 payers have agreed to install the Rhyme system, and Rhyme has signed up a number of large health systems to use the product. Initially, he said, clinicians paid for the service, but now Rhyme is beginning to find payers to foot the costs and to let clinicians use it for free, which would open Rhyme up to smaller practices.

EHR companies themselves are beginning to offer automation, too. Epic, for example, has created a tool for prior authorization as part of its Epic Payer Platform. Like Rhyme, it requires payer cooperation, because information goes back and forth between clinician and payer in what is called bi-directional exchange.

The Epic product is still in its pilot phase. Epic reported that several large health systems were using its product in conjunction with a specific payer – for instance, Mayo Clinic with Blue Cross and Blue Shield of Minnesota and Ochsner Health with Humana. According to Epic, the arrangement reduced Mayo’s denials due to additional documentation requests by 63% for professional billing.

Automating with just one payer still means the clinician has to deal with manual processes at other payers, but a large clinician could have sufficient volume with that one payer to make the arrangement useful.
 

Will payers automate prior authorization?

Ultimately, payers may take the automation business away from vendors, offering a free product to all clinicians. But don’t hold your breath. Payers first have to rebuild their electronic systems to accommodate an electronic connection with providers. Even then, some payers might hold back from automating, forcing practices to continue manually processing some prior authorizations.

Efforts are underway, however, to mandate payers to support prior authorization automation. For this to happen, payers would have to revamp their data so that it could be easily read by practices’ EHRs. This would mean adopting a specific interoperability standard called Health Level 7 Fast Healthcare Interoperability Resources (FHIR).

Toward this goal, the Centers for Medicare & Medicaid Services proposes to require payers to adopt FHIR by January 2026. (CMS still has to finalize the rule.) Experts say the two-year ramp-up time is needed because it takes extensive work for payers to translate their data into FHIR.

The only payer so far to switch to FHIR for prior authorization is Regence in Washington state. In a pilot project, it has automated prior authorization with just one provider, MultiCare Connected Care, an accountable care organization (ACO), also in Washington state.

Anna Taylor, associate vice president of population health and value-based care at MultiCare, explained how the arrangement works. “Two separate entities are sharing one operational process,” she told this news organization. “That means they can have a digital conversation back and forth, so it is much easier to resolve prior authorization issues.” 

Unlike many vendor products, the Regence service is free. And while the vendors market only to large organizations, most doctors in the MultiCare arrangement are in independent practices. Ms. Taylor said these doctors have been “enthusiastic” about the arrangement.

The results of the pilot are impressive. Ms. Taylor said automation has resulted in a 233% productivity gain for MultiCare clinicians, and 89% of submissions to Regence get an immediate response.

There is a potential downside, however, to working directly with payers. A direct connection to clinicians allows payers to access the doctor’s clinical notes, which could make many doctors uneasy. But Ms. Taylor said Regence only has access to the “discrete data fields” on MultiCare’s EHR dashboard, not to the notes themselves.

The ultimate goal of the Regence-Multicare project is to include more payers and clinicians. Ms. Taylor said two of the 27 other payers that MultiCare works with are “highly interested,” but it would take a lot of work for them to get connected with practices and other clinicians. 

Ultimately, payers could offer automation and third-party vendors might then fade away. However, physicians may resist working directly with payers if the arrangement requires full access to their medical records.

A version of this article first appeared on Medscape.com.

You can’t argue with success, unless you are an insurance company faced with covering medications shown to improve obesity.

The ability of drugs originally designed for diabetes management to reduce body weight has spiked demand and taxed supplies, according to the U.S. Food and Drug Administration, which included semaglutide (both Wegovy and Ozempic) on its Drug Shortages List as of May 31, 2023.

Meanwhile, clinicians and patients report that insurance companies are pushing back against coverage of these medications that mimic glucagon-like peptide 1 (GLP-1) because of the costs. A recent study conducted by Prime Therapeutics, a pharmacy benefit management organization, showed that individuals who started GLP-1 drugs for weight loss and who were adherent to the treatment averaged a 59% increase in health care costs after 1 year; for those in a subgroup analysis who were treatment adherent, the increase in health care costs was 98%.

“Insurance coverage for obesity treatment is challenging, particularly regarding medications,” said Scott Kahan, MD, director of the National Center for Weight and Wellness at George Washington University, Washington, in an interview. Employers must opt in for patients to have coverage for these medications; therefore, relatively few patients have had access at reasonable out-of-pocket costs, he said.

For example, the University of Texas stated on its website that its prescription drug plans will no longer cover drugs with the active ingredients semaglutide (Wegovy) or liraglutide (Saxenda) for weight loss as of Sept. 1, 2023. Both products are FDA-approved for weight management, whereas the equally popular Ozempic is currently approved only as a treatment for diabetes. The school’s website noted that the current price of the drugs, which cost the plan more than $5 million per month as of May 2023, outstrips the most expensive cancer agents.

The University of Texas also found that among its patients, the compliance rate for those who began Wegovy or Saxenda for weight loss was only 46%, which was not enough to justify continued coverage. The plan advised patients to approach their insurers directly.

Eventually, more information may prompt more support from insurance across a range of medications, Dr. Kahan noted. “Most insurers are wanting cost-effectiveness data in order to support their investments in broader coverage,” he said.

However, costs do vary with and without insurance; some medications are less expensive than others without significant differences in outcomes, so encourage patients to explore all the options and not just one brand, Dr. Kahan said.
 

Educate patients on plan details

Clinicians can’t guarantee coverage, but they can offer guidance to their patients, according to said Andrew Kraftson, MD, an endocrinologist and internal medicine physician at the University of Michigan, Ann Arbor, who specializes in the care of people with obesity.

Unfortunately, some of the challenges to obtaining insurance coverage for weight-loss medications lie in the plan details because some insurers have a blanket prohibition against the use of weight-loss medications, he said.

If patients did not look for this particular aspect of coverage at the time of enrollment in their chosen plan, they may not have known about this exclusion, and they are disappointed to find that they are ineligible for weight-loss medications despite medical circumstances, Dr. Kraftson said in an interview.

If weight-loss medications are covered, prior authorization often is required, Dr. Kraftson added.

“Unfortunately, the requirements vary from insurer to insurer, and this can present challenges for the busy clinicians who may not have dedicated staff to assist with these authorizations. Sometimes, the requirements are exactingly particular, and denials can commonly occur,” he said.

Some insurers will cover weight-loss medications for an initial period then require a certain degree of weight loss before renewing the approval, Dr. Kraftson said.

“While this is reasonable, sometimes it is necessary to titrate a medication more slowly to help a patient get used to the medicine, so they may not reach the required weight loss in the time required by the insurer,” he said. “As such, the medical professional is ‘punished’ for trying to be safe and patient-sensitive, and the patient may lose coverage of the medicine.”

Clinicians can help patients increase their chances for insurance coverage by providing a patient instruction guide to walk them through the steps that allow the patient to make inquiries with their own insurer, Dr. Kraftson said.

This guide should instruct patients on how to read their prescription coverage card to correctly contact their insurer, along with a guide to medical coverage terminology.

Lauren Oshman, MD, also of the University of Michigan, heads a collaborative quality initiative in the state known as Michigan Collaborative for Type 2 Diabetes (MCT2D). Dr. Oshman and her colleagues created a user-friendly list of terms to help patients understand their plans and better advocate for coverage (see below). The list was designed to guide patients with diabetes but applies to any medication.
 

Learn the lingo (common insurance terms and definitions)

• Deductible: Predetermined amount that must be paid annually before insurance pays for anything.
• Copayment: Set amount paid for a prescription.
• Coinsurance: Amount you pay after your deductible is met. Your insurance pays their portion. Coinsurance only applies to prescriptions and services covered under your health plan.
• Medication tier: Levels of insurance medication coverage; you play a smaller amount for a lower tier and a higher amount for a higher tier.
• Out-of-pocket max: Annual limit on what you pay before insurance covers 100% of covered services. Deductibles, copayment, and coinsurance all apply toward your out-of-pocket maximum.
• Prior authorization: Request made by your doctor to insurance company for coverage of a medication.
• Quantity limit: Limitation on the number of pills covered for a period of time.
• Step therapy: Medication you must have tried prior to approval of a nonpreferred medication, typically prior to trying a more expensive medication.

(Source: Learn the Lingo: A Guide to Common Insurance Terms and Definitions, courtesy of Lauren Oshman, MD, and MCT2D)

Also, make sure patients understand that they need to find out whether they have a deductible and if so, how much it is, Dr. Kraftson said.

Pros and cons of compounding

Compounded drugs are not approved by the FDA; however, that does not mean they are not available, and patients may pursue them as an option for weight-loss drugs.

In a statement issued on May 31, 2023, the FDA cited reports of adverse events associated with the use of compounded weight-loss drugs as a lower-cost alternative to the approved product. The FDA emphasized that the agency does not review compounded versions of weight-loss drugs for safety, efficacy, or quality.

Dr. Kraftson cited the lack of quality control, transparency, and safety data as reasons to discourage his patients from pursuing compounded medications.

“If a patient insists on pursuing it, then I review the position statement from the Obesity Medicine Association,” he said. The OMA statement recommends that anti-obesity medications undergo clinical trials and noted the lack of FDA oversight on these products. The OMA statement also advises compounded peptides to be “legally produced by companies whose identities are readily disclosed, and who have documented manufacturing processes compliant with oversight by applicable regulatory agencies.”
 

Tracking outcomes might boost coverage

Robust data on the long-term cost-effectiveness of weight-loss medications are lacking, although this is changing, Dr. Kraftson said. A 2022 study published last year in the Journal of Managed Care and Specialty Pharmacy showed that a 2.4-mg dose of semaglutide was cost-effective, compared with no treatment, diet and exercise, and other anti-obesity medications based on gains in quality of life.

“Regardless, insurers are not as motivated by long-term cost effectiveness,” Dr. Kraftson said. Insurers are accustomed to employee turnover and are more likely to be motivated by short-term costs and benefits, he said. “Obesity treatment provides some short-term benefit, but the majority of the benefit can be experienced when we look at the long-term horizon,” he said.

Looking ahead, “We need better ways to account for the myriad benefits experienced by patients with successful weight control beyond what is currently measured as metrics of success, including better ways to qualify and quantify quality-of-life benefits,” Dr. Kraftson said.

Also, clinicians should address the stigma associated with obesity, Dr. Kraftson said.

“We would not see the spate of coverage restrictions if we were talking about heart disease or cancer; insurers can get away with this because obesity is held to a different standard and patients with obesity are used to being undertreated and mistreated by the medical community and society,” he said. “We need to better account for the true costs of excess weight/obesity beyond what is traditionally accepted. This would help make the case for the cost-effective nature of treatment.”

Dr. Kraftson and Dr. Oshman disclosed no relevant financial relationships. Dr. Kahan had no financial conflicts and serves on the Medscape Editorial Advisory Board.

You can’t argue with success, unless you are an insurance company faced with covering medications shown to improve obesity.

The ability of drugs originally designed for diabetes management to reduce body weight has spiked demand and taxed supplies, according to the U.S. Food and Drug Administration, which included semaglutide (both Wegovy and Ozempic) on its Drug Shortages List as of May 31, 2023.

Meanwhile, clinicians and patients report that insurance companies are pushing back against coverage of these medications that mimic glucagon-like peptide 1 (GLP-1) because of the costs. A recent study conducted by Prime Therapeutics, a pharmacy benefit management organization, showed that individuals who started GLP-1 drugs for weight loss and who were adherent to the treatment averaged a 59% increase in health care costs after 1 year; for those in a subgroup analysis who were treatment adherent, the increase in health care costs was 98%.

“Insurance coverage for obesity treatment is challenging, particularly regarding medications,” said Scott Kahan, MD, director of the National Center for Weight and Wellness at George Washington University, Washington, in an interview. Employers must opt in for patients to have coverage for these medications; therefore, relatively few patients have had access at reasonable out-of-pocket costs, he said.

For example, the University of Texas stated on its website that its prescription drug plans will no longer cover drugs with the active ingredients semaglutide (Wegovy) or liraglutide (Saxenda) for weight loss as of Sept. 1, 2023. Both products are FDA-approved for weight management, whereas the equally popular Ozempic is currently approved only as a treatment for diabetes. The school’s website noted that the current price of the drugs, which cost the plan more than $5 million per month as of May 2023, outstrips the most expensive cancer agents.

The University of Texas also found that among its patients, the compliance rate for those who began Wegovy or Saxenda for weight loss was only 46%, which was not enough to justify continued coverage. The plan advised patients to approach their insurers directly.

Eventually, more information may prompt more support from insurance across a range of medications, Dr. Kahan noted. “Most insurers are wanting cost-effectiveness data in order to support their investments in broader coverage,” he said.

However, costs do vary with and without insurance; some medications are less expensive than others without significant differences in outcomes, so encourage patients to explore all the options and not just one brand, Dr. Kahan said.
 

Educate patients on plan details

Clinicians can’t guarantee coverage, but they can offer guidance to their patients, according to said Andrew Kraftson, MD, an endocrinologist and internal medicine physician at the University of Michigan, Ann Arbor, who specializes in the care of people with obesity.

Unfortunately, some of the challenges to obtaining insurance coverage for weight-loss medications lie in the plan details because some insurers have a blanket prohibition against the use of weight-loss medications, he said.

If patients did not look for this particular aspect of coverage at the time of enrollment in their chosen plan, they may not have known about this exclusion, and they are disappointed to find that they are ineligible for weight-loss medications despite medical circumstances, Dr. Kraftson said in an interview.

If weight-loss medications are covered, prior authorization often is required, Dr. Kraftson added.

“Unfortunately, the requirements vary from insurer to insurer, and this can present challenges for the busy clinicians who may not have dedicated staff to assist with these authorizations. Sometimes, the requirements are exactingly particular, and denials can commonly occur,” he said.

Some insurers will cover weight-loss medications for an initial period then require a certain degree of weight loss before renewing the approval, Dr. Kraftson said.

“While this is reasonable, sometimes it is necessary to titrate a medication more slowly to help a patient get used to the medicine, so they may not reach the required weight loss in the time required by the insurer,” he said. “As such, the medical professional is ‘punished’ for trying to be safe and patient-sensitive, and the patient may lose coverage of the medicine.”

Clinicians can help patients increase their chances for insurance coverage by providing a patient instruction guide to walk them through the steps that allow the patient to make inquiries with their own insurer, Dr. Kraftson said.

This guide should instruct patients on how to read their prescription coverage card to correctly contact their insurer, along with a guide to medical coverage terminology.

Lauren Oshman, MD, also of the University of Michigan, heads a collaborative quality initiative in the state known as Michigan Collaborative for Type 2 Diabetes (MCT2D). Dr. Oshman and her colleagues created a user-friendly list of terms to help patients understand their plans and better advocate for coverage (see below). The list was designed to guide patients with diabetes but applies to any medication.
 

Learn the lingo (common insurance terms and definitions)

• Deductible: Predetermined amount that must be paid annually before insurance pays for anything.
• Copayment: Set amount paid for a prescription.
• Coinsurance: Amount you pay after your deductible is met. Your insurance pays their portion. Coinsurance only applies to prescriptions and services covered under your health plan.
• Medication tier: Levels of insurance medication coverage; you play a smaller amount for a lower tier and a higher amount for a higher tier.
• Out-of-pocket max: Annual limit on what you pay before insurance covers 100% of covered services. Deductibles, copayment, and coinsurance all apply toward your out-of-pocket maximum.
• Prior authorization: Request made by your doctor to insurance company for coverage of a medication.
• Quantity limit: Limitation on the number of pills covered for a period of time.
• Step therapy: Medication you must have tried prior to approval of a nonpreferred medication, typically prior to trying a more expensive medication.

(Source: Learn the Lingo: A Guide to Common Insurance Terms and Definitions, courtesy of Lauren Oshman, MD, and MCT2D)

Also, make sure patients understand that they need to find out whether they have a deductible and if so, how much it is, Dr. Kraftson said.

Pros and cons of compounding

Compounded drugs are not approved by the FDA; however, that does not mean they are not available, and patients may pursue them as an option for weight-loss drugs.

In a statement issued on May 31, 2023, the FDA cited reports of adverse events associated with the use of compounded weight-loss drugs as a lower-cost alternative to the approved product. The FDA emphasized that the agency does not review compounded versions of weight-loss drugs for safety, efficacy, or quality.

Dr. Kraftson cited the lack of quality control, transparency, and safety data as reasons to discourage his patients from pursuing compounded medications.

“If a patient insists on pursuing it, then I review the position statement from the Obesity Medicine Association,” he said. The OMA statement recommends that anti-obesity medications undergo clinical trials and noted the lack of FDA oversight on these products. The OMA statement also advises compounded peptides to be “legally produced by companies whose identities are readily disclosed, and who have documented manufacturing processes compliant with oversight by applicable regulatory agencies.”
 

Tracking outcomes might boost coverage

Robust data on the long-term cost-effectiveness of weight-loss medications are lacking, although this is changing, Dr. Kraftson said. A 2022 study published last year in the Journal of Managed Care and Specialty Pharmacy showed that a 2.4-mg dose of semaglutide was cost-effective, compared with no treatment, diet and exercise, and other anti-obesity medications based on gains in quality of life.

“Regardless, insurers are not as motivated by long-term cost effectiveness,” Dr. Kraftson said. Insurers are accustomed to employee turnover and are more likely to be motivated by short-term costs and benefits, he said. “Obesity treatment provides some short-term benefit, but the majority of the benefit can be experienced when we look at the long-term horizon,” he said.

Looking ahead, “We need better ways to account for the myriad benefits experienced by patients with successful weight control beyond what is currently measured as metrics of success, including better ways to qualify and quantify quality-of-life benefits,” Dr. Kraftson said.

Also, clinicians should address the stigma associated with obesity, Dr. Kraftson said.

“We would not see the spate of coverage restrictions if we were talking about heart disease or cancer; insurers can get away with this because obesity is held to a different standard and patients with obesity are used to being undertreated and mistreated by the medical community and society,” he said. “We need to better account for the true costs of excess weight/obesity beyond what is traditionally accepted. This would help make the case for the cost-effective nature of treatment.”

Dr. Kraftson and Dr. Oshman disclosed no relevant financial relationships. Dr. Kahan had no financial conflicts and serves on the Medscape Editorial Advisory Board.

You can’t argue with success, unless you are an insurance company faced with covering medications shown to improve obesity.

The ability of drugs originally designed for diabetes management to reduce body weight has spiked demand and taxed supplies, according to the U.S. Food and Drug Administration, which included semaglutide (both Wegovy and Ozempic) on its Drug Shortages List as of May 31, 2023.

Meanwhile, clinicians and patients report that insurance companies are pushing back against coverage of these medications that mimic glucagon-like peptide 1 (GLP-1) because of the costs. A recent study conducted by Prime Therapeutics, a pharmacy benefit management organization, showed that individuals who started GLP-1 drugs for weight loss and who were adherent to the treatment averaged a 59% increase in health care costs after 1 year; for those in a subgroup analysis who were treatment adherent, the increase in health care costs was 98%.

“Insurance coverage for obesity treatment is challenging, particularly regarding medications,” said Scott Kahan, MD, director of the National Center for Weight and Wellness at George Washington University, Washington, in an interview. Employers must opt in for patients to have coverage for these medications; therefore, relatively few patients have had access at reasonable out-of-pocket costs, he said.

For example, the University of Texas stated on its website that its prescription drug plans will no longer cover drugs with the active ingredients semaglutide (Wegovy) or liraglutide (Saxenda) for weight loss as of Sept. 1, 2023. Both products are FDA-approved for weight management, whereas the equally popular Ozempic is currently approved only as a treatment for diabetes. The school’s website noted that the current price of the drugs, which cost the plan more than $5 million per month as of May 2023, outstrips the most expensive cancer agents.

The University of Texas also found that among its patients, the compliance rate for those who began Wegovy or Saxenda for weight loss was only 46%, which was not enough to justify continued coverage. The plan advised patients to approach their insurers directly.

Eventually, more information may prompt more support from insurance across a range of medications, Dr. Kahan noted. “Most insurers are wanting cost-effectiveness data in order to support their investments in broader coverage,” he said.

However, costs do vary with and without insurance; some medications are less expensive than others without significant differences in outcomes, so encourage patients to explore all the options and not just one brand, Dr. Kahan said.
 

Educate patients on plan details

Clinicians can’t guarantee coverage, but they can offer guidance to their patients, according to said Andrew Kraftson, MD, an endocrinologist and internal medicine physician at the University of Michigan, Ann Arbor, who specializes in the care of people with obesity.

Unfortunately, some of the challenges to obtaining insurance coverage for weight-loss medications lie in the plan details because some insurers have a blanket prohibition against the use of weight-loss medications, he said.

If patients did not look for this particular aspect of coverage at the time of enrollment in their chosen plan, they may not have known about this exclusion, and they are disappointed to find that they are ineligible for weight-loss medications despite medical circumstances, Dr. Kraftson said in an interview.

If weight-loss medications are covered, prior authorization often is required, Dr. Kraftson added.

“Unfortunately, the requirements vary from insurer to insurer, and this can present challenges for the busy clinicians who may not have dedicated staff to assist with these authorizations. Sometimes, the requirements are exactingly particular, and denials can commonly occur,” he said.

Some insurers will cover weight-loss medications for an initial period then require a certain degree of weight loss before renewing the approval, Dr. Kraftson said.

“While this is reasonable, sometimes it is necessary to titrate a medication more slowly to help a patient get used to the medicine, so they may not reach the required weight loss in the time required by the insurer,” he said. “As such, the medical professional is ‘punished’ for trying to be safe and patient-sensitive, and the patient may lose coverage of the medicine.”

Clinicians can help patients increase their chances for insurance coverage by providing a patient instruction guide to walk them through the steps that allow the patient to make inquiries with their own insurer, Dr. Kraftson said.

This guide should instruct patients on how to read their prescription coverage card to correctly contact their insurer, along with a guide to medical coverage terminology.

Lauren Oshman, MD, also of the University of Michigan, heads a collaborative quality initiative in the state known as Michigan Collaborative for Type 2 Diabetes (MCT2D). Dr. Oshman and her colleagues created a user-friendly list of terms to help patients understand their plans and better advocate for coverage (see below). The list was designed to guide patients with diabetes but applies to any medication.
 

Learn the lingo (common insurance terms and definitions)

• Deductible: Predetermined amount that must be paid annually before insurance pays for anything.
• Copayment: Set amount paid for a prescription.
• Coinsurance: Amount you pay after your deductible is met. Your insurance pays their portion. Coinsurance only applies to prescriptions and services covered under your health plan.
• Medication tier: Levels of insurance medication coverage; you play a smaller amount for a lower tier and a higher amount for a higher tier.
• Out-of-pocket max: Annual limit on what you pay before insurance covers 100% of covered services. Deductibles, copayment, and coinsurance all apply toward your out-of-pocket maximum.
• Prior authorization: Request made by your doctor to insurance company for coverage of a medication.
• Quantity limit: Limitation on the number of pills covered for a period of time.
• Step therapy: Medication you must have tried prior to approval of a nonpreferred medication, typically prior to trying a more expensive medication.

(Source: Learn the Lingo: A Guide to Common Insurance Terms and Definitions, courtesy of Lauren Oshman, MD, and MCT2D)

Also, make sure patients understand that they need to find out whether they have a deductible and if so, how much it is, Dr. Kraftson said.

Pros and cons of compounding

Compounded drugs are not approved by the FDA; however, that does not mean they are not available, and patients may pursue them as an option for weight-loss drugs.

In a statement issued on May 31, 2023, the FDA cited reports of adverse events associated with the use of compounded weight-loss drugs as a lower-cost alternative to the approved product. The FDA emphasized that the agency does not review compounded versions of weight-loss drugs for safety, efficacy, or quality.

Dr. Kraftson cited the lack of quality control, transparency, and safety data as reasons to discourage his patients from pursuing compounded medications.

“If a patient insists on pursuing it, then I review the position statement from the Obesity Medicine Association,” he said. The OMA statement recommends that anti-obesity medications undergo clinical trials and noted the lack of FDA oversight on these products. The OMA statement also advises compounded peptides to be “legally produced by companies whose identities are readily disclosed, and who have documented manufacturing processes compliant with oversight by applicable regulatory agencies.”
 

Tracking outcomes might boost coverage

Robust data on the long-term cost-effectiveness of weight-loss medications are lacking, although this is changing, Dr. Kraftson said. A 2022 study published last year in the Journal of Managed Care and Specialty Pharmacy showed that a 2.4-mg dose of semaglutide was cost-effective, compared with no treatment, diet and exercise, and other anti-obesity medications based on gains in quality of life.

“Regardless, insurers are not as motivated by long-term cost effectiveness,” Dr. Kraftson said. Insurers are accustomed to employee turnover and are more likely to be motivated by short-term costs and benefits, he said. “Obesity treatment provides some short-term benefit, but the majority of the benefit can be experienced when we look at the long-term horizon,” he said.

Looking ahead, “We need better ways to account for the myriad benefits experienced by patients with successful weight control beyond what is currently measured as metrics of success, including better ways to qualify and quantify quality-of-life benefits,” Dr. Kraftson said.

Also, clinicians should address the stigma associated with obesity, Dr. Kraftson said.

“We would not see the spate of coverage restrictions if we were talking about heart disease or cancer; insurers can get away with this because obesity is held to a different standard and patients with obesity are used to being undertreated and mistreated by the medical community and society,” he said. “We need to better account for the true costs of excess weight/obesity beyond what is traditionally accepted. This would help make the case for the cost-effective nature of treatment.”

Dr. Kraftson and Dr. Oshman disclosed no relevant financial relationships. Dr. Kahan had no financial conflicts and serves on the Medscape Editorial Advisory Board.

“What do you think about the whole Israel thing?”

That question came at the end of an otherwise routine appointment.

My answer surprised her, but she didn’t push it. She paid her copay, scheduled a follow-up for 3 months, and left.

As I’ve written before, I try to avoid all news except the local weather. The sad reality is that most of it is bad and there’s nothing I can really do about it. It only upsets me, which isn’t good for my mental health and blood pressure, and if I can’t change it, what’s the point of knowing? It falls under the serenity prayer.

Of course, some news stories are too big not to hear something. I pass TVs in the doctors lounge or coffee house, hear others talking as I stand in line for the elevator, or see blurbs go by when checking the weather. It’s not entirely unavoidable.

I’m not trivializing the Middle East. But, to me, it’s not part of the doctor-patient relationship any more than my political views are. You run the risk of driving a wedge between you and the person you’re caring for. If you don’t like their opinion, you may find yourself less interested in them and their care. If they don’t like your opinion on news, they may start to question your ability as a doctor.

That’s not what we strive for, but it can be human nature. For better or worse we often reduce things to “us against them,” and learning someone is on the opposite side may, even subconsciously, alter how you treat them.

That’s not good, so to me it’s best not to know.

Some may think I’m being petty, or aloof, to be unwilling to discuss nonmedical issues of significance, but I don’t see it that way. Time is limited at the appointment and is best spent on medical care. Something unrelated to the visit that may alter my objective opinion of a patient – or theirs of me as a doctor – is best left out of it.

I’m here to be your doctor, and to do the best I can for you. I’m not here to be a debate partner. Whenever a patient asks me a question on politics or news I always think of the Monty Python skit “Argument Clinic.” That’s not why you’re here. There are plenty places to discuss such things. My office isn’t one of them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“What do you think about the whole Israel thing?”

That question came at the end of an otherwise routine appointment.

My answer surprised her, but she didn’t push it. She paid her copay, scheduled a follow-up for 3 months, and left.

As I’ve written before, I try to avoid all news except the local weather. The sad reality is that most of it is bad and there’s nothing I can really do about it. It only upsets me, which isn’t good for my mental health and blood pressure, and if I can’t change it, what’s the point of knowing? It falls under the serenity prayer.

Of course, some news stories are too big not to hear something. I pass TVs in the doctors lounge or coffee house, hear others talking as I stand in line for the elevator, or see blurbs go by when checking the weather. It’s not entirely unavoidable.

I’m not trivializing the Middle East. But, to me, it’s not part of the doctor-patient relationship any more than my political views are. You run the risk of driving a wedge between you and the person you’re caring for. If you don’t like their opinion, you may find yourself less interested in them and their care. If they don’t like your opinion on news, they may start to question your ability as a doctor.

That’s not what we strive for, but it can be human nature. For better or worse we often reduce things to “us against them,” and learning someone is on the opposite side may, even subconsciously, alter how you treat them.

That’s not good, so to me it’s best not to know.

Some may think I’m being petty, or aloof, to be unwilling to discuss nonmedical issues of significance, but I don’t see it that way. Time is limited at the appointment and is best spent on medical care. Something unrelated to the visit that may alter my objective opinion of a patient – or theirs of me as a doctor – is best left out of it.

I’m here to be your doctor, and to do the best I can for you. I’m not here to be a debate partner. Whenever a patient asks me a question on politics or news I always think of the Monty Python skit “Argument Clinic.” That’s not why you’re here. There are plenty places to discuss such things. My office isn’t one of them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

“What do you think about the whole Israel thing?”

That question came at the end of an otherwise routine appointment.

My answer surprised her, but she didn’t push it. She paid her copay, scheduled a follow-up for 3 months, and left.

As I’ve written before, I try to avoid all news except the local weather. The sad reality is that most of it is bad and there’s nothing I can really do about it. It only upsets me, which isn’t good for my mental health and blood pressure, and if I can’t change it, what’s the point of knowing? It falls under the serenity prayer.

Of course, some news stories are too big not to hear something. I pass TVs in the doctors lounge or coffee house, hear others talking as I stand in line for the elevator, or see blurbs go by when checking the weather. It’s not entirely unavoidable.

I’m not trivializing the Middle East. But, to me, it’s not part of the doctor-patient relationship any more than my political views are. You run the risk of driving a wedge between you and the person you’re caring for. If you don’t like their opinion, you may find yourself less interested in them and their care. If they don’t like your opinion on news, they may start to question your ability as a doctor.

That’s not what we strive for, but it can be human nature. For better or worse we often reduce things to “us against them,” and learning someone is on the opposite side may, even subconsciously, alter how you treat them.

That’s not good, so to me it’s best not to know.

Some may think I’m being petty, or aloof, to be unwilling to discuss nonmedical issues of significance, but I don’t see it that way. Time is limited at the appointment and is best spent on medical care. Something unrelated to the visit that may alter my objective opinion of a patient – or theirs of me as a doctor – is best left out of it.

I’m here to be your doctor, and to do the best I can for you. I’m not here to be a debate partner. Whenever a patient asks me a question on politics or news I always think of the Monty Python skit “Argument Clinic.” That’s not why you’re here. There are plenty places to discuss such things. My office isn’t one of them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Can busy primary care offices continue to care for patients with diabetes? No one would argue that it is involved and takes effort, and health care providers are bankrupt when it comes to sparing additional time for this chronic disease. With roughly 37 million people living with diabetes and 96 million with prediabetes or early type 2 diabetes, and just over 8,000 practicing endocrinologists in the United States, we all need to make time especially in primary care to provide insight and holistic care. With limited time and budget, how do we do this?

First, decide to be involved in caring for patients with diabetes. Diabetes is best managed by interprofessional care teams, so you’re not going it alone. These teams may include physicians; pharmacists; physician assistants; advanced practice nurses; registered nurses; certified diabetes care and education specialists (CDCES); dietitians; and other professionals such as social workers, behavioral health professionals, medical assistants, and community health workers. Know which professionals are available to serve on your team, either within your clinic or as a consultant, and reach out to them to share the care and ease the burden. Remember to refer to these professionals to reinforce the diabetes intervention message to the patient.

Second, incorporate “diabetes only” appointments into your schedule, allowing time to focus on current comprehensive diabetes treatment goals, barriers/inertia for care. Remember to have short-interval follow-up as needed to keep that patient engaged to achieve their targets. Instruct your office staff to create diabetes appointment templates and reminders to patients to bring diabetes-related technologies, medication lists, and diabetes questions to the appointment. When I implemented this change, my patients welcomed the focus on their diabetes health, and they knew we were prioritizing this disease that they have for a lifetime. These appointments did not take away from their other conditions; rather, they often reminded me to stay focused on their diabetes and associated coconditions. 

Taking the time to establish efficient workflows before implementing diabetes care saves countless hours later and immediately maximizes health care provider–patient interactions. Assign specific staff duties and expectations related to diabetes appointments, such as downloading diabetes technology, medication reconciliation, laboratory data, point-of-care hemoglobin A1c, basic foot exam, and patient goals for diabetes care. This allows the prescriber to focus on the glycemic, cardiologic, renal, and metabolic goals and overcome the therapeutic inertia that plagues us all.

Incorporating diabetes-related technology into clinical practice can be a significant time-saver but requires initial onboarding. Set aside a few hours to create a technology clinic flow, and designate at least one team member to be responsible for obtaining patient data before, during, or after encounters. If possible, obtaining data ahead of the visit will enhance efficiency, allowing for meaningful discussion of blood glucose and lifestyle patterns. Diabetes technology reveals the gaps in care and enhances our ability to identify the areas where glycemic intervention is needed. In addition, it reveals the impact of food choices, activity level, stress, and medication adherence to the person living with diabetes. 

Finally, be proactive about therapeutic inertia. This is defined as a prescribers’ failure to intensify or deintensify a patient’s treatment when appropriate to do so. Causes of therapeutic inertia can be placed at the primary care physician level, including time constraints or inexperience in treating diabetes; the patient level, such as concerns about side effects or new treatment regimens; or a systemic level, such as availability of medications or their costs. Be real with yourself: We all have inertia and can identify areas to overcome. Never let inertia be traced back to you.

Not all inertia lives with the health care provider. Patients bring apprehension and concerns, have questions, and just want to share the frustrations associated with living their best life with the disease. Don’t assume that you know what your patients’ treatment barriers are; ask them. If you don’t have an answer, then note it and come up with one by the next follow-up. Remember that this is a chronic disease – a marathon, not a sprint. You don’t have to solve everything at one appointment; rather, keep the momentum going.

Let’s put this into clinical practice. For the next patient with diabetes who comes into your office, discuss with them your intention to prioritize their diabetes by having an appointment set aside to specifically focus on their individual goals and targets for their disease. Have the patient list any barriers and treatment goals they would like to review; flag your schedule to indicate it is a diabetes-only visit; and orient your staff to reconcile diabetes medications and record the patient’s last eye exam, urine albumin-to-creatinine ratio, A1c result, and blood glucose data. During this encounter, identify the patient’s personal targets for control, examine their feet, and review or order necessary laboratory metrics. Explore the patient-reported barriers and make inroads to remove or alleviate these. Advance treatment intervention, and schedule follow-up: every 4-6 weeks if the A1c is > 9%, every 2 months if it’s 7% to < 9%, and every 3-6 months if it’s < 7%. Utilize team diabetes care, such as CDCES referrals, dietitians, online resources, and community members, to help reinforce care and enhance engagement. 

We need to take steps in our clinical practice to make the necessary space to accommodate this pervasive disease affecting nearly one-third of our population. Take a moment to look up and determine what needs to be in place so that you can take care of the people in your practice with diabetes. Laying the groundwork for implementing diabetes-only appointments can be time-consuming, but establishing consistent procedures, developing efficient workflows, and clearly defining roles and responsibilities is well worth the effort. This solid foundation equips the office, health care providers, and staff to care for persons with diabetes and will be invaluable to ensure that time for this care is available in the day-to-day clinical practice.

A version of this article first appeared on Medscape.com.

Can busy primary care offices continue to care for patients with diabetes? No one would argue that it is involved and takes effort, and health care providers are bankrupt when it comes to sparing additional time for this chronic disease. With roughly 37 million people living with diabetes and 96 million with prediabetes or early type 2 diabetes, and just over 8,000 practicing endocrinologists in the United States, we all need to make time especially in primary care to provide insight and holistic care. With limited time and budget, how do we do this?

First, decide to be involved in caring for patients with diabetes. Diabetes is best managed by interprofessional care teams, so you’re not going it alone. These teams may include physicians; pharmacists; physician assistants; advanced practice nurses; registered nurses; certified diabetes care and education specialists (CDCES); dietitians; and other professionals such as social workers, behavioral health professionals, medical assistants, and community health workers. Know which professionals are available to serve on your team, either within your clinic or as a consultant, and reach out to them to share the care and ease the burden. Remember to refer to these professionals to reinforce the diabetes intervention message to the patient.

Second, incorporate “diabetes only” appointments into your schedule, allowing time to focus on current comprehensive diabetes treatment goals, barriers/inertia for care. Remember to have short-interval follow-up as needed to keep that patient engaged to achieve their targets. Instruct your office staff to create diabetes appointment templates and reminders to patients to bring diabetes-related technologies, medication lists, and diabetes questions to the appointment. When I implemented this change, my patients welcomed the focus on their diabetes health, and they knew we were prioritizing this disease that they have for a lifetime. These appointments did not take away from their other conditions; rather, they often reminded me to stay focused on their diabetes and associated coconditions. 

Taking the time to establish efficient workflows before implementing diabetes care saves countless hours later and immediately maximizes health care provider–patient interactions. Assign specific staff duties and expectations related to diabetes appointments, such as downloading diabetes technology, medication reconciliation, laboratory data, point-of-care hemoglobin A1c, basic foot exam, and patient goals for diabetes care. This allows the prescriber to focus on the glycemic, cardiologic, renal, and metabolic goals and overcome the therapeutic inertia that plagues us all.

Incorporating diabetes-related technology into clinical practice can be a significant time-saver but requires initial onboarding. Set aside a few hours to create a technology clinic flow, and designate at least one team member to be responsible for obtaining patient data before, during, or after encounters. If possible, obtaining data ahead of the visit will enhance efficiency, allowing for meaningful discussion of blood glucose and lifestyle patterns. Diabetes technology reveals the gaps in care and enhances our ability to identify the areas where glycemic intervention is needed. In addition, it reveals the impact of food choices, activity level, stress, and medication adherence to the person living with diabetes. 

Finally, be proactive about therapeutic inertia. This is defined as a prescribers’ failure to intensify or deintensify a patient’s treatment when appropriate to do so. Causes of therapeutic inertia can be placed at the primary care physician level, including time constraints or inexperience in treating diabetes; the patient level, such as concerns about side effects or new treatment regimens; or a systemic level, such as availability of medications or their costs. Be real with yourself: We all have inertia and can identify areas to overcome. Never let inertia be traced back to you.

Not all inertia lives with the health care provider. Patients bring apprehension and concerns, have questions, and just want to share the frustrations associated with living their best life with the disease. Don’t assume that you know what your patients’ treatment barriers are; ask them. If you don’t have an answer, then note it and come up with one by the next follow-up. Remember that this is a chronic disease – a marathon, not a sprint. You don’t have to solve everything at one appointment; rather, keep the momentum going.

Let’s put this into clinical practice. For the next patient with diabetes who comes into your office, discuss with them your intention to prioritize their diabetes by having an appointment set aside to specifically focus on their individual goals and targets for their disease. Have the patient list any barriers and treatment goals they would like to review; flag your schedule to indicate it is a diabetes-only visit; and orient your staff to reconcile diabetes medications and record the patient’s last eye exam, urine albumin-to-creatinine ratio, A1c result, and blood glucose data. During this encounter, identify the patient’s personal targets for control, examine their feet, and review or order necessary laboratory metrics. Explore the patient-reported barriers and make inroads to remove or alleviate these. Advance treatment intervention, and schedule follow-up: every 4-6 weeks if the A1c is > 9%, every 2 months if it’s 7% to < 9%, and every 3-6 months if it’s < 7%. Utilize team diabetes care, such as CDCES referrals, dietitians, online resources, and community members, to help reinforce care and enhance engagement. 

We need to take steps in our clinical practice to make the necessary space to accommodate this pervasive disease affecting nearly one-third of our population. Take a moment to look up and determine what needs to be in place so that you can take care of the people in your practice with diabetes. Laying the groundwork for implementing diabetes-only appointments can be time-consuming, but establishing consistent procedures, developing efficient workflows, and clearly defining roles and responsibilities is well worth the effort. This solid foundation equips the office, health care providers, and staff to care for persons with diabetes and will be invaluable to ensure that time for this care is available in the day-to-day clinical practice.

A version of this article first appeared on Medscape.com.

Can busy primary care offices continue to care for patients with diabetes? No one would argue that it is involved and takes effort, and health care providers are bankrupt when it comes to sparing additional time for this chronic disease. With roughly 37 million people living with diabetes and 96 million with prediabetes or early type 2 diabetes, and just over 8,000 practicing endocrinologists in the United States, we all need to make time especially in primary care to provide insight and holistic care. With limited time and budget, how do we do this?

First, decide to be involved in caring for patients with diabetes. Diabetes is best managed by interprofessional care teams, so you’re not going it alone. These teams may include physicians; pharmacists; physician assistants; advanced practice nurses; registered nurses; certified diabetes care and education specialists (CDCES); dietitians; and other professionals such as social workers, behavioral health professionals, medical assistants, and community health workers. Know which professionals are available to serve on your team, either within your clinic or as a consultant, and reach out to them to share the care and ease the burden. Remember to refer to these professionals to reinforce the diabetes intervention message to the patient.

Second, incorporate “diabetes only” appointments into your schedule, allowing time to focus on current comprehensive diabetes treatment goals, barriers/inertia for care. Remember to have short-interval follow-up as needed to keep that patient engaged to achieve their targets. Instruct your office staff to create diabetes appointment templates and reminders to patients to bring diabetes-related technologies, medication lists, and diabetes questions to the appointment. When I implemented this change, my patients welcomed the focus on their diabetes health, and they knew we were prioritizing this disease that they have for a lifetime. These appointments did not take away from their other conditions; rather, they often reminded me to stay focused on their diabetes and associated coconditions. 

Taking the time to establish efficient workflows before implementing diabetes care saves countless hours later and immediately maximizes health care provider–patient interactions. Assign specific staff duties and expectations related to diabetes appointments, such as downloading diabetes technology, medication reconciliation, laboratory data, point-of-care hemoglobin A1c, basic foot exam, and patient goals for diabetes care. This allows the prescriber to focus on the glycemic, cardiologic, renal, and metabolic goals and overcome the therapeutic inertia that plagues us all.

Incorporating diabetes-related technology into clinical practice can be a significant time-saver but requires initial onboarding. Set aside a few hours to create a technology clinic flow, and designate at least one team member to be responsible for obtaining patient data before, during, or after encounters. If possible, obtaining data ahead of the visit will enhance efficiency, allowing for meaningful discussion of blood glucose and lifestyle patterns. Diabetes technology reveals the gaps in care and enhances our ability to identify the areas where glycemic intervention is needed. In addition, it reveals the impact of food choices, activity level, stress, and medication adherence to the person living with diabetes. 

Finally, be proactive about therapeutic inertia. This is defined as a prescribers’ failure to intensify or deintensify a patient’s treatment when appropriate to do so. Causes of therapeutic inertia can be placed at the primary care physician level, including time constraints or inexperience in treating diabetes; the patient level, such as concerns about side effects or new treatment regimens; or a systemic level, such as availability of medications or their costs. Be real with yourself: We all have inertia and can identify areas to overcome. Never let inertia be traced back to you.

Not all inertia lives with the health care provider. Patients bring apprehension and concerns, have questions, and just want to share the frustrations associated with living their best life with the disease. Don’t assume that you know what your patients’ treatment barriers are; ask them. If you don’t have an answer, then note it and come up with one by the next follow-up. Remember that this is a chronic disease – a marathon, not a sprint. You don’t have to solve everything at one appointment; rather, keep the momentum going.

Let’s put this into clinical practice. For the next patient with diabetes who comes into your office, discuss with them your intention to prioritize their diabetes by having an appointment set aside to specifically focus on their individual goals and targets for their disease. Have the patient list any barriers and treatment goals they would like to review; flag your schedule to indicate it is a diabetes-only visit; and orient your staff to reconcile diabetes medications and record the patient’s last eye exam, urine albumin-to-creatinine ratio, A1c result, and blood glucose data. During this encounter, identify the patient’s personal targets for control, examine their feet, and review or order necessary laboratory metrics. Explore the patient-reported barriers and make inroads to remove or alleviate these. Advance treatment intervention, and schedule follow-up: every 4-6 weeks if the A1c is > 9%, every 2 months if it’s 7% to < 9%, and every 3-6 months if it’s < 7%. Utilize team diabetes care, such as CDCES referrals, dietitians, online resources, and community members, to help reinforce care and enhance engagement. 

We need to take steps in our clinical practice to make the necessary space to accommodate this pervasive disease affecting nearly one-third of our population. Take a moment to look up and determine what needs to be in place so that you can take care of the people in your practice with diabetes. Laying the groundwork for implementing diabetes-only appointments can be time-consuming, but establishing consistent procedures, developing efficient workflows, and clearly defining roles and responsibilities is well worth the effort. This solid foundation equips the office, health care providers, and staff to care for persons with diabetes and will be invaluable to ensure that time for this care is available in the day-to-day clinical practice.

A version of this article first appeared on Medscape.com.

Look at this guy – NFL Chargers jersey and shorts with a RVCA hat on backward. And next to him, a woman wearing her spin-class-Lulu gear. There’s also a guy sporting a 2016 San Diego Rock ‘n Roll Marathon Tee. And that young woman is actually wearing slippers. A visitor from the 1950s would be thunderstruck to see such casual wear on people waiting to board a plane. Photos from that era show men buttoned up in white shirt and tie and women wearing Chanel with hats and white gloves. This dramatic transformation from formal to unfussy wear cuts through all social situations, including in my office. As a new doc out of residency, I used to wear a tie and shoes that could hold a shine. Now I wear jogger scrubs and sneakers. Rather than be offended by the lack of formality though, patients seem to appreciate it. Should they?

At first glance this seems to be a modern phenomenon. The reasons for casual wear today are manifold: about one-third of people work from home, Millennials are taking over with their TikTok values and general irreverence, COVID made us all fat and lazy. Heck, even the U.S. Senate briefly abolished the requirement to wear suits on the Senate floor. But getting dressed up was never to signal that you are elite or superior to others. It’s the opposite. To get dressed is a signal that you are serving others, a tradition that is as old as society.

Kaiser Permanente

Think of Downton Abbey as an example. The servants were always required to be smartly dressed when working, whereas members of the family could be dressed up or not. It’s clear who is serving whom. This tradition lives today in the hospitality industry. When you mosey into the lobby of a luxury hotel in your Rainbow sandals you can expect everyone who greets you will be in finery, signaling that they put in effort to serve you. You’ll find the same for all staff at the Mayo Clinic in Rochester, Minn., which is no coincidence.

Suits used to be standard in medicine. In the 19th century, physicians wore formal black-tie when seeing patients. Unlike hospitality however, we had good reason to eschew the tradition: germs. Once we figured out that our pus-stained ties and jackets were doing harm, we switched to wearing sanitized uniforms. Casual wear for doctors isn’t a modern phenomenon after all, then. For proof, compare Thomas Eakins painting “The Gross Clinic” (1875) with his later “The Agnew Clinic” (1889). In the former, Dr. Gross is portrayed in formal black wear, bloody hand and all. In the latter, Dr. Agnew is wearing white FIGS (or the 1890’s equivalent anyway). Similarly, nurses uniforms traditionally resembled kitchen servants, with criss-cross aprons and floor length skirts. It wasn’t until the 1980’s that nurses stopped wearing dresses and white caps.

photo of painting MiguelHermoso/CC-BY-SA-4.0

In the operating theater it’s obviously critical that we wear sanitized scrubs to mitigate the risk of infection. Originally white to signal cleanliness, scrubs were changed to blue-green because surgeons were blinded by the lights bouncing off the uniforms. (Green is also opposite red on the color wheel, supposedly enhancing the ability to distinguish shades of red).

But in outpatient medicine, the effect size for preventing infection by not wearing a tie or jacket is less obvious. In addition to protecting patients, it seems that wearing scrubs and donning On Cloud sneakers might also be a bit of push-back from us. Over time we’ve lost significant autonomy in our practice and lost a little respect from our patients. Payers tell us what to do. Patients question our expertise. Choosing what we wear is one of the few bits of medicine we still have agency. Pewter or pink, joggers or cargo pants, we get to choose.

The last time I flew British Airways everyone was in lounge wear, except the flight crew, of course. They were all smartly dressed. Recently British Airways rolled out updated, slightly more relaxed dress codes. Very modern, but I wonder if in a way we’re not all just a bit worse off.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]

Look at this guy – NFL Chargers jersey and shorts with a RVCA hat on backward. And next to him, a woman wearing her spin-class-Lulu gear. There’s also a guy sporting a 2016 San Diego Rock ‘n Roll Marathon Tee. And that young woman is actually wearing slippers. A visitor from the 1950s would be thunderstruck to see such casual wear on people waiting to board a plane. Photos from that era show men buttoned up in white shirt and tie and women wearing Chanel with hats and white gloves. This dramatic transformation from formal to unfussy wear cuts through all social situations, including in my office. As a new doc out of residency, I used to wear a tie and shoes that could hold a shine. Now I wear jogger scrubs and sneakers. Rather than be offended by the lack of formality though, patients seem to appreciate it. Should they?

At first glance this seems to be a modern phenomenon. The reasons for casual wear today are manifold: about one-third of people work from home, Millennials are taking over with their TikTok values and general irreverence, COVID made us all fat and lazy. Heck, even the U.S. Senate briefly abolished the requirement to wear suits on the Senate floor. But getting dressed up was never to signal that you are elite or superior to others. It’s the opposite. To get dressed is a signal that you are serving others, a tradition that is as old as society.

Kaiser Permanente

Think of Downton Abbey as an example. The servants were always required to be smartly dressed when working, whereas members of the family could be dressed up or not. It’s clear who is serving whom. This tradition lives today in the hospitality industry. When you mosey into the lobby of a luxury hotel in your Rainbow sandals you can expect everyone who greets you will be in finery, signaling that they put in effort to serve you. You’ll find the same for all staff at the Mayo Clinic in Rochester, Minn., which is no coincidence.

Suits used to be standard in medicine. In the 19th century, physicians wore formal black-tie when seeing patients. Unlike hospitality however, we had good reason to eschew the tradition: germs. Once we figured out that our pus-stained ties and jackets were doing harm, we switched to wearing sanitized uniforms. Casual wear for doctors isn’t a modern phenomenon after all, then. For proof, compare Thomas Eakins painting “The Gross Clinic” (1875) with his later “The Agnew Clinic” (1889). In the former, Dr. Gross is portrayed in formal black wear, bloody hand and all. In the latter, Dr. Agnew is wearing white FIGS (or the 1890’s equivalent anyway). Similarly, nurses uniforms traditionally resembled kitchen servants, with criss-cross aprons and floor length skirts. It wasn’t until the 1980’s that nurses stopped wearing dresses and white caps.

photo of painting MiguelHermoso/CC-BY-SA-4.0

In the operating theater it’s obviously critical that we wear sanitized scrubs to mitigate the risk of infection. Originally white to signal cleanliness, scrubs were changed to blue-green because surgeons were blinded by the lights bouncing off the uniforms. (Green is also opposite red on the color wheel, supposedly enhancing the ability to distinguish shades of red).

But in outpatient medicine, the effect size for preventing infection by not wearing a tie or jacket is less obvious. In addition to protecting patients, it seems that wearing scrubs and donning On Cloud sneakers might also be a bit of push-back from us. Over time we’ve lost significant autonomy in our practice and lost a little respect from our patients. Payers tell us what to do. Patients question our expertise. Choosing what we wear is one of the few bits of medicine we still have agency. Pewter or pink, joggers or cargo pants, we get to choose.

The last time I flew British Airways everyone was in lounge wear, except the flight crew, of course. They were all smartly dressed. Recently British Airways rolled out updated, slightly more relaxed dress codes. Very modern, but I wonder if in a way we’re not all just a bit worse off.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]

Look at this guy – NFL Chargers jersey and shorts with a RVCA hat on backward. And next to him, a woman wearing her spin-class-Lulu gear. There’s also a guy sporting a 2016 San Diego Rock ‘n Roll Marathon Tee. And that young woman is actually wearing slippers. A visitor from the 1950s would be thunderstruck to see such casual wear on people waiting to board a plane. Photos from that era show men buttoned up in white shirt and tie and women wearing Chanel with hats and white gloves. This dramatic transformation from formal to unfussy wear cuts through all social situations, including in my office. As a new doc out of residency, I used to wear a tie and shoes that could hold a shine. Now I wear jogger scrubs and sneakers. Rather than be offended by the lack of formality though, patients seem to appreciate it. Should they?

At first glance this seems to be a modern phenomenon. The reasons for casual wear today are manifold: about one-third of people work from home, Millennials are taking over with their TikTok values and general irreverence, COVID made us all fat and lazy. Heck, even the U.S. Senate briefly abolished the requirement to wear suits on the Senate floor. But getting dressed up was never to signal that you are elite or superior to others. It’s the opposite. To get dressed is a signal that you are serving others, a tradition that is as old as society.

Kaiser Permanente

Think of Downton Abbey as an example. The servants were always required to be smartly dressed when working, whereas members of the family could be dressed up or not. It’s clear who is serving whom. This tradition lives today in the hospitality industry. When you mosey into the lobby of a luxury hotel in your Rainbow sandals you can expect everyone who greets you will be in finery, signaling that they put in effort to serve you. You’ll find the same for all staff at the Mayo Clinic in Rochester, Minn., which is no coincidence.

Suits used to be standard in medicine. In the 19th century, physicians wore formal black-tie when seeing patients. Unlike hospitality however, we had good reason to eschew the tradition: germs. Once we figured out that our pus-stained ties and jackets were doing harm, we switched to wearing sanitized uniforms. Casual wear for doctors isn’t a modern phenomenon after all, then. For proof, compare Thomas Eakins painting “The Gross Clinic” (1875) with his later “The Agnew Clinic” (1889). In the former, Dr. Gross is portrayed in formal black wear, bloody hand and all. In the latter, Dr. Agnew is wearing white FIGS (or the 1890’s equivalent anyway). Similarly, nurses uniforms traditionally resembled kitchen servants, with criss-cross aprons and floor length skirts. It wasn’t until the 1980’s that nurses stopped wearing dresses and white caps.

photo of painting MiguelHermoso/CC-BY-SA-4.0

In the operating theater it’s obviously critical that we wear sanitized scrubs to mitigate the risk of infection. Originally white to signal cleanliness, scrubs were changed to blue-green because surgeons were blinded by the lights bouncing off the uniforms. (Green is also opposite red on the color wheel, supposedly enhancing the ability to distinguish shades of red).

But in outpatient medicine, the effect size for preventing infection by not wearing a tie or jacket is less obvious. In addition to protecting patients, it seems that wearing scrubs and donning On Cloud sneakers might also be a bit of push-back from us. Over time we’ve lost significant autonomy in our practice and lost a little respect from our patients. Payers tell us what to do. Patients question our expertise. Choosing what we wear is one of the few bits of medicine we still have agency. Pewter or pink, joggers or cargo pants, we get to choose.

The last time I flew British Airways everyone was in lounge wear, except the flight crew, of course. They were all smartly dressed. Recently British Airways rolled out updated, slightly more relaxed dress codes. Very modern, but I wonder if in a way we’re not all just a bit worse off.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]

CHICAGO—The VA could save nearly $10,000 annually per patient in the Mountain West region referral area by administering lower-level hematology/oncology care within the system instead of in the community, according to a new analysis.

The findings reflect that the community care encouraged by the MISSION Act is more expensive than US Department of Veterans Affairs (VA) care, said report lead author Alyson Clough, PharmD, a clinical pharmacy specialist with the George E. Wahlen Veterans Affairs Medical Center (VAMC) in Salt Lake City, Utah, in an interview. Clough and colleagues presented the poster at the 2023 annual meeting of the Association of VA Hematology/Oncology.

The 2018 MISSION Act expanded the eligibility for non-VA community services within the VA. “If a veteran requires care that a VA cannot provide in-house, lives in a state/territory without a full-service VAMC, and/or lives further than a certain distance/time from a VA Medical Center, then the veteran may be eligible to receive care in the community,” Clough said.

For the new analysis, the researchers focused on the Salt Lake City VAMC referral area, which spans about 125,000 square miles in Utah, Idaho, and Nevada. “While the MISSION Act helped give those veterans more options for specialty care—including hematology/oncology—many veterans are still driving several hours on a routine basis for chemotherapy treatment and injection therapies, even in the community setting,” Clough explained.

The researchers looked at the costs of “low-risk cancer care,” which Clough said consists of “chemotherapy or immunotherapy that is less likely to cause significant side effects during the infusion, is typically nonhazardous, and/or can be administered via a short infusion [30 minutes or less] or an injection.”

In fiscal year 2022, the VA paid more than $5.7 million for community care services for 380 veterans in the referral area, about $15,060 each, according to the analysis. In contrast, the average cost for 1774 veterans within the VA system was $5424. “By retaining or re-establishing hematology/oncology veteran care within VA, we estimate cost savings of approximately $9636 per unique veteran.”

Specifically, the researchers wrote that the average care costs were $5297 per veteran in the community vs $1143 at the VA, and average drug costs were $9763 per veteran in the community vs $4281 in the VA. These amount to total costs of $15,060 per veteran in the community vs $5424 in the VA.

Low-risk services “are ideal to bring to more isolated regions,” Clough noted. “Traveling and/or finding accommodations for pets can be very difficult for veterans during chemotherapy treatments. Bringing care to the veteran increases veteran convenience, reduces need for transportation, reduces out-of-pocket cost to the veteran, and can improve care coordination.”

It’s not clear why VA care is cheaper than community care, she said, “but it may be related to the [higher] patient volumes we see in our VA facilities.” Lower overhead costs and government pricing contracts for chemotherapies/injectables could also be factors, Clough explained. In an interview, Todd Wagner, PhD, Stanford University Professor in the Department of Surgery and Director of the Health Economics Research Center at the VA, said the analysis needs risk adjustment for cancer severity and other illnesses and comorbidities that could affect cancer treatment. “In our work, sicker veterans get care in VA, and healthier veterans are choosing VA-purchased care [in the community].”

He noted that in the new analysis, the VA care looks much cheaper. “I'm struggling with that result: It flies in the face of our past work,” he said. He added that an analysis should also look at surgery and radiation. “VA has a tradition of providing high-value medications at a lower cost. But VA’s costs of surgery and radiation tend to be more expensive.”

Clough does not plan more research in this area. For now, she said, her site is working to expand to include infusion clinics at local VA community-based outpatient clinics as part of the Close to Me program. The program, launched by the VA in 2022, aims to provide cancer services at community-based outpatient clinics, mobile infusion units, and patient homes.

“As part of this service, we are looking to maximize video-based and phone visits between our existing oncology staff and veterans living in more isolated areas, coordinate labs/imaging locally, and deliver infusion and/or injectable therapies to the veteran,” Clough said.

In addition, she said, “We currently have a dedicated hematology/oncology trained pharmacist and 2 infusion nurses working to expand the service and deliver veteran care in these remote areas.”

There was no funding for this study, and the authors have no disclosures. Wagner discloses grant funding to his institutions from the VA, the National Institutes of Health, the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, and the Heinz Foundation. 

CHICAGO—The VA could save nearly $10,000 annually per patient in the Mountain West region referral area by administering lower-level hematology/oncology care within the system instead of in the community, according to a new analysis.

The findings reflect that the community care encouraged by the MISSION Act is more expensive than US Department of Veterans Affairs (VA) care, said report lead author Alyson Clough, PharmD, a clinical pharmacy specialist with the George E. Wahlen Veterans Affairs Medical Center (VAMC) in Salt Lake City, Utah, in an interview. Clough and colleagues presented the poster at the 2023 annual meeting of the Association of VA Hematology/Oncology.

The 2018 MISSION Act expanded the eligibility for non-VA community services within the VA. “If a veteran requires care that a VA cannot provide in-house, lives in a state/territory without a full-service VAMC, and/or lives further than a certain distance/time from a VA Medical Center, then the veteran may be eligible to receive care in the community,” Clough said.

For the new analysis, the researchers focused on the Salt Lake City VAMC referral area, which spans about 125,000 square miles in Utah, Idaho, and Nevada. “While the MISSION Act helped give those veterans more options for specialty care—including hematology/oncology—many veterans are still driving several hours on a routine basis for chemotherapy treatment and injection therapies, even in the community setting,” Clough explained.

The researchers looked at the costs of “low-risk cancer care,” which Clough said consists of “chemotherapy or immunotherapy that is less likely to cause significant side effects during the infusion, is typically nonhazardous, and/or can be administered via a short infusion [30 minutes or less] or an injection.”

In fiscal year 2022, the VA paid more than $5.7 million for community care services for 380 veterans in the referral area, about $15,060 each, according to the analysis. In contrast, the average cost for 1774 veterans within the VA system was $5424. “By retaining or re-establishing hematology/oncology veteran care within VA, we estimate cost savings of approximately $9636 per unique veteran.”

Specifically, the researchers wrote that the average care costs were $5297 per veteran in the community vs $1143 at the VA, and average drug costs were $9763 per veteran in the community vs $4281 in the VA. These amount to total costs of $15,060 per veteran in the community vs $5424 in the VA.

Low-risk services “are ideal to bring to more isolated regions,” Clough noted. “Traveling and/or finding accommodations for pets can be very difficult for veterans during chemotherapy treatments. Bringing care to the veteran increases veteran convenience, reduces need for transportation, reduces out-of-pocket cost to the veteran, and can improve care coordination.”

It’s not clear why VA care is cheaper than community care, she said, “but it may be related to the [higher] patient volumes we see in our VA facilities.” Lower overhead costs and government pricing contracts for chemotherapies/injectables could also be factors, Clough explained. In an interview, Todd Wagner, PhD, Stanford University Professor in the Department of Surgery and Director of the Health Economics Research Center at the VA, said the analysis needs risk adjustment for cancer severity and other illnesses and comorbidities that could affect cancer treatment. “In our work, sicker veterans get care in VA, and healthier veterans are choosing VA-purchased care [in the community].”

He noted that in the new analysis, the VA care looks much cheaper. “I'm struggling with that result: It flies in the face of our past work,” he said. He added that an analysis should also look at surgery and radiation. “VA has a tradition of providing high-value medications at a lower cost. But VA’s costs of surgery and radiation tend to be more expensive.”

Clough does not plan more research in this area. For now, she said, her site is working to expand to include infusion clinics at local VA community-based outpatient clinics as part of the Close to Me program. The program, launched by the VA in 2022, aims to provide cancer services at community-based outpatient clinics, mobile infusion units, and patient homes.

“As part of this service, we are looking to maximize video-based and phone visits between our existing oncology staff and veterans living in more isolated areas, coordinate labs/imaging locally, and deliver infusion and/or injectable therapies to the veteran,” Clough said.

In addition, she said, “We currently have a dedicated hematology/oncology trained pharmacist and 2 infusion nurses working to expand the service and deliver veteran care in these remote areas.”

There was no funding for this study, and the authors have no disclosures. Wagner discloses grant funding to his institutions from the VA, the National Institutes of Health, the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, and the Heinz Foundation. 

CHICAGO—The VA could save nearly $10,000 annually per patient in the Mountain West region referral area by administering lower-level hematology/oncology care within the system instead of in the community, according to a new analysis.

The findings reflect that the community care encouraged by the MISSION Act is more expensive than US Department of Veterans Affairs (VA) care, said report lead author Alyson Clough, PharmD, a clinical pharmacy specialist with the George E. Wahlen Veterans Affairs Medical Center (VAMC) in Salt Lake City, Utah, in an interview. Clough and colleagues presented the poster at the 2023 annual meeting of the Association of VA Hematology/Oncology.

The 2018 MISSION Act expanded the eligibility for non-VA community services within the VA. “If a veteran requires care that a VA cannot provide in-house, lives in a state/territory without a full-service VAMC, and/or lives further than a certain distance/time from a VA Medical Center, then the veteran may be eligible to receive care in the community,” Clough said.

For the new analysis, the researchers focused on the Salt Lake City VAMC referral area, which spans about 125,000 square miles in Utah, Idaho, and Nevada. “While the MISSION Act helped give those veterans more options for specialty care—including hematology/oncology—many veterans are still driving several hours on a routine basis for chemotherapy treatment and injection therapies, even in the community setting,” Clough explained.

The researchers looked at the costs of “low-risk cancer care,” which Clough said consists of “chemotherapy or immunotherapy that is less likely to cause significant side effects during the infusion, is typically nonhazardous, and/or can be administered via a short infusion [30 minutes or less] or an injection.”

In fiscal year 2022, the VA paid more than $5.7 million for community care services for 380 veterans in the referral area, about $15,060 each, according to the analysis. In contrast, the average cost for 1774 veterans within the VA system was $5424. “By retaining or re-establishing hematology/oncology veteran care within VA, we estimate cost savings of approximately $9636 per unique veteran.”

Specifically, the researchers wrote that the average care costs were $5297 per veteran in the community vs $1143 at the VA, and average drug costs were $9763 per veteran in the community vs $4281 in the VA. These amount to total costs of $15,060 per veteran in the community vs $5424 in the VA.

Low-risk services “are ideal to bring to more isolated regions,” Clough noted. “Traveling and/or finding accommodations for pets can be very difficult for veterans during chemotherapy treatments. Bringing care to the veteran increases veteran convenience, reduces need for transportation, reduces out-of-pocket cost to the veteran, and can improve care coordination.”

It’s not clear why VA care is cheaper than community care, she said, “but it may be related to the [higher] patient volumes we see in our VA facilities.” Lower overhead costs and government pricing contracts for chemotherapies/injectables could also be factors, Clough explained. In an interview, Todd Wagner, PhD, Stanford University Professor in the Department of Surgery and Director of the Health Economics Research Center at the VA, said the analysis needs risk adjustment for cancer severity and other illnesses and comorbidities that could affect cancer treatment. “In our work, sicker veterans get care in VA, and healthier veterans are choosing VA-purchased care [in the community].”

He noted that in the new analysis, the VA care looks much cheaper. “I'm struggling with that result: It flies in the face of our past work,” he said. He added that an analysis should also look at surgery and radiation. “VA has a tradition of providing high-value medications at a lower cost. But VA’s costs of surgery and radiation tend to be more expensive.”

Clough does not plan more research in this area. For now, she said, her site is working to expand to include infusion clinics at local VA community-based outpatient clinics as part of the Close to Me program. The program, launched by the VA in 2022, aims to provide cancer services at community-based outpatient clinics, mobile infusion units, and patient homes.

“As part of this service, we are looking to maximize video-based and phone visits between our existing oncology staff and veterans living in more isolated areas, coordinate labs/imaging locally, and deliver infusion and/or injectable therapies to the veteran,” Clough said.

In addition, she said, “We currently have a dedicated hematology/oncology trained pharmacist and 2 infusion nurses working to expand the service and deliver veteran care in these remote areas.”

There was no funding for this study, and the authors have no disclosures. Wagner discloses grant funding to his institutions from the VA, the National Institutes of Health, the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, and the Heinz Foundation. 

The Centers for Medicare & Medicaid Services 2022 National Quality Strategy is described as an “ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals.” The strategy calls for a multidisciplinary, person-centric approach for individuals throughout the continuum of care, with an emphasis on historically underresourced communities. It is a commendable goal for an overburdened U.S. health care system that spends more than other high-income counties yet experiences poorer outcomes. But whole-person, person-centered care cannot be achieved under current misaligned quality measures that fail to measure what we purport to value: the quintuple aim of improved health outcomes, cost savings, patient satisfaction, clinician well-being, and health equity.
 

Lifestyle first

Clinical practice guidelines for many chronic diseases recommend lifestyle intervention as the first and optimal treatment. A growing body of evidence supports lifestyle behavior interventions to treat and, when used intensively, even reverse common chronic conditions such as cardiovascular disease, obesity, and type 2 diabetes, while also providing effective prevention for those conditions. However, no current quality measures consider lifestyle interventions. In fact, some quality measures unintentionally penalize physicians for successfully treating or reversing disease through lifestyle behavior interventions while rewarding clinicians for meeting process measures – usually adherence to medication – regardless of whether health outcomes improved.

Rewarding medication adherence for the treatment of diseases in which lifestyle is a primary therapy (such as hypertension), combined with other health care constraints (lack of lifestyle education, time to spend with patients, and infrastructure support) incentivizes physicians to skip the conversation about lifestyle changes and go straight to medication prescription. Meanwhile, the clinician who takes the extra time to guide a patient toward lifestyle interventions that could treat their current disease and prevent future diseases – without side effects – is penalized.

Misaligned quality measures like these can stifle clinical judgment and risk reducing the practice of medicine to mindless box-checking. In many cases, patients are not even informed that lifestyle behavior change may be a treatment option (much less the first recommended option) for their conditions. This delivery of care is not person-centered and, in fact, may raise questions about the adequacy of informed treatment consent.
 

Reimbursement barriers

Lifestyle medicine is a growing medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions. Since certification began in 2017, almost 2500 US physicians and 1000 nonphysician health professionals have earned certification. Health systems, including the U.S. military, are increasingly integrating lifestyle medicine. There have been advancements since one survey found that more than half of lifestyle medicine clinicians reported receiving no reimbursement for lifestyle behavior interventions. However, barriers, especially in fee-for-service systems, still inhibit many patients from receiving insurance coverage for comprehensive, interdisciplinary, and whole-person treatments called intensive therapeutic lifestyle change (ITLC) programs.

Existing comprehensive lifestyle programs that patients are eligible for (ie, the Diabetes Prevention Program and intensive behavioral therapy) are often so poorly reimbursed that clinicians and health systems decline to offer them. An example of a well-reimbursed ITLC program is intensive cardiac rehabilitation (ICR), which remains underutilized and limited to a narrow segment of patients, despite ICR›s proven benefits for managing comorbid risk factors such as hemoglobin A1c and weight. Even when lifestyle intervention programs are available and patients are eligible to participate (often through shared medical appointments), patient copays for the frequent visits required to achieve and sustain behavior change – or the lack of reimbursement for interdisciplinary team members – discourage engagement.
 

Penalizing successful outcomes

Despite the fact that lifestyle behaviors are top contributors to health and, conversely, contribute to up to 80% of chronic diseases, few quality measures focus on screening for lifestyle factors or treating diseases with lifestyle interventions. An example of an existing quality measure is screening or treatment for harmful substance use.

Specific quality measures that penalize lifestyle medicine approaches include pharmacotherapy for type 2 diabetes, dyslipidemia, osteoporosis, and gout as well as approaches to rheumatoid arthritis.

Statins offer a useful example of the conundrum faced by clinicians who want to offer lifestyle interventions. A lifestyle medicine primary care physician had a patient covered by Medicare Advantage who was diagnosed with hyperlipidemia. The patient had total cholesterol of 226 and a triglycerides level of 132. Instead of prescribing the routine statin, the physician prescribed lifestyle behavior modifications. Within 3 weeks, the patient›s total cholesterol improved to 171 and triglycerides to 75. This was a great success for the delighted patient. However, the CMS 5-Star Rating System assigned the primary care physician a grade of C rather than A, which put the physician›s 5-star rating at risk. Why? Because the system bases its score largely on medication compliance. The physician was penalized despite achieving the optimal health outcome, and at a lower cost than with medication. This misalignment does not incentivize patient-centered care because it disregards patient preference, shared decision-making, and evidence-based practice.
 

Risk adjustment

Rather than automatically managing disease with ever-increasing quantities of costly medications and procedures, lifestyle medicine clinicians first pursue a goal of health restoration when appropriate. But Medicare risk adjustment incentivizes physicians to manage rather than reverse disease. How much Medicare pays health plans is determined in part by how sick the patients are; the sicker the patient, the more Medicare pays, because those patients› costs are expected to be higher. This ensures that health plans are not penalized for enrolling sicker patients. But a physician utilizing diet alone to achieve remission in a patient with type 2 diabetes is penalized financially because, when the risk is adjusted, diabetes is no longer listed among the patient›s conditions. So, Medicare pays the physician less money. That misalignment incentivizes clinicians to manage the symptoms of type 2 diabetes rather than achieve remission, despite remission being the ideal clinical outcome.

Realigning quality measures

Quality measures were developed to quantify health care processes and outcomes, and to ensure the delivery of safe care to all patients. However, over time the number of quality measures has swelled to 2500, evolving into a confusing, time-consuming, and even soul-crushing responsibility for the physician.

Instead of relying heavily on process measures, we must incentivize outcome measures that honor patient autonomy and allow clinicians to offer lifestyle intervention as the first line of treatment. Risk-score calculations should be adjusted so that we stop incentivizing disease management and penalizing disease reversal.

CMS’s proposed development of “a universal foundation” of quality measures is an opportunity to begin the realignment of quality measures and values. This foundation is intended to establish more consistent and meaningful measures, reduce clinician burnout by streamlining the reporting process, and advance health equity. For this change to be successful, it is vital that lifestyle behavior interventions – optimal nutrition, physical activity, restorative sleep, social connections, stress management, and avoidance of harmful substances – become the foundation of universal quality measures. This will ensure that every clinician is incentivized to discuss lifestyle behaviors with patients and pursue the first clinical step recommended by clinical practice guidelines for most chronic diseases. Only then can we truly deliver high-value, whole-person, person-centered care and achieve the quintuple aim.

Dr. Patel is president-elect, American College of Lifestyle Medicine; Lifestyle Medicine Medical Director, Wellvana Health, Midland, Tex. She has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Centers for Medicare & Medicaid Services 2022 National Quality Strategy is described as an “ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals.” The strategy calls for a multidisciplinary, person-centric approach for individuals throughout the continuum of care, with an emphasis on historically underresourced communities. It is a commendable goal for an overburdened U.S. health care system that spends more than other high-income counties yet experiences poorer outcomes. But whole-person, person-centered care cannot be achieved under current misaligned quality measures that fail to measure what we purport to value: the quintuple aim of improved health outcomes, cost savings, patient satisfaction, clinician well-being, and health equity.
 

Lifestyle first

Clinical practice guidelines for many chronic diseases recommend lifestyle intervention as the first and optimal treatment. A growing body of evidence supports lifestyle behavior interventions to treat and, when used intensively, even reverse common chronic conditions such as cardiovascular disease, obesity, and type 2 diabetes, while also providing effective prevention for those conditions. However, no current quality measures consider lifestyle interventions. In fact, some quality measures unintentionally penalize physicians for successfully treating or reversing disease through lifestyle behavior interventions while rewarding clinicians for meeting process measures – usually adherence to medication – regardless of whether health outcomes improved.

Rewarding medication adherence for the treatment of diseases in which lifestyle is a primary therapy (such as hypertension), combined with other health care constraints (lack of lifestyle education, time to spend with patients, and infrastructure support) incentivizes physicians to skip the conversation about lifestyle changes and go straight to medication prescription. Meanwhile, the clinician who takes the extra time to guide a patient toward lifestyle interventions that could treat their current disease and prevent future diseases – without side effects – is penalized.

Misaligned quality measures like these can stifle clinical judgment and risk reducing the practice of medicine to mindless box-checking. In many cases, patients are not even informed that lifestyle behavior change may be a treatment option (much less the first recommended option) for their conditions. This delivery of care is not person-centered and, in fact, may raise questions about the adequacy of informed treatment consent.
 

Reimbursement barriers

Lifestyle medicine is a growing medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions. Since certification began in 2017, almost 2500 US physicians and 1000 nonphysician health professionals have earned certification. Health systems, including the U.S. military, are increasingly integrating lifestyle medicine. There have been advancements since one survey found that more than half of lifestyle medicine clinicians reported receiving no reimbursement for lifestyle behavior interventions. However, barriers, especially in fee-for-service systems, still inhibit many patients from receiving insurance coverage for comprehensive, interdisciplinary, and whole-person treatments called intensive therapeutic lifestyle change (ITLC) programs.

Existing comprehensive lifestyle programs that patients are eligible for (ie, the Diabetes Prevention Program and intensive behavioral therapy) are often so poorly reimbursed that clinicians and health systems decline to offer them. An example of a well-reimbursed ITLC program is intensive cardiac rehabilitation (ICR), which remains underutilized and limited to a narrow segment of patients, despite ICR›s proven benefits for managing comorbid risk factors such as hemoglobin A1c and weight. Even when lifestyle intervention programs are available and patients are eligible to participate (often through shared medical appointments), patient copays for the frequent visits required to achieve and sustain behavior change – or the lack of reimbursement for interdisciplinary team members – discourage engagement.
 

Penalizing successful outcomes

Despite the fact that lifestyle behaviors are top contributors to health and, conversely, contribute to up to 80% of chronic diseases, few quality measures focus on screening for lifestyle factors or treating diseases with lifestyle interventions. An example of an existing quality measure is screening or treatment for harmful substance use.

Specific quality measures that penalize lifestyle medicine approaches include pharmacotherapy for type 2 diabetes, dyslipidemia, osteoporosis, and gout as well as approaches to rheumatoid arthritis.

Statins offer a useful example of the conundrum faced by clinicians who want to offer lifestyle interventions. A lifestyle medicine primary care physician had a patient covered by Medicare Advantage who was diagnosed with hyperlipidemia. The patient had total cholesterol of 226 and a triglycerides level of 132. Instead of prescribing the routine statin, the physician prescribed lifestyle behavior modifications. Within 3 weeks, the patient›s total cholesterol improved to 171 and triglycerides to 75. This was a great success for the delighted patient. However, the CMS 5-Star Rating System assigned the primary care physician a grade of C rather than A, which put the physician›s 5-star rating at risk. Why? Because the system bases its score largely on medication compliance. The physician was penalized despite achieving the optimal health outcome, and at a lower cost than with medication. This misalignment does not incentivize patient-centered care because it disregards patient preference, shared decision-making, and evidence-based practice.
 

Risk adjustment

Rather than automatically managing disease with ever-increasing quantities of costly medications and procedures, lifestyle medicine clinicians first pursue a goal of health restoration when appropriate. But Medicare risk adjustment incentivizes physicians to manage rather than reverse disease. How much Medicare pays health plans is determined in part by how sick the patients are; the sicker the patient, the more Medicare pays, because those patients› costs are expected to be higher. This ensures that health plans are not penalized for enrolling sicker patients. But a physician utilizing diet alone to achieve remission in a patient with type 2 diabetes is penalized financially because, when the risk is adjusted, diabetes is no longer listed among the patient›s conditions. So, Medicare pays the physician less money. That misalignment incentivizes clinicians to manage the symptoms of type 2 diabetes rather than achieve remission, despite remission being the ideal clinical outcome.

Realigning quality measures

Quality measures were developed to quantify health care processes and outcomes, and to ensure the delivery of safe care to all patients. However, over time the number of quality measures has swelled to 2500, evolving into a confusing, time-consuming, and even soul-crushing responsibility for the physician.

Instead of relying heavily on process measures, we must incentivize outcome measures that honor patient autonomy and allow clinicians to offer lifestyle intervention as the first line of treatment. Risk-score calculations should be adjusted so that we stop incentivizing disease management and penalizing disease reversal.

CMS’s proposed development of “a universal foundation” of quality measures is an opportunity to begin the realignment of quality measures and values. This foundation is intended to establish more consistent and meaningful measures, reduce clinician burnout by streamlining the reporting process, and advance health equity. For this change to be successful, it is vital that lifestyle behavior interventions – optimal nutrition, physical activity, restorative sleep, social connections, stress management, and avoidance of harmful substances – become the foundation of universal quality measures. This will ensure that every clinician is incentivized to discuss lifestyle behaviors with patients and pursue the first clinical step recommended by clinical practice guidelines for most chronic diseases. Only then can we truly deliver high-value, whole-person, person-centered care and achieve the quintuple aim.

Dr. Patel is president-elect, American College of Lifestyle Medicine; Lifestyle Medicine Medical Director, Wellvana Health, Midland, Tex. She has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Centers for Medicare & Medicaid Services 2022 National Quality Strategy is described as an “ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals.” The strategy calls for a multidisciplinary, person-centric approach for individuals throughout the continuum of care, with an emphasis on historically underresourced communities. It is a commendable goal for an overburdened U.S. health care system that spends more than other high-income counties yet experiences poorer outcomes. But whole-person, person-centered care cannot be achieved under current misaligned quality measures that fail to measure what we purport to value: the quintuple aim of improved health outcomes, cost savings, patient satisfaction, clinician well-being, and health equity.
 

Lifestyle first

Clinical practice guidelines for many chronic diseases recommend lifestyle intervention as the first and optimal treatment. A growing body of evidence supports lifestyle behavior interventions to treat and, when used intensively, even reverse common chronic conditions such as cardiovascular disease, obesity, and type 2 diabetes, while also providing effective prevention for those conditions. However, no current quality measures consider lifestyle interventions. In fact, some quality measures unintentionally penalize physicians for successfully treating or reversing disease through lifestyle behavior interventions while rewarding clinicians for meeting process measures – usually adherence to medication – regardless of whether health outcomes improved.

Rewarding medication adherence for the treatment of diseases in which lifestyle is a primary therapy (such as hypertension), combined with other health care constraints (lack of lifestyle education, time to spend with patients, and infrastructure support) incentivizes physicians to skip the conversation about lifestyle changes and go straight to medication prescription. Meanwhile, the clinician who takes the extra time to guide a patient toward lifestyle interventions that could treat their current disease and prevent future diseases – without side effects – is penalized.

Misaligned quality measures like these can stifle clinical judgment and risk reducing the practice of medicine to mindless box-checking. In many cases, patients are not even informed that lifestyle behavior change may be a treatment option (much less the first recommended option) for their conditions. This delivery of care is not person-centered and, in fact, may raise questions about the adequacy of informed treatment consent.
 

Reimbursement barriers

Lifestyle medicine is a growing medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions. Since certification began in 2017, almost 2500 US physicians and 1000 nonphysician health professionals have earned certification. Health systems, including the U.S. military, are increasingly integrating lifestyle medicine. There have been advancements since one survey found that more than half of lifestyle medicine clinicians reported receiving no reimbursement for lifestyle behavior interventions. However, barriers, especially in fee-for-service systems, still inhibit many patients from receiving insurance coverage for comprehensive, interdisciplinary, and whole-person treatments called intensive therapeutic lifestyle change (ITLC) programs.

Existing comprehensive lifestyle programs that patients are eligible for (ie, the Diabetes Prevention Program and intensive behavioral therapy) are often so poorly reimbursed that clinicians and health systems decline to offer them. An example of a well-reimbursed ITLC program is intensive cardiac rehabilitation (ICR), which remains underutilized and limited to a narrow segment of patients, despite ICR›s proven benefits for managing comorbid risk factors such as hemoglobin A1c and weight. Even when lifestyle intervention programs are available and patients are eligible to participate (often through shared medical appointments), patient copays for the frequent visits required to achieve and sustain behavior change – or the lack of reimbursement for interdisciplinary team members – discourage engagement.
 

Penalizing successful outcomes

Despite the fact that lifestyle behaviors are top contributors to health and, conversely, contribute to up to 80% of chronic diseases, few quality measures focus on screening for lifestyle factors or treating diseases with lifestyle interventions. An example of an existing quality measure is screening or treatment for harmful substance use.

Specific quality measures that penalize lifestyle medicine approaches include pharmacotherapy for type 2 diabetes, dyslipidemia, osteoporosis, and gout as well as approaches to rheumatoid arthritis.

Statins offer a useful example of the conundrum faced by clinicians who want to offer lifestyle interventions. A lifestyle medicine primary care physician had a patient covered by Medicare Advantage who was diagnosed with hyperlipidemia. The patient had total cholesterol of 226 and a triglycerides level of 132. Instead of prescribing the routine statin, the physician prescribed lifestyle behavior modifications. Within 3 weeks, the patient›s total cholesterol improved to 171 and triglycerides to 75. This was a great success for the delighted patient. However, the CMS 5-Star Rating System assigned the primary care physician a grade of C rather than A, which put the physician›s 5-star rating at risk. Why? Because the system bases its score largely on medication compliance. The physician was penalized despite achieving the optimal health outcome, and at a lower cost than with medication. This misalignment does not incentivize patient-centered care because it disregards patient preference, shared decision-making, and evidence-based practice.
 

Risk adjustment

Rather than automatically managing disease with ever-increasing quantities of costly medications and procedures, lifestyle medicine clinicians first pursue a goal of health restoration when appropriate. But Medicare risk adjustment incentivizes physicians to manage rather than reverse disease. How much Medicare pays health plans is determined in part by how sick the patients are; the sicker the patient, the more Medicare pays, because those patients› costs are expected to be higher. This ensures that health plans are not penalized for enrolling sicker patients. But a physician utilizing diet alone to achieve remission in a patient with type 2 diabetes is penalized financially because, when the risk is adjusted, diabetes is no longer listed among the patient›s conditions. So, Medicare pays the physician less money. That misalignment incentivizes clinicians to manage the symptoms of type 2 diabetes rather than achieve remission, despite remission being the ideal clinical outcome.

Realigning quality measures

Quality measures were developed to quantify health care processes and outcomes, and to ensure the delivery of safe care to all patients. However, over time the number of quality measures has swelled to 2500, evolving into a confusing, time-consuming, and even soul-crushing responsibility for the physician.

Instead of relying heavily on process measures, we must incentivize outcome measures that honor patient autonomy and allow clinicians to offer lifestyle intervention as the first line of treatment. Risk-score calculations should be adjusted so that we stop incentivizing disease management and penalizing disease reversal.

CMS’s proposed development of “a universal foundation” of quality measures is an opportunity to begin the realignment of quality measures and values. This foundation is intended to establish more consistent and meaningful measures, reduce clinician burnout by streamlining the reporting process, and advance health equity. For this change to be successful, it is vital that lifestyle behavior interventions – optimal nutrition, physical activity, restorative sleep, social connections, stress management, and avoidance of harmful substances – become the foundation of universal quality measures. This will ensure that every clinician is incentivized to discuss lifestyle behaviors with patients and pursue the first clinical step recommended by clinical practice guidelines for most chronic diseases. Only then can we truly deliver high-value, whole-person, person-centered care and achieve the quintuple aim.

Dr. Patel is president-elect, American College of Lifestyle Medicine; Lifestyle Medicine Medical Director, Wellvana Health, Midland, Tex. She has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.