Practice Management

After her emergency medicine group was acquired by a staffing firm backed by a large private equity (PE) firm, Michelle Wiener, MD, said the workflow changes came swiftly.

“Our staffing has been greatly reduced,” the Detroit physician said. “At this point, we have no say in anything. We have no say in the scheduling. We aren’t allowed to see what is billed under our name. The morale has really gone down.”

Dr. Wiener, who practices at Ascension St. John Hospital, said she and fellow physicians have repeatedly brought their concerns to TeamHealth, which in 2015 took over St. John Emergency Services PC. TeamHealth is owned by PE giant Blackstone.

“It’s very frustrating,” Dr. Wiener said. “We’re taking it from all sides.”

Blackstone and Ascension St. John did not respond to this news organization’s request for comment.

TeamHealth would not respond directly to questions about the Ascension St. John Hospital physicians or their concerns.

Spokesman Josh Hopson provided only a general statement: “TeamHealth is committed to making sure that clinicians have the resources and support needed to provide first-class care to patients, particularly with regard to staffing and compensation. TeamHealth has and will always put patient care first, and that is not impacted by its ownership model.”

Acquisitions of medical practices and hospitals by PE firms are rapidly growing, with more than 1,400 PE deals in health care in 2021 totaling upwards of $208 billion, according to PitchBook Data Inc., a Seattle-based firm that tracks mergers and acquisitions.

Some physicians praise the partnerships as an opportunity to improve technology and efficiency, whereas others decry them as raising patient costs and lowering the quality of care. A recent UC Berkeley study found that PE ownership of medical practices was linked to consumer price increases for 8 of 10 specialties, most notably oncology and gastroenterology.
 

What should you expect after PE acquisition?

Since his practice partnered with a PE firm in 2020, Milwaukee-based otolaryngologist Madan Kandula, MD, said he has found the changes positive. The practice has grown and improved operations in finance, accounting, compliance, and information technology, said Dr. Kandula, founder and CEO of Advent, an ENT practice with 15 clinics in four Midwestern states.

Dr. Kandula said his group already had a sound business practice, and that the goal of partnering with a PE firm wasn’t to change day-to-day operations but to propel the organization forward.

“From patient load to visit time to how we staff our clinics, there has been no change,” he said. “My private equity firm does not, [and] cannot, impose their will on our clinical decisions.”

Experts say the impact of PE acquisitions on individual physicians often depends on where a doctor ranks in the organization, what stage they are in their career, and how much control they had over the deal.

“It’s the older physicians who are usually selling the practice and getting the big payout,” said Anjali Dooley, a St. Louis–based health law attorney who counsels physicians about PE deals. “The younger doctors are usually not part of the deal, as they may still be employees. They don’t have any negotiating power. Hopefully, there is some transparency, but sometimes there is not, and they are blindsided by the deal.”

When it comes to workload, most PE-owned groups are put on a production-based model, such as a wRVU-based model, said Roger Strode, a Chicago-based health law attorney who focuses on health care mergers and acquisitions. Most already operate under such a model, but there might be some changes after a buyout.

Staffing may also change, added Ms. Dooley. The PE firms may want to add partners or companies already in their portfolios to create efficiencies, causing training or workflow changes.

In a hospital buyout, changes may depend on whether a department is a significant revenue generator for the hospital, Ms. Dooley noted.

PE firms frequently favor higher revenue–generating specialties, such as neurosurgery, cardiology, orthopedics, gastroenterology, and plastic surgery. They closely scrutinize departments said that make less money, such as the emergency department or primary care, Ms. Dooley said. Physicians or teams that don’t fit the firm’s cost-efficiency plans may be terminated or replaced.

On the other hand, Mr. Strode said physicians may see improved electronic health records and collections.

“Some of your overall overhead costs may be reduced, because they’re better at it,” Mr. Strode said. “When you’ve got more scale, the cost per patient, the cost per hour, the cost per procedure, goes down, and the cost that’s applied against your production will go down. As [practices grow], they have more bargaining power with payers and you can potentially get better rates. At least, that’s the promise.”

Analysts note that PE health care acquisitions show no signs of slowing and that it pays for physicians to know what to expect and how to cope if their practice or hospital is acquired. Whether physicians have some control over a buyout or are blindsided by the transition, it’s critical to know what to consider, how workloads might change, and your options for settling in or settling up.

The PE industry has about $2 trillion lined up for potential investments in 2023, said Ms. Dooley.

“PE firms are looking at health care to expend some of this dry powder,” Ms. Dooley continued. “If done correctly, PE firms that are aware of health care regulations, compliance, and patient care issues can ... remove redundant services and improve ... efficiencies, but the bad is when that doesn’t happen, and the quality of care goes down or there are patient safety risks.”
 

How to prepare for and cope with PE partnerships

If your practice is considering a PE partnership, it’s important to explore the terms and conditions and carefully weigh the pros and cons, said Gary Herschman, a Newark, N.J.–based attorney who advises PE-owned physician groups.

“My recommendation is that physicians at a minimum conduct due diligence on all potential strategic options for their groups, and then make an informed decision regarding whether a partnership transaction is right for their group, as it’s not right for every group,” he said.

When Texas cardiologist Rick Snyder, MD, was considering PE partnerships, he spoke with physicians who made similar deals to determine whether they were satisfied years later, he said. In April, Snyder’s practice, HeartPlace, the largest physician-owned cardiology practice in Texas, was acquired by US Heart & Vascular, a practice management platform backed by PE firm Ares Management.

“I called every group that I knew that had done private equity for any meaningful amount of time,” Dr. Snyder said. “For the first year or two, everybody is in the honeymoon period. If the model is going to succeed or break down, it’s not going to be in the first year or two. So I wanted to talk to groups that had done this for a longer amount of time and find out what their pitfalls were. What would they have done differently? Has it been a productive relationship? Did they grow?”

Dr. Snyder, president of the Texas Medical Association, said his practice met with seven or eight firms before choosing one that best met their needs. His group wanted a platform that preserved their clinical autonomy, governance, and culture, he said. They also wanted to ensure they were not entering into a “buy and flip” scenario, but rather a “buy and build” plan.

“Thus, financial capital was not sufficient, they also had to have intellectual capital and relationship capital on their bench,” he said. “When we found the partner that embraced all of these factors as well as a history of buying and long-term building, we pulled the trigger and partnered with Ares and US Heart & Vascular Management. The partner we chose did not offer us the most money. We put a premium on these other criteria.”

“I always tell docs, know the culture of your group and your vision,” he said. “Before you go down that route, ask yourself what you want to accomplish and if it makes sense having a private equity partner to accomplish that vision with.”

For younger physicians or those with little control over buyouts, experts recommend they review their contracts and consider consulting with an attorney to better understand how the deal may affect their earnings and career prospects.

Those who have a much longer career runway need to weigh whether they want to work for a PE-linked practice, Mr. Strode said. For some, it’s time to check when their noncompete agreements end and find a position elsewhere.

Also, physicians should know their rights and the laws in their states regarding the corporate practice of medicine. Statutes vary by state, and knowing the provisions in your state helps doctors recognize their legal rights, learn possible exceptions to the requirements, and know the penalties for violations.

In Michigan, a group of physicians and other health professionals at Ascension St. John has voted to unionize. Doctors hope that the union, which includes advanced practice clinicians, nurse practitioners, and physician assistants, will help improve patient care and protect working conditions for staff, Dr. Wiener said.

She advises physicians who are unhappy after acquisitions to speak up and stick together.

“That’s the biggest thing I think physicians should start doing,” she said. “Support each other and stand up. You are stronger together.”
 

Why is PE so attracted to health care?

PE firms typically buy practices or hospitals, work to make the entities more profitable, and then sell them, with the goal of doubling or tripling their investment over a short period. In general, PE firms aim for annual returns exceeding 20% after 3-7 years.

These firms know that health care is relatively recession-proof, that providers have third-party payers, and that the industry is fragmented and requires more efficiency, Ms. Dooley said.

When PE practice acquisitions started gaining momentum about 12 years ago, traditional hospital-based specialties such as anesthesiology and radiology were prime targets, said Mr. Strode.

At the same time, increasing challenges in private practice, such as declining compensation from payers, pressure to participate in value-based care programs, and rising regional competitors have fueled more physician groups to partner with PE firms, Mr. Herschman noted.

Physicians who partner with PE firms often benefit by having new access to capital to grow their practices, cost savings through group purchasing, and the ability to compete with larger health groups, Mr. Herschman said.

Questions remain, however, about how PE involvement affects health care use and spending. An April 2023 JAMA Viewpoint article called out the lack of oversight and regulation in the health care/PE space, suggesting that a stronger framework for regulation and transparency is needed.

A 2022 study in JAMA Health Forum that examined changes in prices and utilization associated with the PE acquisitions of 578 dermatology, gastroenterology, and ophthalmology physician practices from 2016 to 2020 found that prices increased by an average of 11%, and volume rose by 16%, after acquisition.

“We found that acquisitions were associated with increases in health care spending and utilization, as well as some other patterns of care like potential upcoding,” said Jane M. Zhu, MD, an author of the study and assistant professor at Oregon Health & Science University in Portland.

Another recent study that Dr. Zhu coauthored, published in Health Affairs, found that physician practices acquired by PE firms experience greater staff turnover and rely more heavily on advanced practice professionals than doctors.

“To the extent that that turnover indicates physicians are dissatisfied after private equity comes in, that’s really important to investigate further,” Dr. Zhu said.

PE firms owned 4% of U.S. hospitals in 2021 and 11% of nursing homes, according to a Medicare Payment Advisory Commission (MedPAC) report. The report does not include 2021 data on medical practices but notes that from 2013 to 2016, PE firms acquired at least 2% of physician practices. Estimates of PE deals are probably lower than actual numbers because of the lack of comprehensive information sources, according to the MedPAC report.

A version of this article appeared on Medscape.com.

After her emergency medicine group was acquired by a staffing firm backed by a large private equity (PE) firm, Michelle Wiener, MD, said the workflow changes came swiftly.

“Our staffing has been greatly reduced,” the Detroit physician said. “At this point, we have no say in anything. We have no say in the scheduling. We aren’t allowed to see what is billed under our name. The morale has really gone down.”

Dr. Wiener, who practices at Ascension St. John Hospital, said she and fellow physicians have repeatedly brought their concerns to TeamHealth, which in 2015 took over St. John Emergency Services PC. TeamHealth is owned by PE giant Blackstone.

“It’s very frustrating,” Dr. Wiener said. “We’re taking it from all sides.”

Blackstone and Ascension St. John did not respond to this news organization’s request for comment.

TeamHealth would not respond directly to questions about the Ascension St. John Hospital physicians or their concerns.

Spokesman Josh Hopson provided only a general statement: “TeamHealth is committed to making sure that clinicians have the resources and support needed to provide first-class care to patients, particularly with regard to staffing and compensation. TeamHealth has and will always put patient care first, and that is not impacted by its ownership model.”

Acquisitions of medical practices and hospitals by PE firms are rapidly growing, with more than 1,400 PE deals in health care in 2021 totaling upwards of $208 billion, according to PitchBook Data Inc., a Seattle-based firm that tracks mergers and acquisitions.

Some physicians praise the partnerships as an opportunity to improve technology and efficiency, whereas others decry them as raising patient costs and lowering the quality of care. A recent UC Berkeley study found that PE ownership of medical practices was linked to consumer price increases for 8 of 10 specialties, most notably oncology and gastroenterology.
 

What should you expect after PE acquisition?

Since his practice partnered with a PE firm in 2020, Milwaukee-based otolaryngologist Madan Kandula, MD, said he has found the changes positive. The practice has grown and improved operations in finance, accounting, compliance, and information technology, said Dr. Kandula, founder and CEO of Advent, an ENT practice with 15 clinics in four Midwestern states.

Dr. Kandula said his group already had a sound business practice, and that the goal of partnering with a PE firm wasn’t to change day-to-day operations but to propel the organization forward.

“From patient load to visit time to how we staff our clinics, there has been no change,” he said. “My private equity firm does not, [and] cannot, impose their will on our clinical decisions.”

Experts say the impact of PE acquisitions on individual physicians often depends on where a doctor ranks in the organization, what stage they are in their career, and how much control they had over the deal.

“It’s the older physicians who are usually selling the practice and getting the big payout,” said Anjali Dooley, a St. Louis–based health law attorney who counsels physicians about PE deals. “The younger doctors are usually not part of the deal, as they may still be employees. They don’t have any negotiating power. Hopefully, there is some transparency, but sometimes there is not, and they are blindsided by the deal.”

When it comes to workload, most PE-owned groups are put on a production-based model, such as a wRVU-based model, said Roger Strode, a Chicago-based health law attorney who focuses on health care mergers and acquisitions. Most already operate under such a model, but there might be some changes after a buyout.

Staffing may also change, added Ms. Dooley. The PE firms may want to add partners or companies already in their portfolios to create efficiencies, causing training or workflow changes.

In a hospital buyout, changes may depend on whether a department is a significant revenue generator for the hospital, Ms. Dooley noted.

PE firms frequently favor higher revenue–generating specialties, such as neurosurgery, cardiology, orthopedics, gastroenterology, and plastic surgery. They closely scrutinize departments said that make less money, such as the emergency department or primary care, Ms. Dooley said. Physicians or teams that don’t fit the firm’s cost-efficiency plans may be terminated or replaced.

On the other hand, Mr. Strode said physicians may see improved electronic health records and collections.

“Some of your overall overhead costs may be reduced, because they’re better at it,” Mr. Strode said. “When you’ve got more scale, the cost per patient, the cost per hour, the cost per procedure, goes down, and the cost that’s applied against your production will go down. As [practices grow], they have more bargaining power with payers and you can potentially get better rates. At least, that’s the promise.”

Analysts note that PE health care acquisitions show no signs of slowing and that it pays for physicians to know what to expect and how to cope if their practice or hospital is acquired. Whether physicians have some control over a buyout or are blindsided by the transition, it’s critical to know what to consider, how workloads might change, and your options for settling in or settling up.

The PE industry has about $2 trillion lined up for potential investments in 2023, said Ms. Dooley.

“PE firms are looking at health care to expend some of this dry powder,” Ms. Dooley continued. “If done correctly, PE firms that are aware of health care regulations, compliance, and patient care issues can ... remove redundant services and improve ... efficiencies, but the bad is when that doesn’t happen, and the quality of care goes down or there are patient safety risks.”
 

How to prepare for and cope with PE partnerships

If your practice is considering a PE partnership, it’s important to explore the terms and conditions and carefully weigh the pros and cons, said Gary Herschman, a Newark, N.J.–based attorney who advises PE-owned physician groups.

“My recommendation is that physicians at a minimum conduct due diligence on all potential strategic options for their groups, and then make an informed decision regarding whether a partnership transaction is right for their group, as it’s not right for every group,” he said.

When Texas cardiologist Rick Snyder, MD, was considering PE partnerships, he spoke with physicians who made similar deals to determine whether they were satisfied years later, he said. In April, Snyder’s practice, HeartPlace, the largest physician-owned cardiology practice in Texas, was acquired by US Heart & Vascular, a practice management platform backed by PE firm Ares Management.

“I called every group that I knew that had done private equity for any meaningful amount of time,” Dr. Snyder said. “For the first year or two, everybody is in the honeymoon period. If the model is going to succeed or break down, it’s not going to be in the first year or two. So I wanted to talk to groups that had done this for a longer amount of time and find out what their pitfalls were. What would they have done differently? Has it been a productive relationship? Did they grow?”

Dr. Snyder, president of the Texas Medical Association, said his practice met with seven or eight firms before choosing one that best met their needs. His group wanted a platform that preserved their clinical autonomy, governance, and culture, he said. They also wanted to ensure they were not entering into a “buy and flip” scenario, but rather a “buy and build” plan.

“Thus, financial capital was not sufficient, they also had to have intellectual capital and relationship capital on their bench,” he said. “When we found the partner that embraced all of these factors as well as a history of buying and long-term building, we pulled the trigger and partnered with Ares and US Heart & Vascular Management. The partner we chose did not offer us the most money. We put a premium on these other criteria.”

“I always tell docs, know the culture of your group and your vision,” he said. “Before you go down that route, ask yourself what you want to accomplish and if it makes sense having a private equity partner to accomplish that vision with.”

For younger physicians or those with little control over buyouts, experts recommend they review their contracts and consider consulting with an attorney to better understand how the deal may affect their earnings and career prospects.

Those who have a much longer career runway need to weigh whether they want to work for a PE-linked practice, Mr. Strode said. For some, it’s time to check when their noncompete agreements end and find a position elsewhere.

Also, physicians should know their rights and the laws in their states regarding the corporate practice of medicine. Statutes vary by state, and knowing the provisions in your state helps doctors recognize their legal rights, learn possible exceptions to the requirements, and know the penalties for violations.

In Michigan, a group of physicians and other health professionals at Ascension St. John has voted to unionize. Doctors hope that the union, which includes advanced practice clinicians, nurse practitioners, and physician assistants, will help improve patient care and protect working conditions for staff, Dr. Wiener said.

She advises physicians who are unhappy after acquisitions to speak up and stick together.

“That’s the biggest thing I think physicians should start doing,” she said. “Support each other and stand up. You are stronger together.”
 

Why is PE so attracted to health care?

PE firms typically buy practices or hospitals, work to make the entities more profitable, and then sell them, with the goal of doubling or tripling their investment over a short period. In general, PE firms aim for annual returns exceeding 20% after 3-7 years.

These firms know that health care is relatively recession-proof, that providers have third-party payers, and that the industry is fragmented and requires more efficiency, Ms. Dooley said.

When PE practice acquisitions started gaining momentum about 12 years ago, traditional hospital-based specialties such as anesthesiology and radiology were prime targets, said Mr. Strode.

At the same time, increasing challenges in private practice, such as declining compensation from payers, pressure to participate in value-based care programs, and rising regional competitors have fueled more physician groups to partner with PE firms, Mr. Herschman noted.

Physicians who partner with PE firms often benefit by having new access to capital to grow their practices, cost savings through group purchasing, and the ability to compete with larger health groups, Mr. Herschman said.

Questions remain, however, about how PE involvement affects health care use and spending. An April 2023 JAMA Viewpoint article called out the lack of oversight and regulation in the health care/PE space, suggesting that a stronger framework for regulation and transparency is needed.

A 2022 study in JAMA Health Forum that examined changes in prices and utilization associated with the PE acquisitions of 578 dermatology, gastroenterology, and ophthalmology physician practices from 2016 to 2020 found that prices increased by an average of 11%, and volume rose by 16%, after acquisition.

“We found that acquisitions were associated with increases in health care spending and utilization, as well as some other patterns of care like potential upcoding,” said Jane M. Zhu, MD, an author of the study and assistant professor at Oregon Health & Science University in Portland.

Another recent study that Dr. Zhu coauthored, published in Health Affairs, found that physician practices acquired by PE firms experience greater staff turnover and rely more heavily on advanced practice professionals than doctors.

“To the extent that that turnover indicates physicians are dissatisfied after private equity comes in, that’s really important to investigate further,” Dr. Zhu said.

PE firms owned 4% of U.S. hospitals in 2021 and 11% of nursing homes, according to a Medicare Payment Advisory Commission (MedPAC) report. The report does not include 2021 data on medical practices but notes that from 2013 to 2016, PE firms acquired at least 2% of physician practices. Estimates of PE deals are probably lower than actual numbers because of the lack of comprehensive information sources, according to the MedPAC report.

A version of this article appeared on Medscape.com.

After her emergency medicine group was acquired by a staffing firm backed by a large private equity (PE) firm, Michelle Wiener, MD, said the workflow changes came swiftly.

“Our staffing has been greatly reduced,” the Detroit physician said. “At this point, we have no say in anything. We have no say in the scheduling. We aren’t allowed to see what is billed under our name. The morale has really gone down.”

Dr. Wiener, who practices at Ascension St. John Hospital, said she and fellow physicians have repeatedly brought their concerns to TeamHealth, which in 2015 took over St. John Emergency Services PC. TeamHealth is owned by PE giant Blackstone.

“It’s very frustrating,” Dr. Wiener said. “We’re taking it from all sides.”

Blackstone and Ascension St. John did not respond to this news organization’s request for comment.

TeamHealth would not respond directly to questions about the Ascension St. John Hospital physicians or their concerns.

Spokesman Josh Hopson provided only a general statement: “TeamHealth is committed to making sure that clinicians have the resources and support needed to provide first-class care to patients, particularly with regard to staffing and compensation. TeamHealth has and will always put patient care first, and that is not impacted by its ownership model.”

Acquisitions of medical practices and hospitals by PE firms are rapidly growing, with more than 1,400 PE deals in health care in 2021 totaling upwards of $208 billion, according to PitchBook Data Inc., a Seattle-based firm that tracks mergers and acquisitions.

Some physicians praise the partnerships as an opportunity to improve technology and efficiency, whereas others decry them as raising patient costs and lowering the quality of care. A recent UC Berkeley study found that PE ownership of medical practices was linked to consumer price increases for 8 of 10 specialties, most notably oncology and gastroenterology.
 

What should you expect after PE acquisition?

Since his practice partnered with a PE firm in 2020, Milwaukee-based otolaryngologist Madan Kandula, MD, said he has found the changes positive. The practice has grown and improved operations in finance, accounting, compliance, and information technology, said Dr. Kandula, founder and CEO of Advent, an ENT practice with 15 clinics in four Midwestern states.

Dr. Kandula said his group already had a sound business practice, and that the goal of partnering with a PE firm wasn’t to change day-to-day operations but to propel the organization forward.

“From patient load to visit time to how we staff our clinics, there has been no change,” he said. “My private equity firm does not, [and] cannot, impose their will on our clinical decisions.”

Experts say the impact of PE acquisitions on individual physicians often depends on where a doctor ranks in the organization, what stage they are in their career, and how much control they had over the deal.

“It’s the older physicians who are usually selling the practice and getting the big payout,” said Anjali Dooley, a St. Louis–based health law attorney who counsels physicians about PE deals. “The younger doctors are usually not part of the deal, as they may still be employees. They don’t have any negotiating power. Hopefully, there is some transparency, but sometimes there is not, and they are blindsided by the deal.”

When it comes to workload, most PE-owned groups are put on a production-based model, such as a wRVU-based model, said Roger Strode, a Chicago-based health law attorney who focuses on health care mergers and acquisitions. Most already operate under such a model, but there might be some changes after a buyout.

Staffing may also change, added Ms. Dooley. The PE firms may want to add partners or companies already in their portfolios to create efficiencies, causing training or workflow changes.

In a hospital buyout, changes may depend on whether a department is a significant revenue generator for the hospital, Ms. Dooley noted.

PE firms frequently favor higher revenue–generating specialties, such as neurosurgery, cardiology, orthopedics, gastroenterology, and plastic surgery. They closely scrutinize departments said that make less money, such as the emergency department or primary care, Ms. Dooley said. Physicians or teams that don’t fit the firm’s cost-efficiency plans may be terminated or replaced.

On the other hand, Mr. Strode said physicians may see improved electronic health records and collections.

“Some of your overall overhead costs may be reduced, because they’re better at it,” Mr. Strode said. “When you’ve got more scale, the cost per patient, the cost per hour, the cost per procedure, goes down, and the cost that’s applied against your production will go down. As [practices grow], they have more bargaining power with payers and you can potentially get better rates. At least, that’s the promise.”

Analysts note that PE health care acquisitions show no signs of slowing and that it pays for physicians to know what to expect and how to cope if their practice or hospital is acquired. Whether physicians have some control over a buyout or are blindsided by the transition, it’s critical to know what to consider, how workloads might change, and your options for settling in or settling up.

The PE industry has about $2 trillion lined up for potential investments in 2023, said Ms. Dooley.

“PE firms are looking at health care to expend some of this dry powder,” Ms. Dooley continued. “If done correctly, PE firms that are aware of health care regulations, compliance, and patient care issues can ... remove redundant services and improve ... efficiencies, but the bad is when that doesn’t happen, and the quality of care goes down or there are patient safety risks.”
 

How to prepare for and cope with PE partnerships

If your practice is considering a PE partnership, it’s important to explore the terms and conditions and carefully weigh the pros and cons, said Gary Herschman, a Newark, N.J.–based attorney who advises PE-owned physician groups.

“My recommendation is that physicians at a minimum conduct due diligence on all potential strategic options for their groups, and then make an informed decision regarding whether a partnership transaction is right for their group, as it’s not right for every group,” he said.

When Texas cardiologist Rick Snyder, MD, was considering PE partnerships, he spoke with physicians who made similar deals to determine whether they were satisfied years later, he said. In April, Snyder’s practice, HeartPlace, the largest physician-owned cardiology practice in Texas, was acquired by US Heart & Vascular, a practice management platform backed by PE firm Ares Management.

“I called every group that I knew that had done private equity for any meaningful amount of time,” Dr. Snyder said. “For the first year or two, everybody is in the honeymoon period. If the model is going to succeed or break down, it’s not going to be in the first year or two. So I wanted to talk to groups that had done this for a longer amount of time and find out what their pitfalls were. What would they have done differently? Has it been a productive relationship? Did they grow?”

Dr. Snyder, president of the Texas Medical Association, said his practice met with seven or eight firms before choosing one that best met their needs. His group wanted a platform that preserved their clinical autonomy, governance, and culture, he said. They also wanted to ensure they were not entering into a “buy and flip” scenario, but rather a “buy and build” plan.

“Thus, financial capital was not sufficient, they also had to have intellectual capital and relationship capital on their bench,” he said. “When we found the partner that embraced all of these factors as well as a history of buying and long-term building, we pulled the trigger and partnered with Ares and US Heart & Vascular Management. The partner we chose did not offer us the most money. We put a premium on these other criteria.”

“I always tell docs, know the culture of your group and your vision,” he said. “Before you go down that route, ask yourself what you want to accomplish and if it makes sense having a private equity partner to accomplish that vision with.”

For younger physicians or those with little control over buyouts, experts recommend they review their contracts and consider consulting with an attorney to better understand how the deal may affect their earnings and career prospects.

Those who have a much longer career runway need to weigh whether they want to work for a PE-linked practice, Mr. Strode said. For some, it’s time to check when their noncompete agreements end and find a position elsewhere.

Also, physicians should know their rights and the laws in their states regarding the corporate practice of medicine. Statutes vary by state, and knowing the provisions in your state helps doctors recognize their legal rights, learn possible exceptions to the requirements, and know the penalties for violations.

In Michigan, a group of physicians and other health professionals at Ascension St. John has voted to unionize. Doctors hope that the union, which includes advanced practice clinicians, nurse practitioners, and physician assistants, will help improve patient care and protect working conditions for staff, Dr. Wiener said.

She advises physicians who are unhappy after acquisitions to speak up and stick together.

“That’s the biggest thing I think physicians should start doing,” she said. “Support each other and stand up. You are stronger together.”
 

Why is PE so attracted to health care?

PE firms typically buy practices or hospitals, work to make the entities more profitable, and then sell them, with the goal of doubling or tripling their investment over a short period. In general, PE firms aim for annual returns exceeding 20% after 3-7 years.

These firms know that health care is relatively recession-proof, that providers have third-party payers, and that the industry is fragmented and requires more efficiency, Ms. Dooley said.

When PE practice acquisitions started gaining momentum about 12 years ago, traditional hospital-based specialties such as anesthesiology and radiology were prime targets, said Mr. Strode.

At the same time, increasing challenges in private practice, such as declining compensation from payers, pressure to participate in value-based care programs, and rising regional competitors have fueled more physician groups to partner with PE firms, Mr. Herschman noted.

Physicians who partner with PE firms often benefit by having new access to capital to grow their practices, cost savings through group purchasing, and the ability to compete with larger health groups, Mr. Herschman said.

Questions remain, however, about how PE involvement affects health care use and spending. An April 2023 JAMA Viewpoint article called out the lack of oversight and regulation in the health care/PE space, suggesting that a stronger framework for regulation and transparency is needed.

A 2022 study in JAMA Health Forum that examined changes in prices and utilization associated with the PE acquisitions of 578 dermatology, gastroenterology, and ophthalmology physician practices from 2016 to 2020 found that prices increased by an average of 11%, and volume rose by 16%, after acquisition.

“We found that acquisitions were associated with increases in health care spending and utilization, as well as some other patterns of care like potential upcoding,” said Jane M. Zhu, MD, an author of the study and assistant professor at Oregon Health & Science University in Portland.

Another recent study that Dr. Zhu coauthored, published in Health Affairs, found that physician practices acquired by PE firms experience greater staff turnover and rely more heavily on advanced practice professionals than doctors.

“To the extent that that turnover indicates physicians are dissatisfied after private equity comes in, that’s really important to investigate further,” Dr. Zhu said.

PE firms owned 4% of U.S. hospitals in 2021 and 11% of nursing homes, according to a Medicare Payment Advisory Commission (MedPAC) report. The report does not include 2021 data on medical practices but notes that from 2013 to 2016, PE firms acquired at least 2% of physician practices. Estimates of PE deals are probably lower than actual numbers because of the lack of comprehensive information sources, according to the MedPAC report.

A version of this article appeared on Medscape.com.

Case 1: A 48-year-old female with a 10-year history of left-sided Ulcerative Colitis (UC) has been well controlled on an injectable biologic for 5 years. Her last colonoscopy one year ago was normal without erythema or friability. She presents for an interim visit due to an increase in stool frequency from 2 to 4 bowel movements a day. She denies urgency, nocturnal bowel movements, or blood in her stool. She is concerned about a disease flare and wonders if she is on the right medication. She just saw a TV ad for a new oral UC medication and wants to switch because she prefers an oral medication to an injectable one. Physical exam was normal and in-office flexible sigmoidoscopy demonstrates no change in her colon appearance. You advise her to stay on the biologic because she is still considered well-controlled. She insists on being switched to the new oral medicine. When you probe her more, she says that the TV ad she saw shows people getting the medicine leading normal lives, which has enormous appeal to her.



Case 2: A 52-year-old healthy male is referred for colonoscopy evaluation. He reports no change in bowel habits with rare blood in his stool and thinks his uncle had colon cancer at age 48. He is anxious and not very receptive to having a procedure. He recently saw a TV advertisement promoting non-colonoscopy-based colon cancer screening. You recommend a colonoscopy based on his family history, but he insists on stool-based screening.

AGA

Massachusetts General Hospital

In bioethics terms, DTCA can be beneficial in facilitating patient autonomy and promoting justice. For example, DTCA can “even the playing field” by ensuring that patients have equitable access to information about available treatments regardless of their socioeconomic status. In doing so, it can empower patients and allow them to have more meaningful discussions with their health care providers and make more informed decisions. In addition, patients may be introduced to alternative testing modalities (i.e., stool-based CRC screening) that, while not necessarily the best screening modality given individual risk (as in Case 2), may offer benefit with greater acceptance compared to inaction (i.e., no screening). Last, the idea of direct-to-consumer “omics” profiling has empowered patients as “citizen scientists” and led to the advent of “biohacking” among the lay population. In doing so, it has challenged the previous bounds of patient autonomy in healthcare by broadening the types of personal health data available to individuals, even when the clinical utility of this data may not yet be clear.

On the flip side, it is undeniable that DTCA of medical products is driven by commercial interests. Branded drugs are primarily, if not exclusively, promoted in DTCA, but these drugs may not always align with standard of care treatment recommendations. A study published in February 2023 in JAMA found that drugs with lower added clinical benefit and higher total sales were associated with higher DTCA spending.

With patients entering medical encounters with preconceived notions of what drugs they want to be prescribed based on media exposure, the ability of health care providers to provide sound medical advice regarding treatment may be circumvented. A patient’s preferred therapy based on exposure to DTCA may sharply contrast with their provider’s recommendation based on their experience and expertise and knowledge of the patient’s unique clinical history.
 

Unreasonable expectations

An additional potential downside of DTCA is that it can instill unreasonable expectations on the part of patients that the advertised product will benefit them. While DTCA is required to be fair and balanced in reporting benefits and risks, it is difficult to meaningfully address nuanced clinical risks in a brief TV ad and patients may come away with a skewed view of the risk-benefit equation. Furthermore, social media advertising and associated formats may not provide the same level of digestible information as other forms of media and are targeted to individuals likely to identify with the product. Finally, as stated above, only branded products (vs. generics) are advertised. Branded products are generally more costly, and where less expensive and equally effective therapies exist societal costs need to be considered. This can lead to inequities in distributive justice which is the societal allocation of resources. The more the healthcare market is driven towards higher costs in one segment, the less resources are available in another. This may affect regions where healthcare resources are limited.
 

Shared decision-making

Returning to the 3 cases above, in case 1 the UC patient’s awareness of new treatment options has prompted a shared decision-making discussion. She has a renewed interest in exploring a different route of medication administration because of DTCA. In spite of the patient seemingly well-controlled on her current IBD therapy and minor fluctuations in symptoms that might otherwise be a reason to observe more closely, the patient sees this as a reason to change her treatment based on her impression from the DTCA.

Regarding case 2, disease awareness and CRC screening acceptance is itself a positive outcome. Although commercially driven, the outcome/benefit to society leads to a decrease in disease burden and is a ready alternative with established benefits compared to no screening.

Regarding the proactive “omics-curious” IBD patient in case 3, despite the patient’s disappointment with the DCTA-promoted test’s limited clinical utility at this time, the patient may be communicating a general openness to novel approaches to treating IBD and to advancing her understanding of her disease.

So where does that leave you as a clinician?

As of today, if you live in the U.S., DTCA is a reality. As you navigate day-to-day patient interactions, it is important to keep in mind that your first obligation is to your patients and their best medical interests. Having a well-informed and engaged patient is a positive effect of DTCA over the past 30 years despite the challenging discussions you sometimes are forced to have. In many cases, patients are more self-aware of and engaged in their health and are acting on it due to direct acquisition of information from DTCA platforms. As a clinician, you have an ethical obligation to educate your patients and manage expectations, even when those expectations may be formed on the basis of DTCA with inherent conflicts of interest for promoting a product. Moreover, though certain products may be trendy or promoted on a popular science basis, the underlying technology (i.e. stool-based screening or metagenomics) and/or resultant data are likely not well understood by the typical lay patient, such that it may be difficult for a patient to comprehend how the product may not be particularly informative or inappropriate with respect to their personal medical history without additional counseling. Despite the potentially awkward clinician-patient dynamic precipitated by DTCA, these moments do offer an opportunity for you to gain rapport with your patients by taking the time to fill in the gaps of their understanding of their treatment plans, alternatives, individual risk factors and/or disease while gaining a greater appreciation for what they may personally prioritize with respect to their own health. Ultimately, as we transition further toward precision medicine approaches in healthcare, shared interest in individualized health decisions, at least partially informed by DTCA, is a positive outcome.

Dr. Sloan is a chief medical officer at Abivax. He is a member of the AGA Ethics Committee for COI. David A. Drew, PhD is assistant professor of medicine, Harvard Medical School, Boston. He is director of the Massachusetts General Hospital Biobanking, Clinical & Translational Epidemiology Unit, Boston. He is a member of the AGA Ethics Committee.

Case 1: A 48-year-old female with a 10-year history of left-sided Ulcerative Colitis (UC) has been well controlled on an injectable biologic for 5 years. Her last colonoscopy one year ago was normal without erythema or friability. She presents for an interim visit due to an increase in stool frequency from 2 to 4 bowel movements a day. She denies urgency, nocturnal bowel movements, or blood in her stool. She is concerned about a disease flare and wonders if she is on the right medication. She just saw a TV ad for a new oral UC medication and wants to switch because she prefers an oral medication to an injectable one. Physical exam was normal and in-office flexible sigmoidoscopy demonstrates no change in her colon appearance. You advise her to stay on the biologic because she is still considered well-controlled. She insists on being switched to the new oral medicine. When you probe her more, she says that the TV ad she saw shows people getting the medicine leading normal lives, which has enormous appeal to her.



Case 2: A 52-year-old healthy male is referred for colonoscopy evaluation. He reports no change in bowel habits with rare blood in his stool and thinks his uncle had colon cancer at age 48. He is anxious and not very receptive to having a procedure. He recently saw a TV advertisement promoting non-colonoscopy-based colon cancer screening. You recommend a colonoscopy based on his family history, but he insists on stool-based screening.

AGA

Massachusetts General Hospital

In bioethics terms, DTCA can be beneficial in facilitating patient autonomy and promoting justice. For example, DTCA can “even the playing field” by ensuring that patients have equitable access to information about available treatments regardless of their socioeconomic status. In doing so, it can empower patients and allow them to have more meaningful discussions with their health care providers and make more informed decisions. In addition, patients may be introduced to alternative testing modalities (i.e., stool-based CRC screening) that, while not necessarily the best screening modality given individual risk (as in Case 2), may offer benefit with greater acceptance compared to inaction (i.e., no screening). Last, the idea of direct-to-consumer “omics” profiling has empowered patients as “citizen scientists” and led to the advent of “biohacking” among the lay population. In doing so, it has challenged the previous bounds of patient autonomy in healthcare by broadening the types of personal health data available to individuals, even when the clinical utility of this data may not yet be clear.

On the flip side, it is undeniable that DTCA of medical products is driven by commercial interests. Branded drugs are primarily, if not exclusively, promoted in DTCA, but these drugs may not always align with standard of care treatment recommendations. A study published in February 2023 in JAMA found that drugs with lower added clinical benefit and higher total sales were associated with higher DTCA spending.

With patients entering medical encounters with preconceived notions of what drugs they want to be prescribed based on media exposure, the ability of health care providers to provide sound medical advice regarding treatment may be circumvented. A patient’s preferred therapy based on exposure to DTCA may sharply contrast with their provider’s recommendation based on their experience and expertise and knowledge of the patient’s unique clinical history.
 

Unreasonable expectations

An additional potential downside of DTCA is that it can instill unreasonable expectations on the part of patients that the advertised product will benefit them. While DTCA is required to be fair and balanced in reporting benefits and risks, it is difficult to meaningfully address nuanced clinical risks in a brief TV ad and patients may come away with a skewed view of the risk-benefit equation. Furthermore, social media advertising and associated formats may not provide the same level of digestible information as other forms of media and are targeted to individuals likely to identify with the product. Finally, as stated above, only branded products (vs. generics) are advertised. Branded products are generally more costly, and where less expensive and equally effective therapies exist societal costs need to be considered. This can lead to inequities in distributive justice which is the societal allocation of resources. The more the healthcare market is driven towards higher costs in one segment, the less resources are available in another. This may affect regions where healthcare resources are limited.
 

Shared decision-making

Returning to the 3 cases above, in case 1 the UC patient’s awareness of new treatment options has prompted a shared decision-making discussion. She has a renewed interest in exploring a different route of medication administration because of DTCA. In spite of the patient seemingly well-controlled on her current IBD therapy and minor fluctuations in symptoms that might otherwise be a reason to observe more closely, the patient sees this as a reason to change her treatment based on her impression from the DTCA.

Regarding case 2, disease awareness and CRC screening acceptance is itself a positive outcome. Although commercially driven, the outcome/benefit to society leads to a decrease in disease burden and is a ready alternative with established benefits compared to no screening.

Regarding the proactive “omics-curious” IBD patient in case 3, despite the patient’s disappointment with the DCTA-promoted test’s limited clinical utility at this time, the patient may be communicating a general openness to novel approaches to treating IBD and to advancing her understanding of her disease.

So where does that leave you as a clinician?

As of today, if you live in the U.S., DTCA is a reality. As you navigate day-to-day patient interactions, it is important to keep in mind that your first obligation is to your patients and their best medical interests. Having a well-informed and engaged patient is a positive effect of DTCA over the past 30 years despite the challenging discussions you sometimes are forced to have. In many cases, patients are more self-aware of and engaged in their health and are acting on it due to direct acquisition of information from DTCA platforms. As a clinician, you have an ethical obligation to educate your patients and manage expectations, even when those expectations may be formed on the basis of DTCA with inherent conflicts of interest for promoting a product. Moreover, though certain products may be trendy or promoted on a popular science basis, the underlying technology (i.e. stool-based screening or metagenomics) and/or resultant data are likely not well understood by the typical lay patient, such that it may be difficult for a patient to comprehend how the product may not be particularly informative or inappropriate with respect to their personal medical history without additional counseling. Despite the potentially awkward clinician-patient dynamic precipitated by DTCA, these moments do offer an opportunity for you to gain rapport with your patients by taking the time to fill in the gaps of their understanding of their treatment plans, alternatives, individual risk factors and/or disease while gaining a greater appreciation for what they may personally prioritize with respect to their own health. Ultimately, as we transition further toward precision medicine approaches in healthcare, shared interest in individualized health decisions, at least partially informed by DTCA, is a positive outcome.

Dr. Sloan is a chief medical officer at Abivax. He is a member of the AGA Ethics Committee for COI. David A. Drew, PhD is assistant professor of medicine, Harvard Medical School, Boston. He is director of the Massachusetts General Hospital Biobanking, Clinical & Translational Epidemiology Unit, Boston. He is a member of the AGA Ethics Committee.

Case 1: A 48-year-old female with a 10-year history of left-sided Ulcerative Colitis (UC) has been well controlled on an injectable biologic for 5 years. Her last colonoscopy one year ago was normal without erythema or friability. She presents for an interim visit due to an increase in stool frequency from 2 to 4 bowel movements a day. She denies urgency, nocturnal bowel movements, or blood in her stool. She is concerned about a disease flare and wonders if she is on the right medication. She just saw a TV ad for a new oral UC medication and wants to switch because she prefers an oral medication to an injectable one. Physical exam was normal and in-office flexible sigmoidoscopy demonstrates no change in her colon appearance. You advise her to stay on the biologic because she is still considered well-controlled. She insists on being switched to the new oral medicine. When you probe her more, she says that the TV ad she saw shows people getting the medicine leading normal lives, which has enormous appeal to her.



Case 2: A 52-year-old healthy male is referred for colonoscopy evaluation. He reports no change in bowel habits with rare blood in his stool and thinks his uncle had colon cancer at age 48. He is anxious and not very receptive to having a procedure. He recently saw a TV advertisement promoting non-colonoscopy-based colon cancer screening. You recommend a colonoscopy based on his family history, but he insists on stool-based screening.

AGA

Massachusetts General Hospital

In bioethics terms, DTCA can be beneficial in facilitating patient autonomy and promoting justice. For example, DTCA can “even the playing field” by ensuring that patients have equitable access to information about available treatments regardless of their socioeconomic status. In doing so, it can empower patients and allow them to have more meaningful discussions with their health care providers and make more informed decisions. In addition, patients may be introduced to alternative testing modalities (i.e., stool-based CRC screening) that, while not necessarily the best screening modality given individual risk (as in Case 2), may offer benefit with greater acceptance compared to inaction (i.e., no screening). Last, the idea of direct-to-consumer “omics” profiling has empowered patients as “citizen scientists” and led to the advent of “biohacking” among the lay population. In doing so, it has challenged the previous bounds of patient autonomy in healthcare by broadening the types of personal health data available to individuals, even when the clinical utility of this data may not yet be clear.

On the flip side, it is undeniable that DTCA of medical products is driven by commercial interests. Branded drugs are primarily, if not exclusively, promoted in DTCA, but these drugs may not always align with standard of care treatment recommendations. A study published in February 2023 in JAMA found that drugs with lower added clinical benefit and higher total sales were associated with higher DTCA spending.

With patients entering medical encounters with preconceived notions of what drugs they want to be prescribed based on media exposure, the ability of health care providers to provide sound medical advice regarding treatment may be circumvented. A patient’s preferred therapy based on exposure to DTCA may sharply contrast with their provider’s recommendation based on their experience and expertise and knowledge of the patient’s unique clinical history.
 

Unreasonable expectations

An additional potential downside of DTCA is that it can instill unreasonable expectations on the part of patients that the advertised product will benefit them. While DTCA is required to be fair and balanced in reporting benefits and risks, it is difficult to meaningfully address nuanced clinical risks in a brief TV ad and patients may come away with a skewed view of the risk-benefit equation. Furthermore, social media advertising and associated formats may not provide the same level of digestible information as other forms of media and are targeted to individuals likely to identify with the product. Finally, as stated above, only branded products (vs. generics) are advertised. Branded products are generally more costly, and where less expensive and equally effective therapies exist societal costs need to be considered. This can lead to inequities in distributive justice which is the societal allocation of resources. The more the healthcare market is driven towards higher costs in one segment, the less resources are available in another. This may affect regions where healthcare resources are limited.
 

Shared decision-making

Returning to the 3 cases above, in case 1 the UC patient’s awareness of new treatment options has prompted a shared decision-making discussion. She has a renewed interest in exploring a different route of medication administration because of DTCA. In spite of the patient seemingly well-controlled on her current IBD therapy and minor fluctuations in symptoms that might otherwise be a reason to observe more closely, the patient sees this as a reason to change her treatment based on her impression from the DTCA.

Regarding case 2, disease awareness and CRC screening acceptance is itself a positive outcome. Although commercially driven, the outcome/benefit to society leads to a decrease in disease burden and is a ready alternative with established benefits compared to no screening.

Regarding the proactive “omics-curious” IBD patient in case 3, despite the patient’s disappointment with the DCTA-promoted test’s limited clinical utility at this time, the patient may be communicating a general openness to novel approaches to treating IBD and to advancing her understanding of her disease.

So where does that leave you as a clinician?

As of today, if you live in the U.S., DTCA is a reality. As you navigate day-to-day patient interactions, it is important to keep in mind that your first obligation is to your patients and their best medical interests. Having a well-informed and engaged patient is a positive effect of DTCA over the past 30 years despite the challenging discussions you sometimes are forced to have. In many cases, patients are more self-aware of and engaged in their health and are acting on it due to direct acquisition of information from DTCA platforms. As a clinician, you have an ethical obligation to educate your patients and manage expectations, even when those expectations may be formed on the basis of DTCA with inherent conflicts of interest for promoting a product. Moreover, though certain products may be trendy or promoted on a popular science basis, the underlying technology (i.e. stool-based screening or metagenomics) and/or resultant data are likely not well understood by the typical lay patient, such that it may be difficult for a patient to comprehend how the product may not be particularly informative or inappropriate with respect to their personal medical history without additional counseling. Despite the potentially awkward clinician-patient dynamic precipitated by DTCA, these moments do offer an opportunity for you to gain rapport with your patients by taking the time to fill in the gaps of their understanding of their treatment plans, alternatives, individual risk factors and/or disease while gaining a greater appreciation for what they may personally prioritize with respect to their own health. Ultimately, as we transition further toward precision medicine approaches in healthcare, shared interest in individualized health decisions, at least partially informed by DTCA, is a positive outcome.

Dr. Sloan is a chief medical officer at Abivax. He is a member of the AGA Ethics Committee for COI. David A. Drew, PhD is assistant professor of medicine, Harvard Medical School, Boston. He is director of the Massachusetts General Hospital Biobanking, Clinical & Translational Epidemiology Unit, Boston. He is a member of the AGA Ethics Committee.

In July, the Centers for Medicare and Medicaid Services released the 2024 Physician Fee Schedule (PFS) proposed rule on proposed policy changes for Medicare payments. The proposed rule contains 2,883 pages of proposals for physician, hospital outpatient department, and ambulatory surgery center (ASC) payments for calendar year 2024. For gastroenterologists, there was good news and bad news.

CMS proposed to decrease the RVU conversion factor from $33.8872 in 2023 to $32.7476 in 2024, which would result in a 3.36% cut to physician payment. Medicare physician payments have been cut each year for the better part of a decade, with additional cuts proposed for 2024.

According to the American Medical Assocition, Medicare physician payment has already declined 26% in the last 22 years when adjusting for inflation, and that’s before factoring in the proposed cuts for 2024. Physicians are one of the only health care providers without an automatic inflationary increase, the AMA reports.

AGA opposes additional cuts to physician payments and will continue to advocate to stop them. AGA and many other specialty societies support H.R. 2474, the Strengthening Medicare for Patients and Providers Act. This bill would provide a permanent, annual update equal to the increase in the Medicare Economic Index, which is how the government measures inflation in medical practice. We will continue to advocate for permanent positive annual inflation updates, which would allow physicians to invest in their practices and implement new strategies to provide high-value care.

But in some positive news from the 2024 Medicare PFS, the Hospital Outpatient Prospective Payment System (OPPS) and the ASC proposed rules include increased hospital outpatient departments and ASC payments, continued telemedicine reimbursement and coverage through 2024, and a second one-year delay in changes to rules governing split/shared visits. Specifically:

OPPS Conversion Factor: The proposed CY 2024 Medicare conversion factor for outpatient hospital departments is $87.488, an increase of 2.8%, for hospitals that meet applicable quality reporting requirements.

ASC Conversion Factor: The proposed CY 2024 Ambulatory Surgical Center conversion factor is $53.397, an increase of 2.8%, for ASCs that meet applicable quality reporting requirements. The AGA and our sister societies continue to urge CMS to reduce this gap in the ASC facility fees, when compared to the outpatient hospital facility rates, which are estimated to be a roughly 48% differential in CY 2024.

Telehealth: CMS proposes to continue reimbursing telehealth services at current levels through 2024. Payment for audio-only evaluation and management (E/M) codes will continue at parity with follow-up in-person visits as it has throughout the pandemic. Additionally, CMS is implementing telehealth flexibilities that were included in the Consolidated Appropriations Act 2023 by allowing telehealth visits to originate at any site in the United States. This will allow patients throughout the country to maintain access to needed telehealth services without facing the logistical and safety challenges that can surround in-person visits. CMS is proposing to pay telehealth services at the nonfacility payment rate, which is the same rate as in-person office visits, lift the frequency limits on telehealth visits for subsequent hospital and skilled nursing facility visits, and allow direct supervision to be provided virtually.

Split (or shared) visits: CMS has proposed a second one-year delay to its proposed split/shared visits policy. The original proposal required that the billing provider in split/shared visits be whoever spent more than half of the total time with the patient (making time the only way to define substantive portion). CMS plans to delay that through at least Dec. 31, 2024. In the interim, practices can continue to use one of the three key components (history, exam, or medical decision-making) or more than half of the total time spent to determine who can bill for the visit. The GI societies will continue to advocate for appropriate reimbursement to align with new team-based models of care delivery.

Notably, the split (or shared) visits policy was also delayed in 2023 because of widespread concerns and feedback that the policy would disrupt team-based care and care delivery in the hospital setting. The American Medical Association CPT editorial panel, the body responsible for creating and maintaining CPT codes, has approved revisions to E/M guidelines that may help address some of CMS’s concerns.

For more information on issues affecting gastroenterologists in the 2024 Medicare PFS and OPPS/ASC proposed rules, visit the AGA news website.

Dr. Garcia serves as an advisor to the AGA AMA Relative-value Update Committee. She is clinical associate professor of medicine at Stanford (Calif.) University, where she is director of the neurogastroenterology and motility laboratory in the division of gastroenterology and hepatology, and associate chief medical information officer in ambulatory care at Stanford Health Care.

Dr. Mehta serves as an alternate advisor to the AGA AMA Relative-value Update Committee. She is associate chief innovation officer, Penn Medicine, and associate professor of medicine and health policy, University of Pennsylvania, Philadelphia.

Neither author has relevant conflicts of interest.

In July, the Centers for Medicare and Medicaid Services released the 2024 Physician Fee Schedule (PFS) proposed rule on proposed policy changes for Medicare payments. The proposed rule contains 2,883 pages of proposals for physician, hospital outpatient department, and ambulatory surgery center (ASC) payments for calendar year 2024. For gastroenterologists, there was good news and bad news.

CMS proposed to decrease the RVU conversion factor from $33.8872 in 2023 to $32.7476 in 2024, which would result in a 3.36% cut to physician payment. Medicare physician payments have been cut each year for the better part of a decade, with additional cuts proposed for 2024.

According to the American Medical Assocition, Medicare physician payment has already declined 26% in the last 22 years when adjusting for inflation, and that’s before factoring in the proposed cuts for 2024. Physicians are one of the only health care providers without an automatic inflationary increase, the AMA reports.

AGA opposes additional cuts to physician payments and will continue to advocate to stop them. AGA and many other specialty societies support H.R. 2474, the Strengthening Medicare for Patients and Providers Act. This bill would provide a permanent, annual update equal to the increase in the Medicare Economic Index, which is how the government measures inflation in medical practice. We will continue to advocate for permanent positive annual inflation updates, which would allow physicians to invest in their practices and implement new strategies to provide high-value care.

But in some positive news from the 2024 Medicare PFS, the Hospital Outpatient Prospective Payment System (OPPS) and the ASC proposed rules include increased hospital outpatient departments and ASC payments, continued telemedicine reimbursement and coverage through 2024, and a second one-year delay in changes to rules governing split/shared visits. Specifically:

OPPS Conversion Factor: The proposed CY 2024 Medicare conversion factor for outpatient hospital departments is $87.488, an increase of 2.8%, for hospitals that meet applicable quality reporting requirements.

ASC Conversion Factor: The proposed CY 2024 Ambulatory Surgical Center conversion factor is $53.397, an increase of 2.8%, for ASCs that meet applicable quality reporting requirements. The AGA and our sister societies continue to urge CMS to reduce this gap in the ASC facility fees, when compared to the outpatient hospital facility rates, which are estimated to be a roughly 48% differential in CY 2024.

Telehealth: CMS proposes to continue reimbursing telehealth services at current levels through 2024. Payment for audio-only evaluation and management (E/M) codes will continue at parity with follow-up in-person visits as it has throughout the pandemic. Additionally, CMS is implementing telehealth flexibilities that were included in the Consolidated Appropriations Act 2023 by allowing telehealth visits to originate at any site in the United States. This will allow patients throughout the country to maintain access to needed telehealth services without facing the logistical and safety challenges that can surround in-person visits. CMS is proposing to pay telehealth services at the nonfacility payment rate, which is the same rate as in-person office visits, lift the frequency limits on telehealth visits for subsequent hospital and skilled nursing facility visits, and allow direct supervision to be provided virtually.

Split (or shared) visits: CMS has proposed a second one-year delay to its proposed split/shared visits policy. The original proposal required that the billing provider in split/shared visits be whoever spent more than half of the total time with the patient (making time the only way to define substantive portion). CMS plans to delay that through at least Dec. 31, 2024. In the interim, practices can continue to use one of the three key components (history, exam, or medical decision-making) or more than half of the total time spent to determine who can bill for the visit. The GI societies will continue to advocate for appropriate reimbursement to align with new team-based models of care delivery.

Notably, the split (or shared) visits policy was also delayed in 2023 because of widespread concerns and feedback that the policy would disrupt team-based care and care delivery in the hospital setting. The American Medical Association CPT editorial panel, the body responsible for creating and maintaining CPT codes, has approved revisions to E/M guidelines that may help address some of CMS’s concerns.

For more information on issues affecting gastroenterologists in the 2024 Medicare PFS and OPPS/ASC proposed rules, visit the AGA news website.

Dr. Garcia serves as an advisor to the AGA AMA Relative-value Update Committee. She is clinical associate professor of medicine at Stanford (Calif.) University, where she is director of the neurogastroenterology and motility laboratory in the division of gastroenterology and hepatology, and associate chief medical information officer in ambulatory care at Stanford Health Care.

Dr. Mehta serves as an alternate advisor to the AGA AMA Relative-value Update Committee. She is associate chief innovation officer, Penn Medicine, and associate professor of medicine and health policy, University of Pennsylvania, Philadelphia.

Neither author has relevant conflicts of interest.

In July, the Centers for Medicare and Medicaid Services released the 2024 Physician Fee Schedule (PFS) proposed rule on proposed policy changes for Medicare payments. The proposed rule contains 2,883 pages of proposals for physician, hospital outpatient department, and ambulatory surgery center (ASC) payments for calendar year 2024. For gastroenterologists, there was good news and bad news.

CMS proposed to decrease the RVU conversion factor from $33.8872 in 2023 to $32.7476 in 2024, which would result in a 3.36% cut to physician payment. Medicare physician payments have been cut each year for the better part of a decade, with additional cuts proposed for 2024.

According to the American Medical Assocition, Medicare physician payment has already declined 26% in the last 22 years when adjusting for inflation, and that’s before factoring in the proposed cuts for 2024. Physicians are one of the only health care providers without an automatic inflationary increase, the AMA reports.

AGA opposes additional cuts to physician payments and will continue to advocate to stop them. AGA and many other specialty societies support H.R. 2474, the Strengthening Medicare for Patients and Providers Act. This bill would provide a permanent, annual update equal to the increase in the Medicare Economic Index, which is how the government measures inflation in medical practice. We will continue to advocate for permanent positive annual inflation updates, which would allow physicians to invest in their practices and implement new strategies to provide high-value care.

But in some positive news from the 2024 Medicare PFS, the Hospital Outpatient Prospective Payment System (OPPS) and the ASC proposed rules include increased hospital outpatient departments and ASC payments, continued telemedicine reimbursement and coverage through 2024, and a second one-year delay in changes to rules governing split/shared visits. Specifically:

OPPS Conversion Factor: The proposed CY 2024 Medicare conversion factor for outpatient hospital departments is $87.488, an increase of 2.8%, for hospitals that meet applicable quality reporting requirements.

ASC Conversion Factor: The proposed CY 2024 Ambulatory Surgical Center conversion factor is $53.397, an increase of 2.8%, for ASCs that meet applicable quality reporting requirements. The AGA and our sister societies continue to urge CMS to reduce this gap in the ASC facility fees, when compared to the outpatient hospital facility rates, which are estimated to be a roughly 48% differential in CY 2024.

Telehealth: CMS proposes to continue reimbursing telehealth services at current levels through 2024. Payment for audio-only evaluation and management (E/M) codes will continue at parity with follow-up in-person visits as it has throughout the pandemic. Additionally, CMS is implementing telehealth flexibilities that were included in the Consolidated Appropriations Act 2023 by allowing telehealth visits to originate at any site in the United States. This will allow patients throughout the country to maintain access to needed telehealth services without facing the logistical and safety challenges that can surround in-person visits. CMS is proposing to pay telehealth services at the nonfacility payment rate, which is the same rate as in-person office visits, lift the frequency limits on telehealth visits for subsequent hospital and skilled nursing facility visits, and allow direct supervision to be provided virtually.

Split (or shared) visits: CMS has proposed a second one-year delay to its proposed split/shared visits policy. The original proposal required that the billing provider in split/shared visits be whoever spent more than half of the total time with the patient (making time the only way to define substantive portion). CMS plans to delay that through at least Dec. 31, 2024. In the interim, practices can continue to use one of the three key components (history, exam, or medical decision-making) or more than half of the total time spent to determine who can bill for the visit. The GI societies will continue to advocate for appropriate reimbursement to align with new team-based models of care delivery.

Notably, the split (or shared) visits policy was also delayed in 2023 because of widespread concerns and feedback that the policy would disrupt team-based care and care delivery in the hospital setting. The American Medical Association CPT editorial panel, the body responsible for creating and maintaining CPT codes, has approved revisions to E/M guidelines that may help address some of CMS’s concerns.

For more information on issues affecting gastroenterologists in the 2024 Medicare PFS and OPPS/ASC proposed rules, visit the AGA news website.

Dr. Garcia serves as an advisor to the AGA AMA Relative-value Update Committee. She is clinical associate professor of medicine at Stanford (Calif.) University, where she is director of the neurogastroenterology and motility laboratory in the division of gastroenterology and hepatology, and associate chief medical information officer in ambulatory care at Stanford Health Care.

Dr. Mehta serves as an alternate advisor to the AGA AMA Relative-value Update Committee. She is associate chief innovation officer, Penn Medicine, and associate professor of medicine and health policy, University of Pennsylvania, Philadelphia.

Neither author has relevant conflicts of interest.

Andrea Partida, DO, an obstetrician and gynecologist in Enid, Okla., loves her new assistant.

The 15 or 20 minutes she used to spend on documentation for each patient visit is now 3. The 2-3 hours she’d spend charting outside clinic hours is maybe 1.

All that time saved allows her to see two to five more patients a day, provide better care to each patient, and get more involved in hospital leadership at Integris Health, where she works.

“I have a better work-life balance with my family,” Dr. Partida said. “I leave work at work and get home earlier.”

You’ve probably figured out the plot twist: Dr. Partida’s assistant is not a person – it’s artificial intelligence (AI).

Dr. Partida uses IRIS, a tool from OnPoint Healthcare Partners, part of a fast-growing niche of AI medical scribes designed to automate onerous data entry. The evolution of generative AI – specifically, large language models, such as ChatGPT – has led to a rapid explosion of these tools. Other companies in the space include Abridge, Ambience Healthcare, Augmedix, DeepScribe, Nuance (part of Microsoft), and Suki. The newest kid on the block, Amazon Web Services, announced the launch of HealthScribe in July.

These tools – some of which are already on the market, with more on the way – record patient visits and generate notes for treatment and billing. Earlier iterations combine AI with offsite human scribes who provide quality control. But more and more are fully automated, no human required. Some also offer video recording and foreign language translation.

The promise is alluring: Ease your workload and reclaim hours in your day so you can spend more time with patients or try that “work-life balance” thing you’ve heard so much about.

But do these tools fulfill that promise?

According to Dr. Partida and other doctors who spoke with this news organization, the answer is a resounding yes.
 

A tech solution for a tech problem

“I believe a lot of doctors see patients for free. They get paid to do paperwork,” said Anthony J. Mazzarelli, MD, JD, MBE, co-president and CEO of Cooper University Health Care, in Camden, N.J.

Indeed, for every hour U.S. clinicians spend with their patients, they may spend 2 more hours documenting in electronic health records (EHRs), estimates show. About half of doctors, especially those in primary care, report feeling burned out, and some 42% say they want to quit clinical practice.

Enter AI scribes.

“The holy grail in medicine right now is improving burnout while also maintaining or improving productivity and quality,” said Patricia Garcia, MD, associate clinical information officer for ambulatory care at Stanford (Calif.) Health Care. “These ambient digital scribes have the potential to do just that.”

While anyone can buy these products, their use has been mostly limited to pilot programs and early adopters so far, said Dr. Garcia, who has been helping to pilot Nuance’s digital scribe, DAX, at Stanford.

But that’s expected to change quickly. “I don’t think the time horizon is a decade,” Dr. Garcia said. “I think within a matter of 2 or 3 years, these tools will be pervasive throughout health care.”

Since introducing these tools at Cooper, “our doctors’ paperwork burden is significantly lighter,” said Dr. Mazzarelli, who decides which technologies Cooper should invest in and who monitors their results. In Cooper studies, physicians who used DAX more than half the time spent 43% less time working on notes.

“They spend more time connecting with their patients, talking with them, and looking them in the eye,” Dr. Mazzarelli said. That, in turn, seems to improve patient outcomes, reduce doctor burnout and turnover, and lower costs.

The AI scribes, by virtue of eliminating the distraction of note taking, also allow doctors to give their full attention to the patient. “The patient relationship is the most important aspect of medicine,” said Raul Ayala, MD, MHCM, a family medicine physician at Adventist Health, in Hanford, Calif., who uses Augmedix. The digital scribe “helps us strengthen that relationship.”
 

What’s it like to use an AI medical scribe?

The scribes feature hardware (typically a smartphone or tablet) and software built on automatic speech recognition, natural language processing, and machine learning. Download an app to your device, and you’re ready to go. Use it to record in-person or telehealth visits.

In the first week, a company may help train you to use the hardware and software. You’ll likely start by using it for a few patient visits per day, ramping up gradually. Dr. Partida said she was comfortable using the system for all her patients in 6 weeks.

Each day, Dr. Partida logs in to a dedicated smartphone or tablet, opens the app, and reviews her schedule, including details she needs to prepare for each patient.

At the start of each patient visit, Dr. Partida taps the app icon to begin recording and lays the device nearby. She can pause as needed. At the end of the visit, she taps the icon again to stop recording.

The AI listens, creates the note, and updates relevant data in the EHR. The note includes patient problems, assessment, treatment plan, patient history, orders, and tasks for staff, along with medications, referrals, and preauthorizations. A human scribe, who is also a physician, reviews the information for accuracy and edits it as needed. By the next morning, the data are ready for Dr. Partida to review.

Fully automated versions can generate notes much faster. Jack Shilling, MD, MBA, an orthopedic surgeon at Cooper University Health Care, in Voorhees, N.J., uses DAX. A new feature called DAX Express – which uses OpenAI’s GPT-4 but no humans – provides him with a draft of his clinical notes in just seconds.
 

How accurate are AI notes?

The accuracy of those notes remains an open question, Dr. Garcia said – mostly because accuracy can be hard to define.

“If you asked five docs to write a note based on the same patient encounter, you’d get five different notes,” Dr. Garcia said. “That makes it hard to assess these technologies in a scientifically rigorous way.”

Still, the onus is on the physician to review the notes and edit them as needed, Dr. Garcia said. How light or heavy those edits are can depend on your unique preferences.

Dr. Shilling said he may need to lightly edit transcripts of his conversations with patients. “When someone tells me how long their knee hurts, slight variability in their transcribed words is tolerable,” he said. But for some things – such as physical exam notes and x-ray readings – he dictates directly into the device, speaking at a closer range and being less conversational, more exact in his speech.
 

Should you let patients know they’re being recorded?

The federal Health Insurance Portability and Accountability Act (HIPAA) does not require providers to inform patients that their face-to-face conversations are being recorded, said Daniel Lebovic, JD, corporate legal counsel at Compliancy Group, in Greenlawn, N.Y., a company that helps providers adhere to HIPAA rules.

But make sure you know the laws in your state and the policies at your health care practice. State laws may require providers to inform patients and to get patients’ consent in advance of being recorded.

All the doctors who spoke to this news organization said their patients are informed that they’ll be recorded and that they can opt out if they wish.
 

How much do AI scribes cost?

As the marketplace for these tools expands, companies are offering more products and services at different price points that target a range of organizations, from large health care systems to small private practices.

Price models vary, said Dr. Garcia. Some are based on the number of users, others on the number of notes, and still others on minutes.

Amazon’s HealthScribe is priced at 10 cents per minute. For 1,000 consultation transcripts per month, with each call averaging 15 minutes, it would take 15,000 minutes at a total cost of $1,500 for the month.

In general, the rapidly growing competition in this space could mean prices become more affordable, Dr. Garcia said. “It’s good that so many are getting into this game, because that means the price will come down and it will be a lot more accessible to everybody.”

A version of this article appeared on Medscape.com.

Andrea Partida, DO, an obstetrician and gynecologist in Enid, Okla., loves her new assistant.

The 15 or 20 minutes she used to spend on documentation for each patient visit is now 3. The 2-3 hours she’d spend charting outside clinic hours is maybe 1.

All that time saved allows her to see two to five more patients a day, provide better care to each patient, and get more involved in hospital leadership at Integris Health, where she works.

“I have a better work-life balance with my family,” Dr. Partida said. “I leave work at work and get home earlier.”

You’ve probably figured out the plot twist: Dr. Partida’s assistant is not a person – it’s artificial intelligence (AI).

Dr. Partida uses IRIS, a tool from OnPoint Healthcare Partners, part of a fast-growing niche of AI medical scribes designed to automate onerous data entry. The evolution of generative AI – specifically, large language models, such as ChatGPT – has led to a rapid explosion of these tools. Other companies in the space include Abridge, Ambience Healthcare, Augmedix, DeepScribe, Nuance (part of Microsoft), and Suki. The newest kid on the block, Amazon Web Services, announced the launch of HealthScribe in July.

These tools – some of which are already on the market, with more on the way – record patient visits and generate notes for treatment and billing. Earlier iterations combine AI with offsite human scribes who provide quality control. But more and more are fully automated, no human required. Some also offer video recording and foreign language translation.

The promise is alluring: Ease your workload and reclaim hours in your day so you can spend more time with patients or try that “work-life balance” thing you’ve heard so much about.

But do these tools fulfill that promise?

According to Dr. Partida and other doctors who spoke with this news organization, the answer is a resounding yes.
 

A tech solution for a tech problem

“I believe a lot of doctors see patients for free. They get paid to do paperwork,” said Anthony J. Mazzarelli, MD, JD, MBE, co-president and CEO of Cooper University Health Care, in Camden, N.J.

Indeed, for every hour U.S. clinicians spend with their patients, they may spend 2 more hours documenting in electronic health records (EHRs), estimates show. About half of doctors, especially those in primary care, report feeling burned out, and some 42% say they want to quit clinical practice.

Enter AI scribes.

“The holy grail in medicine right now is improving burnout while also maintaining or improving productivity and quality,” said Patricia Garcia, MD, associate clinical information officer for ambulatory care at Stanford (Calif.) Health Care. “These ambient digital scribes have the potential to do just that.”

While anyone can buy these products, their use has been mostly limited to pilot programs and early adopters so far, said Dr. Garcia, who has been helping to pilot Nuance’s digital scribe, DAX, at Stanford.

But that’s expected to change quickly. “I don’t think the time horizon is a decade,” Dr. Garcia said. “I think within a matter of 2 or 3 years, these tools will be pervasive throughout health care.”

Since introducing these tools at Cooper, “our doctors’ paperwork burden is significantly lighter,” said Dr. Mazzarelli, who decides which technologies Cooper should invest in and who monitors their results. In Cooper studies, physicians who used DAX more than half the time spent 43% less time working on notes.

“They spend more time connecting with their patients, talking with them, and looking them in the eye,” Dr. Mazzarelli said. That, in turn, seems to improve patient outcomes, reduce doctor burnout and turnover, and lower costs.

The AI scribes, by virtue of eliminating the distraction of note taking, also allow doctors to give their full attention to the patient. “The patient relationship is the most important aspect of medicine,” said Raul Ayala, MD, MHCM, a family medicine physician at Adventist Health, in Hanford, Calif., who uses Augmedix. The digital scribe “helps us strengthen that relationship.”
 

What’s it like to use an AI medical scribe?

The scribes feature hardware (typically a smartphone or tablet) and software built on automatic speech recognition, natural language processing, and machine learning. Download an app to your device, and you’re ready to go. Use it to record in-person or telehealth visits.

In the first week, a company may help train you to use the hardware and software. You’ll likely start by using it for a few patient visits per day, ramping up gradually. Dr. Partida said she was comfortable using the system for all her patients in 6 weeks.

Each day, Dr. Partida logs in to a dedicated smartphone or tablet, opens the app, and reviews her schedule, including details she needs to prepare for each patient.

At the start of each patient visit, Dr. Partida taps the app icon to begin recording and lays the device nearby. She can pause as needed. At the end of the visit, she taps the icon again to stop recording.

The AI listens, creates the note, and updates relevant data in the EHR. The note includes patient problems, assessment, treatment plan, patient history, orders, and tasks for staff, along with medications, referrals, and preauthorizations. A human scribe, who is also a physician, reviews the information for accuracy and edits it as needed. By the next morning, the data are ready for Dr. Partida to review.

Fully automated versions can generate notes much faster. Jack Shilling, MD, MBA, an orthopedic surgeon at Cooper University Health Care, in Voorhees, N.J., uses DAX. A new feature called DAX Express – which uses OpenAI’s GPT-4 but no humans – provides him with a draft of his clinical notes in just seconds.
 

How accurate are AI notes?

The accuracy of those notes remains an open question, Dr. Garcia said – mostly because accuracy can be hard to define.

“If you asked five docs to write a note based on the same patient encounter, you’d get five different notes,” Dr. Garcia said. “That makes it hard to assess these technologies in a scientifically rigorous way.”

Still, the onus is on the physician to review the notes and edit them as needed, Dr. Garcia said. How light or heavy those edits are can depend on your unique preferences.

Dr. Shilling said he may need to lightly edit transcripts of his conversations with patients. “When someone tells me how long their knee hurts, slight variability in their transcribed words is tolerable,” he said. But for some things – such as physical exam notes and x-ray readings – he dictates directly into the device, speaking at a closer range and being less conversational, more exact in his speech.
 

Should you let patients know they’re being recorded?

The federal Health Insurance Portability and Accountability Act (HIPAA) does not require providers to inform patients that their face-to-face conversations are being recorded, said Daniel Lebovic, JD, corporate legal counsel at Compliancy Group, in Greenlawn, N.Y., a company that helps providers adhere to HIPAA rules.

But make sure you know the laws in your state and the policies at your health care practice. State laws may require providers to inform patients and to get patients’ consent in advance of being recorded.

All the doctors who spoke to this news organization said their patients are informed that they’ll be recorded and that they can opt out if they wish.
 

How much do AI scribes cost?

As the marketplace for these tools expands, companies are offering more products and services at different price points that target a range of organizations, from large health care systems to small private practices.

Price models vary, said Dr. Garcia. Some are based on the number of users, others on the number of notes, and still others on minutes.

Amazon’s HealthScribe is priced at 10 cents per minute. For 1,000 consultation transcripts per month, with each call averaging 15 minutes, it would take 15,000 minutes at a total cost of $1,500 for the month.

In general, the rapidly growing competition in this space could mean prices become more affordable, Dr. Garcia said. “It’s good that so many are getting into this game, because that means the price will come down and it will be a lot more accessible to everybody.”

A version of this article appeared on Medscape.com.

Andrea Partida, DO, an obstetrician and gynecologist in Enid, Okla., loves her new assistant.

The 15 or 20 minutes she used to spend on documentation for each patient visit is now 3. The 2-3 hours she’d spend charting outside clinic hours is maybe 1.

All that time saved allows her to see two to five more patients a day, provide better care to each patient, and get more involved in hospital leadership at Integris Health, where she works.

“I have a better work-life balance with my family,” Dr. Partida said. “I leave work at work and get home earlier.”

You’ve probably figured out the plot twist: Dr. Partida’s assistant is not a person – it’s artificial intelligence (AI).

Dr. Partida uses IRIS, a tool from OnPoint Healthcare Partners, part of a fast-growing niche of AI medical scribes designed to automate onerous data entry. The evolution of generative AI – specifically, large language models, such as ChatGPT – has led to a rapid explosion of these tools. Other companies in the space include Abridge, Ambience Healthcare, Augmedix, DeepScribe, Nuance (part of Microsoft), and Suki. The newest kid on the block, Amazon Web Services, announced the launch of HealthScribe in July.

These tools – some of which are already on the market, with more on the way – record patient visits and generate notes for treatment and billing. Earlier iterations combine AI with offsite human scribes who provide quality control. But more and more are fully automated, no human required. Some also offer video recording and foreign language translation.

The promise is alluring: Ease your workload and reclaim hours in your day so you can spend more time with patients or try that “work-life balance” thing you’ve heard so much about.

But do these tools fulfill that promise?

According to Dr. Partida and other doctors who spoke with this news organization, the answer is a resounding yes.
 

A tech solution for a tech problem

“I believe a lot of doctors see patients for free. They get paid to do paperwork,” said Anthony J. Mazzarelli, MD, JD, MBE, co-president and CEO of Cooper University Health Care, in Camden, N.J.

Indeed, for every hour U.S. clinicians spend with their patients, they may spend 2 more hours documenting in electronic health records (EHRs), estimates show. About half of doctors, especially those in primary care, report feeling burned out, and some 42% say they want to quit clinical practice.

Enter AI scribes.

“The holy grail in medicine right now is improving burnout while also maintaining or improving productivity and quality,” said Patricia Garcia, MD, associate clinical information officer for ambulatory care at Stanford (Calif.) Health Care. “These ambient digital scribes have the potential to do just that.”

While anyone can buy these products, their use has been mostly limited to pilot programs and early adopters so far, said Dr. Garcia, who has been helping to pilot Nuance’s digital scribe, DAX, at Stanford.

But that’s expected to change quickly. “I don’t think the time horizon is a decade,” Dr. Garcia said. “I think within a matter of 2 or 3 years, these tools will be pervasive throughout health care.”

Since introducing these tools at Cooper, “our doctors’ paperwork burden is significantly lighter,” said Dr. Mazzarelli, who decides which technologies Cooper should invest in and who monitors their results. In Cooper studies, physicians who used DAX more than half the time spent 43% less time working on notes.

“They spend more time connecting with their patients, talking with them, and looking them in the eye,” Dr. Mazzarelli said. That, in turn, seems to improve patient outcomes, reduce doctor burnout and turnover, and lower costs.

The AI scribes, by virtue of eliminating the distraction of note taking, also allow doctors to give their full attention to the patient. “The patient relationship is the most important aspect of medicine,” said Raul Ayala, MD, MHCM, a family medicine physician at Adventist Health, in Hanford, Calif., who uses Augmedix. The digital scribe “helps us strengthen that relationship.”
 

What’s it like to use an AI medical scribe?

The scribes feature hardware (typically a smartphone or tablet) and software built on automatic speech recognition, natural language processing, and machine learning. Download an app to your device, and you’re ready to go. Use it to record in-person or telehealth visits.

In the first week, a company may help train you to use the hardware and software. You’ll likely start by using it for a few patient visits per day, ramping up gradually. Dr. Partida said she was comfortable using the system for all her patients in 6 weeks.

Each day, Dr. Partida logs in to a dedicated smartphone or tablet, opens the app, and reviews her schedule, including details she needs to prepare for each patient.

At the start of each patient visit, Dr. Partida taps the app icon to begin recording and lays the device nearby. She can pause as needed. At the end of the visit, she taps the icon again to stop recording.

The AI listens, creates the note, and updates relevant data in the EHR. The note includes patient problems, assessment, treatment plan, patient history, orders, and tasks for staff, along with medications, referrals, and preauthorizations. A human scribe, who is also a physician, reviews the information for accuracy and edits it as needed. By the next morning, the data are ready for Dr. Partida to review.

Fully automated versions can generate notes much faster. Jack Shilling, MD, MBA, an orthopedic surgeon at Cooper University Health Care, in Voorhees, N.J., uses DAX. A new feature called DAX Express – which uses OpenAI’s GPT-4 but no humans – provides him with a draft of his clinical notes in just seconds.
 

How accurate are AI notes?

The accuracy of those notes remains an open question, Dr. Garcia said – mostly because accuracy can be hard to define.

“If you asked five docs to write a note based on the same patient encounter, you’d get five different notes,” Dr. Garcia said. “That makes it hard to assess these technologies in a scientifically rigorous way.”

Still, the onus is on the physician to review the notes and edit them as needed, Dr. Garcia said. How light or heavy those edits are can depend on your unique preferences.

Dr. Shilling said he may need to lightly edit transcripts of his conversations with patients. “When someone tells me how long their knee hurts, slight variability in their transcribed words is tolerable,” he said. But for some things – such as physical exam notes and x-ray readings – he dictates directly into the device, speaking at a closer range and being less conversational, more exact in his speech.
 

Should you let patients know they’re being recorded?

The federal Health Insurance Portability and Accountability Act (HIPAA) does not require providers to inform patients that their face-to-face conversations are being recorded, said Daniel Lebovic, JD, corporate legal counsel at Compliancy Group, in Greenlawn, N.Y., a company that helps providers adhere to HIPAA rules.

But make sure you know the laws in your state and the policies at your health care practice. State laws may require providers to inform patients and to get patients’ consent in advance of being recorded.

All the doctors who spoke to this news organization said their patients are informed that they’ll be recorded and that they can opt out if they wish.
 

How much do AI scribes cost?

As the marketplace for these tools expands, companies are offering more products and services at different price points that target a range of organizations, from large health care systems to small private practices.

Price models vary, said Dr. Garcia. Some are based on the number of users, others on the number of notes, and still others on minutes.

Amazon’s HealthScribe is priced at 10 cents per minute. For 1,000 consultation transcripts per month, with each call averaging 15 minutes, it would take 15,000 minutes at a total cost of $1,500 for the month.

In general, the rapidly growing competition in this space could mean prices become more affordable, Dr. Garcia said. “It’s good that so many are getting into this game, because that means the price will come down and it will be a lot more accessible to everybody.”

A version of this article appeared on Medscape.com.

TOPLINE:
 

Taking a proton pump inhibitor (PPI) with the cyclin-dependent kinase 4/6 (CDK4/6) inhibitor palbociclib could diminish the full therapeutic benefit of palbociclib in women with breast cancer and lead to worse progression-free survival (PFS) and overall survival, new data suggest.

METHODOLOGY:

• The study retrospectively identified 1,310 women with advanced breast cancer receiving palbociclib using South Korean nationwide claims data.
• Overall, 344 women in the concomitant group, those who were coadministered a PPI for more than one-third of their palbociclib treatment duration, were propensity-score matched to 966 women who did not have PPI exposure: the nonconcomitant group.
• Main outcomes were time to progression and death, presented as PFS and overall survival.

TAKEAWAY:

• Median clinical PFS was significantly shorter by about 15 months in the concomitant PPI group vs. the nonconcomitant group (25.3 vs. 39.8 months; adjusted hazard ratio, 1.76).
• Concomitant PPI use was also associated with shorter overall survival (HR, 2.71).
• Overall, 83.1% of patients in the concomitant group were alive at 1 year vs. 94.0% in the nonconcomitant group (P < .001), and 69.5% vs. 89.3%, respectively, were alive at 2 years (P < .001), though the median overall survival was not reached in either group.
• In a subgroup analysis, concomitant PPI use was associated with shorter clinical PFS (HR, 1.75 for those receiving endocrine-sensitive treatment and 1.82 for those receiving endocrine-resistant treatment), and shorter overall survival (HR, 2.68 in the endocrine-sensitive subgroup and 2.98 in the endocrine-resistant subgroup).

IN PRACTICE:

“The findings suggest that taking PPIs with palbociclib may interrupt the full therapeutic benefits of palbociclib,” the authors conclude. “Physicians should be cautious when prescribing PPIs to patients who are receiving palbociclib.”

SOURCE:

The study, led by Ju-Eun Lee, MS, PharmD, School of Pharmacy, Sungkyunkwan University, South Korea, was published online in JAMA Network Open.

LIMITATIONS:

The study was limited by its retrospective design and use of claims data as well as the inability to confirm whether patients actually took the PPI medication.

DISCLOSURES:

The authors report no relevant financial relationships. The study reported no commercial funding.

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

TOPLINE:
 

Taking a proton pump inhibitor (PPI) with the cyclin-dependent kinase 4/6 (CDK4/6) inhibitor palbociclib could diminish the full therapeutic benefit of palbociclib in women with breast cancer and lead to worse progression-free survival (PFS) and overall survival, new data suggest.

METHODOLOGY:

• The study retrospectively identified 1,310 women with advanced breast cancer receiving palbociclib using South Korean nationwide claims data.
• Overall, 344 women in the concomitant group, those who were coadministered a PPI for more than one-third of their palbociclib treatment duration, were propensity-score matched to 966 women who did not have PPI exposure: the nonconcomitant group.
• Main outcomes were time to progression and death, presented as PFS and overall survival.

TAKEAWAY:

• Median clinical PFS was significantly shorter by about 15 months in the concomitant PPI group vs. the nonconcomitant group (25.3 vs. 39.8 months; adjusted hazard ratio, 1.76).
• Concomitant PPI use was also associated with shorter overall survival (HR, 2.71).
• Overall, 83.1% of patients in the concomitant group were alive at 1 year vs. 94.0% in the nonconcomitant group (P < .001), and 69.5% vs. 89.3%, respectively, were alive at 2 years (P < .001), though the median overall survival was not reached in either group.
• In a subgroup analysis, concomitant PPI use was associated with shorter clinical PFS (HR, 1.75 for those receiving endocrine-sensitive treatment and 1.82 for those receiving endocrine-resistant treatment), and shorter overall survival (HR, 2.68 in the endocrine-sensitive subgroup and 2.98 in the endocrine-resistant subgroup).

IN PRACTICE:

“The findings suggest that taking PPIs with palbociclib may interrupt the full therapeutic benefits of palbociclib,” the authors conclude. “Physicians should be cautious when prescribing PPIs to patients who are receiving palbociclib.”

SOURCE:

The study, led by Ju-Eun Lee, MS, PharmD, School of Pharmacy, Sungkyunkwan University, South Korea, was published online in JAMA Network Open.

LIMITATIONS:

The study was limited by its retrospective design and use of claims data as well as the inability to confirm whether patients actually took the PPI medication.

DISCLOSURES:

The authors report no relevant financial relationships. The study reported no commercial funding.

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

TOPLINE:
 

Taking a proton pump inhibitor (PPI) with the cyclin-dependent kinase 4/6 (CDK4/6) inhibitor palbociclib could diminish the full therapeutic benefit of palbociclib in women with breast cancer and lead to worse progression-free survival (PFS) and overall survival, new data suggest.

METHODOLOGY:

• The study retrospectively identified 1,310 women with advanced breast cancer receiving palbociclib using South Korean nationwide claims data.
• Overall, 344 women in the concomitant group, those who were coadministered a PPI for more than one-third of their palbociclib treatment duration, were propensity-score matched to 966 women who did not have PPI exposure: the nonconcomitant group.
• Main outcomes were time to progression and death, presented as PFS and overall survival.

TAKEAWAY:

• Median clinical PFS was significantly shorter by about 15 months in the concomitant PPI group vs. the nonconcomitant group (25.3 vs. 39.8 months; adjusted hazard ratio, 1.76).
• Concomitant PPI use was also associated with shorter overall survival (HR, 2.71).
• Overall, 83.1% of patients in the concomitant group were alive at 1 year vs. 94.0% in the nonconcomitant group (P < .001), and 69.5% vs. 89.3%, respectively, were alive at 2 years (P < .001), though the median overall survival was not reached in either group.
• In a subgroup analysis, concomitant PPI use was associated with shorter clinical PFS (HR, 1.75 for those receiving endocrine-sensitive treatment and 1.82 for those receiving endocrine-resistant treatment), and shorter overall survival (HR, 2.68 in the endocrine-sensitive subgroup and 2.98 in the endocrine-resistant subgroup).

IN PRACTICE:

“The findings suggest that taking PPIs with palbociclib may interrupt the full therapeutic benefits of palbociclib,” the authors conclude. “Physicians should be cautious when prescribing PPIs to patients who are receiving palbociclib.”

SOURCE:

The study, led by Ju-Eun Lee, MS, PharmD, School of Pharmacy, Sungkyunkwan University, South Korea, was published online in JAMA Network Open.

LIMITATIONS:

The study was limited by its retrospective design and use of claims data as well as the inability to confirm whether patients actually took the PPI medication.

DISCLOSURES:

The authors report no relevant financial relationships. The study reported no commercial funding.

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

A few months ago, a close friend called me in a panic.

Her mother had been on an oral treatment for relapsed multiple myeloma for nearly 1 year. Originally, she had been prescribed the oral pill pomalidomide as part of her regimen, but it had caused cytopenias, constipation, and nausea even at lower doses. Now, she was tolerating her new pill, ixazomib, quite well.

Then, without so much as a letter from her insurance company, the patient’s pharmacy called to tell her that ixazomib was no longer covered without a peer-to-peer conversation given its cost.

The peer to peer left the oncology team and patient even more frustrated. After leaving the team on hold for nearly an hour, the insurance company denied the request for ixazomib. The hematologist conducting the peer-to-peer did not seem to understand why the patient had discontinued her previous medication.

Ultimately, the patient was forced to return to the old, less expensive drug. Since going back to pomalidomide, she has needed multiple dosing changes to manage the intense drug side effects.

I wish that stories like this were uncommon. I am often reminded of the ongoing challenges related to prior authorization when I see colleagues regaling the Twitterverse with their latest horror stories about an insurance company rejecting standard of care treatment or imaging. The data confirm the frequency of these experiences. Among a general cohort of physicians, the American Medical Association has reported that most practices complete 29 prior authorizations per physician every week and spend on average 14.6 hours, or nearly 2 full business days, of staff time each week on these requirements.

Given the growing burden of prior authorization, reform has now become a major policy issue at the federal and state level. Within the past year, organizations like the American Society of Clinical Oncology have released policy positions on prior authorization and are devoting sizable advocacy dollars to fight payers’ ability to enact it. Entire sections of the ASCO education book are devoted to detailing the negative effects of prior authorization, and recent ASCO-commissioned surveys have highlighted alarming statistics about how prior authorization harms patient care.

As a practicing oncologist, I welcome increased attention to the burdens of prior authorization. This attention shows that our professional organizations care about one of the largest contributors to burnout.

But as a researcher who studies systems of care, I worry that focusing our collective ire on health insurance companies is somewhat misplaced or unlikely to succeed.

Why? Because policy statements, Tweets, and legislation ignore the fact that prior authorization is a self-inflicted wound caused by decades of pharmaceutical companies, health systems, oncologists, and guideline bodies failing to factor costs of care into clinical practice.

Making cost-conscious oncology care a priority would be ideal, but it is also a tall order. That leaves health insurers as the main roadblock to otherwise unconstrained health care costs. And prior authorization is what results.

But, as costs continue to rise uncontrollably, the prior authorization system has ballooned out of control and reining in this system will be quite a challenge. Perhaps, we can look to my oncology practice at a Veterans Affairs Medical Center as a guide.
 

A self-inflicted wound

In oncology, most medications and imaging are subject to prior authorization, particularly higher-cost items, and dealing with prior authorization typically requires an army of staff. As enrollment in commercial health plans or Medicare Advantage skyrockets, prior authorization will only become more prevalent in oncology.

Why is this happening?

The lazy answer to this question is because health insurance companies put profits over patients.

However, prior authorization is a symptom, not a disease. And that symptom is exploding cancer care costs. The causes of high costs are varied: Pharmaceutical companies and device manufacturers set ungodly prices for drugs; oncologists and other specialists are often reimbursed for volume of care, not quality; and hospitals and health systems charge incredible amounts for routine labs and imaging, amounts that are orders of magnitude higher than what these services actually cost.

There is no easy solution to fix the drivers of such costs. One approach to rein in drug costs would be to allow Medicare to negotiate drug prices and set site-neutral pricing.

Another would be to incentivize doctors or health systems to reduce the use of high-cost services. But physicians are often unaware of the costs of a given treatment to a system or patient, and practices reimbursed by volume of care typically have little incentive to curb overall spending.

We are then left with payers, the primary means of reimbursing care and, specifically, utilization management, such as prior authorization and restrictive formularies, as the major mechanism to reduce this spending.
 

Prior authorization is broken

Here’s the rub though: Although payers are incentivized to curb costs through prior authorization, the data that they have to adjudicate therapeutic appropriateness are often terrible.

Administrative claims contain no data on biomarkers or performance status and are notoriously bad at reflecting basic information, such as a patient’s stage of cancer. For instance, the positive predictive value of claims-based algorithms to identify stage IV breast cancer is well below 50%, meaning that a claims algorithm that classifies a patient as stage IV is wrong more often than right.

If payers had better data, they could be more selective in their prior-authorization requirements. In other words, if payers could reliably identify who has metastatic breast cancer, an aromatase inhibitor, a common, well-accepted adjuvant therapy in hormone-positive, late-stage breast cancer, wouldn’t need prior authorization. What we have now is an inefficient system that sets prior authorization as a guardrail for most oncology care and then forces doctors to submit all relevant information about a patient to justify their treatment choices.

Keeping up with oncology treatment advances is also a challenge and requires tremendous expertise. Many insurers delegate their prior-authorization responsibilities to medication management companies, such as Magellan Rx or New Century Health, who maintain proprietary treatment pathways.

These companies anchor their prior authorization requirements to common guidelines. That would be fine if guideline-producing bodies like the National Comprehensive Cancer Network provided more firm recommendations on high-value treatments.

The NCCN recommendations, however, are expert-driven more than evidence or value driven. Often, therapies with less evidence make it into recommended treatment guidelines, and in some cases, the NCCN will equally recommend five options for treating a certain cancer, even when there is an obvious lower-cost option.

The effect of this, however, is that payers may then cover these five options, despite a 40-fold price difference among them, but then lean on requiring prior authorization for everything rather than being selective. Broad rather than targeted use of prior authorization alongside well-known issue like uncertain time lines, huge numbers of forms, and nonexperts doing peer to peers make for a huge mess.
 

What can we do?

How can we begin to solve the prior authorization crisis? A first step would be for guideline bodies to have more teeth in their recommendations. If NCCN and other guideline bodies, for instance, incorporated cost into their recommendations and designated these as “preferred” regimens, then clinicians could have better direction on therapy selection and payers could align their prior authorization policies with those recommendations. If patients had adverse effects with low-cost drugs, then a preferred alternative could be specified in such guidelines rather than subject patients, like my friend’s mother, to a toxic drug.

Second, payers could tailor the intensity of prior authorization requirements to the type of physician and clinical scenario at hand. Payers have rich data on practice patterns of oncologists. Payers should incentivize oncologists who follow guideline-based, high-value treatment pathways by lowering the need for frequent peer-to-peers or other prior authorization for “good performers.” This strategy, often termed gold carding, would use relief from prior authorization as a carrot.

Similarly, payers could reward practices that implement clinical pathways that enforce high-value care. For example, a practice could develop a treatment pathway that emphasizes access to urgent care to avoid hospitalizations as well as prioritizes access to relatively lower cost but equally effective options for therapy. If a payer reviewed and approved the pathway, perhaps payers could propose relief of future prior authorizations for practices whose oncologist practice on this pathway.

Third, payers could step up the intensity of prior authorization for certain high-cost or low-value treatments and lessen requirements for more routine services. For example, if every initial staging PET-CT required a peer to peer, oncologists would spend most of the day on the phone. Rather, lower-level tasks such as imaging may require a simple electronic EHR message, whereas high-cost items such as indefinite systemic therapy may require more frequent peer to peers.

Fourth, health systems and real-world data companies should devise better data sharing partnerships with payers so that payers could automatically examine attributes that clarify the choice of therapy. For example, if a payer could view that a patient had estrogen receptor/progesterone receptor–positive early-stage breast cancer post surgery, perhaps that payer would not require a prior authorization for an aromatase inhibitor. These real-time data sharing partnerships could reduce friction points in the system.

Finally, researchers and other groups should partner with payers to continually examine the effectiveness of any prior-authorization program. If a prior-authorization policy is no longer effective because evidence changes and evolves, then payers should consider retiring it.

In my primary oncology practice at a VA Medical Center, none of my treatments require an external prior authorization. Why? Because our local practice agreed to an established formulary, and national treatment pathways firmly specify a recommended treatment course.

Do I sometimes go off pathway? Yes, when I feel there’s a compelling reason. But that requires a structured electronic form to a central pharmacy body. I get a response within 24 hours, with no onerous prior authorization form or lengthy peer to peer.

Though there are plenty of unique qualities about the VA, the fact is that health systems and guideline bodies assuming the burden of cost containment could reduce prior-authorization requirements from payers.

Ultimately, the goal should be for oncologists to choose the highest-value treatment possible. Perhaps then, when the end-goal of cost-conscious oncology care with payers maintain an arm’s length from the patient-doctor relationship, we could all stop shouting at the wind about the burden of prior authorization.

Dr. Parikh is a medical oncologist and faculty member at the University of Pennsylvania, Philadelphia, and the Philadelphia VA Medical Center, an adjunct fellow at the Leonard Davis Institute of Health Economics, and senior clinical advisor at the Coalition to Transform Advanced Care. He reported conflicts of interest with GNS Healthcare, Nanology, Cancer Study Group, Embedded Healthcare, Veterans Affairs, PCF, National Palliative Care Research Center, MUSC, and Flatiron Health.
 

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

A few months ago, a close friend called me in a panic.

Her mother had been on an oral treatment for relapsed multiple myeloma for nearly 1 year. Originally, she had been prescribed the oral pill pomalidomide as part of her regimen, but it had caused cytopenias, constipation, and nausea even at lower doses. Now, she was tolerating her new pill, ixazomib, quite well.

Then, without so much as a letter from her insurance company, the patient’s pharmacy called to tell her that ixazomib was no longer covered without a peer-to-peer conversation given its cost.

The peer to peer left the oncology team and patient even more frustrated. After leaving the team on hold for nearly an hour, the insurance company denied the request for ixazomib. The hematologist conducting the peer-to-peer did not seem to understand why the patient had discontinued her previous medication.

Ultimately, the patient was forced to return to the old, less expensive drug. Since going back to pomalidomide, she has needed multiple dosing changes to manage the intense drug side effects.

I wish that stories like this were uncommon. I am often reminded of the ongoing challenges related to prior authorization when I see colleagues regaling the Twitterverse with their latest horror stories about an insurance company rejecting standard of care treatment or imaging. The data confirm the frequency of these experiences. Among a general cohort of physicians, the American Medical Association has reported that most practices complete 29 prior authorizations per physician every week and spend on average 14.6 hours, or nearly 2 full business days, of staff time each week on these requirements.

Given the growing burden of prior authorization, reform has now become a major policy issue at the federal and state level. Within the past year, organizations like the American Society of Clinical Oncology have released policy positions on prior authorization and are devoting sizable advocacy dollars to fight payers’ ability to enact it. Entire sections of the ASCO education book are devoted to detailing the negative effects of prior authorization, and recent ASCO-commissioned surveys have highlighted alarming statistics about how prior authorization harms patient care.

As a practicing oncologist, I welcome increased attention to the burdens of prior authorization. This attention shows that our professional organizations care about one of the largest contributors to burnout.

But as a researcher who studies systems of care, I worry that focusing our collective ire on health insurance companies is somewhat misplaced or unlikely to succeed.

Why? Because policy statements, Tweets, and legislation ignore the fact that prior authorization is a self-inflicted wound caused by decades of pharmaceutical companies, health systems, oncologists, and guideline bodies failing to factor costs of care into clinical practice.

Making cost-conscious oncology care a priority would be ideal, but it is also a tall order. That leaves health insurers as the main roadblock to otherwise unconstrained health care costs. And prior authorization is what results.

But, as costs continue to rise uncontrollably, the prior authorization system has ballooned out of control and reining in this system will be quite a challenge. Perhaps, we can look to my oncology practice at a Veterans Affairs Medical Center as a guide.
 

A self-inflicted wound

In oncology, most medications and imaging are subject to prior authorization, particularly higher-cost items, and dealing with prior authorization typically requires an army of staff. As enrollment in commercial health plans or Medicare Advantage skyrockets, prior authorization will only become more prevalent in oncology.

Why is this happening?

The lazy answer to this question is because health insurance companies put profits over patients.

However, prior authorization is a symptom, not a disease. And that symptom is exploding cancer care costs. The causes of high costs are varied: Pharmaceutical companies and device manufacturers set ungodly prices for drugs; oncologists and other specialists are often reimbursed for volume of care, not quality; and hospitals and health systems charge incredible amounts for routine labs and imaging, amounts that are orders of magnitude higher than what these services actually cost.

There is no easy solution to fix the drivers of such costs. One approach to rein in drug costs would be to allow Medicare to negotiate drug prices and set site-neutral pricing.

Another would be to incentivize doctors or health systems to reduce the use of high-cost services. But physicians are often unaware of the costs of a given treatment to a system or patient, and practices reimbursed by volume of care typically have little incentive to curb overall spending.

We are then left with payers, the primary means of reimbursing care and, specifically, utilization management, such as prior authorization and restrictive formularies, as the major mechanism to reduce this spending.
 

Prior authorization is broken

Here’s the rub though: Although payers are incentivized to curb costs through prior authorization, the data that they have to adjudicate therapeutic appropriateness are often terrible.

Administrative claims contain no data on biomarkers or performance status and are notoriously bad at reflecting basic information, such as a patient’s stage of cancer. For instance, the positive predictive value of claims-based algorithms to identify stage IV breast cancer is well below 50%, meaning that a claims algorithm that classifies a patient as stage IV is wrong more often than right.

If payers had better data, they could be more selective in their prior-authorization requirements. In other words, if payers could reliably identify who has metastatic breast cancer, an aromatase inhibitor, a common, well-accepted adjuvant therapy in hormone-positive, late-stage breast cancer, wouldn’t need prior authorization. What we have now is an inefficient system that sets prior authorization as a guardrail for most oncology care and then forces doctors to submit all relevant information about a patient to justify their treatment choices.

Keeping up with oncology treatment advances is also a challenge and requires tremendous expertise. Many insurers delegate their prior-authorization responsibilities to medication management companies, such as Magellan Rx or New Century Health, who maintain proprietary treatment pathways.

These companies anchor their prior authorization requirements to common guidelines. That would be fine if guideline-producing bodies like the National Comprehensive Cancer Network provided more firm recommendations on high-value treatments.

The NCCN recommendations, however, are expert-driven more than evidence or value driven. Often, therapies with less evidence make it into recommended treatment guidelines, and in some cases, the NCCN will equally recommend five options for treating a certain cancer, even when there is an obvious lower-cost option.

The effect of this, however, is that payers may then cover these five options, despite a 40-fold price difference among them, but then lean on requiring prior authorization for everything rather than being selective. Broad rather than targeted use of prior authorization alongside well-known issue like uncertain time lines, huge numbers of forms, and nonexperts doing peer to peers make for a huge mess.
 

What can we do?

How can we begin to solve the prior authorization crisis? A first step would be for guideline bodies to have more teeth in their recommendations. If NCCN and other guideline bodies, for instance, incorporated cost into their recommendations and designated these as “preferred” regimens, then clinicians could have better direction on therapy selection and payers could align their prior authorization policies with those recommendations. If patients had adverse effects with low-cost drugs, then a preferred alternative could be specified in such guidelines rather than subject patients, like my friend’s mother, to a toxic drug.

Second, payers could tailor the intensity of prior authorization requirements to the type of physician and clinical scenario at hand. Payers have rich data on practice patterns of oncologists. Payers should incentivize oncologists who follow guideline-based, high-value treatment pathways by lowering the need for frequent peer-to-peers or other prior authorization for “good performers.” This strategy, often termed gold carding, would use relief from prior authorization as a carrot.

Similarly, payers could reward practices that implement clinical pathways that enforce high-value care. For example, a practice could develop a treatment pathway that emphasizes access to urgent care to avoid hospitalizations as well as prioritizes access to relatively lower cost but equally effective options for therapy. If a payer reviewed and approved the pathway, perhaps payers could propose relief of future prior authorizations for practices whose oncologist practice on this pathway.

Third, payers could step up the intensity of prior authorization for certain high-cost or low-value treatments and lessen requirements for more routine services. For example, if every initial staging PET-CT required a peer to peer, oncologists would spend most of the day on the phone. Rather, lower-level tasks such as imaging may require a simple electronic EHR message, whereas high-cost items such as indefinite systemic therapy may require more frequent peer to peers.

Fourth, health systems and real-world data companies should devise better data sharing partnerships with payers so that payers could automatically examine attributes that clarify the choice of therapy. For example, if a payer could view that a patient had estrogen receptor/progesterone receptor–positive early-stage breast cancer post surgery, perhaps that payer would not require a prior authorization for an aromatase inhibitor. These real-time data sharing partnerships could reduce friction points in the system.

Finally, researchers and other groups should partner with payers to continually examine the effectiveness of any prior-authorization program. If a prior-authorization policy is no longer effective because evidence changes and evolves, then payers should consider retiring it.

In my primary oncology practice at a VA Medical Center, none of my treatments require an external prior authorization. Why? Because our local practice agreed to an established formulary, and national treatment pathways firmly specify a recommended treatment course.

Do I sometimes go off pathway? Yes, when I feel there’s a compelling reason. But that requires a structured electronic form to a central pharmacy body. I get a response within 24 hours, with no onerous prior authorization form or lengthy peer to peer.

Though there are plenty of unique qualities about the VA, the fact is that health systems and guideline bodies assuming the burden of cost containment could reduce prior-authorization requirements from payers.

Ultimately, the goal should be for oncologists to choose the highest-value treatment possible. Perhaps then, when the end-goal of cost-conscious oncology care with payers maintain an arm’s length from the patient-doctor relationship, we could all stop shouting at the wind about the burden of prior authorization.

Dr. Parikh is a medical oncologist and faculty member at the University of Pennsylvania, Philadelphia, and the Philadelphia VA Medical Center, an adjunct fellow at the Leonard Davis Institute of Health Economics, and senior clinical advisor at the Coalition to Transform Advanced Care. He reported conflicts of interest with GNS Healthcare, Nanology, Cancer Study Group, Embedded Healthcare, Veterans Affairs, PCF, National Palliative Care Research Center, MUSC, and Flatiron Health.
 

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

A few months ago, a close friend called me in a panic.

Her mother had been on an oral treatment for relapsed multiple myeloma for nearly 1 year. Originally, she had been prescribed the oral pill pomalidomide as part of her regimen, but it had caused cytopenias, constipation, and nausea even at lower doses. Now, she was tolerating her new pill, ixazomib, quite well.

Then, without so much as a letter from her insurance company, the patient’s pharmacy called to tell her that ixazomib was no longer covered without a peer-to-peer conversation given its cost.

The peer to peer left the oncology team and patient even more frustrated. After leaving the team on hold for nearly an hour, the insurance company denied the request for ixazomib. The hematologist conducting the peer-to-peer did not seem to understand why the patient had discontinued her previous medication.

Ultimately, the patient was forced to return to the old, less expensive drug. Since going back to pomalidomide, she has needed multiple dosing changes to manage the intense drug side effects.

I wish that stories like this were uncommon. I am often reminded of the ongoing challenges related to prior authorization when I see colleagues regaling the Twitterverse with their latest horror stories about an insurance company rejecting standard of care treatment or imaging. The data confirm the frequency of these experiences. Among a general cohort of physicians, the American Medical Association has reported that most practices complete 29 prior authorizations per physician every week and spend on average 14.6 hours, or nearly 2 full business days, of staff time each week on these requirements.

Given the growing burden of prior authorization, reform has now become a major policy issue at the federal and state level. Within the past year, organizations like the American Society of Clinical Oncology have released policy positions on prior authorization and are devoting sizable advocacy dollars to fight payers’ ability to enact it. Entire sections of the ASCO education book are devoted to detailing the negative effects of prior authorization, and recent ASCO-commissioned surveys have highlighted alarming statistics about how prior authorization harms patient care.

As a practicing oncologist, I welcome increased attention to the burdens of prior authorization. This attention shows that our professional organizations care about one of the largest contributors to burnout.

But as a researcher who studies systems of care, I worry that focusing our collective ire on health insurance companies is somewhat misplaced or unlikely to succeed.

Why? Because policy statements, Tweets, and legislation ignore the fact that prior authorization is a self-inflicted wound caused by decades of pharmaceutical companies, health systems, oncologists, and guideline bodies failing to factor costs of care into clinical practice.

Making cost-conscious oncology care a priority would be ideal, but it is also a tall order. That leaves health insurers as the main roadblock to otherwise unconstrained health care costs. And prior authorization is what results.

But, as costs continue to rise uncontrollably, the prior authorization system has ballooned out of control and reining in this system will be quite a challenge. Perhaps, we can look to my oncology practice at a Veterans Affairs Medical Center as a guide.
 

A self-inflicted wound

In oncology, most medications and imaging are subject to prior authorization, particularly higher-cost items, and dealing with prior authorization typically requires an army of staff. As enrollment in commercial health plans or Medicare Advantage skyrockets, prior authorization will only become more prevalent in oncology.

Why is this happening?

The lazy answer to this question is because health insurance companies put profits over patients.

However, prior authorization is a symptom, not a disease. And that symptom is exploding cancer care costs. The causes of high costs are varied: Pharmaceutical companies and device manufacturers set ungodly prices for drugs; oncologists and other specialists are often reimbursed for volume of care, not quality; and hospitals and health systems charge incredible amounts for routine labs and imaging, amounts that are orders of magnitude higher than what these services actually cost.

There is no easy solution to fix the drivers of such costs. One approach to rein in drug costs would be to allow Medicare to negotiate drug prices and set site-neutral pricing.

Another would be to incentivize doctors or health systems to reduce the use of high-cost services. But physicians are often unaware of the costs of a given treatment to a system or patient, and practices reimbursed by volume of care typically have little incentive to curb overall spending.

We are then left with payers, the primary means of reimbursing care and, specifically, utilization management, such as prior authorization and restrictive formularies, as the major mechanism to reduce this spending.
 

Prior authorization is broken

Here’s the rub though: Although payers are incentivized to curb costs through prior authorization, the data that they have to adjudicate therapeutic appropriateness are often terrible.

Administrative claims contain no data on biomarkers or performance status and are notoriously bad at reflecting basic information, such as a patient’s stage of cancer. For instance, the positive predictive value of claims-based algorithms to identify stage IV breast cancer is well below 50%, meaning that a claims algorithm that classifies a patient as stage IV is wrong more often than right.

If payers had better data, they could be more selective in their prior-authorization requirements. In other words, if payers could reliably identify who has metastatic breast cancer, an aromatase inhibitor, a common, well-accepted adjuvant therapy in hormone-positive, late-stage breast cancer, wouldn’t need prior authorization. What we have now is an inefficient system that sets prior authorization as a guardrail for most oncology care and then forces doctors to submit all relevant information about a patient to justify their treatment choices.

Keeping up with oncology treatment advances is also a challenge and requires tremendous expertise. Many insurers delegate their prior-authorization responsibilities to medication management companies, such as Magellan Rx or New Century Health, who maintain proprietary treatment pathways.

These companies anchor their prior authorization requirements to common guidelines. That would be fine if guideline-producing bodies like the National Comprehensive Cancer Network provided more firm recommendations on high-value treatments.

The NCCN recommendations, however, are expert-driven more than evidence or value driven. Often, therapies with less evidence make it into recommended treatment guidelines, and in some cases, the NCCN will equally recommend five options for treating a certain cancer, even when there is an obvious lower-cost option.

The effect of this, however, is that payers may then cover these five options, despite a 40-fold price difference among them, but then lean on requiring prior authorization for everything rather than being selective. Broad rather than targeted use of prior authorization alongside well-known issue like uncertain time lines, huge numbers of forms, and nonexperts doing peer to peers make for a huge mess.
 

What can we do?

How can we begin to solve the prior authorization crisis? A first step would be for guideline bodies to have more teeth in their recommendations. If NCCN and other guideline bodies, for instance, incorporated cost into their recommendations and designated these as “preferred” regimens, then clinicians could have better direction on therapy selection and payers could align their prior authorization policies with those recommendations. If patients had adverse effects with low-cost drugs, then a preferred alternative could be specified in such guidelines rather than subject patients, like my friend’s mother, to a toxic drug.

Second, payers could tailor the intensity of prior authorization requirements to the type of physician and clinical scenario at hand. Payers have rich data on practice patterns of oncologists. Payers should incentivize oncologists who follow guideline-based, high-value treatment pathways by lowering the need for frequent peer-to-peers or other prior authorization for “good performers.” This strategy, often termed gold carding, would use relief from prior authorization as a carrot.

Similarly, payers could reward practices that implement clinical pathways that enforce high-value care. For example, a practice could develop a treatment pathway that emphasizes access to urgent care to avoid hospitalizations as well as prioritizes access to relatively lower cost but equally effective options for therapy. If a payer reviewed and approved the pathway, perhaps payers could propose relief of future prior authorizations for practices whose oncologist practice on this pathway.

Third, payers could step up the intensity of prior authorization for certain high-cost or low-value treatments and lessen requirements for more routine services. For example, if every initial staging PET-CT required a peer to peer, oncologists would spend most of the day on the phone. Rather, lower-level tasks such as imaging may require a simple electronic EHR message, whereas high-cost items such as indefinite systemic therapy may require more frequent peer to peers.

Fourth, health systems and real-world data companies should devise better data sharing partnerships with payers so that payers could automatically examine attributes that clarify the choice of therapy. For example, if a payer could view that a patient had estrogen receptor/progesterone receptor–positive early-stage breast cancer post surgery, perhaps that payer would not require a prior authorization for an aromatase inhibitor. These real-time data sharing partnerships could reduce friction points in the system.

Finally, researchers and other groups should partner with payers to continually examine the effectiveness of any prior-authorization program. If a prior-authorization policy is no longer effective because evidence changes and evolves, then payers should consider retiring it.

In my primary oncology practice at a VA Medical Center, none of my treatments require an external prior authorization. Why? Because our local practice agreed to an established formulary, and national treatment pathways firmly specify a recommended treatment course.

Do I sometimes go off pathway? Yes, when I feel there’s a compelling reason. But that requires a structured electronic form to a central pharmacy body. I get a response within 24 hours, with no onerous prior authorization form or lengthy peer to peer.

Though there are plenty of unique qualities about the VA, the fact is that health systems and guideline bodies assuming the burden of cost containment could reduce prior-authorization requirements from payers.

Ultimately, the goal should be for oncologists to choose the highest-value treatment possible. Perhaps then, when the end-goal of cost-conscious oncology care with payers maintain an arm’s length from the patient-doctor relationship, we could all stop shouting at the wind about the burden of prior authorization.

Dr. Parikh is a medical oncologist and faculty member at the University of Pennsylvania, Philadelphia, and the Philadelphia VA Medical Center, an adjunct fellow at the Leonard Davis Institute of Health Economics, and senior clinical advisor at the Coalition to Transform Advanced Care. He reported conflicts of interest with GNS Healthcare, Nanology, Cancer Study Group, Embedded Healthcare, Veterans Affairs, PCF, National Palliative Care Research Center, MUSC, and Flatiron Health.
 

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

A new lawsuit alleges that Cigna uses artificial intelligence (AI) algorithms to inappropriately deny “hundreds or thousands” of claims at a time, bypassing legal requirements to complete individual claim reviews and forcing providers to bill patients in full.

In a complaint filed recently in California’s eastern district court, plaintiffs and Cigna health plan members Suzanne Kisting-Leung and Ayesha Smiley and their attorneys say that Cigna violates state insurance regulations by failing to conduct a “thorough, fair, and objective” review of their and other members’ claims.

The lawsuit says that, instead, Cigna relies on an algorithm, PxDx, to review and frequently deny medically necessary claims. According to court records, the system allows Cigna’s doctors to “instantly reject claims on medical grounds without ever opening patient files.” With use of the system, the average claims processing time is 1.2 seconds.

Cigna says it uses technology to verify coding on standard, low-cost procedures and to expedite physician reimbursement. In a statement to CBS News, the company called the lawsuit “highly questionable.”

The case highlights growing concerns about AI and its ability to replace humans for tasks and interactions in health care, business, and beyond. Public advocacy law firm Clarkson, which is representing the plaintiffs, has previously sued tech giants Google and ChatGPT creator OpenAI for harvesting Internet users’ personal and professional data to train their AI systems.

According to the complaint, Cigna denied the plaintiffs medically necessary tests, including blood work to screen for vitamin D deficiency and ultrasounds for patients suspected of having ovarian cancer. The plaintiffs’ attempts to appeal were unfruitful, and they were forced to pay out of pocket.

The plaintiff’s attorneys argue that the claims do not undergo more detailed reviews by physicians and employees, as mandated by California insurance laws, and that Cigna benefits by saving on labor costs.

Clarkson is demanding a jury trial and has asked the court to certify the Cigna case as a federal class action, potentially allowing the insurer’s other 2 million health plan members in California to join the lawsuit.

I. Glenn Cohen, JD, deputy dean and professor at Harvard Law School, Cambridge, Mass., said in an interview that this is the first lawsuit he’s aware of in which AI was involved in denying health insurance claims and that it is probably an uphill battle for the plaintiffs.

“In the last 25 years, the U.S. Supreme Court’s decisions have made getting a class action approved more difficult. If allowed to go forward as a class action, which Cigna is likely to vigorously oppose, then the pressure on Cigna to settle the case becomes enormous,” he said.

The allegations come after a recent deep dive by the nonprofit ProPublica uncovered similar claim denial issues. One physician who worked for Cigna told the nonprofit that he and other company doctors essentially rubber-stamped the denials in batches, which took “all of 10 seconds to do 50 at a time.”

In 2022, the American Medical Association and two state physician groups joined another class action against Cigna stemming from allegations that the insurer’s intermediary, Multiplan, intentionally underpaid medical claims. And in March, Cigna’s pharmacy benefit manager, Express Scripts, was accused of conspiring with other PBMs to drive up prescription drug prices for Ohio consumers, violating state antitrust laws.

Mr. Cohen said he expects Cigna to push back in court about the California class size, which the plaintiff’s attorneys hope will encompass all Cigna health plan members in the state.

“The injury is primarily to those whose claims were denied by AI, presumably a much smaller set of individuals and harder to identify,” said Mr. Cohen.

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

A new lawsuit alleges that Cigna uses artificial intelligence (AI) algorithms to inappropriately deny “hundreds or thousands” of claims at a time, bypassing legal requirements to complete individual claim reviews and forcing providers to bill patients in full.

In a complaint filed recently in California’s eastern district court, plaintiffs and Cigna health plan members Suzanne Kisting-Leung and Ayesha Smiley and their attorneys say that Cigna violates state insurance regulations by failing to conduct a “thorough, fair, and objective” review of their and other members’ claims.

The lawsuit says that, instead, Cigna relies on an algorithm, PxDx, to review and frequently deny medically necessary claims. According to court records, the system allows Cigna’s doctors to “instantly reject claims on medical grounds without ever opening patient files.” With use of the system, the average claims processing time is 1.2 seconds.

Cigna says it uses technology to verify coding on standard, low-cost procedures and to expedite physician reimbursement. In a statement to CBS News, the company called the lawsuit “highly questionable.”

The case highlights growing concerns about AI and its ability to replace humans for tasks and interactions in health care, business, and beyond. Public advocacy law firm Clarkson, which is representing the plaintiffs, has previously sued tech giants Google and ChatGPT creator OpenAI for harvesting Internet users’ personal and professional data to train their AI systems.

According to the complaint, Cigna denied the plaintiffs medically necessary tests, including blood work to screen for vitamin D deficiency and ultrasounds for patients suspected of having ovarian cancer. The plaintiffs’ attempts to appeal were unfruitful, and they were forced to pay out of pocket.

The plaintiff’s attorneys argue that the claims do not undergo more detailed reviews by physicians and employees, as mandated by California insurance laws, and that Cigna benefits by saving on labor costs.

Clarkson is demanding a jury trial and has asked the court to certify the Cigna case as a federal class action, potentially allowing the insurer’s other 2 million health plan members in California to join the lawsuit.

I. Glenn Cohen, JD, deputy dean and professor at Harvard Law School, Cambridge, Mass., said in an interview that this is the first lawsuit he’s aware of in which AI was involved in denying health insurance claims and that it is probably an uphill battle for the plaintiffs.

“In the last 25 years, the U.S. Supreme Court’s decisions have made getting a class action approved more difficult. If allowed to go forward as a class action, which Cigna is likely to vigorously oppose, then the pressure on Cigna to settle the case becomes enormous,” he said.

The allegations come after a recent deep dive by the nonprofit ProPublica uncovered similar claim denial issues. One physician who worked for Cigna told the nonprofit that he and other company doctors essentially rubber-stamped the denials in batches, which took “all of 10 seconds to do 50 at a time.”

In 2022, the American Medical Association and two state physician groups joined another class action against Cigna stemming from allegations that the insurer’s intermediary, Multiplan, intentionally underpaid medical claims. And in March, Cigna’s pharmacy benefit manager, Express Scripts, was accused of conspiring with other PBMs to drive up prescription drug prices for Ohio consumers, violating state antitrust laws.

Mr. Cohen said he expects Cigna to push back in court about the California class size, which the plaintiff’s attorneys hope will encompass all Cigna health plan members in the state.

“The injury is primarily to those whose claims were denied by AI, presumably a much smaller set of individuals and harder to identify,” said Mr. Cohen.

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

A new lawsuit alleges that Cigna uses artificial intelligence (AI) algorithms to inappropriately deny “hundreds or thousands” of claims at a time, bypassing legal requirements to complete individual claim reviews and forcing providers to bill patients in full.

In a complaint filed recently in California’s eastern district court, plaintiffs and Cigna health plan members Suzanne Kisting-Leung and Ayesha Smiley and their attorneys say that Cigna violates state insurance regulations by failing to conduct a “thorough, fair, and objective” review of their and other members’ claims.

The lawsuit says that, instead, Cigna relies on an algorithm, PxDx, to review and frequently deny medically necessary claims. According to court records, the system allows Cigna’s doctors to “instantly reject claims on medical grounds without ever opening patient files.” With use of the system, the average claims processing time is 1.2 seconds.

Cigna says it uses technology to verify coding on standard, low-cost procedures and to expedite physician reimbursement. In a statement to CBS News, the company called the lawsuit “highly questionable.”

The case highlights growing concerns about AI and its ability to replace humans for tasks and interactions in health care, business, and beyond. Public advocacy law firm Clarkson, which is representing the plaintiffs, has previously sued tech giants Google and ChatGPT creator OpenAI for harvesting Internet users’ personal and professional data to train their AI systems.

According to the complaint, Cigna denied the plaintiffs medically necessary tests, including blood work to screen for vitamin D deficiency and ultrasounds for patients suspected of having ovarian cancer. The plaintiffs’ attempts to appeal were unfruitful, and they were forced to pay out of pocket.

The plaintiff’s attorneys argue that the claims do not undergo more detailed reviews by physicians and employees, as mandated by California insurance laws, and that Cigna benefits by saving on labor costs.

Clarkson is demanding a jury trial and has asked the court to certify the Cigna case as a federal class action, potentially allowing the insurer’s other 2 million health plan members in California to join the lawsuit.

I. Glenn Cohen, JD, deputy dean and professor at Harvard Law School, Cambridge, Mass., said in an interview that this is the first lawsuit he’s aware of in which AI was involved in denying health insurance claims and that it is probably an uphill battle for the plaintiffs.

“In the last 25 years, the U.S. Supreme Court’s decisions have made getting a class action approved more difficult. If allowed to go forward as a class action, which Cigna is likely to vigorously oppose, then the pressure on Cigna to settle the case becomes enormous,” he said.

The allegations come after a recent deep dive by the nonprofit ProPublica uncovered similar claim denial issues. One physician who worked for Cigna told the nonprofit that he and other company doctors essentially rubber-stamped the denials in batches, which took “all of 10 seconds to do 50 at a time.”

In 2022, the American Medical Association and two state physician groups joined another class action against Cigna stemming from allegations that the insurer’s intermediary, Multiplan, intentionally underpaid medical claims. And in March, Cigna’s pharmacy benefit manager, Express Scripts, was accused of conspiring with other PBMs to drive up prescription drug prices for Ohio consumers, violating state antitrust laws.

Mr. Cohen said he expects Cigna to push back in court about the California class size, which the plaintiff’s attorneys hope will encompass all Cigna health plan members in the state.

“The injury is primarily to those whose claims were denied by AI, presumably a much smaller set of individuals and harder to identify,” said Mr. Cohen.

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

A petition demanding an end to maintenance of certification (MOC) requirements from the American Board of Internal Medicine (ABIM) gained traction among oncologists in late July, garnering nearly 7,500 signatures in 10 days.

The MOC program, “originally intended to uphold the standards of medical practice and promote lifelong learning, has evolved into a complex and time-consuming process that poses significant challenges to practicing physicians,” according to the petition launched on July 21 by hematologist-oncologist Aaron Goodman, MD. The MOC “has become burdensome, costly, and lacks evidence to support its effectiveness in improving patient care or physician competence.”

Dr. Goodman, assistant professor at the University of California, San Diego, is scheduled to debate the matter with ABIM President and Chief Executive Officer Richard J. Baron, MD, during a Healthcare Unfiltered podcast recorded and hosted by Chadi Nabhan, MD. In the August 3 podcast, Dr. Goodman and Dr. Baron will respond to questions posed via tweets, Dr. Goodman said.

A Twitter survey posted by Dr. Nabhan in advance of the debate asked physicians whether the cost of the MOC, the time required for testing, or data sharing by ABIM is most bothersome. Of 158 respondents, 71% selected “all of the above.”
 

ABIM touts MOC ‘values’  

The ABIM requires an initial certification assessment that costs thousands of dollars and must be repeated every 10 years. The annual MOC requirements, which were tacked on within the last decade, involve tests that cost $220 for the first certificate a physician holds and about $120 for each subsequent one.

Over the course of his career, Dr. Goodman estimates he will spend over $40,000 to maintain his three ABIM boards in medicine, hematology, and oncology.

The ABIM did not immediately respond to a request for comment on the petition and debate, but a page on the ABIM website touts the “values of MOC” and says there is “compelling evidence” that the MOC improves the value of care without sacrificing quality and that board-certified physicians earn more.

According to the website, the MOC program “provides doctors with a pathway to know that they are staying current in the medical knowledge they use to treat patients and make important care decisions daily.” The ABIM also says that the “program has evolved to include new assessment options and an increased recognition of the work doctors do every day” and that the ABIM “continuously collaborates with doctors to increase the relevance of exams.”

Aniruddha Singh, MD, also weighed in on the value of MOC in a July 13 ABIM blog post. Dr. Singh is a member of this year’s Cardiovascular Disease Traditional, 10-Year MOC Exam Approval Committee and program director for the General Cardiovascular Fellowship at Drexel University College of Medicine, Reading, Pa.

In his post, Dr. Singh states that the MOC “facilitates a broader perspective on a range of topics [and] enables me to delve deeper into relevant areas, fostering a comprehensive understanding that enhances my quality of care.”
 

Growing resistance

Although Dr. Goodman acknowledged the merit of board testing every decade or so, physicians already do continuing medical education (CME) to keep up-to-date on their specialties. Dr. Goodman believes that most physicians, other than those who work for ABIM, would agree that MOC is a waste of time and money.

“It’s a pain-in-the-ass module that you sit at home and Google – it’s not really any sort of assessment,” nor does it help protect the public, said Goodman. The MOC is ultimately “just a money grab.”

According to the ABIM’s website, the nonprofit has net assets of more than $73.2 million as of June 30, 2022. Last year, the ABIM’s revenue hit $71.9 million, with more than half coming from MOC fees and 48% from certification.

The ABIM also says it spent $58 million in 2022. A breakdown shows about 63% of that money went to administering (28%), researching (13%), overseeing (4%), and developing (18%) the certification and MOC exams and program. ABIM’s CEO Dr. Baron makes about $1.2 million a year, according to recent tax filings. The COO makes about $550,000 from the ABIM and “related” organizations.

Fed up with the requirements and cost, Dr. Goodman decided to launch the petition to see if others agreed and how many.

His petition, addressed to the ABIM, expresses “deep dissatisfaction” with the ABIM MOC program and “respectfully request[s] that the ABIM take immediate action to eliminate the MOC program and adopt alternative, less burdensome methods of ensuring physician competence and continuous professional development.” Dr. Goodman, alongside Vinay Prasad, MD, a hematologist-oncologist and professor at the University of California, San Francisco, reiterated these points in a piece highlighting the petition.

Shortly before the petition went public but after he had been vocal on Twitter about issues with the MOC, Dr. Goodman said he received an invitation to join the ABIM Board of Governors. “My hypothesis is they are trying to ‘friend’ me, so I get credentialed, and they get me to stop yelling. It just made me more pissed off. I don’t want to be any part of that,” he said.

H. Jack West, MD, a thoracic oncologist and associate professor at City of Hope Comprehensive Cancer Center, signed the petition without hesitation.

Dr. West agreed with Dr. Goodman that the 10-year ABIM recertification is sufficient. He also denounced the ABIM testing process, costs, and content, saying he found the questions “so ambiguous that even knowing everything about the subject, I found the assignment of the ‘best’ answer to be a Talmudic interpretation.”

“The questions seem to have a sadistic level of complexity and ambiguity baked into them, rather than being a direct assessment of knowledge,” he explained.

The ABIM is also “completely opaque” about their process of developing questions and defining answers, Dr. West said. And “the ABIM offers no data to support that their processes improve any clinical outcomes.”

Yet, the MOC “forces physicians to spend several hundred dollars every year as well as an incredible amount of their time jumping through hoops at the behest of ABIM to satisfy these imposed requirements,” Dr. West said. The time spent satisfying these requirements is also “strip-mining physician morale” by taking time away from families and personal lives.

As for ABIM finances, Dr. West said the organization offers no justification for “the extortionate costs imposed by this de facto monopoly.”

The glimpses we do see, however, “indicate an organization spending on a lavish condominium and offering conspicuously generous remuneration to its own leadership. The only thing that is assured by the ABIM’s MOC program is that it is wildly profitable for the ABIM,” he added.

In a tweet, he called on physicians to take a stand: “If you think MOC is good, say it. Otherwise, if you don’t sign [the petition], ask yourself why you don’t have the courage & character to do so.”
 

Next steps?

Dr. Goodman’s petition lays out potential alternatives to the MOC that “would better support physician competence and continuing education without imposing unnecessary hurdles.”

Alternatives include encouraging voluntary, accessible, and evidence-based CME programs to promote lifelong learning among physicians, establishing a system for peer evaluation and feedback, encouraging self-assessment, and fostering a culture of continuous quality improvement.

Dr. Goodman’s goal is to garner at least 10,000 signatures and reach out to credentialing committees around the country with the results to promote alternatives to MOC. As of the morning of August 1, the petition had more than 7,900 signatures.

He also gives Dr. Baron credit for his willingness to have a conversation about the MOC and intends for that conversation to be a civil, respectful debate.

“I can’t think of anything he could say that will convince me [MOC] is the right thing to do, but we’ll see what he has to say,” Dr. Goodman said.

A version of this article appeared on Medscape.com.

A petition demanding an end to maintenance of certification (MOC) requirements from the American Board of Internal Medicine (ABIM) gained traction among oncologists in late July, garnering nearly 7,500 signatures in 10 days.

The MOC program, “originally intended to uphold the standards of medical practice and promote lifelong learning, has evolved into a complex and time-consuming process that poses significant challenges to practicing physicians,” according to the petition launched on July 21 by hematologist-oncologist Aaron Goodman, MD. The MOC “has become burdensome, costly, and lacks evidence to support its effectiveness in improving patient care or physician competence.”

Dr. Goodman, assistant professor at the University of California, San Diego, is scheduled to debate the matter with ABIM President and Chief Executive Officer Richard J. Baron, MD, during a Healthcare Unfiltered podcast recorded and hosted by Chadi Nabhan, MD. In the August 3 podcast, Dr. Goodman and Dr. Baron will respond to questions posed via tweets, Dr. Goodman said.

A Twitter survey posted by Dr. Nabhan in advance of the debate asked physicians whether the cost of the MOC, the time required for testing, or data sharing by ABIM is most bothersome. Of 158 respondents, 71% selected “all of the above.”
 

ABIM touts MOC ‘values’  

The ABIM requires an initial certification assessment that costs thousands of dollars and must be repeated every 10 years. The annual MOC requirements, which were tacked on within the last decade, involve tests that cost $220 for the first certificate a physician holds and about $120 for each subsequent one.

Over the course of his career, Dr. Goodman estimates he will spend over $40,000 to maintain his three ABIM boards in medicine, hematology, and oncology.

The ABIM did not immediately respond to a request for comment on the petition and debate, but a page on the ABIM website touts the “values of MOC” and says there is “compelling evidence” that the MOC improves the value of care without sacrificing quality and that board-certified physicians earn more.

According to the website, the MOC program “provides doctors with a pathway to know that they are staying current in the medical knowledge they use to treat patients and make important care decisions daily.” The ABIM also says that the “program has evolved to include new assessment options and an increased recognition of the work doctors do every day” and that the ABIM “continuously collaborates with doctors to increase the relevance of exams.”

Aniruddha Singh, MD, also weighed in on the value of MOC in a July 13 ABIM blog post. Dr. Singh is a member of this year’s Cardiovascular Disease Traditional, 10-Year MOC Exam Approval Committee and program director for the General Cardiovascular Fellowship at Drexel University College of Medicine, Reading, Pa.

In his post, Dr. Singh states that the MOC “facilitates a broader perspective on a range of topics [and] enables me to delve deeper into relevant areas, fostering a comprehensive understanding that enhances my quality of care.”
 

Growing resistance

Although Dr. Goodman acknowledged the merit of board testing every decade or so, physicians already do continuing medical education (CME) to keep up-to-date on their specialties. Dr. Goodman believes that most physicians, other than those who work for ABIM, would agree that MOC is a waste of time and money.

“It’s a pain-in-the-ass module that you sit at home and Google – it’s not really any sort of assessment,” nor does it help protect the public, said Goodman. The MOC is ultimately “just a money grab.”

According to the ABIM’s website, the nonprofit has net assets of more than $73.2 million as of June 30, 2022. Last year, the ABIM’s revenue hit $71.9 million, with more than half coming from MOC fees and 48% from certification.

The ABIM also says it spent $58 million in 2022. A breakdown shows about 63% of that money went to administering (28%), researching (13%), overseeing (4%), and developing (18%) the certification and MOC exams and program. ABIM’s CEO Dr. Baron makes about $1.2 million a year, according to recent tax filings. The COO makes about $550,000 from the ABIM and “related” organizations.

Fed up with the requirements and cost, Dr. Goodman decided to launch the petition to see if others agreed and how many.

His petition, addressed to the ABIM, expresses “deep dissatisfaction” with the ABIM MOC program and “respectfully request[s] that the ABIM take immediate action to eliminate the MOC program and adopt alternative, less burdensome methods of ensuring physician competence and continuous professional development.” Dr. Goodman, alongside Vinay Prasad, MD, a hematologist-oncologist and professor at the University of California, San Francisco, reiterated these points in a piece highlighting the petition.

Shortly before the petition went public but after he had been vocal on Twitter about issues with the MOC, Dr. Goodman said he received an invitation to join the ABIM Board of Governors. “My hypothesis is they are trying to ‘friend’ me, so I get credentialed, and they get me to stop yelling. It just made me more pissed off. I don’t want to be any part of that,” he said.

H. Jack West, MD, a thoracic oncologist and associate professor at City of Hope Comprehensive Cancer Center, signed the petition without hesitation.

Dr. West agreed with Dr. Goodman that the 10-year ABIM recertification is sufficient. He also denounced the ABIM testing process, costs, and content, saying he found the questions “so ambiguous that even knowing everything about the subject, I found the assignment of the ‘best’ answer to be a Talmudic interpretation.”

“The questions seem to have a sadistic level of complexity and ambiguity baked into them, rather than being a direct assessment of knowledge,” he explained.

The ABIM is also “completely opaque” about their process of developing questions and defining answers, Dr. West said. And “the ABIM offers no data to support that their processes improve any clinical outcomes.”

Yet, the MOC “forces physicians to spend several hundred dollars every year as well as an incredible amount of their time jumping through hoops at the behest of ABIM to satisfy these imposed requirements,” Dr. West said. The time spent satisfying these requirements is also “strip-mining physician morale” by taking time away from families and personal lives.

As for ABIM finances, Dr. West said the organization offers no justification for “the extortionate costs imposed by this de facto monopoly.”

The glimpses we do see, however, “indicate an organization spending on a lavish condominium and offering conspicuously generous remuneration to its own leadership. The only thing that is assured by the ABIM’s MOC program is that it is wildly profitable for the ABIM,” he added.

In a tweet, he called on physicians to take a stand: “If you think MOC is good, say it. Otherwise, if you don’t sign [the petition], ask yourself why you don’t have the courage & character to do so.”
 

Next steps?

Dr. Goodman’s petition lays out potential alternatives to the MOC that “would better support physician competence and continuing education without imposing unnecessary hurdles.”

Alternatives include encouraging voluntary, accessible, and evidence-based CME programs to promote lifelong learning among physicians, establishing a system for peer evaluation and feedback, encouraging self-assessment, and fostering a culture of continuous quality improvement.

Dr. Goodman’s goal is to garner at least 10,000 signatures and reach out to credentialing committees around the country with the results to promote alternatives to MOC. As of the morning of August 1, the petition had more than 7,900 signatures.

He also gives Dr. Baron credit for his willingness to have a conversation about the MOC and intends for that conversation to be a civil, respectful debate.

“I can’t think of anything he could say that will convince me [MOC] is the right thing to do, but we’ll see what he has to say,” Dr. Goodman said.

A version of this article appeared on Medscape.com.

A petition demanding an end to maintenance of certification (MOC) requirements from the American Board of Internal Medicine (ABIM) gained traction among oncologists in late July, garnering nearly 7,500 signatures in 10 days.

The MOC program, “originally intended to uphold the standards of medical practice and promote lifelong learning, has evolved into a complex and time-consuming process that poses significant challenges to practicing physicians,” according to the petition launched on July 21 by hematologist-oncologist Aaron Goodman, MD. The MOC “has become burdensome, costly, and lacks evidence to support its effectiveness in improving patient care or physician competence.”

Dr. Goodman, assistant professor at the University of California, San Diego, is scheduled to debate the matter with ABIM President and Chief Executive Officer Richard J. Baron, MD, during a Healthcare Unfiltered podcast recorded and hosted by Chadi Nabhan, MD. In the August 3 podcast, Dr. Goodman and Dr. Baron will respond to questions posed via tweets, Dr. Goodman said.

A Twitter survey posted by Dr. Nabhan in advance of the debate asked physicians whether the cost of the MOC, the time required for testing, or data sharing by ABIM is most bothersome. Of 158 respondents, 71% selected “all of the above.”
 

ABIM touts MOC ‘values’  

The ABIM requires an initial certification assessment that costs thousands of dollars and must be repeated every 10 years. The annual MOC requirements, which were tacked on within the last decade, involve tests that cost $220 for the first certificate a physician holds and about $120 for each subsequent one.

Over the course of his career, Dr. Goodman estimates he will spend over $40,000 to maintain his three ABIM boards in medicine, hematology, and oncology.

The ABIM did not immediately respond to a request for comment on the petition and debate, but a page on the ABIM website touts the “values of MOC” and says there is “compelling evidence” that the MOC improves the value of care without sacrificing quality and that board-certified physicians earn more.

According to the website, the MOC program “provides doctors with a pathway to know that they are staying current in the medical knowledge they use to treat patients and make important care decisions daily.” The ABIM also says that the “program has evolved to include new assessment options and an increased recognition of the work doctors do every day” and that the ABIM “continuously collaborates with doctors to increase the relevance of exams.”

Aniruddha Singh, MD, also weighed in on the value of MOC in a July 13 ABIM blog post. Dr. Singh is a member of this year’s Cardiovascular Disease Traditional, 10-Year MOC Exam Approval Committee and program director for the General Cardiovascular Fellowship at Drexel University College of Medicine, Reading, Pa.

In his post, Dr. Singh states that the MOC “facilitates a broader perspective on a range of topics [and] enables me to delve deeper into relevant areas, fostering a comprehensive understanding that enhances my quality of care.”
 

Growing resistance

Although Dr. Goodman acknowledged the merit of board testing every decade or so, physicians already do continuing medical education (CME) to keep up-to-date on their specialties. Dr. Goodman believes that most physicians, other than those who work for ABIM, would agree that MOC is a waste of time and money.

“It’s a pain-in-the-ass module that you sit at home and Google – it’s not really any sort of assessment,” nor does it help protect the public, said Goodman. The MOC is ultimately “just a money grab.”

According to the ABIM’s website, the nonprofit has net assets of more than $73.2 million as of June 30, 2022. Last year, the ABIM’s revenue hit $71.9 million, with more than half coming from MOC fees and 48% from certification.

The ABIM also says it spent $58 million in 2022. A breakdown shows about 63% of that money went to administering (28%), researching (13%), overseeing (4%), and developing (18%) the certification and MOC exams and program. ABIM’s CEO Dr. Baron makes about $1.2 million a year, according to recent tax filings. The COO makes about $550,000 from the ABIM and “related” organizations.

Fed up with the requirements and cost, Dr. Goodman decided to launch the petition to see if others agreed and how many.

His petition, addressed to the ABIM, expresses “deep dissatisfaction” with the ABIM MOC program and “respectfully request[s] that the ABIM take immediate action to eliminate the MOC program and adopt alternative, less burdensome methods of ensuring physician competence and continuous professional development.” Dr. Goodman, alongside Vinay Prasad, MD, a hematologist-oncologist and professor at the University of California, San Francisco, reiterated these points in a piece highlighting the petition.

Shortly before the petition went public but after he had been vocal on Twitter about issues with the MOC, Dr. Goodman said he received an invitation to join the ABIM Board of Governors. “My hypothesis is they are trying to ‘friend’ me, so I get credentialed, and they get me to stop yelling. It just made me more pissed off. I don’t want to be any part of that,” he said.

H. Jack West, MD, a thoracic oncologist and associate professor at City of Hope Comprehensive Cancer Center, signed the petition without hesitation.

Dr. West agreed with Dr. Goodman that the 10-year ABIM recertification is sufficient. He also denounced the ABIM testing process, costs, and content, saying he found the questions “so ambiguous that even knowing everything about the subject, I found the assignment of the ‘best’ answer to be a Talmudic interpretation.”

“The questions seem to have a sadistic level of complexity and ambiguity baked into them, rather than being a direct assessment of knowledge,” he explained.

The ABIM is also “completely opaque” about their process of developing questions and defining answers, Dr. West said. And “the ABIM offers no data to support that their processes improve any clinical outcomes.”

Yet, the MOC “forces physicians to spend several hundred dollars every year as well as an incredible amount of their time jumping through hoops at the behest of ABIM to satisfy these imposed requirements,” Dr. West said. The time spent satisfying these requirements is also “strip-mining physician morale” by taking time away from families and personal lives.

As for ABIM finances, Dr. West said the organization offers no justification for “the extortionate costs imposed by this de facto monopoly.”

The glimpses we do see, however, “indicate an organization spending on a lavish condominium and offering conspicuously generous remuneration to its own leadership. The only thing that is assured by the ABIM’s MOC program is that it is wildly profitable for the ABIM,” he added.

In a tweet, he called on physicians to take a stand: “If you think MOC is good, say it. Otherwise, if you don’t sign [the petition], ask yourself why you don’t have the courage & character to do so.”
 

Next steps?

Dr. Goodman’s petition lays out potential alternatives to the MOC that “would better support physician competence and continuing education without imposing unnecessary hurdles.”

Alternatives include encouraging voluntary, accessible, and evidence-based CME programs to promote lifelong learning among physicians, establishing a system for peer evaluation and feedback, encouraging self-assessment, and fostering a culture of continuous quality improvement.

Dr. Goodman’s goal is to garner at least 10,000 signatures and reach out to credentialing committees around the country with the results to promote alternatives to MOC. As of the morning of August 1, the petition had more than 7,900 signatures.

He also gives Dr. Baron credit for his willingness to have a conversation about the MOC and intends for that conversation to be a civil, respectful debate.

“I can’t think of anything he could say that will convince me [MOC] is the right thing to do, but we’ll see what he has to say,” Dr. Goodman said.

A version of this article appeared on Medscape.com.

Outsourcing certain staff functions in a practice to outside contractors working in remote locations has become commonplace in many medical practices.

Health care outsourcing services, also known as virtual assistants (VAs), were already booming in 2017, when volume grew by 36%. Then, the COVID-19 pandemic in 2020 normalized off-site work, which was a boon to outsourcing providers.

The most popular services being outsourced today by medical practices include billing, scribes, telephone calls to patients, and processing prior authorizations.

“Outsourcing is not for everyone, but I’ve seen it work for many practices,” said Lara Hochman, MD, a practice management consultant in Austin, Tex. She said that practices have used outsourcing to solve problems like high staff turnover, tight budgets, and inefficient use of staff.

When in-house staffing is insufficient or not appropriately aligned with the task, outsourcing can produce big savings, said Teri Deabler, a practice management consultant with the Texas Medical Association.

For example, she said that a client was paying an in-house accountant $80,000 a year. When the accountant retired, she was replaced with a part-time bookkeeper earning $20,000 while her accounting work was outsourced at a cost of $20,000 a year. “The practice’s costs for this service were cut in half,” Ms. Deabler said.
 

What functions lend themselves to outsourcing?

Clinical services are rarely outsourced by individual practices – although hospitals now outsource numerous clinical services – but virtually any kind of administrative service can be contracted out. Outsourcing used to be limited mainly to billing and off-hours phone services, but today, more services are available, such as scribing, processing prior authorizations, accounting and bookkeeping, human resources (HR) and payroll, interactions with social media, recredentialing, medical transcription, and marketing.

Meanwhile, the original outsourced services have evolved. Billing and collections may now be handled by off-shore VAs, and phone services now deal with a wider variety of tasks, such as answering patients’ questions, scheduling appointments, and making referrals.

Ron Holder, chief operating officer of Medical Group Management Association in Englewood, Colo., said that some outsourcing services can also adjust the amount of work provided based on the customer’s needs. “For instance, an IT outsourcer may allow you to scale up IT support for a new big tech project, such as installing a new electronic health record,” he said.

The outsourced service provider, who might work in another state or another country, is connected to the practice by phone and electronically, and represents the practice when dealing with patients, insurers, or other vendors.

“No one, including patients and your physicians, should know that they are dealing with an outsourced company,” said Mr. Holder. “The work, look, and feel of the outsourced functions should be seamless. Employees at the outsourcer should always identify themselves as the practice, not the outsourcing service.”

Dr. Hochman said that many outsourcing companies dedicate a particular worker to a particular practice and train them to work there. One example of this approach is Provider’s Choice Scribe Services, based in San Antonio. On its website, the company notes that each scribe is paired with a doctor and learns his or her documentation preferences, EMR use, and charting requirements.
 

What medical practices benefit most from outsourcing?

All kinds and sizes of practices contract with outsourcing firms, but the arrangement is particularly useful for smaller practices, Mr. Holder said. “Larger practices have the economies of scale that allow services to be in-house,” he said, “but smaller practices don’t have that opportunity.”

Dr. Hochman added that outsourcing firms can be hired part-time when the practice doesn’t have enough work for a full-time position. Alternatively, a full-time outsourcing firm can perform two or more separate tasks, such as scribing while handling prior authorizations, she said.

Outsourcing is also useful for new practices, Ms. Deabler said. “A new practice is not earning much money, so it has to have a bare-bones staff,” she said. “Billing, for example, should be contracted out, but it won’t cost that much, because the outsourcer typically charges by volume, and the volume in a new practice is low.”

Meanwhile, Mr. Holder said that the outsourcing of prior authorization work can particularly benefit specialty practices because they typically have a lot of prior authorizations to deal with.
 

The pros and cons of outsourcing

Experts with experience in outsourcing agree there are both pluses and minuses. “Practices with outsourced workers have less overhead, don’t have to deal with staff turnover, and costs may be lower than for in-house staff,” Ms. Deabler said. “However, you have limited control over outsourced workers and the practice may seem more anonymous to patients, so you need to consider this option very carefully.”

“With outsourcing, you lose control,” said John Machata, MD, a recently retired solo family physician in Wickford, R.I. “You’re trusting someone else to do work that you could do anyway.”

When he briefly considered outsourcing the practice’s billing many years ago, he found that billing companies wouldn’t handle bills that took a lot of work, such as getting in touch with the insurance company and explaining the patient’s situation. “They would only handle the easy bills, which the practice could do anyway,” he said.

However, he does think that answering services may be useful to outsource. “Patients are more inclined to call an anonymous entity than the doctor,” he said. When he gave patients his cell phone number, he said that some patients held off from calling because they didn’t want to bother him.

“Outsourced staff should be less expensive than in-house staff,” said Daniel Shay, an attorney at Gosfield & Associates in Philadelphia. “On the other hand, you are liable for the outsourcer’s mistakes. If your outsourced billing company is upcoding claims, your practice would be on the hook for repayment and penalties.”

Mr. Holder said: “An outsourcer ought to be more efficient at its chosen task because that is what they know how to do. This is a plus at a small practice, where the practice manager may need to do the billing, HR, IT, marketing, some legal work, and accounting,” he said. “No one person can do all of those things well.”

He added, however, “If you choose outsourcing and then decide you don’t like it, it’s difficult to unwind the arrangement. Staff that have been dismissed can’t easily be hired back, so it shouldn’t be an easy decision to make.”

Also, sometimes the staff at offshore outsourcing firms may have accents that are harder for patients to understand, and the offshore staff may not readily understand a U.S. caller. However, Dr. Hochman said that practices often have a chance to interview and select specific persons on the offshore team who best fit their needs.
 

Offshore outsourcing

Outsourcing firms have been moving abroad, where costs are lower. Typical venues are India and the Philippines because there are larger percentages of people who speak English. Since 2020, demand at offshore medical billing companies has been growing faster than their domestic counterparts, according to a recent analysis.

The difference in price can be substantial. In 2020, the average salary for scribes in India was $500 a month, compared with $2,500 for scribes in the United States.

However, offshore outsourcing is starting to face limitations in some places because of privacy issues, according to David J. Zetter, a practice management consultant in Mechanicsburg, Pa. He pointed to a new Florida law that limits use of offshore vendors because they deal with confidential patient information. The law, which became effective July 1, requires that any protected health information must be maintained in the United States or Canada.

“This will make it very hard for many types of offshore vendors to operate in Florida,” he said. He noted that Florida is the only state with such a restriction, but similar proposals are under consideration in a few other states, such as Texas.
 

How to select the right company

Mr. Zetter said that the biggest mistake practices make when choosing a company is failing to take enough time to examine their choice. “Quite often, practices don’t validate that companies know what they are doing,” he said. “They get a recommendation and go with it.”

“Choose a company with experience in your specialty,” Mr. Zetter advised. “Speak with the company’s clients, not just the ones the company gives you to speak to. You should ask for the full list of clients and speak to all of them.”

Ms. Deabler said that it’s fairly easy to find respected outsourcing companies. “Colleagues can make recommendations, state and specialty societies can provide lists of preferred vendors, and you can visit vendors’ booths at medical conferences,” she said. She added that it’s also easy to find evaluations of each company. “You can Google the company and come up with all kinds of information about it,” she said.

Mr. Shay said that practices should make sure they understand the terms of the contract with a VA. “Depending on how the contract is worded, you may be stuck with the relationship for many years,” he said. “Before you sign an outsourcing contract, you need to make sure it has a reasonable termination provision.”

Because vetting companies properly can require extensive work, Ms. Deabler said, the work can be given to an experienced practice management consultant. “The consultant can start with a cost-benefit analysis that will show you whether outsourcing would be worthwhile,” she said.
 

Working with outsource service providers

Mr. Holder said that doctors should keep track of what the outsourcer is doing rather than simply let them do their work. “For example, doctors should understand the billing codes they use most often, such as the five levels of evaluation and management codes, and not just blindly rely on the billing company to code and bill their work correctly,” he noted.

Ms. Deabler said that companies provide monthly reports on their work. “Doctors should be reading these reports and contacting the company if expectations aren’t met,” she said.

Even in the reports, companies can hide problems from untrained eyes, Mr. Holder said. “For example, anyone can meet a metric like days in accounts receivable simply by writing off any charge that isn’t paid after 90 days.”

“You need to be engaged with the outsourcer,” he said. “It’s also a good idea to bring in a consultant to periodically check an outsourcer’s work.”
 

Will outsourcing expand in the future?

Mr. Holder said that the increasing use of value-based care may require practices to rely more on outsourcing in the future. “For instance, if a practice has a value-based contract that requires providing behavioral health services to patients, it might make sense to outsource that work rather than hire psychologists in-house,” he said.

Practices rarely outsource clinical services, but Mr. Holder said that this may happen in the future: “Now that Medicare is paying less for telehealth, practices have to find a way to provide it without using expensive examining room space,” he said. “Some practices may decide to outsource telehealth instead.”

Mr. Shay said that there are many reasons why outsourcing has a strong future. “It allows you to concentrate on your clinical care, and it is a solution to problems with turnover of in-house staff,” he said. “It can also be more efficient because the service is presumably an expert in areas like billing and collections, which means it may be able to ensure more efficient and faster reimbursements. And if the work is outsourced overseas, you can save money through lower worker salaries.”

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

Outsourcing certain staff functions in a practice to outside contractors working in remote locations has become commonplace in many medical practices.

Health care outsourcing services, also known as virtual assistants (VAs), were already booming in 2017, when volume grew by 36%. Then, the COVID-19 pandemic in 2020 normalized off-site work, which was a boon to outsourcing providers.

The most popular services being outsourced today by medical practices include billing, scribes, telephone calls to patients, and processing prior authorizations.

“Outsourcing is not for everyone, but I’ve seen it work for many practices,” said Lara Hochman, MD, a practice management consultant in Austin, Tex. She said that practices have used outsourcing to solve problems like high staff turnover, tight budgets, and inefficient use of staff.

When in-house staffing is insufficient or not appropriately aligned with the task, outsourcing can produce big savings, said Teri Deabler, a practice management consultant with the Texas Medical Association.

For example, she said that a client was paying an in-house accountant $80,000 a year. When the accountant retired, she was replaced with a part-time bookkeeper earning $20,000 while her accounting work was outsourced at a cost of $20,000 a year. “The practice’s costs for this service were cut in half,” Ms. Deabler said.
 

What functions lend themselves to outsourcing?

Clinical services are rarely outsourced by individual practices – although hospitals now outsource numerous clinical services – but virtually any kind of administrative service can be contracted out. Outsourcing used to be limited mainly to billing and off-hours phone services, but today, more services are available, such as scribing, processing prior authorizations, accounting and bookkeeping, human resources (HR) and payroll, interactions with social media, recredentialing, medical transcription, and marketing.

Meanwhile, the original outsourced services have evolved. Billing and collections may now be handled by off-shore VAs, and phone services now deal with a wider variety of tasks, such as answering patients’ questions, scheduling appointments, and making referrals.

Ron Holder, chief operating officer of Medical Group Management Association in Englewood, Colo., said that some outsourcing services can also adjust the amount of work provided based on the customer’s needs. “For instance, an IT outsourcer may allow you to scale up IT support for a new big tech project, such as installing a new electronic health record,” he said.

The outsourced service provider, who might work in another state or another country, is connected to the practice by phone and electronically, and represents the practice when dealing with patients, insurers, or other vendors.

“No one, including patients and your physicians, should know that they are dealing with an outsourced company,” said Mr. Holder. “The work, look, and feel of the outsourced functions should be seamless. Employees at the outsourcer should always identify themselves as the practice, not the outsourcing service.”

Dr. Hochman said that many outsourcing companies dedicate a particular worker to a particular practice and train them to work there. One example of this approach is Provider’s Choice Scribe Services, based in San Antonio. On its website, the company notes that each scribe is paired with a doctor and learns his or her documentation preferences, EMR use, and charting requirements.
 

What medical practices benefit most from outsourcing?

All kinds and sizes of practices contract with outsourcing firms, but the arrangement is particularly useful for smaller practices, Mr. Holder said. “Larger practices have the economies of scale that allow services to be in-house,” he said, “but smaller practices don’t have that opportunity.”

Dr. Hochman added that outsourcing firms can be hired part-time when the practice doesn’t have enough work for a full-time position. Alternatively, a full-time outsourcing firm can perform two or more separate tasks, such as scribing while handling prior authorizations, she said.

Outsourcing is also useful for new practices, Ms. Deabler said. “A new practice is not earning much money, so it has to have a bare-bones staff,” she said. “Billing, for example, should be contracted out, but it won’t cost that much, because the outsourcer typically charges by volume, and the volume in a new practice is low.”

Meanwhile, Mr. Holder said that the outsourcing of prior authorization work can particularly benefit specialty practices because they typically have a lot of prior authorizations to deal with.
 

The pros and cons of outsourcing

Experts with experience in outsourcing agree there are both pluses and minuses. “Practices with outsourced workers have less overhead, don’t have to deal with staff turnover, and costs may be lower than for in-house staff,” Ms. Deabler said. “However, you have limited control over outsourced workers and the practice may seem more anonymous to patients, so you need to consider this option very carefully.”

“With outsourcing, you lose control,” said John Machata, MD, a recently retired solo family physician in Wickford, R.I. “You’re trusting someone else to do work that you could do anyway.”

When he briefly considered outsourcing the practice’s billing many years ago, he found that billing companies wouldn’t handle bills that took a lot of work, such as getting in touch with the insurance company and explaining the patient’s situation. “They would only handle the easy bills, which the practice could do anyway,” he said.

However, he does think that answering services may be useful to outsource. “Patients are more inclined to call an anonymous entity than the doctor,” he said. When he gave patients his cell phone number, he said that some patients held off from calling because they didn’t want to bother him.

“Outsourced staff should be less expensive than in-house staff,” said Daniel Shay, an attorney at Gosfield & Associates in Philadelphia. “On the other hand, you are liable for the outsourcer’s mistakes. If your outsourced billing company is upcoding claims, your practice would be on the hook for repayment and penalties.”

Mr. Holder said: “An outsourcer ought to be more efficient at its chosen task because that is what they know how to do. This is a plus at a small practice, where the practice manager may need to do the billing, HR, IT, marketing, some legal work, and accounting,” he said. “No one person can do all of those things well.”

He added, however, “If you choose outsourcing and then decide you don’t like it, it’s difficult to unwind the arrangement. Staff that have been dismissed can’t easily be hired back, so it shouldn’t be an easy decision to make.”

Also, sometimes the staff at offshore outsourcing firms may have accents that are harder for patients to understand, and the offshore staff may not readily understand a U.S. caller. However, Dr. Hochman said that practices often have a chance to interview and select specific persons on the offshore team who best fit their needs.
 

Offshore outsourcing

Outsourcing firms have been moving abroad, where costs are lower. Typical venues are India and the Philippines because there are larger percentages of people who speak English. Since 2020, demand at offshore medical billing companies has been growing faster than their domestic counterparts, according to a recent analysis.

The difference in price can be substantial. In 2020, the average salary for scribes in India was $500 a month, compared with $2,500 for scribes in the United States.

However, offshore outsourcing is starting to face limitations in some places because of privacy issues, according to David J. Zetter, a practice management consultant in Mechanicsburg, Pa. He pointed to a new Florida law that limits use of offshore vendors because they deal with confidential patient information. The law, which became effective July 1, requires that any protected health information must be maintained in the United States or Canada.

“This will make it very hard for many types of offshore vendors to operate in Florida,” he said. He noted that Florida is the only state with such a restriction, but similar proposals are under consideration in a few other states, such as Texas.
 

How to select the right company

Mr. Zetter said that the biggest mistake practices make when choosing a company is failing to take enough time to examine their choice. “Quite often, practices don’t validate that companies know what they are doing,” he said. “They get a recommendation and go with it.”

“Choose a company with experience in your specialty,” Mr. Zetter advised. “Speak with the company’s clients, not just the ones the company gives you to speak to. You should ask for the full list of clients and speak to all of them.”

Ms. Deabler said that it’s fairly easy to find respected outsourcing companies. “Colleagues can make recommendations, state and specialty societies can provide lists of preferred vendors, and you can visit vendors’ booths at medical conferences,” she said. She added that it’s also easy to find evaluations of each company. “You can Google the company and come up with all kinds of information about it,” she said.

Mr. Shay said that practices should make sure they understand the terms of the contract with a VA. “Depending on how the contract is worded, you may be stuck with the relationship for many years,” he said. “Before you sign an outsourcing contract, you need to make sure it has a reasonable termination provision.”

Because vetting companies properly can require extensive work, Ms. Deabler said, the work can be given to an experienced practice management consultant. “The consultant can start with a cost-benefit analysis that will show you whether outsourcing would be worthwhile,” she said.
 

Working with outsource service providers

Mr. Holder said that doctors should keep track of what the outsourcer is doing rather than simply let them do their work. “For example, doctors should understand the billing codes they use most often, such as the five levels of evaluation and management codes, and not just blindly rely on the billing company to code and bill their work correctly,” he noted.

Ms. Deabler said that companies provide monthly reports on their work. “Doctors should be reading these reports and contacting the company if expectations aren’t met,” she said.

Even in the reports, companies can hide problems from untrained eyes, Mr. Holder said. “For example, anyone can meet a metric like days in accounts receivable simply by writing off any charge that isn’t paid after 90 days.”

“You need to be engaged with the outsourcer,” he said. “It’s also a good idea to bring in a consultant to periodically check an outsourcer’s work.”
 

Will outsourcing expand in the future?

Mr. Holder said that the increasing use of value-based care may require practices to rely more on outsourcing in the future. “For instance, if a practice has a value-based contract that requires providing behavioral health services to patients, it might make sense to outsource that work rather than hire psychologists in-house,” he said.

Practices rarely outsource clinical services, but Mr. Holder said that this may happen in the future: “Now that Medicare is paying less for telehealth, practices have to find a way to provide it without using expensive examining room space,” he said. “Some practices may decide to outsource telehealth instead.”

Mr. Shay said that there are many reasons why outsourcing has a strong future. “It allows you to concentrate on your clinical care, and it is a solution to problems with turnover of in-house staff,” he said. “It can also be more efficient because the service is presumably an expert in areas like billing and collections, which means it may be able to ensure more efficient and faster reimbursements. And if the work is outsourced overseas, you can save money through lower worker salaries.”

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

Outsourcing certain staff functions in a practice to outside contractors working in remote locations has become commonplace in many medical practices.

Health care outsourcing services, also known as virtual assistants (VAs), were already booming in 2017, when volume grew by 36%. Then, the COVID-19 pandemic in 2020 normalized off-site work, which was a boon to outsourcing providers.

The most popular services being outsourced today by medical practices include billing, scribes, telephone calls to patients, and processing prior authorizations.

“Outsourcing is not for everyone, but I’ve seen it work for many practices,” said Lara Hochman, MD, a practice management consultant in Austin, Tex. She said that practices have used outsourcing to solve problems like high staff turnover, tight budgets, and inefficient use of staff.

When in-house staffing is insufficient or not appropriately aligned with the task, outsourcing can produce big savings, said Teri Deabler, a practice management consultant with the Texas Medical Association.

For example, she said that a client was paying an in-house accountant $80,000 a year. When the accountant retired, she was replaced with a part-time bookkeeper earning $20,000 while her accounting work was outsourced at a cost of $20,000 a year. “The practice’s costs for this service were cut in half,” Ms. Deabler said.
 

What functions lend themselves to outsourcing?

Clinical services are rarely outsourced by individual practices – although hospitals now outsource numerous clinical services – but virtually any kind of administrative service can be contracted out. Outsourcing used to be limited mainly to billing and off-hours phone services, but today, more services are available, such as scribing, processing prior authorizations, accounting and bookkeeping, human resources (HR) and payroll, interactions with social media, recredentialing, medical transcription, and marketing.

Meanwhile, the original outsourced services have evolved. Billing and collections may now be handled by off-shore VAs, and phone services now deal with a wider variety of tasks, such as answering patients’ questions, scheduling appointments, and making referrals.

Ron Holder, chief operating officer of Medical Group Management Association in Englewood, Colo., said that some outsourcing services can also adjust the amount of work provided based on the customer’s needs. “For instance, an IT outsourcer may allow you to scale up IT support for a new big tech project, such as installing a new electronic health record,” he said.

The outsourced service provider, who might work in another state or another country, is connected to the practice by phone and electronically, and represents the practice when dealing with patients, insurers, or other vendors.

“No one, including patients and your physicians, should know that they are dealing with an outsourced company,” said Mr. Holder. “The work, look, and feel of the outsourced functions should be seamless. Employees at the outsourcer should always identify themselves as the practice, not the outsourcing service.”

Dr. Hochman said that many outsourcing companies dedicate a particular worker to a particular practice and train them to work there. One example of this approach is Provider’s Choice Scribe Services, based in San Antonio. On its website, the company notes that each scribe is paired with a doctor and learns his or her documentation preferences, EMR use, and charting requirements.
 

What medical practices benefit most from outsourcing?

All kinds and sizes of practices contract with outsourcing firms, but the arrangement is particularly useful for smaller practices, Mr. Holder said. “Larger practices have the economies of scale that allow services to be in-house,” he said, “but smaller practices don’t have that opportunity.”

Dr. Hochman added that outsourcing firms can be hired part-time when the practice doesn’t have enough work for a full-time position. Alternatively, a full-time outsourcing firm can perform two or more separate tasks, such as scribing while handling prior authorizations, she said.

Outsourcing is also useful for new practices, Ms. Deabler said. “A new practice is not earning much money, so it has to have a bare-bones staff,” she said. “Billing, for example, should be contracted out, but it won’t cost that much, because the outsourcer typically charges by volume, and the volume in a new practice is low.”

Meanwhile, Mr. Holder said that the outsourcing of prior authorization work can particularly benefit specialty practices because they typically have a lot of prior authorizations to deal with.
 

The pros and cons of outsourcing

Experts with experience in outsourcing agree there are both pluses and minuses. “Practices with outsourced workers have less overhead, don’t have to deal with staff turnover, and costs may be lower than for in-house staff,” Ms. Deabler said. “However, you have limited control over outsourced workers and the practice may seem more anonymous to patients, so you need to consider this option very carefully.”

“With outsourcing, you lose control,” said John Machata, MD, a recently retired solo family physician in Wickford, R.I. “You’re trusting someone else to do work that you could do anyway.”

When he briefly considered outsourcing the practice’s billing many years ago, he found that billing companies wouldn’t handle bills that took a lot of work, such as getting in touch with the insurance company and explaining the patient’s situation. “They would only handle the easy bills, which the practice could do anyway,” he said.

However, he does think that answering services may be useful to outsource. “Patients are more inclined to call an anonymous entity than the doctor,” he said. When he gave patients his cell phone number, he said that some patients held off from calling because they didn’t want to bother him.

“Outsourced staff should be less expensive than in-house staff,” said Daniel Shay, an attorney at Gosfield & Associates in Philadelphia. “On the other hand, you are liable for the outsourcer’s mistakes. If your outsourced billing company is upcoding claims, your practice would be on the hook for repayment and penalties.”

Mr. Holder said: “An outsourcer ought to be more efficient at its chosen task because that is what they know how to do. This is a plus at a small practice, where the practice manager may need to do the billing, HR, IT, marketing, some legal work, and accounting,” he said. “No one person can do all of those things well.”

He added, however, “If you choose outsourcing and then decide you don’t like it, it’s difficult to unwind the arrangement. Staff that have been dismissed can’t easily be hired back, so it shouldn’t be an easy decision to make.”

Also, sometimes the staff at offshore outsourcing firms may have accents that are harder for patients to understand, and the offshore staff may not readily understand a U.S. caller. However, Dr. Hochman said that practices often have a chance to interview and select specific persons on the offshore team who best fit their needs.
 

Offshore outsourcing

Outsourcing firms have been moving abroad, where costs are lower. Typical venues are India and the Philippines because there are larger percentages of people who speak English. Since 2020, demand at offshore medical billing companies has been growing faster than their domestic counterparts, according to a recent analysis.

The difference in price can be substantial. In 2020, the average salary for scribes in India was $500 a month, compared with $2,500 for scribes in the United States.

However, offshore outsourcing is starting to face limitations in some places because of privacy issues, according to David J. Zetter, a practice management consultant in Mechanicsburg, Pa. He pointed to a new Florida law that limits use of offshore vendors because they deal with confidential patient information. The law, which became effective July 1, requires that any protected health information must be maintained in the United States or Canada.

“This will make it very hard for many types of offshore vendors to operate in Florida,” he said. He noted that Florida is the only state with such a restriction, but similar proposals are under consideration in a few other states, such as Texas.
 

How to select the right company

Mr. Zetter said that the biggest mistake practices make when choosing a company is failing to take enough time to examine their choice. “Quite often, practices don’t validate that companies know what they are doing,” he said. “They get a recommendation and go with it.”

“Choose a company with experience in your specialty,” Mr. Zetter advised. “Speak with the company’s clients, not just the ones the company gives you to speak to. You should ask for the full list of clients and speak to all of them.”

Ms. Deabler said that it’s fairly easy to find respected outsourcing companies. “Colleagues can make recommendations, state and specialty societies can provide lists of preferred vendors, and you can visit vendors’ booths at medical conferences,” she said. She added that it’s also easy to find evaluations of each company. “You can Google the company and come up with all kinds of information about it,” she said.

Mr. Shay said that practices should make sure they understand the terms of the contract with a VA. “Depending on how the contract is worded, you may be stuck with the relationship for many years,” he said. “Before you sign an outsourcing contract, you need to make sure it has a reasonable termination provision.”

Because vetting companies properly can require extensive work, Ms. Deabler said, the work can be given to an experienced practice management consultant. “The consultant can start with a cost-benefit analysis that will show you whether outsourcing would be worthwhile,” she said.
 

Working with outsource service providers

Mr. Holder said that doctors should keep track of what the outsourcer is doing rather than simply let them do their work. “For example, doctors should understand the billing codes they use most often, such as the five levels of evaluation and management codes, and not just blindly rely on the billing company to code and bill their work correctly,” he noted.

Ms. Deabler said that companies provide monthly reports on their work. “Doctors should be reading these reports and contacting the company if expectations aren’t met,” she said.

Even in the reports, companies can hide problems from untrained eyes, Mr. Holder said. “For example, anyone can meet a metric like days in accounts receivable simply by writing off any charge that isn’t paid after 90 days.”

“You need to be engaged with the outsourcer,” he said. “It’s also a good idea to bring in a consultant to periodically check an outsourcer’s work.”
 

Will outsourcing expand in the future?

Mr. Holder said that the increasing use of value-based care may require practices to rely more on outsourcing in the future. “For instance, if a practice has a value-based contract that requires providing behavioral health services to patients, it might make sense to outsource that work rather than hire psychologists in-house,” he said.

Practices rarely outsource clinical services, but Mr. Holder said that this may happen in the future: “Now that Medicare is paying less for telehealth, practices have to find a way to provide it without using expensive examining room space,” he said. “Some practices may decide to outsource telehealth instead.”

Mr. Shay said that there are many reasons why outsourcing has a strong future. “It allows you to concentrate on your clinical care, and it is a solution to problems with turnover of in-house staff,” he said. “It can also be more efficient because the service is presumably an expert in areas like billing and collections, which means it may be able to ensure more efficient and faster reimbursements. And if the work is outsourced overseas, you can save money through lower worker salaries.”

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

At DDW in May, the AGA Ethics Committee sponsored a well-attended clinical symposium focused on key legal, regulatory, and ethical considerations relating to use of artificial intelligence (AI) in health care.

It was a thought-provoking discussion of how to ethically and equitably design and regulate these exciting new technologies to maximize their potential to achieve meaningful improvements in health for our patients while avoiding unintended consequences.

Indeed, one of the vexing challenges in this space is the fact that many AI algorithms and resulting tools are proprietary, impeding the ability to achieve the level of transparency necessary to understand data inputs, outputs, and outcomes, and assess for potential algorithmic bias.

This is an area that remains largely unregulated, with a lack of common standards to guide responsible design, development, and adoption of these tools. This is something that is top of mind for federal regulatory agencies, including the Food and Drug Administration, which in September 2022, announced plans to expand its regulation of AI-powered clinical decision support tools as medical devices.

There are also attempts underway to harmonize standards and reporting for health AI and educate end-users on how to evaluate these technologies to drive their responsible adoption. For example, the Coalition for Health AI, a community of academic health systems, organizations, and expert practitioners of AI and data science, recently released its Blueprint for Trustworthy AI Implementation Guidance and Assurance for Healthcare in April 2023. This is a topic we will surely hear more about in the coming years, and one I encourage you to read about in greater depth as it is truly eye-opening.

In this month’s issue of GI & Hepatology News, we update you on a new fatty liver disease nomenclature (including several new acronyms) that will be critical to incorporate into your clinical practice moving forward. In a new recurring article reprinted from Gastro Hep Advances, we highlight important Pearls from the Pros from hepatologists Dr. Lawrence Friedman and Dr. Paul Martin on the management of incidental hepatic steatosis. Our August Member Spotlight features Orlando-based gastroenterologist Dr. Mariam Naveed, who shares her passion for medical education and experience starting a new GI fellowship program.

We hope you enjoy these and all the stories featured in our August issue.

Megan A. Adams, MD, JD, MSc
Editor-in-Chief

At DDW in May, the AGA Ethics Committee sponsored a well-attended clinical symposium focused on key legal, regulatory, and ethical considerations relating to use of artificial intelligence (AI) in health care.

It was a thought-provoking discussion of how to ethically and equitably design and regulate these exciting new technologies to maximize their potential to achieve meaningful improvements in health for our patients while avoiding unintended consequences.

Indeed, one of the vexing challenges in this space is the fact that many AI algorithms and resulting tools are proprietary, impeding the ability to achieve the level of transparency necessary to understand data inputs, outputs, and outcomes, and assess for potential algorithmic bias.

This is an area that remains largely unregulated, with a lack of common standards to guide responsible design, development, and adoption of these tools. This is something that is top of mind for federal regulatory agencies, including the Food and Drug Administration, which in September 2022, announced plans to expand its regulation of AI-powered clinical decision support tools as medical devices.

There are also attempts underway to harmonize standards and reporting for health AI and educate end-users on how to evaluate these technologies to drive their responsible adoption. For example, the Coalition for Health AI, a community of academic health systems, organizations, and expert practitioners of AI and data science, recently released its Blueprint for Trustworthy AI Implementation Guidance and Assurance for Healthcare in April 2023. This is a topic we will surely hear more about in the coming years, and one I encourage you to read about in greater depth as it is truly eye-opening.

In this month’s issue of GI & Hepatology News, we update you on a new fatty liver disease nomenclature (including several new acronyms) that will be critical to incorporate into your clinical practice moving forward. In a new recurring article reprinted from Gastro Hep Advances, we highlight important Pearls from the Pros from hepatologists Dr. Lawrence Friedman and Dr. Paul Martin on the management of incidental hepatic steatosis. Our August Member Spotlight features Orlando-based gastroenterologist Dr. Mariam Naveed, who shares her passion for medical education and experience starting a new GI fellowship program.

We hope you enjoy these and all the stories featured in our August issue.

Megan A. Adams, MD, JD, MSc
Editor-in-Chief

At DDW in May, the AGA Ethics Committee sponsored a well-attended clinical symposium focused on key legal, regulatory, and ethical considerations relating to use of artificial intelligence (AI) in health care.

It was a thought-provoking discussion of how to ethically and equitably design and regulate these exciting new technologies to maximize their potential to achieve meaningful improvements in health for our patients while avoiding unintended consequences.

Indeed, one of the vexing challenges in this space is the fact that many AI algorithms and resulting tools are proprietary, impeding the ability to achieve the level of transparency necessary to understand data inputs, outputs, and outcomes, and assess for potential algorithmic bias.

This is an area that remains largely unregulated, with a lack of common standards to guide responsible design, development, and adoption of these tools. This is something that is top of mind for federal regulatory agencies, including the Food and Drug Administration, which in September 2022, announced plans to expand its regulation of AI-powered clinical decision support tools as medical devices.

There are also attempts underway to harmonize standards and reporting for health AI and educate end-users on how to evaluate these technologies to drive their responsible adoption. For example, the Coalition for Health AI, a community of academic health systems, organizations, and expert practitioners of AI and data science, recently released its Blueprint for Trustworthy AI Implementation Guidance and Assurance for Healthcare in April 2023. This is a topic we will surely hear more about in the coming years, and one I encourage you to read about in greater depth as it is truly eye-opening.

In this month’s issue of GI & Hepatology News, we update you on a new fatty liver disease nomenclature (including several new acronyms) that will be critical to incorporate into your clinical practice moving forward. In a new recurring article reprinted from Gastro Hep Advances, we highlight important Pearls from the Pros from hepatologists Dr. Lawrence Friedman and Dr. Paul Martin on the management of incidental hepatic steatosis. Our August Member Spotlight features Orlando-based gastroenterologist Dr. Mariam Naveed, who shares her passion for medical education and experience starting a new GI fellowship program.

We hope you enjoy these and all the stories featured in our August issue.

Megan A. Adams, MD, JD, MSc
Editor-in-Chief