PulseThe

ofWinter 2019

continued on page 2

A look back on a busy year...• BCBSM designated 129 primary practices

(363 physicians) as patient-centered medical home (PCMH), representing 93 percent of TPA primary care physicians.

• BCBSM awarded 248 specialty practices (805 physicians) with value-based reimbursement (VBR), resulting in 89 percent of TPA specialists receiving this additional payment.

• 363 primary care physicians received value-based reimbursement, a 24.9 percent increase in those receiving a 30 percent or higher VBR with PCMH designation. Seventy-one percent of our primary care practices with care managers are receiving an additional 5 percent VBR for Provider Delivered Care Management.

• TPA received low-cost benchmark performer status for the seventh year in a row from Blue Cross Blue Shield of Michigan, enabling our physicians to receive an additional 10 percent value-based reimbursement.

The Physician Alliance staff worked closely with

physicians, practice staff, practice resource team

members and partners to focus on improving

quality metrics, practice revenue, patient

education and care, and more. New pilot projects

were launched, including three related to diabetes.

Additional resources were devoted to identifying

gaps in care, minimizing errors in data analysis

and reporting, and educating TPA members on

important healthcare updates. Overall, 2018 was

a successful year for the physician organization

and its members. Here are some highlights:

• Strong efforts from practices resulted in a 39 percent improvement in e-prescribing for controlled substances from 2015 (3.1 percent) to 2018 (42.1 percent).

• Strategic focus on gaps in care resulted in over 45,000 gaps reviewed, with 7,500 gaps entered into Health e-Blue, and a 18% average gap closure rate for TPA.

• More than 1.3 million patients with over 70 million attributed records are loaded into Wellcentive, our disease registry (compared to 65,000 in 2011).

QUALITY IMPROVEMENT

PRACTICE TRANSFORMATION

2

Dear members,

Happy New Year! This time of year allows us to reflect on the successes and lessons learned of the past year, while kicking off new goals and objectives.

Last year brought many new projects, education initiatives and accomplishments (see cover story for some highlights). Our organization worked with our physicians and practice staff to improve quality metrics, patient care and revenue. Our physicians achieved excellent standards in the patient centered medical home care model, resulting in improved value-based reimbursement for most. Since our organization’s founding in 2011, we have facilitated more than $200 million in revenue, with over $177 million paid to our physician members. This is a big milestone to achieve in only seven years!

Rest assured that our staff continues to think strategically and creatively to help you improve quality metrics and revenue. Diagnostic coding and risk adjustment will be hot topics in 2019, as will diabetes prevention and management (as part of the Organized Systems of Care transition plan), practice management and data analytics. Education opportunities will be available on key issues so look to your inboxes and mailboxes for information on upcoming programs.

Teamwork has been the key to our success! TPA staff and the practice resource team continue to be your support as we tackle the changes and challenges in healthcare together. We look forward to a successful new year for all of us.

In good health,

Michael R. MaddenPresident & CEO

President’s MESSAGE

A look back continued from page 1

• Additional patient education materials were created to help initiate conversations between practice staff and patients on key health issues, including diabetes prevention, breast cancer screening, unnecessary antibiotic use and more. By the end of 2018, 10 posters, three Rx non-prescription pads and seven action plans/self-management forms were available for download or online ordering on TPA’s website (Learning Center tab). Arabic translated diabetes management and diabetes prevention posters will be available by mid-February.

• Nine education events focused on a multitude of critical health issues, including coding, diabetes prevention and management and medical malpractice prevention.

• Sixty-six percent of primary care practices participated in prediabetes education, a requirement of TPA’s Organized System of Care transition plan.

• TPA’s My Doctors mobile app was updated to include an option to save preferred pharmacy information, add tags for individual family members, and search for local urgent care centers. <

EDUCATION & OUTREACH

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These are a few of the more than 70,000 available diagnostic codes available to health care providers. Knowing the correct codes to document in a patient’s medical record are critical to identifying the care needed to appropriately treat the patient. These codes help determine the patient’s disease burden and subsequent risk score.

Risk adjustment scoring is based on a patient’s health, chronic conditions, age, gender and other demographics. This combination better represents the actual complexity of care provided to patients. Risk adjustment scores are higher for patients with greater disease burdens, indicating they most likely need more care and more likely to develop complications.

Appropriate diagnostic coding helps paint a picture of the patient’s severity of illness (risk burden) for payers and others. This helps payers assign appropriate resources to treat the patient and determine how well a physician is managing a patient’s health and cost (risk adjusted cost performance).

“Accurate diagnostic coding assigns risk to a population and communicates the “health” or “sickness” of a patient to the payer as well as to other health care providers,” said Karen

Swanson, MD, chief medical officer at The Physician Alliance and a primary care physician. “Accurately risking a population will affect physician reimbursement from payers so it is incumbent (upon physicians) to improve on their coding skillset.”

When physicians are presented with disappointing outcome data, a relatively common response is ‘my patients are sicker’,” noted Swanson. “However, if your coding doesn’t back this claim, the payers won’t recognize the difference in the patient’s health and increased need of care.”

Diagnostic coding plays a critical role in managing, and eventually lowering, the overall total cost of care for a population and individual patients. Diagnostic codes reported in the patient’s medical record and on claims determine the disease burden and risk score. Many practices assign care managers and focus more care coordination on these high-risk individuals.

Capturing chronic diseases in a medical record helps to properly assess a patient’s health and ensure appropriate funds are earmarked for patient care. Appropriate diagnostic coding can be viewed as an inverse relationship: the more codes documented alerts to a possible greater risk burden, leading to

lower risk adjusted cost. Documentation must support the patient’s health status and codes in the medical record. Following the MEAT documentation criteria (Monitor, Evaluate, Assess, Treat) ensures appropriate information is included to support coding.

The weight of risk adjustment scores on physician reimbursement reinforces the importance of appropriate coding because the impact will be felt by all physicians, explained Swanson. Primary care physicians with a high risk adjusted cost performance may not be able to participate in narrow networks and have decreased reimbursement. Primary care physicians also can be impacted by referring patients to specialty physicians with high risk adjusted cost performance, making it important for specialists to correctly code to ensure continued referrals.

The Physician Alliance board of managers voted to share diagnostic coding reports of all TPA physicians with members in 2019. The reports will be distributed by specialties and allow physicians to view their own coding level and compare to colleagues.

Visit The Physician Alliance website (www.thephysicianalliance.org) for tip sheets and resources related to coding and other important health topics. <

The impact of diagnostic coding on new payment structuresStepping on a frog. Walking into

a lamppost. Bitten by a cow.

Sucked into jet engine. Problems

in relationship with in-laws.

4

The healthcare industry is constantly changing. Billing codes, documentation requirements, screening criteria and HIPAA compliance are a few of the areas facing ongoing evolution. With the always moving current in the field, education is a critical component of The Physician Alliance business to ensure physicians and practices achieve high quality scores, patient care and reimbursement.

Over the past few years, TPA created a multitude of resources to address the challenges facing physician practices. Many of these topics and items are results of input from physicians and practice staff.

Among the resources are patient education posters and forms on HEDIS quality metrics and the Blue Cross Blue Shield of Michigan Resource Stewardship Initiative. Coding pocket cards and tip sheets help practices stay abreast of key billing codes and metrics.

Last year, TPA hosted nine seminars and webinars focused on topics such as diabetes prevention and management, coding tips and avoiding medical malpractice claims. Many of these programs were videotaped and available to members for future viewing. TPA’s mobile app, Physician Education, brings much of this information to physician fingertips for easy access and viewing.

“Physicians and practice staff have so much information to continually process, from patient care to coding requirements and more,” said Sharon Ross, NP, RN, executive vice president of population health at The Physician Alliance. “Our (TPA) priority is to help our members stay updated on key issues to assist them in their practices.”

The Physician Alliance website:www.thephysicianalliance.orgKey resources available on the Learning Center tab

Physician Education mobile app:Available on Apple and Google Play storesSearch “The Physician Alliance Physician Education”<

EDUCATION RESOURCES help physicians address evolving healthcare industry

These resources are available at no cost to TPA physicians as a member benefit. A list of patient education materials that can be printed and/or ordered from TPA’s website:

FOR

MS

POST

ERS

FLY

ERS

Patient asthma self-management (9 years and under)Patient asthma self-management (10 years and older)Patient diabetes self-management Patient diabetes action plan Patient healthy lifestyle self-management (17 years and under)Patient healthy lifestyle self-management (18 years and older)Patient heart failure self-management goals

My Doctors mobile app Rx ‘non-prescription pad’ (antibiotics) Rx ‘non-prescription pad’ (PEDIATRICS antibiotics)Rx ‘non-prescription pad’ (low back pain)

6 tips for managing low back pain 6 tips women should know about Pap tests 6 facts you should know about using antibiotics for bronchitis 6 ways to manage your diabetes 6 tips for lowering diabetes risk Wellness exam reminder/checklist 6 facts about breast cancer screening 6 facts about colorectal cancer screeningManaging bronchitis

Check out what’s available

5

401(k)/Wealth ManagementHollander & Lone

Cyber liability insuranceHuntington Insurance

Document ScanningSharecare Health Data Services

Financial Planning Services*Vantage Pointe

Legal ServicesRickard & Associates, P.C.

Medical Answering ServiceAmbs Call Center

Medical Debt CollectionTransworld Systems, Inc.

Medical Malpractice InsuranceCoverys

Medical Supplies J & B Medical Supply

Medical Waste ServicesBio-MED Medical Waste

Mortgage & Banking ServicesHuntington Bank

Office Supplies & SolutionsOffice Depot

Practice Management Services*Kona Medical Consulting

Revenue Cycle Management*Coronis Health

Social Media Management4MJ Social

*Joining in February 2019

The Affiliate Partners program is a popular benefit for The Physician Alliance members. Companies participating in the program offer cost-effective, innovative solutions to help reduce business overhead costs and optimize business performance. TPA members receive special rates on premium products and services.

The following list includes our current Affiliate Partners. Special offers and additional details on each partner’s products and services can be found at www.thephysicianalliance.org, click on the Affiliate Partners tab.

Save money and timewith these preferred partners

6

CMO CORNER

By Karen Swanson, M.D.

continued on page 7

An October 2018 study in the Journal of the American Medical Association analyzed over 8,400 telehealth appointments for patients with symptoms of upper respiratory infections through American Well’s Online Care Group. Sixty-six percent of these patients suffering from a cold received a prescription for an antibiotic. Patient satisfaction scores were significantly higher if the treating provider prescribed an antibiotic with 90 percent of patients prescribed an antibiotic giving the doctor five out of five stars. Physicians with low rates of antibiotic prescribing received low satisfaction rates. No other factors were as strongly associated with patient satisfaction as whether an antibiotic was prescribed. Not surprisingly, a 2018 Dartmouth Hitchcock study found that patients who were prescribed opioids for musculoskeletal pain were 32 percent more likely to report high patient satisfaction.

Should physicians prescribe antibiotics or opioids to patients to make them happier or should physicians practice evidence-based medicine? A non-physician colleague of mine told me the story of his pregnant afebrile wife who had a “bad cold,” and was informed she “just had a virus” after evaluation by her primary care physician. She then visited an urgent care center, was again diagnosed with a viral infection and told she did not need an antibiotic. At that point, feeling miserable, she began to cry and the urgent care physician prescribed an antibiotic. This vignette describes the situation many of us face every day. We are attempting to educate people who are feeling horrible and really believe a Z-pack will cure them. Most physicians are aware of antibiotic stewardship but also realize the patient will be happier if they can leave with the antibiotic de jour.

A June 2018 JAMA study showed 41 percent of antibiotics in outpatient settings were not indicated. This JAMA study is consistent with other studies concluding physicians overprescribe antibiotics for upper respiratory tract infections and acute bronchitis. The Centers for Disease Control and Prevention estimates about 30 percent, or 47 million, of annual outpatient antibiotics are unnecessary.

Why do physicians continue to overprescribe antibiotics when they are intimately aware of the side effects and lack of evidence-based medicine? There are probably a variety of reasons, including physicians wanting to avoid confrontation with “the customer.” It is less cumbersome to write a script than deliver effective patient communication. In a 2018 Annuals of Internal Medicine study, researchers found it takes physicians approximately 20 seconds less to prescribe rather than educate. It is difficult to defend a 20-second difference as reason for not prescribing an antibiotic and educating the patient.

Several studies have demonstrated that the time spent communicating with the patient is the most powerful predictor of patient satisfaction. Most urgent care centers and telehealth providers are reimbursed on shear volume and satisfaction scores. Patients can select their telehealth provider after reviewing the physician’s ranking. PCPs are also pressured to evaluate patients quickly in a fee for service system. PCPs are ranked on Healthgrades and other online platforms for their “helpfulness,” compassion, etc.

Should Physicians Give Patients What They Want?It’s no surprise to busy physicians that prescribing antibiotics for the treatment of

common cold symptoms leads to higher patient satisfaction scores. The same can be

said for opioid prescriptions for pain. But should these medications be prescribed?

7

continued from page 6

How can physicians responsibly prescribe antibiotics and keep their patients satisfied? There are five key elements to avoiding an antibiotic prescription and satisfying a patient who expects an antibiotic for an upper respiratory infection or bronchitis:

1. Demonstrate compassion while acknowledging the patient’s symptoms. Stating “you just have a cold” can be a huge patient dissatisfier.

2. Explain why antibiotics are not needed and inform patients about possible adverse drug events.

3. Provide positive treatment recommendations. A patient is much more likely to be satisfied without receiving an antibiotic prescription if they receive specific recommendations on over-the-counter medications that may improve their symptoms.

4. Provide a contingency plan for patients who do not feel better in a specified time or if they feel substantially worse.

5. Display a poster in the examination room educating patients on appropriate antibiotic use.

As a participant in Blue Cross Blue Shield of Michigan’s Resource Stewardship Initiative, TPA works with physicians to decrease utilization of certain services, including antibiotic use for bronchitis. These focus areas are also part of the Health Effectiveness Data Information Set (HEDIS) measures, a common metric system that payers use to evaluate a practice’s quality performance. To support physician efforts in reducing the use of unnecessary antibiotics, TPA created a series of education materials to help initiate conversations and educate patients. <

A sample of materials available at no cost to TPA practices:

• 6 facts you should know about using antibiotics for bronchitis poster

• Managing bronchitis poster

• Rx ‘non-prescription pad’ (antibiotics) flyer

• Rx ‘non-prescription pad’ (PEDIATRICS antibiotics) flyer

Find these materials and others at www.thephysicianalliance.org, click the Learning Center tab, then Patient Education Materials.

Get help simplifying the complex concept of diagnostic coding! Ethica* provides physician practices with hands on, face to face assistance accurately capturing diagnostic codes. Our team can help you decrease or avoid loss of revenue and loss of referrals to other providers who appropriately code and have lower risk adjust cost of care. Some services include:

Need help capturing diagnostic codes?

• Diagnostic coding education

• New Medicare coding education

• EIDM account set up

• Review of current forms and processes

• Specialty specific diagnostic codes per claim reports-practice and provider level

• Specialty specific quick reference pocket coder cards

• Biller survey

• Chart review for coding opportunities

For more information and to schedule an appointment, visit www.ethicaholdings.com or info@ethicaholdings.com.

*Ethica is a wholly-owned subsidiary of The Physician Alliance.

20952 12 Mile, Ste. 130St. Clair Shores, MI 48081

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US POSTAGE

PAIDST. JOHN HEALTH

Dennis Ramus, MD Chairperson

Daniel Megler, MD Vice Chairperson

Trpko Dimovski, MD Treasurer

William Oppat, MD Secretary

Eugene Agnone, MD

Mazin Alsaqa, MD

Bruce Benderoff, DO

Paul Benson, MD

Dennis Bojrab, MD

Michael Little, MD

Sidney Simonian, DO

Kevin Thompson, MD

Robert Zaid, DO

Michael R. Madden President & CEO

Robert Asmussen Senior Business Advisor

Heather Hall Executive Director, Corporate Communications

Jennie Lekich Director, Clinical Informatics

Katrina Mackrain Executive Director, Business Intelligence

Michele Nichols Vice President, Administrative Services & Business Development

Carolyn Rada, RN, MSN Vice President, Operations

Sharon Ross, RN, MSN, NP Executive Vice President, Population Health

Oleg Savka Director, Systems and Informatics

Ashley Shreve Director, Practice Transformations

Karen Swanson, MD Chief Medical Officer

TPA Leadership Team TPA Board of Directors

www.thephysicianalliance.org Follow us on Twitter: @ThePhysAlliance

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To ensure TPA news and announcements reach you, please make certain any changes in contact information (name, email, address, phone) are shared with us. Send to thephysicianalliance@thephysicianalliance.org.

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