Preventive Care - Is It Still Possible?

Charles Whitney was burning out. In the six years since the primary-care physician left the U.S. Air force for a civilian practice, Whitney and his partners at the University of Pennsylvania practice were trying to make up for declining reimbursements by seeing more patients and working longer hours. In fact, Whitney was so overworked he had taken to sleeping on the office sofa to get an early jump on the previous day’s paperwork. It was during one of his office overnights in 2003 that Whitney had his epiphany.

“I remember laying there unable to sleep thinking ‘This is ridiculous. I’m sleeping on the couch to get work done.’ I didn’t have any emotional energy left for my family,” he recalls. “First we cut out the fat, then the meat, and then the organs of what we did. The amount of time we could spend with each patient was shrinking and the priorities were the sickness. I was practicing ‘sick care.’ Something had to give.”

Luckily something gave. A few months later, the university offered Whitney an opportunity to work in a pilot practice designed to promote preventive care. He was so intrigued by the practice’s concierge model that after the sponsorship ended, he bought it. Today the practice, Revolutionary Health Services, has 200 patients and is growing, and Whitney finally feels he is practicing medicine the way he should be.

Whitney’s radical change in the very nature of his practice worked for him. But you don’t necessarily have to do what he did to get a more preventive care-focused practice. Even within the standard fee-for-service practice model, preventive care is still alive and profitable, if you’re willing to make some changes to your work habits.

There are ways to find the time and get reimbursed. The trick is knowing what quagmires to watch out for and what to do about them. Here’s our guide.

Where did the time go?

No doubt there is a problem out there. Physicians everywhere are scrambling to see more patients each day, but does that really mean preventive services are the first to go? Well, that could depend on how you define “preventive healthcare.”

For our purposes, let’s clarify that preventive healthcare refers to evidence-based treatments, screenings, and counseling proven to keep people healthier by detecting illnesses earlier, tracking disease progression more closely, and helping patients avoid behaviors that lead to problems in the first place. Everything from colonoscopies to nutrition counseling to diabetic foot exams would fall into this rubric. We’re not referring to so-called “alternative” treatments that people may find helpful to their general sense of well-being but whose actual health benefits have not been well established.

According to a 2003 Duke University study, “Primary Care: Is There Enough Time for Prevention?,” preventive healthcare services, which largely include quality-of-life indicators such as skin cancer screenings or diet and behavioral counseling, would take 7.4 hours a day to provide, leaving only 30 minutes a day for critical and chronic disease care. And that’s not a realistic balance considering the number of patients with chronic care needs, says Whitney. “[Doctors] need adequate time to do preventive medicine. Most people need at least an hour for a physical - not the half hour they usually get.”

But still others argue that providing preventive services needn’t take a lot of time. Michael Parkinson, primary-care physician and past president of the American College of Preventive Medicine, contends the answer isn’t spending more time per patient, but rather properly utilizing the time you do have.

“The evidence is that patients aren’t really looking for an hour-long lecture from a doctor about nutrition, exercise, or whatever. They’re looking for brief interventions that show the physician cares, that they listen to what [the patient] says, and then follow up,” says Parkinson. It may be just a matter of increasing pre-exam organization, sticking to what’s been proven, and then referring patients to specially trained nonphysician providers for more detailed counseling.

“Counseling needs take up a lot of time. Doctors haven’t been trained to do the intensive behavioral counseling that is needed to quit tobacco, for example. It would be totally unreasonable to put that burden on our doctors,” says David Grossman, a pediatrician and medical director of Group Health Cooperative, a Seattle-based multispecialty practice with more than 900 physicians. Instead, the practice refers patients to its wellness classes for such behavior counseling.

Small practices, though, don’t necessarily have access to a bevy of nutrition counselors, smoking cessation support groups, and wellness classes. Still, there are ways to create those extra minutes that can make a big difference in keeping patients healthy. Here are some suggestions:

• Create flow sheets for chronic conditions. Make a list of “Five Things I Need to Check During an Exam” to use with patients who have diabetes or asthma, for example. Better yet, suggests practice consultant Elizabeth Woodcock, make a list of “Five Things I Need to Do Ahead of Time” before you see a patient with a chronic condition.

• Schedule appropriately and realistically. Make sure your schedulers are giving you extra time to see new patients, those with chronic conditions, and others who fall into certain pre-defined risk categories.

• Deal with no-shows gracefully. If you have a no-show, don’t stand around gnashing your teeth - just move on. That time now belongs to you and your other patients. Also, if you have patients who are chronic no-shows (and for whatever reason you won’t let them go) consider only scheduling their appointments during your lunch hour. If they show up, so be it, you’re eating on the run. If they don’t, you get to have lunch.

• Use your staff. Don’t put all the burden on yourself; make sure your nonphysician staff is trained to do everything they’re capable of so that you’re making the best of use of your own time with the patient. Peter Anderson, one of three physicians at Hilton Family Practice in Newport News, Va., developed in 2003 his Family Team Care plan, which utilizes specially trained nurses and medical assistants to do thorough patient histories. Since turning these duties over to his staff, Hilton Family Practice sees almost 40 patients a day, up from 24; doctors work an average of 45 hours a week, down from 50; and Anderson says his income has increased by $70,000 a year.

“I’ve been practicing for 25 years and I’ve never given this type of quality. … [Family Team Care] allows all the nurses to spend the time that leads to that annual physical, which is an extremely important part of good care.”

Money woes

Dwindling payer reimbursements are real and they are a large reason physicians across the nation are sprinting to see more patients. According to the Physicians Practice 2008 Fee Schedule Survey, the national average for commercial insurer’s reimbursement rates is now only 10 percent higher than what Medicare pays for E&M codes. The average reimbursement for a 99213 (a mid-level established office visit) is $71.67, compared to Medicare’s $59.80. For a 99214, the average reimbursement is $97.36 compared to Medicare’s $89.89.

“The low rates of reimbursement are major deterrents to improving the delivery of both preventive services and primary care generally,” says Parkinson. “In many areas of the country commercial rates are equal to or actually lower than Medicare.”

Try these tips for getting the most out of each visit:

• Code for time. E&M visits that gobble more than 50 percent of the exam time for patient counseling can be billed using time-based codes, which may earn you a higher reimbursement, if you code for it correctly. Remember that the discussion must be well documented and must sound plausible.

• Bring them in. If you have an EMR, use it to track patients who are due for follow-up appointments or preventive services and call them in. While some patients are good about coming back in for annual check-ups without being reminded, others might let it slip. A phone call can get more traffic through your door.

• Use preventive codes. Take advantage of preventive codes 99406 and 99407, which are for smoking and tobacco cessation counseling. Most payers pay for these codes, but many physicians don’t think to use them.

• Look for free money. Be on the lookout for federal and state grants that are providing monetary incentives for administering preventive services to various populations. Check with state and local medical societies to see what’s available.

“The time and help are there if you just look for it,” says Woodcock.

A perfect world

But still, as more and more research brings forth an increasing number of recommended preventive procedures, time and reimbursement will continue to be challenges. Physicians like Whitney, Grossman, and Parkinson think the solution involves changing the bigger picture and adopting the medical home concept. Supporters of this model contend that if patients have a central primary-care physician directing their healthcare, enhanced communication within a patient’s healthcare team would go a long way to providing optimal care.

The medical home model certainly isn’t anything new (it was first introduced in 1967 by the American Academy of Pediatrics) but over the past few years it has been gaining momentum and popularity among medical societies. It’s also the model behind Group Health Cooperative’s successful system. Serving more than half a million patients in Washington and Idaho, GHC’s physicians are salaried and encouraged to provide preventive care under an advanced medical home model.

“Having a primary-care physician to steer the healthcare experience sounds kind of basic - like mom and apple pie - but the truth is American medicine has gotten far away from that and many people do not have an identified primary-care physician and see a lot of specialists. They do not have good coordination going on,” says GHC’s Grossman. “[The current] medical system does not value primary care - it values specialty care over primary care. It makes it challenging for typical practices to develop a financial system that works or allows them to be proactive in terms of taking care of their patients.”

But GHC is proactive with its patient communication - sending them, for instance, an annual birthday greeting that, in addition to the obligatory well-wishes, reminds them of any preventive services or exams that are due, based on their age, gender, and health record. During exams, physicians check which preventive measures the patient hasn’t yet had and offers recommendations. It’s this simplified system, says Grossman, that allows GHC patients to receive the care they truly need.

“Fee for service models [aren’t] conducive to continuous care service - they reward excessive service and tend to undervalue proactive and preventive services in general. [We’re] lucky not to practice under fee for service and have the ability to take our docs off that hamster wheel. They focus on [their patient population] and provide greater depth and breadth of care without having to refer them to a lot of specialists. Outside docs don’t have time because they need to see more patients to make income targets and it’s easier to send someone to a specialist.”

Making patients into wellness partners

But some say there’s more to bringing preventive services to the exam room than in-house organization and broad systematic changes. Doctors also need to successfully navigate the changing relationship between the physician and the patient. While doctors who practiced medicine 40 or 50 years ago could expect the balance of power to be firmly on their side, today’s patients are arming themselves with information before they walk into the exam room. Parkinson sees moving away from that dictatorial relationship as a good thing.

“We’ve trained patients to see doctors as being in charge of their health. That’s a 70-year and unfortunately incorrect model for healthcare. The entire trend is changing,” he says.

The current model, he says, is designed to empower patients with the information they need to make better choices for their own health.

Because information flow to and from the patient is so important in that model, it needs to be controlled. Here are some steps you can take to equip you and your patients with the best information:

• Create thorough intake forms. Encourage your patients to think about the details of what prompted them to make an appointment and what information they need to share with you. Create an intake form they can fill out online or upon check-in. If they are telling you more pertinent information upfront, you can save time by not playing the guessing game.

• Become the information spigot. Sources for information are everywhere. If it’s not through proactive practice-initiated approaches such as GHC’s birthday letters, patients are finding answers online from popular Web sites such as WebMD. The downside is that your patients are likely to find misinformation on the Internet, and you don’t want to have to spend time decoding what your patients are learning from dubious sources.

“The Internet is wonderful and terrible at the same time,” argues internal medicine physician Mark Shields, senior medical director of Advocate Physician Partners in Chicago. “It’s hard for patients to know what is reliable, but we can say ‘this information is reliable.’ You go to your doctor because you trust them and you trust your doctor to give you good sources.”

Shields’ practice, with some 3,200 physicians, in 2003 built its own sophisticated consumer-oriented Web, loaded with information about common health issues, and since then has seen an increase of up to 10 percent in the number patients coming in for preventive-care screenings. But there’s no need to reinvent the wheel: The best bet for you is to get in front of the problem by identifying existing Web sites with information you can trust.

Knowledge is power. If you know where the obstacles lie and how to overcome them, you can provide the standard of healthcare you expect and your patients deserve.

Kellie Rowden-Racetteis an associate editor with Physicians Practice. She can be reached at kellie.rowden-racette@physicianspractice.com.

This article originally appeared in the May 2009 issue of Physicians Practice.