Make pediatric practice great again!

I began the January 2016 Peds v2.0 article “Expediting medical documentation” by stating that my “theme” for this year’s articles is the “retaking” of pediatric practice for ourselves and our patients. I continue this discussion by borrowing a slogan from one of our presidential candidates, in the hopes that pediatricians can be motivated to implement needed reforms that will make practices more efficient, improve the care we provide to patients, and enhance the lives of pediatric providers. I have been inspired by many positive e-mail conversations I’ve had with concerned pediatricians to believe that we can, with some concerted effort, turn things around.

Pediatric practice was once great!

Most of us went into pediatric practice for any numbers of good reasons. We enjoy taking care of children and their families, and have a challenging job that is never the same from one day to the other. It’s a vocation where we make a difference-sometimes small, sometimes profound-in the lives of others. We constantly improve our knowledge and skills in situations where years of training and experience show their benefits. Our work environments are pleasant, and staff and patients for the most part are kind, helpful, and involved. And best of all, our patients are cute, and the young ones are light and easy to pick up!

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Most mature pediatricians recall a kinder, gentler time when pediatric practice was indeed “great.” In my view, the heyday of pediatric practice was in the 1980s when medical care was largely fee-for-service, and insured patients received a super bill that they submitted to insurance companies for reimbursement. There was no managed care or prior authorizations. In the 1980s, there were no electronic health records (EHRs), Health Insurance Portability and Accountability Act (HIPAA), or Clinical Laboratory Improvement Amendments (CLIA) ‘88 regulations, and our paper charts allowed us to spend more time with patients. Charting took minutes and, in an efficient office, physicians could easily see 30 or 40 patients a day and provide quality care to each. Today, with our complicated EHRs, most pediatricians are hard pressed to see 25 patients a day.

So why the problems?

If left to our own devices, practice would indeed be wonderful, but we live in an imperfect world. Medical practices must generate revenue, keep overhead down, and make EHRs work for us and not against us. However, impediments to providing good care are numerous. Insurance companies hold the purse strings for patient care and limit access to needed medications and diagnostic studies. Requests for prior authorizations pile up on our desks, and getting patients inexpensive but necessary medications can take hours of staff time. In addition, government oversight and regulation further burden our efforts. And sadly, in order to continue to retain staff privileges, we are further hindered by the need to participate in Maintenance of Certification (MOC), taking hours away from clinic time and adding to our stress levels.

NEXT: Starting the revolution

Begin the revolution

In order to regain the “greatness” of pediatric practice, we need to enumerate the obstacles to care for pediatrics in general as well as for our individual practices. This will help us determine if there is any “low-hanging fruit” ripe for change, so we can establish our priorities. Keep in mind that all practices are unique, and a problem/obstacle for one is not a problem for others. What may be a problem for a pediatrician in private practice may not be an issue for a pediatrician employed by a medical center. Similarly, academic pediatricians are likely to have concerns unique to their situations.

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There are many resources available for pediatricians seeking reform, including the state chapters of the American Academy of Pediatrics (AAP), as well as the many sections and councils within the AAP. I’d like to think the focused articles I’ve written in Peds v2.0, albeit brief, can help pediatricians improve workflow and make practices more efficient.

Pediatricians should communicate with like-minded colleagues who wish to influence those who make decisions affecting our ability to provide quality patient care. I personally have had luck communicating with state legislators when insurance companies are restricting patient care or not reimbursing for what has become standard-of-care services. State legislators can compel insurance companies to cover needed services such as photoscreening, for example. It is also time for pediatricians, who have been traditionally timid, to raise their voices as a group to request and, if necessary, demand that changes be made to our healthcare system. I point you to Rebel.md website to read dozens of blogs by physicians who express feelings that many of us try to repress.

Let me get off the soapbox by just saying that alone a single voice is not often heard, but when you add your voice to others, the voices become an uproar and produce results. Therefore, employed and academic physicians can have productive conversations with administration and managers to effect change. Similarly, hospital policies can be changed through constructive dialog, but only if one stops complaining and makes the effort to organize support.

What needs to change?

Contemporary Pediatrics has conducted annual surveys of readers, and these surveys have revealed that the stress level among pediatricians is high, in large measure because of concerns relating to providing adequate care, practice and personal revenue, and impediments such as the Affordable Care Act (Figure). To this list I would add high patient deductibles, complicated EHRs, requests for prior authorizations, and looming pay-for-performance changes to our current reimbursement model.

NEXT: Here's the plan!

Now here’s my plan!

It would seem that we need to have more time with patients; reduce EHR and paperwork hassles; overcome impediments such as meaningful use and prior authorizations; and increase revenue whenever possible. We also need to practice good medicine! No problem if you heed the following suggestions.

Worry about today, not tomorrow.

We spoke about low-hanging fruit a moment ago. Firstly, it is pointless to worry about regulations that don’t affect us or may (or may not) affect us in the future. For example, few Medicaid-enrolled practices generate enough revenue from compliance with EHR-use incentive programs to make participation worthwhile, and, in case you haven’t heard, meaningful use requirements are being phased out. Unlike our colleagues in family and internal medicine enrolled in Medicare, pediatricians will not be penalized by refusing participation in incentive programs. Likewise, if you are not affected by any accountable care organizations (ACOs) implementing pay-for-performance measures, just don’t worry about this situation until the need arises. Most Peds v2.0 practices are already achieving or surpassing the quality measure thresholds that qualify us for the best reimbursements.

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Additionally, it is never wrong to request that patients make their own follow-up appointments for ancillary services or tests. Patients can schedule their visits with specialists or go for labs or x-rays when handed referrals or lab and x-ray requisitions. This empowers the patient, and frees your staff from unnecessary tasks. Similarly, care coordination services are beyond the scope of most small practices. However, insurance companies including Medicaid have care coordinators on staff as well as social workers that can assist patients in need.

NEXT: Reduce hassle

Reduce or eliminate hassles!

Recent Peds 2.0 articles dealt with improving your efficiency with EHRs (March 2014) and writing more concise notes (January 2016). Focus on templates, shortcuts, voice dictation, and, perhaps most importantly, time stamping notes that are concise and accurate. Use macros to make note writing quick and efficient. If you make a sincere effort to simplify notes, you will be rewarded by being able to spend more quality time with patients and less time in front of computer screens.

Prior authorizations (PAs) for patient meds one of the worst practice hassles, in my opinion. The need to deal with PAs can be reduced or even eliminated by keeping current copies of insurance company formularies always up to date and available as pdf files on your computer desktop. If you are in doubt whether a med is preferred, check the formulary. Rather than go through the laborious process of contacting the insurance company to pursue PA denials (this can take literally hours for staff, believe me), have your nurse call the pharmacy to see what alternative medications are available, have her call in the revised prescription, and have the pharmacy contact the patient. This simple procedure saves hours and hours (and hours) of staff time. There are even online services that will assume your prior authorization chores for you, such as http://www.parxsolutions.com/ and www.covermymeds.com.

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As discussed above, don’t hesitate to challenge insurance claims and work with other pediatricians in your community, the state chapter of the AAP, the state Insurance commissioner, and the state legislature, if necessary, to ensure payment for appropriate care.

Change your model of care.

Healthcare delivery is changing. Consider providing some services via Telehealth so you can get reimbursed for services you now provide for free (ie, treatment for conjunctivitis or adjustment of meds for attention-deficit/hyperactivity disorder [ADHA] or asthma). If you are concerned regarding those patients with high deductibles that make parents reluctant to seek care for their children, consider alternative payment models. Although I am no longer in private practice, I have often wondered if practices could consult with their attorneys and accountants and run 2 “practices” out of 1 location, one that accepts insurance and one that under a different tax identification number can accept reduced payments. I wonder if any of the readers of this article have done just this. If you have done so, please contact me at Andrew.schuman@ymail.com and let me know the details involved so I can share these with our colleagues.

Don’t worry about MOC.

It appears that the American Board of Pediatrics (ABP) is ready to change our current model of MOC. There are now more ways to get MOC Part 4 credit, and the ABP is considering changing its test to one that is open book. Stayed tuned as I plan to write a more comprehensive update later this year regarding the status of MOC reform. In the meantime, I would leave satisfying MOC requirements to the last year of your 5-year cycle.

Greatness soon will be ours again!

It would seem that many of the obstacles to rebuilding the “greatness” of pediatric practice can be easily overcome. We need to master our EHRs, document visits more efficiently, and apply a few practice tweaks that give us more time to enjoy providing patient care. We also need to ignore whenever possible the many government mandates and regulations that can make practice less personal and more tedious. We can have confidence that government healthcare reform will continue to be tangled in red tape, so procrastination is a very viable pathway to reclaiming our practices and our lifestyles.

Don’t worry, be happy! I, for one, look forward to returning to a kinder, gentler, and less complicated pediatric healthcare system. 

NEXT: Fixing healthcare

Dr Schuman, section editor for Peds v2.0, is adjunct assistant professor of pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.