ACP Targets Growing Physician Paperwork Burden

This entry was submitted by Keith vom Eigen, MD, PhD, MPH, FACP, who is Chair of the Health and Public Policy Committee for the Connecticut Chapter.

A local pharmacist called recently to tell me that the glucose test strips my patient had been using were no longer covered by her insurance.  He couldn’t determine which brand her insurance might cover, and I was unable to find the information on-line.  I swallowed hard and resigned myself to the dreaded insurance company phone call.  After winding my way through several automated menus, I was finally able to get to a real person — who then transferred me to a different company administering the pharmacy plan.  I tried to remain calm as I repeated my, and the patient’s, identifying information multiple times, speaking with four different people.   It took half an hour, much of it on hold, to finally get an answer to my simple question.  I suppose the insurance company saved a few dollars by shifting the patient to a different glucometer brand, but at what cost to the pharmacist, the patient and the physician?  How long will it be before they decide to switch to yet another brand, requiring the same ordeal all over again?

The growing burden of paperwork and regulatory hassle is sapping the joy out of medical practice, especially in Primary Care.  Many of us are frustrated by the bureaucracy that limits the time we can spend with patients and that adds little value to patient care.  Excessive paperwork and regulation are significantly adding to physician “burn-out.”  Of course we need to do something about the rapidly escalating cost of care, but it seems that every cost-saving measure comes with another form to fill out or hoop to jump through.  Doctors struggling with the rapid adoption of EHRs often feel more like data entry clerks, and have to scale back their time with patients to manage the information flow and data reporting requirements.  And who can figure out, let alone comply with, Medicare and Medicaid regulations?

I was pleased to learn recently that ACP is actually trying to do something about the problem.  A new initiative called Patients Before Paperwork aims to “reinvigorate the patient-physician relationship by challenging unnecessary practice burdens.”  ACP has developed the program to identify administrative burdens, gather evidence to support advocacy and educational efforts, and assist physicians in implementing mitigation strategies.  Through a survey and focus groups, ACP has identified three priority areas to target: EHR Usability, Quality Reporting and Dealing with Insurance Companies.  The College is currently working on a policy paper that will outline recommendations to address the problem, as well as a toolkit for ACP Chapters to facilitate discussion and help identify solutions.  If you would like to help in the effort, you can send information to ACP ( on how the practice burdens you are facing impact your ability to care for patients, as well as solutions that you have developed in your own practice, and how you think ACP can help address the problem.  Let’s work together to reduce these burdens to make health care more effective for patients, as well as more meaningful and satisfying for physicians.

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Gun Violence: Still A Public Health Issue

The three-year anniversary of the Sandy Hook Elementary School shooting in Newtown is cause for reflection here in Connecticut.   Sadly, little has changed since then.  However, for the first time in 19 years we’ve seen a glimmer of hope to lift the ban on funding for gun violence prevention research.  The American College of Physicians is advocating strongly for lifting this ban.  Our organization joined together with 23 others to urge Congress to act (see the letter).

I live in one of the 25 U.S. cities or towns named Madison, after the Father of the Constitution and primary author of the Bill of Rights.  I bring this up because the second amendment has become such a source of polarity in our country. While you will frequently hear people debate the “intent of the founding fathers” when it comes to constitutional questions, one cannot argue with the fact that the world was a different place in 1789 when the Bill of Rights was crafted.  In the late 18th century, there was suspicion that a federally controlled military force might overthrow state governments; Madison himself felt it was important to have state militias that could protect the public from the federal army.  However, during the War of 1812, civilian militias were largely ineffective and it was determined that a strong standing army was required.  In the 21st century, the states and federal government have a different relationship.  For the most part, we have been secure within our borders.  We have a strong standing military.  The idea that all able-bodied men between 19 and 45 will need to be called upon to quell an insurgence related to imperial designs by another country or by terrorists (or maybe zombies?) is far-fetched.

On the other hand, the statistics about gun related deaths seemingly speak for themselves. So far, in 2015, gun violence is responsible for 12,533 deaths in the United States [this data is available at]. We’ve already had 353 mass shootings in 2015 (defined as the shooting of four or more people); a list can be found at  National data on causes of death in 2013, reported by the CDC, also reveals that of the 33,169 gun-induced deaths, 21,175 were self-inflicted.  Since the horror of Newtown, 555 children have succumbed to firearm violence; that is one every other day.  How could we not be outraged?  The 12,533 gun homicides this year are more than Ebola virus has killed worldwide (11,315); not only that, only 1 of those Ebola deaths has occurred in the U.S., yet Ebola elicits much more angst and hand-wringing than gun violence.  Nonsense perpetrated by the NRA about self-defense does not justify the ongoing slaughter.  If you need to be convinced, read the Violence Policy Center’s analysis of FBI and National Crime Victimization Survey Data.  In it, you will learn that in 2012, only 259 gun-related justifiable homicides were recorded against over 8,000 criminal homicides and 20,000 suicides or unintentional deaths caused by firearms (in CT, there were 0 justifiable homicides).

This country’s irrational love affair with firearms continues, at the expense of thousands of American lives.  We have to make it clear that firearm violence is a public health issue.  It’s preposterous that we cannot make substantive progress towards addressing the problem.  Let Congress hear your outrage.

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New ACP Guideline Regarding Generic Drugs

Last week, The American College of Physicians released a new guideline addressing the use of generic medications.  The authors addressed 5 questions: 1) How commonly are brand-name medications used when a generic version is available? 2) How does the use of generic medications influence adherence?  3) What is the evidence that brand-name and generic medications have similar clinical effects? 4) What are the barriers to increasing the use of generic medications? 5) What strategies can be used to promote cost savings through greater generic medication use?

In response to the first question, the committee looked at several studies of Medicare beneficiaries which revealed that from one-fourth to more than one-third of the time, such patients were receiving brand-name drugs when identical generic versions were available.  It was recognized that in the VA system, with its central formulary, there is a much greater use of generics. However, it is also notable that physicians frequently choose newer, more expensive medications when older, similarly effective medications could be chosen – even when guidelines support the use of the less expensive drug – and that changing this behavior might result in greater savings than using identical generics.

Regarding adherence, there is evidence that use of generics is associated with greater adherence.  By extension, this would be expected to lead to cost savings because downstream costs are lower when adherence is higher.  The data is mainly observational; it is unlikely a randomized controlled trial will ever be done.

A long-standing concern has been that generics could be therapeutically inferior to their brand-name counterparts.  The FDA only requires bioequivalence, which is determined by looking at pharmacological parameters rather than therapeutic outcomes.  The debate over thyroid hormone is probably the best known controversy in this regard.  The committee reviewed evidence showing that, with a few exceptions, there is no reason to suspect inferior therapeutic performance.

Barriers to greater use of generics are discussed.  Most of the discussion centers on provider and patient preferences, driven by perceptions of efficacy or safety.  Some states prohibit automatic generic substitution, so the fact that providers often refer to medications, with available generics, by the trade name results in more brand-name prescriptions.  There is a brief discussion of the link between physician acceptance of industry gifts and likelihood of reporting the use of brand-names at a patient’s request.

The paper concludes by listing strategies for promoting more use of generics, which will be expected to result in cost savings.  Provider-level strategies include EMRs that provide formulary status of medications in CPOE and academic detailing (see my last blog post for a reference to this); it has not been determined if “gift bans” will positively affect prescribing behavior.  Patient-level interventions, such as education campaigns, have not been well-studied.  At the payer level, payment reform is expected to have the most dramatic impact on use of generics as a cost-containment strategy.

The recommended “best practice advice” is that clinicians should prescribe generic medications, if possible, rather than more expensive brand-name medications.  There is a table that summarizes the advice and opportunities to implement the strategy.  I urge you to review the guideline.

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Escalating Drug Prices Are Unsustainable

The release of several new, astonishingly expensive, specialty medications has renewed the discussion over prescription drug pricing.  The new hepatitis C drugs, Harvoni ($94,500 for a 12-week course) and Sovaldi ($84,000 for a 12-week course) are emblematic.  Kaiser Health News reported, “If all 3 million people estimated to be infected with the virus in America are treated at an average cost of $100,000 each, the amount the U.S. spends on prescription drugs would double, from about $300 billion in one year to more than $600 billion.”  The new cholesterol-lowering PCSK9 inhibitors are not quite as pricey ($14,000 per year) but would be applicable to a much larger population of patients.

At the Fall Board of Governors meeting, we heard an address from Jerry Avorn, Professor of Medicine and Chief of Pharmacoepidemiology at Harvard.  He spoke to the issue of medication costs and educated on sources of information, such as the Campaign for Sustainable Rx Pricing.  Another topic of discussion was the controversial 21st Century Cures Act, which seeks to promote development and shorten the approval of new drugs and devices, but at what appears to be the cost of neutering the FDA – more accurately, encouraging the agency to accept lower forms of evidence to support approval.  In June Dr. Avorn coauthored a Perspective piece in the New England Journal of Medicine on the subject which last week engendered several interesting replies.   In his address to the BOG, he also asked us to pick up the mantle of education through academic detailing.  An excellent resource for this is the Alosa Foundation, which has  a number of modules that reinforce evidence-based medication use.  In keeping with ACP’s High Value Care initiative, it is important to recognize that the issue is not only cost, but value – how much benefit for the money spent.  But the other critical step towards reining in pharmaceutical costs is to get legislation that will allow Medicare to negotiate drug prices.  Check out this Wall Street Journal piece on that topic and look for the link to the report from Carleton University and Public Citizen.  This is something for which we should continue to advocate.

This is obviously a complex topic, about which I have only scratched the surface.  I encourage you to maintain awareness and lend your voice to the conversation.

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Last month, ACP released a position paper on telemedicine in primary care settings.  The use of telemedicine is growing rapidly, so the policy recommendations are timely.  In the paper, four types of telemedicine are described: 1) asynchronous, which consists of sending information to be used at a later time – the example given is a radiograph of a broken bone being sent to an orthopedist who will see the patient subsequently; 2) synchronous, in which real-time interaction between physicians and patients occurs, such as a physician conducting “e-visits” or a rural community health center connecting remotely with a physician; 3) remote patient monitoring, where data is accumulated and then forwarded to the physician for interpretation and action – for example, blood pressure measurements, which are electronically forwarded to the primary physician; and 4) mobile health care services, such as the use of mobile technology to send texts to promote healthy behaviors or track conditions.

The paper outlines 13 specific recommendations, several with sub-recommendations. Most particularly there is a clear call for the existence of a valid patient-physician relationship.  If there is not an existing, ongoing relationship, several steps should be taken to establish such a relationship, including consulting with a physician who currently oversees the patient’s care.  There are also recommendations for public policy including guidelines for data security, licensing and reimbursement.  I encourage you to review the Position Paper.

Coincidentally (or not), the Cochrane Collaboration published their review “Interactive telemedicine: effects on professional practice and healthcare outcomes” the same week. Their findings in the end were not so robust: use in the management of heart failure is no better than face-to-face or telephone delivery of care; there is some evidence for improved glycemic control in diabetes; cost and acceptability are not clear due to limited data reported for these outcomes. Not much to go on.  Unfortunately, though, many studies that have come out in the past 18 months were not included because of the time and effort required for such a rigorous review from the time it was initiated, highlighting the difficulty in trying to conduct systematic reviews when a topic is rapidly evolving.

In Connecticut, Governor Malloy signed into law Public Act 15-88, which took effect October 1.  The act requires that the provider communicate through real time using two-way technology; has access to or knowledge of the patient’s medical history; give the patient his/her license number and contact information; and conform to the standard of care expected for in-person care.  Prescription of controlled substances in prohibited, as is charging of a facility fee.  The act also sets requirements for insurers.

Have a comment or relevant experience?  Share it with us!



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Physician Wellness & Burnout

A lot of attention is being directed towards Physician Wellness, and its opposing condition, Physician Burnout.  And with good reason: evidence is mounting that highly stressed physicians may not provide high quality patient care.  Physicians with burnout are more likely to self-report medical errors, have lower empathy scores, and have higher job dissatisfaction, which in turn results in lower patient satisfaction and a lower likelihood that patients will follow treatment recommendations.  As we begin to understand the etiology and consequences of burnout, it becomes even more important to pursue prevention strategies.

Resilience is the burnout antidote.  Three general themes arise when examining what determines resilience among physicians.  First, there are job-related sources of gratification: finding meaning in relationships with patients and success in practice, in terms of efficacy (diagnostic, therapeutic, etc.).  Second, there are practices or routines that physicians use to counteract stress, which include engaging in leisure-time activities, professional development, establishing boundaries between work and life and ensuring time with family and friends, and self-reflection, to name a few.  Third, there is the adoption of certain attitudes, such as acceptance or realism (not engaging in wishful thinking), self-awareness, and recognition of when change is needed.  I mentioned in a previous post that the ACP Board of Governors is pursuing a theme of “Restoring the Narrative”.  This relates to the first theme, finding meaning in practice.

You might also remember that I distributed a questionnaire to explore some of these themes and the sources of burnout that you encounter.  We will be reviewing the results of the survey at the Annual Chapter Meeting on October 30, so I hope you will be there!

Notably, ACP has established a new criterion for the Chapter Excellence Award: “the chapter has a practice satisfaction and/or physician wellness program which may include programs that promote resilience and practice efficiencies.”  The Connecticut Chapter is developing a Physician Wellness Committee, and we are interested in your ideas about what form this might take.  If you want to be involved with the committee, let me know!

Last, I refer you to the work of Drs. Christine Sinsky and Mark Linzer, who have been pioneers in this area:  Christine Sinsky, In Search of Joy in Practice; Mark Linzer, Epidemic of Physician Burnout presentation.  For those of you in the New Haven area, look for Dr. Sinsky to appear at Yale Medical Grand Rounds the first week in October.





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ICD-10 is coming…

As I write this, the ICD-10 Countdown Clock on the CMS website reads 54 Days, 14 Hours, 22 Minutes, and 13 Seconds (no, 8 Seconds, 5…). The fact that this clock exists gives you some idea of the import of this transition and the anxiety it is provoking. ICD-10 refers to the International Classification of Disease, tenth edition, published by the World Health Organization (WHO). ICD-9 has been in use since January, 1979. WHO started work on ICD-10 in 1983, but did not finish until 1992. Other countries started implementing it in the late ‘90s. In fact, the United States is one of the few developed countries that has not yet made the transition. We made the change from ICD-9 for coding and classifying mortality data from death certificates in 1999. The Department of Health and Human Services proposed in 2008 that we begin using ICD-10-CM, the Clinical Modification and ICD-10-PCS, the Procedural Coding System, for reporting. The recommendation became rule with an implementation date of October 2013. That got pushed back twice, and now we are finally staring down the drop-dead date of October 1, 2015.

Hopefully, your preparations to manage the transition are well underway. If not, CMS suggests the following steps: talk with your practice management vendor; be sure systems have been upgraded to the 5010 standards; discuss implementation with billing services and payers, including discussing with payers if contracts are affected; identify necessary changes in workflow and address staff training needs; conduct test transactions in advance of the October 1 deadline to be sure they are successfully received.  [CMS ICD-10 Basics]

ACP provides resources to address the ICD-10 transition: check them out here.


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