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The Vitals - November 2015

Internal Medicine Alert - Infectious Disease Alert - Clinical Cardiology Alert
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New Survey Shows a Sliver of Optimism Among Some Physicians

MIAMI – It might not actually be good news, but the 2015 Practice Profitability Index has some not-so-bad news: U.S. physicians’ profitability outlooks are flattening out rather than trending downward.

The index, based on a survey of more than 5,000 physicians conducted by CareCloud and QuantiaMD, indicates that more physicians now expect to see profitability staying the same rather than declining in the year ahead. Still, nearly one-third of physicians still hold a negative view.

In fact, declining reimbursement and rising costs were the top two challenges again this year, although the transition to ICD-10 replaced the Affordable Care Act as the third greatest challenge. ICD-10 was identified as a factor hampering profitability for more than half of the respondents, while three in five expressed doubts about their readiness for the new coding system, according to the survey.

On the other hand, fewer physicians with ownership stakes said they are looking to give them up. While about a fourth of physicians are still looking to make a change, primarily due to administrative burdens, profitability challenges, and regulatory pressures, according to the report, the share of physician owners looking to sell or merge declined from 2014.

The interactive online survey was conducted during July and August this year. Results include:

  • Flat profits are expected by 35% of physicians in the next year; 31% expect a negative trend
  • Declining reimbursement is the top threat to profitability for more than 60% of respondents.
  • Administrative work, not patient care, takes up at least one day a week for 64% of physicians responding to the survey.
  • Three in five physician owners are not looking to sell or merge, with administrative work the impetus for those who are.
  • Billing and collections are targeted for improvement by 40% of physician respondents.

“The past few years have brought significant industry changes to physician practices – from Meaningful Use to the ACA and ICD-10. The convergence of these monumental shifts, compounded by other challenges like declining reimbursement, has put a strain on many practices,” report authors write. “However, this year’s PPI indicates a potential, albeit slow, shift in sentiment. The share of physicians looking ahead with positive or flat profitability expectations is growing, while the share convinced of a downward path is declining. It remains to be seen if this year’s PPI reflects the start of a turnaround in physician outlooks.”

Related [Live Webinar] December 10: Identifying and Addressing Burnout

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Higher-Cost Care Reduces Malpractice Claims Against Physicians

BOSTON – Money might not be able to buy happiness, but it does appear to help protect physicians against having malpractice claims filed against them.

That’s according to a recent report, published in BMJ, the British Medical Journal, which finds that higher-spending physicians face fewer malpractice claims.

The study led by Harvard Medical School researchers notes that nearly three-quarters of physicians report practicing defensive medicine, at a cost of as much as $50 billion annually in the United States.

Despite the widespread use of defensive medicine, little research exists on its effectiveness in protecting against malpractice claims.

The research combined data on 18,352,391 hospital admissions in Florida during 2000-09 with data on the malpractice histories of the 24,637 physicians who treated the patients. With 4,342 malpractice claims filed against physicians, 2.8% per physician-year, rates of malpractice claims ranged from 1.6% per physician-year in pediatrics to 4.1% per physician-year in general surgery and obstetrics and gynecology.

Yet, in six out of seven specialties, higher-spending physicians faced fewer legal actions. Among internal medicine physicians, for example, those in the bottom 20% of hospital spending –about $19,000 per hospitalization –faced a 1.5% probability of being accused of malpractice compared to 0.3% in the top spending quintile – about $39,000 per hospital admission.

In another example, obstetricians who performed more C-sections, often used in defensive practice, were less likely to face a malpractice claim.

"It has remarkably been unknown whether defensive medicine 'works' or whether the majority of U.S. physicians could be incorrect in believing that greater spending is associated with reducing malpractice liability," said lead author Anupam Jena, associate professor of health care policy at Harvard Medical School.

"The threat of malpractice is a very salient risk for most practicing physicians, particularly in high-risk specialties," added co-author Seth Seabury of the University of Southern California. "If physicians perceive that higher spending can protect them from malpractice claims, then they are likely to practice defensively even if they feel that the additional spending is unnecessary or offers no clinical benefits to patients."

Previous research by Jena and Seabury found that the typical physician spends nearly 11% of his or her career with an open malpractice claim and that, in some high-risk specialties, the lifetime risk of being sued is nearly 100%.

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Shared Incentives with Physicians, Patients Work Best to Improve Lipids

PHILADELPHIA – Who needs to be incentivized to improve lipids in primary care practice – the physicians or the patients?

A new study, published recently in the Journal of the American Medical Association, suggests the answer is both.

The report, from University of Pennsylvania researchers and colleagues finds that shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a modest reduction of low-density lipoprotein cholesterol (LDL-C) levels after 12 months

Background information in the articles notes that taking statins to lower cholesterol reduces the risk of heart attack by about 30%, but the use of the drugs is limited for a variety of reasons, including under-prescribing or physicians’ failure to intensify treatment when indicated, as well as poor medication adherence among patients.

The study, which involved 1,503 patients, sought to determine if financial incentives to physicians or patients are helpful in remedying the situation. To do so, 340 primary care physicians in three healthcare delivery systems in the Northeast were randomly assigned to one of four groups: control, physician incentives, patient incentives, or shared physician-patient incentives.

In the control group, neither physicians nor patients received incentives tied to outcomes, although patients received up to $355 each for trial participation. Meanwhile, physicians in the physician incentives group were eligible to receive up to $1,024 per enrolled patient meeting LDL-C goals, while patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. In the final group, those incentives were shared by physicians and patients.

After 12 months, the average reduction in LDL-C levels for patients was 25.1 mg/dL for patients in the control group; 25.1 mg/dL for patients in the patient incentives group; 27.9 mg/dL for patients in the physician incentives group and 33.6 mg/dL for patients in the shared physician-patient incentives group. The last was the only statistically significant decline, according to the results.

"Reducing LDL requires two basic actions," said senior author Kevin G.M. Volpp, MD, PhD. "First, physicians have to prescribe the appropriate medication. Second, patients have to consistently take the medication. Previous studies focused on incentivizing one group or the other have produced only moderate improvements for patients, but when we look at it as a two-way street where patients and physicians each bear responsibility, the findings then become consistent with what we might intuitively expect."

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Physicians Most Likely to Dismiss Patients for Infant Vaccine Refusal

AURORA, CO – How often physicians “fire” parents who refuse infant vaccines varies considerably but appears to have some relationship to practice setting and state policy, according to a new study.

The study, published recently in the journal Pediatrics, notes that about 20% of pediatricians report dismissing families who refuse infant vaccinations, but there is substantial variation in how refusal is handled.

Because the practice of dismissal is controversial and discouraged by the American Academy of Pediatrics, a study team led by University of Colorado researchers sought to determine more about physicians who jettison patients over the issue.

Using a nationally representative survey conducted from June to October 2012, the researchers looked at pediatricians and family physician respondents, focusing on reported prevalence of parental refusal of one or more vaccines in the infant series, physician response to refusal and the association between often/always dismissing families and provider/practice characteristics and state exemption laws.

With an overall survey response rate of 66%, 534 out of 815, 83% of physicians reported that in a typical month, 1.0% or more of parents refused one or more infant vaccines, and 20% reported that more than 5% of parents refused. Of the 51% of respondents who reported that they always/often required parents to sign a form if they refused, the rate was much higher among pediatricians, 64%, than family physicians, 29%.

In terms of dismissing families if they refused one or more vaccinations, pediatricians were also more likely to do that than FPs – 21% vs. 4%.

The pediatricians who dismissed families were more likely to be in private practice. From the South and reside in a state without a philosophical exemption law.

“In states in which philosophical exemptions are allowed, only 9% of Peds report dismissing families for refusing vaccines in the infant series versus 34% in states that do not allow philosophical exemptions (P , .0001),” study authors point out. “Twelve percent of physicians in states with an easy exemption process dismissed families, versus 22% in states with a medium exemption policy and 28% in states with a difficult exemption process.”

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