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Doing well by doing good: making prevention profitable

Offering preventive services isn't just the right thing to do clinically; it can be a real revenue booster

From the March 1997 ACP Observer, copyright © 1997 by the American College of Physicians.

By Christine Kelly

Talk about preventive medicine, and many physicians think of lengthy exams that ruin their appointment schedules and yield little in the way of reimbursement. But far from hurting your practice's bottom line, experts say that putting prevention into practice can be profitable-and the right thing to do.

"To many physicians, preventive care is like speaking a second language," said Charles Lewis, MACP, professor of medicine at the University of California, Los Angeles. "Some of us are bilingual; most aren't. Some of us practice wellness; most don't find it salient." And despite major initiatives like the government's "Put Prevention into Practice" (PPIP) campaign, which was designed to improve the delivery of preventive care services, the number of physicians who regularly provide preventive services remains disappointing, Dr. Lewis said.

Even when they think that emphasizing prevention is the right thing to do, physicians may worry about meeting the patients' needs. "When the patient comes in for acute care, we feel we are operating on our own agendas if we bring up preventive care," said Timothy McAfee, MD, MPH, associate director of preventive care at Seattle's Group Health Cooperative of Puget Sound. "Yet preventive care is one of the top distinguishers of a patient's satisfaction with a physician. If patients feel you are taking that extra step, they are more likely to keep you as their doctor."

And in today's managed care environment, keeping patients happy through preventive care means more than just a busy practice; it means higher patient satisfaction survey scores and additional income. Four of the nine standards used by the National Committee for Quality Assurance to measure quality in managed care plans, for example, look at prevention, and health plans are increasingly rewarding physicians for their use of preventive services.

Kaiser Permanente-Colorado, for example, mails a 51-question health risk appraisal form to all new patients asking about the use of cigarettes, alcohol and sunscreen, as well as risk factors for cancer and cholesterol. The HMO gives the results to primary care physicians, who can use the data to decide which preventive services are needed. "We're trying to make it easy for physicians to deliver preventive care services," explained Ned Calong, MD, MPH, the HMO's chairman of preventive medicine. "When doctors see that patient's chart, they see the summary as well."

And at Aetna/U.S. Healthcare, physicians who perform certain preventive services can boost their pay by about 3%. For example, the insurer reviews physician use of influenza and pneumococcal vaccinations in the over-65 population. According to Ronald Brooks, MD, one of the HMO's medical directors, practices that document higher immunization rates are paid not only for providing the shots, but also a bonus for performing closer to the optimal immunization rate. The HMO also measures its physicians' adherence to nationally recognized guidelines for mammography, Pap smears, stool for occult blood and diabetic eye exam rates.

Aetna/U.S. Healthcare also pays doctors for completing prevention-oriented CME courses on topics like breast and colon cancer, domestic violence, cholesterol, HIV/AIDS and low back pain. "Compensation is increased if all doctors in an office complete a monograph and successfully answer the questions," Dr. Brooks explained. By both completing CME and providing preventive services, he said, physicians can boost their overall earnings by 5%.

In addition to taking advantage of incentives from large payers, physicians can do the following in their own practices to make prevention easier-and more profitable:

  • Use evidence-based screening tests. Medicare reimburses for flu shots; insurers like Aetna/U.S. Healthcare pay for Pap smears, pneumococcus and flu shots. They do so because there is ample literature showing the vaccines are cost effective and reduce morbidity and mortality.

    Another procedure that has been shown to be effective-but one that many patients resist-is flexible sigmoidoscopy. Greg Glance, ACP Member, who has been doing the procedure in his Asheville, N.C., practice since 1985, is able to persuade nearly 75% of eligible patients-even those who have to pay out-of-pocket-to undergo the procedure by spending time explaining it. "The light and scope were paid for the first year," he said, "and there's little maintenance." Just as importantly, he said, is the fact that of every 10 patients, he finds two or three with problems.

  • Avoid inappropriate screening. "The important thing about preventive care is that it changes as more research is performed," explained Lynn Soban, RN, director of the government's PPIP project. The PPIP "Clinician's Handbook" lists recommendations from major authorities, including ACP, on which preventive services to perform. "Not everyone agrees on the evidence," said Ms. Soban. "This way you can find out what your professional organization advocates."

    What if your association's preventive care recommendations don't mesh with those of other professional groups? According to Herbert J. Waxman, FACP, ACP's Senior Vice President for Education, you should use your own judgment. "What happens to the patient should be a reflection of the doctor's judgment plus appropriate evidence-based guidelines," he said. "ACP, for example, doesn't recommend that women in the fifth decade automatically have annual mammograms, but each doctor needs to work out what is best for the individual patient. Some patients don't want to deal with uncertainty, others don't want to be tested unless there is a benefit. Doctors need to take into consideration patient wishes and medical circumstances."

    Dr. McAfee from Group Health Cooperative of Puget Sound said that physicians must look at claims for efficacy of new screening techniques with a critical eye. "We need to hold ourselves to a higher standard for prescribing screening services," he said, "and to make sure we are adding value to life when we suggest something like a PSA test."

    Paul Frame, MD, a Cohocton, N.Y., physician who was a member of the U.S. Preventive Services Task Force, which created the PPIP clinician handbook, pointed out other time wasters: annual physicals for asymptomatic patients, routine electrocardiograms, extensive chemistry profiles. "Talk more and test less," he counseled.

  • Save time by delegating. Rely on nurses, not physicians, to do most of the patient education. "Nurses can talk about mammograms while taking blood pressures," according to Linda Kinsinger, ACP Member, clinical assistant professor of medicine at the University of North Carolina at Chapel Hill. "Receptionists can pass out brochures and help with screening appointments."

    Receptionists at Kaiser Permanente-Colorado facilities, for example, check patient charts and hand out health risk appraisal questionnaires. This support enables physicians to spend time talking to patients about preventive tests or making changes in their lifestyles. Even these types of brief messages from doctors are effective in changing behaviors, studies show.

    In addition, getting staff involved in prevention may have an added benefit. "Staff morale improves when they participate in preventive care," said Dorothy Lane, FACP, MPH, president of the Association of Teachers of Preventive Medicine and professor of preventive medicine at SUNY at Stony Brook.

  • Promote and build your practice. The Heart and Vascular Institute of Texas in San Antonio uses preventive services to market itself in a competitive market. Representatives from the group, for example, attend about a dozen health fairs each year and provide blood pressure checks, body fat analysis and coupons for cholesterol checks. According to Mark Mehlen, chief operating officer, the practice has tripled its business since it opened three years ago. "Our health fairs always attract a response," Mr. Mehlen said, "and even those who don't use our services pass our names on to family and friends."
  • Add new services. The Preventive Medical Center of Marin in San Rafael, Calif., has incorporated the services of osteopathic physicians and a nutritionist, psychotherapist, acupuncturists and physical therapists into a single group practice setting. Because the physicians and therapists attract new patients, many of who pay out-of-pocket for services not covered by health plans, these nontraditional staffers more than pay for themselves. "Patients come to the practice because of our multi-disciplinary approach to preventive care," said Elson M. Haas, MD, the group's medical director. "They choose us over other practices."
  • Improve your coding. Preventive screening is not always correctly coded. Insurers may pay more for time spent on preventive services than for routine problems, according to Lew Pincus, MD, an internist in Lancaster, Texas, so bring in a consultant to analyze your coding.
  • Install data-collection systems. While delivering preventive services is complex, only 1% of physicians rely on computers to make the process easier, according to Larry Bickey, MD, MPH, chief of clinical preventive medicine at the State of California Department of Health Services. "Studies show that we as doctors don't do well at remembering whether a patient is up-to-date on a mammogram or occult blood smear," he said. "In rapid-paced office visits, we usually don't have the time or the systems to do it."

    And while computer software packages can create standardized forms to help with documentation, data collection and reminders for appropriate tests or counseling, they must be flexible. "Most systems allow you to enter 'yes' or 'no' whether a procedure was done," advised Dr. Frame from the PPIP project. "But if you're tracking Pap smears and a patient has had a hysterectomy, or if she refused the Pap smear, you need to be able to indicate this. You also need the capability to change the protocol for a particular patient who might need screening more frequently than the system indicates. And you need to cancel out of the system in case of death or terminal illness."

  • Establish a preventive care atmosphere. "Use your office environment to cue your patients about preventive care," said UCLA's Dr. Lewis. "Let your patients know you believe in wellness and you want to be asked about preventive care services." He uses mammogram reminder signs on the receptionist desk and finds patient brochures and videos useful.

Christine Kelly is a Philadelphia-based freelance writer specializing in health care.


For more on preventive care: a resource list

A Skill Building Course to Improve Your Performance of Office Based Preventive Services. Cassettes range from an overview of available office systems to effective behavior change counseling. The American College of Preventive Medicine: 312-467-9271.

Put Prevention into Practice. The kit, which ACP's Research Center helped evaluate, includes a revised "Clinician's Handbook of Preventive Services," patient flow charts, prevention prescription pads, reminder post cards, sticky notes, alert stickers, waiting room posters and examination room charts. Available from the Government Printing Office (202-783-3238) or the American Academy of Family Physicians (800-274-3949).

The Health Status Tracker. This software allows physicians to enter specific patient details such as why a patient declined a test or preventive service and allows physicians to change screening protocols for individual patients. Primary Care Institute, 5215 Centre Ave., Pittsburgh, PA 15232. Phone: 412-623-1376; Web site demo: http://www.ssh.edu/pci/html.

Annual Session. A course at Annual Session, "Evidence for and Against Screening: Breast, Colon and Prostate," will explore the use of various screening tests. The session will be held Sunday, March 23, from 11 a.m. to 12:30 p.m. and will be conducted by Harold C. Sox Jr., FACP.

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