Speaker 1:
You are listening to Your Practice Made Perfect, support, protection, and advice for practicing medical professionals brought to you by SVMIC.

Renee Tidwell:
Hey everyone, welcome to Your Practice Made Perfect. I'm Renee Tidwell and I'm back to host this episode today. We're going to talk through some of the shifts in the healthcare landscape and how they may impact your practice in the coming years. The good news is there are some exciting things like the potential opportunities for your practice given the changing landscape, but there are also some not so exciting things. So today we're going to discuss all of these things with an expert in the field who has 30 years of experience, Elizabeth Woodcock. Elizabeth, welcome to the show.

Elizabeth Woodcock:
Thanks so much.

Renee Tidwell:
Before we get started, I would love to give our listeners a little background on you. Could you just share a little bit about yourself before we start?

Elizabeth Woodcock:
Awesome. Be more than happy to. I've been fortunate enough to serve in the role of a trainer, an author, and a consultant in practice management for, as you mentioned now 30 years. And for most of those years I have aided the team at SVMIC as you all have delivered some amazing practice management expertise to your clients for so many years. And in my free time, I teach at Emory University in the School of Public Health, and I also run a small organization of children's hospitals and academic medical centers that is focused on patient access.

Renee Tidwell:
Well, I know you've been a great asset to us and I'm excited to hear what you have to share with our listeners today. So before we get into the specifics of the episode, let's start with just the overarching things that healthcare providers can expect to experience, as healthcare continues to change, what trends are you seeing?

Elizabeth Woodcock:
Well, the first trend is definitely an imbalance of supply and demand. And let me unpack that for just a second in that it's not a huge surprise post-COVID that a lot of patients who did not receive care, I know I'm one of them during that time period, are now coming back. Colonoscopies, for example, I was working with a practice that had 600 patients waiting in a queue. So supply and demand definitely out of balance, and I think that's creating some challenges for practices today as we're trying to accommodate patients. The other big thing that's sort of a post-COVID trend is staffing practice still really, really being impacted by the staffing crisis. That has seemed to kind of come away, but it just is affecting especially smaller practices. If you have one or two key personnel, a medical assistant, an awesome front office team member who has left, it really is disruptive.
And Renee, if you don't mind my mentioning last but not least, and this may elicit some frustration from some of our listeners, but to me the other COVID impact that physicians are feeling right now is the fact that during the first part of COVID, insurance companies kept taking in premiums. It's not like they called a practice and said, "Oh, by the way, I know your employees are not going to be receiving care because it's COVID and we can't even walk into a doctor's office." They didn't give us some sort of break in terms of premiums. And so they kept taking premiums, premiums, premiums, kept taking in dollars, and one of the challenges that we're seeing now is their stock prices went way up in the last two years.
And so in order to sustain those stock prices, they've really, really put a lot of pressure on really practices as well as hospitals our entire field with prior authorizations, with challenges related to denying care for medical necessity. So I think more so than the past, particularly three years, we're seeing a lot of pressure from the insurance companies who really have an economic incentive not to pay.

Renee Tidwell:
That sounds pretty stressful. I want to hit back first on the supply and demand. That's something I personally hadn't really thought of before. Obviously, people weren't going in, but these standard tests that people need done, how does a practice go about managing that demand right now? How do you prioritize and get back to a norm?

Elizabeth Woodcock:
Yeah, it's a really great question. Again, some specialties are particularly of impact. I use the example of gastroenterology, but you could say the same thing with primary care, with orthopedics, we could go down the list. I think the biggest challenge that I'm seeing is as lead times to schedule appointments go up, what happens is our non-arrival rate also goes up. So let me explain what I'm talking about there. And again, it's sort of intuitive, Renee, let's say you schedule something for a test or-

Renee Tidwell:
I just need a physical. It's like three or four months just to get in for a physical right now.

Elizabeth Woodcock:
Oh, and I think that's good. For my doctor, I know it's more than six months, but let's say you do that, you schedule a physical in six months. Well, you're a busy professional. A week before the appointment you go, "Oh, oh, I scheduled this thing six months ago, but I've got an important meeting with my team and so I can't attend the appointment." So what happens is as physicians get busier and busier and busier, the schedule actually gets less and less utilized. So it's like a vicious cycle. So the biggest issue I would say, Renee is instill a gap management program. And what I mean by that is making sure that you and your team are looking at tomorrow, looking at next Monday, like looking just in this smaller window and making sure that all of those cancellations that might've happened because you were scheduling so far in advance that you're refilling those with appointments. Because my research shows that utilization is running at about 70 to 75%, which is not very good because we really, really need to make sure that those seats of the airplane, if you will, are full.

Renee Tidwell:
Absolutely, absolutely. So once we've got that figured out, let's hop back over to the insurance side of things. Obviously, these trends are also be changing as we get back maybe hopefully away from COVID a little bit and get back into a new norm or a new swing of things. Let's go ahead and talk about the reimbursement side. What exactly is going to impact those large and small practices?

Elizabeth Woodcock:
Well, I think despite this trend I described in terms of the commercial payers really putting a lot of pressure on reimbursement, we did get some good news from the federal government who released its final rule in November, and that good news really opens up the door for some... I'll use the term creative reimbursement strategies, so they're all very compliant. When I use the term creative, I don't mean anything that would smack of anything that would be inappropriate.
But what's interesting Renee is that I find a lot of physicians kind of get stuck in the, well, let me go ahead and just bill for my office visits without realizing that there are reimbursement opportunities for taking care of patients, for example, out of the office, which is a big trend. You're answering all these calls, you're taking care of all these messages. There's a lot of frustration of practices for doing all of this work and feeling like they're not getting paid for it. Well, the good news is that there are some payment opportunities.

Renee Tidwell:
Elizabeth, I know physicians are doing a lot more out of office work like you just mentioned, but telephone calls, messaging, as far as this out of office type work, what can physicians look forward to in the coming years, as far as reimbursement goes specifically?

Elizabeth Woodcock:
Thanks for asking that question. Let me take us back in time just a little bit in that in basket messaging or pool messaging, or I think some systems even call them beans, like the messages that are coming in from patients they actually can be billed for under certain circumstances. The CPT codes that I'm talking about are 99421, 99422 and 423. So these are CPT codes that are for quote-unquote online digital evaluation management services. Now, I mentioned that there are some rules that certainly want to attend to, but even health systems like Cleveland Clinic, the University of California, San Francisco, big health system in Houston, Houston Methodist, they're billing for these. So this isn't, I would say industry standard, but it's very, very close to that. So definitely pays to review those. Those have been around for a couple of years now, but I'm still finding that practices are unaware of them and or are not interested in exploring them. But I do think the time is now because there's so much pajama time that physicians are spending with patients. As you mentioned for that out-of-office care.

Renee Tidwell:
There's not much of a break these days for them, it doesn't seem like.

Elizabeth Woodcock:
I was just going to mention that in the final rule, there is a new set of codes for principal illness navigation, and these actually include some... Again, I'm going to use the term creative opportunities, but caregiver training, think about how much time and a practice, maybe it's a newly diagnosed Parkinson's patient for a neurologist. A lot of the time the medical assistant, the LPN, the registered nurse, they're going to be spending time with that patient's loved one talking about how to care for him, her or they, and really spending time on that caregiver training. Renee, today there's no reimbursement opportunity, but starting in January 1st, 2024, there indeed is a opportunity to code and be paid for that caregiver training. It's really exciting.

Renee Tidwell:
That's great news because I know my grandmother, for instance, had Alzheimer's. She didn't spend a lot of time being treated, but the family spent a lot of time talking through what do we need to be looking for and to know that a physician can actually get reimbursed for some of that time now is a great change. What other changes are we seeing out of this final rule?

Elizabeth Woodcock:
Well, interestingly enough, let me extend that caregiver training to the fact that therapists can bill for it, psychologists can bill for it. So if for example, a practice does have some of these additional health professionals, again, that was kind of off the table, only the MD or DO could bill, but now we're seeing a little bit more of an extension in terms of the billable provider. Another opportunity that I just absolutely love is a set of codes, or actually it's one code that was played with about three years ago, and the government sort of tossed it partially because the industry said, "Hey, this is going to open Pandora's box in terms of billing," but it actually is a cognitive load reimbursement. Doesn't that sound funny?

Renee Tidwell:
Talk to me about that. What exactly does that mean?

Elizabeth Woodcock:
Well, basically the government... And I'm actually quoting from the final rule, this cognitive load, "Building a relationship with a patient." So this is sort of meant for... It doesn't actually tie to any specialty, but presumably it is primary care. Anyone with longitudinal care, maybe endocrinology, rheumatology, already mentioned neurology, where there is a development of a relationship with the patient. So this code is meant to be sort of like an extra kick, an add on payment, a little bit of a bonus for that cognitive load. It is, and if I may let me read it, visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed healthcare services. And so the code is G2211. Again, nice little add-on for that cognitive load.

Renee Tidwell:
Can you give me more of an example like that? So it's not necessarily going to be the primary care physician that's taking advantage of that, right? It's going to be more of the specialties.

Elizabeth Woodcock:
It's a good question. It is meant for primary care as well.

Renee Tidwell:
Okay.

Elizabeth Woodcock:
I was just mentioning those specialties because I think at first, a lot of people... The sort of buzz was, oh, this is for a family practitioner and internist, but it's actually there is no specialty designation for it. No, if you will, taxonomy code that is associated with reimbursement. And I did want to mention here Renee, because I think it's important is this is a code to be used for Medicare. But what I love about this final rule, and the reason I think it's really important to pay attention to is that it often is the bellwether for reimbursement across our industry. As you know, we don't have a single payer system in the US, but Medicare is our leading payer and often is kind of the first one that sort of starts the ball rolling. So it'll be interesting to see if our commercial payers and or Medicaid pick this up in the future.

Renee Tidwell:
What else is changing?

Elizabeth Woodcock:
Well, unfortunately, if I may kind of introduce the unfortunate news is basically the reimbursement is softening for practices by 3.4%. Again, that is a 3.4% decrease for the conversion factor because of some shenanigans with budget neutrality. Basically overall, the reimbursement will be reduced for physicians by 1.25%. That does compare drum roll to hospitals, which are receiving a 3.1% increase. And once again, this year you might ask why. Why are doctors less important than hospitals or less valuable? It is because of the way years and years and years ago that the reimbursement rates were set up, the actual methodology. And so once again, this year there is buzz in the industry that Congress will come back and say like, "Okay, we need to make a change because this is not fair to do to one segment of the healthcare industry, in terms of that declining reimbursement."

Renee Tidwell:
What other threats are you seeing to medical practices due to these changes?

Elizabeth Woodcock:
Well, I don't want to say it's due to these changes, but one of the other interesting things that we've seen in the last few years is really a rise of what I'm going to call consumerism. And I use that as a general term, and I think we all feel it ourselves, which is, you know what? I don't want to wait. You mentioned Renee three to four months for a physical, I don't want to wait that long. And so it used to be that we didn't really have any other option. I mean, I guess you could choose another family practitioner internist in your community, but that was kind of the extent of it.
But today, if you log on online and you just pick a primary care visit, I mean, there are so many options. I'm not in any way suggesting they're quality, the same level of quality, but the reality is there are options. They're more convenient. We're seeing Best Buy, Dollar General, I mean, are you kidding me? But yes, Dollar General, you can now get an appointment at Dollar General for a medical physical, let alone Walmart, Walgreens, I mean, let's go on and on. The competitive landscape is really shifting, and it used to be limited to urban markets, but actually the new trend now is the So-called healthcare deserts. That's the rural and suburban markets where there may not be as many physicians, but that's where these companies are turning their attention to.

Renee Tidwell:
Yeah, I would definitely think in some of the more rural places, especially places like Dollar General where you're seeing some of these newer companies pop up, the urban market seems more competitive as it is, so it seems like it would make sense if they're going to have that it would happen there. So Elizabeth, with all of these changes, how does it differ depending on the specialty?

Elizabeth Woodcock:
Well, every year Renee, the Medicare final rule, the Centers for Medicare and Medicaid services does publish an estimated impact on specialties, and this year we saw three specialties that were receiving, I mentioned before this 1.25 overall decrease, but these specialties just because of the changes in the codes that they commonly use are going to see a boost in reimbursement. So these are family medicine, HEM/ONC and endocrinology. On the opposite end of the spectrum, however, interventional radiology, IR, [inaudible 00:16:59], which is nuclear medicine and vascular surgery, and as we know IR and vascular surgery share a lot of CPT codes, they're actually going to be receiving declines. And in fact, for interventional radiology and vascular surgery, this is multiple years in a row that their reimbursement rates have been softened. So in addition to the 1.25%, they're also seeing a decline of 3 to 4%. Again, that's just an estimate. It's not like they'll be on the remittances. Medicare will take off 3%. Those are just estimates, but they generally play out pretty well because CMS is using its claims' database to make those estimates.

Renee Tidwell:
That's quite a bit though and a decent impact on a practice, especially if you consider that it's been several years in a row that they're continually taking that hit.

Elizabeth Woodcock:
Yes.

Renee Tidwell:
Elizabeth, some of our listeners may already know this, but enlighten me just a little bit. Is this pretty common or is this kind of a big year for these changes or is this something that can be expected year after year?

Elizabeth Woodcock:
It's a great question, Renee, and generally there's going to be changes each and every year for Medicare, and then they sort of roll out, some of them do to the other insurance companies in the years to come. And so this is generally, I would say a... I'll use the term an exciting year for the final rule, but there's no massive like, oh, my gosh, 20% this or 20% that. It's generally a little bit of up and a little bit of down. If I may talk for a few minutes about telemedicine because we didn't discuss that as relates to COVID, but of course, many practices if not all adopted some level of telemedicine within their practices, and we've seen those volumes really decrease particularly in the last 12 months. However, it is important to note that if you are doing telemedicine in your practice, which you absolutely can get reimbursed by Medicare, is that please, please, please make sure that using the place of service code for telemedicine, that is 10, that is one zero, and that means that you're in the patient's home.
There is a place of service code for telemedicine, but it is paying at about a 40% decline as compared to using place of service 10. So it does, I think really paying attention, even just keeping your ear to the ground. I happen to be married to a physician and we always do sort of an annual like, "Okay, Rick, let me tell you what, here are the five things that are going to be applicable to your specialty." Because keeping that ear on the ground can mean a big, big financial impact as you look at the year ahead.

Renee Tidwell:
That's great information. Elizabeth, it sounds like you're a great asset to your husband's practice, but for a new physician or maybe even someone, a seasoned physician that's been in practice a while, how do they get this information if they don't have you to help them out? How can they stay on top of all of this stuff? Because it does sound like even just implementing a few of these small things can make a big impact on a practice over the course of a year.

Elizabeth Woodcock:
Well, I'm going to throw the ball back into y'all's court. Because I do think SVMIC does an amazing job of keeping its subscribers informed, and I really will say that because physicians who are your customers are always really complimentary about all the great information that y'all disseminate. So I do think SVMIC is a great source. In addition to that, please, please know that generally the medical society, this is state and local and or the Physician's Specialty Association are really going to be key, particularly the latter because they're going to call over maybe for example, OB-GYN would really focus on ACOG or American College of Cardiology for cardiologists because they're going to look through this... I'm embarrassed to say, 2900 page final rule, and they will pull out the information that are really applicable to their specialty.

Renee Tidwell:
So you don't have to really reinvent the wheel here. They're sources out there already trying to help out with this information it sounds like.

Elizabeth Woodcock:
Absolutely. Although it is kind of light reading this 2709 page final rule.

Renee Tidwell:
I can't imagine. Elizabeth, are there any other reimbursement opportunities that our listeners should be aware of?

Elizabeth Woodcock:
Renee, I love the screening tool for Social determinants Of Health. Medicare has decided to pay for that in the 2024 and beyond. And you may be like, what are you talking about? SDOH is the acronym for Social determinants Of Health, and this is things like education and housing and social stability so that physicians can really ask holistically about the patient. And I got to be honest, this is one of those areas where I think physicians already do that by and large, but again, don't get paid for it. And that's why I love this reimbursement opportunity is it's something that many practices already do, but we have to be a little bit more formal.
So you can use an assessment tool, they're free of charge, the government doesn't have a certain one that you have to use. You can use an assessment tool, and then you ask patients about, again, kind of housing, education, health literacy, how that impacts their care. Now the exciting part about this is that this reimbursement, which looks like it is going to be about 15 to 25 dollars can be added on to Medicare annual wellness visits. Hello. So exciting. And again, it's a screening tool, so I don't have to have somebody take out six or seven or eight minutes of their day to ask these questions of the patient. It can actually be a tool that I can code and bill for. Very exciting.

Renee Tidwell:
So this may be a dumb question, but is this something a physician's office would do every time they see a patient or once a year?

Elizabeth Woodcock:
It's a good question. In terms of frequency, we haven't seen all the rules related to that, but that's something that I would highly recommend looking into because to your point, you can get paid for things like smoke and cessation counseling and this risk assessment tool that I've been talking about. But oftentimes, there are limitations about how much you can actually get paid for it per year or per time period. So definitely want to take a look at that as well as any preventive services, and we'll drop those in the show notes. There's a wonderful link for all of the preventive services. And I should also mention on the top left-hand corner, it tells you which services can be billable by telemedicine. And you might think like, when am I going to do telemedicine? But I love this idea. I actually got from a neurology practice I was talking about this whole idea of it takes forever to get into be seen, this appointment lead time.
So as they were calling to confirm patients and they realized patients either couldn't come, maybe they had a child care issue or work issue, they offered them the ability to be seen by telemedicine. So they didn't do this proactively, but it sort of was like that alternative. And what they were able to then do is kind of keep the use of those appointment slots and of course, give great care to those patients and then schedule them for an in-person visit as they could be accommodated. So again, back to that tool, it does offer you the ability to see what can be payable by telemedicine.

Renee Tidwell:
I love that idea though. And as a patient, I mean, I've got kids, I've had to cancel appointments that I've really wanted to keep. That's a great opportunity for the physician and the patient I feel like to continue their care.

Elizabeth Woodcock:
I agree. And Renee, I should mention that Medicare does pay for E&M office visits by telemedicine. Actually, if you use the right place of service code, that 10, it pays at the same rate as seeing the patient in person. So as you mentioned, while you may not lead with that, it could be a great alternative for time starved at patients. And it's a really great alternative to losing that appointment slot altogether and still being able to care for the patient.

Renee Tidwell:
Well, and then if you lose the appointment, then you may have staff that are trying to... If you've got a wait list or something, call around, they're spending time, which is also money, trying to fill that spot. So I think that's a great option for some specialties. I know we've got a couple things to add to the show notes. Before we wrap up though, is there anything else you want to share with us?

Elizabeth Woodcock:
Well, I think 2024 is going to be a great year. Despite all of our challenges. We have to remember that we are really fortunate to be able to have a great, great opportunity to care for our communities. So despite all the challenges that we've talked about in terms of reimbursement, it's truly an honor to work with medical practices and I think it will be another great year 2024. Thanks so much for having me.

Renee Tidwell:
Thank you so much, Elizabeth. This has been super informative and I think a great episode. Our listeners are really going to enjoy. Listeners, again, we are going to have several things linked in the show notes. Take a look at that, reach out to us if you have any questions. And with that, we're going to say goodbye.

Speaker 1:
Thank you for listening to this episode of Your Practice Made Perfect. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast. The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policy holders are urged to consult with their personal attorney for legal advice as specific legal requirements may vary from state to state and change over time.