Patients Hesitate to Disagree

Patients don’t want to disagree with their doctors, even though they would like a say in treatment decisions, according to a survey published in the Archives of Internal Medicine, July 9, 2012.

When asked, more than 9 out of 10 people said they could visualize asking questions and discussing preferences with their doctors, and 80% said they had the ability to disagree.  But when it came down to it, only 14% of patients reported that they would actually challenge their doctor if he or she recommended a treatment that conflicted with their preferences.

Nearly half of those unwilling to disagree feared being labeled as “difficult”; 40% worried such actions would damage their relationship with the physician; and more than half thought disagreeing with their doctor might negatively affect their care.

The online research involved 1,340 adults who were told to imagine that they had heart disease.  They were then asked the extent to which they would like to be involved in their treatment decisions.  The treatments might include options such as medications, bypass surgery or angioplasty—which have similar long-term outcomes, said Dominick Frosch, from the Palo Alto Medical Foundation Research Institute and the University of California, Los Angeles.

Nearly 70% of the survey participants said they preferred making medical decisions together with their doctor, each contributing equally to decisions about treatment.

“We know when patients are surveyed directly they really want to participate in their medical decisions, but are very nervous about this idea of pushing back against doctor recommendations for fear of being labeled a ‘bad patient,’” said Dr. Michael Barry, president of the Informed Medical Decisions Foundation and a primary care doctor at Massachusetts General Hospital in Boston. 

Barry did not participate in the research but his foundation financed it. “I think getting over that culture—that there’s a right answer based as a clinician on your preferences—is what we’re facing. Clinicians are the experts in the options and the outcomes of the options, but patients are experts in what’s best for them.”

Despite current focus on patient-centered care, the authors found that these fears prevent shared decision making.  They noted that poor communication itself can cause inferior outcomes.   A study published in July, 2012 in the journal Perspectives on Psychological Science reinforced this with findings that patients’ feelings of autonomy, competence and relatedness were associated with better mental and physical health.

Frosch cited patients who won’t take their hypertension medication because they didn’t want it in the first place as an example of miscommunication that can lead to worse outcomes.  Frosch said that when it comes to doctors they need to “create a safe space for patients to be able to speak up and express their preferences.” 

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Documenting and Billing for Care Plan Oversight

Home Health & Hospice

There is one service that is not face-to-face that physicians can be reimbursed for by Medicare—care plan oversight (CPO) of patients receiving home health or hospice.  Because the rules are complicated, many physicians simply don’t bill for this service.  Here we’ll try to break it down.  
To bill, CPO services must take at least 30 minutes in a calendar month. The services do not need to be provided on the same day, but the total services over the course of a month must add up to at least half an hour.  Medicare uses two HCPCS codes to pay for CPO:  G0181 is for home health, and G0182 is for hospice. 

YOU CAN BILL FOR TIME SPENT:

• Reviewing charts, reports and treatment plans
• Reviewing diagnostic studies that weren’t associated with a face-to-face encounter
• Phone calls with other health care professionals involved in the patient’s care who are not employees of the practice
• Conducting team conferences
• Discussing drug treatment and interactions (not routine prescription renewals) with a pharmacist
• Coordinating care if physician or non-physician practitioner time is required
• Making and implementing changes to the treatment plan

YOU MAY NOT BILL FOR THE TIME YOU SPEND:

• Renewing prescriptions
• Talking with fellow employees at the practice
• Travel time
• Preparing or submitting claims
• Talking to the patient’s family, even if discussing treatment plan changes
• Holding informal consults with physicians who are not treating the patient
• Working on discharge services
• Interpreting test results at an E/M visit

GOOD HABITS

• Keep a log of the patients you provide CPO to; use this as a reminder to pull those charts at the end of the month. 
• Keep a simple CPO log in each of these charts and document the date, total time and a brief description of the services as you provide.  Sign this documentation.
• At month end gather the logs, total the time and bill for those for whom you provided at least 30 minutes of CPO.  Put the beginning and end dates of the month as the dates of service and be sure to put the provider number of the home health agency or hospice on the claim form.

For more information or questions, or to receive written materials about billing for care plan oversight, call Kaye Holbrook at 408.773.4359 or email your request to kholbrook@pathwayshealth.org.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Need More Friends? Maybe Not

“Friending” current and former patients on Facebook is probably not a good idea; in fact it’s not a good idea at all.  This is the advice the British Medical Association is handing out to physicians.

In the BMA’s social media guide they state that “because of the power imbalance that can exist in any doctor-patient relationship,” it’s important to establish a professional boundary. They state that it can be difficult to maintain those boundaries with all the personal information available on Facebook.

The BMA suggests physicians politely decline friend requests.  They write:

“Given the greater accessibility of personal information, entering into informal relationships with patients on sites like Facebook can increase the likelihood of inappropriate boundary transgressions, particularly where previously there existed only a professional relationship between a doctor and patient.

“Difficult ethical issues can arise if, for example, doctors become party to information about their patients that is not disclosed as part of a clinical consultation. The BMA recommends that doctors and medical students who receive friend requests from current or former patients should politely refuse and explain to the patient the reasons why it would be inappropriate for them to accept the request.”

For instance, what if you were to see a picture posted of your patient in a bar drinking a beer.  You know that with his medical condition he should strictly avoid alcohol.  Do you bring this up at his next visit, or let it go because he did not share this with you himself?

The BMA guidance 1) suggests that physicians adopt conservative privacy settings on their online profiles, 2) warns doctors to respect patient confidentiality, and 3) advises they declare conflict of interest.

The social media policy of the American Medical Association does not come right out and say physicians should not “friend” patients, but says they should “maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just, as they would in any other context.”  It also suggests doctors “should consider separating personal and professional content online.”   

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Not All Physicians Honest with Patients

A 2009 survey of 1,891 practicing physicians from across the US aimed to find out how many of them adhered strictly to the Charter on Medical Professionalism endorsed by 100+ professional groups around the world and the US Accreditation Council for Graduate Medical Education.  It requires openness and honesty in physician communications with patients.

A large majority agreed completely that physicians should fully inform patients about risks and benefits of interventions.  They also agreed that they should never disclose confidential information to unauthorized people.

• But about 1 in 3 did not completely agree with telling patients about serious medical errors.
• Nearly 1 in 5 did not completely agree that physicians should never tell a patient something untrue.
• Almost 2 of 5 did not completely agree that they should disclose to patients their financial relationships with drug and device companies.
• More than 1 in 10 said they had told patients something that was not true during the previous year.

The authors of the research represent Harvard Medical School, the Mongan Institute for Health Policy, University of Massachusetts and other august bodies.  They stated that, “Our findings raise concerns that some patients might not receive complete and accurate information from their physicians, and doubts about whether patient-centered care is broadly possible without more widespread physician endorsement of the core communication principles of openness and honesty with patients.”  

Source:  http://content.healthaffairs.org/content/31/2/383.abstract

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 23.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Early Discussions About Prognosis Urged

Individualizing Care

The American Society of Clinical Oncology (ASCO) is calling on physicians, medical schools, insurers, and others to help improve quality of life for people with advanced cancer by discussing the full range of palliative care and treatment options soon after patients are diagnosed with advanced, incurable cancer. 

Currently, physicians talk about prognosis early in the course of advanced disease less than 40% of the time. (In addition to guidelines for physicians, ASCO also released a guide to help patients broach the subject of prognosis and care options with physicians.) 

Critical issues are tackled in a comprehensive article published in the Journal of Clinical Oncology.  

They include:

• Consideration of clinical trials
• Initiating conversations about poor prognosis
• Guidelines for discontinuing cancer-directed treatments
• Individualizing approaches to care
• Empowering patients
• Maximizing quality of life

“Patients with advanced incurable cancer face complex physical, psychological, social, and spiritual consequences of disease and its treatment. Care for these patients should include an individualized assessment of the patient’s needs, goals, and preferences throughout the course of illness,” say the authors.  

The complete article can be accessed at:  http://jco.ascopubs.org/content/early/2011/01/24/JCO.2010.33.1744.full.pdf+html

Time for Hospice?

Pathways can assist you in managing the care  of complex patients, while providing care at home. 

We can help you determine the likely prognosis and if the life expectancy is six months or less, we can suggest ways to approach the patient and family about changing the focus of care from cure to comfort.

If you like, Pathways can have a nurse visit to explain hospice to appropriate patients and families, so that they will have sufficient information to make an informed decision about using their hospice benefit.