Nov 10, 2015

How to spur Congress to act: 7 essential elements of storytelling

Republished with permission from AMA Wire®

The struggle with electronic health records (EHR) is real, and Congress needs to hear from physicians.  But how can you make your story compelling? How can you pen a tale that cuts to the heart of the matter and inspires your members of Congress to take action? These seven elements of storytelling—recommended by an expert on engaging members of Congress—will help you craft the most potent version of your story.

In an AMA Very Influential Physicians (VIP) webinar last week, Brad Fitch, president and CEO of the Congressional Management Foundation, delivered expert advice on how physicians can compose and position their personal EHR stories in an effort to persuade Congress to take action against meaningful use Stage 3 and further progression of the program’s troublesome regulations.
Why is storytelling important for this cause?
Storytelling is a key part of the psychology of persuasion. We feel, and then we decide. In order for Congress to understand the detrimental effect meaningful use regulations have on daily practice, physicians need to deliver a perspective that will show the impact on their lives and the lives of their patients.
Members of Congress deal with a lot of data, spreadsheets and graphs every day, Fitch said. This type of information is being delivered to them all the time. But only physicians can communicate the personal stories from the front lines and drive them to act.
The 7 elements of storytelling
Your story should be brief. One page, single-spaced, is about 500 words. This length will take approximately four to six minutes to read aloud. If a story is too long, your members of Congress could lose interest, particularly with the numerous other demands for their attention, Fitch said, answering a listener’s question
Mark Twain once said, “I would have written a shorter letter, but I didn’t have the time.” Condensing your story can be difficult, but take the time to make it concise. A shorter story is more memorable and can leave a lasting impression, Fitch said.
When crafting your story, Fitch recommends using these seven elements of storytelling to most effectively communicate your experience with EHRs and regulations:
1.   “The Want”: Begin with the end in mind.
Know what you want before you begin. Do you want your member of Congress to understand how EHRs have increased costs to your practice or impacted the delivery of care to patients? A good storyteller begins knowing what the end product should deliver emotionally.

Consider various tactics and methods to achieve your goal in the story. Your goal can be to flatter, surprise, or evoke empathy or urgency. You are the Steven Spielberg of your story. What effect do you want to have on your audience?
2.   “The Opening”: Set the stage and establish the stakes.
Your first sentence or two should make your reader want to know more. What is at stake for patients, their families or you as the physician providing their care? As much as possible, think about the effect these regulations have on your ability to deliver quality care to your patients.

Members of Congress are listening for the component that tells them, “If I don’t do X, then Y will happen.”
3.   “Paint the Picture”: The details and senses of your story.
When you experienced the moment you are writing about, what did you see, hear, touch, taste and smell? These are the elements that will get your members of Congress involved in the story.

Remember to use adjectives to enhance the power of your narrative. Make it real. Be practical, specific and graphic—don’t hold anything back! What descriptive words could make your story compelling and interesting? For example, substitute “morose” for “sad” or use the word “devastated” rather than “upset.” These are the kinds of impact words that paint the picture of your story.
4.   “The Struggle”: Describe the fight.
Identify the conflict. Real struggles in life are mental, philosophical, emotional, physical—even internal. Every story has a protagonist and an antagonist, and the interactions between these two is where the conflict lies.

Don’t hesitate to play the underdog. Members of Congress love to come to the aid of the underdog. They want to help David win the battle against Goliath. Play that strength.
5.   “The Discovery”: Always surprise the legislator.
What did you learn or realize in the moment of your story? Find this answer and deliver it when it will have the most impact. Then describe how that learning impacted your life, the lives of your patients, the future of your practice and your ability to deliver quality care.

You may not have a discovery, but is there a part of your story that might surprise the legislator? If you can add a twist—a moment that truly delivers the scope of your struggle—then use it.
6.   “We Can Win!”: Introduce the potential of success and joy.
Success in a story is when the hero or heroine wins the fight or struggle. Joy is when the audience can participate and take part in the celebration of victory. If you can hook your members of Congress into feeling the impact of success and the joy that will follow, they become a part of your cause.

Think: “Senator/Representative, we have the opportunity to ….” Then describe how that victory will enhance your practice and the lives of patients and their families.
7.   “The Button”: Finish with a hook.
As you end your story, come up with a last line your members of Congress will always remember. Be thoughtful when composing your final line. Write it out and make it perfect. Have your ending sentence memorized when you’re speaking in person. This way, your member of Congress will remember it for the rest of the day.

Fitch related a particularly salient example. While delivering his story to a Congressman regarding his inability to acquire necessary medication, a veteran described a moment when his granddaughter asked him, “Poppy, why do your hands shake?” He looked at the Congressman and said, “What should I tell her?” This kind of hook will tug at the heart strings of your members of Congress and stay with them.
Once your story is drafted, revised and final, deliver it to your member of Congress. Visit to send your story directly to Congress by email.
Remember to take your time. A well-crafted story, no matter how small, can hold remarkable power.
How to more actively reach your members of Congress
Become a member of the AMA’s “Very Influential Physicians (VIP)” program by visiting the AMA Grassroots Advocacy Web page to take part in future activities. You also can log in to view the full 7 elements of storytelling webinar.
By AMA staff writer Troy Parks

Nov 9, 2015

Health Insurers’ Narrow Networks Putting Squeeze on Patients

Health insurance companies are sharply limiting the number of physicians and hospitals they include in their networks as a tool to limit how much they have to pay in covered benefits. Narrow networks are booming in plans sold both through employer-sponsored insurance and on the Affordable Care Act (ACA) marketplace exchanges.

These moves leave patients out in the cold, and squeezed for the costs of health care the plans aren’t covering. The popular news media and scientific literature have been filled with stories lately about narrow networks. Here’s a roundup.

ACA Plans Lack Specialists

As many as 14 percent of health plans on the ACA exchanges lack physicians in at least one key specialty. That’s what researchers from Harvard’s T. H. Chan School of Public Health reported in the Journal of the American Medical Association. (“Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act,” JAMA, Oct. 27, 2015.)

“We found this practice among multiple states and issuers,” the authors wrote. “This likely violates network adequacy requirements, raising concerns regarding patient access to specialty care. Such plans precipitate high out-of-pocket costs and may lead to adverse selection (i.e., sicker individuals choosing plans with broader networks), which is similar to concerns over restrictive drug formularies.”

Rheumatologists, endocrinologists, and psychiatrists were the specialists most often missing from the plans.

Texas Leads in “X-small” ACA Networks

Texas has more “x-small” networks (45 percent) on the ACA exchange than any other state in the network. That’s what the Leonard Davis Institute of Health Economics (LDI) at the University of Pennsylvania found. (“State Variation in Narrow Networks on the ACA Marketplaces,” published by the Robert Wood Johnson Foundation, August 2015.) Those super-shrunken networks offer access to 10 percent or fewer of the physicians in a rating area. 

This study looked at plans issued by 267 carriers across 355 networks in all 50 states. It used “t-shirt size” ratings of x-small (less than 10 percent), small (10 percent-25 percent), medium (25 percent-40 percent), large (40 percent-60 percent), and x-large (more than 60 percent). The variation was extensive. Some states, such as Delaware, Kansas, and North Dakota, have mostly large or x-large networks. Others don’t at all.

Here are the states with the most x-small or small networks:
  • Georgia – 83 percent
  • Florida – 79 percent
  • Oklahoma – 78 percent
  • California – 75 percent
  • Texas – 73 percent
  • Arizona – 73 percent
In an earlier study, the authors at the Davis Institute found that 41 percent of silver plans on the ACA exchanges were x-small or small. 

Half of ACA Hospital Networks Are Narrow

Patients’ choice of hospitals on the ACA exchange plans is similarly limited. That’s what the McKinsey Center for U.S. Health System Reform found. (“Hospital networks: Evolution of the configurations on the 2015 exchanges,” published by McKinsey & Co., April 2015.)

“Across the country, close to half of the 2015 networks that consumers can choose from are narrowed; in the largest cities, almost two-thirds of the networks are narrowed,” the report states.

The report defines a “narrow” network as having 70 percent or fewer of local hospitals participating. An “ultra-narrow” network has 30 percent or fewer participating.

“Many consumers, however, do not appear to understand the choices available to them or the impact of those choices (especially limits on access to care),” McKinsey found. “In our consumer survey, 44 percent of those who bought an ACA plan for the first time this year reported that they did not know the network configuration associated with their plan.”

Half of ACA Plans Don’t Cover Out of Network

Another study found that 47 percent of the plans sold on the federal ACA exchange have no coverage for out-of-network care. In Texas, that number is 67 percent. (“Almost Half of Obamacare Plans on Federal Marketplace Lack Out-Of-Network Coverage,” published by HealthPocket, Oct. 7, 2015.)

That, HealthPocket explains, means “the plans will not cover the costs except in the case of a medical emergency or if a prior authorization from the plan had been formally submitted and then approved by the health plan.”

Narrow Networks Forcing Patients to the ED

Because of narrow networks, a survey of emergency department doctors found, patients are showing up sicker in the emergency department. Also, emergency physicians are finding fewer primary care doctors and specialists to whom they can refer patients for follow-up. (“Insurance Industry Drives Patients to Sacrifice Necessary Medical Care,” published by American College of Emergency Physicians [ACEP], Oct. 26, 2015.)

Specifically, the national study of emergency physicians found:
  • 73 percent of the doctors see more Medicaid patients because insurance companies don’t provide enough primary care or specialty physicians for their patients.
  • 65 percent see more patients in the emergency department, in large part because health insurance companies don’t provide enough primary care physicians to support the community.
  • 60 percent have difficulty finding specialists for their patients, because of narrow networks.
  • More than 80 percent treat patients who said they had difficulty finding specialists to care for them because health plans have narrow networks.  
“This is a scary environment for patients,” said Jay Kaplan, MD, president of ACEP. “The insurance companies are shifting costs onto patients and medical providers as they attempt to increase their bottom lines, and this threatens the foundation of our nation’s medical care system.”

Health Plans Mount Lackluster PR Campaign

Trying to escape the cascade of negative publicity, the insurance industry issued a report blaming physicians’ overcharges for medical care as the cause of “surprise bills.” (“Texas doctors, insurers taking ‘balance billing’ fight public,” Houston Chronicle, Oct. 11, 2015; “Doctors fire back at insurance industry report on what Texans are charged for ER visits,” Quorum Report, Oct. 8, 2015)

It didn’t work. The news media saw right through it and reported this comment from TMA President Tom Garcia, MD:
This so-called report is nothing more than a desperate smoke screen to divert attention from the real problem. The health insurance industry games the system to keep more of patients’ premium dollars by forcing patients to seek care out of network. Then they have the gall to criticize what some doctors’ bill for that care.
And the San Antonio Express-News published a response to the study from William W. Hinchey, MD. 

“Insurers want your local pathologist in the network only for inpatient hospital services but not for your outpatient services — even when the pathologist wants to be in your network for both,” Dr. Hinchey explained. “The insurance company ultimately decides who will be in or out of your network. Essentially the insurers are saying to the physicians: We want you some of the time but not all the time.”

The Real Truth About Balance Billing

A TMA study examines how insurance plans’ network designs and payment decisions leave many Texans with “surprise bills” for health care services.

Inadequate and limited physician networks that insurers sell today are leaving patients with unpaid bills. Unfortunately, Texas consumers are learning the limits of the coverage they bought just when most need coverage, especially in emergencies. The consumer is no longer satisfied with the not-very-well-explained, varying levels of savings that insurance networks create, especially if that means a greater financial burden in emergencies. Yet, despite network shortcomings, consumers do not want to be left without the choice of plans that offer network benefits.

Nov 5, 2015

What Exactly IS Wrong With EHRs?

Many thanks to David Fleeger, MD, of Austin, a member of the TMA Board of Trustees, for taking the time to explain electronic health records and Meaningful Use on this TV show. He even managed to work in "Meaningless Use."

Sep 30, 2015

Get Social This Month With a Free Book Excerpt From TMA

Looking for a road map to arrive at a stronger social media presence? This month, we’re offering help to get you more social savvy.

During October, visit the TMA Education Center to download a free excerpt of Get Social: Put Your Practice on the Social Media Map by TMA’s Steve Levine and Debra Heater. Get Social explains how to use popular social media sites like Twitter, Facebook, YouTube, and others. The book offers handy tools and insights for physicians, medical students, and office staff interested in engaging with patients, and the public, on these platforms. You’ll also find advice and best practices for using social media responsibly and avoiding potential HIPAA pitfalls.

Download your free excerpt. The free excerpt will be available through Oct. 31. 

Jun 8, 2015

AMA Calls for Two-Year ICD-10 Grace Period If It Can’t Stop the Train

(CHICAGO) – Following up on yesterday’s story (ICD-10: Stop This Freight Train ... Or At Least Install Seat Belts!), we can report that the American Medical Association House of Delegates today unanimously adopted the Texas-backed proposal to ask the federal government to adopt a two-year, penalty-free grace period following the expected Oct. 1 mandatory implementation of the new ICD-10 coding system.

As the Reference Committee on Legislation noted in its report, “Our AMA will continue to prioritize our existing AMA policy that first seeks to stop the implementation of the ICD-10 code set and, only if a delay is not feasible, seek mitigation strategies.”

The delegates voted without objection in support of the grace period plan, which the reference committee cobbled together based on suggestions from the Alabama and Texas delegations as well as other states. The adopted language reads:

If a delay of ICD-10 implementation is not feasible, that our American Medical Association ask the Centers for Medicare & Medicaid Services (CMS) and other payers to allow a two-year grace period for ICD-10 transition, during which physicians will not be penalized for errors, mistakes, and/or malfunctions of the system. Physician payments will also not be withheld based on ICD-10 coding mistakes, providing for a true transition where physicians and their offices can work with ICD-10 over a period of time and not be penalized.

That our AMA educate physicians of their contractual obligations under Medicare and insurance company contracts should they decide to not implement ICD-10 and opt to transition to cash-only practices which do not accept insurance.

That our AMA aggressively promote this new implementation compromise to Congress and CMS since it will allow implementation of ICD-10 as planned, and at the same time protect patients’ access to care and physicians’ practices.

That our AMA provide the needed resources to accomplish this new compromise ICD-10 implementation and make it a priority.

That our AMA seek data on how ICD-10 implementation has affected patients and changed physician practice patterns, such as physician retirement, leaving private practice for academic settings, and moving to all-cash practices and that, if appropriate, our AMA release this information to the public.

Jun 7, 2015

ICD-10: Stop This Freight Train ... Or At Least Install Seat Belts!

(CHICAGO) -- Staring down the muzzle of the Oct. 1 mandatory deadline to implement the ICD-10 coding system, the American Medical Association House of Delegates searched for multiple ways to help U.S. physicians dodge a dangerous bullet.

Thanks to strong lobbying from AMA, the Texas Medical Association, and other physician groups, the original Oct. 1, 2013, ICD-10 deadline has been pushed back twice.

Dr. Fuller testifies at AMA

Both TMA and AMA still formally oppose ICD-10. They've pointed out that many physicians, especially those in small practices, are still not ready to use the new coding language. Some cite the high cost of transition; others blame electronic health record vendors that have not yet made ICD-10-compliant software available. Those who aren't ready run the risk of having all or some of their Medicare, Medicaid, and commercial insurance claims going unpaid.

TMA supports H.R. 2126, the Cutting Costly Codes Act of 2015, by U.S. Rep. Ted Poe (R-Humble), which would prohibit the government from requiring physicians and health care providers to use ICD-10.

Texas physicians at the AMA meeting spoke out about the dangers they foresee, especially for primary care practices. Greg Fuller, MD, a family physician from Keller, said the wide array of medical problems primary care physicians treat is forcing them to try to learn thousands of new codes.

"We need to stop ICD-10," Dr. Fuller told the Reference Committee on Legislation. "Any delay in pay is going to kill these practices."

Dr. Villarreal at reference committee

E. Linda Villarreal, MD, an internist in the Rio Grande Valley, said she is concerned about the ramifications for access to care in South Texas, many parts of which already face a dire shortage of physicians. "I've taken three courses in ICD-10, and I still don't get it," Dr. Villarreal said.

But Washington watchers say Congress has no stomach for delaying the implementation date one more time. "The ICD-10 Coalition has done a better job than [medicine has] over the past four years," one delegate said.

That leaves organized medicine in a tough spot, said Fort Worth pediatrician Gary Floyd, MD, a member of the TMA Board of Trustees. Groups like AMA and TMA must continue to push for a last-minute reprieve and at the same time work to protect their members from the likely upheaval that will come with ICD-10, he explained.

"Our message is this," Dr. Floyd said, "don't give up the ship, but make sure the lifeboats are manned and at the ready."

Physicians line up to testify on ICD-10

One likely outcome of the House of Delegates meeting will be a directive for AMA to push the Centers for Medicare & Medicaid Services (CMS) for some leeway for physicians who can't master the intricacies of ICD-10 right away.

"We simply need to implement ICD-10 as planned and ask for a grace period where we are not held financially accountable for improper coding in order to protect our patients access to care and to protect physicians’ practices," said Alabama urologist Jeff Terry, MD, who has been an outspoken critic of ICD-10 for the past several years. He said a bill introduced last week in Congress by U.S. Rep. Gary Palmer (R-Alabama) would set up such a grace period.

In testimony before the reference committee today, Dr. Terry, Dr. Floyd, and others outlined a series of protections they want AMA request from CMS:

  • Two years with no penalties for incorrect coding;
  • Two years with no bounty-hunting auditors looking for coding errors;
  • A promise of no delay in payments to physicians; and
  • Acceptance of ICD-10 codes with less-than-optimal degrees of specificity.

Dr. Floyd describes the terms of

the ICD-10 grace period.

The reference committee's recommendations are expected early Monday, and the full House of Delegates will debate the issues before the meeting ends on Wednesday.

TMA offers extensive ICD-10 coding training materials, including specialty-specific online ICD-10 documentation training, on-demand webinars, and customized on-site ICD-10 training.

Sue Bailey, MD, Elected Speaker of AMA House of Delegates

(CHICAGO) -- With an uncontested race, the outcome was all but certain ... but the celebration was real.

After a four-year stint in the No. 2 spot, Fort Worth allergist Sue Bailey, MD, today won election as speaker of the American Medical Association House of Delegates. She moved up one notch after the current speaker -- Andy Gurman, MD, of Pennsylvania, was chosen AMA president-elect.

"I love this house, and I love this organization," Dr. Bailey said after the delegates elected her by acclamation. "I look forward to continuing our robust work to improve the health of our nation together."

Dr. Henkes nominating Dr. Bailey

David Henkes, MD, of San Antonio, chair of the Texas Delegation to the AMA, placed Dr. Bailey's name in nomination. "Sue Bailey is a good person, a nice person, a wise person, and a wonderful mentor," Dr. Henkes said. "I guarantee you, the physicians of Texas would follow wherever she leads – and this house would be well-advised to do the same."

Dr. Bailey has a long history of service to organized medicine, beginning with her stints as chair of the medical student sections of both the Texas Medical Association and the AMA. She chaired the TMA Council on Communication and served as speaker of the TMA House of Delegates before winning election as TMA's 145th president in 2010. She also was president of the Tarrant County Medical Society.

At the AMA, she has served as chair of the Texas Delegation, as a member and chair of the AMA Council on Medical Education, and as the AMA representative on the board of the Accreditation Council for Continuing Medical Education. She has served as vice speaker of the AMA House of Delegates since 2011.

Dr. Gurman (l) congratulates Dr. Bailey

Dr. Bailey is an allergist in private practice at Fort Worth Allergy and Asthma Associates. She previously served as an associate consultant at the Mayo Clinic's department of pediatrics in Rochester, Minn. She is board certified in allergy, and immunology, and pediatrics.

Dr. Bailey received her medical degree from Texas A&M Health Science Center College of Medicine and later served on the A&M Board of Regents. She completed her residency in general pediatrics and her fellowship in allergy/immunology at Minnesota's Mayo Graduate School of Medicine.

May 18, 2015

Failure to Address Physician ICD-10 Concerns, Misalignment of Federal Health IT Priorities are Strategic Blunders

This article was originally published in Digitized Medicine on May 18, 2015. Reprinted with permission.

Texas Representative Ted Poe has introduced H.R. 2126, the Cutting Costly Codes Act of 2015.   This legislation would prohibit the federal government from requiring physician offices to comply with the proposed transition to ICD-10 codes. “The new ICD-10 codes will not make one patient healthier," Representative Poe said. "What it will do is put an unnecessary strain on the medical community who should be focused on treating patients, not implementing a whole new bureaucratic language.” He has clearly listened to the Texas Medical Association (TMA) which has consistently advocated for postponement of ICD-10 on behalf of 48,000 physician members. 

I am one of those Texas physicians who is thankful that a congressman has listened to us. If this bill were passed it would postpone ICD-10 and call for the GAO to study the issue, but it does not propose any solutions. Although I am in favor of this bill, I agree with the cry of many healthcare stakeholders that we need a solution to move away from the antiquated ICD-9 codes. It seems likely that a bill that does not propose an alternative solution will have difficulty getting passed. 

I am hopeful, though, that debate about this bill might illuminate two major flaws in national health IT strategic planning. The current ICD-X strategy which includes no roadmap to ICD-11 will set up the U.S. healthcare industry for strife and conflict in the 2020s when we see the rest of the world leveraging integration between ICD-11 and SNOMED to improve quality of care and control costs while we struggle to gain value from what will then be an antiquated ICD-10 coding system. 

The first flaw is the lack of a strategic plan or roadmap at a national level for ICD-X conversions.  For example, there is no mention of ICD-10 or ICD-11 planning in ONC's federal health IT strategic plan 2015-2020. It is difficult to trust a strategic plan that fails to account for the tremendous burden that an ICD-10 and/or ICD-11 conversion brings to the healthcare industry. The ICD-10 tactical delays can be directly attributed to conflicting strategic national healthcare priorities which resulted in an overlap of  initiatives at the local level, such as the Meaningful Use Program and e-prescribing requirements, and created unreasonable, concurrent burdens on physicians. Tactical delays like this can be avoided through more effective strategic planning at the national level. 

It is particularly disconcerting that there is no national roadmap to ICD-11. As I previously wrote, the U.S. is planning to achieve a short-term tactical goal of replacing antiquated ICD-9 codes while the rest of the world is closing in on their long-term strategic goal of implementing ICD-11. Informatics experts are in agreement that ICD-11 is superior to ICD-10 and is much more integrated with SNOMED codes. Unless we develop a long-term ICD-11 strategy, we are destined to be in the same predicament in the 2020s when we will be struggling with a tactical goal to get off of last century’s ICD-10 with no roadmap in place to align that effort with other healthcare priorities. 

The second flaw is the lack of an effective process during ICD-X conversion planning to identify and address the concerns of grass root physicians who see patients every day. Failing to address physician concerns prior to developing the ICD-10 solution to the replacement of ICD-9 was a strategic blunder. Perhaps the most significant physician concern is the tremendous burden placed on physician practices by the ICD-10 conversion. Optimal planning on how to replace antiquated ICD-9 codes really should include discussions on how we might best reduce or avoid that burden. At the very least, we should discuss how best to reduce that burden in the future, because physicians see ICD-11 coming around the corner. 

For example, we should discuss the possibility of converting from use of ICD-9 or ICD-10 to use of SNOMED codes in physician practices. Physicians would not have to learn new ICD-X codes each time administrators decide a conversion is necessary. Use of SNOMED codes mapped to ICD-X codes would be less disruptive to physician work flow and be more cost effective for physician practices as compared to complying with future ICD-X conversion mandates. 

The analysis on how best to resolve the ICD-9 problem should address physician concerns and result in a strategic plan that is determined to have the highest potential to improve healthcare quality at the lowest cost.  So what are some attributes of the optimal strategic planning effort? It would be included in ONC's federal  health IT strategic plan. It would include a national roadmap to ICD-11. It would include a comparative analysis of the cost/benefits of completing a conversion of ICD-10 versus a direct conversion from ICD-9 to ICD-11. It would include an analysis of  the potential to replace ICD-9 or ICD-10 codes in physician practices with SNOMED codes. And it would include a process to identify and address the concerns of physician practices throughout the planning stages.