Jeff Bendix

 has begun charging for some electronic messages its doctors send to patients.

On November 17 the Cleveland Clinic began billing patients’ insurers for messages that typically take more than five minutes to answer and require a doctor’s “medical expertise,” according to 

 on the Clinic’s website. Among these are:

check-ups on care for long-term conditions, and

Message charges will be billed to patients’ insurers. For Medicare beneficiaries, that could result in an out-of-pocket charge of between$3 and $8. Most commercial insurers cover these messages at little or no cost to the patient, the Clinic says. However, patients with plans that don’t cover messages could see charges anywhere between $33 and $50.

“The provider looking at your message might be reviewing the information you sent over and changing part of your treatment plan, or recommending you get a test to learn more. They might need to look at your medical history and do an in-depth review of your records to make sure they give you the best possible advice,” according to the announcement.

The Clinic uses the MyChart electronic health record for its messaging system.

questions about an issue for which the patient was seen within the past seven days,

check-ins that are part of follow-up care after a procedure, or

The Clinic’s announcement comes at a time of financial stress for hospitals and hospitals. The median year-to-date operating margin index for hospitals was -0.1% in September, for a ninth straight month of negative actual operating margins, according to findings in the latest 

Primary care doctors seemingly endorse getting reimbursed for electronic messaging. In a recent 

, 86% said reimbursement for responding to queries through emails, texts, or phone calls was an important tool for enhancing access to care and improving outcomes.

But PatientRightsAdvocate.org, a nonprofit organization advocating price transparency, takes a different view. In 

 on cleveland.com, founder and chairman Cynthia A. Fisher calls the practice “egregious.”

“Billing them [patients] for electronic messages to their providers is just the latest attempt to wring even more blood from the stone,” she said.

This article originally appeared on Medical Economics®. 

Articles

Cleveland Clinic begins charging for doctors’ time spent responding to some electronic messages.

Five minutes of a doctor’s time could cost patients $50

The Centers for Disease Control and Prevention (CDC) has significantly revised its guidelines for 

 and emphasize the need for doctor-patient communication when making prescribing decisions.

The 2022 Clinical Practice Guidelines updates the CDC’s 

2016 Guideline for Prescribing Opioids for Chronic Pain

 in deciding whether to prescribe opioids for pain, the appropriate medication and dosage, duration of the initial prescription, and assessing and addressing the potential harms of opioid use.

“The science on pain care has advanced over the past six years,” Debbie Dowell, MD, MPH, chief clinical research officer for CDC’s Division of Overdose Prevention said in a news release announcing the guidelines. “During this time, CDC has also learned more from people living with pain, their caregivers, and their clinicians. We’ve been able to improve and expand our recommendations by incorporating new data with a better understanding of people’s lived experiences and the challenges they face when managing pain and pain care.”

While the 2016 guidelines were intended solely for primary care doctors, the 2022 document’s intended audience includes nurse practitioners and physician associates. They are aimed at categories of outpatient clinicians such as dentists, physical medicine and rehabilitation specialists, neurologists, and emergency clinicians providing pain management for patients being discharged from emergency departments.

The 100-page guideline document includes 12 recommendations grouped into four categories, including:

Determining whether to initiate opioids for pain,

Deciding the duration of the initial prescription and conducting follow-ups,

Selecting opioids and determining the appropriate dosages, and

Assessing the risks and addressing potential harms of opioid use

The guidelines differ from the 2016 version in a number of areas. For example, they reflect new data showing that nonopioid therapies, such as non-steroidal anti-inflammatory drugs, are at least as effective as opioids for many common types of acute pain such as low back and neck pain and pain related to musculoskeletal injuries.

Another area of difference concerns opioid tapering. Recommendations outline situations when clinicians should consider tapering either to a reduced dosage or to discontinued use, and discussing any tapering-related decisions with patients.

In addition, the 2022 guidelines update recommendations for opioid dosage regarding:

Suggestions for the lowest starting dose for patients new to opioid use,

Morphine milligram equivalent doses for commonly prescribed opioids, and

Approaching potential dosage increases with an emphasis on principles of safe and effective pain treatment that allow for individual circumstances and flexibility in care

The CDC notes that many of the public comments it received while drafting the new guidelines reflected difficulties some people have had with accessing pain care, or concern that making recommendations too specific could result in the guidelines, or parts of them, becoming rigid policies and laws.

To avoid that possibility, the agency says, it chose to highlight general principles rather than specific prescription dosages and durations. It also reminds clinicians that the guideline “provides recommendations only and is intended to support, not supplant, clinical judgment and individualized, person-centered decision-making.”

This article originally appeared on Medical Economics®.

Revisions to 2016 document focus on provider flexibility and unique circumstances of every prescribing decision.

CDC updates opioid prescribing guidelines

 in access to timely health care are growing more acute, a new study finds, and for reasons not directly related to the 

The study’s authors analyzed trends in non-financial barriers to care access from 1999 to 2018 among 590,000 individuals who identified as Black, Asian, Hispanic/Latino or White. The barriers they examined included:

inability to contact a provider by telephone,

appointments not being available soon enough,

Data for the study came from the National Health Interview Survey.

The researchers found that the overall prevalence of barriers to timely care increased from 7.1% in 1999 to 13.5% in 2018, but the increase was unevenly distributed by race and ethnicity. Asians and Whites experienced prevalence increases of 5.74% and 5.85%, respectively, compared with 7.95% for Blacks and 8.0% for Hispanics/Latinos.

Similar differences were apparent in reports of specific barriers to timely care. For example, the number of Whites saying they delayed care due to long wait times increased by 1.23%. For Asians the increase was 2.60%, for Blacks 2.73% and for Hispanics/Latinos it was 3.86%. And the number of Asians citing lack of transportation as a barrier grew by 0.38%, compared with 0.92% for Whites, 1.01% for Hispanics/Latinos, and 2.73% for Blacks.

The authors note that while their study focuses on barriers separate from insurance coverage and care affordability, “the complexity of the US health care system makes it implausible to isolate these [barriers] from an individual’s health insurance status and overall financial situation.”

The authors say, their findings point to “a worsening societal failure to deliver timely medical care,” and that “attempts to improve access to care through improving access to insurance coverage alone [through the Affordable Care Act] may be inadequate—and may not be enough to reduce 

Instead, they say, efforts to reduce disparities in care access requires broader societal reforms in areas such as education, housing, urban planning and transportation. Moreover, the historical segregation of Blacks and Latinos means they are more likely to live in medically underserved areas, causing them to visit emergency departments for primary care-treatable conditions, creating a need for “a multisectoral effort to improve spatial accessibility to high-quality primary care clinics and health care professional for minoritized race and ethnicity groups.”

The study, “Trends in Racial and Ethnic Disparities in Barriers to Timely Medical Care Among Adults in the US, 1999-2018” was published online October 28 in 

Problem extends beyond costs of care and health insurance, study finds.

Inequality in care access is getting worse

Primary care practices traditionally have used phone calls to check on the status of patients who’ve recently been discharged from the hospital and address any problems that might cause them to be readmitted. But automatic 

 might be a better way to accomplish those goals, a new study finds.

The study’s authors note that while follow-up phone calls are somewhat effective in reducing unplanned 

, they require a significant time commitment, often go un- answered, and generally reach patients only once.

As an alternative, they designed a 30-day post-discharge 

 using automated texting, with patient needs identified by the messaging platform escalated to practice staff for follow-up. They implemented the program at a university-affiliated primary care practice for five months in 2021.

Then they compared use of acute care resources—defined as emergency department (ED) visits or hospital readmissions-- among recently discharged patients with acute care resource use at a practice with a similar patient population but without the texting intervention. In all, the study included 1,885 patients with 2,617 discharges, including 1,051 from the intervention practice and 1,556 from the control practice.

They found that after implementing the texting program, the odds of acute care resource use within 30 days of discharge were 41% lower than at the practice without the texting program. Moreover, the program integrated easily into the workflow of the practice’s care management team, for whom responding to calls from recently discharged patients was already part of the daily routine.

A further benefit of the program, researchers say, was its positive reception among patients. More than eight in 10 responded to at least one of the introductory text messages, a rate far higher than responses to post-discharge phone calls.

While the authors don’t provide any definitive reasons as to why texting reduces acute care use, they theorize that more frequent check-ins and relative ease of patient-initiated outreach result in earlier identification of potential problems and a greater likelihood that those problems can be handled by the practice rather than in an acute care setting.

Evaluation of an Automated Text Message–Based Program to Reduce Use of Acute Health Care Resources After Hospital Discharge” was published online October 26 in 

In study, use of text messages reduced post-discharge ED admissions and hospital readmissions.

Texting found more effective than phone calls for hospital discharge follow-ups

That is among the findings to emerge from a recent survey of physicians and health care administrators regarding levels of physician burnout, its causes, and physician satisfaction with their job and employer. The survey of 354 administrators and 66 employers was sponsored jointly by Jackson Physician Search and the Medical Group Management Association.

Asked if they are experiencing burnout—which the survey defined as “the long-term, cumulative 

 and depersonalization that doctors experience amid growing burdens in the practice of medicine—65% of the physicians “strongly” or “somewhat” agreed, up from 61% in 2021. Asked if doctors at their institution were burning out, 73% of administrators or managers strongly or somewhat agreed, compared with 68% last year.

When it comes to the reasons for burnout, however, the views of doctors and administrators diverged. Forty percent of doctors said their employer was either entirely to blame for their burnout or bore more of the blame than the general nature of a physician’s work. But only 19% of administrators or managers ascribed physician burnout to those two causes.

Regardless of the reasons for their feelings of burnout, a slight majority of respondents (51%) said they had considered leaving to work for a new health care employer during the past year, while 41% said they had thought about leaving medicine to work in a different field, and 36% had thought about 

. In a poll taken earlier in 2022 by MGMA and the website 

 40% of medical practices said they had a physician who resigned or retired early during the past year due to burnout.

 programs were another area of disagreement between doctors and administrators highlighted by the survey. When asked if their employer organization has a formal physician retention/engagement program, 8% of doctors said yes, 70% said no, and 22% weren’t sure. By contrast, 19% of administrators or managers said their organization had such a program, while 54% said theirs did not, and 27% weren’t sure.

When it comes to reducing burnout, a 2021 MGMA Stat survey found it to be a low priority, with 86% of health care leaders reporting they had no formal plan or strategy for it. Programs that did exist were in the form of:

Investing in specialty-specific EHRs that are more intuitive and provide more functionality to help team members follow up on outstanding tasks;

Adopting formal physician wellness committees; and

Developing a one-on-one coaching/mentoring system

The survey concludes by noting that “awareness [of burnout] alone will not prevent physicians from exiting the profession in the coming years. It will require empathy and organizational efforts to restore professional relationships that make high-quality care delivery a sustainable reality, producing healthier outcomes and margins in the process.

Despite prevalence, few institutions have formal programs for addressing burnout.

Burnout among doctors continuing to rise, survey finds

Researchers surveyed more than 107,000 HCWs across a wide range of health care-related occupations in 2019, 2020 and 2021-22 to measure and compare both individual levels of emotional exhaustion (EE) and workers’ perception of EE among their colleagues. They found that the overall EE rate among HCWs jumped from 31.8% in 2019 to 40.4% in 2021-22. The increase in individuals’ perception of EE among others—what the authors call the emotional exhaustion climate—was from 54% to 65%.

Perhaps surprisingly, EE among the three categories of physicians studied—residents, attending/staff physicians and physicians not working in a hospital—remained the same or declined between 2019 and 2020 a result the authors attribute to decreases in patient volume and the flexibility offered by telehealth resulting from the pandemic.

But the situation reversed dramatically in the following years, so that by 2021-22 the percentage of residents reporting EE had increased from 24.6% to 34.4%, from 33.4% to 40.1% among attending/staff physicians, and 29% to 34.6% among doctors not working for a hospital. These were, the authors say, “the largest single-year increases reported by any roles across any time frame, exceeding what was found during a three-year period when EHRs were introduced nationally.”

Among non-physicians, the largest growth in EE—from 27% to 39%—was among physical, occupational and speech therapists. Other occupations seeing significant increases included technologists (32% to 43%), technicians (33% to 42%), administrative support staff (29% to 38%), and nurses (40.6% to 49.2%).

Based on their findings and those of other studies, the authors call HCW burnout a “parallel pandemic that will be felt for many years to come.” Addressing it, they say, will require focusing on HCW well-being using both institutional and individual resources. Moreover, those resources need to be evidence-based and accessible to all employees, and their use must be role-modeled by organizational and institutional leaders.

The study, “Emotional Exhaustion Among U.S. Health Care Workers Before and During the COVID-19 Pandemic, 2019-2021” was published September 21 on JAMA Network Open.

This article originally appeared on Urology Times®.

A new study reveals how the COVID-19 pandemic worsened the already significant problem of burnout among doctors and other health care workers (HCWs).