Discussion
The Center for Executive Medicine is an internal medicine and family medicine group practice in metropolitan Dallas, Texas consisting of three physicians. Most of our patients pay an annual membership fee to receive around-the-clock access to our physicians and staff. We additionally maintain a significant population of “scholarship” patients who do not pay the annual membership fee. There is no difference in the level of access or care provided for scholarship patients.
We use a comprehensive electronic medical record; the screening process for osteoporosis begins with dedicated EMR review for every patient in our practice on a regular (generally not less than quarterly) basis, even absent an interval office visit. EMR programming flags any patient at risk for developing osteoporosis, meaning all women over the age of 50 are flagged in the system for BMD testing. All patients are flagged by EMR or the physician for vitamin D deficiency, chronic steroid use, chronic warfarin use, or multiple fractures as an adult. Flags in the system prompt communication from CEM staff with the patient for further discussion on the importance of screening. Communication from physicians and staff further improves patient adherence to screening recommendations.
Most patients agree to DEXA screening when that recommendation is relayed by practice nursing staff. The programmatic nature of the process prompts our staff to act on agreed screening protocols, such as that for DEXA screening in all women over 65 and younger women when appropriate. Physicians then can intervene with patients not screened following an initial recommendation to do so. When a patient agrees to DEXA screening, based on either the recommendation communicated via the nursing staff or direct interaction with the physician, a chart note is generated, and our staff coordinates procedure scheduling.
Our staff place future reminders to verify that the screening was completed and reviewed by the physician in a timely manner. After the DXA report has been reviewed by the physician, entering the T-score into the EMR and communicating results to the patient satisfies the reminder flag in the EMR. When possible, subsequent BMD measurements are scheduled with the same imaging unit to facilitate consistent readings for trends in BMD. The interval for subsequent re-measurement is determined by the physician based on the current reading, risk factors, patient preference, whether treatment is undertaken.
We have achieved a rate of osteoporosis screening higher than those provided to patients in other settings. We believe that our systematic approach to screening based on agreed protocols, which are then automated using the electronic medical record system results in superior screening rates. Others have not found a consistent association between EMR use and screening, and some have found that primary care visits where EMR is used resulted in fewer preventive services provided to eligible patients [15].
Beyond the effective use of our EMR system, we believe that our focus on prevention increases screening rates. Most primary care physicians are tasked with the management of 2,000 - 5,000 patients. MDVIP practices establish a goal of 600 patients per physician. Each CEM physician manages between 100 and 200 patients. Limiting patient population size allows our physicians to expand their time and efforts preparing for each patient, improving patient education on the long-term benefits of screening for diseases like osteoporosis, communicating test results and explaining the rationale for interventions.
Approximately 20% of our patients receive care under "scholarship" status, where the annual membership fee has been waived. Fee-waived members receive the same enhanced physician access and same medical care as other members. We considered whether patient socioeconomic status might affect screening rates achieved. In women in both groups (age 50 or greater and age 65 or greater), the screening rate for “scholarship” patients was at least as high as that for the membership overall (95.4% in the age 50 or greater group and 100% in the age 65 or greater group). We have previously found a similar lack of difference in care in scholarship members in colon cancer screening rates [16]. Further, the MDVIP comparator patient population are also enrolled in membership-fee based concierge medicine practices.
In 2016 approximately 31% of Medicare beneficiaries were enrolled in a Medicare Advantage plan, of those approximately two-thirds were enrolled in HMO Plans. Medicare PPO members are provided with more flexibility to see physicians outside of the plan’s provider network, albeit potentially at increased cost. PPO member osteoporosis screening rates were higher than HMO, but this association has not been seen consistently in other care measures [17].
While direct data is not available at present, it may be that the size of patient population per physician or number of patients seen per day may be inversely related to completion of osteoporosis screening. This might explain the graded increase in screening rate from Medicare HMO to PPO, to MDVIP, to CEM with each population potentially receiving more focused attention than the prior.