THE LOWEST COST FOR THE HIGHEST RETURN

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By Susanne Madden | May 11, 2011

It happens every day in a busy medical practice — the things that need doing often get done by whomever can do it at the time. But that can be a costly mistake, as you might inadvertently have your most highly compensated staff members attending to some of the lowest level tasks.

For example, my company recently assessed a client's vaccine management program. After financial losses had been identified, the practice had taken several measures to ensure that every vaccine was tracked and billed appropriately. With profit margins being very thin on such inventory, only one missed vaccine may be enough to wipe out a single day's profits. The group's nursing supervisor had been tasked with putting together the tracking program, and the process included performing inventory counts at the end of each day — which were then compared to charge entry reports to ensure that everything was billed correctly.

The problem? The nursing supervisor was the one spending an hour each day performing the counts. Considering that the practice also employed medical assistants who were paid far less than the supervisor, we recognized immediately that the most expensive resource was being used to perform a lower-level task — one that lesser-paid employees could be trained to do instead.

However, the benefit realized was not simply freeing up the nursing supervisor's time for more high-level functions. There is a domino effect created when resources are redeployed to different tasks. By focusing her time at the end of the day on returning patient phone calls, it not only improved work flow and patient service, but also freed up physician time by releasing them from phone duty. This allowed the physicians to see more patients at the end of the day and get out of the office in a timely manner. So not only were savings gained by having the medical assistant take over the inventory counts, but new revenue was created by releasing physicians from returning phone calls and putting them back in the exam room instead.

Where else can you realize savings in your practice? Start with your office manager: How does she spend her time?

At one office, we discovered that charges were not being posted to the practice management system in a timely fashion because the office manager was the only one allowed to post them. Most days she was so busy that she could only input a fraction of the volume of charges being generated. So these superbills were stacking up and cash flow was suffering. Every two weeks she would come in on the weekend and attempt to get caught up. For this she was paid extra. Because coding mistakes had been made in the past when charges were entered, the practice felt that the office manager should be responsible for ensuring that these charges were posted error-free. With three staff members on the billing team, there was no shortage of helping hands to get the work done; we just needed to remove that task from the office manager's to-do list.

But how could we also satisfy the group's desire to have quality control at the front end of the process? We simply took the hour a day that the office manager was spending inputting charges, and instead had her spend that time spot-checking posted charges for accuracy. Within a matter of weeks, charges were cleaned up, cash flow greatly improved, and posting inaccuracies became few and far between, giving even more time back to the office manager.

In your own practice, take a look at tasks that are being performed by your most expensive resources. Have each staff member list the daily tasks they work on. Can any of those tasks be carried out by other lesser-paid employees or maybe outsourced altogether? One example would be to use an automated system to send out appointment reminders rather than having your receptionists spend an hour on the phone each day making those calls. Or perhaps your physicians are handling administrative tasks that a nurse, medical secretary, or bookkeeper could be trained to do instead? By creating a list of tasks being performed throughout your practice, you can assign the best resource — the most effective, for the least cost — to carry out each job. You may be surprised at just how much you save and how much more productive your practice can be with just a few simple tweaks.

OBAMA HEALTHCARE PLAN DEALT A SETBACK

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By RICARDO ALONSO-ZALDIVAR, Associated Press Ricardo Alonso-zaldivar, Associated Press – Wed May 11, 7:06 pm ET

WASHINGTON – President Barack Obama's main idea for getting quality health care at less cost was in jeopardy Wednesday after key medical providers called his administration's initial blueprint so complex it's unworkable.

Just over a month ago, the administration released long-awaited draft regulations for "accountable care organizations," networks of doctors and hospitals that would collaborate to keep Medicare patients healthier and share in the savings with taxpayers. Obama's health care overhaul law envisioned quickly setting up hundreds of such networks around the county to lead a bottom-up reform of America's bloated health care system.

But in an unusual rebuke, an umbrella group representing premier organizations such as the Mayo Clinic wrote the administration Wednesday saying that more than 90 percent of its members would not participate, because the rules as written are so onerous it would be nearly impossible for them to succeed.

"It's not just a simple tweak, it's a significant change that needs to be made," said Donald Fisher, president of the American Medical Group Association, which represents nearly 400 large medical groups around the country providing care for roughly 1 in 3 Americans. Its members, including the Cleveland Clinic, Intermountain Healthcare in Utah, and Geisinger Health System in Pennsylvania, had been seen as the vanguard for accountable care.

The medical groups say they are worried they will be left holding the bag for losses, that the government has designed things so there is no easy way to tell which patients are part of the program, and that there's no reliable way to adjust for patients who are sicker and require closer follow-up and more expensive treatments.

The deadline for public comments on the proposed regulations is still weeks away, but Fisher said "we needed to get their attention early on, so (the administration) could be thinking about how major changes are needed to make these regulations viable."

Medicare spokesman Brian Cook said the agency is doing extensive outreach to explain and take feedback on the regulations and hat "we will carefully consider this input."

"We are confident that providers' decisions on whether to participate in the program will be made on the basis of the final rule, which will reflect the feedback we receive," added Cook.

Many in the health care industry were silent partners backing Obama's overhaul law, but disappointment over the accountable care rules has put a chill into the relationship. During the congressional debate, Obama extolled Mayo and Geisinger, holding them up as a model of what he wanted to achieve for the nation. Industry criticism of his administration's proposal has been building up for weeks in online forums.

"This has all the hallmarks of a party that nobody comes to, unless there is a serious rethinking," said former Medicare administrator Gail Wilensky, who ran the agency under President George H.W. Bush.

Wilensky said the idea of coordinating care isn't the problem, but "it sounds like (the administration) really overshot the mark."

The regulations are "overly prescriptive, operationally burdensome, and the incentives are too difficult to achieve to make this voluntary program attractive," the medical group association said in its letter. One of the major problems seems to be that medical groups have little experience in managing insurance risk, and the administration blueprint rapidly exposes them to potential financial losses.

Without major changes, "we fear that very few providers will enroll ... and that (Medicare) and the provider community will miss the best opportunity to inject value and accountability into the delivery system."

Private insurers are also experimenting with versions of the accountable care idea, but successful adoption by Medicare is seen as the key to spreading it across the country. The Obama administration had estimated as much as $960 million in savings from the first three years of the program, and bigger amounts thereafter.

Fisher, the medical association head, said he does not think the administration will easily back off its approach, because on paper it saves the government money.

Medicare's New Annual Wellness Visit

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Don't be bamboozled into thinking this is a preventive medicine service — it's not.

"I'm calling to schedule that new Medicare physical I heard about on the news today." Sound familiar? This is what primary-care practices are now hearing and since only a few weeks separated the release of the Physician Fee Schedule Final Rule and the implementation on January 1, 2011, physician practices have been scrambling to get ready.

The Patient Protection and Affordable Care Act of 2010 added a new benefit for Medicare recipients called an Annual Wellness Visit. Contrary to patient and physician expectations, it is not a physical exam or preventive medicine service, as defined by CPT codes 99381-99397. In fact, those services remain noncovered and if billed they will be denied as routine by Medicare.

The initial Annual Wellness Visit has more in common with the unpopular Welcome to Medicare Visit, also called the Initial Preventive Physical Examination. Patients who are newly enrolled in Medicare are still — and only — eligible for the Welcome to Medicare Visit in the first year of their Medicare enrollment.

A patient is eligible for the initial wellness visit if she has been enrolled in Medicare for longer than 12 months and has not received a Welcome to Medicare visit in the past 12 months. Let's say a patient enrolls in Medicare on July 1, 2010. She is eligible for a Welcome to Medicare visit from July 1, 2010 until June 30, 2011. She schedules her visit on May 5, 2011. She will then be eligible for her first wellness visit after May 6, 2012 — one year after the Welcome to Medicare visit.

A different patient, however, enrolled in Medicare February 1, 2008. On January 1, 2011, he became eligible for the initial wellness visit. He calls immediately and is scheduled for February 5, 2011 for his initial visit.

This visit requires:
• Taking or updating his medical and family history;
• Establishing a list of current providers and suppliers of medical care;
• Height, weight, BMI calculation (or waist circumference), blood pressure, and "other routine measurements as deemed appropriate";
• Detection of any cognitive impairment that he may have by direct observation, with consideration of information from medical records, patient reports, concerns raised by family members;
• Review for the potential for depression based on use of an appropriate screening instrument;
• Review of his functional ability and level of safety, based on direct observation, or use of a screening questionnaire;
• Establishment of a written screening schedule, such as a checklist, for the next 5-10 years based on recommendations of the US Preventive Task Force and Advisory Committee on Immunization Practices, and the patient's health status, screening history, and age-appropriate covered Medicare services;
• Development of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway — including mental health conditions or risk factors, or conditions identified through an previously performed Welcome to Medicare Visit (or this visit), and a list of treatment options and their associated risks and benefits; and
• Furnishing of personalized health advice and referral, as appropriate, to health education or preventive counseling programs aimed at reducing identified risk and improving self management — including weight loss, smoking cessation, fall prevention, and nutrition.
(End of life planning was removed as a requirement.)

What's the code for the service? G0438: Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit.

The visit has 4.74 Relative Value Units, for a national payment of $159.25.

By Betsy Nicoletti | January 12, 2011