Physician Income - The Keys to Maximization

Ten Ways to Make Positive Changes at Your Medical Practice in 2012

2012-02-13T10:13:00.000-08:00

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By Craig Koniver, MD | January 5, 2012

Now that 2011 is behind us, I think we can look back and say that it was a rocky, up and down, transition type of year for many of us. For me, I went through several transitions in my practice — first changing to no insurance and then next, changing from a traditional type practice to a new mobile practice model.

I can tell you this — 2012 already feels different. There is positive energy in the air. As an integrative medicine doctor, I widely accept and believe in energy healing and I can tell you that the energy has shifted with this change in year. 2012 is about positivity, fresh starts, and rejuvenation.

The question truly becomes: What will you choose to focus on in your practice? Certainly there will be those among us who choose to pay attention to the negative and view their practice through the lens of half-empty. But, I believe that 2012 is about changing your perspective.

Here are my top 10 items I think you should choose to focus on in the new year:

1. Connections with Your Patients: Above all else, this is the heart of medicine — for far too long we have been focused on the pill or the surgery or the protocol. Put those things aside this year and instead focus on developing strong and meaningful connections with all of your patients.

2. Social Media Integration: 2012 represents a fantastic opportunity to truly become a social media wizard. Start your blog, get your Facebook fan page fired up, and start making some YouTube videos. The more you spread your personal message, the better.

3. Show Your Vulnerability More: Patients want us to be human, to make mistakes but then apologize for them. The more we become vulnerable in front of our patients, the more human we are and that only leads to more trust.

4. Innovate One Thing: At least one area of your practice needs a make-over or even a do-over. Now is the perfect time to innovate and try something brand new.

5. Slow Down: In this crazy health insurance environment the squeeze is to either super-size or downsize — join a large group/ hospital/ corporate structure or go completely solo. No matter which direction you go, try slowing down instead of speeding up.

6. Embrace the Digital Landscape: Do you e-mail with your patients, use Skype, or even text message? Have you purchased an iPad but don’t know how to make it work for you. Now is the time to get going and make the automated software out there work for you.

7. Start a Blog: While Facebook and YouTube are great tools, far and away, blogging helps you more than anything else. By writing about health and your personal views on health and well-being you will not only help your patients learn more about you, you will learn more about yourself from the writing process.

8. Work Flow Efficiency: Far too many doctors do not spend enough time tweaking how efficient they can be with their work flow. So much time is wasted in the hallways and exam rooms when it could be used more efficiently. Don’t you want to get home at the end of the day?

9. Say Yes: Practice saying only yes — the more you do so, you will find that yes is always a choice for you. 2011 was about saying no; 2012 is about saying yes.

10. Leave The Room Brighter: I always liked the saying about leaving the room a little bit brighter than when you entered. Make 2012 your year to exit all of your rooms a little bit brighter.

I wish you and your family and your practice a very Happy New Year! This really will be the best year yet for all of us!

E-mailing With Patients: Think Before You ‘Send’

2012-01-31T06:08:00.000-08:00

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By Ericka L. Adler | September 28, 2011

Most of my communication with physician clients is conducted via e-mail. And yet, as a patient, I have never communicated with any physician in this manner. Why is this?

The use of e-mail is said to offer numerous benefits to physicians, such as an increase in efficiency and productivity. E-mailing is often faster, easier, and can be written and reviewed at the convenience of both parties, so as to cause less interruption and distraction to physicians during the work day. Additionally, e-mails are great documentation for future reference and can be printed and placed in the patient chart. E-mails can effectively be used for communicating test results, reminding patients of appointments, making appointments, prescribing medications, and, in some cases, following up on treatments and patient wellness. When used properly, electronic communication can free up valuable physician and staff time and decrease the need for in-person appointments and phone consultations.

Like anything in healthcare, however, there are always some restrictions and concerns. When it comes to e-mail, I typically warn my clients of the following:

1. E-mail should not be used for emergencies. You should set a maximum response time (i.e., 48 hours) that you will be able to meet and let patients know ahead of time. Patients should also know that the e-mail may be reviewed by others in your office in order to achieve the fastest response.

2. Limit e-mail use to situations you are prepared to handle. If you want to refill prescriptions but not give medical advice via e-mail, that is your decision. Make this policy known to your patients and do not make any exceptions.

3. Make sure patients know what security measures you have taken with your e-mail system and that you are not responsible if they choose to allow access to their e-mail account by a third party.

4. Don’t use your personal e-mail address. Set up an address that can be discontinued should the e-mail “experiment” not work. Consider a trial e-mail period to see whether e-mail is an advantage or disadvantage for your practice.

5. Be careful what you put in writing. If you do not want to give advice, limit your e-mail conversations to non-diagnosis related advice such as referrals to specialists, clarifying statements you made to patients, or answering general questions. When patients are seeking medical advice for a condition that has not been examined in person, always have them schedule an appointment. Be aware of the laws in your state and malpractice risk that may be created by unclear or untimely advice on which a patient relies.

6. Consider whether access to e-mail is something for which you should charge patients. You may not be reimbursed for time spent e-mailing with patients, and establishing a safe e-mail system may be expensive. If you choose to charge patients, consult with legal counsel to make sure you are not violating any laws or payer contracts.

7. Consider whether your e-mails should contain a disclaimer. I have a client who provided e-mail advice to a patient one Friday evening who complained of flu-like symptoms. My client recommended fluids, rest, etc., and to come in for an appointment on Monday if he did not feel better. The patient’s condition worsened and he died over the weekend. At no time did the patient contact the physician again or go the emergency room, relying instead on the e-mail. Whether reasonable or not, patients often blindly follow a physician’s advice. Although liability can never be avoided completely, a disclaimer on your e-mails that reminds patients they cannot rely on e-mail advice without an exam might help. In addition, the disclaimer should remind patients to make an appointment or to go to the emergency room if symptoms persist or worsen. Legal counsel can help you draft something appropriate for your needs.

Although I cannot cover all of the benefits and risks of using e-mail in this blog, I do recommend careful consideration when introducing e-mail to your practice. Make sure you develop a written policy for how access to e-mail will work in your practice and have such policy acknowledged by participating patients before you push that “send” button.

New Year Comes with New Challenges in Healthcare Reimbursement

2012-01-13T07:15:00.000-08:00

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By Sue A. Irwin, MCS-P | December 12, 2011

Everyone in healthcare revenue management has been not so quietly “freaking out” for the past six months. This tension is going to continue for at least another 24 months. There are so many changes happening right now and yet to come that we all know and are totally convinced that this is going to substantially impact cash flow for medical providers.

First the good news, it appears that Congress is going to “fix” the SGR mess with a two-year deal in which physician reimbursement levels are either frozen or there is an up to 2 percent increase in reimbursement from Medicare. As most other contracts that doctors have with insurance companies on reimbursement are dependent on Medicare’s level of reimbursement, many feel that Congress is not going to lose political clout with the AMA and all other medical groups by making the physicians angry. The reason they are making it a two-year “fix” is thought to be because they don’t want to have to deal with the SGR next year during a big election.

Now for the scary news, 5010 is going into effect on January 1, 2012. Many people think that just because CMS stated they won’t enforce the rules for 90 days, the doctors don’t need to worry about filing 5010 claims. THIS IS NOT TRUE. Sure, you won’t get fined for not being able to process claims in the 5010 format. But, you also won’t get paid for claims not in the 5010 format to Medicare. I think that’s a heck of a “fine.”

It gets worse, many state Medicaids have stated that they will not be ready for 5010 on time. All insurance companies and clearinghouses are scrambling like mad to get the 5010 format working. All the practice management software companies are also scrambling. The problem everyone seems to be having is trying to do the testing. Since there are so many entities needing to test, scheduling is proving to be a nightmare. Remember, every practice management software system has to test with each clearinghouse and each insurance as well as any other computer programs with whom they interface. The clearinghouses have to test with all their customers as well as all their customers’ insurance carriers. Then there is the really problematic issue where the different Medicare carriers have to test with the different state Medicaid programs for “cross-over” claims. Let’s see, two government agencies have to communicate effectively. Gives you a warm, fuzzy feeling doesn’t it?

The next factor to throw into the pot is it is a new year and many people have new insurance coverage. Also, it’s time for all those deductibles to be applied. Historically, reimbursement amounts drop in January and February. Some of the drop is due to insurance reimbursements going to deductibles and the patients then being responsible. Other parts of the decrease are due to patients forgetting to give you their new insurance information. This means contacting the patients after the claims have been denied to find out the proper information and then going through that whole submission process again.

Many of us in the healthcare reimbursement world feel that the normal decrease in dollars reimbursed in January and February is just a very small portion of the decrease we will see in the first quarter of 2012. As has been reiterated everywhere, please make sure you have some type of line of credit to keep your office running during this turbulent time. It is better to be prepared for failure on the parts of the different insurance companies and not need it, than to find out you desperately need cash flow and it can’t be found.

The last factor for consideration now is the revised ABN (Advanced Beneficiary Notice of Noncoverage), Form CMS-R-131. This form (that has a release date of 3/2011 printed in the lower left hand corner) is available on the CMS website. This revised form replaces ABN-G, ABN-L, and NEMB. Use of the revised ABN form is mandatory starting January 1, 2012. Any of your old stockpiled ABNs are no longer valid and if you are audited, they will not ‘pass inspection’ and you will have problems. I’ve always been a big fan of being proactive to avoid problems.

If I have not depressed you too much, have wonderful holidays … before the ax falls!!

The Upcoming Medicare Reimbursement Decision: What Will You Do?

2012-01-08T08:38:00.000-08:00

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By J. Scott Litton, Jr., MD | December 2, 2011

As we draw closer to the end of yet another passing year, unfortunately the story remains the same. I finished my residency in 2003 and can remember reading about the looming reimbursement decline proposed by the flawed SGR formula.

Year after year, the same Medicare reimbursement problem persists, yet our lawmakers have neglected to mend the flawed SGR formula. Rather than to correct the problem, the Congress has only placed a temporary short term fix. Now that 2011 is drawing to the end, the story yet again remains the same. Some years have seen a small one percent increase, however the past few years have essentially kept the reimbursements static without a decline being observed.

Our economic woes are essentially unchanged from last year. Physicians now find themselves faced with the difficult choice of deciding whether or not to continue accepting the flat reimbursements from CMS or to withdraw from the program altogether. The problem with the flat reimbursements is that our costs of maintaining a practice increase annually. Medical supply costs increase, insurance costs increase, and employees must be given routine raises in order to be retained. For my solo practice in the rural south, withdrawing from Medicare would be a very difficult decision to make. I have a large panel of Medicare patients who depend on me for their care. However, the perception of physicians by the general population is that we are all independently wealthy and we should be able to tolerate a decline in reimbursements for the good of the national economy.

The proposed payment reduction for 2012 is a 27 percent decrease. For those of us in private practice this reimbursement decrease will be disastrous. Unfortunately, I have already begun making preparations for this payment decrease. My practice has been receiving a large increase in new patient applications due to another physician's upcoming retirement. At this point, all new patients with Medicare are being placed on hold until a decision regarding our reimbursements has been determined by the Congress. If the reimbursement decrease is allowed to take place, I will be unable to accept any new Medicare patients.

My existing Medicare patients have been asking me what I plan to do for the past several weeks now. My answer to them is that I will not ever completely withdraw from Medicare and will never withdraw as their treating physician. I have been in private practice for more than eight years now and a very large percentage of my Medicare patients have been with me since my first year in practice. However, my answer to them is that I will not be able to take on new Medicare patients if the decrease in reimbursements does come to pass.

Being both a practicing physician and head of a business is very complex. As physicians, we long to be able to treat our patients and not discriminate regarding payment status. However, running a business (private practice) requires that we pay attention to the bottom line so that we can not only pay our staff and our bills, but pay ourselves at the same time. There are several undecided decisions regarding medicine's future. Most notably the upcoming Supreme Court case of determining whether or not the Affordable Care Act is constitutional will have a very large impact. Further, the upcoming presidential election will also have a large emphasis on economics and healthcare in general. We do not know the outcome, however we still have the job of caring for our patients at hand. Until that time, we must make the best decisions not only for our patients but for our medical practice as well.

Making Your Practice More Efficient Means Fewer Staff, More Tools

2011-12-25T10:24:00.000-08:00

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By Craig Koniver, MD - December 8, 2011

Last week, I began telling you how I have created an incredibly lean medical practice that I manage 100 percent by myself. This week I want to give you some practical advice about how you can start creating your very own lean medical practice to start you thinking about how you can manage your practice on your own, by yourself.

The reality is this: Medicine is a business as much it is a noble cause. Yes, we are here to help our patients and yes, we strive to provide outstanding clinical care. But, if we are not able to operate our practices in a lean, efficient manner, the current model of health insurance-based medicine, will slowly, but surely cause great distress.

We are already seeing this. Survey after survey reveals an alarming trend — doctors in primary-care medicine are underpaid, dissatisfied, and leaving the profession faster than ever before. Reforming healthcare sounds great on paper, but the reality is we cannot reform a system that is completely broken. If we as primary-care physicians truly want to provide the very best care in the most efficient manner, we need to start over. We need a brand new way of practicing medicine.

Here are some simple steps you can take with the goal of helping you take those first small steps and give you the confidence you need to do so.
In order to become the lean practice you need to help move medicine in a better direction, you have to start thinking as if you are working by yourself. Yes, having staff can be very helpful, but in order to create a new breed of medicine, we as physicians need to think and act differently. Here are a few simple and practical ideas to get you started:

[Note: In these tips, I mention several companies. I am in no way, shape, or form affiliated with these companies. I have found them to be helpful, but this does not mean these mentions are an endorsement.]

1. Organize Your Inbox: By “inbox,” I mean everything coming at you: phone calls, faxes, e-mails, forms, you name it. Every day it seems we get slammed with more and more requests. In the current model of most practices, we use our staff to deflect and delay those messages, but ultimately our days are filled with constant interruptions. As such, we grow accustomed to the reactionary style of practice — answer each question as it comes at us or delay and procrastinate.

My solution: Use a program like Evernote to keep your life organized. Evernote allows you the ability to forward everything coming at you into one large, digital filing cabinet. You can use Evernote on all devices (desktops, smartphones, iPads, etc.) so that all of your information is with you all of the time.

I have set up several notebooks in Evernote for clinical practice: refills, faxes, phone calls, etc. Now I either “act” on the message or I send it to Evernote to be “batched” later. This way, I can stay focused on each task and free myself from the feelings of being overwhelmed.

I also set up a notebook for every bill I pay. I scan in all paper mail, bills, etc., and now I have a simple yet comprehensive trail of everything I spend money on. Evernote has allowed me to maintain a running tally of everything in my life and organizing my practice this way has completely freed me up to be more available and efficient at the same time.

2. Enjoy Your Patient Messaging: We have grown so accustomed to the idea that a “visit” is when the patient comes into the office. Most of us are still using paper charts to document each visit. Some of us have progressed to EHRs. But most of us still see each visit as a separate event. Another way of viewing visits is that they are chapters of a book of your patient’s health. As such, each visit does not stand alone but weaved together, tell the story of your patient. In this context, messages, labs, radiology reports, consultations, etc., are all part of that patient story. Relying on EHRs or paper charts that are provider-only can only tell part of that story.

3. Streamline your day: Yes, answering the phone with a human voice provides comfort for the patient and allows them to get their questions to a live person. But having to field phone calls all day long is extremely inefficient and promotes the notion that you, the physician are available at your patients’ will.

Instead of answering my phone calls, I use a virtual office using Grasshopper. All of my phone calls are routed to different mailboxes that I assign. Each phone call I get is transcribed by a software program directly to my e-mail inbox. No, the transcription is not perfect, but the voice message is also attached to each e-mail so I can make sure I know who is calling me and for what reason.

I am no longer available to my patients at every aspect of the day. But, I do get back to them all when I make the time in my schedule. Using Grasshopper saves me tons of time to both see patients and respond to others on a daily basis.

Becoming lean is necessary to free yourself to offer the most efficient and comprehensive care that you seek. It also allows your business to thrive and not get stuck by the traditional health insurance forces that slow and temper many medical practices. My goal here was to show you some practical, real-life tools and scenarios that allow you, the doctor, to practice medicine in an efficient manner. The goal is obviously not to cut corners, but rather to be able to build a practice that is strong, flexible, and comprehensive for your patients and you.

With Friends Like These…

2011-09-30T18:34:00.000-07:00

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By Bob Keaveney | August 31, 2011

In case you've been wondering how little influence physicians hold in Washington these days, consider how the triple-blow of health reform, deficit cutting, and ordinary Medicare spending adjustments will likely affect you.

For starters, wait until you get a load of Medicare's new Independent Payment Advisory Board. Very little notice has been given to this powerful new board created by the health reform act, but that will soon change. Its job is to help a spendthrift Medicare become fiscally sustainable. Unlike its predecessor — a board called MedPac, whose cost-cutting recommendations to Congress are just that — the new group's actions become law unless explicitly overturned by Congress, and its remedies will mostly be limited to cutting payments to doctors.

What's happening now to American physicians is the result of a long-term cultural shift in the way society views you and your role in public life. Physicians, America has demoted you. Previous generations saw you as vital experts offering crucial advice and service to individuals and families, mostly via the private sector. Today, doctors are viewed as anonymous "providers" in a healthcare system that is better understood as a quasi-public utility than as a private industry.

Many of you have noticed that shift for years now and have resented it (my inbox is proof of that), but the practical effects have been minor compared to what you'll see in the environment brought on by health reform, which represents, I think, the final piece in your transformation from vital professional to public utility employee.

Where were physicians' voices during the debate over how to shape reform? You were talking, but, alas, you weren't (and still aren't) speaking with one voice, and in any case our elected leaders weren't listening. Doctors again took it on the chin in August, when Congress at last resolved its protracted debate over the debt ceiling by creating yet another deficit-reduction commission. This one will be charged with finding $1.2 trillion worth of debt reduction (at minimum) by Thanksgiving. Failure triggers draconian cuts, including a 2 percent reduction in payments to hospitals and physicians, amounting to $130 billion over 10 years. Perhaps the commission can avoid the trigger by agreeing to an actual proposal, but any such agreement would surely include Medicare cuts. Eric Zimmerman, a hospital industry lobbyist, told the Boston Globe that his clients are trying to decide which is worse, the automatic cuts "or whatever the committee recommends."

And all of it is on top of the 30 percent payment cut that doctors face in January as part of Medicare's usual process of reconciling its sustainable growth rate formula with its actual costs. That threatened cut has always been overturned by Congress at the 11th hour, usually replaced by a token payment increase. It’s an annual Washington tradition as predictable as the presidential pardoning of a Thanksgiving turkey. But this could be the year that conservatives, infused with budget-cutting zeal, might force real reductions.

There was a time when American physicians had real influence in Washington. That time has passed.

Perry, Romney and Their Healthcare Stances - TIME TO PAY ATTENTION

2011-09-14T07:39:00.000-07:00

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By Marisa Torrieri | September 9, 2011

Chances are, you caught (or at least heard about) the jabs between GOP candidates Mitt Romney, Massachusetts’s former governor, and Texas Gov. Rick Perry on healthcare reform, social security, and job creation at the most recent Republican presidential candidate debate.

One of the most memorable moments, Ponzi scheme-social security comparisons aside: Perry taking a dig at the Massachusetts mandate requiring people to buy health insurance, and Romney defending it.
Not even two days later, news pundits are speculating how the two assumed frontrunners, who joined six other candidates at Ronald Reagan Presidential Library for one of the first major political sparrings of the 2012 elections, would tackle healthcare reform.

And although it’s early in the 2012 presidential campaigns, physicians — especially those who aren’t fans of the Affordable Care Act, sometimes referred to as “Obamacare” — should take the time to familiarize themselves with the GOP candidates’ healthcare platforms. Or at least their evolving platforms.

A quick candidate healthcare platform guide published by Becker’s Hospital Review in the wake of the debates outlined the basics. As expected, there are some notable differences between the two frontrunners. Perry believes job creation can improve healthcare, as it would allow employed consumers to be covered by employer-sponsored health plans. He also is in favor of repealing the Affordable Care Act. Romney, meanwhile, reportedly supports a national version of his Massachusetts universal health program, but not at the expense of raising taxes.

But an editorial in the New Jersey Star-Ledger compared pinning down Republican presidential candidates on specifics to getting “a measles shot into the arm of a wriggling toddler.”

“Mitt Romney, the former Massachusetts governor whose plan was the model for the Affordable Care Act, now insists that what’s good for a state isn’t necessarily good for a nation,” Star-Ledger editors wrote. “To coax votes from conservatives, he is backpedaling from a sensible program that provides insurance for 96 percent of Massachusetts residents.”

Editors also noted that Perry, who supposedly finds healthcare mandates “repulsive,” signed an executive order that all teenage girls in his state receive the HPV vaccine to prevent cervical cancer. Perry was reminded of this stance by another GOP candidate, Texas Rep. Ron Paul — who is also a physician — during the debate. The order signed by Perry was never enacted into law and he has since backtracked his stance on the controversial initiative.

Furthermore, while Perry is critical of the Massachusetts plan, he also has stated that “the answer to healthcare issues in this country can be found in the states,” the editorial noted.

Like we said, it’s still early. Many of you are just getting to know these candidates.

Perhaps physicians should consider that the Affordable Care Act is still in its infancy: Some changes that went into law only recently revealed themselves. It may be too soon to weigh its effectiveness in favor of ideological healthcare changes envisioned by the likes of Perry or Romney.

Regardless of how they feel today, physicians should keep their eyes peeled and their ears tuned to what GOP frontrunners are saying today, as healthcare reform will definitely be a big-ticket issue for many years to come.

20 Questions to Ask Your EHR Vendor

2011-08-25T05:16:00.000-07:00

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Whether your practice is shopping around for an EHR or waiting for upgrades, it’s good to know what you’re in for, technology- and time-wise. That’s why we asked our readers, practice consultants, IT experts, and members of our Physicians Practice Group on LinkedIn to submit their thoughts for the most crucial questions you should be asking your vendor. Here are our favorites:

1. Do you have an implementation team that will make an assessment of the readiness of your practice and staff?

2. Do you have a user group that meets annually and that has a listserv for sharing information online?

3. Do you have a dashboard report to track phone message turnaround time by nurses and providers?

4. How often do you update your software; what updates are you planning for your next two releases?

5. Have your clients been more successful with a "big bang" implementation approach or a phase-in approach?

6. What happens when your office is hit by a disaster; are the records safe?

7. How many providers in our specialty use this system? Can you refer our practice to at least three who have set up this current version to see how it went?

8. Which systems failed implementation or were replaced within 24 months of implementation?

9. How many clients can demonstrate they have achieved their ROI?
10. Can we load our insurance contracts and see apples-to-apples performance comparisons?

11. Do you carry cyber and privacy liability insurance coverage?

12. Will an EHR migration absorb all of the patient demographics through a reverse migration from the billing data?

13. How often are coding updates incorporated (if the vendor provides this component)?

14. Do you, the vendor, have a complete inventory of drug, allergy, food interactions and their respective alerts incorporated into the system and again, how often is the database updated?

15. What is the pricing structure, by practitioner? By location? Are there different prices for varying types of practitioners?

16. Is the specific system version you are proposing: the same system that won the awards you tout; the same one that’s CCHIT/ONC certified; and the same one that is certified as interoperable with our regional health information exchange or health information organization?

17. You say your system is template-driven and completely customizable. For my specific specialty, how much time do I need to devote to populate and customize the templates to become functional in my practice?

18. What reporting capabilities are natively embedded in your system? Is it a separate module? How easy is it to generate my own custom reports?

19. To achieve meaningful use qualification, do you have dashboards and other tools to allow me to evaluate how our providers are doing in the specific areas needed to qualify for ARRA/HITECH funds?

20. Do you have a money-back guarantee for Stage 2 and Stage 3 of meaningful use qualification?

CMS SEEKS PROVIDERS TO TEST BUNDLED PAYMENTS

2011-08-24T03:21:00.000-07:00

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August 23, 2011 - Mary Mosquera

Healthcare providers will be able to apply to participate in one or more of the initial four models to test the use of bundled payments and their incentives for improving patient care and their outcomes, according to the Centers for Medicare and Medicaid Services.

VALUE: A CRITICAL ELEMENT FOR A HEALTH PRACTICE

2011-07-20T08:43:00.000-07:00

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Have you ever taken a few moments to ask yourself: “What about medicine do I value?”

This is an important exercise; because your answer directly affects your encounters with your patients. And one of the aspects of medicine which gets little attention is how to increase the value of your physician/patient relationship. We hear great talk about insurance reform, government oversight, and optimal billing practices, but the crux of the problems with healthcare start with what happens in the exam room. This is where the art of medicine truly shines: one doctor/ one patient working together to help the patient reach better health.

Unfortunately with declining insurance reimbursements, increasing government bureaucracy, and patient demands, we are forced to see more and more patients every day. Combine this with pressure to stick to ever-changing guidelines and protocols, and we as physicians are now in the middle of some stressful pressures.

One of the key tools you can use to start to grab your stake back from this chaos is to start slowing down and concentrating on value.

Medicine is a unique sector of our economy — it is more personal, more sacred, and I would argue more valued than other sectors. It is also a sector of our economy where the cost has been confused within the services we provide (no other service or retail industry runs on the credit system that the medical system does with its reliance on insurance reimbursements at a later date for services provided). For most doctors, there is a dichotomy — either focus on patient care (and sacrifice revenue) or focus on revenue (and sacrifice on patient outcomes). But there is a way to achieve both: focus on value.

In terms of an economic concept, value is often confused with price. When purchasing services or retail items, we tend to neglect value and focus on price. The interesting aspect to this is that when a remarkable service or product is able to convey value to us, we tend to forget about price and focus on value. Those companies that place a high level of attention on value are able to achieve higher levels of reimbursement than those companies that focus on price. Stop for a moment and think about your personal experience with this. We all have had interactions with companies where they have provided extraordinary services or products and we become fans and want to interact more and more.

In medicine we can use these same principles to help guide us in the exam room. But we have to first ask and understand what we value. As providers we are all unique and bring our very own individual characteristics, personas, and flare into each patient encounter. As an example to illustrate this point, one of the things I value is options. And so I take pride in offering my patients tons of options in terms of how they can better achieve their health goals. As a result of placing this value of options in all of my patient encounters, I have developed a strong reputation in my community for “outside the box” thinking and now have patients come to see me for this exact reason. And so the value I bring into the exam room directly translates to the value the patient takes from the exam room.

But there are so many areas that one can value. Here is a short list of core “values”:

• Feeling validated
• Feeling listened to
• Feeling respected
• Building an alliance
• Having an ally
• Intellectual thinking
• Kindness
• Precision

The amazing aspect to value is that when you focus on value, you not only help your patients feel better (patients will always feel better when these core values are being met), but you also increase your bottom line. By bringing value into the exam room, you will be able to develop stronger patient relationships and this will directly bring you more income. You will be able to attract new patients easier and your patients will be more inclined to fight with you to get what you are owed by the insurance companies. And if you engage in any additional revenue stream (selling nutritional supplements, on-site lab/ radiology services, others), your patients will want to spend their money on what you recommend. Put simply, they will want to spend their dollars where they experience true value.

You can start today: spend some time asking what you value and then start bringing that value into the exam room!

By Craig Koniver, MD | June 30, 2011

THE COMMON TRAITS OF LONG-TERM WEALTH

2011-06-16T08:31:00.000-07:00

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By Ike Devji, J.D. | May 24, 2011

I have been fortunate to work with some of the most successful people in America through the course of my career. All of them excel at something; medicine, business, real-estate development, science, and even the arts. What this vastly diverse crowd has in common (besides money) though are a set of traits that have made them not only good at what they do but wealthy and successful by any standard in a long-term and predictable way; here are a few of the most notable ones:

They Work Hard: Nearly all of them are the source of their own wealth. That is, they get up every day and commit themselves to the practice of some profession with skill, passion and diligence. They always strive to be smarter, more informed about their market and more skilled at what they do than the day before.

They Never Take Their Market Position for Granted: They understand that in a down economy discount solution, product, and service providers emerge in every market. They know competitors will be selling price first and many consumers won’t see the differences until they have been poorly served. They make sure their marketing efforts, network, and professional relationships are as important and well-nurtured as they were before the reached their current level of success. “Good Enough” is not part of their vocabulary.

They are Team Players: They look for every way to add value and collaborate with other top service providers in their field so that they are a natural part of every project or client they are involved with. They associate with other best-of-class teams and attend professional education and networking events on a regular basis.

They Are Proactive, Not Reactive: They take preventative care of their health, business, and known liabilities and plan to avoid problems, not manage them. They understand that a small amount of time and resources directed at these issues now will save them vast amounts of energy and money in the future and gives them the greatest number of options. They understand that preventing an illness, whether physical or financial is almost always better than treating it.

They Understand Wealth is Finite and Fragile: They live very well, but also “well within” their means. They are willing and able to adjust their lifestyles and spending to adjust for market realities and income fluctuations. They have money in the bank, not just on their wrists, and can handle fluctuations is cash flow and earnings as well as most common unplanned expenses without panic or liquidating large assets at a bad time in the market. They get that an important part of wealth is “having some.”

They Prioritize and Do “Boring” Things Before Spending on Lifestyle: They buy life, health, and disability insurance, get estate and asset-protection planning, stick to savings and investment plans and other things that often have a hard time competing with new cars and vacations. They are financially disciplined and meet the mental commitments they have made to their families and future wealth and success before meeting today’s “wants.”

They Create Success Maintenance Teams: They identify top professionals in various areas, create relationships with them and act decisively to implement their suggestions and expertise. They have control of their egos and understand that as bright and successful as that are, they are better off being surrounded by experts in areas outside their field. They know “what they don’t know” and are willing and able to delegate responsibility to others and let go enough to be free to do what they are best at, which is never everything.

They read sources of information that present a wide range of expert guidance and stimulate critical thinking. They know that their learning is a lifetime process and they never stop.

Medical Marketing: Meeting the Needs of Your Patients

2011-06-14T09:05:00.000-07:00

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By Randall Wong, MD | June 9, 2011

One of the basic tenets of marketing is to know your customer. By doing so, you should identify the needs of the customer, and, if you are able to provide a solution to his or her problem, you are likely to make a sale and build a relationship.

In healthcare, our patients are the customers and we, too, must understand the needs of our patients if we are to build a successful practice. We must respond to meet their needs, or they'll find another practice that will.

We can do this in many ways. For example, we can provide convenient office hours (early, late, weekend) and transportation. We can integrate a patient portal with our EHR.
Our patients and potential patients are spending more and more time conducting independent research for their own health needs. Whether to find answers to their health questions or doctors to help them, they’re seeking solutions on the Internet.

“Baby Boomers” (ages 45-54) now spend equal amounts of time on the Internet and TV. Younger age groups spend most of their time online rather than in front of a television set.

A study by The Pew Research Center’s Internet & American Life Project reveals 80 percent of Internet users are looking for answers to health-related questions as of 2011.

If we follow the marketing rule of “know your customer,” we should be the first to provide these solutions. Health professionals are the logical choice to be providers of health-related content on the Internet, for we are the experts.

Those physicians that understand this and participate by starting and maintaining a website full of rich and relevant content will have the most marketing success. Why not create a website of your own that reveals your expertise?

It’s been said “If you build it, they will come.”

Here’s to your success!

EHR SUPERSTARS AND THE REST OF US

2011-06-05T10:29:00.000-07:00

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By Daniel Essin, MA, MD, FAAP, FCCP | May 30, 2011

Barring a disability, everyone can walk. But climbing to the summit of Mt. Everest involves walking, and then some.

Not everyone can do it and of those who could, not everyone is willing to make the commitment and exert the effort. Of those who try, some die in the attempt, often as a result of faulty decision making. Those who reach the summit and return to tell about it are genuine superstars. Imagine that you are a space alien and you want to understand the limitations of human walking. If you capture a group of those who had scaled Mt. Everest, any study results or conclusions that you generate might be very interesting but they would not tell you much that was relevant to understanding the limitations that the average human encounters when walking. Your sampling error would skew your results and would you conclude that there were few limitations.

Any physician that has done research or read research papers is aware of the sampling error. It is a criticism that is often raised about scientific studies and it is often justified criticism. Even with good planning and statistical consultants, it's easy to design a study that has residual sampling and technique errors. This is compounded if there are factors that the researchers were not aware of, which would have influenced the study design had they only known.

A great example is that of a biologist studying limb regeneration in amphibians who produced some truly extraordinary results. The problem was that no one could reproduce the results no matter how closely they followed the published techniques and methods. One biologist was so perplexed that he went to personally observe the procedure. The bottom line: The original researcher was a chain smoker and had been blowing tobacco smoke on the preparations throughout the study but was totally oblivious to the fact that it might affect the outcome or even that it should be mentioned.

Let's recall that many physicians have spent the better part of the past 20 to 30 years making attempts to implement and adopt EHRs. Many have made multiple attempts and have spent vast amounts of time and money. Out of this group, a few have had sufficient success to be noteworthy. These are the superstars.

When "slow adoption" is questioned, what is being asked is why ordinary doctors haven’t done what the superstars have done. The answer is, of course, that they are not superstars. They have watched the superstars and noted the number of failed attempts and the expense of the "successes" and correctly concluded that the technology was not ready for prime time.

The current program to incentivize the adoption of EHR is based on the kind of data that the space aliens would have gathered from the Mt. Everest climbers, which suggests that it may take a bit of work but it is basically no problem. Will a bribe make someone successful when there no data that would predict success? Would $40,000 induce an average person to climb Mt. Everest? Would they succeed if they tried? It's more likely that they would die in the attempt or be sent back from the first base camp.

The expectations of the legislators and the politically connected IT types that are fanning the EHR flame are based on flawed data caused by sampling error. They have concocted a program based on the assumption that it is only $40,000 or so that stands between the average doctor and superstar success. It would be more productive to direct the money toward studying the failed attempts to identify the root causes, i.e. the intrinsic flaws in the programming languages, databases, and application-development tools that have led so many bright developers to produce software that has failed so badly in spite of their best efforts.

THE LOWEST COST FOR THE HIGHEST RETURN

2011-05-24T10:35:00.000-07:00

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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

2011-05-20T14:08:00.000-07:00

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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

2011-05-10T20:29:00.000-07:00

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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

A FEW IDEAS FOR TRIMMING THE FINANCIAL FAT IN YOUR PRACTICE

2011-04-27T18:43:00.000-07:00

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Although financial fees are not necessarily hidden, they can appear in unexpected places, such as small business accounts that have no monthly maintenance fees but do have transaction limits. Medical practices tend to have numerous monthly transactions that can be billed at small rates and could quickly add up to a big expense.
When overdraft, monthly maintenance and transaction fees stack up, it’s a good idea to tackle the nickel-and-diming effect of these fees. Begin by doing some research. Assess your practice’s banking activities and determine which banking institution offers services that are well suited for your practice and its needs.

Ways to Cut Costs

The American Medical Association suggests that if your practice is located in a building with other practitioners, sharing common service expenses, such as a drop box, can help cut costs for all involved. Also, by consolidating your practice’s accounts into one bank, you can reduce fees — and interest from the accounts can be used to pay these fees. Negotiating with your bank may also help reduce some fees if you can’t find a fair fixed rate.
There are multiple benefits of banking online for practitioners looking for lower costs and more convenience. Online banking eliminates running to the bank to order new checks or transfer funds between accounts. You can also monitor the balance of accounts easily with automatic alerts that can protect your practice from overdraft fees. Many financial institutions also offer Remote Capture services for check depositing. Typically, your bank will supply you with a check scanner which connects to your computer and a secure Internet connection. Your staff runs patient checks through the scanner, which digitally deposits the funds to your practice bank account.
Online banking can also make paying bills easier. Instead of sending checks in the mail and remembering multiple due dates, you can pay expenses automatically on a set schedule. In some cases, bills from certain vendors can be sent to your practice electronically. Another benefit of online banking is easy access to your practice’s account history.

Protecting Your Investment

Minimizing your costs keeps your practice financially lean and viable; however, sometimes the unexpected can happen. Natural disasters, such as hurricanes or floods that can damage your office and even your own health, can interrupt your business and can be very expensive if you are not prepared.
Here are some useful ways to support your practice during these difficult economic times:

Line-of-credit loan. An unsecured line of credit does not require collateral and can be a useful tool for filling in gaps between insurance payments. When money is tight, this loan can help you continue payroll without interruption or pay for necessary but unexpected costs. Because unsecured lines of credit tend to have higher interests rates, it is wise to pay off these loans as soon as possible.
Insurance. Property, liability, disability and business interruption insurance coverage may be another monthly expense; however, when the unexpected occurs, these are invaluable ways to protect everything you’ve worked hard to build.
Business credit card. For new practices, this card can help establish credit. It can also provide overdraft protection for your business checking account. However, these cards can have high interest rates if the monthly balances are not paid off.

Source: MD News

50 things to Know About the Proposed ACO Regulations

2011-04-11T19:28:00.000-07:00

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Written by By Scott Becker, JD, CPA, R. Brent Rawlings, JD, Barton Walker, JD, and Lindsey Dunn | April 04, 2011

This article briefly outlines 50 things to know about the Medicare Shared Savings Program proposed rule — which established Medicare accountable care organizations — released by the U.S. Department of Health and Human Services on March 31. The article begins with a summary of key 45 provisions included in the proposed regulations and then provides five general observations regarding the ACO program, as established by the regulations.

45 key provisions in the proposed ACO regulations

1. ACO Participants cannot participate in other Medicare shared savings programs. A Medicare provider cannot participate in the Shared Saving Program as an ACO participant if it also participates in the independence at home medical practice pilot program or other Medicare programs that include shared savings.

2. An ACO may include the following types of groups of providers:
•   ACO professionals (i.e., physicians and hospitals meeting the statutory definition in a group practice arrangement);
•   Networks of individuals practices of ACO professionals;
•   Partnership or joint venture arrangements between hospitals and ACO professionals;
•   Hospital employing ACO professionals; and
•   Other Medicare providers and suppliers as determined by the HHS Secretary.

3. The regulations provide for a once-a-year start date of Jan. 1. Under the proposed rule, ACOs would apply for the three-year program and, if accepted, would be part of a cohort of ACOs joining the Shared Savings Program every Jan. 1.

4. ACO agreements will be for three years with one-year performance measurement periods.

5. Medicare fee-for-service beneficiaries will be retroactively assigned to ACOs based on primary care utilization during a performance year. "We are proposing to assign beneficiaries for purposes of the Shared Savings Program to an ACO if they receive a plurality of their primary care services from primary care physicians within that ACO."

6. Beneficiaries will not be assigned to more than one ACO.

7. Beneficiaries will not receive advance notice of their ACO assignment. However, providers participating in ACOs will be required to post signs in their facilities indicating their participation in the program and to make available standardized written information to Medicare fee-for-service beneficiaries whom they serve. Additionally, all Medicare patients treated by participating providers must receive a standardized written notice of the provider's participation in the program and a data use opt-out form.

8. CMS expects 5 million Medicare beneficiaries to receive care from providers participating in a shared savings program.
9. An ACO must have at least 5,000 beneficiaries. If an ACO accepted into the program falls short of the 5,000 requirement, it will be placed on a corrective action plan.

10. The board of an ACO must include some Medicare beneficiaries. "Another of the proposed patient-centered criteria discussed previously is the requirement that ACOs provide for patient involvement in their governing processes. We are proposing that, in order to satisfy this criterion, ACOs will be required to demonstrate a partnership with Medicare FFS beneficiaries by having representation by a Medicare beneficiary serviced by the ACO, in the ACO governing body."

11. The ACO board must include representation from all ACO participants. CMS requires this in order ensure all ACO participants are provided "an appropriate proportionate control over the ACO's decision-making process."

12. No more than 25 percent of board seats can be held by non-ACO participants such as entrepreneurial companies. "In order to be eligible for participation in the Shared Savings Program, the ACO participants must have at least 75 percent control of the ACO's governing body."

13. The proposed regulations do not require an ACO to become a separate legal entity with a separate Tax Identification Number. However, CMS recognized not requiring this could make it more difficult for CMS to audit ACO performance. Thus, it is seeking comment on whether all ACOs should be required to be formed as separate legal entities.

14. The ACO can enter into a one-sided or two-sided shared savings agreement. Under the first "one-sided" risk model, an ACO that creates a savings of at least 2 percent would get 50 percent of the money above that threshold, but it would have no penalty if it spent more in the first and second year. Under the "two-sided" model, an ACO could receive 60 percent of the money above the threshold but also would be penalized if it led to higher costs. By the third year of the program, all ACOs would become responsible for losses.

15. Cost targets, from which savings will be calculated, will be based on retrospective review of aggregate beneficiary-level data for the assigned population. Spending targets will be compared to actual spending and any savings above the ACO's minimum savings rate (generally 2 percent), will be shared between CMS and the ACO.

16. CMS will set spending benchmarks based on three years of data. These will be set with a higher weighting on the most recent year and the lowest weighting on the year three years ago (i.e., a 60, 30, and 10 rating). There are several adjustments to the benchmarking.

17. Generally there is no savings shared or costs to be borne unless savings are at least 2 percent above or below the benchmark. The higher the number of beneficiaries, the lower the minimum savings rate. For smaller populations (e.g., 5,000 beneficiaries), the minimum savings rate can be higher (i.e., up to 3.9 percent). However, there are exceptions to the rule for rural ACOs.

18. The ACO entity is responsible for distributing savings to participating entities. Medicare will pay the savings to the ACO, which will distribute it to participants in the ACO.

19. ACOs will be subject to a withhold of shared savings to offset possible future losses. "The ACO will be subject to a 25 percent withhold of shared savings in order to offset any future losses under the two-sided model." If an ACO completes its three-year agreement, it can recoup the 25-percent withhold. If an ACO terminates its agreement before the three-year requirement, CMS will retain any portion of shared savings withheld.

20. To be eligible to receive shared savings, the ACO must also meet certain quality standards. There are five standard measures for quality or areas. These include patient care giver experience, care coordination, patient safety, preventive health and at risk population/frail elderly health. CMS will designate scoring and measurement concepts. "Each of the [five] domains is equally weighted in determining an ACO's overall quality performance score, regardless of whether the ACO is in Track 1 or Track 2."

21. An ACO must develop a process to promote evidence-based medicine, patient engagement and coordination of care.

22. ACOs must have a patient survey tool in place.
23. ACOs must have a process for evaluating the health needs of the population it serves.
24. ACOs must have systems to identify high-risk beneficiaries and develop individual care plans for target populations.

25. An ACO must report and maintain a database of all ACO participants and their National Provider Identifiers.
26. ACOs must have a compliance plan and conflicts of interest policies and means to screen ACO participants.
27. ACOs must get approval for any changes in ACO participants (i.e., providers) during the three-year contract period.

28. Where an ACO's structure or participants changes during a term, CMS has five different ways it may respond. In some cases, the ACO will be allowed to move forward in the program. In others, it would be required to start over with a new three-year agreement. In some cases, the ACO would no longer be eligible for the Shared Savings Program. (See page 137 of the proposed regulations for the full list of CMS responses.)

29. Primary care providers may only participate in one ACO. However, a hospital can participate in more than one ACO, as can non-primary care medical and surgical providers.

30. Physicians eligible for primary care provider status include internal medicine, general practice, family practice and geriatric medicine specialists.
31. At least 50 percent of an ACO's primary care physicians must be meaningful EHR users as defined by the HITECH Act and subsequent Medicare regulations.

32. Each ACO will have significant public reporting requirements in a standardized format. Name; location; contact; participating providers; identification of participants in joint-ventures between ACO professionals and hospitals; identification of representatives on the governing body; associated committees and leadership; quality performance standard scores; shared savings information, total proportion of savings distributed to participants; and total used to support quality performance will be reported publicly.

33. ACOs must have a data-use agreement with CMS. However, Medicare beneficiaries assigned to ACOs can opt-out of data sharing. The ACO must supply beneficiaries with a form that allows them to opt-out.

34. CMS will share aggregate population data regarding the ACO's population several times per year. Data from CMS will include financial performance; quality performance scores; aggregate metrics on the assigned beneficiary population; utilization data at the start of the agreement period based on historical beneficiaries; and identification of historically assigned beneficiaries used to calculate the benchmark.

35. CMS may monitor to ensure they are not avoiding at-risk beneficiaries or distributing unapproved marketing materials in addition to a whole range of other issues. In regards to marketing materials, CMS must approve any marketing materials or other communications promoting the ACO.

36. ACOs must agree to be open wholly to audits. "We further propose that, if such data are generated by ACO participants or another individual or entity, or a contractor, or subcontractor of the ACO or the ACO participants, such ACO participant, individual, entity, contractor, or subcontractor must similarly certify the accuracy, completeness, and truthfulness of the data and provide the government with access to such data for audit, evaluation, and inspection."

37. The regulations set forth 16 grounds for termination of an ACO's shared savings agreement with CMS. Examples of these grounds include failure to report quality standards or failure to meet quality thresholds and avoidance of at-risk beneficiaries. (A full list of the 16 grounds can be found on pg. 409 of the proposed regulations.)

38. There are several concepts which are not subject to appeal by an ACO if it is terminated from the program by CMS. (A list of these can be found on pg. 412 of the proposed regulations). ACOs may appeal an initial determination if it is not prohibited for administrative or judicial review.

39. CMS can change the program during a contract term, but can't change the rules regarding the eligibility requirements of an ACO, calculation of the shared savings rate and beneficiary assignment.

40. CMS and the OIG have proposed waivers with regard to Civil Monetary Penalty, Antikickback and Stark laws solely as to relationships wholly related to an ACO. For Stark and Antikickback, the waiver applies only to distributions of shared savings (not any other financial relationships). To view the CMS and OIG guidance, click here.

41. Preliminary guidance from IRS available. The IRS has issued preliminary guidance to provide tax-exempt entities information on participating in ACOs. To view the IRS guidance, click here.

42. Preliminary guidance from antitrust agencies available. The FTC and DOJ have also issued a proposed statement of antitrust enforcement policy as to ACOs. According to the guidance, ACO participants will not be challenged if they have a combined share of less than 30 percent of the common service in each area. If outside the safe zone it can still proceed if less than 50 percent. If more than 50 percent it must receive an approval to participate. If less than 50 percent, it doesn't need a review, but can request one. To view the antitrust guidance click here.

43. The core concepts of the ACO program are to achieve better care for individuals, better health for populations and lower growth for Medicare expenditures.

44. Comments on the proposed rule will be accepted for 60 days after the proposed rule is published in the Federal Register (expected April 7, 2011, so until June 6, 2011).

45. The ACO program is scheduled to go into effect on Jan. 1, 2012.

General observations on the ACO program

46. Will require massive bureaucracy. Given the scope of the regulations and the number of actions and approvals to qualify and participate and be accountable as an ACO, the ACO regulations likely will require the establishment of a massive bureaucracy. In some ways, it's a different form with much more integration than providers that manage a Medicare advantage plan system but with arguably even more complexity.

47. Regulations are idealistic. The regulations in many ways speak of what is viewed by CMS as ideal concepts in healthcare, concepts used as platitudes such as "patient-centered care," "patient engagement" and many other terms. It will be fascinating to see how the actual practical hard-nosed implementation meshes with such ideals.

Further, the regulations speak of the kind of leadership expected in ACOs as though government can choose leaders or dictate what they look like in what we know is an imperfect world and where the reality of capitalism and a free market. In reality, who leads such organizations is never going to be as clean and clear as the regulations seem to believe and the leaders won't fit a certain stereotype.

48. Regulations limit business involvement. The program set forth the kind of negative attitude that one might expect from CMS towards business and further tends to reflect CMS' demonization of business and insurance. For example, while some might think business involvement is needed to drive this, the regulations specifically require that business interests cannot make up more than 25 percent of the board in ACOs.

49. Regulations require beneficiary representation in ACO governance. The program requires a means for equal and shared governance in ACOs and requires beneficiaries to have a say in the ACO governance. Specifically, the proposed regulations require the ACO governing body to include including "a Medicare beneficiary serviced by the ACO."

50. Regulations favor PCPs. The ACO regulations — much like intended reform in the 90s — view the primary care physician as the leader of patients' healthcare and really relegates many other parties to being cost centers. Language regarding PCP roles is somewhat glowing, further suggesting this perspective.

HOW TO BE SUCCESSFUL IN THIS REFORM-DRIVEN, ACO WORLD

2011-04-10T18:37:00.000-07:00

www.managedcarealt.com

1. Post-acute facilities must become masters of the Medicare system. Those who only provide Medicare services to their long-term residents who have a decline in condition, go to the hospital, and return with a skilled Part A benefit will not be successful in the long run. Your facility must be prepared to be a leader in short-term, post-acute care, and be ready and willing to link with other post-acute care providers such as home health and medical homes. If you have not previously been considered a leader in post-acute short stay rehabilitation, reach out to external consultation or management services to assist you in correctly positioning your business.

2. Understand your hospital CEO’s world. If you do not have a relationship with the C-suite office holders of your local hospital, you need to cultivate these relationships in earnest. Too many post-acute care providers do not envision their leadership role as equal to that of a hospital CEO. While the requirements and compensation may differ, the roles for overall organizational leadership are the same. With this understanding, you can establish your local knowledge base of how your partners are responding to reform.

3. Understand the impact on your physicians. Many physicians have realized that it is simply financially detrimental to their practice to leave their offices and see patients in post-acute settings. We must develop alternative opportunities to partner with physicians’ groups and ACOs to provide timely, quality physician attention to patients, particularly those at-risk for re-admission to the acute care setting. As reform continues to evolve, both ACOs and physicians’ practices will be incentivized to control unplanned re-hospitalizations will be more participatory in identifying solutions to these issues. Your role as a post-acute care provider is to work with your physician community now to begin to identify opportunities. This may include the addition of nurse practitioners or physician’s assistants to support physician presence within your facility. Facilities with a higher percentage of short-term post-acute care patient days will have more leverage in working with others to possibly have additional physician presence funded by other sources.

4. Align your medical director leadership for the future. Medical directors cannot be relied upon to simply be the physician of record for the preponderance of your patients. This practice raises significant issues related to the medical director’s mandated regulatory expectation to oversee all medical care. This cannot be accomplished if they are the attending physician for most patients. Your medical director needs to be actively engaged in clinical education and pathway development in alignment with local ACO models, an active liaison to other physicians, and an active participant in the evolution of medical care at the post-acute care setting.

5. Know the impact of healthcare reform on your discharge planners. Be aware that the role of the case managers and discharge planners will evolve and change. Some will find themselves held accountable for unplanned re-hospitalizations, particularly if patients choose to seek post-acute care in a setting not within the ACO network. The patient’s right to choose an ACO may remain but it is realistic to assume that once this choice is made, the ACO directs post-acute care placement, just as an acute care hospital directs patient placement on certain specialty areas of a hospital today. If discharge planners are held accountable for re-hospitalization rates, it will be the responsibility of the post-acute care providers to keep them actively engaged.

6. Your competitors are now your partners. As ACO networks mature, you will likely receive admissions from sources other than hospitals, including home health, skilled nursing, assisted living, medical homes, and hospices. Non-medical support services may report findings to physicians or ACO admissions coordinators who may direct admissions to your setting. You need to be keenly aware of the numerous providers in your areas, their role in an ACO network, and how you will interdependently work with each other for the successful care of each patient you may share.

7. Take care of sick people. Patients who admit to a post-acute care setting on Thursday with a diagnosis of pneumonia simply cannot be readmitted to an acute setting two days later with…pneumonia. Regrettably, many facilities have staff who feel that any level of health decline requires hospitalization. This causes a significant strain on the patient’s quality of care as well as the cost of that care.

8. Assess your clinical prowess and make changes. The clinical talent and skills of your staff must be assessed and necessary skills must be acquired quickly. This may require additional certification and education along with re-examination of the distribution of licensed staff, particularly LPNs/LVNs and RNs. Regularly scheduled skill checks (at least annually) and ongoing skills development will be essential.

9. Monitor your performance and share your results. This is another opportunity where the data can be your best friend or your downfall. Clearly, the current primary metric to be measured and managed is unplanned re-hospitalizations. It will be important in your regular conferences with ACO leaders (see #2) that you can clearly articulate and illustrate how you are monitoring the metrics most important to your ACOs, and candidly address the issues which impact performance to those metrics. Make no mistake: In the new world of healthcare reform, your “report card” changes. It is much more than a successful survey experience.

10. Educate your direct customers. When these initiatives begin to play out and directly impact the lives of your customers, it will be a time of confusion and angst for many. This presents a tremendous leadership opportunity for you to become a public voice and positive influence. Yes, care delivery will change, but quality will improve as well. The responsibility falls to us as healthcare leaders to clearly communicate what will occur within our specific markets, positively inform the public, and guide them through these changes. We must be seen as helping our customers through the changes within our local healthcare systems.

Much will continue to evolve in the months and years to come related to the passage of health reform. The accompanying regulations are yet to be released as of this writing. Will the three-day required hospital say be upheld with reform? Where will the rights of patients fall in choosing their post-acute care service provider? How will your specific healthcare community respond to reform? These issues, and others, will continue to be a part of the changing reform landscape. Your active partnership in leading your post-acute care setting and your community is critical to success. *

* From an online article in Long-Term Living Magazine posted 3-01-2011, written by Glen Roebuck, Sr. V.P. of Operations, Health Dimensions Group

New CMS estimate for upcoming Medicare reimbursement cut is highest ever scheduled at nearly 30 percent!

2011-03-28T09:40:00.000-07:00

AMA, 130 Medical Organizations Call for Bipartisan Solution to Medicare Physician Payment System

March 10, 2011
WASHINGTON – The AMA was joined by 130 state and medical specialty societies in sending a letter to both the U.S. House of Representatives and Senate calling for a permanent solution this year to the broken Medicare physician payment formula. The letter was sent on the same day that CMS announced, in a letter to MedPAC, that the cut set to occur on January 1 would be 29.5 percent - the highest ever scheduled.
“The new estimate from CMS should serve as a wake up call to Congress that physicians who serve Medicare and TRICARE patients are facing a debilitating cut of nearly 30 percent on January 1,” said Cecil B. Wilson, M.D., AMA President. “This cut is the highest ever scheduled under the broken Medicare physician payment system, and it threatens access to care for our nation’s seniors, military families, and the baby boomers now entering Medicare.”
In the joint letter, the 131 organizations urged Congress to work in a bipartisan, bicameral manner to enact permanent reform this year. The organizations noted that the cycle of scheduled cuts and frequent short-term delays cause disruptions for patients and physicians. In 2010 alone, Congress acted five times to pass short-term measures to stop scheduled Medicare physician payment cuts.
“The AMA will work with policy-makers on both sides of the aisle to replace the broken Medicare physician payment system with a system that better reflects the costs and practice of 21st century medical care, and provides stability for physicians and their Medicare patients,” Dr. Wilson said.

Many Hospitals and Doctors Plan to adopt EHRs

2011-03-24T18:20:00.000-07:00

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Four-fifths of the nation’s hospitals, and 41 percent of office-based physicians, currently intend to take advantage of federal incentive payments for adoption and meaningful use of certified electronic health records (EHR) technology, according to survey data released by the Office of the National Coordinator for Health Information Technology (ONC). The survey information was released as the registration period opened for the Medicare and Medicaid EHR Incentive Programs.Non-hospital-based physicians and other eligible professionals can obtain incentive payments of as much as $44,000 under Medicare or $63,750 under Medicaid. Under both Medicare and Medicaid, eligible hospitals may receive millions of dollars for implementing and meaningfully using certified EHR technology.

The data comes from surveys commissioned by ONC and carried out in the course of regular annual surveillance by the American Hospital Association (AHA) and the National Center for Health Statistics (NCHS), an agency of HHS’ Centers for Disease Control and Prevention (CDC).
The NCHS survey found that 41 percent of office-based physicians are currently planning to achieve meaningful use of certified EHR technology and take advantage of the incentive payments. Four-fifths of these, or about a third of all office-based physicians (32.4 percent), responded that they will enroll during Stage 1 of the programs. Only 14 percent of respondents said they were not planning to apply for meaningful use incentives. Additional survey data from NCHS show that significantly increasing numbers of primary care physicians have already adopted a basic EHR, rising by 50 percent from 19.8 percent of primary care physicians in 2008 to 29.6 percent in 2010. Basic EHRs provide a beginning point for use of electronic health records in physician offices, but most physicians would need to further upgrade their EHR systems or their use of the systems in order to qualify for meaningful use incentive payments. To qualify for incentive payments, under the Medicare EHR Incentive Program, providers must achieve meaningful use of certified EHR technology, under regulations issued by CMS and ONC. Medicaid providers can receive their first year’s incentive payment for adopting, implementing, and upgrading certified EHR technology but must demonstrate meaningful use in subsequent years in order to qualify for additional payments.

Information about the incentive payments program is available on the CMS website at www.cms.gov/ehrincentiveprograms .

New Medicare Billing System Part of Small Business Lending Act

2011-03-24T18:15:00.000-07:00

http://www.managedcarealt.com/

According to reports, the Small Business Lending Act signed into law this past June includes an anti-fraud provision that will require Medicare to do more to prevent fraud.

"Medicare fraud has been a problem for far too long," notes Alan Weinstock, insurance broker at www.MedicareSupplementPlans.com. "CMS uses an outdated billing system which I understand actually helps to facilitate over $60 billion in Medicare fraud annually."

Under the new provision, the Centers for Medicare and Medicaid Services (CMS) will be required to stop its long-held policy of approving claims without first verifying them.

Medicare Billing Software

Part of what the law implements is new Medicare billing software with a predictive modeling component, a type of analytical technology that already has been adopted in the credit card industry to identify potentially fraudulent bills. Medicare billing contractors will be required to use the new technology for hospitalization and outpatient services, which make up the bulk of Medicare's spending. It is estimated that predictive modeling could save the government more than $20 billion a year.

CMS is required to launch a competitive bidding process by January 2011 for predictive modeling software contractors and then begin actually implementing the technology by July in the 10 states with the highest Medicare fraud rates. U.S. Senator George LeMieux (R-FL), who coauthored the Small Business Lending Act and wrote the Medicare anti-fraud initiative, has a personal interest since Florida is one of the states where Medicare fraud rates are the highest.

After the first year of implementation, Health and Human Services will be required to submit a report to Congress detailing the actual savings on Medicare fraud. If the savings are substantial, some of that money could be used to implement the technology in 10 more states.

A Third Judge Validates Health Care Overhaul Law

2011-03-17T09:22:00.000-07:00

A third federal judge upheld the constitutionality of the Obama health care law on Tuesday, reinforcing the divide in the lower courts as the case moves toward its first hearings on the appellate level.

Judge Gladys Kessler of Federal District Court for the District of Columbia became the third appointee of President Bill Clinton, a Democrat, to reject a constitutional challenge to the Affordable Care Act. Two other federal district judges, both appointed by Republican presidents, have struck down the law’s keystone provision, which requires most Americans to obtain health insurance starting in 2014.
One of those judges, in a case filed in Florida, ruled that the rest of the law could not be severed from that provision, and suggested that the entire act was therefore invalid. The Justice Department, which represents the Obama administration in the cases, has asked the judge for clarification of his ruling, which left states confused about whether to continue carrying out the law.
Although the issue will almost certainly be determined by the Supreme Court, each lower court ruling contributes to the balance of legal opinion that the justices will consider. More than 20 challenges to some aspect of the sprawling act have been filed around the country. Oral arguments in the first appellate reviews are scheduled for May and June.
The District of Columbia case was filed by five individuals represented by the American Center for Law and Justice, a conservative Christian legal group.
Judge Kessler adopted the government’s position on whether Congress’s authority to regulate interstate commerce is so broad that it can require people to buy a commercial product. Past Supreme Court decisions have established the standard that Congress can control “activities that substantially affect interstate commerce.”
The judge suggested in her 64-page opinion that not buying insurance was an active choice that had clear effects on the marketplace by burdening other payers with the cost of uncompensated medical care.
“Because of this cost-shifting effect,” she wrote, “the individual decision to forgo health insurance, when considered in the aggregate, leads to substantially higher insurance premiums for those other individuals who do obtain coverage.”
Judge Kessler added: “It is pure semantics to argue that an individual who makes a choice to forgo health insurance is not ‘acting,’ especially given the serious economic and health-related consequences to every individual of that choice. Making a choice is an affirmative action, whether one decides to do something or not do something.”
The judge also tossed out a claim that the law restricted the plaintiffs’ exercise of religious freedom because the mandate to buy health insurance conflicted with their belief that God would provide for their well-being. She wrote that such a burden, if it existed at all, was too minor to require invalidation of the law.

HOW TO SELECT AN EHR FOR YOUR PRACTICE

2011-03-02T09:50:00.000-08:00

www.managedcarealt.com

Basically, three steps are involved in this process: assessment, planning, and selection.

1. ASSESSMENT - what do you want, what do you need, what can you afford? Assess the practice to identify opportunities to improve processes for patient care, improve your staff morale and integrate health care informations technology into your practice. Decide whether or not to use outside help - such as the regional extension centers established by the HITECH Act or a private consultant - to assist you in finding the best product for your specific needs.

2. PLANNING - Identify goals, priorities, and barriers. Identify what are your highest priority needs, features and functions of an EHR from the practice perspective. Make your staff aware of the anticipated changes in processes and workflow and seek their input regarding specific priorities you may not have identified. Consider how to handle legacy paper charts and new paper-based data that will inevitably accompany new and follow-up patients. One of the options you can consider is to scan patient charts, thus making an electronic image which may or may not be searchable.

3. SELECTION - Be certain of your practice's requirements before making a final decision. Do you need a new billing system (practice management system)? If you do not, does your current practice management system support an interface to an EHR. If you are happy with your current practice management system, do not believe high-pressured sales pitches that indicate you must use an integrated practice management/EHR package. Focus your decision on the activities you do 95% of your time. Consider what your employees indicate their needs are: e.g. email, instant messaging, patient education tools and forms. Remember that there is no guarantee that even the maximum Medicare or Mediaid incentive payments will totally cover the costs of implementing an EHR.

A final suggestion would be to issue a Request for Proposal. This will structure the selection process and allows the risks and benefits to be identified clearly up front.

Private Practice Physicians - the Need to Collaborate

2011-02-14T18:20:00.000-08:00

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According to a recent article in "Physician Practice" written by Ken Terry, a staggering 40 percent of physicians say they plan to leave patient care within the next three years, according to a recent poll by the Physicians Foundation. That spells big trouble for healthcare reform and for medicine in general. If even half of that number of doctors retire, find administrative positions, or leave healthcare entirely, we’re going to have medical assistants taking care of patients and the remaining doctors tearing out their hair in frustration.

While 68 percent of the physicians who responded to the survey think the Affordable Care Act (ACA) will hurt their practices, reform is not the only factor that has made so many doctors unhappy. The continuing threat of a 30 percent reduction in Medicare fees, the increasing pressure on doctors to get electronic health records, and market forces that threaten independent practice are all on the minds of physicians these days. Thirty-four percent of the respondents said that reform is the factor that will have the greatest impact on their practices in coming years; but 36 percent named the impending Medicare cut.

Meanwhile, trends that have been gathering for years or decades are snowballing on private-practice doctors. For instance, practice expenses have long been rising faster than revenues. In that context, the Medicare cutback is only the coup de grace. And the increased hiring of doctors by hospitals, which now employ more than half of all U.S. physicians, imperils the private practitioners that are left in hospital-dominated markets. By promoting payment bundling and the formation of accountable care organizations, many doctors fear, the reform law will make it even more difficult for independent practices to survive.

This explains some of the findings of the recent physician survey:

• Eighty percent of respondents said the ACA will harm private practice;
• Sixty-eight percent opposed payment bundling;
• More than half of respondents said that reform will cause patient volume to increase, but 69 percent said they can’t handle any more patients; and
• Sixty percent said that they would close or restrict their practices to certain categories of patients. Of those physicians, 93 percent said they’d close their practices to or limit the number of Medicaid patients they treated, and 87 percent said they’d do the same with Medicare patients.

The Physicians Foundation report that includes the survey results also incorporates several case studies of practices and healthcare organizations that are pursuing various reform or alternative reimbursement models. These include patient-centered medical homes, accountable care organizations (ACOs), and concierge practices. But the study doesn’t indicate what percentage of physicians are pursuing such models. My unscientific guess is that most doctors in private practice are planning do to little beyond changing their payer mix, or, in some cases, acquiring EHRs in the hope of qualifying for the government’s ARRA incentives.

This reactive posture guarantees that physicians will be at the mercy of payers and/or hospitals during the rapid changes that lie ahead. But it need not be that way. As a recent Trendspotter points out, some physicians are forming IPAs or reviving physician-hospital organizations to take advantage of reform trends.

The AMA recently sent a letter to the Centers for Medicare and Medicaid Services (CMS), asking the agency to take a number of steps to ease the transition of private practices to the new era of accountability. Among other things, the AMA would like the government to make it easier for IPAs to bargain with payers; provide loans and technical assistance to small practices so they can join together to build ACOs; and introduce new reimbursement methods that will cover the costs of doing population health management.

What all of this reflects is the need for physicians to come together and use their clout as the real providers of care to win concessions that will preserve private practice. Unless physicians assert themselves and learn how to work with their colleagues to coordinate care and improve quality, they may soon have no choice but to join large healthcare organizations that are building ACOs or other structures capable of assuming financial risk.

So if you’re thinking about throwing in the towel, says Mr. Terry, there may be an alternative that will allow you to keep practicing medicine without giving up your independence. But it will require organization and the willingness to collaborate with your colleagues.

Doctors: 6 Gripes about the health care law

2011-01-10T14:12:00.000-08:00

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NEW YORK -- Now that health reform is law, many physicians are complaining that while it may help their patients, it doesn't go far enough to help doctors. Among their gripes, doctors say the legislation continues to leave them vulnerable to lawsuits and decreasing Medicare payments.

CNNMoney.com fact-checked their concerns and here's what we found:

We can be sued into oblivion.

Doctors' fear of multi-million dollar lawsuits is pushing them to practice "defensive medicine." More doctors are ordering additional tests and procedures not based on need but fear of liability.

The government estimates that cost of medical malpractice is less than 2% of overall health care spending. Industry experts say defensive medicine accounts for about 10% of health care costs, or more than $100 billion annually. "It only takes one multi-million dollar lawsuit to eliminate my ability to provide for my family," Dr. Andrew Morton, primary care physician.

What's in the law: The legislation doesn't impose a cap on damages from lawsuits. Instead, the law authorizes the Secretary of Health & Human Services to award five-year grants to states to test alternatives to lawsuits, including health courts and early disclosure laws.

A timely apology is all families usually want, experts say. Disclosure laws would allow doctors to apologize for errors and resolve any dispute without going to court. However experts say that apology could be admissible in any future lawsuit.

Medicare threatens to cut my pay every year.

Every year, doctors say their cost of doing business is rising much faster than what Medicare pays them. In fact, they say, payments have been falling. According to the law, a Federally mandated formula is used every year to determine payment rate based on the health of the economy. Payment rates have been cut for the past 8 years, although Congress has stepped in each year except for one to block them. This year, a 21% pay cut has gone into effect and Congress has yet to block it.
Faced with these cuts, doctors say they could stop accepting new Medicare patients or even drop existing ones. Medicare is a federally funded program that provides health insurance for about 45 million Americans age 65 or older.

What's in the law: The legislation does not provide for a permanent solution to the threat of yearly Medicare pay cuts.

Pay raise not enough.

Doctors say new bonuses mandated by the legislation are a welcome benefit but fear they could be offset by other measures.

What's in the law: Beginning in 2011 and in effect until 2016, the law established a 10% Medicare bonus payment to care providers who bill at least 60% of their charges for primary care services.
General surgeons also get a 10% Medicare bonus payment beginning in 2011 until 2016 if they practice in underserved areas.

Removal of co-pays will hurt my income.

Beginning in 2011, the legislation eliminates co-payments and co-insurance for preventive services and exempts preventive services from deductibles under the Medicare program.

Many of us are still drowning in school debt.

What's in the law: The legislation set aside $125 million for scholarships and other financial assistance in 2010. For 2011 through 2014 hospitals and other institutions will get money to boost their primary care training programs, but how much is unknown.

Insurers are still meddling in my work.

What's in the law: The legislation does not address prior authorizations.

Physician Offices Exempted From the Red Flags Rule!

2010-12-13T19:40:00.000-08:00

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On November 30, 2010, bill S 3987, "Red Flags Program Clarification Act of 2010" was introduced to the Senate and was unanimously passed. This bill provides clarity that small businesses, like physician offices, are not classified as "creditors" and therefore are exempt from the Red Flags Rule.

On December 7, 2010, the House of Representatives also agreed to the bill by a voice vote. As of that date, it was on it's way to the President's desk for signature.

S 3987 amends the Fair Credit Reporting Act (FCRA) for the purposes of narrowing the definition of the term "creditor" to include only entities that use consumer reports, furnish information to consumer reporting agencies, or to others who extend credit.

New Medical Billing Software Mandated Under Small Business Lending Act

2010-12-05T10:27:00.000-08:00

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CMS Policy for Outpatient Therapy Caps for Calendar Year 2011

2010-11-18T14:22:00.000-08:00

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Therapy Caps for 2011 will be $1,870.00. THE EXCEPTIONS PROCESS WILL CONTINUE UNCHANGED FOR THE TIME FRAME DIRECTED BY THE CONGRESS.

Rehabilitation services are included within the global part A per diem payment that the Skilled Nursing Facility (SNF) receives under the prospective payment system for the covered stay.

Limitations do not apply to any therapy services billed under the Home Health PPS, inpatient hospitals or the outpatient department of hospitals, including critical access hospitals.

http://www.cms.gov/therapyservices/

After the Mid-Term Elections...What Next for "Obamacare"?

2010-11-15T20:35:00.000-08:00

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There seems to be a concensus of opion that there was never a chance that Republican mid-term victories - even under the most optimistic projections - would or could unravel the health care reform law. Even if the Republicans had managed to capture both houses of Congress, the health care reform law was in no danger of repeal. Any attempt by Congress to repeal the bill would be vetoed by President Obama, and the Republicans lack the 67 Senate votes necessary to override a Presidential veto.

If the GOP cannot outright eliminate the law, can they render it powerless by denying it funding? The law mandates federal funding of more than 100 key components of the bill, most notably grants to states to establish insurance exchanges by 2014 as well as the $500 billion necessary to provide subsidies toward individual purchases of insurance in the exchanges. Federal taxpayers are also picking up, for the first several years, nearly all of the additional Medicaid expenses associated with the expansion of Medicaid eligibility.

Holding up the federal budget by threatening the shutdown of the government is a very risky tactic for the GOP to pursue. Many voters are weary of partisanship and are expecting Congress to make something good happen...the American electorate wants results.

It seems that some minor "revision" around the softest edges of the health care reform bill is likely. The business community is appalled at the new Form 1099 reporting requirement appended to the law. This requirement compels businesses to issue a Form 1099 to every vendor from copy repairmen to bartenders - to whom the company pays $600 or more during a year. House Republicans will likely attract enough Senate Democrats to repeal that provision.

There has been some speculation of an attempt to repeal the "Free Rider Surcharge" of the bill - i.e. the penalty employers will pay beginning in 2014 if they fail to offer affordable coverage to full-time employees who instead obtain subsidized coverage in the insurance exchanges. Business has many justifications for opposing the Free Rider Surcharge. However, if the insurance exchange concept survives until 2014 and employers find that their employees have another, taxpayer-subsidized option for health coverage available, a great many employers may simply terminate their group coverage. Although this will undoubtedly improve the business' bottom line, it could be disastrous for the nation's.

The Congressional Budget Office - in its estimation of the first decade's cost of the bill at $1 trillion - assumed only about 4-5 million Americans who have insurance today will lose it by 2019 as a result o the health reform law. One recent study suggested that the cost of federal subsidies in the insurance exchanges rises about $300 billion for every additional six million Americans who seek exchange-based coverage. If the 4-5 million person estimate balloons to 40-50 million, the first decade's costs of the program skyrockets to $2.5-$3 trillion, a number that is simply not sustainable.

We shall see.

ICD-10

2010-11-06T22:31:00.000-07:00

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ICD-10

Many of the issues we encounter today with the ICD-9 diagnosis and procedure code sets are resolved in ICD-10. Listed in the table below are some of the differences we will encounter between the two code sets:

ICD-9                                                        ICD10

Approximately 13,000 codes                   Approximately 68,000 available codes
3-5 Characters in Length                           3-7 Characters in Length
First digit may be alpha or numeric          Digit 1 is alpha, 2&3 are numeric, 4-7 are alpha or numeric
Limited space for adding new codes       Flexible for adding new codes
Lacks detail                                                Very Specific
Lacks laterality                                            Has laterality (i.e. codes designating left vs. right)

The American Asspcoation of Orthopaedic Surgeons, along with 11 other healthcare organizations, released a study conducted by Nachimson Advisors, LLC, which suggests that HHS has underestimated the cost of implementing the ICD-10 code set. According to the study results, the implementation cost for a three-physician practice could be as much as $83,290, while a 100-physician practice might pay more than $2.7 million.

The impact of this shift is substantial. Not only does the new code set include five times as many codes as the ICD-9 code set, the different arrangement of codes will require more documentation, revised forms, retraining of staff and physicians, and changes to software and other information technology. Changes in reimbursement patterns may also result from the increased specificity of the new code set.

Implementing these two requirements—the next generation HIPAA transaction standards (5010) and the ICD-10 code sets—will result in many potential costs to physicians. Among these costs are staff education and training, changes in health plan contracts, coverage determinations, increased documentation, changes to superbills, information technology system changes, and possible cash flow disruption.

In addition to billing software modifications necessitated by this momumental change, analyzing the impact of ICD-10 on a practice’s business processes will also be costly. As health plans modify their contracts to include the more specific codes, they may also alter their payment schedules, resulting in changes to a practice’s cash flow.

Analyzing the impact of ICD-10 on a practice’s business processes will also be costly. As health plans modify their contracts to include the more specific codes, they may also alter their payment schedules, resulting in changes to a practice’s cash flow.

According to the study, the move to the ICD-10-CM will increase documentation activities about 15 percent to 20 percent. This translates into a permanent increase of 3 percent to 4 percent of physician time spent on documentation for ICD-10-CM. As the study notes: “This is a permanent increase, not just an implementation or learning curve increase. It is a physician workload increase with no expected increase in payment, due to the increased requirements for providing specific information for coding. Electronic health record systems will not be able to eliminate the extra time requirement.”

In light of the unavoidable added cost to the practice due to mandated implementation of ICD-10 coding, every physician should conduct a detailed analysis of his business costs. Outsourcing the most time consuming and labor intensive administrative aspect of the practice - medical claims and accounts receivable management - could very possibly offset the income lost as a result of professional time spent on increased medical record documentation.

COST IMPACT OF THE IMMINENT HIPAA 5010 AND ICD-10 IMPLEMENTATIONS WILL BE MONUMENTAL ON ALL HEALTHCARE PROFESSIONALS!

2010-11-06T22:23:00.000-07:00

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HIPAA 5010

HIPAA 5010 is the next step towards implementing Administrative Simplification between Healthcare Covered Entities – generally Healthcare Providers, Payers and Clearinghouses. HIPAA 5010 paves the way for further standardization providing Trading Partners better communication and more efficient, less expensive business processes.Current HIPAA transactions are at version 4010A1. In January 2009, CMS mandated conversion to HIPAA version 5010 by January 1, 2012. While HIPAA 5010 is not a rewrite of 4010A1,there are significant changes. For example, the following generic enhancements have been made to all of the HIPAA standards (TR3):

Consistent TR3 formats – standardized front matter and appendices
Consistent implementation instructions
Clearly defined situational requirements
Addresses approximately 500 industry requested changes
5010 will reduce the need for Companion Guides by providing clearer instructions in the TR3 guides themselves
Major Functional Changes
Supports ICD-10 (There is no way to send an ICD-10 diagnosis code in any of the 4010A1 transactions. HIPAA 5010 supports ICD-9 only, ICD-10 only and dual usage of ICD-9 and ICD-10)
Clarifies National Provider ID (NPI) Instructions
The current 4010A1 standards give direction on how to report NPIs. 5010 states which NPI should be sent. The instructions state that a provider always reports NPI at the lowest level of specificity.

UPDATE FOR ARIZONA PROVIDERS

2010-10-28T12:40:00.000-07:00

www.managedcarealt.com

Beginning October 1, the Arizona Health Care Cost Containment System, the state's Medicaid program, has cut coverage for basic health services such as physicals, most dental care, podiatry, some organ transplants, and other programs. The state also has cut benefits for medical equipment such as insulin pumps, hearing aids, cochlear implants, computer-controlled lower limbs and joints, and other equipment. State officials say the cuts were necessary to deal with the state's budget crisis and an increase in the number of enrollees due to the bad economy. The benefits cuts are projected to save an estimated $20 million through the end of June. More than 1.3 million state residents were enrolled in this program as of September 1, 2010. For more information, visit http://www.azahcccs.gov/.

Initial Decision - Outsourced or In-house Billing

2010-10-24T19:09:00.000-07:00

www.managedcarealt.com

One of the largest decisions a Provider needs to make is whether or not to outsource his or her medical billing. This decision has to be based on whether or not an outsourced billing company can increase the bottom line of your practice.

We have been in business for over a decade now because of our success in doing just that for physicians and ancillary providers in all specialties.

Managed Care Alternatives was founded in February of 1999 by our President and CEO, Michael T. Williams. Prior to starting this company, Mr. Williams served for 11 years as Western Regional Vice-President of Arizona’s largest PPO network. Therefore, we know the tactics of the insurance plans to reduce your reimbursements and we know how to appeal those reductions successfully. With our assistance, several practices in various specialties over the years have advanced from being on the verge of closing their doors to, instead, being prosperous business entities receiving insurance payments over $1,000,000 within two years of signing a contract with us.

A competent billing service should be able to provide you with a substantial reduction in many of your day-to-day frustrations and financial challenges. These include: practice management software issues, cash flow issues due to denied or delayed payment of claims, patient requests for extended payment plans, etc. Each and every one of these issues takes your time away from the activity you were trained to do: managing and treating the healthcare needs of your patients.

Few providers realize just how much it costs them to absorb all of the expenses associated with maintaining a billing staff in-house. Payroll taxes, workers compensation insurance and health insurance premiums, and many others expenses impact your cash flow and reduce your annual income. If your billing staff is not achieving the results you expect as far as collections from insurance companies and patients are concerned, the negative impact to you and your practice is even greater.

Ask yourself the following questions:

1. Is your overall frustration level regarding your billing/business office very high? 2. Are you facing a major capital investment in new hardware or software? 3. Are you having a difficult time keeping or hiring experienced billing staff? 4. Are you spending too much time on the business aspect of medicine? 5. Are you concerned that your staff has knowledge of your income? 6. Are hardware, software, and information technology issues disrupting the operation of your practice? 7. Are you so dependent upon your office manager that if he/she were to leave, your Practice’s financial situation could be dramatically impacted – at least in the short term?

If you answer yes to most of the preceding questions, you should consider outsourcing your billing.

Another reason you might want to consider outsourcing your billing now even if you were hesitant to do so in the past is that the fact of the matter is: times are changing. The powers that be in Washington are legislatively mandating the degree to which every provider and the businesses that serve them must comply with pre-determined standards in many areas. If you don’t – whether purposefully or simply because of an innocent oversight - the financial penalties and impact on your practice will be significant.

Is your Practice in compliance with the Red Flag rule? Are you familiar with the government mandated changes for your medical office regarding the increased specificity of privacy rules and the introduction of Health Information Exchanges? Is your Practice familiar with the compliance dates and ramifications of ANSI 5010 and the conversion from ICD-9 to ICD-10?

Unfortunately, very few providers – or their employees - find themselves in the position of managing to stay current with all of the new government mandated rules or constantly changing insurance plan billing requirements. The reality is that there is absolutely not enough time…and time is your most valuable asset.

The Practice Management software we utilize for our clients’ billing is a technologically state-of-the-art, web-based program that incorporates a highly-rated Electronic Health Records component that is guaranteed to be “meaningful-use” compliant. The EHR component is completely integrated with the software we use to do our clients’ billing and completely eliminates any difficulties trying to incorporate electronic medical records from one vendor’s EHR/EMR package into another vendor’s practice management/billing software. Should you choose to utilize this product in conjunction with our billing services, you will be eligible for the government’s significant incentive payments – if, of course, you meet the governmental requirements mandated for the Provider compliance with “meaningful use” guidelines.

We can also offer you electronic eligibility verification and e-prescribing capability.

Please call us today at (602) 246-0756. We will increase the bottom line of your practice, see that you remain well aware of governmental deadlines and compliance issues, and ease the stress of daily hassles you – as a medical professional whose time is the most valuable asset you possess – should not have to experience.

Thank you.