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Patients as consumers want the highest level of medical service they can afford. Some are willing to pay premium rates for greater access to their primary care provider and more personalized medical attention. With increasing cuts in reimbursable income, more doctors are attracted to the concept of Concierge Medicine. But, given the disparities that exist in healthcare delivery, is this such a favorable trend? Our Special Report looks at all sides of this practice management concept that is gaining more currency within the healthcare profession.
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By J&C Research Associates
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Improving Patient Satisfaction and Customer Care
This edition of the Jackson & Coker Industry Report takes a different focus. A chief concern of hospital administrators and practice managers is improving patient satisfaction. After all, patients who are treated competently and have a positive experience during their medical office or hospital visit are more likely to speak favorably of the facility and of those who cared for them. Outstanding patient care results in favorable public relations, resulting in more patient visits that boost the facility’s financial bottom line.
One perspective on improving patient satisfaction is offered in our guest feature article entitled “Healthcare Means Patient Cure And Customer Service—Customer Service Really Does Matter.” It is a personal commentary written by Dale Mask, whose consulting firm provides customer service training to various industries including health care. Mr. Mask explains the importance of medical facilities treating patients as valuable consumers of healthcare services. In his view, demonstrating quality customer care is at the heart of responsible health care delivery.
A different perspective on enhancing patient satisfaction is set forth in our Special Report: “Concierge Medicine—A Growing Trend?” Simply put, some patients are willing to pay a monthly or yearly retainer—and additional fees for service—in order to receive more personalized attention, including no-wait visits, communicating with their provider via cell phone and e-mail, and other benefits associated with “boutique medicine.”
Needless to say, the concept of concierge medicine is not without ethical controversy, especially considering the fact that millions of Americans have no insurance coverage at all (see our March edition on Universal Health Care). There are other legal issues associated with transitioning a medical practice to a retainer fee-based model, especially if existing patients can no longer afford treatment.
As always, we don’t propose to have the definitive answers to hot topics debated within the healthcare profession, but we at least put the appropriate questions in proper perspective.
Cordially,
Calvin Bruce
Managing Editor
Weaning Your Hospital off Medicare
Source: HealthLeadersMedia.com
Date: 06/01/2008
The coming baby boomer retirement wave bears with it a wave of Medicare dependents for hospitals to deal with. Hospital administrators know well the difficulties of dealing with Medicare and, as such, may be reluctant to have business depend so greatly on them. So how to wean a hospital off Medicare? An article from HealthLeadersMedia.com explores a number of means to do just that.
-The article points out that consolidation among hospitals is more likely in the coming years. For instance, the states of New York and New Jersey have both determined strategic hospital closings necessary to help certain institutions thrive with lower payment levels. This consolidation wave is not likely to be solely closures and acquisitions but also agreements to cooperate among larger and smaller institutions. Under such agreements, hospitals would share best practices, financial systems, operating agreements, referral support, and even physicians and residents.
-Some forecast cuts in Medicare payouts. Faced with this proposition, some administrators actually want such cuts to occur in order to more quickly bring about solvency within the hospitals that survive the event.
-The article predicts that hospitals will be less able to work over the privately insured to cover Medicare shortfalls. The decline of “cost-shifting” should be accepted sooner rather than later, as hospitals will have to shift costs to a model that doesn’t rely as heavily on private, third-party payers.
-Some hospitals are expanding their offerings as a means of increasing revenues. This diversification leads institutions to focus less on acute care and more on outpatient and wellness care.
-Other hospitals are focusing on quality. The proposed shift to performance-based pay has hospitals focusing more on outcomes and being at the forefront of quality service. Reduced mortality and more positive outcomes, in addition to resulting in healthier patients, will result in higher pay for physicians and hospitals. Forward-looking administrators are altering institutional policies to reflect this coming reality.
-Finally, some hospitals are attempting to make patients care more about their treatment. More compliant patients—patients who follow doctors orders, show up for follow-up appointments, etc—end up placing less of a burden on the system through their healthcare choices. As a result, greater emphasis is being placed on patient education initiatives and follow ups by some hospitals.
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First Medical Tourism Guidelines Issued by AMA
Source: Occupational Health & Safety
Date: 06/18/2008
The American Medical Association adopted nine principles at its annual policy-making meeting in Chicago in order to provide the first ever guidance for patients considering traveling abroad for healthcare. According to the AMA, medical tourism is a small but growing trend in the United States, with 150,000 people heading abroad for medical procedures in 2006.
Among the nine principles adopted, the AMA suggests that patients should be referred only to institutions accredited by recognized bodies such as the Joint Commission International or the International Society for Quality in Health Care. In addition, “local follow-up care should be coordinated and financing arranged to ensure continuity of care when patients return home.”
Until the cost of care in the United States is effectively addressed, the AMA suggests that these principles will help to ensure that the care U.S. patients receive abroad is effective and safe.
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FTC: Clinic Rules Not What Doctor Ordered
Source: Chicago Tribune
Date: 06/14/2008
The FTC has deemed efforts to regulate retail clinics promoted by the Illinois State Medical Society anti-competitive and harmful to consumers. In a letter to a legislator that requested the agency’s input, the FTC indicated concern that a bill to increase regulation by requiring permits, curbing advertising plans and requiring more physician involvement would put the many retail clinics typically staffed by advanced-degree nurses known as Nurse Practitioners at a competitive disadvantage with similar healthcare facilities that are not held to the same standards.
The retail clinic model has been praised by health insurers, employers and consumer groups as a way to address the national problem of access to medical care. Unlike most doctors’ practices, most clinics are open seven days a week, twenty-four hours a day. Merchant Medicine, a Minneapolis-based research and consulting firm, suggests that nearly 1,000 retail clinics exist in the U.S. This number will likely continue to grow, as bigger retailers forge ahead with further development.
Doctors claim that their primary concern with the retail clinics is not loss of income, but proper patient care.
It is believed that the FTC’s letter will thwart the legislation, although it is unlikely that action will be taken on the bill until November.
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Debt Load
Source: H&HNMag.com
Date: 06/01/2008
Uncompensated care—including both charity and bad debt—rose to $31.2 billion in 2006, approximately 5.7% of total hospital expenses for the year. The underinsured are quickly becoming as big a source of bad debt as the uninsured. As a result, hospitals are adopting some new and controversial measures to make good on invoices.
A large and increasing amount of debt comes from the after-insurance portion of the hospital bill, as patients fail to pay the balances remaining after their insurance provider has paid. This has led to a push among hospital administrators to adopt front-end solutions. These include software that estimates—with the help of practice and payer histories— charges before treatment is administered, providing patients a firm number to expect after their insurance has paid its portion. Some also engage in up-front payments, with verification of coverage and payment authorizations performed before treatment is administered.
Controversially, some institutions are utilizing credit scores to make decisions on payment plans and eligibility for charity care. Critics cite the possible effect of such policies on the treatment uninsured patients may receive, but proponents cite the limited application of such policies and financial straits in which hospitals find themselves today.
To encourage faster payments, some institutions are making portals for online payments available to patients. Adventist Health Services expects some 10% of patient payments within its system to be online by the end of 2009, up sizably from 2.7% in 2008.
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Minnesota Adopts Bill Creating Medical Homes
Source: amednews.com
Date: 06/16/2008
In May, Minnesota adopted a bill designed to boost preventative care through new types of physician payment, care coordination, and health information technology. Supported by the Minnesota Medical Association, the bill offers patients the opportunity to choose a medical home and provides publicly and privately funded pay for physicians to coordinate care. The care coordination payment is intended to encourage doctors to see fewer patients in their office but give better care to more patients over time by communicating with them more over phone, email, in group settings or through an office care coordinator. The e-prescribing provision requires all physicians to send prescriptions electronically by Jan. 1, 2011; however, the act does not include funds to help physicians adopt e-prescribing. The standard for qualification as a medical home is not due to be spelled out until July 2010.
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Universal Healthcare Momentum
Source: Physician’s News Digest
Date: 06/01/2008
Continuing the trend of individual states acting to solve their healthcare woes on their own, a universal healthcare bill is making its way through the New Jersey State Senate. The first part of the bill, two years in the making, has passed the Budget and Appropriation Committee as well as the Health and Human Services and Senior Citizens Committee. Proponents look to get final passage in both houses by June 30th and begin passing the second part of the bill soon thereafter.
The bill, proposed by State Senator Joseph Vitale, expands eligibility and outreach for New Jersey FamilyCare, establishes a coverage mandate for children, and reforms aspects of the individual and small employer healthcare markets. The second phase will create a state-managed, commercial grade plan for all residents of New Jersey and a collaborative care system for the remaining uninsured.
The plan was assembled over two years with the aid of 20 experts in the field. It also includes reforms aimed at allowing premium differentials to young adults making up to 350% of the poverty level. People on individual plans would be protected from rate hikes limited to 15% annually.
Concern expressed by physician groups point out possible spikes in healthcare utilization in underinsured areas after the passage of the bill, possibly overwhelming the health worker infrastructure in such areas. This, they warn, could result in physician migration to avoid forced participation, which would deprive already needy areas of even more healthcare workers. Proponents point to the need to address underinsured and uninsured citizen needs as overriding these concerns.
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Barcode Systems to Reduce Hospital Drug Errors Not Foolproof
Source: MedPageToday
Date: 07/01/2008
Designed to prevent drug errors in hospitals, the barcodes that are supposed to match up drugs and dosages with patients may themselves be subject to errors, according to a study performed by University of Pennsylvania researchers.
The study of barcodes use in five hospitals found nurses overrode alerts indicating problems in 4.2% of patients, which accounted for 10.3% of all medications ordered. The study also found instances of inability to scan codes or correctly use them among nurses.
The study monitored barcode usage in one 470-bed academic tertiary care Midwestern hospital and four hospitals that are part of a 929-bed healthcare system. The researchers shadowed nurses, interviewed staff about systems, and looked at reasons given for overrides.
The study found 15 ways of working around barcodes, including duplicate patient ID bands carried on nurses’ wrists, nurses carrying numerous pre-scanned meds at once, and nurses disabling system alarms so as not to disturb patients. These opened the door for any number of medical errors.
The study found valuable benefits to the use of barcodes despite these troubling flaws. The study authors counted 23,828 alerts resulting in user change rather than user override. These findings are generally in keeping with previous studies indicating deviation from protocol and human error as the primary factors in system flaws.
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The Administrator’s Desk: Dealing With PTO Time
Source: Physician’s Practice
Date: 06/01/2008
The old practice of delineating specific numbers of days for vacation, personal, and sick leave is, in some cases, giving way to a new system of Paid Time Off (PTO) hours from which employees can draw at their discretion. While easier and more flexible for employees, this can present a headache for administrators if improperly implemented. An article in Physician’s Practice examines some ways to keep PTO policies straight and your office productive.
PTO presents a number of possible benefits for practices implementing such policies. PTO, for example, eliminates the administrative chore of tracking reasons for absences. In addition, it minimizes unscheduled absences on the part of employees since they no longer have to call in. In a 2007 study of business with PTO plans, it was found that illnesses account for only 34% of absences, with the vast majority made up of an assortment of personal reasons other than illness. The study also found that PTO banks are the best tool for controlling absence according to employees working under such systems.
Problems are possible with the PTO model, however. Some employees, in an effort to retain as many days off as possible, may come into work sick, running the risk of infecting others. Employees also run the risk of blowing through all time off earlier in the year, leaving no time for eventualities later in the year. If an employee has run through her time off in the first half of the year and falls ill during flu season, administrators will need to add additional sick days for that employee, which can result in staffing and scheduling problems. The author recommends making sure employees are aware of this possibility and that they plan to keep at least five days in the bank in case they are needed.
The article recommends striking a balance between rollover and expiring leave in order to keep employees from “squirreling” away leave hours and eventually leaving the practice short staffed for a massive vacation. As to the total amount of leave to give employees, the article suggests this figure be based on the individual needs of a practice. It is not uncommon for employees to have 14 days of leave in their first year and up to 27 days leave depending on how long they have worked with the practice. Policies should be structured with the dual goals of presenting a positive recruiting tool for potential employees and offering one’s staff a variety of choices for their time off.
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Employment & Compensation
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No Cash? No Insurance? No Problem: Dermatologists Barter for Business
Source: Dermatology Times
Date: 06/01/2008
In the face of numerous clients without insurance or the ability to pay directly, some dermatologists are returning to the barter system. An article in the June issue of Dermatology Times examines the phenomenon.
The system works due to the foundation put in place by International Monetary Systems’ Barter System—a nationwide network offering barter networks in 50 markets in 18 to 20 states. IMS maintains the network and manages administration of transactions. Clients pay in “barter” dollars, which are transferred by the payee to IMS, which then does the taxes and processing so the dollars are treated like real income. Barter dollars are then usable by the recipient at any participating merchant. In this manner, $300 received for a dermatology procedure can become a $250 car repair and a $50 dinner.
The barter system, according to participants, allows for a number of benefits. Chief among them is an expanded clientele, as the system brings in small business owners who might not have otherwise come in due to lack of personal insurance. This can result in “free” dinners, advertising services, or any number of other services. Doctors are able to trade services with other doctors on the barter system as well, and the system on the whole is regarded as resulting in cheaper, almost wholesale priced goods purchased through barter for participants.
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The Online Healthcare Marketplace: Providing Physicians with a New Revenue Stream
Source: Physician’s Money Digest
Date: 05/30/2008
In June, American Well Systems will sell an online healthcare marketplace product to health plans, which will in turn brand it and make it available to their membership and provider networks. The online healthcare marketplace dissolves the two sticking points for managing fees: physicians do not need to handle co-pay retrieval because payment information has been received and checked against clearinghouse information and the eligibility of an individual’s claim has already been adjudicated before the patient can interact with the provider. Members will be able to contract providers from home; but perhaps more significantly, providers will be able to determine how much, how often and when they will provide services on the system.
Providers will have access to a patient’s history and can decide to not engage with a patient if they feel uncomfortable handling the complexity of the patient’s health. To protect providers against legal suit, providers with the American Well service are covered through the Lexington Insurance Company. It is believed that this new service may allow doctors to become less attached to a particular physical spot, may enable doctors to retire earlier by providing physicians a new revenue stream, and may enable retired physicians to make some money in their retirement.
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AMA Calls Physician Reimbursements Flawed
Source: Los Angeles Times
Date: 06/17/2008
As part of a campaign to reduce inefficiencies in claims payments, the American Medical Association released a report on Monday, June 16th that attempted to “quantify the red tape and hassle that have sent many physicians into cash-only ‘concierge’ practices or early retirement.” According to this report, insurance companies add more than $200 billion a year to the nation’s healthcare tab by failing to properly reimburse doctors. While Medicare paid the set fee 98% of the time, outperforming commercial providers in many areas, there was a great deal of difference in the extent to which private companies paid physician’s bills.
According to the report, 14% of the fees that doctors receive from insurers and Medicare are spent on the process of collecting these fees. Both the insurance providers and physicians are held responsible for administrative waste and inefficiencies; while insurance companies point to significant lag times between the provision of services and the submitting of a claim, physicians note a delay on the part of the insurance company in telling doctors that they need additional information to process a claim. The report concludes that improving the processing of medical claims could reduce the overall cost to patients. The expansion of automated and electronic claims payment is cited as an effort to this end. The AMA holds the banking industry as a model for the health industry to follow.
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Medical Ethics: Patients’ Needs Versus Maximizing Income
Source: Medical Economics
Date: 05/01/2008
The conflict between patient needs and practice income presents a problem for doctors as patients merit the best possible care, but doctors need to repay education debts and generally survive financially. An article in the May issue of Medical Economics examines the ethical conflicts arising between pay and proper care.
With Medicaid cuts a likelihood, physicians—especially primary care physicians, who are generally paid less for equally time-consuming work—are less and less likely to take on Medicaid patients. This, the article judges, constitutes less an ethical conflict than a matter of survival. The trend is not without repercussions, however. As a consequence of fewer total doctors accepting Medicaid, those doctors still seeing Medicaid patients are likely to see more patients.
Doctors may also be tempted at times to perform more tests on patients than necessary. This could result from doctors not giving up, or doctors making sure all bases are covered; but it could also stem from an attempt to boost practice income. Ethicists see this as “revenue enhancement,” which can affect referral habits as well. Physicians could wind up referring to certain clinics in order to get per-referral pay. This changes the physician-patient relationship to a solely buyer-vendor relationship and imposes risks from unnecessary interventions on the patient as well as saddling the patient or payer with unnecessary costs. This is ethically unacceptable.
To save money and time, some doctors may also not inform patients and their families of experimental or costly treatments if they believe there to only be a slim chance of the treatment helping the patient. This is not viewed by the article as an ethical violation, per se, as doctors are not obliged to play hero or inform of treatments they deem futile; but to be safe, full disclosure of possible treatments is generally the way to go.
Dropping, or “divorcing,” patients is another option that some doctors use as a last resort. This happens sometimes due to noncompliance, nonpayment, or inappropriate behavior on the part of the patient. The article claims there is solid ethical ground for such actions so long as the patient is provided prior notice of the “divorce,” alternative treatment recommendations, and emergency care if needed. Overzealous “divorcing to improve Pay For Performance numbers,” however, is an ethical misstep.
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Posting Malpractice Payout Records Evokes Big Outcry
Source: The News & Observer
Date: 07/01/2008
A move by the North Carolina Medical Board to post malpractice data met with stiff resistance from physician groups. The decision made by the North Carolina Medical Board to post malpractice payouts going back seven years on its web page was in keeping with similar decisions by 25 other states but has met with protest from doctors, hospitals, lawyers, and insurers.
Critics contend that disclosure of old malpractice decisions violates confidentiality clauses in some agreements and could potentially expose patient information and the names of plaintiffs were resourceful net browsers to cross-reference doctor names with legal cases. Proponents cite the legal precedents for the posting, pointing out the lack of success of legal challenges in other states. Proponents also cite testimony from malpractice plaintiffs whose procedures were performed before the advent of such systems. These plaintiffs contend that they could have been much helped in making decisions on doctors had such information been available to them.
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Boundary Concerns in Clinical Practice
Source: Psychiatric Times
Date: 04/01/2008
In psychiatry, the ethical lines governing therapist-patient interactions are a possible stumbling block for many a therapist. Unwitting transgression of even one boundary can result in a damaged therapeutic relationship or, worse, disciplinary action. An article in Psychiatric Times examines the potential boundary minefield and offers some helpful advice on negotiating patient interactions without crossing any ethical boundaries.
The author sets out the parameters of therapeutic boundaries, describing them as ill-defined at times and subject to judgment and interpretation. Boundaries depend in part on context, so even the following of a patient into a public restroom may be acceptable if done in the context of furthering the treatment paruresis and with the full consent of the patient.
The article sets out the difference between boundary crossings—slight deviations from established protocol with benign results and intent—and boundary violations—full transgressions of particular ethical guidelines on the part of either the patient or therapist. Crossings, such as offering a patient a ride in inclement weather, can still be sizeable offenses if proper ethical precautions are not taken. In contrast, violations are harmful to the patient—for example, entering into a sexual relationship—and should be avoided at all costs. In the event of a violation, steps should be taken immediately to inform the necessary governing bodies of ethical lapse and redress any wrongs.
The article concludes by calling for increased awareness of boundaries and their underlying issues as well as careful documentation of all patient interactions and maintenance of a low threshold for consultation.
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Med Mal Case in St. Louis County Circuit Court Challenges Doc’s Privacy
Source: Cunningham Group
Date: 06/18/2008
A doctor charged with medical malpractice in a pending suit has challenged the plaintiff’s attorney’s attempts to gain access to records concerning the doctor held by the State Bureau of Narcotics and Dangerous Drugs, the Missouri Physicians Health Program, and the Board of Registration for the Healing Arts; specifically, drug test results and medical reports shared among the agencies. Dr. Michael Impey was disciplined by the Missouri Healing Arts Board, losing his authority to write certain prescriptions.
The plaintiff’s attorney, Paul Passanante, claims that these records are relevant to the case in that they establish that the defendant was still a drug addict at the time of what his client claims was a botched colonoscopy. Passanante argues that these records are not protected by doctor-patient confidentiality as they were part of public testimony and pertain to felonious conduct.
The defendant’s attorneys, lead by Robert Rosenthal, claim that such would infringe on his right to medical privilege, and that such privilege cannot be waived by testimony not provided voluntarily. They also claim that the plaintiff is trying to reach beyond the facts of the malpractice.
The outcome will help determine the reach of privacy of medical information in medical malpractice suits.
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Doctor Put on Hold, Hangs Up, Patient Dies
Source: InjuryBoard.com
Date: 06/10/2008
A radiologist who decided to hang up the phone and fax a report of life-threatening blood clots after being put on hold when trying to contact a patient’s doctor will be held liable for the death of the patient. Rejecting jury instruction, the Virginia Supreme Court decided that the radiologist could not blame the treating doctor for the death of Tawanda Williams by pulmonary embolism.
The radiologist, Cong Le, concluded that Williams had deep vein thrombosis, a dangerous but treatable condition. After Le faxed the report, he neither attempted to contact the patient, whose contact information he had, nor attempted to call back to Kaiser. The information that Williams had a life-threatening blood condition was not acted on by her doctor, and she died six days later.
The Supreme Court determined that Le was ultimately responsible for the communication problems and that this responsibility was not mitigated by the doctor’s failure to read his fax. A new trial will be held in the spring of 2009.
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Private Psychiatrists Offer Free Services to Troops
Source: Associated Press
Date: 05/25/2008
A recent private study estimated that 300,000 troops have post-traumatic stress disorder, and including family members, the number balloons to one million. Although the members of the military and those related to them are experiencing mental health problems on a scale not seen since Vietnam, the military only has one mental health professional in uniform for every thousand troops. While the government has attempted to hire more therapists, it is believed by many that the government does not have the capacity to address the growing need for mental health services on its own. In fact, a recent report by a yearlong task force at the Pentagon concluded that the Pentagon “has neither the money nor staff to support the military and family mental health needs during peacetime, let along [sic] during war.”
Thousands of private therapists have provided free services to troops in an effort to fill the void. Programs such as “Give an Hour” encourage mental health care professionals to make long-term commitments to donating free services to troops. While 1,200 people currently volunteer for this program, its head hopes to find 40,000 volunteers over the next three years. Other volunteer programs intended to promote the mental health of soldiers include “Soldier’s Project” which operates in L.A., Chicago, New York and Seattle, and the “Coming Home Project,” which is based in San Francisco.
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The Crisis of Primary Care Physicians
Source: The Boston Globe
Date: 05/29/2008
As primary care loses its attractiveness as a profession due to poor compensation and plummeting job satisfaction, primary care doctors are quitting and medical students are pursuing other specialties, resulting in a dearth of primary care physicians.
One primary care doctor suggests the system sets the patient and the doctor against each other by requiring primary doctors to serve too many patients; the result is that the patient feels disrespected and under-cared for and the doctor feels overwhelmed and ineffective. In a situation in which appointments are rushed and the doctor does not know her patients, “more medical errors occur and more resources are wasted as expensive tests are substituted for communication.”
To amend this situation, Annie Brewster, an urgent care physician at Massachusetts General Hospital, suggests that reimbursement should be restructured in order to favor more communication, care coordination, disease prevention and chronic disease management. Rather than basing incentives on patient volume, patient incentives should be based on efficient resource use and quality outcomes. Finally, it is suggested that the role of primary care physicians should be re-envisioned to include team leader and patient advocate.
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Intensivists Bring Experience to Critical Care Medicine
Source: Managed Healthcare Executive
Date: 06/01/2008
The Intensive Care Unit is arguably the most significant hospital section due to the constant life and death situations that occur within. Yet, the ICUs of the nation tend to be lacking in intensivists—specially trained, multidisciplinary doctors who coordinate ICU teams in a manner commonly beyond regular physicians.
Studies show that the quality of care in an ICU is highly dependent on the presence of an intensivist. Still, intensivists are present in only 20% of US ICUs. This is due to the cost of an on-staff intensivist as well as a general lack of the specialists in the field. A lack of intensivists in an ICU can raise the price of ICU care, though adding them can add millions to the hospital budget. Further, numbers of intensivists coming out of medical schools have been and are expected to remain flat for some time to come.
As a result, some hospitals have taken to using telemedicine to staff their ICUs with intensivists. Intensivists staff Advanced ICU Care’s ops-center and monitor ICUs around the country over the internet. For emergencies, the intensivists alert the on-site staff and issue directions for them to follow.
The article contends that an intensivist presence can result in lowered predicted mortality and length-of-stay for hospitals that have them. Studies show a 40% reduction in ICU mortality and a 30% reduction in general hospital mortality in facilities with an intensivist on staff. If the length of stay reductions remain true for an institution, having an intensivist on staff could very well result in lowered costs, since the hospital ends up spending less while they keep patients around for shorter times.
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The ‘Secret’ World of Prison Medicine
Source: Ob. Gyn. News
Date: 06/01/2008
Physicians who work in correctional settings suggest that this occupation can be ideal for physicians with an interest in public health. First, they note that the ability to affect inmates’ health and well-being is significant. Second, providing successful health care in the jails takes stress off of other parts of the health care system, as former inmates who receive good care are less likely to use episodic care and more likely to practice preventative health care. Third, health providers in correctional facilities have the opportunity to teach behaviors that stem the spread of communicable diseases like Hepatitis C and HIV. Often, health care providers are safer than custody staff, as health care providers are viewed by inmates as sources of care.
Working in a prison is not without its challenges, such as tight resources and anger from individuals who do not understand why prisoners receive health care when so many are uninsured. However, for those who value the chance to perform effective preventative medicine and are concerned with responsibility to the community, the world of correctional medicine proves a secret that many health care professionals who work within prison walls hope gets out.
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Payer & Reimbursement Issues
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CMS Needs to Improve Oversight of Supplemental Payment Programs
Source: HealthcareFinanceNews
Date: 07/01/2008
The Centers for Medicare and Medicaid Services is doing an insufficient job monitoring payments doled out through supplements to its Medicaid program, according to a report from the U.S. Government Accountability Office. The report urges expedition of efforts to issue a rule implementing additional reporting regulations for Disproportionate Share Hospitals (DSH).
This comes in light of recent and prolonged troubles for the Medicaid system—widely acknowledged to be approaching fiscal insolvency—which the GAO also says needs to better track and review state supplemental payment programs, in which states make supplemental payments to certain providers. These payments are then matched by the federal government. Supplemental payments by states amounted to $23 billion in 2006, of which $17.1 billion was for DSHs.
CMS responded to the GAO recommendations by claiming that the agency is in the process of updating its reporting requirements and implementing the requested rule. No plans were reported regarding state reporting of DSH payments on a facility-specific basis.
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Health Plans Look to the Internet as the Future
Source: StrategicHealthcare.com
Date: 06/01/2008
According to one Blue Cross / Blue Shield representative, everything the healthcare giant does now has a web component. Health plans are increasingly integrating web services into their operations models. An article on StrategicHealth.com examines the ways they’re going about it.
The article identifies six important drivers and trends likely to shape the future of the industry going forward:
-Demand for Lower Healthcare Costs: Plans are using the internet to handle administrative tasks, reducing paperwork and transaction times. The national crisis over prices is making innovative internet cost-saving measures a must.
-Growing Consumerism Movement in Healthcare: The internet is the best channel for plans to deliver information about services, costs, and data on providers. The additional services they can provide result in a product better suited to the increasingly consumer driven market, in which consumers are likely to shop around much more.
-Move to Online Health Records: Health plans are taking the lead in payer-based community health records.
-Increasing Transparency in Healthcare: Payers are increasingly using web info-mediaries to collect, analyze, and communicate quality outcomes and pricing data to consumers.
-Interest in Pay-for-Performance Programs: Incentives such as rewarding consumers for completing online health risk appraisals and health coaching sessions are increasingly in use by payers looking to cut down on the amount doctors have to do beyond treatment and thus cut costs.
-Expanding Government Influence: The government is pushing IT solutions to the healthcare crisis as much as anyone else. Payers are stepping into the leadership roles created by the government and capitalizing on the federally-funded momentum for IT solutions.
The article suggests that plans, due to their nature, are uniquely suited to the virtual world. The internet lowers costs and can result in improved care and better providers. Thrivers in the coming digital world of insurance will be the companies that take advantage of the situation soon.
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New Medicare Rule Ensures Access to Healthcare for Beneficiaries in Rural Areas
Source: Medical News Today
Date: 06/01/2008
Medicare coverage would be extended to services obtained at Rural Health Clinics (RHCs) for the benefit of rural Medicare beneficiaries under a new rule proposed by the Centers for Medicare and Medicaid Services.
The proposed regulation requires RHCs to establish quality assessment and performance improvement (QAPI) programs as well as establishing requirements necessary for RHC participation. Payments to RHCs will be limited to 80% of reasonable costs minus beneficiary co-insurance and deductibles.
The rule would also:
-Implement requirements that the RHCs be located in non-urban areas demonstrating a shortage of healthcare workers.
-Clarify commingling and resource sharing regulations.
-Implement requirement of QAPI programs
Further information on the rule is available in a CMS fact sheet available at www.cms.hhs.gov.
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Public and Private Health Insurances: Stacking up the Costs
Source: Health Affairs
Date: 06/01/2008
Total medical spending for lower income citizens would be lower under public programs than under private insurance, according to a study in the June issue of Health Affairs.
The study was based on analysis of the 2005 Full Year Consolidated File of Medical Expenditure Panel Survey. It examined non-elderly adults and children in families with incomes under 200% of the poverty level. The study focused on Medicaid and SCHIP-insured, uninsured, and privately insured respondents and the healthcare spending levels of those covered.
The study’s major findings included:
-Adults on Medicaid were more likely than privately covered individuals to be in fair or poor health, have fair or poor mental health, and have limited activity, chronic health problems, or have experienced pregnancy.
-Adults with Medicare showed higher spending than privately insured individuals due to their higher likelihood of serious health conditions. The uninsured had the lowest spending levels due to less help sought.
-If the average adult were covered privately instead of by Medicaid, spending would increase $1,500 per year, or 26%. Out of pocket expenditures for that same adult would increase 559%.
The study’s findings indicate that low income families are better served by expanded government funded policies than by tax incentives for private policies. This would be less costly to society and the beneficiaries of the policies if enacted on either the state or national level.
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Aetna, Cigna Rank Highest in Efficiency
Source: The Wall Street Journal
Date: 05/29/2008
A national survey of health plans and their dealings with physicians issued by AthenaHealth Inc., which sells electronic business services to doctors and medical groups, ranked Aetna as the most efficient health insurance provider among 130. Aetna was found to be least likely to deny claims, quickest at resolving claims and the fastest to pay doctors. Cigna ranked second in overall performance. The lowest ranked commercial health insurers were WellPoint Inc and UnitedHealth Group Inc. The survey relied on administrative, medical policy, and financial data from 2007 from 13,000 providers.
On average, in 2007, it took Aetna 27 days to reimburse physicians for their claims. UnitedHealth, on the other hand, averaged a 35 day lapse. Aetna claims that its improved efficiency is due to investments in technology and better clarification of policies with participating doctors.
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Doctor Opens No-Insurance Practice
Source: bangordailynews.com
Date: 06/16/2008
In an effort to simplify the payment process, in July 2008, a family medical practice in Bangor, Maine is instituting the policy that payment is required at the time of service. While the head of the practice, Dr. Karen Hover, will help patients seek reimbursement from their insurers, she will not accept payments from Medicare, MaineCare or private insurance companies. Hover believes that billing insurance companies adds an unacceptable level of bureaucracy and expense to the medical profession. While large multi-provider practices can pay for the small army that is required to undertake this complex billing procedures, the cost of billing for solo practices can be prohibitive. Further, Hover argues that the complexity produced by the sophisticated billing arrangements detracts from care. Hover believes that streamlined fee schedules can be reassuring to the uninsured and attractive to those with high deductibles.
While few doctors have opted to “drop-out” like Hover, the complexities of billing have pushed many doctors to join offices where billing is handled by a centralized staff. With the general push in the medical community away from episodic management, there is reason to believe that we will not see many doctors follow Hover’s footsteps in the future as such micro-practices are ill-equipped to provide the preferred alternative, comprehensive health management.
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Credentialing, Licensure, Quality Management
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Ensuring—and Tracking—Physician Competence
Source: New England Journal of Medicine
Date: 06/01/2008
Continuing Medical Education and instruction with the most up-to-date medical knowledge are essential for ensuring patients are given the best possible treatments. Recognizing this, major initiatives by professional organizations and oversight bodies look to change the certification maintenance and licensure processes to ensure that doctors keep learning throughout their careers.
The American Board of Medical Specialties, the American Board of Internal Medicine, the Federation of State Medical Boards, and a number of other organizations are embarking on competency evaluation initiatives. This move comes in light of studies showing only half of patients are treated according to current best practices, along with evidence of physician performance decline over time.
Licencing and certification maintenance organizations are embracing a Continuous Quality Improvement approach to Maintenance of Certification (MOC). Such an approach requires evidence of continuous learning, practice performance, and improvement in three- to five-year cycles.
All 24 ABMS member boards have submitted MOC plans. The Accreditation Council for Graduate Medical Education has developed Learning Portfolio—an interactive, web-based development tool which will be mandatory. Such tools are meant to allow for physicians to distinguish themselves among their peers as well as providing a “career GPS” for participating physicians.
At the same time, improvements have also been made in Continuing Medical Education. The Accreditation Council for CME released new standards for accreditation, requiring programs focus more on improving Pay for Performance and patient outcomes. Acknowledging the preexisting accreditation, certification, and licensure burdens already placed upon physicians, these groups, working in concert, have the eventual aim of reducing redundancies and streamlining the requirements of their new programs in order to place less of a burden on present and future doctors.
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Networking Sites Become the New Doctors’ Lounge
Source: Managed Healthcare Executive
Date: 01/01/2008
Due to patient loads and the burdens of modern practice, doctors see less of each other all the time. Most practice in groups of five or less and rarely visit their affiliated hospitals. Still, peer-to-peer interaction is necessary for a healthy physician community. Increasingly, doctors are turning to the internet to communicate with their peers.
Prominent among a new crop of physician-oriented social networking sites is Within3, a professional community for physicians, health science researchers, and other healthcare workers. The site now boasts membership from 60 different countries with members representing 125 different specialties. Forty thousand of its members are doctors, with another one to two thousand added each week. The site utilizes real-time authenticated credential-monitoring to maintain a physician exclusive community.
These networks aid in community cohesion and foster consultation and collaboration, which result in projects such as WikiHealthcare, a user-editable healthcare corollary to Wikipedia. Powerful tools such as these are likely to only increase in popularity as the internet becomes more and more integrated with healthcare. The site creators claim they look to be the future of collaboration and consultation in an increasingly connected world in the years to come.
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Funding is Key to Turning Govt’s IT Goals into Reality for Many Hospitals
Source: AHANews.com
Date: 06/01/2008
The plan put forward by the Department of Health and Human Services to achieve a national Information Technology Health Infrastructure aims to provide higher quality care at lower cost and use electronic information to benefit public health, biomedical research, emergency preparedness, and overall national healthcare quality. IT pros around the nation hail the plan but with caution, warning it absolutely needs federal level funding to succeed.
A report released in 2007 by the American Hospital Association reported that 97% of hospitals say the initial costs are either significant or somewhat significant barriers to adoption of an IT healthcare solution. Eighty-seven percent report that the ongoing costs following implementation would constitute a barrier.
Cost is widely regarded as a primary barrier to Electronic Health Records adoption around the nation. Fifteen percent of hospitals in the U.S. have EHRs. That figure, though low, is up from 11% in 2006. The hospitals having implemented EHRs, however, are mostly large, urban, teaching hospitals with more access to capital than their smaller rural counterparts.
Hospital IT pros around the country hold out hope that the next administration will seriously look at the IT proposals and adopt the funding necessary. Otherwise, they say, the plan will remain just a plan.
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Seattle Startup Firm to Build Online Physician Community
Source: iHealth Beat
Date: 06/16/2008
IMedExchange plans to launch a website in June that is intended to allow physicians to openly exchange medical and business advice as well as discuss other personal pursuits. Most of the $2.5 million in funding comes from physicians; the company’s advisory network includes 225 physicians.
IMedExhange’s website will compete with other online medical exchange sites such as Sermo, RelaxDoc, and Within 3. Unlike Sermo, which generates its revenue through subscription fees, IMedExchange plans to generate revenue through advertising. The company aims to sign up 75,000 physicians by 2010.
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Physician Practice Management
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Loss of Patient Information at University Hospital Reveals Risk of Acquiring Physician Practices
Source: AIS’s Health Business Daily
Date: 06/17/2008
A plastic surgeon at the University of Florida-Jacksonville who donated a computer with unsecured personal information on and digital images of his patients and then lost the data when the operating system was removed has brought the risks of acquiring physician practices into relief. Although the surgeon’s computer no longer technically belonged to him after the purchase of the practice by the University, and the University took steps to ensure compliance with the University’s privacy and security policies, the fact that he had personally acquired the computer prior to joining UF may have encouraged the mindset that the computer was “his.” In addition, years in private practice may have encouraged resistance to the university’s privacy and security policies, which do not allow the storage of personal health information (PHI) on any P.C. and which require P.C.s to be disposed of through secure methods.
UF notified 2,000 of the surgeon’s patients and issued a press release describing the incident. While the family to which the surgeon donated the computer claimed they did not view the data, no “malicious intent” was found, and it is often the case that first-time offenders are retrained and allowed to continue working, the plastic surgeon ultimately resigned from the physician group and from his teaching position at UF’s College of Medicine in Jacksonville. In order to prevent such a violation from occurring again, the University has retrained the surgeon’s colleagues and staff, and policies are being reinforced throughout the wider community. No university-wide policy changes were made.
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Re-Examine Your Disability Insurance Policy
Source: Physician’s News Digest
Date: 06/01/2008
After years of limits on disability benefits in physician’s disability policies, momentum now seems to be behind a movement to add more benefits. An article in Physician’s News Digest details some reasons physicians might want to re-examine and renew their disability policies.
The article details the so-called “golden years” of the 70s and 80s, when numerous companies offered a multitude of policies with strong, occupation-specific definitions of disability, with higher purchase and payout limits as well. This changed with the advent of AIDS in the late 80s, leading companies to scale back offerings or face hundreds of millions of dollars in potential payouts. Blood and urine tests became the norm for policy approvals as well.
In recent years, though, there has been a shift back towards more physician-friendly policies. Own Occ—insurance geared toward providing in the event a physician suffers an injury limiting or ending his ability to perform his medical specialty, which pays out at the same rate regardless of whether a new field is chosen—has made a comeback, with five companies now offering the option. In addition, catastrophic disability benefits—which provide additional benefits in the event of an injury that leaves a physician unable to perform basic life tasks—is also now offered by a number of companies.
Companies now offer higher issue limits as well, with amounts payable per month having increased from $10,000 a few years ago to $15,000. Higher participation limits are also the norm. Disability insurance companies are now participating to a greater degree in other companies’ insurance policies. Most disability policies offer up to $15,000 per month for their own policies, but in combination with another company’s policy, the payout goes to $20,000 per month.
After disappearing in the 80s as companies cut costs, true lifetime benefits are making a comeback. These will pay disability to a physician even after retirement, though exceptions exist as to payout levels depending on when the disability-causing accident occurred.
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Small Practice Evolution: Making the Switch to Concierge Medicine
Source: Medical Economics
Date: 05/01/2008
Seeing 3,000 patients at a single practice is, by most measures, a sign of success. So why would any doctor make moves to drastically reduce his clientele? An article in Medical Economics examines the rationale behind such an odd course of action.
The article examines the practice of Pittsburgh pediatrician Scott Serbin, who shrank his practice from more than 3,000 patients to around 300, improving patient relationships and his own enjoyment of the practice in the process. Serbin fits well into a smaller market niche known alternately as Direct, VIP, Boutique, or Retainer Practice. In such arrangements, patients pay an annual fee to keep a doctor essentially on retainer for a year. As of recent, the market has remained small, as the annual fees remained outside the reach of lower and middle income families. As prices drop, however, some expect that so-called “Concierge Medicine” could eventually come to be the primary service for 80% of Americans.
The model is not for everyone, though. The nature of Concierge Practice limits its viability to primary care physicians. It also favors doctors with an already installed sizeable base from which to choose clientele, though this is not necessarily a hard rule.
Concierge Practitioners also need to be prepared to take a financial hit, at least initially, with 30% revenue declines not unheard of as business sorts itself out. An affinity for house calls and more personalized care is also a desired trait. In the end, such an arrangement can result in better service for the patient and increased happiness for the physician.
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