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By J&C Research Associates
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Doctors’ Personalities and Job Performance
In last month’s edition of the Jackson & Coker Industry Report, we spotlighted
research related to factors that impact career satisfaction among physicians.
This month, we take a look at personality testing as it relates to predictable
behavior, findings that can apply to medical practitioners.
Our special report, “Personality Tests and Predicting Physician Behavior,”
discusses the types of personality tests available and how they relate to
general personality assessments and medical specialty career assessments. The
value (and limitations) of such testing procedures for physicians and employers
are discussed in the report.
Next month, we will make available results of a survey entitled “Do You Know
Your Personality Type?” A “coming attraction” announcement in this edition
provides more details concerning this complimentary assessment that readers of
JCIR will be able to take online at their convenience in just a few weeks from
now.
Finally, we are pleased to mention a new feature of our newsletter. “Readers’
Forum: Discussions in Healthcare” will focus on timely topics of general
interest to the medical community. Feel free to share your professional views by
participating in the ongoing discussions at your leisure.
Cordially,
Calvin Bruce
Managing Editor
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In terms of basic personality traits, are you “forceful, direct,
results-oriented”? Or perhaps “steady, patient and relaxed”? Or maybe your
fundamental make-up is a mixture of these and other personality types.
Next
month, you will have the opportunity to take a quick online personality
assessment, free of charge. The assessment only takes 10-12 minutes to complete,
and the confidential results will describe your unique personality profile as it
compares with other practitioners in your specialty. With this information in
hand, you can better understand how your personality type impacts your personal
and professional job satisfaction, as well as your working relationship with
colleagues.
Here are remarks of an Anesthesiologist who has taken the
assessment:
“Everyone has to work with others, in small or large groups or
teams. Would you like to understand yourself better so you can become more
effective with those with whom you work, and at the same time, experience more
personal satisfaction? One way is to better understand what we as individuals
bring to the team. DISC is a simple tool to help us to do just that. Give it a
try. It only takes a few minutes and a personal report is generated. It has been
a tremendous help for me.”
Jerry H. Titel, MD, MBA
VP – Medical Affairs
Premier
Anesthesia
Jackson & Coker is pleased to offer this complimentary
self-assessment and appreciates in advance your enthusiastic participation!
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Readers’ Forum: Discussions in Healthcare
There are many timely issues related to the health care industry. In addition to
the topics covered in our regular newsletter content, a new feature will address
important matters in a reader-interactive format. We invite you to participate
regularly in our Readers’ Forum and voice your views on lively discussion topics
such as “Revamping the Health Care System.” We welcome suggestions of topics
that would enhance our ongoing discussions and appeal to a broad segment of the
health care community.
Facing Forward: Cleveland Clinic Performs First U.S. Transplant; Ethical Concerns Remain
Source: Dermatology Times
Date: 02/01/2009
Plastic surgeons at the Cleveland Clinic have reported that the world’s first near-total face transplant was performed at the end of 2008. In order to protect the patient’s identity, the only information available on the patient is that she is a female U.S. citizen with severe facial trauma and that all conventional reconstruction methods were exhausted prior to the transplant.
In order to reconstruct the patient’s mid-face deformity, missing right eye, nose, and upper jaw, the transplant was a graft from a donor which included approximately 80% of the frontal facial skin, both lower eyelids, cheekbones, the nose, the sinuses, and the complete upper jaw.
Despite the surgery’s success, many ethicists and members of the medical establishment continue to express reservations, including concerns over patient consent, long-term risks, and economic feasibility. Currently, it is unclear if the majority of health insurers would cover such an operation and whether health institutions would be willing to undertake the transplants. The few prior transplant operations of this nature have had mixed results.
However, the Cleveland transplant provides evidence that face transplantation may be more than just laboratory research in the future. Already, Boston’s Brigham & Women’s Hospital is looking for a patient to move forward with a transplant, and London’s Royal Free Hospital has announced that there are a number of candidates for the procedure. Medical experts predict that face transplant procedures will parallel the path of organ transplants, whose numbers grew slowly until the discovery of cyclosporine. Factors such as the inducement of immune tolerance and the achievement of positive, long-term outcomes, high patient satisfaction, and insurance coverage will play a critical role in the future of face transplant surgery.
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U.S. to Compare Medical Treatments
Source: New York Times
Date: 02/15/2009
A provision in the $787 billion stimulus bill recently passed by Congress may provide doctors with valuable new information on the effectiveness of treatments for a variety of conditions. Some conservative lawmakers and industry figures believe that the new program will lead to the rationing of health care. Critics call it an excessive intrusion on the part of government into treatment decisions best left between patient and doctor.
The bill in question is meant to address concerns over the lack of consensus evidence as to the efficacy and value of many treatments and allocates $1.1 billion for researchers to compare the effectiveness of various treatments for a list of specific conditions. The money will be used both for reviews of existing studies and for new clinical trials that directly compare treatments for such ailments as depression, severe neck pain, chronic heart failure, and others.
Supporters of this program, including President Obama, say that this research will reduce health care costs by eliminating expensive treatments that do not work as well as other, less expensive options. Critics worry that it will be used to deny insurance coverage for more expensive treatments, even if they are more effective.
Betsy McCaughey, a former lieutenant governor of New York, wrote that under the new program, government employees “will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost-effective.”
Supporters counter by pointing to a report filed with the bill by the House and Senate negotiators who drafted the final version, which says that the money is not intended to be used for coverage mandates or the development of reimbursement policies for any public or private payer. While exact use of the study results by Medicare and related programs has not been prescribed, it is expected that private plans will use the results to decide whether or not to cover new drugs and treatments.
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A.M.A. Joins Several States in Suing Aetna and Cigna
Source: New York Times
Date: 02/10/2009
The American Medical Association (AMA) has joined a lawsuit filed against Aetna and Cigna by the state medical associations of Connecticut, New Jersey, and New York. The lawsuit alleges that the two insurance companies intentionally corrupted a database maintained by Ingenix, a subsidiary of UnitedHealth Group, in order to reduce payments to doctors for out-of-network services.
The Ingenix database contains information on the rates typically charged for medical procedures and is used by the insurers to determine the reimbursement rates for out-of-network services. The state medical associations claim that Aetna and Cigna manipulated the database by doing things such as deleting legitimate high charges, which artificially lowered the “customary rate” determined by the database.
The database has also drawn attention from New York Attorney General Andrew Cuomo, who believes that the lower reimbursements it generated have led to increased costs for consumers. Lawsuits have also been filed against the insurance companies on behalf of consumers, and Aetna said that it was “disappointed” that the medical associations had filed their own lawsuits on top of the consumer suits.
Aetna and UnitedHealth have already agreed to contribute money to the creation of a new database to replace the one maintained by Ingenix.
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Harvard Medical School in Ethics Quandary
Source: The New York Times
Date: 03/02/2009
Harvard Medical School student Matt Zerden—who discovered that one of his professors was a paid consultant to ten drug companies—isn’t the only one concerned about the pharmaceutical industry’s influence on Harvard Medical School’s classroom and affiliated teaching hospitals and institutes. The American Medical School Association recently gave Harvard an “F” grade for how well the school monitors and controls drug industry money. Comparatively, Harvard’s peers, including the University of Pennsylvania, Stanford, Columbia, New York University, and Yale received grades ranging from A to C.
The need for Harvard’s Medical School to improve its industry-related ethics is especially pertinent considering that both the Senate investigation of several medical doctors and the new Massachusetts state law requiring doctors to disclose corporate gifts over $50 could prove potentially detrimental to the school’s reputation.
In response, Harvard Medical School’s dean recently announced the establishment of a committee to re-examine the school’s conflict-of-interest policies. Concerned that pharmaceutical industry scandals in recent years have hurt the medical profession, Harvard students have also secured a requirement that all professors and lecturers disclose industry ties in class.
However, some faculty members and school officials see corporate support as crucial to Harvard’s endowment and to research funds. Additionally, a small group of Harvard students has circulated a petition that calls for “continued interaction between medicine and industry at Harvard Medical School.”
But even considering this, the tens or hundreds of thousands of dollars received by Harvard Medical faculty each year for industry consulting, the many financial ties to Pfizer and Merck, the industry-endowed chairs, rules that do not require professors to report specific monetary amounts received for speaking or consulting, and faculty prize and sponsorship money from pharmaceuticals have left many concerned about the ethics of such connections.
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Governance in Turbulent Times
Source: HealthCare Review
Date: 02/03/2009
Tough times are nothing new for governing boards in the health care field. The introduction of Medicare and Medicaid in the 1960s brought waves to the system, with similar disruptions occurring for each decade since then. All through these, pessimists have proclaimed doom for the health care system. An article in HealthCare Review claims that current uneasiness over American health care is no different from the scares and turbulence of previous eras and will be weathered as such.
The article contends that collapses in the health care industry occur at least in part due to poor decision making on the part of managing boards. Unadvisable reorganizations have often led to ill-conceived missions, and overreaching has led many an institution to collapse and fall short of even its most basic goals.
These new turbulent times see a confluence of economic crisis, decreasing service revenues, increasing demand for services, and generally lower available funds all around. The article argues that governing boards must keep their heads about them in the face of all this. Recommitment to organizational missions is a good manner of centering oneself.
More specifically, note your organization’s status and role with regard to health care in your community, taking pride in the trust placed in your organization by its constituents and, consequently, the trust placed in you as a leader. From there, individual board members should recommit to personally ensuring that the best possible performance of an organization is achieved. This is accomplished through identifying benchmarks and increasing accountability within the board for their attainment. At the same time, any goals set should be within the reach of the institution: not lofty goals meant to increase cash flows, but inward-looking benchmarks engendering a positive atmosphere and ensuring your institution remains a pleasant place to work.
Institutions should ensure they are able to provide the necessary care for their communities. This is, of course, the central mission of just about any hospital. And that is the entire point: In these troubled and troubling times, it is best to return to what you know and do best as a means of maintaining perspective. Above all else, keep your head about you. Organizations flounder most when their leadership is least able to lead.
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Most IRB Rules Don’t Ban Finder’s Fees for Clinical Trials
Source: American Medical News
Date: 03/02/2009
Although the American Medical Association and the American College of Physicians have declared that it is unethical to pay doctors “finder’s fees” for recruiting patients as clinical research subjects, it is estimated that only half of institutional review boards (IRB) address the conflicts of interest posed by the payment incentives.
Additionally, a recent study in the journal IRB: Ethics and Human Research found that only a quarter of IRB policies prohibit investigators from offering finder’s fees, which can range from $2,000--$10,000, to doctors or other health professionals. Fewer than a quarter of IRB policies address the issue of “role conflict” when doctors recruit their own patients as research subjects. Experts recommend that it is important for IRBs to address these conflicts in their policies in order to prevent misunderstandings.
The ethical dilemma of payment incentives for subject recruitment extends outside of the academic context, where most clinical research is directly funded by pharmaceutical companies. While there is a consensus that providing a payment incentive to doctors and other health care professionals for each patient recruited is unethical, it is more difficult to determine if doctors should be reimbursed for the extra time and work involved in recruiting and monitoring patients in clinical trials.
The AMA’s policy, which states that “any financial compensation received from trial sponsors must be commensurate with the efforts of the physician performing the research,” does little to help IRBs and other oversight bodies to distinguish between fair compensation and unethical financial conflict.
Experts assert that great care should be taken to protect patients, who are often suffering and trusting of the medical establishment. The high degree of patient trust makes it especially important that ethics boards ensure that reimbursements paid to a physician are not hidden finder’s fees or other forms of unethical financial incentives that provide a conflict of interest for the physician when considering the patient’s rights.
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Workplace Culture Key to Keeping Docs
Source: Health Leaders Media
Date: 03/02/2009
Can’t figure out why your organization has such a hard time holding on to physicians? Could it be a reason as simple as “I don’t like where I work”? According to a recent study from the American Medical Group Association, the answer could, in fact, be as simple as that. An article from Health Leaders Media explains further.
The study, the 2008 Physician Retention Survey, was conducted electronically from October through December 2008 by fifty medical group members representing 9,985 physicians. Researchers found that the primary reason physicians leave their jobs is due to the “poor cultural fit” of the workplace. The survey also found that physician groups reported average turnover of 6.1% in 2008, with the biggest turnover coming from part-time male physicians over the age of 55 (39% turnover) and from part-time female physicians under the age of 39 (32%). Turnover is expected to increase in the future as more physicians opt into employment models with high demand for services and fewer monetary incentives to stay in one place. The current economic recession also acts as a driver for moving physicians to larger groups or integrated systems, although it also makes the relocation and house-selling process more difficult.
An improvement process may be necessary in practice management, especially in light of the fact that cultural fit will become increasingly important in coming years, as the physician shortage worsens and as physicians move away from private practices into larger organizations. In fact, the 2009 Health Leaders Media Industry Survey found that physician leaders viewed a good work-life balance as the primary factor in determining career satisfaction. Issues such as autonomy, being valued and respected by colleagues, and adequate income were also noted as significant factors.
Some healthcare organizations have already instituted physician retention programs as a way to combat the long-term implications of the physician shortage. Common retention programs include financial incentives such as signing bonuses, guaranteed income, moving expenses, medical school loan forgiveness, malpractice coverage, and even mortgage assistance and rental plans. Often, however, the details of the retention program are less important than the message it sends to physicians – the AMGA survey noted that the likelihood of physicians leaving during the first three years of employment decreased 6% in situations where a retention program was in place.
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Subtleties of Rural Recruitment and Retention
Source: Journal of the ASPR
Date: 02/01/2009
While health care providers look at several factors when choosing a community, from good school systems to opportunities for their spouse, communities also consider factors such as the investment of time and energy when choosing health care providers.
Recruitment and retention efforts in rural communities can be as unique as the communities themselves. Because many rural communities are cohesive units with strong identities, it may be particularly challenging to find a health care provider that is well-suited to the community.
While the acceptance of a provider into the community takes time, the aid and support of local leadership can help institute changes into a rural health care system that enhance physician retention. Because rural communities are more likely to make decisions by a consensus, it is in the interest of incoming health care providers to work within the collective nature of the community.
The National Rural Recruitment and Retention Network (3R Net) holds an annual conference that provides resources from individuals who are able to assist rural communities in finding the right health care provider to fit the community. Additional information is available through the 3R Net web site at www.3rnet.org.
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The Pennsylvania Health Care Crisis: No Farm Team
Source: Physicians News Digest
Date: 02/04/2009
Pennsylvania, like the rest of the nation, faces impending cost increases and service scarcity in the coming decade due to the looming physician shortage. Numerous solutions have been proposed by many parties, but an article in Physicians News Digest posits that the Commonwealth would be best served by following the example of… the 2008 World Series Champion Philadelphia Phillies.
The author, a Pennsylvania State Representative, notes that Philadelphia’s health care costs are likely to spike in the next decade, with the physician shortage reaching the level of a full blown crisis if nothing is done. Pennsylvania has one of the largest, fastest-growing elderly populations in the United States, and Pennsylvania doctors are equally aged. Forty-one percent of Pennsylvania doctors plan to retire within the next ten years, and half of these doctors plan to retire within the next five years. Only 7.8 percent of doctors in Pennsylvania are under the age of 35.
Making matters worse, Pennsylvania is not expecting to significantly increase its population of physicians under their current operations. Less than eight percent of Pennsylvania medical school graduates stay in the state to practice medicine. The solution, the author argues, is for the Pennsylvania government to institute a “farm system” of the sort used in baseball, but for doctors.
Through the use of loan forgiveness programs—such as fully forgiving the loans of doctors promising to stay in-state for ten years (after which retention studies show they are likely to remain indefinitely)—the author argues the Commonwealth will create the farm team resources needed to ensure another generation takes over when the current one retires, hopefully sparing the populace from experiencing a more serious crisis in the coming years.
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Wanted: CEOs with Taproots
Source: Trustee
Date: 02/01/2009
Though no one can really put hard numbers to the phenomenon, there is a general consensus that hospital administrator turnover in small and rural communities is on the rise. Repeated turnover in these communities has a deleterious effect on the whole hospital and its surrounding community, undermining trust and damaging relationships. An article in the February issue of Trustee examines the attitudes trustees need to adopt in order to recruit the right individual to serve as CEO.
As the average tenure length of CEOs trends downward, it is important to ensure that the CEO is the right fit for the challenges of the position. For smaller hospitals, self-reliance is an essential trait. The rural hospital CEO may not have the extensive support staff afforded their larger institutional peers and is expected to play a larger role in financial and clinical decision making. The smaller institution’s CEO is a position affording one the ability to largely run his or her own show, and trustees should be on the lookout for a candidate who looks as though he will thrive in such a position.
Trustees looking to recruit CEOs should look to head off potentially deal-breaking issues before they arise. The primary question should be: “How can we get them to grow a taproot?” Often this entails recruiting the family as much as the candidate. Feasible solutions for spousal employment, education for children, and lifestyle adjustments are necessary components of any recruitment package.
Boards eager to fill a slot quickly are more prone to make errors. The search process is vastly different now than ten years ago, as the education and experience necessary to run a hospital is much more specialized. The process of recruiting must be carefully carried out with a thorough recruitment and background check process, not just acquiring a warm body to fill the spot.
Search firms are yet another vital aspect of the recruitment process. A good firm spends extensive time evaluating leading candidates and informing you of their capabilities with regard to your particular situation. Small and rural hospitals, if at all possible, should seek out search firms specializing in catering to such organizational needs. I
Ideally, your hospital will be able to have a transparent relationship with your search firm, in which you tell them exactly what you’re looking for and they give you a good idea of exactly what they will be able to accomplish for your hospital. Ultimately, though, trustees must remember that the final hiring decision lies with them.
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Community Physician Needs Assessments
Source: H&HN Magazine
Date: 02/17/2009
Recruiting new physicians is likely to become more and more difficult in the future, with the Council on Graduate Medical Education predicting a shortfall of 96,000 physicians in the United States by 2020. In this environment, it is vital for hospitals to have a well-developed plan for recruitment and retention.
Community Physician Needs Assessments (CPNAs) can fulfill this need. A CPNA is a detailed accounting of the hospital’s projected needs for physicians in each specialty. It includes information on the number of physicians in each specialty currently employed by the hospital and combines this with information on the number the hospital is likely to need in the future in order to highlight areas where the hospital has a surplus or deficiency of doctors.
This information allows the hospital to plan its recruitment more intelligently, focusing on the areas where it has the greatest need. It also helps in dealing with regulatory agencies, and is a valuable resource when considering income guarantees for physicians opening a private practice, as it provides the data needed to justify these sorts of financial arrangements.
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Employment & Compensation
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The Boomerang Effect: Hospital Employment of Physicians Coming Back Around
Source: Physicians News Digest
Date: 02/04/2009
During the 1990s, hospitals attempted to control and expand their market share by creating their own physician practices in response to the “managed care threat.” In the short-term, these hospital-owned physician practices resulted in substantial losses for both hospitals and health care systems, and many practices were divested by hospitals within a few years of their acquisition.
Today, the trend of hospital-owned physician practices has re-emerged. Drivers of this trend include:
-Reimbursement issues making practice management more difficult for private practices.
-The desire to curb ancillary revenue and the need for costly equipment to provide these services.
-The need for greater economies of scale concerning medical information technology expenses.
Hospitals, in turn, are increasing demand for physicians due to the following factors:
-Hospitals need to hire physicians to keep up with population / market demands.
-The hiring of physicians allows hospitals to better control quality.
-Physicians with an interest in the financial performance of the hospital tend to improve the institution’s financial performance.
-Specialist physicians may be hired to balance medical staffs and meet community needs.
In light of this, hospitals are experimenting with different models of physician employment. Under the old model, in which physicians reaped profits from the amount of revenue their specialty generated, hospitals were left unsatisfied due to losses they were unable to recoup. The modern model involves an income guaranty period much shorter than the five-year period of the older models.
Other models in use involve the employment of physicians that ensures physician input into hospital governance. Occasionally, hospitals even go so far as to lease the physician’s existing space, providing a steady source of income as well as the feel of independence which comes from practicing medicine in a separate location.
At this point, only time will tell if the combination of these drivers and the change in the hospital-owned physician practice may be more successful than it was in the 1990s.
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Good Sense Services
Source: Southern California Physician Magazine
Date: 02/01/2009
Physicians are by no means immune to the effects of the current economic downturn. There are, however, a number of options available to physicians looking to better serve their patients while at the same time softening the current crisis’ impact on their bottom lines. An article in the February issue of Southern California Physician Magazine takes a closer look.
Clinical trials are one way for physicians to provide patients with free treatment and monetary compensation while also allowing doctors to treat their patients and receive compensation. While many physicians avoid the use of clinical trials due to barriers such as budget negotiations, additional paperwork, protocols and patient management, some recent cooperative agreements between medical institutions should help lower these barriers. The Los Angeles County Medical Association, for example, has teamed up with Integration Solutions to help member physicians get involved in clinical trials through a vendor partner, eCast.
Prescription dispensing is another popular and lucrative way for physicians to make money and help ensure better patient compliance, convenience and satisfaction. A variety of vendor-provided software and hardware is available to help physicians keep track of drugs, bill insurance, and check for drug interactions. However, while physician-handling of patients’ medications can bring in from $5-$15 per prescription, it also has the potential to create conflict-of-interest issues between the physician and the pharmaceutical industry. The AMA supports doctors’ rights to sell medications as long as the patient is aware of their options.
The provision of ancillary medical services, if approached with proper caution and planning, can also help doctors to expand their patient services and revenue. While some services, such as ophthalmologic and cosmetic surgery services, have experienced a recent decline in use, more profitable services, such as pain management, may provide additional patient revenue.
Finally, integrative medicine, in which physicians offer acupuncture, massage, or nutritional supplements, has become a popular source of added revenue in recent years. It should be noted that it is unclear whether the economic downturn will cause patients to forego these alternative medicine forms. Given the state of the economy, it may be wiser for physicians to stick to more traditional care offerings until patient demand is determined.
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The Lowdown on Working Locum
Source: Today’s Hospitalist
Date: 02/01/2009
Working locum tenens allows physicians to try out a lot of different hospitals and positions before settling on a permanent opportunity, a sort of “auditioning” process that removes some of the pressure to settle immediately. Others use the flexibility to pursue additional degrees or interests on the side while developing their professional experience.
Current economic conditions have only increased the appeal of locum work, particularly with hospitals paying premiums for locum tenens services. Many recruiters report that hospitals are booking locum tenens providers up to a year in advance, and most of these physicians report that they love the independence and travel options of the locum lifestyle as well as having a guaranteed income in view.
The job does require an ability to adapt quickly to a new hospital system with its own set of protocols and distinctive corporate culture. Understanding the resources and limitations of a given hospital can be tough, especially as a temporary staff member. Furthermore, the level of education of the nursing staff can vary widely, which presents additional challenges to a traveling doctor.
Constantly being “the new doctor” can also be tough, but it tends to be a buffer to some of the local hospital politics, giving locum doctors a chance to serve as troubleshooters. Acquiring experience at multiple hospitals often results in developing a more diverse set of skills that might be adapted to unusual situations.
Doctors considering working locum tenens assignments should avoid overwhelming caseloads—most physicians agree that it starts being a problem at about 20 patients a day. As with other positions, look at turnover rates, particularly for past locum staff. Additionally, make sure that if you’re working through a placement agency they’ll advocate for you when needed as well as cover medical malpractice and help with travel and scheduling.
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Are Physicians Working Harder?
Source: Healthcare Strategy Group
Date: 01/01/2009
A new report by the Healthcare Strategy Group (HSG) shows that while physicians often say they are working harder than they used to in order to meet their income targets, they are actually seeing fewer patients than in the past.
HSG examined responses to the MGMA Physician Compensation and Productivity Survey and found that, on average, ambulatory encounters were down 9.1% from 1998 to 2007, and hospital encounters were down 54.3 percent. Surgical encounters, on the other hand, were up 26.4 percent.
This decrease may be a result of the increased complexity of modern medicine and may be due in large part to increased administrative responsibilities for doctors. A study by Merritt Hawkins on behalf of The Physicians’ Foundation found that 63% of specialists said that paperwork had forced them to spend less time with their patients, and 94% said that the amount of time they spent on non-clinical paperwork had increased in the last three years.
It is thought that it may be possible to increase physician productivity by shifting some of this paperwork burden onto other employees, and hospitals are likely to attempt to alleviate the physician burden through improved systems and management assistance, but it is unlikely that they will be able to bring about a return to the older model of the physician encounter.
The decrease, the study authors claim, is not necessarily indicative of overall decreased productivity, but rather it reflects the increased complexity of modern medicine and the demands it places upon physicians. HSG’s researchers also raise the impact of physician extenders as an area for further examination, as the available data do not afford the ability to measure said impact. In particular, the article questions the degree to which extenders are able to offset the decrease in physician ambulatory and hospital encounters.
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Do a Site Visit Right
Source: Unique Opportunities
Date: 02/01/2009
A typical site visit ranges from one to three days and provides an opportunity to size up the practice and the surrounding community. It generally includes a series of meetings, tours, and interviews, as well as social gatherings with physicians and administrators and often a tour of the community with a real estate agent.
Roger Bonds, the President of the American Academy of Medical Management, says there are four key questions physicians should consider when approaching a new job opportunity:
-Do you need me? There should be a genuine need for your services. Why are they recruiting, and what will your role be in the entire scheme of healthcare delivery?
-Can I treat my patients how I see fit? Is there a common patient care philosophy you can relate to among the physicians with whom you discuss the practice opportunity?
-Can I live here? Explore the area carefully and consider renting before buying, as this is a critically important question for you and your family.
-Can I trust you? It’s easy to be misled, unintentionally or otherwise, about a new practice; so ask hard questions upfront in order to establish a reassuring trust factor.
To prepare for a site visit, request as much information about the area and the practice as possible. Make inquiries with the local Chamber of Commerce, read the local paper, and use the Internet to uncover the attractive aspects (and possible drawbacks) of the community and, if possible, information concerning the practice itself.
Obtaining a copy of the interview agenda is always helpful, and you should be ready to meet a lot of new people in a short period of time. In fact, many hospitals hold informal breakfasts or lunches with the entire medical staff to introduce candidates.
Bonds suggests a “light system” for determining red flags when talking with staff: “If one surgeon gripes about administration and is negative about the world and about medicine, you may be able to discount that by 100 percent.” But, when you hear the same thing repeatedly, the light might turn from yellow to red and warrant some more research and caution before proceeding.
The best interview candidates come well-prepared and ask questions that show they’ve done their research and want to know more. Try to go home with as much new information as possible, but be ready to do more research based on what you learn during your visit.
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Job Search 101
Source: Unique Opportunities
Date: 02/01/2009
With so many opportunities for medical practice today, Dana Butterfield, the executive vice president and the chief operating officer for the Association of Staff Physician Recruiters, says that “docs can go just about anywhere.” But where? How to decide?
Start early. Too many residents wait for the “11th hour” to start a job search, but starting early pays off. Particularly in the highly competitive market facing healthcare employers, it can pay to sign on early. In fact, some practices grant residents stipends throughout a year or two of their residency to ensure they’ll join upon completion of their training.
One of the first challenges in the whole process is honest introspection—an examination of personal skills, identity, and priorities. This can point towards one type of job or another that will be most professionally satisfying. Marriage and child-rearing plans add in additional factors to consider.
When deciding on a practice, it’s important to look at how the organization treats its physicians. For instance, if they are reluctant to allow residents to talk with staff physicians, that is probably a red flag. Addressing turnover rates and meeting support staff are also important. Finally, assessing the financial stability of a practice or hospital can be challenging, but highly beneficial.
Choosing between do-it-yourself (DIY) job searches and traditional search firms is equally challenging, with clear pros and cons to each. Search firms put a resident through a profile assessment and ask about geographic and practice preferences; then match the resident with jobs in their database. The benefit is simplicity and, potentially, a good match you might not have found on your own. The downside is that you can be bombarded by offers and under pressure to accept a specific opportunity. For those more interested in DIY, the Internet has opened up a plethora of options, from government databases to professional organizations’ job postings.
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The Legal Risks of Integration
Source: H&HN Magazine
Date: 02/24/2009
A recent communication from the American Hospital Association’s Center for Healthcare Governance noted that hospitals have increased their integration efforts with physicians, whether through greater cooperation in co-management between hospitals and physicians, full integration through practice acquisition and employment, mergers of health care systems, or provisions for collective care. The current economic recession also provides incentives for the integration efforts as providers deal with pressure from payers to hold down reimbursement.
However, with integration efforts come two main forms of legal risk. The article reviews these two legal issues--contractual integration and full integration--in order to inform providers of the benefits and risks of integration.
Contractual integration generally requires less initial capital investment, creates financial incentives, and allows contracting parties to retain their independence. At the same time, this type of integration generates multiple risks from state and antitrust laws and from federal fraud and abuse laws that are in place to prevent certain financial considerations from interfering with the delivery of patient care. Additionally, the new Stark IV regulations raise barriers for physician-hospital ventures and require that physicians and hospitals meet 16 criteria in order to meet the “incentive payment and shared savings program” exception to the regulation.
Full integration efforts, on the other hand, avoid many of the risks of contractual integration. While fraud, abuse, and antitrust law risks are significantly reduced, the Federal Trade Commission often uses more aggressive antitrust scrutiny in the case of hospital mergers. However, this type of antitrust risk tends to be limited to those systems with a significant market share.
In order to help prevent these integration risks, the FTC has identified a number of questions for scrutinizing clinical integration efforts. Prior to integration efforts, hospitals are recommended to ask: (1) what kinds of hospital activities have the potential to improve the quality of care; (2) what are the procedures, tools, and systems that will accomplish goals; and (3) what results can be expected from these activities to improve the quality of care?
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Court Sides with Doctors on Privacy of Medicare Claims, Reverses 2007 Ruling
Source: American Medical News
Date: 02/16/2009
In a ruling the American Medical Association considers a major victory for physician privacy and patient protection, a federal appeals court has ruled that third parties are not entitled to receive and publish Medicare physicians’ claims data. Adding to the rejection of that claim, the court stated the information sought would actually be of little if any use to patients, further diminishing the third party’s position.
The decision reverses a district court ruling from August of 2007, in which Consumers’ Checkbook and the Center for the Study of Services sued successfully to obtain selected physicians’ claims data, stating the data would allow them to inform patients on the number of procedures performed by each Medicare physician in 2004 in Illinois, Maryland, Virginia, Washington, and the District of Columbia. Checkbook/CSS operated with the expectation that patients would use the information to seek specific physicians for particular procedures based on their experience as represented by the data Checkbook/CSS published. Critics countered that the volume of procedures performed was not necessarily directly correlative to expertise in performing the procedures.
The US Court of Appeals, in a 2-1 decision, agreed with the critics, finding exposure of the data would amount to unnecessary violations of personal privacy. The figures could be used, it was argued successfully, to determine a specific doctor’s annual Medicare income.
For its part, Checkbook/CSS contends that the decision cuts off the public from a method of assessing the quality of prospective doctors and the Medicare program itself. Checkbook/CSS representatives claim that the freer flow of information is almost always better and that the organization is weighing its options with regard to the appeals process, possibly moving to have the case re-heard “en banc,” meaning all members of the appellate court would need to render a decision.
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It’s No Longer Just Members Who Are Suing Health Plans
Source: Managed Care
Date: 02/01/2009
Health insurers are under fire as lawsuits from new sources come pouring in, but it’s not just plan members who are suing. Class-action suits have increased dramatically from healthcare providers as well as subscribers. Class-action suits against plans almost tripled from the period 1996–1999 to the period 2000–2005, from 4% to 11% of non-zero dollar claims, according to a proprietary analysis of their own data conducted by One Beacon.
While individual doctors in the past were understandably afraid to confront MCOs for fear of being de-listed, the growth of class-action suits has given them a new power to alter carrier business practices and avoid openly biting the hand that feeds them. The new suits tend to fall into three main categories:
-Ingenix/UCR—Two class-action suits in 2002 and 2004 accuse some of the country’s largest insurers of systematically reducing, denying, and delaying payments to doctors for medical care. This type of “multidistrict” litigation has sparked a wave of class-action suits surrounding the use of the Ingenix database and community “usual, customary, and reasonable” (UCR) charges.
-Tiering—A 2008 suit argues that tiering, in which insurers rank physicians and adjust copays based on claims data, defames doctors who score poorly but still provide high-quality, low-cost care.
-Recission—Recissions occur when insurers cancel individual patient policies after receiving particularly large bills. While insurers argue that patients sometimes provide intentionally misleading applications for coverage, patients have fought back by suing over “due diligence,” arguing that plans have not reviewed applications sufficiently and that patients cannot be expected to remember every ailment they have had in the past.
The risks of class-action suits for all firms have increased dramatically. While ten years ago the idea that providers would sue plans was unthinkable, it is now becoming commonplace.
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Hospitalists Score Big with “Black-belt QI”
Source: Today’s Hospitalist
Date: 02/01/2009
“Active bed management,” a program that puts hospitalists in charge of assigning and transferring department of medicine patients throughout the hospital, has been proven to be a successful inpatient resources management tool that can decrease waiting time in the ED.
The results of a study of active bed management, published in the Annals of Internal Medicine, found that this program decreases the time spent waiting in the ED by an average of 98 minutes, decreases diversions because of a full ICU by 27%, increases revenue, and establishes “the hospitalist as the leader in quality improvement.”
However, despite the dramatic successes of active bed management, it is cautioned that the program is a “black belt quality improvement” and those health systems wishing to implement quality improvement should probably start with smaller programs before the bed management program. Issues such as hospitalist-doctor politics and patient control loomed large during the initial implementation of the active bed management. However, clearly defined procedures and the provision of a monthly review of cases by the ED chair and the medicine chair helped to integrate active bed management into the hospital culture within six months.
The next step for active bed management is to put the process online. This will include a web-based program on a laptop with a wireless phone and headset. The system will record all patient processes, from when the patient gets in the ED to when the patients arrives at the hospital.
While the online management option may not be as viable at smaller hospitals, it is suggested that smaller hospitals could implement quality improvement systems in which a partial active bed management systems is in place during the day or by having a physician spend a quarter of his or her schedule helping out during busy times in the ED.
By establishing hospitalists as leaders of nontraditional quality improvement, hospitals have the opportunity to dramatically improve the quality of patient care and satisfaction.
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Overcoming Obstacles of Palliative Care
Source: H&HN Magazine
Date: 02/24/2009
Due in large part to the Robert Wood Johnson Foundation’s national initiative to promote end-of-life care in the 1990s, palliative care programs began to be integrated into the medical establishment. However, while hospital-based palliative care programs are still not as widespread as they need to be, those hospitals that have instituted palliative care programs have been able to provide effective treatment for patients with advanced illnesses.
The Hospital-Based Palliative Care Consortium (HBPCC) has revitalized the effort to integrate palliative care programs into hospitals. The program has created a consortium of hospitals that disseminate palliative care tools and best practices. The comprehensive palliative care curriculum was provided to more than 300 hospitals and health systems, and over eighty of these medical institutions have participated in site visits to the HBPCC-participant hospitals.
Research of the HBPCC hospitals has provided information on best practices for overcoming the barriers of palliative care program establishment. In order to integrate a palliative care program into the health system, the following basic measures should be completed: (1) form a planning team, (2) conduct a needs assessment, (3) make the case within the organization, (4) develop the palliative care program elements, (5) monitor and evaluate the program, (6) fund the program, and (7) ensure marketing and public relations efforts for the program.
Along with these measures, hospitals and health systems should be conscious of the importance of designing the palliative care program to have the greatest impact on patient care, building support for the program among the hospital’s constituents, determining what data are important to clinicians and administrators for monitoring program performance, and beginning the program with a limited number of diagnoses. With proper planning and integration, a palliative care program can be a valuable addition to any health system.
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Toward Revising the Ethical Boundaries of Research With Noncompetent Subjects
Source: The American Journal of Psychiatry
Date: 02/01/2009
As the population of the elderly increases in size, so too grows the percent of the population that is at risk for neurodegenerative disorders. And with this increase comes the need for scientific progress in the prevention and treatment of dementia.
However, in order for the necessary scientific progress to begin, a number of ethical and practical difficulties of research must be addressed, particularly regarding patients’ rights when the patient is either at-risk for cognitive impairment or suffers from cognitive impairment. This issue is especially important for dementia research because the most valuable research consists of studies conducted on at-risk patients or those already suffering from dementia.
Much has been written about ethical research practices when the subjects are cognitively impaired. The APA offers the warning that “the purposes of attending to assessment of the capacities of potential research subjects is to ensure that only subjects capable of giving consent are asked to make decisions about research participation. This protects both subjects’ interests and the integrity of the research process.”
To address this issue, some experts have proposed the solution of “leeway consent” from a health care proxy. A recent article by Karlawish et. al., which provides quantitative data on the attitudes about dementia research, consent, and leeway consent, found that individuals were more likely to be comfortable with the concept of leeway consent. This type of consent focuses on the idea that the proxy may grant consent only when there is a strong reason to believe that the subject would have wanted consent. Additionally, changes in the field of biomedical research may have an impact of the consent of individuals to become subjects in a study if the study’s benefits and risks are in his or her best interest.
Difficult questions arise, however, when proxies or subjects must make a choice between studies that offer both high benefits and high risks, when the proxy consents but the noncompetent subject resists, or if countervailing feelings of family members are taken into account. One thing is for certain: The process of determining appropriate moral boundaries depends of the accumulation of more relevant quantitative data.
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Survey: Surgeons Bemoan Reimbursement, Work Hours
Source: Urology Times
Date: 02/01/2009
Is the practice of surgery burning out its practitioners while at the same time dissuading future doctors from entering the field? Findings from a recent survey seem to indicate the answer is “yes.” Although there has been an increase in the demand for surgical treatment from the aging population, the supply of surgeons has decreased in recent years. Studies show that this gap in supply and demand may be due in part to surgeons’ dissatisfaction with specific aspects of their careers.
The national Lifestyles in Surgery Today (LIST) survey, conducted by the University of California Medical Center, had a respondent pool with a mean age of 46 years. Forty-five percent of respondents were general practice surgeons, and 80% of respondents practiced in a non-university or non-VA setting. The survey found that while 85% of respondents were satisfied with their careers, nearly 75% were unhappy with the total hours worked, the working schedule, and work reimbursement. Additionally, surgeons who work in a non-university setting are three times more likely to be unhappy with their careers than surgeons who work in a university or VA setting. Surgeons who are dissatisfied with payer reimbursement are also almost six times more likely to be dissatisfied with their career.
The LIST survey, which is designed to study surgeons’ level of satisfaction with their career and lifestyle and to indentify risk factors for dissatisfaction, helps to inform the recruitment and retention efforts of the American College of Surgeons. The results of this study dovetail with findings indicating that there is declining interest in surgical fields among medical students and that surgeons retire earlier—all factors that experts attribute to career changes, lifestyle concerns, and burnout. Experts further recommend that ways to improve the surgeon experience need to be found, since oncoming demographic trends are likely to exacerbate the problem.
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Payer & Reimbursement Issues
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Physician Fee Schedule Survey: Are You Getting Your Slice?
Source: Physicians Practice
Date: 02/01/2009
It is generally acknowledged that physician reimbursement is in a shoddy state nowadays, but how bad is it really? Research from Physicians Practice suggests the average practice charging for certain procedures associated with a midlevel-established office visit can wind up collecting less than the going rate for a haircut!
This low reimbursement reflects doctors’ average collections from payers and is likely to increase when factoring in patient financial responsibilities, which have, in recent years, trended upwards. But payer fees are the largest source of income for most practices, even as reimbursements for office visits decline.
Since payers base their payments on a percentage of Medicare payouts, the average payer payouts fluctuate with the government-run system’s numbers. Physicians Practice researchers found three major points in their research of charge and reimbursement rates.
-Reimbursement is generally low across most specialties.
-Reimbursement is low across the nation.
-The best way of coping is to set reasonable goals considering the first two findings, and negotiate from there for the best you can get.
Keeping these points in mind, the article encourages physicians to take into account the payer’s mindset in negotiations. When a physician requests an increase, they are compared against the rest of the payer’s market to determine if it really benefits the payer to increase payment to that particular physician. The authors recommend comparing three or four plans to identify the lowest payer, then considering dropping that payer, as the relationship is likely unprofitable for your practice.
Another useful strategy is to get your top 10 codes and divide the payer’s rate for each code by the RVUs Medicare gives each code in its fee schedule. Your result is the payer’s conversion factor—the number they use to determine payments. Applying this conversion factor across each code gives you a full payment schedule for a particular payer.
The article further recommends maintaining as positive a relationship as possible with a payer. Constant, positive contact with a payer builds a trusting relationship, which can be a significant plus in the event of later negotiations.
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HIP Model Has Potential: MDwise Delivers Indiana’s HIP Program
Source: Managed Healthcare Executive
Date: 02/01/2009
As state Medicaid programs face growing pressures from policy changes, demand and financing, reform initiatives at the state level will be needed to provide short-term health care solutions until national reforms are initiated. Indiana’s subsidized Healthy Indiana Plan (HIP), which is delivered by Anthem and Indiana’s local Medicaid plan, MDwise Inc., provides a model of a successful reform initiative.
The HIP includes a high-deductible health plan and health savings account offered to low-income adults who wouldn’t otherwise qualify for Medicaid. In doing so, it addresses the needs of underserved populations, includes consumer-driven strategies not previously applied in Medicaid, and incentivizes personal responsibility among members. The plan is funded by contributions of 2%-5% of members’ income, state and federal matching Medicaid funds to pay the balance between members’ contributions and the required deductible, and employer contributions. All contributions are deposited into a Personal Wellness and Responsibility (POWER) account up to a total of $1,100.
Behind the POWER account is a design strategy that encourages individuals to seek and use medical homes and to take advantage of preventative services. Thus far, the personal responsibility focus of the POWER accounts has been proven to be successful. Since November 2008, fewer than 200 HIP members (0.5%) were terminated for nonpayment of their monthly contribution.
As of December 2008, the program had enrolled nearly 35,000 members. State officials predict the program will eventually enroll a total of 120,000 adults earning less than 200% of the federal poverty level. The current economic recession is almost certain to increase the number of HIP applications, as well as increase the need for funding.
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Controlling Variations in Spending Critical to Healthcare Reform
Source: Healthcare Finance News
Date: 02/26/2009
The differences in the health care spending growth rates between states arise largely from discretionary decisions by physicians and the influence of available health care resources. Additionally, a payment system that rewards growth and higher use shares some of the blame; this according to results of the Dartmouth Atlas Project, recently published in the New England Journal of Medicine, which provide a detailed analysis of Medicare spending. The study found that huge inefficiencies in the U.S. health care system are harming the nation’s ability to expand access to care. Fortunately, in many regions, spending is growing relatively slowly, and reformers can learn from these regions and encourage high-cost, high-growth regions to change.
The analysis found that Medicare’s national average for enrollee spending was $8,304 in 2006 and that national spending grew at an annual rate of 3.5% from 1992-2006. New York had the highest spending per enrollee at $9,564, while Hawaii had the lowest, at $5,311. However, the study also noted that growth rates and spending per enrollee do not always run parallel courses, and that sometimes high growth states start from a low-spending base or vice versa.
At the current spending rates, researchers estimate that Medicare will be in debt by $660 billion in 2023, but that by reducing the annual growth in spending from 3.5% to 2.4% Medicare could save $1.42 trillion and turn the deficit into a surplus. Fortunately, small differences in spending can make a large difference in the long-term financial stability of Medicare and in the ability to increase coverage of the uninsured.
The Dartmouth Atlas Project’s authors believe that physicians can lead the effort to reform health care delivery, payment, and spending systems. By realigning private and public payment schemes to benefit quality performance over the volume of services, the medical establishment should be able to both provide high quality care and control spending. However, physicians and the medical establishment will need help in their reform efforts from payers and policy makers in order to re-design the payment system so that high-cost care is not rewarded at the expense of quality treatment.
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Doctors Win ICD-10 Coding Reprieve, Compliance Now Due by 2013
Source: American Medical News
Date: 02/02/2009
The Centers for Medicare & Medicaid Services’ proposal for the adoption of a new version of the International Classification of Diseases code sets (ICD-10) by October 2011 has been put on hold thanks to a last minute Bush Administration decision. As a result, physicians will have an additional two years to familiarize themselves with the new codes and prepare their practices for the transition.
The ICD-9 codes—currently used to list patient diagnoses on claims and procedures—are nearly 30 years old and considered insufficient to reflect modern health care reality. ICD-10, by comparison, has roughly 155,000 codes, providing more data and detail within the codes. Proponents claim this will result in more timely electronic claims processing by reducing requests from payers for further information. Adoption of the technology necessary to implement the standards is expected to cost the average three-physician clinic upwards of $84,000.
Critics, however, protested that the 2011 adoption date fell too soon. Under the newly adopted rule, the adoption deadline has been pushed back to October 1, 2013. Additionally, a delay was implemented in CMS plans for an April 1, 2010 deadline for the adoption of 5010 electronic transaction standards, a prerequisite for moving to ICD-10. The new deadline for that adoption is January 1, 2012, and any further changes must be made either by new CMS regulation or congressional act.
CMS also finalized cessation of Medicare payments for three “never events,” events that should never occur in a medical setting: surgery on the wrong patient, surgery on the wrong body part, and the wrong surgical procedure.
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Credentialing, Licensure, Quality Management
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Patient Privacy – The New Threats
Source: Physicians Practice
Date: 03/01/2009
Patient privacy is a cornerstone of the patient-provider relationship. The complexities of modern health care provision, however, pose numerous threats to this essential aspect of the health care pact. An article in the March issue of Physicians Practice reviews the potential new threats to patient privacy that arise from medical records requests vis-à-vis HIPAA privacy regulations. Different procedures are recommended in response to records requests from the following parties:
-Attorneys: When a request for medical records comes from an attorney, HIPAA requires that the only situation in which patient records can be disclosed without specific patient permission is for the purposes of treatment, payment, and operations. Therefore, all other requests are not granted. This is true in all legal situations.
-Health plans: Health plans have the ability to audit patient records at any time, and they have patient consent by virtue of the forms that members sign when they join the plan. However, it is becoming more frequent for health plans to request a sampling of charts in order to ensure they have the proper case mix. Health plans have no right to view records of patients who are not their members; nor do they have the right to see the health information of members prior to when they joined the health plan.
-Employers: The increasing number of employers who are self-insured means that employers are also increasingly asking to see patient records. These self-insured employees have the same right as other payers to examine medical records, but there is a gap in HIPAA protections concerning patients’ rights to shield their medical records from their employers’ scrutiny.
-Medicare: Physician practices should expect to be audited by CMS’s “recovery audit contractors” (RAC). Legal experts say that the RACs aren’t any more threatening to physicians than Medicare carriers, and that the CMS has imposed limitations on the number of records that can be reviewed by RACs and how often they can audit a practice.
-Patients: The majority of requests for medical records come from patients themselves. Even if patients ask doctors not to put certain facts in their medical records or not to release certain records, physicians are not allowed to exclude pertinent medical facts from patient records.
While record requests are not a big threat to a practice, it must be recognized that they are still important factors in practice management.
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Low-Tech Safety
Source: Health Leaders Media
Date: 02/04/2009
While a great deal of attention has been paid to high-tech methods for improving patient safety, including new technologies like radio frequency identification and computerized medical records, some of the most effective ways to easily improve safety may be very low-tech. High-tech solutions can be valuable, but they can also require more effort on the part of doctors and nurses, making them difficult to use in an emergency situation where working quickly may save a life. In these sorts of situations, simpler solutions may have a bigger effect on patient safety.
Kaiser South San Francisco Medical Center, for example, was able to achieve dramatic declines in medication errors by having nurses who were dispensing medication wear a brightly colored vest that let others know they should not be disturbed. While there was some resistance to the program initially, this faded after medication errors were reduced by 47 percent in the first unit that tried it. The program then spread to the rest of the hospital, and after 30 days, medication errors were down 20 percent. The program has since been expanded to other Kaiser hospitals, and other, similar initiatives are being developed, such as installing red floor tiling around medication stations to provide another visual indicator that a nurse should not be interrupted.
A study by a group in the anesthesiology department at Penn State Hershey Medical Center suggests that a similarly low-tech idea may also have a profound impact on patient safety. This group tried to measure the effect on safety of standardizing medication labels. Since conducting a trial of this sort on real patients would raise serious ethical concerns, they used an artificial test where anesthesiologists, residents, and nurses were asked to draw medication from containers with colored labels at gradually increasing speeds. They found that the participants made fewer near-mistakes when the colors of the labels on the syringe and the medication bottle matched. They also found that errors were reduced when participants had to peel a label off of the medication bottle and place it on the syringe.
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Safety Versus Dignity: A Balancing Act
Source: ACP Hospitalist
Date: 02/01/2009
The balance between patient privacy and safety is often a difficult one to maintain in a health care setting. Health care providers are torn between the rights of patients to have privacy and the need to protect patients, especially elderly patients, from falling. A Journal of General Internal Medicine study found that weakness, poor cognitive status, medications, IV tubing and polls, fall history, and inadequate staffing are risk factors for falls. Patients who fall tend to have a longer length of stay and greater costs of care.
In response to these concerns, many hospitals have created protocols to prevent inpatient falls, usually based on identifying those patients who are at risk for falling. Some of these protocols include wrist band identification, remaining with the patient while the patient is going to the bathroom, or the use of toileting schedules.
However, while these measures relieve doctors’ concerns, they do little to protect the privacy and dignity of the patient. In 2006, the British Geriatrics Society launched a campaign called “Behind Closed Doors: Using the toilet in private.” The campaign seeks to help patients, regardless of age and ability, to choose to use the toilet in private in health care settings. It is recommended that patients are assessed by their level of mobility and safety to determine the best method of transporting a patient to a restroom or bedside commode.
Yet even this ambitious campaign recognizes that this may not always be possible with regard to very high-risk patients. Meanwhile, doctors and hospitals are left to ponder the question of patient privacy vs. safety, without any clear answer in sight.
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Resident Leadership in the Patient Safety Initiative at the University of New Mexico Health Sciences Center
Source: Accreditation Council for Graduate Medical Education (ACGME) Bulletin
Date: 01/01/2009
Patient safety programs often do not seek the input of residents, but a new program at the University of New Mexico Health Sciences Center provides a model for making them an integral part of the process.
The hospital surveyed residents to find out what they thought the primary concerns for patient safety were. The residents’ responses were a bit surprising in some ways. The often-discussed problem of resident fatigue, for example, was not one of the residents’ primary concerns. They were far more concerned about issues such as emergency department overcrowding and adequacy of nurse staffing.
After conducting the survey, the hospital staged a retreat to develop recommendations on how to address the top-rated problems, with residents from each department invited. The recommendations were then adopted by the hospital’s quality improvement committees as formal missions.
The hospital reassesses progress on the recommendations every six months. It is still very early in the process, with the first six-month review having been completed only recently; but there is evidence that some of the recommendations have been implemented and have begun to improve patient safety.
One of the interesting results of this process was that it revealed that residents were more concerned about broad issues related to communication and efficiency than specific issues related to administering care. While some national safety guidelines focus on specific, measurable goals such as time for antibiotic delivery, residents seemed to think that the best ways to improve patient safety involved creating a better-functioning work environment.
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States Must Address Differences in Health IT Policy, Experts Say
Source: iHealthBeat
Date: 02/25/2009
Recently, the National Governors Association’s State Alliance for e-Health conference determined that the current regulatory framework for patient privacy and consent may hinder the creation of a nationwide health information network. Because current laws and policies regulating the use of electronic health data vary by state and even within states, agencies may interpret privacy regulations differently in regards to the sharing of electronic health data.
In response to this issue, the Health Information Security and Privacy Collaboration (HISPC) has issued a number of recommendations for facilitating a national health information network. HISPC’s recommendations are as follows:
-States must first document their current health information privacy laws.
-States should establish either an interstate agreement or a uniform law that states could adopt to facilitate the sharing of health records.
-States should clarify their positions on the terms for patient health data disclosure without patient consent and the terms for receiving consent.
Reactions to these recommendations have been mixed. Many members of the medical establishment are concerned that the recommendations do not clearly outline a viable path for states to use concerning the governing of health information. Concerns regarding the governance of health information are especially pertinent since the potential privacy risks associated with electronic health records will increase with the potential uses of the data.
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Indiana University Students Get Their Own PHRs
Source: Healthcare IT News
Date: 02/25/2009
The Indiana University of Health Center recently launched an online personal health record (PHR), NoMoreClipboard.com, for students at its Bloomington campus. The PHR program allows students to create secure, password-protected personal health records that include information on allergies, current and past conditions, and other medical information. Additionally, students will be able to import medical information from the health center’s electronic health record system into their PHR after a visit to the health center.
The PHRs will be used in conjunction with the University’s registration forms, and students will be able to send information from their PHR to medical professionals outside the University.
Indiana University’s initiative parallels efforts by the new presidential administration to foster health care IT adoption, improve care, and reduce overall healthcare costs.
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Physician Practice Management
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Your Money: Do You Have Enough Insurance?
Source: Physicians Practice
Date: 03/01/2009
Many physicians are unsure of how much and what type of insurance is needed for their practice. While some physicians choose to cut costs by self-insuring for life insurance, others load up on life insurance as an investment. However, the best policy lies somewhere in the middle of these two extremes, with appropriate consideration of the physician’s overall financial plan.
When considering life and disability insurance, physicians should take into consideration questions regarding their family’s emotional and lifestyle needs, retirement goals, and children’s education needs. In cases where the family includes one high earner and one stay-at-home spouse, permanent insurance, such as whole-life or universal life, may be the best option to provide for a family’s financial needs.
Disability insurance, while often overlooked, is important to consider because if you become disabled for a long period of time, this type of insurance guarantees that retirement funds will be available to you. It is also recommended that even if a practice has group disability coverage, a small individual policy with the flexibility to boost coverage may be useful if the insured physician ends up in a group that doesn’t provide disability insurance in the future.
Fewer physicians are retiring with continuing health insurance benefits, making it important for physicians to factor in the cost of buying private health insurance during the gap, as well as extra expenses not covered by Medicare.
It is recommended that physicians determine whether long-term care insurance is needed on an individual basis. Long-term care premiums can be tax-deductible for self-employed doctors, and life insurance may also offer some physicians an investment opportunity. Because some types of long-term insurance offer an investment component that can boost benefits in the case of strong financial markets or come with guarantees on premiums and the death benefit, these types of plans provide physicians with valuable financial opportunities.
However, the most important consideration when choosing an insurance strategy is to make certain that the strategy fits the individual’s financial plan, rather than trying to make insurance serve as an investment vehicle.
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Practice Management: Managing Risks When Practicing in Three-Party Care Settings
Source: Psychiatric Times
Date: 02/03/2009
Psychiatric practices operating within third-party organizations such as managed care face limited resources and often distant and complex administration. Under current economic conditions trends towards this type of care are likely to continue, making “autonomy-enhancing” alternatives to paternalistic care a necessary tool for psychiatric practices to balance best practice and high standard of care with limited resources and uncertain risk.
Psychiatrists must deal with relatively short face-time with patients, limited numbers of sessions based on insurance budgets, inpatient/outpatient considerations, and care for the uninsured. Cost-effective practices such as screening with patient questionnaires and providing generic prescriptions can help, while case-specific treatment for more autonomous patients such as paranoid patients with schizoid or avoidant traits who drop in and out of treatment can help balance their needs with the limited resources of the practice.
Adopting these types of practices requires solid knowledge of the accompanying ethical and legal requirements. Malpractice standards can vary widely from state to state. A psychiatrist’s care might fall below the “standard of care” if, for example, he failed to conduct an adequate risk assessment of a suicidal patient, or prescribed a medication without informing the competent patient about the potential side effects.
Of course, it is vital to distinguish between optimal and sufficient care—meeting the standard of care requires a combination of coordination and communication.
Evidence-based guidelines should underlie the decisions and practices outlined above. Particularly when dealing with HMOs and PPOs, these can provide a clear map for treatment in a given situation.
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Don't Be Afraid to Discuss Obesity with Patients
Source: Medical Economics
Date: 02/05/2009
A recent study at the Mayo Clinic found that only one in five obese patients (body mass index equal to or greater than 30) are actually listed as obese on their medical chart. The few who were diagnosed were twice as likely to have developed a weight-management plan with their doctor, suggesting that under-diagnoses and an unwillingness on the part of doctors to discuss obesity with patients may be getting in the way of important weight-management treatment.
Since obesity is so clearly linked to higher risk of heart disease, diabetes, cancer, hospitalization, and early death, why do doctors have trouble discussing it with patients? Being perceived as being offensive, time constraints, and lack of reimbursement for preventative medicine all likely contribute to this widespread hesitancy. The study suggested that doctors were more likely to diagnose obesity if the patient had already developed symptoms of an associated disease.
Doctors should consider the potential liability associated with failure to discuss obesity with an at-risk patient. The risk is remote, but an analogy could be drawn to a patient who gets lung cancer and sues their doctor for failing to warn about the dangers of smoking. A simple note on a medical chart that the risks of obesity and the possible weight-treatments plans were discussed puts a doctor in a defensible position if the patient suffers a heart attack, for example.
For high-risk surgeries such as bariatric surgery, discussing weight-management with obese patients is essential, particularly since referring doctors can be included in lawsuits.
One simple method is to include potential preventative medicine on the intake history or provide informational material to interested patients. However, it’s essential that conversations and materials provided be documented.
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