CMS finalizes physician fee schedule

CMS came out with their final physician fee schedule this afternoon, and yep, that whopping 21 percent cut is there.

From the CMS press release:

“The Administration tried to avert the pending fee schedule cut in the FY 2010 budget proposal that it submitted to Congress, and remains committed to repealing the SGR,” said Jonathan Blum, director of the CMS Center for Medicare Management. “In the meantime, CMS is finalizing its proposal to remove physician-administered drugs from the definition of ‘physicians’ services’ for purposes of computing the physician fee schedule update. While this decision will not affect payments for services during CY 2010, CMS projects it will have a positive effect on future payment updates.”

So far, Congress’ attempts to fix the SGR payment formula have fizzled and talk of a long-term solution doesn’t seem to be gaining much traction in Washington. It remains to be see what Congress will do about the 2010 cut in payments, or if a health reform bill with touch it.

We'll have more here on the final rule and the other provisions in there next week.

Snowe Job

So much for Olympia Snowe’s attempt at bi-partisanship. Her extended olive branch was wilted by the big bad public option, ushered in by democrats Reid and Pelosi. Will the public option be in the final bill? And in what form — with a trigger, an opt-out clause? Although pushing a government run health plan is the current hot-button reform issue, the larger question in this cantankerous debate remains unanswered: how will the final bill curtail our runaway healthcare spending?
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Obama said that healthcare reform was necessary for the solvency of our economy. That was a huge part of his pitch. Well at the beginning at least. Remember the little border town McAllen, Texas, featured in the New Yorker story by Atul Gawande. His article was accompanied by a graphic showing a patient as an ATM machine. It explored why some communities across the nation spend triple the amount of Medicare dollars as other communities, without added health benefits. President Obama read it and put it on his staff’s reading list.

Peter Orszag has said that eliminating this type of variation could cut Medicare expenses nationally by as much as 30% and actually improve the quality of care. That’s what I call reform. But what happened to Orszag?

McAllen Texas should have been at the heart of our healthcare reform debate. This small town that spends way too much of our precious healthcare resources is a microcosm of our system’s overall problem — across-the-board overuse of medicine.

Obama understands this. So do his cadre of healthcare eggheads. Unfortunately it’s just too difficult to explain because somehow intelligent use of healthcare services always gets politically tangled with the R word: Rationing.

The Best States to Practice Medicine

Wondering which states are friendliest to private-practice physicians? It's a question I get often, ever since Physicians Practice debuted its Best States to Practice feature (updated biannually) in 2003. The latest update will be in the November issue but you can see it now. We examined all 50 states in categories like malpractice climate, physicians per-capita, and level of state income tax. But we did something different this year that I'm kind of excited about.

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Instead of putting all the data in a magic blender and divining some overall "top 5" list, we decided to show you which states did the best in each category, and which tended to show up repeatedly on the bottom. We put all this in an easy-to-read chart. If you don't see your state, it's because you live somewhere that did not distinguish itself for either good or bad reasons.

Have fun with the list. Meanwhile, help your colleagues out: In the comment section below, tell us which state you're practicing in and then give it a grade, A - F. Tell us whether you'd move if you could, or whether you're happy where you are.

Introducing our Newest Blogger

Please allow me to introduce our newest Practice Notes blogger, Gerald O'Malley, DO.

Dr. O'Malley is the director of research in the largest, busiest emergency department in Philadelphia and will be writing regularly about his experiences as a big-city ED doc.

If you, too, are a physician interested in blogging for Practice Notes, e-mail Bob Keaveney at bob.keaveney@cmpmedica.com. We're looking for physicians able to commit to at least one blog post a week about your own experiences in practice, observations about the state of healthcare, your efforts to have a balanced life, etc.

Gerald O'Malley, DO: How medicine is like buying tires

I have figured out what is the most irritating thing about emergency medicine (and that’s saying something, given all the irritating things that plague the ED physician).

It’s not the third year surgical resident with a face like a pasty Picasso sketch (from his early “sallow” period) that rolls his beady little bloodshot eyes thinking, “If I could only tell this idiot what I really think of him and his rule out APPY consult.” It’s not the frustration of having to buy the coffee and make the coffee, but not getting to drink the coffee, because while I was wrestling with a booger-encrusted alcoholic, the coffee pot poachers drank it all.

I have come to the conclusion that the single biggest irritant in practicing emergency medicine is when patients have all their tests and even surgeries at another hospital and then show up at my ED and expect me to deal with the complications (usually in the middle of the night, when getting medical records from another hospital is impossible).
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I practice in a city with a dozen different teaching hospitals in a five-mile radius. I’ve had patients undergo open heart surgery in one hospital, be discharged home, and then present to my ED on the same day complaining of chest pain. Naturally, the patient has no records that I can access, because he has never been a patient at my hospital and even if he had, it wouldn’t help because any record of recent procedures are all at the other hospital.

Good luck trying to contact the surgeon at the other hospital to return a page — if I’m lucky, I might get the on-call guy covering for the group that has no idea who the patient is or what procedure was done. Most times, the patients have no idea what procedure was performed and don’t bother to bring in any discharge paperwork from the first hospital.

My wife bought four new tires for her Toyota and within a day, trouble began. One tire went flat and needed to be replaced; the tire pressure indicator light came on numerous times, and the tires needed to be rotated and serviced. Each time a problem developed, my wife went back to the same tire shop and argued with the same tire guy who was convinced that my wife was somehow sabotaging his tires. She wouldn’t dream of going to a different tire shop and try to tell her story, because the guy in the second tire shop (analogous to me) wouldn’t have the first clue what the guys in the first tire shop had done.

Why do patients assume that medicine works any differently than buying tires?

The patients aren’t the only ones that assume medical information is somehow easy to access. Recently, a patient was delivered to my ED after having vomited in the back of an ambulance while being transported home after a prolonged stay in a neighboring hospital.

This patient had spent the better part of a year in the neighboring hospital and had undergone numerous procedures and had finally recovered sufficiently to go home, but became carsick on the way and instead of turning around and returning to the originating hospital (which was less than a half-mile away), the patient was delivered into my care — minus any information about the recent extended hospital stay.

A valiant attempt to retrieve some information from the other hospital was stymied because it was the weekend and the medical records department was closed. Fortunately, my emergency medicine brethren from the other hospital recognized my plight, and at great personal and financial risk to themselves, looked up and shared the details of the patient’s medical history, medications, and recent hospitalization with me, risking the wrath of the administrative HIPAApotami that monitor these sorts of things.

At least the tire guys don’t have to worry about violating HIPAA regulations.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

Is the public option alive again?

For the last several weeks, I have been trying to follow the developments of the public option debate. I had pretty much given it up for dead, but then some in Washington are trying to revive it.

Sen. Harry Reid said yesterday that the melded Senate bill headed to the floor soon would include a government-run health plan to compete with private payers. (House Democratic leaders, meanwhile, also say their proposal will have a government plan.)
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The Senate plan includes a proposal some call an “escape hatch,” where states could pass a law opting out of the public option. It’s in the hands of the CBO right now for cost analysis.

But even with that opt-out option, does Reid stand a chance in rallying enough support for the public option bill? Especially considering Republicans (including the key vote from Sen. Olympia Snowe of Maine) are united against any form of legislation with a public option. Aides tell the NY Times that he’s a short of the goal, so are we back to the public option being dead?

And if it does pass, I wonder if states would actually opt out? And what about the conservative states that have high numbers of uninsured – would they opt out? If it’s not available in every state, then wouldn’t that defeat the purpose of lowering costs and covering more Americans? Well, perhaps it’s too early to begin mulling all of that, especially considering that by the time I finish this post, the public option could be dead again.

Red Flags rule update

The House unanimously passed a bill last week that would exempt small practices from the FTC’s new Red Flags identity theft rule, which goes into effect Nov. 1, HealthLeaders Media reports.
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Practices (and other entities) with 20 or fewer employees would not be covered under the requirement, which requires entities considered creditors — pretty much most medical practices — to develop policies for preventing, identifying and responding to identity theft.

Now the bill moves to the Senate.

The bill also exempts an entity that knows all of its customers individually, only performs services in or around the customers’ homes, or has not experienced incidents of identity theft and identity theft is rare for businesses of that type. It’s up to the FTC to determine what entity meets that requirement.

Considering that enforcement of the rule has been pushed back a few times, most recently from Aug. 1 to Nov. 1, and the deadline is just days away, chances are your practice has already developed a Red Flags policy. A show of hands in an audience during the MGMA annual conference earlier this month revealed a vast majority of practices there already had plans in place.

Surely that isn’t a wasted effort, as protecting patients from identity theft is good business. But perhaps the smaller practices may be able to breathe a little easier (particularly those still scrambling to get a policy in place) if the exemption passes.

Melissa Young, MD: The Search is Over, Now the Fun Begins

In my previous posts, I wrote about the search for the perfect EMR. Did I find it? Wait, wait…I can’t type while I laugh hysterically. The short answer is “no.” The EMR I chose is not perfect. Oh, I still think that compared to the others I looked at, it is far and away the most appropriate choice for me. But, perfect? Certainly not.

And I say this after having spent an inordinate amount of time trying to make it work the way I would like it to work. I had the luxury of being able to “play” with it before I actually had patients to see. I was even able to use it remotely before I had my office computers. Heck, even before I had an office. This was courtesy of my VAR (don’t ask me what it stands for, all I know is that they are the go-between between me and the EMR company). They were able to provide me with remote training, and I was able to create templates while I was getting the office ready.

But there is a huge difference between theoretical answers to questions in a template, and the long rambling stories my patients like to tell. And since there were very few endocrinologists using the software, the pre-built plan templates were missing a lot of the labs I commonly order (and the ones I uncommonly order).
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I must say I have been pleased with my ability to create a consult letter (one that meets Medicare’s requirements – although soon it may not matter if they get rid of the consultation codes) minutes after seeing a patient (sometimes while the patient is still checking out at the front desk).

I also like being able to instantly find out what “that pill (I) stopped” was, even from home. And when the prescription faxing function works, that’s great, too. Only problem is it’s been hit and miss with that. I’ve been telling patients to call the pharmacy before they head over to make sure the prescription went through.

And although I had heard patients complain in the past about other docs who “hide behind that damn computer all the time,” it does not appear that my patients mind me tapping on the screen. My tablets are small enough that I can look over the screen at the patient and maintain eye contact. As an aside, I did have a tough time finding a computer cart that was small enough to fit in the exam room, sturdy enough to be wheeled around and low enough that people of short stature (i.e. me) could use it while sitting that didn’t cost as much as a small car.

Am I reaping all the benefits of using an EMR? No, not yet. But I can still see the potential. I am working with my VAR to make things work. I am modifying templates as I go along. I am periodically pulling out my hair. And I look forward to the first follow-up patient whose note I can partly write by clicking “past note.” Let’s hope it works.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

MD plus MBA

You know those days when you feel like you need a business degree to run your practice?

You’re not alone, and in fact, more physicians are pursuing post-graduate business degrees, according to a new report from Cejka Search and the American College of Physician Executives.
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One-third of physician executives have an advanced business degree — an MBA, master’s of medical management, master’s of public health, or master’s of health administration.

Most of the physician execs have an MBA and are filling the roles of medical director, chief medical officers, division chiefs, and department chairs.

Cejka Search officials say physicians are getting more education to advance their careers, and that it’s a requirement for those positions. Rather than rely on experience alone to learn these business skills, many physicians are learning practice management in the classroom. Physician executives in those management positions with advanced degrees also earn more than those without (11 percent more with an MBA, for example).

As we’ve noted before in coverage on docs getting MBAs, the extra time and money for school isn’t for everyone. You have to decide why you need an advanced degree. Although the day to day running of your practice may feel like it requires the degree, it’s clearly more suited for those considering a career in healthcare leadership.

More H1N1 help

In an effort to improve the coordination of care this flu season, the AMA has launched a Web site (www.amafluhelp.org) they are calling the “nation’s first comprehensive Web-based patient flu health-assessment program.”

The idea is patients can assess the severity of their symptoms, and share their information online with their provider (both must register to use the system). There are also tools for physicians to help them monitor their patients’ symptoms, facilitate treatment, and manage the practice’s work flow. (The site is free, but physicians may decide to charge patients for online monitoring.)

The last part – managing the influx of patients this flu season – was the topic of this month’s podcast. And if you haven't already seen it, check out our H1N1 resource page.

On keeping your blog professional

How careful are you about what details you include in your blog or updates on Facebook and Twitter? As more and more physicians join the online din of social media, they may find themselves treading on thin ice when it comes to privacy and professionalism.

Take this perhaps extreme example of a nursing student who was expelled for blogging. Guest blogger Michelle Fabio writes about it at Better Health and Kevin Pho posted about it today.

The student’s is a crazy story. She blogged about witnessing childbirth, and wrote some arguably unprofessional things about the experience (for starters, that the baby was “a wrinkly, bluish creature, all Picasso-like and weird, ugly as hell, covered in god knows what, screeching and waving its tentacles in the air.”). Without a hearing, she was expelled. She sued and a judge ordered her to be reinstated.

The judge determined she didn’t violate confidentiality, but clearly she crossed some professional boundaries here.

This story comes just as I am reporting on this very topic for an upcoming column about whether physicians are unwittingly violating patient confidentiality on their blogs and social media outlets.
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Medical students caught some flack recently about their online conduct after a survey found they were posting inappropriate material on Facebook and Twitter. Thirteen percent of it was found to violate patient confidentiality and 60 percent was considered unprofessional.

Some hospitals and schools and maybe practices are banning social media. That’s a bad idea. Simply cutting off online communications ignores the benefits of networking, marketing, innovating, and sharing ideas and experiences (a point well made by Paul Levy on his blog).

So what’s the solution? Perhaps a policy that outlines what is an isn’t appropriate (for the cases when common sense doesn’t prevail). The survey suggests these cases aren’t as extreme as one might think, so maybe some kind of written rules are in order.

I spoke with Better Health’s founder Dr. Val Jones yesterday, who told me in general doctors are so terrified about violating HIPAA that they usually ultra scrutinize their posts. (And her bloggers all follow the Healthcare Blogger Code of Ethics.) But she did caution that docs should use common sense, and remember that anything posted online is not private.

But, another point she made that I thought was particularly interesting, is that healthcare professionals should not shy away from blogging and engaging online. She said that doctors have “a moral obligation to get their voices heard online.” Indeed, the Internet rewards those who are loud more than those who are right. And doctors must get out there and combat misinformation. (Her main example was the misinformation propagated by Jenny McCarthy who claims vaccines are linked to autism. Where was the chorus of doctors setting the record straight online when this garbage spread?)

What do you think? Should online interaction be encouraged or banned? How can doctors make sure they are staying professional (and legal) when posting online – or is that even a problem, considering most are able to rely on common sense?

Do you have electronic alert fatigue?

Do you at times ignore those nagging electronic alerts?

I spoke with a physician recently who told me his office doesn’t use all the electronic reminders offered by his EHR. They are great, and they use them, he told me, but too many can prompt some docs to ignore them. “There can be a bit of fatigue,” he said.

Reminders and alerts can be helpful, but they can be overkill. A recent study of nearly 1,200 electronic alerts sent to doctors at a VA medical center and five clinics in Houston found that physicians failed to click open the alerts nearly 20 percent of the time, according to American Medical News.
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For 7.7 percent of the time, docs using EHRs failed to take action on clinical meaningful abnormal results within a month, and more than a quarter of the tests that initially were overlooked resulted in a new disease diagnosis.

However, doctors were more likely to follow up on results when radiologists took the extra step of calling instead of relying on only EHR alerts. The study said systems should be designed to leave important alerts on the screen until physicians take action on them. Another recommendation was to reduce information overload for physicians.

Another study last spring on e-prescribing systems found that many docs found the alerts more annoying than helpful.

So the technology might offer plenty of benefits, but it also requires a change in the practice work flow.

Congress considering fix to Medicare payment formula

It looks like the flawed Medicare payment system is finally getting some serious attention.

Senate Democrats are planning a vote soon on a bill that would permanently eliminate the sustainable growth rate (SGR), the formula used to determine Medicare payment rates. As you probably know all too well, that formula has and will continue to threaten payment cuts each year. Congress usually steps in at the last minute to reverse the cuts, but a 21 percent cut was looming for 2010, and there has yet to be a permanent fix.
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The bill, introduced last week by Sen. Debbie Stabenow (D-Mich.) and separate from the main three health reform bills, would reset the SGR to zero for 2010 and beyond. This basically means it erases the $245 billion debt accumulated from last-minute fixes to avoid deep payment cuts, according to MedPage Today.

Among the major healthcare reform bills being worked out in Congress, the House bill scraps the SGR and later replaces it with the Medicare Economic Index, and the Senate Finance bill fixes it for just one year. That accounts for some of the cost difference between the bills.

The AMA, which supports the bill, launched a campaign last week including a television ad. “Congress can no longer put a band-aid on the problem,” AMA President J. James Rohack, MD, said in a statement.

But the cost (and the fact that the bill doesn’t really explain how to pay for the $245 billion) and the speed (it’s scheduled for a quick floor vote) has made some skeptical about this solution to the Medicare payment system.

So perhaps there are better ways to fix the SGR, but at least it's getting some real attention in Washington.

Melissa Young, MD: Solo doesn't mean all by myself

I am going to take a break from talking about my EMR choice for now to talk about something I learned along the way about solo practice. See, I had resigned myself to the idea that from now on, it would be all me, all the time. That I would have to plan all the little details of every little thing that went into the practice.

And I supposed I could continue to think that and to act that way. Or I could accept the fact that there are people and organizations that can make things a little easier, or at least a little less expensive.

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For example, I had created and budgeted for a marketing plan. Now, first of all, a mentor from SCORE (an organization of retired business people who counsel entrepreneurs) questioned my need to advertise since most of my patients would come from referrals. And I later realized that the local hospital I was applying for privileges at would be more than happy to arrange ways for me to network. And the physicians who found out that I was coming were eager to ask for and hand out my cards.

I also had planned on coming up with patient education material, completely forgetting that while drug companies cannot spare me a pen or sticky note, they can provide me with ample copies of educational pamphlets, books, and Web sites.

I have found that the hospital has an excellent diabetes education center, so I don’t have to personally teach the patients how to use a glucometer or how to inject insulin (although I will probably continue to show them the basics).

At my old practice, my staff scheduled patients’ radiology tests. I was worried that I would be spending time on this task, but when I called the hospital to find out who the contact person was, I also found out that all I had to do was fax a request with a note saying, “Please contact patient with schedule.”

And thankfully, I have an administrative assistant who is bright and able to work independently. Even when I was still a fellow, I was told that your staff can make you or break you. The office has only been open for two weeks (she’s actually been around for four weeks, helping me get things ready), but she has been able to handle the unexpected tasks that come with starting up a practice.

And lastly, I am blessed with a very supportive husband who has helped with everything from billing to hanging diplomas.

I suppose I could do it all if I had to. And I really thought I did. But now I realize that I don’t have to do it all. Sure, I am still physician/employer/janitor/manager, not to mention wife/mother/friend/daughter/sister. But help is out there — and even better, sometimes it’s free.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

About that Individual Mandate

What are your thoughts on the proposed government requirement that everyone purchase insurance? My Physicians Practice column for November is on the mandate, a version of which is included in every major reform legislation. In it, I argue that "most Americans, including those who are currently insured, [don't] have the slightest idea how this new mandate will affect them or what it will cost them. And I doubt that they’re going to feel good about it when they find out."

Is it the government's place to require people to buy something? Some have argued that such a demand is unconsitutional. I realize states require automobile owners to purchase car insurance, but they don't require people to own a car.

Especially with health insurance, which is very expensive, what obligation does the government have to make sure people can afford it? Most mandate proponents would say that there must be adequate subsidies for low-income people, yet it's clear to me that the Senate Finance bill passed this week does not contain adequate help.

Is it possible, in the absence of an individual mandate, to achieve universal health coverage? Or is that the wrong objective? Perhaps it would be better to strive for universal access -- that is, making sure it's available and affordable for everyone, and perhaps encouraging its purchase but not requiring it?


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For the record, I have previously argued for a mandate. I don't think universal coverage is possible without one, and I don't think effective health reform is possible without universal coverage. But any mandate should come within the context of a robust market where ALL people have choices about which insurer they want covering them, same as with car insurance, homeowner's insurance, etc. Make the health insurers compete for individual consumer business. But that would require shaking up the employer-based coverage system, something no one is proposing.

Your thoughts, please ...

From MGMA: Cleveland Clinic's approach

How has the Cleveland Clinic developed a reputation for delivering high quality care at comparatively low costs?

Of course, there isn’t a single answer to that or a step-by-step path other organizations can take to emulate them. But speaking at the MGMA annual conference in Denver this morning, CEO Toby Cosgrove offered a few insights on what they have done to achieve that reputation.
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Perhaps one of the most notable differences in their model is that physicians are all salaried. They all receive one-year contracts, and extensive annual reviews determine their salary for the next year. “No incentive forces us to do more or less,” Cosgrove told the crowd.

Cleveland Clinic isn’t alone in physician salaries, and Cosgrove said he gets some skepticism about the approach. But he says it can be done across the country and may reduce unnecessary tests or procedures. The salaries are based on national averages for each specialty.

Another unique feature is that the healthcare organization is organized around organ systems and diseases, so that, for example, heart surgeons and cardiologists are sharing the same water cooler. This is how collaboration and innovation happen, he said. And it’s patient-centric.

Cleveland Clinic also works hard to measure quality, publishing annual outcome books for each institute. Then there’s the EHR connecting the nine community hospitals and 17 health centers. It’s been expensive and time-consuming, he said, adding “I don’t think we’ve saved a penny.” But it will improve quality, which eventually may cut costs.

One really interesting approach they have adopted was the creation of two Chief Experience Officers to improve patient satisfaction. This came after Cosgrove was challenged by an attendee at an event in which he speaking who asked what Cleveland Clinic did about the patient experience and whether they taught empathy. They hadn’t focused on that, so Cosgrove made some changes.

Cosgrove also detailed the organization’s employee wellness programs, such as free yoga classes and healthier food in the cafeteria. (He made headlines for adopting a policy of not hiring smokers.) This area is where the country needs to focus on to really cut the cost of healthcare in the U.S., he said. Forty-percent of premature deaths are caused by behavior, he said.

Referring to the healthcare reform debate in Washington, Cosgrove said, “All this won’t do anything to control costs,” adding the country must reduce the burden of chronic diseases.

From MGMA: Are you really managing risk?

What do you do if a patient acts inappropriately to a nurse? Or if the patient’s family is threatening to your staff?

And what if one of your employees has been out on disability for months, showing no signs of returning to work?

It’s these issues that practices must consider — and have policies in place to deal with — or be at risk for lawsuits. In other words, managing risk in a practice is more than malpractice and HIPAA.
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For one of the sessions here at the annual MGMA conference in Denver, attorney Judith Holmes and physician Hans Hansen went over some other areas where practices may be at risk. Here are a few examples to consider (and some thoughts on what you should be doing to mitigate that risk):

• Workplace violence from patients, family, current or former employees. You should train staff to deal with potentially violent situations, adopt a zero tolerance policy toward threats, and develop a procedure for reporting and handling these situations.

• Privacy concerns from employee Internet use. Talk with your staff and train them on using the Internet wisely (we’re talking Facebook, personal email, and … worse), and again develop a written policy.

• Equal pay. Time to dust off those job descriptions and make sure you are always documenting your compensation decisions.

The list goes on, but it comes back to having policies in place. The two presenters stressed that practices need sound, written procedures for these situations. And don’t forget to train your staff. Holmes said training “is the wisest investment you can make,” adding, “It’s your best defense against lawsuits and EEOC claims.”

The idea is you'll know what to do when about that threatening patient or the difficult employee.

From MGMA: What are you waiting for?

If you haven't invested in an EHR, what are you waiting for?

It's a question that has come up several times here at the MGMA annual conference in Denver, so I thought I'd post it in hopes that readers might weigh in.

Some say it's fear of cuts to Medicare reimbursement, which leave practices unsure about their revenue. Others say it's a confusion and anticipation over what EHRs will qualify for federal incentives under the stimulus package. And then there's the healthcare reform push in Washington, which seems to change by the minute, leaving practice anxious about how they will be affected.

I imagine it's several reasons, but I am interested to hear what is keeping you from taking the plunge.

One practice's experience with in-office drug dispensing

Practices are always looking for ways to boost revenue. What about in-office medication dispensing?

For one family practice in Anchorage, Alaska, acting as a sort of pharmacy has paid off big time with patient satisfaction, said practice manager Cindy Tollefsen, speaking during a session at the MGMA conference in Denver. And the idea is it will eventually bring in additional income.
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It took a lot of work, though. There was a lot of planning, as the practice worked out security issues (they redesigned the office), staffing (hired a full time staffer), marketing. But the result has been cheaper drugs and happy patients, Tollefsen said.

The practice is just breaking even on it how, which she attributed to a way-too-big initial order. They have too much stock right now that they can’t move. But there’s a huge value in the patient satisfaction, she said.

What do you think? Would that be possible for your practice? Worth the investment and effort?

T.R. Reid at MGMA: Why doesn't the U.S. health system cover everyone?

Why doesn’t the U.S. provide healthcare coverage to every citizen?

It’s a question Washington Post correspondent and author T. R. Reid posed as he sought to explore what the U.S. can learn from other countries’ healthcare systems. All the other industrialized counties manage to cover everyone – and spend less money doing so – so why don’t we?

Reid, who spoke this morning at the MGMA annual conference in Denver and recently published his book The Healing of America, concluded with this thought, that seems to get at that vexing question: “If you don’t make a moral commitment (to cover everyone), you end up with a system like ours…. We’ve got to make that commitment to fix our healthcare system.”
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It’s on this point that Reid drops his reporter objectivity. Healthcare coverage, of lack thereof, he said, is a fairness issue, a question of what is decent, humane, and just.

Reid spent about three years traveling the word and exploring the four main models of healthcare coverage that exist, which range from socialized medicine of Britain to the out-of-pocket model (if you can afford it, you get it) of Angola and other poor countries.

The U.S. has all four models, but other industrialized countries – you know, the ones that cover everyone – chose one model and they make it work.

Why one model? It’s “vastly simpler and vastly cheaper,” he said. It’s also fairer. In each country, including the U.S., the design of the healthcare system reflects the values of the countries, he argues. Other countries have sat down and made the decision to cover every citizen. And the U.S. hasn’t. Real reform, he said, won’t be achieved until the U.S. makes that decision.

“If the U.S. could find the political will to provide healthcare for everybody, the other rich countries can show us the way,” he said.

Perhaps unsurprisingly, he wasn’t very optimistic about real reform passing in Congress this fall. The plans would still leave millions of Americans uninsured, which still means a costly, inefficient, and, he argues, unfair system.

Melissa Young, MD: The Search for the Perfect EMR, Part 3

The search is over.

Well, sort of. I mean, I’m done searching. But perfect? No. I wouldn’t say that. There are days I have plenty else to say (none of which can be published uncensored), but perfect? No.

Don’t get me wrong. I still think that among the different EMRs I looked at, I made the right choice with e-MDs. It was right for my budget — I wasn’t going to “settle” for one just because it was cheap (or free even) if it didn’t have the features I wanted, but I also didn’t have unlimited funds. (I did have other start-up expenses, you know, like exam tables and a new bathroom and such.) It had a decent number of endocrine templates, although I still made a lot of my own. It was fairly easy to make these templates, although there was a lot of trial and error. And my VAR has been pretty responsive to my cries for help (I’ve even got their cell phone numbers).

But perfect it is not.
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Going back to the templates — yes, easy enough to create, if you know what questions you usually ask, and what answers you expect, and just how you want that to look when it’s printed as a sentence. But it takes time. Time that most practicing physicians don’t have. I had the luxury of starting to create these while I was on “vacation” from my prior practice. And there are nuances you don’t expect until you try to create a note. Little things like where the period goes, and what conjunction to use, and do you let the user type in the answer or is it all multiple choice.

I have also discovered that a lot of labs and tests I order aren’t on existing templates, so I’ve had to add those on, too. I guess that’s the problem with being a specialist in a field where there are so few of us. I guess nobody else who seriously uses the system has bothered to add these things before.

And there are things you don’t discover until you’ve gone live with patients. Like there’s no good way to quickly enter the dozen of supplements they take when the patient brings a list of brand names but has no idea what the active ingredients are.

And there have been technical bumps in the road, too. I think I have to put my VAR’s tech support on speed dial. They usually address my issues quickly, and they do a lot remotely. I hate calling for help, but I know my limits. I’m a decent end user of technology, but I am not a tech person. So hallelujah for remote access.

Before you think that all I have are complaints, let me make this disclaimer: I am very critical of things. I think all doctors are, or should be. We are taught to look for what is wrong with things.

I believe in my EMR. I believe that once I have worked out the bugs that it will make my staff and me more efficient. It will certainly save me space that would be taken up by paper files. It saves my secretary from pulling a chart to put a lab result in it or to give to me if a patient calls with a question. From the comfort of her desk, she can put the patient on hold, call over her shoulder, “John wants to know if you said increase his basal rate to 1.0.” And I, in the middle of reviewing someone else’s labs (that have automatically been faxed into the EMR), can pull up my note on John and tell her to say, “Yes, that is precisely what I said.”

I hope to save on paper — both making me green and saving me green. No more printed faxes. No more cover sheets. No more print outs of lab results that just say “pending.” It will remind me, when I am overworked and the patients merge into one giant faceless patient, that it is time for Mrs. Smith’s DXA, that Bob needs a flu shot, and that Mr. Doe owes the practice $50 in no-show fees. (Hmm, perhaps a topic for another post.)

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

H1N1 resources for your practice

As flu season gets underway, your practice will be on the front lines of the outbreak. Are you ready?

To help you prepare, we've developed an H1N1 flu resource page with information and links. Now is the time to develop a plan to handle an influx of patients and possibly a diminished staff.

Are you getting a flu shot?

Do you plan to get the flu shot? How about the H1N1 vaccine?

Considering the hype around getting the vaccine distributed and readying your practice for the flu onslaught, it surprised me that most health care workers likely won’t be getting vaccinated themselves.

So should it mandatory?
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Historically only 40 percent of healthcare workers get vaccinated from the seasonal flu. Why? Perhaps it’s many of the same reasons the general public hesitates. Maybe they are skeptical the vaccine will work, or they are convinced they won’t get sick.

Now, many hospitals and healthcare organizations are mandating the flu vaccine. New York State is requiring it, and large hospital chains like the Hospital Corp. of America, MedStar Health, and the UC Davis Health System are mandating it, according to NPR. Here's a pretty strongly-worded opinion in favor of mandatory vaccinations for healthcare workers.

Opponents of the requirement say it’s infringing on their rights.

But what is the hesitation? Wouldn’t it make sense to keep yourself flu-free and avoid spreading it to patients? Should it be required?

And are you planning on getting the flu shot? Why or why not?

Should we tax soda?

Should the government tax soda pop, Kool Aid, and other sugary drinks, as a way of funding increased healthcare access and reducing obesity, especially in kids?

Honestly, I'm torn. I'd love to know your thoughts.

On the one hand I can see the obvious benefits. Some $14.9 billion a year could be raised by a mere 1 cent-per-can tax, researchers say. There's no question that high cigarette taxes have prompted many people to quit, and discouraged many more young people from starting. And I do think sugared soda is the Marlboro Man of our time.

But my libertarian side is kicking in here.
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1. If we tax soda, why not candy? And if we tax candy, why not, say, red meat? Or how about products with trans fats? New York City, the Emerald City of Nanny States, has already banned its restaurants from using trans fats. What about diet sodas? And where is all this going, really? Is there to be no end of regulating people's personal behavior "for their own good." Yes, I know the argument: "We're all paying for it." But isn't that an argument against the welfare state, rather then for the nanny state? These are generally zero calories but some have said they should be taxed, anyway.

2. Who's to say a 1-cent-tax would be effective in driving people away from Coke? Wouldn't it need to be much higher, in the cigarette-tax range, before it would have any effect? About half the states already have soda taxes and I'm aware of no research suggesting that these taxes have been anything more than a source of funding for government, to which they have become addicted, not an effective method of driving down obesity or reducing soda consumption in those states. So, what kind of tax are we talkting about here?

OK, let me have it. No one sees more of America's large behinds than the people who read this blog. Yes or no on a soda tax? And what else (or more), if anything, should the government do to reduce the size of out waistlines?

850,000 doctors' personal data stolen

It’s usually patients’ information practices and companies work hard to protect and that you hear about being stolen. This time it’s doctors’ personal data.

A file containing identifying information for every doc in the country contracted with a Blues-affiliated insurance plan was on a laptop stolen from a BlueCross BlueShield employee, according to American Medical News. The computer contained information on about 850,000 doctors -- and all of the data were unencrypted.
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Names, addresses, tax ID numbers, and national provider identifier numbers for about 850,000 physicians were on the computer. And as many as 187,000 used their Social Security number as a tax ID or NPI number.

Apparently a company employee downloaded the unencrypted data — did I mention it was unencrypted? — onto his personal computer to work on it from home, which officials said was a big company no-no.

It’s not clear yet whether there has been any identity theft from the data.
It kind of makes you stop and think for a second whether you are protecting sensitive data on your laptop. It’s a topic next month’s Tech Doctor column addresses. (Sign up for the e-newsletter to receive the column, which goes out on the 15th of each month.)

The more mobile we become, the more our laptops becomes our portable office. But it’s far too easy to obtain sensitive data from a stolen laptop. Think about the spreadsheets and documents that could contain health or personal information on your patients. If that’s the case, perhaps it’s time to look into disk encryption software. As our Tech Doctor will tell you, you can just do a search for disk encryption applications and you will find a range of solutions.

In the meantime, consider some of these tips on from a recent story on computer network security:

1. Install a firewall to restrict outside access to your system.
2. Encrypt e-mails when sending messages to people outside of your network, and establish a Web site for patients to log in to access their personal information.
3. Ask your software vendors what security measures they offer.
4. Establish firm guidelines for employee computer use and stick to them.

Obama rallies physicians for reform

It was a sea of white coats Monday in the White House Rose Garden as President Obama hosted a photo op with 150 doctors from around the country.

“Nobody has more credibility with the American people on this issue than you do,” Obama told the doctors, saying the “people who are most supportive of reform are the very medical professionals who know the health care system best.”
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Doctors surely see the need for reform every day. Obama noted, “They’ve seen far too much of the time they want to devote to taking care of patients spent filling out forms and haggling with insurance companies about payments. These doctors know what need to be fixed about our health care system and they know what health insurance reform will do.”

Besides taking a few minutes to reiterate what is in the proposals coming out of congressional committees, Obama was rallying support from the medical community. Last week, his campaign network Organizing for America, started raising money for doctor-themed ads.

A June poll found that almost 75 percent of Americans said they trust doctors to recommend the right course for reform, according to Politico. And Obama is counting on docs to speak out in support.

But clearly, not everyone in the healthcare community supports his plans, and there doesn’t seem to be consensus on what health reform should look like. In our own Great American Physician survey, we found most docs agree the system needs fixing, but the solutions varied.

What do you think of Obama's approach to rally physician support?

Melissa Young, MD: The Search for the Perfect EMR, Part 2

After narrowing down my EMR choices to two, I scheduled site visits for each. Oh, let me preface this by saying I did ask a practice management consultant that I had met at a conference what his opinion was of my two options. He said that they were both good choices (not helpful), that they had very similar features (again, not helpful), but that e-MDs had better ratings for customer service than the other company I was looking at. (I was asked not to publicly diss any specific companies or products, I’m not hiding anything from you. It’s really a fairness issue, and my experience might not be representative of the company overall. Also, I’m not being compensated by any company that I may praise)

He said that “Company B” had become more and more popular, and rightly so, as they do have a good product, but that their customer service ratings had gone down as they grew because they couldn’t keep up.
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So the closest endocrinologist who uses e-MDs is about 45 minutes north of me. I had spoken to the office manager (a.k.a. wife) of the senior partner and the staff was expecting me. I sat in the receptionist’s area and observed how the workflow went. I liked the ease at which they could check patients in, refill their prescriptions, and answer questions with a couple of clicks of a mouse. Mr. Joe Somebody would call, ask if his prescription had been called in, and without getting up from her seat, the secretary could tell him that yes, yesterday afternoon it was called in to XYZ pharmacy. Mrs. So-and-so showed up for her appointment and her insurance card was scanned in – no more mistaken ID numbers. It seemed that from a front-desk perspective (and I later learned from a billing perspective), that it made the workflow seamless and smooth.

I was, however, a little disappointed that the providers (MDs and PAs) didn’t use the system to its fullest potential. Some put notes in. Some used templates from time to time, but at other times free texted their note (which does not allow the system to come up with appropriate codes), and some still hand wrote notes for the most part. I asked a couple of them why. They blame themselves for not taking the time to learn to use the available templates and for not creating templates they would like. Having done the remote demo, I knew that there was a lot of potential as far as note creation, use of forms, creation of letters, interfacing with labs, e-prescribing, etc.

Company B didn’t have any endocrinologist in New Jersey that used their product. So off I went to New York, about an hour away, to meet with Dr. DM. I had spoken to him on the phone the week prior and after I said Fridays were best for me, he said Friday would be fine, but that he didn’t have patients in the afternoon so I may not be able to see him in action. I said that was fine, so we arranged for my meeting with him at 1 p.m.

I got there a little early, and found a waiting room full of people. But, I figured, I’m early, I’ll wait. So I did. A long time. During which I had the unpleasant learning experience about the value of a closed glass window separating waiting room visitors from staff who have no qualms about talking about other patients. Loudly. But that deserves a post in itself. As does a discussion about where to let chatty drug reps wait if they are going to gossip about other doctors.

But I digress. After waiting over an hour and a half, Dr. DM’s secretary called in me. Well, thank goodness, I thought. But when I got inside, she pointed to the phone and said, “That’s for you.” For me? How could it be for me? It was a rep from Company B asking me why I was there. I was flabbergasted. I told him I was there for a site visit. “And Dr. DM wasn’t aware?” Expletives went off in my head, but I was able to (semi) calmly say, “Of course, he was aware. I talked to him last week and made this appointment.” The rep said he didn’t understand why he was called. Well, neither did I. And did I mention during none of this had Dr. DM even bothered to stick his head out and say, “I’m sorry for the wait” or “Hello,” for that matter? At this point, I was convinced that staying was pointless. Besides, I still had an hour-long drive home.

I was seething the entire drive home. Still, I told myself, it’s not Company B’s fault that one of their clients is a jerk. But a couple of days later, I got a call from one of their reps. “I heard there was a little snafu last week, and wanted to know what happened.” A snafu? Wanted to know what happened? Didn’t the rep who sent me to Dr. DM know what happened? Didn’t the rep who called that day know what happened? She offered to set me up for another site visit. I said there was no way I was driving an hour again. She asked if it had to be at an endocrinologist’s office. I said so long as the practice saw a lot of diabetics it would be fine. She gave me names of rheumatologists, dermatologists, orthopedists, gastroenterologists. In the middle of her list, I got disconnected. She never called back. I don’t know if she thinks I hung up on her.

I still think Company B’s product is good. And clearly lots of people think so. It is very popular. But I figured, if this is how their customer service is when they are still trying to make a sale, what will it be like after I’ve signed the dotted line?

And so, I’ve made my choice. In my next post, I’ll tell you about my experience in getting the EMR up and ready to go.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

How to survive the financial storm

The recession has arrived for private medical practices, and the the Medical group Management Association has just released data showing how bad things have gotten out there. Using its data from multispecialty groups as a "proxy for overall trends," the MGMA found that revenue last year was down 1.9 percent, while procedures and patient volumes have declined by 9.9 percent and 11.3 percent, respectively.

And folks, here's what might be the scariest part: These numbers don't even include data from 2009, when the strongest affects of the recession took hold (although it is now clear that the recession actually started in late 2007). So things are getting worse, not better. Meanwhile, health reform is almost certain to bring tighter controls on Medicare spending, to include not only reduced payments but also a whole new way of paying physicians designed to shift from volume to quality. That's sensible in theory but we'll have to see how it works in practice. One thing is clear to me, though: You can talk all you want about waste, fraud, and abuse, but you don't bring down healthcare costs without reducing pay to providers, period.

So. What to do about it? Below I've linked to a number of articles Physicians Practice has done on how to lower costs, get more patients, and be more efficient in a number of key ways.

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Cutting costs:
Here's how to cut costs without compromising quality. And another.

Here's an article on managing your overhead. And another.

Marketing:
Losing Patients? Here's how to get more.

And how to keep the ones you have.

Efficiency
Not sure where to start? Start by looking at your own practice's data. Here's what to look for. And here's how to understand what's probably the msot important report of all -- your accounts receivable reports.

We are heading into a very bracing period of time in private practice. The next decade will be more challenging than the one we're leaving. You simply don't have the luxury any longer of practicing the way you always have. Your survival is at stake now.

Show me the money

Here’s the lead in a recent New York Times article: If Grady Memorial Hospital succeeds in closing its outpatient dialysis clinic, Tadesse A. Amdago, a 69-year-old immigrant from Ethiopia, said he would begin “counting the days until I die.”

It’s meant to tug at your heartstrings, and it does. There’s a bit of reflexive anger, too. Closing a facility that provides life-saving healthcare simply doesn’t register in our national psyche. After all, this is the United States, not Ethiopia.
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Nine paragraphs later the reader learns that Grady Memorial Hospital lost more than $33 million last year — about 40% of its patients are uninsured and 25% are on Medicaid. Grady is on the frontlines, serving the neediest. But compassion alone can’t stem that kind of red-ink hemorrhaging; it takes money, lots of it. Where’s it going to come from?

Our current healthcare debate sorely lacks honest discussion about the true costs of delivering medical services. If the economy were booming, it would be an easier time to talk about reform. But it’s not. We’re approaching double-digit unemployment and people are jittery about money.

I once asked Harold Freeman, the head of Ralph Lauren Cancer Center in Harlem, what the main barriers to cancer screening and care in Harlem were. He gave a world-weary sigh and said, “Money. The lack of it. That’s the biggest barrier.”

In 1965, out-of-pocket expenses made up 44% of healthcare spending; today it’s 12%. Of course we get better care today; we’re also more shielded from the actual costs. But hospitals and clinics that serve poor patients aren’t shielded. They struggle on, and some, like Grady Memorial, have to close because they can no longer dish out up to $50,000 a year per dialysis patient, some of whom have availed themselves of the thrice-weekly treatments for years.

So when politicians talk about healthcare reform, our first response should be: Show me the money.

Stricter Stark rules take effect today

Stricter self-referral rules go into effect today, prompting many physicians and hospitals to rework or cancel contracts.

The Stark law revisions restrict arrangements where hospitals contract with physician-owned entities to provide ancillary services, such as imaging services. Basically, CMS has expanded the scope of designated health services to cover the entity providing the service (the doctor’s offices), consultant Susanne Madden tells me. (Susanne is writing next week’s PEARLS column on the topic, so be sure to sign up that e-newsletter.)

So, what does this all mean?
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Under the new regulations, doctors are no longer exempt from Stark rules, so it’s as if a physician is billing for his own referral services, Madden says. It’s as if they are sending patients to themselves, where before, it wasn’t considered self-referring.

Now, doctors and hospitals are left to quickly revise those contracts. Hospitals may choose to build out their own imaging services, for example. Or it looks like the hospitals may get creative to be able to contract for these services, as physicians could lease equipment or space.

How does the change effect your practice? What do you think of the expanded Stark rules?

Podcast: H1N1 prep

Are you ready for flu season?

Many practices can likely expect an influx of patients either calling with concerns about the H1N1 virus or showing up for appointments with flu symptoms. Then there’s the possibility of staff getting ill, further taxing the practice’s day-to-day operations.

So now’s the time to prepare. Is your staff cross-trained to handle all the duties? Do you have a scheduling plan to handle the extra appointments?

For this month’s podcast, I spoke with consultant Nick Fabrizio about what practices should be doing to prepare for flu season. Have a listen, and tell us here what you are doing to get ready.