How do you feel about accepting Medicare?

Will you stop accepting Medicare because of the looming rate cut?

Time is running out for Congress to step in and block a 21 percent Medicare reimbursement rate cut set for Monday. Some docs are saying they will stop taking Medicare patients, Kaiser Health News reports.

The AMA continues their intense lobbying effort to have Congress repeal the cuts and the faulty SGR payment formula on which the rates are based. But in the meantime, they are also providing information to their members, including how to remove themselves from the Medicare program and help their patients find other doctors, AMA according to CNN.

If you’re losing money every time you see a Medicare patient, why keep seeing them? Primary-care physician and blogger Kevin Pho (KevinMD) put it this way: Duty and conscience. He references fellow doc and blogger Dr. Robert Lambert’s post on the topic. Dr. Lamberts writes:

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“So why in the world do I accept M/M still? Why would I continue to make my life so difficult? Two words: duty and calling. I view my seeing M/M patients as a social responsibility (especially Medicare). These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income. So far.”

Dr. Lamberts says his conscience and tolerance of pain keep him accepting Medicare, but that he is sympathetic to docs who drop insurance and Medicare. For some, the conscience isn’t enough to stay in business.

Congress has consistently stepped in in the past to stave off the payment cuts, most recently just a few months ago to extend the deadline to March 1. But what if they fail to act this time? What will you do? How do you feel about accepting Medicare patients?

After the healthcare summit, now what?

Perhaps it’s little surprise that little was accomplished yesterday at Obama’s healthcare summit. The issue has become far too partisan. I thought the NY Times summed it up nicely here:

“If there was any question about how deeply divided Republicans and Democrats are about how to reshape the American health care system, consider that they spent the first few hours of President Obama’s much-anticipated health care forum on Thursday arguing over whether they were in fact deeply divided.”

In the end, Republicans rejected the idea of voting for Obama’s bill, and Democrats are considering pushing it through without their support. (I tend to think this is a path they should have taken a long time ago. Some issues should be legislated without all the bipartisan wrangling for votes. Why not just rely on the simple majority and pass some form of reform? Had they taken that route far sooner, perhaps the bill wouldn’t be the weaker version of insurance reform it is now.)

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The Times does note a few things the Republicans and Democrats agree on: the need for more regulation of insurers, and the idea that government should help individuals and small businesses pool purchasing power for insurance. How to accomplish these things? Now that’s where they disagree.

Americans similarly agree on certain elements of reform (tax credits to small businesses, a health insurance exchange, financial help for low to middle income), according to the latest Kaiser Family Foundation poll. The same poll shows Americans split (43 percent to 43 percent) on the healthcare reform legislation, though.

And another interesting point in the poll is that most Americans — 59 percent — say the delays are “more about both sides playing politics,” and 25 percent say they are “more about Republicans and Democrats having disagreements.”

Twenty-two percent want Congress to put healthcare on hold, and 19 want to see them pull the plug on the effort for 2010.

Randall Wong, MD: Docs can use the Internet safely

There is a trend on the Internet: more and more people are going online for health information. As reported by Reuters two weeks ago, more than half of Americans turned to the Internet for health information. While 51 percent used the Internet for health information, only 5 percent used e-mail as a method to communicate with their doctors.

Meanwhile, doctors continue to avoid use of the Internet, including medical blogging, publishing, Twitter, Facebook, email, etc.?

Clearly our patients have migrated to the Internet and there's nothing we can do about it. But maybe the migration can be beneficial, and there may be parts of the Internet we physicians can actually embrace instead of discounting the entire medium as a whole. Maybe we can meet them there.
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Many docs cite the legal uncertainty about giving health advice over a blog, Web site, or email. There is tremendous fear of medical liability when a doc gives an opinion, in the office or otherwise.

I am sympathetic, but I remain steadfast that we should be producing reliable health information on the Internet. We have a moral responsibility to make credible information available to the public and to our patients. I am not crazy, but consider this carefully. There is no reason why docs shouldn't be using the Internet to provide good health information on the Web. It is safe.

Let me explain. Fifty-one percent of Americans turned to the Internet, but fewer even queried their doctor in the form of an e-mail. Why?

Patients are out there looking for information. They are not out there looking for medical advice. There is a huge difference.

There is a difference between looking for the top 10 reasons of a sore throat versus looking for advice on how to treat your own sore throat.

In the same way, what is the liability to listing factual information about the 10 most common causes of sore throat? You are listing facts. You are not offering your opinion. There is no medical advice transmitted. So, you are safe.

Remember how we get into trouble. We have liability issues when we offer bad advice. Not bad information, but when we make a bad decision. Offering advice over the Internet is a bad decision, but offering information is not.

Allow me to beat a dead horse. There is something we are forgetting about ourselves. We are figures of authority. The authority comes from our own use of the information we have accumulated over the years and melding it with our experience. It's called clinical acumen. It will keep docs safe in their ivory towers. It will not socialize anything.

The Internet lacks health information, and we can change that. The Internet is not asking for our clinical judgment. There is a difference. It is our clinical acumen that will keep us ultimately separate and distinct from the Internet.

Now, get writing.

Gerald O'Malley, DO: Pattern recognition in the ER

ER doctors (and nurses) rely on pattern recognition to practice the type of medicine that is forced upon us when we take control of 75 patients all crammed into a space designed to hold 48 (with another 30 in the waiting room).

As Malcolm Gladwell described in his wonderful book “Blink,” good ER physicians develop reliable intuitive senses regarding the myriad ways that different diseases can present in different people and subconsciously search for patterns that guide clinical judgment. Many times, ER physicians “blink” instead of “think” (although I like to believe that we spend an awful lot of time thinking) and we learn to rely on and to trust our clinical judgment and our ability to recognize subtle patterns while caring for our patients.

What becomes really difficult to do over time, is to not bring that habit home and begin making instantaneous judgments about our spouses, our families, friends, and neighbors.
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I can recall many times that I’ve been introduced to someone outside of the ER and my first thought is, “My gosh, this guy is a tool. I bet he loves to watch grass grow, believes in global warming, and picks at mosquito bites until they bleed.” All that from a handshake and a “How do you do!” I genuinely feel sorry for any guy that my daughter brings home (I’ve got a couple of years before that becomes a serious concern) because the guy has about 11 seconds to convince me that I shouldn’t squeeze his head like a zit.

Pattern recognition is an inexact science and some are better at it than others. As a resident I used to think, “I can smell diabetes as soon as I walk in a room.” That’s not really true, I can’t “smell” diabetes, but I learned pretty quickly how to recognize the subtle clues of poorly controlled occult diabetes that might escape a non-emergency medicine trained or less astute clinician; the sticky film of sweat on the back of the neck, the two or three soft drinks consumed while waiting for me to get in the room, obesity, the general state of being unkempt and sloppy (because the constant interruptions to the daily routine caused by the disease do not allow for meticulous grooming), the thin film of greasy sheen under the eyes. There is no science behind this – these are observations that I’ve made over the course of a 15-year career in emergency medicine and caring for dozens of patients that have not yet received the diagnosis of diabetes mellitus.

During emergency medicine residency, the young physician is trained to do amazing things. One colleague told me that when he graduated residency, he believed he could sew somebody’s head back on (he has since modified his own inflated sense of his abilities). One of the most valuable things we can teach young ER physicians is to apply their intuitive ability to “blink” instead of “think” correctly, because, according to Gladwell, good clinicians are more often than not correct in their “snap judgments” which can probably lead to less testing, less time wasted, and less cost to the healthcare system. A good “blink” reflex comes in handy outside the ER when dealing with salesmen, auto mechanics, and (especially) lawyers.

What is not so easy to learn is how to turn off the “blink” and getting to know friends and acquaintances outside of the ER on a deeper level. Forming opinions of people with little or no exposure to them is not a great way to develop long-lasting and meaningful relationships.

Trendspotter: RACs Are Now Encouraged to Search For Fraud

There’s good reason for physicians to be worried about Medicare’s new Recovery Audit Contractors, better known as “the RACs.” Like auditors for Medicare carriers, the RACs seek to recover money for the government by finding evidence of overpayments to hospitals and physicians. What makes these four private companies different from traditional auditors is that they’re being paid a percentage—9 to 12 percent—of whatever they recover from providers. (See “Medicare’s New Bounty Hunters” in the current issue of Physicians Practice.)

While the January 1 launch of the permanent, nationwide RAC program was a wake-up call for providers, there hasn’t been much concern that the RACs would actively seek out fraud. They are supposed to forward fraud cases to CMS, but they have no financial motivation to ferret it out, says Jessica Gustafson, a Southfield, Mich.-based attorney who specializes in Medicare audits. “The financial incentive is for them to do the audit,” she points out, because that’s how they make money.

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But something in that equation changed recently. CMS has decided to provide formal training to the RACs on how to identify fraud and where to refer fraud cases. It is also developing a database to track fraud referrals. Needless to say, this will give the contractors’ personnel an extra incentive—although not yet a financial one—to look for fraud wherever it may lurk.

CMS chose this course after the Office of the Inspector General (OIG) in the Department of Health and Human Services examined what the RACs were doing about fraud—which was not much. During the three-year pilot that preceded the current program, an OIG report says, the RACs turned over evidence of fraud to CMS in only two cases. CMS wasn’t aware of these cases, according to the report, but has now forwarded them to OIG for further development.

OIG’s interest reflects the Obama Administration’s crackdown on fraud and abuse in the Medicare and Medicaid programs. “The government thinks they can whack close to 10 percent of their healthcare spending by nailing people for fraud,” says David Glaser, a healthcare attorney in Minneapolis who defends physicians against Medicare audits. “So concern is warranted, because they’re coming after you and it’s a way of reducing healthcare costs that doesn’t offend anyone except physicians.”

When does a pattern of improper coding become fraud? “The majority of audits involve a pattern of medically unnecessary services,” says attorney Abby Pendleton, one of Gustafson’s colleagues. “That’s a common reason for denial of claims. When does it rise to the level of fraud and abuse? It’s got to be pretty extreme.”

The government’s definition of fraud is vague, says Glaser. If a single claim error is viewed as an honest mistake, but a series of errors is regarded as fraud, he notes, that definition ignores the likelihood that someone who makes one mistake is likely to repeat it. “Say a lab had one code wrong a couple hundred times. Should the false claims law apply?” He has also seen an overpayment of $150,000 to one doctor regarded as evidence of fraud, while another physician who got a $3 million overpayment merely had to refund it.

In any case, the RACs are still less likely to turn up fraud than a Medicare auditor would be. The OIG report notes, “We recognize that RACs are not responsible for identifying potential fraud; however, we believe that there may be a disincentive for RACs to refer cases of potential fraud because they do not receive their contingency fees for cases determined to be fraud.” Let’s hope that it remains that way: the RACs should not have a financial incentive to find fraud and turn in physicians who may have made honest mistakes.

Meanwhile, the government needs to develop a better definition of fraud and a more reliable method of identifying it. Certainly, some providers are cheating the government, and they should be caught and punished. But especially when private contractors are enlisted in this effort, there is a danger that physicians may be wrongly accused unless CMS carefully supervises the anti-fraud effort.

Jennifer Frank, MD: CME ... with baby

It seemed like a great idea at the time. You know, like a year in advance. I applied to present at the American Academy of Family Physicians Annual Conference. Between the time I applied and the time my presentation was accepted, I discovered (happily) that I was pregnant.

My new baby would be about 3.5 months at the time of the conference. I figured it was doable and set out to make the arrangements to attend (along with my husband and three older kids). As an academic physician, it is important to keep publishing and presenting, even when life is happening.

A few weeks into my maternity leave, I found myself madly putting the finishing touches on my presentation. In between diaper changes and breastfeeding sessions, I did pub med searches, printed up articles, and finessed my PowerPoint presentation. Shortly after returning to work, I practiced my presentation for colleagues, received their feedback and made the necessary changes. I uploaded my “finished” presentation the day before we were to fly to Boston. I was ready for the presentation. I wasn’t so sure, though, about traveling with four kids on a plane, staying in a hotel, and navigating to the conference every day with a baby in tow.
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We arrived in Boston on time and got settled into the hotel. Fortunately, I had realized, in a rare moment of sanity, that once I left work on Monday evening, I would not have a chance to practice my presentation again before I did it live. So, there was no pressure trying to fit in one more practice or rewrite before my session was scheduled. My wonderful husband took all four kids on the day of my presentation so that I could focus.

And, it went great. The room was packed with interested colleagues, my talk went well, and I had the chance to connect with other family physicians who shared my interest. My husband even walked our kids past the room where I was talking so they could see Mommy.

For the rest of the conference, I had a guest attending with me — my 3.5-month-old son. We attended CME lectures together (when he allowed it), strolled the convention center floor in search of gadgets for his sisters and brother, met up for lunch with friends from residency and past jobs, and spent a lot of time waiting for an opening in one of the very few restrooms with a diaper changing station.

I was apprehensive about bringing my little guy with me to a professional activity. As a working mom, I often feel pressure (mostly from myself) to keep personal and professional roles separate. This represented a definite merging of the two. However, it went remarkably well. I received mostly encouraging smiles and comments from my family physician colleagues at the conference. I was grateful for the CME I did manage to attend. I was proud of my husband and I for attempting something so challenging…and succeeding.

Obama's healthcare compromise

President Obama presented his compromise healthcare legislation today (in advance of Thursday's healthcare summit in Washington), in an attempt to bridge the differences between the House and Senate versions that have stalled.

According to the White House’s announcement, Obama’s legislation:
• Provides a middle class tax cut for health care and reduces premium costs, to help make coverage more affordable for 31 million Americans.
• It sets up a health insurance market through state-based insurance exchanges
• Gives the government authority to block premiums rate hikes and claim denials

It also closes the Medicare prescription drug “donut hole,” increases the threshold for a tax on high-end insurance plans, and eliminates the Senate provision that exempted Nebraska from paying increased Medicaid expenses, according to CNN. And it does not include the public option.

Thoughts on his proposal?

Melissa Young, MD: The second physician

I was talking a couple of weeks ago to an internist. She had been in solo practice for a couple of years, and then she hired a former co-resident as a second physician. He left the practice after less than two years, and she has since hired a second “second physician.” I told her that I am currently in the process of finding someone for my practice.

During the course of the conversation, I couldn’t help but think back to when I was first hired at my old practice. When I was the second person. It’s a tough transition — for the new person, for the senior partner, for the staff, and for the patients. Even for new patients.

I still remember the sting of being told by patients that they had really wanted an appointment with Dr. Senior, but they couldn’t get in to see him soon enough, so they got me instead. Ouch. Well, most of them decided I wasn’t so bad after all, and actually were glad to see me in follow-up, or at least weren’t upset that they weren’t seeing their first choice.
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Well, what could I expect? My senior partner had been in practice in the community for over 12 years when I came around. All the local docs knew him. They spoke very highly of him to their patients. Who was this newcomer? Is she any good? It took years before I was recognized as my own person, someone worthy of sending patients to, someone to refer family to.

The staff had done things the same way for years. My partner’s way. He was the boss. He set the tone of the office. Sure, there were things I did my way, but it was often met with resistance. “Are you sure? Dr. Senior doesn’t do it that way.” And when we hired a third partner, he was met with the same reluctance to change things. “This is the way we do things around here; it’s how we’ve always done it.”

So when I bring a new physician on board, I plan to have new patients scheduled with her. I’m sure many of them will have been referred to me by their PCP’s, or that they will have heard about me from family and friends. Will they give my staff a hard time about scheduled with “the new doctor?” To make matters worse, she’ll be straight out of fellowship, just like I was.

I’m sure she’ll have her own unique way of doing things. Will my staff be flexible enough to handle it? Will I? Will she?

I hope for her sake that the transition will be minimally painful. I’d hate to have to look for a second “second” and start yet another transition.

A call for relaxing meaningful use critiera

Quite a few groups have criticized the draft meaningful use requirements as being too complex and nearly impossible to comply with. Now, the Health IT Policy Committee has called for relaxation of the standards that providers must meet to receive EHR incentive funding.

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As it stands, providers would have to perform 25 different measures in the areas of care coordination, privacy, quality and safety, etc. But in their recommendation submitted to David Blumenthal, the national coordinator for health IT, the group asked that the government abandon an “all or nothing” approach and allow providers to defer up to five measures from 2011 to 2013.

However, the group said certain measures should remain mandatory, such as e-prescribing and computerized order entry.
(CMS is accepting public comment on the meaningful use rules through mid-March and is expected to publish its final rule in late spring.)

What do you think? Is the criteria currently far too complex?

Don McDaniel: What's eHealth all about?

I’ve spent the past few weeks attending a number of healthcare information technology meetings focused on achieving interoperability in healthcare — so-called eHealth. You see, we have a major trading partner issue in healthcare — even if we gave every physician and hospital in America an EHR, all we would achieve are a group of discrete applications that don’t share information by and between them.

In other words they won’t be able to communicate with each other. This is a real problem — a real practical problem because unfortunately, because consumers, of course, attend care givers widely and without attention to what information system they use!

So, there’s been a lot of discussion about how to facilitate all these disparate systems to connect, communicate, and make the amalgam (the integrated data) information that is actionable.
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The Institute of Medicine (IOM) reports that about 1.5 million patients are injured each year because of adverse-drug events; events that presumably could be eradicated if we have true mission-critical healthcare information sharing.

While at the mHealth Conference, I saw a number of applications built and positioned for mobile devices — and this makes perfect sense in a world which is quickly becoming hardware- and even appliance-agnostic. These applications include a number of mobile phone applications to enhance disease management services and even review images remotely. We should be prepared for the integration of mobile systems.

At the eHealth Initiative’s annual meeting in DC, I learned about a number of functioning local information exchanges, mostly led by large Integrated Delivery Networks. For example, Boston HealthNet with it anchor tenant Boston Medical Center, has developed a health exchange that includes the BMC hospitals and eight to 10 discrete community health centers (FQHCs), allowing clinicians access to real time medication history for any patient seen throughout the system. This is one of what is today a limited group of operating health information exchanges; what I’ve described at BMC is really still an isolated HIE, but the promise is evident and I think the train has left the station.

I encourage you to do your homework, and seriously evaluate opportunities to pursue and engage a health information exchange. By the way, if you are a provider, and even if you plan to purchase an EHR, you will not be able to achieve meaningful use in the later adoption years without a relationship with a health information exchange. Food for thought.

Randall Wong, MD: Web tools to help you micromanage

I use two different services to track statistics on my Web pages. Using either Google Analytics or StatCounter, I can keep track of any information related to the traffic, or visitors, that come to my site. It's very sophisticated software, yet easy to use, and it's free. It allows you to micromanage.

If you own a Web site, analyzing the traffic to your site can give you some valuable insights about your visitors. To state it another way, you can get an idea of what people like and don't like about your Web site. Here are a few data points to keep an eye on:
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Unique and return visitors — This is some basic information that simply tells you how many new visitors you are getting to your Web site. Usually the number reflects the number of new visitors over the last, say, 30 days. Return visitors are also important; that number reflects how many loyal readers you have. Both are important. New visitors tell you if you are marketing correctly and returning readers let you know if you are providing content (on your Web page, that is) that interests people.

You can tell the country/state/city of origin, Web browser used, how they learned of your site, etc. You can even know the IP address of the computer used to visit your Web site. This is helpful if you are concerned about building a local following, say, for a medical practice.

Length of stay — On average, a person browsing on the Web, takes fewer than three seconds to decide if they should stay on, or leave, a Web page. Traffic data can tell you how long a visitor stayed, the average time spent on your web site and even what they liked to read. For instance, I know that my average visitor spends almost three minutes looking at something on my blog. I also know they read 1.92 articles each visit. This means that most people are pretty interested in the blog.

Popular articles — I can tell the top 10 articles read on my blog. This gives me a great idea of what subjects to write about again, and which to avoid. I am awful in predicting which articles will be a hit. By knowing what my readers like to read, I can publish content more directed to their interests. This would not be possible without tracking data.

Real-time data — You have the ability to monitor the activity of every visitor to your Web site in real time. You don't have to wait until the next week, next month or even the next day.

Exit/entry data — This can give you an idea of what attracted a person to your site and where they were on your site when they decided to leave. What got their attention and what turned them off?

Keyword data — What keywords are commonly used to search for you? This is extremely helpful in writing articles to gain SEO (Search Engine Optimization) ranking, placing AdWords campaigns, and describing what you do.

Search engines — Similar to keywords, you also learn the popular search engines used to bring the traffic to you. You'll be surprised how much difference there can be between the popular search engines. If I find success with a particular search engine, I'll try and maximize my SEO for that engine. When you find you are doing something right, stick to it!

So what does this mean? There are free tools for you to analyze any aspect of your Web page. This is no different than paying a consultant to analyze the strengths and weaknesses of your office staff. You stress about the quality of your "front line," that is, the people that answer your phones and greet patients as they arrive. Your Web page is no different.

By analyzing the many aspects of your traffic, you can easily gain the insights needed to turn them into patients. Best of all, the information is free, there is no catch, and it's not watered down. It's what Google does and what Web 2.0 means: open access.

Gerald O'Malley, DO: Philadelphia ER in the recent snowstorms

During the recent snowstorms in Philadelphia, the ER staff was sequestered for about 36 hours as part of the emergency disaster planning. Being required to stay at work caring for strangers while your own family is at home in the middle of the worst snowstorm in history, in some cases with no electricity, should bring out the worst in most people — but ER people are a strange breed.

Throughout Wednesday afternoon, as the blizzard progressed and the blanket of snow became thicker and heavier, nurses, techs, and doctors straggled in and arrived early, to be sure that they could make it in for their night shift. The mood was one of genial complaining and fatalistic good humor.
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“What are all these drug addicts doing here?”

“The methadone clinic across the street is closed. They put a sign on the door to go the ER. They came here for their methadone and now they can’t get home.”

“Can’t we stick them all in one room - the waiting room for instance - instead of having them lying around underfoot?”

The ER staff cared for the patients and paramedics that managed to make it into the ER and passed the downtime having snowball fights in the parking lot and using cafeteria trays as makeshift toboggans to slide down the snow-covered concrete steps of the hospital. Those that brought food shared it with their colleagues and patients and the rest ate whatever the cafeteria served up. The cafeteria stayed open all night serving up hamburgers and cheesesteaks while the salads got soggy. The staff worked and slept in shifts, finding an empty gurney wherever one was available.

Nurses, techs, and residents that couldn’t sleep entertained each other by gossiping and telling stories or watching TV (the most common request from the staff after the storm was that they wanted the hospital to provide Cinemax for the TV in the lounge for the next blizzard).

As the night progressed and the general volume decreased, conversations became hushed and more intimate. The wee hours of the cold night led to the revelation that You-know-who and So-and-so hooked up at the holiday party and What’s-his-name’s son is back in jail. We also learned that my colleague (that I’ve been working with for three years) turned down a music scholarship to Julliard to take on the burden of medical school debt, and two of our nurses were in Haiti helping with the relief effort.

Thursday morning arrived brilliantly and the whole city seemed like it was shining from the ground up. Every hard surface was nestled in a soft white blanket of silence. It was beautiful. Relief workers began to straggle in and tired nurses, techs, and residents were allowed to leave in a reverse-seniority order throughout the day.

During the winter of ’94-’95 there were several severe ice storms that crippled Philadelphia and left us stranded overnight several times. It’s funny how the long snowy day’s journey through the night always seems worse when you are actually living it. Some of my fondest memories of residency were those nights that we were trapped in the ER by our jobs and our duties. I suspect that this blizzard of 2010 will provide fond memories for another generation of residents and interns, although they probably won’t realize it for awhile.

Trendspotter: Where Hospitalist Communications Fall Short

By Ken Terry


One of the persistent problems in our healthcare system is the communication gap between inpatient and outpatient care. The increasing use of electronic health records hasn’t really resolved this problem, because, unless ambulatory-care physicians are using the same EHR that their hospital is, comprehensive information about a patient’s inpatient care is still hard to obtain in a timely manner. Discharge summaries are supposed to contain this data, but they often arrive too late to be helpful; and even if a primary-care doctor receives this document soon after a patient’s discharge, it may be missing key information.

A recent study in the Journal of General Internal Medicine found that tests pending at discharge were mentioned in only a quarter of discharge summaries and that only 13 percent of the summaries stated what those tests were. “We already know that outpatient providers aren’t very good at following up on pending tests documented in the discharge summary,” commented Dr. Martin Were of the Regenstrief Institute, the study’s author, in an article about the study’s findings. “Imagine how much worse the follow-up is when pending tests aren’t even documented.” Were added that the growing use of hospitalists and the tendency to discharge sick patients faster make the situation even more alarming.

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The discontinuity of care between hospitalists and outpatient physicians has been mentioned in a number of studies. Internist Robert Wachter of the University of California San Francisco, one of the hospital movement’s leaders, told me a few years ago that good hospitalists believe it is essential to contact referring doctors when one of their patients is discharged. “They ‘get’ that sending the patient back to the primary-care physician without the right information and without a phone call is a bad thing to do, both for the patient and in terms of the program’s credibility,” he said. But he admitted that some hospitalists in some programs are not very good about calling outpatient physicians; they might have a nurse or house doctor do it.

Even if the hospitalist does call the primary care doctor, he or she might not mention a pending test. The hospitalist might think it’s more important to focus on the most relevant issues in a brief call. There are also reasons why pending tests might not be documented in a discharge summary, Were points out. For example, multiple consultants order tests at different stages during a hospitalization. To find out which were pending, the hospitalist might have to pull information from several different hospital systems. Of course, that would not be the case in a hospital with a computerized physician order entry system—but only about 15 percent of hospitals have CPOE.

Even if hospitalists are aware of all pending tests, Were notes, they must distinguish between which are important enough to include in a discharge summary. Outpatient physicians will be annoyed if they are prompted to follow up unnecessarily on tests such as kidney function or CBC tests if the results had been normal throughout a patient’s hospitalization.

Another major issue is confusion over who has responsibility for following up on pending tests in the hospital, Were notes. Even if a primary-care physician knows about a pending test, he or she may feel that the inpatient physician should follow up. Hospitalists, on the other hand, may believe that, after a patient is discharged, the outpatient physician is responsible for all aspects of that patient’s care. But if a pending test is not documented, Were believes, it should be the responsibility of the hospitalist to follow up on it.

Blogger Kevin Pho observes, “Some hospitals have post-discharge clinics where hospitalists do the follow-up themselves, but that’s not commonplace. We clearly have a ways to go in bridging the communication gap between hospitalist and outpatient physician.”

This is an area that deserves much more attention, especially given the shockingly high readmission rate of Medicare patients. Part of the solution is to give hospitalists better tools and incentives for communicating all key inpatient data to primary care physicians, whether on the phone or in the discharge summary. In addition, as we build electronic health record systems in hospitals and physician offices, national health IT policy should prioritize the creation of electronic connectivity between inpatient and outpatient care settings.

Podcast: Michael Howe, former CEO, CVS MinuteClinic

What can you learn about your practice from the retail industry? It's a question I recently discussed with Michael Howe, former CEO of CVS MinuteClinic, which has in many ways redefined the care-delivery model.

For our February podcast, Mr. Howe chatted about how he thinks care delivery will continue to evolve, how different generations have different expectations of their physicians, and what physicians can learn from other industries outside of healthcare.

Listen to the podcast here, and join the conversation below.

Jennifer Frank, MD: What I love

Recently, I have rediscovered two old loves – soccer and ballet. Starting with a somewhat flighty dance instructor when I was three, I took ballet until I was in college. The discipline of the exercises and reassurance of doing things “the right way” is satisfyingly attractive. (Is it any wonder I found my home in medicine?) Soccer was a given in the suburb where I was raised and I dutifully played from elementary school until college.

With my focus on pre-medicine studies and the need for excellent grades to get into medical school, soccer and ballet fell aside as I pursued my ultimate goal of becoming a doctor.

In medical school, the work only became harder and the limits on my time and energies more stringent. The second year of medical school closed and I saw the end of heavy-duty “book” studying, but quickly transitioned into all-night call shifts and real-life learning from patients. Completing residency before the 80-hour work week rule, I remember 100+ hour weeks that found me asleep on the desk on L&D.
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During a “light” rotation in residency, I signed up for a four-week pottery class to rediscover a part of me that wasn’t related to medicine. I managed to attend two or three of the sessions, but didn’t have time to go back to get my completed projects. All that is left of my lessons are clay encrusted tools on the back of a garage shelf.

After residency, I suddenly had a lot more time and money…for the two months between graduation and the birth of my first child. Four kids later, residency a fading memory, and a more predictable schedule, I realized that if I don’t reclaim old passions and discover new ones now, I will next be exploring extracurricular options in my assisted living facility.

So, I signed up for a ballet class at the local Y and accepted an invitation to play on an over-30 women’s soccer team.

My ballet classes, open to adults and teens, have been populated solely with young women who have been alive for a shorter amount of time than has elapsed between now and the last time I donned tights. I can only imagine what they think of me as I glide through plies and pirouettes. Despite the limits of my older body, I love it. I look forward to my ballet class with eager anticipation every week. Gone is the need to be the best in the class. I am doing it simply for the love of doing it.

I am similarly enjoying soccer. We are not a great team. We lose every time and rarely score a goal. Once again, there is no pressure. Our team is not striving for a playoff title and no one is trying to shine in order to secure a college scholarship. Sitting on the bench for a few minutes is a privilege not a punishment.

I have finally finished my training and found a job that combines my interests and abilities. I am married with kids. I am terribly busy, but have learned not only the importance, but the absolute joy of reconnecting with a long-forgotten part of me.

Melissa Young, MD: Getting ready for doctor No. 2

I verbally offered a position to another physician. She has verbally accepted. Now to formalize the agreement.

By the way, she called me the other day because her husband is in a panic that she is declining other offers without having seen a contract from me. Let me say here, that I know this person. I’ve known her for the last five years. We joke that I have taught her everything she knows. I know her family. I visited her in the hospital when she had a baby. We have visited each other’s houses. She is confident that I will not bail on her or be unfair.

So I spent some time this past week preparing a skeleton contract.
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I spent an hour or so with a lawyer discussing other contract stipulations. Aside from the obvious salary, benefits, and vacation time, there was discussion about termination – with or without cause – ownership of records, revenue other than that from patient care, etc. Points I really had not given a lot of thought to. It did seem rather boilerplate, and sounded familiar, having had a similar contract when I was an employed physician.

I want to be fair to her. But I also want to be a smart businessperson. How much can I spend on her as far as CME? How much PTO can I really afford for her to have? How much am I willing to share of what comes in, and how much should she contribute to the practice? What counts as expenses directly related to her employment?

I’m not sure if it would have made a difference if I were hiring a stranger. Would I be less generous? Or would I be worried that the other person would balk at my proposal, and therefore would I be more lenient, say with the restrictive covenant?

The lawyer was quite helpful, going down a checklist, telling me if I seem overly nice or too stringent. She will have the written contract to me in a couple of days, and after I review it, and amend it if needed, I will send it off to my potential future partner. Will she have a lawyer review it? I don’t know. I know every advice column says you should. I have yet to meet a doc who has. Will she just sign on the dotted line, or will we go back and forth with changes?

I also had a conversation today with a solo doc who is now on her second “second physician.” That transition from solo to group is tough, not just on the senior partner, but also on the patients and the staff.

I remember being that second doc. More on that next week.

What do you do to stay healthy?

Robert E. Kramer had run out of excuses for not taking his own advice to be physicially fit. So he took up running. In this month's Physician Writer Search column, Dr. Kramer tells about how he worked up to regular runs and dropped some weight:

"By 38, I proudly realized that I was a runner. I had finally accomplished what I had put off for all of those years. I was in the best shape of my life and felt truly healthy."

But, he continues, a couple years later he had fallen off the wagon and realized there is always something lurking to throw him off his running routine. He writes:

"In the end I’ve learned an important lesson. Living a healthy lifestyle, day after day, month after month, will always be a lifelong struggle. It helps me relate to my patients, who often face even greater obstacles than I do in their bid to be healthier. I keep reminding them that lifestyle change is a marathon, not a sprint."

What do you do to stay healthy?

WellPoint's possible effect on reform

Health insurer WellPoint’s obscene rate hike has some onlookers speculating that the move could revive the stalled healthcare reform legislation.

The 39 percent rate hike for some California customers (in light of the insurer’s $2.7 billion profit last quarter) is a good example to President Obama for why reform is necessary. A White House spokesman said, “You’d be hard-pressed to find a better example of why reform is so urgent, and it’s going to continue to be part of the case the president makes,” according to the Washington Post.
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The bills are stalled because, as the Post puts it “Democrats in the house can’t accept the health care bill that Democrats in the Senate have produced, and vice versa.” But the rate hike news might help make a case for the need to at least give the reform efforts a try again.

And meanwhile, that 21 percent Medicare physician payment cut is scheduled to take effect in a couple weeks, unless of course Congress takes action again. The AMA has stepped up its lobbying efforts to persuade lawmakers to permanently repeal the SGR formula.

Randall Wong, MD: Online ads, part 2

Last week AdSense was introduced as a way for Web pages to display advertising and generate potential revenue. AdWords is the other arm of Google advertising where advertisers pay to place the ads.

AdWords can generate traffic to your web site without achieving a high page ranking with the search engines. AdWords are three-line (commonly text) ads with the headline in bold. These are paid ads that appear in the right panel of search results page or randomly on a Web page. With AdWords, you, the advertiser, pay Google to run the ads.
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The key to the ad placements is the relevance of the ad to the content of the Web page or subject of the search. Google matches the keywords used in the headline with the content of what you are reading.

If you Google the phrase “adhesive bandages,” the Google ads on the right panel are paid by the advertisers that sell bandages.

The order in which the ads are placed are a function of the keywords used in the headline, the "strength" of the advertiser and the "quality" of the ad.

• Keywords - depending upon the keywords you choose to use in the headline, the more expensive. Google keeps track of all words used in actual searches and ranks them (look up 'keyword finder'). In theory, the more often a word is used for a search, the more traffic that word will generate. For example, using "Band-Aid" instead of adhesive strip might increase the cost of your ad.

• Subject category - The subject you choose, for instance "healthcare," may be quite competitive and may prove to be more costly. A more competitive category will drive up the price of available keywords.

• Advertisers that have a strong relationship with Google and place lots of ads get special attention and rates. This shouldn't be alarming; this is true of any business.

• Good ad/bad ad - Every ad is tracked. Google will keep count of the number of "impressions," that is, the number times an ad is shown. Google counts the number of clicks an ad generates. If the ad fails to generate enough traffic (say, two to three clicks per 1,000 impressions) the ad may get yanked. More successful ads that generate more clicks may increase placement.

As an advertiser, it is important to know that you can control every aspect of your ads.

• Budget - You pay only when your ad is clicked. The fee you pay Google is based upon the price paid per click. If your ad has 500 impressions (that means 500 hundred times your ad was placed), but only generated four clicks, you pay for the four clicks. You may set up a budget of how much you want to spend per day, per week, or per month.

• Location - You decide what region of the country to run your ad.

• Timing - You are able to control when the ads are run. Your ad may have a contact phone number. Why have the ad shown at 2 a.m. or weekends?

So what does this mean? Placing Google ads, or AdWords, are a great economical way to advertise your practice on the Web. Your advertising is targeted to the people looking for you. You pay only for "clicks" or people interested in your ad.

AdWords is a great, effective way to generate traffic to your Web site via targeted marketing.

Gerald O'Malley, DO: Violence in the ER

My job as an emergency physician is analogous to my brother’s job as a NYC police officer in that it is often defined by hours of monotony punctuated by moments of sheer terror.

We deal with the consequences of brutality every day and sudden, explosive violence is never far away. My ER is located in one of the worst neighborhoods in Philadelphia and we have very large but unarmed security guards that provide protection to hospital employees, patients, and visitors. They don’t get enough recognition.

Despite our best efforts, a determined assailant can threaten the entire ER.
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Recently, a man caved in his wife’s skull with a claw hammer because she smoked up all his crack while he was out. She suffered multiple skull fractures and brain injury, and while we were working with the trauma team to stabilize her, the assailant posed as the patient’s brother and tried to get through security into the treatment area of the ER in order to do…something. Fortunately, a Philadelphia police officer recognized him and arrested him before he made it into the trauma room.

Another guy broke his girlfriend’s neck, her jaw, her nose, and three of her ribs and while she was in the CT scanner, he checked into triage under a fake name with a complaint of an injured thumb. He sneaked out of the FastTrack, where he had been triaged and was moving through the ER going room to room and peeking through curtains looking for our trauma patient in order to do…what? One our techs noticed him, approached and challenged him, and after a few minutes of excuses, he bolted through the ambulance doors into the Philadelphia night.

We have discussed the hard economic realities of installing, maintaining, and manning metal detectors in the ER, but we all agree that a realistic cost-benefit-threat analysis concludes that it makes no sense. As a faculty, we thought that metal detectors would send the wrong message to the community we serve – that we don’t trust them or we feel threatened by them. Interestingly, a pair of surveys from 1997 (one of them conducted right here in the City of Brotherly Homicide) suggest that patients in an urban ER waiting room actually feel safer with metal detectors and do not feel that their privacy is being invaded.

I was robbed at gunpoint in high school while working the night shift at an ice cream shop. I’ve never had a gun pulled on me in the ER. Yet.

Trendspotter: Apple iPad is already attracting physician attention

By Ken Terry


The new Apple iPad is causing a stir in the medical world, even though no electronic medical record software has yet been designed specifically for it. One indication of this interest comes from a physician survey by Epocrates, a leading vendor of software for mobile devices. Of the respondents to this poll, conducted just before the iPad’s launch, nine percent said they would buy one immediately. Another 13 percent said they would get an iPad within a year, and 38 percent said they were interested in the product but needed more information to make a decision.

One reason for physicians’ curiosity about the iPad is that it uses the same operating system and has the same finger-activated pressure screen as the iPhone and the iPod Touch. According to Epocrates, which has just announced its compatibility with the iPad, more than one of five physicians is using its applications on either of those devices. The fact that the iPad’s screen size is almost as big as a full-size tablet’s doesn’t hurt, nor does its svelte weight (just 1.5 pounds).

Moreover, the basic features of the iPad—web access, e-mail, photos, video and music playback, electronic books, and access to 140,000 applications—probably appeal to tech-savvy docs. But many physicians are also intrigued by the idea that the iPad might someday be used for EMRs and various modes of inpatient documentation and ordering.

According to Satish Misra at iMedicalApps:

“Rumors abound that Apple is already pitching the iPad in LA-area hospitals as the replacement for the old physician clipboard. For outpatient practices already running a Mac-based EMR, MacPractice has already announced development plans for an iPad interface. According to their press release, they plan to develop apps that will allow patients to fill out registration, medical history, and other forms on the iPad. For physicians, it will integrate with the MacPractice EMR to manage schedules, view patient records, and even enter clinical notes.”
Read moreHowever, Misra notes, most EMRs run on the Windows operating system; while there’s already a Citrix application that allows an iPad to use Windows as a dumb terminal, that would eliminate the cool interface that is the iPad’s biggest selling point. Also, the iPad has no digital handwriting capability. And its handwriting recognition probably has to be better than that of the “digital ink” in tablet PCs, which some physicians find too slow and clunky, Misra says.

I’d also point that there’s a problem with the iPad’s lack of a keyboard. Although many physicians like pressure screens and the ability to scroll or select with their fingers, a certain amount of typing (or, alternatively, dictation with voice recognition software) is inevitable when documenting visits in an EMR. The iPad features an onscreen keyboard, but physicians have found such keyboards to be only marginally usable in other computer tablets. You can also tap on an external keyboard when the iPad is in its docking station, but that is not a portable feature.

A few other drawbacks should also be mentioned: While the iPad contains a rechargeable battery, it cannot be removed and exchanged with a fresh battery. If you believe that the iPad battery will go 10 hours without a charge, as Apple claims, that’s probably sufficient for daily use with an EMR. But some observers are skeptical about that. And a survey of physicians conducted by Software Advice about the features physicians desire in a tablet shows that the iPad falls short in several areas:

“It lacks a large number of features that healthcare professionals deemed important, such as resistance to dust and hospital fluids and disinfectants (the iPad does not have sealed ports); fingerprint access to the system (HIPAA compliance); barcode scanning (patient safety); and an integrated camera (documenting diagnosis). In fact, you could argue that the iPad’s difficulty in being disinfected or kept clean of hospital fluids is a deal breaker for healthcare workers.”

Of course, conventional tablets also have problems, including the fact that most are heavier and have a shorter battery life than the iPad does. But many physicians like tablets and have had success in using them with their EMRs. Whether or not the iPad becomes a major competitor in the EMR space will probably depend on whether Apple adds some new physician-friendly features and on the willingness of EMR vendors to write applications for the Apple operating system.

Jennifer Frank, MD: My try-athlon

I am pretty physically active. This shouldn’t be confused with being physically fit. I am one of the few Americans who enjoy exercise. In contrast to my husband, I don’t look at my exercise sessions as grueling opportunities to do my best. I consider them more leisurely forays into a combination of “me time” and a healthy behavior that benefits mind, body, and soul.

For the past few summers, my husband competed with a relay team in a local half Iron Man triathlon. I am suitably impressed by anyone who runs a race, personally viewing running as a form of torture perfected by the Army, in which I served.

Nevertheless, I get caught up in the excitement at the finish line and cheer loudly for him as he comes into the home stretch. At these moments, I (briefly) envision that one day, I too will compete in a marathon and picture myself crossing the finish line, thrilled with my mighty accomplishment. Soon, though, I remember that this involves running, which I detest, and the dream floats away.

I am considering being part of my husband’s relay team this summer. He would run, I would swim. Once we find a willing cyclist, our team will be set. Read more
My husband studies me as I make this announcement. “You have to swim in the lake,” he reminds me.

“I know,” I respond, acting offended. One of my faults is that I often leap before I look, later regretting my rashly made decisions to do everything from the aforementioned joining the Army to agreeing to write another journal article. We discuss it more seriously. I think about it as I do my laps at the YMCA. I asked him when I have to make my final decision. “I need to know by March what you’re going to do,” he responds. He already has a lead on a cyclist.

So yesterday, I pushed myself harder at the YMCA. Instead of my usual leisurely, and admittedly short, swimming workout, I vowed to do a mile swim in the shortest time possible. I will have to swim 1.25 miles during the triathlon and want to make sure this is something I can do easily in the pool before I take it out to the open water.

I was successful in swimming my mile. I felt that I could have even gone longer, had I the time to spare before I was ousted from the pool to make way for swimming lessons. I will not advertise my time here – let me practice a bit first before I have to confess that. I proudly bragged to my husband that I accomplished this goal.

“I knew you could swim a mile,” he says bursting my bubble. “You just need to be able to do it faster…and longer.”

My medical training has prepared me well to take up a challenge. As a mom, I would love to set the example for my kids that you can start something new at any age and successfully accomplish your goals. So, we will see if this tired and exhausted, not-quite-stellar athlete, mom, and doctor is up to the challenge. More to come…

New Tip of the Week on Career Development

For our next round of Tips of the Week, we have contributions from Michelle Mudge-Riley, a doctor who now consults for physicians about developing their careers or transitioning into nonclinical jobs.

We first heard from Michelle in 2006 with her series for the journal called "The Ex-Doctor's Diary." Check out a few of her essays here, here, here, here, and here.

I also spoke with her for a podcast, where we discussed some of the chief complaints from practicing physicians and ways to find new ways to practice that will enhance their life and career.

Look for more tips from Michelle this month and join the conversation in the comments here.

Melissa Young, MD: More on the patient portal

So just when I was about to give up on the whole patient portal thing (see last week’s blog entry), a patient decides he wants to sign up.

You know that foreign language class you took in high school, after which you could sort of carry on a slowly spoken grammatically incorrect conversation? You know how you can now recognize certain words in that language but can’t put two words together?

Well, that’s how it was for us the first time a patient actually decided to plunk down his portal registration fee and sign the authorization form. Heck, our training was three months ago! We got as far as scanning in the form. Uh, now what? Some e-mail is supposed to be automatically generated, right? And then…?
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Before we could completely figure that out, two more patients signed up. We thought we had followed all the necessary steps, but something seemed to be missing. We called a patient to find out if she received an e-mail with her username and password. No. Hmmm.

We broke out the user manual. We went through the steps again. Ah-hah! We had missed a step, a click of the mouse. We rescanned the authorizations forms and clicked away. Ah-hah (again)! Now we got a window with the patient’s username and password. We must be in business now.

I checked the administrator’s account on the portal. Yup. There were three patients on there. I sent one a message. I didn’t hear back. I sent another. Still no answer. I have no way of knowing whether the messages went through. I have not received a “read receipt.” I’m a little embarrassed to call and say, “Hey, you know that thing you paid $25 for? Is it working?”

I like having an electronic medical record. I really do. I like having minimal amounts of paper sitting around the office. I am also one who enjoys e-communication in general. I e-mail, text, IM, Facebook, chat, and (obviously) blog. I would love a secure way to communicate with my patients. And apparently, some of my patients want to e-communicate with me. I just wish there was some way to verify what goes on in the ethereality that is the Internet.

Do you ask patients to refer you to others?

Have you ever asked your patients to refer you to their friends and family? I am not talking about a small, passive sign in the waiting room that says your practice appreciates referrals. I mean, face-to-face suggesting your patient refer you to others.

For an upcoming story for the journal, I am looking into some guerrilla marketing tactics practices can use to bring more patients in the door. Stewart Gandolf, a founding partner of Healthcare Success Strategies, offered perhaps the simplest, cheapest way to market yourself - ask for referrals - yet physicians don't do it.
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As a patient, it wouldn't necessarily cross my mind to refer my physician (although, I have referred my primary-care doc to a few friends who recently moved to town or were searching for a new doc). We usually assume the docs are too busy and don't want more patients.

But if a physician says to me (ideally after I thank her and tell her how much I appreciate her), "Sara, you know, I'd like to ask you a favor. If you like what we have done for you today, I'd like to help someone else in the same way." Or something along those lines where she basically plants the seed in my head - with a tactful and rehearsed line - to refer her.

Perhaps physicians don't want to do it because they feel like they will come across as needy or sleazy, Gandolf says. Hence the need for a tactful script. And it seems like a no-brainer way to get more patients.

Randall Wong, MD: Online ads, part 1

Google is an advertising agency. Its main advertising strategy is based upon those three lined ads that pop up on the right side of a results page, sometimes on top of your e-mail and randomly placed within a Web site. There are two arms of Google's advertising program: AdSense and Adwords.

The text-based Google ads are the core of Google's main source of revenue (there are other types of ads, but the text ads are the most ubiquitous). The ads are there because they are relevant to something you are reading, in your search results, in your e-mail or on the Web site you are visiting. Google is about targeted advertising.
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In the case of AdSense, if you own a Web page, you may place Google ads on your page for free. When visitors come to your page and click on one of these ads, you get paid. The more clicks you generate, the more you get paid. It's a risk free way to monetize your site to generate income.

Based on the content of your page/e-mail, Google places only ads that are relevant. Google has a ranking system that places only the more competitive ads for viewing. Don't worry, all you have to do is paste some code within your Web page, and Google does the rest. It automatically generates and changes the ads for you. That's it. Easy.

The amount of revenue you generate from AdSense is based upon the value of the ad (how much the advertiser is paying Google), the competition for the product (and keywords used), and your Web site traffic. The more people click, the more you generate.

As an AdSense user, you may filter the types of ads that appear. You may also block specific Web sites (say your competitor's Web site) from appearing on your page.

What Does This Mean? Truthfully, there is really little direct benefit for a medical practice or physician to use AdSense on a Web site promoting your own practice in terms of using it to monetize your site.

I use AdSense on both my Web pages. Some specialized equipment is needed for post-op recovery from retinal surgery. Several companies that rent this equipment advertise via AdWords/AdSense, and their ads to show up on my surgical pages. I probably make enough money to cover the costs of hosting the site, etc.

There are high volume sites that attract 10,000 or more visitors a month. At these numbers, AdSense revenue can be meaningful.

I have different expectations for my blog. The purpose of my blog, if you don't remember, is to promote the use of the Web as a credible source of health information. I work hard on the content of my blog. I am proud of the information and the manner in which I am publishing my articles.

AdSense places ads from “competing” sites. Most of these sites aren't worth a darn as most are really peddling a product with phony content. The value? AdSense brings these competitors to my readers' attention, only for my readers to realize the value of my site.

Enough for this week. Next week, Part 2: AdWords. This will be a more obvious tool for you!

Trendspotter: Making patients pay when the insurance company won't

By Ken Terry


Imagine you’re a patient in a hospital and you need an emergency procedure such as a CABG or an appendectomy. You have insurance, but the surgeon, who’s in a rush to perform the procedure, neglects to inform you (or doesn’t know) that the anesthesiologist she has chosen is not in your plan’s network. The anesthesiologist doesn’t tell you, either.

As a result, you might get stuck with a bill far higher than what you would pay if had you known — or perhaps not. After all, if you’ve had a heart attack, you’re not likely to demand an in-network anesthesiologist. Nevertheless, you will probably be angry when you receive a bill for what seems like an astronomical amount, representing the difference between the doctor’s charges and the insurance payment.

A Texas law that went into effect last year allows patients who get stuck with big, unexpected medical bills to request mediation in certain situations. The legislation applies only to people who are in fully insured PPOs and who owe an out-of-network provider more than $1,000 after deductibles, coinsurance, and copayments. Patients in self-insured plans, indemnity plans, Medicare, or Medicaid are not covered. Neither are the uninsured. The only providers affected are hospital-based physicians such as anesthesiologists, radiologists, pathologists, neonatologists, and ED specialists.
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An eligible patient may ask for mediation if the hospital-based physician did not disclose that he or she was not under contract to the patient’s health plan and did not disclose his or her charges in advance for the services to be provided. The State Office of Administrative Hearings may select a mediator, or the parties may agree to use a particular mediator.

According to a Dallas Morning News story, mediators are not sure whether they want to participate, because the law requires them to determine whether anybody is acting in “bad faith” during the mediation process. That might represent a hospital administrator not showing up for a hearing or a party withholding material information, for example. The mediators say they are afraid they would never be hired again if they told the Texas Medical Board that a doctor was acting in bad faith.

More troubling is the implication that some providers charge disproportionate amounts to plans they do not contract with and then bill patients for the balance. The newspaper piece notes that most facility-based physicians in North Texas work for one of a few companies that hold contracts with hospitals. Without much competition, they are in a good position to charge whatever they want. But the hospital-contracted firms say that they are in the networks of most major health plans in the area and that 90 percent of their patients are covered by Medicare, which does not allow balance billing.

The Texas law is much more circumscribed than some other states’ limits on balance billing. California has banned all balance billing for emergency care at the urging of the state Department of Managed Health Care. The California Supreme Court last year upheld the legislation in the case of out-of-network ED physicians, who have to accept the patient’s insurance as payment in full. Connecticut, Pennsylvania, and Alabama also prohibit balance billing.

Some observers say that the core of the dispute over balance billing is how much insurance companies should pay out-of-network providers. The use of an Ingenix database to determine the proper amounts that plans should pay non-contracted physicians has been challenged both by New York Attorney General Andrew Cuomo and by medical societies in New York, New Jersey, Connecticut, North Carolina, and Texas. Cuomo won a settlement from UnitedHealth Group, Ingenix’s owner, which has agreed to fund a new, independent database, and Aetna has agreed to do the same. These moves should lead to fairer reimbursement of out-of-network providers. But they are unlikely to end the controversy over balance billing, especially in hospitals and emergency rooms.

As long as physicians feel they’re being underpaid by health plans, most of them will balance-bill insured patients where they can. But not all. One Texas doctor responded to the Dallas Morning News article in these terms: “What is wrong with the anesthesiologist [who balance-bills patients]? Is that why she/he became a doctor? To put people into bankruptcy? Cases like this make me sick. Who am I? I'm a private physician who routinely writes off whatever my patients can't pay.”

Gerald O'Malley, DO: I can't help you, part 3

In the ER we are frequently tasked with trying to help people that really don’t have emergency problems.

The system just isn’t designed to accommodate satisfactorily individuals with nonemergent problems, and my patients frequently become frustrated at my inability to assist them, although occasionally I have a small victory.

A patient showed up at 9:00 a.m. one day complaining of ringing in her ears for the past two months. Her primary-care doctor had made an appointment for her to see a specialist — in another three months. The high-pitched ringing was worse at night. She couldn’t sleep and was nearly suicidal. Read more
I spent 45 minutes on the phone with her insurance company and her primary-care doctor securing a referral and pleading with the specialist, and I got her an appointment at 1:00 p.m. that same day. During those 45 minutes, another six patients showed up in the ER and their care was delayed for hours while I negotiated on the phone. My patient was lucky — the specialist agreed to see her expeditiously.

As bad as things are now, I suspect that the day is coming when the specialist will just say, “I’m sorry. It is simply not worth it for me to take on this additional work and risk.” At that point it won’t matter how long I stay on the phone and no amount of pleading or bargaining or cajoling will matter. We have to savor these quiet triumphs.

Another patient wanted me to do something about the ganglion cyst on her wrist. It had been present for “a while” but had recently begun to interfere with her work, which was exotic dancing. The cyst rubbed against the pole and caused pain. She also wanted me to treat her hyperthyroidism.

“Who told you that you have hyperthyroidism?”
“Well that’s what causes you to do everything real fast, right?” she said. “Well, I talk real fast and I dance real fast too.”

She gave me a short demonstration of how quickly she can dance. The nurses loved that picture.

“So I figure that I have hyperthyroid and I need something to treat it to help me slow down.”
“Do you do a lot of cocaine?”
“Not a lot — only when I’m at work or at home.”
“I’m sorry, I can’t help you.”

Jennifer Frank, MD: Community helpers

Today, my kindergartner is dressing up as a “community helper” for school. Choices are abundant — firefighter, police officer, or teacher. She chose to be a doctor.

This is flattering. I don’t see myself as a community helper most days. Paperwork machine, drug dispenser, lecturer, cajoler — those are my roles. Of course, as a family physician, one of my main objectives is to help not only my patients but the community as a whole.

As my daughter heads off in her long white coat with her Fisher-Price doctor’s kit, I consider how I will feel if she chooses to be a doctor, not just for today, but for all of her days. Many doctors tend to discourage their children from pursuing a career in medicine. Burdens of managed care, reimbursement, and paperwork are onerous. Training is long and difficult. The lifestyle can be grueling. Family life can suffer. You can make more money doing things that don’t require the better part of your 20s and early 30s and exact the same emotional toll.
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I would recommend her to carefully consider a future in medicine. She wants to be a wife and mother one day — and will be quite devoted, judging by the attention she shows to her dolls and stuffed animals. Being a wife and mother is hard work; it is important work. Many physicians start considering marriage and parenthood around the time they are choosing residencies and jobs. At the very moment all of your hard work in medical school is paying off in the form of a top choice residency or a position with a prestigious clinic or medical school department, you need to seriously consider other people’s needs — your spouse, your kids, your family.

Female physicians face unique challenges. Some specialties are still male-dominated and venturing into these arenas may require a thick skin and selective hearing. Even in female-friendly specialties, the physician may be the leader of a care team, a clinic, or a department in which she oversees other women — possibly other physicians, but also mid-level providers, nurses, administrative staff. Women are often unkind to other women and can undermine their success in leadership roles.

There are other challenges. Paperwork is time consuming. Medicine is a profession, not a job, and its demands on your time and attention have no limits. As a colleague once stated, “Medicine is a jealous mistress.” Your colleagues are often ambitious perfectionists who can display an amazing array of unhealthy behaviors.

Despite potential disadvantages, I would still encourage my children to consider this most rewarding of careers. The benefits of being a physician are innumerable. There are monetary benefits — physicians still make a great living. Physicians tend to be respected and admired. There is job security and tremendous flexibility in how and where you practice. Most importantly, you make a difference numerous times each day. You are invited into the most wonderful, painful, frightening, joy-filled, and ordinary moments of peoples’ lives. At the end of the day, it is still a privilege to practice medicine.

Melissa Young, MD: The patient portal

A patient portal has been touted as a time saver, an efficient and secure way for patients to communicate with the office. It’s supposed to save money and effort, too, by decreasing time spent by the staff and the physician on the phone.

I cross my fingers. Quite honestly, two weeks ago, I considered ditching the whole thing.

First of all, it took more effort than I envisioned to get it going. It doesn’t help that you are required to develop a “portal authorization form,” something for the patients to fill out saying that they understand the purpose of the portal and what their responsibilities are, etc, etc. But the vendor can’t give you a template for this form. They can’t give you an example. I didn’t really understand the explanation for why they can’t. Ah, but Google is a wonderful thing, and I found one.
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Then there are the various disclaimers you have to post (that the vendor can’t help you with either). You know the disclaimers like, “we try to keep your information private, but well, stuff happens and we can’t be held responsible if someone hacks into the site,” and “if you received this in error, please tell us, otherwise you will be in big trouble.”

And let’s talk about the cost. It seemed like a minimal expense compared to everything else at first. But now that there are a million other things to pay for, and I’m looking around to find the least expensive toilet paper, I realize that there is no such thing as a minimal expense. I had planned to offer the service for free, but I was advised to at least charge an administrative fee. I chose to have a one-time fee, as opposed to a yearly one.
And I figured that two to three patients a month would cover the annual fee I pay.

Well, perhaps I over-estimated the number of patients who would be interested. After having the portal up and running for almost three months, we had people express interest in using it, but nobody who had actually signed up.

Until two weeks ago. And that just gave me fodder for next week’s blog entry.