Trendspotter: Do We Want Hospitals to Run Health Care?

By Ken Terry

Major changes in the healthcare delivery system are coming, and they will affect every physician. The question is whether those changes will have the effect we all want or whether they will lead to unintended consequences that we don’t want.

Back in the 1990s, during the debate over the Clinton plan and in the period following its rejection, hospitals and physicians began preparing for what they assumed was going to be a massive shift to prepaid managed care. While that never happened, many physicians joined larger single-specialty and multispecialty groups, and hospitals purchased many practices, some of which they later returned to their owners. Something similar is happening now as hospitals snap up practices right and left in anticipation of a reform-driven shift to various types of financial risk. According to one estimate, around half of the doctors in the country are already working for hospitals, and there are some markets where hardly any private practices still exist.

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Some experts believe that the fragmentation of our delivery system is responsible for much of our out-of-control spending and the poor quality of care, especially at the primary level. In that view, the disorganization of American medicine, coupled with fee for service and overspecialization, encourages redundant, wasteful, and even harmful care. But I question whether hospitals and healthcare systems are the right agents to reduce this fragmentation by employing more and more physicians.

The problem with the hospital-centric view of the world is that it’s all about hospitals. Whether for-profit or not-for-profit, hospitals seek to maximize their revenues, their market share, and their competitive advantage. In that sense, they’re very much like corporations in any other field. When they employ physicians, they’re thinking about the value of each doctor’s admissions – about $1.5 million per year, on average – and whether they want their competitors to get those referrals. They may also be considering how a particular physician or group can help sustain or grow existing or new service lines and feed new imaging equipment.

Having hospitals run a revamped, better-organized system creates other issues as well. One is related to the mal-distribution of specialists, which is endemic across the country. Some communities are saturated with specialists, while other communities have very few or no specialists in certain key fields. As hospitals control an increasing percentage of physicians, some facilities will not be able to provide certain kinds of care, because the competing hospital in town has locked up all of the specialists who are capable of providing those services.

There is much validity in the concept of “accountable care organizations”--combinations of hospitals and doctors that can provide particular services or types of services for a budgeted payment, with the ability to share in cost savings. ACO supporters say that these organizations might be “virtual” organizations that tie together independent practices and hospitals through information technology. Unfortunately, however, one outcome of the move toward ACOs and payment bundling—both goals of the reform legislation—might be the growth of hospital power in many communities. And I don’t think we should place responsibility for the future of healthcare in the self-interested hands of hospitals.

I’m not predicting that this is the only possible result of current trends. We’re also facing the influx of millions of newly insured patients in 2014, and it’s clear that there won’t be enough primary-care physicians to care for them. That will be true even if every primary-care doctor in the country is working for a hospital by then. So we’re going to see an increasing emphasis on community health centers, which have received a steep increase in funding from the Obama Administration. Those clinics, which now care mostly for poor patients who have little money, will soon be seeing more middle-class patients—just as retail clinics do. So they will be competing with hospitals, but I don’t see them ever having the same power and influence that the healthcare systems do.

What we need now is for policymakers to give some serious thought to the long-term implications of the trends that are now being set in motion. It’s always easier to make course corrections along the way than to deal with unintended consequences later on.

Jennifer Frank, MD: An "oops" of epic proportions

An acquaintance recently reminded me of a painful episode in my parenting history. “I was telling someone about you yesterday,” she started. “My friend was giving me grief for not bringing our daughter to the doctor right away when she had a wrist fracture. I told them that you missed your son’s clavicular fracture and you’re a doctor.” Ouch.

Two summers ago, our oldest son was playing with a friend while we were attending a minor league baseball game. His friend swung him around and let go. Our son landed on his outstretched arm and started crying.

My husband brought him back to where I was sitting with our daughters. He seemed like he was in a lot of pain, but it was hard to tell if he had fractured something. I palpated along his humerus, rotated his hand back and forth, looked for swelling. He could move his arm but said his shoulder hurt. It wasn’t dislocated and I couldn’t find anything specifically wrong. So, we comforted him with cotton candy, stayed for another 30 minutes to watch the end-of-game fireworks and headed home.
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Our son alternately appeared totally fine and then would start crying and complaining about his arm hurting. On the drive home, my husband and I debated the necessity of a trip to the ER. I did a more careful exam in our kitchen once we arrived home. He was guarding his arm a bit but told us that it felt better. It was late and we were all tired. I imagined how we would be triaged on a busy Saturday night in the ER and pictured waiting with a sleepy, cranky kid for hours. We gave him some ibuprofen and put him to bed, planning to take him in the next morning if it was still hurting him.

By the next morning, he seemed better. He was playing happily in his room. Every once in awhile he would complain of his arm hurting, but as he tends to be overly dramatic at times, we weren’t sure how much he was actually bothered by his arm. I would spy on him as he played Legos to see if he was using that arm or not. He seemed to hold it close to his side but would use it if needed. I still wasn’t sure. We decided to keep observing him.

By Tuesday morning when he was still complaining of arm pain, we took him to his family doctor. Unfortunately, he had suffered a clavicular fracture. Fortunately, he had self treated it by holding it flexed and close to his body. He was fitted with a cool-looking arm sling that offered a little bit more protection until the bone healed itself.

Of course, my husband and I both felt terrible, and still do, that we – two physicians – missed this in our own child. However, it helps me to comfort my patients’ parents when they too miss something and serves as a good reminder why I don’t doctor my own kids.

CMS could get new director

After more than three years without a permanent leader, CMS might have a new administrator. Obama plans to nominate to the post Donald Berwick, MD, a pediatrician, health policy scholar, and CEO of the Institute for Healthcare Improvement.
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Berwick, who would need to be confirmed by the Senate, has challenged doctors and hospitals to provide better care at lower cost, and that payments should be based on the value of services, not the volume, according to the NY Times.

As the head of CMS, Berwick would certainly have his work cut out for him in the wake of the healthcare reform legislation.

MGMA applauded the news in a statement: “As healthcare organizations and professionals shape a reformed healthcare delivery system, his knowledge and proven leadership will be critical to success.”

Melissa Young, MD: Selection bias on physician rating sites

A couple of weeks ago, a patient from my prior practice said that she Googled me to find my new location. She said that in addition to finding my new address, she also found my practice address, and an article about me that had been written while I was at my old office.

Out of curiosity, I decided to Google myself. I found the above links, but I also found links to physician rating sites. I clicked on them to see how patients were rating me. I found that almost without exception, I had either no ratings or very poor ratings.

At first glance, my one-star ratings in nearly every category make me look like a horrible physician with no bedside manner, whom no one would recommend to family or friends. I also apparently had incompetent, discourteous staff. But a closer reveals that there is only one rating. One rating by a very angry patient. One who thinks I need “to learn to be a human.”
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These ratings were all dated (where available) in the spring of last year. I can only assume that they were made by the same person. One Web site had two ratings. One with single stars across the board, dated in the spring of last year, and one with four to five stars, dated within the last three to four months.

Now, personally I don’t care if one or two disgruntled patients rate me poorly. I suspect they are noncompliant and possibly were dismissed from my practice. But other patients might care, patients who may assume that these ratings represent how most of my patients feel about me. And what happens if the payers start caring?

Who is going to take the time to go to theses sites to rate a physician? Most satisfied patients don’t feel the need to rate their physicians. Even at the best restaurants, I’m sure the kitchen hears more complaints then praise. How many store managers have customers call about an employee’s good job? And how many get calls about a bad job?

Oh sure, there are customers who will let an employer know when someone goes above and beyond, but for the most part, satisfied people don’t feel it necessary.

And the same goes for physician rating sites. I have patients I have treated for years. Some who moved out of state who still come to see me. I have new patients who used to see other docs but have chosen to see me because I have seen their neighbor, coworker, friend, or relative, and have been told that they will like me and my practice better.

Would they do that if I needed “to learn to be a human”? Referrals like that beat online ratings any day.

Tax season podcast

In honor of tax season upon us, we've produced a tax-themed podcast this month.

I recently spoke with Michael Williams, managing partner of Weitz & Williams CPAs and a member of the National CPA Healthcare Advisors Association. He's also known as the Head Coach to the Wealthy Physician.

We discussed some of the changes to this year's tax code that could affect physicians. Click here for the podcast.

For a full list of our podcasts, check out this page.

Randall Wong, MD: Start building your Web site

Here is a list to get your new Web page started. Remember that not all components are easy to implement nor will they be ready in a day. Get started, but be patient. You most likely do not have all the components ready or figured out, but move forward.

A Web page is always a work in progress. This means it can always be better, but it also means that you can change things you don't like! Your Web page will not be built in a day. It will be impossible for your Web page to be everything to everyone. I would suggest you pick a few items that you feel are important.

You may want to make this a team building exercise by asking the staff, the administration, and your co-doctors for their suggestions and top choices for a Web page. You will be surprised how much this will validate your office staff!

I would suggest easy-to-complete items to start. This will give you the feeling of progress and accomplishment.

Here are my suggestions:
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• Contact page — Here you will list a name of a person. You need to include the practice/business address, e-mail (preferably of the contact person), phone number, and fax number. You are a service-oriented business. You want to add a personal feel by giving your patients a specific name.

• Map — A few weeks ago, we went over how easy it is to put yourself on the map. Just as easy is creating a link to a Google map of your office.

• Hours of operation

• Accessibility — Is there free parking? If not, do you validate? Which floor and where is the wheelchair access?

• Insurance list

All of these are easy to complete and can be done in a very short time. These are also the basic elements patients are looking for on the Web.

Items to add later:

• Bios of the doctors — Include a short biography about who you are and what you do. Keep it short and less than a page ("above the fold"). A picture is really important for the same touchy feely reasons as listing a real name on the contact page. People want to see what you look like. Use this same picture in other places to start branding yourself.

I would take the time to have each bio written in the same format and style and preferably by the same person. This will make it easier for a patient to find the information. Regarding style, it may be time for all of you to get new pictures taken for the sake of consistency and maintaining style (hint: go to Sears for a digital portrait).

• New patient forms — Have these available for download from your Web site. It saves everyone time. These are probably best if available as a .pdf file. They are more secure and will print exactly the way you want them.

• Staff pictures — These are highly underrated. People love to see who they are talking with when they call and schedule appointments and surgery, etc. Realizing that turnover may be high, you may want to include a picture and only one or two lines about them. Update only every few months if you like. Stick to first names only. Here’s an example: "Bill schedules appointments and works in our downtown office. He has been with Acme Associates for five years and loves to get to know everyone!"

The items above should take precedence over adding graphics, although you may need to choose a theme and color scheme early on. They can all be changed later on. Remember, you want your Web page to provide information first, then look pretty.

More next week.

Trendspotter: Health Reform Will Be Mixed Bag for Physicians

By Ken Terry

The historic reform bill that Congress passed on Sunday will immediately affect physicians, but the impact will be much greater in the long term.

First, some expansion of coverage will occur within six months of President Obama’s signature on the bill—whether or not the Senate adopts an accompanying measure that would add House-sponsored changes. The bill will immediately allow parents to cover their young adult children and will prohibit children from being denied insurance because of their health status. Adults can’t have their coverage dropped when they get sick, and people who can’t get coverage because of their health condition will be eligible for beefed-up high risk insurance pools. All of these measures, coupled with small business tax credits for buying insurance, should reduce the number of patients who can’t pay their bills by the end of this year.

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The really major impact, however, will come in 2014, when the big Medicaid expansion and the individual mandate to purchase insurance kick in. By 2019, these provisions will expand coverage to an estimated 32 million people, providing physicians with many more insured patients.

The health insurance exchanges for uninsured individuals and small businesses will also be launched in 2014. Health plans that participate in those exchanges will be required to offer a minimum level of benefits, and catastrophic plans will be available only to those under 30 and those who are exempt from the mandate to buy coverage. Moreover, people who have skimpy plans at work and/or who pay more than 10 percent of their income for it will be able to buy insurance through the exchanges. The plans offered in these government-sponsored markets will also have fairly low out of pocket maximums. All of these provisions, again, will increase the number of patients who are insured and will therefore be able to afford your services—assuming you take Medicaid.

On the other hand, the expansion of coverage will lead to a massive increase in consumer demand that physicians will be expected to handle a few years from now. The legislation does include provisions to increase the supply of primary care, and recent increases in primary-care reimbursement by Medicare—albeit at the expense of specialists—should begin to attract more doctors to the primary-care fields. But much more needs to be done. For one thing, the debt burden of new residency graduates must be reduced if we expect more of them to become, say, internists rather than endocrinologists.

There are also cost control provisions in the bill—mainly pilots of new Medicare payment approaches--that could lead to lower reimbursement for physicians. Whether it’s accountable care organizations, payment bundling, or value-based purchasing, the days of unrestricted fee for service are drawing to a close. Many physicians will be unhappy about this. They don’t want to take financial risk, either alone or in tandem with other physicians and hospitals. But some kind of quality-based or budget-based approach to reimbursement, both by government and private payers, is inevitable, because the current level of cost growth is unsustainable. This will probably mean that more physicians will go to work for hospitals, and that small private practices will become less viable. But market forces are already pushing health care in both of those directions.

Meanwhile, Congressional leaders have promised the AMA that they will enact some kind of “fix” to prevent physician Medicare payments from being cut 21 percent this year and more later on. Presumably, they will find some savings in the overall national budget to cover the $200 billion plus cost of that fix over 10 years. But that is isn’t part of the reform legislation that just passed or the reconciliation bill that is now before the Senate.

Obviously, the payment method that has Medicare has used to reimburse physicians for the past decade is not viable and must be replaced. Congress’s last-minute passage of bills to prevent pay cuts to doctors, year after year, is ample proof of that. But there’s no chance that Congress will simply decide to give physicians what they want under fee-for-service Medicare. So get ready for changes in how you’re paid by both Medicare and private payers. This is no longer going to be your father’s healthcare system.

Gerald O'Malley, DO: Legislative tyranny

I wanted to write an essay this week about the residency match and the excitement (and disappointment) that happens this time every year along with St. Patrick’s Day in the ER. We celebrated in the hospital by sharing several big pots of traditional Irish stew (my dad’s recipe) and my wife’s soda bread and tea brack with the Pogues and Clancy brothers on the CD player. I started to write that essay, but the words just wouldn’t come.

The congressional approval of the healthcare takeover bill is so profoundly unjust I can’t not write about it. So much has been written and said about the legislation that the House approved late Sunday night – what more is there to say?

From an emergency medicine perspective there’s a lot to say. Every ER doc that I know desperately wants healthcare reform. We went into this line of work to help people. It’s really hard to help people that have no insurance. They don’t practice routine health maintenance, they can’t afford the medications we prescribe, we can’t get them in for follow-up appointments, and forget about seeing specialists. Patient advocacy is ten times more difficult for people with no insurance. The people of this country deserve a better system, but this massive government entitlement is not the fix. In the words of my father, this thing is a dog’s breakfast.
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I had a lot of trouble figuring out which bill was the relevant one. Try Googling “I want to read the healthcare reform bill” and then sift through all the variations of the bill that have been posted online. I finally found the relevant reconciliation amendment and my computer crashed three times while attempting to download a pdf of a summary of the bill. The Table of Contents is 14 pages long! I read as much of the original bill as possible but when a document is filled with this much gobbledygook, no one can possibly understand what is being said, and I can guarantee that most members of Congress didn’t read the damn thing. (You can read all 2,310 pages of H.R. 4872 plus the 153 pages of the reconciliation act at http://thomas.loc.gov/.)

Why does this need to be so dense and complicated? Why didn’t Congress entertain smaller and less intrusive fixes that will serve to bring down the cost of healthcare but not set us on the road to a single payer (i.e. governmental) system? Why not allow consumers to buy health insurance across state lines? Why not allow for health savings accounts that can serve as investment vehicles? Why not allow for a variety of healthcare insurance options that provide for catastrophic coverage with flexible premiums depending on the deductible that we want to pay? Why can’t we buy our health insurance the same way that we buy car insurance? Congress and the President seem determined to establish a national healthcare system similar to the British National Healthcare System, which is the third largest employer in the world, behind Indian Railways and the Chinese army.

I’ll tell you one thing that you won’t find anywhere in this bill — tort reform. The trial layers saw to that.

There is an avalanche of legal challenges to this monstrosity and I’ll probably financially support several. I feel like I have to — the national deficit is so huge and the debt is so massive I’ll probably wind up paying close to 50 percent of my income in taxes as will my children and grandchildren. Medicare and Medicaid and Social Security are broke and we cannot afford another massive entitlement. I don’t believe what my government is telling me about how this action won’t negatively affect the economy. This is so unfair to taxpayers and future generations of Americans.

In New York, bricks were thrown through the windows of legislators that voted for the bill. I’m truly afraid for my country.

Jennifer Frank, MD: Consequences

Sometimes being a doctor is like being a parent. You worry about your patients, you lecture, you cajole, you warn. Sometimes your patients act like children (and sometimes your patients are children). They do what you tell them not to do (“I told you not to drink while taking the Flagyl.”). They don’t really believe you when you tell them that if they don’t get their diabetes under better control, they will be starting dialysis. They often look up to you, respect you, and see you as an authority.

As a parent, I maintain a careful balance between preventing and allowing consequences. My kids are young, so I still have this power. “If you miss the bus, you will not get dessert tonight.” Action leads to consequence. I can also intervene to prevent the consequence. “Okay, you forgot your lunch, I will drop it off at school on my way to work.” I realize that as my children get older I will be less able to protect them from the consequences of their actions. This is one of the hard parts about being a parent.

As a doctor, I have less control over consequences. My interactions with patients are, in the grand scheme of things, relatively brief. I also am paid and duty-bound to prevent consequences – I don’t allow a person to get lung cancer to prove that smoking is actually bad for you. I do everything I can to prevent lessons from being learned the hard way.
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Despite my best efforts, consequences often find my patients. The years of overeating and lack of physical activity eventually lead to diabetes. Forgoing the statin and continuing to smoke leads to a second heart attack.

During a recent discussion with one of the senior residents, she revealed the struggle she is experiencing with seeing a patient suffer the consequences of a poor choice. The resident did everything right for her young teenage patient. She counseled her on safe sexual practices, the value of delaying sexual activity since she was so young, the need for contraception and barrier protection should she make the decision to have intercourse, and the importance of being prepared for “heat of the moment” decisions.

Despite a close therapeutic bond, despite a parent who was accepting and supportive of her daughter’s decisions, despite a prescription for contraception, this young girl is pregnant. The resident did everything right but could not save her patient from the consequences.

This can be heartbreaking as a doctor (or a parent). You wonder where you went wrong, what you could have said differently, if you missed something that could have prevented this from occurring. The sad fact is that our control (as doctors and as parents) is uncertain and often almost completely absent. We have influence but little actual power. Where we do have power is in our presence – walking beside our child or patient (or friend, sibling, spouse, or parent) as they face a consequence. As a family physician, this is a role I gladly and willingly take.

Health reform happening

Finally, after months of political wrangling, the House passed the healthcare bill approved by the Senate on Christmas Eve. The 219-212 vote last night sent the bill to President Obama. After the vote, the House also adopted a package of changes to it, which were agreed to in negotiations among House and Senate Democrats the White House, the NT Times explains, which now goes to the Senate for action this week.

The bill requires most Americans to have health insurance, adds 16 million people to Medicaid, subsidizes coverage to low- to middle-income people, and sets up an insurance exchange.

So eventually, an estimated 32 million more Americans will have health insurance, which means you could be seeing more patients in your office. Are you ready for that? Check out our recent story about how to prep your practice for reform’s new patients.

Melissa Young, MD: How my EMR stacks up

In previous posts, I wrote about my journey towards finding an EMR. I did lots of research. I read multiple articles online and in print. I looked at the surveys. I asked the experts. I had demos, online and live. I did site visits. And eventually, I made my choice.

But despite this somewhat obsessive search for the perfect EMR (this was probably the most important decision I had to make at the time), I have still found imperfections. This part doesn’t work as smoothly as I had hoped. This needs tweaking. This part is inconvenient. This part is just nonfunctional. And since the grass is always greener on the other side of the fence, I have from time to time wondered if, perhaps, there could have been a better choice.

Now don’t get me wrong. Most of the time, the EMR works (nearly) flawlessly. It performs all the major functions that I need it to. It makes my life and the life of my staff infinitely easier than it would have been had we had paper charts. The schedule, chart, and billing information are at our fingertips. Everything gets documented without a six-inch stack of paper.
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Patients who come with their previous records of the last 10 years can leave with their epic saga in their hands because we don’t need to keep the hard copies. When a patient calls because he needs a refill, I can say, “No you don’t. I gave you 90 days and two refills on December 12. ABC Pharmacy on Main Street has your scrip.” Since I can copy their last visit, I can ask (as if from memory), “So has that ache in your left leg gotten better?” or “Has your daughter had the baby?”

But I was most reassured earlier this week when I attended an EMR seminar. I almost didn’t go. After all, I’m not in the market for a new one. But part of the lecture was going to be on getting the Medicare incentive for that all-too-nebulous “meaningful use,” and I figured it would be a good networking event, so I went.

The first third of the seminar was how to choose an EMR and how to implement it. The second was “the top 10 questions EMR vendors don’t want you to ask.” Although I didn’t “need” that information, it did make me feel good about my choice. And that’s because I knew from experience what the answers were. Questions about backing-up data, customer support, ease of implementation, work flow, etc.

Listening to the questions and the things to look for in an EMR, I knew that if someone asked me if I would choose my EMR again, I would have to say that based on what I had to compare it with, and knowing what I know about it now, I definitely would.

Don McDaniel: The eligible provider that stimulus forgot

I visited recently with a group of providers in southern California that are preparing to implement a new EHR system. The group is a large multispecialty practice with more than 150 physicians — all eligible professionals in Stimulus-speak — and derives a significant portion of its work and hence a lot of its revenue from treating Medicare patients.

The CIO of the group asked me what they should expect in terms of incentive payments pursuant to the HITECH Act of 2009’s ARRA — and I immediately said, “Well of course your physicians will all be eligible, and likely for the maximum incentive payment of $44,000 per eligible professional over five years.”

He looked at me like I had two heads, and commented that almost all of its Medicare revenue comes from treating Medicare Advantage (MA) participants. Then it hit me: Does HITECH treat MA providers differently than providers that participate with the original Medicare program?
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I had to research this — and found to my utter disbelief that the answer is yes. The process to qualify for incentives as a provider to Medicare recipients under several MA contracts is much more stringent than what we’ve come to learn about Medicare eligibility.

You see, if a provider doesn’t generate enough Medicare Allowable Charges (MAC) (from seeing “original” Medicare patients) to garner incentives because of the size and scope of their MA practice, they have to pass the 80-80-20 rule with one MA organization — essentially a commercial insurer that provides covered services to Medicare recipients under a contract with CMS.

In other words, they have to be nearly exclusive with one organization that pays 80 percent of their overall MA payments, perform at least 80 percent of their overall Medicare business with MA patients, and practice in a clinical setting at least 20 hours per week.

So, the MA portion of the incentive really only applies to treating essentially exclusively one MA Organization’s (MAOs) patients. For example, a payer-organization like Kaiser Permanente comes to mind. Never mind that many physicians with MA practices have contracts with multiple MAOs.

One question is why was the bill written this way? Could have been that it was an oversight, so in the rush to get the bill released in February 2009, details were missed or left out. A conspiracy theorist might contend that since the current administration has made no secret of its disdain for the MA program, this slight is just a manifestation of a policy desire.

Nonetheless, it stands that a number of hardworking physicians will be affected by this hole. So what can you do if you’re affected by this? You need to mobilize all available advocacy resources at your disposal to make a collective voice heard that CMS has to develop a methodology that recognizes your standing as a Medicare provider, regardless of the source of your revenue from that program. May the force be with you!

Randall Wong, MD: TV versus the Internet

Is the authority of the Internet greater than that of TV? I just read an article by Paul Stubenbordt entitled "As Seen on TV." In the article, he cites the power and influence of TV and recommends it as the favored choice for advertising for docs. He writes, "Like no other medium, people really do believe what they see on TV."

If TV is still No. 1 for docs, then I'd have to say that the Internet is a very, very close second (I was going to say “No. 2”). We all hear about it every day, an assumed authority called the Internet. Somehow TV and the Internet are de facto places of authorities. I wonder where libraries rank?

But doctors are the real authorities. I wrote earlier about the authority that doctors have earned. Doctors are probably as high an authority figure as we have in our society...maybe as high as police officers. Authorities receive automatic credibility.

How about taking the No. 1 authority (that's us) to lend credibility to the Internet?
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If TV is still No. 1, it is only because there are so few docs that have yet to embrace the Internet. There are very few who have learned how to use the Web to effectively promote themselves and their practices.

With so little competition, if you were to start right now, you'd have a respectable Web presence within the next six months.

Remember, your goal is to achieve a ranking within the top 10 of a search, not No. 1. Engage the Internet in any format you prefer:

• Text and images are the old time standard. Web pages and blogs are popular examples. Common uses for a Web page are to show off your practice and to blog about your medical knowledge (not necessarily your expertise).

• Power Point presentations via SlideShare.net are an easy way to start a Web presence. You can upload the presentation just the same way you'd upload a YouTube video. Why not use the same PP presentation you just gave at a local talk?

• Video - you can be as basic (a very popular way though) as using the webcam on top of your computer or you can have a full scale production, whatever you like. The video can be placed on YouTube and other social media sites, including your own Web page. The topic can be an infomercial about yourself or your practice. You might also consider talking about H1N1 availability at your office.

• Images - services such as Flickr share images. You could upload clinical presentation on poison ivy showing different pics of the offending plants and the resultant skin rashes. This presentation would then be linked to you and/or your Web page and practice.

The Internet needs more docs. However you want, engage the Internet. We are the authorities on health. There is a paucity of good, credible health information on the Internet. Share your authority with the public. Use any format to get started, start slowly and proceed at your pace. Make the Internet credible. Patients should be learning from us, not TV.

Match Day nostalgia

OK, Practice Notes readers, this post really requires your contribution.

On Kevin MD's blog, Brian Eule wrote about Match Day (which is today), the third Thursday of March when the nation's graduating medical school students find out to which residency program they have been matched.

Eule writes: "Much of the future of their field will remain unknown, as the country works through health care reform. But for the country’s newest class of doctors, today will give them a little more information as to their futures as doctors."

I'd like to invite you to recall and share your Match Day experience here. What was the process like at your school? How did you feel?

Gerald O'Malley, DO: The mushroom mystery

On Tuesday morning I received an urgent phone call from a colleague who works in another ER. He told me about a patient who he saw with a possible severe mushroom ingestion and poisoning. The patient was a friend of his. My colleague had secured emergency consulting privileges for me from the medical staff president and asked me to see the patient. I was scheduled to work a moonlighting shift that evening at my friend’s shop, so I promised to stop in and see the patient before work.

Thirty minutes later I received an urgent e-mail from Dr. Kevin Osterhoudt, the director of the Philadelphia Poison Control Center about a mushroom-poisoned patient somewhere in the city.

My first thoughts were “My God – are there TWO patients? Is someone selling poisoned mushrooms on the streets of the city? Do we have a public health crisis on our hands?”

A quick phone call to Poison Control clarified the situation. One patient. No epidemic. No need to call in the health department or to shut down the farmer’s market where our patient bought her mushrooms. At least not yet — but the chase was on.
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I saw the patient a few hours later. The patient was a professional and a very health-conscious individual who rarely ate meat and bought her produce at the organic food market. Her symptoms began about three hours after eating the morels that she bought at the Reading Terminal Market. The patient and her husband were both in the ER at midnight — he was on death’s door; she was a lot worse. There were no more reports of mushroom poisoned patients in the Delaware Valley in the interim.

Abdominal pain, diarrhea, bloody vomiting, volume contraction, hypotension, dysrhythmias, acidosis…everything needed to kill a young woman. Except mushroom poisoning. There are seven or eight known toxic syndromes associated with poisonous mushrooms, but neither this patient nor her husband showed the characteristic signs of any of the known syndromes. No liver toxicity consistent with Amanita phylloides, no renal toxicity to suggest Cortinarius species or Amanita smithiana, no central nervous system toxicity to suggest Gyromitra species (the “false morels”).

What the hell was killing these people?

I called the Poison Control Center and consulted with the brilliant Dr. Fred Henretig. He agreed — didn’t sound like any mushroom he had ever heard of. I felt reassured when Fred concurred that this wasn’t a mushroom — this sounded more like some kind of pre-formed toxin like a Staphylococcal toxic shock syndrome.

The patients improved. The first 36 hours were terrifying. The next 36 hours were tense but hopeful — double and triple checking hemodynamics and fluid status and pressor dosages. The fourth and fifth days were joyful, watchful, prayerful. The critical-care specialists were heroic and never left her side. God watches out for drunks and doctors.

The mushroom questions never stopped. For the past week I’ve answered dozens of questions from family members, nurses, doctors, and Poison Center personnel about the mushroom poisoning that never was. Amazing how stories take on a life of their own.

Drs. Osterhoudt and Henretig think that it is worthwhile discussing this case at the next Poison Control Center Grand Rounds in the context of mushroom poisonings in general (rare but terrifying) and more specifically when we, as a Poison Control Center and a public resource, should pull the trigger to initiate a public health alert.

I’ve invited the patient and her husband to attend.

Trendspotter:Healthcare Reform Is First Step To Shore Up Deteriorating System

By Ken Terry

Many pundits have weighed in on the likely consequences of not passing healthcare reform, which is expected to come to a head within the next few days. But a recent blog post by Matthew Mintz, MD, an internist in Washington, DC, puts things in perspective for physicians.

Judging by his essay, Mintz is neither a Tea Partier nor a single payer advocate like those who belong to Physicians for National Health Program (PNHP). Both the Tea Party and PNHP oppose the reform bill—the former because it would expand government intervention in healthcare, and the latter because it fails to put government in charge of healthcare. Mintz is not concerned that the proposed legislation would give the government too much power; rather, he worries that, in the absence of reform, the healthcare system will continue to deteriorate. In fact, he believes that while the reform bill deserves to pass because it expands insurance coverage, healthcare will decline even if it's adopted. What’s missing, he says, are more stringent cost control measures and a plan to increase the supply of primary care.

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Writes Mintz: “Though our dysfunctional system and plans for reform may not affect you now, things will get worse. Without addressing costs, premiums will continue to go up and even more patients will lack the ability to afford health care coverage. Without addressing the bureaucracy of insurance paperwork and the pay disparity between specialists and primary care physicians, students will continue to go into non-primary care fields and current primary care doctors will retire. In addition, our nation is only getting older and fatter, and thus sicker and more expensive.”

Despite the shortcomings of the reform bill, Mintz views it as an essential step toward providing everyone with high-quality care at an affordable cost. If the legislation is voted down, he points out, Congress will probably not revisit the issue for a long time to come. By then, he says, things will be so bad that everyone will be demanding reform.

I agree with Mintz on the politics of reform, and I also concur that the system’s decline will accelerate unless the federal government takes decisive action. But several elements in the bill could help slow cost growth. One is the proposed Independent Medicare Advisory Board, which would theoretically have more power than the current Medicare Payment Advisory Commission (MedPAC) to make changes in Medicare reimbursement. While the proposal has elicited strong opposition from the healthcare industry, including medical societies, it's needed because Congress is too political to make the required cost-cutting decisions. The problem with the proposal in its current form is that it takes hospitals, physicians, and drug companies off the table for the next decade. So it would not have much practical effect unless later legislation gave the independent board real authority.

Another provision in the bill would encourage the formation of accountable care organizations – combinations of hospitals and physicians that would share in whatever savings they produced for Medicare by improving coordination of care. Most likely, big healthcare systems would take advantage of that opportunity. There are also demonstration projects for payment bundling and enhanced home care for chronically ill seniors. Many hospitals are already preparing for payment bundling—which would provide a single payment for multiple kinds of services, such as acute and post-acute care—by employing more physicians.

Last but not least, the Senate bill that forms the backbone of the final reform legislation places 1 to 2 percent of hospitals’ Medicare reimbursement at risk for meeting quality and efficiency targets. While the bill is not specific about physician incentives, it proposes studying physician utilization patterns before deciding how much of your reimbursement to put at risk.

As for increasing the attractiveness of primary care to young doctors, the bill would shift some Medicare funds from specialists to primary-care physicians—a direction in which CMS has already started moving.

Needless to say, the AMA and many specialty societies oppose most of these initiatives. So if Washington is really interested in cost control, it’s unlikely to get much help from physicians. And yet, if both public and private health spending growth is not restrained, an increasing percentage of patients will no longer be able to afford your services.

Jennifer Frank, MD: Breastfeeding... at work

I have breastfed all four of my kids. I strongly believe the research – breast is best. It is the healthiest nutrition for babies and provides long term health benefits. It is healthier for mom allowing the average mom to consume an extra 500 calories a day. A definite fringe benefit!

Returning to work at six to 12 weeks after the birth of each child, I have pumped at work, on call, while traveling, and even on the road one very chaotic day. Both personally and professionally challenging, it causes me to appreciate why so many of my patients give up breastfeeding shortly after returning to work.

I breastfed my first child until he was five months, having to wean him rather quickly in anticipation of a deployment to Afghanistan that fortunately never occurred. My second child “fired me” after eight months. She was and remains a daddy’s girl and I secretly think she preferred a bottle from dad to milk from mom. My third child was 14 months old when we gave it up by mutual agreement. Number Four is a tenacious breastfeeder, continuing to almost exclusively breastfeed at eight months, despite our daily attempts to convince him of the benefit of eating cheerios, squash, or oatmeal.

After doing this four times, I have learned two important things.
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You must allow time to breastfeed or pump. This means getting up a little early (if my husband is reading this, he is probably snorting with laughter as he usually gets up over an hour before I do and brings me coffee in bed), carving out time in your clinic schedule to pump, and taking frequent breaks no matter what you are doing to breastfeed or pump – whether you are teaching at a conference, in the airport, or at a restaurant.

I have found it helpful to make a 15-minute appointment with myself in each half-day of clinic to allow me time to pump. This gives me enough breathing room to actually get it done, despite a hectic schedule. Sometimes I have to leave a meeting early or arrive late so that I can take care of what needs to be done.

One thing I struggled with was how to inform colleagues, staff, and residents what I was doing without making them uncomfortable. I heard about one woman who had a picture of a cow she would hang on her office door whenever she was pumping to let everyone know she was occupied. That seemed a little too strange and self-deprecating to me (what new mom wants to be compared to a cow?!?). I made a laminated sign that informs people of what I am doing and how long I will be gone that I put on my chair in clinic when I head off to my office to pump.

It is not easy to continue to breastfeed once you return to work. Like every other aspect of combining the personal and professional gracefully, it requires patience, planning, persistence, and practice.

Melissa Young, MD: How much am I getting paid?

At my former job, as an employed physician, I didn’t really know how much I was getting paid for each patient encounter. Yes, we had a meeting with our billing department. I’m not quite sure why, since the bottom line was well, it is what it is, and the answer to any question was “I’ll run a report.” Yes, a report I rarely ever saw.

Oh, yes, I saw how much was charged each month and how much was collected and how much was written off. But I wanted more information. I asked on numerous occasions for a breakdown of how much we were getting paid for each E&M code. I asked for a breakdown of our contracted rates with each payer. Apparently, they could not tell me what the rates were per se, but they could tell me what percentage of Medicare “since that’s public.” Sure, they could. But they didn’t.

So when I ventured off on my own, and submitted my change of address and change of TIN to the insurance companies, I did so without really knowing what my contracted rates were and without knowing whether they would or had changed. Probably unwise on my part. But at the time, my only concern was being credentialed and getting paid something. Anything.
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So I mentioned in my last post that my husband is my biller. And he feels I am not being paid what I should be. I figured, I will get the practice up and going and look at the numbers and see what payers are paying what, and then go back and renegotiate as needed. Well, he got tired of waiting for me, so he spoke to someone who negotiates insurance contracts. He said she gasped when she heard what I was being paid. Apparently, not enough.

But she needs a copy of my contracts. And guess what. I don’t have a copy of any but one. Yes, again, foolish on my part. I need to know at the very least, when they expire, because if we are going to renegotiate, we need to do so around the time I am supposed to re-up.

I am going to have to have someone (me, my husband, my staff) call the insurance companies and ask for a copy of my contract. I wonder how cooperative they will be. It’s always a challenge getting a human on the phone. We have all spent many frustrated hours being transferred, getting disconnected and trying to get these stupid voice activated systems to work. I’d swear they do it on purpose. My secretary thinks they listen in on her and laugh as she swears at the phone in frustration. I have a sinking feeling that getting these contracts is going to be like pulling teeth.

Blog War: Concierge Medicine

Readers, today begins an occasional series in which Senior Editor/Blog Mistress Sara Michael and Editorial Director Bob Keaveney will take opposing views on some hot topic affecting physicians, then invite you all to join the fray.

The subject of our inuagural Blog War: Concierge Medicine: The Savior of Private Practice Medicine, or Evil Unethical Trend?

From Bob:
I’ve written about concierge medicine in the past. For background, a typical concierge (sometime called retainer or boutique) practice charges an annual or monthly "membership fee" directly to patients, who in return get a different level of access to the physician — usually longer and more frequent visits. They can usually get the doctor on the phone pretty quickly, and many offer e-mail communication, too. A concierge physician might have a few hundred patients rather than a few thousand. Concierge practices — the good ones, anyway — run the way primary practices are supposed to run: With doctors getting to know their patients, becoming truly part of their lives, and spending enough time with them to talk and listen.Read more

That's not possible to do within the confines of the ordinary modern practice. The economics don’t work because primary healthcare today is about volume. Doctors have too many patients to spend more than 10 minutes or so with any one of them. Even when you do see 30 patients a day, in primary care you're way behind your specialist colleagues when it comes to income. That's why so few med students are opting for careers in primary care anymore.

So, for me, concierge medicine is a response to a dysfunctional economic climate that allows primary care doctors to do their jobs in the way they always dreamed — and in a way that's best for patients. Sara, what's your beef with that?

From Sara:
The trend of concierge medicine troubles me. I am not insensitive to the struggles many primary-care physicians face, but concierge medicine is far from being a solution to declining reimbursements and not enough time with patients. Instead, it’s a harbinger of what’s wrong with the system as a whole. The model flies in the face of any commitment to community and public health, which I think should be at the foundation of medical care.
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Concierge medicine further divides our population into those can afford quality care, and those who can’t. What happens to the hundreds of other patients who decide they can’t afford the $1,500 to $3,000 (or more) annual fee? What about those who have had the same physician for years, and who may have trouble finding another primary-care physician? I think basic quality primary care should be afforded to every American and concierge medicine in many ways exacerbates the problem.

Randall Wong, MD: My favorite social networks

My favorite social networks are Twitter, Facebook, and LinkedIn. They differ by the demographic that uses them, but are great avenues for attracting attention to my Web sites or blog. While I am not able to tout all the advantages of social media in one post, these are a few ways I use the different sites.

I use Twitter to "tweet" about new articles I've written for my blog. It is a very common way to let people know about new items on my Web site, and thus, attract more readers.

Once an article is written for my blog, I will copy the URL, or Web address for my article, and go to bit.ly (yes, that's all you have to type in). Bit.ly is a URL shortener and reduces the number of characters of the URL. (Tweets can be no more than 140 characters long).

I will then "tweet" about the new article just posted on the blog. I will usually write a short comment and then add the abbreviated URL. By clicking on the shortened link, a reader can go straight to the Web site and read the article.

At the same time, Feedburner will have been "pinged" that I have a new article and will automatically send a message, or "tweet," to Twitter. I have set this up automatically.
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Those who follow me on Twitter, and those looking for tweets about eye disease, will be alerted about a new article on my blog. Many people who use Twitter are in an Internet-related business and far fewer are related to healthcare.

Facebook is very popular among the younger generation. It is frequented by teens and younger (although they are supposed to be at least 18 years old), college kids (and the parents of all these kids). It is also becoming a very popular place to find...businesses.

I have a "Fan Page" on Facebook. A Fan Page differs from a regular social account in a few ways. First, people/patients may become a "fan" instead of a "friend." Fans do not have to be recognized by you, the owner of the page, for them to make comments on the Fan Page. This is different than becoming a friend on a regular social page where the owner has to "friend" each person in return to send messages, etc.

Many docs have found difficulty friending patients/visitors due to the fear of establishing a doctor/patient relationship. Fan Pages avoid all of this. Any person who chooses to be a fan may post messages and comments on your site. Fans might comment about what a great doc you are, the convenience of your office location, your neat Web site, etc.

Other differences? You can advertise your Fan Page by subject, by demographic, etc. Many, many corporations have started this method of advertising and have their own Fan Page on Facebook.

Lastly, I have set it up so that every new article I write on my blog gets transferred to Facebook. My fans may read my articles there and comment or share my article with others. My younger patients, who don't e-mail as much as the older generation, prefer to keep up with me and my blog via FB.

LinkedIn is very similar to Facebook although it really is a social network for the business world. It has some of the same advantages of FB, but has some unique attributes. While it is nowhere as social as FB, it relies heavily on FOAF (friend of a friend) business networks.

There are a respectable numbers of health related groups (interest groups) that have formed at LinkedIn. LinkedIn lists my excerpts of my blog. My readers via LinkedIn can click on the excerpts which take them right to my blog.

So what does this all mean? Each of the social networks, and there are dozens, seem to have their own demographic. Depending upon the personality of each media, you may choose to network.

For instance, FB appeals more to my younger patients. They don't seem to check e-mail as much as the older folks, so providing my articles and an information page about me (aka Fan Page) on FaceBook makes it more convenient for them. FB is becoming so large, it is becoming a "Web active" subset of the Internet, that is, most people using FB tend to be very active users of the Internet. Corporate America has noticed. My older, more business oriented patients, follow me on LinkedIn.

These are great ways to start using social media to get news out about your practice. You don't have to understand all the ramifications of each network before you begin. These are simple ways that I have found to be useful.

Gerald O'Malley, DO: The heroes of Haiti

This post is dedicated to the men and women of the U.S. Naval Medical Corps serving aboard the U.S.N.S. Comfort.

One of my former residents came to the hospital last week to visit. His name is Adam Cooper, and he graduated from residency three years ago, tried a couple of different jobs, but made the decision to enter the U.S. Navy as a medical corps officer about a year ago, so now I have to call him Lieutenant Adam Cooper. Recently, Adam was mobilized as part of the largest relief effort ever conducted in the history of the U.S. Navy: the rescue effort in Haiti. Adam wanted to come back to the hospital and “hug every one of the attendings for the four years of torture” that we put him through during residency.

Adam shared some of the 3,000 pictures that he took of his time on the U.S.N.S. Comfort and on the devastated island itself. Horrific images of severe trauma, necrotizing infections, and gangrene against a backdrop of collapsed buildings in a broken country. The pictures also told a story of heroism, valor, and tenacity by the members of the U.S. military — the true heroes of Haiti.

Adam kept his promise and hugged all of us amid backslaps and high-fives, and then we all sat down as he gave the details of his mission to rescue and aid the victims of the earthquake and provide 21st century medical care to a country with a 17th century infrastructure in an environment of biblical destruction.
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Adam was the only emergency medicine trained physician as part of a team consisting of family practitioners, surgeons, pediatricians, nurses, and naval corpstaff. The team treated over a thousand patients in 12 days, moving critically ill and injured people from the rubble onto helicopters and boats to the operating rooms on board the Comfort, recovering them and getting them back to some level of definitive care. The team worked under the most extreme conditions — an aftershock knocked out the CT scanner on the ship for four days and several of the portable X-ray machines burned out. Suddenly, Adam and the team discovered what bedside diagnosis was like in the 1950s.

The diseases and trauma that the team saw would give any physician nightmares. Among the fractures and amputations and solid-organ injuries and dehydration and sepsis and abandoned children, the team treated six cases of tetanus, cerebral malaria, and delivered a half-dozen babies, the births of which were complicated by seizures, eclampsia, and open pelvic fractures in one of the mothers. According to a study by UCSF, in 2007, approximately 15 percent of the population of Haiti was living with HIV/AIDS.

The team coordinated with members of the international relief effort including military representatives from Israel, France, England, and other countries as well as NGOs like the Red Cross and Doctors Without Borders.

Adam said that every member of the team work 20 hours each day for two weeks straight. He compared is to “the worst shift you’ve ever worked in the ER — all day every day” and he thanked us all again for the time and teaching.

I’ve never been so proud of one of my former residents. In a small way, I almost feel like I spent some time in Haiti with Adam — just like the old days.

Trendspotter: Physicians Remain Leery of EHRs, Despite Government Incentives

By Ken Terry

The results of recent surveys suggest that a majority of physicians intend to buy electronic health record systems within the next few years. But software vendors interviewed at a recent annual meeting of health IT professionals aren’t yet seeing any stampede of doctors to acquire EHRs. And the Medical Group Management Association (MGMA) has expressed reservations about the ability of physician groups to meet the “meaningful use” criteria for government financial incentives. That casts some doubt on the eagerness of doctors to adopt EHRs.

A study by consulting firm Accenture shows that 58 percent of physicians in groups of 10 or fewer doctors who don’t have an EHR plan to get one in the next two years. Four of five non-EHR-using doctors under the age of 55 are gearing up to go digital, according to the survey. Three quarters of the non-users say they’d buy an EHR through a hospital if the facility subsidized it, and the average amount of subsidy these doctors expect is about half of the EHR’s cost.

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Another survey, by EHR vendor athenahealth and physician social network Sermo, finds that 80 percent of Sermo’s online users have a favorable opinion of EHRs and believe that these systems can improve patient care. Seventy-three percent say that the patient benefits of an EHR justify the financial costs. But most respondents agree that EHRs are expensive to purchase and maintain; 54 percent agree with the statement that EHRs slow physicians down; and barely more than 50 percent believe that EHRs have been designed with physicians in mind.

I’m somewhat skeptical of the latter survey, since it was co-sponsored by an EHR vendor. Also, physicians who participate in Sermo’s online network are not necessarily representative of doctors as a whole. I’d guess that a far smaller percentage of physicians view EHRs favorably than this survey indicates. As for the Accenture study, I’m struck by the fact that 61 percent of the non-EHR-users want to adopt because of the threat of Medicare/Medicaid penalties down the line, and only 51 percent are motivated by the federal subsidies for EHR adoption. What that tells me is that physicians are being reluctantly dragged into this deal.

One reason for their reluctance and their skepticism about government incentives is the difficulty of achieving meaningful use. In an MGMA survey, member practices said that the hardest requirements to meet were providing electronic copies of medical records to 80 percent of patients requesting them within 48 hours and providing electronic copies to all requesting patients within 96 hours. The majority of respondents also foresaw problems in using clinical decision support and submitting quality data. More than two-thirds of the respondents said that the use of EHRs would reduce productivity. Thirty-one percent said that productivity would drop more than 10 percent.

The latter MGMA findings and the similar one from the Sermo/athenahealth survey show that physicians remain apprehensive about the financial impact of EHRs on their practices. This impact is related not only to cost, but also to productivity. Dr. Daniel Palestrant, CEO of Sermo, commented, “It is clear from the survey that current EHR solutions are imperfect, with cost, resource allocation, and ease of use being areas that could stand great improvement. Discussion amongst the Sermo physician community supports the survey’s findings of ‘holes’ in current offerings and, more broadly, the notion that EHRs have a long way to go towards delivering on the promise of cost savings, freed resources, and better medicine.”

Nothing exhibited at last week’s conference in Atlanta of the Health Information Management and Systems Society (HIMSS) really represented a breakthrough in EHR design. Some vendors were offering components of EHRs that stressed connectivity more than documentation. That’s important, because the ability of EHRs to exchange data with other information systems remains poor. Also, many physicians find it difficult to document visits in EHRs. There have been some advances in “natural language processing,” which enables computers to parse the meaning of text and sort medical terms into EHR fields. When that’s ready for prime time, many more physicians will be enthusiastic about EHRs, because they won’t be required to enter data. But that’s probably at least 10 years away, and the government incentives for EHRs will be available only from 2011 to 2015.

In the meantime, doctors will have to adjust to the realities of current EHRs if they want to win federal subsidies and avoid later penalties. Let’s hope that as the market expands, EHR vendors will reinvest some of their profits in developing products that are easier to use and that help physicians improve quality and efficiency more than those now on the market.

Jennifer Frank, MD: Making friends, Part 3

I have previously written about the struggles I face as a busy, working mom to establish close friendships, or let’s face it, even loose friendships with other moms like me – moms who spend most of their time away from the people that are closest to their hearts.

I joined a meetup.com group to meet other working (outside the home) moms and have been pleasantly surprised by the result. No bosom buddies yet, but I have enjoyed the few activities I have attended. I am even hosting my first event this weekend – a movie afternoon at our house. Friday night will find me madly cleaning the toy room in order to create the illusion that in addition to working full time and parenting four young kids, my house is always immaculately clean.

Last night, I had the opportunity to do something I normally avoid like the plague (or agree to attend and then spend the days leading up to the event inventing ever more fabulous excuses for canceling). There is a new surgeon in town and she is a girl. She hosted a meet and greet for other female physicians at a local restaurant.
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I get a fair number of invites to meet new physicians or see new office space or hear about new services. Usually, I am not even remotely tempted to give up time with my family to attend. However, when I received Dr. Collette’s invitation in the mail, I decided to go. Maybe it was the hot pink lettering and zebra print background on the invite. It might have been the informality of combining the “Doctor” title with her first name – not since I lived in the south have I been “Dr. Jen.”

I think, though, it was most likely the little note that accompanied the invitation. It described the benefits of female providers meeting, working with, and supporting other female providers. I like that. I wanted to meet this lady. Most of all, I wanted to reward her outreach effort by accepting the invitation.

So, yesterday evening, I headed out to the reception. I admit that I regretted having accepted as I drove to the restaurant. I would have preferred to head right home even knowing that dinnertime chaos awaited me. But, I reasoned with myself, I accepted and wasn’t sure how many other physicians would take the time to go. I also told myself that there were probably other female physicians in my place – busy with work and home and eager to meet other people with whom they share a common bond.

I took an immediately liking to the new doc in town – approachable and down-to-earth. I also had the chance to meet a half-dozen women doctors. One even brought her 9-month-old son – another bond. It was nice to converse with these fellow physicians and moms and wives and women.

It has inspired me to get together with my practice partners and host our own female physician get together. I will let you know if anyone accepts our invitation.

Melissa Young, MD: My biller, my husband

After having paid about 10 percent of collections to our billing department when I was at my old group practice, I had to make a decision about who would do the billing for my new practice.

I had found a couple of billing companies that would take less (heck, no one I know has a company that takes 10 percent). But even 5 percent seemed like a lot. And I was pretty jaded after my prior experience. You know there was a time that our collections were way down one month, allegedly because the person responsible for our billing went on vacation and stuffed our billing slips in a drawer instead of delegating them to someone else.

Plus, anything less than $10 was just written off apparently. I know $10 may not seem like much, but let’s say that even two patients a day owed $10, that’s more than $7,000 a year! Now, I understand, if you’re paid hourly, you don’t care if you collect $10 or $10,000, you shuffle your papers and make an occasional call, but if you get a denial, then so be it.
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So, after careful consideration, we (meaning my husband and I) decided that my husband would do my billing. After all, other than me, who else truly has an interest in how much gets collected? Who’s going to look at every claim, every invoice, every EOB? And who’s going to figure, yes, it is worth the 44-cent stamp to send that statement for $2.29.

Now my husband’s not a biller by trade. But he took the requisite courses and is proficient at math, and quite honestly, I think he’s got a little obsessive-compulsive trait in him. This of course is great in a biller. But my husband also has a full-time “real” job, and because of my hours, he is also a very hands-on dad. So he does the billing during his lunch hour (he’s always grateful for the drug rep lunches), in the evenings, and on the weekends.

We had some technical difficulties at first, as he learned the practice management system and our clearinghouse’s software, but he has it down pretty good now. Sure, he gets frustrated at making phone calls to insurance companies, especially when he can’t get a human on the phone (which is all the time), and the phone calls from patients who say they shouldn’t owe anything because they have a secondary insurance (which would have been good to know when they came for their visit).

But he says, strangely enough, that he kind of likes doing my billing, and I like having him come to the office everyday. And if the time ever comes that the world doesn’t need engineers, he has something to fall back on.

MGMA survey: Meaningful use criteria mean decreased productivity

Changes in practices’ operations to meet the EHR meaningful use criteria would lead to decreased productivity, according to new research by the MGMA.

Nearly 68 percent of respondents said physician productivity would decrease, and 31 percent said that it would dip by 10 percent, according to the poll. Practices were asked to estimate the change in productivity from implementing all the 25 meaningful use criteria.

“If the final rule mirrors those outlined in the current proposal, there is a significant risk that the program will fail to meet the intent of the legislation, and that a historic opportunity to transform the nation’s healthcare system will be missed.” MGMA President and CEO William F. Jessee, MD, FACMPE, said in a statement.
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MGMA’s research also identified which criteria would be hard to achieve:
• The proposed requirement that 80 percent of all patient requests for an electronic copy of their health information be fulfilled within 48 hours (45.9 percent) and
• The proposed requirement that 10 percent of all patients be given electronic access to their health information within 96 hours of the information being available (53.5 percent).

In a recent podcast, Robert Tennant of the MGMA, explained to me that these criteria that require practices to deliver electronic copies of health information in a timely manner would be particularly troublesome. He said it would require many practices to acquire patient portals, which are often separate systems from their EHRs. This could be a costly proposition.

However, for those practices that said they didn’t currently use an EHR, about 42 percent said it was “very likely” that they would attempt to qualify for the EHR incentives. Another 18 percent said it was “likely.” But there is that more than 23 percent who said it was “very unlikely” or “unlikely” that they would.

Unsurprisingly, among those with an EHR, nearly 83 percent said it was “likely” or “very likely” that they would try to qualify for the incentives.

What do you think? Will these requirements have a major impact on your practice's productivity?

Randall Wong, MD: Put yourself on the map

Ever wonder what businesses get placed on a Google map as the result of a search? Placing yourself on Google Maps is easy.

It's free and you can do it all by yourself. Millions of people use Google Maps for searching businesses, including doctors. Use this free service to start your Web presence and advertise your practice. You don't even need a Web page to do this.

Start with a Google account. As with all Google branded services; Gmail, Reader, Documents, AdWords, AdSense, etc., you must have an e-mail account. It's free, and from there you can sign up for additional products. I use Gmail, Calendar, Documents, Reader, Buzz, AdWords, and AdSense regularly. Don't worry, they all work well and I have no spam issues.
Then search for “Google Local Business.” You should be able to find the link for the Local Business Center, which may vary depending upon your location. Click on the link, and it will take you to the sign up window for Google Maps. If you have a Gmail account, sign in. If you don't, you may start one now.
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Fill in your business information — it’s all self explanatory. If you have Web site, enter the URL. People interested in your business can click and view your Web site. If you do NOT have a web site, no big deal. Your map simply won't list a URL. You can add one later if you like.

For reasons we'll see, enter your main phone number of your practice. Ideally, use a number that patients will be using to call and make an appointment, i.e. don't put your back, private line or cell number.

For the description, I suggest you use a keyword tool to help you pick some of the words that are routinely used for your line of business. For instance, click on Google's Keyword Tool and try a few words that you would choose to describe yourself. The goal is to use words that are commonly used to find you or similar practices.

As an example, you are more likely to choose "family medicine practice" versus "pediatric and geriatric medicine" as the latter descriptors are not used as often.

As you can see, you may add photos, or even a video of your practice.
By the way, once you are "up," you can check out your listing. Maps and directions are automatically provided by Google. You can even track the top 10 keywords people used to find your ad. Using this information, you can tweak your description.

Submit your data after checking your accuracy. You can change anything you want if you are in doubt and change your mind.

Remember the phone number? Google will either call you to give you a secret code to verify that the user info is legit, or send you a postcard. The call will occur as soon as you hit the submit button versus waiting two to three weeks for a postcard. (I would suggest that if you are able to answer your main office number "live" use the telephone. If you cannot answer the phone "live," because you have an electronic attendant, use the postcard.)

In a short while, you will be "on the map." Great job. You are done.

More on Medicare payment shenanigans

In case you missed the latest in the Medicare payment shenanigans in Washington, the Senate voted again last night to delay the 21 percent cuts. (This after Sen. Bunning blocked the bill last week.)

Now, Congress has until April 1 to fix the flawed payment formula.

From AMA President J. James Rohack, MD: “Physicians are outraged by the Senate’s failure to act before the March 1 deadline, as their patients and practices are hurt by the continued instability in the Medicare system.”

He continues to say, “The vicious cycle of short-term delays … must come to an end.”

Trendspotter: AMA To Give Small Practices a Helping Hand in Launching EHRs

By Ken Terry

Small physician practices are less likely than big groups to have electronic medical records—and there’s a reason that goes beyond cost. They lack the resources and the technical knowledge to implement these complex systems. The support and training that vendors offer is frequently inadequate, especially for physicians who aren’t especially computer-savvy. And the vendors freely admit that they don’t have sufficient staff to cope with the expected influx of new EHR buyers who want to show meaningful use by 2011, when the government incentives start flowing.

Under the HITECH provisions of the American Recovery and Reinvestment Act (ARRA), the government is required to create health IT regional extension centers (HITRECs) across the country to help up to 100,000 primary-care physicians install EHRs in their practices. The Office of the National Coordinator for Health IT has allocated nearly $600 million for this purpose, and 60 HITREC grants will be handed out by the end of March.
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Some healthcare systems are taking advantage of the Stark exception to subsidize EHR purchases by non-employed staff physicians, and far more are trying to get their employed practices online. But in either case, the demands of working with a multitude of small practices to implement EHRs exceeds the capacities of most hospital IT staffs. Moreover, the hospital IT people have expertise in inpatient systems but know little about ambulatory-care EHRs.

The AMA is trying to help fill the gap by creating a new web portal that will “provide physicians access to information, products, services, and resources to help facilitate medical practice and ease adoption of health information technology.” While the AMA will give doctors access to e-prescribing and lab ordering applications via the portal, now in beta test mode, AMA’s partner, Dell Perot Health Care Systems, will help physicians implement their EHRs. According to Dell Perot, the AMA will initially offer its member an Allscripts EHR, and it appears that other products will be made available later.

No pricing was available at press time. But, since Dell Perot will host the EHRs on a remote server, upfront and maintenance costs will be lower than they would be if the program and the patient data were hosted on an in-office server.

The big question is how effective Dell Perot can be in working with small physician practices. Both companies have extensive experience in helping hospitals set up and integrate their systems, and Perot—which merged with Dell last year—has also done a lot of outsourcing work for hospitals. The company has also been helping some big healthcare systems, such as Memorial Hermann in Dallas and Tufts Medical Center in Boston, ramp up EHRs in the offices of affiliated physicians. But small independent practices outside the orbit of a healthcare system present a different set of challenges.

In an interview with Physicians Practice, Jamie Coffin, vice president of Dell Healthcare and Life Sciences, pointed out that Dell has helped computerize lots of small businesses in non-medical fields. Of course, that doesn’t mean too much, because EHRs and healthcare are much more complex than, say, a bookkeeping system in a restaurant chain.

Part of the small-practice solution, Coffin indicates, is to use remote training and support tools. Dell Perot will install the hardware, do a “brief touch” in the practice to get the software running, and then follow up online. This does not leave much room for change management or handholding, and practices that cannot figure out how to use the software quickly might drop it, as many have before. But based on Dell Perot’s success to date in working with healthcare systems, they’re hopeful that this approach will also click in private practices.

In any case, Coffin points out, the AMA-Dell venture will fill a need as physicians scramble to show meaningful use. “The real question is whether EHR vendors can scale to the number of installations they have to do over the next 36 months,” he says. “It’s not a cost question for them, it’s an issue of whether they can scale to the demand. They’re going from 1,000 implementations a year to 10,000-20,000 or more. That’s one reason why they’re looking at companies like Dell and Perot.”

Gerald O'Malley, DO: Some thoughts on the healthcare summit

Today, I worked a 7-3 shift in the ER while our political leaders were meeting to talk about what to do with healthcare. Ironic, considering there are roughly two dozen physicians in Congress and not one was seated at the table. Can you have a serious summit on energy policy without engineers? Can you have a serious summit on national security without law enforcement experts? The only members of the government that actually have any experience with the actual delivery of healthcare were absent, which should tell you everything you need to know about the healthcare summit of 2010.

As the snow swirled around outside in the most recent snowpocalypse to affect the city this winter, we struggled to get our patients out of the waiting room and into an exam room as quickly as possible. We waded through their poorly described complaints and tried to identify any life threatening problems quickly and efficiently.

We probably saved a half-dozen lives in eight hours; an acute myocardial infarction and a stroke, an ectopic pregnancy, an acute appendicitis, and a septic old lady were all “rocked and locked” — a euphemism for getting the job done quickly and expeditiously. In addition, we treated a number of “non-life threats” — broken bones and lacerations and asthma attacks and strep throats.
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We tried to follow the proceedings on TV and online whenever we could, but I had to wait to get home to watch the news in order to digest the proceedings.

I heard a lot of sound bites (mostly from Republicans) asking for tort reform, but beyond the sound bite, there was no follow-up discussion. The trial lawyers have spent so much money buying access and influence that I doubt any meaningful tort reform is possible.

Some idiot congressman actually suggested that a plan for “stealth patients” be written into the bill in order to “root out Medicare fraud.” He said that we should send “fake patients claiming to have broken legs” to MRI centers and if “they continue to treat them like broken legs, then we know there is fraud going on.” There are so many things wrong with that statement, including the fact that broken legs are not diagnosed by MRI, that I don’t know where to begin, and what’s worse is that this half-wit congressman was actually describing something that had been proposed by Senator Tom Coburn, who is an obstetrician! Maybe the physicians shouldn’t be at the table, if they are going to make ridiculous suggestions like that!

After work I picked up my kids and was driving home when I received a “remember that patient you saw the other day” phone calls from my vice chairman: “Gerry, you need to meet with risk management next week to talk about this case.” You don’t actually need malpractice to be sued — all you need is a bad outcome.

What are the odds that this patient was a “stealth patient” or someone that is already talking with a lawyer?

Newsweek's Fineman opposes health reform

Anyone notice Howard Fineman's column in Newsweek today? Too bad it took him a bout with food poisoning in Argentina to realize what I've been saying for months: that health care is simply too expensive in the United States, and that the reform proposals currently on the table would not do enough to reduce the cost of care.

As Fineman, a left-of-center guy, puts it:

"President Obama proclaims his plan (whatever it finally is) to be 'reform.' But from what I can see, it would merely feed, at taxpayer expense, 30 million currently 'uncovered' people into a wasteful system that doesn't have either the price-signaling power of a marketplace or the sweeping overview and control of a state-run bureacracy."

Almost exactly right. Almost.

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The only thing wrong with that statement is the implication that all or most of the 30 million newly insured Americans would get coverage "at taxpayer expense." Actually, many would be forced to buy overpriced insurance at THEIR OWN expense.

Fineman noted that he got perfectly adequate, if less frilly, care in Argentina, for at least half of what it would have cost him in the U.S., even after accounting for the currency-value difference, and wonders: "Where does all that extra money go?"

Jennifer Frank, MD: My voice

I have laryngitis. This is my first bout with the sickness that takes your voice. I can squeak out a few words before I start coughing. I can whisper pretty well for several sentences before I get tired of whispering or my audience gets tired of trying to hear me. However, I am definitely unable to continue my current voice-related duties.

At home this weekend, I had to discipline without my voice. This led to two things. First, I let some things go that normally would have found me yelling either up or down the stairs to “stop chasing each other,” “brush your teeth like I told you to three times already,” or ask “is your room clean yet?”

Second, I got a lot more exercise since I had to physically locate myself in the same room as the kids if I cared enough about their current infraction to reprimand them. That tired me out quickly. So, I found it easier to just hang out wherever they were. This allowed me to watch them more closely which made it less necessary to correct them as my proximity had a disciplining effect.
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The unintended effect was that I spent more quiet time with my kids — my daughter read me a story, I taught my other daughter how to play Connect Four, I explored all of the Lego weapons my son had repurposed into even more powerful weapons, and I got some great belly laughs out of my infant son.

At work on Monday morning, I had to critically evaluate my schedule. Clinic on Monday afternoon would prove challenging for both me and my patients if I had to whisper through questions and instructions. I reviewed my appointments and was able to identify which ones needed primarily my hands or eyeballs and would allow minimal conversation. Not surprisingly, I determined that most actually needed to hear me, so they had to be rescheduled.

I couldn’t pick up the phone for the telephone conference I had planned, that would need to be rescheduled. I had a couple of important meetings to attend — both requiring at least some input from me. I considered writing down my thoughts, but was able to express everything I needed to say with a few well chosen words, thumbs up or down, and a few shakes of my head. At the conclusion of both meetings, I felt that the things that I needed to communicate had, in fact, been communicated. It is both humbling and embarrassing to consider how many more words I would have used had it been easier to do so.

Being quiet today has other benefits. When I did speak, everyone listened. They wouldn’t be able to hear me otherwise. Ironic — I usually raise my voice to be heard better. I also feel more quiet and calm. I am thinking before I speak (a rarity) because I have to save up my words to exert maximum effect. It is evident that this would be a good practice every day.