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.