The NPI Debate Heats Up

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Questionable Benefits for Providers

[By Darrell Pruitt; DDS]pruitt

I really hate lies!

Even though I have been a member of the American Dental Association [ADA] for 26 years, and intend to remain a member for the rest of my life, I cannot stand by silently any longer while my professional organization uses lies and/or deception to trick trusting members into volunteering for NPI numbers. 

Now, to see what I mean, please read what the ADA tells dentists about the benefits of the NPI number http://www.ada.org/prof/resources/topics/npi.asp

  • 1. Once implemented across the entire health care industry, the NPI will be accepted by all dental plans as a valid provider identifier on electronic dental claims and other standard electronic transactions.
  • 2. Dentists will not have to maintain multiple, arbitrary identifiers required by dental plans, nor will they have to remember which number to use with which dental plan.
  • 3. NPIs introduce an important element of standardization to electronic transactions that should improve transaction acceptance rates.   

Questionable Benefits Review

See what I mean? Now let’s review:  

  • 1. Number one clearly benefits only insurers and number three is unwashed tyranny.  The smell of sweet buzzwords counter-balancing the odor of the verb “should” immediately revealed to me traditional PR hucksterism … and I’ve seen better. The NPI number, which is conveniently necessary for electronic transactions, will only make it cheaper for insurers to deny claims.  I think anyone can see that denials will increase for natural, bottom line reasons.
  • 2. That leaves benefit number two – reduction of ID numbers – as dentists’ last hope of a return on investment in the voluntary NPI.  And, ROI could take a while.  In the first place, how much do multiple identification numbers actually slow dentistry production in a computerized dental office?  Why don’t we get silly?
  • 3. Of all things, for the ADA to list simplification as a benefit of the NPI is embarrassing, but here is what will make a few ADA leaders avoid each other in the halls of Headquarters next week. Even though the promise of simplification is lame, it is technically the only benefit the NPI number lends dentists and their patients.

Enter the AAFP

Here now, is some fresh bad-news for certain ADA leaders and members who trusted their advice. 

In an article that was posted yesterday on the American Academy of Family Physicians (AAFP) website, it looks like CMS reneged on simplification.

http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20080829keep-ptans.html

PTANS 

“Notice to physicians: Hold on to your Medicare Provider Transaction Access Numbers [PTANs], also known as legacy numbers which were to have been retired after the mandatory use of National Provider Identifier [NPI] numbers on May 23.” CMS has found another use for those old PTANs.”

Imagine that.  Instead of eliminating all of those identifiers as promised, the NPI is just one more number to add to the hard drive.

Assessment

Regardless, patients don’t suffer harm from all this, right?  Wrong. 

I’ll describe harm from HIPAA, the biggest blunder in the history of dentistry, and medicine, next time. 

Conclusion

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Health Insurers Secrets

Seven Things you don’t Know about Health Insurance

By Staff Reporters

“Myth Busters”

Wrapped up in all the noise these days are myths on health insurance that were perhaps once true – or maybe never were.

So, here’s a look at seven things you probably didn’t know about your health insurer.

Link: http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/7SecretsOfHealthInsurers.aspx

Conclusion

Your thoughts are appreciated; especially from insurance agents, industry insiders and medical providers; please opine and comment.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Healthcare Stock Performance

Doing Well by Doing Good – To Date in 2008

By Staff Reporters

According to Anne Zieger of FierceHealthFinance, healthcare stocks are doing well.

The Standard & Poor’s Benchmark

With healthcare facing some of its biggest financial challenges in years, particularly a growth in bad debt and slides in federal reimbursement, you wouldn’t think that industry stocks would be doing too well.

An Illogical Market

As usual, however, the market has followed its own logic, bringing several healthcare stocks to high points and pushing up the overall value Standard & Poor’s healthcare stocks average by 4.4 percent (compared with a 7.9 percent drop in the overall index). 

Meanwhile, mutual funds focused on healthcare are up 6.84 percent over the past three months, according to Morningstar, the only category of stock funds in positive numbers during this period.

Big Pharma and Biotechnology Driven

And, San Francisco Chronicle analysts say that rising healthcare stock performance is driven more by biotechs and big-pharma than provider companies. Their strong performance is partly due to improved performance by the stocks themselves, but also due to investors running away from finance and energy as well. 

Healthcare stocks have also been pushed up by foreign investors with strong currencies, who have been on the prowl to take over U.S. companies with below-expected valuations.

The Gainers

Big gainers among the S&P 500 include generic drug-maker Barr, Amgen, Varian Medical Systems and King Pharmaceuticals. 

On the other hand, it’s not all good news in this sector, as several managed care companies have lost value, including UnitedHealth Group and Aetna.

Assessment

Of course, hospital companies like HMA and Tenet haven’t done well, lately.

Conclusion

You thoughts and comments are appreciated; especially from wealth managers, financial professionals, insiders or investment advisors.

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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23 and Me

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Personal DNA Analysis and Reporting 

[By Staff Reporters]

Ever wondered why you were left-handed and your sibling or parent wasn’t?

A not-so-new new company, 23andMe, provides an analysis of DNA, where you can learn more about yourself, your immediate family and even your ancestry.

Target Markets

Those who would be especially interested in this personal genome service include:

Methodology

Customers [sic patients] submit a small saliva sample that is processed using a proprietary custom DNA chip. The resulting data is then presented on a secure website using interactive tools that offer information about ancestry, inherited traits and disease risk.

Board of Directors

This is no lightweight company. It technology founders include:

  • Linda Avey
  • Anne Wojcicki
  • Esther Dyson

While its’ medical advisors are:

  • Uta Francke; MD [Professor of Genetics and Pediatrics, Stanford University].
  • Itsik Pe’er; PhD [Assistant Professor of Computer Science, Columbia University].
  • Peter A. Underhill; PhD [Senior Research Scientist, Stanford University].

Assessment

You can also better understand your genetic tendencies for things like obesity or health issues.

There is even an interactive blog: http://spittoon.23andme.com

Users can find other members with similar genetic makeup and start discussions. And, it is $999 to order a kit for the DNA test. 

Conclusion

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Healthcare Focused Tax Attorneys

Avoiding the “Managed Care Ripple Effect”

By Dr. David Edward Marcinko; MBA, CMP™

The healthcare industrial complex represents a large and diverse industry, and the livelihood of other synergistic professionals who advise doctors depend on it as well. These include tax and estate attorneys who themselves wish to avoid the collateral ripple effects of the current healthcare debacle.

Lawyer as Financial Planner

As a tax, estate planning or bankruptcy lawyer, you already know that almost every legal magazine around has articles or advertisements proposing that you become a financial planning professional or business consultant to your physician clients.

Moreover, lawyers of all stripes are being pushed toward interdisciplinary alliances by encroachment on their turf by the Big Four accounting firms. With audits of publicly held companies now a commodity, the giant accounting firms are getting more of their revenues from consulting, and that puts them into direct competition with attorneys, MBAs, actuaries and other management and financial service professionals.

Avoiding a Medical Career

Of all careers, you know how absolutely onerous it is to practice medicine today, and are finally thankful that you did not take that career route many years ago.

So, like your neighbor the accountant, you begin to explore that potential of developing a service line extension to your legal practice, in order to assist your medical colleagues who have been hit on hard economic times. In fact, you soon realize that more than 90,000 trust, probate and estate planning attorneys like yourself are interested in pursuing financial planning in the next decade. Sure, you know it’s difficult to get a CLU or variable annuity license, or become a Certified Financial Planner™ (CFP), but earning your law degree was no cinch either.

And, you reckon, advising physicians has got to be easier than law, or less stressful than the corporate lifestyle of your MBA trained brother-in-law, right?

So, you set out to stretch your legal horizons and explore the basic legal nuances of those topics not available in law school when you were a student.  Things like medical fraud and abuse; managed care compliance audits and Medicare recoupments; OSHA, HIPAA and EPA standards; anti-trust issues; and managed care contract dilemmas or de-selection appeals.

Assessment

What a brave new world the legal profession has become! Even the American Bar Association’s commission on multi-disciplinary practice has recommended that lawyers be permitted to share fees and become partners with financial planners, money managers and other similar professionals.

As a real life example, the venerated Baltimore brokerage firm of Legg Mason Inc. teamed-up a few years ago, with the Boston law firm of Bingham Danna, LLC, to create one of the first marriages between a law and securities firm.  

And so, if you want in on the challenge, and bucks, you’d better acquire at least a working knowledge of healthcare administration, or perhaps help craft some new case law, or assist your doctor-clients in some fashion; otherwise, you will remain a legal document producer.

Disclaimer: Dr. Marcinko, a court approved expert witness and former Certified Financial Planner™, is also founder of the Certified Medial Planner™ program for all fiduciary consultants in health economics, financial planning and medical practice management www.CertifiedMedicalPlanner.com

Conclusion

Your thoughts are appreciated; please opine? Is this new industry concept a viable one?

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Dental Managed Care Survey

Delta Dental Plans Association (DDPA)

By Darrell K. Pruitt; DDS

The common sense truth about managed-care dentistry was recently confirmed by Delta Dental data mining.

Preliminary Oral Care Report

Concerning what one can do to assure the best oral care for oneself or one’s family; allow me to share some significant news about research that has not yet been formally published.

On the morning of August 14 2008, less than two weeks ago, a representative for Delta Dental Plans Association (DDPA) revealed the results of an in-house study that confirms that remaining with the same dentist for the long term prevents fillings.

The 2008 National Dental benefits Conference

It was during the first day of the 2008 National Dental Benefits Conference in ADA Headquarters in Chicago that Maxwell H. Anderson DDS, the dental affairs advisor for DDPA, located in Oak Brook Illinois, announced that by data mining their proprietary dental claims over 11 years, Delta uncovered evidence-based information revealing that clients who change dentists regularly are likely to receive more fillings than those who stay in consistent “dental homes” where they are content.

Dr. Anderson told the audience of about a hundred dentists and dental industry representatives that “The greatest hazard to teeth is changing dentists.”

A Righteous Finding

I find it remarkable, as well as noble, that a managed care insurance company like Delta, based on preferred provider lists that are valid for only 12 months at a time, would voluntarily reveal findings that can only bring harm to their business model.

However, when one thinks about it, Delta’s results clearly make sense. If a patient or family of patients is comfortable with a dental team, they are more likely to keep their check-up appointments as well as take better care of their teeth at home. And, consequently, enjoy better health.

Perhaps Delta came to the righteous conclusion that to hide such landmark findings would be unethical?

Assessment

How do preferred-provider lists cause more fillings?

When dentists can rely on a dental care broker like Delta Dental for new patients, there is an inherent absence of accountability that occurs when guided by the invisible hand of competition in the marketplace, naturally. That is an undeniable fact. Managed care dentistry is dentistry by the lowest bidder with no quality control; also an undeniable fact.

Note: Dr. Pruitt, an attendee of the 2008 National Benefits Conference on August 14 and 15 in ADA Headquarters, is the sole proprietor of a fee-for-service dental practice in Fort Worth, Texas. He represents only himself for the benefit of dental patients. His name cannot be found on any preferred provider list. Report posted with permission.

Conclusion

Your thoughts and suggestions are appreciated. Are this dentist’s “facts” and quality assessment true; please opine and comment?

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Coming Healthcare Worker-Shortage

It’s All in the Demographics

[A New AAHC Report]

[By Staff Reporters]

Current domestic policies will not avert a US health work-force crisis, according to a new report released by the Association of Academic Health Centers [AAHCs]. Moreover, it recommends developing a national planning body to unite efforts to slow/end work-force shortages.

The Report

The association’s report, “Out of Order, Out of Time: The State of the Nation’s Health Workforce,” points to a long and growing list of challenges. These include projected shortages in primary care and nursing; as the baby-boomer wave of retiring physicians and increasing medical needs of the growing elderly population exacerbate.

Lifestyle Preferences

Also, as reported in the American Medical News, on August 25, other issues fueling shortages of health-care workers include lifestyle preferences (regular work hours and family), economic disparities, rising medical school debt loads, and a dwindling pool of medical school faculty, with fragmented health care work-force policymaking.

Assessment

If this all isn’t enough to discourage new entrants from joining the healthcare industry, the plummeting value of present-day small-to-medium sized private medical practices just might.

In fact, our Publisher-in-Chief, Dr. David Edward Marcinko was recently interviewed by the American Medical News on this very topic. And, the un-edited version of that interview will appear in an upcoming issue of the Medical Executive-Post, shortly after AMNews publication.

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Conclusion

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Of Hospital CXOs

Benchmarks versus Hunches

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

By Hope Rachel Hetico; RN, MHA, CMP™

Managing Editor

As administrators and physician-executives, we have often wondered about the managerial thought processes of some former hospital CXOs.

Our History in Georgia

For example, since arriving in Atlanta in the early 1980s, we have seen more than a dozen hospitals and five free-standing outpatient treatment centers shuttered due to fiscal insolvency.  Included among the closures were urban and suburban entities, as well as private and public organizations following both profit and not-for-profit business models. 

The recent public plight of Grady Memorial Hospital, our only Level III trauma center, is another good illustration. And, there seems to be no commonality among the casualties. 

CXO Hunches

We can only surmise that these healthcare organizations were run according to CXO “hunches” regarding cash flow analysis, revenue augmentation and cash conversion cycles, etc.

If true, this reinforces our belief that, although providing high-quality medical care remains the primary concern of all healthcare organizations, profitability does matter … and the maxim “no margin, no mission” still applies. 

CXO Benchmarks

Fortunately, we are better informed today as real [entity specific] business benchmarks – not best guesses – can be used to help us make wiser strategic and more profitable financial decisions for almost any healthcare organization.  

Assessment

Therefore, we are grateful for the opportunity to edit this blog’s companion print journal guide, Healthcare Organizations [Financial Management Strategies] www.HealthcareFinancials.com

It’s a behemoth at 1,200 pages – in 2 volumes – and produced in arm’s length fashion by iMBA, Inc www.MedicalBusinessAdvisors.com

We trust you, and your healthcare organization, will review, use and profit by it.

Print TOC: http://www.stpub.com/pdfs/toc_ho.pdf

PS: Don’t forget to review-read-rave and rant online at this communications forum:

www.HealthcareFinancials.wordpress.com

Conclusion

Let benchmarks, this blog, and Healthcare Organizations: [Financial Management Strategies] take precedence over your gut in guiding your decisions.

orders@STPub.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Practicing Medicine “Bare”

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Understanding Hold-Harmless Managed Care Contract Clauses

[By Dr. Charles F. Fenton, III; JD]

Most doctors would not think of “practicing medicine bare”; yet perhaps the definition of this term should be re-framed?

Historical Definition

In the past, the term “practicing-bare” meant that a medical provider did not have malpractice insurance.

However, some current managed care contracts require that providers not only have certain limits of malpractice insurance coverage, but also furnish the company with evidence of same. Therefore, some of these providers are under the impression that they are not “practicing-bare.”

Hold Harmless Clauses

Unfortunately, most medical providers have no protection from adverse results arising out of a “Hold-Harmless” clause in a managed care contract or provider-agreement. And, most malpractice insurance companies do not provide such coverage.

So, if your malpractice insurance company does not provide coverage for such events, it is incumbent upon you and your associations to lobby malpractice insurance carriers to provide this coverage.

An additional rider, at an additional premium for Hold-Harmless coverage, would help the doctor sleep better at night.

Contract Considerations

The first question doctors should ask is: Would I consider practicing without malpractice insurance?

If the answer to this question is “no”, then the next question that should be asked is: “Why am I assuming the risk under the Hold Harmless Clause?” 

If you cannot provide a lucent answer to this question (stating: “I have no choice,” is not a lucent answer!), then you should consider not signing the managed care contract.

Judgment Proof

Nonetheless, if a medical provider has signed a managed care contract, then they should understand that they are essentially practicing bare, and should take steps to reduce this exposure. In effect, the provider should attempt to become “judgment-proof.”

Such a step does present its own risks. Ultimately, the first step for every physician who signs a managed care contract, with hold harmless agreement, is to read the contract and then consult an attorney or other professional. Of late, plaintiff-attorneys are beginning to make inroads in suing managed care companies. The managed care attorneys foresaw such events and provided protection for the company in the contracts most providers have signed.

As your patients and other plaintiffs become successful in suing and recovering from managed care companies, those companies are going to seek indemnity from you; the provider. Unless you protect yourself, you are likely to become a collateral casualty to some degree or another.

The current practice of medicine presents may perils and risks to doctors and other providers. A doctor may not be able to insure against all these risks, and should take defensive steps to avoid future problems.

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Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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The NPI and One DDS’s Opinion

A Dentist Offers his View on the NPI Deadline Issue

pruitt

By Darrell Pruitt, DDS

I have a unique perspective of the National Provider Identifier [NPI] issue. 

As a dentist who has no contracts with any insurance company, I refuse to apply for an NPI number. Legally, I am not compelled to “volunteer” for the number, regardless of whether it is a mandate or not.  HHS does not license dentists. States do. Texas says that it is fine by them for me to practice here on the east side of Fort Worth.

Why Volunteer?

Why should I volunteer for the NPI mess?

The NPI does nothing to improve the quality of care I provide. It benefits only payers, and any time anyone fouls up at National Plan & Provider Enumeration System [NPPES], it can only mean one thing – payments will be delayed, earning insurers even more interest on money meant to pay for work already done and long gone out the door.

I should remind you that inflation is due to soar soon as well, making the reimbursement worth even less to the provider the longer it is delayed.

The IRS

And, there is more.

I assume you heard about the IRS sticking their fat fingers into the pie. That happened just recently, completely unexpectedly.

Now the IRS can delay claims as well if one has an NPI number. What a mess. Why would I want to be part of it? If having an NPI forces me to raise my fees, it hurts my patients.

Part of the Hippocratic Oath is to do no harm. It is clearly unethical for a doctor to have an NPI number. Allow me to show you how far ethics will take a Texas dentist these days.

My Situation

Since I am not on any managed care plans, my BCBSTX-covered dental patients who I have treated for years did not pick me off of BCBSTX’s annual preferred provider list. They chose my practice as a consistent dental home, year after year, because they were more than likely referred by a satisfied patient.

When the BCBSTX agents sold my patients’ employers their dental plans, the insured was told to tell employees that they could see any dentist they choose. This is called a traditional indemnity plan, which honors freedom of choice as opposed to the cheaper managed care plans that penalize clients for not going to dentists that the insurance company prefers.

The Managed Care Misnomer

Calling managed care in dentistry “insurance” is a misnomer. It is actually nothing more than a discount dental brokerage service with annual lists of the lowest bidders in the market, and there is no quality control.

Until recently, I have had an unwritten agreement with BCBSTX that I would honor their insurance by allowing their clients to pay only their estimated part of the dental bills, and I would wait for BCBSTX’s share to come later in the mail – however long that takes.

That is called “accepting assignment,” and it is based on trust between dentists and BCBSTX, and is a favor to patients, not a requirement.

I have to say that BCBSTX is so slow at paying their part of their clients’ bills that patients would soon become very impatient if they had to wait as long for their money as I have to wait for mine. My practice, as well as my patience, can tolerate delays … up to a point.

In the end, if a claim is unreasonably delayed by an insurer, I can ultimately call on the state insurance commission to fight for fairness for my patient. Who can I complain to if payment is delayed by the IRS?

Assessment

In the last week, BCBSTX rejected three of my claims because I don’t have an NPI.  What am I to do?  

Ultimately, I may have to go against my own ethics and apply for an NPI number in order to stay in business.

The NPI does nothing to improve the quality of care I provide to my patients. It only delays payment.

Conclusion

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Physician Owned Hospitals

New Patient Disclosure Rules

Staff Reporters

According to Bloomberg News, August 19, 2008, doctors with financial stakes in hospitals where they work must tell patients being referred to those facilities about the ownership link, under new rules from Medicare.

Patient Queries

Patients who ask about investors in a physician-owned hospital must be furnished with a list of all doctors, and their immediate family members, who own or have an investment interest and make referrals.

Assessment

Medicare is seeking to make it harder for doctors to boost their payments by referring patients to their own facilities; and it already bars self-referrals for 11 services. The agency said it would end reimbursement agreements with physician-owned hospitals that don’t follow the new disclosure requirements.

Conclusion

What do you think about this, “if they don’t ask – don’t tell” policy; your informed opinions and comments are appreciated. Is it too much disclosure, or not enough?


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ICD-10 Code Set Disagreements

MGMA Targets Implementation Date

Staff Reporters

The Medical Group Management Association [MGMA], who previously has published commentary and material from our Executive-Post Editor-in-Chief, Dr. David Edward Marcinko, believes that the Centers for Medicare & Medicaid Services’ [CMS] proposed Oct. 1, 2011 compliance date for full implementation of the International Classification of Diseases, Tenth Revision (ICD-10) code sets is not workable.

Numerous Challenges

According to an August 19th edict, the MGMA said the government must overcome numerous challenges before the health care industry can fully implement ICD-10. The proposed rule for the next generation of the Health Insurance Portability and Accountability Act (HIPAA) electronic transactions (ANSI X12 version 5010), released with the ICD-10 proposed rule, must be put in place prior to ICD-10 and MGMA believes this will take several years for full implementation and testing.

Assessment

Because ICD-10 contains 10 times the number of codes as ICD-9, the newer code set will require vast changes for medical groups, hospitals and other health care facilities. MGMA surveys found that 95 percent of medical practices would have to purchase software upgrades for their practice management systems or buy all new software, while 64 percent concluded that they would have to purchase code-selection software, and 84 percent stated that they did not think public and private health plans would be ready to accept claims with ICD-10 codes by October 2011.

Conclusion

Your thoughts are appreciated. Will you be ready for ICD-10; please opine and comment.


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Stark Amendments [I-II-III]

A Review for Physicians, Consultants and Advisors

By Dr. David Edward Marcinko; MBA, CMP™

By Dr. Charles F. Fenton, III; FACFAS, Esq.biz-book2

The Stark Amendment to the Omnibus Budget Reconciliation Act of 1989 was a step by the federal government to prohibit physicians from referring patients to entities in which they have a financial interest.  Originally, the Stark amendment applied only to referral of Medicare patients to clinical laboratories in which the physician had a financial interest.

 

 

Stark I Provisions

The Stark Amendment provides that if a physician (including a family member) has a financial interest in a clinical laboratory, then he may not make a referral for clinical laboratory services if payment may be made under Medicare. A financial interest is an ownership interest, an investment interest, or a compensation arrangement.

Exceptions

There are certain exceptions to the Stark Amendment. For example; if a physician personally provides the service or if a physician or employee of a medical group, provides the services.

Safe Harbor Regulations

Like the Safe Harbor Regulations [SHRs], the Stark Amendment permits physician investment in large entities and provides an exception for rural providers. Under the Stark Amendment, large entities are defined as publicly traded entities with assets greater than $100 million.

But, there are certain other exceptions that are similar to the safe-harbor regulations. They include items such as provision for rental of office space, employment and service arrangements with hospitals, and certain service arrangements. These arrangements must be at arms-length and at fair market value.

Stark II

Stark II was passed in 1993 to modify and expand the Stark amendment.  In particular, it acts to bring numerous other entities, besides clinical laboratories, within the prohibitions of the Stark amendment. 

Stark III

The Federal Register notes that “Stark III” regulations went into effect on March 26, 2008.

Link: http://mamedicallaw.com/blog/2008/06/15/what-do-i-need-to-know-about-the-stark-iii-rules/

Assessment

Self-referral and over utilization may become less of a problem as managed care makes further in roads in medical practice control and quasi-subrogation. Future legislation is likely to address the concerns of the financial incentives towards under utilization of ancillary medical services.

Update

Quote: Self-referrals

Docs and dollars: This one’s a twofer. The first is a hotly-discussed NEJM paper showing that urologists (not radiation oncologists, as we’ve covered earlier) owning a stake in radiation therapy equipment tend to recommend that equipment more often than docs without an ownership stake. The second is a less-publicized government report showing that surgeons with a stake in device distributors also recommend those devices more than other surgeons. This shouldn’t surprise anyone — doctors are human, after all. The Stark laws designed to prevent physician self-referral, for some reason, make an exception for the IMRT conflict-of-interest in the first paper. And I don’t think any legislation foresaw the physician-owned-distributorships in the second article.

-Austin Frakt PhD

Conclusion

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Stark III Legislation

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Self-Referral Rules Unveiled

[Staff Reporters]

cms

The Centers for Medicare and Medicaid Services [CMS] recently reported changes to the Stark self-referral ban that could have a significant effect on physician-hospital relationships and Physician-Hospital-Organizations [PHOs]. 

Final IPPS Regulations

The new changes appeared in the final Inpatient Prospective Payment System [IPPS] regulation unveiled on July 31, and due for publication in the August 19th 2008 Federal Register [FR].

“Standing-in-the-Shoes” and other Issues

The healthcare industry will soon have to navigate new Stark rules on issues like percentage-based compensation, per-click arrangements and other “stand-in-the-shoes” legal analysis. And, it’s time to sunset “under-arrangements” with physicians because CMS finalized its revised definition of entities that provide Designated Health Services (DHS) under Stark.

But, CMS also cleared a path for returning to Stark compliance over unsigned physician contracts, and clarified how providers can end the “period of disallowance,” when a Stark violation renders Medicare claims un-payable.

Assessment

According to the Report on Medicare Compliance [8/11/08], the Stark self-referral law bans Medicare payments to entities providing DHS if patients were referred by physicians with an ownership, investment or compensation relationship with the DHS entity.

Conclusion

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Asset Allocation Portfolio Decisions

A Historical Perspective for Physicians

[By Jeffery S. Coons; PhD, CFP®]

Managing Principal-Manning & Napier Advisors, Inc

Dr. Jeff Coons

To a large extent, your investment objectives are driven by your investment time horizon and the needs for cash that may arise from now until then. Once these objectives have been set, you must decide how to allocate assets in pursuit of your goals.

Establishing the appropriate asset allocation for a physician’s [any investor] portfolio is widely considered the most important factor in determining whether or not you meet your investment objectives. In fact, academic studies have determined that more than 90% of a portfolio’s return can be attributed to the asset allocation decision.

The following will provide a historical perspective on the risks which need to be balanced when making the asset allocation decision, and the resulting implications regarding the way this important decision is made by investors today.

Growth versus Capital Preservation Balance

The asset allocation decision (i.e., identifying an appropriate mix between different types of investments, such as stocks, bonds and cash) is the primary tool available to manage risk for your portfolio.  The goal of any asset allocation should be to provide a level of diversification for the portfolio, while also balancing the goals of growth and preservation of capital required to meet your objectives.

Allocation Decisions

How do investment professionals make asset allocation decisions? 

One way is a passive approach, in which a set mix of stocks, bonds and cash is maintained based on a historical risk/return tradeoff.  The alternative is an active approach, in which the expected tradeoff between risk and return for the asset classes is based upon the current market and economic environment.

Can any single mix of stocks, bonds and cash achieve your needs in every market environment that may arise over your investment time frame? If such a mix exists, then it is reasonable for you to maintain that particular passive asset allocation. 

On the other hand, if no single mix exists that will certainly meet your objectives over your time frame then some judgment must be made regarding the best mix for you on a forward-looking basis. This case implies that some form of active decision making is required when determining your portfolio’s asset allocation.  To answer this question, let’s consider the historical tradeoff between the pursuit of growth and the need to preserve capital over various investment time frames.

The Need for Growth

Our first conclusion is that you have to be willing to commit a majority of your assets to stocks to pursue capital growth, but even an equity-oriented portfolio is not guaranteed to meet your growth goals over a long-term time period. 

To provide some historical perspective using Ibbotson data, a mix of 50% stocks and 50% bonds provided an 8.9% annualized return from 1926-1998, but failed to surpass what many consider to be a modest return of 8.0% in approximately 49% of the rolling ten and twenty year periods over this time.  In fact, a portfolio of 100% stocks provided an 11.2% annualized return, but failed to surpass 8.0% in almost 1 of every 3 ten-year periods and more than 1 of every 4 twenty-year periods.

This data also reflects the difficulty through history of consistently achieving an 8.0% rate even with an aggressive mix of stocks and bonds.  In this time of high flying stock markets, it is important to keep in mind that taking more risk is no guarantee of higher returns.  However, what is clear from this data is the importance of allowing a manager the flexibility to achieve meaningful exposure to stocks in attractive market environments to pursue the goal of long-term capital growth.

The Need for Capital Preservation

Of course, there is a clear risk of long-term declines in an equity-oriented investment approach, especially for a portfolio dealing with interim cash needs (e.g., a defined benefit plan with ongoing benefit payments, a defined contribution plan with participants having different dates until retirement, or an endowment with ongoing withdrawal needs).

An illustration of the sustained losses that may result from heavy allocations to stocks is the fact that 1 of every 4 one year periods and 1 of every 10 five-year periods resulted in a loss for a portfolio of 100% stocks.  Even the 50% stock and 50% bond portfolio has seen losses in almost 1 of every 5 one-year periods and more than 1 of every 25 five-year periods over the past 73 years of available data.  Thus, it is clear that no single mix of investments is likely to meet all of the needs for a portfolio in every market environment.

The Need for Active Management of Risk

The analysis to this point has discussed the need to balance long-term growth and preservation of capital, and it has summarized the tradeoff between these conflicting goals. There remains, however, an important issue regarding the appropriate stock exposure for you in the current  environment.  Even though returns over the long-term may have been strong for an all-stock portfolio, your returns will be very much dependent on the market conditions at the start of the investment period.

To set up this discussion, consider the risk of failing to achieve a target return of 5%, 8% or 10% in the S&P 500 over the last 44 years.

 

           FAILURE RATES OF TARGET RETURNS

               IN STOCKS [1955-1998]

 

 

 

 

1 Year

 

3 Years

 

5 Years

 

10 Years

 

% Periods with Less Than a 5% Return:

 

 

32%

 

 

15%

 

 

17%

 

 

13%

 

% Periods with Less Than an 8% Return

 

 

38%

 

 

29%

 

 

27%

 

 

32%

 

% Periods with Less Than a 10% Return

 

 

41%

 

 

41%

 

 

41%

 

 

44%

 

Taking the risk of failing to achieve your return goals one step further, does this risk increase with an expensive stock market?  Looking at several different stock valuation measures, the U.S. stock market is currently at historically extreme levels.  As an example, the S&P Industrials price-to-sales ratio was 2.0 at the end of 1998.  High valuation measures are often associated with periods of high volatility in stocks, and a price-to-sales ratio greater than 1.0 (i.e., ½ of current level) has historically been considered high.

 

FAILURE OF STOCKS TO MEET GOALS WHEN S&P INDUSTRIALS PRICE-TO-SALES RATIO IS GREATER THAN 1.0 [1955-1998]

 

 

 

 

1 Year

 

3 Years

 

5 Years

 

10 Years

 

% Periods with Less Than a 5% Return:

 

 

42%

 

 

26%

 

 

24%

 

 

45%

 

% Periods with Less Than an 8% Return

 

 

47%

 

 

55%

 

 

55%

 

 

79%

 

% Periods with Less Than a 10% Return

 

 

49%

 

 

71%

 

 

71%

 

 

97%

 

The data in the table above indicates that high market valuations significantly increase the risk of failing to achieve even moderate return goals.  In all, there were 50 quarters from 1955 to 1998 in which the S&P Industrials price-to-sales ratio was over the 1.0.  During these periods, strong returns were possible, but less likely to be sustained than when there are less optimistic valuations in the market. 

While this does not mean that a major correction or bear market will necessarily occur, the risk of failing to meet your goals is clearly higher than average based upon this data.  Because the market is a discounting mechanism, the positive economic environment we see today may become over discounted, resulting in moderate returns until fundamentals catch up with the optimism.

Assessment

Clearly, history tells us that no single mix of assets may provide both long-term capital growth and stability of market values in all market and economic conditions.

Far too often, physician investors and investment professionals take a passive approach to asset allocation, relying on past average returns and correlations to determine asset allocation without a full understanding of the long periods of time in history over which there are significant deviations from long-term averages.

Conclusion

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IT Start-Up QWAQ

Introducing QWAQ Forums

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

QWAQ Forums, yes that name is spelled correctly, is a new start-up company in Palo Alto, California. Founded in 2006 by CEO Gregory Nuyens and CTO David Smith, it just raised $7 million in venture capital funding. Early customers include industry giants Intel and BP.

What It Is?

QWAQ is a [Software-as-a-Service [SaaS] provider that combines enterprise-wide collaboration with a three-dimensional interface environment, akin to Second Life, etc. It provides virtual workspaces for program management, virtual offices and virtual operations centers. Most interestingly, its users create virtual avatars, and meet with co-workers in a 3-D environment to share and edit documents and use other business applications.

For example, QWAQ users upload, share and edits documents like MSFT® WORD files, MSFT-PowerPoint® slides, Open Office® and MSFT-Office® documents. Users can launch FireFox® in a forum to browse the web. There are also VOIP and text chat capabilities 

The Healthcare Connection

QWAQ, it seems, is already popular with some doctors like radiologists in different locations who use medical imaging applications inside its forums. And, applications can be co-located and employed behind hospital or health enterprise firewalls, for added security protection.

Assessment

This new-wave application currently lacks granular permissions as all documents can be copied by anyone in the Forums; which are self-invited and self-hosted. Yet, it does seem to possess, next-generational “fly.”

Link: www.QWAQ.com

Conclusion

Current cloud computing competitors include Central Desktop, Basecamp and PBwiki; while MSFT-SharePoint dominates the collaboration space.

But, since no one else offers the 3-D experience of QWAQ, your opinions and comments are appreciated; especially from radiologists and all those HIT experts “out there.”  

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Defined Benefit Plans for Physicians

Making a Comeback in 2008?

[By Staff Reporters]fp-book1

During the past decade, defined benefit plans have fallen out of favor due to excessive red tape, high administration costs, and IRS scrutiny. However, some experts claim that this trend may be about to reverse.

Suited for Older Doctors

For an older physician-executive who has little in retirement savings, a few young employees (or no employees), but adequate income to start setting a great deal of it aside, the defined benefit plan makes a great deal of sense in that contributions are not limited as they are in defined contribution plans.

Considerations

However, there are other good reasons to reconsider a defined benefit plan.

For instance, a doctor-employer can take into consideration prior years of service and adjust the benefit formula to meet his or her needs. In certain cases, this could result in putting away everything a person makes each year.

The only snag is the interplay between the defined benefit and defined contribution limits that is mandated by Section 415(e) of the Internal Revenue Code. Defined contribution plans have annual contribution limits, while defined benefit plans have annual benefit limits. Under the pension changes signed into law in August 1996 as part of the minimum wage bill, Section 415(e) was eliminated on Jan. 1, 2000, removing this obstacle to the creation of new plans.

Limitations on Qualified Plans

Section 415 limits the amount of benefits that can be provided under qualified pension plans. These limits are indexed for inflation.

For 2007, a defined benefit plan cannot provide for the payment of benefits which exceed the lesser of $180,000 or 100% of the participant’s average compensation for the highest three consecutive years of service, i.e., the three consecutive years during which the participant had the greatest aggregate compensation. The amount of annual additions (i.e., employer contributions, employee contributions and forfeitures) that can be made to a defined contribution plan for 2007 is limited to the lesser of $45,000 or 100% of a participant’s compensation for the limitation year.

Over-Funding Risks

Defined benefit plans still suffer from the risk of over-funding. Excess accumulations can be effectively confiscated up to 50% between penalties, federal, state, and possibly local income tax. The likelihood of over-funding was exacerbated by some pension changes included in the General Agreement on Tariffs and Trade (GATT) passed in December 1994. These changes required use of the 30-year Treasury bond interest rate in calculating funding requirements.

Previously, lump-sum payouts were calculated using the Pension Benefit Guaranty Corporation [PBGC] interest rate, which was lower and more predictable than the T-bond rate. A higher rate results in a lower lump sum withdrawal at retirement.

Assessment

One solution is to keep the pension plan in place when the doctor-business owner retires if interest rates have increased. The doctor should take the maximum annual benefit from the plan and wait for interest rates to drop so that he or she can withdraw the remainder of the balance in a lump sum.

Link: http://www.mondaq.com/article.asp?articleid=51226

Conclusion

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Next-Gen Health Accountants and Tax Advisors

Avoiding the “Managed Care Ripple Effect”

By Dr. David Edward Marcinko; MBA, CMP™

The healthcare industrial complex represents a large and diverse industry, and the livelihood of other synergistic professionals who advise doctors depend on it as well. These include CPAs, tax specialists and Enrolled Agents [EAs] who themselves wish to avoid the collateral ripple effects of the current healthcare debacle.

Unappreciated CPAs Working Diligently

The nation’s 330,000 or so CPAs know little about the new healthcare dynamics and managerial accounting mechanics. Many often feel as though they are laboring away in obscurity and that their doctor clients do not appreciate what they do or how hard they work.

If you are a CPA, your workweek is ridiculously long, especially January through April; and you often deliver bad news to your clients. You do not earn a generous salary, but you do receive their ire for your efforts.

The Epiphany

So, you begin to scratch your head and ponder, quietly at first, and then out loud. Perhaps managing the medical practice(s) of a physician, or providing consulting services to other medical professional is a business and financial planning opportunity that won’t require a new client base? You can keep your accounting practice during the first four months of the year, and supplement your income with something that may actually earn more than you are making now. 

A light then goes off in your head, epiphany!  Enter the CPA/PFS designation, exhorting doctor clients to “never underestimate the value”, through an additional 750 hours of financial planning experience and a six-hour comprehensive examination.

New Wave Terms and Definitions

However, new-wave terms such as capitated medicine; per member-per month fixed fees; payment withholds; activity based costing with CPT codes; utilization and acuity rates; and other investment, business and economic nomenclature is likely quite unfamiliar to you.

Furthermore, you may not have the temperament to be a fiduciary, responsible for the financial affairs of others. Then you realize that MBAs and actuaries may actually be the new denizens of the healthcare bean counting and practice management scene. Rather than present numerics of the historic past, they make logical and mathematical inferences about the future. Slowly, you realize that this has occurred because these professionals are proactive, not reactive, as the accounting profession is loosing its premier advisory position within the medical profession.

And, since some doctors are paid a fixed fee amount, regardless of the number of services performed, these futuristic projections are the most important accounting numbers in healthcare today.

Assessment

In fact, your research suggests that as a result, there are now several accountant managers and broker-dealers on the investment scene, as well as an increasing number of accounting-financial planning firms, such as Miller Ray & Houser Business Advisors and CPAs, in Atlanta, who set up a separate investment advisory firm to which they refer clients. 

Moreover, the AICPA is providing encouragement to CPAs who wish to provide more professional client services by building a financial planning practice for the new millennium.

Disclaimer: Dr. Marcinko, a member of the Microsoft accounting network, is Founder of the Certified Medial Planner™ program for all fiduciary advisors in health economics, finance and medical practice management www.CertifiedMedicalPlanner.com

Conclusion

Your thoughts are appreciated; please opine?

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Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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A Fresh Look at Annuities

An Often Maligned Insurance-Investment Vehicle

[By Staff Reporters] 

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Most doctors are familiar with fixed annuities (particularly during periods of high interest rates like two decades ago), which come in two basic varieties—the traditional single or multiple-year initial rate guarantee product or the market value adjusted (MVA) interest rate product.

Once the guaranteed rate ends however, the physician-investor is at the mercy of the insurance company’s renewal rate.

MVAs have offered higher interest rates but function much like bonds if surrendered before the end of the guarantee period. If interest rates have declined, the cash surrender value increases and vice versa. This can be mitigated by “laddering” as one would do with bonds.

Literature Review

In his article “Annuities on the Horizon” (Financial Strategies, Fall 1996, pp. 44–46, Investors Financial Group Inc.), author Clifford Jack acquainted financial advisors and others with a recoup of vintage annuities.

For instance, while variable annuities were historically limited to the most basic of investment portfolios, many now offer portfolios that include international equity, mid-cap equity, high yield bonds, REITS, ETFs, and global bonds with many different fund management companies. Others include multiple guaranteed accounts offering competitive interest rates, which provide the flexibility to make a tax-free transfer into these types of accounts or to dollar cost average into the equity accounts.

Indexed Annuities

The equity indexed annuity product allows participation in the upside of the S&P 500 Index by crediting an interest rate that is tied directly to the performance of the index. Most guarantee a percentage participation rate that varies depending on the current interest rate environment. If the contract is held until the end of the guarantee period, investors can be assured of a return of original premium, plus a minimum guaranteed interest rate of 3%.

An equity indexed-annuity is likely to outperform fixed annuities when interest rates are low and variable annuities when the market is trending downward. They permit participation in stock market-like rates of return with downside protection. And, for retirement age physician investors, look at immediate versions of equity index annuity products, which link income payments to an index and thereby offer an inflation hedge.

Assessment

Faced with a rocky market and unknown interest rate scenarios, annuities may be a consideration to the portfolios of suitable physicians; if costs are appreciated, other qualified retirement plans fully funded and time-line long. Comments on this often contentious topic, are appreciated. Are these annuities an insurance product, investment product, or both; and why not use a “purer-play for same?”

***

critics

***

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners(TM)

Introducing and Explaining “Knol”

Another Not-So New Idea!

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

By Hope Rachel Hetico; RN, MHA, CMP™

[Managing Editor]

Just launched in December 2007, Knol is a new online competitor of Wikipedia. And, interestingly, it is becoming a haven for physicians.

According to its Website

A “knoll” is an authoritative article about a specific topic; or “unit of knowledge.”  Knol is limited by invitation to contributors and readers, to-date.

The Wikipedia Difference

In a key departure from Wikipedia’s all-comers sensibility, however, the new service will be edited as a “moderated collaboration”, where any reader can make suggested edits to a knoll, which the author may then choose to accept, reject or modify before becoming visible to the public.

Behemoth Backing

The site is backed by Google®, but the company may not even own its URL.

Our Opinion

As former and current traditional-media publishers, editors, and writers, we love the idea that authors and contributors remain in control of their content. It creates somewhat of a crowd-sourcing buzz to Knol.

And, much like a wiki, there are community tools which allow multiple nodes of interactions between readers and authors; i.e., read, rant, rave or write, etc.

But, the concept and execution is not new, radical or as innovative as its originator’s seem to suggest. And obviously, not so for the healthcare space where doctors, nurses, scientists and researchers, and all sorts of medical providers are used to more stringent peer-review standards.

An Earlier Healthcare Success Story

For example, the Comprehensive Health Dictionary Series was started by email collaboration in 2005.  Its genesis sprang from those who suggested that changes in health and managed care appeared malignant, as many industry segments, professionals and patients suffered because of it. This tumult was so great, that many Americans and the HDS founders realized that they could no longer assume definitional stability of non-clinical health administrative terms. The resulting managerial and business chaos was legion.

And so, since knowledge is power in times of great flux, codified information protects us all from physical, economic, financial and emotional harm!

Coupled with a Collaborative Lexicon Query Serviceand a modified and moderated interactive social network, we maintained continuous subject-matter expertise, professional and user input, with peer-reviewed editors and experts; just like the Knol of today.

In fact, after our internet and email collaboration, three successful printed dictionaries were ultimately released in 2006 and 2007 as a result of the initial successful initiative; and more are to come in 2008 and 2009.

Detailed information, including Tables of Contents, Celebrity Forewords, unique features, reviews and ordering access may be obtained from: www.HealthDictionarySeries.com

Assessment

Moderation is also important to keep posting vandals out of any serious knowledge aggregation effort. This moderated and collaborative Executive-Post blog, for example, is attacked at least a dozen times daily; most are usually repelled automatically, but human intervention is constantly required for its posts and comments.

You just can’t lie and get away with impunity; here.

Conclusion

We certainly congratulate the righteous “new” old-school founders of Knol on its recent launch. It may not replace wikipedia as your search engine of choice, but it is nice to have an alternative.

And, doctor-colleagues sure do seem to like it, although a better medical alternative might be MEDSCAPE, MEDDialog, WebMD, or the new Medpedia service [www.medpedia.com], as previously described on the Executive-Post:

Yet, a singular query remains, considering the educational networking phenomena that are electronic blogs, journals, wikis, online diaries, etc. “What took you so long – seriously?

Moreover, we believe the marketing driven advertising nature of the Knoll beast will make its integrity, highly suspect [vis-a-vie Google’s AdSense program].

In other words, if eyeballs can be reached and /or monetized … they can be slanted.

Link: https://healthcarefinancials.wordpress.com/2008/08/12/

Please opine on this method of edited knowledge aggregation; pro or con. Your comments are appreciated.

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker:If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Fractional Interests in Real-Estate

What is it Really Worth?

Staff Writers

If real-estate constitutes a large portion of your estate, as a mature physician, you should be familiar with how fractional interests are valued. This may be especially true during the current sub-prime mortgage debacle in this country.

It’s all About Control and Marketability

Fractional interests are generally subject to two general categories of valuation adjustments: [1] lack of control and [2] lack of marketability.

Lack of Control Discounts

Typically, appraisers first determine the value of the underlying real-estate asset as a single interest, applying one or a combination of approaches, including (1) the income approach, (2) the replacement cost approach, or (3) the comparable sales approach.

Determining Factors

In analyzing a fractional ownership interest, the appraiser needs to understand what investment risk and return factors change as the physician investor moves from fee-simple ownership to a fractional interest.

And, when the fractional interest is in the form of a partnership or other unincorporated business format, additional analysis will be necessary since these organizational forms are based upon contractual agreements among the investing parties, and upon state statutes that apply to each type.

It is usually somewhat difficult to obtain meaningful valuation data for fractional interests, and the total discounts realized are usually not separable into lack of control and lack of marketability factors. Numerous studies have been conducted by reputable valuation firms; with often ambiguous results.

Probably the most reliable data in determining lack of control discounts are those derived from the sale of minority blocks of stock of a real-estate corporation and those for publicly traded REITs.

Lack of Marketability Discounts

With respect to lack of marketability discounts, the best source appears to be sales of restricted stock, which show larger discounts for OTC stocks versus NYSE or ASE securities. These restricted stock studies cover a span from the late 1960s through today and traditionally indicated an average price discount of 35% until a few years ago. Today of course, this discount has increased with recent events.

Additional evidence comes from studies of IPOs by comparing the IPO stock price with the price at which the company’s stock traded in private transactions prior to the IPO. These studies indicate lack of marketability discounts of 40% to 50%, or more, in some cases today.

Assessment

Data from past studies provided appraisers, and physician-investors, with a solid arsenal of analytical weapons and data to draw from when a fractional ownership interest was to be appraised. Again, the situation has drastically changed in 2008, and into the near-future, at least.

Conclusion

Do you own any other fractional investments; like plans or boats? In today’s environment, how do you value fractional interests in real estate? Please comment and opine; the more experiential the better.

Related Information Sources:

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Who’s a Crummey Power Holder?

IRS Attacks Crummey Powers

Staff Reporters

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In the [in]famous 1991 case of Cristofani v. Commissioner, the Tax Court ruled that the IRS had improperly disallowed gift-tax exclusions to contingent beneficiary grandchildren while allowing exclusions for withdrawal rights given to the donor’s children. The IRS had reasoned that the withdrawal rights of the contingent beneficiary grandchildren did not constitute gifts of present interests in property.

Literature Review

An article by Lawrence Brody and Stephen B. Daiker, “IRS Questioning Legitimacy of Crummey Powerholders” [Journal of Financial Planning, October 1996, pp. 34–35, Institute of Certified Financial Planners (303) 759-4900], presented the IRS’s position with respect to limited withdrawal powers given to trust beneficiaries to qualify transfers to the trust(s) as annual exclusion gifts.

Technical Advice Memorandum

In a July 1996 Technical Advice Memorandum [TAM], the IRS ruled that none of the withdrawal powers granted in that case were gifts of present interests in property and, therefore, did not entitle the donor to gift-tax annual exclusions. These particular irrevocable trusts did not require that actual notice of the withdrawal rights be given to the beneficiaries, and the powerholders had no beneficial trust interest other than the Crummey power.

Also, notices were given to powerholders only days prior to expiration of the withdrawal period, and the trust bank account was not funded until after expiration of the withdrawal period. The IRS also believed that there was a “prearranged understanding” that the Crummey withdrawal right would not be exercised or that doing so would result in unfavorable consequences—including possible disinheritance.

The IRS position

The IRS position seemed to be that if the powerholder has no economic interest in the trust to provide an incentive to allow the withdrawal right to lapse, the annual exclusion will not, in its view, be available. This common-sense approach to Crummey powerholders unfortunately does not clarify whose rights can or cannot be counted.

Assessment

Most likely, there will be additional litigation or rulings in this area, but it appears that medical practitioners, and their advisors, should ascertain that trusts require actual notice to beneficiaries of limited withdrawal rights; that timely notices and trust funding be provided; and that there be no evidence of a “prearranged understanding” regarding withdrawals.

Conclusion

Your thoughts on Crummey powers are appreciated; please opine and comment. Has the situation changed drastically, if at all, since this ruling?

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker:If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com 

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Risky Non-Qualified Deferred Compensation Plans

Are They Worth the Risk to Physician Executives?

By Staff Reporters

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The use of nonqualified deferred compensation plans in corporate healthcare administration has grown substantially in the past 10 years; for several reasons.

Reasons for Popularity

For example, senior physician-executives are becoming subject to lower contribution and benefit limits in qualified plans, are involved in more mid-career change hires, are being subjected to greater emphasis on performance-based compensation, and may experience higher income tax rates in a potential democratic administration in 2009.

Any financial advisor who works with senior physician-executive clients participating in such plans must thoroughly understand how nonqualified plans work and how they can affect every aspect of an executive’s finances.

Advantages

The advantage of tax deferral offered by nonqualified plans may, however, be more than offset by the risks to which the funds in these plans are subjected. Physician-executives should carefully evaluate their exposure to a retirement income shortfall, which may result from having a major portion of one’s retirement nest egg tied to unsecured capital. Individual indemnity insurance may need to be purchased to protect against this risk.

Guidelines

Some useful guidelines for the physician-executive and his/her financial consultant follow:

  • Review nonqualified plan documents, especially when plan provisions require client action or change.
  • Summarize the provisions of previously signed deferral agreements and other nonqualified plan statements, especially amount, timing, and method of payouts.
  • Analyze financial security under various retirement scenarios.
  • Review current estate plan instruments to determine if trusts are funded with nonqualified plan assets.
  • Update the asset allocation model to reflect any constraints imposed by the nonqualified investments.
  • Plan for potential constructive receipt.
  • Modify projected annual cash flows to allow for additional Medicare tax payments.
  • Quantify future payments from all nonqualified plans and the effect on marginal tax rates.

Assessment

The risks involved in the tax deferral offered by nonqualified plans occur because a senior physician-executive may:

  • Bet his or her long-term security on the viability of a single company.
  • Become over-dependent on unsecured funds.
  • Incur extra estate taxes because of failure to properly plan for plan distributions.
  • Fail to diversify because of limited investment alternatives in the plan.
  • Become subject to the constructive receipt problem and possibly to FICA tax at an earlier than expected time.

Conclusion

Please comment and opine on the above relative to the current tax structure, as well as a potential future change by political fiat?

Related Information Sources:

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Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Fiduciary Burden of Participant-Directed Investment Plans

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An Emerging Issue for Physician-Executives

[By Jeffery S. Coons; PhD, CFP]

Managing Principal-Manning & Napier Advisors, Inc

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The goal of designing a participant-directed investment menu should be to provide enough diversification of roles to allow participants to make an appropriate trade-off between risk and return, without having so many roles as to create participant confusion. 

Medical Administrative Burden

Ultimately, the burden on plan administrators and physician executives is to adequately educate employees and is largely driven by the investment decisions we require them to make in the plan, with more choices necessitating a greater understanding of the fundamental differences between and appropriate role for each choice.  The logical questions that arise when selecting options on a menu are:

  • Are there clear differences among the options?
  • Are these differentiating characteristics inherent to the option or potentially fleeting?
  • Are the differences among options easily communicated to and understood by the typical plan participant?
  • Most importantly, if participants are given choice among these different options, can the decisions they make reasonably be expected to result in an appropriate long-term investment program?

Fiduciary Concerns and Liabilities

All this adds up to additional fiduciary concerns for the health care entity and plan sponsor. 

For example, can the typical participant understand growth and value as concepts when even the experts can not agree on their definitions? The use of style based menus for self-directed plans bring this issue to the forefront. What about investment strategy?  What choices are we expecting the participant to make when offering growth and value styles for one basic asset class role? 

Finally, beyond the responsibility to provide effective education, what other fiduciary issues are associated with style categorization for a participant-directed investment menu?

Effective Style Communications

Consider whether the differences among manager styles can be effectively communicated to the average participant.  Because the general style categories of “growth” and “value” are not well defined, we are expecting the participant to understand how the manager is making investments in a fundamental manner and the differences in risk/return characteristics of these alternative approaches.  This exercise is difficult for investment professionals and trustees, so it will be even more unlikely to be properly understood by an average participant.

Given Assumptions

Let’s assume for the moment that there is an effective means for understanding the different risk and return characteristics of two managers investing in what is ultimately the same basic asset class.  When allowing the choice of these two differing approaches, what decision can the participant make?  There are four possibilities:

  1. Select the single manager whose investment philosophy makes the most sense overall to the participant;
  2. Time the decision of when to move from one management philosophy to another;
  3. Split the allocation between the two managers; or,
  4. Give up from confusion and do not participate in the plan.

We have already discussed the difficulty of the first choice, so let’s consider the second possibility.  This decision is an extremely risky choice that typically leads to poor or even catastrophic performance. 

Why?  Timing decisions such as this are typically based upon recent past performance, which is cyclical in nature.  In essence, investors generally chase after yesterday’s returns and invest in funds after their period of strong relative performance.  The strong flows into S&P 500 Index funds and growth/momentum firms of today were preceded by flows into value/fundamentally-oriented investment firms a few years ago. 

In fact, a Journal of Investing academic article in the Summer of 1998 (“Mutual Fund Performance: A Question of Style”) found that mutual funds changing their investment style had the worst performance of any style individually.

Allocation Choices

The next choice is to split the allocation between growth and value.  While this approach may mean that the participant will not under-perform significantly when any one style is out-of-favor, it also means that the participant will generally never out-perform either.

Nevertheless, by combining two halves of the same basic universe within an asset class, it is likely that the basic performance of the asset class will result (i.e., index-like returns).  Since the participant is paying the higher expenses of active, value-added mutual funds, the end result is likely to be index-like returns less the significantly greater fees and consistent under-performance over the long-term.

Assessment

While there may be participants who can handle the investment process, the previous discussion illustrates why it remains an open question whether educational efforts and typical menu choices provided by plan fiduciaries will be adequate from a regulatory and legal standpoint.

However, while it is unreasonable for participants to select the single best manager, it is reasonable for trustees to choose managers by defining investment policy and objectives that focus on characteristics like broad asset classes. 

And; do you think that by creating an investment menu that removes soft, overlapping, and largely qualitative distinctions such as style; plan sponsors can take a significant step toward mitigating the potential for participant confusion that inevitably could lead to litigation?

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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New Academic Drug-Detailing Model

“Impartial Experts” May Launch Soon

Staff Reporters

According to the Wall Street Journal, July 31 2008, the federal government could start paying impartial experts to visit doctors to talk about the safety, effectiveness and cost of prescription drugs and other treatments.

Enter the New “Detailers”

These “academic detailers” would give presentations along the lines of those given by Big-Pharma drug representatives, while the federally funded presentations would provide a counterweight to the industry messages on specific drugs.

And, according to a confidential source, one can only wonder if these folks will be selected on the basis of, er, their “physical attributes” like those detailers “back-in-the-day”, among other professional considerations?

Assessment

Seriously, Senator Herb Kohl, a Wisconsin Democrat, held a hearing on the issue earlier this year and is one of the sponsors of a bill that authorizes the government to contract with nonprofit groups such as medical societies, schools of medicine and pharmacy, to create the educational materials.

It also directs officials to contract with 10 entities – drawn from academic institutions, state or local governments and non-profit groups – to train and deploy health care professionals to educate physicians and other drug prescribers.

Conclusion

Your thoughts and comments are appreciated; is this proposition a real value-added service, or yet another governmental boondoggle?

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Innocent-Spouse Tax Relief

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Getting the IRS Facts

[Staff Writers]

Married physicians and other couples generally choose to file a joint tax return because they get the best tax breaks from that filing status; despite elimination of the “marriage penalty” several years ago.  

However, joint filing has its downside. One spouse can be held fully liable for all the tax due—even if all of the income was attributable to the other spouse. What’s more a divorce does not limit a spouse’s liability—even if the decree requires the other spouse to pay the taxes.

IRS Reform Act

There is, however, a way out: The taxpayer can apply to the IRS for innocent spouse relief. What’s more, the IRS Reform Act, as previously discussed in the Executive-Post, liberalized the rules for obtaining relief.

Get the FAQs

Some time ago, the IRS released answers to frequently asked questions [FAQs] about the innocent spouse rules. The IRS release spells out policies and procedures that apply to innocent spouse requests.

Q. What kind of relief is available?

A. There are three kinds of relief: (1) innocent spouse relief; (2) separation of liability; and (3) equitable relief. Each category has different requirements and procedures.

Q. What are the rules for innocent spouse relief?

A. To qualify for innocent spouse relief, a taxpayer must meet all of the following conditions:

• The taxpayer filed a joint return with an understatement of tax.

• The understatement was due to erroneous items of the other spouse.

• At the time the return was signed, the taxpayer did not know and had no reason to know of the understatement of tax.

• Taking into account all of the facts and circumstances, it would be unfair to hold the taxpayer liable for the understatement.

Q. What are the rules for separation of liability?

A. Under this type of relief, the joint return understatement is divided between the spouses, according to their earnings and assets. To qualify for separate liability, the taxpayer must meet either of the following requirements at the time of the request:

1. The taxpayer is no longer married to, or is legally separated from, the spouse with whom the joint return is filed. For this purpose, a taxpayer is no longer married if he or she is widowed.

2. The taxpayer was not a member of the same household as the spouse at any time during the 12-month period ending on the date of the request. However, a request for separation of liability may be denied if the taxpayer or spouse transferred assets to avoid paying tax or the taxpayer had knowledge of any of the incorrect items when the joint return was filed.

Q. Will the IRS grant a request for separation of liability if a husband and wife are still married, but have been separated for at least 12 months for an involuntary reason such as incarceration or military duty?

A. Separation of liability applies to all taxpayers who have been living apart for 12 months or more preceding the filing of a claim.

Q. What are the rules for equitable relief?

A. Equitable relief is available only if a taxpayer does not qualify for innocent spouse relief or separation of liability. The IRS must determine that it would be unfair to hold the taxpayer liable, taking into account all the facts and circumstances. Unlike innocent spouse relief or separation of liability, equitable relief may apply to an underpayment of tax properly shown on a return.

Q. What factors will the IRS consider in deciding whether to grant equitable relief?

A. The following factors will be considered:

• Current marital status

• Abuse experienced during the marriage

• The taxpayer’s reasonable belief, at the time the return was signed, that the tax was going to be paid

• Current financial hardship

• Underpayment or understatement attributable to the nonrequesting spouse

• Lack of significant benefit received by the requesting spouse.

Bear in mind, however, that this list is not all-inclusive.

Q. What if one spouse forged the other’s name on a joint return? Does the nonsigning spouse qualify for relief?

A. Relief is available, but not under the innocent spouse rules. If a spouse can prove that his or her signature was forged, and there was no tacit consent to the signing, the return is invalid for that spouse.

Q. If a spouse signs an examination report that lists omissions of income, does that mean he or she had knowledge of the items giving rise to the deficiency?

A. No. The innocent spouse rules make it clear that knowledge has to do with what was known at the time the return was signed.

Q. How do state community property laws affect a taxpayer’s ability to qualify for relief?

A. Community property laws are not taken into account by the IRS for purposes of any request for relief from liability.

Q. Do the new relief rules apply to any outstanding tax liability?

A. The rules apply to (1) unpaid balances as of July 22, 1998, and (2) liabilities arising after July 22, 1998, and as amended.

Q. How does a taxpayer request relief?

A. The taxpayer should file Form 8857, Request for Innocent Spouse Relief, along with a statement providing additional information for the IRS to consider. One form can cover multiple years. The IRS will automatically consider all three types of relief when processing a request.

Assessment

It is not know how many medical professionals are familiar with the above; but it is likely very few. That’s why the sage advice of a CPA or tax attorney is always helpful.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Hospitals: http://www.crcpress.com/product/isbn/9781439879900

Physician Advisors: www.CertifiedMedicalPlanner.org

Product Details  Product Details

Introducing Medpedia

A Not-So New Idea!

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

By Hope Rachel Hetico; RN, MHA, CMP™

[Managing Editor]

Medpedia, an online medical encyclopedia launching later this year, aims to have the open-source, evolving, and comprehensive nature of Wikipedia.

According to its Website

The Medpedia Project is an extraordinary global effort to collect, organize and make understandable, the world’s best information about health, medicine and the body and make it freely available on the website www.Medpedia.com

Physicians, health organizations, medical schools, hospitals, health professionals, and dedicated individuals are coming together to build the most comprehensive medical resource in the world that will benefit millions of people every year.”

The Wikipedia Difference

In a key departure from Wikipedia’s all-comers sensibility, however, the new encyclopedia will be edited only by those with advanced degrees in medicine and biomedical science, and the site is taking online applications from would-be volunteer editors – MDs, biomedical research PhDs, and clinicians who will be screened in a rigorous internal review process, according to a July 23rd press release.

Incubator Backing

The site is backed by an incubator, called Ooga Labs, and it will run text ads, while Harvard Medical School is giving the site some seed content.

Medpedia’s advisers include current and former deans from the medical schools at Harvard, Stanford and Michigan and the school of public health at UC Berkeley, while the site will pull in public domain content from the likes of the Center for Disease Control and Prevention [CDC], the National Institute of Health [NIH] and the Food and Drug Administration [FDA].

Other health and medical organizations that are supporting Medpedia include the American College of Physicians [ACP], the [Oxford Health Alliance (OxHA.org)], the Federation of Clinical Immunology Societies, [FOCIS], and the European Federation of Neurological Associations [EFNA]. These groups are contributing content and promoting participation in Medpedia to their members.

Assessment

A wiki is an electronic collection of web pages designed to enable anyone who accesses it to contribute or modify content, using a simplified internet markup language. It is named after the Hawaiian term for “quick.”

But, the concept and execution in late 2008 of www.Medpedia.com is not new or exactly as innovative as its originator’s seem to suggest; in the healthcare or any other space.

An Earlier Healthcare Success Story

For example, the Comprehensive Health Dictionary Series was started by email collaboration in 2005.  Its genesis sprang from those who suggested that changes in health and managed care appeared malignant, as many industry segments, professionals and patients suffered because of it. This tumult was so great, that many Americans and the HDS founders realized that they could no longer assume definitional stability of non-clinical health administrative terms. The resulting managerial and business chaos was legion.

And so, since knowledge is power in times of great flux, codified information protects us all from physical, economic, financial and emotional harm!

By its very nature, the Comprehensive Health Dictionary Series was ripe for electronic aggregation and modified wiki-styled creation; with periodic updates by engaged-readers working in the fluctuating health care industrial complex. Internet connectivity was the best way for the Health Dictionary Series to be edited and revised to reflect the changing lexicon of terms, as older words were retired, and newer ones continually created. 

Moreover, we did not simply listen to our colleagues, visitors, submitters and clients; we believed that true innovation means putting development tools in their hands, stepping back, and allowing them to lead the way!  And, it was so.

Coupled with our Collaborative Lexicon Query Service and a modified and moderated interactive social network, we maintained continuous subject-matter expertise, professional and user input, with peer-reviewed editors and experts; just like the Medpedia’s of today.

In fact, after our internet and email collaboration, three successful printed dictionaries were ultimately released in 2006 and 2007 as a result of the initial successful initiative; and more are to come:

The Dictionary of Health Insurance and Managed Care

http://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_5?ie=UTF8&s=books&qid=1217414309&sr=1-5

The Dictionary of Health Economics and Finance

http://www.amazon.com/Dictionary-Health-Economics-Finance-Marcinko/dp/0826102549/ref=sr_1_3?ie=UTF8&s=books&qid=1217414309&sr=1-3

The Dictionary of Health Information Technology and Security

http://www.amazon.com/Dictionary-Health-Information-Technology-Security/dp/0826149952/ref=sr_1_2?ie=UTF8&s=books&qid=1217414309&sr=1-2

Detailed information, including Tables of Contents, Celebrity Forewords, unique features, reviews and ordering access may be obtained from: www.HealthDictionarySeries.com

Conclusion

And so, we certainly congratulate the righteous old-school founders of Medpedia on its upcoming launch. Yet, a singular query remains, considering the social networking cultural phenomena that are Facebook, MySpace, Twitter etc. “What took you so long – seriously?”

Moreover, we believe the marketing driven advertising nature of the beast will make its integrity, highly suspect [vis-a-vie big pharma].

In other words, if eyeballs can be reached and/or monetized … they can be slanted.

Please opine on this method of edited medical; knowledge aggregation; pro or con. Your comments are appreciated.

Related Information Sources:

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Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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New-Wave Medically Focused Financial Advisors

Avoiding the “Managed Care Ripple Effect”

By Dr. David Edward Marcinko; MBA, CMP™

The healthcare industrial complex represents a large and diverse industry, and the livelihood of other synergistic professionals who advise doctors depend on it as well. These include financial planners and investment advisors who themselves wish to avoid the collateral ripple effects of the current health and managed care debacle.

Future Growth Potential in Financial Services

As a CFP, CFA, financial planner, CPA, investment advisor or general securities representative, you realize that the financial service sector is going to become the next great growth opportunity of the 21st Century.

Even H & R Block and the Charles Schwab Corporation are trying to build medical professional interest in their respective firms and compete with your independent practice. They are fervently wooing away one group or another to interface with their embryonic management, accounting or advisory programs.

For example, it has been estimated that more than one-third of the nations 60,000 accounting firms are contemplating the introduction of investment and medical management services to their business line. 

Another 100,000 solo CPAs are interested in personal financial planning for their physician and lay professional clients; a survey several years ago of senior CPA partners conducted by Prince & Associates of Shelton, Conn., revealed that more than 60 percent were “highly interested” in offering investment management services, and three quarters of those said they were evaluating the best approach for their firms.

The Migration to Advisory Services

Meanwhile, more than 260,000 of the nation’s brokers are moving into the investment advisory and financial planning business because securities sales and transactions are being commoditized by the internet’s World Wide Web.

In another survey several years ago, conducted for the old International Association for Financial Planning [the older IAFP is now the Financial Planning Association, or FPA], clearly demonstrated the dominance of registered investment advisors [RIAs], over stockbrokers [regardless of nomenclature derivatives], among clients 35-49 years old.

With the average Merrill Lynch private client well over 60, and the firm and industry imploding in 2008, it’s easy to spot the future vulnerability of this business model.

Valued Industry Players

When asked to determine the added value of key industry players, baby boomers in a more recent Dalbar study ranked financial planners first, followed by stockbrokers, CPAs, mutual fund companies, insurance agents, and commercial bankers, respectively.

Even if you are a CFP® or investment adviser, and despite the proliferation of investment advisors, evidence suggests that your individual impact is still narrow.

Furthermore, a Prince & Associates study of 778 affluent individuals, each with more than 5 million dollars to invest, examined the relationship between clients and their providers of five key financial services; retirement planning, estate planning, investment management, executive benefits and health-disability insurance.  Prince found that 59 percent of the clients had been serviced in only one area by a particular advisor.

Despite the significant assets of each client, the advisers have been unsuccessful at broadening these relationships — a key indicator that many affluent clients do not have a primary financial adviser.

Medical Niche Players

Among the challenges you face to broaden your influence is to offer your clients value-added services, perhaps by establishing your expertise in the medical niche and capitalize on being different; as in the Certified Medical Planner™ online health economics program of iMBA, Inc.

You must not be just another of the more than 250,000 or so individuals who claim to be financial planners, with a collective universe of an additional 700,000 or so who purport to be financial advisors, in some fashion or another. You must begin to develop the strategic competitive advantage of practice management knowledge to synergize with your existing financial service and product line.

Integration of Disciplines is Key for the Healthcare Space

Integrated practice management and financial planning will also become much more competitive among physicians because of the above professional fusions.

No one is suggesting therefore that you abandon your core financial advisory business for business management. It is merely a fact that medicine has drastically changed during the past decade, and the knowledge that you used yesterday will no longer be enough for you to get by on in the future.

Assessment

Medical practice management is the natural outgrowth of traditional financial planning services, and investment advice, in turn, is central to the implementation of a contemporary medical office business plan. The most successful physician-focused financial planners therefore, will be those who incorporate medical management services into their practices.

Disclaimer: Dr. Marcinko, a former stock broker, Certified Financial Planner and investment advisor is Founder of the Certified Medial Planner™ program for all fiduciary consultants in health economics, finance and medical practice management www.CertifiedMedicalPlanner.com

Conclusion

Your thoughts are appreciated; please opine?

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Domestic Healthcare Access Survey

Join Our Mailing List

Still an Elusive System for Many

[By Staff Reporters]

Access to health care in the United States continues to elude more and more Americans, and the nation’s health care system hasn’t improved overall, even though the U.S. spends more on medical care than any other industrialized nation, a new Commonwealth Fund survey shows.

The Study

The authors compared average performance in the United States to those of top-rated performers across the country and abroad. Overall, the U.S. score averages just 65 out of a possible 100, falling far short of benchmarks with wide gaps in all dimensions of the health system, while the score was lower than that achieved in the Commonwealth Fund’s 2006 scorecard, according to  HealthDay, on July 17, 2008.

Efficiency Scores Low

For example, scores for efficiency were particularly low, held down by fragmented, poorly coordinated care; lack of access that leads to avoidable hospitalizations; variations in costs with no return in quality; lack of investment in information technology; and very high insurance overhead costs.

USA is Dead-Last

Although no pun is intended, the United States is now “dead-last” among 19 industrialized nations in premature deaths that might have been prevented by better access to health care. In 2006, the United States was 15th on the list.

The scorecard also found that health care varies widely from state to state, region to region, and from one hospital and health plan to another, while the difference between the best and worst performers can be as much as fivefold.

On the positive side, mortality rates in hospitals improved 19 percent over the past five years, the result of concentrated public-private efforts to improve hospital safety.

Adult-Resources

Related Findings also Disappoint

Related other findings of the scorecard included:

  • Basic preventive care hasn’t improved, with only 50 percent of all adults receiving recommended preventive care, such as cancer screenings.
  • Health insurance premiums continue to rise faster than wages. In 2007, 41 percent of adults said they had medical debt or trouble paying medical bills, up from 34 percent in 2005.
  • The number of primary care doctors using electronic medical records rose from 17 percent in 2001 to 28 percent in 2006, but this gain still lags some other countries where 98 percent of doctors use electronic records.

Assessment

Disparities in health care continue to be pervasive, with minority, low-income and uninsured adults more likely to wait to see a doctor and encounter delays and poorly coordinated care. Also, they have worse dental care, more uncontrolled chronic disease, more avoidable hospitalizations, and worse outcomes.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

Product Details  Product Details

Implications of Portfolio Withdrawals for Physician Investors

Obtaining Income in a Low Interest-Rate Economic Ecosystem

By Jeffery S. Coons; PhD, CFP®

Managing Principal-Manning & Napier Advisors, Inc

The general trend of declining interest rates experienced over the last decade and a-half, part of a long-term trend Manning & Napier Advisors, Inc. had focused on since the early 1980’s, created new challenges for managing investment portfolios with regular and significant cash withdrawals. And, this report will provide an analysis of the investment implications of withdrawals in light of the secular shift in the economic and market conditions; for all physician, healthcare executives, and financial advisors  The analysis aims to guide decisions as to the appropriate level of withdrawals from an account in this environment.

Restricted Ability to Generate Income

Declining interest rates restrict the ability to generate income from high quality investments, so a greater proportion of a given withdrawal requirement must come from the potential price appreciation of the securities. 

Of course, the inherently volatile nature of the financial markets makes price appreciation the less predictable of the sources of total return available to fund withdrawal needs. The natural questions that arise from this observation include:

·      What withdrawal rate inhibits the ability to pursue long-term capital growth as a primary investment objective?

·      What withdrawal rate may create a significant risk of a sustained deterioration of capital?

·      What is a reasonable range of withdrawal rates given the relatively low interest rate environment that we face?

Interest Rates and Dividend Yields

The answer to the first question can be derived by looking at interest rates and dividend yields of the recent past.  For example, with a dividend yield of 1.0%-2.0% on stocks (e.g., the current yield on the S&P 500 Index as of December 1999 is 1.2%) and yields on intermediate-term and long-term fixed income securities between 6.0% and 6.5% (e.g., as of December 1999, a one-year Treasury Bill has a yield of 6.0% and a thirty-year Treasury bond has a yield of 6.5%), growth-oriented portfolios should have generally produced a level of income adequate to allow 2.5%-3.5% withdrawals on an annual basis. 

Thus, rates of withdrawal of less than 3.5% generally should not inhibit the pursuit of long-term capital growth as a primary investment objective.

High End Results

To establish the high end of the achievable withdrawals under a management approach pursuing long-term capital growth, consider some additional historical evidence. 

For example, assume that withdrawals are taken from each of three portfolios (i.e., 100% stocks, 80% stocks/20% bonds, and 50% stocks/50% bonds using data from Ibbotson Associates, Inc.) starting at the beginning of 1973.  How many years did it take to regain the original capital of the portfolio? 

As can be seen in the table below, it took between 4-8 years for these portfolios to recover from the 1973-74 bear market with a 5.0% withdrawal rate.  If withdrawals are at a 7.5% rate per year, over ten years elapsed before the original capital was restored.  Finally, with a 10.0% withdrawal rate, it took between 13-15 years to restore the capital. 

While the 1973-74 bear market was severe, it is not the worst bear market that can be used to illustrate the risk of significant withdrawals taken when the portfolio’s market value is depressed.  The clear conclusion is that withdrawals of greater than 5.0% are a potential impediment to pursuing long-term capital growth, given the long periods required to restore capital for the various growth-oriented asset mixes offered in this analysis.

 

 

When Was Original (12/72) Capital Restored?

 

 

5.0% W/D

7.5% W/D

10.0% W/D

100%
Stock       

 

9/80

(7.75 years)

 

6/83

(10.5 years)

 

6/86

(14.5 years)

 

80% Stock/ 20% Bond

 

9/80

(7.75 years)

 

3/83

(10.25 years)

 

6/86

(14.5 years)

 

50% Stock/ 50% Bond

 

12/76

(4.0 years)

 

3/83

(10.25 years)

 

3/87

(15.25 years)

 

Understanding Market Value

Another key issue to remember is that the withdrawal rates above are a percentage of current market value, so the dollar value of the cash withdrawn from the account is assumed to decline in a bear market. 

However, most of us think of our withdrawal needs in terms of dollars instead of percentages (e.g., $50,000 from a $1,000,000 account, which translates to 5%).  If we attempt to maintain the dollar value of withdrawals in bear market periods, the percentage of current market value being withdrawn actually increases, and the impact on the portfolio far exceeds the example provided above. 

To demonstrate, consider maintaining withdrawals of $50,000, $75,000 and $100,000 on an account with a $1,000,000 market value as of 12/72 (see table below).  In the case of a $50,000 annual withdrawal, approximately 8-10 years elapse before the original $1,000,000 market value is restored.  If the withdrawals are $75,000 per year, 13 years elapse for the 50/50 asset mix and almost 19 years pass for the 80/20 asset mix before the $1,000,000 is restored.  For the 100% stock portfolio, nearly 25 years elapse before the original $1,000,000 is restored.

Finally, for $100,000 withdrawals off of a $1,000,000 market value in 1972, all capital in the account is depleted within 10-15 years given these withdrawals.  Thus, the risk of significant cash withdrawals having a detrimental impact on the ability to preserve and grow capital is much more pronounced when withdrawals remain high in dollar terms.

 

 

When Was Original Capital ($1,000,000 in 12/72) Restored?

 

 

$50,000 W/D

$75,000 W/D

$100,000 W/D

100% Stock

 

3/83

(10.25 years)

 

9/97

(24.75 years)

 

Capital Depleted

9/83

 

80% Stock/ 20% Bond

 

12/80

(8.0 years)

 

9/91

(18.75 years)

 

Capital Depleted

3/85

 

50% Stock/ 50% Bond

 

9/80

(7.75 years)

 

3/86

(13.25 years)

 

Capital Depleted

9/87

 

Pursuing Long-Term Capital Growth

So far, the major point we have established is that a withdrawal rate of 2.5%-3.5% may be achievable without hampering the pursuit of long-term capital growth, but withdrawals of 5% or greater may have a significant impact on the ability to manage for growth. 

Therefore, accounts expected to experience withdrawals of 4%-5% (or greater) should be managed with a goal of satisfying these withdrawal needs on a regular basis first, with the pursuit of capital growth taking secondary importance. 

However, the analysis provided above also implies that there is a rate of withdrawals that forces us to focus on capital preservation, because depletion of capital is a likely outcome. For withdrawals in the range of 10.0%, the example above shows that the risk of depletion of capital is significant at these high annual levels, especially if the withdrawals are on a dollar basis and not adjusted by the decline of current market value in a bear market.

In fact, with long-term U.S. government bond yields at approximately 6.0%-6.5%, annual withdrawals greater than 7.5% are likely to be too high to allow a manager to effectively pursue long-term capital growth without a high degree of risk to the capital of the account. That is, since attempts to provide returns above the current Treasury yields imply risk of volatility, and volatility can lead to the examples provided above, withdrawals at 7.5% or more and maintained on a dollar basis imply a high likelihood that original capital will be depleted over a 15-20 year period.  In general, the current level of yields in the market imply that management of a portfolio requiring over 7.5% per year in withdrawals faces a strong possibility of depleting capital under any scenario, and so portfolio management should focus on dampening market volatility so as to extend the life of the capital for as long as possible as it is drawn down.

Determining Appropriate Level of Withdrawals

The final question (i.e., the appropriate level of withdrawals) is driven by both the physician client’s need for the assets and the parameters outlined above:

 

1.    Withdrawals less than 3.5% of current market value should not inhibit the pursuit of long-term capital growth as a primary objective.

2.    Withdrawal rates between 3.6% and 7.4% require a primary focus on satisfying withdrawal needs over the market cycle, possibly with a secondary goal of long-term capital growth to protect future withdrawal needs.

3.    Withdrawal rates greater than 7.5% are likely to result in a depletion of capital, so the goal should be to manage the draw down of capital by dampening year-to-year volatility of the portfolio.

 

While we all would like to achieve capital growth, the ability to pursue growth-oriented strategies depends on the flexibility to moderate withdrawals, if required by market conditions, and on the overall reliance on these assets. 

As an example, an endowment or personal corpus can control its withdrawals to some extent, but there is a level beyond which the belt cannot be tightened without harming the services being funded. 

Another example comes from someone living primarily on an IRA account, especially after becoming accustomed to the high (and falling) interest rate/high asset return environment of the last fifteen years. Aggressively pursuing capital growth in the face of large withdrawals may result in exposure to significant risk of depletion of the IRA assets when other sources of income are unavailable.  If, on the other hand, the IRA was a small part of the wealth available in retirement, then there is some flexibility to work towards long-term capital growth. 

Finally, a defined benefit retirement plan may have an outside source of funding to help restore capital (i.e., contributions from the employer), but defined contribution and Taft-Hartley plans have much less of a safety net.  As a result, the risk taken to pursue growth in the face of significant withdrawals must take into account the nature of the assets and the problems associated with a deterioration of capital in the account.

Assessment

Portfolio withdrawals can have a significant impact on the ability of a wealth manager, or physician investor, to preserve capital and pursue long-term capital growth.  However, while lessening the level of withdrawals will help provide flexibility for the manager to pursue these goals, the need for the assets may require that withdrawals are maintained at a certain level.  Once withdrawals are minimized, the manager should focus on investment goals that correspond with this minimum level. 

If withdrawals are below 3% of current market value, pursuit of long-term capital growth can be a primary objective. Withdrawals between 4% and 7.5% of market value on an annual basis require a focus on working towards satisfying these annual needs. Long-term capital growth, in this case, should be a secondary goal. 

Finally, if withdrawals are above a 7.5% annual rate, then the investment management approach should focus on preserving capital and dampening market volatility so as to work towards allowing the assets to last as long as possible as they are drawn down.

Conclusion

As demonstrated above, income withdrawals can have a significant impact on the ability of a wealth manager, or physician investor, to preserve capital and pursue long-term capital growth. Does the current low interest-rate environment, and present financial ecosystem, mimic the above historic scenario and can it suggest strategies to be pursued today? Please opine and comment.

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Physician Advisors: www.CertifiedMedicalPlanner.org

Speaker:If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com 

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Prescription Data-Mines and Insurance “Credit-Reports”

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The End to “Rx” Privacy? 

[By Staff Reporters}

Collecting and analyzing [HIPAA protected?] personal health information [PHI] in commercial databases is a fledgling, but exploding industry, despite privacy concerns.

Industry Leaders

For example, Milliman’s IntelliScript provides personal drug profiles to insurers. And, Ingenix’s MedPoint is owned by UnitedHealth, the corporation that owns UnitedHealthCare. UHC is also the nation’s second-largest health insurance company.

Large Data Bases

Both firms created their large profiles by mining rich databases of prescription drug histories [eRXs], kept by pharmacy benefit managers [PBMs], which help insurer’s process drug claims. The data-base then aggregates and ranks the information, based on the drugs and dosages, dates filled and refilled, therapeutic class, and the name and address of prescribing doctor; etc. Higher scores imply higher health insurance premium costs.

Thus, prescription data is used to “rate” or economically judge potential insured patients via these “health credit-reports.”

***

matrix pills

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Assessment

And so, while politician’s debate how to regulate electronic medical records [EMRs], and attorneys monitor HIPAA policies, some health insurers have already begun tapping into other information sources such as clinical and pathological laboratories, as well. And, other sources are sure to follow.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Improving Inter/Intra Professional Relations

Establishing Rapport within the Medical Community

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

By Hope Rachel Hetico; RN, MHA, CMP™

Managing Editor

In our consulting work, publishing, speaking engagements and relate professional endeavors, we are often asked how to establish and even increase professional visibility in a particular medical, or even alternative-medial community.

While there is no-one-size-fits-all answer, the following are useful “tips and pearls” to enhance your awareness among known, and unknown, physician colleagues in your geographic locale.

A Few “Tips and Pearls”

  • Send office announcements to all health professionals in the community. Include pharmacies, pediatricians, family practitioners, PAs and NPs, concierge practices, chiropractors and alternative medical provides, convenient-care and convalescent facilities. All are potential sources of patient referrals.
  • Meet other health professionals personally and establish a one-to-one relationship with them. This will serve to educate them to your abilities and practice.
  • Send written reports to all practitioners who refer patients.
  • Do not hesitate to refer patients for consultations, as indicated. This is not only good business sense, but good medicine.
  • Use novel business cards, such as the new CD-ROMs cut into the size of a standard business card, by One Voice Technologies, of San Diego. For about a dollar, depending upon quantity, you can order a labeled disc with all the business information of a standard card, which also functions as a CD-ROM containing up to 100 megabytes of multi-media data about your medical practice or specialty.

Assessment

Please feel free to send in your own “tips” and favorite professional relationship building ideas.

Conclusion

What differentiates you from the competition, and how did you become know in your local medical community; please opine and comment?

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Eroding Doctor-Patient Relationships

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The “Bed-Side Manner” Deterioration Continues

[By Staff Reporters]

A growing chorus of discontent suggests that the once-revered doctor-patient relationship is on the rocks.

Results

About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins University [JHU] study published in the journal, Medicine, while two recent studies show that whether patients trust a doctor strongly influences whether they take their medication, according to the New York Times, on July 29, 2008.

Tell-all-Books

In bookstores, there is now a new genre of “what your doctor won’t tell you” books promising previously withheld information on everything from weight loss to heart disease, while the Internet is bristling with frustrated comments, blogs, text-messages and wiki’s, etc., from patients.

Raison Detra’

Reasons for the frustration include declining reimbursements and higher costs that give doctors only minutes to spend with each patient, news reports about medical errors and drug industry influence fueling patients’ distrust, and the rise of direct-to-consumer drug advertising and medical Web sites that have taught patients to research their own medical issues and made them more skeptical and inquisitive.

Of course, related quality improvement initiatives seem to be loosing ground.

Assessment

One can only wonder if more extensive use of physician-extenders; like PAs, CRNAs, CNMWs, NPs and DNPs are part of the solution; as well as well-trained limited licensed providers like podiatrists, dentists, optometrists and psychologists; along with walk-in, on-site and retail medical clinics, etc?

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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***

Medicare GAO Report on Radiology

Prior Imaging-Authorization Suggested

Staff Reporters

As reported in the Wall Street Journal, on July 14, 2008, Medicare may be soon requiring prior authorization to curtail unnecessary utilization of CT scans, MRIs and other forms of medical imaging, a new Government Accounting Office [GAO] report suggests.

The Medicare Report

To cut imaging costs, Medicare has been reducing certain physician payments, sifting through its data to spot improper claims, and educating medical practitioners about the issue. But, the GAO reported that post-payment claims review alone is inadequate to manage medical imaging – one of the fastest growing parts of Medicare – and suggests that Medicare include prior authorization as a possible front-end tactic.

The Findings

The GAO pointed to new evidence of imaging overuse in physician practices, including:

  • The proportion of Medicare spending on in-office imaging rose from 58 percent to 64 percent from 2000 to 2006.
  • Imaging became an increasingly large slice of doctors’ revenue pie. For example, cardiologists got 36 percent of their total Medicare revenue from in-office imaging in 2006, compared with 23 percent in 2000.
  • In-office imaging spending per Medicare patient varied widely nationwide in 2006, from $62 in Vermont to $472 in Florida.

Assessment

What might proponents of the classic Dartmouth Study on healthcare quality say about these findings?

Conclusion

Please comment on the above; opinions from health economists, actuaries and our radiology colleagues are especially welcomed.

Speaker:If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com 

Subscribe Now:Did you like this Medical Executive-Post, or find it helpful, interesting and informative? Want to get the latest ME-Ps delivered to your email box each morning? Just subscribe using the link below. You can unsubscribe at any time. Security is assured.

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Patients Challenging Medical Invoices and Bills

Root Cause is Money, Failure-to-Disclose and Frustration

[By Staff Reporters]

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Patients are challenging their medical bills with lawyers and lawsuits, out of frustration about the lack of up-front disclosure over costs by doctors and hospitals.

Involve More than a Few Cases

For example, after being charged $82,282 for a 23-hour stay in doctor-owned Westfield Hospital for two operations on her abdomen, a 56-year-old West Penn Township woman called the hospital and her insurer for an explanation.

Not satisfied with the response, she hired a lawyer and notified a reporter, after which Westfield officials said she was overcharged due to human error.

In another 2006 class-action Seattle lawsuit that was expected to have a ripple effect on consumers and hospitals, two patients of the Virginia Mason Medical Center filed suit against the center and won, after which Virginia Mason agreed to pay back an estimated $60 million to more than 3,200 patients who over six years had been charged ”overhead” for procedures performed in hospital-owned clinics – in some cases adding 60 percent to the price patients would have been charged for the same procedure performed by the same doctors in their offices.

Assessment

Although private legal action over medical bills is hard to track, the number of billing and coverage complaints filed with the Pennsylvania Attorney General’s health care unit has risen steadily, with the 2,000 or more complaints so far this year representing a five or six percent increase over last year; according to Morning Call, July 13, 2008.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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***

Physician Malpractice Liability Immunity

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Free Charity Medical Care?

[By Staff Reporters]insurance-book

Sen. Mike Enzi [R-Wyoming], the senior Republican on the Senate Health, Education, Labor and Pensions Committee [HELP], recently introduced legislation that would allow physicians and other medical professionals to volunteer their services at charity clinics and community health centers free from medical liability concerns.

Query

What is your opinion on this idea, given that there are more than 42 million uninsured Americans, in need? Please comment and explain? We are especially interested in hearing from doctors, lawyers, actuaries and health economists.

Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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Reining In the Tax Collector

IRS Restructuring and the Reform Act

Staff Writers

The “IRS Restructuring and Reform Act” is finally helping some professionals like doctors protect themselves from tax liens and levies

Prior to the Act

Before the IRS Restructuring and Reform Act went into effect almost a decade ago, matters concerning tax liens or levies were routine at the IRS, causing serious problems for medical professionals and family-owned businesses [FOBs]. Revenue officers issued notices of liens and levies merely as they deemed appropriate.

Since the Act

However, since the Reform Act went into effect, revenue officers have been required to obtain a supervisor’s approval before initiating collection activities or issuing notices of liens or levies. Now, supervisors review and investigate a case before a lien or levy is issued (i.e., homes and family business stock).

Specifically, for example, the supervisor must review the balance due from the taxpayer and confirm that the indicated collection action is appropriate given the amount owed by the taxpayer. This provision went into effect immediately upon passage of the act.

However, the effective date for automatic collection activities was delayed until Jan. 1, 2001. This delay was because most liens and levies are automated. Errors commonly occur in automatic liens and levies, but the IRS is working to introduce a human element into the transactions. Many doctors and family business professionals are taking advantage of the lien review requirement, helping clients avoid harsh collection activities.

Jeopardy Assessments Forbidden

In a related change, no jeopardy or termination assessments may be made without written review and written approval of the IRS chief counsel. Within five days of any jeopardy assessment, the IRS must provide the taxpayer with a written statement indicating the reason for taking action. As a result, substantially fewer jeopardy and termination assessments have been made. In addition, some family business professionals and doctors report they have been able to avoid jeopardy assessments and often challenge the basis for making the assessment.

Wage Levy

Under the Act, the IRS must release and cancel a wage levy once an agreement is made that the tax liability is uncollectible. If a wage levy is issued, tax-payers now have a firmer foundation for negotiating an end to the levy. This is helpful because, previously, levies were continued despite un-collectibility.

Seizure

Unless collection is in jeopardy, any property used in the business and personal property may not be seized without approval of an IRS district director. In determining whether to grant such approval, the taxpayer’s future ability to earn income will be taken into account. This provision has helped many substantially reduce the seizure of their business assets. Taxpayers have a right to contest a levy and to prevent or limit orders of seizures in appropriate cases.

IRAs and Qualified Plans

The IRS can continue to levy on IRA’s or qualified plan balances. However, the 10% excise tax on early withdrawals will no longer apply; this avoids the harsh double penalty of the past. If a doctor is faced with an IRS levy on an IRA or qualified plan, s/he may not want to withdraw the funds from an IRA or qualified plan to pay the obligation. The withdrawal will result in a 10% excise tax.

However, if the doctor pays the taxes with an IRS levy in place, the penalty is avoided. Some financial consultants report they have issued memoranda to their clients on this subject. For example, a taxpayer who previously had a federal tax lien placed on his or her property can have the lien discharged by posting a bond or by depositing the taxes. The cash deposited can be refunded if there is no deficiency, or if the deficiency is reduced. Such bonds are now being used in appropriate cases.

Liens

The IRS must notify a taxpayer if it intends to place a lien on the taxpayer’s property. The taxpayer then can request a hearing within 30 days. He or she also may contest any levy, unless collection of tax is in jeopardy. Doctors routinely are requesting hearings, using this procedure to terminate liens.

In addition, the taxpayer can request an installment agreement prior to levy. Thirty days after a hearing, the taxpayer can appeal the decision to the Tax Court. The act thus provides statutory appeals rights to taxpayers who are subject to a federal tax lien.

The hearing must be impartial and fair. The right of judicial review also ensures that the appeals officers act fairly. Taxpayers are informed of all their rights under these provisions. Congress has imposed a clear cut obligation on the IRS to consider alternatives to liens, such as posting of bonds, installment agreements, or offers in compromise. Thus, the medical professional has several alternatives to now consider. The right of judicial review is a major expansion of taxpayers’ rights.

Employment Taxes

The right of statutory appeal and the right of possible alternative obligations opens up a whole new area of appeal for the doctor and other taxpayers. The Reform Act permits early referral of disputes regarding independent contractors and similar matters. This should permit faster resolution of cases regarding employment status (employee or independent contractor). Many family businesses and/or medical practices contract with individuals employed by an outsourcing firm. The number of audits in this area has increased, and the IRS often regards the individual doctor as an employee of the medical practice or family business. In addition, the IRS has been encouraged to use mediation and arbitration to resolve disputes.

Offers-in-Compromise

Under the Act, the IRS must to consider factors such as equity or hardship when considering offers in compromise. The IRS is expected to forgo interest and penalties in appropriate cases. Rejected offers are subject to administrative review. Some medical professionals are finding the IRS more readily accepting of compromise offers.

Harassment

Many of the protections from harassment afforded to individuals by the Fair Debt Collections Practice Act in the commercial area have been extended to IRS collections. Some of those rights include not calling the taxpayer late at night, not harassing the taxpayer, and not dealing with the taxpayer if s/he has an authorized representative. If a violation occurs, the taxpayer can sue for negligent disregard of the Code. Here too, some doctors report that harassment-type activities have declined.

Innocent-Spouse Relief

The act contains significant provisions designed to protect innocent taxpayers from the tax misdeeds of their spouses the “innocent spouse relief” provision. The Tax Court can review any denials of innocent spouse relief.

Under the new rules, there must be actual knowledge of a tax misdeed before a taxpayer is considered “not innocent.” In the past, the test was whether the taxpayer knew or should have known about the other spouse’s tax misdeeds. Innocent spouse relief is easier to obtain under the “actual knowledge” test and is used routinely now.

Innocent spouse relief also is available on a partial basis. A taxpayer is relieved of liability on a partial basis even if he or she knew about the misdeeds, provided he or she did not know the extent of the misdeeds.

Thus, the spouse should not be liable for the portion of the understatement he or she had no knowledge of. This usually is as an alternative to a complete relief. All provisions (except the automatic lien provision) apply to any liability for taxes arising before, on, or after July 22, 1998.

Assessment

Since the IRS Reform Act passed, some doctors are working to protect themselves from tax collection activities or assessments. This is particularly true in innocent spouse cases. It bodes well therefore, for all family businesses, health practices, physician-executives and medical professionals to become and remain familiar with the provisions in the IRS Reform Act addressing such activities. You may just become grateful for this knowledge one day.

Conclusion

Your thoughts, comments and experiences on any or all of the above topics, are appreciated.

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

Subscribe Now: Did you like this Executive-Post, or find it helpful, interesting and informative? Want to get the latest E-Ps delivered to your email box each morning? Just subscribe using the link below. You can unsubscribe at any time. Security is assured.

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Referrals: Thank you in advance for your electronic referrals to the Executive-Post.

Blue Cross – Blue Shield Administrative Survey

Cost Trends Demonstrate a Decline in 2007

By Douglas B. Sherlock; CFA

PRESS RELEASE REPORT

Gwynedd, Pennsylvania

The per-member [pm] administrative cost growth for BC/BS declined from 6.1% in 2006, to 4.3% in 2007. Adjusted to eliminate the effect of a shift in product mix, administrative expense growth declined from 6.5% in 2006 to 2.5% in 2007. Administrative expenses were 10.4% of premium equivalents in 2007. And, plans reported total administrative expenses of $25.36 PMPM. 

All cited values exclude investment and non-operating income and expense, income taxes and miscellaneous business taxes.

Sherlock Expense Evaluation Report

These results are excerpted from the Sherlock Expense Evaluation Report, a benchmarking study comprising the results of 23 Blue Cross Blue Shield Plans surveyed by the Sherlock Company. More than 90% of participants also participated in the prior year’s survey and nearly 80% have five or more years of experience participating in our benchmarks.

Benchmarks and Metrics

The Sherlock Company benchmarks include thousands of operational and financial performance metrics. Besides Blue Plans, other universes include Independent / Provider-Sponsored plans, Medicare Advantage plans, Medicaid plans and larger plans. Collectively, the 46 plans serve approximately 36 million insured Americans.

Administrative Growth

The growth in administrative expenses ranged from a high of 10.0% for Medical and Provider Services to a low of 0.2% for Corporate Services.

In fact, the Sherlock Company said that, “The increasing emphasis of these Plans on Medicare Advantage had a profound effect on their expense trends. After holding constant the product mix, corporate service costs per member declined by 6.2% and provider and medical management costs increased by 2.2%.”

Assessment

Additional information is available in the Sherlock Expense Evaluation Report. We have also published a summary in July 2008 edition of the Plan Management Navigator accessible at www.sherlockco.com/docs/navigator/navigator-08-07.pdf

Conclusion

Your thoughts and comments on the above findings are appreciated? Do they agree, or disagree, with your factual or heuristic cost impressions of this institutional space?

###

The Sherlock Company www.sherlockco.com based in Gwynedd, Pennsylvania, provides informed solutions for health plan financial management. Since its founding in 1987, Sherlock Company has been known for its impartiality and technical competence in service to its clients.

Contact: Douglas B. Sherlock; CFA for more information.

215-628-2289, sherlock@sherlockco.com or visit www.Sherlockco.com 

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Risk Management: It’s Not All About Medical Malpractice Anymore

Book Review

By Murray J. Goodman; MD

In the narrow world of our day-to-day practice, orthopaedic surgeons often think of risk management strictly in terms of avoiding exposure to medical liability lawsuits. But, in the book Insurance and Risk Management Strategies for Physicians and Advisors, author, physician, and healthcare economist David E. Marcinko has assembled a cadre of experts who address the broader issue of risk management.

Link: http://www.amazon.com/Insurance-Management-Strategies-Physicians-Advisors/dp/0763733423/ref=sr_1_3?ie=UTF8&s=books&qid=1217606361&sr=1-3

15 Chapter Overview

This book examines the many important risks that we, as physicians, face daily in the practice of medicine. You may not think of life insurance, sexual harassment, Medicare fraud, marital divorce, and privacy issues as part of a risk management plan, but they are. Dr. Marcinko has written a book that provides an initial reference point for these diverse issues.

Each of the 15 chapters covers a single area, providing a broad overview as well as specific information and recommendations. This book addresses the personal, professional and business risks physicians face on a daily basis.

Personal Insurance Matters

The personal side of insurance is first, beginning with a discussion on insuring the doctor’s life. The chapter explains the various types of policies available, as well as various permutations and combinations of policy provisions. It briefly discusses both health insurance and long-term care insurance. It includes the critical features to look for in selecting a long-term care policy for yourself and the necessary criteria for successfully filing a claim under such a policy.

Practice Insurance Matters

Many orthopaedic practices are also small businesses, so property insurance and the business uses of life insurance, such as in buy-out and succession planning, are covered. The author reviews the use of restrictive covenants and employment contracts, providing examples of what works and what does not. One of the questions this chapter addresses is the difference in applicability between a restrictive covenant with regard to a departing employed physician and a restrictive covenant included in the sale of a medical practice.

Compliance Topics and Medical Workplace Regulations

Recent actions by the Department of Justice [DOJ] and activities of the Office of the Inspector General [OIG] regarding Medicare have focused attention on compliance issues. The text provides a good overview on medical documentation and healthcare compliance, including a summary of record-keeping obligations.

In addition, the author includes pointers on how a medical practice can avoid running afoul of the federal False Claims Act, fraud and abuse statutes, Stark and safe harbor laws, and the “alphabet soup” of HIPAA, OSHA, and ERISA regulations. Risks involved with serving as an expert witness, doing peer review and taking call are also covered. The discussions are as timely as those sponsored by the AAOS. The chapter on medical malpractice even includes a discussion of physician self-regulation and expert witness discipline.

Sexual Harassment Issues

The section on sexual harassment explains what constitutes a hostile work environment and what the physician’s role should be in risk avoidance. Complimenting an employee’s dress or telling a slightly off-color joke may seem innocent enough, but not if they meet the two criteria that determine offensive behavior and can lead to a lawsuit. Violence in the workplace is discussed as it relates to patients and employees, both as perpetrators and as victims. The author recommends that every orthopaedic practice have a policy and a plan in place to deal with these issues should they arise.

Malpractice Liability and Going to Court

One-quarter of the book is devoted to medical liability risks. Although the discussion of the medical liability crisis might be a bit dated and only too familiar to many readers, the section on the anatomy and procedures of a medical liability trial and the physician defendant’s role in that process is excellent. From subpoena to verdict, the process is laid out. Written by a malpractice attorney who is also a physician, the chapter provides solid advice on how to respond to the subpoena, secure the medical record [make an exact copy and seal it], and find personal counsel.

Pre-Nuptial Agreements, Divorce and Asset Protection

The financial risks of divorce are rarely covered in books geared to medical professionals, but this text examines them in detail. It also discusses prenuptial agreements and the special circumstances surrounding older divorcing medical professionals. Final chapters cover asset protection principles and how to select insurance and financial advisers who specialize in serving medical professionals.

Recommended Reading

Each chapter is authored by an expert in that particular field, but the text has a uniform consistency and approach, listing basic principles and citing specific examples to illustrate the issues involved. Ample references are provided, including written texts and articles, case law, and Internet Web sites. The table of contents is functional, and the index is well-organized for quick reference.

Insurance and Risk Management Strategies for Physicians and Advisors[Jones and Bartlett Publishers, Sudbury, Mass] is a comprehensive examination of risk management strategies. It does not provide specific legal or financial advice, but it does provide a background in many areas germane to the practical aspects of maintaining a medical practice in this millennium. Although not a stand-alone text, it gives the reader the vocabulary and information necessary to take many of these issues to the next level.

Assessment

“This book is recommended reading for those about to enter the practice of medicine; those already in practice will find it a helpful reference when seeking resources on a particular issue”.

Personal

My wife tells me that because it also addresses the personal and emotional issues affecting physicians’ lives, it is suitable for spouses as well.

Note: Murray J. Goodman, MD, is a member of the Medical Liability Committee. He can be reached at mj-goodman@comcast.net June 2008 AAOS Now http://www.aaos.org/news/aaosnow/jun08/managing2.asp

From the article of the same title AAOS Now (06/08) Goodman, Murray J.

http://www.asoa.org/resources/practice-mgmt-news/practice-management-news.cfm

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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PHYSICIANS: www.MedicalBusinessAdvisors.com
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HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
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Events-Planner: August 2008

AUGUST 2008

Staff Writers

“Keeping track of important health economics and financial industry meetings, conferences and summits”

August 1: Print Edition Healthcare Journalism: If you would like to “step-up-your-game” and be considered as a peer-reviewed contributor to the third edition of: The Business of Medical Practice [Advanced Profit Maximizing Techniques for Savvy Doctors]; just contact Ann at: MarcinkoAdvisors@msn.com  There are several chapter topics still available.

August 4-5: The 6th Annual World Congress Leadership Summit on Healthcare Quality; Boston, MA

August 13: Care Coordination for Managed Medicaid Health Plans, World Research Group, Chicago, Ill.

August 24-27: 7th Annual Medical Quality Colloquium, Harvard University, Cambridge, MA.

Please send in your meetings and dates for listing in the next issue of our Events-Planner: MarcinkoAdvisors@msn.com

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Physician Recruiting Success

Senior Leadership’s Contribution
By Allison McCarthy; MBA

If you’re recruiting physicians to your organization, then you probably feel challenged by internal disconnects that hinder your progress. More than likely you deal with one or more of them daily. And for many of these issues you need your senior leader to be your ally, champion and advocate, helping you navigate around those obstacles.

But, exactly what skill set within your leader is your most important resource? And how can you optimize those attributes when you need them?

Leading-Up

Leading up is one of the physician recruiter’s greatest challenges. Getting the right amount of time and attention (to establish an internal environment attractive to candidates) is critical to successfully bringing new physicians into the organization.

Beyond that, it is about having your senior leader play the right role at the right time in the recruitment process to deliver results. Their most vital contributions are:

1. Establishing Priorities
Medical staff development planning and priority setting are senior leadership obligations. And, in today’s high demand/shrinking supply of physicians, most organizations and their senior leadership need to improve their recruitment planning to get ahead of the competition. With the average time to fulfill a recruitment project for some specialties taking 24 months or longer, many recruitment assignments need to start two to three years ahead of projected need. That means having solid delineation of recruitment priorities – not just for the coming 12 months but for the next three or more years. Medical staff development planning and priority setting is the obligation of senior leadership.

2. Clearing Clutter
Some recruitment priorities are unsettling to members of your existing medical staff. Others are important to only a select group and lack organization-wide urgency.

As a result, we can face internal team members that encumber success – either purposefully or innocently obstructing candidate advancement through the interview process. In those instances, your senior leader needs to clear the way – either by negotiating with saboteurs or motivating the unresponsive. This then leads to the third attribute.

3. Communicating the Vision
Establishing physician recruitment as a strategic core competency is not easy. So much of what it takes to achieve the desired goal – a recruited physician – requires many pieces and parts of organizational input and participation. To create that involvement necessitates that the entire enterprise understands the “why” behind the recruitment agenda. Senior leadership must regularly communicate the vision behind the effort.

Only leadership can motivate the parties needed to be involved. Only leadership can establish its urgency among conflicting agendas and clarify priorities when there is uncertainty. Only leadership can guide the necessary cultural change so the organization is receptive to and welcoming of new physicians.

We often assume that because someone is a leader they know what to do. We also know what happens when we assume (you know the old saying right?). But we are the organizational experts on physician recruitment. We are also senior leadership’s eyes and ears to organizational reactions and reverberations.

So, our senior leaders need us to direct them to what is needed. Some key strategies to do that include:

a]. Collecting/Sharing Market Intelligence
David Cottrell in Monday Morning Choices said, “The process of discovering reality includes examining the facts and separating them from feelings and egos.” Regularly sharing information from articles or external statistical resources can help leadership understand the realities of the market and the challenges of recruiting specific specialties needed.

Further, tracking and trending prospect feedback about our opportunities provides the justification senior leaders need to enhance package elements and make them more market attractive. While we can share this information anecdotally, it doesn’t have the same impact on those we are trying to influence. Senior leaders come from a data-driven world. They spend their days reviewing financial statistics and operational performance findings. So, we need to translate our recruitment findings into their decision-making language if we want to influence and change the outcome.

b]. Tracking the Recruitment Process
Not dissimilar to the above, benchmarking the various touch points in the recruitment process identifies the gaps and obstacles that need to be addressed.

A simple spreadsheet that captures those key dates when the candidate moves from one stage in the recruitment process to the other illustrates those situations when consistently there are delays in response by the organization. Match that with candidate rejection feedback and you tell a compelling story about the internal issues that need to be addressed by your senior leader.

c]. Sharing the Wins
All of us need positive reinforcement and your senior leadership and internal organization are no different. Beyond communicating successes, it also means giving credit to those who participated in reaching the goal. When you see all pistons firing – everyone is on-board and doing their part, and the process flows as it should – celebrate those victories and recognize those that contributed in obtaining the prize.

By doing so, inertia often gets lifted by illustrating that success feels good. Momentum is generated for the next recruitment assignment and the entire process has established credibility by demonstrating how much more can be accomplished when there is team energy and involvement.

“Leaders push boundaries. They desire to find a better way. They want to make improvements. They like to see progress. All these things mean making changes, retiring old rules, inventing new procedures.”
John Maxwell

Assessment

As a former in-house recruiter and a consultant to organizations today, I know many health care enterprise senior leaders are looking to the physician strategy team to direct and guide the ways they can be most effective. That is not only an obligation but an opportunity to be leadership’s partner in fulfilling this vital strategic agenda. There is no greater reward!

Conclusion

And so, what do you think, and do, about physician recruiting success? Your thoughts and comments are appreciated.

Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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