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ADA “Transparency” in Health IT [Part II]

It all Depends on the Meaning of the Word  

[See Part I]: https://healthcarefinancials.wordpress.com/2008/10/30/ada-%e2%80%9ctransparency%e2%80%9d-in-health-it-part-i/

By Darrell K. Pruitt; DDS

 

http://community.pennwelldentalgroup.com/forum/topic/show?id=2013420%3ATopic%3A14837

“If you want to be respected by others the great thing is to respect yourself. Only by that, only by self-respect will you compel others to respect you.”

Fyodor Dostoevsky

“The Insulted and Humiliated” – 1861

A few days ago, San Antonio Express-News reporter Don Finley interviewed outgoing American Dental Association president Dr. Mark Feldman about the future of dentistry.  Dr. Feldman lamented that the US presidential candidates have yet to mention dentists in their plans for healthcare.  In fact, the title of the article is “Group wants dental health to be part of candidates’ talk.”

http://www.mysanantonio.com/health/31239029.html

ADA Plea’s “Not Reassuring”

As a dentist with an intense interest in maintaining complete control of the way I choose to practice dentistry, I have to say that Dr. Feldman’s groveling plea for attention was not reassuring. Others, including opportunists who would take advantage of my dental patients, are also watching.  Those who are paying attention easily catch on to hints of weakness as well. 

For example, Dr. Feldman must not have impressed San Antonio very much because immediately following the Express-News article, someone allowed two anonymous and very bitter people who hate dentists to post their comments, while rejecting at least three Texas dentists’ comments defending the profession.  Anyone can see that the San Antonio Express-News openly scorns Dr. Mark Feldman and the ADA.

Not Defending the Dental Brand  

It is no secret that the ADA never defends itself on the Internet. Time and again I proved that such negligence in protecting one’s brand creates a huge vulnerability. The pitiful part about low self-esteem is that those who work for the candidates also pick up on the weakness of our organization and see no political traction in concerning themselves with our patients’ interests. 

Sadly, the once reliable respect does not look forthcoming for Dr. John Findley either. Nobody in the media noticed his arrival as president, so the ADA had to spend money to purchase a press release.

http://www.marketwatch.com/news/story/texas-dentist-assumes-presidency-american/story.aspx?guid=%7B1824CA4A-C3F6-4CF3-A34B-C7043DE38E45%7D&dist=hppr

Assessment

Effective public relations on the Internet cannot be purchased, and defense of the ADA is hobbled by its obsolete command-and-control business model – an early example of a fat, slow-moving dinosaur facing the challenges of evolution in a transparent marketplace.

Conclusion 

To me, the press release seems pitiful. We can do better. We must do better. Our patients are depending on us. We are the only ones who care for them. Your thoughts are appreciated; please opine and comment.

Publisher’s Comment:

Now, after reading this two part series, is there no one here to rid of us of this meddlesome dentist; or is he correct?

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Anonymous Doctor Rating Websites

Worthwhile or Worthless?

By Staff Writers

All medical professionals are aware of the power of the internet and the rise of anonymous MD rating sites. These include RateMDs.com, WLPT-Zagat, Vimo, Careseek, Drscore and a host of others. But, however cool and empowering they may seem; their value is still questioned.

Assessment

And so, we would like to get your input (along with other readers, subscribers and experts) on the value of these social sites for patients and consumers, as well as the possible risks and benefits for MDs.

Conclusion

Your thoughts and comments are appreciated; real life stories and anecdotes are encouraged.

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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ADA “Transparency” in Health IT [Part I]

It all Depends on the Meaning of the Word  

By Darrell K. Pruitt; DDS

http://community.pennwelldentalgroup.com/forum/topic/show?id=2013420%3ATopic%3A14837

It is my hope that the walls are beginning to close in on the American Dental Association’s healthcare IT hobbyists and other ambitious stakeholders who stoically tolerate harm to dental patients for the common good and personal power.  Supporting HIPAA is the most egregious blunder ADA leaders have ever made.  As the effort collapses because of natural reasons, those who hang onto absurdity the longest will lose the most.  Fair is fair. Those who recklessly promoted HIPAA have done long term damage to my professional organization.  I cannot let this continue. 

“Seal of Approval” 

I will show you irrefutable evidence that the once strong ADA, whose legendary “ADA Seal of Approval” was highly respected in the marketplace before it went on sale, is now a vulnerable empty shell.  In an age when transparency trumps talking points, the ADA is hemorrhaging credibility every time President Dr. John Findley opens his mouth.  In his address to the House of Delegates a couple of days ago, Dr. Findley said that he “values and promotes ‘transparency,’ which he defined as an openness and honesty that helps build and maintain trust”.

http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3272

Evidence-Based Dentistry

After two and a half years of asking questions to virtually every officer in the ADA, including Dr. Findley, I can tell you with certainty that ADA leadership still just does not get it.  It is impossible for one to use the word “transparency” as a buzzword successfully.  The term is not vague like “Evidence-Based Dentistry,” which of course can mean whatever stakeholders need it to.

“Intelligent Dental Marketing?” 

We must face this fact, friends:  Between the ADA’s chronic paralyzing fear of trouble from the FTC and the progressive loss of respect in the marketplace, the ADA can no longer offer adequate and uncontaminated representation for dentists and their patients.  In my opinion, a large part of the problem is that the ADA has gone commercial.  I might tolerate ads on our website, but they better be expensive and few. However, did you know that the ADA is in commercial partnership with an outside PR firm to sell practice marketing to ADA members?  It is called “Intelligent Dental Marketing.”  I think it is an atrocious idea.

Assessment

Here is a question about intelligent marketing which nobody will answer:  If two ADA members, the only two dentists in a small town, both use IDM, which one will get the better deal?

Conclusion 

I say that if the ADA has to sell stuff to dentists to keep dues low, that is an unethical business arrangement which favors third parties and does nothing to improve patient care.  I think downsizing is a far better idea. 

What do you think? All comments are appreciated.

[Part II will be posted soon]

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Developing a Sound Investment Portfolio

Asset Class Investing for Today, and Beyond

Staff Reporters

In 1997, The Prudent Investor’s Guide to Beating the Market was released by John Bowen Jr., and published by Irwin Professional Publishing.  Since then, it has become somewhat of a classic. And so, the time may be right to review the basic concepts it exposes during the current climate of marketplace turmoil, volatility and the impending recessionary financial ecosystem.  

Basic Concepts

In the book, Bowen describes the concepts necessary to develop a sound portfolio of asset class investing. These include:

• Utilize diversification effectively to reduce risk—While diversification is generally good; realize that bad diversification also exists. If your investments move together (or in tandem), this is ineffective diversification.

• Dissimilar price-movement diversification enhances returns—The most important component of investing is understanding correlation coefficients (dissimilar price movements). By combining assets with low correlations, the physician investor can lower the overall portfolio risk while enhancing risk-adjusted rates of return. If two portfolios have the same average return, the one with the lower volatility will have the greater compound rate of return over time.

• Utilize institutional asset class mutual funds—This belief stems from markets being efficient. Therefore, the best way to add value to mutual funds is to diversify into asset class mutual funds so you can achieve dissimilar price movements that will allow you to diversify effectively.

• Diversify globally—If you have all your money in a single country, you will not achieve diversification because those investments, on average, tend to move together.

• Design portfolios that are efficient—Your portfolio should be designed to provide you with the highest rate of return for the level of risk with which you are comfortable.

Stay the Course

Bowen believes the secret to asset class investing is having the discipline to stay-on-track. He further states that the investor must stay the course and avoid market timing, because it simply does not work. He tells his readers that only through a patient, long-term perspective will they realize their financial goals. He states that more than 90% of the market gain recorded each year has been concentrated in a single 30-day period.

Risk Management

To determine how much risk any physician-investor is willing to take, Bowen suggests looking at the 1973–1974 domestic stock market performance. These two years experienced the worst financial recession since World War II. In selecting the risk tolerance that’s appropriate, physicians and other investors should consider their optimal portfolio at its average risk level. Bowen believes that just because Wall Street doesn’t acknowledge the existence of those years, doesn’t mean you shouldn’t.

Assessment

He also states that you should only be in the equity market if your time horizon exceeds five years. This way, you’ll be able to weather the business cycles with peace of mind.

For any portfolio less than five years, Bowen states that it should be predominantly made up of fixed income securities. He also states that most portfolios should consist of a money market account, a one-year corporate bond, a five-year government fund, a US large company fund, a U.S. small company fund, an international large company fund, and an international small company asset class mutual fund.

Conclusion

The original book is written in a clear and concise format. It gives a history of the market and shows the reader what works, what doesn’t, and explains why. The book should again be a prerequisite reading for physician-investors and financial advisors; especially today.

Any thoughts, opinions 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

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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Understanding Financial Derivatives

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Beware the Toxicity

By Dr. David Edward Marcinko; MBA, CMP™

According to Jeff Coons PhD CFP™ a financial derivative is a security whose value is derived from one or more underlying securities. Derivatives can range from financial securities as simple as a stripped bond, or pooled mortgage, to extremely complex securities customized for a particular investor’s risk management needs. And, some physician-investors know that perhaps the simplest form of derivative is a short-sale, where you can place a bet that some asset you own will go down, so that you are covered whichever way the asset moves. 

Volatile Investment Vehicles

Even though derivative securities in some contexts can be a key source of volatility in the financial markets, these securities may be useful tools in the portfolio management process.  Likewise, just as the basic asset classes discussed in the E-P may be separated into a series of expected cash flows, any given derivative security may be understood as a series of date or event contingent cash flows.

Basic Derivatives

Two basic derivative securities created from more traditional fixed income securities are pooled mortgage securities and strips: 

  1. A stripped security represents either principal or interest payments from some underlying fixed income security.  As an example, a principal-only Treasury strip represents the face value payment of an U.S. Treasury bond, while an income-only Treasury strip represents the right to the coupon payments of a particular U.S. Treasury bond. 
  2. A pooled mortgage security is a derivative security that represents ownership in a collection of mortgages.  An interesting feature of a pooled mortgage security is the principal pay-down, with shares of the pooled mortgage security returned at face value as mortgages are refinanced and/or repaid. Refinancing and prepayment of mortgages tend to happen when the original mortgage rate is above currently available mortgage rates, so pooled mortgages with higher coupon rates will tend to have the greatest prepayment risk.

For example, physician-investors recall the dramatic decline in mortgage rates during 2002 that led to a significant increase in refinancing activity, which in turn resulted in significant prepayment risk for many holders of pooled mortgage securities. The current CDS meltdown, in 2008, is another example.

Credit Default Swaps

A credit default swap (CDS) is a derivative contract in which a buyer makes a series of payments to a seller and, in exchange, receives the right to a payoff if a credit instrument goes into default or, on the occurrence of a specified credit event, for example bankruptcy or restructuring. The associated instrument does not need to be associated with the buyer or the seller of this contract; thus one factor of their “amorphous toxicity” today.

Assessment

Credit default swaps are now the most widely traded form of credit derivative! But, when the smartest financial guys on Wall Street designed derivatives and credit default swaps, they forgot to ask one thing; what if the parties on the other side of the bet don’t have the money to pay up?

Conclusion

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For-Profit versus Not-For-Profit Healthcare

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An Often Contentious Problem

[By Staff Writers]

Hospital             

In general industry, as well as in healthcare, there has been a longstanding discussion on the relative efficiencies of for-profit businesses versus not-for-profits, which concerns the very merits of competition itself.

The Studies

According to Robert James Cimasi MHA, ASA, AVA, CMP™ of Health Capital Consultants in St Louis, a number of recent studies, some more controversial than others, have investigated the effect of tax status on the relative costs and quality of services at these different types of hospitals.

For example, Bob Cimasi of www.HealthCapital.com reported that one study, published in the New England Journal of Medicine (NEJM), compared Medicare spending (adjusted for local costs, patient demographics, and the types and numbers of local healthcare providers and facilities) in markets with only non-profit hospitals, only for-profit hospitals, and those with both types.

The results for the years studied, 1989, 1992, and 1995, showed that the government spends more for every type of service studied (hospital, physician, home health, and other facility services) in those areas with only for-profit hospitals. Costs for areas with only not-for-profit hospitals were the lowest, with spending in markets with both for-profit and not-for-profit hospitals falling in the middle of the range.

This study also tracked adjusted mean per capita spending for hospitals that had a change in their tax status.

For the period of the study, 1989-1995, they found that areas where all hospitals were non-profit, and remained so, had cost increases of $866, compared with $1,295 for areas where non-profits converted to for-profit status. Areas with only for-profit hospitals had cost increases of $1,166 from 1989-1995, whereas those which changed to non-profit hospital areas had the smallest cost increases of $837.

These results may indicate that the tax status of hospitals affects the costs of health services provided by physician providers and other healthcare facilities. Further, this reported effect, if real, may be considered by many to be detrimental to the public good. In the six years examined by this study, the difference in costs between these market types was indicated to have grown from 12.7% to 16.5%. In 1995, annual Medicare spending was $732 higher per enrollee in markets with only for-profit hospitals than in non-profit markets. This difference may be extrapolated to $5.2 billion dollars in total extra annual costs to Medicare.

Even More Studies

Other studies, according to Cimasi, have examined these cost differences and have found them to result from increased administrative and ancillary services costs. For-profits appear to spend less on personnel, charity care, hired help, and length of stay than not-for-profits. Moreover, spending differences are reflected in measurements of outcomes and quality. A study of death rates has presented them to be 6-7% lower in not-for-profit hospitals as compared to for-profits and 25% lower for teaching hospitals.[1]

The fact that costs in those markets with both for-profit and not-for-profit hospitals were in the middle of the range may be interpreted as resulting from the averaging of costs from these different classifications of organizations. However, the behavior of the not-for-profit class was apparently also affected by this “competition” with for-profits in mixed markets. For example, studies have shown that charitable care by non-profits in these markets is reduced to levels similar to those provided by for-profits. 

dhimc-book

The NEHJM Editorial

A NEJM editorial, several years ago, discussing several hospital costs studies attributes these higher costs to a lack of competition (or other motivation such as charity) that might act to prevent for-profit companies from seeking to maximize their profits at the cost of the public good.

“Market medicine’s dogma, that the profit motive optimizes care and minimizes costs, seem impervious to evidence that contradicts it.” Then further, “The competitive market described in textbooks does not and cannot exist in health care for several reasons.”[2]

Thus, even if competition could improve care and lower costs, this isn’t happening because expected results from competition are missing in the healthcare markets.

Competition

An examination of hospital competition is also of interest, as many hospital markets are too small to support more than one hospital (a monopoly) or more than a very few competing organizations. The authors of the NEJM editorial went on to cite hospital monopolies and “virtual monopolies” as one of the barriers to competition, stating that roughly half of Americans live in markets too small to support medical competition and that for-profit chains have focused acquisitions on these markets.

More Barriers

The next barrier discussed is constraints on consumer demand imposed by illness. The authors point to the difficulties consumers have in comparing costs, outcomes, and quality in order to choose among competing services.

Lastly, the fact that the government makes the purchasing decisions and pays the majority of healthcare costs, rather than the consumers or employers who are using the services, is presented as a significant barrier to competition.

Assessment

Many healthcare planners find these studies to be a stark illustration of the argument that the benefits of competition for profits are lost whenever competitive market controls are absent to prevent the abuses of profiteering. As one might expect, for-profit hospital companies might point out that this is the case for both not-for-profit and for-profit dominated markets.

References:

1. Wolfe, S. M., M.D., Editor, “Hidden Rip-off in U.S. Health Care Is Unmasked In New England Journal of Medicine Articles.” Health Letter 15: 9, Public Citizen Health Research Group, (Sept. 1999):

2. Woolhandler, S. and Himmelstein, D. U. “When Money Is the Mission — The High Costs of Investor-Owned Care.” NEJM 341: 6 (Aug. 5, 1999): 444

Conclusion

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The Great eHR Debate

Another IT Challenge for Dentists

By Darrell K. Pruitt; DDS

I posted this on my surrogate blog (Baltimore Sun). I’m hoping to gather a crowd of town-folks to witness me send a collection of door-to-door scoundrels on down the road. 

http://www.topix.net/forum/source/baltimore-sun/T0GLLJEPSJAJJDBCJ/p5#lastPost

“EHR Debate of the Century – Pruitt vs. All Comers”

Allow me to invite you to the “EHR Debate of the Century – Pruitt vs. All Comers”

Kevin Henry, editor for Dental Economics, has invited healthcare IT experts other than me to a debate concerning electronic health records in dentistry.  I posted my acceptance of the challenge here.

http://community.pennwelldentalgroup.com/forum/topic/show?id=2013420%3ATopic%3A14917

Dental Economics

http://community.pennwelldentalgroup.com/forum/topic/show?id=2013420%3ATopic%3A14859

When I read that he was entertaining questions for a panel of experts, I hammered out twenty or so questions in less than five minutes and posted them below his comment.  Every one of my questions is a subterranean stinker except for the last two.  Those two are as sweet as honey. 

This Could be Fun

I have to assume that the other unnamed and unarmed experts are healthcare IT stakeholders, not principals like me.  Since I’m defending my patients’ turf instead of the price of a company’s stock, I cannot and will not lose.  This could get exciting.  Wake the kids.  I’ll also do my best to spread the word about the train wreck in my own way.

I must take this opportunity to acknowledge the courage of PennWell and specifically Mr. Henry for stepping out in front of the vast silent, lost crowd to offer consumers transparency at last, and perhaps just in time.  I will never forget your help in my efforts to salvage evidence-based miracles that my future grandchildren might still be able to enjoy, if we’re lucky.

“The events going on right now are the seeds of a unification of faith and honor of all thirteen colonies on our continent.  The smallest fracture between us now will be like a tiny carving into a small oak sapling, which will grow large over time, and future generations will be able to read our failure in giant letters.” 

Thomas Paine, Chapter III, “Common Sense.”  1776

OSEBD

If we are to reap miracles from Open Source Evidence-Based Dentistry [OSEBD], we cannot afford to disappoint our patients the first time out with a loser EHR that ADA President Dr. John Findley says dentists will have to accept – regardless of the Hippocratic Oath.  The interoperability that Findley does not understand but nevertheless promises the nation will never be realized if leadership continues with this reckless, parasite-infested course in healthcare IT adoption.

Open-Source EBD using trustworthy data will only get one chance at trust.  Contrary to what Findley says, EHRs are not inevitable.  It is abysmally foolish for a bureaucrat to suggest that the nation’s dentists, 85% of whom are sole-proprietor small business owners, will abandon their own Constitutional Rights for the common good.  That is being far too generous with others’ rights, Dr. Findley.

Bribing the Doctors

Until both dentists and patients trust EDRs, interoperability simply will not happen anywhere.  Consider this:  EMR adoption by physicians is going so badly that HHS Secretary Michael Leavitt had to bribe 1,200 physicians just to try EMRs.  Do you know the difference between EMRs and EDRs?  EMRs make tremendous sense. 

Bribing the Dentists?

How many dentists will the next Secretary have to bribe?  Taxpayers should be warned that investing in EHRs in dentistry is a waste of healthcare dollars until Personal Identification Information (PII) is removed from them.  What, I ask you, could be simpler than that?  “And, what about the interoperability with physicians’ records?” a deeply-rooted healthcare IT stakeholder might timidly ask.  Forget the MDs.  Forget Newt Gingrich.  Forget ONCHIT.  And especially, with extreme prejudice, forget the National Association of Dental Plans (NADP).  Let’s set up our own system, with or without the ADA, collectively fine tune it to our own needs which only practicing dentists truly understand, and make the opportunists come to us for once, damn it.  Just because physicians’ practices are so terribly infested with parasites that they cannot move into the future should not stop dentists from leading the way using precedent-setting innovation in a free market.

Assessment 

Even before Secretary Leavitt addressed the ADA House of Delegates in 2006, which Kevin Henry mentioned in the invitation to the coming debate, I wrote that maintaining EDRs with personal information is like storing bombs with fuses.  It is still earthly stupid.  So are we, the nation’s dentists, going to sit back in our lawn chairs and watch for the muddy explosion?    Not me.  I’m going to defuse the sucker.  You just sit back and watch. 

Conclusion

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