Teaching Bedside Manners

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Notes on Learning Ethics and Compassion

[By Staff Reporters]red-appple

According to a report cited by the New York Times, January 29th 2009, the journal Academic Medicine [AM] published its findings on medical ethics and professional compassion in the academic teaching environment.

Traditional [Last-Gen] Mindset

Unfortunately, it often seems a negative truism that good doctor bedside manner is something you are born with, rather than a learned behavior.  Think Gregory House; MD.

The Academic Medicine Report

However, a new study published in this month’s issue of Academic Medicine seems to prove that effort does matter, and that compassionate learning is possible. Even established physicians and clinicians can be re-inspired to adopt new humanistic skills, becoming better teachers and role models in the process.

Assessment

Will increased transparency in medicine and emerging collaborative health 2.0 initiatives change this traditional point-of-view?

Conclusion

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About the AHCJ

Advancing Public Understanding of Healthcare Issues

Staff Reportersmedfrd1210

According to its website, the Association of Health Care Journalists [AHCJ] is an independent, nonprofit organization dedicated to advancing public understanding of health care issues. 

Currently, there are more than 1,000 members in the AHCJ www.HealthJournalism.org

History

The idea for an Association of Health Care Journalists was born at a conference of health care reporters in Bloomington, Ind., in March of 1997. As it happened, several journalists, who had felt the need for such a group, crossed paths at that conference, which was sponsored by the Henry J. Kaiser Family Foundation. J. Duncan Moore, a reporter for Modern Healthcare magazine, and Melinda Voss, then a health reporter for the Des Moines Register, organized the initial meeting.

Mission

The mission of the Association of Health Care Journalists is to improve the quality, accuracy and visibility of health care reporting, writing and editing. AHCJ is classified as a 501(c) (6), a nonprofit professional trade association.

Goals

  1. To support the highest standards of reporting, writing, editing, and broadcasting in health care journalism for the general public and trade publications.
  2. To develop a strong and vibrant community of journalists concerned with all forms of health care journalism.
  3. To raise the stature of health care journalism in newsrooms, the industry, and the public, as a whole.
  4. To promote understanding between journalists and sources of news about how each can best serve the public.
  5. To advocate for the free flow of information to the public.
  6. To advocate for the improvement of professional development opportunities for journalists who cover any aspect of health and health care.

Assessment

For membership and contact information:

Association of Health Care Journalists
Missouri School of Journalism
10 Neff Hall –
Columbia, MO 65211 USA

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Do we need more journalists reporting on the status of the healthcare industrial complex; or do we need real subject matter experts? Nevertheless, we are supporters of healthcare journalistic transparency.

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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Ban on Referenced Based Drug Pricing

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A Medicare and CMS Three-Sixty

[By Staff Reporters]rboa_16

According to Jane Zhang and Vanessa Fuhrmans of the Wall Street Journal, on January 10, 2009, the last days of the Bush administration saw a proposed ban that allows private insurers to charge Medicare beneficiaries stiff penalties if they choose brand-name drugs instead of cheaper generic drugs.

Referenced Based Pricing

Under reference-based drug pricing, the penalty for insisting on a brand-name drug often amounts to the price difference between the drug and the generic version, plus a copayment. In some cases, that leaves patients paying the full price of the brand-name drug. In contrast, buyers of brand-name drugs when there is no generic equivalent are charged just a copayment. Nearly 10% of drug plans used the pricing technique to steer beneficiaries to lower-cost generics www.HealthDictionarySeries.com 

CMS Announcement

Of course, the announcement from the Centers for Medicare and Medicaid Services came after lawmakers and patient advocates protested that reference-based pricing made it difficult for consumers to calculate drug costs.

CMS Renouncement

But, the agency reversed itself 360 degrees this week, proposing to ban such pricing for the 2010 drug plans. The WSJ reported that complicated formulas made it “very difficult to accurately convey the extent of expected out-of-pocket spending” for prescription drugs. And, “The basis for this decision is our belief that reference-based pricing may be inherently misleading to beneficiaries and inconsistent with our goal of improving transparency.”

The Pfizer-Wyeth Drug Deal

Following the ban, investors appeared skeptical about the just announced Pfizer-Wyeth drug deal. Pfizer will pay $68 billion for Wyeth, which is the biggest in the drug sector since 2000. The merger comes as Pfizer faces the difficult hurdle of dealing with patent expirations for some of its biggest drugs, including its cholesterol-lowering Lipitor, which makes up about 25% of the company’s overall sales.

Assessment

The ban is part of CMS’s criteria for prescription-drug plans that insurers will offer for 2010. The criteria won’t be final until March, leaving a narrow window for the Obama administration to change them.

Conclusion

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About Hiperwall.com

Cool New Video Wall Creations – for Medicine?

Staff Reporters56371220

Hiperwall software enables anyone to build a scalable, high performance video wall from ordinary computers, monitors and an ethernet network.

Many Content Types

Hiperwall allows viewing in any combination of content types:

 

  • Ordinary graphic images
  • Extremely large graphic images, up to 1 gigabyte or larger
  • Digital movies, including standard and HDTV format
  • Streaming content from cameras and other live sources
  • Live “sender” feeds that let a room full of people view the constantly changing screen displays of one or more computers

Hiperwall has the ability to resize and relocate each content object anywhere on the video wall, within a single monitor or across multiple monitors. It is as easy as moving and resizing windows on the desktop of your personal computer. Hiperwall also provides advanced capabilities like zoom, rotation, shading and transparency, enabling users to examine content with increased flexibility and effectiveness. It is based on technology originally developed by researchers from the University of California at Irvine, and is now available for use by anyone www.Hiperwall.com

Assessment

Now, what does this all have to do with healthcare? Well, think digital radiology, cardiology, PET, CT and MRI scans, and others graphically intensive specialties? For example, an early client was Stanford University Medical School and Samsung Electronics. Still, with few other clients and only a hand-full of employees, consider overall costs, viability and follow-up support. Nevertheless, on January 24, 2009 – Information Week named the company as the “Startup-of-the-Week.”

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated; especially from you daring early-adopters, out there! Think PACS [picture archiving and communication systems].

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 and the Recession

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Physician and Hospital Pricing Pressure

[By Staff Reporters]life-preserver

As reported in Modern Physician Online, by Dan Bowman, new metadata coming from the federal government suggests that the current financial meltdown and domestic recession has impacted hospital and physician charges, as implicated by their revenues.

USBLS on Physician Charges

According to data from the US Bureau of Labor Statistics [USBLS], retail prices charged by doctors rose 2.9 percent in 2008, compared with 4.1 percent the year before. Wholesale prices for physicians were up 1.2 percent last year, compared with 4 percent in 2007.

USBLS on Hospital Charges

Hospitals meanwhile, were up 5.9 percent in 2008, compared with 8.3 percent the year before. Wholesale prices for hospital services, for their part, were up 1.5 percent last year, falling from a 3.8 percent increase in 2007.

Assessment

Link: www.ModernHealthcare.com

Conclusion

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Valuation and Small Business Appraisal Basics

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Applied Methodology with “Hands-On” Practice for Doctors                      

By Lester Barenbaum; PhD

By Michael Saponara; JD, CPAhands2

The market value of a publicly traded company’s equity can be calculated at a point in time by multiplying its share price by the number of shares of common stock outstanding.  The share price is determined in the public marketplace by buyers and sellers who trade the stock. 

The Buyers

Buyers of publicly traded company shares such as IBM expend money now (invest) for the right to receive uncertain future economic benefits. The price (value) an investor pays for a share is based upon his or her assessment of the size, timing and certainty of receiving future economic benefits. 

The Sellers

Likewise, a seller of IBM equity is willing to forego his or her expectation of future economic benefits if the investor believes that the benefits given up are worth less than the proceeds (value) from selling the ownership position.  Thus, the share price of IBM at a given point in time represents the value of future economic benefits as perceived by buyers and sellers of IBM equity at a point in time.

Assessment

This value is observable through transactions in the marketplace. In contrast, closely held businesses generate also economic benefits for their owners but the value of those companies cannot be directly observed by activity in traded markets.

Link: bizvaluationsbarenbaum11

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Conclusion

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On Episodes of Medical Care

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Another Medical Payment Paradigm Shift

einstein

[By Ann Miller; RN, MHA]

 “Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius — and a lot of courage — to move in the opposite direction.”

Currently, the Centers for Medicare and Medicaid Services [CMS] pay hospitals a single prospectively determined amount under the inpatient prospective payment system [IPPS] for all care given to an inpatient. Physicians who provide other care to patients are paid separately – accordingly to a Medicare physician fee schedule – for each service they perform http://www.HealthDictionarySeries.org

The ACE Project

A newer project, called the Acute Care Episode demonstration, will soon test whether a global payment will better align the incentives for both types of providers leading to better quality and greater efficiency; beginning in January 2009 www.HealthcareFinancials.com.

Bundled Payment Advocates

Like Einstein’s statement on simplicity, we are believers in bundling payments for medical providers. If done correctly, episodic medical care bundling may be an acceptable compromise for all. The current Medicare payment system treats physicians like virtual offending criminals. Every potential health claim is fraud; although this situation probably wouldn’t change. Any formula that buries E&M coding is a system worth evaluating. Many docs easily double the number of patients seen if paperwork and documentation was not so onerous. Not sure this is always a good thing; however. Bundling forces physicians to reevaluate, what is necessary and what isn’t. There is a much unnecessary productivity in medical care. “Too much friction – not enough movement” 

Assessment

Fee-for-service medicine has a way of creating business that need not be created. Will less be done under bundled care – will diagnostic care be upgraded for increased reimbursements?  Will episodic coding consultants come out of the wood-work? Maybe! And, can we can look at the DRG and MS-DRG experience as a potential harbinger of the future?

Conclusion

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What’s Up with Plaid Management?

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A “Cold-Call” Cowboy for Financial Advisors

[By An Anonymous Subscriber]gears

We have been getting annoying cold robo-calls, monthly for about a year now, from one Tim Smith. It seems as though Mr. Smith is a financial services matchmaker from Plaid Management, who brokers deals between clients and those in the financial services [sales] industry desperate for them. His firm may also do this with patients and medical professionals too; but, at what cost?

Our Internet Search

So, as a financial advisory firm, we did a web search for his company in Houston. Of course, you can too. According to the site, Smith founded The Plaid Group as a resource to help companies improve financial performance by simplifying and stabilizing their business operations. So, he is not working for the client prospect or patient-consumer; at all. But, he does seem to have a marketing history that includes a Fortune 500 Diversified Financial Services Corporation; and in a gamut of industries that include CPAs, IT, law, training, employee assessment folks, and marketing firms. Yet we know nothing else about him, good or bad, sans his cheesy and automated cold-call techniques.

Why Plaid?

Plaid is a fabric with a consistent, repeatable, and predictable pattern. Like Tim, we’ve taken that idea and applied it to his constant gear-like marketing activities.

Assessment

In other words, we have placed his firm on our Do Not Call list; with email message block. If inclined, you can too; or not! The decision is your own; but caveat emptor. Here is the contact info:

The Plaid Group
PO Box 25247
Houston, TX 77265-5247
713-627-3569 info@plaidgroup.com

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Conclusion

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Quality Improvement Origins in Healthcare

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Lessons Learned from the Business Space

[By Henry H. Goldman PhD CPCM]

“We arrived in different ships, but we’re all in the same boat now.”

The real beginnings of the “Quality Initiative” in the United States came after W. Edwards Deming, Joseph Juran, and others returned from Japan in the late 1950s. These men and their colleagues had answered a call from the United States Government to assist in the reconstruction of Japanese industry following World War II. Their techniques and methodologies had raised the industrial output of Japan to heights not previously envisioned. Along with this huge increase in industrial output was the understanding that Japanese made products were better than similar products produced in the United States. That, somehow, the Japanese culture had contributed to a level of quality heretofore not seen.

INTRODUCTION

American industries had begun to feel the impact of Japanese manufacturing by the mid 1980s. Pre-war imports from Japan had, noticeably, lacked quality. The goods were shoddily produced, had not warranties, were unreliable, and “cheap” in every sense of the word.

The quality of Japanese goods arriving in the United States and Western Europe during the late 1970s and into the 1980s was higher than anyone had expected. The rules set down by Deming and Juran had permitted the manufacturing of goods of superior quality. The Japanese began to be recognized, world-wide, for their output of electronic goods, of automobiles, and other sectors of the economy that required very detailed hands-on work. In most cases, robots rapidly replaced the hands-on applications and computer directed production became the norm. Most American industrial output was mechanized, but not as yet computerized nor was the manufacturing output heavily robotic.

PRECURSORS TO THE QUALITY INITIATIVE

Practicing managers, management theorists, and teachers of management at the nation’s colleges and universities began to recognize that changes would be necessary in management as a discipline if the United States, in particular, was to keep up with the quality production seen first in a rebuilt Western Europe and then in Japan. A number of ideas were put forth that were, ultimately, to become the under pinning of what was to be the American quality initiative.

The first well known “new management” technique, developed in the late 1960s by Peter Drucker, James Odione, J.D. Batten, and others was “Management by Objectives” (MBO). The purpose and objective of MBO was to motivate managers to really accomplish something. “Managing by Objectives” permitted managers to set down for themselves a strategic plan. Implementation of this plan was the identification of what the manager, in concert with senior management, could realistically accomplish in a given time period. David N. Chalk carried this idea forward in his, “Management by Commitment.” Chalk suggested that MBO did not go far enough. Much of what should have been achieved had not been accomplished. He strongly advocated MBC. The “commitment” was in the form of a written contract. There were penalties if the contract was not met. Managers working in a MBC environment were encouraged to keep senior management well aware of any problems that might hinder the meeting of the specified goals and objectives. There was a “no surprise” management style in MBC oriented companies.

Peter Pyhrr wrote his groundbreaking book, Zero-Base Budgeting: A Practical Management Tool for Evaluating Expenses, in 1973. ZBB quickly became a management buzzword and Pyhrr’s book rapidly became the most purchased business book in history, to that time. The underlying advantage of Zero-Based Budgeting was that the managers had to be given the authority and the responsibility to manage their own budgets. Line item budgets were no longer necessary. Managers, working under ZBB, requested a “least-cost” budget. This was a budget that permitted the manager’s functional area to meet its mission, but at a minimum level required to discharge that mandate. The technique effectively raised the intuitive thinking of managers. It had the effect of reducing operating expenses, overall. An additional benefit came from the mental exercises that determined which programs would go and which would not. It permitted excess funds to be redirected to the improvement of product quality and the improvement of the firm’s business processes.

While American managers and American industry was still trying to digest ZBB and the changes that it wrought another management idea came forth. Professor William Ouchi, then teaching at the University of California, Los Angeles, published his, Theory Z: How American Business can meet the Japanese Challenge, in 1981. This was the first widely read recognition that the Japanese were doing something right. It was the first recognition that American industry had not understood the thrust of the Japanese effort to produce quality products at an affordable price. These ideas, then, became the floor for what would become the American Quality Initiative in the late 1980s and has held forth strongly into the new millennium.

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model

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THE EVOLUTION OF BUSINESS QUALITY PROGRAMS IN THE UNITED STATES

If ZBB was the management buzzword of the 1970s and early 1980s, “Total Quality Management” (TQM) was the first quality buzzword. TQM became a new way of life in American industry. Companies all over the United States began to learn how to apply the Deming-Juran ideas of quality in their own product areas. Book publishers were inundated with TQM oriented manuscripts. Dozens of books were published on quality. Like ZBB before it, TQM was offered in all sorts of industries, service and manufacturing. One began to hear of TQM in colleges and universities, TQM in health care, TQM in service industries. TQM was everywhere. The idea of quality that TQM advocated was not often understood. Quality was now to become everyone’s job. Ford Motor Company went on television to advertise that “Quality was Job One.” The new Quality Initiative required, ideally, that quality began at the lowest level in the corporation and rose to the top, while, at the same time, quality was pushed downward in the organization.

Each employee on an assembly line, for example, had to become “his brother’s keeper.” Since everyone’s job was “quality”, it was necessary to repair the damage done by another that may not have completed the job. Maybe someone else had to tighten the screw to avoid the quality control office from sending the product back to salvage and rework. Teamwork became the rule, rather than the exemption. Other “managerial” words began to creep into the vernacular of corporations: “empowerment,” “customer service,” “quality circles,” etc. Ford Motor Company at one time had nearly 5,000 suppliers. Each product delivered to Ford had to be inspected at the inbound point. Inbound Inspection was a department unto itself. It employed hundreds of inspectors spread across tens of sites, all of which were geographically dispersed. Under TQM – Job One, suppliers had to agree that their products would meet certain specific quality requirements agreed to by both the supplier and by Ford. If the supplier agreed to provide Ford with only the highest quality of goods, then Ford would not perform inbound inspection. Only about ten percent of Ford’s vendors would or could commit to that level of excellence. The resulting savings in reducing the number of inbound inspections and the reassignment of quality inspectors saved Ford millions of dollars over the past two decades.

The Total Quality Management ideal was evidenced in a number of ways. Those companies that implemented a TQM, or, as some called it, TQMS, for Total Quality Management System(s) program, quickly discovered that “quality” was only one part of the overall Initiative. There were, in fact, ten clearly identifiable aspects of TQM, each of which was a stand-alone attribute of Total Quality Management, and/or, all subsequent quality programs like the Malcolm Baldridge Award Program, ISO 9000, Six Sigma, and the host of programs and theories accompanying any quality installation. The include, but are not limited to “Benchmarking,” Business Process Re-engineering “BPR,” Continuous Quality Improvement (CQI), and “Continuous Process Improvement” (CPI). Each of these represented a change in management style or, in some case, a change in corporate culture. These are discussed below.

Customer Involvement:

The “Q” in TQM includes the full product/service life cycle. This demands that the customers’ needs, desires, and requirements be fully integrated into the design and development of the products or services. This argues that the customer is an equal partner in the cycle. It follows then; that customer requirements can be directly converted into specific design and definite production and delivery schedules. These issues can be addressed in a team dedicated to this end. The Japanese utilize “Quality Function Deployment Teams” (QFDT). This fully integrated approach results in better designs, fewer design changes, faster production, earlier delivery, and with an overall higher quality.

Management Responsibilities:

Under TQM, quality is accepted as everyone’s job, but it goes beyond that. There must be a perception that everyone has a commitment to quality. This is really a link-back to the “Management by Commitment” (MBC) doctrine of the late 1970s and early 80s. It remains, however, management’s firm responsibility for the highest perceived as well as actual quality.

Management has as its primary task under TQM to acquire participation and commitment from both the organization’s internal and external customers. Participation, involvement, and commitment are tied together as management responsibilities for producibility.

Company Cultural Change:

The toughest part of implementing any quality program in any company or institution is changing the organization’s culture. The chief executive officer must be committed to change, not just give lip service to it. The core to TQM or, for that matter, any of the several quality programs, is the buy-in of senior management to change the culture of the organization to support the individual’s pursuit of quality.

The cultural change requires a complete reorientation of job descriptions and duties. It requires a collaborative rather than an adversarial work force. The phrase, “it’s not my job,” cannot work in a quality environment. Quality programs cannot work where employees refuse to be “their brothers’ keepers.” This collaborative working system is difficult to implement, but not impossible to achieve. It involves certain basic changes to the traditional American work ethic of “rugged individualism.” It suggests that the individual employee must become a partner in the enterprise and be just as concerned about quality as the CEO. Quality really does become everybody’s business.

Quality requires new thinking about the relationships that have traditionally existed between labor and management. It requires a new direction for American industry; a new partnership must be forged between management and the shop floor, between management and staff, and between line and staff management.

Statistical Orientation:

Statistical thinking is a basic element in all of the quality programs, but especially in Total Quality Management. Statistics has become the communication tool of TQM. Several different statistical concepts are invoked for the purpose of eliminating surprises. Statistical Process Control (SPC) and Statistical Quality Control (SQC) are evaluatory techniques used to measure the increase in quality output.

The statistical controls guide both management and production processes. “Statistical thinking strives to separate the common causes of variation from the special causes so that both can be controlled and improved.”

Statistical controls are necessary in order to measure the differences in improvement. They are required to accurately measure the changes brought on by installing any quality program, but especially, TQM.

Continuous Measurable Improvement (CMI):

Each process, regardless of whether it’s a management, engineering, marketing, production, or support function is subject to continuous improvement that can be measured based on the statistical controls discussed above. The idea of cmi (always expressed in lower case to indicate that it is a process rather than a program) is to increase the satisfaction of both the internal and external customer bases. The long-term goal of cmi is to increase satisfaction, while lowering employee time and material cost. This process has to become a way-of-life for each member of the organization, top to bottom, and bottom to top.

Employee Empowerment:

TQM describes individual participation and commitment as “empowerment.” Each employee becomes, at the same time, both a producer and a consumer. All individuals must be granted the authority to make quality decisions at their own levels of responsibility. The employees must demand and deliver products or services at the highest possible quality. This empowerment for high quality flows down through the organization and out the door until the product reaches the end user. Perfection is the goal, anything less is or should be unacceptable.

Individual commitment to and participation in the quality concept allows an employee to reject a product that he or she perceives as having fallen below that goal of perfection. It stops products from being delivered in order to make schedules when it is understood that the customer will return the item for repair, or in some cases, for completion. The empowered, committed, participative employee will make every effort to satisfy the customer, regardless of what that may entail.

Employee empowerment, individual participation, and committed management represents a whole new direction for American industry. This becomes an entirely new way to manage the quality function. It changes the mentality of the worker. It places quality ahead of other objectives such as cost or speed of delivery. Quality becomes the primary objective.

Vendor Quality; Supplier Integration:

Quality must begin outside the company, flow through it, and exit to the end user. Vendor quality, therefore, must be assured. When the supplier is involved and brought into the quality process, the supplier becomes and integral component of TQM or whatever quality process is being used. If the actual quality of the materials is “perfect” than the need for receiving inspection is eliminated. The materials arrive when needed, need not be inspected, and are immediately inserted into the manufacturing process. The Quality Initiative calls this process “Just-In-Time” (JIT).

This approach calls for a commitment on the part of the supplier that results in lengthy, exclusive (single source) agreements. It demands that suppliers adopt their own Quality Initiative. It becomes an upstream – downstream partnership.

Teamwork:

Teamwork is the essence and strength of all quality programs, but especially of TQM, not in the sense of the 1980s idea of “Quality Circles”, but as a whole new approach to teamwork. Teams can be created along functional lines or the teams can be cross functional. Teams can be problem solving or they can be innovative. They can even be both. These teams can become quality deployment teams. In every sense, they are teams with multi-departments represented. Production can learn to work with marketing, engineering with sales. Outside departments become partners with production. Vendor representatives can serve on “satisfaction teams.”

The entire operation is based on teamwork; working together to achieve mutually agreed upon goals. Teamwork permits the creation of a fully integrated management system with quality as its overriding goal.

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Entrepreneur

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Competitive Benchmarking:

This feature of all quality programs is defined as the continuous process of measuring products, services, and techniques against the perceived leaders in the field.

The basic idea is to gain a competitive advantage through a strict and detailed comparison of your company to your competition. If you can’t be better, can you at least be different? These differences can be seen in companies like FedEx and UPS. Both are carriers of small packages. FedEx relies on its reputation for being the “best.” The story is told that management expert Tom Peters was so used to having FedEx answer the phone on the first ring that when he called and the phone was not answered immediately, he concluded that he had misdialed. UPS, on the other hand, does not want to be a FedEx. They are different. UPS is a certified ISO 9003 service supplier. The company adheres to the ISO standard as set forth in the ISO Quality Manual. Unfortunately, the customer service staff at UPS has not been brought under the “quality umbrella.” Most of them are unaware of what the ISO Certification means. Hence, quality falls down. It is not enough just to write the numbers on your trucks, it has to be written in the hearts and minds of the employees.

Benchmarking suggests that we should learn as much as we can about our competitors, including trying to understand their strategies. If we emulate the best in our industry, if we discover their secrets, we just might become better than they are.

Cycle Time Reduction:

Under all of the quality programs, cycle time is defined as the length of time it takes to deliver a product or service, from inception to customer acceptance and satisfaction. All of the current quality programs, as a by-product, reduce cycle time. Close cooperation among the various components of quality programs will reduce cycle time. There can only be quicker response, faster production, and higher customer satisfaction. Shorter cycle time (sometimes called “fast cycle time”) will decrease costs, increase management effectiveness, and ensure overall satisfaction with the product or the service.

Quality, in all of its manifestations, is truly the wave of the future. Quality has applicability in every type of organization. When manufacturing and service companies, government and education, realize that customer satisfaction must become the highest goal of all organizations, then will the quality of American goods and services match or exceed the perceived quality of products and services made or offered offshore.

To accomplish this, we must begin to think along new lines, we must come to believe that, “quality involves living the message of the possibility of perfection and infinite improvement, living it day in and day out, decade by decade.”

ISO 9000: AN OVERVIEW

ISO 9000 is a universal, quality assurance (not quality “control”) management system endorsed by European Union and many other countries, particularly those in Southeast Asia. It is a checklist of functions, policies and rules considered necessary to assure the quality of a company’s products and services. The ISO 9000 family of standards was designed to be a generic process that can be used by manufacturing and service companies, worldwide.

The ISO 9000 family of standards sees quality as a process. Thus, the standard examines quality from beginning to end-user and considers service to be a part of the overall standard. ISO 9000 was developed by the International Standards Organization, and details about the scope and implementation of the standard were established in 1987. The standards have been revised several times since then, most recently in 2001.

The ISO standards have been broadened over the last few years to include issues dealing with non-quality. As an example, there is a set of environmental standards now used worldwide under the general heading of ISO 14000. A brand new ISO standard has just been announced that will deal with “Knowledge Management” as a distinct discipline. This standard was codified and published in late, 2002.

SIX SIGMA

The most recent innovation in quality assurance is known as “Six Sigma.” Six Sigma takes the statistical elements present in Total Quality Management and in ISO 9000 and raises them to the most important piece of quality. The overall goal of Six Sigma is bottom-line improvement. As such, it differs little from the other techniques. The proponents of this methodology claim that a full-scale implementation of Six Sigma will do at least the following:

  • Increase productivity
  • Reduce cycle time
  • Highlight reduced defects
  • Have high levels of outgoing quality
  • Standardize improvement efforts within the organization
  • Simplify improvement efforts, i.e., Business Process Engineering (BPR)
  • Improve customer satisfaction
  • Make a “dramatic” increase in the bottom-line

All of the ISO families of standards make use of trained auditors who assist companies wanting to achieve ISO certification. It can take up to a full year for an organization to become ISO 9000 certified. Companies and other kinds of organizations accomplishing the certification are well recognized in countries around the world. In Singapore or Malaysia is common to see full-page advertisements in the local newspapers heralding the accomplishment. A senior government official will usually preside at the ceremony where the certification document is present by ISO executives. Generally, companies must be recertified every three years, sooner if necessary.

Six Sigma auditors are referred to by their level of accomplishment under Six Sigma guidelines. There are four levels of inspectors’ training:

Black Belt:

The Black Belt level is held by individuals who have been trained in the Six Sigma methodology and have experience in leading Functional Process Improvement Action Teams.

Green Belt:

Holders of the Six Sigma Green Belt are team members in the Six Sigma Process Improvement Action Teams.

Master Black Belt:

The holder of this level of achievement acts as the organization-wide Six Sigma Program Manager. He or she, oversees Black Belts and improvement projects, while providing guidance to Black Belts as necessary. A Master Black Belt teaches other Six Sigma students and helps them to achieve higher level status.

Six Sigma Champion:

Usually a top executive or senior manager who “talks-the-talk”, and “walks-the-walk”, of Six Sigma. He/she is the catalyst behind the organization’s Six Sigma implementation. He/she has the ear of executive management.

SUMMARY

Each one of the techniques that have been developed to assist companies grow their quality have merit. Some are much easier to implement than are others. Some require a great deal of structure, while others are more informal. The Baldridge Criteria, for example, permits organizations to perform their own self-study. They can measure themselves against the criteria. Help is available, if required.

The ISO and Six Sigma methodologies are, understandably, quite complex in of themselves. Consulting firms, worldwide, have devoted their efforts to qualify their clients to the appropriate program. Implementation and certification can become very expensive, not including recertification after three years, as in the case of the ISO 9000 family of standards.

Each of these programs has helped to raise the idea of perceived and real quality, both to the internal customer, the employees, and to the external customer. These criteria have spun off even more complex standards that have become industry-specific. There are now standards that have been pattered after the ISO 9000 standard applicable to the automotive industry. Another set of standards has been applied to the aerospace industry. Boeing and Airbus build their aircraft with a set of ISO 9000-like standards, unique to the individual company.

Overall, these varying techniques have prioritized quality to become a focus point on product and service. Those companies that ignore quality will not be successful in the new era of global business.

 

REFERENCES ON GENERAL QUALITY ISSUES

·         Byham, William C. ZAPP! The Lightening of Empowerment. New York: Harmony Books, 1988. ISBN 0-517-58283-X.

·         Dobyns, Lloyd and Clare Crawford-Mason. Quality or Else: The Revolution in World Business. Boston: Houghton-Mifflin, 1991. ISBN 0-395-57439-0.

·         Harrington, H. James. The Improvement Process: How America’s Leading Companies Improve Quality. New York: McGraw-Hill, 1987. ISBN 0-07-026754-5.

·         Wellins, Richard. S., William C. Byham and Jeanne M. Wilson. Empowered Teams: Creating Self-Directed Work Groups that Improve Quality, Productivity, and Participation. San Francisco: Jossey-Bass, 1991. ISBN 1-55542-353-1.

·         Zeithaml, Valarie A., A. Parasuraman and Leonard L. Berry. Delivery Quality Service: Balancing Customer Perceptions and Expectations. New York: Free Press, 1990. ISBN 0-02-935701-2.

REFERENCES ON BENCHMARKING

·         Bogan, Christopher E. and Michael J. English. Benchmarking for Best Practices: Winning Through Innovative Adaptation. New York: McGraw-Hill, 1994. ISBN 0-07-006375-3.

·         Leibfried, Kathleen H. J. and C. J. McNair. Benchmarking: A Tool for Continuous Improvement. New York: Harper Business, 1992. ISBN 0-88730-548-2.

REFERENCES ON ISO 9000

·         Rabbitt, John T. and Peter A. Bergh. The ISO 9000 Book: A Global Competitor’s Guide to Compliance and Certification. White Plains, NY: Quality Resources, 1993. ISBN 0-8144-5175-6; 0-527-91721-4.

REFERENCES ON TOTAL QUALITY MANAGEMENT

·         Berry, Thomas H. Managing the Total Quality Transformation. New York: McGraw-Hill, 1991. ISBN 0-07-005071-6.

·         Biech, Elaine. TQM for Training. New York: McGraw-Hill, 1994. ISBN 0-07-005210-7.

·         Caronelli, Marlene. Total Quality Transformations. Amherst, MA: HRD Press, 1991. ISBN 0-87425-161-3.

·         Crosby, Philip B. Quality is Free: The Art of Making Quality Certain. New York: New American Library, 1979.

·         Garvin, David A. Managing Quality: The Strategic and Competitive Edge. New York: The Free Press, 1988. ISBN 0-02-911380-6.

·         Guaspari, John. I Know it When I See It: A Modern Fable About Quality. New York: AMACOM, 1985. ISBN 0-8144-5787-8.

·         Harrington, HJ. Total Improvement Management: The Next Generation Performance Improvement. New York: McGraw-Hill, 1995. ISBN 007-026770-7.

·         Hunt, V. Daniel. Quality in America: How to Implement A Competitive Quality Program. Homewood, IL: Business One Irwin, 1992. ISBN 1-55623-536-4.

·         Saylor, James H. TQM Field Manual. New York: McGraw-Hill, 1992. ISBN 0-07-157791-2.

BOOKS BY JOSEPH M. JURAN

·         Juran on Leadership for Quality: An Executive Handbook. New York: The Free Press, 1989. ISBN 0-02-916682-9.

·         Juran on Planning for Quality. New York: The Free Press, 1988. ISBN 0-02-916681-0.

·         Juran’s Quality Control Handbook. New York: McGraw- Hill, 1988. ISBN 0-07-033176-6.

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Conclusion

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RIA Merger Mania and the Medical PPMC Fiasco

What is Old is New Again -or- Lessons Learned

By Dr. David Edward Marcinko; MBA, CMP™

 dr-david-marcinko9According to the article Great Expectations-Disappointing Realities that recently appeared in Registered Representative, a trade magazine for the financial services industry, by John Churchill, the booming stock market of the last five years saw many Registered Investment Advisory [RIA] firms sell a portion of their future cash flows in return for cash and stock in an acquiring consolidating firm. This is known as a roll-up, or consolidator, business model. I am quite familiar with it, as both a doctor and financial advisor. I believe my dual perspective of both camps is somewhat unique, as well.

The NYSE Collapse

As the stock market collapsed in 2008-09, many RIAs who previously sold stakes to these “roll-up” consolidator firms began scrambling to pay quarterly preferred disbursements.  What gives, many implored? As a reformed Certified Financial Planner™, RIA representative, financial advisor and insurance agent, I can draw many parallels from these present day RIA consolidators to the similar Physician Practice Management Corporation roll-up fiasco of 1999-2000? Indeed, I can, and will [www.HealthcareFinancials.com]

My Experience with Medical Practice Consolidators

As a clinician and surgeon, I was the past president of a privately held regional Physician Practice Management Corporation [PPMC] in the Midwest. I assumed this route about a decade ago, by happenstance and background, when I helped consolidate 95 solo medical practices with about $50 million in revenues. But, our small company’s IPO roll-up attempt was aborted due to adverse market conditions, in 1999. Fortunately, a conservative business model based on debt, not the equity which was all the rage at the time, saved us right before the crash of 2000. So, we harvested fiscally conservative physicians who lost only a few operational start-up bucks; but no significant dollars.

On the other hand, those PPMCs roll-ups based on equity lost much more. In fact, according to the Cain Brothers index of public PPMCs, more than 95% of all equity value was lost by doctor-investors hoping to cash in on Wall Street’s riches they did not rightly deserve; not by practicing medicine but by betting on rising stock prices. So, projecting a repeat disaster from medicine, to the contemporary RIA consolidator business model, was not a great leap for me. And unfortunately, this was one of the few times I was all too correct in my prognostications.

PPMC’s Today

The type of medical consolidator or roll-up, formally called the Physician Practice Management Corporation [PPMC], was left for dead by the year 1999. Even survivors like Pediatrix Medical Group saw its stock drop precipitously. And, more than a few private medical practices had to be bought back by the same physicians that sold out to the PPMCs originally.

RIA Example

I sure hope this does not occur with FAs, as well. But, if an entity is being bought back and accounts receivables are being purchased, FAs should be careful not to pick this item up as income twice. The costs can be immense to the RIA practice, as later clients of mine learned the hard way.

Buy-Backs

For example, let’s say a family practice [or RIA?] purchased itself back from a PPMC, or RIA consolidator. Part of the mandatory purchase price, approximately $200,000 (the approximate net realizable value of the accounts receivable), was paid to the PPMC to buy back accounts receivable [ARs] generated by the physicians buying back their practice. Now, if an office administrator unknowingly begins recording the cash receipts specifically attributable to the purchased accounts receivable as patient fee income; trouble begins to brew. If left uncorrected, this error can incorrectly added $200,000 in income to this practice and cost it (a C Corporation) approximately $70,000 in additional income tax ($200,000 in fees x 35% tax rate). The error in the above example is that the PPMC [or RIA consolidator] must record the portion of the purchase price it received for the accounts receivable as patient [advisory] fee income. The buyer practice has merely traded one asset – cash – for another asset, the accounts receivable [ARs].  When the practice collects these particular receivables, the credit is applied against the purchased accounts receivable (an asset), rather than to patient [RIA] fees.  

RIA Revolution Follows PPMC Evolution

Today, surviving medical PPMCs are evolving from first generation multi-specialty national concerns, to second generation regional single specialty groups [my type], to third generation regional concerns, and finally to fourth generation Internet enabled service companies providing both business to business [B2B] solutions to affiliated medical practices, as well as business like consumer health solutions to plan members [healthcare 2.0]. I trust this sort of positive morphing will occur, over time, with the RIA consolidators. Perhaps yes, or no [www.HealthDictionarySeries.com]

RIA Consolidators

Among the most distressed RIA roll-up entities today may be the publically traded National Financial Partners and its more than 180 acquired firms, with more than 320 members in 41 states and Puerto Rico. NFP specializes in life insurance and wealth transfers, corporate and executive benefits, and financial planning and investment advisory services. Jessica M. Bibliowicz has been NFP’s President and CEO since inception in 1999. She is the daughter of Sandy Weill, and a member of the Board of Overseers for the Weill Medical College and Graduate School of Medical Sciences of Cornell University. NFP’s stock has declined from a high of $56 more than a year ago, to a current trading range of $3-4.           

And the Question Is?

And so, the question that MDs and RIAs should have asked when contemplating this business model was simply this: would I but the stock of an acquiring roll-up company if I were not part of the deal?

Valuable Consideration

Why? When MDs and RIAs sell to a consolidator, part of their “valuable consideration” is stock equity, so confidence and a conscientious work ethic is important. But, these “‘sell-out” entities are not retirement vehicles according to former financial advisor Hope Rachel Hetico; RN, MHA, CMP™ – a nurse executive and managing partner for www.MedicalBusinessAdvisors.com. Hope is also managing editor of this blog forum.

Assessment

More pointedly, according to one seller mentioned in the Churchill article,

“the whole [consolidator] pyramid is built on cash flows based on incremental growth and hugely optimistic projections of that growth”.  

Conclusion

Rest assured, the consolidator business model can be very successful; just think H. Wayne Huizenga’s Blockbuster Video and Waste Management, Inc. And so, your thoughts and comments on this Medical Executive-Post are appreciated? Why didn’t consolidation work in medicine, or with the RIAs? Or, reframed, why did consolidation work in the garbage collections industry and video store space? Can the fiercely independent RIA space learn something from the fiercely independent medical space?

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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About National Compliance Services, Inc.

Want, Need or Risk Reduction Mechanism?
Staff Reporters

cmp-logo6

As readers and subscribers to the Medical Executive Post, and our related print periodicals, dictionaries and books are aware, choosing the right financial consulting firm, or consultant, is always a challenging task www.HealthCareFinancials.com Today, this is true more than ever, given the financial meltdown and the all too obvious shenanigans of Wall Street www.HealthDictionarySeries.com Lay and physician investors alike are affected; along with related financial advisors of all stripes, degrees and designations [spurious or more credible] www.MedicalBusinessAdvisors.com

National Compliance Services

According to the National Compliance Services, Inc. [NCS] website, an experienced team of customer-oriented professionals is in place that strives to meet personal and corporate compliance needs so that clients can focus on areas of expertise www.NCSonline.com

A Protean Focus

NCS operates in the financial compliance and regulatory services industry. Its strength may be in providing efficient, and reasonably priced products and services for many different sub-arenas, such as: investment and financial advisors, hedge and mutual funds, stock-brokers and broker-dealers. Their customized services are designed to structure a compliance program that is appropriate for any individual, or firm’s unique regulatory needs. NCS works to ensure compliance with applicable federal and/or state rules and regulations.

Range of Products and Services

NCS has offered its personalized services to more than 6,000 clients, both domestically and internationally. Their consultants include former regulatory examiners, accountants, attorneys, and other individuals with extensive hands-on industry experience.

Verification Services

NCS also offers a standard or customized line of verification services to Mutual Funds, Hedge Funds, Custodians, Broker-Dealers, Investment Advisers, and Third-Party Vendors. Verification services can be customized to include any or all of the following:

  • Firm Registration/Notice Filing with the Proper Jurisdiction(s)
  • Adviser Representative Registration(s)
  • Adviser Representative Degree(s) or Professional Designation(s)
  • Firm Reported Disciplinary History
  • Adviser Representative Reported Disciplinary History
  • Proper Registration of Solicitors
  • Proper Registration of Wholesalers and Third-Party Vendors
  • Bank Background and Activity Reports, and
  • OFAC Checks, etc.

Assessment

Moreover, claims of verification for over 15,000 Registered Investment Advisers, and Investment Adviser Representatives, seem plausible. For example, NCS recently contacted www.CertifiMedicalPlanner.com to verify the good-standing of a member and charter-holder.

Contact Info:

For further information, please contact:

Alex Aghyarian
National Compliance Services, Inc
Verification Technician
Phone: 561.330.7645 ext 302 and Fax: 561.330.7044
aaghyarian@ncsonline.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Verification in most any space is worthwhile of course; but is membership in a vague or nebulous organization helpful or harmful to the uninitiated?

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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An Open Letter on eMRs from Hayward Zwerling MD

On eMRs Dangers and Expenses

Submitted by Darrell K. Prutt; DDS55909808

Like communicable diseases that nobody wants to discuss; eMRs are dangerous, incredibly expensive and not worth having for free.  

A Fresh Look at eMRs

A couple of weeks ago, Hayward Zwerling, M.D. uncovered a fresh look at what makes current eMRs so lame, and clinically described the underlying problem in a blunt way that only a doctor with clinical experience can do. Dr. Zwerling’s informative comment on Boston.com is in response to Lisa Wangsness’ Jan. 1 article, “Letter highlights hurdles in digitizing health records.”  

We should have known that CCHIT would draw parasites for natural reasons.   

http://people.boston.com/articles/nation/?p=articlecomments&activityId=6778798549471809193

Dr. Hayward Zweling Speaks

Under the Federal Government’s direction, CCHIT has been given the task of promoting IT (information technology) within the health care industry. Approximately half of CCHIT’s Board of Directors work for medical insurance companies, commercial medical informatic companies, physicians employed by very large group practices or eMR companies. As a result, CCHIT’s priorities have been tailored to reflect the interests of it’s Board of Directors, rather than the needs of the physicians and the health interests of our society at large.

CCHIT Force

CCHIT is now attempting to coerce physicians to purchase specific, expensive and “CCHIT certified” electronic medical record programs, which are designed to collect medical information. This information is “quantified; ” thereby creating a huge repository of all US healthcare interactions. As 16% of the US GDP is spent on healthcare, the amount of information that will be stored in these databases is massive and will eventually be available (for sale) to third parties. One can logically conclude that those organizations that have access to this information will be able to exert a hugh influence on the future of US healthcare.

Enter the Non-CCHIT Vendors

There are now several hundred non-CCHIT certified eMRs on the market which provide low cost and innovative solutions that are not otherwise available to physicians. If CCHIT’s influence remains unchecked, many small eMR companies will be forced out of business. The end result will be extremely disruptive to small medical practices, while forcing them to adopt expensive and bloated software while creating a frighteningly comprehensive healthcare database.

Unique Position

As a practicing physician who also has more than 15 years experience incorporating IT into small medical practice, I am in a unique position to understand the needs of the healthcare community and the potential of health IT. I am a firm believer that the appropriate use of health IT can improve the quality of healthcare. However, it is my opinion that the Federal Government needs to force the Certification Commission for Health Information Technology to alter their priorities so that they mirror the needs of the the majority of the medical community, rather than the interests of CCHIT’s Board of Directors and their representative companies. This can only be accomplished by replacing CCHIT’s Board of Directors, who has a financial interest in the health information technology industry, with people who have no financial connection to the medical-health IT-pharmaceutical industrial complex.

Eisenhower’s Farewell Address

In President Eisenhower’s Farewell Address, he said ” … we must guard against the acquisition of unwarranted influence … by the military-industrial complex … Only an alert and knowledgeable citizenry can compel the proper meshing of the huge industrial and military machinery … so that … liberty may prosper …”

The size of US’s medical-health IT-pharmaceutical industrial complex now rivals the size of its’ military-industrial complex and the parallel between the two industries is too obvious to be discounted. If we choose to ignore this historical precedent, then the future of healthcare in the USA will be controlled by several powerful industries, whose priorities do not necessarily parallel the health interests of our society. And once these industries take control of the health industry, their political influence will ensure that they will remain in control for many decades into the future.

Hayward Zwerling; MD, FACP, FACE

President, ComChart Medical Software

The Lowell Diabetes & Endocrine Center

Information Resources, LLC, Denver, Colorado

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Emergence of Online Doctors

Health 2.0 e-Consultations

Staff Reporters

insurance-book3

Did you ever wish that you could talk to a doctor without schlepping all the way to a crowded medical office where you’ll probably pick up even more germs? Well, if you live in Hawaii, you may be in luck. 

 

Computerworld Speaks to the Healthcare Industry

According to Computerworld, January 15, 2009, the Hawaii Medical Service Association (HMSA) just launched a new program where patients can connect with doctors over a standard Internet connection or telephone. The service is available 24 hours a day to anyone in the state.

Several Medical Specialties Available

Customers of the insurer pay $10 and non-HMSA members pay $45 per session. About 140 local doctors, including family physicians, cardiologists, ophthalmologists, pediatricians, psychiatrists and surgeons, have signed up to be available for questions.

Is Hawaii the Vanguard?

“HMSA’s Online Care is making Hawaii’s health care system more accessible to patients by overcoming the constraints of time, distance, mobility or lack of insurance,” so says Michael Gold, HMSA’s executive vice president and chief operating officer.

Assessment

HMSA, an independent licensee of the Blue Cross and Blue Shield Association, also notes that this is the first health plan in the US to provide state residents with online service. Now, we ask, is it coincidental that Hawaii is President-elect Barack Obama’s home state?

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. For example, what are the liability issues of this new health 2.0 dialog?

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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Medicare SGR Formula Fix

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The Daschle Imperative

[By Staff Reporters]caduceus

According to American Medical News, January 19, 2009, Tom Daschle, appearing at his first confirmation hearing to be Health and Human Services [HHS] secretary, pledged to replace Medicare’s sustainable growth rate [SGR] formula with a system that bundles payments in an attempt to reward good patient outcomes.

Recommendations

Apparently, Daschle also promised to examine inefficiencies in private Medicare plans, discourage tobacco use, support the training of primary care physicians and work with lawmakers in a bipartisan manner. Reports suggested that Medicare’s SGR formula “just isn’t working right.”

Expiring Patches

The latest in a series of temporary SGR reform payment patches expires at the end of 2009. If Congress doesn’t act before Jan. 1, 2010, doctors will undergo an estimated 21% Medicare pay cut. Any new formula should focus on bundling payments based on episodes of care instead of paying per procedure. Daschle said in the News reported, “I’m not one who supports the so-called performance- based approach, but I do believe that there are episodic ways with which to look at reimbursement that give us a lot more latitude” to reward better outcomes.

Assessment

He did not elaborate further.

Conclusion

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Protecting Your Pension

A Book Report for “Dummies”

Staff Reportersnyse

According to one review, this aptly-titled book Protecting Your Pension for Dummies [Wiley-July 2007, 978-0-470-10213] has proven to be prophetic in its early warnings against money-hungry financial advisors [FAs].

Watch the “Advisors”

The text, written by pension litigators Robert D. Gary and Jori Bloom Naegele, cautioned about hidden fees for financial advisors, lack of benchmarks for financial performance, inappropriate and risky investments, and heavily weighted distribution of plan investments in shaky company stock; etc. In other words, the traditional industry “bar of suitability”, is both ethically and legally low.

Assessment

For example, did you know that the financial services [read “sales”] industry has no definition for the term “financial advisor?”  According to one source, it can be a “butcher, baker or candle-stick maker.” Of course, there are many fine financial services salesmen and consultants “out-there”. But, finding one may be difficult. And, does it not seem that an increasingly number of pundits, like the authors of this book, and others, suggest their numbers are fewer and farther between than the industry itself suggests?

Terms: www.HealthDictionarySeries.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Are medical professionals, and the lay public, finally realizing that far too many of these FAs [read stock-brokers] are not fiduciaries working on your behalf; do not have to disclose conflicts of interest, and do not put client interests first?

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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Troubles Brewing for Physician Owned Hospitals

Financial Problems Predicted

Staff Reporterscrazy-house

According to the Wall Street Journal, January 22, 2009, a bill making its way through Congress to provide more low-income children with health-insurance coverage might mean financial trouble for scores of physician owned hospitals.  

 

Emergence and Growth

The very existence of doctor-owned hospitals is controversial. But, their numbers have tripled to about 200 since 1990.

The Supporters

Supporters say these hospitals, which usually focus on several lucrative services, such as cardiac care or orthopedics, are highly efficient, saving expenses for both patients and insurance programs, including Medicare.

More: www.HealthcareFinancials.com

The Critics

Critics say physicians who refer patients to hospitals with an ownership stake drive up costs, because they order more tests or perform unnecessary surgery. They argue that such hospitals also cherry pick healthy patients hurting surrounding non-profits hospitals.

Assessment

According to Pete Stark, chairman of the House Ways and Means health subcommittee, the proposed legislation would prohibit “the unethical kickbacks that physicians receive from ownership hospitals, most of which are of questionable safety and quality.”

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Do you agree, or disagree with the thesis; why or why not? Does this mean that not-for-profit hospitals, for-profit entities, or those hospitals with training programs don’t order un-needed tests? Are these hospitals and physician-investors, “crazy” or colorful and sane? 

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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Discount Dentistry Brokers

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More … on Sleazy Defenseless Companies

By Darrell K. Pruitt; DDS

I just came across a deceptive advertisement for a discount dentistry broker.

Yea, I know! What’s new? 

Why do we as healthcare providers silently allow naïve consumers to be so brazenly misled by sleazy businesses like Universal Benefit Plans and Universal Dental Plan, when we know they cheat their clients out of healthcare dollars?

Massachusetts Non-Profits

In a press release that announces their joint outreach initiative to aid Massachusetts nonprofits, it says Universal Dental Plan provides “… guaranteed rate discounts of 20-50% on all procedures.”

http://news.prnewswire.com/DisplayReleaseContent.aspx?ACCT=104&STORY=/www/story/01-06-2009/0004949991&EDATE=

Off the Top 

Just think – 20-50% off what – a super-inflated “retail” price? Dentists’ overhead easily tops 60%. If a dentist is losing 10% of his or her retirement just to do an intricate procedure for a gullible and trusting consumer who has no idea what is happening, how well do you think that work of art will chew? 

A Madoff Investment

Universal Dental Plan sounds almost as good as a Bernard L Madoff Investment, except that Ponzi tycoon Madoff accidentally promised quality before the wheels fell off. Universal Benefit Plans and Universal Dental Plan are sleazy companies who will never attempt to defend themselves on the Internet. They know better.

Assessment

This has been fun. Let’s do it again. And, if sleazy attorneys don’t like what I have to say about these two sleazy clients, come and get me.  But you better bring a ladder and a sack lunch. I’m not worried. I’ve said the same thing about Delta Dental, and they haven’t the guts to face me either [“Such a ‘Sleazy’ Company” on this Medical Executive-Post].

https://healthcarefinancials.wordpress.com/2008/09/19/%E2%80%9Csuch-a-sleazy-company%E2%80%9D/

Note: Dr. Pruitt blogs at PenWell and other dental sites, where this post first appeared.

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Conclusion

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ADA Mission Creep

Will that Be “Paper” or “Electrons?”pruitt1

[By Darrell K. Pruitt; DDS]

What is the mission of the American Dental Association? Is it the ADA’s obligation to keep failing dental insurance companies afloat – regardless of how much it raises the cost of providing dental care in the nation? Even necessary fee increases limit access. And so, what can the ADA possibly be thinking?

ADA News Online 

Recently, an article written by Arlene Furlong was posted on the ADA News Online with the title, “ADA studies scanning – Paper claim filers may benefit from sending scanned, printed radiographic images.”

http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3319

Of Possible Benefit 

The title promises that paper claim filers may benefit from scanned radiographic images. Do you know who definitely will benefit if radiographs don’t have to be returned to dentists? Two Dental insurance companies who were quoted in the article: American Health Insurance Plans [AHIP] and Delta Dental Plans Association [DDPA]. See: “Such a ‘Sleazy’ Company”.

https://healthcarefinancials.wordpress.com/2008/09/19/%E2%80%9Csuch-a-sleazy-company%E2%80%9D/

Outline of Arlene Furlong’s Article:

THE PROBLEM

“Dentists and their office staff report frustration in trying to keep track of varying policies.”

THE CAUSE

“Third-party payers continue to use different criteria to determine when images are needed to support claims adjudication, and if and how those radiographs will be returned to dentists.”

THE QUALIFIED SOLUTION

“Dentists who use digital radiography and file electronic claims can easily submit images electronically.”

THE COST

“Standard images, including single periapical films, panorex films and full-mouth films were scanned on four different scanners priced between $99 and $299.”

In addition, in order for a dentist to legally transmit digital patient information contained in one scanned periapical radiograph, one must be a HIPAA-covered entity. Furlong failed to mention the HIPAA liability that is not a problem with paper. It happens often when she writes articles as a favor to eHR stakeholders.

ADA CONCLUSION

Dr. Jeffrey Sameroff, a member of the ADA Councils on Dental Practice and Dental Benefit Programs (CDP) says:

“We still recommend dentists file electronic claims, but this option might be the next best thing for dentists who still submit on paper.”

THE QUALIFICATION

“Delta Dental Plans Association [DDPA} members told the councils that printed images from scanned radiographs would be adequate for initial claim review.”

Blue Cross Blue Shield Association and the National Association of Dental Plans [NADP] did not respond.

Ambiguous

The ambiguity and non-committal is obviously the reason that in spite of Dr. Sameroff’s enthusiasm, Furlong can only promise that it may or may not benefit ADA members to follow the advice in her article – but that we should nevertheless do it anyway just to get along with everyone. [The issue of whether the method of sending insurance companies radiographs affects dental care for patients is not addressed].

My Critique

This means that even after buying a scanner, Delta Dental can capriciously make the dentist still send the originals anyway. How good is that investment? Does it provide hope of a return, or does it encourage stakeholders to delay payments to dentists and pocket the interest? When insurance consultants question my ability to properly diagnose dental problems without actually meeting my patients, I will always mail them original radiographs that I expect to be returned because I think it should cost the insurance company a token amount of money to demand information from me.  Who cares if the US Post Office pockets some profit.  Postal workers need jobs too.

Unfettered

Without some sort of restraint, why should Delta Dental stop second-guessing me if delaying payment costs them nothing – even when I am expected to provide for free whatever they request to help their clients receive the benefit that Delta owes them?

What exactly is the mission of the ADA?

I would be a very foolish businessman to fall for this transparent trick – perpetrated by the ADA Councils on Dental Practice and Dental Benefit Programs (CDP). Of course, I’m not new in the neighborhood. I recall a similar article from May 9, 2006 by Arlene Furlong that most ADA members either never read or don’t remember. Its optimistic title is “It’s time to apply for a national provider identifier.” http://www.ada.org/prof/resources/topics/npi.asp

Selling Points

In order to persuade members to “volunteer” for the NPI, Furlong provided three selling points. As you can see for yourself, they are as laughable as Dr. Jeffrey Sameroff’s comments:

1. Providers, including dentists, will not have to maintain multiple, arbitrary identifiers required by dental plans, nor remember which number to use with which plan.

2. Electronic claims function more efficiently by introducing another element of standardization to processing.

3. It contains no vital intelligence about the provider’s name, location, specialty, patients or qualifications.

Rationalization

And so, to think that the best of Furlong’s three rationalizations – for “volunteering” – for an NPI number! The very best reason she gives for ADA members to trustingly expose their businesses’ proprietary information as FOIA – disclosable data – data which would otherwise be considered Constitutionally-protected private business information – is so that dental office managers will not have to remember numerous numbers.

DDPA 

What will sleazy dental insurance companies like Delta Dental do with the FOIA-disclosable information that ADA members are tricked into allowing them to manipulate?  Delta Dental, with the help of Arlene Furlong and the CDP, will determine American dentists’ reputations and pay scales according to their proprietary algorithms which will always seem to favor Delta Dental’s profitability and not their clients’ welfare.  It is called “P4P,” or Pay-for-Performance and it is part of George Bush’s mandate for healthcare reform.

Assessment

The CDP, a rogue collection of ambitious stakeholders, not practicing dentists, has expensive solutions that are desperately reaching for non-problems to solve. For every dollar I must raise my fees for even good ideas, a child in my neighborhood goes to bed with a toothache. Shouldn’t the ADA be more concerned about access to care than insurance companies’ postage expense?

Conclusion

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Defining Medical Sentinel-Events

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Shedding Light on Unexpected Occurrences

[By Staff Writers]lighthouse2

According to the Joint Commission on the Accreditation of Healthcare Organizations [JCAHO]:

“A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.”

About The Joint Commission

The Joint Commission on the Accreditation of Healthcare Organizations is an independent, not-for-profit organization. The Joint Commission accredits and certifies more than 15,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

Mission 

In support of its mission to improve the quality of health care provided to the public, the Joint Commission includes the review of organizations’ activities in response to sentinel events in its accreditation process, including all full accreditation surveys and random unannounced surveys.

Sentinel Event Glossary of Terms

Link: http://www.jointcommission.org/SentinelEvents/se_glossary.htm

Assessment

Of course, there are other accrediting organizations besides the JCAHO. These include DNV Healthcare Inc., a division of the Norwegian company Det Norske Veritas [DNV]. DNV has recently been charged with immediately determining if hospitals are in compliance with the Medicare Conditions of Participation [COP]. The company’s authority to accredit hospitals runs through September 26, 2012. DNV joins the American Osteopathic Association [AOA] as the only other national hospital accrediting agency approved by the Centers for Medicare and Medicaid Services [CMS].

Conclusion

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HIT and Privacy Issues

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Complications Retard Links to Medical Data

[By Staff Reporters]56371998

According to the New York Times, January 18, 2009, President-elect Barack Obama’s plan to link up doctors and hospitals with new information technology, as part of an ambitious job-creation program, is imperiled by a bitter and seemingly intractable dispute over how to protect the privacy of electronic medical records [eMRs and eHRs].

Health Law Policy and Administration

Lawmakers, caught in a cross-fire of lobbying by the health care industry and consumer groups, have thus far been unable to agree on privacy safeguards that would allow patients to control the use of their medical records.

Congress Steps-In

Congressional leaders plan to provide $20 billion for such technology in an economic stimulus bill whose cost could top $825 billion. The Times reported in a speech outlining his economic recovery plan, that Mr. Obama said, “We will make the immediate investments necessary to ensure that within five years all of America’s medical records are computerized.”

Assessment

Digital medical records could prevent medical errors, save lives and create hundreds of thousands of jobs, as Mr. Obama has said in the past. But, can they really? Many posts and comments on this blog suggest otherwise. 

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Conclusion

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ICD-10 Deadline Delay Achieved

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Two-Year Postponement Announced

[By Staff Reporters]

The Department of Health and Human Services [DHHS] just released the final rule for implementing the ICD-10 [International Classification of Diseases] CM [Clinical Modification] and ICD10-PCS [Procedure Coding System] insurance coding initiatives.

The Delay

The compliance deadline was shifted from October 1, 2011; as proposed in the original rule; to October 1, 2013.

What it is?

The ICD provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and given a code, up to six characters long. Such categories can include a set of similar diseases.

Assessment

The proposed rule was issued last August and presented for public comments.

Conclusion

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Of Financial Certifications and Designations

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The “Too Numerous to Count” Syndrome

[By Dr. David Edward Marcinko; MBA, CMP™]

Dr. MarcinkoThe following list of certifications enumerates only a partial exposure of the often nebulous field of “financial planning credentials” that presently exist in the market place. 

Good … and Not So

Some of these professional designations are awarded to individuals in the financial planning or financial “advisory” space after [some] diligent study and [often not so] arduous testing; others not so.

Disclaimer: I am a reformed Certified Financial Planner®, Series 7 [stock-broker], 63 and 65 license holder, and RIA representative who also held all applicable insurance and security licenses.

The individuals hold not only proper education [some only reguire a HS diploma or GED] as evidenced by the credential; the holders are often people of ethics [hopefully] and competence [usually]. But, not all credentials are the same. Some credentialing bodies have higher educational requirements that also require years of experience and a thorough background search. Others are awarded after only a few hours of study and, most all, remain non-fiduciary in nature.

Too Many To Count – Syndrome

In medicine, the abbreviation TNTC is well known. Sometime, I think this term is better applicable to the plethora of “credentials” in the financial services industry.

dhimc-book1

The Designation Line-up

A brief description for some of these financial designations [not degrees] follows:

  • AAMS – Accredited Asset Management Specialist
  • AEP – Accredited Estate Planner
  • AFC – Accredited Financial Counselor
  • AIF – Accredited Investment Fiduciary
  • AIFA – Accredited Investment Fiduciary Auditor
  • APP – Asset Protection Planner
  • BCA – Board Certified in Annuities
  • BCAA – Board Certified in Asset Allocation
  • BCE – Board Certified in Estate Planning
  • BCM – Board Certified in Mutual Funds
  • BCS – Board Certified in Securities
  • C3DWP – 3 Dimensional Wealth Practitioners
  • CAA – Certified Annuity Advisor
  • CAC – Certified Annuity Consultant
  • CAIA – Chartered Alternative Investment Analyst
  • CAM – Chartered Asset Manager
  • CAS – Chartered Annuity Specialist
  • CCPS – Certified College Planning Specialist
  • CDFA – Certified Divorce Financial Analyst
  • CEA – Certified Estate Advisor
  • CEBS – Certified Employee Benefit Specialist
  • CEP – Certified Estate Planner
  • CEPP – Chartered Estate Planning Practitioner
  • CFA – Chartered Financial Analyst
  • CFE – Certified Financial Educator
  • CFG – Certified Financial Gerontologist
  • CFP – Certified Financial Planner
  • CFPN – Christian Financial Professionals Network 
  • CFS – Certified Fund Specialist
  • CIC – Chartered Investment Counselor
  • CIMA – Certified Investment Analyst
  • CIMC – Certified Investment Management Consultant
  • CLTC – Certified in Long Term Care
  • CMFC – Chartered Mutual Fund Counselor
  • CMP – Certified Medical Planner™
  • CPC – Certified Pension Consultant
  • CPHQ – Certified Professional in Healthcare Quality
  • CPHQ – Certified Physician in Healthcare Quality
  • CPM – Chartered Portfolio Manager
  • CRA – Certified Retirement Administrator
  • CRC – Certified Retirement Counselor
  • CRFA – Certified Retirement Financial Advisor
  • CRP – Certified Risk Professional
  • CRPC – Chartered Retirement Planning Counselor
  • CRPS – Chartered Retirement Plan Specialist
  • CSA – Certified Senior Advisor
  • CSC – Certified Senior Consultant
  • CSFP – Certified Senior Financial Planner
  • CSS – Certified Senior Specialist
  • CTEP – Chartered Trust and Estate Planner
  • CTFA – Certified Trust and Financial Advisor
  • CWC – Certified Wealth Counselor
  • CWM – Chartered Wealth Manager
  • CWPP – Certified Wealth Preservation Planner
  • ECS –  Elder Care Specialist
  • FAD – financial Analyst Designate
  • FIC – Fraternal Insurance Counselor
  • FLMI – Fellow Life Management Institute
  • FRM – Financial Risk Manager
  • FSS – Financial Services Specialist
  • LIFA – Licensed Insurance Financial Analyst
  • MFP – Master Financial Professional
  • MSFS – Masters of Science Financial Service Degree
  • PFS – Personal Financial Specialist
  • PPC – Professional Plan Consultant
  • QFP – Qualified Financial Planner
  • REBC – Registered Employee Benefits Consultant
  • RFA – Registered Financial Associate
  • RFC – Registered Financial Consultant
  • RFG – Registered Financial Gerontologist
  • RFP – Registered Financial Planner
  • RFS – Registered Financial Specialist
  • RHU – Registered Health Underwriter
  • RPA – Registered Plans Associate
  • WMS – Wealth Management Specialist

This list is intentionally incomplete and it is not intended to be an endorsement of any credential by the Institute of Medical Business Advisors, Inc www.MedicalBusinessAdvisors.com

Alphabet Soup

Obviously, these “professional” designations spread across multiple industries. For example there is an alphabet of designations in the brokerage and securities field, another alphabet in the insurance industry and within the insurance industry, designations exist for those who meet face to face with prospective customers, another for those who provide client service and yet another in underwriting the various insurance products. Certainly when the designations are complied in a list such as that above, they present a dizzying array of apparent qualifications.

Assessment

While in general, education for the financial service [and medical] professional is good for everybody, there are certain things that you should do as proper due diligence to protect your family and your financial assets. What are they?

Disclaimer: I am also founder of the Certified Medical Planner™ online educational program in health economics for financial advisors and medical management consultants. www.CertifiedMedicalPlanner.org

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

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[Un] Predictable HIM Behavior

Predictable Reaction – Unknown Results

By Darrell K. Pruitt; DDSpruitt8

I posted this on the PennWell forum, and notified Lisa A. Algeo, editor of Advance for Health Information Professionals website, that I intend to adjust her reputation. 

http://community.pennwelldentalgroup.com/forum/topics/itching-to-start-something-in?page=1&commentId=2013420%3AComment%3A23719&x=1#2013420Comment23719

A few weeks ago, on December 15, when I posted “Itching to Start Something in HIM’s neighborhood,” I think we all suspected that my Advance website project would not end well for Advance. 

http://community.pennwelldentalgroup.com/forum/topics/itching-to-start-something-in

This is how I closed the initial comment of the doomed conversation:  “If I get any action, I’ll post it here on this thread. If there are no responses from the stakeholders, we’ll have some fun with the website itself.”

Time to Have Fun 

You knew it would happen. I consider it my civic duty to make an example of the Advance website and its archaic, slow-moving editorial policies.  I intend to make it clear to impressionable good ol’ boys that these days, customers should never be taken for granted.  Any one of us can reach out and grab you.  And now, the time has come to publicly adjust the reputation of an editor to show you how it is done.

Advance for Health Information Professionals

It looks like the information management specialists at the Advance for Health Information Professionals website cannot manage this provider’s information. That is regrettable, but it is as predictable as human nature in the absence of competition. The leaders of the Advance website, which caters to healthcare IT vendors, forgot that providers like me are the market.  That is a predictable poor business habit that reliably develops when there is lack of accountability in the marketplace.  It was this mentality produced the 1975 East-German Trabant automobile – the worst car ever.  Four years later, similar market protectionism in the US spawned the 1979 Ford Pinto – the second worst car ever.  Now we have eMRs that are so poor that they require Medicare kick-backs to entice doctors to even try them. 

History to Decide

In a few years, history could easily show that value and safety in healthcare didn’t matter as much to the Obama administration as preserving American jobs in the healthcare IT industry. That would be a harmful and avoidable waste.  As far as I can tell, it is up to me to stop healthcare IT before it gets to dentistry, any way I can.  If it becomes entertainment, so be it. Up until today, I had been graciously allowed to post occasional comments following the inviting Advance article “Help Write the History of HIM (Health Information Management).”  (no byline)

http://community.pennwelldentalgroup.com/forum/topics/will-pawlenty-drive-dentistry

Medical Executive-Post

Over the last month, I provided the website some of my best (polite) work.  Versions of the several of the pieces I posted on the Advance website went on to become fairly popular with Medical Executive-Post’s audience.

https://healthcarefinancials.wordpress.com/?s=darrell+pruitt+dds

Creative Disagreements 

Even though I was admittedly looking for a [polite] fight going into this adventure, I still thought there was a chance that information professionals, of all people, would be interested in an accurate history of HIM – including the perspective of a provider who is on the business end of their expensive and dangerous products.  As incredible as it sounds, it turns out that some information professionals don’t want truth at all. Creative history is not beyond the ethics of this type of ambitious, mandate-hugging collection of entrepreneurs.

Many of you who should know better; still cite a widely discredited 2005 Rand study that estimates that $77 billion will be saved in healthcare if providers will just go ahead and purchase expensive IT products. It makes no difference to this crowd that the study – funded by healthcare IT interests – was transparently one sided in favor of those who purchased the results as a business investment.

Advance Editor Responds 

Yesterday, shortly after submitting “Will Pawlenty drive dentistry out of Minnesota?” to the Advance website, I received the following email from Lisa A. Algeo, editor of Advance for Health Information Professionals (except dentists).

Hi Mr. Pruitt;

“I’m going to stop posting your comments, as they really aren’t relevant toward the article you’re posting on. Our audience does not consist of dentists.”

Sincerely,

Lisa A. Algeo

Editor

LAlgeo@advanceweb.com

Assessment

It is my opinion that Lisa A. Algeo and Advance for Health Information Professionals are irrelevant.  Now let’s see if I can make my opinion stick on Google, just like I did for another Advance contributor, Mark Rempe, vice president of Iron Mountain Health Information Services. 

Reference: (See “Bad move, Mark Rempe”) http://community.pennwelldentalgroup.com/forum/topics/itching-to-start-something-in?page=1&commentId=2013420%3AComment%3A22893&x=1#2013420Comment22893

Or; just googlesearch his name – my comment will return to his first page soon. Information is the product and digitalization the tool. Not the other way around. 

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Was this predictable HIM behavior from Advance? 

Note: Dr. Pruitt blogs at PenWell and others sites, where this post first appeared.

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 Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

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The Health Dictionary Series

What it is – How it works

By Dr. David Edward Marcinko; MBA, CMP™

By Hope Rachel Hetico; RN, MHA, CMP™

dhimc-book11

Each useful and up-to-date printed reference dictionary in the 3 volume comprehensive “Health Dictionary Series” Wiki project lists and defines more than ten thousand plus words, abbreviations, acronyms, slang-terms, initialisms and specialized non-clinical health terms; alphabetically.

First conceived as an ambitious and much needed project by the Institute of Medical Business Advisors Inc, in 2007, www.MedicalBusinessAdvisors.com, the “Health Dictionary Series” will contain more than 50,000 items upon completion in 2010; to be updated periodically thereafter. Three dictionaries have been released, to date 

For All Medical Specialties

Physicians, dentists, medical practitioners and allied healthcare professionals; clinic, practice and hospital administrators, managers and executives; nurses, business, graduate and medical school students; benefits managers, TPAs, HMOs and payers; financial planners, accountants, insurance agents and IT consultants; government officials, policy and decision makers, and all savvy patient consumers will find a wealth of information in these 4 volumes.

An iMBA Wiki Project

Your contributions are invited as a modern health 2.0 initiative.

Assessment

The series has even been electronically coupled as an interactive Wiki-like Collaborative Lexicon Submission Service; or social network to maintain continuous subject-matter expertise and peer-reviewed user input. And so, you too are invited to submit terms and join us.

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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Product DetailsProduct DetailsProduct Details       

Making Safer Investment Decisions

Taking Necessary Steps in 2009 

By Sean G. Todd, Esq; M. Tax, CFP®, CPA

Staff Writersfp-book2

It’s tough to tell how much a single physician-investor can do to preserve their assets in 2009, particularly with unprecedented government intervention in world markets. But, here are some general ideas to employ as markets and economies hopefully stabilize in the New Year.

In the Beginning 

Start with a plan – or review an old one. Physicians should be able to articulate their long-term investment goals. If you can’t discuss such goals in detail, not just “I want to make money”; it might be time to meet with a professional; or at least DIY. Much of the riskiest investing, overbuying and panic selling during the late 1990s and early 2000s, could have been avoided if physicians and individual investors had sought advice for achieving long-term specific goals such as retirement, medical practice succession planning, or a child’s college education.

A Fiscal Asset Check-Up 

Check all your assets in the bank. As a result of new federal economic bailout legislation, the Federal Deposit Insurance Corporation [FDIC] temporarily raised the per-deposit account, per bank coverage level from $100,000 to $250,000 through Dec. 31, 2009. Certain retirement-related accounts carry $250,000 of FDIC coverage, but again, check in with your bank to make sure you’re covered, and if not, get the right advice for moving funds so you don’t incur an unexpected tax liability or transfer fee. 

Understand Risk

Review your risk tolerance. Having a financial plan doesn’t mean make the plan and leave it to sit for years. In working with physician-clients during their investment reviews, we often discuss investment goals and feelings about them. Unfortunately, some non-clients and laymen [doctors, too!] are still unaware of all their investment risk exposure. We often see more risk in physician portfolios than what we believe to be prudent.      

Stay the Course 

Prepare to stay invested. Stock downturns are always filled with panic selling – and buying. If your financial plan is sound, be prepared to stay the course, and make sure to address your investment priorities. While times are tough, it’s wise to examine all your investment choices, your current investment portfolio to be sure it makes sense. Given a proper allocation, you’ll hopefully reap rewards when the market returns. 

Credit Gut Checks 

Check your credit: no one knows how long it might take to unravel the nation’s current credit situation. That’s why creditworthy doctors and other individuals might want to delay looking for new lines of credit until things loosen, and it’s definitely a good time to schedule review of each of your latest credit reports at staggered intervals throughout the next year. Why? Because in tough economies and times of tight credit, identity theft might be on the rise, and you’ll need to make sure the information on your credit data is truly your own. 

Cash is King 

Pay attention to your cash. Traditionally, many financial advisors said that you should have an emergency fund of at least three to six months’ worth of living expenses in case your practice or job situation goes south. But, the folks from the Institute of Medical Business Advisors www.MedicalBusinessAdvisors.com who sponsor this blog and communications forum, suggest even more for some employed physicians [12-24 months].

Liquid Opportunities

But, the market turbulence we’ve experienced also highlights the need to be somewhat liquid in your investment positions so you can take advantage of certain opportunities. Not every investment that’s lost value is necessarily a bad investment, and with careful study, you should be able to have cash on reserve so you can capitalize on legitimate opportunities.

Budget Priorities 

It’s a good time to make a budget or re-assess the one you have. Though the federal government would love you to start spending again and lift the economy, that doesn’t mean you have to jump in with both feet. Keep your spending smart, and your debt low so to achieve savings and investment priorities that will do you the most good when the economy and the market come back. 

Assessment 

Now, you may begin to realize these are the simple steps which are needed to review and address. This can be a DIY project, or you can seek the advice of a physician focused financial advisor or related professional.

Conclusion

Nevertheless, by giving priority to your financial planning endeavors, you may avoid some costly mistakes, in 2009. And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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 Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

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Checklists: Homer Simpson’s Moment of Clarity on Medical Quality

Accountants do it – Attorneys do it – Why Not Docs?

By Dr. David Edward Marcinko; MBA, CPHQ, CMP™insurance-book2

Like the Nike slogan, hospitals should just do-it! Make checklists, that is! A new report by the Associated Press, on January 15, 2009, suggests simple checklists might improve medical quality and save hospitals $15 billion a year.  

NEJM Study

The study was led by Atul Gawande MD, now a Harvard surgeon and medical journalist, and just published in the New England Journal of Medicine [NEJM]. The 19-item checklist, used in the study, was far more detailed than what is required for most institutions. In summary, doctors who followed a checklist of steps cut death rates from surgery, almost in half, and complications by more than a third in a large study on how to avoid blatant operating room mistakes.

The Checklist

The 19 point surgical checklist was developed by the World Health Organization [WHO] and includes common sense, and inexpensive, measures like these two:

  • Prior to the patient being given anesthesia, make sure relevant anatomy is marked, and everyone knows if the patient has an allergy.
  • After surgery, check that all the needles, sponges and instruments are accounted for.
  • Before the checklist was introduced, 1.5 percent of patients in a comparison group died within 30 days of surgery at eight hospitals. Afterward, the rate dropped to 0.8 percent — a 47 percent decrease. Duh; as Homer Simpson might say! Not exactly rocket science; is it?

Skeptics Exist

However, Dr. Peter Pronovost – a Johns Hopkins University researcher in my hometown of Baltimore – led a highly influential checklist study a few years back on cutting infection rates from various intravenous tubes. He was a skeptic of this study because the researchers collected their own data and acknowledged the possibility that results were partly skewed because folks perform better when observed.

A Next-Gen Quality Proponent

I have been a fan of Atul since his medical school and surgical training days as a resident at Brigham and Women’s Hospital in Boston. I even cited him as a precocious young up-start in the preface of my book, Insurance and Risk Management Strategies for Physicians and Advisors. His own works, of course, are best-sellers: Complications: A Surgeon’s Notes on an Imperfect Science, and Better: A Surgeon’s Notes on Performance. In fact, I often posit that he is a leading example of next-gen quality gurus, following in the foot-steps of Robert Wachter MD before him, and John E. Wennberg MD, MPH of the Dartmouth Atlas, before Bob.

My Experiences

Yet, far too many medical quality issues are being blindly addressed with powerful information technology systems. But, do we really need RFID tags to ensure proper side surgery, or bar codes bracelets for newborns? For example, while a medical student from Temple University back in the late seventies, I was observing surgery during an orthopedic rotation and noted the wrong extremity had been prepped and draped, awaiting the surgeons’ incision. Luckily, my big mouth was an advantage at the time. Decades later, at birth, I helped deliver my own daughter and immediately splashed a (far-too-large) swatch of gentian-violet on her left heel as an identifier; cheap … effective … simple. It did horrify the youngish nursing staff, but not so the more mature PICU staff. These, and related issues, might be alleviated with some managerial common sense; along with a dose of mindset change.

Assessment

With the Obama administration about to spend massive amounts of money on eHRs and other sophisticated – but largely unproven and non inter-operable HIT systems – medical quality improvement measures; perhaps it’s time to take a breath, think and KISS! 

Most medical practices, clinics and hospitals ought not [should not] operate at full capacity, and maybe the best patient care is driven by demand (needs) – and not the supply driven (wants) of administrators, doctors, stockholders and private [physician owned] hospitals and/or other stakeholders. Still, financial advisors do-it, automobile mechanics do-it; so why don’t docs and hospitals do it… the checklist-thing?

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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Financial Advisory “F” Bomb

Placing Client Interest before Self-Interest

Staff Writers

cmp-logo5

We are taking an informal poll, and are asking two key questions of financial intermediary modernity.

 

#1. As a financial advisor, regardless of designation, do you require a brokerage arbitration agreement; or not? Why or why not?

#2. Does this document place client interest first – as in a true fiduciary relationship – at all times? Please explain your rationale.

#3. Regardless of your philosophy – pro or con – regarding the use of arbitration agreements, do you give clients the option of selecting a fiduciary relationship; or not? Is it in writing?  

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Please respond; clients, doctors, laymen and FAs; etc. Is this query the ultimate “F” bomb?

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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Market Driven Healthcare

Keep Practicing Medicine

By Dr. David Edward Marcinko; MBA, CMP™

By Hope Rachel Hetico; RN, MHA, CMP™biz-book2

In the second edition our book, the Business of Medical Practice, we cite Regina E. Herzlinger, PhD, the Nancy R. McPherson professor of business administration and chair at Harvard Business School, and mother of a physician-daughter. Regina was a guest lecturer at Piedmont Hospital, here in Atlanta, GA last year, as we were fortunate to heed her advice decades ago.

Herzlinger Speaks

In her musings, Regina opines that there is little wonder that some physicians become depressed and want to give up their careers entirely when pondering the future of medicine, managed care and related compensation issues?

Healthcare Update

In fact, the newest Medicare Trustees Report projects a 4.7% reduction in physician reimbursements in 2009 and 37% in cumulative cuts over the next nine years. It notes that each year for the next decade will feature a roughly 5% cut in doctors’ pay – unless Congress steps in – while the costs to physicians of providing care increase by more than 2%. Trustees also noted that spending on Medicare Part B continues to rise at alarming levels and puts growing strain on beneficiary and government pocketbooks.

In response, the Bush administration repeated its call for nearly $36 billion in Medicare reductions over five years to hospitals and non-physicians, and pushed again for a physician quality reporting program that would lead to reimbursements based on individual performance against predetermined standards. What path the new Obama Administration will pursue is still not known?

Market Driven Healthcare

Nevertheless, Herzlinger implores in her book, Market Driven Healthcare, “don’t give up practice, yet.” Pragmatically, the future is bright and offers great opportunity to early adaptors who have the foresight to change medicine for the better and be handsomely compensated, too! But, physicians’ inability to deal with competitive market forces is well known and many are loath to deal with them.

Assessmentcmp-logo4

And so, one way is to seek a strategic competitive advantage is with additional education through a traditional Master’s Degree in Business Administration (MBA); or a new-wave online distance-education resource like the Certified Medical Planner program in health economics and medical management for financial advisors and healthcare consultants (CMP™). Tuition, textbooks and fees may be tax deductible. In this way, doctors may maintain their place as salary and compensation leaders in the U.S. labor force www.CertifiedMedicalPlanner.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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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About Hyoumanity

The Persistent Non-Diagnosis Dilemma

By Dr. David Edward Marcinko; MBA, CMP™dr-david-marcinko4

It is well known that computerized information systems [CIS] are increasingly being used to analyze the cost-effectiveness and quality of care given by medical providers. And, providers are slowly receiving clarity in the methods used to track their practice patterns, whether the tracking includes the cost of the practice, quality of care (such as frequency of preventive services that a practice provides), and/or outcomes monitoring.

Using information systems for such purposes is part of the growing field of medical informatics, which can be defined as the applied science at the junction of the disciplines of medicine, business, and information technology, which supports the healthcare delivery process and promotes measurable improvements in both quality of care and cost-effectiveness [Source: Medical College of Wisconsin, and www.HealthDictionarySeries.com].

Health Risk Assessment Data

Although HRA data are not generally used to profile care processes per se, such measures help to determine which members are at highest risk for chronic illness in the future, such as heart disease. And, according to our Business of Medical Practice print-book colleague – Brent A. Metfessel MD, MIS – patients usually fill out such surveys directly, as many Internet sites have sprung up which include free HRAs and calculation of risk scores. Included in HRA surveys are smoking history, dietary habits, general health questions, energy levels, emotional health, driving habits, and other parameters. Providers may use these results as guides to ascertain which members need the most intensive intervention and thus help prevent poor future outcomes http://www.springerpub.com/prod.aspx?prod_id=23759

None address the emerging problem of persistent non-diagnosis, however.

The Problem

Therefore, Bradley Kittredge of Hyoumanity suggests that a significant dilemma is emerging when addressing – or not addressing – HRA data relative to persistent non-diagnosis. In other words, the persistent non-diagnosis dilemma may represent a significant under-recognized and under-addressed emerging problem in our healthcare system today.

Not Iatric

This situation is unlike iatrogenic conditions which may be defined as those conditions that are physician induced [complications, “never-events”, allergic reactions, un-necessary treatments, interventions and/or surgery, etc]. More formally; iatros means physician in Greek, and-genic, meaning induced-by, is derived from the International Scientific Vocabulary [ISV]. Combined, of course, they become iatrogenic, meaning physician-induced. Iatrogenic disease is obviously, then, disease which is caused by a physician [www.iatrogenic.org].

The Definition

Blogger Kittredge – an MBA/MPH candidate for 2009 at the Haas School of Business at UC Berkeley and a Brian Maxwell Fellow – defines persistent non-diagnosis as:

“any patient who experiences clinical symptoms that five or more doctors are unable to diagnose.”

And, he opines that every day, thousands of Americans are desperately seeking answers to complex medical conditions that doctors are unable to diagnose.

Quality Improvement Initiatives

Findings ways to improve the process of diagnosis and the handling of these tough cases for both patients and doctors will reduce costs, improve health outcomes, and dramatically impact lives. It is the stuff of such medical quality improvement icons like Robert M. Wachter MD, Professor and Associate Chairman of the Department of Medicine at UCSF and my colleague and print-journal Foreword contributor David B. Nash; MD, MBA of the Jefferson Medical College in Philadelphia, PA www.HealthcareFinancials.com

Assessment

Currently, Brad is working to build an online tool to assist with complex and difficult diagnoses, which he considers among the biggest problems in medical care. His technical off-spring, Hyoumanity, is committed to improving awareness and understanding of the prevalence, causes, and implications of persistent non-diagnosis – and misdiagnosis – and to the development of tools to assist and empower patients and doctors to resolve complex cases [http://hyoumanity.blogspot.com]. We wish him well.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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 Organizations: www.HealthcareFinancials.com

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Non-Profit Hospital Accountability

Raising the Ethical Bar

Staff Reportersred-cross3

According to the Wall Street Journal, December 18 2008, Senator Charles Grassley – ranking Republican on the Senate Finance Committee – is weighing proposing legislation in early 2009 that would hold nonprofit hospitals more accountable for the billions of dollars in annual tax exemptions they enjoy.

Minimal Levels of Care Sought

The legislation would require non-profit hospitals to spend a minimum amount on charity care, and set curbs on executive compensation and conflicts of interest. Disclosure requirements would also be increased.

Assessment

Under the new legislation, penalties would be imposed on nonprofit hospitals that fail to meet the new requirements, while penalties could escalate from taxes and fines to stripping a hospital of its federal-tax exemption if it continues to misbehave.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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 Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Medical Tourism and Values Based Health Insurance

Join Our Mailing List

Two Emerging Medical Business Models

[By Dr. David Edward Marcinko; MBA, CMP™]dr-david-marcinko10

Last year, nurse-executive Hope Hetico; RN, MHA from www.MedicalBusinessAdvisors.com and I wrote a chapter on physician compensation for the book Practicing Medicine in the 21st Century. The book was edited by David B. Nash; MD, MBA of Jefferson Medical College, in Philadelphia. One of us [DEM] attended medical school at Temple University, so David clearly does not hold a grudge against us. Nevertheless, in the publication, we identified these two emerging trends that have grown even stronger with the passage of time:

Values Based Health Insurance Model

According to Mark Fendrick, MD and Michael E. Chernew, PhD, instead of the one size fits all approach of traditional health insurance, a “clinically-sensitive” cost-sharing system that supports co-payments related to evidence-based value for targeted patients seems plausible.

In this model, out-of-pocket costs are based on price and a cost/quality tradeoff in clinical circumstances: low co-payments for interventions of highest value, and higher co-payments for interventions with little proven health benefit. Smarter benefit packages are designed to combine disease management with cost sharing to address spending growth.

Medical Tourism and the Global Healthcare Model

American businesses are extending their cost-cutting initiatives to include offshore employee medical benefits, and facilities like the Bumrungrad Hospital in Bangkok Thailand (cosmetic surgery), and the Apollo Hospital in New Delhi India (cardiac and orthopedic surgery) which are premier examples for surgical care. Both are internationally recognized institutions that resemble five-star hotels equipped with the latest medical technology. Countries such as Finland, England and Canada are also catering to the English-speaking crowd, while dentistry is especially popular in Mexico and Costa Rica.

Although this is still considered “medical tourism,” Mercer Health and Benefits was recently retained by three Fortune 500 companies interested in contracting with offshore hospitals and JCAHO has accredited 88 foreign hospitals through a joint international commission. To be sure, when India can discount costs up to 80%, the effects on domestic hospital reimbursement and physician compensation may be assumed to increase downward compensation pressures.

Assessment

Another commentator on this topic is hospitalist Robert Wachter, MD; a blogger at Wachter’s World.

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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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The Build or Buy Decision in HIT

Out-Source or In-House?

Staff Writers

ho-journal6An important consideration when looking at the development of new health information technological functionality is whether to obtain the system from an outside vendor or build the system using primarily internal staff.

 

Criterion

Basically, according to healthcare Chief Information Officer [CIO] Richard Mata MD MIS, such a build or buy decision depends on the following aspects:

· Availability of internal resources to hire the highly skilled staff needed to create a new system;

· Availability of vendors with proven expertise in the area of technology relevant to the new project; and

· Flexibility of the vendors to customize their products, for hospitals or health entities, with unique needs.

Consultants versus FTEs

The temptation to use consultants rather than FTEs to develop and implement the new system needs exploring.

Advantages

On the positive side, finding consultants that have highly specialized expertise relevant to the project is often less difficult than finding such expertise in people willing to come on board as FTEs. Such expertise in clinical informatics may be critical to the success of the project.

Disadvantages

On the negative side, the cash outlay for multiple consultants can be staggering, especially if multiple consultants come on board with long-term contracts and retainers. Specialized consultants may charge up to $150 to $200 dollars per hour, quickly draining the most robust of IT budgets. Consultants should be used for just that — consulting. They exist on the project for their expertise and transfer of knowledge to the rest of the staff. To use consultants to do the hands-on tasks of actually building the system is generally not an optimal use of the consultant’s time. Consultants, if used at all, should typically be used on a temporary basis to share their expertise and advice during critical parts of the project.

Off the Shelf Applications

Overall, buying an application off the shelf may be favored for more sophisticated healthcare applications. For example, computerized order entry and eMR systems have a number of dedicated vendors that are vying to achieve market share. For major projects, distributing request for information (RFI) packages to selected vendors enables physician-executives and senior management to critically evaluate the different vendors in parallel, in the end selecting finalists and the vendor of choice. A critical requirement when evaluating vendors is that they have a strong client reference base. The best predictor of future success is past success, and thus multiple existing satisfied clients are essential in the chosen vendor.

Hospitals and Healthcare Systems

Larger academic or tertiary care systems, however, tend to have more access to expertise and more significant customization requirements. Consequently, building a home-grown system rather than outsourcing the work to a vendor may be the best strategy for such institutions.

Vendors

When working with vendors, one should be strategic in price negotiations. One suggestion is to link part of the vendor compensation to the success of the implementation. This puts the vendor partially “at risk” for project success and thus provides additional incentive for vendor cooperation. Additionally, one should not purchase a system or services from the initial bid. It is critical that more than one vendor bids for the project to provide a pricing and negotiation advantage.

There is nothing that states only one vendor can be chosen for a project.

Best-of-Breed

Although obtaining everything from one vendor can lead to a more seamless integration and prevent the juggling of multiple vendor relationships, using more than one vendor may in some cases lead to a higher quality end product. This is known as the “best of breed” approach and is a viable option, in particular for complex projects where a single vendor does not adequately meet user needs.

For more basic administrative systems, there are also off-the-shelf products from vendors that may be applicable. Where there is less need for customization, a single vendor may work out very well. Where there are significant unique needs that require customization, once again it may be best to develop the system internally or outsource the work to multiple vendors.

Assessment

There is also the issue of small or rural hospitals that have limited resources. For such institutions, investments in more complex information systems may be difficult. Consequently, many vendors offer “stripped down” versions of their systems at a more affordable price, specifically tailored to the small hospital. The ability to customize the system for unique needs, however, is significantly more limited.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. When launching a health information technology systems, how do you decide the question; in-source or outsource?

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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Dysfunctional Health Economics

Why Americans Pay More for Healthcare

Staff Reporterslife-preserver

According to Diana M. Farrell, Eric S. Jensen, and Bob Kocher, the US spends more on health care than comparable countries do and more than its wealth would suggest. Here’s how—and why.

 Link: The McKinsey Quarterly Report

http://www.mckinseyquarterly.com/Health_Care/Strategy_Analysis/Why_Americans_pay_more_for_health_care_2275

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Dentists – Don’t Crush that Fax

Just Hand Me the [Dental] Pliers

By Darrell K. Pruitt; DDSpruitt4

 

An article written by Arlene Furlong for the ADA News titled “HHS launches online health history tool,” was posted yesterday on ADA News Online. http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3388

The article announces the updated online (or paper) family health history that is a free download from HHS.  (See “Surgeon General’s Family History Initiative”)

http://hhs.gov/familyhistory

Just Imagine 

Imagine this: If this catches on, dentists will no longer have to wait until patients are finished filling out their health histories before being seated for treatment. There’s more. Dentists will no longer have to mail health history forms to patients prior to their appointments – an arguably unreliable method of avoiding the non-productive time spent waiting. There are occasions when the patients appear for their appointment just in time, with our health history form in their hands – sometimes in the envelope we sent a few days before. After introducing themselves to Janis, my office manager, they ask for a pen and clipboard.

The Options as I See Them

Option 1: If a dentist has a paperless practice, soon the uniformly-accepted document will be available for automatic download into the patient’s digital file, any time of the day, without anyone in the office lifting a finger.  However, for the modern convenience, there are modern liabilities.  The dentist must be a HIPAA-covered entity and assume significant risk of a breach that can adversely affect the welfare, and trust of the dentist’s patients. 

Option 2:  If a dentist has an office computer, but the patients’ treatment records are paper, the digital information can be printed for insertion into the patient’s folder, and then deleted.  HIPAA is not involved unless the information is stored digitally – as in, “We are sorry to inform you, Mrs. Aschbacker, but (insert name) neglected to delete your digital health history from one of our computers, and regretfully, we were hacked.” 

Option 3:  If a dentist does not have a computer, then a simple fax link will work swell.  HIPAA can be completely avoided.  But most importantly, patients’ privacy is not risked in a modern way.

Consider this Instead

I consider this to be either the first chance for healthcare providers to take control of the establishment of interoperability for the benefit of the principles in healthcare (providers and patients), or it is the last chance for it to happen if left to the stakeholders (everyone else).

HHS History 

The HHS health history includes not only the patient’s health information, but also questions the health of his or her relatives.  If one’s relative has cancer, emotional problems or even an addiction, how likely is it that the participant will be honest if he or she fears data breaches?  Breaches must be stopped for e-miracles to appear in healthcare. That is a fact. Now, dream with me a second!

Imagine the research capabilities if citizens are allowed to opt-in to an Internet platform and readily confide even their most personal health secrets.  It is simple to understand that the tightly held real or imagined symptoms are sometimes the most important.  These are also the secrets that some will not discuss with anyone but the doctor. It is my opinion that until we reliably de-identify eHRs, install a double-key security to access the records controlled by the owners of the information, and put the control of the development of miracles in the hands of the principles, eHRs will be dangerous, forever.  Trust only happens once in a lifetime.  We must not betray the interests of our patients for short-term, wasted bailout money, ADA.

Seeking Uniformity in CCHIT Requirement  

A uniform government-supported hybrid solution to interoperable health records is a beautiful idea in so many ways – especially expense.  It simply makes common sense to include fax connections in the CCHIT requirements [www.HealthDictionarySeries.com]. Consider what might happen in a hospital emergency room if the Internet goes down for some reason – it happens.  My advice is, don’t destroy those fax machines just yet.  They might come in handy – especially in a disaster.  That is why aircraft are built with redundant controls. Please consider it. 

Information is the product and digitalization the tool.  Not the other way around.

American Dental Association

I told the ADA about the hybrid fax idea a few weeks ago. Yet fax machines were not yet mentioned in Furlong’s article.  Why not?  Since the idea did not originate in the traditional chain of slow and measured thought that does not always begin with a principle, I assume its sudden presentation was too “out of nowhere” for the good ol’ boys to handle.  It is my opinion that the leadership model of the ADA is not flexible enough to think laterally very quickly.  That easily restricts timely movement that transparency demands, making the dinosaur very slow to react and defenseless in silence.

Assessment

Come on, boys, get with it. Do something relevant; or not!

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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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Note: Dr. Pruitt blogs at PenWell and others sites, where this post first appeared.

Hospital-Based Home Care Agencies

An Emerging and Evolving Industry

By Dr. David Edward Marcinko; MBA, CPHQ™, CMP™

By Thomas A. Muldowney; MSFS, CLU, ChFC, CFP® CMP™

By Hope Rachel Hetico; RN, MHA, CPHQ™, CMP™ho-journal8

Over the past decade, the home care industry has evolved away from agencies that are affiliated with hospitals and toward independent, non-facility-based agencies.

 

The Numbers

The number of home care agencies in the U.S. fell nearly 10% in this period, to 13,313 in 2006 from 14,670 in 1996. But, as the total number of home care agencies slipped over these 10 years, the number of agencies that were hospital-based plunged by more than one-third, to 1,636 from 2,563 in 1997.

Assessment

And, hospital-based home care agencies accounted for just 12.3% of all agencies in 2007-08, down notably from 17.0% in 1997.

More: www.HealthcareFinancials.com

Conclusion

Your thoughts and comments on this Medical Executive-Post are appreciated.

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Medicaid Supplemental Needs Trusts

Filling a Growing Space

By Dr. David Edward Marcinko; MBA, CPHQ™, CMP™

By Thomas A. Muldowney; MSFS, CLU, ChFC, CFP® CMP™

By Hope Rachel Hetico; RN, MHA, CPHQ™, CMP™dhimc-book2

Some states now allow family and friends (not the individual Medicaid applicant) of a disabled individual to establish a trust, either inter vivos or testamentary, that permits distributions of income or principal without jeopardizing the beneficiary’s right to Medicaid, Supplemental Security Income, and other public benefits.

Of Trusts and Trustees

The trust allows the trustee discretion to make payments directly to the provider of goods and services for the beneficiary’s benefit to supplement public benefits. The beneficiary may be a disabled person of any age who is expected to have long-term needs (medical, social, psychological, and so on).

The Limits

There are no limits on the amount of income or principal that otherwise may be expended on the beneficiary’s behalf. After the disabled beneficiary’s death, the state has no right of recovery against the funds remaining in the trust because the trust was funded with the assets of someone other than the disabled beneficiary. The trust is truly supplemental; its assets may pay for lifestyle comforts, but not for any expense covered under Medicaid.

Assessment

Thus, a son or daughter could establish such a trust to provide additional comforts to a parent in a Medicaid-paid nursing home without jeopardizing that parent’s right to continuing Medicaid support. Upon the death of the parent, the trust remainder can then revert to the child.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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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Disclosures Lacking in Drug Studies

New – Dark Alley – Report on Drug Studies

Staff Reportersdark-alley

A report in Bloomberg News, January 13, says that drug regulators haven’t done enough to force disclosure of financial conflicts among the researchers who conduct clinical trials of medications and medical devices.

 

Quid-pro-Quo

Financial connections between companies that make drugs and devices, and the doctors and other researchers who test them on humans, may compromise the safety of patients in studies and the integrity of the results.

According to the report, lawmakers led by Senator Charles Grassley [Republican from Iowa] have raised concern that conflicts of interest among doctors and manufacturers may influence prescribing decisions.

Assessment

Furthermore, the report said the “FDA should ensure that sponsors submit complete financial information for all clinical investigators.”  Is this a new or novel idea?

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Is this entire “pay-2-play” or “quid-pro-quo” idea another dark-alley of drug research and development; or not?

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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UnitedHealth Group Shenanigans

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Ingenix’s Lack of Independence Cited

[By Dr. David Edward Marcinko; MBA]

dem2

According to Melissa Dahl, Jeff Rossen and Robert Powell of msnbc.com on Jan. 13th, 2009, UnitedHealth Group agreed to pay $50 million in a settlement after being accused of over charging millions of Americans for health care.

The Investigation

An investigation was launched after receiving hundreds of complaints about Oxford Insurance and its parent company, which claims to rely on “independent research from across the health care industry” to determine reimbursement rates.

Faux Independence

In actuality though, it relies on the well known firm, Ingenix, a research arm owned by UnitedHealth Group. The allegations are that Ingenix has been manipulating the numbers so insurance companies pay less.

Other Insurers under Investigation

Although UnitedHealth Group and Oxford Insurance were the only entities investigated, other major insurers use Ingenix, including Aetna, CIGNA and WellPoint/Empire BlueCross BlueShield.

CEO Bill McGuire

The $50 million UnitedHealth Group will pay as the settlement will be used to create a nonprofit organization that will determine reimbursement rates for patients. William W. McGuire MD was the CEO of United from 1992 until his ignominious resignation in 2006, because of his involvement in an employee stock options scandal. Hence, rise of the insider moniker; “Useless Healthcare.”

Assessment

According to blogger Robert Laszewski,

“The big losers here are the docs. The result is going to be about the same and their medical societies will now have less reason to challenge the customary and reasonable system than they did before.”

As a medical practitioner, I eschewed contracts with this company a decade ago. Relative to peers, I was never so happy! Some companies just can’t seem to learn, or change their culture. But, the more important question to ask: is this indicative of an isolated rogue company, or the entire health insurance industry?

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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US Communications Decency Act

Our Disclaimer

By Dr. David Edward Marcinko; MBA

Editor-in-Chiefdr-david-marcinko5

Section 230 of the US Communications Decency Act:

“No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider.”

Thank you.

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Medicaid Trusts

Debunking the Myths

By Dr. David Edward Marcinko; MBA, CPHQ™, CMP™

By Thomas A. Muldowney; MSFS, CLU, ChFC, CFP® CMP™

By Hope Rachel Hetico; RN, MHA, CPHQ™, CMP™fp-book1

Some advisors, doctors, clients, patients and elders may believe that one way of avoiding the consumption of their assets, which they will use for nursing home care, is by transferring their resources into trusts. By putting their assets in trusts, elders and others believe that these assets will not be exposed to unwanted use and will be protected from claims by nursing home providers.

OBRA 1993 and DRA 2005

However, federal and state laws have severely reduced the use of trusts for this purpose; OBRA ’93 provided many of these restrictions. DRA’05 reduced it even more. Under this and earlier legislation, corpus and income of an inter vivos (a living trust) or self-settled trust are deemed to be resources of the grantor (and his or her spouse) even if the terms of the trust give full power of income and principal distribution to the trustee. (If any person creates a trust, even one that is irrevocable, that provides income to the original grantor, the trust is considered a grantor trust and will not work as an asset protection trust against the claims of lawful creditors – such as Nursing homes or medical providers.) 

Eliminated Trusts

Furthermore, certain trusts, including those in which the beneficial interest terminates when the beneficiary becomes institutionalized (conversion trusts) and those that require remaindermen approval for distributions of principal to the lifetime beneficiary (condition precedent trusts), have been eliminated as asset protection trusts.

Approved Trusts

Other trusts have been expressly approved. These include supplemental care trusts for disabled individuals not yet age 65, income assignment trusts for people affected by state income caps, and pooled fund accounts managed by nonprofit corporations.

Ancillary Benefits

The OBRA legislation also appears to have continued to make it possible to create irrevocable trusts in which the grantor retains only the income and the trustee has no discretion to distribute principal. By eliminating a trustee’s discretion to distribute principal, these trusts effectively protect the trust assets from being deemed legally available to the grantor for nursing home costs. Only the mandated income payments could legitimately be considered by state social service agencies.

The Advisor’s Role

Therefore, a financial planner of advisors can recommend “income-only” Medicaid qualifying trusts to those clients who wish to dispose of assets in order to qualify for Medicaid. The client can establish such a trust and receive its income. The income in excess of a personal needs allowance, determined on a state-by-state basis, and must be spent on medical costs. If the income amount is less than the client’s medical needs, the balance of the medical cost will be paid by Medicaid (unless the client lives in an income “cap” state). The trust corpus will not be available, as it has, in effect, been given away. The client’s purpose to protect principal has been carried out.  DRA’05 extends the look-back to sixty months. 

Assessment

So even income only trusts are under scrutiny if they were established as a means by which a grantor expected to qualify for Medicaid. Thus, if an income only trust is established, it must be established long before the application for Medicaid and before the 60 month look-back period.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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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Geriatric Care Management

Information for Advisors

By Dr. David Edward Marcinko; MBA, CPHQ™, CMP™

By Thomas A. Muldowney; MSFS, CLU, ChFC, CFP® CMP™

By Hope Rachel Hetico; RN, MHA, CPHQ™, CMP™dhimc-book4

According to the Dictionary of Health Insurance and Managed Care”, www.HealthDictionarySeries.com geriatric care managers (GCMs) and case managers (CMs), including those working with licensed agencies, often develop an initial assessment; design and implement plans; investigate and identify available LTC resources; supervise aides and LTC services; coordinate family support consistent with its resources; and accommodate client needs, preferences, and budget. GCMs and CMs may be the most important contact with many elders on a regular basis, because they are generally familiar with available private and public resources.

Long Term Care Plans

An LTC plan that includes the coordination of all services (legal, medical, social, financial, and so on) has to be developed, implemented, monitored, and modified as necessary. Low-cost or medically insured services should be incorporated into the care plan when available and appropriate. The GCM is usually the best person to coordinate these services.

Private LTC Management and Insurance

Private LTC management has become an industry. The industry is fragmented, but it is starting to operate on a national scale. Services for elders are available from diverse sources. GCMs often run their own licensed agencies or care-management companies. CMs work in licensed private agencies and for government, not-for-profit, and religious agencies.

Assessment

But, the question remains, is there a real need for LTC insurance, or are there better economic and societal ways to deal with this financial issue?

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

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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About PhoneFactor.com

New Corporate or Website Login Authentication Technology

By Alison Hill

By Darrell Pruitt; DDS

Staff Reporters56371998

Medical records are one of the most important documents to protect from identity thieves. If a hacker gets a patient’s medical records, they get the key to that person’s personal kingdom—insurance information, financial information, and access to very private matters that can affect job status, eligibility for mortgages—the implications are enormous.

What it Is

PhoneFactor is a simple two-factor authentication service that provides far greater security than usernames and passwords. The service can use any phone (mobile or landline) as a second form of authentication. It can be setup in minutes and eliminates the need for tokens, smart cards or certificates. The basic service is free with advanced modules available for enterprise-wide deployments. PhoneFactor solves the identity theft problem, protects patient privacy in real-time, and is so easy to use that doctors take to it instantly.

How it Works

Suppose a physician needs to remotely access a patient’s hospital files from his/her private practice office. The doctor keys his user ID and password into the hospital network. His/her cell phone rings instantly, prompting him/her to confirm the login. If the doctor keys in a PIN on his phone, s/he is given access. But, if not, the IT department back at the hospital is alerted immediately, access to the network is denied, and the attack is thwarted. The patient file is not compromised.

Assessment

PhoneFactor’s popularity is emerging in the medical industry as regulatory agencies push for additional security measures to ensure that only authorized individuals have access to hospital systems and patient data. The Health Insurance Portability and Accountability Act [HIPAA] and many state pharmacy boards are calling for strong authentication when accessing patient records or prescribing medicine through online systems. To comply, health care organizations must require more than a user name and password before allowing access to their systems. Often, these additional forms of authentication are not user-friendly. Many require users to carry a security token or other device, or restrict them to logging in from a particular computer.

Conclusion

www.PhoneFactor.com is purported to solve the security problems noted above. It does so by adding a second factor of authentication to any existing corporate or website login. We ask users and early-adopters to please comment and opine on this new service, and Medical Executive-Post. Your experiences are appreciated.  

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Hospital Capital Structure

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Understanding the Cost of Capital

[By Calvin W. Wiese; MBA, CPA]

[Staff Writers]

It is critical to understand and to measure the total cost of capital. Lack of understanding and appreciation of the total cost of capital is widespread, particularly among not-for-profit hospital executives.

Capital Structure Defined

The capital structure includes long-term debt and equity; total capital is the sum of these two. Each of these components has cost associated with it. For the long-term debt portion, this cost is explicit: it is the interest rate plus associated costs of placement and servicing. For the equity portion, the cost is not explicit and is widely misunderstood.

Capital Structure of Hospitals

In many cases, hospital capital structures include significant amounts of equity that has accumulated over many years of favorable operations. Too many physician and healthcare executives wrongly attribute zero cost to the equity portion of their capital structure. Although it is correct that generally accepted accounting principles continue to assign a zero cost to equity, there is opportunity cost associated with equity that needs to be considered. This cost is the opportunity available to utilize that capital in alternative ways.

Cost of Capital

In general, the cost attributed to equity is the return expected by the equity markets on hospital equity. This can be observed by evaluating the equity prices of hospital companies whose equity is traded on public stock exchanges. Usually the equity prices will imply cost of equity in the range of 10% to 14%; at least prior to the recent Wall Street meltdown.

Cost of Equity Exceeds Long-Term Debt

Almost always, the cost of equity implied by hospital equity prices traded on public stock exchanges will substantially exceed the cost of long-term debt. Thus, while many hospital executives will view the cost of equity to be substantially less than the cost of debt (i.e., to be zero), in nearly all cases, the appropriate cost of equity will be substantially greater than the cost of debt.

Weighted Average Cost of Capital

Hospitals need to measure their weighted average cost of capital. WACC is the cost of long-term debt multiplied by the ratio of long-term debt to total capital plus the cost of equity multiplied by the ratio of equity to total capital (where total capital is the sum of long-term debt and equity).

Hospital

Assessment

WACC is then used as the basis for capital charges associated with all capital investments. Capital investments should be expected to generate positive returns after applying this capital charge based on the WACC.

Conclusion

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Hospice Care Flourishing

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Varying Program Types

[By Dr. David Edward Marcinko; MBA, CPHQ™, CMP™]

[By Thomas A. Muldowney; MSFS, CLU, ChFC, CFP®, CMP™]

[By Hope Rachel Hetico; RN, MHA, CPHQ™, CMP™]dhimc-book3

According to the “Dictionary of Health Insurance and Managed Care”, hospices offer custodial and health care for terminally ill people with six months or so, to live. 

In and Out-patient Programs Available

While most hospice care can be provided at the patient’s home, there are inpatient care programs at some nursing homes depending on the circumstances of the patient. Hospice services are palliative and supportive.

Payment

Hospices are usually paid by Medicare or Medicaid.

Assessment

35.5% of Patients Receiving Hospice Care in The U.S. Stayed Less Than 7 Days.‏

Conclusion

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Weighted Role of Commercial Health Insurance

Understanding Disproportional Influence

By Dr. David Edward Marcinko; MBA,

ho-journal4Most domestic health care is paid for by some type of insurance, whether private or governmental. Most private health insurance is purchased through employers who, to a great degree, make most of the buying decisions. Employer coalitions have emerged but, in general, most command leverage on price rather than quality or value. This often leaves healthcare providers as the only advocates for the quality, choice and access concerns of consumers.

Business Impact

According to Robert James Cimasi, writing and opining in the print journal: Healthcare Organizations [Financial Management Strateges] www.HealthCareFinancials.com, despite the fact that businesses bear less of the total U.S. healthcare premium dollar (approximately 25%) than government or individuals; corporate buyers and their coalitions and associations have asserted substantial, if disproportionate, influence over healthcare companies.

Best Community Interest Debate

Whether or not this is necessarily always in the best interests of consumers or the community at large is a matter of heated debate. What is generally acknowledged is that the relative bargaining position of buyers and providers in a given market has a dramatic impact on healthcare provider financial performance.

Healthcare is Different

Much like F. Scott Fitzgerald’s different-rich; keep in mind that healthcare differs in several respects from other industry sectors, in that:

  • There is more than one class of buyers: there are patients, families (proxies), insurance companies, and employers, each with different objectives.
  • The single largest payer, the government, both dictates a large portion of the healthcare pricing structure and strongly influences the rest.
  • There is a crucial divide or (“disconnect”) between consumer and payer.
  • A lack of information regarding consumer needs and quality of providers impedes the purchasers of health insurance from selecting the optimal plan.

Assessment

Of course, the impact of the Obama administration on this topic has yet to be seen. 

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Is this commercial influence on health insurance good or bad; please share your experiences with us.

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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High-Tech Infection Tracking

The Hershey Experience or High-Tech Gamble?

Staff Reporters

gambling

At Hershey Medical Center, in Pennsylvania, a sophisticated computer program now serves as a watchdog for infection outbreaks.

 

 

Internet Enabled Health 2.0

According to the Associated Press, December 30 2008, with a few mouse clicks on a Web browser, the hospital’s infection-control staffers can quickly generate reports with charts and graphs illustrating how many patients within a particular unit are infected, and which lab specimen contained the germs; etc.

Assessment

Some Pennsylvania health officials view the nascent technology as a critical tool for helping hospitals reduce health care costs by identifying potential systemic infection-control problems sooner than is possible by reviewing paper records by hand. Other pundits may not agree!

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Will the data be reported for hospital quality improvement initiatives; or cloistered from stakeholders? And, will infection tracking and rate reporting finally become something more than a high-tech gamble?

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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An Open Letter to President [Elect] Barack Obama

Recognize and Protect Americans’ Right to

Health Information Privacy in Health IT

By Prudence Gourguechon; MD

By Elizabeth Clark; PhD, ACSW, MPH

US Capitol

Dear President-elect Obama:

We look forward to your inauguration with the hope that you will restore the public’s trust in the nation’s institutions which has been so badly shaken by the failed policies of the Bush Administration over the past eight years.  Nowhere is trust more important than in the delivery of quality health care and particularly for effective mental health care. 

Accordingly, we ask that you assure Americans that health information technology legislation under the Obama Administration will preserve and protect the patient’s right to health information privacy rather than erode or eliminate that right.”

We are encouraged that your nominee for DHHS Secretary, Senator Tom Daschle, has made prior statements reflecting support for the right to health information privacy in health IT legislation:

The issue of privacy touches virtually every American, often in extremely personal ways.  Whether it is bank records or medical files or Internet activities, Americans have a right to expect that personal matters will be kept private.  Today, in too many ways, however, our right to privacy is at risk.  Our laws have not kept up with sweeping technological changes.  As a result, some of our most sensitive, private matters end-up on databases that are then sold to the highest bidder.  That is wrong, it’s dangerous, and it has to stop.[1]

We are further encouraged by the recent statements of Senate Majority Leader Reid and House Majority Leader Hoyer that Congress should get the items in the stimulus package right “the first time.”[2]  In 2004, President Bush announced a goal of ensuring that most Americans health records would be accessible in an electronic health information system by 2014.[3]  The Department of Health and Human Services has pushed to accomplish that goal while demonstrating little commitment to preserving the individual’s right to HI privacy.[4]  HHS under the Bush Administration ignored the earlier HHS findings that strong privacy protections are essential if the full benefit of health IT is to be realized.[5]  The Bush Administration “replaced” the individual’s right of consent for the disclosure of identifiable health information adopted in the HIPAA Privacy Rule by the Clinton Administration, with “regulatory permission” for millions of covered entities and their business associates to disclose identifiable health information without the individual’s consent and over his or her objection.[6]  This policy reversal stripped Americans of their traditional health information privacy protection and essentially turned the HIPAA “Privacy” Rule into a disclosure rule.

In the past five years since the amended HIPAA Privacy Rule was put into effect, there have been more than 40,000 complaints of health information privacy violations of the HIPAA Privacy Rule, but HHS has not imposed a single civil penalty.[7]  Since January 2005, the privacy of more than 42 million electronic health records has been breached or compromised.[8]  Currently 250,000 Americans each year are victimized by health identity theft.[9]  A recent HIT industry survey found that all of the electronic health information systems currently in use are “severely at risk of being hacked” and the health information stolen or altered.[10]  According to Department of Justice figures, 67% of health care businesses that use health IT have been the victims of cybercrime resulting in the health IT systems of more than 80% of those businesses being down five hours or more at a cost of tens of thousands to hundreds of thousands of dollars.  Health care businesses reported the greatest duration of downtime of any category of business.[11]  Electronic data breaches increased by nearly 50% last year.[12]

It is, therefore, not surprising that nearly 70% of Americans have heard or read about medical records being lost or stolen, and most of those believe that computerized health records are the most vulnerable.  Approximately, 21 million Americans believe their medical records already have been lost or stolen.[13]

Even the Bush Administration has conceded belatedly that privacy protections are essential for public acceptance of a health IT system and that those protections must include the right of the individual to make an “informed decision” about the collection, use and disclosure of individually identifiable health information.[14]  HHS Secretary Leavitt recently stated, “Consumers shouldn’t be in a position to have to accept privacy risks they don’t want.”[15]

Other groups that have been hesitant in the past to support privacy protections have recently begun to acknowledge that health IT legislation must require privacy protections in the “forefront of all technological standards” and must assure the public that identifiable health information will be disclosed only with the patient’s consent.[16]  Even the Department of Homeland Security has recently adopted Fair Information Privacy Practices consistent with the Privacy Act of 1974 that require individual consent for the collection, use, dissemination, and maintenance of personal information.[17]

There should be no question that Americans have a right to privacy for highly personal health information.  The right to informational privacy was recognized by Congress as a “fundamental right” of all Americans protected by the Constitution in the Privacy Act of 1974 and by HHS under the Clinton Administration when it issued the original HIPAA Privacy Rule.[18]  According to prevailing case law, the Constitutional right to privacy for highly personal health information is now so well established that no reasonable person could be unaware of it.[19]  The right to health information privacy is also protected by the physician-patient privilege recognized in 43 states,[20] and the psychotherapist-patient privilege recognized in all 50 states, the District of Columbia and in Federal common law.[21]  The right to privacy of personal information including health information is also protected by the tort law or statutory law of all 50 states,[22] and 10 states include a specific right to privacy in their state constitutions.[23] 

HHS, under both the Bush and Clinton Administrations, has recognized that health information privacy is essential for quality health care because patients will not disclose information necessary for accurate diagnosis and treatment unless they are confident that their right to health information privacy will be protected.[24]  The patient’s right of consent for the disclosure of identifiable health information is also a core element of the standards for the ethical practice of health care for virtually all health professionals.[25]

Accordingly, we ask that you take a truly patient-centered approach to health IT and that you ground a national electronic health information system in the core concept of professional ethics which provides that, where possible, informed consent will be obtained for the disclosure of an individual’s identifiable health information.[26]

We recommend that you adopt the patient-centered, ethics-based approach to health IT set forth in the TRUST Act (H.R. 5442) which was introduced by Congressman Ed Markey in the last Congress and was co-sponsored by former Congressman Rahm Emanuel, current Energy and Commerce Chairman Henry Waxman and 13 other House members. 

The country needs a new direction in health information technology legislation that preserves and protects fundamental rights and acknowledges that, while health IT may provide benefits in the future, it also poses an immediate threat to the right to privacy that Americans cherish and expect.

With the greatest respect and hope for the future.

Prudence Gourguechon; MD

President

American Psychoanalytic Association

Elizabeth Clark; PhD, ACSW, MPH

Executive Director

National Association of Social Workers                           

 

For more information, contact:

James C. Pyles, Esq.                                                   

Powers Pyles Sutter & Verville, PC                                

1501 M Street, N.W., 7th Floor                                      

Washington, D.C.  20005                                               

202/466-6550                                                                

jim.pyles@ppsv.com                                                     

For the American Psychoanalytic Association            

James K. Finley

750 First Street, N.E.

Suite 700

Washington, D.C.  20002

292.366-8315

jfinley@naswdc.org

For the National Association of Social

Workers

 

REFERENCES:


[1]  Statement by Senator Tom Daschle on the establishment of the Congressional Privacy Caucus, Cong. Record-Senate, S11777 (Dec. 14, 2000).

[2]  Top Democrats Give Longer Timetable for Stimulus Bill, The Washington Post, A2 (Jan. 5, 2009).

[3]  “President Bush’s Technology Agenda,” (Jan. 20, 2004). http://www.whitehouse.gov/infocus/technology/economic_policy200404/chap3.html

[4]  Health Information Technology, Efforts Continue but Comprehensive Privacy Approach Needed for National Strategy, GAO-07-988T, p. 3 (June 19, 2007); Health Information Technology, Early Efforts Initiated but Comprehensive Privacy Approach Needed for National Strategy, GAO-07-238, p. 4 (Jan. 10, 2007).

[5]  65 F.R. 82,466 (Dec. 28, 2000).

[6]  Compare, “Our regulation will ensure that those consents cover the routine uses and disclosures of health information, and provide an opportunity for individuals to obtain further information and have further discussions, should they so desire.”  65 F.R. 82,474 (Dec. 28, 2000) with “The consent provisions…are replaced with a new provision…that provides regulatory permission for covered entities to use or disclose protected health information for treatment, payment and health care operations.”  67 F.R. 53,211 (Aug. 14, 2002). 

[7]  Health Information Privacy/Security Alert (Jan. 5, 2008).

[9]  “Panel:  Electronic Health Records May Save Money, But Can They Keep Information Safe?”  CQ Healthbeat News (June 19, 2008).

[10] “Electronic Records at Risk of Being Hacked, Report Warns,” Search CIO.com (Sept. 19, 2007).

[11] Cybercrime Against Businesses, 2005, U.S. Dept. of Justice, Bureau of Justice Statistics, Special Report, pp. 6, 13, 16, 18-19 (Dec. 2008).

[12] Data Breaches Up Almost 50%, The Washington Post, D2 (Jan. 6, 2009).

[13] “Millions Believe Personal Medical Information has Been Lost or Stolen,” Harris Poll (July 15, 2008). 

[14] “Individual Choice Principle,” HHS Privacy Principles (Dec. 15, 2008). http://www.hhs.gov/healthit/documents/NationwidePS_Framework.pdf

[15] HHS News Release (Dec. 15, 2008).

[17] Privacy Policy Memorandum, Department of Homeland Security, p.3 (Dec. 29, 2008).

    http://www.dhs.gov/xlibrary/assets/privacy/privacy_policyguide_2008-01.pdf

[18] Pub. L. 93-579, sec. 2(a)(4):  “The Congress finds that the right to privacy is a personal and fundamental right protected by the Constitution of the United States.”  “Privacy is a fundamental right.”  65 F.R. 82,464 (Dec. 28, 2000). 

[19] Gruenke v. Seip, 225 F.3d 290, 302-03 (3rd Cir. 2000).  See also, Sterling v. Borough of Minersville, 232 F.3d 190, 198 (3rd Cir. 2000). 

[20] See, e.g., Northwest Mem. Hosp. v. Ashcroft, 362 F.3d 923 (7th Cir. 2004).

[21] Jaffee v. Redmond, 116 S.Ct. 1923 (1996).

[22] HHS Finding, 65 F.R. 82,464 (Dec. 28, 2000).

[23] Those states are Alaska, Arizona, California, Florida, Hawaii, Illinois, Louisiana, Montana, South Carolina, and Washington.

[24] National Privacy and Security Framework, p.1, Dept. of HHS (Dec. 15, 2008); 65 F.R. 82,468 (Dec. 28, 2000). 

[25] Finding of National Committee on Vital and Health Statistics, report to Sec. Leavitt, p. 3 (June 22, 2006).

[26] American Medical Association policy, H-315.978 Privacy and Confidentiality, reaffirmed 2001.

 

Locum Tenens Medical Practitioners

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Employment Considerations of a Nomadic Lifestyle

By Dr. David Edward Marcinko; MBA, CMP™

autos1

Locum Tenens [LT] is an alternative to full-time employment for most medical specialties. And, although having never personally used this business model myself [my past work history does include moonlighting, acting as an assistant surgeon, litigation support duties, and/or weekend / after-hours employment], this business model is increasingly attractive to many doctors.

Addressing the Physician Shortage

It is well known that the physician shortage is especially acute in rural America where LT recruiting firms do at least 60% of their business. For example, the National Rural Health Association [NRHA] and the federal Office of Rural Health Policy [ORHP] reports that roughly 25 percent of the U.S. population lives in rural America, but only 10 percent of US physicians practice in these areas. There are 2,157 Health Professional Shortage Areas [HPSA’s] in frontier areas of all states and US territories; compared to 910 in urban areas.

Benefits and Disadvantages

Younger physicians seem to enjoy the travel and excitement of the LT model, while mature physicians like to practice at their leisure. Of course, the lack of a permanent office presence, with its potential equity build-up and little community involvement, may be considered drawbacks of the LT business model

Employment Factors

LT employment factors to consider include third-party employment firm reputation, malpractice insurance, credentialing, travel and relocation expenses [which are negotiable].  

Salary Considerations

A recent survey by LocumTenens.com revealed the following salary considerations:

www.CertifiedMedicalPlanner.org

Assessment

Moreover, a LT firm typically will not cover taxes. 

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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