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In Severe Pandemic, Officials Ponder Disconnecting Ventilators

Understanding the So-Called New York Protocol

By Sheri Fink

ProPublica NewsEmergency Sign

With scant public input, state and federal officials are pushing ahead with plans that — during a severe flu outbreak — would deny use of scarce ventilators by some patients to assure they would be available for patients judged to benefit the most from them. 

The plans have been drawn up to give doctors specific guidelines for extreme circumstances, and they include procedures under which patients who weren’t improving would be removed from life support with or without permission of the families. 

The plans are designed to go into effect if the U.S. were struck by a severe flu pandemic comparable to the 1918 outbreak that killed an estimated 50 million people worldwide. State and federal health officials have concluded that such a pandemic would sicken far more people needing ventilators than could be treated by the available supplies. 

VA Guidelines

Many of the draft guidelines, including those drawn up by the Veterans Health Administration, are based in part on a draft plan New York officials posted on a state web site two years ago and subsequently published in an academic journal. The New York protocol, which is still being finalized, also calls for hospitals to withhold ventilators from patients with serious chronic conditions such as kidney failure, cancers that have spread and have a poor prognosis, or “severe, irreversible neurological” conditions that are likely to be deadly. 

New York officials are studying possible legal grounds under which the governor could suspend a state law that bars doctors from removing patients from life support without the express consent of the patient or his or her authorized health agent. 

Medicare Payment

State and federal officials involved with drafting the plans say they have been disquieted by this summer’s uproar over whether Medicare should pay for end-of-life consultations with families. They acknowledged that the measures under discussion go far beyond anything the public understands about how hospitals might handle a severe pandemic. 

By every indication, state and federal officials expect to weather this year’s flu season without having to ration ventilators. That assumes that the H1N1 virus will not mutate into a more serious killer, the vaccines against it and the other seasonal flus will continue to prove effective, and any dramatic surges in the number of patients in need of ventilators will occur in different parts of the U.S. at different times. 

In recent months, New York officials have met three times with physicians, respiratory therapists and administrators to rehearse how their plan might play out in hospitals in a severe epidemic. In one of those “tabletop exercises,” participants suggested that the names of triage officers charged with making life and death choices among patients at each hospital should be kept secret. The secrecy would be needed, participants said in interviews, to avoid pressure and blame from colleagues caring for patients who were selected to be taken off life support. 

When they posted their plan on the web in coordination with a video conference in 2007, New York officials promised to solicit public input. Since then, they have consulted with medical and legal professionals and other experts, but few members of the general public, and the plan has remained unchanged. They declined to make the comments they have gathered immediately available for review, and those comments are not published on the Health Department’s Web site

In the initial proposal, officials called public review “an important component in fulfilling the ethical obligation to promote transparency and just guidelines.” 

The academic publication of the plan envisaged the use of focus groups to solicit comment from “a range of community members, including parents, older adults, people with disabilities, and communities of color.” Those have not been held. 

Beth Roxland, the current executive director of the New York State Task Force on Life and the Law, said the ethicists included in the state’s planning process focused largely on vulnerable populations. “Even if we didn’t have direct input from vulnerable populations,” she said, “their interests have been well accounted for.” Roxland said that public comment solicited when the ventilator plan was posted on the Health Department Web site was “sparse.” 

Dr. Guthrie Birkhead, Deputy Commissioner of the Office of Public Health for New York State said he wondered whether it was possible to get the public to accept the plans. “In the absence of an extreme emergency, I don’t know. How do you even engage them to explain it to them?” 

Even so, other states, hospital systems and the Veterans Health Administration—which has 153 medical centers across all states — have drafted protocols that are based in part on New York’s plan. The inclusion and exclusion criteria for access to ventilators, however, are different. For example, under the current drafts, a patient on dialysis would be considered for a ventilator in a VA hospital in New York during a severe pandemic, but not in another New York hospital that followed the State’s plan, which excludes dialysis patients. The VA’s exclusion criteria are looser because the patient population it is charged with serving is typically older and sicker than in other acute care hospitals. Different states, reflecting different values, have also established different criteria for who gets access to lifesaving resources. 

IOM Input

The Institute of Medicine, an independent national advisory body, is expected to release a report on Thursday morning, at the request of the U.S. Department of Health and Human Services, that will recommend broad guidelines to help guide planners crafting altered standards of care in emergencies. At an open meeting held to inform the report on Sept. 1, participants described successful public exercises related to allocating scarce resources in Utah and in a Centers for Disease Control and Prevention study conducted in Seattle. 

Questions about how hospitals would handle massive demand for life support equipment arose when New York state health department officials ran exercises based on a scenarios involving H5N1 avian influenza.

“They kept running out of ventilators,” said Dr. Tia Powell, director of the Montefiore-Einstein Center for Bioethics and former executive director of the New York State Task Force on Life and the Law, which was asked to address the problem. “They immediately recognized this is the worst thing we’ve ever imagined. What on earth are we going to do?” 

Officials calculated that 18,000 additional New Yorkers would require ventilators in the peak week of a flu outbreak as deadly as the 1918 pandemic. Only a thousand machines would be available, the officials estimated. The state’s acute care hospitals in 2005 had about 6000 ventilators, 85% of which were normally in use. A moderately severe pandemic would have resulted in a shortfall of 1256 ventilators, health officials found. 

In 2006, New York planners convened a group of experts in disaster medicine, bioethics and public policy to come up with a response. After months of discussion, the group produced the system for allocating ventilators. They first recommended a number of ways that hospitals could stretch supply, for example by canceling all elective surgeries during a severe pandemic. The state has also since purchased and stockpiled 1700 Pulmonetic Systems LTV 1200 ventilators (Cardinal Health Inc., NYSE) — enough to deal with a moderate pandemic but not one of 1918 scale. 

Officials realized those two measures alone would not be enough to meet demand in a worst-case scenario. Ventilators were costly, required highly trained operators, and used oxygen, which could be limited in a disaster. 

Ventilator Rationing

The group then drew up plans for rationing of ventilators. The goal, participants said, was to save as many lives as possible while adhering to an ethical framework. This represented a departure from the usual medical standard of care, which focuses on doing everything possible to save each individual life. Setting out guidelines in advance of a crisis was a way to avoid putting exhausted, stressed front line health professionals in the position of having to come up with criteria for making excruciating life and death decisions in the midst of a crisis, as many New Orleans health professionals had to do after Hurricane Katrina.

The group based its plans, in part, on a 2006 protocol developed by health officials in Ontario, Canada which relied on quantitative assessments of organ function to decide which patients would have preference for an intensive care unit bed. The tool, known as the Sequential Organ Failure Assessment (SOFA) score, is not designed to predict survival, and not validated for use in children, but the experts adopted it in light of the lack of an appropriate alternative triage system. 

This summer, New York officials brought the state’s plan to groups from several New York hospitals for the tabletop exercises. They met behind closed doors to assess how hospitals might implement the proposed measures if the H1N1 pandemic turned unexpectedly severe this fall. In the fictional scenario, paramedics were ordered not to place breathing tubes into patients until physicians “can assess whether they meet the criteria to be placed on a ventilator.’’ 

Problems were immediately apparent. Dr. Kenneth Prager, a professor of medicine and director of clinical ethics at Columbia University Medical Center, was concerned about the lack of awareness of the plan among the larger public and the majority of the medical community. Societal input “is totally absent,” he said and called for more outreach to the public. “Maybe society will say, ‘We don’t agree with your plan. You may think it’s ethically OK; we don’t.'” 

The Protocol

The protocol, he said, would also place a great burden on clinicians charged with selecting which patients would be removed from life support. Physicians were concerned doctors involved in the legitimate and painful selection processes might be inappropriately construed as “death squads.” “We facetiously dubbed them the ‘death squad’ or the ‘guys in the back room’,” Prager said. He envisioned family members breaking down and screaming when they found out their loved ones would be disconnected from ventilators. “It really is a nightmare.” 

Even so, he felt that the plan – and its effort to save the greatest number of patients – was ethically appropriate. “If we don’t use triage, people will die who would have otherwise been saved,” he said, because a number of ventilators are “being used to prolong the dying process of patients with virtually no chance of surviving.” 

Doctors at the exercises feared that they would be sued by angry patients if they followed the draft guidelines. “There’s absolutely no legal backing for physicians,” said Lauren Ferrante, a medical resident at Columbia University Medical Center. “Who’s to say we’re not going to get sued for malpractice?” 

New York State law forbids doctors from removing living patients from ventilators or other life support except in cases where the patient has clearly stated such wishes, for example in a living will, or through his or her legal health care agent. Other sources of liability could come from federal and state anti-discrimination laws or claims of denial of due process. 

New York officials said they were currently working out legal options for implementing the plans, such as gubernatorial emergency declarations or emergency legislation. 

“You can take something today that’s not necessarily active and overnight flip the switch and make it into something that has those teeth in it,” said Dr. Powell, who served on the committee that drafted the plan.

Dr. Powell cautioned that it is critically important to maintain flexibility in the guidelines. Any rationing measures taken in a disaster must be calibrated to need and severity. 

Guidelines can also promote investment in new technology, such as cheaper, easier to use ventilators that would make rationing less likely. Already at least one company, St. Louis-based Allied Healthcare Products, is marketing a line of ventilators specifically for use in disasters. 

Some states, including Louisiana and Indiana, have adopted laws that immunize health professionals against civil lawsuits for their work in disasters. Other states, including Colorado, have drawn up a series of relevant executive orders that could be applied to address these issues.

Assessment 

Dr. Carl Schultz, a professor of emergency medicine at the University of California at Irvine and co-editor of the forthcoming textbook, Koenig and Schultz’s Disaster Medicine (Cambridge University Press), is one of the few open critics of the establishment of altered standards of care for disasters. He says the idea “has both monetary and regulatory attractiveness” to governments and companies because it relieves them of having to strive to provide better care. “The problem with lowering the standard of care is where do you stop? How low do you go? If you don’t want to put any more resources in disaster response, you keep lowering the standard.” 

Federal officials disagree. “Our goal is always to provide the highest standard of care under the circumstances,” said RADM Ann Knebel, deputy director of preparedness and planning at the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services. “If you don’t plan, then you are less likely to be able to reuse, reallocate and maximize the resources at your disposal, because you have people who’ve never thought about how they’d respond to those circumstances.”

Note: Sheri Fink is a reporter for the ProPublica news service, which first published this article.

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Whither Physician Self-Portfolio Management?

Do it Yourself Considerations

By Clifton N. McIntire, Jr.; CIMA, CFP®

By Lisa Ellen McIntire; CIMA, CFP®fp-book

In order to self create and monitor an investment portfolio for personal, office, or medical foundation use, the physician investor should ask him/herself three questions:

1. How much do I have invested?

2. How much did I make on my investments?

3. How much risk did I take to get that rate of return?

How Am I Doing?

Most doctors and health care professionals know how much money they have invested. If they don’t, they can add a few statements together to obtain a total. Few actually know the rate of return achieved during last year’s debacle, or so far this year in 2009. Everyone can get this number by simply subtracting the ending balance from the beginning balance and dividing the difference. But, few take the time to do it. Why? A typical response to the question is, “We were doing fine” -or- “We did terrible last year.”

But, ask how much risk is in the portfolio and help is needed. Nobel laureate Harry Markowitz, PhD said, “If you take more risk, you deserve more return.” Using standard deviation, he referred to the “variability of returns” –  in other words, how much the portfolio goes up and down, its volatility.

Your Own Portfolio

How, and even whether or not to create and manage your own portfolio, is what this brief post is about.

First, you must determine what to do with your investments. How much risk can be taken and what is the time frame? You must understand the concept of risk vs. reward and write an investment policy statement.

Next, the assets that will be used for investment must be selected. This involves asset allocation and mixing different styles of investment management to achieve the desired results, and is the point where you go it alone, or professional investment managers are selected.

Be sure to review expenses, like wrap accounts, service fees, AUMs, commissions and compare mutual funds with private money management.

Monitor

Once the initial portfolio is in place, the performance must be monitored to assure compliance with the investment policy.  Here’s where you consider 401k or 403(b) plans, pension plans, retirement accounts, as well as how to change doctor trustees or managers when necessary.

Assessment

Finally, consider the role of professional consultants. Now after all of this, if you still want to do it yourself rather than be a doctor, the entire process will be professionally illustrated. An actual physicians’ financial plan with investing portfolio was reviewed previously, along with the steps taken to improve returns and reduce risk.

Link: https://healthcarefinancials.wordpress.com/2009/09/03/evaluating-a-sample-physician-financial-plan-iii/

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Encrypt or De-identify PHI

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[By Darrell K. Pruitt; DDS]pruitt

The United States’ advancement in Healthcare Information Technology, which has the potential to lead to wonderful money-saving cures through research using trustworthy interoperable health records, is currently stopped cold by patient security problems that are only getting worse. Our lawmakers cannot get around the security obstacle without resorting to authoritarian means using CMS’s power to withhold providers’ discounted payments and threats of obscene fines from the HHS and the FTC. History shows that tyranny is not tolerated well in this part of the world. Lawmakers can get their butts voted smooth out of office in my neighborhood.

HITECH  

Here is something nobody mentions: Despite the current hope in a thick, political fantasy called HITECH, encryption of patients’ Protected Health Information [PHI] is a non-starter in the land of the free. Everyone knows that resourceful, cynical Americans will simply never trust encryption to protect their secrets, and will reliably withhold important information from their eMRs – one way or another. Doctors as well as patients can be expected to go out of their way to sabotage technology they fear. We all intuitively know this is true, don’t we? We aren’t so naïve to think all the players will happily play by the rules, are we? And I think we can all agree that an untrustworthy digital health record in an emergency room is worse than no patient information at all. Security is a grand problem with eMRs that started with HIPAA changes in 2003 that made eHRs so slippery. And the problem is clearly not being resolved. Not yet.

Public Lacks Trust 

Regardless of the campaign donations which follow him, there is nothing Newt Gingrich and his entrepreneurial friends in high places can do about the public’s lack of trust in encryption. It gets worse: Encryption hasn’t a chance of isolating PHI from dishonest employees in doctors’ offices, and slippery digital patient data can be moved soo easily. Everyone knows that as well, don’t they? It is estimated that two-thirds of the identities stolen in the nation are lifted from doctors’ offices. That’s us, Doc. HIPAA is not only irrelevant, it is an expensive distraction – it gives future ID theft victims a false sense of security.

HIPAA Approved 

De-identifying digital records is not mentioned in HITECH as a HIPAA-approved method of security. Yet it is the ONLY solution that promises to be even more secure than paper records. Because of heavy stakeholder stakes in hospital care, it will take longer for CEO-types to embrace patient-friendly de-identification. Other than identifiers such as names, social security numbers, birthdates, addresses and other items that have street value, NOBODY cares what is in a dental record. I actually think this opens a tremendous opportunity for someone courageous in the Texas Dental Association to discuss the feasibility of de-identification of dental records. Otherwise, instead of leading the nation in solving security problems, the TDA will look just as stupid as the ADA.

Encryption would also provide a dangerous false sense of security in eMRs – that is if it had a chance in the marketplace. But encryption will never go far because consumers simply won’t buy it. That is a marketplace fact that stoically optimistic HIT stakeholders are trying hard to avoid. They also know they are running out of time. Deadlines are quickly approaching for both HIPAA and the Red Flags Rule that providers are far from prepared for.

Former Attorney Speaks 

Bill Lappen, a former attorney and author of the ad I copied below, as well as a partner with his brother David in the de-identified health record venture says: “Since no identifying information is ever entered, a hacker can’t determine whose information is shown.”

So in addition to protecting one’s practice against dishonest or vindictive employees, de-identification of dental records would make hacking a dentist’s computer a complete waste of time, and hackers wouldn’t endanger dental patients and bankrupt dentists.

My Confidence 

I confidently tell you that soon, someone smart will come upon the unprecedented idea that the ultimate answer to our security problem in healthcare will be de-identification of medical records, not encryption. De-identification allows a compromise of privacy for only a miniscule percentage of physicians’ patients. We cannot allow that to stand in the way of better health for everyone else. Those special cases are so few that I am confident that they can be dealt with individually. We simply must move forward. I’ll have to retire some day. I may need help from Medicare.

Encryption gives us only danger and protects nobody but a thief with a key.

Assessment 

We’ve wasted enough time on HITECH and HIPAA, as well as CCHIT. It’s time to say no to stakeholders and pay attention to patients’ needs instead of those who would needlessly increase the cost of their care. Stimulus money attracts cockroaches.

In the name of Hippocrates, disregard the tainted HIPAA mandate. It is dangerous, and especially absurd in dentistry.

Link: http://www.theopenpress.com/index.php?a=press&id=58568

Life-Saving Patient Information can be Online, Anonymous and Usable

Published on: September 26th, 2009 12:19am

By: blappen

Los Angeles, CA (OPENPRESS) September 26, 2009 — Hospital Emergency Rooms need instant access to patient medical information. Allergic reactions and dangerous drug interactions can be deadly. Time is critical. Until now, privacy was a large concern. Two brothers, who have developed medical software over the past 15 years, think they have a simple first step towards moving patient information on to the internet.

“The ER doesn’t need to look up the information by patient name” said Bill Lappen, a former attorney. “We have implemented secure systems in the past, but no matter how secure we make the site, we have to assume that it will be hacked” added David Lappen, a computer design engineer from Stanford. “But providing instant access to life-saving information is too important to ignore”, he added. To protect patient privacy, their system does not know to whom the medical information belongs. Since the person’s identifying information is never on the system, it can’t be stolen. “By enabling anonymous entry, we have protected people’s privacy while allowing them to put their life-saving information in a place where it can be instantly accessed when needed”, added Bill Lappen.

www.AMCC.me is the public service website they created. It allows anyone to enter medical information anonymously. The site provides a random ID which the user carries in his/her wallet. For someone to see that user’s medical information, they merely enter the ID into the site. Unless the user has given them their ID, the information shown is meaningless. That same information, when associated with a patient, can save their life.

Since no identifying information is ever entered, a hacker can’t determine whose information is shown. “Secure patient-controlled Electronic Medical Records are now available on the internet” said David Lappen. A sample ID has been set up on the site to allow users to evaluate the concept before setting up their own free ID.

Contact:

Bill Lappen

Bill@AMCC.me

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Whither Health Information Technology – Seriously?

Is it Really About Quality Improvement?

By Staff ReportersSurgeons

Health information technology (HIT) allows comprehensive management of medical information and its secure exchange between health care consumers and providers. Broad use of HIT has the potential to improve health care quality, prevent medical errors, increase the efficiency of care provision and reduce unnecessary health care costs, increase administrative efficiencies, decrease paperwork, expand access to affordable care, and improve population health.

Improving Patient Care

  • Interoperable HIT can improve individual patient care in numerous ways, including:
  • Complete, accurate, and searchable health information, available at the point of diagnosis and care, allowing for more informed decision-making to enhance the quality and reliability of health care delivery.
  • More efficient and convenient delivery of care, without having to wait for the exchange of records or paperwork, and without requiring unnecessary or repetitive tests or procedures.
  • Earlier diagnosis and characterization of disease, with the potential to thereby improve outcomes and reduce costs.
  • Reductions in adverse events through an improved understanding of each patient’s particular medical history, potential for drug-drug interactions, or (eventually) enhanced understanding of a patient’s metabolism or even genetic profile and likelihood of a positive or potentially harmful response to a course of treatment.
  • Increased efficiencies related to administrative tasks, allowing for more interaction with and transfer of information to patients, caregivers, and clinical care coordinators and monitoring of patient care.

Assessment

Link: http://healthit.hhs.gov/portal/server.pt?open=512&objID=1327&parentname=CommunityPage&parentid=112&mode=2&in_hi_userid=11113&cached=true A Letter from David Blumenthal, MD.

Conclusion

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Stockholder Suit Targets Troubled Mental Health Chain

Psychiatric Solutions, Inc

By Robin Fields, ProPublica – September 22, 2009 5:01 pm EDTCaduceus

Psychiatric Solutions Inc. the nation’s leading provider of inpatient mental health care is being sued by stockholders who claim the company issued “false and misleading statements” about troubles at one of its hospitals.

The Lawsuit

The lawsuit, filed Monday in U.S. District Court in Tennessee, alleges that PSI violated securities laws by downplaying problems at Riveredge Hospital near Chicago and waiting too long to tell shareholders how they had affected the company’s bottom line.

The Investigations

Investigations last year by the Chicago Tribune and ProPublica detailed violence, sexual abuse and neglect at PSI facilities from coast to coast, including Riveredge. In several instances, PSI facilities were cited for not reporting patient deaths and injuries as required, federal and state records showed. In response to the reports, the Justice Department opened an investigation and the Illinois Department of Children and Family Services froze admissions of foster children to Riveredge.

The Allegations

The lawsuit alleges that PSI’s statements – particularly those indicating the admissions hold would end soon and that other regulatory deficiencies had been fixed – inflated the company’s stock price, helping company leaders reap millions from insider sales. In early 2009, PSI announced that its 2008 results had fallen short of estimates. Its share price dropped about 35 percent on the news.

Assessment

Through a spokesman, PSI called the lawsuit “wholly without merit.” “We have at all times operated, and will continue to operate in full compliance with the rules and regulations of the Securities and Exchange Commission,” John Van Mol said in a written statement.

Note: Robin Fields is a reporter for the ProPublica news service, which first published this article.

Conclusion

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Understanding Expenses and Investment Portfolio Performance

A Direct Relationship

By Clifton N. McIntire, Jr.; CIMA, CFP®

By Lisa Ellen McIntire; CIMA, CFP®fp-book

Expenses can play an important role in portfolio performance. You don’t hear much about expense ratios in an up market, like early 2007. If your account was up +28 percent, whether the expense was 3 percent or 1 percent doesn’t seem to make much difference. But, let the market decline, like it did later on in October 2007 and we change our perspective. A 10 percent portfolio decline plus charges of 3 percent equals a 13 percent decline. Now we need a 15 percent increase net of fees just to get even.

The Four Cost Horsemen

Basically you have four cost areas:

  1. Custody—someone must hold the stocks and bonds, collect dividends and interest, prepare tax information for the government, issue monthly statements, and send checks.
  2. Commissions—orders must be executed, transfer securities into and out of your account, trades settled.
  3. Investment Decisions—the money manager must be paid.
  4. Monitoring Performance and Advice—usually an investment management analyst is engaged to provide this service; as well as write the investment policy statement and prepare the asset allocation study.

Portfolio Size

Naturally, size makes a difference. For a doctor’s stock account with a $200,000 total value, all of the above can be accomplished for annual fees between 2.00 and 3.00 percent. An account with $1,500,000 in total assets part bonds and part stocks would pay annual fees between 1.25 and 1.75 percent depending on the ratio of stocks and bonds. These are annual fees and are all-inclusive. Commissions, portfolio management fees, and statements check charges are all included. One quarter of the annual fee is charged every three months. Family related accounts are generally grouped for a quantity fee discount.

Assessment

Some financial consultants prefer to use mutual funds with smaller accounts. A charge of 1 percent per year for their service with a stated minimal fee is common practice. This does not include fees deducted from the account by the mutual fund (anywhere from .50 to 2.50 percent) or commissions paid by the fund managers for trade executions. 

Morningstar Report: Morningstar Expense Ratio Results

Conclusion

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Introducing Somnath Basu; PhD MBA

Our Newest ME-P Thought-Leader in Finance and Economics

By Ann Miller; RN, MHA

[Executive Director]Dr. Basu

Dr. Somnath Basu is a Professor of Finance at California Lutheran University and the Director of its California Institute of Finance. Dr. Basu is also a Professor of the Helsinki School of Economics Executive MBA Program. He earned his BA in Economics, University of Delhi, MBA (Finance), Marquette University and a PhD (Finance), University of Arizona.

Publications and Experience

Dr. Basu is extensively published in the field of investments and financial planning and is an award winning teacher. He has significant consulting experience with US Fortune 100 companies, advising institutional money managers and in developing proprietary personal investment software. Dr. Basu is actively involved with financial planning organizations including the National Endowment for Financial Education (NEFE), the CFP Board of Standards, International CFP Board and the Financial Planning Association. He coauthored the book (with Block and Hirt), “Investment Planning for Financial Professionals” McGraw Hill, May 2006 which is widely used by financial planning programs nationwide. 

AssessmentCLU

To regular our ME-P readers, Dr. Basu’s opinions are well known and not without controversy. But, whether you agree with him or not, his commitment to the industry and his economics and financial planning students is solid. And, always adhering to the Socratic dialog tradition of candor intelligence and goodwill.

Link: https://healthcarefinancials.wordpress.com/2009/04/09/i-jealously-shake-my-fist-at-somnath-basu/

Link: https://healthcarefinancials.wordpress.com/2009/04/16/dr-somnath-basu-replies-to-the-cfp%c2%ae-mis-trust-controversy/ 

Conclusion

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ReThinking Medical Professional Autonomy in the Era of Obama Care

Eying Contemporary Medical Ethics in Healthcare Reform

By Render S. Davis; MSA, CHE

And, Staff Reportersbiz-book

Not so long ago, a physician’s clinical judgment was virtually unquestioned. Now with the advent of clinical pathways and case management protocols, many aspects of treatment are outlined in algorithm-based plans that allied health professionals may follow with only minimal direct input from a physician. Much about this change has been good. Physicians have been freed from much tedious routine and are better able to watch more closely for unexpected responses to treatments or unusual outcomes and then utilize their knowledge to chart an appropriate response.  

Restrictive Protocols

What is of special concern, though, is the restrictive nature of protocols in some managed care plans that may unduly limit a physician’s clinical prerogatives to address a patient’s specific needs. Such managed care plans may prove to be the ultimate bad examples of “cook book” medicine. While some may find health care and the practice of medicine an increasingly stressful and unrewarding field, others are continuing to search for ways to assure that caring, compassionate, and ethically rewarding medicine remain at the heart of our health care system.

Assessment

Link: For another opinion: http://healthcareorganizationalethics.blogspot.com/2009/09/obamas-speech-good-ethics-and-good.html

Conclusion

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On Increasing Price Transparency in Medicine

About NewChoiceHealth.com

By Staff ReportersCalculator-Scope

NewChoiceHealth, Inc. is an online comparison shopping marketplace built to provide healthcare consumers a way to save money. With NewChoiceHealth.com, consumers can easily locate medical facilities and compare medical procedure costs for services like MRIs, CT scans, mammograms, and more. Patients may shop nationwide, or right in their own local market from over 20,000 medical facilities for over 400 of the most commonly performed medical procedures.

Employer Portal

The site also features an employer portal to combat the rapidly escalating costs of healthcare. A Medical Cost Action Plan (mCAP) is reported to deliver an independent, unbiased, measurable plan which segments employer’s medical cost consumption categories into measurable Consumer Healthcare Efficiency Indices (CHEI) to deliver an actionable plan that reduces healthcare costs.

The Founder

CEO and Founder Brad Myers is a medical cost expert with 24 years of broad experience and extensive knowledge in medical cost informatics, healthcare insurance, managed care, clinical laboratory, and health and life insurance. His website message to ME-P readers, and others, is “shop & save!”

Assessment

Employee passion drives price transparency to healthcare consumers through the web site www.NewChoiceHealth.com Give it a click, for more information, and tell us what you think!

Conclusion

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Ask an Advisor – Must an Insurance Claim CramDown be Accepted?

Calling on Insurance Professionals to Expose the “Wizard” Behind the Curtain

By ME-P Staff ReportersOp-Ed

We received the following request recently. Apparently, this ME-P reader-nurse sustained a covered loss with valid home insurance property-casuality claim. It resulted in disagreement with her insurance adjuster [a common occurrence]. The adjuster cited his/her supervisor’s insistence on claim settlement and closure.  The nurse’s general contractor thinks the monetary amount is significant [$50,000 range after three independent estimates]. The insurance company wants to settle for about half that amount. 

What say you about this scenario?   

INSURED

Dear Big Insurance Company Adjuster

”Many thanks for reaching out to us by phone yesterday. Please be aware that we did not agree to partial payment or supplements and are sorry for any confusion. 

We would however, be pleased to assist by informing your management of our declination of same. Thus, there is no need to issue any payments at this time.

It seems to make far more sense to get all the numbers together with our general contractor and then arrive at a consensus before moving forward. As you know, this was our original plan. We appreciate your deeper understanding of these very complex issues.”

Your Small Client 

INSURANCE ADJUSTER

Dear Client

“This email will serve as a follow up to our telephone call yesterday. I am sorry we were disconnected but I attempted to call you several times and I was unable to leave a message. I am attaching a copy of the updated Big Insurance Company estimate which reflects those changes made due to additional information gathered during my second inspection of your property on September 8th.  Also you will find an updated Replacement Cost Letter.

As discussed, due to the fact we know we owe you the value of the attached estimate, I am processing the actual cash value payment in the amount of $ XYZ. Any additional payments will be handled as supplements. Please feel free to contact me with any questions.

Your Big Insurance Company Adjuster

MANAGEMENT

Dear Client

Also, my management told me I need to proceed with issuing payment based on the amount I know I owe you [insured] as of now, and that I should handle any further negotiations as supplements. I have already discussed this with your husband.

Your Big Insurance Company Adjuster

Assessment

After some internet research, our RN reader discovered that abut 85% of all folks accept inadequate PC insurance payments after being strong-armed by their insurance company in various ways. She is determined to be made whole and indemnified. She also understands that future negotiations and “supplements” after acceptance are typically not favorable to her, and she wishes to maintain her leverage by not accepting them. Can she refuse to cash the check, if sent to her, until satisfied? She is not feeling in good hands, at the moment!

Industry Indignation Index: 85%

Audio Razz: Click to play :

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Must our reader “accept assignment” in the form of this under payment cram-down? How can she expose the Wizard of Oz manager behind the curtain? Will she be the “squeaky wheel” of informed insureds who “get the economic grease” they deserve. Should our Industry Indignation Index percentage be higher, or lower? Is the audio razz deserved, or not. What can she do? Insurance agent and attorney input is appreciated.

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den window

On Healthcare Inventory Management

Understanding Fundamental Principles

By Staff Reporters

www.HealthcareFinancials.com

According to industry inventory management expert Mr. David Piasecki, healthcare inventory is a term that describes medical items used in the delivery of healthcare services or for patient use and resale. Much like Durable Medical Equipment, a certain safety margin of stock should always be available. Inventory ranges from normal administrative office supplies to highly specialized chemicals and reagents used in the clinical laboratory. It should be distinguished from capital supplies, such as major equipment, instruments, and other items that are not used up faster than inventory or related inventory wastes.

Historical Review

Historically, asset utilization ratios provided information on how effectively the enterprise used its inventory assets to produce revenues, or deplete its cash. For example, the inventory turnover ratio (ITR) determines the total volume of inventory turnover (change) during a pre-determined accounting period (month or quarter). It is defined as cost of inventory purchased for the period, divided by average inventory (AI) at cost.

Consulting Firms

Dunn and Bradstreet, the supply chain management – consulting firm and others, do not provide exact comparatives for private healthcare ITR. Nonetheless, ITR is useful as an internal performance indicator of inventory turnover speed and cash flow enhancement. Currently however, for public hospitals, 60 – 75 days is estimated to be the average time for inventory turnover.HOFMS

www.HealthcareFinancials.com

The main problem with traditional ITR, similar analyses such as AI and ICP, and the usual inventory costing methods (e.g., last-in first-out, first-in first-out, specific identification, average costs), and even just-in-time inventory costing, is that they do not embrace Supply Chain Inventory Management. This occurs because sources of profit or loss are not recognized in the traditional inventory cost accounting equation:

Assessment

Cost of goods sold = beginning inventory + net purchases – ending inventory

Conclusion

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The VistA Client Server System

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What it is – How it works

By ME-P Staff ReportersME-P Rack Servers

According to Dr. Richard Mata MS, a client-server system configuration occurs when one or more “repository” computers [ known as “servers”] store large amounts of data but perform limited processing. Communicating with the server(s) are client workstations that perform much of the data processing and often have graphical user interfaces (GUIs) for ease of use.

High Functionality

Both customizability and resource use is high, depending on the desired sophistication. Many clinical medical information systems that process data directly related to patient care use this configuration.

VA Example

For instance, the Veterans Health Administration, which has implemented what is likely the largest integrated healthcare information system in the United States, uses client-server architecture. Known as the Veterans Health Information Systems and Technology Architecture (VistA), this system provides technology infrastructure to about 1,300 care facilities, including hospitals and medical centers, outpatient facilities, and long-term care centers. VistA utilizes a client-server architecture that links together workstations and personal computers using software that is accessed via a graphical user interface.

Assessment

Overall, for hospitals that have the financial and manpower resources for a significant investment in IT, client-server architectures are the fastest-growing and typically the most preferred of the system architectures, due in large part to their local adaptability and flexibility to meet changing hospital and medical center needs.

Conclusion

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Introducing Dr. Leila M. Hover

Our Newest ME-P Thought-Leader

By Ann Miller; RN, MHA

[Executive-Director]

Dr. Lee Hover

Leila M. Hover, D. Med. Hum, has a varied background having worked in OB/GYN and as a Clinic Supervisor in a Planned Parenthood Center. She served as Director of a hospital medical library, and then as Director of Scientific Information in several medical communications/advertising organizations.

Interest in Concierge Medicine

Her doctoral dissertation topic was concierge medicine, in which she has a continuing interest.

Assessment

Dr. Hover is a member of the Institutional Review Board of the Atlantic Health System in New Jersey and the Bioethics Committee of Overlook Hospital in Summit, New Jersey. She is also a principal at Information Developers, a medical literature research and document retrieval organization.

ME-P Shout-Out

And so, please give a warn ME-P “shout-out” to Dr. Lee Hover, our newest thought-leader. 

Conclusion

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Understanding Medical Cost Accounting

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A Subset of Managerial Accounting

By ME-P Staff Reporters

Managerial and medical cost accounting is not governed by generally accepted accounting principles (GAAP) as promoted by the Financial Accounting Standards Board (FASB) for CPAs. Rather, a healthcare organization costing expert may be a Certified Cost Accountant (CCA) or Certified Managerial Accountant (CMA) designated by the Cost Accounting Standards Board (CASB), an independent board within the Office of Management and Budget’s (OMB) Office of Federal Procurement Policy (OFPP).

The Cost Accounting Standards Board

CASB consists of five members, including the OFPP Administrator who serves as chairman and four members with experience in government contract cost accounting (two from the federal government, one from industry, and one from the accounting profession). The Board has the exclusive authority to make, promulgate, and amend cost accounting standards and interpretations designed to achieve uniformity and consistency in the cost accounting practices governing the measurement, assignment, and allocation of costs to contracts with the United States.

Codified at 48 CFR

CASB’s regulations are codified at 48 CFR, Chapter 99.  The standards are mandatory for use by all executive agencies and by contractors and subcontractors in estimating, accumulating, and reporting costs in connection with pricing and administration of, and settlement of disputes concerning, all negotiated prime contract and subcontract procurement with the United States in excess of $500,000. The rules and regulations of the CASB appear in the federal acquisition regulations.

North American Industry Classification System (NAICS) codes are used to categorize data for the federal government.  In acquisition they are particularly critical for size standards.  The NAICS codes are revised every five years by the Census Bureau.  As of October 1, 2007, the federal acquisition community began using the 2007 version of the NAICS codes at www.census.gov/epcd/www/naics.html

Cost Accounting Standards

Healthcare organizations and consultants are obligated to comply with the following cost accounting standards (CAS) promulgated by federal agencies:

  • CAS 501 requires consistency in estimating, accumulating, and reporting costs.
  • CAS 502 requires consistency in allocating costs incurred for the same purpose.
  • CAS 505 requires proper treatment of unallowable costs.
  • CAS 506 requires consistency in the periods used for cost accounting.

The requirements of these standards are different from those of traditional financial accounting, which are concerned with providing static historical information to creditors, shareholders, and those outside the public or private healthcare organization.

AssessmentTwo Doctors

Functionally, most healthcare organizations also contain cost centers, which have no revenue budgets or mission to earn revenues for the organization.  Examples include human resources, administration, housekeeping, nursing, and the like.  These are known as responsibility centers with budgeting constraints but no earnings.  Furthermore, shadow cost centers include certain non-cash or cash expenses, such as amortization, depreciation and utilities, and rent. These non-centralized shadow centers are cost allocated for budgeting purposes and must be treated as costs http://www.CertifiedMedicalPlanner.org

MORE:  CASE MODEL EOQ 1

Conclusion

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Happy New Year 5770 and 5771

       We wish all our Jewish Subscribers a Happy and Healthy

New Year 5770

 5770 

The Shofar is a ram’s horn blown as a wind instrument, sounded in Biblical times chiefly to communicate signals in battle and announce certain religious occasions and in modern times chiefly at synagogue services on Rosh Hashanah and Yom Kippur.

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Branch Davidian David Koresh is Dead

Take it … from a Forensic Dentist

By Darrell K. Pruitt; DDSpruitt

For those who might be interested, these two plaster models are proof David Koresh died in the Mt. Carmel disaster.

Please allow me to offer I have been a forensic dentist since shortly after graduating from dental school in 1982. I have helped ID victims of two plane wrecks at DFW – Delta 191 in 1985 and Delta 1141 in ’88. I also helped identify the victims of Mount Carmel in 1993.

Some may choose to stop reading now, because I see no need to refrain from describing forensics to this crowd. After all, one sees it on TV these days. For those who stay, it is my wish that you find this adventure interesting.

The Branch Davidian Disaster

At the time of the Branch Davidian disaster, Tarrant County (Fort Worth) had a contract with McLendon County (Waco) for autopsy services. Along with 49 other dentists, I volunteered to help with the ID chores. I spent 8 days at the county morgue sorting through badly burnt and rapidly decaying cadavers of men, women and far too many children. There were so many fragments of ammunition that exploded from the heat, that one could hardly see the skeletons in x-rays of the body bags.

There was a lot of .223 (AR-15) and 7.62 mm (AK – 47) ammunition, both unfired bullets and their exploded casings. I also saw 9 mm and .45 cal. (handgun) ammunition. In addition, I saw the empty casing of a spent 50 mm (not caliber) round. That could also be called a 2 inch artillery shell. It was not fired during the skirmish. It was probably a military souvenir. I witnessed it because it was “melted” into a mass of comingled, badly burnt bodies. Those on site near Waco simply loaded the mass of ammunition and flesh into the body bag in one piece.

Even though the Davidians were not armed with a 50 mm gun, I read a report that there were two .50 cal. semi-automatic sniper guns side-by-side and pointed at the front doors, with ammunition. One thing I immediately found curious about the body-bag x-rays were the numerous “Y” shaped metal pieces, about 3/16″ long. In some bags they were everywhere, while they weren’t present in others. Any guesses? I’ll tell you later.

Plaster ModelsKoresh's_models 

The plaster model on the left is from an impression of Koresh’s teeth post mortem, 33 years of age. The model on the right was from when he was 15 years old. Is it the same person? Notice the inclinations of the front teeth. His lateral incisors are positioned a little more palatally than the centrals in both models. It may be difficult for the layperson to recognize, but there is a stainless steel crown on Koresh’s left second molar that was there when he was 15. Note the consistency of missing teeth. Notice the consistent shapes of teeth. Once a team member opened the right bag, it was an immediate positive ID.

The fresh extraction socket of the bicuspid on Koresh’s right was because the tooth was extracted post mortem for DNA analysis – not to ID Koresh, but to ID the 60 or so kids who were in the compound that burned to the ground. By the way. We could smell the accelerant. It was Coleman fuel, and it was spread from the inside of the compound. From what I saw and sensed, it is my opinion that government forces did not start the fires.

What else can we tell from the models? The gums and soft tissue had been burnt away, leaving only the bone around the teeth. If one looks closely, one can see a fracture line on his right central incisor. It was where the top of the front tooth was fractured off when Koresh fell forward and struck his mouth on a hard object, possibly the floor. The piece of the tooth was found among the fragments scooped up in the body bag. It was super-glued back in place before the impression was taken.

So How Did Koresh Die?

The back half of Koresh’s skull was missing when the bag was opened, but in the bag were found some skull fragments which were burned and others barely scorched. This tells us it wasn’t the fire that killed him. There was a hole in the middle of the forehead almost 1/4 inch in diameter, with a “starburst” – like scoring of the bone radiating from the edges of the wound. This was later determined to be caused by a .223 bullet. The radiating “starburst” means that the barrel of the gun was contacting Koresh’s head when the bullet was fired. Any ideas yet? Was it a self-inflicted wound?

More clues: The body of Steve Schneider, Koresh’s second in command, was found not far from Koresh’s. Schneider had a hole in the roof of his mouth caused by a 9 mm bullet. For those who don’t know, the .223 round is a rifle bullet, while the 9 mm is likely a handgun. So here is the theory: Schneider did Koresh in the hallway with an AR – 15 that was found close by, and then did himself with his pistol. Anybody have any guesses about the thousands of pieces of metal shaped like “Y”s that littered the body bags?

Zipper Teeth

It is my understanding that this spring a dental forensics course will be offered at the Southwest Dental Conference in Dallas, and it is open to everyone. If forensics interests you, there could come a time when your community might desperately need your help, especially if you are trained in the techniques of identifying victims in a mass disaster. I attended the course two years ago. It was fascinating.

Assessment

In closing, let me leave you with this: I remember late in the evening following a long, hard day at the morgue, I witnessed something that struck me as so ironic that I impulsively giggled out loud. In one of the body bags was a military-style vest designed for carrying ammunition and tools of warfare The label on the inside of the collar read “David Koresh Survival Gear.” David Koresh marketed his own signature line of survival Gear. Get it?

Managing Editor’s Note: We may occasionally publish an article that, while off ME-P topic, may be of interest to our readers. We trust this is one such publication.

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The ME-Pr [Photo Sharing Feature]

With Apologies to Flickr

By ME-P Staff Reporters

A New Feature Launch [Beta]

We are proud to introduce an exciting new Medical Executive-Post feature called the ME-Pr. Our goal is to aggregate and help subscribers make their blog related photographs available to those in our ecosystem who appreciate them; comical or sad, interesting or ironic, shocking or banal; or just plain iconoclastic. We hope ME-Pr will make these things possible … and more! To do this, we want you to send us your photos and videos so we can post, redact and make them searchable.

ME-Pr Rules of Engagement

1. You must own your photos or videos.

2. We reserve the right to post them, or not.

3. These terms and conditions may change without notice.

4. You must be a ME-P subscriber.

Join Our Mailing List

Assessment

So, check us out daily to stay apprised of the latest developments. The fact that you’ve read this post with nothing but text to keep your interested is our proof-of-concept. What are you waiting for? 

Ann at: MarcinkoAdvisors@msn.com

SAMPLE

Prudential Ambulance

The irony of this Prudential insurance logo on an ambulance in Waltham, a city in Middlesex, MA, is obvious and very cheesy!

Conclusion

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Understanding the Medicare Prospective Payment System

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Origins of Diagnostic Related Groups

By Dr. David Edward Marcinko; MBA, CMP™

[Editor-in-Chief]dem21

The Medicare Prospective Payment System (PPS) was introduced by the federal government in October, 1 1983, as a way to change hospital behavior through financial incentives that encourage more cost-efficient management of medical care. Under PPS, hospitals are paid a pre-determined rate for each Medicare admission. Each patient was classified into a diagnosis-related group (DRG) on the basis of clinical information. Except for certain patients with exceptionally high costs (“outliers”), the hospital is paid a flat rate for the DRG, regardless of the actual services provided.

Enter the DRGs

Each Medicare patient is classified into a DRG according to information from the medical record that appears on the bill:

  • principal diagnosis (why the patient was admitted);
  • complications and co-morbidities (other secondary diagnoses);
  • surgical procedures;
  • age and patient gender; and
  • discharge disposition (routine, transferred, or expired).

Medical Records DocumentationMedical Records

Diagnoses and procedures must be documented by the attending physician in the patient’s medical record. They are then coded by hospital personnel using ICD-9-CM nomenclature. This is a numerical coding scheme of over 13,000 diagnoses and more than 5,000 procedures. The coding process is extremely important since it essentially determines what DRG will be assigned for a patient. Coding an incorrect principal diagnosis or failing to code a significant secondary diagnosis can dramatically affect reimbursement.

DRG Categories

Originally, there were more than 490 DRG categories defined by the Centers for Medicare and Medicaid Services (CMS, formerly known as the Health Care Financing Administration [HCFA]). Each category was designed to be “clinically coherent.” In other words, all patients assigned to a DRG are deemed to have a similar clinical condition. The PPS is based on paying the average cost for treating patients in the same DRG.  Each year CMS makes technical adjustments to the DRG classification system that incorporates new technologies (e.g., laparoscopic procedures) and refines its use as a payment methodology. CMS also initiates changes to the ICD-9-CM coding scheme. The DRG assignment process is computerized in a program called the “grouper” that is used by hospitals and fiscal intermediaries. It was last significantly updated by CMS in 2006.

Assessment

Each year CMS also assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year.  The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000, for example, means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average; and so on.

Conclusion

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ME-P Thought-Leader [MD] in the News

Brian J. Knabe MD of Savant Capital Management

By Max Alexander

Dow Jones Newswires; 212-416-2245 Brian J. Knabe MD

Lots of doctors get burnt out dealing with the business end of medicine. But Brian Knabe, a family practice physician in Rockford, Ill., had such a passion for crunching numbers that he became a financial planner.

Knabe, 42 years old, still sees patient’s two half-days a week. He also teaches residents for another half-day at the University of Illinois – College of Medicine.

Most of the week, he’s a certified financial planner with Savant Capital Management.

“I hear all the jokes,” says Knabe, “the most popular being some version of, ‘Hey I guess my portfolio’s doing so badly, they had to bring in the doctor.'”

When the laughter dies down – it doesn’t take long – people often ask what motivated him to transition from medicine into finance.

His short answer is what you’d expect from a wealth adviser: “I wanted to diversify my career.”

The long answer includes a lifelong passion for math that runs in the family. Knabe’s father and brother are both engineers, and the doctor himself majored in bioengineering at Marquette University. “In college, I loved calculus, statistics and differential equations,” he says.

Growing up in Rockford, his best friend was Brent Brodeski, a partner at Savant, and Knabe had been a client of the firm since 1995. “For years, I joked with Brian, ‘If you ever get bored with medicine, you can join us,'” says Brodeski. “Three years ago he called and said, ‘I’ll take you up on that.’ I was floored.”

Knabe wasn’t bored with medicine. “I love taking care of patients, and the intellectual stimulation of the field,” he says. “So I told the partners at Savant that I would only do this if they allowed me to continue practicing medicine part-time.” Meanwhile, he went back to Marquette and got his CFP credentials.

About half of Knabe’s financial clients are doctors, who appreciate his insider’s knowledge of their work and financial issues. Both fields involve privacy and trust, he notes, and both involve planning for the future. They also involve an element of uncertainty.

Sometimes his advice is specifically health-related.

“One client I was working with was a couple where the husband had a terminal illness,” recalls Knabe. “I worked closely with the family in planning living will issues and durable power of attorney for health care. I’ve helped other clients wade through health insurance and disability issues.”

Yes, financial clients do sometimes ask him for medical advice, but he stops them before they can unbutton their shirt.

“If they have a problem and need a diagnosis, I’ll tell them where to go to get a second opinion,” he says.

Link: http://online.wsj.com/article_email/BT-CO-20090914-711325-kIyVDAtMEM5TzEtNDIxMDQwWj.html 

Managing Editor’s Note:Become a CMP

Dr. Knabe is also enrolled in the www.CertifiedMedicalPlanner.com program in health economics and medical practice management for financial advisors and healthcare consultants.

Conclusion

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About Docs4PatientCare

Politically Involved Physicians

By Staff ReportersUS Senate

Docs4PatientCare is a grassroots organization of concerned physicians committed to the establishment of a health care system that preserves the sanctity of the doctor-patient relationship, promotes quality of care, supports affordable access to all Americans, and protects patients’ freedom of choice.

Mission

According to their website, Docs4PatientCare urges patients and physicians to get involved in the current healthcare debates in order to preserve the good qualities of our healthcare system, address the problems, while preventing their bureaucratic destruction.

Board Members

President: Hal Scherz, MD
Vice President: Fred Shessel, MD
Secretary: Tod Rubin, MD
Treasurer: Joanne Thurston CPA

Board of Directors

Scott Barbour, MD
Carl Capelouto, MD
Ron Anglade, MD
Terry Murphy, MD
Mike Koriwchak, MD
Barry Zisholtz, MD

Assessment

D4PC is a group of practicing physicians uniting to represent the interests and concerns of both patients and doctors in the healthcare reform debate.  D4PC endorses the concept of needed healthcare reform, but recognizes it can only be accomplished by proceeding in a cautious and responsible manner. Their recommendations seek to enable them to reach this goal without requiring the nationalization of the entire American healthcare system.

But, should medical professionals be involved in such political organizations?

Link: http://docs4patientcare.org

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Are these sorts of organizations a form of self-aggrandizement; or not? Can you cite any others? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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List of Healthcare IT Trade Associations

Advancing Medical Practice Success with Strategic Relationships

By Staff ReportersHDS

To be efficient in healthcare delivery today, doctors must partner and understand the resources and affiliations that are available to them. Here is a brief list of several healthcare trade associations and leading industry vendors submitted for your review.

AHIMA
The American Health Information Management Association (AHIMA) is the premier association of health information management professionals. AHIMA’s 51,000 members are dedicated to the effective management of personal health information needed to deliver quality healthcare to the public. Founded in 1928 to improve the quality of medical records, AHIMA is committed to advancing the health information management profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning.

EHRA
HIMSS EHRA is a trade association of Electronic Health Record (EHR) vendors that addresses national efforts to create interoperable EHRs in hospital and ambulatory care settings. HIMSS EHRA operates on the premise that the rapid, widespread adoption of EHRs will help improve the quality of patient care and the productivity of the healthcare system. The primary mission of the association is to provide a forum for the EHR vendor community relative to standards development, the EHR certification process, interoperability, performance and quality measures, and other EHR issues that may become the subject of increasing government, insurance and physician association initiatives and requests.

HIMSS
HIMSS (Healthcare Information and Management Systems Society) is the healthcare industry’s membership organization exclusively focused on providing leadership for the optimal use of healthcare information technology and management systems for the betterment of human health. Founded in 1961 with offices in Chicago, Washington D.C., and other locations across the country, HIMSS represents approximately 17,000 individual members and some 275 member corporations that employ more than 1 million people. HIMSS frames and leads healthcare public policy and industry practices through its advocacy, educational and professional development initiatives designed to promote information and management systems’ contributions to ensuring quality patient care.

HITSP
The Healthcare Information Technology Standards Panel serves as a cooperative partnership between the public and private sectors for achieving a widely accepted and useful set of standards specifically to enable and support widespread interoperability among healthcare software applications, as they will interact in a local, regional, and national health information network for the United States. Comprised of a wide range of stakeholders, the Panel will assist in the development of the U.S. Nationwide Health Information Network (NHIN) by addressing issues such as privacy and security within a shared healthcare information system. The Panel is sponsored by the American National Standards Institute (ANSI) in cooperation with strategic partners such as the Healthcare Information and Management Systems Society (HIMSS), the Advanced Technology Institute (ATI), and Booz Allen Hamilton. Funding for the Panel is being provided via the ONCHIT contract award from the U.S. Department of Health and Human Services.

HL7
Health Level Seven is an American National Standards Institute (ANSI)-accredited Standards Developing Organization (SDO) operating in the healthcare clinical and administrative data arena. It is a not-for-profit volunteer organization made up of providers, vendors, payers, consultants, government groups, and others who develop clinical and administrative data standards for healthcare. Health Level Seven develops specifications; the most widely used being a messaging standard that enables disparate healthcare applications to exchange keys sets of clinical and administrative data.

MSHUG
Microsoft Healthcare Users Group (MS-HUG) unified with the Healthcare Information and Management Systems Society (HIMSS) as part of the HIMSS Users Group Alliance Program in October 2003. The unification strengthens the commitment of HIMSS and MS-HUG to better serve their members and the industry through a shared strategic vision to provide leadership and healthcare information technology solutions that improve the delivery of patient care.

WEDI
The Workgroup for Electronic Data Interchange [WEDI’s] goal is to improve the quality of healthcare through effective and efficient information exchange and management. They aim to provide leadership and guidance to the healthcare industry on how to use and leverage the industry’s collective knowledge, expertise, and information resources to improve the quality, affordability, and availability of healthcare.

Assessment

As the health information technology industry evolves, we will continue to contribute our expertise to foster ideas that shape the future of healthcare by offering more examples similar to the above.

Conclusion

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Take the Lost Managed Care Contract Challenge!

Illustrative Case Model – Are You CMP™ Worthy?

By Staff Reporterscmp-logo

The Hope Outreach Medical Clinic (HOMC) is a private, for-profit, single specialty medical clinic in a south-eastern state. It submitted its bi-annual Request for Proposal (RFP) to continue its current managed care fixed-rate contract. Upon review of the RFP, however, Sunshine Indemnity Insurance Company, the managed care organization (MCO), denied the contract request for the upcoming year.

Seeing Economic Estimates

In shock, the clinic’s CEO asked the clinic’s administrator to work with its legal team to develop a defensible estimate of economic damages that would occur as a result of the lost contract. The clinic intended to bring suit against the MCO for breach-of-contract. However, the administrator is not an attorney and is loathe to-enter the fray. After consideration however, he decided to assist in filing the Statement of Claim (SOC) because he realized that changes in patient services (unit) volume would be a valid economic surrogate. He then requested the following information from his controller, in order to develop a change in economic profit [damages] estimate.

Change in patient visits (unit) volume

  1. Fees (price) per patient (unit)
  2. Marginal (incremental) cost per patient (unit)
  3. Change in current fees (prices)
  4. Patient volume (units) affected

Key Issues:

  1. Fee (price) per patient (units) may be obtained from the fee schedule used by the MCO to pay HOMC.
  2. Marginal (incremental) costs per patient (unit) are approximated using variable costs.
  3. Higher cost payors exist because lower patient volumes raise the average cost per patient (unit) due to existing fixed costs.

Assessment

Medical management consultants, are you up to answering this challenge? We dare you to respond!

Visit: www.CertifiedMedicalPlanner.com

Conclusion

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The Largest Purchaser of Domestic Healthcare?

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It’s the Government – Silly

By Ann Miller; RN, MHA

[Executive Director]ERT Prison Healthcare

By far, our federal government is the largest purchaser of healthcare services, according to Robert James Cimasi MHA, AVA, CMP™ of Health Capital Consultants, in St. Louis, MO; and many others.

Obama Care

Although the government faces immense pressure to control healthcare costs, especially during the current HR 3200-3400 debates, it also faces pressure to expend additional funds in order to achieve its ostensible primary mission in its involvement in healthcare, i.e., to expand and improve public health.

Federal Payment Schemes

In many ways the government has led the way for cost control through its development of resource-based reimbursement, prospective payment systems, budget limitations and other payment schemes. However, its conflicting goals have led it to approach these controls in a hesitant and piecemeal manner rather than effecting bold, comprehensive reforms.

Consider, for example, the lack of government intervention in the face of mounting pressure to remove some of the barriers preventing a reduction in US pharmaceutical costs.

Assessment

Today, most experts agree that Uncle Sam pays for at least 51% of domestic healthcare when Medicare, Medicaid, SHIPS, the VA, Indian and Prison Healthcare Systems are considered. In fact, according to our Publisher-in-Chief, Dr. David Edward Marcinko; MBA:

‘We already have a single payer health system in this country, but most folks just don’t realize it.”

Conclusion

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Do Financial Advisors Add Value to Retail Portfolios?

Some Consultants Emphatically Say … No!

By Staff Reportersfp-book1

Nope! So says Andre’ Cappon, Guy Manual, Stephan Mignot and Seth Varnhagen of the CBM Group, Inc; a consulting firm in Manhattan, New York. In fact, while writing in Registered Rep – a trade magazine for FAs in September 2009 – they estimate that long-term real (adjusted for inflation), actual (after taxes, fees and market timing) returns for the average retail investor, to be around 0 percent. That’s right; not the 8-12 percent usually attributed to long term investing trends.

Or; do you simply have the wrong type of Financial Advisor [FA]?

Visit: www.CertifiedMedicalPlanner.com Do you need a fiduciary advisor? Who really knows for sure?

About the CBM Group

Founded in 1992, the CBM Group is a general management consulting firm specialized in the financial services industry. Their goal is to help leading financial institutions, and their financial advisors, create and sustain the competitive advantages necessary to thrive in the global marketplace.

Link: www.theCBMGroup.com

Assessment

Despite the math, and numerics like Ibbotson charts showing impressive long-term gains, on average retail investors — like doctors, medical professionals and ME-P readers — have made very little actual return on their savings; according to CMB.

Link: http://registeredrep.com/advisorland/marketing_selling/0901-small-investment-return/index.html

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Does your FA add value to his/her fees of 1-3%; or are they a drag on your portfolio’s performance. Ever consider “doing it yourself”  like some medical institutions www.HealthcareFinancials.com 

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

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Soliciting Textbook Peer-Reviewers and Experts

Business of Medical Practice

Ann Miller; RN, MHA

[Executive Director]biz-book

Please contact me if you would like to serve as a peer-reviewer for the third edition of our popular textbook, “Business of Medical Practice”.

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

If interested, please email me and send in a bio. A non-disclosure agreement is required.

Email: MarcinkoAdvisors@msn.com

In return for conscientious industry and expertise, if accepted, we may offer you a possible mention, blog promotion and/or book acknowledgement … such a deal! 

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

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A Doctor – Economist’s Solution for Health Reform

My Laundry Wish List for all US Healthcare Stakeholders

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]Fox News

As President Obama speaks, prods and cajoles, and Congress returns to session to begin work again on HR 3200-3400 or similar, I believe that for any healthcare reform effort to work successfully for the American people – not necessarily be adopted – we need to consider the following in no particular prioritized order:

  • Insurance portability uncoupled from patient employment
  • Health insurance regional exchanges with inter-state purchase competition
  • Doctor, drug, DME and hospital pricing and payment transparency for HSAs, and all of us
  • Modifying or eliminating AMA owned CPT Codes®; a huge money maker for them
  • Abandoning ala’ carte medicine for values-based outcomes
  • Reduce JCAHO influence; encourage competition from Norwegian Det Norske Veritas [DNV]
  • Reduce big-pharma influence thru-out the entire medical education, career and care pipeline
  • End DTC advertising from big-pharma
  • Promote wholesale drug purchase competition, MC bidding and generic drugs
  • Encourage evidence-based medicine, not expert-based medicine
  • Less pay for medical specialists with a  re-evaluation of the hospitalist concept
  • Advance the dying art of physical diagnosis, teach and embrace Paretto’s 80/20 rule for clinic issues
  • Reduce lab test, diagnostic imaging and testing
  • Encourage private 24/7/365 medical offices and clinics; and on-site and retail clinics
  • Abandon P4P, medical homes and disease management ideas
  • Give more economic skin-in-game to patients relative to health benchmarks
  • Concretize the “never-event” prohibitions and include a list of patient health responsibilities
  • More pay for primary care docs and internists
  • Adopt digital records and cloud computing for patients
  • Phase in true eHRs incrementally; and abandon CCHIT for open source SaaS
  • Promote Health 2.0 social media.
  • Augmented scope of practice, numbers and pay for NPs and DNPs, etc
  • Reduce pay for CRNAs and increase it for staff RNs
  • Develop step down triage and treatment units to reduce the number of full service ERs
  • Increase medical, osteopathic, dental, optometric and podiatric medical school classes
  • Increased practice scope for dentists, podiatrists and optometrists
  • Make some sort of catastrophic HI mandatory, much like auto insurance for all
  • End pre-existing conditon health insurance contract clauses
  • More choice  and end of life control for the terminally ill patient
  • Increase marketplace competition with fewer political and financial “externalities”.
  • Teach basic healthcare topics in school and encourage physical exercise
  • Health and insurance education should be, but is not, the “answer” for Americans
  • Protect borders and discourage undocumented illegals
  • Adopt medical malpractice tort reform
  • Make all stakeholders fiduciaries 
  • No public “option” unless you like food stamps, Section 8 housing, public transportation and schools
  • Budget deficit neutrality
  • Joe Wilson is both a bright guy – and a jerk
  • Slow down!

Assessment

Recently, while in the Baltimore/Washing area, I was asked by several reporters to opine on the healthcare debate; which I did so freely having never been known as the shy type. And, regular readers will note that many of these items have been used as posts or comments on this ME-P. Unfortunately, my “laundry list” interview was pre-empted by two local but boisterous town-hall meetings with respective passionate politicians. It was redacted no doubt, but never broadcast. Thus, I missed the potential for my “five minutes” of fame. C’est la vive!

Conclusion

There you have it; direct and straight forward. And so, your thoughts and comments on this Medical Executive-Post are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Dr. Pruitt Invites Dr. Cohen to Discuss eDRs

Where is the ADA’s Representative?

By Darrell K. Pruittpruitt; DDS

He or she should have been talking with me long ago. I have the audience and I’m giving you that opportunity I promised you, Dr. Donald Cohen.

Rest Easy

I’m aware that I possibly make you uncomfortable, considering how “unprofessionally” I’ve publicly treated lesser devoted HIPAA consultants. Rest easy! As soon as I read your article, I could tell that you’re different from your colleagues I’ve met. First of all, like me, you’re a dentist. That’s very important. Secondly, your credentials are impressive and reveal that compliancy is not a hobby for you like it is for others. Nobody can accumulate a history as impressive as yours without professional dedication. The last point, and the most important of the three, you seem honest about HIPAA compliance.

A Professional

It wasn’t lost on me that in your article you were professionally non-judgmental of the Rule. Instead of trying to justify a defenseless law, your job is to help dentists comply with the mandate as it is written or risk significant fines. Like tax-collecting, someone’s got to do the job of delivering bad news. You have a legitimate purpose to be involved in the dental industry, even if what you teach makes little difference at all if a dentist’s records are breached. I argue that following the inevitable bankruptcy from a breach, HHS fines are hardly a deterrent. And that is the issue: eDRs containing patient identifiers are too risky for the marketplace.

Electronic Dental Records

I think you would have to agree that eDRs are going nowhere until records are safe, and encryption is not going to be sufficient to protect dentists against dishonest employees. Ambitious bureaucrats in waiting, such as HIPAA consultants Travis Criswell, Sharalyn Fichtl, Kelly Mclendon and Olivia Wann – not a dentist among them – hooked their careers to the HIPAA mandate to avoid the tough sales jobs competition otherwise demands in the free market. All four share an authoritarian misconception that since it is the law, dentists will be forced to purchase their products – even if they are utterly senseless. I think we both know that they are oh so wrong. I promised earlier to give you an opportunity to publicly support truth in eDRs if you so choose. Perhaps we could rationally discuss in front of everyone how dentists can wriggle free of the approaching mess. There is no pressure here, other than this is public invitation. Since you haven’t made unrealistic claims about eDRs like others have, I am not interested in hounding you further. I simply ask you to consider responding to the article I posted in your name on PennWell titled “Dr. Donald Cohen’s opportunity.”

http://community.pennwelldentalgroup.com/forum/topics/dr-donald-cohens-opportunity

Assessment

I sincerely appreciate the respect you have shown me, and I pledge to afford you the same. Of all the consultants I have approached with my concerns about HIPAA and eDRs, you are the first to even acknowledge a problem simply by posting my concerns. I think you have the courage to face the realities of the marketplace, while others foolishly think dentists are a captive market.

Note: I submitted this to be posted following an August 28th press release posted by HIPAA consultant Dr. Donald Cohen titled, “Dentists Should Know about New HIPAA Rules.”

http://www.dentalblogs.com/archives/administrator/dentists-should-know-about-new-hipaa-rules/comment-page-1/#comment-35672

If you are interested in discussing the topics of interoperability with fax machines, de-identified eDRs and security that surpasses paper records, in front of you is the opportunity to address your largest audience yet, Dr. Cohen. I’m self-syndicated.

Note: Do you realize that if Dr. Cohen takes me up on the offer, this will be the first time two dentists have openly discussed eDRs on the Internet? Do you think it’s about time?

Conclusion

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INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Take the DME Inventory Switching Challenge!

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 Calling all Administrators and Management Consultants – Are You CMP™ Worthy?

 [By Staff Reporters]ME-P Logo.2

The new administrator for the ABC Medical Clinic understood that all inventory costing methods were acceptable to use in his Durable Medical Equipment [DME] department. LIFO, FIFO, specific identification, and the average cost method are all attractive methods under different circumstances in the business cycle, and companies may use the method that best fits their circumstances.

Reducing Taxes

For example, if ABC wished to reduce corporate income taxes in a period of inflation and rising prices, it would use LIFO. If matching DME sales revenue with the current cost of DME goods sold was desired, LIFO would also be used. Unfortunately, LIFO may charge against DME revenue the cost of DME not actually sold, and LIFO may allow the ABC Medical Clinic to manipulate net income by varying the time-periods it makes additional DME purchases. On the other hand, FIFO and specific identification method allows a more precise matching of ABC revenue with historic DME costs. However, FIFO too, can promote “paperless-phantom profits,” while specific identification can promote possible income manipulation.  It is only under FIFO that net income manipulation is not possible.

CEO – 2 – CFO [Case Model]

“Let’s go with FIFO,” the new administrator said to his Chief Financial Officer, Bert. “The profits will make us look good to the home office and we can always switch back to LIFO if inflation starts back-up again, right Bert?” He mused, but he was not amused because freedom of choice does not include changing DME inventory methods every few years, especially if only to report higher income. “The switching of methods violates the basic tenet of consistency, which requires the use of the same inventory cost and accounting methods in preparing financial reports and statements,” Bert emphatically stated.

Key Issues

1) Is this sort of inventory costing and maneuvering permissible?

2) What is its justification?

3) How is it notated in financial reports?

4) Is this sort of thing ethical?

Assessment

“The switching of methods violates the basic tenet of consistency, which requires the use of the same inventory cost and accounting methods in preparing financial reports and statements,” Bert emphatically stated.

Conclusion

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

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Improving Patient Control of eHRs

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Traditional Command-Control Option Dying Out … Slowly!

[By Staff Reporters]Hospital Access Management

NewYork-Presbyterian Hospital recently introduced a new personal electronic health record [eHR] enabling patients to access medical information wherever and whenever they need it. Called myNYP.org, the system uses Microsoft’s HealthVault and Amalga technologies to offer patients the ability to select and store personal medical information generated during visits to NewYork-Presbyterian.

About NewYork-Presbyterian

NewYork-Presbyterian Hospital is one of the most comprehensive university hospitals in the world, with leading specialists in every field of medicine. The hospital is composed of two renowned medical centers, NewYork-Presbyterian Hospital/Columbia University Medical Center and NewYork-Presbyterian Hospital/Weill Cornell Medical Center, It is affiliated with two Ivy League medical institutions, Columbia University College of Physicians and Surgeons and Weill Cornell Medical College.

Assessment

MyNYP.org uses a “pull model” in which patients proactively opt to copy their medical data into their own personal health record and access that information using a secure username and password with any Web-enabled device. And yes, online bill pay features are available.

Conclusion

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Off-Road Touring with Dr. Marcinko [Part VIII]

Interview with David B. Lumsden; MD

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Dateline: Baltimore Maryland,Dr. Lumsden Formal August 10, 2009.

About David B. Lumsden MD

Dr. David Lumsden; MS, MA practices general orthopedic surgery and trauma as a board certified surgeon and partner with Orthopedic and Hand Surgery Associates in Baltimore, Maryland. He completed his training in community health at Towson State University, earned Master’s Degree in Anatomy / Neuroanatomy at University of Maryland/Baltimore and Exercise Physiology at University of Maryland, College Park. He is a graduate of Penn State University School of Medicine. Dr. Lumsden completed his internship and residency at Union Memorial Hospital with associative residency training at Johns Hopkins and the world renowned Shock Trauma Center at the University of Maryland, Baltimore City. 

Our Brief Interview

When I caught up with David during a recent house-call visit, we discussed many things; especially the American Affordable Health Choices Act [HR-3200]. Unfortunately; I did not have my audio-recorder with me. So, here are a few points of interest about him that I jotted down, from memory, in my ever-present reporter’s notebook. No doubt, I missed many more:

  • He became a physician as a career change in mid-life.
  • He has read HR 3200 in its’ entirety.
  • He hired an attorney for HR 3200 interpretation and review.
  • He is for healthcare reform, but against HR 3200.
  • He is against a public health care plan.
  • He is against individual insurance mandates.
  • He does 10-12 house-calls every month.
  • He does not charge MC, MD or VA house-call patients; rarely bills them and/or accepts assignment without balance billing.
  • He regularly operates on same, under similar terms.
  • He does other pro-bono work.
  • He practices defensive medicine.
  • He is for tort reform.
  • He is not a member of the AMA with no plans to join.

Assessment

Review and vote for -or- against HR 3200 here: http://www.opencongress.org/bill/111-h3200/text

About Off Road with Dr. MarcinkoDavid Lumsden; MD

These sporadic off-road segments will continue through-out my 2009 summer promotional tour. Formal attendance increased toward the later part of the summer as the Obama Administration’s healthcare debates heated up. Our many local book stores and sponsors noted a spike in our CD and book sales, as well as interest in our online www.CertifiedMedicalPlanner.com program and premier quarterly guide: Healthcare Organizations [Journal of Financial Management Strategies] www.HealthcareFinancials.com

Part VII: https://healthcarefinancials.wordpress.com/2009/09/01/off-road-touring-with-dr-marcinko-part-vii/

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

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How Proprietary HIT Vendors May Demolish Health Reform

Top Five Issues from the Longman Report

By Staff ReportersNetwork

Here are the top five quotes from the Longman Report. The author, Phillip Longman, is a senior fellow at the New America Foundation and the author of: “Best Care Anywhere: Why VA Health Care Is Better than Yours as well as The Next Progressive Era: A Blueprint for Broad Prosperity.

http://www.newamerica.net/people/phillip_longman

The List 

1. Twenty years after the digital revolution, only an astonishing 1.5 percent of hospitals have integrated information technology systems. Almost all experts agree that in order to begin to deal with the problems of the health care system, this has to change. 

2. Done right, digitized health care could help save the nation from insolvency while improving and extending millions of lives at the same time. Done wrong, it could reconfirm Americans’ deepest suspicions of government and set back the cause of health care reform for yet another generation. 

3. Thanks to the stimulus bill, $20 billion is about to be poured into buggy, expensive, proprietary software that will not bring the benefits the Obama administration hopes for. Rather, it will amount to a giant bailout of a health IT industry whose business model has never really worked. 

4. The VA’s open-source software allowed a nurse in Topeka, Kansas, to adapt for her own work a bar-code scanner she saw used at a rental-car agency. Her innovation cut the number of medication-dispensing errors in half at some facilities, and saved thousands of lives. 

5. While a few large institutions have managed to make meaningful use of proprietary health IT, these systems have just as often been expensive failures. In 2003, Cedars-Sinai Medical Center in Los Angeles tore out a “state-of-the-art” $34 million proprietary system after doctors rebelled and refused to use it.

Assessment 

http://www.newamerica.net/publications/articles/2004/the_best_care_anywhere 

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Take the Hospital eHR Implementation Challenge!

Illustrative Case Model – Are You CMP™ Worthy?

By Staff Reporters Washington DC

The fictitional Washington Hospital is embroiled in the healthcare reform debate and interested in implementing an electronic health record (EHR) for its major clinic areas. The flagship hospital currently utilizes a legacy-based system and several of the clinics have independently purchased software programs to provide a more inclusive electronic data base particular to that clinic.

Scenario

In addition, each of the software programs purchased in specific clinics has been modified to serve their own needs. The other satellite hospitals and clinics are not linked to the flagship hospital and have independent systems, applications and software in place. The hospital is interested in obtaining one EHR system that can be used in a standardized and uniform methodology and process throughout all of its hospitals and clinics.

Key Issues

Should the Washington Hospital?

1) Abandon the clinic’s software programs in lieu of a more centralized EHR?

2) Assess various EHR systems for healthcare providers available in the marketplace, comparing a series of hospital and clinic developed requirements against vendor capabilities?

3) Obtain an EHR product that provides interface to the existing clinic software products?

4) Assess whether the EHR vendors totally comply with HIPAA and privacy regulations as well as update their systems automatically with HIPAA changes?

5) Have the vendors assess the existing system/applications/software programs currently in use at each of the hospitals and clinics and determine the best application configuration?

6) Utilize the internal Information Technology staff to develop an interface solution?

Assessment

Medical management consultants, are you up to answering this challenge? We dare you to respond! Visit: www.CertifiedMedicalPlanner.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Evaluating a Sample Physician Financial Plan III

Stress Testing Results a Decade Later

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

[By Hope Rachel Hetico; RN, MHA, CPHQ, CMP™]dave-and-hope4

We are often asked by physicians and colleagues; medical, nursing and graduate students, and/or prospective clients to see an actual “comprehensive” financial plan. This is a reasonable request. And, although most doctors who are regular readers of this Medical Executive-Post have a general idea of what’s included, many have never seen a professionally crafted financial plan. This not only includes the outcomes, but the actual input data and economic assumptions, as well.

The ME-P Difference

And so, in a departure from our pithy and typically brief journalistic style, we thought it novel to present such a plan for hindsight review. But; we present same in a very unusual manner befitting our iconoclastic and skeptical next-generation Health 2.0 philosophy. And, we challenge all financial advisors to do same and compare results with us.

How so?

By using a real life plan constructed a decade ago and letting ME-P reader’s review, evaluate and critique same.

  • Part I is for a married drug-rep, then medical school student [51 pages] with no children.
  • Part II is for the same mid-career practicing physician [28 pages] with 2 children.
  • Part III is for the same experienced practitioner at his professional zenith [56 pages].

Part III: Sample Financial Plan III

Fiduciary Advisors

fp-book2

As former financial advisors and licensed insurance agents – and a reformed certified financial planner – it is our duty to act as economic fiduciaries for clients. In other words; to put client interests above our own. This culture was incumbent in our participatory online www.CertifiedMedicalPlanner.org educational program in health economics and medical practice management; since inception in 2000.

Assessment

And so, as Edward I. Koch famously asked as Mayor of New York City from 1978-1989: “how am I doing”; we sought to ask and answer same. What did we do right or wrong; and how were our assumptions correct or erroneous?  As Certified Professionals in Healthcare Quality this is the question we continually seek to answer in medicine. And, as health economists, this is the financial advisory equivalent of Evidence Based Medicine [EBM] or Evidence Based Dentistry [EBD] etc. It is a query that all curious FAs should ask.

Note: Be sure to review sample plan I and II, right here:

Link: Sample Financial Plan I

Link: Sample Financial Plan II

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. As a financial advisor, accountant, financial planner, etc., we challenge you to lay bare your results as we have done. And, be sure to “rant and rave” – and – “teach and preach” about this post in the style of Socrates, with Candor, Intelligence and Goodwill, to all. Doctors – chime in – too. 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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ASSUMPTIONS

Sample Mega Plan for a New Physician

Joe Good, a 30-year-old pharmaceutical sales representative, and his pregnant wife Susie Good, a 30-year-old accountant, sought the services of a certified financial planner because of a $150,000 inheritance from Joe’s grandfather. The insecurity about what to do with the funds was complicated by their insecurity over future employment prospects, along with Joe’s frustrated boyhood dream of becoming a physician, along with only a fuzzy concept of their financial future.

After several information-gathering meetings with the CFP, concrete goals and objectives were clarified, and a plan was instituted that would assist in financing Joe’s medical education without sacrificing his entire inheritance and current lifestyle. They desired at least one more child, so insurance and other supportive needs would increase and were considered, as well. Their prioritized concerns included the following:

1. What is the proper investment management and asset allocation of the $150,000?

2. Is there enough to pay for medical school and support their lifestyle?

3. Can they indemnify insurance concerns through this transitional phase of life,  including the survivorship concerns of premature death or disability?

4. Can they afford for Susie to be the primary bread winner through Joe’s medical school,   internship, and residency years?

5. Can they afford another child?

Current income was not high, and current assets were below the unified estate tax-credit. Therefore, income and estate-planning concerns were not significant at that time.

After thoroughly discussing the gathered financial data, and determining their risk profile, the CMP™ made the following suggestions:

1. Reallocate the inheritance based on their risk tolerance, from conservative to long-term growth.

2. Maximize group health, life, and disability insurance benefits.

3. Supplement small quantities of whole life insurance with larger amounts of term insurance.

4. Create simple wills, for now.

Sample Mega Plan for a Mid-Life Physician

A second plan was drawn up 10 years later, when Joe Good was 40 years old and a practicing internist. Susan, age 40, had been working as a consultant for the same company for the past decade. She was allowed to telecommunicate between home and office. Daughter Cee is nine years old, and her brother Douglas is seven years old.

The preceding suggestions had been implemented. The family maintained their modest lifestyle, and their investment portfolio grew to $392,220, despite the withdrawal of $10,000 per year for medical school tuition. The financial planning aspects of the family’s life went unaddressed. Educational funding needs for Cee and Douglas prompted another frank dialogue with their CMP. Their prioritized concerns at this point were as follows:

1. Reallocation of the investment portfolio

2. Educational funding for both children

3. Tax reduction strategies

4. Medical partnership buy-in concerns

5. Maximization of their investment portfolio

6. Review of risk management needs and long-term care insurance

7. Retirement considerations

The following suggestions were made:

1. Grow the $392,220 nest egg indefinitely.

2. Project future educational needs with current investment vehicles.

3. Maximize qualified retirement plans with tax efficient investments.

4. Update wills to include bypass marital trust creation, and complete proper testamentary planning, including guardians for Cee and Douglas.

5. Retain a professional medical practice valuation firm for the practice buy-in.

Sample Mega Plan for a Mature Physician

At age 55, Dr. Joseph B. Good was a board-certified and practicing internist and partner of his group. Susan, age 55, was the office manager for Dr. Good’s practice, allowing her to provide professional accounting services to her husband’s office and thereby maximizing benefits to the couple from the practice. Daughter Cee was 24 years old, and her brother Douglas was 22 years old. The preceding suggestions had been implemented.  They upgraded their home and modest lifestyle within the confines of their current earnings. They did not invade their grandfather’s original inheritance, which grew to $1,834,045. Reallocation was needed. The other financial planning aspects of their lives had gone unaddressed. Retirement and estate planning issues prompted another revisit with their original CMP’s junior partner.

Their prioritized concerns at this point were as follows:

1. Long-term care issues

2. Retirement implementation

3. Estate planning

4. Business continuity concerns

The following suggestions were made:

1. Analyze the cost and benefits of long-term case insurance, funded with current income until retirement.

2. Reallocate portfolio assets and  plan for estate tax reduction, with offspring and charitable planning consideration..

3. Retain a professional practice management firm for practice sale, with proceeds to maintain current lifestyle until age 70.

If you want the opportunity to reach a personalized weekly audience of health care industry insiders, innovators and watchers, the Medical Executive-Post and its educational forums may be right for you?

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[Executive Director]

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On Regional Extension Centers [RECs]

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Another New Governmental Machination?

[By Staff Reporters]

A Regional (health information) Extension Center [REC] is similar to a Health Information Organization [HIO] that brings together healthcare stakeholders within a defined geographic area and governs Health Information Exchange [HIE] among them for the purpose of improving health and care in that community.

Fundamental to this definition is the meaning of Health Information Exchange and Health Information Organization. A Health Information Organization (HIO) is an organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards.

Thus, the goal of an REC is to act as a local support organization to help doctors install electronic health records and use them to achieve improved quality, efficiency, and continuity of care.

Past and Present

The RECs are based on the example of agricultural extension offices, established over 100 years ago by Congress, which offered rural outreach and educational services across the country.

Today, the HITECH Act amends Title XXX of the Public Health Service Act by adding Section 3012, Health Information Technology Implementation Assistance. This section provides supportive services for the rest of the HITECH Act. Section 3012 (a) establishes the Health Information Technology Extension Program (Extension Program). The Extension Program provides grants for the establishment of Health Information Technology 

Assessment

Link: Regional Extension Center

Link: http://www.chhs.ca.gov/initiatives/HealthInfoEx/Documents/SUMMIT%20DOCUMENTS/RECSummitSlides_FinalDraft-7-15.pdf

Link: HIT Extension Program – Regional Centers Cooperative Agreement Program

Conclusion

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E. A. Poe and Touring with Dr. Marcinko [Part VII]

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Edgar Allan Poe, Church Hospital, Johns Hopkins and Me

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Dateline: Baltimore MarylandPoe, August 7, 2009

To the entire world, Church Home and Hospital, formerly known as the Washington Medical College, was where Edgar Allan Poe died on October 7, 1849. Located in Upper Fell’s Point, it was also where many doctors were trained who served in the Union and Confederate armies during the Civil War. But for me, its emergency room seemed like home, as a local inner city youth, back-in-the-day.

Link: http://www.eapoe.org/balt/poechh.htm

About Fells Point

Fell’s Point is an historic waterfront community just east of Baltimore’s Inner Harbor. The Fells Point Historic District occupies the area from Gough Street south to the water’s edge, roughly between Caroline and Chester Streets. Established in 1763, Fells Point is a city, state and National Historic District and boasts over 161 buildings on the National Register, along with the oldest standing residence in Baltimore City, the Robert Long House at 812 S. Ann Street. The neighborhood is home to dozens of unique retail shops, restaurants and pubs; along with our community Church Home and Hospital; and its more famous behemoth neighbor up the street, Johns Hopkins University Hospital and Medical School.

Link: http://www.fellspoint.us/

It was as a freshman medical student, visiting “the Johns”, where I first met J. Alex Haller Jr. MD – the world famous Children’s-Surgeon-in-Charge of Johns Hopkins Hospital, and pectus excavatum surgical pioneer, from 1964 until 1997. As well as pediatric heart surgeon Helen Brooke Taussig MD (1898 – 1986), developer of a famous operation to alleviate “blue baby” syndrome, and who first warned the public on the dangers of thalidomide. JHU is also where I played stick-ball as a kid, in the hospital parking lot. But, I digress.

Link: http://www.msa.md.gov/msa/educ/exhibits/womenshall/html/taussig.html

Church Home and Hospital and Me

My first visit to the Church Home Hospital ER was to repair a forehead laceration which was sustained after a fall onto one of Baltimore’s famous brick steps.

The second was to re-attach my right hallux [big toe] after almost completely severing it on a piece of glass [broken beer bottle].

My final visit was to repair a thigh laceration. Of course, my younger brother made two subsequent visits, over the years, as well. On all occasions we were sutured and repaired by Raymond Atkins MD; following his career as a junior and senior attending resident, fellow and well into private practice. In a time before eMRs; Dr. Ray would later tell us that just hearing the name “Marcinko” was enough medical history for him to commence his trip to the ER. God bless you Dr. Atkins and Church Home and Hospital.

Assessment

As a student of the city, I knew of Church Home Hospital and Edgar Allan Poe before ever learning of Haller, Taussig or Atkins. But, they all made impressions on me, in one way or another. I just had to revisit the sites and  them, if only in memory

About Off Road with Dr. Marcinko

These sporadic off-road segments will continue through-out my 2009 summer promotional tour. On the one hand, formal attendance at several engagements was a bit sparse because of the death of several recent celebrities and entertainer types.

On the other hand, local book stores and sponsors noted a spike in our  book sales, as well as interest in our online www.CertifiedMedicalPlanner.org program.

Part VI: https://healthcarefinancials.wordpress.com/2009/08/27/off-road-touring-with-dr-marcinko-part-vi/

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Tell us what you think about this trip down memory lane? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Events Planner: September 2009

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Events-Planner: SEPTEMBER 2009

Staff WritersLobster

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

Welcome to this issue of the Medical Executive-Post and our Events-Planner. It contains the latest information on conferences, news, and relevant resources in healthcare finance, economics, research and development, business management, pharmaceutical pricing, and physician/entity reimbursement!  Watch for a new Events-Planner each month.

First, a little about us! The Medical Executive-Post is still a newcomer. But today, we have almost 25,000 visitors and readers each month from all over the country, in addition to our growing subscriber base. We have been a successful collaborative effort, thanks to your contributions.  As a result, we are adding new resources daily.  And, we hope the website continues to provide the best place to go for journals, books, conferences, educational resources, tools, and other things you need to establish the value your healthcare consulting and financial advisory intervention. And so, enjoy the Medical Executive-Post and our monthly Events-Planner with our compliments. 

A Look Ahead this Month

Sept 1: Print Edition Healthcare Journalism: If you would like to “step-up-your-game” and be considered as a peer-reviewed contributor to the third print edition of: The Business of Medical Practice [Health 2.0 Profit Maximizing Techniques for Savvy Doctors]; contact Ann at: MarcinkoAdvisors@msn.com. There are several chapter topics still available. Now, the important dates:

Sept 11: New England Healthcare Association Conference, Boston, MA.

Sept 13: Medicare and Medicaid AHIP Conference, Washington, DC.

Sept 13: Schwab Impact, Convention Center, San Diego, CA

Sept 14: Medicare RAC Summit, Washington, DC.

Sept 15: DOL Employees Benefits Conference, Washington, DC

Sept 18: Healthcare Compliance Association Conference, Minneapolis, MN.

Sept 21: Healthcare Financial Management Conference, Chicago, Ill

Sept 21: GIPPS Interactive Workshop, CFA Institute, Boston, MA

Sept 22: Health Plan Innovation Conference, Chicago, Ill.

Sept 24: Executive Forum Public-Private Employer Partnerships, Atlanta.

Sept 25: Family Office Symposium, FINRA, Aventura, FL

Sept 30: Consumer Health Management Conference, Alexandria, VA.

Conclusion

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Join Our Mailing List

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 

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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