Insights on the Rise and Future of Participatory Health 2.0 for Physicians and Podiatrists*

[What is it – How it works]

By Dr. David Edward Marcinko; MBA, CMP

By Professor Hope Rachel Hetico; RN, MHA, CPQH, CMP

www.CertifiedMedicalPlanner.org

Introduction

In 1995, the primary use of the internet was e-mail for the masses. Next, doctors linked to hospitals and MCOs for clinical information and insurance benefits coverage. Today, physicians are finding deeper avenues for the Internet and cloud computing:

  • Queries from patients, newsletters, podcasts and educational links.
  • Continuing education, consultations and professional presentations.
  • Nurse connectivity and lab results with alerts for abnormal values.
  • Computerized Physician Order Entry Systems.
  • Picture Archiving and Communication systems and clinical imaging.
  • Appointments, open scheduling digital transcription services and administration.
  • eMRs and clinical groupware, etc

DEFINITIONAL OBSCURITY

The broad term eHealth was introduced in 2000. It refers to the use of computers, networks and the internet to store and manage medical records, instead of paper files. According to the WHO, it refers to components delivered, enabled and supported through the use of technology. It may involve administrative, financial and clinical communication between providers, patients and payers; like referrals and e-prescribing. More formally, eHealth provides stakeholder access to databases, knowledge resources, checklists and decision support tools to guide healthcare service delivery. https://healthcarefinancials.wordpress.com/?page_id=21352&preview=true

But, ever since the term “web 2.0″ was first used in 2004, there has been much definitional obscurity about its’ true impact in medicine. And, although no one’s defined it clearly, we think the health-on-the-internet evolution falls into 3 categories.

Health ON THE INTERNET

Health 1.0

This is the dying healthcare system of today. Information is communicated from doctors to patients. It is a basic B2C [business-to-consumer] website as the internet became one big encyclopedia by aggregating knowledge silos. Some doctors maintain websites, others do not. Nevertheless, Health 1.0 has a command and control hierarchy; doctors on top of the pyramid, patients on the bottom.

Health 2.0

According to Matthew Holt [personal communication] Healthcare 2.0 may be defined as:

“The foundation of healthcare 2.0 is information exchange plus technology. It employs user-generated content, social networks and decision support tools to address the problems of inaccessible, fragmentary or unusable health care information. Healthcare 2.0 connects users to new kinds of information, fundamentally changing the consumer experience (e.g., buying insurance or deciding on/managing treatment), clinical decision-making (e.g., risk identification or use of best practices) and business processes (e.g., supply-chain management or business analytics)”.

And so, if Health 1.0 was a static book, Health 2.0 is a dynamic discussion http://www.health2advisors.com

Example: The power of the internet is illustrated in the phenomenon of “crowd-sourcing.” In this context, the term means to harvest the reach of social networking [wisdom of crowds] to solve a problem. A knowledge seeker asks a question and participants respond.  For example, readers can participate on the www.MedicalExecutivePost.com or www.BusinessofMedicalPractice.com sites to improve the administration of any medical practice. And, www.PodiatryPrep.com is an example of how podiatrists connect for global board certification assistance.

Health 2.0; plus

The Dictionary of Health Insurance and Managed Care defines this emerging hybrid as a bridge uniting the philosophy of contemporary Health 2.0 with futuristic Health 3.0 technologies. Cisco System’s HealthPresence is one example developed in 2010, by Dr. T. Warner Hudson. Using the network as a platform, HealthPresence combines video, audio and information to create an environment similar to what patients experience when they visit their own doctor.

https://healthcarefinancials.wordpress.com/2010/01/28/about-the-cisco-healthpresence-medical-delivery-model/

And, firms like 23andMe, Navigenics, DeCodeMe, CollabRx and Cure Together, hope that genomics and aggregated patient experiences will advance fast enough so the current epidemic of “more diagnosis with less ability to change outcomes” will morph into one where knowing your  future averts adverse medical consequences.

Health 3.0

Soon, patients will not only be seeking information; but actionable intelligence – whether it is artificial or real. Patients will communicate almost as with another patient or doctor. The internet won’t just blindly do what we tell it to do – it will think and represent some amazing opportunities. For example, imagine your toilet running a SMAC 20 and then being instantly notified of the results by your smart phone? Or; use your iPhone to send pictures and streaming videos of conditions for a second opinion www.KnockingLive.com

Read the entire white paper here: Podiatry.Today.Participatory Healthcare

What is the Future of Collaborative Medicine? http://www.podiatrytoday.com/what-future-collaborative-medicine

*Note: Dr. Marcinko was requested to author this white paper for podiatrists [Doctors of Podiatric Medicine]. As a thought-leader, he and Ms. Hetico are often cited in journals like: Managed Care Executive, Healthcare Informatics, Medical Interface, Journal of the American Medical Association; Business Journal for Physicians and Physician’s Money Digest. He also writes for professional organizations like the Medical Group Management Association (MGMA), American College of Medical Practice Executives (ACMPE), American College of Physician Executives (ACPE), American College of Emergency Room Physicians (ACEP), Humana Health and PhysiciansPractice.com. His works have been archived by academic institutions like the UCLA School of Medicine, Medical College of Wisconsin, University of North Texas Health Science Center, Washington University School of Medicine, University of Pennsylvania Medical and Dental Libraries, Southern Illinois College of Medicine, University at Buffalo Health Sciences Library, University of Michigan Dental Library, and the University of Medicine and Dentistry of New Jersey, among others.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Applicability to all medical professionals, and specialists, is obvious. 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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Insurance and Risk Management Strategies for Physicians and Advisors

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A Vital Handbook for Doctors

[By ME-P Staff Reporters and their Consulting Advisors]

Product Details

For practicing physicians, selecting a knowledgeable insurance advisor and developing a comprehensive personal and corporate risk management plan can be a daunting task. As a consequence of today’s litigious environment in the healthcare industry, physicians must now carefully assess their personal and practice risks as they seek to be indemnified should an event or cause of action occur. This process requires integrated knowledge of the healthcare industrial complex, as well as the rapidly changing insurance industry.

The Reality

Fortunately, Insurance and Risk Management Strategies for Physicians and Advisors confronts the reality that insurance planning in healthcare is decidedly more complex than most other businesses or professions and, in an easy-to-understand manner, explains to physicians and insurance professionals the background, theory, and practicalities of medical risk management and insurance planning.

Certified Medical Planner® Dr. David Edward Marcinko and his team of contributing authors go into great depth on the growing range of insurance planning options in order to assist physicians, and their advisors, to choose the “right” course that balances risk, cost, time, outcome as well as his or her own personal risk tolerance life style.

Insurance and Risk Management Strategies for Physicians and Advisors is ideal for medical professionals and the insurance advisors who seek to serve them, as well as for financial planners, insurance agents and healthcare business advisors wishing to re-educate and help doctors by adding lasting value to their client relationships.

Assessment

Includes tools, templates, case studies, glossary of terms, and examples required to make insurance issues “come alive” in a real world setting

From the Foreword:

“Insurance and Risk Management Strategies for Physicians and Advisors is an essential textbook because it explains to physicians and insurance professionals the background, theory, and practicalities of medical risk management and insurance planning.  The insurance haze is lifted by dual-degreed editor, and Certified Medical Planner© Dr. David Edward Marcinko, and his team of contributing authors.

Insurance and Risk Management Strategies for Physicians and Advisors fulfills its promise as a peerless tool for physicians wanting to make good decisions about the risks they face. It is also ideal for financial planners, insurance agents and healthcare business advisors wishing to re-educate and help doctors by adding lasting value to their client relationships. With time at a premium for all, and so much information packed into one well-organized resource, this book should be on the desk of every physician, or financial advisor serving the healthcare space.

Simply stated, if you read this compelling text with a mind focused on the future, the time you spend will be amply rewarded.”

Lloyd M. Krieger, MD, MBA
Rodeo Drive Plastic Surgery
The Rodeo Collection
421 North Rodeo Drive
Beverly Hills, CA 90210
Phone: 310.550.6300
Fax: 310.550.6363
Email: lkrieger@ucla.edu
http://www.RodeoDrivePlasticSurgery.com

Conclusion

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About the Number Needed to Treat [NNT] Calculation and Medical Outcomes Website

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A “New” Clinical Numeric

By Professor Hope R. Hetico; RN, MHA, CMP™

[Managing Editor]

Professor Hope Hetico

This new physician-led medical website  http://www.thennt.com/ seeks to explain to patients and physicians how well a particular treatment or medicine is likely to work based on a statistical model called the “Number Needed to Treat.”

Calculation

This is not really a new calculation, as it has been know for many years. In fact, I review and teach it in several of my undergraduate, graduate and business school courses [healthcare administration, statistics, epidemiology, infection control, community health, etc], and have been doing so for a few years now. My students are always amazed by it.

Brief Definition

The NNT is “a measurement of the impact of a medicine or therapy by estimating the number of patients that need to be treated in order to have an impact on one person.”

Detailed Definition

According to wikipedia; the number needed to treat (NNT) is an epidemiological measure used in assessing the effectiveness of a health-care intervention, typically a treatment with medication. The NNT is the number of patients who need to be treated in order to prevent one additional bad outcome (i.e. the number of patients that need to be treated for one to benefit compared with a control in a clinical trial). It is defined as the inverse of the absolute risk reduction.

The NNT was first described in 1988. The ideal NNT is 1, where everyone improves with treatment and no-one improves with control. The higher the NNT, the less effective is the treatment. Variants are sometimes used for more specialized purposes.

One example is number needed to vaccinate. NNT values are time-specific. For example, if a study ran for 5 years and it was found that the NNT was 100 during this 5 year period, in one year the NNT would have to be multiplied by 5 to correctly assume the right NNT for only the one year period (in the example the one year NNT would be 500).

Source: http://en.wikipedia.org/wiki/Number_needed_to_treat

NNT Video

Take a quick look behind the numbers with this video presentation:

http://www.thennt.com/the-nnt-explained

Assessment

For more information:

http://www.physiciansnews.com/2010/10/06/new-website-by-docs-shows-data-on-treatment-outcomes/

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Give em’ a click and tell us what you think http://www.thennt.com? Do you use the concept of NNT in your clinical medical practice; why or why not? 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.

Channel Surfing

Have you visited our other topic channels? Established to facilitate idea exchange and link our community together, the value of these topics is dependent upon your input. Please take a minute to visit. And, to prevent that annoying spam, we ask that you register.

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The LLC Defined for Physicians

A Hybrid Business Entity

By Staff Reporters

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A limited liability company (LLC) is a form of business entity some physician use that can provide many advantages to a physician medical practice owner.

Definition

As the name indicates, there is limited liability to the physician. Therefore, the practice owner’s personal assets are protected from claims against the practice and also from practice business debts, unless of course, the owner personally guaranteed any business debts.

No Absolute Immunity

But, limited liability protection is not absolute. There are instances where a doctor owner’s personal assets can be reached.

Assessment

Limited liability protection is similar to that of a corporation. However, unlike a C corporations, an LLC is a “pass-though” entity for taxation purposes. The benefit of being a pass through entity is that there is only one level of tax imposed on the LLC’s earnings. With a C corporation, the earnings are taxed at the corporate level and taxed again at the shareholder level when the earnings are distributed to shareholder.

Thus, the LLC can be considered a hybrid between a corporation and a partnership.

Charitable Business Planning and the LLC

http://www.chslegacy.org/giftlaw/article.jsp?WebID=GL2007-1230&D=201010

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. What type of business entity is your medical practice, and why? 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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Healthcare Organizations: www.HealthcareFinancials.com

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Useful Managed Care Patterns and Procedural Utilization Trends

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Part One of Two

By Dr. David Edward Marcinko MBA

[Publisher-in-Chief]

If you read this ME-P regularly or have read my earlier blogs, you know that I am writing a book on practice management for the private medical practitioner.

The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors]; third edition: www.BusinessofMedicalPractice.com

Link: Front Matter BoMP – 3

And, a recent story in the Chicago Tribune on the difficult business life of private practitioners today reminds me that I need to keep my nose to the grindstone.

For example, knowing your medical contract negotiation objectives, gathering information on the choices of contracts and discount payment systems, and understanding the pitfalls to watch for when evaluating a contract are the keys to any successful negotiation process.

Reimbursement Contract Negotiations

According to the sanofi-aventis Pharmaceutical Company Managed Care Digest Series, for 2008-10, the following pattern and trend comparative information has been empirically determined and may provide a basic starting point for practitioners to share business management, facilities, personnel, and other records for enhanced contract negotiation success.

www.managedcaredigest.com

hos

Procedural Utilization Trends

  • Among all physicians in a single-specialty group practice, invasive cardiologists averaged the most encounters with total hospital inpatient admissions down from the prior year. However, encounters rose for cardiologists in multispeciality group practices.
  • Echocardiography was the most commonly performed procedure on HMO seniors, followed by coronary artery bypass graft surgery. Group practices performed cardiovascular stress tests for circulatory problems most often.
  • CT studies of the brain and chest were the most common studies for HMO seniors, while MRI head studies were the most common diagnostic test on commercial HMO members.
  • Colonoscopy was the most common digestive system procedure on senior HMO members, while barium enemas were more common on commercial members.
  • Hospital admission volume decreased for allergists, family practitioners, internists, OB/GYNs, pediatricians, and general surgeons.
  • Internists ordered more in-hospital laboratory procedures than any other physicians in single-specialty groups.
  • Non-hospital MD/DOs used in-hospital radiology services most frequently, continuing a three-year upward trend.
  • Pediatricians averaged the most ambulatory encounters, down from the prior year.
  • Non-hospitalist internists ordered a higher number of in-hospital laboratory procedures than any other single medical specialty group, but allergists and immunologists increased their laboratory usage.
  • The number of ambulatory encounters increased for general surgeons, while group surgeons had the most cases. Capitated surgeons, of all types, had a lower mean number of surgical cases than surgeons in groups without capitation. Surgeons in internal medical groups also had more cases than those in multi-specialty groups.
  • The average number of total office visits per commercial and senior HMO visits fell, along with the number of institutional visits for both commercial and senior HMO members.
  • The average length of hospital stay for all commercial HMO members increased to 3.6 days but decreased to 6 days for all HMO members.
  • The total number of births increased for commercial HMO members served by medical group practices, and decreased for solo practitioners.
  • More than one-third of all medical groups use treatment protocols, rising from the year before. Multi-specialty groups were more likely to use them than single-specialty groups, who often develop their own protocols. The use of industry benchmarks to judge the quality of healthcare delivery also increased.
  • Outcome studies are most common at larger medical groups, and multi-specialty groups pursue quality assurance activities more often than single-specialty groups.
  • Provider interaction during office visits is increasingly coming under scrutiny. Patients approve of cardiologists more frequently than allergists and ophthalmologists.

Assessment

Obviously, the above information is only a gauge since regional differences, and certain medical sub-specialty practices and carve-outs, do exist.

Part Two: Useful Managed Care Provider, Staffing, Activity and Financial Trends

Conclusion

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Higher Spending on Healthcare Doesn’t Always Deliver Quality

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Law of Diminishing Returns

[By Staff Reporters] 

Health plans that spend the most on care don’t always deliver the best quality, concludes a new report from the National Committee for Quality Assurance (NCQA).

The Costly Chronic Illnesses

Insurers said they spend most on five costly, common chronic illnesses–asthma, cardiovascular disease, chronic obstructive pulmonary disease, diabetes and hypertension.

However, there was a high degree of variation among plans and no clear correlation between resource use and quality.

Quality Medial Management

Assessment

Sources:

http://www.fiercehealthpayer.com/story/insurers-high-spending-care-doesnt-always-deliver-quality/2010-10-15?utm_medium=nl&utm_source=internal

http://theincidentaleconomist.com/wordpress/how-do-we-rate-the-quality-of-the-us-health-care-system-%e2%80%93-infrastructure/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+TheIncidentalEconomist+%28The+Incidental+Economist+%28Posts%29%29

Is this like the domestic public education system, or a modification of the Laffer Curve in economics?

Conclusion

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On the US Budget Deficit in 2010

Now North of $1.3 Trillion Dollars

By Children’s Home Society of Florida Foundation

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The federal fiscal year for 2010 concluded on September 30th. The Office of Management and Budget and Department of Treasury have released the official figures for fiscal year 2010. The deficit was $1.294 trillion.

Geithner Speaks

Treasury Secretary Tim Geithner noted that the cost of the financial rescue of banks and automotive companies was lower than expected. He stated, “By carefully managing the emergency initiatives to stop the financial panic and by accelerating our exit from those investments, we have significantly lowered the cost to taxpayers, bringing the costs of the financial rescue down by more than $240 billion this year.”

TARP

The Troubled Asset Recovery Program (TARP) cost to Treasury was $9 billion in 2010. During this year, the Federal Government also spent $52.6 billion to support the housing industry through troubled lenders Freddie Mac and Fannie Mae.

Deficit Concerns

The deficit declined slightly from 10% in 2009 to 8.9% of the 2010 gross domestic product (GDP). Tax receipts for 2010 were $2.16 trillion or 14.9% of the economy. Government expenditures were $3.45 trillion or 23.8% of the economy. Senate Budget Committee Ranking Minority Member Judd Gregg (R-NH) expressed concern about this deficit and noted, “These abrupt and shocking changes in our fiscal situation cannot be dismissed as “inherited” problems when the tally of the majority’s spending spree has climbed into the trillions.”

Assessment

The Fiscal Commission appointed by President Barack Obama is developing a plan to reduce the deficit. The target for the Fiscal Commission is to reduce the current 8.9% GDP deficit down to 3% of GDP within five years.

Editor’s Note: Your editor and this organization take no position with respect to the many financial and tax options that are available to Congress. This information is offered as a public service to our readers.
Conclusion

And so, your thoughts and comments on this ME-P are appreciated. How does this state of affairs affect the healthcare industrial complex? 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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Physician Advisors: www.CertifiedMedicalPlanner.com

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Hospital Personnel and Physician Recruitment

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Understanding Professional Employer Organizations [ PEOs]

By Eric Galtress

www.BusinessofMedicalPractice.com

One way to improve human resources [HR] is to recruit physicians, nurses, technicians, allied healthcare providers and other hospital personnel who bring in a certain expertise and disseminate it to other employees.

Hospitals, larger practices and medical clinics are increasingly hiring materials managers from other industries, for example, to upgrade their materials management capabilities; so why not medical and other related professionals, as well?

 Hospitals Lag Conventional Industry

And, hospitals often lag far behind other industries with regard to professional human resource activities. For example, hospitals can hire personnel with experience in other professionals settings in order to gain new perspectives in physician management and leadership.  With these new perspectives, agreements with doctors and other providers can be renegotiated to make a hospital or clinic more competitive.

Internal Recruitment

www.HealthcareFinancials.com

Internally, improving the financial performance of any healthcare organization is a skilful balance between cinching the belt and investing in the right growth strategies.  Whether that strategy calls for expanding a clinic, moving into a key market, or adding a new clinical program, recruiting the right physicians and medical personnel becomes all important in achieving economic goals.  Without physicians and ancillary personnel there are no patients.  Indeed, doctors, nurses, and providers are key drivers in any healthcare organization’s growth strategy.

Simply put, finding and hiring the right medical professionals is a surefire prescription for success.  A winning centralized operational process includes: needs and criteria determinations; materials for sales, marketing and recruiting; interviews and onsite visits; and the correct reimbursements package with employment contract.

External Recruitment

www.HealthcareFinancials.com

External recruitment, on the other hand, may involve use of a professional employer organization (PEO) as hospitals and healthcare entities may find that employee leasing, also referred to as co-employment, can be an effective strategy to combat the spiraling costs of having a professional recruitment and clerical support staff.  PEOs can offer financial and administrative benefits to hospitals, which in turn, can increase staff loyalty and reduce turnover.  Office-based physicians will find that the personnel services of an employee leasing company will give them more time to address the efficiency of their practices and the quality of care they provide for patients.

Simply put, instead of the healthcare organizations, clinic, hospital, or practitioner being the employer of record of the workplace employees, this responsibility is outsourced to an off-site PEO that specializes in hiring, retention, labor management, and cost control. 

Assessment

In a PEO, the healthcare organization retains functional control of the employees, and the PEO handles the HR management issues.  The PEO can provide these HR services more cost effectively by combining employee groups and servicing their needs along with the employees of the many other healthcare organizations they already serve.  Outsourcing becomes a matter of simple economics.

Conclusion

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Understanding Healthcare Conflicts of Interest

A Modern Ethical Dilemma

By Render Davis

www.BusinessofMedicalPractice.com

Conflicts of interest are not a new phenomenon in medicine. In the fee-for-service system, physicians controlled access to medical facilities and technology, and they benefited financially from nearly every order or prescription they wrote.  Consequently, there was an inherent temptation to over-treat patients.  Even marginal diagnostic or therapeutic procedures were justified on the grounds of both clinical necessity and legal protection against threats of negligence. 

Traditional Medical Care

While it can be construed that this represented a direct conflict of interest, it could also be argued that most patients were well served in this system because the emphasis was on thorough, comprehensive treatment – where cost was rarely a consideration.  It was a well known adage that physicians “could do well, by doing good.” 

Managed Medical Care

In managed care, the potential conflicts between patients and physicians took on a completely different dimension.  By design, in health plans where medical care was financed through prepayment arrangements, the physician’s income was enhanced not by doing more for his or her patients, but by doing less.  Patients, confronted with the realization that their doctor would be rewarded for the use of fewer resources, could no longer rely with certainty on the motives underlying a physician’s treatment plans.  One inevitable outcome was the continuing decline in patients’ trust in their physicians.  This has been exacerbated to some degree by revelations of significant financial remuneration to physicians by pharmaceutical and medical products firms for their services as researchers or active participants on corporate-funded advisory panels, calling into question the physician’s objectivity in promoting the use of company products to their peers or patients.

Higher Concerns

Conflicts of interest may also create concerns at a much higher level, as evidenced by the issues raised in 2008 litigation against Ingenix, a company that for more than a decade, provided information to the insurance industry on payments to out-of-network physicians for their “usual and customary rates (UCR).” As noted in court documents, Ingenix was a wholly-owned subsidiary of United Healthcare and the UCR information sold by the company to insurers may have been fundamentally biased in favor of the insurers, causing patients to pay larger out-of-pocket fees.  As a result, New York attorney general Andrew Cuomo filed suit against Ingenix.  This action was followed by suits brought against major insurers by the American Medical Association and several state medical groups for systematic underpayment to members, based on the biased data. 

Assessment

To date, there have been monetary settlements, but the issue continues to raise growing concerns regarding conflicts of interest among the key payers for health care.

Conclusion

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Docs on Pharma Payroll Have Blemished Records

Limited Credentials

By Charles Ornstein , Tracy Weber and Dan Nguyen
ProPublica, Oct. 18, 2010, 11:52 p.m.

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The Ohio medical board concluded [1] that pain physician William D. Leak had performed “unnecessary” nerve tests on 20 patients and subjected some to “an excessive number of invasive procedures,” including injections of agents that destroy nerve tissue.

Yet the finding, posted on the board’s public website, didn’t prevent Eli Lilly and Co. from using him as a promotional speaker and adviser. The company has paid him $85,450 since 2009.

In 2001, the U.S. Food and Drug Administration ordered [2] Pennsylvania doctor James I. McMillen to stop “false or misleading” promotions of the painkiller Celebrex, saying he minimized risks and touted it for unapproved uses.

Still, three other leading drug makers paid the rheumatologist $224,163 over 18 months to deliver talks to other physicians about their drugs.

In Georgia

And in Georgia, a state appeals court in 2004 upheld [3] a hospital’s decision to kick Dr. Donald Ray Taylor off its staff. The anesthesiologist had admitted giving young female patients rectal and vaginal exams without documenting why. He’d also been accused of exposing women’s breasts during medical procedures. When confronted by a hospital official, Taylor said, “Maybe I am a pervert, I honestly don’t know,” according to the appellate court ruling.

Last year, Taylor was Cephalon’s third-highest-paid speaker out of more than 900. He received $142,050 in 2009 and another $52,400 through June.

Leak, McMillen and Taylor are part of the pharmaceutical industry’s white-coat sales force, doctors paid to promote brand-name drugs to their peers — and if they’re convincing enough, get more physicians to prescribe them.

Drug companies say they hire the most-respected doctors in their fields for the critical task of teaching about the benefits and risks of their drugs.

ProPublica Investigates

But an investigation by ProPublica uncovered hundreds of doctors on company payrolls who had been accused of professional misconduct, were disciplined by state boards or lacked credentials as researchers or specialists.

This story is the first of several planned by ProPublica examining the high-stakes pursuit of the nation’s physicians and their prescription pads. The implications are great for patients, who in the past have been exposed to such heavily marketed drugs as the painkiller Bextra and the diabetes drug Avandia — billion-dollar blockbusters until dangerous side effects emerged.

“Without question the public should care,” said Dr. Joseph Ross, an assistant professor of medicine at Yale School of Medicine who has written about the industry’s influence on physicians. “You would never want your kid learning from a bad teacher. Why would you want your doctor learning from a bad doctor, someone who hasn’t displayed good judgment in the past?”

To vet the industry’s handpicked speakers, ProPublica created a comprehensive database [4] that represents the most accessible accounting yet of payments to doctors. Compiled from disclosures by seven companies, the database covers $257.8 million in payouts since 2009 for speaking, consulting and other duties. In addition to Lilly and Cephalon, the companies include AstraZeneca, GlaxoSmithKline, Johnson & Johnson, Merck & Co. and Pfizer.

Although these companies have posted payments on their websites — some as a result of legal settlements — they make it difficult to spot trends or even learn who has earned the most. ProPublica combined the data and identified the highest-paid doctors, then checked their credentials and disciplinary records.

Not all Companies Comply

That is something not all companies do.

A review of physician licensing records in the 15 most-populous states and three others found sanctions against more than 250 speakers, including some of the highest paid. Their misconduct included inappropriately prescribing drugs, providing poor care or having sex with patients. Some of the doctors had even lost their licenses.

More than 40 have received FDA warnings for research misconduct, lost hospital privileges or been convicted of crimes. And at least 20 more have had two or more malpractice judgments or settlements. This accounting is by no means complete; many state regulators don’t post these actions on their web sites.

In interviews and written statements, five of the seven companies acknowledged that they don’t routinely check state board websites for discipline against doctors. Instead, they rely on self-reporting and checks of federal databases. Only Johnson & Johnson and Cephalon said they review the state sites.

ProPublica found 88 Lilly speakers who have been sanctioned and four more who had received FDA warnings. Reporters asked Lilly about several of those, including Leak and McMillen. A spokesman said the company was unaware of the cases and is now investigating them.

“They are representatives of the company,” said Dr. Jack Harris, vice president of Lilly’s U.S. medical division. “It would be very concerning that one of our speakers was someone who had these other things going on.”

Leak, the pain doctor, and his attorney did not respond to multiple messages. The Ohio medical board voted to revoke Leak’s license in 2008. It remains active as he appeals in court, arguing that the evidence against him was old, the witnesses unreliable and the sentence too harsh.

In an interview, McMillen denied nearly all of the allegations in the FDA letter and blamed his troubles on a rival firm whose drug he had criticized in his presentations.

“I’m more cautious now than I ever was,” said McMillen, who said he also does research. “That’s why I think a lot of the companies use me. I’m not taking any risks.”

Taylor said that the allegations against him were “old news” from the 1990s and that regulators had not sanctioned him. “It had nothing to do with my skills as a physician,” said Taylor, noting that he speaks every other week around the country and sometimes abroad. “Even my biggest detractors in that situation lauded my skills as a physician. That’s what’s most important.”

Disclosures are just the start

Payments to doctors for promotional work are not illegal and can be beneficial. Strong relationships between pharmaceutical companies and physicians are critical to developing new and better treatments.

There is much debate, however, about whether paying doctors to market drugs can inappropriately influence what they prescribe. Studies have shown that even small gifts and payments affect physician attitudes. Such issues have become flashpoints in recent years both in courtrooms and in Congress.

All told, 384 of the approximately 17,700 individuals in ProPublica’s database earned more than $100,000 for their promotional and consulting work on behalf of one or more of the seven companies in 2009 and 2010. Nearly all were physicians, but a handful of pharmacists, nurse practitioners and dietitians also made the list. Forty-three physicians made more than $200,000 — including two who topped $300,000.

Physicians also received money from some of the 70-plus drug companies that have not disclosed their payments. Some of those interviewed could not recall all the companies that paid them, and certainly not how much they made. By 2013, the health care reform law requires [5] all drug companies to report this information to the federal government, which will post it on the Web.

The busiest — and best compensated — doctors gave dozens of speeches a year, according to the data and interviews. The work can mean a significant salary boost — enough for the kids’ college tuition, a nicer home, a better vacation.

Top Paid Speakers

Among the top-paid speakers, some had impressive resumes, clearly demonstrating their expertise as researchers or specialists. But others did not –contrary to the standards the companies say they follow.

Forty five who earned in excess of $100,000 did not have board certification in any specialty, suggesting they had not completed advanced training and passed a comprehensive exam. Some of those doctors and others also lacked published research, academic appointments or leadership roles in professional societies.

Experts say the fact that some companies are disclosing their payments is merely a start. The disclosures do not fully explain what the doctors do for the money — and what the companies get in return.

In a raft of federal whistleblower lawsuits [6], former employees and the government contend that the firms have used fees as rewards for high-prescribing physicians. The companies have each paid hundreds of millions or more to settle the suits.

The disclosures also leave unanswered what impact these payments have on patients or the health care system as a whole. Are dinner talks prompting doctors to prescribe risky drugs when there are safer alternatives? Or are effective generics overlooked in favor of pricey brand-name drugs?

“The pressure is enormous. The investment in these drugs is massive,” said Dr. David A. Kessler, who formerly served as both FDA commissioner and dean of the University of California, San Francisco School of Medicine. “Are any of us surprised they’re trying to maximize their markets in almost any way they can?”

From Drug Reps to Doc Reps

For years, drug companies bombarded doctors with pens, rulers, sticky notes, even stuffed animals emblazoned with the names of the latest remedies for acid reflux, hypertension or erectile dysfunction. They wooed physicians with fancy dinners, resort vacations and personalized stethoscopes.

Concerns that this pharma-funded bounty amounted to bribery led the industry to ban most gifts voluntarily [7]. Some hospitals and physicians also banned the gift-givers: the legions of drug sales reps who once freely roamed their halls.

So the industry has relied more heavily on the people trusted most by doctors — their peers. Today, tens of thousands of U.S. physicians are paid to spread the word about pharma’s favored pills and to advise the companies about research and marketing.

Recruited and trained by the drug companies, the physicians — accompanied by drug reps — give talks to doctors over small dinners, lecture during hospital teaching sessions and chat over the Internet. They typically must adhere to company slides and talking points.

These presentations fill an educational gap, especially for geographically isolated primary care doctors charged with treating everything from lung conditions to migraines. For these doctors, poring over a stack of journal articles on the latest treatments may be unrealistic. A pharma-sponsored dinner may be their only exposure to new drugs that are safer and more effective.

Oklahoma pulmonologist James Seebass, for example, earned $218,800 from Glaxo in 2009 and 2010 for lecturing about respiratory diseases “in the boonies,” he said. On a recent trip, he said, he drove to “a little bar 40 miles from Odessa,” Texas, where physicians and nurse practitioners had come 50 to 60 miles to hear him.

Seebass, the former chair of internal medicine at Oklahoma State University College of Osteopathic Medicine, said such talks are “a calling,” and he is booking them for 2011.

The fees paid to speakers are fair compensation for their time away from their practices, and for travel and preparation as well as lecturing, the companies say.

Dr. Samuel Dagogo-Jack has a resume that would burnish any company’s sales force: He is chief of the division of endocrinology, diabetes and metabolism at the University of Tennessee Health Science Center. Dagogo-Jack conducts research funded by the National Institutes of Health, has edited medical journals and continues to see patients.

While most people are going home to dinner with their families, he said, he is leaving to hop on a plane to bring news of fresh diabetes treatments to non-specialist physicians “in the trenches” who see the vast majority of cases.

Since 2009, Dagogo-Jack has been paid at least $257,000 by Glaxo, Lilly and Merck.

“If you actually prorate that by the hours put in, it is barely more than minimum wage,” he said. (A person earning the federal minimum wage of $7.25 would have to work 24 hours a day, seven days a week for more than four years to earn Dagogo-Jack’s fees).

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Big Pharma Benefits

For the big pharmaceutical companies, one effective speaker may not only teach dozens of physicians how to better recognize a condition, but sell them on a drug to treat it. The success of one drug can mean hundreds of millions in profits, or more. Last year, prescription drugs sales in the United States topped $300 billion, according to IMS Health, a healthcare information and consulting company.

Glaxo’s drug to treat enlarged prostates, Avodart — locked in a battle with a more popular competitor — is the topic of more lectures than any of the firm’s other drugs, a company spokeswoman said. Glaxo’s promotional push has helped quadruple Avodart’s revenue to $559 million in five years and double its market share, according to IMS.

Favored speakers like St. Louis pain doctor Anthony Guarino earn $1,500 to $2,000 for a local dinner talk to a group of physicians.

Guarino, who made $243,457 from Cephalon, Lilly and Johnson & Johnson since 2009, considers himself a valued communicator. A big part of his job, he said, is educating the generalists, family practitioners and internists about diseases like fibromyalgia, which causes chronic, widespread pain — and to let them know that Lilly has a drug to treat it.

“Somebody like myself may be able to give a better understanding of how to recognize it,” Guarino said. Then, he offers them a solution: “And by the way, there is a product that has an on-label indication for treating it.’’

Guarino said he is worth the fees pharma pays him on top of his salary as director of a pain clinic affiliated with Washington University. Guarino likened his standing in the pharma industry to that of St. Louis Cardinals first baseman Albert Pujols, named baseball player of the decade last year by Sports Illustrated. Both earn what the market will bear, he said: “I know I get paid really well.”

Is Anyone Checking Out There?

Simple searches of government websites turned up disciplinary actions against many pharma speakers in ProPublica’s database.

The Medical Board of California filed a public accusation against psychiatrist Karin Hastik in 2008 and placed her [8] on five years’ probation in May for gross negligence in her care of a patient. A monitor must observe her practice.

Kentucky’s medical board placed Dr. Van Breeding on probation [9] from 2005 to 2008. In a stipulation filed with the board, Breeding admits unethical and unprofessional conduct. Reviewing 23 patient records, a consultant found Breeding often that gave addictive pain killers without clear justification. He also voluntarily relinquished his Florida license.

New York’s medical board put Dr. Tulio Ortega on two years’ probation [10] in 2008 after he pleaded no contest to falsifying records to show he had treated four patients when he had not. Louisiana’s medical board, acting on the New York discipline, also put him on probation [11] this year.

Yet during 2009 and 2010, Hastik made $168,658 from Lilly, Glaxo and AstraZeneca. Ortega was paid $110,928 from Lilly and AstraZeneca. Breeding took in $37,497 from four of the firms. Hastik declined to comment, and Breeding and Ortega did not respond to messages.

Their disciplinary records raise questions about the companies’ vigilance.

“Did they not do background checks on these people? Why did they pick them?” said Lisa Bero, a pharmacy professor at University of California, San Francisco who has extensively studied conflicts of interest in medicine and research.

Disciplinary actions, Bero said, reflect on a physician’s credibility and willingness to cross ethical boundaries.

“If they did things in their background that are questionable, what about the information they’re giving me now?” she said.

Sanctions Found

ProPublica found sanctions ranging from relatively minor misdeeds such as failing to complete medical education courses to the negligent treatment of multiple patients. Some happened long ago; some are ongoing. The sanctioned doctors were paid anywhere from $100 to more than $140,000.

Several doctors were disciplined for misconduct involving drugs made by the companies that paid them to speak. In 2009, Michigan regulators accused one rheumatologist of forging a colleague’s name to get prescriptions for Viagra and Cialis. Last year, the doctor was paid $17,721 as a speaker for Pfizer, Viagra’s maker.

A California doctor who was paid $950 this year to speak for AstraZeneca was placed on five years’ probation by regulators in 2009 after having a breakdown, threatening suicide and spending time in a psychiatric hospital after police used a Taser on him. He said he’d been self-treating with samples of AstraZeneca’s anti-psychotic drug Seroquel, medical board records show.

Other paid speakers had been disciplined by their employers or warned by the federal government. At least 15 doctors lost staff privileges at various hospitals, including one New Jersey doctor who had been suspended twice for patient care lapses and inappropriate behavior. Other doctors received FDA warning letters for research misconduct such as failing to get informed consent from patients.

Pharma companies say they rely primarily on a federal database listing those whose behavior in some way disqualifies them from participating in Medicare. This database, however, is notoriously incomplete.

The industry’s primary trade group says its voluntary code of conduct is silent about what, if any, behavior should disqualify physician speakers.

“We look at it from the affirmative — things that would qualify physicians,” said Diane Bieri, general counsel and executive vice president of the Pharmaceutical Research and Manufacturers of America.

Some physicians with disciplinary records say their past misdeeds do not reflect on their ability to educate their peers.

Family medicine physician Jeffrey Unger was put on probation [12] by California’s medical board in 1999 after he misdiagnosed a woman’s breast cancer for 2½ years. She received treatment too late to save her life. In 2000, the Nevada medical board revoked Unger’s license for not disclosing California’s action.

As a result, Unger said, he decided to slow down and start listening to his patients. Since then, he said, he has written more than 130 peer-reviewed articles and book chapters on diabetes, mental illness and pain management.

“I think I’ve more than accomplished what I’ve needed to make this all right,” he said. During 2009 and the first quarter of 2010, Lilly paid Unger $87,830. He said he also is a paid speaker for Novo Nordisk and Roche, two companies that have not disclosed payments.

The drug firms, Unger said “apparently looked beyond the record.”

Companies Make their Own Experts

Last summer, as drug giant Glaxo battled efforts to yank its blockbuster diabetes drug Avandia from the market, Nashville cardiologist Hal Roseman worked the front lines.

At an FDA hearing, he borrowed David Letterman’s shtick [13] to deliver a “Top Five” list of reasons to keep the drug on the market despite evidence it caused heart problems. He faced off [14] against a renowned Yale cardiologist and Avandia critic on the PBS NewsHour, arguing that the drug’s risks had been overblown.

“I still feel very convinced in the drug,” Roseman said with relaxed confidence. The FDA severely restricted access to the drug last month citing its risks.

Roseman is not a researcher with published peer-reviewed studies to his name. Nor is he on the staff of a top academic medical center or in a leadership role among his colleagues.

Roseman’s public profile comes from his work as one of Glaxo’s highest-paid speakers. In 2009 and 2010, he earned $223,250 from the firm — in addition to payouts from other companies.

Pharma companies often say their physician salesmen are chosen for their expertise. Glaxo, for example, said it selects “highly qualified experts in their field, well-respected by their peers and, in the case of speakers, good presenters.”

ProPublica found that some top speakers are experts mainly because the companies have deemed them such. Several acknowledge that they are regularly called upon because they are willing to speak when, where and how the companies need them to.

“It’s sort of like American Idol,” said sociologist Susan Chimonas, who studies doctor-pharma relationships at the Institute on Medicine as a Profession in New York City.

“Nobody will have necessarily heard of you before — but after you’ve been around the country speaking 100 times a year, people will begin to know your name and think, ‘This guy is important.’ It creates an opinion leader who wasn’t necessarily an expert before.”

To check the qualifications of top-paid doctors, reporters searched for medical research, academic appointments and professional society involvement. They also interviewed national leaders in the physicians’ specialties.

In numerous cases, little information turned up.

Las Vegas endocrinologist Firhaad Ismail, for example, is the top earner in the database, making $303,558, yet only his schooling and mostly 20-year-old research articles could be found. An online brochure [15] for a presentation he gave earlier this month listed him as chief of endocrinology at a local hospital, but an official there said he hasn’t held that title since 2008.

And several leading pain experts said they’d never heard of Santa Monica pain doctor Gerald Sacks, who was paid $249,822 since 2009.

Neither physician returned multiple calls and letters.

A recently unsealed whistleblower lawsuit against Novartis [16], the nation’s sixth-largest drug maker by sales, alleges that many speakers were chosen “on their prescription potential rather than their true credentials.”

Speakers were used and paid as long as they kept their prescription levels up, even though “several speakers had difficulty with English,” according to the amended complaint filed this year in federal court in Philadelphia.

Speaking to Each Other

Some physicians were paid for speaking to one another, the lawsuit alleged. Several family practice doctors in Peoria, Ill., “had two programs every week at the same restaurant with the same group of physicians as the audience attendees.”

In September, Novartis agreed to pay [17] the government $422.5 million to resolve civil and criminal allegations in this case and others. The company has said it fixed its practices and now complies with government rules.

Roseman, who has been a pharma speaker for about a decade, acknowledged that his expertise comes by way of the training provided by the companies that pay him. But he says that makes him the best prepared to speak about their products, which he prescribes for his own patients. Asked about Roseman’s credentials, a Glaxo spokeswoman said he is an “appropriate” speaker

Assessment

Getting paid to speak “doesn’t mean that your views have necessarily been tainted,” he said.

Plus pharma needs talent, Roseman said. Top-tier universities such as Harvard [18] have begun banning their staffs from accepting pharma money for speaking, he said. “It irritates me that the debate over bias comes down to a litmus test of money,” Roseman said. “The amount of knowledge that I have is in some regards to be valued.”

Related News:

Editor’s Note: ProPublica Director of Research Lisa Schwartz and researcher Nicholas Kusnetz contributed to this report

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Brief Summary of “Meaningful-Use” for eHRs

Objectives Listed

By Shahid N. Shah MS

www.BusinessofMedicalPractice.com

In 2009, the ARRA HITECH bill coined the term “meaningful use” and was a game-changer in the healthcare IT industry. In a series of regulations, the Recovery Act specifically required the following.

Summary of MU

Here are the substantive Meaningful Use objectives of the new ARRA HITECH bill:

  • Use Computer Provider Order Entry (CPOE).
  • Implement drug-drug, drug-allergy, drug-formulary checks.
  • Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®.
  • Maintain active medication list.
  • Maintain active medication allergy list.
  • Record demographics.
  • Record and chart changes in vital signs.
  • Record smoking status for patients 13 years and older.
  • Incorporate clinical lab-test results into EHR as structured data.
  • Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, and outreach. This is a common feature in EHRs.
  • Report ambulatory quality measures to CMS or the States.
  • Implement 5 clinical decision support rules relevant to specialty or high clinical priority, including diagnostic test ordering, along with the ability to track compliance with those rules.
  • Check insurance eligibility electronically from public and private payers.
  • Submit claims electronically to public and private payers.
  • Provide patients with an electronic copy of their health information upon request.
  • Capability to electronically exchange key clinical information among providers of care and patient-authorized entities.
  • Perform medication reconciliation at relevant encounters and each transition of care.
  • Provide summary care record for each transition of care and referral.
  • Capability to submit electronic data to immunization registries and actual submission where required and accepted.
  • Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
  • Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities
  • Generate and transmit permissible prescriptions electronically.
  • Send reminders to patients per patient preference for preventive/follow-up care.
  • Provide patients with timely electronic access to their health information within 96 hours of information being available to the EP.
  • Provide clinical summaries for patients for each office visit.

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Understanding Hierarchical Condition Category Management for MAPs

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An Emerging Management Trend for Medicare Advantage Plans [MAPs]

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

So called Hierarchical Condition Category Management (HCCM) is an emerging healthcare management trend designed to accurately reflect the health status of Medicare Advantage Plan [MAP] members and to help them remain financially viable in Part D of the system.

HCCM Indications

Since the Medicare risk adjustment payment system uses clinical coding information to calculate risk premiums for Medicare Managed Care Organizations (MMCOs), HCCM seems best to address the following:

  • CMS risk adjustment system.
  • Strategic and financial implications for Medicare plans.

Assessment

Any initiatives required to effectively managed care under a risk adjustment payment system is ripe for HCCM and the key success factors associated with these initiatives.

Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936901/

Conclusion

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*** 

Creditor and Asset Protection Strategies for Medical and Other Professionals

IRAs, Education IRA [Coverdell Accounts], 529 Plans, Qualified and Non-Qualified Annuities and Insurance – in the State of Ohio

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By Edwin P. Morrow III, J.D., LL.M., MBA, CFP®, RFC®
Wealth Specialist – Manager, Wealth Strategies Communications
Ohio State Bar Association Certified Specialist, Estate Planning, Probate and Trust Law – Key Private Bank – Wealth Advisory Services
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Hi Ann and All ME-P Readers

Would you be interested in posting this article on creditor and asset protection and planning for retirement accounts and similar? It is highly useful for physicians and other professionals

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Assessment

Link: Creditor Protection for IRAs Annuities Insurance August 2010 NBI CLE[1]

Conclusion

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Mortgage Investors Join Outcry Against Banks

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Coordinated Strategies Emerging

[By Karen Weise ProPublica: Oct. 18, 2010, 1:18 p.m.]

Homeowners, and at times the government, have long complained that banks and other companies that service mortgages aren’t good at their job of collecting monthly payments, modifying loans and processing foreclosures. Now, a new cast of characters are piling on the criticism: the servicer’s own clients, the investors that actually own the mortgages.

The Servicers

Servicers handle the day-to-day of working with homeowners on behalf of the investors, who bought bundled mortgages from Wall Street. But investors are now threatening servicers with legal action. Just like homeowners, investors are frustrated by the poor job in modifying loans that servicers have been doing. They also say servicers are looking out for themselves, not investors’ interests as their contracts typically require.

For example, Investor Bill Frey, who runs the securities firm Greenwich Financial Services, says servicers view investors as “a Thanksgiving turkey to be carved up and shared among them-selves.” Investors can range from foreign governments and hedge funds to college endowments and pension funds. During the housing bubble, they gobbled up AAA-rated bonds created by pools of mortgages. Now that defaults and foreclosure are mounting, investors argue that flaws in how loans are serviced are costing them billions of dollars.

They say servicers have often dragged out foreclosures to rack up fees and refused to reduce second mortgages to make modifications sustainable. Investors often prefer modifications to foreclosures. But for modifications that won’t ultimately prevent a homeowner from defaulting, investors still prefer quick foreclosures so they can recoup their money and move on.

Of Terminal In-Decision

“Terminal indecision is not good,” says Frey. “If it can be fixed, fix it. If it can’t, nix it.”

Servicers have been slow [1] to modify mortgages—something we’ve written [1] about many times [2] — and when they do modify loans, homeowners are still saddled with other debt from second mortgages and home equity lines. Even after modifications under the government’s program, homeowners typically still must spend almost two-thirds of their income to pay off their mortgage and other loans, like credit cards or second mortgages.

Emerging Paperwork Scandal

The current mortgage paperwork scandal [3] adds more fuel [4] to the fire as major servicers have halted foreclosures because of potential paperwork irregularities around the country. Concerns are also growing that banks may not have properly transferred loans into the mortgage pools in the first place. “This deficient approach undermines the integrity and the operational framework of the housing finance and mortgage system as it exists today,” the Association of Mortgage Investors wrote [5] in a press release.

(For more on the growing scandal, check out our recent explanation of the main players involved.)

The Mortgage Bankers Association, which represents most major servicers, did not respond to ProPublica’s request for comment.

Legal Strategies

Investors from across the country have been coordinating legal strategies for over a year ago, with the effort ramping up in early spring, according to Frey. Since then, more and more investors have formed a loose consortium, gaining momentum “like a snowball going downhill,” he says. In the last month alone, the group added other investors that own an additional $100 billion in mortgage bonds.

They have not filed any suits yet, Frey says, because the group is first trying to grow even more. Also, since each investor group has different, nonmortgage business with the banks, some investors have conflicting interests in how to proceed, he says. The consortium now represents investors that own more than $600 billion in mortgage securities, which is around a third of the entire mortgage securitization market. The group includes 65 major mortgage investors; Bloomberg reported that large investment companies including Black Rock, PIMCO and Fortress are part of the effort, as are the quasi-governmental Fannie Mae and the Federal Home Loan Banks, which both own private securitized loans.

Coordinating investors is no easy task, since the mortgage bonds were sliced and diced to be sold off to investors around the world. To assert legal rights, investors must coordinate to prove that they collectively represent a certain percentage of each mortgage pool, or in some cases, a certain percentage of each slice of each mortgage pool. (The Wall Street Journal [6] and Bloomberg [7] both describe how Texas-based attorney Talcott Franklin is coordinating a clearinghouse to keep track of the various investments.)

Once investors have standing in each pool, they have the legal right to pressure servicers and trustees to improve or face litigation. The group says they have the legal authority to act in over 2,300 deals.

Investors say servicers must reduce or cancel second mortgages entirely before adjusting the primary loan, since that follows the legal pecking order of how loans should be paid off. But investors say servicers have are dragging their feet in reducing second mortgages to protect their own books, since the largest servicers — Bank of America, Citigroup, JPMorgan Chase and Wells Fargo — also own almost 60 percent of the $1 trillion second lien market.

Bank

Congressional Oversight Panel

A Congressional Oversight Panel concluded in April that there is “tension” between Treasury’s goal of supporting reductions to second mortgages and Treasury’s interest in ensuring that writing down second liens doesn’t severely weaken banks’ balance sheets. The panel wrote than when a servicer owns the second lien, the “inexorable conflict of interest” will more likely lead to modifications on the first loan, “as it benefits the bank at the expense of the mortgage-backed security investors.”

We’ve previously reported [8] that mortgages servicers frequently tell homeowners that investors are the roadblock to loan modifications, even though few mortgage deals actually restrict modifications.

Servicers are also supposed to act like watchdogs and report back to investors when they identify loans they suspect didn’t meet the lending standards promised when the bonds were initially sold to investors. If the banks did misrepresent the quality of the loans initially, the banks would have to buy back the invalid mortgages from the investors. But in many cases, the servicers are subsidiaries of the banks that sold the bonds, which investors say helps explain why servicers have been dragging their feet. Bloomberg noted [7] an analyst’s report that said mortgage repurchases could total over $179 billion.

Original Link: http://www.propublica.org/article/investors-join-outcry-against-mortgage-servicers

Assessment

According to an investor letter cited [6] in the Wall Street Journal, in some mortgage pools that have high default rates, the banks have not repurchased any loans when the servicers are subsidiaries of the banks that sold the bonds. Investors say this is all no small matter. Since the country’s mortgage market is heavily dependent on government support right now, they insist servicers make good on their contracts before start buying loans and supporting the mortgage market again.

Related Articles:

  1. http://www.propublica.org/article/mod-program-falling-short-of-govts-vague-goals
  2. http://www.propublica.org/article/loan-mod-profiles-runaround
  3. http://www.propublica.org/blog/item/biggest-banks-ensnared-as-foreclosure-paperwork-problem-broadens
  4. http://www.businessweek.com/news/2010-10-13/document-flaws-may-lead-investors-to-fight-mbs-deals.html
  5. http://www.propublica.org/documents/item/association-of-mortgage-investors-press-release-oct.-1-2010
  6. http://online.wsj.com/article/SB10001424052748704814204575508143329644732.html
  7. http://www.bloomberg.com/news/2010-09-23/mortgage-investors-target-banks-using-texas-lawyer-s-novel-clearing-house.html
  8. http://www.propublica.org/article/when-denying-loan-mods-loan-servicers-often-blame-investors-wrongly

Conclusion

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Understanding Medical Practice Stock Sale vs. Assets Sale

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Insights for Physician-Focused Financial Advisors

By Dr. Charles F. Fenton III, FACFAS, JD

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In most cases, healthcare knowledgeable financial advisors [FAs] recommend that the physician buyer of a medical practice solely purchase the assets of the practice and not the stock of the practice itself http://www.CertifiedMedicalPlanner.org

A Risk Reduction Strategy

Why? By purchasing selected assets, the buyer is ensured that he will not become responsible for the known or unknown liabilities of the corporation; thus a risk reduction strategy. In prior days, avoiding purchasing the stock of the corporation was a wise recommendation www.MedicalBusinessAdvisors.com

Enter the Managed Care Era

However, with the advent of managed care, the purchase of the stock of the corporation can provide the new practitioner with certain competitive advantages.

For example, it may take a new practitioner three to nine months to get onto enough managed care panels to make the practice profitable. Purchase of the stock of the corporation ensures the new practitioner of acquiring the Federal tax identification number of the corporate entity.

Assessment

Since most managed care corporations identify providers by the Federal tax identification number, purchase of the stock of the corporation should allow the new practitioner to be enrolled on managed care panels in a shorter period of time. Instead of applying anew to the managed care entity, the new practitioner merely needs to be listed as a new member of a provider already on the managed care panel.

Conclusion

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The Business of Medical Practice

Transformational Health 2.0 Skills for Doctors [third edition]

By Dr. David E. Marcinko MBA, CMP™  [Editor-in-Chief]
By Prof. Hope Rachel Hetico RN, MHA, CPHQ, CMP[Managing Editor]

The third edition of this now classic 775 page textbook, to be released in November 2010 and copyrighted in 2011, seeks to answers questions like these and many others:

The Vital Survival Queries for Savvy Doctors

  • Does Health 2.0 enhance or detract from traditional medical care delivery, and can private practice business models survive?
  • How does transparent business information and reimbursement data impact the modern competitive healthcare scene?
  • How are medical practices, clinics, and physicians evolving as a result of rapid health and non-health related technology change?
  • Does transparent quality information affect the private practice ecosystem?

Answering these questions and more, this newly updated and revised edition by Springer Publishing of NYC is an essential tool for doctors, nurses, and healthcare administrators; management and business consultants; accountants; and medical, dental, business, and healthcare administration graduate and doctoral students.

The Classic Book

A Managerial Discussion for Doctors

Written in plain language using non-technical jargon, the text presents a progressive discussion of management and operation strategies. It incorporates prose, news reports, regulatory and academic perspectives with health 2.0 examples, blog and internet links, as well as charts, tables, diagrams, URL citations, and website references, resulting in an all-encompassing resource. And, it also integrates various medical practice business disciplines—from finance and economics to marketing to the strategic management sciences—to improve patient outcomes and achieve best practices in the healthcare administration field.

The Expert Contributors

With contributions by a world-class team of expert authors from www.MedicalBusinessAdvisors.com among others, the third edition covers brand new information, including:

  • The impact of Web 2.0 technologies on the health care industry
  • Internal office controls for preventing fraud and abuse
  • Physician compensation with pay-for-performance trend analysis
  • Health economics, finance and accounting
  • Human resources and medical practice staffing
  • Medicare compliance, quality improvement and healthcare law and policy
  • Healthcare marketing, advertising, CRM, and public relations
  • eMRs, mobile IT systems, medical devices, and cloud computing,
  • and much more!

Assessment

A core textbook for financial advisors and management consultants:

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Conclusion

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Defining the Accountable [Health] Care Organization

ACO Glossary of Terms from CMS, etc

By Staff Reporters

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According to Wikipedia, an Accountable Care Organization, or ACO for short, is a health system model with the ability to provide and manage patients, in the continuum of care across different institutional settings, including at least ambulatory (outpatient) and inpatient hospital care and possibly post acute-care in some cases.

Payment is consolidated rather than ala’ carte’, and generally considered cost effective and “bundled”.

Budgetary Accountability

Furthermore, ACOs have the capability of planning budgets and resources and are of sufficient size to support comprehensive, valid, and reliable performance measurements.

Source: http://en.wikipedia.org/wiki/Accountable_care_organization

CMS Definition

Now, aaccording to the CMS Office of Legislation; Section #1899.

ACO Definition: accountable care organization

Medical Provider Market Power and the American Hospital Association

AHA definition: AHA – ACOs

Assessment

The ACO model is one of the latest designs for managing healthcare costs and especially Medicare costs, and is gaining traction among policymakers desperate to control costs and boost quality in healthcare.

Conclusion

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About the Editor-in-Chief

Dr. David Edward Marcinko, a former residency director, department chairman, and hospital vice-president in Atlanta GA, retired from clinical practice at the age of 45 after selling his Ambulatory Surgery Center to a public company. As a fellow and board certified surgeon, he authored more than two dozen medical and business textbooks in three languages, teaching and operating in the EuroZone, co-founding a pre-IPO PPMC, and forming a series of successful internet ventures while still maintaining a 60 hour work week.  

His companies have created dozens of cognitive products in the last few years that maintain a comfortable lifestyle that started from his home office after retirement. Dr. Marcinko picked up an MBA degree, became a certified financial planner and insurance agent, and developed a cult following thru collaborative on-ground and online education for physicians, financial advisors and management consultants. A social media pioneer and publisher, this Medical Executive-Post is an influential syndicated blog with thousands of content contributions from nationally know experts. 

Dr. Marcinko is a highly sought after futurist and speaker in the areas of health economics, financial planning, medical practice management and related entrepreneurial e-insights for intersecting sectors in the healthcare industrial complex.

Edited with Professor Hope Rachel Hetico of the Institute of Medical Business Advisors [iMBA] Inc www.MedicalBusinessAdvisors.com

Financial Planning and Risk Management Handbooks for Doctors 

Content Exchange and Vocabulary Standards for eMRs

Understanding Terms and Definitions

By Shahid N. Shah MS

As per the HHS rules, vocabulary standards are standardized nomenclatures and e-code sets used to describe clinical problems and procedures, medications, and allergies for eMRs. Some commons terms and definitions are listed below:

Terms and Definitions

  • ASTM’s CCR – for most of your basic patient summary exchange needs the CCR will meet your needs. If you’re moving from low or no interoperability today to some interoperable capabilities then CCR is your best starting place.
  • International Classification of Diseases, 9th Revision, Clinical Modifications (ICD-9- CM) or SNOMED CT® should populate a problem list. If you’re not familiar with both standards and are unsure where to start, go with ICD-9 for problem lists. SNOMED is not commonly supported in the broad EMR industry but ICD-9 support is quite common so start there.
  • Health Level Seven (HL7) Clinical Document Architecture (CDA) Release 2 (R2) Level 2 CCD – for more advanced patient summary exchange needs the HL7 CDA is recommended. If you’re already supporting CCR exchange and it’s not meeting your needs then HL7 CDA is the next logical place to go.
  • For patient summary exchanges, HHS expect the following fields to be populated: problem list; medication list; medication allergy list; procedures; vital signs; units of measure; lab orders and results; and, where appropriate, discharge summary.
  • ICD-9-CM [ACD-10] or American Medical Association (AMA) Current Procedural Terminology (CPT®) Fourth Edition (CPT–4) to populate information related to procedures. Both of these standards are support broadly by most existing vendors so going with either or both is good.
  • For medication lists, HHS requires the use of codes from a drug vocabulary the National Library of Medicine has identified as an RxNorm drug data source provider with a complete data set integrated within RxNorm.
  • For lab results, HHS requires the use of LOINC® to populate information in a patient summary record related to lab orders and results when LOINC® codes have been received from a laboratory and are retained and subsequently available in your EMR. HHS states that in instances where LOINC® codes have not been received from a laboratory, the use of any local or proprietary code is permitted. HHS does not require these local or proprietary codes to be converted to LOINC® codes in order to populate a patient summary record.
  • For the purposes of electronic prescribing, your vendor must be capable of using NCPDP SCRIPT 8.1 or NCPDP SCRIPT 8.1 and 10.6. With respect to a vocabulary standard, your vendor must use codes from a drug vocabulary currently integrated into the NLM’s RxNorm. For the purposes of performing a drug formulary check, your vendor must be capable of using NCPDP Formulary & Benefits Standard 1.0 adopted by HHS (73 FR 18918).
  • There are standards required for insurance data like eligibility checking and submissions of claims. ASC X12N and NCPDP standards (Versions 4010/4010A and 5010 and Versions 5.1 and D.0, respectively) should be used for these transactions. It’s important to realize that Version 4010 is being phased out in favor of Version 5010 so your vendors need to support both at this time and must be able to move exclusively to Version 5010 in the future.
  • For the purposes of electronically submitting calculated quality measures required by CMS or by States, your vendor must be capable of using the CMS PQRI 2008 Registry XML Specification. Going forward, HL7 Quality Reporting Document Architecture (QRDA) Implementation Guide based on HL7 CDA Release 2 may be allowed but for now focus on the CMS PQRI requirements until HHS provides more guidance in the future.
  • For the purposes of submitting lab results to public health agencies, your vendor must be capable of using HL7 2.5.1.
  • For the purposes of electronically submitting information to public health agencies for surveillance and reporting, your vendor must be capable of using HL7 2.3.1 or HL7 2.5.1 as a content exchange standard. At this time HHS not required adverse event reporting nor have they adopted a specific vocabulary standard for submitting information to public health agencies for surveillance and reporting.
  • For the purposes of electronically submitting information to immunization registries your vendor must be capable of using HL7 2.3.1 or HL7 2.5.1 as a content exchange standard and the CDC maintained HL7 standard code set CVX -Vaccines Administered18 as the vocabulary standard.

Assessment

www.BusinessofMedicalPractice.com

Conclusion

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Understanding the Medical Records R[e]Volution

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It’s Not All about Electronic Records

By Dr. David Edward Marcinko; MBA, CMP™

[Editor-in-Chief]

Introduction

To understand the medical records revolution that has occurred this decade, put your self for a moment in the position of a third-party payer; ie; a private insurance company, Medicare or Medicaid etc.

For example, you want to know if Dr. Joel Brown MD actually gave the care for which he is submitting a [super] bill or invoice. You want to know if that care was needed. You want to know that the care was given to benefit the patient, rather than to provide financial benefit to the provider beyond the value of the services rendered.

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Of Doubts and Uncertainty

Can you send one of your employees to follow Dr. Brown around on his or her office hours and hospital visits?  Of course not! You cannot see what actually happened in Dr. Brown’s office that day or why Dr. Black ordered a PET scan on the patient at the imaging center. What you can do however, is review the medical record that underlies the bill for services rendered from Dr. Blue. Most of all, you can require the doctor to certify that the care was actually rendered and was indicated. You can punish Dr. White severely if an element of a referral of a patient to another health care provider was to obtain a benefit in cash or in kind from the health care provider to whom the referral had been made. You can destroy Dr. Rose financially and put him in jail if his medical records do not document the bases for the bills he submitted for payment.

The Payment Paradigm Shift

This nearly complete change in function of the medical record has precious little to do with the quality of patient care. To illustrate this medical records evolution/revolution point, consider only an office visit in which the care was exactly correct, properly indicated and flawlessly delivered, but not recorded in the office chart. As far as the patient was concerned, everything was correct and beneficial to the patient. As far as the third-party payer is concerned, the bill for those services is completely unsupported by required documentation and could be the basis for a False Claims Act [FCA] charge, a Medicare audit, or a criminal indictment.  We have left the realm of quality of patient care far behind.

mobile EHR health

Provider Attitude Adjustments Required

Instead, medical practitioners must adjust their attitudes to the present function of patient records.  They must document as required under pain of punishment for failure to do so. That reality is infuriating to many since they still cling to the ideal of providing good quality care to their patients and disdain such requirements as hindrances to reaching that goal. They are also aware of the fact that full documentation can be provided without a reality underlying it. “Fine, you want documentation?  I’ll give you documentation!”

Computer Charting and eMRs

Some doctors have given in to the temptation of “cookbook” entries in their charts, canned computer software programs or eMRs listing all the examinations they should have done, all the findings which should be there to justify further treatment.  Many have personally seen, for example, hospital chart notes which describe extensive discussion with the patient of risks, alternatives and benefits in obtaining informed consent when the remainder of the record demonstrates the patient’s complaint that the surgeon has never told her what he planned to do; operative reports of procedures done and findings made in detail which, unfortunately, bear no correlation with the surgery which was actually performed.

Assessment

Whether electronic medical records (eMRs) will be helpful regarding fraud prevention, in the future is still not known. But, it is at best naive and more frequently closer to a death wish to think that a practitioner can beat the system, with handwritten notes, computer generated records, or fabricated eMR documentation.

Conclusion

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Financial Planning & Risk Management Handbook for Doctors and Financial Advisors

Financial Planning and Risk Management Handbooks for Doctors and Financial Advisors

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On Evidence-Based Clinical Medical Guidelines

About the Institute for Clinical Systems Integration [ICSI] 

By Brent A. Metfessel MD, CMP™

 

The Institute for Clinical Systems Integration (ICSI) is a strong proponent of the value of evidence-based clinical guidelines, and cites the following objections that make their implementation and acceptance more difficult.

 

The Issues

These issues generally apply to technology assessments as well:

  • Guidelines are a legal hazard:  There is a fear that following a guideline that turns out to be wrong increases the risk of litigation.  Good guidelines, however, are evidence-based and not opinion-based drivers of care.  Furthermore, once a review of the literature takes place and is synthesized into a preliminary guideline, multi-specialty physician focus groups review the guidelines prior to finalization.  The strength of evidence supporting each conclusion is usually stated, highlighting areas of remaining scientific uncertainty.  “Evidence hierarchies” are often used as aids to grading recommendations, with meta-analysis, systematic reviews, and randomized controlled trials being at or near the top of the hierarchy in strength, with narrative reviews, case reports, and medical opinion pieces being considered the weakest forms of evidence.  This provides additional checks and balances to guideline development.
  • Guidelines are cookbook medicine:  Guidelines are just that – guidelines.  Each patient should be provided treatment according to his/her individual needs.  Evidence-based clinical guidelines are based on extensive reviews of the literature and are applicable to the vast majority of cases for a particular clinical condition but not necessarily all cases.  In the case of practice pattern evaluation or profiling, comparisons of such patterns to medical guidelines can help identify overall systematic variations from the norm rather than variations due to particular patients with special needs.
  • Guidelines do not work:  When used as the sole basis for practice improvement, this statement contains some truth. However, when incorporated into a systematic continuous quality improvement approach, they have been shown to improve practice patterns and reduce variation.
  • Physicians will not use guidelines:  Once physicians know that the guidelines are based on a sound review of the medical literature, practitioner buy-in greatly increases.  In addition, clinicians need to realize that clinical guidelines are only one part of the total treatment picture since a team approach to patient care is becoming the norm.
  • Guidelines need validation through actual outcomes data:  This is correct when based on a continuous quality improvement approach, but is incorrect if outcomes are based on individual events.  Local implementation of guidelines can be compared to outcomes data one or two years after implementation.  Depending on the actual level of practice pattern improvement, minor alterations can be made to the guidelines to reflect local needs.

Guideline Adaptation

National guidelines in some cases may need adaptation to local patient needs and concerns.  For example, a practice in a major metropolitan area where specialty care is readily available differs in major ways from a rural practice which is based more on primary care.  Practices where many patients are poor or on public assistance also differs from practices in affluent areas.  When used as basic guides to appropriate practice, however, clinical guidelines can significantly decrease practice variation.

Evidence Based Medicine

With the recent emphasis on evidence-based medicine and on decreasing the time lag between evidence publication and its effect on actual patient care, a number of agencies have added clinical guideline and technology assessment development to their task lists.  Such agencies include specialty societies such as the American College of Cardiology (ACC), private companies and non-profit organizations, governmental bodies such as the Agency for Health Care Research and Quality (AHRQ), and MCOs that review the scientific evidence for the purpose of determining coverage policy.

Assessment

MCOs may post medical coverage policies on the Web for physicians to access, and these generally contain narrative justifications (often with evidence grading) in terms of why a particular procedure or diagnostic test may or may not be covered based on level of efficacy shown in scientific studies.  It is important to note that for many high-tech or new procedures, different MCOs may have somewhat different coverage policies based on variation in terms of interpreting the evidence, especially in areas where the science is less certain.

Conclusion

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On Dr. Enthoven’s “Managed Competition” in Healthcare

A Historical Essay Review for all Stakeholders

By Hope Rachel Hetico RN, MHA, CPHQ, CMP™

[Managing Editor]

www.BusinessofMedicalPractice.com

Princeton PhD economist Alain Enthoven’s 1993 paper in Health Affairs on managed competition is almost two decades old (health care markets have changed greatly since then), but not in his prescription for change.

Still Relevant Today

Of course, some ideas are outdated, but many expressed ideas are still very relevant today and embodied in several provisions espoused by advocates for additional contemporary healthcare reform.

In fact, we have mentioned the “Father of Managed Care” in all three versions of our textbook; including the newest third edition for 2011: The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors]  www.BusinessofMedicalPractice.com

Assessment  

We therefore recommend that every healthcare stakeholder read the paper entirely; and then decide for your-self.  

Link: Managed Competition

Conclusion

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Concerning ShareCare.com

A New Consumer Health Information Internet Portal

By Staff Reporters

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Founded in 2009, Sharecare is an interactive social QA platform created by Jeff Arnold and Dr. Mehmet Oz in partnership with Harpo Studios, HSW International, Sony Pictures Television and Discovery Communications.

Health Information Search Simplified

Sharecare is designed to greatly simplify the search for quality healthcare information and provide consumers with the necessary tools to make smart health choices and live healthier lives. Its’ mission is to answer the world’s questions of health and achieve a collective wisdom by developing a comprehensive database of all of the questions of health and wellness and actively recruiting industry experts to answer them. Leading physicians, nurses, hospitals, clinics, authors, healthcare companies and non-profits connect, interact and share their collective expertise encouraging consumers to ask, learn and act upon questions of health.

Assessment

Sharecare is dedicated to providing consumers with information they can trust and connecting them with industry experts and other knowledgeable consumers in order to educate, empower and continue the conversations of health. All doctors should be aware of it.

Conclusion

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About D’Alessio & Tocci LLP, CPAs

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New Partner Onboard

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About M. Howard Pell CPA

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Assessment

Visit: http://dalecpa.com/

Conclusion

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The Effects of Healthcare Reform Legislation on Physician Compensation

Is a Future Look Predicated on the Past?

By Dr. Brian J. Knabe; CFP® CMP™

By Dr. David Edward Marcinko; MBA CMP™

By Prof. Hope Rachel Hetico; RN, MHA CPHQ CMP™

www.BusinessofMedicalPractice.com

With the passage of healthcare reform legislation, officially known as the Patient Protection and Affordable Care Act of 2010, many questions remain regarding its effect upon physicians’ livelihood.

Undoubtedly this bill moves the healthcare system several steps closer to a socialized model, but the effects on physicians’ salaries and compensation models are far from clear.

Other Countries

One way to see the effect that this shift may have on compensation is to look to other countries, many of which already have a more socialized system in place.

According to the CRS Report for Congress, US Health Care Spending:  Comparison with Other OECD Countries http://assets.opencrs.com/rpts/RL34175_20070917.pdf) US specialists rank near the top in compensation compared to these other countries, trailing the Netherlands and Australia.  The average specialist in the US made $230,000 in this survey.  The comparable salary in Canada is $161,000, $150,000 in the UK, and $253,000 in the Netherlands.  Generalists in the US are at the top in terms of compensation with an average of $161,000.  This compares to $107,000 in Canada, $118,000 in the UK, and $117,000 in the Netherlands.

Inflation Adjustments

Another indicator of physician salary trends is the change in compensation adjusted for inflation.  According to the American Medical Association, the inflation-adjusted income for the average patient care physician declined from $180,930 to $168,122 from 1995 to 2003, a 7% decrease. And, the inflation adjusted decrease is more substantial given the low interest rate environment thru 2010, and going forward.

Physician Net Income Chart

  Average net income
  1995 2003 Decrease
All patient care physicians $180,930 $168,122 7%
Primary care physicians $135,036 $121,262 10%
Medical specialists $178,840 $175,011 2%
Surgical specialists $245,162 $224,998 8%

Source: http://www.ama-assn.org/amednews/site/free/prsc0724.htm

Given these trends, as well as the fact that an increasing percentage of healthcare payments are coming from dwindling government sources, it is likely that physician salaries will decline as “healthcare reform” legislation is implemented.  In fact, it is likely that this trend will accelerate.  A 15% to 25% inflation-adjusted decline in salaries over the next decade is a reasonable prediction.

Assessment

It is also important to note that the level of student debt in the US continues to rise, while college and medical education are usually subsidized in other countries.  Many foreign physicians graduate with no student loan debt.  The ratio of debt level to salary in the US continues to become more onerous for new physicians.

Conclusion

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Seeking Your Favorite Health 2.0 Patient Story

Collaborative Care – Not Yet So Collaborative

Ann Miller RN MHA

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Please send in your favorite story [serious, humorous, poignant, personal, etc] or anecdote on participatory medicine and electronic patient connectivity. If selected, it may be posted on the ME-P or used in our new book in a blinded or named fashion; or on an individual or aggregated basis.

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On e-Confidentiality Conflicts in Medicine

Understanding the Potential Role of eMR Compromise

By Render Davis MHA CHE

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Whether it is an employer interested in the results of an employee’s health screening; an insurer attempting to learn more about an enrollee’s prior health history; the media in search of a story; or health planners examining the potential value of national health databases, the confidential nature of the traditional doctor-patient relationship may be compromised through demands for clinical information by parties other than the patient and treating caregivers. 

Impact of eMRs

In addition, without clear safeguards the growth in use of electronic medical records may put personal health information at risk of tampering or unauthorized access.  Clearly, employers and insurers are interested in the status of an individual’s health and ability to work; but does this desire to know, combined with their role as payers for health care, constitute a right to know?  The patient’s right to privacy remains a volatile and unresolved issue.

Assessment

Counter to this concern is the recognition that electronic records may dramatically improve communications by offering greater accessibility of information to clinicians in the hospital or office potentially reducing medical errors through elimination of handwritten notes, increased use of built in prompts and clinically-derived triggers for orders and treatments, and development of pathways for optimal treatments based on clinically valid and tested best practices.

Conclusion

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Essay on Healthcare Leadership

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Versus Healthcare Management

[By Eugene Schmuckler PhD, MBA and Dr. David Edward Marcinko MBA]

Many times, individuals or physicians will use the terms management and leadership synonymously. In actuality the terms have significantly different meanings.

For example, Warren Bennis describes the difference between managers and leaders as “Managers do thing right, Leaders the right thing.”

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leadership

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The Managers

Managers are those individuals who have as their primary function managing a team of people and their activities. In effect, managers are those who have been given their authority by the nature of their role and ensure that the work gets done by focusing on day to day tasks and their activities.

On other hand, a leader’s approach is generally innate in its approach. Good leadership skills are difficult to learn because they are far more behavioral in nature than those skills needed for management. Leaders are also very focused on change recognizing that continual improvement can be achieved in their people and their activities can be a great step towards continued success.

Leadership Development

Perhaps some of the best training grounds for the development of leaders are the military. The Marine Corps slogan is “A Few Good Men” and the military academies at Annapolis (Navy), New London, Connecticut (Coast Guard), Colorado Springs (Air Force), and West Point (Army) all have as their main mission, the development of leaders. This is done by a number of different techniques. At graduation, the new officers, regardless of the branch of service, have been taught, and more importantly, have internalized the following: communicate the missions, sensitivity matters, real respect is earned, trust and challenge your soldiers. It is due to these lessons that many graduates of the military academies go on to positions of leadership in the private sector as well as in government.  Communicating the mission refers to conveying to those who work with us what are practice is hoping to accomplish and the role of each employee in achieving that goal. Given an understanding and awareness of the mission, when confronted with a barrier, employees are able to face hard problems when there is no well-defined approach by which to deal with them.

Sensitivity does matter – A leader treats each employee with respect and dignity, regardless of race, gender, cultural background or particular role they actually perform in the practice. Consider how many legal suits are filed against any type of organization, whether it is a medical practice or a large manufacturing facility due to perceived disparate treatment towards the employee based on race, religion, gender sexual preference or other non-work related issues.

Real respect is earned – Having initials after one’s name and the wearing of a lab coat does not automatically entitle an individual to respect. Formal authority has been found to be one of the least effective forms of influence. Only by earning the respect of your staff as well as your patients can you be sure that your intent will be carried out when you are not present. Setting the example in performance and conduct, rather than ‘do as I say, not as I do,” level of activity enables one to exert influence far greater than titles.

Trust and challenge your employees – How many times have practices sought to hire the best and brightest only to second guess the employee. Eric Schmidt, the CEO of Google, describes his management philosophy as having “… an employee base in which everybody is doing exactly what they want every day.” Obviously there are certain policies and procedures, but at the same time, the leader enables decision making to the lowest possible level. This also enables employees to question why certain policies and procedures are still being followed when more effective and efficient methods are available.  (How the Army Prepared Me to Work at Google, Doug Raymond, Harvard Business)

Internal Faults

The phrase “Physician, heal thyself” (Luke 4:23, King James Version) means that we have to attend to our own faults, in preference to pointing out the faults of others. The phrase alludes to the readiness of physicians to heal sickness in others while sometimes not being able or will to heal themselves.  By the same token, it now is necessary for us to learn how to manage ourselves. It suggests that physicians, while often being able to help the sick, cannot always do so, and when sick themselves are no better placed than anyone else (Gary Martin, phrases.org.uk/meanings/281850.html, 2010).

Self Development

“We will have to learn how to develop ourselves. We will have to place ourselves outside the boundaries where we can make the greatest contribution. And we will have to stay mentally alert and engaged during a 50-year working life, which means knowing how and when to change the work we do” (Managing Oneself, Harvard Business Review – Jan. 2005 – pp 100-109, by Peter Drucker).  Although one’s IQ and certain personality characteristics are more or less innate and appear to remain stable over time there are individual capabilities that enable leadership and can be developed. Enhancement of these capabilities can lead to the individual being able to carry out the leadership tasks of setting direction, gaining commitment, and creating alignment. These capabilities include self-management capabilities, social capabilities and work facilitation capabilities.

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Assessment

Without question, while it is possible to cram for at test and graduate at the top of one’s class, that does not assure   leadership ability. We all know at least one person who scores at the highest levels on cognitive measures but would be incapable of pouring liquid out of a boot if the instructions were written on the heel.

Conclusion

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Congratulations to Laureate Professor Robert Edwards

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Test-tube Baby Pioneer Wins Nobel Prize in Medicine

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STOCKHOLM — Robert Edwards of Britain won the 2010 Nobel Prize in medicine today for developing in-vitro fertilization, a breakthrough that has helped millions of infertile couples worldwide have children.

Assessment

Edwards, an 85-year-old professor emeritus at the University of Cambridge, started working on IVF as early as the 1950s. He developed the technique, in which egg cells are fertilized outside the body and then implanted in the womb, together with gynecologist surgeon Patrick Steptoe, who died in 1988.

Conclusion

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Doctor-Why Is It So Difficult to Save?

A Poetic Tale: Gurus of Marketing

By Somnath Basu PhD MBA

What is in spending today that cannot wait?

Surprisingly, the answer in not so much a financial one but much more one that is sociological and psychological in nature. Much of the answers lie in how we, as a society, react to the titillations carried through media that cajole us to spend even in the face of distressing financial conditions while exhorting us mercilessly to do so during economic bubbles.

Our spending on basic living needs is not the issue here. It is the add-ons, the options bundles, much like when we buy a car. The basic need of going from A to B as simply as possible fade when we consider issues of images (yellow Ferraris, superfast Vettes, 57 Mustangs, etc.), or comfort (plush leather, auto all) and all the other complex factors that go behind the “bundling options” decisions. Behind all these images are some very clever folks who subtly or not so subtly, intrude in our mind and link connections between our desired images and a product that seems to exclusively cater to it.

Consumer [Physician] Behavior

This realm of the study of the purchase decision process lies in the academic arena of consumer behavior and market research. Some very smart folks study how we make these spending decisions, in every possible combination. They study how kids get excited about various toys when they watch Sponge Bob or Barney on Nickelodeon and suggest their appeasement possibilities. They copiously study every buying habit of yours when you save oh-so-many dollars because you used your grocery’s preferred card(s).

Of course your credit card company knows these already down to the details of what you charged $3.25 for on your card. The popular magazines and journals know exactly what type of people read their rag, down to the last details of the number of kids you have and whether you eat out more than five times a week. In turn, for most consumers, it is extremely difficult to resist such consumption spurring. Understanding our own personal financial health condition is somewhat akin to most people not wanting to conduct their own surgery and self-medication of their own appendicitis, no matter that drugstores may any day introduce do-it-yourself kits! In a nutshell, we are quite helpless.

Just Imagine

Imagine you are parents of two or three kids and you both work. You come back home at the end of a long hard work day after picking up the kids from various activities and figure out the day’s dinner protocol. After that, tuck them in bed and sit in front of a TV to relax and enjoy your personal quality time a bit. This is your prime relaxation time. Your guards are finally down.

Obviously, it also happens to be prime time TV for which corporations pay top $ to be in front of you. Wafting through the TV (or from the newspaper / magazines or radio for the snobbier) come through subtle and not so subtle images of a happier you skiing down some fine Colorado powder or on a Caribbean beach sipping umbrella-clad drinks. Pictures of yourself – a happy retired millionaire at 40 or so. And, you know what happy people do. Next morning the natural query is to enquire about credit possibilities on your home equity or credit card. What chance do we have to resist being like such beautiful people? Our present is all we know of our future and how can we step into this future without a happier now!

My Proposal

A friend once proposed this financial study to me. Call up a financial advisor, one you do not know, pls. Maybe someone from the yellow pages or from the local classifieds with lots of credentials after their name, preferably starting with a “C”, though any alphabet soup will do.  Ask them what you should do with the $200,000 you just inherited. Now watch for the effects of the underlying corporate marketing gurus to come through to you – fangs and all.

Assessment

Who can protect us from this onslaught? Not corporations, politicians, bureaucrats or government. Can things get worse? We’ll have to wait and see what kind of a mess we get into, or not, when the Consumer Protection Act of the financial reform bill gets implemented and understood over time.

Conclusion

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

NOTE: Somnath Basu is a Professor of Finance at California Lutheran University and the creator of the innovative AgeBander (www.agebander.com) retirement planning software.

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On the Current Domestic Economic Headwinds

About Consumer Confidence in October 2010

By Sean G. Todd, Esq., M. Tax, CFP©, CPA

Physicians and all consumers are feeling less confident the longer our economy continues to recover slowly; in fact it is at the lowest level in 7 months [47.5]. Just so you understand the significance of this low number:  a reading of 100 or greater would indicate strong growth; and the index has not reached that level since mid 2007.  

Index Critical

Why is this index critical? Well, two-thirds of the U.S. economy is dependant upon consumer spending.  As confidence falls so to will spending and so to will any sustained economic recovery. Contributing factors include sustained high unemployment and unfavorable business conditions. Few believe any improvement in economic growth is likely to happen in the coming months.  A surprising statistic is that in September, the number of consumers calling business conditions “bad” outweighed those saying conditions are “good” by nearly 6 to 1.  Consumers appear to be waiting on sustained job growth which is not being reported in any sector. 

Questioning the Headwind

Here is why I questioned whether this is really a headwind.  Take a second to digest these one month percentage gains:  37.6%; 33.1%; 28.5%; 27.6% and 25.6%.  Can you think of the companies posting such returns?  Here they are: Carmax, Office Depot, J.C. Penny, Nordstrom and Best Buy, respectively.  Dumbfounded? Carmax is the best performing stock in the S&P500 index this month – not a gold stock or tech company. Carmax sells used cars.  This is sharp contrast to the index number being reported above. I think it is interesting that Costco is not one of the companies named. The index appears to be nothing but a number so should we actually be tracking what consumers do and not how they answer some survey which is the basis for the index number. Or this could just be another case of pent up demand?  The savings rate has risen during this downturn and credit card usage is also down – so some consumers might again feel comfortable making the new purchase commitment after spending the past year being a non-consumer.  

Of course, other analysis may indicate that smaller retailers are not experiencing the same level of renewed activity and the economic outlook still looks grim. It seems it is not going to get a lot worse, just that it is not going to be getter better quick enough for most.

Home Sales

As doctors and most all individuals come to grips with not being able to sell their homes for a value they once thought possible, we are apt to suggest that we might see increased activity in the home improvements sector as individuals just decide to make the upgrade to their existing home while they wait this whole real estate mess out. 

Assessment  

How can all this help you financially?  You are seeing exactly why you cannot base your investment decisions on the latest headline or try to time the market.  Baseball singles and doubles in the investment world will score more runs than trying to hit a home run (timing the market). 

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. So, what is your financial planning strategy for hitting singles and doubles? 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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About HealthCareTownHall.com

Informed Healthcare Reform Dialogue

By Staff Reporters

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Milliman is the host of this blog to encourage an informed dialogue about healthcare reform.

Complications

Healthcare is complicated, and there is no single, silver-bullet answer to the question of “How do we best improve the current system?”  

Assessment

But, thoughtful discussions will help move reform in the right direction and mend the fractured system; especially in terms of entitlements, costs and spending, etc.

  Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Visit www.HealthCareTownHall.com and tell us what you think? 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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Benchmarking Study Survey on Physician Sales and Service

ME-P Reader Participation Sought for the Corporate Health Group

By Carolyn Merriman

President, Corporate Health Group

401-886-5588 ext. 201

www.corporatehealthgroup.com

Dear David and ME-P Subscribers, Readers and Visitors

I hope this finds you well and busy. I am sure you are pleased with the publication of the updated text book. Thank you again for allowing me to participate by authoring Chapter 33: Professional Relations.

www.BusinessofMedicalPractice.com

ME-P Reader Participation Requested 

I am sending this along to my fellow consultants asking them to seek their client’s participation. I thought you might be able to post or push out to your ME-P readers.

The CHG 

Corporate Health Group (CHG) is conducting our third benchmarking study on Physician Sales and Service. The success of this study depends on the survey being distributed to the appropriate people to be completed. Because I know that you have many contacts in physician sales and service, I am hopeful that you would forward the survey to those contacts and encourage them to participate. To show CHG’s appreciation you will receive a complimentary copy of the results including the trended data from the 2005 and 2008 studies.

Viral Contacts Sought

If you, or your subscribers and partners, should also happen to have a contact that is a large system or association we have the ability to set up a unique organization code that those completing the survey would enter in the “organization” section. CHG would in return give them a report that shows the overall trended data (2005, 2008, 2010) – compared to their organization’s data. If you want a code, please contact jstratton@corporatehealthgroup.com or 309-647-5456 for this set-up.

Contact Instructions 

Instructions on sending the survey to your contacts:

1. Below you will find a brief description of the survey along with a html message that could be used in your communication to your contacts. In order to use the html embedded in this email you must “forward” the message. It is set-up so that you could “forward” the message and simply delete the top portion of this message.

2. If you are unable to forward this html message, I have created a link to the survey.

The Physician Sales and Service Survey  

Physicians still direct the vast majority of inpatient healthcare in the marketplace – as many as 80% of patients enter the doors of hospitals and facilities at the direction of physicians. Notwithstanding he movement toward a consumer-driven market – many hospitals, health systems and large specialty practices have turned to physician sales or referral development programs to grow their business. Unfortunately, motivating physicians to change referral patterns is a daunting task under the best of circumstances and the lack of industry “best practices” complicates the situation even further.

View image001.png in slide show

Third Benchmarking Study

September 2010 Corporate Health Group (CHG) launched their third benchmarking study of Physician Sales and Service. The National survey will obtain new trends and craft comparisons and a gap analysis of data captured 2005, 2008 and now 2010. The survey (a mix of open and closed ended questions) is available online and respondents will get a free Executive Summary. The results will provide detailed management and benchmarking data for physician sales managers and healthcare executives to benefit their programs for future success!

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Events Planner: October 2010

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Events-Planner: OCTOBER 2010

By Staff Writers

“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 relative newcomer. But today, we have almost 175,000 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.

So, enjoy the Medical Executive-Post and this monthly Events-Planner with our compliments. 

A Look Ahead this Month – Now, the important dates:

October 09-12: FPA annual conference, Denver, Co.

October 26-29: Schwab Impact Meeting, Boston, MA.

Please send in your meetings and dates for listing in the next issue of our Events-Planner.

MarcinkoAdvisors@msn.com

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

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