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    Later, Dr. Marcinko was a vital and recruited BOD  member of several innovative companies like Physicians Nexus, First Global Financial Advisors and the Physician Services Group Inc; as well as mentor and coach for Deloitte-Touche and other start-up firms in Silicon Valley, CA.

    As a state licensed life, P&C and health insurance agent; and dual SEC registered investment advisor and representative, Marcinko was Founding Dean of the fiduciary and niche focused CERTIFIED MEDICAL PLANNER® chartered professional designation education program; as well as Chief Editor of the three print format HEALTH DICTIONARY SERIES® and online Wiki Project.

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Mobile Trends and their Impact on the [Medical] App Market

Mobile World Congress Review

By Markus Pohl

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Some major trends about the mobile apps market were clearly visible at the Mobile World Congress in Barcelona this week. How will trends like new operating systems, new devices, new technologies, developer migration, etc. affect the global apps market? Here is a quick rundown:

Symbian is dead long live Windows 7

This is probably the biggest single piece of news to emerge from last week’s event. Windows 7 will be used as the primary OS for Nokia’s smartphone portfolio. According to Mr. Elop (Nokia CEO) there will be a two year transition time before all new devices are being shipped with the OS from Microsoft, but from our discussions with Microsoft and Nokia we realize that there is a large amount of pressure to make that period as short as possible, especially as it will become even more difficult to convince developers to develop for Symbian, a dead end platform. The co-existence of Nokia phones running on WindowsPhone 7, Symbian and MeeGo presents a challenge. The future of MeeGo seems to be very uncertain even though Nokia and Intel stated their intent to offer an alternative platform especially for non smartphone devices.  Windows 7 will definitely become a very interesting platform for developers in the future. If it will meet the expectations of those two giants is not clear just yet.

Tablets are everywhere

All major and quite a few smaller OEMs presented their answer to the iPad. They were probably the most touched and intensively tested devices at the MWC. Apple created this new market and sold almost 15 million iPads in only 9 months. Not many analysts forecasted this tremendous success (including us). Samsung unveiled the Galaxy Tab’s successor the Galaxy Tab 10.1 based on Android’s avatar for tablets: Honeycomb. LG, HP, HTC, Motorola, RIM, Lenovo and Toshiba all announced devices at the MWC 2011. RIM plans to release its super Playbook’s WiFi version late in Q1 2011, and HSPA+ and LTE, office software capability, multitasking OS, along with Flash, HTML5 and open internet standards in H2 2011. HP also unveiled Touchpad, a webOS based tablet. ZTE will accelerate its expansion on smart devices by launching lightweight tablets based on Honeycomb, which will be due in Q3 2011. Malata, a smaller Chinese vendor, only showed its portfolio of tablets in Barcelona. What it shows: There will be hundreds of tablets launched by the end of 2011. It is going to be the year of the tablets. Make sure your apps look good on them.

Broad awareness for m-Health and home monitoring

mHealth was clearly the biggest cross industry topic on the conference. Most of the OEM and operators as well as big fishes like Qualcomm and IBM showed some of their solutions which make use of a mobile device to support the treatment of a patient. Interesting that most of the mHealth solutions where not smartphone centered but made use of a specific device. Only smaller players which showed their solutions in the health care pavilion where mainly smartphone focused.  Home monitoring has been another interesting cross industry area which caught a lot of attention during the week. Telco companies used an entire pavilion, the “Embedded House”, to showcase their offerings. It became clear that the Telco industry will compete against the energy industry in that promising market.

Cross platform development is becoming more visible

It is clear that in the following years developers will face increasing challenges in developing apps for multi app platforms. There are some promising cross platform development tools and platforms out there which should gain more attention in the near future. There are a growing number of companies concentrating on those services such as Service2Media, Mobile Distillery, ideas2mobile and Geniem. Another interesting concept that showcased at the event is Kinoma by Marvell. This could be described as an app store within an app store. Marvell claims that apps running in the Kinoma environment must be developed only once and work on Android and Windows 7 operating systems.

Assessment 

Stay updated with our “App Market Monitoring”.

Link to blog post: http://www.research2guidance.com/gsma-mobile-world-congress-in-barcelona-impact-on-the-app-market/

Link to picture: http://www.research2guidance.com/wp-content/uploads/2011/02/2011-02-21-Barcelona.png

Twitter: #Mobile #Trends And Their Impact On The #App #Market – MWC Review: http://bit.ly/eMy2JR

About research2guidance:

research2guidance is a Berlin-based market research company specialized in the mobile industry. The company’s service offerings include comprehensive market studies, as well as bespoke research and consultancy.

Contact:

Markus Pohl

research2guidance

+49 30 609 893 363

markus.pohl@research2guidance.com

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Medical Practice Social Media Marketing Plan Survey

Medical Practice Marketing Plan Survey for Doctors?

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“We’re considering integrating social media into our medical practice marketing plan,” Dr. Joseph Frank Stankowsy started out saying.

Then he backtracked—“Yet, all we hear about it is what we can’t do from a HIPAA and security compliance perspective.”

And so, do you incorporate social media into your medical practice marketing plan? Please vote and opine here.

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Remember Tax Deadline Day is April 18th 2011

Tax Emancipation Day is April 15th 2011

By Dr. Gary L. Bode MSA, CPA, PC

In the 2011 tax filing season, taxpayers have until Monday, April 18 to file their 2010 tax returns and pay any tax due. Emancipation Day, a holiday observed in the District of Columbia, falls this year on Friday, April 15. By law, District of Columbia holidays impact tax deadlines in the same way that federal holidays do; therefore, all taxpayers will have three extra days to file this year. Taxpayers requesting an extension will have until October 17 to file their 2010 tax returns.

Who Must Wait to File

For most taxpayers, the 2011 tax filing season starts on schedule. However, tax law changes enacted by Congress and signed by President Obama in December mean some people need to wait until mid to late February to file their tax returns in order to give the IRS time to reprogram its processing systems. The IRS recently announced February 14, 2011 as the start date for processing these delayed tax returns.

Some taxpayers, including those who itemize deductions on Form 1040 Schedule A, will need to wait until February 14, 2011 to file. This includes taxpayers impacted by any of three tax provisions that expired at the end of 2009 and were renewed by the Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010 enacted December 17, 2010. Those who need to wait to file include:

  • Taxpayers Claiming Itemized Deductions on Schedule A. Itemized deductions include mortgage interest, charitable deductions, and medical and dental expenses as well as state and local taxes. In addition, itemized deductions include the state and local general sales tax deduction that was also extended and that primarily benefits people living in areas without state and local income taxes.
  • Taxpayers Claiming the Higher Education Tuition and Fees Deduction. This deduction for parents and students, covering up to $4,000 of tuition and fees paid to a post-secondary institution, is claimed on Form 8917. However, the IRS emphasized that there will be no delays for millions of parents and students who claim other education credits, including the American Opportunity Tax Credit extended last month and the Lifetime Learning Credit.
  • Taxpayers Claiming the Educator Expense Deduction. This deduction is for kindergarten through grade 12 educators with out-of-pocket classroom expenses of up to $250. The educator expense deduction is claimed on Form 1040, Line 23 and Form 1040A, Line 16.

Assessment

In addition to extending those tax deductions for 2010, the Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act also extended those deductions for 2011 and a number of other tax deductions and credits for 2011 and 2012, such as the American Opportunity Tax Credit and the modified Child Tax Credit. The Act also provides various job creation and investment incentives, including 100% expensing and a 2% payroll tax reduction for 2011. Those changes have no effect on the 2011 filing season.

http://www.amazon.com/Financial-Planning-Handbook-Physicians-Advisors/dp/0763745790/ref=sr_1_1?ie=UTF8&s=books&qid=1276795609&sr=1-1

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On eMRs and Disease Management

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One Clinical Area Where Electronic Benefits May Exceed Paper’s Molecules

By Dr. David Edward Marcinko [Publisher-in-Chief]

www.BusinessofMedicalPractice.com

One area where technology assessments, clinical guidelines, and especially eMR aggregated data can make a true difference in patient care is in disease management.

The DMAA

The Disease Management Association of America (DMAA) defines disease management as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant”. 

Disease management supports the physician-patient relationship and places particular significance on the prevention of exacerbations and complications of chronic diseases using evidence-based clinical guidelines and integrating those recommendations into initiatives to empower patients to be active partners with their physicians in managing their conditions.

Disease Targets

Typically, targets for disease management efforts include chronic conditions such as asthma, diabetes, chronic obstructive pulmonary disease, coronary artery disease, and heart failure, where patients can be active in self-care and where appropriate lifestyle changes can have a significant favorable impact on illness progression.

Link: Front Matter BoMP – 3

Outcomes Measurement

The DMAA also emphasizes the importance of process and outcomes measurement and evaluation, along with using the data to influence management of the condition.

Assessment

Although claims and administrative data can be used to measure and evaluate selected processes and outcomes, eMRs will be needed to capture the full spectrum of data for analyzing illness response to disease management programs and to support necessary changes in care plans to improve both intermediate outcomes (such as lab values), and long-range goals (such as the prevention of illness exacerbations, managing co-orbidities, and halting the progression of complications).

Is this where eMRs can shine far and above traditional ink and paper medical records?

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Why a Physician’s Charitable Contribution was Denied

Setty Gundanna Viralam et ux. v. Commissioner [A Case Model]

By Children’s Home Society of Florida Foundation

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In Setty Gundanna Viralam et ux. v. Commissioner; 136 T.C. No. 8; No. 21355-03 (13 Feb 2011), the Tax Court denied a deduction for a charitable gift to an organization maintaining donor advised funds for doctors. In addition to not receiving the charitable deduction, the doctor was subject to capital gains tax on sale of the stock and an accuracy-related penalty.

Physician Example

Dr. Viralam is a medical practitioner. In 1998, Dr. Viralam sold his 50% interest in a medical practice for $2,262,500, producing a taxable gain of $2,261,750. Dr. Viralam had joined a membership organization of doctors named Xelan. He paid a $975 membership fee for the “Xelan tax reduction plan.”

Xelan Foundation

Based upon promotional materials that promised “a tax reduction” program, Dr. Viralam transferred appreciated stock to the Xelan Foundation (“Foundation”) in 1998. The Foundation indicated that Dr. Viralam could create an account described variously as a “donor advised fund” or “family public charity.” The fund was available for “charitable giving, income tax reduction planning, estate tax reduction, educational funding and future retirement planning.”

The Xelan Foundation had been recognized by the IRS as a public charity and was included in IRS Publication 78. In addition, the Foundation had obtained an opinion letter from the Conner & Winters law firm on deductibility of gifts. In their opinion letter, Conner & Winters suggested that gifts to the Foundation were more likely than not to be deductible. However, the opinion letter declined to issue an opinion on the specific grants or educational programs of the Foundation donor advised funds.

The Gifting Mechanism

Following Dr. Viralam’s gift of stock with fair market value of $262,433 and cost basis of $131,360, the Foundation sold the gifted stock and provided him with a receipt. The receipt included the Sec. 170(f)(8) statement that “no goods or services” were transferred in exchange for the gift.

At the recommendation of Dr. Viralam, the Foundation accountant distributed $15,500 to religious organizations for the next two years. However, his Foundation account also made distributions to the University of Pennsylvania of $70,299. Dr. Viralam’s son Vinay was at that time a student at that university. The IRS audited Dr. Viralam and issued a notice of deficiency for 1998. The IRS denied the charitable deduction, assessed a tax on the sale of the appreciated stock by Xelan Corporation and also accessed an accuracy-related penalty under Sec. 6662.

The Court and IRS Opines

The court noted that under Sec. 170(c)(2), a charitable contribution is permitted if it is given to “a foundation organized and operated exclusively for charitable or educational purposes.”

The IRS claimed that the supposed “student loan” to Vinay showed that Dr. Viralam had “never surrendered dominion and control” over the fund. When Dr. Viralam created the fund in 1998, he anticipated that his three children would receive most of the fund for their college expenses. The initial distributions for the benefit of Vinay were made and “the Foundation’s approval of petitioner’s son as a student loan beneficiary was perfunctory.”
While it was true that the Foundation had been granted exempt status and was listed in Publication 78, the issue of the operation exclusively for the benefit of charitable purposes remained. Even though the purported donor advised fund was supposedly for charitable purposes, the facts indicated that Dr. Viralam had retained dominion and control.

The Sec. 170(f)(8)(A) receipt issued by Xelan Foundation indicated that there were no “goods or services” provided in consideration of the gift. However, the “student loans” were clearly within the regulatory definition of “cash, property, services, benefits and privileges.” Because the student loans were contemplated as part of the fund benefits, the gift failed the “no goods or services” test. Under Sec. 170(f)(8), there is “no deduction” if that test is failed.

Assessment

Because there was no charitable deduction, Dr. Viralam is also taxable on the long-term capital gain produced by sale of the stock in 1998. In addition, the penalty under Sec. 6662 applied. Dr. Viralam pointed to the legal opinion by the law firm Connor & Winters. However, that legal opinion explicitly excepted a potential student loan program. In the view of the court, the arrangement fails the “too good to be true” test. In the view of a reasonable person, a taxpayer should realize that this gift to provide university-level educations for children would not be deductible.

Conclusion

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

Healthcare Organizations: www.HealthcareFinancials.com

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Improving Revenue Cycles at a West Coast Public Hospital?

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Mr. Johnson was the chief financial officer (CFO) of a 222-bed teaching hospital in southern California. Mr. Johnson recognized a lot of problems with the processes within the various revenue cycle departments he managed which impacted cash flow for the facility.  Mr. Johnson met with the hospital chief executive officer (CEO) to express his concerns and the fact that he felt his existing staff did not have the expertise to fix many of the problems they were facing.

Ms. Thomas, the hospital CEO, agreed with Mr. Johnson’s evaluations and concerns and the two prepared a package for the Board of Supervisors to submit a request for proposal to several revenue cycle improvement vendors.  This request was approved by the Board and sent to several vendors with known successful track records in this area.  During the next several weeks the responses were evaluated and a final vendor selected.

It was determined through a Revenue Cycle Performance Evaluation completed by the vendor prior to the kick-off of the engagement that the largest opportunity for improved cash would be to address the bottlenecks in the cash flow, the excessive days in accounts receivable, the backlogged accounts in denied claims and improved process through the entire revenue cycle at this public hospital.

When the engagement began, the net days in accounts receivable were 103 and the time from discharge to final bill was 33 days. The vendor was engaged for a four-year period to provide cash acceleration and revenue cycle improvement on a “pay for performance” [P4P] fee structure.  A historical review of the hospital’s financial data determined an average monthly collection amount (baseline) the hospital was achieving each month prior to the start of this engagement.  The P4P fee structure required the vendor to reach the baseline each month before the hospital was required to pay any profession fees for the services of the vendor.

KEY ISSUES:

What could the hospital do to realize immediate benefits with regard to:

– accelerated cash flow?

– reduced days in accounts receivables?

– streamlined revenue cycle processes?

– better trained existing staff?

– return on investment?

MORE: Rev Cycle Mgmnt

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Healthcare Organizations: www.HealthcareFinancials.com

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A Survey to Understand the Modern Doctor-Patient Milieu

Doctors – Take Our Professional Contentment [“Happiness”] Survey

By Ann Miller RN MHA

[Executive-Director]

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Today, when patients communicate through instant messaging, Twitter, Facebook, and other Web 2.0 electronic mediums, they might feel that health providers are already more like the virtual “Doctor” than the all-too-human “Bones.”

The Contemporary Practice Milieu

Before long, according to one technology expert, 20% – 50% of all doctor-patient communication will be virtual. But we suggest you pause before rocketing ahead into this brave new future that advocates call Health 2.0—the application of social media tools to the health care environment.

Electronic technology in all of its forms has obviously had a profound impact on medicine. We focus here on just one of its most notable effects: the changing doctor-patient relationship. We believe Health 2.0 has the potential to deepen this relationship—or not. It depends on how you use it.

Our Guidance

There are an almost overwhelming number of social media tools for managing the doctor-patient relationship. How do you choose the right ones? We offer some guidance in this essay by focusing on three issues:

  • What matters most in the doctor-patient relationship?
  • What counts as a good relationship?
  • How should you use social media tools to build a relationship?

We have found that there is no one best way to use Health 2.0 technology. But, there is just one rule. As the novelist E.M. Forster said, “Only connect.”

The Survey

And so, we ask you to opine:

  • Has your doctor-patient relationship changed in recent years with the rise of the Internet search engines like “Dr. Google and Dr. Oogle” [for dentists] and the push to empower patients to take a greater role in their own care via HD-HCPs, private or direct payment models, etc?
  • Are patients more demanding of your time and attention than in the past? Do they understand the economic pressures that affect your practice? Do they care, or should they even care?
  • How do you handle noncompliant or uncooperative patients? What strategies work best or least? Is this issue underappreciated by the people pushing to base a greater portion of reimbursement on quality measures and outcomes?
  • How much time each week do you spend on paperwork, phone calls to payers, insurance companies, and other administrative tasks? How much has this increased in the last few years? Have you reached your breaking point, yet?

Assessment

Please give us your thoughts and opinions in the text box below.

Conclusion

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

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

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko 

Practice Management: http://www.springerpub.com/product/9780826105752

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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Silverman, Jennifer. “Impact of Virtual Visits on Doctor-Patient Relationship Unclear: an end to ‘true medicine’?” Ob.Gyn. News 38.21 (2003): 29.

CBO Director Elmendorf Discusses Budget Deficits

Considering the Fiscal Commission Recommendations

By Children’s Home Society of Florida Foundation

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Last week, on February 10th, the House Budget Committee held a hearing and Congressional Budget Office (CBO) Director Douglas Elmendorf discussed the federal budget deficit. Director Elmendorf emphasized the importance of addressing the deficit and also noted that the Fiscal Commission recommendations are a useful addition to the current discussion.

Of Paul Ryan

Chairman Paul Ryan noted that there still is a major problem with unemployment. According to Chairman Ryan, the recession ended in June of 2009 and between that time and December of 2010, “payroll employment rose by a mere 6/100 of 1% (0.06%).” Chairman Ryan noted that it is essential to restore growth in America. He advocated “low taxes, reasonable regulations sound money and spending restraint.”

Of Chris Van Hollen

Ranking Member Chris Van Hollen (D-MD) also responded to Director Elmendorf. He indicated a willingness to address the deficit. Rep. Van Hollen suggested that “Democrats and Republicans must work together now to put our nation on a fiscally sustainable path and we stand ready to do that.”

Assessment

However, Rep. Lloyd Doggett (D-TX) expressed concern that Chairman Ryan was focusing excessively on spending rather than on tax deductions. Rep. Doggett noted, “Dollar for dollar, cutting funding for cancer research or local law enforcement has the same effect on the deficit as closing a tax loophole that allows a Wall Street corporation to benefit by stashing their tax dollars offshore.” Rep. Doggett suggests that tax deductions will need to be reduced in order to address the deficit challenge.

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.

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

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

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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Meet Speaker Dr. David Edward Marcinko MBA

Management Expert, Social Media Pioneer, Journalist and Financial Advisor

www.BusinessofMedicalPractice.com

I am available for a limited number of speaking engagements each year. As social media’s leading integrated voice for medical and financial service professionals, the ME-P voice was noted by the WSJ.com in 2009, which said thatThis website is packed with great information.” And, medical information technology  and eMR guru Alberto Borges MD recently opined You do have an exceptional website”. 

The ME-P’s Reach

With over 250,000 visitors, the ME-P is among the web’s most influential and prominent platforms. I frequently discuss the precarious intersection among medical practice management, financial services, health economics and related social media in keynote speeches, panel discussions, and media interviews. 

Journalist

I also use my two decade long medical, surgical, business management and financial advisory practice and journalistic experiences to engage the private practice community, culminating in the third edition of our book: The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors].

Locale

I am based near Atlanta, GA, so travel for speaking opportunities is not problematic and very inexpensive.

Curriculum Vitae

Here is my CV: DEM Formal CV

Please contact me if you’re interested in having me engage your divese audience: MarcinkoAdvisors@msn.com

Sincerely,

Dr. David Edward Marcinko; MBA

Certified Medical Planner™
www.CertifiedMedicalPlanner.com

My Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

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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The Uniform Prudent Investor Act versus Fiduciary Accountability

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A Primer and Review for Financial Advisors

By Dr. David Edward Marcinko MBA, CMP™

www.CertifiedMedicalPlanner.org

More than a decade ago Charles L. Stanley, CFP™ gave an overview of the legislation and highlights areas of change for financial advisors and planners and to the financial services industry. To date, the Uniform Prudent Investor Act (UPIA) has been enacted in most states. Essentially, the act changed the legal criteria for “prudent investing” for trusts. All assets owned by a trust are considered “investments” for purposes of the Uniform Prudent Investor Act. Consequently, if a trust owns a life insurance policy or an annuity, it is considered an “investment” for purposes of the UPIA. Trustees and their advisors are subject to the act.

Background Review

The UPIA (California Probate Code Article 2.5) was adopted by the Uniform Conference of Commissioners on Uniform State Laws in 1994. When determining whether or not certain investing is “prudent,” the standard is applied to the whole portfolio rather than to individual investments.

The UPIA radically changes the analysis of risk. The UPIA considers that risk is unavoidable. For example, fixed income instruments carry the risk of loss of purchasing power, even though the principal may not be reduced in terms of real numbers. Risk is often desirable so long as it is sufficiently compensated. The UPIA seeks to compel the trustees to analyze the trade-offs between risks and returns, taking into consideration the needs and objectives of the trust.

Restrictions Reduced

The restrictions on what type of investments can be held in trust have been eliminated. The trustee can invest in anything that plays an appropriate role in achieving the risk/return objectives of the trust and that meets the other requirements of prudent investment. The trustee’s duty to diversify trust assets is codified in the UPIA. It is now recognized that proper effective diversification may enhance returns and/or reduce risk at the same time.

The UPIA rejected the traditional trust rule that generally prohibited “delegation of duty” by trustees, especially the duty of investment of trust assets. Delegation is now permitted, subject to safeguards. Agents are now made liable if they do not follow the new law.

What Must a Trustee Do to Comply with the Act?

According to Stanley, to comply with the UPIA, trustees must review trust assets and make and implement decisions to either keep or discard assets in order to bring the trust portfolio into compliance with the purposes, terms, distribution requirements, and other circumstances of the trust:

  • The trustee must diversify the assets of the trust unless it is prudent not to do so (16048). For example, it would not be acceptable for the trust to hold all municipal bonds.
  • The trustee must either comply with the Act in full or have the trust amended to restrict the requirements to diversify trust assets.
  • The trustee must delegate if he or she believes that he or she doesn’t the expertise to perform certain functions, this is particularly anticipated in the area of investment management. The trustee is expected to document all of the above to be available for review either by beneficiaries and/or courts should they become involved. This includes a written Investment Policy Statement. The act doesn’t specifically require this, but how would one prove they had been acting as a prudent trustee without documentation?
  • The trustee must periodically review the circumstances, assets and any professional delegates whom he or she has retained to assist him or her. The portfolio must be periodically rebalanced to maintain the established risk/reward characteristics identified in the Investment Policy Statement. This is not specifically stated, but is implied in ¤16047(b) and is a part of proper portfolio management under Modern Portfolio Theory. The act requires the costs of management to be “reasonable.”
  • The trustee must deal impartially with beneficiaries when there are two or more beneficiaries and must invest impartially, taking into account the differing interests of the beneficiaries.

Note: In most states, trust language can draft the trustee out of any and all requirements of the Uniform Prudent Investor Act. Many attorneys are doing this. So check trust language carefully.

Assessment

This essay is not a “final answer” in regard to compliance with the Uniform Prudent Investor Act. Financial advisors should consult with a competent attorney if you have any questions about a specific application with a specific physician investor or other client.

http://www.amazon.com/Financial-Planning-Handbook-Physicians-Advisors/dp/0763745790/ref=sr_1_1?ie=UTF8&s=books&qid=1276795609&sr=1-1

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. How has the fiduciary standard altered the above Act; or the current Dodd-Frank Act [Wall Street Reform and Consumer Protection Act]? 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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Why m-Health App Developers Won’t Make Money with Current Pay-Per Download Business Models

A Broadening Business Model

By Markus Pohl

markus.pohl@research2guidance.com

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Despite the hype around mobile health applications and big market projections mobile health app developers will not be able to create big revenues with a pay per download business models. But how will mHealth apps generate enough sustainability to meet the rising expectations during this hype phase? And how will mHealth business models evolve in the next five years?

The Hype 

Mobile health applications are experiencing a second hype phase after first enthusiasm in the early 2000s. By looking back a few years we can see how the business will evolve in the future. Business models of traditional mHealth solutions which long existed before the smartphone app market hype already showed the revenue sources which will become important in the future. Traditional mHealth solutions from 2000-2008 have typically been sold in bundles, which include connectivity charges, a device, and the application and/or service charge. In the more sophisticated traditional mHealth solutions the price for the application and the application sales revenues were minor contributors to the total revenue generated by the solution. Frequently the price for the app was not even disclosed.

First Gen  

The first generation of mHealth solutions in the new smartphone applications market have adopted a narrow range of business models, concentrating on revenues generated from application download sales, and subscriptions for content access over a period of time; average of 4-8 USD per download depending on the app store. In a very few cases publishers have linked the application to a device/sensor or service, such as the WiThing Scales Sync which provides a free application for use with a scale which is sold through the publisher’s website.

Broadening Business Model 

The business model will broaden once more when the enabling technology becomes sufficiently advanced. Sensors and special devices that are designed to take advantage of the smartphone interface will facilitate more advanced applications, and at the same time healthcare industry players with the capability of providing complex service offerings will enter the market. These factors will allow revenue generation through multiple sources apart from application downloads including for example through service charges for HCPs remotely monitoring patients’ health condition, or through product sales for special devices and sensors that relate to an application’s functionality.

As the market develops, applications will facilitate the sale of products and services such as medications through a compliance application or a mobile pharmacy application. These device and service sales will become the major revenue source for mHealth application providers by 2015.

Advertising revenues will become a revenue stream, as it will across the smartphone application market and will add to the mHealth providers’ income but only to a little extent.

Assessment 

As opposed to the traditional model, connectivity will not be part of the bundle, as most smartphone users will already have some kind of data plan.

Today’s dominant pay per download business model will give way to those other revenue stream. Developers of mHealth applications should be aware of that and adopt their products and service accordingly.

To see more details on the future trends in mHealth business models please have a look at the “Mobile Health Market Report 2010-2015”.

About research2guidance:

research2guidance is a Berlin-based market research company specialized in the mobile industry. The company’s service offerings include comprehensive market studies, as well as bespoke research and consultancy.

Contact:

research2guidance

+49 30 609 893 363

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.

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

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

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

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

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Some Thoughts on the Marginal Healthcare Dollar

Can this Vital Buck be More Efficiently Used?

By Dr. David Edward Marcinko MBA CMP™

[Editor-in-Chief]

Recently, healthcare economist Austin Frakt PhD offered these points about healthcare dollars spent on the margin:

1. Spending on health is not without value. It does improve lives [See Cutler]. Yet, we spend much to get that value.

2. Price per QALY is very high [See Aaron’s series on spending and his other on quality).

3. Just staying within the realm of health, the price per QALY on another “service” might be a lot lower [like nutrition, exercise, and healthy habits, etc].

http://theincidentaleconomist.com/wordpress/could-the-marginal-health-care-dollar-be-put-to-better-use/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+TheIncidentalEconomist+%28The+Incidental+Economist+%28Posts%29%29

Note: The quality-adjusted life year (QALY) is a measure of disease burden, including both the quality and the quantity of life lived. It is most often used in assessing the value for money of a medical intervention. The QALY model requires independent utility, neutral risk and constant proportional tradeoff behavior.

Understanding Marginal Profit

Recalling the equation: Profit = (Price x Volume) – Total Costs

We could amend it and say that:

Total Profit = P x V – (FC + VC) or: Total Profit = Price x Volume – (Fixed Costs + Variable Costs)

However, most medical office or clinic contracts today are based not on total profit, but on additional or marginal profit, because overhead costs always remain and clinic fixed costs are not important in contracted medicine.

And, for other pricing decisions, the equation can again be re-written, to emphasize variable costs, as follows: Marginal Profit = (P x V) – VC.

In other words, the marginal benefit must exceed the marginal cost of practice.

Cost-Volume-Profit Analysis

Now, once a basic understanding of marginal profit and medical cost behavior is achieved, the techniques of cost-volume-profit analysis (CVPA) can be used to further refine the managerial cost and profit aspects of the medical office business unit. CVPA is thus concerned with the relationship among prices of medical services, unit volume, per unit variable costs, total fixed costs, and the mix of services provided.

Assessment

Austin felt that if [*]od were jointly designing all health-related systems and functions of society and government – He’d look at the marginal cost/QALY over all possible ways to spend the next dollar and pick the smallest. How about you?

But, it’s not always going to be on health care services and it probably isn’t given what we’re already spending for those and what we’re getting for that spending.

Conclusion

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INSURANCE:Risk Management and Insurance Strategies for Physicians and Advisors

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Be Heard on the Leading Doctor-Advisor Platform

Submit an Essay or Article and Have a Voice

By Ann Miller RN MHA

[Executive-Director]

The Medical Executive-Post is the web’s only social media platform for doctors, and their advisors, with more than a quarter million visits to date. Professional medical administration and financial services organizations, as well as a core group of influential media voices, read the ME-P routinely. Newspaper reporters and editors also read the ME-P – so this is an opportunity to get noticed by major media outlets.

Our Reach

You can reach this influential audience by submitting a guest opinion or essay on any topic related to health economics, finance, medical practice management, financial planning or related subject matter of interest to our target audience. Articles of about 500-1,500 jargon-free words in length, and free of grammatical and spelling errors, are preferred. Accepted pieces will be published on the ME-P blog platform. Authors retain co-rights to their pieces, which may be published elsewhere.

Assessment

Articles can be sent here for consideration:

MarcinkoAdvisors@msn.com

Conclusion

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

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

Healthcare Organizations: www.HealthcareFinancials.com

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

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Fed Chair Bernanke Defends Bond Purchases

Before House Budget Committee

By Children’s Home Society of Florida Foundation

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Federal Reserve Chair Ben Bernanke appeared on February 9 before the House Budget Committee. He defended the plan by the Federal Reserve to purchase another $600 billion of government bonds. This would bring the total holdings of the Federal Reserve to approximately $2.6 trillion. Previously, the Federal Reserve lowered interest rates close to zero and purchased $1 trillion of bonds to support the financial markets.

Rationale

Chairman Bernanke pointed to four factors that in his view justified the additional bond purchases.

First, the unemployment level continues to be approximately 9%.

Second, he expects unemployment to remain high and inflation to remain low “for some time.”

Third, it is likely the federal funds rate will remain quite low as long as there is high unemployment and low inflation.

Fourth, the initial purchase of $1 trillion of bonds and the proposed additional $600 billion bond purchase are both appropriate and manageable. He suggests that there will be opportunity “to tighten monetary policy when needed.” The Federal Reserve has sufficient capability to sell the bonds and reduce its holdings as needed.

Fiscal Policy

Chairman Bernanke also addressed fiscal policy. He noted that it is important “to put the budget on a sustainable trajectory.” Chairman Bernanke spoke approvingly of the plans advocated by the National Commission on Fiscal Responsibility and Reform. He suggested that there is now a “much-needed conversation” on the deficit.

Paul Ryan

House Budget Chair Paul Ryan (R-WI) agreed that it is important to address the deficit. He observed that the projected $1.5 trillion deficit this year would increase the publicly-held debt. That public debt was 40% of the economy in 2008 and will rise to 69% of the economy by the end of the year.

Chairman Ryan stated, “Endless borrowing is not a strategy. We must restore the foundations of economic growth – low taxes, spending restraint, reasonable regulations and sound money – to help restart the engines of economic growth and job creation.”

Chris Van Hollen

The Ranking Member of the House Budget Committee is Rep. Chris Van Hollen (D-MD). He indicated to Chairman Bernanke, “I commend you and your colleagues at the Fed for using various forms of monetary policy to promote maximum employment and stable prices.” However, Rep. Van Hollen also agreed that it is important to create “a responsible plan to bring down and then eliminate the primary budget deficit.”

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.

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

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

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

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

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Understanding the Collaborative Shift in Bedside Manner

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Doctor-Patient Relations in the Modern Era

[By Mario Moussa PhD]

[By Jennifer Tomasik MS]

www.BusinessofMedicalPractice.com

When it comes to the doctor-patient relationship, Health 2.0 needs guidelines. Several leading health providers have begun to call for them. We think guidelines would, among other things, help define the right mix of virtual and live communication.

Our relationship strategies take a step in this direction. Such a framework can be used to start a productive dialogue among health providers about social media. A hospital committee or some other governing body could easily use Web 2.0 tools—a blog or a wiki—to start the discussion. Before long, there would be ample case material to flesh out general principles.

Health 2.0 Needs Guidelines

Guidelines would also address a big barrier to using Health 2.0: getting paid. Currently reimbursement policies do not cover electronic communication, so physicians have little financial incentive to use it. In a 2003 study, only 9% of physicians were willing to use e-mail to communicate with patients. This has something to do with old habits. But it has a lot to do with payment schedules, too. Guidelines should feature the research that shows the positive health outcomes of strong physician-patient relationships and how social media tools help build relationships. In today’s “pay for performance” market, these outcomes help build credibility for wired communication.

Training Support

We also think Health 2.0 guidelines need to be supported by training. Studies show that training in interviewing and interpersonal skills produces substantial differences in the quality of care. Training in Health 2.0 communication would likely have a similar impact.

Assessment

Paradoxically, as patients can access and control more data, they have a greater need for trusted physicians who communicate well using various mediums. As Ted Epperly, President of the American Academy of Family Physicians, has said, patients need “wise counsel” in sifting through the prodigious amounts of information available via Health 2.0. And physicians as well as patients need to learn how to navigate this environment. No longer the sole authoritative source of medical information, physicians need to adapt, becoming an experienced partner and guide for inquiring patients. Training can help doctors get comfortable in this new role.

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.

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

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko 

Practice Management: http://www.springerpub.com/product/9780826105752

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

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

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Anderson, James G., Eysenbach, Gunther, and Rainey, Michelle R. “The Impact of CyberHealthcare on the Physician–Patient Relationship.” Journal of Medical Systems. 27 (2003): 67 – 84.

Kaplan, Sherrie H., Greenfield, Sheldon, Gandek, Barbara, et al. “Characteristics of physicians with participatory decision-making styles.” Annals of Internal Medicine. 124.5 (1996): 497–504

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The Continuing Debate over Electronic Medical Records Systems

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Are We There Yet? – In Healthcare Organizations

[By Richard J. Mata MD, MS]

Dr. Mata

Paper-based medical records have been in existence for centuries and their gradual replacement by computer-based records has been slowly underway for over twenty years in western healthcare systems.

Computerized information systems have not achieved the same degree of penetration in healthcare as is seen in other sectors such as finance, transportation, and the manufacturing and retail industries.

Further, deployment has varied greatly from country to country and from specialty to specialty and in many cases has revolved around local systems designed for local use.

The DHHS

In a 2005 DHHS study, national penetration of electronic health records (EHRs) may have reached over 90% in primary care practices in Norway, Sweden, and Denmark (2003), but has been limited to 17% of physician office practices in the U.S. (2001-2003). By 2011, and the ACA, this number may now be approaching 20-25% in the US but adoption may actually be slowing.

The ISMS Vision

According to the Illinois State Medical Society there is a “Sweeping Vision for EHRs”:

  • EHRs will provide a comprehensive view of all patient information
  • Quality of care will be improved.
  • Physicians will more easily be able to review the “complete” medical record.
  • An appropriately configured EHR system will provide “alerts” and “notices” to help health care providers incorporate best practices into patient treatments. Ideally clinical decision support should be built in and be evidence-based.

Medical errors can be reduced:

  • Treatment and administrative costs will be reduced.
  • Public health will be improved.

Defining Electronic Records Systems

The 2003 Institute of Medicine (IOM) Patient Safety Report describes an EHR as encompassing:

  • a longitudinal collection of electronic health information for and about persons;
  • [immediate] electronic access to person- and population-level information by authorized users;
  • provision of knowledge and decision-support systems [that enhance the quality, safety, and efficiency of patient care] and
  • support for efficient processes for health care delivery.

IOM Report

A 1997 IOM report, The Computer-Based Patient Record: An Essential Technology for Health Care provides a more extensive definition:

A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems).

The EHR definitional model document developed by the Health Information and Management Systems Society (HIMSS, 2003) includes “a working definition of an EHR, attributes, key requirements to meet attributes, and measures or ‘evidence’ to assess the degree to which essential requirements have been met once EHR is implemented.”

IOM Re-Deux

In another IOM report, Key Capabilities of an Electronic Health Record System [Tang, 2003], identifies a set of eight core care delivery functions that EHR systems should be capable of performing in order to promote greater safety, quality and efficiency in health care delivery. The eight core capabilities that EHRs should possess are:

  1. Health information and data. Having immediate access to key information – such as patients’ diagnoses, allergies, lab test results, and medications – would improve caregivers’ ability to make sound clinical decisions in a timely manner.
  2. Result management. The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would increase patient safety and the effectiveness of care.
  3. Order management. The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance legibility, reduce duplication, and improve the speed with which orders are executed.
  4. Decision support. Using reminders, prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.
  5. Electronic communication and connectivity. Efficient, secure, and readily accessible communication among providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events.
  6. Patient support. Tools that give patients access to their health records, provide interactive patient education, and help them carry out home monitoring and self-testing can improve control of chronic conditions, such as diabetes.
  7. Administrative processes. Computerized administrative tools, such as scheduling systems, would greatly improve hospitals’ and clinics’ efficiency and provide more timely service to patients.
  8. Reporting. Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease surveillance.”

Assessment

After reviewing the above, are we there yet in – 2011?

Conclusion

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About the ME-P Rolling Fundraising Campaign

A Message from the Founder and CEO

By Dr. David Edward Marcinko; MBA, CMP™

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I began medical practice in the early 1980’s as an associate, junior partner and finally senior partner. While I wasn’t a smashing academic or business success, I wasn’t unsuccessful either. Although my patients loved my – never been sued – my journey began to create and aggregate the best medical practice management information available to help private doctors of all degrees and designations. I’ve been writing, editing, publishing and speaking on healthcare administration and related financial and economics topics ever since; both in print and online.

The result is that our handbooks, textbooks, CDs and journals are the sum total of all those printed moments of “practice-business-art” discovered by traditional contributing authors and others like me. Additionally, knowledgeable colleagues across the country add their time and energy to the vast, ever-growing store of electronic knowledge that the ME-P has become since 2006. This crowd-sourced model keeps all information current and timely for the modern and ever-changing healthcare industrial complex. In fact, here is what one reader-reviewer said of our efforts:

This comprehensive multi-authored text contains over 450 pages of highly specific and well-documented information that will be interest to physicians in private practice, academics, and in medical management. [Chapters are] readable, concise yet complete, and well developed. I could have used a book like this in the past and I will certainly refer to it frequently now.”

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But, what’s really remarkable about this ME-P is that it continues to be the product of cognitive volunteers working one entry at a time. And, because we are advertiser-light, those of us who create and use the ME-P have to protect and sustain it. That’s what the annual ME-P fundraising campaign is all about. And, it’s why I’ve made my personal donation. I hope you’ll choose to join me today in making a donation of $20, $35, $50 or whatever you can to keep the ME-P free.

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ICD-10 is Not an Airplane

It’s Another Part of HIPAA the ADA Won’t Discuss

By D. Kellus Pruitt DDS

A couple of days following the heads up I posted concerning the imminent upgrade from the tedious ICD-9 coding system to the ICD-10 that is said to be exponentially more complicated, informatics specialist Tom Sullivan posted a signal to fellow coders nationwide: “7 tactics for making ICD-10 urgent.”

http://www.healthcareitnews.com/blog/7-tactics-making-icd-10-urgent 

If you are fed up with unfunded, non-productive and ineffective mandates like I am, I imagine an alert to coders to create urgency in your practice makes your ear lobes burn bright red as well.

Tedious Administrative Tasks 

According to Sullivan, the ICD-10 presents providers with new requirements for “care management protocols, clinical and financial databases and reports, reimbursement, registries, quality management and research.” These requirements do not promote patients’ best interests. These tedious administrative tasks only enable HIPAA-covered entities to get paid.

ADA

If you are a HIPAA-covered dentist with a voluntary but permanent 10-digit NPI number which is required for ICD-10 compliancy, are you aware if ADA leaders have yet described the ICD-10 coding system any better than they described the NPI number that Delta Dental, BCBSTX, as well as the ADA aggressively promoted years ago?

Who knows? The ICD-10 may not even apply to dentistry. Somewhere deep in the HIPAA Rule, there might be a footnote that says “except in dental practices.”

Department of Dental Informatics

This isn’t the first time I’ve heard rumors about HIPAA’s nasty surprises for dentists. Five years ago this month, “quality” control through dental informatics was enthusiastically but perhaps prematurely revealed to me by an excited spokesman for the ADA Department of Dental Informatics. It was his email that equipped me with everything I needed for this 5 year adventure.

Shortly afterwards, the topic of HIPAA became so poisonous for ADA officials to discuss that the misled leaders who unwittingly signed on to promote digital fantasies in dentistry only rarely appeared in print and never on the internet – leaving the responsibility of informing naïve and trusting ADA members about the downsides of EHRs to those who sell EHRs.

Nevertheless, following three years of official silence about HIPAA from the ADA, in the last 14 months there have been two commentaries published in the JADA which promote quality control in dentistry. The first was written by James Bader DDS and appeared in the December 2009 edition of the JADA titled “Challenges in quality assessment of dental care.”

http://jada.ada.org/cgi/content/full/140/12/1456  

Quality Control 

The second commentary concerning quality control was written by Editor Michael Glick DMD titled ““When good may not be good enough — The need for clinical performance measures in dentistry.” (I’m no longer able to access JADA online).

EBD 

HIT stakeholders Bader and Glick, who are both fervent supporters of Evidence Based Dentistry as well as paperless dental practices, carefully tiptoe around what looks to me like an oppressive, micromanaged future for dentists. They both argue what must be a desperate committee-approved talking point – that quality assessment is critically important for ADA members so that fully-licensed dentists will have digital, Evidence-Based proof that their care is better than dental therapists’ who work for much less money.

Are ADA leaders sitting around a big table in ADA Headquarters when they think up this crap?

In addition, the cloistered committee concludes that patients’ opinions of their dentists is too difficult to collect and less reliable than algorithms based on dental claims and other data provided by the ICD-10 (?).

In fact, Dr. Bader is so confident in Evidence-Based digital results, he dismisses the need for any patient involvement in quality assessment: “Patient satisfaction has been shown to be associated only weakly with other assessments of quality of care, which means that it cannot be used as a surrogate for measures of technical quality.” Try telling that to a formerly satisfied dental patient who suddenly must pick his or her next dentist from a “preferred” provider list of strangers.

Assessment 

You mean like Ingenix’s measures of technical quality, Dr. Bader? In 2008, NY Attorney General Andrew Cuomo spanked the UnitedHealth subsidiary for selling algorithmic excuses to insurers to be used to cheat out-of-network physicians.

Conclusion

If you are a small business owner who reasonably asks to be paid no more and no less than what one is owed as quickly as possible – if not immediately like all other businesses in the land of the free – I’m pretty sure Sullivan’s 7 pearls intended to make ICD-10 more urgent for doctors will light up the lobes again. 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.

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

Healthcare Organizations: www.HealthcareFinancials.com

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About ME-P Plagiarism and Cryptomnesia

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What is DOC Cop?

Ann Miller RN MHA

[Executive Director]

According to my mother, and George Lundberg MD [former editor of the Journal of the American Medical Association], plagiarism is bad and a form of scientific misconduct, even fraud, and such findings can be hazardous to your career.

About DOC Cop

DOC Cop is a plagiarism, cryptomnesia and collusion detection SaaS tool that creates reports displaying the correlation and matches between documents or a document and the Web. DOC Cop does not take copyright or ownership of your material. It does not retain your material beyond the time it takes to generate your report. DOC Cop gathers the evidence, and provides the information required for you to judge whether plagiarism, cryptomnesia or collusion has occurred

Assessment

Don’t plagiarize on the ME-P; or anywhere! If you do, you will be caught by me, or DOC Cop.

Link: http://www.doccop.com

ME-P electronic typewriter

Conclusion

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Professional HR Options for Physicians

Understanding Professional Medical Employer Organizations

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By Eric Galtress

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“In-house service and support activities are monopolies.  They have little incentive to improve productivity. In fact, they have considerable disincentive to improve their productivity. Clerical, maintenance and support work, do not make a direct and measurable contribution to the bottom line.”

–“Sell the Mailroom” by Peter F. Drucker

As a medical practitioner, labor Law compliance begins with the hire of your very first practice employee. Thus, a well managed human resources (HR) function should be an area of strategic focus by the medical executive, regardless of practice size or the number of employees. Consideration of this vital role can help contribute to an efficient, highly effective and productive professional staff committed to the goals of the practice encompassing a positive and nurturing culture evident to your patients, while maintaining your competitive edge.

Costly HR

HR is the major expense driver of today’s medical practice and addresses staffing requirements, wages and other compensation, payroll and tax compliance, labor law compliance, employee benefits, training, employee turnover, safety, risk management and workers’ compensation. These responsibilities must be performed in accordance with State and Federal guidelines, beginning with the hire of your very first employee.

Employer Requirements

At specific employee level thresholds, employers are required to comply with a growing number of employee-related requirements including State and Federal Laws.  A partial list is shown even though the total number is vast considering each and every State has its own extensive regulatory and compliance burden. These laws govern the proper method of how employees must be treated and paid, as well as ensuring that their rights in the workplace are protected. State and Federal Regulators each create vast amounts of workplace legislation every year, many of which become law. In most cases, the specific requirement (either State or Federal) that affords the employee the most workplace rights and/or protection and benefits takes precedence over the other.  Non-compliance can subject the practitioner/business owner to hefty fines, penalties, business interruption, litigation, and in some cases, even practice failure.

In most cases, these HR efforts are backed by labor attorneys, service providers, brokers and other consultants. Given the typical size of a medical practice, this presents a compelling argument that practices should consider taking advantage of an innovative alternative:  being able to delegate (outsource) part or most of the HR burden as well as the employee/employer related liabilities.

Outsourced Services

Simply put, instead of the practitioner/staff performing the HR requirements, part or most of this responsibility can be outsourced to an off-site HR services provider that specializes in labor law compliance, employee management and cost control. The practitioner retains functional control of the employees and the service provider handles the HR issues. Added value is achieved by the practice in receiving these services more cost effectively since their needs are combined with those of the many other practices and businesses the provider already serves. Outsourcing is a matter of simple economics, enabling the practitioner to gain relief from cumbersome employee administration, while enhancing productivity and benefits for the staff members.

Link: Front Matter BoMP – 3

Assessment

The HR outsourcing relationship is not to be confused with a Physician Practice Management Company (PPMC).  The HR services provider has no financial interest or ownership whatsoever in the practice.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Have you ever used a medical PEO? 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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An Argument for Wikileaks in US Healthcare

On Allscripts CEO Glen Tullman

By Darrel K. Pruitt DDS

In 2008, Allscripts CEO Glen Tullman told Alex Nussbaurm of Bloomberg.com that physicians should take out loans to invest in his EHR product “to ensure that doctors have some skin in the game.” What did you expect? How much charm does it take to sell federally subsidized products when everyone knows that they’re mandated anyway?

Life Sans Blumenthal 

Yesterday, Nicole Lewis posted “Health IT’s Future without David Blumenthal” – a glowing and arguably deserved tribute to Dr. David Blumenthal who is leaving the ONC

http://www.informationweek.com/news/healthcare/leadership/showArticle.jhtml;jsessionid=0OLOEMENGCENJQE1GHRSKH4ATMY32JVN?articleID=229201216&pgno=1&queryText=&isPrev=

From where I’m sitting, it’s clear that Tullman used Lewis and InformationWeek to score more points with Washington and Wall Street, while continuing to marginalize the interests of those who actually take out loans to purchase his product: “David shepherded ONC through a very critical time . . . the creation, definition, and implementation of meaningful use, which really is a way to ensure that physicians actually use electronic records to improve care, but also that taxpayers get good value for their investment.” What about the doctor’s investment and more importantly, if a doctor is busy clicking on links to qualify for meaningful use dollars, who is accountable to the patients?

I don’t know about you, but it’s not difficult for me to recognize that like other HIT stakeholders whose careers are propped up by easy mandates rather than finicky satisfied customers, Tullman indeed has solid free-market reasons to play to investors and politicians while fearing his customers. They’re pissed at the man.

A Nationwide Survey           

HCPlexus recently partnered with Thompson Reuters to conduct a nationwide survey of almost 3,000 physicians concerning their opinions of the quality of health care in the near future considering the Patient Protection and Affordable Care Act (PPACA), Electronic Medical Records, and their effects on physicians and their patients. (See “5-page Executive Summary”)

http://www.hcplexus.com/PDFs/Summary—2011-Thomson-Reuters-HCPlexus-National-P

“Sixty-five percent of respondents believe that the quality of health care in the country will deteriorate in the near term. Many cited political reasons, anger directed at insurance companies, and critiques of the reform act – some articulating the strong feelings they have regarding the negative effects they expect from the PPACA.”

At this crucial time when Republicans are already threatening to cut off remaining HITECH funding, whose job will it be to break the news to HHS Secretary Kathleen Sebelius that the EHR savings she was counting on to fund a major portion of healthcare reform are only as valuable as CEO Tullman’s politically-correct fantasy? Pop! From what Nicole Lewis writes, my bet is that the Secretary won’t take the news well: “[Sebelius] reiterated that the successful adoption and use of HIT is fundamental to virtually every other important goal in the reform of the nation’s health care system.” Such pressure from the top down will make it even more difficult for HIT stakeholders, including insurers and politicians, to disown the most egregious. crowd-pleasin’, bi-partisan blunder in medical history since blood-letting was declared Best Practice by popular demand.

According to the HCPlexus-Reuters survey results, one in four physicians think EHRs will actually cause more harm than help in spite of Dr. Blumenthal’s best efforts. I wonder if the escalating bad press about EHRs helped Blumenthal decide to return to his academic position at Harvard. Of course, the controversy over HITECH is nothing new. There have been signs for years that EHRs, including Allscripts products, will neither improve care nor provide taxpayers (our grandchildren) a good value for their investment.

If Tullman was unaware of the highly critical HCPlexus-Reuters study when he assured InformationWeek that his subsidized product has value in the marketplace, he must have been aware of the disappointing news concerning two other recent studies performed by Public Library of Sciences (PLoS) and Stanford which also confirm that EHRs do not improve care. So imagine what it’s like to be one of Tullman’s new, naïve and trusting customers who are expected to use the product for something it’s not designed to do.

My Opinion 

It’s my opinion that Tullman’s apparently incorrigible business ethics have no place in the land of the free, and that more transparency in healthcare would help protect the nation from such politically-connected tyrants. Tullman, a long-time Chicago friend of Barack Obama and a Wall Street sweetheart, would still be just another domesticated CEO if it weren’t for the bi-partisan mandate for electronic health records that help Allscripts, Obama and Wall Street more than clueless patients.

Assessment 

If you want to seriously cut costs in US healthcare as well as cut our grandchildren’s taxes, demand transparency from not just the doctors and patients, but from stakeholders as well. Protected communications between good ol’ boys in healthcare are hardly diplomatic cables about military secrets and always increase the cost of healthcare.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. So when do you want to get the website started? I’m here to serve wherever you need me. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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

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Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Legal Strategies for Doctors Sheltering Employment Income

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Strategies for Medical Professionals to Consider in 2011

[By Sean G. Todd Esq, CPA, CFP®]

Thomas Stanley, author of “The Millionaire Next Door” (1996), revealed according to his findings at the time, two-thirds of millionaires in the U.S. were self-employed or small-business owners.  Also noted was the fact that even more people work for external companies and run small home-based businesses on the side. You need to spot the correlation – the tax code is written for the small business owner as there are massive tax-planning opportunities that are not subject to the standard income limitations.

Tax Reduction Opportunities

Perhaps one of the greatest tax-reduction opportunities is the use of small business retirement plans! Under current laws, the IRS typically does not include money contributed to these plans in the profits of a business owner or self-employed individual. If an affluent taxpayer can delay excessive spending until retirement, current taxation on those funds can be avoided.

In applying the right planning, additional income can be sheltered by maximizing the use of small business healthcare plans and employee benefits plans is another option. When our clients utilize health savings accounts, health reimbursement arrangements and Section 125 plans, expenses that would have been above the deduction thresholds for individual taxpayers can be paid on a pretax basis through the business.

Putting the Kids to Work

Another legal income sheltering strategy that we counsel our investment advisory clients on is to put offspring on the payroll of a business. We require them to work – which is not a bad thing in the least. Doing so provides two major benefits: FICA and federal unemployment taxes may not need to be paid if the child is a minor, and the child may be able to contribute to a Roth IRA out of earned income. Employing a spouse garners similar results. As an aside, we always try to be clear on “Who is the boss” in these situations. When utilizing the employment strategy, one must account for the annual cap on the amount of FICA an individual must pay, one spouse can be compensated substantially higher than the limit. Doing so may mean that one spouse pays less into the Social Security system, but it also gives a couple the opportunity to invest privately instead of putting it in the hands of the Social Security system. We and our clients prefer this strategy.

Legal Strategies for Sheltering Investment Income

We are a big user of technology in our advisory practice with allows our clients to utilize another underutilized tax reduction technique commonly missed by stockbrokers which is “tax lot matching”. This technique allows our clients to specify which shares of a stock or mutual fund he or she is selling, as opposed to the default IRS method of first in, first out (FIFO). Tax lot matching can provide huge savings when shares of a stock that show little gain, or even a loss, are sold instead of shares from long-term investments that show substantial gains.

Our affluent investors like doctors, with children, have utilized additional opportunities to shelter investment income and gains from the IRS. We utilize an account which provides a unique tax savings opportunity. When our client parent owns highly appreciated shares of stock, we “gift” the stock to a child and have the child sell it and then report a portion of the profits on the child’s substantially lower tax bracket. This type of planning requires knowledge of income taxes, estate tax laws and legal issues — all of which we confidently provide to our clients.

Section 529 Plans

We have counseled our affluent parents and grandparents of a unique opportunity to use Section 529 plans to shift money out of their estates and shield the growth of substantial amounts from future income taxes, if used for the college expenses of any family member. Under the Internal Revenue Code, any donor can gift up to five times their annual gift exclusion limit into a Section 529 account for a child, as long as multiple gifts to the same person aren’t given in the five years following. With the top estate tax bracket exceeding 50%, this can equal an estate tax savings of more than $25,000 for every $50,000 gift.

Charitable Works

Last but not least, we advise our affluent investors who have a charitable streak to avoid donating cash as much as possible. The IRS allows investors to donate substantially appreciated securities to nonprofit organizations and take a charitable deduction for the full amount. This saves investors the trouble of having to sell the assets themselves, pay tax on the gain and give smaller donations to the charity. In short, donate the stock and keep the cash.

“Grey Area” Strategies to Avoid

As mentioned before, the IRS has no problem with affluent investors avoiding as much taxation as legally allowable. Still, no article about affluent tax-planning strategies would be complete without a warning about the practices that can land you in hot water and wearing the orange jumpsuit. Even though you may overhear people bragging about these strategies at cocktails parties, be forewarned – they can lead to fines and even jail time.

Offshore Trusts

The most popular of the abusive tax strategies that receives heavy IRS prosecution is offshore asset trusts. While it may sound very tax savvy and sophisticated to have a Swiss or Cayman Islands bank account, these accounts are illegal when used to avoid U.S. income taxes. Additionally, the various post-9/11 regulations put strict limits on how much money can be transferred offshore and for what purposes. If someone recommends that you use one of these trusts, you’ll want to get second and third opinions from independent tax professionals.

Non-Arm’s-Length Transactions

The IRS also frowns on affluent investors conducting “non-arm’s-length” transactions to avoid taxation. These are tax planning strategies often done by “do-it-yourself” individuals. In short, all transactions among related parties should be conducted as if they were made between complete strangers. For example, parents who sell appreciated real estate to their children for half of the market value (to avoid paying tax on the gain) would not likely do this with a complete stranger. Affluent tax strategies that are not done in an arm’s-length fashion are subject to IRS action.

FLPs

Family Limited Partnerships (FLP) have become a popular way of attempting to transfer assets to the next generation, with the parents both retaining control of the assets and avoiding gift tax rules. While there are instances where such partnerships can be properly structured, they are abused enough to garner heavy scrutiny from the IRS. Utilizing a FLP can provide many income and estate tax advantages. Properly implementing and using a FLP requires proper professional counsel and advice. We strongly discourage anyone from trying to “do-it-yourself” with this level of tax planning.

Financial Planning

Developing and implementing an effective tax strategy is a key component to a successful financial plan. An effective tax strategy does not put out of the realm of possibility the fact that someone making hundreds of thousands of dollars to pay close to the same amount of taxes, as someone earning just a fraction of that. The key is to be deliberate and strategic about employing legal affluent tax planning strategies well in advance of your tax-filing deadline. Doing so will ensure that you and your family members, not the IRS, are the ultimate beneficiaries of your hard work.

Assessment 

What is one of the greatest tax-planning opportunities to come along in decades? We utilize this strategy everyday with our clients. Sadly, many affluent investors are not permitted to use them because their adjusted gross incomes are too high. What is the opportunity? In the alternative, our clients fund a non-deductible traditional IRA. While these IRAs don’t provide upfront deductions or tax-free withdrawals, the earnings can still accumulate on a tax-deferred basis over the long-term. How can all this help you financially?  You are seeing exactly why a solid investment plan needs to take into account tax planning.  Implementing tax strategies are guaranteed wins for our clients.  What is your tax strategy?

Here is the level of confidence we have in our ability to develop a beneficial strategy for you.  Take advantage of our offer to meet with you confidentially without cost or obligation.  Based on our meeting and a review of your strategy, we will put in writing the opportunities available to you.  After receiving this written strategy, you get to decide how best to implement the same.  Our strategy relies on competence in trusts and estates, income taxes and financial instruments and capitalizes on the ability to integrate each of these disciplines.

Conclusion

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

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Is Informatics the The Curse of Healthcare Reform?

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Medical Coding Complications and Greed

[By Darrell K. Pruitt DDS]

Coding complications in government healthcare ALWAYS favor the house — CMS guarantees it with lawsuits and whistleblower rewards that could attract dishonest employees. Are you careful who you hire?

Complications 

Complications in healthcare informatics – including 5-digit CPT® code mistakes as well as foul-ups that involve physicians’ “voluntary” 10-digit National Provider Identifier numbers – ALWAYS grant insurers more time to pay past-due bills owed to their clients and their clients’ doctors.

Call me Cynical 

Call me cynical, but if interest rates climb ever higher as predicted, watch for unexplained, proportional increases in coding errors to help fund insurance CFOs’ bonuses while raising the cost of healthcare even more without improving value. Is it any wonder why Americans don’t get the quality of healthcare we purchase compared to citizens in other countries? Tax-payers in my neighborhood are begging for in-network providers who put their patients’ interests ahead of insurers’ as much as allowed by insurers’ self-serving rules – without committing fraud. As a general rule, healthcare stakeholders accommodate parasites more than principals.

CPT® Codes and Patient Care 

Accurate CPT® coding may have nothing to do with patient care, but CMS makes it nevertheless important to physicians. Whereas the most innocent NPI foul-ups reliably delay payment and never turn out well for providers, the new fraud and abuse provisions of the Patient Protection and Affordable Care Act [ACA] can cause an innocent coding mistake on a Medicare claim to land the doc in court with charges of fraud depending on the quality of employees one hires – but only if the error favors the provider and not the payer. In June, David Burda posted “Attorney tells audience to brace for a storm of whistle-blower lawsuits” on ModernHealthcare.com.

http://www.modernhealthcare.com/article/20100623/NEWS/306209989/-1

Of Whistle-Blower Lawsuits

Burda reports that healthcare attorney Joanne Judge, a partner with Stevens & Lee in Reading, Pa., predicts a significant increase in whistle-blower lawsuits simply because the new law makes it far too easy for a dishonest employee to file an unwarranted lawsuit. No longer is there a requirement for the whistleblower, who stands to win money from his or her patriotic effort, to directly witness the crime. That kind of idea could catch on in this economy.

computer-hardware1

“The new law also converts accidental Medicare overpayments to providers into potential false claims, Judge said. She said the law considers an overpayment as fraud if the overpayment isn’t identified by the provider and returned to the government within 60 days. Judge said that will require providers to beef up their internal billing systems to detect an overpayment as soon as possible and then send Medicare back its money.”

Assessment 

What can possibly go wrong with that plan? Thorough background checks on all new employees is increasingly important, doc. For my employment security issues, I’ve learned to depend on Richard at Investigation Resource Service out of Dallas. He’s never let me down (This is not a paid ad).

Conclusion

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

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Understanding CPT® Code Payment Components

Determinations More Complex than Most Believe

By Staff Reporters

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Currently, there are more than 10,000 physician services designated by the current procedural terminology (CPT®) or healthcare common procedure coding system (HCPCS) codes.  Each reflects the three major cost drivers of a particular procedure:

  • Physician work effort or the relative value unit (RVUw) of medical providers’ work efforts, pre-service, intra-service and post-service time.

Patients may exhibit anxiety when examined orduring procedures resulting in the need for additional timeand effort by the physician to respond to and prepare for the examination or procedure. This uniformly adds moretime and stress to the pre-service and intra-service period as doctors respond to constantly changing behavior, questionsand level of cooperation in varying specialties.  Follow-up communicationwith employers, family, friends and concerned others requires increased post-service times.

  • Practice expenses (RVUpe), including non-physician costs but excluding medical malpractice coverage premiums.

The practice expense component of the resource-based relative value scale (RBRVS) includes clinicalstaff time, medical supplies, and medical equipment.  Often, the costsof supplies and equipment are not proportional to practicesize.  Major factorsaffecting practice expense are the volume of telephone, cell, or Internet management services, and the case management and administrative work required. For example, high patient turnover requires more examination rooms to maintain physician efficiency. High volume requires moreclerical staff to deal with larger patient-flow volume and resulting phone calls, difficultiesdressing and undressing patients, and is marked by increasedcomplexity and time in collecting laboratory specimens.  Thesefactors must be accounted for in any resource-based practiceexpense study and in the resulting practice expense calculationsfor medical services; and

  • Malpractice (RVUm) representing the cost of liability insurance.

The RBRVS system assigns RVUs to cover the malpractice expensesincurred by physicians. These malpractice RVUs, originally calculatedfor office-based physicians, may systematically undervaluethe practice liability costs for some specialties. The prolonged statutes of limitation on some legalactions may result in increased malpracticerisk exposure for physicians providing such services [i.e., pediatricians]. The differences in exposure may not be calculated in theRBRVS system, and were not included in initial studies.  Specialty specific survey data for malpractice expenseshould be used for this component when assigning final RVU valuations.  Without specialty-specific CPT® codes, however, there was no wayto do this objectively.

Conclusion

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FINANCE: Financial Planning for Physicians and Advisors
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Why Doctors DO NOT Need eMRs?

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Why Doctors DO NEED Patient Collaboration Tools!

By Shahid N. Shah MS

As a doctor, it seems as though you’re being told by everyone that you need to jump into electronic health records and electronic medical records software; that’s like telling you that you need to manage patients’ records and is so obvious as to be useless advice.

Focus on Patient Care

Of course, it’s true you need tools to manage records but that’s just the first step. Try not to think about or talk about EMRs; instead, focus on patient care collaboration tools. Here are the kinds of collaboration you need to do on a daily basis and where EMRs and EHRs usually do not help you:

Collaborative Tools

  • Reach out and market to new patients and communicate with existing patients that you may have lost touch with; you need tools that will promote you and your practice so that you can convert visitors to your website into paying patients and clients.
  • Register new patients and maintain patient data – find and work with tools that make the patient fill out major portions of your EMR for you; think of it as “self-service” EMR with tools that can be exposed on your website so that patients can do it themselves.
  • Help cover your medical risks by presenting medical liability coverage information to patients via your website using tools that can prove that they read the materials like informed consent, surgical prep, preparing for a procedure, etc.
  • Allow patients to see their schedule and help manage their appointments directly; if airlines can coordinate and manage aircraft and seats you should be able to get a system that allows patients to schedule an appointment with you.
  • Encourage the use of personal health records (PHRs) and make sure you review and link to the patient’s PHRs. This allows you to be ready to pull data from the PHRs in the future and get out of daily data entry when possible.
  • Get feedback about your practice and patient satisfaction using online surveys.
  • Be able to and receive send secure e-mails and documents to colleagues instead of playing phone tag or faxing constantly.

Assessment

As you can see from the simple list above, when people tell you to use EMRs they forget that the EMR is not only not enough but may be the wrong thing to focus on if you’re looking to streamline operations.

Link: Front Matter BoMP – 3

http://www.BusinessofMedicalPractice.com

Conclusion

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

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

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To PAR or Not to PAR?

The Essential Question for Most Medical Providers

By Staff Reporters

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Ever since 1992, doctors are paid per resource-based relative value unit (RBRVU) and according to the lesser of the actual billed charges or the fee schedule amount. But, there are two types of providers. 

  • Those who accept Medicare assignment only bill the patient for the co-payment, which is usually 20%. 
  • Those who do not accept Medicare assignment are offered a lower fee schedule of 95% of the approved schedule, which is a 115% maximum fee limit of the approved schedule.

So, how does this work in real life?

Example:

A participating physician’s approved fee schedule charge of $100 would yield $80 from Medicare and $20 from the patient.

A non-participating (Non-Par) doctor with charges of $200, and with an approved fee schedule of $100, would yield: $109.25 = (.95 X $100) X 1.15 entirely from the patient. If the Non-Par doctor selects payment type on a case-by-case basis, Medicare will pay its portion of the bill directly to the physician, but the doctor must accept the Non-Par fee schedule.

Assessment

Continuing our example yields: (.8 X $95) plus the patient’s co-payment of (.2 X $95), OR $76 plus $19 = $95.00.

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.

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

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

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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Do Physician Investors and/or their Financial Advisors Use and Abuse Modern Portfolio Theory?

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The Cultural Clash of Passivity versus Activity

By Dr. David Edward Marcinko MBA CMP™

www.CertifiedMedicalPlanner.org

[Publisher-in-Chief]

Ninety-three year old Professor Harry Markowitz PhD, coined the phrase “modern portfolio theory” [MPT] and concluded that investors are rewarded for taking certain risks but may not get rewarded for taking others. He developed the notion of an “efficient frontier” for different groups of asset classes and the idea that the higher the expected return, the higher the risk.

The Brinson, Hood, Beebower Study

In their 1986 study, Brinson, Hood, and Beebower attempted to measure three investment activities: (1) asset class selection, (2) market timing, and (3) security selection. They concluded that asset class selection had, by far, the greatest effect on the risk/return characteristics of a portfolio (some 93.6% of performance). But the most startling conclusion was that, if left alone, investment policy would have produced a higher average return than when market timing and security selection were taken into account. These latter factors actually reduced the average return over a 10-year period.

The Fama & French Study

In 1982, Fama and French found that three factors—market exposure, company size, and “value”—were systematic risks that explained the vast majority of equity market returns. “U.S. small-cap value stocks” is therefore a discreet asset class possessing all three of these systematic risks.

Most physicians and financial advisors are aware of modern portfolio theory but some fail to apply the principles to actual investor situations. Three examples: (1) using erroneous asset-class definitions, (2) using actively managed funds, and (3) relying on market timing. The abuse of modern portfolio theory can create portfolios loaded with latent risks that, on the surface, appear benign.

Not all Agree

Not everyone is in agreement with modern portfolio theory. Some detractors agree in principle, recognizing, for example, that “value” stocks have had higher returns than “growth” issues but they cite the cause as “mispricing” rather than risk.

Assessment

Institutional investors have gradually increased their commitment to passive strategies from virtually zero 20 years ago to 30% or more in the last decade [Think: Vanguard].

Individual and physician investors, on the other hand, have less than a 5% commitment.

Note: “Modern Portfolio Theory: Fact or Fiction?,” Gerard F. Stellwagen and Robin P. LaCouture, NAPFA Advisor, July 1997, pp. 1–7, National Association of Personal Financial Advisors for Fee-Only Financial Advisors.

Conclusion

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How to Choose eMR and HIT Consultants

Seeking Unbiased – Not Vendor Driven – Advice

By Shahid N. Shah, MS

www.BusinessofMedicalPractice.com

When you choose to implement your medical records technology, you’ll want to be sure that you get sound and unbiased advice. If you think the selections and decisions are too complicated to do by yourself so getting help is prudent. After you’ve learned more about RECs, which can give you free advice and help, look at some paid consultants as well because most RECs will simply choose a few local consultants that marketed themselves well to the RECs and not because the consultants are necessarily good at their jobs.

Consulting Types

The kinds of consultants you will need include:

  • Meaningful Use (MU) Consultant. An MU consultant should only be needed if you’re going after government stimulus funds. This is a person that knows how a medical practice works, inside and out, and all the legal and regulatory details about Meaningful Use. This is not a typical IT contractor or technical consultant; it must be someone who is focused on MU. Because you will not get increased government reimbursements unless you meet MU, the MU Consultant is probably more important than your IT consultant. The MU consultant should help you figure out whether or not you qualify for incentives, how to take advantage of incentive program, how to use RECs, how to ensure that you can qualify for MU without disrupting your practice and losing money, and finally whether you should even care about MU.
  • A good MU Consultant will tell you when to walk away from MU and not implement certain technologies just as readily as when to implement it.
  • Another major thing to focus on when choosing an MU consultant is to be sure that they know your local area’s rules, regulations, and technology providers (not national).
  • Try to make sure that your MU Consultants are paid very little upfront and will share the risk with you as you try to achieve success. They should get paid when you get paid and should not be paid full price unless you get incentive payments from the government. 
  • EMR Consultant. If you’re ready to buy an EMR the MU Consultant can help you pick products but getting advice from an EMR Consultant who knows all the hundreds of packages (and doesn’t just know 1 or 2 that he’s seen before) and which one will be best for you may be worth investing in. Be careful if your EMR Consultant is coming from a REC or a vendor side – ask them to disclose any ties to the products they are helping you select. Some EMR consultants are business focused and others are technically focused; you should pick the one based on what your needs are: for example, if you’re great at technology, choose a business-focused consultant (and vice-versa). 
  • IT Consultant. This is something that’s obvious but you need excellent advice on hardware, software, inter-office networking, Internet connectivity, bandwidth analysis, and a whole host of other technology needs. 
  • Integration Consultant. Most people forget this consultant because it’s not obvious but in order to make sure that all the medical records data you’re collecting can be shared in between your systems, your hospital, and with the government you need an integration consultant. Their job is to know all the relevant standards like HL7, DICOM, CCR, CCD, XML, etc. along with things like HL7 routers and tools that can share medical data records between your EMR, practice management system, and health information exchanges (HIEs).

Assessment 

Front Matter BoMP – 3

Conclusion

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

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

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko 

Practice Management: http://www.springerpub.com/product/9780826105752

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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Thinking Beyond Portfolio Asset Allocation

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Don’t Forget Your Spending Policy – Doctors

By Dr. David Edward Marcinko MBA CMP™

www.CertifiedMedicalPlanner.com

[Publisher-in-Chief]

If you are economically literate – or read the ME-P regularly – you may be tired of hearing the familiar saw, “the single most important determinant of investment results over time is asset allocation.”

But, as most of us realize, this glosses over critical obstacles to building personal wealth—taxes, inflation, and spending policy. A doctor’s spending policy itself is as critical as asset allocation in preserving wealth, as well as for all investors who understand the trade-offs: there are both allocation and spending strategies that stand to preserve wealth and insulate against excessive equity risk at the same time.

Income versus Security

In proving his point a decade ago, the author—Roger Hertog in “Income Versus Security”— traced the growth of a $1 million portfolio during the period of 1960–1994. He showed that while an all-stock portfolio would have experienced a compound growth rate of 10.1%, an all-bond portfolio of 7.4%, and an all T-bill portfolio of 6.1%, these growth rates dropped to 8%, 5%, and 3.7%, respectively, after taxes and conservative transaction costs. When further reduced by inflation, they dropped to 3.1%, 0.2%, and -1%, respectively. Stocks still nearly tripled in real value after taxes.

Next, Hertog factored in spending. He showed that the greater the equity exposure, the more likely investors will preserve or increase their levels of real spending and wealth. Also, he demonstrated how a spending policy of a fixed percentage of the portfolio; or of spending all the income is ill-suited to estate building. He arrived at an optimum allocation of 60% stocks and 40% bonds with a policy of spending all stock dividends but only spending interest to the extent it exceeds inflation. This latter spending policy adjusts for the fact that in – unlike today but perhaps again in the near future – an inflationary environment a portion of bond interest is a return of principal. This type of asset allocation and spending policy resulted in the greatest amount of growth over the years and gained on inflation. Hertog contends that the 60/40 allocation provides an appealing combination of growth and protection.

IOW: It gives investors a milder ride.

Assessment

Over the 35-year period studied, a 60/40 mix returned almost as much as the all-stock portfolio both before taxes and after taxes and achieved some 75% of its real after-tax growth. Also, the portfolio’s worst year was only half as bad as the all-stock portfolio. Hertog believed that balancing with bonds softened the downside. But – what about the “flash-crash” of 2008-09?

Note: “Income Versus Security: Do You Have To Choose?” Roger Hertog, Trust & Estates, March 1997, pp. 44–62, Intertec Publishing Corporation.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Is the bull market in bonds over? Do you believe Hertog? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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

Our Other Print Books and Related Information Sources:

Health Dictionary Series: http://www.springerpub.com/Search/marcinko

Practice Management: http://www.springerpub.com/product/9780826105752

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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Has the HIT Bubble Already Popped?

Long Before Reaching … Dentistry

[By Darrell K. Pruitt DDS]

HCPlexus recently partnered with Thompson Reuters to conduct a nationwide survey of almost 3,000 physicians about their opinions of the quality of health care in the near future considering the Patient Protection and Affordable Care Act (PPACA), Electronic Medical Records, and their effects on physicians and their patients. (See “5-page Executive Summary”)

http://www.hcplexus.com/PDFs/Summary—2011-Thomson-Reuters-HCPlexus-National-P

Results:

“Sixty-five percent of respondents believe that the quality of health care in the country will deteriorate in the near term. Many cited political reasons, anger directed at insurance companies, and critiques of the reform act – some articulating the strong feelings they have regarding the negative effects they expect from the PPACA.”

What’s more, one in four physicians think eHRs will cause more harm than help. So what’s the accepted threshold for the Hippocratic Oath to come into play?

Do you also find excitement in healthcare reform’s surprises? Experiencing the sudden, last minute turns healthcare reform has taken lately is like riding shotgun with Mayhem behind the wheel, texting. Here’s other discouraging news from the same HCPlexus-Thompston Reuters survey: “A surprising 45% of all respondents indicated they did not know what an ACO is, exposing a much lower awareness of ACOs versus the broader implications of PPACA. It appears there has been a lack of physician education in this area.”

ACOs Defined 

Since I also had no idea what an ACO is, I searched the term and came across a timely article that was posted on NPR only days ago titled, “Accountable Care Organizations, Explained.”

http://www.npr.org/2011/01/18/132937232/accountable-care-organizations-explained

Author Jenny Gold writes: “ACOs are a new model for delivering health services that offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs.” Does that remind anyone of insurance HMO promises just before the bad idea collided with surprisingly intelligent consumers in the early 1990s? Kelly Devers, a senior fellow at the nonprofit Urban Institute, is quoted: “Some people say ACOs are HMOs in drag,” There’s a sharp turn nobody warned us about.

HMO Differentiation 

Further blurring the difference between ACOs and HMOs, Gold adds “An ACO is a network of doctors and hospitals that shares responsibility for providing care to patients. Under the new law, ACOs would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.” I wonder if we’ll see a resurrection of HMO gag orders preventing physicians from discussing effective but expensive treatment alternatives not offered by the ACO.

As expected, not only are hospitals and doctors competing for the opportunity to run ACOs, but so are former HMO insurance agents. Devers explains, “Insurers say they can play an important role in ACOs because they track and collect data on patients, which is critical for coordinating care and reporting on the results.” As a provider, do you trust UnitedHealth’s Ingenix data mining tendencies? A few years ago, NY State Attorney General Andrew Cuomo spanked the company for selling insurers pseudo-scientific excuses to cheat out-of-network physicians.

Just like Health Maintenance Organizations don’t maintain health, insurer-based Accountable Care Organizations will not bring accountability to care any more than the Patient Protection and Affordable Care Act provides patient protection and affordable care. And since I’m exposing blatant bi-partisan deceptions, there is no privacy or accountability in the Health Insurance Portability and Accountability Act, and the “HIPAA Administrative Simplification Statute and Rules Act” doesn’t.

HITECH Funding

Gold suggests that because HITECH rules were written intentionally vague in order to push the envelope of stakeholders’ imaginations, similar to HIPAA’s ineffective security rules I suppose, the doctors’ predictable ignorance of ACOs is understandable.

But then again, all this may not even matter in a few months. According to Howard Anderson, Executive Editor of HealthcareInfoSecurity.com, HITECH funding itself is threatened. He recently posted “GOP Bill Would Gut HITECH Funding – Unobligated HITECH Act Funds Would be Eliminated.”

http://www.govinfosecurity.com/articles.php?art_id=3306

Assessment

While Obama’s healthcare reform teeters between two houses, I encourage consumers to plead with their lawmakers to stop being suckered in by cheap, meaningless buzzwords sprinkled in the titles of bills. I’m hoping we can at least get them to read a little deeper. Be on your toes. Mayhem is “recalculating.”

Conclusion

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

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A Doctor-Financial Advisor Makes the Case for Stock-Market Timing

Do a Growing Number of Stock-Market Timers Outperform?

By Dr. David Edward Marcinko MBA CMP™

www.CertifiedMedicalPlanner.com

[Publisher-in-Chief]

Money management styles tend to fall in and out of favor in cycles. When the market goes through a sustained bull market, buy-and-hold becomes the proclaimed path to investing success as I have opined previously. But, when the market enters a bear phase, like the flash crash of 2008-09, there is renewed belief in market timing as I now try to explain.

The Studies

And yet, studies of actual results of professional money managers using market-timing techniques reveal that the average timer’s results, like the average mutual fund, slightly lag behind the market indexes. But a growing number of timers consistently outperform the market over a full market cycle. When risk-adjusted return is used as the standard to measure performance, even the average market timer outperforms the market by a notable margin. A study of 25 market timers by Wagner, Shellans, and Paul (1992) during the period 1985–1990 (both bull and bear) shows that the level of risk assumed by the average timer was 40–60% below the S&P 500, even after subtracting fees, and the returns were comparable to the S&P 500.

Marketplace Phases

History has shown that starting from the market’s last high water mark, the market typically goes through three phases: (1) a correction, (2) a recovery to breakeven, and (3) a move to new highs. A study of the 108-year period from 1885 to 1993 reveals that the average correction phase consumed 32% of the time period and the return to breakeven exhausted an additional 44%. The market spent only 24% of the time moving to new highs. This is the only time that typical buy-and-hold investors saw their investments appreciate. This makes the stock market an extremely inefficient money-making vehicle.

Since the market timer who sold at the top will have more money at the bear market bottom than the buy-and-hold investor, the study indicates that the timer may have between 26% and 54% more to invest on the upswing. The study also shows that a timer does not have to be perfect in discerning entry and exit points. In fact, he or she can miss 20% of the advance, participate in 20% of the decline, and lose money as much as 47% of the time and still have an average gain equal to the net average gain for the buy-and-hold investor.

Assessment

Of course, it is quite a feat to obtain all the returns attributable from the buy-and-hold strategy while being in the market about half the time. 

Note: “Why Market Timing Works,” Jerry C. Wagner; The Journal of Investing; Summer of 1997, pp. 78–81, Institutional Investor, Inc.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Did I make my case? Are you a market timer or buy-hold strategist; and why? Did this strategy work until the market meltdown of 2008-09; how about since then? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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

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[Do] eHRs Fail to Improve Healthcare Quality?

I told you so … wow! That felt really, really good!

By D. Kellus Pruitt DDS 

If you haven’t been following the bad news for electronic health records that has broken in the popular media in the last few days, you may be unaware of recent studies that are about as welcome in Washington DC as Wikileaks revelations of diplomatic farts – but much more serious. Healthcare reform itself is in the balance, and President Obama’s credibility with mandates is already shot.

Records will show that a few politically-incorrect troublemakers knew all along that EHRs will fail to save money or improve the quality of healthcare – ever – unless doctors and patients are involved in their development. This troublemaker warned dentists 5 years ago about how HIT stakeholder and former Speaker of the House Newt Gingrich deceived naïve ADA Delegates about benefits of eHRs to dental patients. In turn, 3 years later, the ADA’s HIT stakeholder, Dr. Robert Ahlstrom, deceived Bush’s HHS Secretary Michael Leavitt with biased, self-serving testimony he gave to the NCVHS. (See “Dr. Robert H. Ahlstrom’s controversial HIPAA testimony” that I posted in 2008.)

http://community.pennwelldentalgroup.com/forum/topics/dr-robert-h-ahlstroms

Do you still not agree that long ago, I told you so?

At a time when President Obama’s healthcare reform is teetering between the Houses, just wait until lawmakers catch the news I’m bringing to you hours, days or even weeks ahead of Fox News: Transparency just caused a huge chunk of anticipated funding for reform to evaporate like American’s property values. After billions of stimulus dollars have been gleefully spent benefiting influential healthcare stakeholders rather than principals, the bi-partisan feel-good digital fantasy is bankrupt. Pop goes the bubble.

Although there have been minor news reports of growing disappointment in eHRs for years, the results of two recent studies by Public Library of Sciences (PLoS) and Stanford clearly expose the lack of value of eHRs for Americans. We’ve been had.

The WSJ 

On January 21, the Wall Street Journal posted an article titled, “Study Looks For, Can’t Find Much Evidence of E-Health’s Benefits,” by Katherine Hobson.

http://blogs.wsj.com/health/2011/01/21/study-looks-for-cant-find-much-evidence-of-e-healths-benefits/

Hobson writes: “With the U.S. and the U.K. heading full steam towards electronic medical records and other health IT applications, how much evidence is there that they improve care?

Not a whole lot, according to a review of existing research on the topic published this week by PLoS Medicine. While governments and other proponents are claiming that digitizing health records can save lives and increase efficiency, the review’s ‘key conclusion is that these claims need to be scrutinized before people invest quite large sums of money in these technologies,’ Aziz Sheikh, lead author of the study and a professor of primary care research and development at the Center for Population Health Sciences at the University of Edinburgh, tells the Health Blog.’”

US News & World Report

And; only hours ago, US News & World Report posted a story titled “Electronic Record-Keeping Alone May Not Boost Health Care.” (no byline).

http://health.usnews.com/health-news/managing-your-healthcare/policy/articles/2011/01/25/electronic-record-keeping-alone-may-not-boost-health-care

“Electronic health records have so far done little to improve the quality of health care in the United States, a new study states.

Researchers from the Stanford University School of Medicine analyzed data on use of electronic records from 2005 through 2007. The data came from a nationwide physician survey that encompassed nearly 250,000 outpatient visits.”

The ADA 

So how does the truth about eHRs affect ADA leadership’s stubborn push for paperless practices in dentistry? Well, if as a trusting ADA member, you haven’t already swallowed the propaganda, now wouldn’t be a good time to convert to paperless.

eDRs

Though my unpopular but accurate statements about eDRs eventually got me in secret trouble with vetted, anonymous Texas Dental Association officials, I predicted this week’s bad news years ago on the TDA online forum. Unfortunately, my warnings to other TDA members about the ADA’s biggest blunder in history were censored by the TDA Executive Director without warning or explanation. Why? She isn’t accountable to anyone and “Image is everything.” (ADA/IDM slogan).

Just how difficult can it be to recognize that eHRs are inefficient in dental practices for simple, common sense reasons? First of all, dental records which involve prevention and treatment of disease in the lower third of the face rarely include laboratory test results like medical records which concern the whole body. In addition, dentists maintain tenfold fewer thin patient charts than physicians’ thick ones. So if the value of eHRs are questionable for hospital care involving millions of charts, I think dentists are safe to ignore Presidential eHR mandates. The bottleneck in dental offices isn’t the front desk, it’s the dentist … or at least it should be. As for thumbing your nose at a Presidential mandate, I wouldn’t get too concerned. Obama also mandated that the prison at Guantanamo Bay was to be closed over a year ago. It didn’t happen, and nobody went to jail.

Unfunded Mandates 

Unfunded mandates just don’t carry the respect they once did when they were less common and actually made sense. Considering the absurdity of eHRs in dentistry, worse things could happen for trusting, clueless Americans.

Those who represent our concerns in government probably don’t yet realize that in the last four days, the price of healthcare reform skyrocketed even further out of reach, and we simply cannot borrow any more money from our grandchildren just to throw it away on expensive hi-tech crap. As for myself, I’m sending this ME-P to my national and state representatives: Cornyn, Hutchison, Barton, Burgess, Harris, Davis, Patrick and Veasey, I hope you will contact your representatives as well. The Internet makes it so easy these days to educate those who would otherwise determine our future based on deception from healthcare stakeholders.

Assessment 

I publicly challenge Dr. Robert Ahlstrom, who is currently a member of the ADA Council on Dental Practice and chair of the Members Advisory Group to an Internet discussion concerning electronic health records in dentistry. It’s the same unanswered challenge I issued to the influential dentist over 3 years ago: I still say electronic dental records are an expensive hobby paid for by dental patients in higher fees, and they do nothing to improve patient care. What do you have to say about that, Dr. Robert Ahlstrom? You know you’re going to have to face me again and again, so please don’t disappoint ADA members by continuing to hide. It makes the whole ADA look cowardly.

Conclusion

Always remember: I told you so, Dr. Robert Ahlstrom. And so, your thoughts and comments on this ME-P are appreciated. How do you select an eMR consultant? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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

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