Defining the Accountable [Health] Care Organization

ACO Glossary of Terms from CMS, etc

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

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

Budgetary Accountability

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

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

CMS Definition

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

ACO Definition: accountable care organization

Medical Provider Market Power and the American Hospital Association

AHA definition: AHA – ACOs

Assessment

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

Conclusion

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About the Editor-in-Chief

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

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

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

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Content Exchange and Vocabulary Standards for eMRs

Understanding Terms and Definitions

By Shahid N. Shah MS

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

Terms and Definitions

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

Assessment

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Understanding the Medical Records R[e]Volution

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It’s Not All about Electronic Records

By Dr. David Edward Marcinko; MBA, CMP™

[Editor-in-Chief]

Introduction

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

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

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Of Doubts and Uncertainty

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

The Payment Paradigm Shift

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

mobile EHR health

Provider Attitude Adjustments Required

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

Computer Charting and eMRs

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

Assessment

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

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On Evidence-Based Clinical Medical Guidelines

About the Institute for Clinical Systems Integration [ICSI] 

By Brent A. Metfessel MD, CMP™

 

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

 

The Issues

These issues generally apply to technology assessments as well:

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

Guideline Adaptation

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

Evidence Based Medicine

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

Assessment

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

Conclusion

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Concerning ShareCare.com

A New Consumer Health Information Internet Portal

By Staff Reporters

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

Health Information Search Simplified

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

Assessment

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

Conclusion

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About M. Howard Pell CPA

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Assessment

Visit: http://dalecpa.com/

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The Effects of Healthcare Reform Legislation on Physician Compensation

Is a Future Look Predicated on the Past?

By Dr. Brian J. Knabe; CFP® CMP™

By Dr. David Edward Marcinko; MBA CMP™

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

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

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

Other Countries

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

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

Inflation Adjustments

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

Physician Net Income Chart

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

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

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

Assessment

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

Conclusion

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Seeking Your Favorite Health 2.0 Patient Story

Collaborative Care – Not Yet So Collaborative

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

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On e-Confidentiality Conflicts in Medicine

Understanding the Potential Role of eMR Compromise

By Render Davis MHA CHE

www.BusinessofMedicalPractice.com

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

Impact of eMRs

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

Assessment

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

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. What do you think about this confidentiality conflict and the role of eMRs? 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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Essay on Healthcare Leadership

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Versus Healthcare Management

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

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

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

***

leadership

***

The Managers

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

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

Leadership Development

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

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

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

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

Internal Faults

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

Self Development

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

***

Product Details

***

Assessment

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

Conclusion

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Congratulations to Laureate Professor Robert Edwards

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Test-tube Baby Pioneer Wins Nobel Prize in Medicine

By Staff Reporters

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

Assessment

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

Conclusion

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Doctor-Why Is It So Difficult to Save?

A Poetic Tale: Gurus of Marketing

By Somnath Basu PhD MBA

What is in spending today that cannot wait?

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

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

Consumer [Physician] Behavior

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

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

Just Imagine

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

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

My Proposal

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

Assessment

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

Conclusion

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

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

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About HealthCareTownHall.com

Informed Healthcare Reform Dialogue

By Staff Reporters

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

Complications

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

Assessment

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

  Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Visit www.HealthCareTownHall.com and tell us what you think? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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Benchmarking Study Survey on Physician Sales and Service

ME-P Reader Participation Sought for the Corporate Health Group

By Carolyn Merriman

President, Corporate Health Group

401-886-5588 ext. 201

www.corporatehealthgroup.com

Dear David and ME-P Subscribers, Readers and Visitors

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

www.BusinessofMedicalPractice.com

ME-P Reader Participation Requested 

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

The CHG 

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

Viral Contacts Sought

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

Contact Instructions 

Instructions on sending the survey to your contacts:

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

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

The Physician Sales and Service Survey  

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

View image001.png in slide show

Third Benchmarking Study

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

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Events Planner: October 2010

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Events-Planner: OCTOBER 2010

By Staff Writers

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

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

First, a little about us! The Medical Executive-Post is still a relative newcomer. But today, we have almost 175,000 visitors and readers each month from all over the country, in addition to our growing subscriber base. We have been a successful collaborative effort, thanks to your contributions.  As a result, we are adding new resources daily. And, we hope the website continues to provide the best place to go for journals, books, conferences, educational resources, tools, and other things you need to establish the value your healthcare consulting and financial advisory intervention.

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

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

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

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

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

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Dealing With Uncertainty in Practice Measurement

Understanding Variations in Medical Care Quality

By Brent A. Metfessel MD, CMP™

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Due to high-profile concerns in terms of the variation in quality of care as well as its affordability, practice pattern measurement is here to stay.  And, until further advances in this area are created, physicians with unexpectedly poor performance ratios, especially in the area of cost-efficiency, should review their data to determine if there are opportunities to improve as well as potential outlier cases contributing to an aberrant value, as well as looking at the health plan methodology for statistical analysis and outlier exclusions. 

Communication is Key

It is important for the physician or other provider being measured to communicate any issues to health plan personnel where possible. Physicians need to remember that practice pattern analysis is a continually evolving field. 

Assessment

Given the state of the art, physicians, specialty societies, and other advocacy groups have a responsibility to work with health plans or other practice measurement agencies to make sure quality improvement is at the forefront, that they are active in giving feedback on health plan practice measurement methods, and that as much as possible a collaborative approach is used in working with health plans and other measurement organizations.

Conclusion

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Vote on What the US Healthcare System Needs?

An Opinion Poll

[Staff Reporters]

HIEs launch tomorrow. So, please vote.

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Conclusion

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Dental Compensation Different than Docs

On Medical Professional Salaries

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A 2003 Survey of Dental Practices reported net income from dentistry-related sources.

Dentists Differ from Doctors

Dentists differ from physicians in that 90% are in private practice. In 2002, the average practitioner’s net income was $174,350. The average dental specialist’s net was $291,250. These figures represent a 0.7% and a 5.8% increase over 2001, respectively.

Assessment

Net income rose steadily since 1986, when general dentists made an average of $69,920 and specialists an average of $97,920. But, by 2010, according to PayScale.com, the average general dentist earned $98,276 – $157,437; a decreasing trend allocated as follows.

Compensation Chart 

Salary  $92,689 – $147,682
Bonus  $1,996 – $19,727
Profit Sharing  $1,038 – $27,514
Commissions  $480.74 – $32,500

Conclusion

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On Ethical Patient Advocacy

Medical Ethics in the Modern Era

By Render S. Davis MHA, CHE

www.BusinessofMedicalPractice.com

Few areas of life are as personal as an individual’s health and people have long relied on a caring and competent physician to be their champion in securing the medical resources needed to retain or restore health and function.

Nevertheless, this philosophy is currently in flux.

Foundation of Medicine

For many physicians, the care of patients was the foundation of their professional calling. However, in the contemporary delivery organization, there may be little opportunity for generalist physician “gatekeepers” or “specialty hospitalists or intensivists” to form a lasting relationship with patients.  These institution-based physicians may be called upon to deliver treatments determined by programmatic protocols or algorithm-based practice guidelines that leave little discretion for their professional judgment.

Personal Values

In addition, the physician’s personal values may be impeded by seemingly perverse financial incentives that may directly conflict with their advocacy role, especially if a patient may be in need of expensive services that may not be covered in their insurance plan, or are beyond the resources of a patient’s HSA or savings account.

Assessment

Marcia Angell, MD., noted during a PBS interview that the “financial incentives directly affecting doctors…put them at odds with the best interests of their patients … and it puts ethical doctors in a terrific quandary.”

Conclusion

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Product Details

Understanding Disease Management

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How Technology Affects Patient Care

By Brent A. Metfessel MD, CMP™ [Hon]

www.BusinessofMedicalPractice.com

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

DMAA Definition

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.

Usual Conditions

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.

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 medical 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-morbidities, and halting the progression of complications).

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Conclusion

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About the Placebo [Medical] Journal

Humor in Medicine

By ME-P Staff Reporters

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According to their website, the Placebo Journal [PJ] is a magazine for physicians whose goal, as its Latin definition states, is “to give pleasure to”. The purpose in starting this “Placebo” brand is to empower physicians with a skill that is sorely lacking today in medicine – humor. 

Placebo Brand Expanding

Recently however, they expanded the placebo brand to physician assistants, nurses, radiology techs and even to patients. By using real life medical stories, all stakeholders can now laugh at the medical system.

Like a Pill?

Like a placebo pill, the PJ produces a positive effect from something of very little substance. They don’t think too much of them-selves because they know it’s a rag tabloid. And, they don’t mean to denigrate the practice of medicine, patients or other physicians. But, they do mean to humanize the medical profession more. It is not only therapeutic, but necessary. Laughter is the key to life!  With the Placebo Journal, the editors want everyone to see the lighter side of the job.

Assessment

The burnout, depression and suicide rate is high among healthcare givers. Humor may heal and help.

Link: http://www.placebojournal.com/default.asp

Conclusion

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Financial Planning for Physicians and Advisors

Our Handbook

By Ann Miller RN, MHA

Managed care and government-led initiatives to control health care costs have decreased physician compensation. Physicians must now carefully plan their practices and seek financial security in a manner that is markedly different from other professionals. To do so, physicians and their advisors must be well informed about the growing range of financial planning options to choose the course that balances risk, cost, time horizon, outcome and their own personal economic style. This innovative guide confronts the reality that personal financial planning for physicians is decidedly more complex than it is in other professions.

Financial Planning for Physicians and Advisors

This handbook describes a personal financial planning program to help doctors avoid the perils of harsh economic sacrifice. It outlines how to select a knowledgeable financial advisor and develop a comprehensive personal financial plan, and includes important sections on: insurance and risk management, asset diversification and modern portfolio construction, income tax and retirement planning, and succession and estate planning. When fully implemented with a professional’s assistance, this book will help physicians and their financial advisors develop an effective long-term financial plan.

Assessment

http://www.jblearning.com/catalog/0763745790/

Conclusion

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Product Details  Product Details

A Poll on RECs

Five Reasons We Think Regional Extension Centers are Reckless

By Houston Neal

Software Advice

http://www.softwareadvice.com/medical

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Hi Dr. Marcinko and all ME-P Readers

I hope you are doing well. I am hosting a poll about RECs on my blog at: http://www.softwareadvice.com/articles/medical/five-reasons-we-think-recs-are-reckless-1092310/#survey 

I’m hoping to get as many participants as possible to make this a meaningful survey. I’d really appreciate your help spreading the word to your ME-P membership.

Digital White e-Paper

The poll coincides with an article I wrote on “5 Reasons We Think Regional Extension Centers are RECkless.” I’m excited to see progress of HITECH Act initiatives, but I’m skeptical that throwing money at the problem will lead to efficient and successful adoption of EHRs.

Assessment

It would also be interesting to read any anecdotes you might have about Regional Extension Centers. Please let me know what you and your readers think:

(512) 364-0117 (office)
(800) 918-2764 (toll free)
houston@softwareadvice.com

Conclusion

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More About Regional Extension Centers

RECs Explained

By Shahid N. Shah; MS 

www.BusinessofMedicalPractice.com

The Meaningful Use and Certification requirements along with the myriad of government regulations around Medicare and Medicaid reimbursements will be too complicated for most physicians to understand and manage on their own. To help out small practices, one of the interesting things funded by the HITECH Act was the creation of the Health Information Technology Extension Program. Via that program, the Department of Health and Human Services is required to invest in Regional Extension Centers (called “RECs” and pronounced like “wrecks”). RECs are designed to offer consulting and technical support to physicians in order to help accelerate adoption of Electronic Health Records (EHRs).

Purpose

The purpose of the RECs is to provide guidance on which products to buy, help reduce prices of software through group purchase agreements, and give technical assistance on implementation and deployment. These services will be free of charge to physicians. However, keep in mind that all RECs are non-profit organizations and most have little or no inherent knowledge about EMRs, EHRs, implementations, deployments, computer skills, etc.; initially they are groups that responded to the grant request in a manner that fulfilled documentation required by the government and will be provided government money to help Physicians become meaningful users [MUs].

No Cost Advice

In the short run no RECs will be very good because they will all be inexperienced. Over the long run, some RECs will become very good at their jobs while other RECs will be mediocre or not good at all; only time will tell which ones will be superb and helpful vs. not. Since RECs will be paid by the government for each physician they sign up, RECs will be very eager to approach and conduct outreach to sign you up. And, it will not cost you anything to sign up and the advice and assistance will be free to MDs.

Assessment

Keep in mind, though, that whenever something is free to you, always think about why it’s free. What does the organization get out of providing you free advice, assistance, knowledge, etc. – in the case of RECs, it’s is money from the government. The good news is that RECs are being told by the government that will only be paid if you become a “meaningful user.” However, the bad news is that some RECs will not be able to do a good job and may give you bad advice.

Conclusion

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Health Plan Management Navigator

Mid-September 2010 Edition

By Douglas B. Sherlock, CFA

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In this edition of Plan Management Navigator, we summarize on the results of selected TPAs. Administrative expenses for core services of selected TPAs were 84% of fees in 2009. This was $11.56 per employee per month (PEPM) or $6.06 per member per month (PMPM). Core Medical product costs were $25.28 PEPM and $11.56 PMPM.

Elite Performers

While the universe of participants was small, at 5 TPAs, the surveyed TPAs may be elite performers. Function-by-function, these TPAs had lower costs than are typically found in competitive products of Blue Cross Blue Shield and Independent/ Provider-Sponsored plans.  They are also typically among the largest 20% of TPAs. Finally, they have accounting systems sufficiently robust to report with the granularity of the Sherlock survey. This may be an indicator of strong management if “you manage what you measure.”

Sherlock Expense Evaluation Report

The summary in Navigator is excerpted from the 2010 TPA edition of the Sherlock Expense Evaluation Report, which is now available to licensees and participants.

Web Conference 

We will host a web conference on Wednesday, September 22 from 2:00 PM to 3:00 PM East Coast Time to discuss the summary results. Doug Sherlock will offer a brief presentation, followed by questions and answers. To participate in the web conference, please register at https://www2.gotomeeting.com/register/ 933935259. Once registered, dial-in information and a link to connect to the web will be provided in a confirmation email. Please note that if more than one person from your firm would like to participant in the conference call and everyone will be in one room, only ONE person needs to register for the conference. 

Assessment

Thank you for your continued interest in our research.

Link: Mid-September 2010 Navigator 09-20

Sherlock Company
sherlock@sherlockco.com
Ph:  215-628-2289
Fax: 215-542-0690

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About LegallyMine.Org

The National Foundation for Asset Protection

[By Staff Reporters]

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Legally Mine is a new name for a company formally known as The National Foundation for Asset Protection. The name change reflects the fact that they are a for-profit company and always have been.

Company Focus

The focus of the company is the education of professionals on the best tools available in the US for the purpose of asset protection.

Healthcare

Medical practitioners have taken a particularly hard hit from trial attorneys, and for years the firm has been the nation’s largest champion in defending them. However; they are not alone and many other professionals find themselves staring down the barrel of a legal shotgun. According to their website, Legally Mine knows the right tools to use in order to stop the loss of assets to legal pariahs, as well as the tools needed to lower tax bills. They not only know the right tools and how to use them, but reportedly know how to teach these concepts to others.

Assessment

The purpose and goals of Legally Mine is to teach professional associations how and why these tools will work and how to implement them.

Visit: http://www.legallymine.org/index.html 

Conclusion

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INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors

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Update on the Estate Tax for MDs and Us All

Senate Refuses Repeal

By Children’s Home Society of Florida Foundation

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On July 21, 2010, Sen. Jim DeMint (R-SC) offered an amendment to the unemployment bill that would repeal the estate tax. Sen. DeMint noted that the White House is creating a difficult environment for “small businesses that are already facing higher income taxes and higher investment taxes.”

The Proposal

The proposed amendment was defeated on a vote of 39-59. Democratic Senators Blanche Lincoln (D-AR) and Ben Nelson (D-NE) supported the abolition of the estate tax. Republican Senators Olympia Snowe (R-ME), Susan Collins (R-ME) and George Voinovich (R-OH) opposed the abolition of estate tax.

Assessment

Sen. Lincoln and Sen. Jon Kyl (R-AZ) continue to advocate an estate tax compromise. Under the compromise, the $3.5 million exemption from 2009 would be increased over 10 years to $5 million and the top 45% estate tax rate would be reduced to 35% over that same time frame.

[picapp align=”none” wrap=”false” link=”term=tax&iid=5237623″ src=”http://view4.picapp.com/pictures.photo/image/5237623/tax-dollars/tax-dollars.jpg?size=500&imageId=5237623″ width=”346″ height=”491″ /]

Editor’s Note: The political pressure on the Senate continues to rise. Following the March death of Houston oilman Dan Duncan with a $9 billion estate, the news media noted that the government had lost $2 to $3 billion on that estate alone. When New York Yankees owner George Steinbrenner passed away with an estimated $1.1 billion estate, news media suggested that he hit a “home run” by dying in 2010 with no estate tax. While action is not likely before the election, there now seem to be two general patterns to a potential Senate compromise. First, the estate tax exemption will start at $3.5 million and increase to a higher number over ten years. Second, the estate tax rate will begin at 45% and decrease again over that same decade. The House majority has held strongly to a $3.5 million exemption and 45% top tax rate, so the final compromise would also need to reflect their preferences.

Conclusion

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2010 m-HEALTH SUMMIT ANNOUNCES NEW SPEAKERS

Panelists Represent Industry, Academia, Non-Profit, and Government Perspectives

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Dear Ann and ME-P Readers

The 2010 mHealth Summit, the must-attend event for all interested in the implementation of mobile technology to advance improved health outcomes, is today announcing newly confirmed speakers who will contribute to the cross-sectoral dialogue during the Summit’s three-day conference program.

Who: The 2010 mHealth Summit is organized by the Foundation for the National Institutes of Health in partnership with the mHealth Alliance and the National Institutes of Health (NIH). The event will advance discussion, collaboration and decision-making at the intersection of mobile technologies and health to advance the delivery of high-impact, sustainable health solutions.

When: November 8-10, 2010, and online at www.mhealthsummit.org
Where: The Walter E. Washington Convention Center, Washington, D.C.
What: The following speakers will join other experts driving transformation in the health ecosystem domestically and internationally.

Academia

  • Dr. Jessica Haberer, MS, Assistant in Health Decision Sciences, Massachusetts General Hospital; Research Scientist, Harvard Institute of Global Health
  • Dr. Patricia Mechael, Center for Global Health and Economic Development at the Earth Institute, Columbia University
  • Donna Spruijt-Metz, Associate Professor, University of California
  • Dr. Robyn Whittaker, Public Health Physician, University of Auckland, New Zealand

Non-Profit

  • Dr. Kelly L’Engle, Behavioral Scientist, Family Health International
  • Josh Nesbit, Executive Director, Frontline SMS: Medic
  • Carrie Varoquiers, President, McKesson Foundation

Private Sector

  • Donald Casey, CEO, West Wireless Health Institute
  • Donald Jones, VP, Business Development, Qualcomm
  • Anthony A. Lewis, Vice President, Open Development, Verizon Wireless
  • Dr. Richard Migliori, EVP and Chief Medical Officer, United Health Group
  • Peter Neupert, Corporate Vice President, Microsoft Health Solutions Group

Government

  • Dr. Charles P. Friedman, Chief Scientific Officer, U.S. Department of Health and Human Services
  • Dr. Jeffrey Shuren, Director, U.S. Food and Drug Administration

Keynotes

  • Aneesh Chopra, U.S. Chief Technology Officer. The White House
  • Francis S. Collins, Ph.D., Director, National Institutes of Health
  • Dr. Julio Frenk, Dean of Faculty, Harvard School of Public Health and former Minister of Health, Mexico
  • Bill Gates, Co-Chair and Trustee, Bill & Melinda Gates Foundation
  • Ted Turner, Chairman, United Nations Foundation

EVENT HIGHLIGHTS:

Network with over 2,000 professionals from the U.S and 30+ countries, and gain unparalleled access to the biggest names in the health, policy and the mobile ecosystem

Learn from keynotes, super sessions, exhibits, and poster presentations

For further information contact:
Kate Barrett at kbarrett@fnih.org, 301 435 2613.
For General Registration and Conference Details, visit: www.mhealthsummit.org
For Media Credentials and Registration, go to: http://mhealthsummit.org/press/registration
Twitter hashtag: #mHS10
Tweet me: #mHealth Summit announces conference new confirmed speakers – www.mhealthsummit.org #mHS10
Note to Editors
: Visit www.mhealthsummit.org/conference/speakers-moderators for a regularly-updated list of confirmed speakers.

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Essay on Medicare Pricing Distortions

In Physician Fee Schedules

By Nancy Chockley PhD
President & CEO
NIHCM Foundation

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Leaving Medicare F-F-S Reimbursement

While there is near universal agreement that we need to move away from Medicare’s fee-for-service [F-F-S] physician payment system, Dr. Robert Berenson argues that in the short term we still need to focus on improving the current physician fee schedule.

Reasons Why?

Not only are the value-based payment systems that most reformers envision still many years from widespread reality, the existing fee schedule prices will serve as the building blocks for some of the newer aggregate payment approaches.

Assessment

In his Expert Voices essay, Dr. Berenson offers thoughts on how to improve the system in ways that both address current payment system woes and serve as a step toward future value-based payment systems.

Link: http://nihcm.org/pdf/NIHCM-EV-Berenson_FINAL.pdf

Contact

phone: 202-296-4426
email: nihcm@nihcm.org
website: www.nihcm.org

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Hospital RFID versus Wi-Fi Technologies

Understanding Wireless Communications and Inventory Tracking Systems

By Staff Reporters

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According to inventory tracking system expert David J. Piasecki, the two wireless technologies currently competing to provide hospitals with better systems for managing equipment inventories are: wireless-fidelity (WiFi) and active RFID. WiFi is the name of the popular wireless networking technology that uses radio waves to provide wireless high-speed Internet connections. The WiFi Alliance is the non-profit organization that owns WiFi (registered trademark) and the term specifically defines WiFi as any “wireless local area network products that are based on the Institute of Electrical and Electronics Engineers’s 802.11 standards.”  Yet, less than 5 percent of North American healthcare facilities are equipped with these real-time locating systems, so the market is currently up for grabs.

Wi-Fi Advantages/ Disadvantages

The advantage of WiFi-based real time locating systems (RTLSs) is that most hospitals already have WiFi networks in place, and many medical devices are equipped with WiFi functionality. Moreover, WiFi vendors such as Aeroscout, Ekahau, and PanGo market their products based on a standards-based non-proprietary functionality. And, development of the so-called “super Wi-Fi” is now on the horizon. The downside of WiFi systems is that hospitals will need to install additional access points to bring the needed functionality to existing networks.

RFID Advantages/ Disadvantages

On the other hand, RFID vendors such as RF Code and Radianse point to the wide application of RFID for asset tracking, and to the technology’s longevity in the industry. Still, RFID tags remain suspect because their ability to efficiently track DME may not be private or secure. Increasingly, WiFi seems more ubiquitous than RFID.

Assessment

Finally, of the three WiFi major vendors, only Ekahau makes a point of stressing that its inventory system is based only on WiFi and not RFID, so the issue isn’t clear cut.  Perhaps it will take both technologies to deploy for hospitals.

Conclusion

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The Rise of Niche Medical Providers

Understanding New Roles and a Changing Delivery Ecosystem

By Staff Reporters

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It is well know that orthopedic and cardiac hospitals have experienced a development boom over the past decade.  And, according to Robert James Cimasi MHA, AVA, CMP™ of Health Capital Consultants, LLC, reimbursement levels for these specialties, and especially surgeries, have been considered to be relatively high in comparison to others, creating the perception that these services are especially profitable.

Reasons for Development

The reasons for specialty hospital development are complex and vary across markets but analysis suggests that three factors are important drivers of this trend nationally:

  • relatively high reimbursements for certain procedures;
  • physicians’ desire for greater control over management decisions affecting productivity; and ,
  • quality and specialists’ desire to increase their income in the face of reduced reimbursement for professional services.

Perspectives

From the perspectives of some observers, the possible “overpayment” for certain specialties’ services is unintentional on the part of payors and is possibly the result of recent productivity gains in those specialties.  The promoters of this reimbursement methodology have asserted,

The challenge for policy makers is to give specialty hospitals the chance to fulfill their promise as focused factories while limiting their opportunities to prosper from cream skimming and preventing problems for patients and communities such activity might cause.

From this singularly preconceived viewpoint, productivity gains through efficient provision of quality services should be discouraged and saddled with the disincentives of lower reimbursement to allow less efficient providers to compete.  That surgical and specialty hospitals focus on a narrower range of procedures and produce quality and efficiency gains over their general acute care hospital competitors is rarely disputed.  Existing hospitals often admit this but then claim that new market entrant hospitals dilute the experience level of their facilities, which then results in a lowering of quality.  This is part of the larger argument that any quality or financial gains made by the surgical or specialty hospitals are the direct result of losses at the general acute care hospitals.  If these hospitals can’t cost shift to subsidize less profitable areas such as emergency departments and intensive care units, the argument goes, then they will be in jeopardy of closing them.

Medical Professionals and ME-P Advisors

Proponents

These proponents assert: “Policy makers seek to encourage competition and give new care delivery models that have the potential to improve quality and lower costs a chance.  However, they also want to maintain quality and patient safety, avoid total as well as per-case cost increases and preserve access to basic services.”

Assessment

In response to the development of niche providers and specialty hospitals, general acute care hospitals often are competing by adding to their offerings in these specialties to create integrated specialty centers or even constructing new specialty hospitals themselves.  In many cases, hospitals seek physician involvement in these developments, through joint ventures or other means.

Channel Surfing the ME-P

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Conclusion

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[Health] Plan Management Navigator

September 2010

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By Douglas B. Sherlock, CFA

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In this edition of Plan Management Navigator, we write on issues that are especially timely for health plans in their current budgeting process. Topics are as follows:

Trends in Health Plan Business Process Outsourcing

This analysis is based on data excerpted from recent editions of the Sherlock Expense Evaluation Report. Outsourcing and the use of external contractors has been increasing, especially in the information systems functional area.

TPAs: A New Universe for SEER

For the first time, we will be publishing on the administrative expenses of Third Party Administrators. We believe that this analysis is unprecedented in its depth and granularity. This publication is helpful for TPAs, those that compete with them and all their business partners.

Dashboard Summary

This reports on results and trends from the three months ended July 2010 for non-public health plans. Because of the timing of the publication of this data, we would expect this to be a leading indicator to national results.

SEER Publication Schedule

In the challenging economic environment and with the advent of health care reform, health plans are trying to identify whether they operate at best practice and, to the degree that they vary from this, what functional areas are the most fruitful for the focus of management attention! This outlines the publication schedule for the peer group that best matches your organization.

Assessment 

By the way, in the next month or so, Navigator will be summarizing the results of the Sherlock universes of TPAs, Medicare plans and Medicaid plans. We also will have an interesting discussion on best practices for Blue Cross Blue Shield Plans and Independent / Provider – Sponsored plans. (Incidentally, the definition of “best practice” that we will employ may be found in the Early July 2010 edition of Plan Management Navigator).

Conclusion

Thank you for your continued interest in our research.

September 2010 Navigator[1]

Sherlock Company
Senior Health Care Analyst
sherlock@sherlockco.com
Ph:  215-628-2289
Fax: 215-542-0690

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Using Charitable Gifts in Business Planning

The “S” Corporation

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By The Children’s Home Society of Florida Foundation

The most common type of corporation is a traditional “C” corporation. All companies whose stock is publicly traded are C corporations. C corporations pay tax on net income at the corporate level. When that income is distributed to shareholders in the form of dividends, the shareholders also pay tax. The result is that C corporation income is taxed twice – once at the corporate level and once at the shareholder level.

“S” Election

“S” corporations resemble C corporations except that they elect to be taxed differently. Not all corporations are eligible to make this election. To make the election, a corporation must have only one class of stock and less than 75 shareholders who are all individuals, estates and certain types of trusts and charities. IRC Sec. 1361. Charitable remainder trusts are not permissible holders of Subchapter S stock.

“Pass-Through” Taxation

An S corporation does not pay tax at the corporate level. Instead, the shareholders of an S corporation must include their share of the S corporation’s income, deductions and credits on the shareholder’s personal tax return – even if that income isn’t actually distributed. This is called “pass-through” taxation because the S corporation “passes” its income, deductions and credits “through” to its shareholders.

Inside and Outside Basis

The concept of tax basis appears regularly in the context of charitable giving. A person’s tax basis in an asset is generally equal to his or her investment in that asset. Often, tax basis is the amount a person paid for an asset (i.e. the asset’s “cost” to the owner). When the fair market value of an asset is more than its tax basis, the asset is appreciated and, if sold, will result in taxable gain to the owner. Charitable giving often allows the owner of an appreciated asset to bypass gain or defer part of the gain.

When working with S corporations, the concept of basis can be confusing. This is because there are two types of basis at issue. The first is the S corporation’s basis in its assets — this is often referred to as inside basis. The second is the shareholder’s basis in his or her S corporation stock – this is often referred to as outside basis.

When a shareholder sells his S corporation stock, the gain or loss on the sale is determined by the difference between the sale price and the outside basis. In the same way, when an S corporation disposes of an asset, the gain or loss to the S corporation is determined by the difference between the sale price and the S corporation’s inside basis in the asset.

 

Gifts of S Corporation Stock – Issues Relating to the Donor

Certain tax-exempt organizations are permissible shareholders of Subchapter S stock. Sec. 1361(c)(6). Therefore, an owner of S corporation stock can make a gift of the stock to a charitable organization and receive an income tax deduction. There are a few issues the donor needs to be aware of, however, before making a gift of Sub S stock to charity.

First, the donor’s ability to use the charitable deduction from the gift of the Sub S stock will be limited to the donor’s cost basis in his or her S corporation stock. Sec. 1366(d)(1) limits the amount of deductions and losses to the donor’s basis in stock and debt of the Sub S corporation. Often the donor of Sub S stock is also the person who established the business. Generally, the business was started with very little capital. Because of this, it is likely that the donor’s cost basis will be very low. If the donor’s basis in his or her stock is very low, the donor will only have a small charitable deduction.

The second issue for the donor to be aware of is minority discount. Generally, when a donor makes a gift of stock, the amount transferred to the charity represents a minority interest in the corporation. When a minority interest is given, it is very likely that the qualified appraiser will apply a discount to the value of the stock.

Finally, the donor of S corporation stock must be aware that there cannot be a binding agreement with the charity to repurchase the stock. If there is a binding agreement, the donor will have to recognize the income from the redemption of the stock and will not receive the benefit of a bypass of capital gain. Because S corporations are closely-held entities, there generally is not a large market for the sale of the stock. Therefore, it is very likely that the corporation will repurchase the stock. The repurchase is permissible, but a binding agreement before the gift is prohibited. Rev. Rul. 78-197.

Gifts of S Corporation Stock – Issues Relating to the Charity

While it is allowable for a charity to own Subchapter S stock, the tax benefits are not as advantageous as the ownership of C corporation stock. With C corporation stock, the charity is not taxable on any stock dividends, nor is it taxable on the gain when it sells the stock. This is not true with S corporation stock. Any income received by the charity for its ownership of Sub S stock is taxable to the charity as unrelated business taxable income. Sec. 512(e). In addition, when the charity sells the stock the gain from the sale is also taxable to the charity as unrelated business taxable income. Sec. 512(e)(1)(B)(ii). Because a charity is often established as a corporation itself, the tax on the gain will be taxed at corporate income tax rates. (corporations do not have a lower, favorable capital gains rate like individual taxpayers).

It is also important for a charity not to enter into a binding agreement with the donor for the sale of the stock. While there are no adverse tax consequences to the charity if such an agreement is made, there are adverse tax consequences to the donor as discussed above. If the charity is aware of the unfavorable tax consequences to the donor from having a binding agreement, it can prevent having an unhappy donor.

The S Corporation Unitrust

A charitable remainder unitrust or CRUT is not a permissible owner of Subchapter S stock. Therefore, if an S corporation shareholder were to transfer even one share of his or her S stock into a CRT, the S corporation election would be terminated and the corporation would become a C corporation the day after the transfer. This would mean that the corporation would be subject to two layers of tax: one at the corporate level and one at the shareholder level.

It is permissible, however, for the S corporation itself to establish a CRUT. Because the S corporation does not have a life expectancy, the CRUT must be established for a term of years not to exceed 20. The S corporation would fund the CRUT with some of its assets. However, it must be careful not to fund the CRUT with substantially all of its assets as discussed below. Because the S corporation is funding the CRUT, it would receive the charitable deduction and also would be the income beneficiary of the CRUT.

Even though the S corporation is entitled to the income tax deduction, because of its pass-through taxation the charitable deduction will flow through to the S corporation shareholders. As mentioned above, however, the deduction to the shareholders will be limited to the shareholders’ cost basis in their Sub S stock.

Potential Reg. 1.337(d)-4 Gain Recognition

When a corporation is liquidated, there is potential tax payable at the corporate level. If it were permissible for a corporation to distribute all of its assets to charity or to a charitable trust, then this tax could be avoided. In order to limit this type of transaction, Reg. 1.337(d)-4 requires recognition of gain at the corporate level if “substantially all” the assets are given to charity or to a charitable remainder trust.

Even though an S corporation is not subject to tax like a C corporation, if an S corporation liquidates the corporation must recognize gain as if the assets were sold. The S corporation does not pay taxes on the gain, but the gain passes through to the shareholders who must report the taxable gain.

The phrase “substantially all” is not defined in Sec. 337(b)(2) or in Reg. 1.337(d)-4. However, there are several other places in the Code in which the phrase “substantially all” is interpreted to mean 85%. Reg. 1.514(b)-1(b)(1)(ii). Reg. 53.4942(b)-1(c). Reg. 53.4946-1(b)(2). Reg. 1.401(k)-1(d)(1)(ii). While these regulations cover a variety of tax issues, it is significant that they uniformly interpret the phrase “substantially all” to mean 85%.

Since the exception under Sec. 337 refers to “an 80%” subsidiary, some counsel have also expressed the belief that “substantially all” could be interpreted to be 80%. Regardless, it is apparent that a transfer of perhaps 65% of assets to charity or to a charitable trust would be permissible under Sec. 337(b)(2). Cautious counsel would be prudent in remaining at or below that level with transfers to charity.

Financial Planning Strategies

While the use of a CRT is more limited with an S corporation then with a C corporation, there is still the possibility of utilizing a CRT when selling a business. For example, Tom and Suzie started a business years ago creating designer clothing for dogs. Tom and Suzie liked the idea of have a corporation to protect them from potential liabilities, but they did not like the idea of the double tax system. Therefore, they established their business as an S corporation. Tom and Suzie are the sole shareholders and are now planning to retire. Over the years they have supported a number of charities that assist in the prevention of cruelty to animals. Tom and Suzie are hoping to use some of the money they receive from the sale of the business to continue to support such charities.

Recently Tom and Suzie have had a number of inquires for the sale of their business. It seems that designer clothing and accessories for dogs has become a booming business. Tom and Suzie met with the gift planner from their favorite charity and like the idea of a CRUT that would pay them an income stream over their two lives. However, they discovered that because they have an S corporation they cannot transfer the stock to a CRT without losing their S election status. Tom and Suzie do not want to convert their business to a C corporation. Tom and Suzie can, however, have the S corporation use some of its assets to fund a CRUT that would pay for 20 years. However, they must take steps to ensure that the CRT is not disqualified.

First, Tom and Suzie have to carefully choose which assets the S corporation will use to fund the CRUT. The value of those assets cannot be substantially all of the value of the corporation. Further, they have to ensure that there is not any unrelated business taxable income while the assets are in the CRUT. Even $1 of unrelated business taxable income will disqualify the tax-exempt status of the CRUT. If Tom and Suzie decide to use any of the corporation’s equipment or inventory, the deduction of the CRUT will be limited to the corporation’s cost basis in those assets, which is very low. The S corporation does own the building and land on which it operates and the value of the land and building represents about 50% of the S corporation assets.

To make sure that the CRUT will work, Tom and Suzie enter into lease agreements with two of their key employees. Under the first lease, the employees will lease the operating assets of the S corporation. Under the second lease, the two employees will lease the building and land. Both leases are fixed payment leases. By establishing the leases, the S corporation can transfer some of its assets into the CRUT and avoid the unrelated business income tax problem.
Once the leases are established, the S corporation will transfer title of the real estate to the CRUT. To avoid potential self-dealing issues, Tom and Suzie decide to select their local bank to serve as trustee of the CRUT. Once the land is transferred to the CRUT, the trustee, along with Tom and Suzie, will negotiate for the sale of the assets and the land and building. After the sale is completed, the CRUT will receive the proceeds from the sale of the real estate and the S corporation will receive the proceeds from the sale of the operating assets.

The sale of the operating assets will trigger gain for the S corporation that will flow through to Tom and Suzie as the shareholders. It is important for Tom and Suzie to leave this cash in the S corporation. This is because the gain from the sale will increase Tom and Suzie’s cost basis in their S corporation stock. The increase in the cost basis will allow them to use more of the charitable deduction that will flow through to them from the S corporation. Over the years, the S corporation unitrust will make payments to the S corporation. So long as the S corporation was not a prior C corporation, the passive income from the CRUT will not pose any problems for the S corporation.

Tom and Suzie are very happy with the sale of their business and that they are able to provide a very nice gift to their favorite charity. They are also very happy that they now get to take a long needed vacation.

Assessment

There are a number of charitable strategies that can be used when selling a business. Tom and Suzie could have established a charitable gift annuity with their Sub S stock. They also could have used a gift and sale strategy. There are other options available to Tom and Suzie if they chose not to keep the S corporation alive for the 20 year term of the trust. This article is the first in a series that will explore the options of using businesses and business assets to fund charitable gifts. Throughout this series, planning options with C corporations, S corporations, partnerships, LLCs and sole proprietorships will be discussed.

Conclusion

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“Massively Confused Investors Making Conspicuously Ignorant Choices”

By Somnath Basu PhD, MBA

How well we make investment decisions depends in part on how reasoned or emotional the decision was. The greater the emotional content the more likely will be the mistake. It is useful for all of us to understand the emotional pitfalls of financial decision-making.

Financial Psychologists

An appropriately titled study by a financial psychologist Michael S. Rashes, “Massively Confused Investors Making Conspicuously Ignorant Choices” cites that the widespread phenomenon witnessed in the market, whereby several stocks with similar ticker symbols all went up in value when positive news was announced about any one of them.

Example: http://ideas.repec.org/a/bla/jfinan/v56y2001i5p1911-1927.html

A case in point is the parallel movement between two entirely unrelated stocks, MCIC (ticker symbol for the telecommunications firm, MCI, bought by Worldcom in 1997), and MCI (ticker symbol for the Massmutual Corporate Investors fund). The acquisition of MCI, the telecommunications firm, in 1997-8 caused an upward movement in its stock (MCIC). That movement was also closely correlated with the upward movement in the stock of Massmutual Corporate Investors (MCI), whose ticker symbol was the same as the telecommunications company’s name. Rampant confusion of this sort strongly supports the notion that irrationality, not rationality, rules the financial markets. Another noted scientist, B. Malkiel suggests that when it comes to investing, people generally follow their emotions, not their reason, their hearts, not their minds.

Behavioral Finance and Economic Gurus

This line of argument has been gaining credibility over the last decade or so, not only among behavioral finance experts, but also economists themselves, as well as stock market pundits and the population at large. There is a strong sense among all these groups that greed, exuberance, fear and herding behavior affect markets as much as or more than calculations of P/E ratios, profit projections, or market benchmarks. The bursting of the stock market bubbles of 2000 and 2008 only confirmed these long-held suspicions. As a result, widely used economic models based on rational investor behavior require some reevaluation and could be found to be unreliable at best and irrelevant at worst.

The Decision Biases

The following is only a partial list of the biases that may be induced in you if the financial decisions you make are based on emotion and not on reason. The list includes the bias name, a descriptive definition and an example of application error. Before closing that next trade you make, a good question to ask yourself is whether any of the biases from the list were included in your financial decision. If so, these decisions too need further evaluation.

1. Over-Confidence:

Over-estimating the chances of correctly predicting the direction of price changes!

Example: Attribute good outcomes (i.e., gains) to your skill while attributing bad outcomes (i.e., losses) to your bad luck.

2. Pride and Regret:

Investors often over-estimate their powers of discerning stock winners from losers. Some physicians and other investors (essentially, active traders) may rapidly sell and buy back stocks, in order to capture expected gains.

Example: Selling your winning picks early and holding onto losers hoping they rebound. Studies show that doing the opposite can increase your annual returns by 3-4%.

3. Cognitive Dissonance:

Suggests that investors experience an internal conflict when a belief or assumption of theirs is proven wrong

Example: It’s easier to remember your winning picks than your losing ones since the latter outcomes disagreed with your earlier beliefs.

4. Confirmation Bias:

Suggests that they try to seek out information that will help confirm their existing views whether those views be right or wrong.

Example: When you hear someone agreeing with your investment decision you feel that person is much more knowledgeable than one who disagrees with you.

5. Anchoring:

A phenomenon whereby people stay within range of what they already know in making guesses or estimates about what they do not know.

Example: The Dow Jones Industrial Average (DJIA), which grew from a value of 41 in 1896 to 9,181 in 1998, does not include dividends. They then value the index in 1998, including dividends, at a whopping 652,230. When asked, investors estimate the value of the DJIA would be if dividends were included, all were way off the mark, keeping their answers close to its familiar value of 9,181. The highest guesses came in at under 30,000, less than 5% of the actual value.

6. Representative Heuristics:

An over-reliance on familiar clues, such as past performance of a stock!

Example: most investors assume that the stock of a company with strong earnings will perform well and that the stock of a company with weak earnings will perform poorly. The law of large numbers suggests however that the exact opposite is much likelier to be true.

Conclusion

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

 

 

Seeking Chief Medical Director

Employment Opportunity for CMD

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By Judy Kliethermes

Centene Corporation is seeking a Chief Medical Director for Managed Health Services, a wholly owned subsidiary and HMO for the state of Wisconsin.  The regional headquarters for Managed Health Services is in Milwaukee.  A Fortune 500 company, Centene Corporation is a national leader in low-cost solutions for high quality health care services for the un-insured and under-insured.

Responsibilities

The Chief Medical Director (CMD) will be responsible for directing and coordinating the medical management, quality improvement and credentialing functions for Managed Health Services. S/he will serve as a clinical advisor and educator of the medical management staff, ensuring the clinical quality and efficacy of patient care. The CMD will identify trends in patient treatment data and proactively develop programs to address improve patient health and wellness needs. 

Assessment

As an integral part of Managed Health Services senior leadership team, the CMD will have an active role in supporting the strategic plans and vision of the organization. 

Conclusion

I would welcome your interest in the Chief Medical Director role.

Sincerely,

Cejka Executive Search
314-236-4429
judyk@cejkasearch.com

The Business of Medical Practice [3rd edition]

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Transformational Health 2.0 Skills for Doctors

By Ann Miller; RN MHA

[Executive Director]

Revised and updated to include the most current information on healthcare administration, the Third Edition of The Business of Medical Practice is an essential business tool for doctors, nurses, and healthcare administrators; management and business consultants; accountants; and medical, dental, podiatry, business, and healthcare administration graduates, managers, and doctoral students.

Journalistic Style

Written in plain language using non-technical jargon, the text presents a comprehensive and progressive discussion of management and operation strategies. It integrates various medical practice business disciplines-from finance to marketing to the strategic management sciences-to improve patient outcomes and achieve best practices in the healthcare administration field.

Returning Contributors

  • Dr. Gary L. Bode; MSA, CPA, CMP™ [Hon]
  • Render S. Davis; MHA, CHE
  • Dr. Charles F. Fenton III; FACFAS, Esquire
  • Eric Galtress
  • Hope R. Hetico; RN, MHA, CMP™
  • Carolyn Merriman; FRSA
  • Dr. Brent A. Metfessel; MS
  • Rachel Pentin-Maki, RN, MHA, CMP[Hon]
  • Eugene Schmuckler; PhD, MBA, CTS
  • Patricia A. Trites; MPA, CHBC, CMP[Hon]

Exciting New Thought-Leaders

And, we seek to breathe additional diversity into this work with these new contributing authors:

  • Suzanne R. Dewey; MBA
  • Dr. Brian J. Knabe; CMP™
  • Parin Kothari; MBA
  • Mario Moussa; PhD, MBA
  • Shahid N. Shah; MS
  • Susan Theuns; PA-C
  • Jennifer Tomasik; MS

Topic Content and Chapters

With 37 chapters, 512 pages, and contributions by a world-class team of expert authors, this new edition – under the direction of Chief Editor Dr. David Edward Marcinko MBA – covers brand new information such as this partial list demonstrates:

  • Web 2.0 Technologies Impact on the Healthcare Industry
  • Office Location, Logistics, Layout and Execution
  • Internal Office Controls for Preventing Waste, Fraud and Abuse
  • Direct-Concierge Medicine and Niche Providers
  • Medical Workplace Violence and Sexual Harassment
  • Office Financial Statements and Analysis
  • Human Resources, Hiring, Firing and Office Staffing
  • Healthcare Marketing, Advertising, and Public Relations
  • Health Economics, Cost and Practice Managerial Accounting
  • Mico-Medical Practice Business Models
  • Incurred but Not Reported [IBNR] Healthcare Claims
  • Revenue Management, Coding and the Cash Conversion Cycle
  • Medical Professional Social Media and Collaborative patient care
  • Healthcare Compliance and Health Law Policies
  • The USA PATRIOT and SAR-BOX Acts
  • Physician Leadership, Communication, and Career Development
  • Patient Service Management and CRM + [plus]
  • Physician Compensation, Micro-Capitation with P-4-P Trend Analysis
  • Office Financial Statements and Analysis
  • Human Resources, Hiring, Firing and Office Staffing
  • Healthcare Marketing, Advertising, and Public Relations
  • EHRs, Mobile IT systems, Medical Devices, SaaS and Cloud Computing
  • Medical Ethics, Participatory Care and Moral Philosophy
  • Health Macro and Micro Economics and Finance
  • Medical Practice Sales and Succession Planning
  • Next-generation Physician Leadership
  • Obama Care American Recovery and Reinvestment Act [ARRA and HITECH]
  • And so much more!

“Live” Website Companion

The “live” online companion for this print textbook is: www.BusinessofMedicalPractice.com

Assessment

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Conclusion

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To Save or To Spend?

Understanding the Decision

By Somnath Basu PhD, MBA

Should we save or spend? What’s good for me and my family? Is the time right for us to be buoyant and optimistic about the future? How do we decide what fraction of our income to spend and how much to save? Isn’t spending a good thing for the economy as we are constantly being reminded about? If we do not spend now, how are we going to feel about all these unfulfilled wants and needs that we have especially when we see others around us fulfilling? How much should I spend for gifts during this holiday season – is that not a good idea to bring cheer to my family? It is a very perplexing set of questions that constantly sway our mind as we try to grapple with what we feel should otherwise be moderately simple decisions. In arriving at these seemingly easy decisions, consumers are facing some of the toughest issues in their everyday lives. It may be useful to dig a bit deeper into the issues related to spending and saving decisions so that we may understand a bit of their complexities and make prudent choices whose outcomes will clearly validate our reasons for doing so.

The Save or Spend Decision

If the decision to save or spend is problematic, it is because it is neither simple nor anything new. We have coped with these same decisions through many generations, and more. The understanding we have collectively arrived at is, however, worth visiting. When we spend, we receive immediate gratification. This “feel good” feeling is so good that we are willing to sacrifice a lot in order to attain this feeling. Saving, on the other hand, is bereft of any such immediate good feeling. The only good feeling that can accrue to us is that we have this “felt’ promise to ourselves that a moment in the future will feel better than both the loss of satisfaction from immediate gratification of wants and the hurt of having unsatisfied wants. Alternately, we may want to save because we feel threatened that a future situation may arise that may lead to more misery tomorrow than the joy gained today. Thus, the main question in trying to answer whether to save or not is whether it is a promise or a foreboding about the future.

Attitudinal Sea Change

Over the last 25 years, our attitude towards spending has undergone a sea change. Even until the early 1980s we were saving in double digits as a nation. Since then, we have slowly moved away from this psyche and have adapted our lifestyles towards spending and consumption on a scale we have never experienced before, historically. By 2006, we were actually spending about one percent more than what we were earning. This change was stimulated by many factors including the plentiful inflow of cheap products from China, a steady rise in income, a considerable increase in the promotion of mass consumption through enticing advertisements in practically all media, the access to cheap credit sources, increasing house prices and the accompanying ability to borrow from the increase in its equity value, etc. Above all else, this shift from saving to spending was overwhelmingly reinforced by the feeling of empowerment in being able to command goods and services for consumption and the enjoyment from the increase in our standards of living that came from our new found affluence. Whereas every generation before us (baby boomers) had sought to leave more for their kids than what they themselves inherited, we reasoned with ourselves that educating our children was sufficient for them to look after themselves. This attitude allowed us also to spend and consume more not only without guilt, but also with pleasure. More so than ever, we got addicted to spending. Nothing felt better than spending.

The Flash Crash of 2008-09

Then came the great recession of 2008-09! The economy plunged, companies laid off workers by the thousands, people who had bought homes even if they could not afford it, on the promise that house prices would never go down, lost their homes. Moreover, the cheap Chinese goods we got used to were being produced by our own national companies so that the economic rebound was now being hailed as a jobless recovery. We had outsourced away all we had for some corporate bottom line and had impoverished ourselves in the process. Only now, we had no savings for the rainy day that had befallen us.

Americans Saving Again

Perhaps one of the more pleasant surprises from this recession is that we turned the clock around on saving and in the short span of two or three years we have our savings level back at five percent. Why did it happen this way in spite of our government encouraging us to spend our way out of this recession? Primarily, this change has come about from the possibility of losing our jobs or enduring deep cuts in our incomes. This fear today is more real than ever before and it seems to have taught us a “savings” lesson that we have all learned. When deciding on whether and how much to spend, we should take absolutely no chances in first putting away a small nest egg for a rainy day or “emergency” fund, in more technical terms. It is imperative that we defend our families in the event of losses in job and income so that we can bear out whatever future storms come by our way. It is only after we have done so should we consider spending. A six-month contingency fund [even more for medical professionals, according to ME-P Editor Dr. David E. Marcinko] should be perhaps the most staple item in our household budget. It is heartening to see the resiliency that runs through our nation’s citizens as we collectively undo our habit of reckless spending.

Assessment

Once we have our emergency nest egg in place, we should consider our spending pleasure. Going “cold turkey” on spending is not advisable either; maybe a gradual weaning away from this compelling habit. Ask yourselves before you spend whether it is a “need” or a “want”. Healthy food and holiday cheer for the family, basic transportation expenses and healthcare are needs. Starbucks coffee is a want. As we prudently spend on needs and wean away from wants we also save. And saving is not only for our future “feel good” consumption. It is also for the immensely gratifying feeling that we will leave something for our children, through whom we will live in the future.

NOTE: Dr. Somnath Basu is a Professor of Finance at California Lutheran University and the Director of its California Institute of Finance. He is also the creator of the innovative AgeBander technology www.agebander.com for planning retirement needs.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Is this portrayal accurate or even applicable to medical professionals?  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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Other Print Books and Related Information Sources:

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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On Hospital Bond Insurers and Credit Enhancement

Understanding the Capital Formation Process

By Calvin W. Wiese CPA MBA

www.HealthcareFinancials.com

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Credit enhancement is commonly used when issuing tax-exempt bonds. Credit providers guarantee the payments promised by the bonds, essentially co-signing. As a party with recognized credibility in the market, the bond provider agrees to make payments on behalf of the obligor in the event the obligor fails to make payments. The effect of this is that the credit rating on the credit enhanced instruments is higher than the underlying credit rating of the hospital obligor.

Credit Enhancement

Credit enhancement is primarily provided by bond insurers and commercial banks. Bond insurers issue insurance policies that cover the payments of principal and interest over the life of the bonds, usually up to 30 years. For this policy, the bond insurer is paid an upfront premium; typically in the range of 40 to 300 basis points (hundredths of one percent) applied to the total principal and interest payments. Effectively, the credit rating of the insured bonds becomes the credit rating of the bond insurer, typically ‘AAA’ or ‘AA,’ instead of the underlying rating of the hospital obligor. The credit enhanced bonds then are priced on the basis of the bond insurer’s credit rating resulting in lower interest rates. The difference between the interest rate based on the hospital obligor’s underlying credit rating and the bond insurer’s credit rating is the savings in interest payments derived by the insurance. The premium paid to the bond insurer is usually about two-thirds of the present value of this interest savings.

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Commercial Banks

Commercial banks issue letters of credit to enhance hospital obligations. Letters of credit basically provide that the issuing bank will make any principal or interest payments that the hospital obligor fails to make. Usually, letters of credit are issued for three to five years with “evergreen” provisions. Evergreen provisions provide the mechanism whereby the letter of credit can be extended for an additional year at each anniversary upon the agreement of the parties (not automatically). An important difference between bond insurance and letters of credit is the term: bond insurance covers the entire term of the bonds, while letters of credit cover less than the entire term (casting uncertainty on the credit enhancement provided by a letter of credit). Another important difference is the fee structure: letters of credit fees are paid on a quarterly basis, while bond insurance premiums are paid upfront.

Letters of Credit

Due to its short term, the letter of credit has to provide a “take out” mechanism that is exercised in the event the letter of credit is not renewed. This “take out” mechanism converts the underlying instrument into a bank loan with a short amortization — usually five to seven years — and a “prime plus” rate of interest.

Assessment

Letters of credit are most commonly used to support variable-rate tax-exempt instruments. These instruments are usually auctioned once a week and a new interest set for the next week. The interest rates are extremely low and make very favorable forms of financing. They do introduce interest rate uncertainty. Although the rates are low, there is no certainty that they will remain low, although they have never traded above about 6% in the 20 or so years they have been in the market. Because of this uncertainty, they are typically limited to something less than half the debt of a hospital.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Has the flash-crash of 2008-09 affected your opinion of the rating agencies? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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