Case-Mix Indices and Expected Value

Quality Measurements, Benchmarks and Ratios

By Brent A. Metfessel MD, MS, CMP™ (Hon)

 

Once an expected case mix index value is calculated for a medical provider or facility, comparison of the provider’s actual practice patterns to the expected value can take place.

Benchmarks

In medical severity case-mix reporting, there are three basic measures that utilize expected values: 

  • Ratio of actual to expected (actual / expected):  This measure is terms a “performance ratio” or an “efficiency ratio”.  A value of about 1.0 would mean that practice patterns are close to the expected target or plan average.  For cost comparisons, a value of slightly below 1.0 might even be more ideal as long as the provision of high-quality care is maintained.
  • The difference between actual and expected values (actual – expected):  This measure is termed the “cost variance” and is very useful for looking at the cost impact of practice variation.  An additional advantage of this measure is it’s approximately normally distribution, unlike performance ratios which are skewed toward the high end.  This means that relatively simple statistics can be used to isolate providers or facilities with high positive cost variances for further analysis. Often, a z-score (number of standard deviations from the mean) of +2 or more is used as the approximate criteria for overly high utilization.  It needs to be noted that a highly negative cost variance can point to care problems as well, in particular problems with patient access to care or underutilization of services, so the reasons for very low cost variances also need to be discovered.
  • The ratio of the expected value to the unadjusted plan average (expected / average):  This measure is the “illness burden” of the provider and becomes a measure of the level of illness in the provider’s patient panel. A high illness burden means that the provider or facility treats patients that are more ill than the average provider or facility. A provider with a high illness burden and yet a reasonable performance ratio means that the provider is highly competent with complex patients and the health plan should give special attention to such providers to keep them as active as possible in the network.

Conclusion

Do you know of any other medical quality measures that utilize expected values; please comment and opine?

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Project Manager and Assistants Wanted

Atlantic Logistics; L.T.D.

A European leader in the transportation business is seeking experienced and professional Project Managers and assistants. There is an immediate need for experienced individuals. Strong computer, organizational, communication and presentation skills with a reliable work ethic is required.

Additional Requirements:
– US Citizens;
– Fluent in English (spoken and written);
– A PC user (MS Office, MS Windows), Internet and e-mail skills;
– High communication skills;
– Credit score over 650 (Experian, Equifax and Trans Union)
– Honest, active, operative and highly responsible.
Employment Terms:
– Position is available in: USA, ALL STATES
– Fixed salary: $ 50,000 per year + additional commissions
– Position is available: full-time/ part-time
– A permanent contract;
– After the first successful project you receive i-phone as bonus, to be always available.

Peter Trabes
HR Director
atlanticlogisticsltd@gmail.com

Convenient Medical Clinics in Wal-Mart

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Survey Profile of Customers

[By Staff Reporters] 

Demographics:

·                                 79% are visits for Adults

·                                 21% are visits for Children

Insurance Status:

·                                 Approximately 55% uninsured

Alternative Considerations:

·                                 40-50% Primary Care Provider

·                                 20-35% Urgent Care

·                                 10-15% ER

·                                 5-10% would have foregone treatment

healthCenter6

Conclusion

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

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Stock Options Query

Question:

My hospital wants to give me some stock options. I am a senior nurse manager. What are hospital stock options anyway, and why are they so popular? Should I ask for cash instead?

IOW: Show me the money! Please advise if you can.

Thank you.

PS: Great blog!

Samuel [Sam] M. Jefferson; RN

Baltimore, MD

Hospital Phantom Stock Plans

 

A Securities Granting Alternative

LaVerne L. Dotson; JD, CPA

As an alternative to granting an interest in stock or awarding stock options, a hospital or healthcare employer may establish a so-called phantom stock or shadow stock plan to its employees.

“Unit” Accounts

Under these arrangements the employee is treated as if he or she had received a certain number of shares of the company stock, but instead of actually issuing shares, the employer establishes an account for the employee.

The employer then issues “units” to the employee’s account. The number of units that the employee receives under such a contractual arrangement is pegged to the price or value of the company’s stock.

Once the units have been credited to the employee, the equivalent of dividends on these units are generally paid to the employee and are reinvested to purchase additional units or deferred with interest.

The plan normally provides for appropriate adjustment in the value of units if changes are made in the capitalization of the stock with respect to which the units are priced. Benefits under such a plan are usually deferred for a specific period of time or an event such as death or retirement. When benefits are payable, they may be paid in cash, either in a lump sum or installments, or in the form of stock.

Tax Considerations

The phantom stock is taxed like any other nonqualified deferred compensation plan. The granting of the phantom stock units is not taxable to the employee. When the cash or stock is distributed to the employee, it is taxed as ordinary income, equal to the amount of cash received or the value of the stock. If the stock distributed is subject to a substantial risk of forfeiture, it will be subject to taxation when such risk lapses in accordance with Code § 83(b).

Assessment

Because a phantom stock plan does not require the actual issuance of shares of the employer’s stock, it may enable the employer to offer much of the practical benefit of stock ownership without causing dilution of equity, securities law problems as to stock that would otherwise have been issued, or other problems such as risking the loss of S corporation status.

Conclusion

And so, what has been your experience with these so-called phantom-stock plans?

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Requesting Help with Case-Mix Adjustments?

Question:

I am the quality improvement co-coordinator for a small rural tertiary care center in the Upper Peninsula of Michigan. We are just beginning to implement case-mixes and newer case-mix severity evaluations.

What is the real purpose of medical case-mix adjustments for a physician or healthcare facility; and how should we proceed?

Thank you.

Sarah J. Silvers-Inen

Medical Quality Coordinator

Marquette, MI

Case-Mix Medical Adjustments

The Centerpiece of Quality Practice Patterns

By Brent A. Metfessel MD, MS, CMP™ (Hon)

It is difficult to construct an adequate medical practice pattern profile without case-mix or risk adjustments. There needs to be an algorithm that adjusts for the medical severity of patient mix. 

For example, a tertiary care center in New York City cannot be compared using unadjusted data with a community hospital outside the city. The tertiary care center will use more resources, and thus cost more, than the community hospital no matter how exemplary the tertiary care center. 

And, a cardiologist cannot be compared to a family practitioner, since in general the cardiologist will see patients of greater severity. 

Algorithms for Case-Mix Adjustment

A wide variety of methodologies exist that are useful for case-mix, risk, and severity of illness adjustment. And, a number of third-party vendors exist that sell software groupers for case-mix categorization.

Since each methodology has different strengths, some MCOs have purchased more than one software package. There is no such thing as a “perfect” adjuster. Five examples of commonly used algorithms follow:

 

·         Diagnosis Related Groups (DRGs) and related adjusters: Originally put into use in the early 1980s, DRGs were intended for use mainly as a methodology for Medicare to determine reimbursement for hospital stays.  Nevertheless, DRGs and their more recent derivatives (Revised DRGs or RDRGs, and All Patient Refined DRGs or APR-DRGs, both of which subclassify each DRG category into three to five severity strata using various algorithms) are useful for inpatient case-mix adjustment.  An example of a DRG category is DRG 89, “Simple pneumonia & pleurisy, age > 17, with CC [complications]”. The same can be said adjusters related to the newest Medical Severity DRGs [MS-DRGs].

·         Episode Treatment Groups™ or ETGs (Symmetry Health Data Systems, Inc.): This data grouper classifies the claims records into episodes of care that track the progress of an acute illness from onset to resolution and includes related diagnoses and treatments.  For more chronic illness episodes, where there is really no defined “onset” or “resolution”, one usually profiles providers on a pre-defined time window, such as a year-long episode. To capture enough episodes for analysis, ETGs generally require a two-year reporting period. Since this case-mix adjuster depicts the longitudinal aspects of care, ETGs are a process-based adjuster, meaning that they emphasize the process of care and the treatment the patient receives over a time course. A member can, and often does, have more than one ETG during a reporting period. An example of an ETG is “Obesity, morbid, with surgery”. There exist over 600 ETG categories, which are granular enough to detect nuances in illness classes and severity but not so large as to lead to significant small cell size problems. ETGs also group pharmacy claims and attach them to the most relevant episode based on priority tables. Over 400 health plans have purchased the grouper as of May, 2003, and 700 by 2008. In addition, Episode Risk Groups™, a derivative of ETGs, can be used prospectively for predictive modeling of cost as well.

·         Adjusted Clinical Groups or ACGs (Johns Hopkins University): ACGs group illnesses into morbidity clusters rather than specific diseases as do ETGs. An example of an ACG is “Acute major and likely to recur”. Since ACGs are based on morbidity clusters, patients with multiple complex illness conditions can be readily identified.  Since each patient has only one ACG for an entire reporting period, such an adjuster is called population-based.  The process of care over time is not as important with such algorithms. In fact, ACGs do not require procedure or CPT codes at all – just ICD diagnoses, age, gender, and member and provider identification fields, which gives the methodology the advantage of input simplicity. There exist over 100 ACGs at present, and they are in use at nearly 200 organizations worldwide. In general there are fewer categories in population-based adjusters than in process-based adjusters, since process-based algorithms need to account for specific diseases.

·         Diagnosis Cost Groups™ or DCGs (DxCG, Inc.):  DCGs are also a population-based grouper.  Although the grouper begins with 184 Condition Categories (ex: “Benign neoplasm of skin”). These Condition Categories are also sorted into hierarchies and aggregated into broader categories. The combinations of Condition Categories that a member has can then be used to predict health care resource utilization based on an overall risk score for each member. This prediction can either be for the current year or for the subsequent year, depending on the model used. Over 100 organizations now use DCGs, and like ACGs they do not require procedure codes. One important feature of DCGs is its ability to be used in predictive modeling of prospective resource use, using a different model than that used for retrospective analysis

·         Age-gender:  In these models, various age and gender strata are used to account for risk.  Generally there are about 9 to 20 strata for age gender, depending on the needs of the health plan. Basically, resource use is moderate in the early years up until about age 5, then decreases through adolescence and the 20s, then slowly rises again in a non-linear fashion until it becomes quite high in the senior years. Females also tend to use more resources during their reproductive years. Of all the models described, age-gender has the least explanatory power for the prediction of resource utilization either retrospectively or prospectively. The ability of a case-mix adjuster to explain variation in resource utilization is determined by the “R-squared” (the square of the correlation coefficient), with the case-mix categories or risk score as the independent variables and a measure of resource use (such as cost) as the dependent variable. Age-gender models have an explanatory power of about 3 – 7% while publications on proprietary adjusters have generally shown that they explain about 30 – 50% of the variation for retrospective analysis. Prospective explanatory power is somewhat less, usually around 15 – 25%.

 

Assessment

Medical providers have the right to ask that reports dealing with health care resource utilization have proper case-mix or severity of illness adjustment, and that resources are available at the health plan or MCO to answer questions concerning the adjustment algorithm and to offer a complete explanation of the case-mix methodology used.

Conclusion

Many MCOs and HMOs now provide literature to physicians and medical providers that discuss the reporting and case-mix methods when the profile reports are distributed. Are you aware of them; please comment and opine on their use, or abuse? 

Related Information Sources:

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Healthcare Organizations: www.HealthcareFinancials.com

Administrative Terms: www.HealthDictionarySeries.com

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Non-Claims Data Outcomes Analytics

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A Costly and Resource Intense Proxy

By Brent A. Metfessel MD, MS, CMP™ (Hon)

biz-book

In a previous Medical Executive-Post, medical claims outcomes analysis was discussed as an indirect proxy for care quality.

And, we asked if anyone could comment on other ways [direct or indirect] to ascertain medical care outcomes using claims, or other data?

Non-Medical Claims Data Analysis

Now, the following are some ways to ascertain outcomes of care using non-medical claims data:

·         Patient satisfaction data may be an indicator of outcomes, since patient satisfaction with care often relates directly to how well a patient has progressed with respect to his/her illness. 

·         Functional status survey data provides a direct subjective account of the severity of illness and/or outcome of treatment, depending on when the survey was given.  A congestive heart patient that reports in a survey that he/she cannot walk up a flight of stairs may show non-responsiveness to treatment that needs addressing.

·         Clinical data analysis is becoming important as more and more organizations are adding clinical data to the claims, such as lab values.  Hemoglobin A1c values, for example, hold the key to how well controlled a diabetic is over the long term. 

Assessment

Unfortunately, the difficulty with non-claims data is that collection of such data can be resource-intensive and costly, depending on the sophistication of the information systems available. Can anyone comment on other ways [direct or indirect] to ascertain medical care outcomes using non-claims data?

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Conclusion

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Genworth Financial Reports on LTC

LTC Survey Results

[By Staff Reporters]

A new study by Genworth Financial Inc., suggests that costs for nursing homes, assisted living facilities and some in-home care services have increased for a fifth consecutive year, and could rise further if a shortage of long-term care workers isn’t resolved.

Results

The survey found that the average annual cost for a private room in a nursing home rose to $76,460, or $209 per day, this year. This was a 17 percent increase over the $65,185 cost in 2004. Meanwhile, nursing home costs this year ranged from $515 per day in Alaska to $125 per day in Louisiana.

###

Mature Woman

Assessment

The cost for assisted living facilities averaged $36,090 nationally, up 25 percent from $28,763 in 2004, while costs ranged from $4,921 per month in New Jersey to $1,981 per month in Arkansas. Obviously, this far exceeds the inflation rate.

Conclusion

And so, does LTC insurance still make sense; or is it better to save and invest privately for eldercare? Please opine, for-or-against this risk transfer insurance vehicle.

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Economic Headwinds for all Physicians

Cold Winds of Recession Ahead? – You Decide

Staff Writers

We previously hinted that there was a strong headwind for the economy with continued pressure on US strength. And, this may be truer in the healthcare industrial complex. In fact, if it has not already done so, the country may well be into a recession; ditto for doctors and medical providers.

Financially Surviving Recession

Some pundits feel that we are either are already in a recession, which may be substantiated by future GDP numbers, or we are sliding into one, slowly. The question for all medical professionals then becomes; “can your personal finances survive a recession”? 

Fortunately, there are several things you can do now to shore up your finances. If we miss a recession, then you are just that much further ahead.  Here are some of the things you need to take a look at:

1) Reduce your debt

It is very important to work as hard as you can to reduce your overall person and corporate debt levels. Existing debt is often the burden pushing us into bankruptcy when there is a change to present income or additional new expenses. Physicians and patients are not immune. Currently, the average American household has almost $10,000 in credit card debt. 

2) Build an emergency cash fund

This is true at any time, but might be more helpful in the near term. Some general economists say to keep 6 months of living-expenses in a cash savings account. This is all well and good in the academic world, but realistically you should shoot for 6-12 months as a partnered private physician, or 12-24 months as an employed doctor. Employment opportunities, or crises, change fast!

3) Review your portfolio

Consider a portfolio review by a professional fiduciary, and/or medically focused financial advisor, and/or health economist. You might be surprised by what a fresh set of eyes might discern. 

For example, are you choosing investments that are likely to make a good recovery? 

We don’t recommend market-timing, but there are strategies available to capitalize on current market conditions. 

Economic Indicators 

The headwinds against the economy keep getting stronger. They are sensed by the following economic indicators:

 

  • Last week, the Census Bureau reported that the number of vacant homes for sale hit a record high. The report showed that 2.9% of US homes, excluding rental properties, were vacant and up for sale in the first quarter. That translated to about 2.28 million properties or the highest quarterly number on record since 1956.  
  • Home prices posted another record decline, as most of the nation’s largest markets suffered double-digit drops last year.
  • Housing prices dropped in February at the fastest rate ever, showing that the housing slump is gaining momentum. 
  • Consumer confidence dropped in April on inflation and job worries. Eroding consumer [patient] confidence foreshadows weakening consumer spending, which could further hurt the already deteriorating economy, and your medical practice. Consumer spending accounts for more than two-thirds of the nation’s economic activity.   
  • Of course gasoline saw a 26% price increase in the cost, per gallon, since April 2007.
  • The dollar continued to drop against the Euro.

Assessment

In this “interesting time”, we have identified several strategies which may be prudent for readers and subscribers of the Executive-Post.

If you plan now, and take the appropriate steps, your personal finances should be able to survive current market conditions. Making the wrong financial moves could easily make you come up short. And, a wrong financial move does include “doing nothing”. 

Conclusion

And so, we welcome the opportunity for you to submit queries to our “Ask-an-Advisor” feature.

Hopefully, we might offer some ideas on how you can benefit from professional management and objective counsel; or use our books, texts, dictionaries, white-papers and/or institutional subscription services.

Not all questions will be answered, of course, but representative queries may be posted.  

Please be aware that you must register as a subscriber-member to “Ask-an-Advisor”.

But, don’t worry; registration is free!

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And, for the physician-executive, CXO, or hospital administrator; and the medical clinic or practice manager, let our 2-volume, 1,200 pages, institutional print journal guide, Healthcare Organizations [Financial Management Strategies] be the blue-print for your future enterprise-wide success. $525/yr. Toll Free: 1-800-251-0381 http://www.stpub.com/pubs/ho.htm

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Healthcare Workplace Advice Survey

Employees Want Financial Planners and Benefit Advisors at the Workplace 

Staff Writers

Survey Results: [Table] 

 

2004

2005

2006

2007

Financial Planners (401K) at Work

43%

43%

38%

49%

Benefits Advisors at Work

N/A

36%

33%

47%

Financial Planners (All Needs) at Work

38%

37%

30%

44%

Source: The 6th Annual MetLife Study of Employee Benefit Trends:

Findings from the National Survey of Employers and Employees: Metlife, April 2008

http://www.whymetlife.com/trends/

Assessment: Is this contemporary trend also true for hospitals, medical clinics and the modern healthcare workplace?

Conclusion: Please comment and opine.

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Administrative Terms: www.HealthDictionarySeries.com

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact him at: MarcinkoAdvisors@msn.com  or Bio: http://www.stpub.com/pubs/authors/MARCINKO.htm

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Hospital Stock and Taxes?

Q: I am a hospital employee. What are the ways that I can acquire stock in my public company without current cash activity; i.e.; taxes; any thoughts?

For example, at this time I do know it is important that any loans be subject to full recourse liability.

I also understand that if the loan is secured by the stock on a non-recourse basis, the transaction may be treated as if it were a grant of an option, and thus there would be no transfer of property until the loan is paid.

Thanks for your help. 

Dr. William Henry Biggerstaff

Costa Mesa, CA  

Securities and Hospital Employees

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Receiving Employer Securities

[By LaVerne L. Dotson; JD, CPA]

There are a number of different methods, other than qualified retirement plans [403(b) and 401(k)], by which hospital stock may be transferred to hospitalists, or other medical employees.

Stock Bonus Plans

The first and simplest method is a stock bonus, whereby the employer makes an outright grant of shares to the employee. In this case, the employee immediately owns his or her shares and has full voting and dividend rights. The employee is taxed at ordinary income rates on the full value of the stock when it is received. This sort of arrangement is very beneficial to the employee, since he or she is able to acquire stock for a cost of the income tax payable on receipt of the stock.

Of course, cash flow may not always be sufficient to support increased income taxes due for non-cash compensation.

Thus, if the employee receives $10,000 worth of stock, he or she has essentially acquired the stock for $2,500, if he or she is in the 25% marginal tax bracket.

Further Restrictions May Apply

However, the hospital employer may insist that when the shares are granted the employee satisfy certain conditions either relating to continued employment for a period of time or attainment of certain performance goals. Until the restrictions are met, the shares cannot be sold and remain subject to forfeiture.

Using restriction periods ensures that employees will hold their shares and helps support employee retention.

Moreover, because grants can be made contingent on meeting specific goals, employers may create a stronger performance linkage than stock price alone.

Assessment

Of course, as soon as the rights to the stock are not subject to a substantial risk of forfeiture, the employee is subject to ordinary income taxation. The amount to be included in income is the excess of the fair market value of the stock at the time it is no longer subject to the risk of forfeiture.

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Conclusion

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

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

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A Six-Sigma Healthcare Primer

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Physicians, Hospital Administrators, Consultants and Executives
By Staff Writers

Read this special report on improving medical care quality and related healthcare delivery initiatives thru manufacturing concepts of six-sigma, by a leading physician-executive and senior six-sigma practitioner from Creative Health, USA.

This feature was prompted by the many inquires after an original post on the same topic.

Our author is Daniel L. Gee MD, Principal from Creative Health USA, in Scottsdale Arizona.

Dr. Gee believes that; “six-sigma is more than simply allocating resources to correct a problem – it’s a proven methodology designed to uncover, isolate, understand, and remedy the root causes of problems”.

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Claims Data Outcomes Analysis

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Understanding “Proxy” Measurements

Brent Metfessel MD

By Brent A. Metfessel MD, MS, CMP™ (Hon)

Medical claims data has clear limitations for outcomes analysis and quality reportage.

Such data only deals with the process of care and does not have information directly pertaining to outcomes except where specified in the ICD-9 codes. 

Thus, one must rely in many cases on proxy measures for outcomes. Proxy measures are process of care metrics that can imply certain outcomes, such as length of an illness episode.

The following are some ways to ascertain outcomes of care using claims data:

·         Complications of care:  The ICD-9 codes directly contain language for denoting outcomes.  There exist codes for wound infection and dehiscence, miscarriage in pregnancy, and general surgical complications.  The coding of a major infection in a cancer patient on chemotherapy is another example of complications-based outcomes obtainable through claims data.

·         Procedure re-performances:  Two coronary artery stent procedures within a six month to a year period may imply failure of the first stent.  However, a medical record check may ultimately be needed since it could also be a stent placed in a new vessel.  Returns to the operating room within a few days of a surgical operation, or an outpatient procedure that turns into an inpatient stay within a few days also implies poor outcomes.

·         Readmission rates:  Two or more hospitalizations for the same episode of care within 30 to 60 days also imply poor outcomes.

·         Episode length analysis:  The length that an episode of care lasts can be compared between providers.  Shorter episodes for acute illnesses imply better outcomes unless it is due to the expiration of a patient or poor access to care.

·         Medication prescribing patterns:  In some conditions the drugs prescribed may imply certain outcomes.  A rheumatoid arthritis patient that needs Remicade® probably has a more severe form of the illness.  Frequent antibiotic switching for an infectious disease such as pneumonia either implies a resistant organism or difficulties in quality of care.

·       Emergency room and hospital utilization:  Frequent ER use or hospitalizations for chronic conditions such as asthma or congestive heart failure imply a poor outcome from outpatient treatment.

Assessment

How reliable are these proxy measures in evaluating medical outcomes?  

Conclusion

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Value-Driven [IT] Healthcare

Leavitt Pitches Financial Transparency

Staff Reporters

According to Diana Manor, Senior Editor for Healthcare Finance News, the Department of Health and Human Services [HHS] Secretary Michael Leavitt was reported to say that he has no intention of slacking off in efforts to drive transparency into the US healthcare system, despite the winding down of the Bush Administration.  

World Health Care Congress

At the Fifth Annual World Health Care Congress, held last week in Washington, DC, Leavitt reported that in his 272 days left as HHS secretary, he has “a continued sense of urgency” and plans on picking up the pace to drive much-needed change. “I am among those who believe our unbridled healthcare costs will bring our economic system to its knees.”

Among initiatives in the works, Leavitt said HHS is consolidating all healthcare quality standards used across its agencies and will publish them in an effort to boost their market-wide use.

Competitive Bidding

HHS is also experimenting with competitive bidding for bundled services, beginning with a Medicaid demo that HHS officials hope to expand in the future.

The Bush value-driven healthcare plan relies on healthcare IT adoption to record quality measures and aggregate and provide cost and quality information to consumers, but adoption by small physician practices remains at, or below, 10 percent. HHS plans in June to push Congress to tie physician Medicare payment incentives to the use of healthcare IT.

Assessment

Apparently, many HIT standards have been developed over the past few years, but are not being developed fast enough. Leavitt pushed for these HIT initiative back in December 2008, without success.

Conclusion

And so, do you think the next HIT push will be successful or not; and please comment why?

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Hospital Employee Benefits

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Tax-Deferred Benefits

[By LaVerne L. Dotson; JD, CPA]

As all readers of the Medical Executive-Post know, there are three categories of benefits that hospitals, healthcare systems, clinics and related medical employers typically provide to their employees, nurses, hospitalists, etc:

  1. Those that are totally income tax-free; some are still taxable for FICA (Social Security and Medicare).
  2. Those that are not taxed at their full economic value; or are taxed at a special preferential rate.
  3. Those in which a tax liability is not incurred until after benefits received.

Tax Deferred Benefits

There are several types of arrangements that allow employees to receive economic benefits currently without having to pay taxes until a later taxable year. Furthermore, some of these arrangements may even provide for a lower taxation rate at that time. These types of benefits are not totally excludable from income forever, however. Rather, they primarily provide deferral of taxable income.

Retirement Plans

The classic example is a retirement plan.  Employers may establish pension, profit sharing, stock-bonus, or annuity plans, as well as 401(k) and 403(b) plans. The tax consequences and most of the formal requirements of these plans are similar. These plans are often referred to as “qualified retirement plans.”

The hospital employer makes contributions on behalf of participating employees. The contributions are placed in a trust fund, custodial account, or annuity contract. The funds are held and accumulated for the benefit of plan participants.

The distribution of the funds to a participant normally occurs no sooner than the participant’s termination of service with the employer, and, no later than attainment of normal retirement age, as defined in the plan. The method of distribution may be a lump-sum payment of all of the employee’s benefits, an installment payment over a number of years (usually 10 to 15), or as an annuity that provides payments over the employee’s and/or spouse’s lifetime.  

The extremely favorable tax consequences of qualified retirement plans are the reason for their popularity. When the hospital makes a contribution on the employee’s behalf to the qualified plan, the employer receives a deduction for the amount contributed; however, the employee will not have to report the contribution as income until the funds are finally distributed.

Contributions to the trust or other qualified fund are accumulated tax-free. Distributions are taxable, but the recipient is generally in a lower marginal tax bracket during retirement than when contributions to the retirement plan were made. This treatment is a truly startling departure from the normal practice under the Code.

Employee FSAs

Assessment

The tax-free accumulation of income (contributions and interest) offers the hospital, clinic or other medical employee great advantage, even if his or her tax rates are the same at the time of deferral as at the time of distribution.

Conclusion

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Hospital Compare Advocacy

CMS, HHS and HQA Team-Up for New Website Tool

[By Staff Writers] 

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In the next initiative of the consumer empowerment and/or patient advocacy movement, it seems that the CMS, HHS and the HQA have just teamed-up to produce a new online tool to help patients compare inpatient services for selected procedures and populations. 

Direct from the Website

Welcome to Hospital Compare. This tool provides you with information on how well the hospitals care for all their adult patients with certain conditions or procedures. This information will help you compare the quality of care hospitals provide. Talk to your doctor about this information to help you, your family and your friends make your best hospital care decisions.

Hospital Compare was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HSS), and other members of the Hospital Quality Alliance: Improving Care through Information (HQA). The information on this website has been provided primarily by hospitals that have agreed to submit quality information for Hospital Compare to make public.

Assessment

The site is still a work-in-progress, but here is the latest direct link:

http://www.hospitalcompare.hhs.gov

Hopefully, conditions and procedures will be added, and subspecialties like pediatrics will be included going forward.

Conclusion

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Quality Profiling in Medicine

Practice Patterns and Outcomes Reporting

By Brent A. Metfessel MD, MS, CMP™ (Hon)

Quality Profiling

Quality medical profiling and healthcare delivery metrics and outcomes analysis look beyond mere healthcare finances and costs. As readers of the Executive-Post are aware, pure financial analysis is the stuff of physician economic profiling; an emerging science to be sure.

Typically, good quality medical care leads to improved costs since stable patients have fewer unplanned visits, less emergency room usage, and a reduced frequency of hospital admissions, all of which save money. 

HEIDIS® Data

The Health Plan Employer Data and Information Set (HEDIS®) contains measures obtainable from claims, survey, provider, membership, and medical record data.

HEDIS® was developed in conjunction with the National Center for Quality Assurance (NCQA) and is a widely accepted specification for quality measures. 

Consumers, managed care organizations, and accrediting bodies have a high level of interest in the evolving HEDIS® metrics, to date.

These measures are divided up into a number of categories:

  • Preventive services:  Includes childhood and adolescent immunization status, breast and cervical cancer screening rates, chlamydia screening in women, assistance with smoking cessation, and well-child visits.
  • Access to care:  Includes access to preventive, primary care, prenatal and postnatal care services.
  • Utilization:  Contains measures of frequency of selected procedures, inpatient utilization such as average lengths of stay for maternity and mental health patients, C-section and VBAC rates, and other measures of inpatient and outpatient utilization.
  • Acute and chronic illness care: Examples are rates of beta-blocker use post-MI, comprehensive diabetes care (such as annual retinal exams), control of high blood pressure, appropriate medications for asthma patients, and follow-up within 30 days after hospitalization for mental illness.
  • Provider data and statistics:  Includes residency completion information, board certification, and provider turnover.
  • Membership statistics:  These measures deal with member demographics and total membership in the health plan.
  • Survey data:  Includes member satisfaction survey results.

Assessment

The NCQA is continually revising its measures in the HEDIS® product and provides new versions annually. But, although HEDIS® contains many measures of quality of care; it provides few measures of actual clinical outcomes.

Conclusion

Have you experienced, or been reviewed, using any of these measures in your own hospitals or healthcare institution; please comment?

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Healthcare Organizations: www.HealthcareFinancials.com

Administrative Terms: www.HealthDictionarySeries.com

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Calculating Historic Asset Returns

Single versus Multi-Period Returns

By Mary A. Lauritano; CFA, MBA

The total return on a financial asset over a single time period is broken down into the income return (dividend or interest) plus the capital change or the change in the market price of the asset (negative or positive). This rate of return is called the holding period return.

Holding period return = Change in asset price (+ or –) plus cash received / Beginning value            

Example:

An investment was purchased by a physician at the beginning of the time period for $150,000. The investor received $20,000 of income from the investment during the period, and the investment was worth $175,000 at the end of the period. The holding period return was:

Holding period return = ($175,000 – $150,000) + $20,000 / $150,000 = 30%                        

Measuring one-period rates of return becomes more difficult when investments are considered over a period of time.

The average return can be computed over a multi-period time span using three methods: dollar-weighted (internal) rate of return, time-weighted (geometric) rate of return, and time-weighted (average method) rate of return.

Each method has its particular use and interpretation.

Dollar-weighted rate of return

The dollar-weighted rate of return measures the performance of the manager and the timing of the external cash flows initiated by the client.

From the physician investor’s viewpoint, this is the best measure of the overall performance of the portfolio because it includes the timing of when funds were added or subtracted. The primary drawback of this measure is that it mixes the timing of the client’s cash flow with the portfolio manager’s performance.

Time-weighted rates of return

Geometric mean vs. arithmetic mean

Put simply, the geometric mean is the compound rate of return and the arithmetic mean is the average rate of return. Geometric returns never exceed arithmetic returns. Geometric return measures past performance; it is the constant rate of return needed in each year to match actual performance over a time period.

Arithmetic return is an unbiased estimate of expected return, assuming the past is equal to the future. Therefore, arithmetic return is a better indicator of future performance.

When it is necessary to measure only that portion of performance due to the investor/manager, the time-weighted (geometric), or annual compound, rate of return is the best measure of the actual historical performance of the manager, because it indicates the annual average return for each dollar given to the account manager.

Assessment

The performance standards of the Association for Investment Management and Research (AIMR), now CMA Institute, require managers to use this geometric method when they report performance.

The time-weighted (arithmetic method) rate of return is the return that occurred in a “typical year” for the account manager. It is the simple arithmetic average of the period-to-period returns produced by the manager, excluding the effects of external cash flows.

The geometric mean return indicates the rate at which wealth grows; the arithmetic mean return indicates the annual average return from investing. The geometric mean is preferred to the arithmetic mean because investors want to know the rate at which wealth grows over time.

Conclusion

What are your thoughts on the above, and how do you determine asset return? Please comment.

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SEIU Economics

Challenging Medicare Economics Rule Changes

Staff Writers

According to Modern Physician, a union representing 12,000 medical interns and residents is the latest organization to get behind a lawsuit seeking to stop a Medicaid economics rule change that would crimp the flow of enhanced payments to safety net hospitals.

Amicus Brief*

In a friend-of-the-court brief filed in U.S. District Court in Washington, the SEIU Healthcare-affiliated Committee of Interns and Residents argues that “the ability to collect above-cost Medicaid payments allows governmental healthcare providers to fulfill Medicaid’s mission by making it possible for safety net hospitals and the medical residents that work in them to provide quality healthcare to the nation’s poorest and most vulnerable citizens.”

Assessment

The lawsuit was filed in March by a coalition led by the National Association of Public Hospitals and Health Systems and including the American Hospital Association and the parties are seeking a preliminary injunction to block the rule from taking effect.

Conclusion

Your comments are appreciated.  

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*Amicus Curiae briefs, a Latin term meaning “friend of the court”, is the name for a brief filed with the court by someone who is not a party to the case.

 

Hospital Employee Auto Benefits

Autos not Taxed at Full Economic Value

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Dr. DEM

As readers of the Medical Executive-Post are aware, there are three categories of benefits that clinics and hospital employers typically provide to their employees, nurses, hospitalists, etc:

  1. Those that are totally income tax-free; some are still taxable for FICA (Social Security and Medicare).
  2. Those that are not taxed at their full economic value; or are taxed at a special preferential rate.
  3. Those in which a tax liability is not incurred until after benefits received.

Taxable Benefits

When a benefit does not qualify for exclusion under a specific statute or regulation, the benefit is considered taxable to the recipient.  It is included in wages for withholding and employment-tax purposes, at the excess of its fair market value over any amount paid by the employee for the benefit.

For example, hospitals often provide automobiles for use by hospitalists, and employees, etc. Treasury regulations exclude from income the value of the following types of vehicles’ use by an employee:

  • Vehicles not available for the personal use of an employee by reason of a written policy statement of the employer
  • Vehicles not available to an employee for personal use other than commuting (although in this case commuting is includable)
  • Vehicles used in connection with the business of farming [in which case the exclusion is equal to the value of an arbitrary 75% of the total availability for use, and the value of the balance may be includable or excludable, depending upon the facts (Treas. Regs. § 1.132-5(g)) involved)]
  • Certain vehicles identified in the regulations as “qualified non-personal-use vehicles,” which by reason of their design do not lend themselves to more than a de minimus amount of personal use by an employee [examples are ambulances and hearses]
  • Vehicles provided for qualified automobile demonstration use
  • Vehicles provided for product testing and evaluation by an employee outside the employer’s work place.

Assessment

If the hospital employer-provided vehicle does not fall into one of the excluded categories, then the employee is required to report his personal use as a taxable benefit. The value of the availability for personal use may be determined under one of several approaches. Under any of the approaches, the after-tax cost to the employee is substantially less than if the hospital employee used his or her own dollars deducted a portion of the cost as a business expense.

Conclusion

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Margin Exchange Regulations

Government, Brokerage and Margin Exchange Requirements

By William H. Mears, CPA, JD 

Under the securities laws (the Securities & Exchange Act of 1934), the Federal Reserve Board is authorized to allow brokerage firms to lend against securities positions and charge interest, up to a legal limit, as outlined in Regulation T of the 1934 Act.

Regulation “T”

Under Regulation T, physicians and clients can borrow from a brokerage firm up to 50% of the long position value of their brokerage account. Under Regulation T, only securities listed on a registered stock exchange, the NASDAQ system, or certain approved over-the-counter stocks may be used in a margin account.

A physician investor who transacts in a margin account will be responsible for maintaining the equity in the account at the legal limit, i.e., the 50% level against a stock portfolio.

For example, if a physician investor has a margin loan of $500,000 against a $1 million stock account, and the value of the stock portfolio decreases to $500,000, the doctor-client will need to immediately repay $250,000 of the loan value, because the account no longer can support a $500,000 margin loan.

If the doctor-client is holding bonds in a margin account, the client may borrow under Regulation T up to 80% of the current market value of the securities. U.S. government and municipal bonds have even higher borrowing power.

Example:

Jim Hojo MD, owns a private healthcare equipment company that his father built into a $10 million business, would like to sell some of the equity of the company to long-time employees.

Jim is advised to sell 30% of his privately held company to an Employee Stock Ownership Plan. Jim was told that under Internal Revenue Code §1042, he will be afforded a tax deferral opportunity on the sale of a portion of the stock of the company to the employees. The delay in the recognition of the capital gains on the sale of a portion of the company to the employees is contingent upon compliance with certain criteria outlined in Code §1042.

Jim takes advantage of this transaction and, as advised, purchases domestic-issue floating rate bonds. He then borrows against the floating rate bonds in a margin account.

Because the bonds have a higher Reg T lending capacity, Jim is allowed to borrow 80% of the market value of the bonds. He takes his loan proceeds and invests in a diversified portfolio of equities.

If he had invested initially in stocks, his borrowing capacity against the stock position would have been limited to 50% of the market value of the account.

Failure to Maintain Regulation T Equity

If a doctor-client fails to maintain the Regulation T-required equity in an account, the client will get a “Reg T call” or a “margin call” from the brokerage firm. The Reg T call will require the doctor to meet the margin requirement through a deposit of cash or securities.

However, if the amount of the margin call is immaterial ($500 or less), the brokerage firm is not required to collect the additional margin requirement. Each brokerage firm will have house rules that further restrict the use and/or the availability of margin accounts.

Since securities in a margin account are held in a street name, a brokerage firm has the right to sell the securities if a Reg T or margin call is not met. Securities held in a street name are simply held for a customer’s account in the name of the brokerage house. If a margin call is not met, a customer will lose the securities in the account that are on margin.

Brokerage Credit Agreements

When opening a margin account, the physician investor must sign a credit agreement, which is not very different from any loan documentation, and a hypothecation agreement, giving the stock-broker the right to pledge the securities to a bank in order to provide for lending capacity. The loan consent agreement allows a brokerage firm to lend securities in a stock loan transaction.

Borrowing Capacity

To determine how much a physician-client can borrow, a series of complicated calculations must be made, and a number of key terms must be identified.

First, the doctor client’s equity in the account must be determined. The equity in the account will be the market value of the account less the debit balance (any outstanding debt). The long market value is the current market price of the securities in the account. The amount available for borrow will be limited by the Reg T restrictions, for example, 50% for securities. Whenever the market value of the securities in a margin account increases, the client will have increased borrowing capacity.

Next and conversely, whenever the value of the securities in a margin account decreases, the client will have a margin call. Excess cash in an account (cash from dividends, interest, or proceeds of sale of securities) will be included in the calculation of the margin call. An account holding cash will have increased buying power that cannot be reduced because of decreases in the market value of the account.

Finally, accounts that fall below the Federal Reserve Board requirements will be restricted in the execution of transactions. Stock exchanges also promulgate rules and regulations that must be complied with. The New York Stock Exchange and the National Association of Securities Dealers require an initial minimum equity of $2,000, or 100% of long market value, and a minimum maintenance requirement of 25% of the long market value [minimums may change without notice].

Assessment

The rules outlined above are for a long [owned securities] margin account. The rules for a short account [borrowed securities] are similar in that an uncovered (or naked) short margin requirement is still 50%, but a covered short sale has a Regulation T limit of 95%.

Conclusion

Have you, or a physician-client, ever been caught in one of these regulatory traps or “margin-calls”, and what was the outcome?

***

Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

Global Healthcare Models

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A New Competitive Threat -or- Next-Gen Boon?

By Dr. David E. Marcinko; MBA, CMP™

[Publisher-in-Chief]

Dr. Marcinko

Did you know that some American businesses are extending their cost-cutting initiatives to include offshore employee medical benefits?

And, facilities like the Bumrungrad Hospital in Bangkok, Thailand (cosmetic surgery), the Apollo Hospital in New Delhi, India (cardiac and orthopedic surgery) are premier examples for surgical care.

Recognized Medical Institutions

It’s true!  Both medical facilities are internationally recognized institutions that resemble five-star hotels equipped with the latest medical technology. Countries such as Finland, England and Canada are also catering to the English-speaking crowd, while dentistry is especially popular in Mexico and Costa Rica.

Medical Tourism

Although this medical business model is still considered “medical tourism,” Mercer Health and Benefits was recently retained by three Fortune 500 companies interested in contracting with offshore hospitals and JCAHO has accredited 88 foreign hospitals through a joint international commission.

Assessment

To be sure, when India can discount costs up to 80%, the effects on domestic hospital reimbursement and physician compensation may be assumed to increase downward compensation pressures.

Conclusion

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Margin Call Models

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Characteristics of the Physician-Investor

[By William H. Mears, CPA, JD]

Generally, a brokerage firm will regulate the use of a margin account by managing the physician client’s risk, and by studying the doctor’s assets and credit history. Margin accounts at brokerage firms are watched carefully to make certain that the brokerage firm does not lose money on the individual. But, when investing on a leveraged basis, physician clients should be aware of the magnification of the market impact on their account, whether favorable or unfavorable.

Margin Investor Awareness

The physician or executive margin-investor should:

• Be sophisticated

• Be of high net worth

• Be aware of the risks

• Be told the horror stories involving leverage, and

• Be aware of the increased returns and liquidity created by margin

Model Tax Rules on Margin Transactions

Investment interest expense can be deducted as an itemized deduction by an individual physician investor only to the extent that the individual has investment income defined as taxable interest, dividends, and short-term capital gains.

Long-term capital gains cannot offset investment interest expense. To the extent that a physician-investor has excess investment interest expenses for a year, these expenses can be carried forward to future years.

If the proceeds of a loan are used to invest in tax-exempt debt, the interest expense incurred to carry that debt will not be deductible for tax purposes.

If the proceeds of a loan are used to invest in tax-exempt debt, such as municipal bonds, the interest expense incurred to carry the debt will not be deductible for tax purposes.

Assessment:

Where you aware of these tax implications on margin before reading this post?

What has been your experience with margin calls, and did you originally fit the criteria above? Please opine and comment?

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Conclusion

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

Margin Accounts for Physicians

What They Are – How They Work

By William H. Mears; CPA, JD

Margin is defined as the capacity to purchase securities with a loan against an existing position.

A Method of Leverage

Using margin, a physician-investor can increase exposure to potential gains and increase returns.

Conversely, by leveraging current investments, a physician investor can increase exposure to market risk.

Where an investor can reinvest margin proceeds and earn a return in excess of the borrowing cost, the investor has increased total return.

Assessment

However, if a physician investor borrows against a position to invest in securities that decline in value, that investor’s loss is in effect doubled (if the investor had margin up to the legal 50% limit).

Example:

Dr. Prince Price, a dentist who has a $1 million portfolio of low-cost basis securities, would like to invest in a new initial public offering (IPO). He feels certain that the stock of this new initial public offering company will skyrocket.

Prince asks his wife if he can take a home equity line of credit against their house to purchase the stock, but his wife, a financial planner, advises against this strategy. She recommends that Prince take a margin loan against his stock portfolio if he really must invest in the IPO. The margin limit on his account is $500,000, or 50% of the current market value of the portfolio.

Prince decides to invest $500,000 in the new IPO. He purchases 50,000 shares of the $10 stock on the offering.

The new stock closes the first day at $20. In 90 days, the stock is worth $50 a share. Prince sells his stock for $50 a share, taking a short-term capital gain of $40 a share. His financing cost on the margin loan, the 7% for 90 days on a loan principal of $500,000, is his opportunity cost and reduces his net economic gain.

Assessment

At the end of the transaction, Prince calculated his net profit as follows:

Gross proceeds:  $2,500,000

Cost basis:            $500,000

Cost of capital:          $8,749

Net profit:            $1,991,251

Conclusion

What has been your personal experience using, or recommending, margin accounts; please comment?

***

Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

Physician Income Maximization

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Next-Gen Rules for Success

Dr. David E. Marcinko; MBA, CMP™

[Publisher-in-Chief]


Money, received by medical professionals as salary in the present, can earn money over a period of time (making the amount ultimately larger than if the same initial sum were received later). And, both the amount of investment return and the length of time it takes to receive that return affect the rate of return (i.e., the value of the return).

This principle, known as the time-value of money (TVM), is a vital compensation issue regarding ultimate wealth accumulation.

Retirement Corpus Estimates

For example, as noted by our firm and according to the March 31, 2005 issue of Physician’s Money Digest, a 47-year-old doctor with $184,000 in annual income would need about $5.5 million dollars for retirement at age 65.

This should serve as a wake-up call that physicians may need to cut personal consumption and professional expenses, and to save more aggressively to harvest the TVM to finance the retirement they’re working toward. Remember, compensation is not the sole arbiter of success. To run your own numbers: http://www3.troweprice.com/ric/RIC/

Therefore, according to Eugene Schmuckler, PhD of the Institute of Medical Business Advisors, Atlanta, GA www.MedicalBusinessAdvisors.com it is not too difficult to imagine the following rules for those innovative doctors wishing to maximize compensation.

Practice Strategies and Wealth Building Rules for Doctors

Rule No. 1: A great idea or competitive advantage can earn generous compensation while still serving the public. It’s a unit-of-one healthcare economy where “Me Inc.” is the standard and physicians must maneuver for advantages that boost credibility among patients and payers.  You must also realize the power of networking, vertical integration and the establishment of prn “medical practices,” which physically or virtually come together to treat a patient or cohort, and then disband when a successful outcome is achieved. 

Rule No. 2:Differentiate yourself among your medical peers. Do or learn something new and unknown by your competitors. Market your accomplishments and let the world know. Be a non-conformist. Doctors should create and innovate; do not blindly follow leaders into oblivion.

Rule No. 3:Challenge conventional wisdom, think outside the box, recapture your dreams and ambitions, and work harder than you have ever worked before. Remember the old saying, “if everyone is thinking alike, then nobody is thinking.” 

Rule No 4:Realize that the present is not necessarily the future. Attempt to see the future and discern your place in it. Master the art of the quick change, and fast but informed decision making. Do what you love, disregard what you don’t, and let the fates have their way with you. Then, decide for yourself if you should be an employer or employee, or adhere to the traditional compensation models.

Assessment

Stay tuned for more on this topic!

We will post some examples of next-generation physicians who are making it under these new rules for success in the modern era.

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

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Concierge Medicine and Anti-Aging Enthusiasts

A Few Wrinkles in a New Medical Specialty

Staff Writers

For thousands of years, magicians, alchemists, even a few fringe medical practitioners have fueled an unbounded optimism that we can blunt the ravages of time, stay younger for longer, maybe even defeat death itself.

Their pitches have usually hinged on some drug, food or device — everything from electricity to yogurt to surgically installing the gonads of animals into our own bodies — that will slow or reverse the aging process.

And, every decade or so, “anti-aging” promoters grasp onto news coming out of research labs and trumpet those developments as the answer we have all been awaiting.

Conclusion

And so, mainstream docs are joining the concierge anti-aging bandwagon in droves. But, with MD endorsements, is the field really a medical specialty at all, and is it more credible or just more risky? Please decide, opine and comment?

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Bad Medical Debt Expense Crunch

More Patients Fiscally Solvent?

[By Staff Writers]

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First there was the housing and credit crunch for us all, and now there is the bad medical debt expense [BMDE] crunch for the healthcare industry.

As a medical professional, if you are struggling to manage your personal, or practice bad debt load – you’re not alone. But, some of the pain may not be necessary.

The Telagent Study

According to a new study, a good percentage of the self-pay accounts receivable [ARs] write-offs, of hospitals and/or private concierge medical practices could have possibly been collected if those entities tightened their initial financial screening procedures.

The study, which was done by Nashville, TN-based vendor Telagent, analyzed receivables between 90 and 180 days old from January 2007 to January 2008. They drew the records from 40 providers, some of which were existing clients.

Researcher Findings

Researchers found that 30 percent of the self-pay accounts were written off as bad medical debt expenses [BMDEs] because patient’s incomes and net worths weren’t obtained or verified.

However, when Telagent did the research, it found that more than 16 percent of the patients being studied could be classified as having high income and/or high net worth, while another 33 percent had moderate household income or net worth.

And so, Telagent suggested that all of these accounts could have been re-billed or outsourced to collections. Meanwhile, another 17 percent of written-off accounts might have qualified for government assistance or charity care programs, the vendor reported.

Assessment

And so, please contact a credit repair specialist, financial advisor or medical practice management expert if you experience this type of personal, practice or corporate credit crunch. Of course, we always encourage you to seek counsel as lack of retaining same may mitigate against you when pursuing legal patient claims in your court of judiciary venue.

Conclusion

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

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

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Locum Tenens Physicians

Alternative Employment Opportunities for Physicians

By Dr. David E. Marcinko; MBA, CMP™

[Publisher-in-Chief]

Dr. Marcinko in New YorkLocum Tenens (LT) is an alternative to full-time employment for most specialties.

Some younger physicians enjoy the travel, while mature physicians like to practice at their leisure. Employment factors to consider include: firm reputation, malpractice insurance, credentialing, travel and relocation expenses (which are all negotiable).

However, a Locum Tenens firm typically will not cover taxes. 

Locum Tenens Compensation

[per 8 hour specialty shift]

 

CRNA

$720 to $880

Family Practice

$400 to $450

Internal Medicine

$400 to $450

Pediatrics

$400 to $430

OB/GYN

$600 to $800

Hospitalist

$520 to $760

General Surgeon

$650 to $750

Orthopedic Surgeon

$800 to $900

Neurosurgeon

$1,300 to $1,400

Anesthesiologist

$1,000 to $1,500

Psychiatrist

$500 to $600

Radiologist

$1,200 to $1,500

Cardiologist

$600 to $750

Source: LocumTenens.com

 

Conclusion

Has anyone used this medical practice employment model; please comment and opine?

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Events-Planner: May 2008

May 2008

Staff Writers

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

  • April 27-May 2: InterOp Conference, Health and Business IT; Mandalay Bay Convention Center, Las Vegas, NV.
  • 7-10: Medicaid Rebates, Annual Meeting; Center for Business Intelligence, Orlando, Fla.
  • 13: Optimization of Network Contracts; World Research Group, Chicago, Illinois. 
  • 14: American College of Healthcare Administrators [ACHA]; Annual Convention, Cincinnati, Ohio.
  • 15: Leadership Summit on Medicare; World Annual Conference, Washington, DC.
  • 19: Medicaid Managed Care Conference; World Research Group, Washington, DC.
  • 19: Medicare Advantage Summit; Financial Research Associates, Alexandria, VA.

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

MarcinkoAdvisors@msn.com

 

 

Estate Planning Glossary for Doctors

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Understanding Terms and Definitions

[Staff Writers]

Text BooksAbsolute assignment: A policy assignment under which the assignee receives full control over the policy and full rights to its benefits. 

Administration: The process of handling the affairs of a deceased person’s estate or a trust.

Administrator: The person or financial institution that is appointed to take care of the estate of a deceased person who died without a will; may be known as a “personal representative

Alternate valuation: With certain exceptions, the value of all property includable in the decedent’s gross estate six months after the decedent’s date of death. If an asset is sold or distributed, its sale price or value on the date of distribution is the alternate value. In either case, the sale or distribution must occur within six months of death.

Alternate valuation date: Six months from the date of death.

Ancillary administration: Probate proceedings in another state.

Attorney in fact: The person holding power to act for another under a Power of Attorney document.

Basis: The value subtracted from the net sales price to calculate gain or loss for capital gains tax purposes.

Beneficial interest: A financial or other valuable interest arising from an insurance policy between owners and key employees.

Beneficiary: Usually refers to a person or entity that is entitled to receive something, for example, a beneficiary of an estate or trust, or a beneficiary of life insurance or retirement benefits.

Bypass trust: An estate planning device (also called a credit shelter trust, family trust, or B trust in “AB” plans where the A trust funds for the marital deduction) used to minimize the combined estate taxes payable by spouses whereby, at the death of the first spouse, the estate is divided into two parts and one part is placed in trust usually to benefit the surviving spouse without being taxed at the surviving spouse’s death, while the other part passes outright to the surviving spouse or is placed in a marital deduction trust. A by-pass trust permits a maximum of from $1.5 million in 2005 to $3.5 million in 2009, to transfer to heirs of the spouses on an estate tax free basis under the unified gift and estate tax. The estate tax disappears completely in 2010

Charitable gift annuity: An arrangement whereby the donor makes a gift to charity and receives back a guaranteed lifetime (or joint lifetime) income based on the age(s) of the annuitant(s).

Charitable lead trust: An arrangement whereby the charity receives an income from a trust for a period of years, then the remainder is paid to non-charitable beneficiaries (generally either the donor or his or her heirs).

Charitable remainder annuity trust: A charitable trust arrangement whereby the donor or other beneficiary is paid annually an income of a fixed amount of at least 5% but not more than 50% of the initial fair market value of property placed in the trust, for life or for a period of up to 20 years; one or more qualified charitable organizations must be named to receive the remainder interest upon the death of the donor or other income beneficiaries, and the value of the charitable remainder interest must be at least 10% of the net fair market value of all property transferred to the trust, as determined at the time of the transfer.

Charitable remainder trust: An arrangement wherein the remainder interest goes to a legal charity upon the termination or failure of a prior interest.

Charitable remainder unitrust: A charitable trust arrangement whereby the donor or other beneficiary is paid annually an income of a fixed percentage of at least 5% but not more than 50% of the annually revalued trust assets, for life or for a period of up to 20 years; one or more qualified charitable organizations must be named to receive the remainder interest upon the death of the donor or other income beneficiaries, and the value of the charitable remainder interest must be at least 10% of the net fair market value of all property transferred to the trust, as determined at the time of the transfer.

Claim: Usually refers to funeral expenses, the debts of a deceased person, and expenses of administration.

Codicil: A legal document, which supplements and changes an existing will; generally used to make minor changes to the original will.

Collateral assignment: When a life insurance contract is transferred to an individual or other party as security for a debt. 

Community property: Ten states (Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, and Wisconsin) use some form of the community property system to determine the interest of a husband and wife in property acquired during marriage.

Conservator:  An adult person or financial institution appointed by a court, who is responsible for a minor child’s or legally incapacitated person’s property until that minor child becomes an adult or the legally incapacitated person becomes competent to be responsible for his or her own property; may be know as “guardian of the estate.”

Crummy trust: A trust established granting a beneficiary a limited power to withdraw income or principal or both. This power is exercisable during a limited period of time each year and is non-cumulative. The power of withdrawal is generally limited to the amount excludable from gift tax liability under the annual gift tax exclusion or to the greater of $5,000 or 5 percent of the trust property.

Declarations: Statements in an insurance contract that provide information about the property or life to be insured and used for underwriting and rating purposes and identification of the property or life to be insured.

Devise:  Refers to an inheritance of real or personal property under a will, or may mean to dispose of real or personal property by will.

Devisee:  A person or entity designated in a will to receive a devise.

Disclaimant: One who makes a disclaimer.

Domicile: One’s home or permanent residence where the laws of the state of a person’s domicile determine what happens to property at death.

Donee: The recipient of a gift.

Donor: A person who makes a gift; may refer to a person who establishes a living trust.

Dower: The life estate of a widow in the property of her husband.

Durable power of attorney: A legal document appointing another person (the Attorney in Fact) to act on behalf of another, even if that person becomes disabled or incapacitated.

Durable power of attorney for healthcare: A legal document that gives another person the power to make certain decisions regarding healthcare.

ERISA: The acronym for the Employee Retirement Income Security Act of 1974, a federal law that established minimum standards for certain employee benefit plans, especially qualified employer retirement plans.

Escheat: Assigning property to the state when a one dies with no known beneficiaries or heirs.

Estate:  All of one’s assets included in an estate for tax purposes; also used to refer to those items of property that are subject to administration in the probate court.

Estate planning: The process of arranging one’s personal and financial affairs.

Executor: The person or financial institution that is appointed to administer the estate of a deceased person who died with a will; also known as a “personal representative.”

Family Limited Partnership: A form of holding property combining some of the advantages of holding property as a corporation with some of the advantages of owning property in a partnership.

Fiduciary:  From the Latin word meaning trust and confidence and used to refer to a person (or entity) that serves in a representative capacity; personal representatives, trustees, guardians, conservators, and agents under powers of attorney are all fiduciaries; to stand in a position of confidence and trust with respect to each heir, devisee, and/or beneficiary.

Formal Probate: A proceeding before a probate judge to determine whether a decedent left a valid will.

Future interest: An ownership interest in property in which unlimited possession or enjoyment of property is delayed until some future time

Generation skipping transfer: A transfer of property, usually in trust, that is designed to provide benefits for beneficiaries who are two or more generations younger than the generation of the grantor.

Generation skipping transfer tax: A transfer tax generally assessed on transfers to grandchildren, great grandchildren and others who are at least two generations younger than the donor.

Generation skipping transfer tax exemption: An exemption from generation-skipping tax for transfers by an individual either during life or at death.

Generation skipping trust: Any trust having beneficiaries who belong to two or more generations younger than the grantor.

Grantor: A person that established a living trust. It is also used to refer to one who is transferring real estate in a deed.

Gross estate: The total property or assets held by a person as defined for federal estate tax purposes.

Guardian: An adult person appointed by a surviving parent in his or her will or by a court, who is responsible for a minor child or legally incapacitated person’s personal care and nurturing.

Heir: Person, who inherits property from the estate of a deceased person who died without a will.

Holographic will: A will entirely in the handwriting of the signer. Although valid in some states in some circumstances, most lawyers advise strongly against such wills

Incapacitated person: A person who is impaired by reason of mental illness, mental deficiency, physical illness or disability, advanced age, chronic use of drugs, chronic intoxication, or other cause (except minority) to the extent of lacking sufficient understanding or capacity to make or communicate responsible decisions.

Inter vivos trust: A living trust.

Intestate:  Refers to dying without a will.

Irrevocable trust: A trust that can no longer be amended or revoked by anyone; most revocable trusts become irrevocable at some time, for example, when the person who established the trust dies.

Joint and survivor insurance: A policy underwritten on the life of two persons, usually husband and wife or business partners.

Joint tenancy with right of survivorship: A form for holding undivided title to property among more than one person. When one of the co-owners dies, the other becomes the sole owner of the property.

Legally incapacitated person: One determined by a court as not capable of handling personal and/or financial affairs

Living trust: A trust that one establishes during one’s lifetime which is not part of one’s will, but is usually established by a separate written trust agreement; an “inter vivos trust” also sometimes referred to as a revocable living trust.

Living will: A legal document stating that the signer does want to be kept alive by artificial or extraordinary means, when there is no expectation of recovery from a physical or mental disability. The enforceability of such documents is unclear in absence of applicable legislation.

Marital deduction: A deduction allowing for the unlimited transfer of any or all property from one spouse to the other generally free from estate or gift tax.

Per stirpes: A way of distributing an estate so that the surviving descendants will receive only what their immediate ancestor would have received if he or she had been alive at the time of death; state laws vary.

Personal representative: The person or financial institution appointed by the probate register or the court to administer a deceased person’s estate

Pour over will: This is a will used to transfer (pour over) into a trust any property that is left in a person’s estate after death.

Power of appointment: A right given to another in a written instrument, such as a will or trust that allows the other to decide how to distribute your property. The power of appointment is “general” if it places no restrictions on who the distributees may be. A power is “limited” or “special” if it limits the eventual distributee.

Power of attorney: A written legal document that gives an individual the authority to act for another. If the authority is to act for the principal in all matters, it is a general power of attorney. If the authority granted is limited to certain specified things, it is a special power of attorney. If the authority granted survives the disability of the principal it is a durable power of attorney.

Primary beneficiary: Beneficiary of a life insurance policy who is first entitled to receive the policy proceeds on the insured’s death.

Probate:  The process of determining if the deceased person left a valid will and admitting that will to probate. When a will is “admitted to probate” it means that the probate register or the probate judge has signed a paper that says the will is admitted to probate. The paper the probate register signs is called a “register’s statement” and the paper that the judge signs is called an “order.”

Probate register: An employee of the probate court authorized to perform certain acts such as the admission of a will to probate in an informal proceeding.

Proceeding:  Involves the court in some type of activity such as the admission of a will to probate in an informal proceeding conducted by the probate register (this may be done by mail and does not involve a court hearing) or in a formal proceeding conducted by the judge in a hearing in the courtroom after proper notice to interested persons.

Qualified disclaimer: A written refusal to accept property from a decedent (by will, by the laws of descent and distribution, by contractual provision, or by beneficiary designation), made within nine months of the decedent’s date of death and delivered to the holder of legal title in such property. This is a common way to transfer property without paying a gift tax.

Qualified domestic trust: A trust arrangement which allows property transferred to a surviving spouse who is not a U.S. citizen to qualify for a special exclusion in lieu of the regular marital deduction; and which ensures that, at the death of the surviving spouse who is not a United States citizen, the assets placed in such a trust will incur federal estate taxation since the tax was avoided at the first spouse’s death

Qualified plan: Plans that qualify for favorable tax treatment under the Internal Revenue Code, and are subject to restrictive rules and extensive regulations. Qualified plans are secured by a trust, as opposed to a nonqualified plan.

Qualified terminable interest property: Property that, were it not “qualified,” would not qualify for the marital deduction in the decedent’s estate.  Because the qualified interest left to the surviving spouse terminates at his or her death (and there are no other rights that would result in inclusion of that property in the surviving spouse’s gross estate). QTIP does qualify for the marital deduction in the decedent’s estate and will be included in the surviving spouse’s gross estate, provided the proper election is made by the decedent’s personal representative.

Rabbi Trust: A trust, owned by the company that holds assets to help meet non-qualified benefit payments. Rabbi trusts are taxable trusts, and trust assets must be available to corporate creditors in the event of a bankruptcy.

Revocable living trust:  A living trust or inter vivos trust that can be amended and revoked, usually by the person who established the trust; the trust may become irrevocable when the one who can amend or revoke the trust dies or becomes incompetent.

Settlor: A person who established a living trust.

Special-use valuation: Pursuant to Code Section 2032A, special-use valuation provides that the “highest and best use” value may be reduced to an appraised “special use” in the gross estate up to $900,000.  This applies to real property used in a farming operation or a trade or business that meets certain requirements, and where certain pre-death qualifications are met and post-death commitments are made.

Sound mind: The testator possesses sound mind for the purposes of making a will if he or she: (1) understands the nature of the act of making a will or codicil thereto, (2) knows the extent and character of the property subject to the will, (3) knows and understands the proposed disposition of that property, and (4) knows the natural objects of his or her bounty (i.e. his or her heirs). Whether the testator was of sound mind is tested (determined) by the state of the testator’s mind at the time the will or codicil is executed (written and signed) and varies by state.

Supervised probate:  A proceeding for the administration of a deceased estate in which there is considerable court involvement; papers that have to be filed with the court and various types of hearings before the probate judge

Tenants in common: A form of asset ownership in which two or more persons have an undivided interest in the asset and the ownership shares are not required to be equal

Testamentary trust: A trust that is part of a person’s will.

Testate:  Refers to dying with a will.

Testator: A person who makes a will.

Trust:  An arrangement, usually established by a written document, to provide for the management and disposition of assets. It normally involves three parties: the person who establishes the trust (sometimes called a donor, grantor, settlor, or trustor), a trustee, and one or more beneficiaries.

Trust declaration [trust instrument]: A document defining the nature and duration of the trust.

Trustee:  An adult individual or financial institution that is designated to be responsible for the administration of a trust. There may be more than one trustee (co-trustees), and an individual and a financial institution may serve as co-trustees.

Trustor: A settlor.

Uniform gifts [Transfers] to minors act [UGMA or UTMA]: A method to hold property for the benefit of a minor, which is similar to a trust but the rules are governed by state law.

Will: A written document which disposes of one’s property at death. The will also is used to nominate personal representatives. It may also be used to express burial and funeral instructions, make anatomical gifts, and designate a guardian and conservator for a minor child or a legally incapacitated adult. 

Conclusion

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

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

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AIM Report on LOS

Briefer Hospital Stays not Always Better

Staff Writers

Briefer hospitalizations are not always best, according to a recent new study published in the Archives of Internal Medicine [AIM].

The PHCCC Study

A study of 15,531 patient medical charts, using hospital billing data from the Pennsylvania Health Care Cost Containment Council [PHCCCC], found that patients diagnosed with a pulmonary embolism [PE] who were discharged after four or fewer days in the hospital, were significantly more likely to die than those who remained in the hospital for five, six or more days. The study was also reported in the Philadelphia Inquirer newspaper.

Assessment

The study sought to determine whether new guidelines that recommend patients identified as being at low-risk for complications be discharged more quickly, were working as intended?

Conclusion

Unfortunately, they apparently weren’t as more than half of those discharged after four days or less had more severe cases.

Now, can this be described as the “ultimate policy in medical cost-containment?” Please comment.

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Disease Management Economics

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The Medicare Health Support Program

[By Staff Writer]

Doctor

The Medicare Health Support Program [MHSP] is a three-year experiment to determine if disease management [DM] can limit pathology and reduce expensive hospital visits for patients with chronic conditions. These typically include congestive heart failure, asthma and diabetes.

But, a new report suggests that this once highly-touted program may actually cost more than it saves.

Preliminary Outcomes

Since 2005, the Centers for Medicare and Medicaid Services [CMS] paid eight outside companies about $360 million to deliver DM services from nurses who periodically called patients to check on their diets, drug use, blood sugars, exercise patters and doctor appointments, etc.

Now, Medicare is still trying to figure out whether the program was able to keep folks healthier. Unfortunately, the New York Times reported that preliminary data indicates DM is unlikely to save money.

Mixed Opinions

Of course, at least two companies that specialize in disease management, Healthways and Health Dialog, are pressing Medicare to continue the project beyond the end of it term, saying the government mishandled the experiment.

But, CMS says the program so far has not reduced medical bills enough to offset the fees the companies are charging the government [about $2,000 per patient/per year].

Assessment

Final MHSP accounting is likely to come next year. And so, it seems that in this case, education and DM might not be “the best prescription.”

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Conclusion

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The Sheffield Group

Candidates for Hire

By Amy Kilcoyne
Director of Placement Services

Sheffield Group                                                  

 

Candidate 1

Siebel Maintenance Release and Support

Experienced in Siebel Sales, Call Center, eCommunication and eFinance modules. Experienced in Siebel integration with external and legacy applications. Successfully undertaken Siebel eFinance 7.5.3 implementation for Siebel Professional Services. Siebel Batch Integration (EIM) team. Expertise in Data Migration between Siebel 7.5 and Siebel 7.8. Experience in ETL tool like Informatica 7.1 and DTS. Participated in Siebel TAM reviews.

Candidate 2

JD Edwards EnterpriseOne

Technical experience in JD Edwards EnterpriseOne products including product versions including 8.10, 8.9, B7334, B7333 (Xe), B7332 and B733 technologies. Application design experience in JD Edwards World product (VersionA7.3 Cum 12) software with project management experience in Electronic Data Interchange (EDI) configuration and a technical knowledge with the Gentran Server NT, Gentran Integration Suite, Gentran Director, Inovis (Harbinger) TLE, GE Information System. Experience primarily focused in the areas of Design, Development, Implementation, Migration, Maintenance and Production support.

Candidate 3

Lawson ERP Analyst

Conduct discovery sessions of HR and Payroll processes; analyze user functions and publish recommendations for process improvements. Provide documentation and lead training sessions on improved processes. Improvements focused on hiring process, benefits automation rules and job and position audit. Assist organization in cyclical upgrade of Lawson applications 8.02 to 8.03.

Candidate 4

PeopleSoft Financials / SCM / HRMS

PEOPLESOFT: PeopleTools 6.X/7.X/8.X, PeopleCode, SQR, Query/Crystal, nVision, Data Mover, Application Engine, Upgrade assistant, Change assistant, Work flow, EDI, App Messaging, Integration Broker, HRMS (HR, Payroll, Base Benefits, Ben Admin, Time and Labor, e-Applications), Financials (AP, GL, AM), SCM (Purchasing, Inventory).

Candidate 5

Senior Lawson Specialist

Successfully led the technical team for the PeopleSoft to Lawson Human Resources/Payroll (7.2.4) conversion for a large Corporation; Successfully developed numerous in-depth Technical Designs for Lawson Interfaces, Batch Reports, Conversions, and Online programs; Interfaced information between the Technical team and Client department personnel.

 

The Sheffield Group, 1 Westbrook Corporate Center, Suite 910, Westchester, IL  60154 or 866-539-9497.

 

Six-Sigma in Healthcare

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Brief History of a Process Improvement Methodology

[By Daniel L. Gee; MD]

The concepts of process improvement [PI] and total quality management [TQM] emerged after WW-II, when the Japanese auto and electronics industries, in a quest to capture the US marketplace, virtually re-coined the term “Made in Japan” from a trademark of inferiority, to a worldwide stigmata of quality and endurance.

First Used in the Automobile Industry

Toyota Motor Company soon became the ideal model to emulate by US companies such as Ford, Motorola and later, General Electric. The Deming model and subsequent Total Quality Improvement/Continuous Improvement [TQI/CI] management initiatives, copied from Japan, evolved with a passion when brought to America. The search for best practices led to the popularity of accolades such as The Malcolm Baldridge Quality Award; an award that became Olympic gold to a company’s marketing campaign.

The quality envelope was pushed further in the 80’s when Motorola Corporation augmented traditional improvement tools with a systematic problem solving method [think problem orientated medical record] based on rigorous statistical analysis. This evolution of a process-oriented problem solving approach soon became the genesis of what is now known as the Six Sigma Methodology.

Goals

The ultimate goal of the Six Sigma model is to find the root causes of variation in a business process, such as healthcare delivery, find the problems that created the variations, determine ways to measure them, and control (or eliminate) the process variations; with the intent of process improvement that has long-term sustainability. The achievement of quality to its greatest extent would be a measured in a quantifiable metric of “sigma”. The greater the sigma level reached, the more efficient the process. 

Six-Sigma Possibilities in Healthcare Delivery

In reaching the six-sigma level, there is almost no variation from the most desired efficient way of doing things. Is this ultimate goal of perfection too ambitious a goal for healthcare? Perhaps!

For service industries in general, and the healthcare industry, specifically, the goal of virtual perfection may be impossible by virtue of the significant number of variables involved.

But, one must consider the implications of a less than almost perfect system.

Mathematical Definition

The term “sigma” is from the 18th letter of the Greek alphabet and represents the statistical symbol for standard deviation. In statistics, a standard bell shaped normal population distribution, one sigma represents a percentage variation from the mean, and two- sigma represents an even greater variance, and so on.

Variations of Virtual Perfection

In Six Sigma vernacular, the bell shaped curve becomes a representation of variation itself; in other words, achieving a “six sigma” process means virtual perfection in the upper standard limits of being 99.99966% good.

Assessment

And, so is the ideal of six-sigma possible in medicine today; or are there just too many variables in the delivery process? How does your perspective change as a physician, CEO, insurance company or patient?  

In other words: Is medicine really different?

Conclusion

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Doctor Economic Profiling

Q: What is physician economic profiling?

My hospital is considering this investigational methodology and many of us are naturally suspect. Can anyone shed some insight on the matter? Is it for real; punitive, instructional, collegial or are we all just paranoid; and/or any or all of the above! Thanks in advance. 

Dr. Joseph Martin Battalion                                                                             South-East Alabama

 

Medicare Part D Electronic Prescribing

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New Four Part Standards

[By Staff Writers]

The Centers for Medicare & Medicaid Services [CMS] finally published regulations which establish Part D electronic prescribing standards for four types of information: 

  • formulary and benefits,
  • medication history,
  • fill status notification, and
  • identification of individual health care providers.

All Need Not Comply

Drug prescribers, dispensers and plan sponsors are not required to implement e­-prescribing under Part D.

But, those who do must comply with the new Medicare standards when using e-prescribing to send prescriptions and prescription related information for covered drugs prescribed for Part D eligible individuals.

Assessment

These new standards supplement the 2006 “foundation” standards that first addressed the exchange of Part D information related to eligibility inquiries and responses; new prescriptions; and changes, renewals, and cancellations of existing prescriptions; according to the Health Industry Watch, in Washington, DC.

Conclusion

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On Physician Peer Review

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New Era Risks

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]insurance-book

The Center for Peer Review Justice is a group of physicians, podiatrists, dentists and osteopaths who have witnessed the perversion of medical peer review by malice and bad faith.

Raison D’etre

Like the American Association of Neurological Surgeons [AANS], they have seen the statutory immunity, which is provided to “peers” for the purposes of quality assurance and credentialing, used as cover to allow those “peers” to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition.

Cause and Goals

Therefore, the group is dedicated to the exposure, conviction, and sanction of doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, that would use peer review as a weapon to unfairly destroy other professionals.

Assessment

www.PeerReview.org is a rallying point and resource center for any medical professional that finds himself in the midst of an unfair and bad faith attack by unethical, malicious “peers”.

Conclusion

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  Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

 

Expert Witness Risks

A New Emerging Modern Peril

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

insurance-bookIn the past, a physician expert witness for the plaintiff was merely an opposing opinion by a learned and/or like colleague. Today, it is becoming a risk management minefield as the AMA and other groups are urging state medical licensing boards to police expert witnesses, which might require expert testimony be considered the practice of medicine.

The AANS

This seems especially true with the Rolling Meadows Illinois based American Association of Neurological Surgeons (AANS).

Feuding Members

Currently, a member of the AANS can file a complaint against any fellow member for testimony as either an expert witness for the plaintiff, or defense witness for the doctor. A committee of four then reviews the court records and requires the accuser to face the accused in a formal review. Sanctions range form three months to a year, to complete expulsion from the association. In the past twenty years, the program has reviewed 27 cases all involving plaintiff testimony. One led to expulsion and ten to suspension.

Assessment

Since 2001, the courts are beginning to take the AANS process seriously. After years of operations without strong legal backing, the program was upheld by the 7th Circuit Court of Appeals, in Chicago by a neurosurgeon whom the group suspended in 1997. So always remember, if you testify falsely, or too far from the norm, you may be at risk.

Conclusion

And so your thoughts, opinions and comments are appreciated?

Speaker: If you need a moderator or a speaker for an upcoming event, Dr. David Edward Marcinko; MBA – Editor and Publisher-in-Chief – is available for speaking engagements. Contact him at: MarcinkoAdvisors@msn.com

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Failure 2 Rescue

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Attention “Condition H” 

[Staff Reporters]

For the fifth straight year, an analysis of errors in our nation’s hospitals found that the most reported patient safety risk is a little-known, but always-fatal, problem called “failure to rescue.”

Definition

The term Failure-To-Rescue [FTR] refers to cases where hospital doctors, nurses or caregivers fail to notice symptoms, or respond adequately or swiftly enough to clinical signs, when a patient is dying of preventable complications in a hospital.

The situation is not new. The term “failure to rescue” was first coined in the early 1990s by Dr. Jeffrey H. Silber, director of the Center for Health Outcomes and Policy Research [CHOPR]. He was looking for a way to characterize the matrix of institutional and individual errors that contribute to patient deaths.

Call ‘Condition H’

Today, to help mitigate the FTR problem, a growing numbers of hospitals across the country allow patients to speak up by activating ‘Condition H,’ a code that summons immediate help.

Assessment

In a Condition “H “alert, patients call the same emergency number that doctors and nurses use.

MORE: Before Code Blue: Who’s minding the patient? [Little-known ‘failure to rescue’ is most common hospital safety mistake.  www.msnbc.msn.com/id/24002334

Conclusion

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Doctor Debtor’s [Brazen Few Increasing?]

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Education and Other Debt-Load Risks

[By Staff Writers]biz-book

Managed care is a prospective payment method where medical care is delivered regardless of the quantity or frequency of service, for a fixed payment, in the aggregate. 

Desperate Students Doctor’s and Healthcare Professionals

Among the many reasons why doctors are financially unhappy, some might even say desperate today, is because a staggering medical student loan debt burden of $100,000-$250,000 is not unusual for new practitioners. For example, the federal Health Education Assistance Loan (HEAL) program reported that for the Year 2002-03, student numbers and default totals include*: 

  • Allopathic Medicine 194, $20,495,446
  • Chiropractic 926, $74,781,238
  • Clinical Psychology 40, $3,051,546
  • Dentistry 342, $40,158,139
  • Health Administration 4, $285,543
  • Optometry 29, $2,481,808
  • Osteopathy 39, $4,988,389
  • Pharmacy 33, $1,320,457
  • Podiatry 127, $17,797,564
  • Public Health 7, $569,733
  • Veterinary Medicine 1, $32,602

Total for all disciplines: 1742, $165,962,465

And, the totals are even higher in 2008

Source: www.defaulteddocs@hrsa.gov

Other Debts

Significant miscellaneous debts incurred by doctors usually include “excessive-wants” more than “actual-needs”. Such extravagances include automobiles, homes, vacations, clothes and depreciating assets or “toys.”

Often, doctors even reckon they are immune from typical small claims debts, or court collection actions, by virtual of their education and career. For example, alleged non-payment of the following de-minimus private debts have allegedly been freely admitted by these doctors for illustrative purposes, despite prior threats of credit agency reporting and other perfectly legal fair debt collection tactics:

Public Non-Payment Rebuke:

  • Mark Hill, MD; Pulaski, New York
  • Tom Pfennigwerth, DPM; Seneca, PA

Assessment

Of course, one wonders, perhaps ironically, about the billing and AR collection practices of such miscreants in their own medical offices; ethics, legality, morality?

Conclusion

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Emergency Room and On-Call Risks

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Next-Gen Doctors Opting-Out

Dr. David E. Marcinko MBA - MSLBy Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Of course, it’s getting more expensive these days to take hospital call as physicians are electing not to take this responsibility because of decreased reimbursement rates. Others opt-out because of a desire to spend more time with family, and/or scheduling conflicts. And, let’s not forget the liability concerns.

Historical Review

But, back in the old days, I recall eagerly signing up for call to make a few extra bucks [it was a very competitive proposition back then], as I started my fledgling practice.  About a decade later, I didn’t make much on-call money any more, but continued my rotation and chalked it all up to societal “pro-bona care”. And, the increased service visibility still garnered me a few lucrative patient referrals. Then, it became a financial and out of office-time loss, and ultimately a great liability headache. Fortunately, I could afford not to do it any more; and quit. Let the younger guys and gals “pay their dues”, I reasoned.

Legal Issues

Now today, there is a growing revolt of specialists against hospital on-call duties that threatens to violate Federal law and lose status as trauma centers. Specialties most likely to refuse include plastic surgery, ENT, psychiatry, neuro-surgery, ophthalmology and orthopedics. And, refusing to respond to assigned call is a violation of Federal law and carries fines as much as $50,000 per case.

Opting –Out

In contrast, refusing to sign up for call does not violate the law, and more physicians are taking this option. The problem opting-out problem is especially acute in California where hospitals are combating the issues with compensation, reporting the miscreant docs to the authorities, or threatening to remove them from staff completely.

Assessment

In turn, doctors are fighting back with lawsuits.

Other Supporting Opinions

Essayist Jeff Goldsmith,President of Health Futures Inc, and Associate Professor of Public Health Sciences at the University of Virginia*recentlyopined that:

“We can expect intensified conflict with private physicians over the hospital’s 24-hour mission and service obligation, specifically providing physician coverage after hours and on weekends. Younger physicians have shown decreased willingness to trade their personal time to cover hospital call in exchange for hospital admitting privileges as their elders did. Those admitting privileges are either less essential or completely unnecessary in an increasingly ambulatory practice environment. The present solution is for hospitals to pay stipends to independent practitioners for call coverage or to contract with single specialty groups large enough to rotate call internally.” 

NOTE: * Goldsmith, Jeff: The Long Baby Boom, by Johns Hopkins University Press, May 2008.

Conclusion

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National Health Insurance [NHI] Survey

MDs Now Favor Reform – According to AIM

Staff Reporters

According to a study just released in the Annals of Internal Medicine [AIM], a majority of doctors now favor national health insurance [NHI] which represents a thought shift over the past five years.

Survey Results

The study conducted last year found that 59 percent of surveyed physicians supported “government legislation to establish national health insurance,” while 32 percent opposed it, and 9 percent remained neutral. In 2002, a similar survey found that 49 percent of physicians supported the concept, while 40 percent opposed it, reported the Washington Post.

Support Varies Among Specialists

The strongest support for NHI was among psychiatrists (83 percent), pediatric sub-specialists (71 percent), emergency room physicians (69 percent), pediatricians (65 percent), internists (64 percent) and family physicians (60 percent). About 55 percent of general surgeons support NIH or double the level of support in 2002.

NIH Definition

Typically, national health insurance plans involve a single, federally administered social insurance fund that guarantees health coverage for everyone, while in most cases these plans eliminate or substantially reduce the role of private insurance companies.

Conclusion

And so, your thoughts and comments on the above report are appreciated.

Institutional: www.HealthcareFinancials.com

Terms: www.HealthDictionarySeries.com

 

 

Hospital IRS Form 990 Tax Burden

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New Schedules – H and K – for Non-Profits

[By Dr. David Edward Marcinko; MBA, CMP™]dem21

As quarterly premium print-subscribers to Healthcare Organizations [Financial Management Strategies] know, the IRS redesigned Form 990 last year.

Form 990 Burden

The new Form 990 is controversial among not-for-profit hospitals (Schedule H) and tax-exempt bond issuers (Schedule K). Schedule H requires hospitals to provide new information on operations, including community benefit levels, charity care, aggregate bad debt expense, Medicare shortfall information and more.

Input Request

Now, the IRS is asking for healthcare sector input to promote uniform reporting, and make sure the form is simple enough for public use. So, through June 1 of this year, Uncle Sam is accepting comments on Form 990 draft instructions. And, the agency will post all comments on its website.

Hospital

FORM: IRS Form 990

Conclusion

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Top Ten Brand-Name Elder Drugs

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Top 10 Brand-Name Drugs Ranked by Prescriptions Filled in PACE*

Mature Woman

Rank

Drug Name

Type of Drug

Median Negotiated Monthly Price

1

Lipitor

Cholesterol

$79.12

2

Plavix

Cardiovascular

$125.91

3

Protonix

PPI

$117.67

4

Nexium

PPI

$145.09

5

Fosamax

Osteoporosis

$79.15

6

Diovan

Cardiovascular

$57.54

7

Aricept

Dementia

$158.49

8

Zetia

Cholesterol

$87.06

9

Actonel

Osteoporosis

$83.60

10

Prevacid

PPI

$146.41

*PACE = Pennsylvania’s Pharmaceutical Assistance Contract for the Elderly (PACE) program

Data Source: PACE utilization data and Hargrave et al. analysis of data on pricing from the CMS Medicare Prescription Drug Plan Finder on Medicare.gov, for the Kaiser Family Foundation.

Publication: Medicare Part D 2008 Data Spotlight: Ten Most Common Brand-Name Drugs, Kaiser Family Foundation, April 2008. http://www.kff.org/medicare/7749.cfm

Assessment

The above is self-explanatory.

Conclusion

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“Executive-Post” Nominations Sought

Seeking Exceptional Advisors and Consultants  

Has your personal financial planner, or corporate financial management advisor, been invaluable to you, your family, medical practice, clinic or healthcare entity? How about that special practice management consultant or health economics business expert? Would you like to give your expert-of-choice the recognition he or she deserves?

The “Executive-Post” is now seeking nominations for our annual list of the best advisors serving physicians, nurses, hospital administrators, medical executives and all stakeholders in the healthcare industrial complex; whether serving needs of a personal, business or corporate nature. We highlight the best minds in areas ranging from physician focused planning, health economics and business management, to enterprise-wide financial management. All are to be listed in a future feature-package on the “Executive-Post!”

CLIENTS who wish to recommend a financial advisor or management consultant for consideration are asked to submit a nomination by December 31, 2008.

ADVISORS who wish to be considered must complete an application form by December 31, 2008.

INFO: Additional information is available MarcinkoAdvisors@msn.com

 

 

Physicians-as-Employees [The Benefits]

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On Tax Free Benefits

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

There are three categories of benefits that hospitals typically provide to their physician [hospitalists], medical, nursing or technical employees; or clinics, office and medical practices provide to their employed staff:

Those that are totally income tax-free; some are still taxable for FICA (Social Security and Medicare).

Those that are not taxed at their full economic value, or are taxed at a special preferential rate.

Those where a tax liability is not incurred until sometime after the employee receives the benefit.

1. Tax-free Benefits

The following are benefits typically provided that are tax-free to physicians and hospital employees:

  • Group term life insurance
  • Accident and health benefits
  • Moving expense reimbursement
  • Dependent care expenses
  • Meals and lodging
  • Adoption expense assistance
  • Use of athletic facilities
  • Employee awards
  • Educational assistance
  • Qualified employee discounts
  • No additional cost services
  • Retirement planning service
  • De minimus benefits
  • Qualified transportation benefits
  • Working condition benefits
  • General fringe benefits
  • Miscellaneous specialized provisions

All tax-free benefits have varying conditions, which can include:

  • What constitutes a benefit to qualify (as defined by the IRS)
  • What constitutes an employee to qualify; the most commonly restricted employee types are S corporation employees who owned greater than 2% of the corporation’s stock in the taxable year, highly compensated employees and key employees.
  • Which employees are excluded
  • Monetary caps
  • IRS reporting requirements
  • Exclusion from what type of taxes (income, FICA and FUTA)

Assessment

And so, what has been your experience with the above; is the tax-free benefits package increasing or shrinking, please comment and opine?

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Conclusion

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Section 83(B) Elections

Considerations for Hospital Employees

Staff Writers 

Internal Revenue Code § 83(b) allows a hospital or other employee who receives employer stock on a tax-deferred basis to be taxed immediately in the year the stock is transferred, regardless of the presence of a substantial risk of forfeiture.

If the employee makes such an election, any subsequent appreciation is not taxable as compensation. Once made, the IRS must approve any change you may want to make.

Indications

There are several reasons why a taxpayer might want to make such an election.

  • First, absent a Section 83(b) election, any appreciation in the value of the stock that occurs after transfer will then be subject to ordinary income taxation at the time of vesting for the full amount by which the then-appreciated fair market value exceeds the amount paid, if any.
  • If a Section 83(b) election is made, any post-transfer appreciation will not be taxed until the stock is sold and will only be subject to capital gain taxation on its ultimate sale.
  • If one expects the restricted property to appreciate substantially before vesting and one plans to hold the property for a long time after it vests, such delay in taxation of the appreciated amount may be a significant benefit.
  • If the taxpayer holds the property until death, any post-transfer appreciation will escape income taxation entirely.

Contra-Indications

  • The main disadvantage of the Section 83(b) election is the triggering of current taxation for the excess of fair market value (without regard to any restrictions or risk of forfeiture) over the amount paid.
  • In addition, the Code provides that, if a Section 83(b) election is made before the lapse of the restrictions and such property is subsequently forfeited due to the failure to meet the conditions, no deduction can be made.
  • Furthermore, if a Section 83(b) election is made and the property later declines in value; only a capital loss is allowed.
  • Finally, the employer receives no deduction for any later appreciation before vesting, nor will the hospital or company be able to take a deduction in the case of transferred stock on any dividends after the transfer that are paid to the employee.

Assessment

The election consists of a written statement, mailed to IRS center where you file your return, within 30 days of the triggering transaction.  It must include everything about the transaction.

Conclusion

Your comments, experiences and opinions on this election are appreciated.

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