Stark III Legislation

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Self-Referral Rules Unveiled

[Staff Reporters]

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The Centers for Medicare and Medicaid Services [CMS] recently reported changes to the Stark self-referral ban that could have a significant effect on physician-hospital relationships and Physician-Hospital-Organizations [PHOs]. 

Final IPPS Regulations

The new changes appeared in the final Inpatient Prospective Payment System [IPPS] regulation unveiled on July 31, and due for publication in the August 19th 2008 Federal Register [FR].

“Standing-in-the-Shoes” and other Issues

The healthcare industry will soon have to navigate new Stark rules on issues like percentage-based compensation, per-click arrangements and other “stand-in-the-shoes” legal analysis. And, it’s time to sunset “under-arrangements” with physicians because CMS finalized its revised definition of entities that provide Designated Health Services (DHS) under Stark.

But, CMS also cleared a path for returning to Stark compliance over unsigned physician contracts, and clarified how providers can end the “period of disallowance,” when a Stark violation renders Medicare claims un-payable.

Assessment

According to the Report on Medicare Compliance [8/11/08], the Stark self-referral law bans Medicare payments to entities providing DHS if patients were referred by physicians with an ownership, investment or compensation relationship with the DHS entity.

Conclusion

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Improving Inter/Intra Professional Relations

Establishing Rapport within the Medical Community

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

By Hope Rachel Hetico; RN, MHA, CMP™

Managing Editor

In our consulting work, publishing, speaking engagements and relate professional endeavors, we are often asked how to establish and even increase professional visibility in a particular medical, or even alternative-medial community.

While there is no-one-size-fits-all answer, the following are useful “tips and pearls” to enhance your awareness among known, and unknown, physician colleagues in your geographic locale.

A Few “Tips and Pearls”

  • Send office announcements to all health professionals in the community. Include pharmacies, pediatricians, family practitioners, PAs and NPs, concierge practices, chiropractors and alternative medical provides, convenient-care and convalescent facilities. All are potential sources of patient referrals.
  • Meet other health professionals personally and establish a one-to-one relationship with them. This will serve to educate them to your abilities and practice.
  • Send written reports to all practitioners who refer patients.
  • Do not hesitate to refer patients for consultations, as indicated. This is not only good business sense, but good medicine.
  • Use novel business cards, such as the new CD-ROMs cut into the size of a standard business card, by One Voice Technologies, of San Diego. For about a dollar, depending upon quantity, you can order a labeled disc with all the business information of a standard card, which also functions as a CD-ROM containing up to 100 megabytes of multi-media data about your medical practice or specialty.

Assessment

Please feel free to send in your own “tips” and favorite professional relationship building ideas.

Conclusion

What differentiates you from the competition, and how did you become know in your local medical community; please opine and comment?

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Healthcare Organizations: www.HealthcareFinancials.com

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Physician Advisors: www.CertifiedMedicalPlanner.com

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Eroding Doctor-Patient Relationships

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The “Bed-Side Manner” Deterioration Continues

[By Staff Reporters]

A growing chorus of discontent suggests that the once-revered doctor-patient relationship is on the rocks.

Results

About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins University [JHU] study published in the journal, Medicine, while two recent studies show that whether patients trust a doctor strongly influences whether they take their medication, according to the New York Times, on July 29, 2008.

Tell-all-Books

In bookstores, there is now a new genre of “what your doctor won’t tell you” books promising previously withheld information on everything from weight loss to heart disease, while the Internet is bristling with frustrated comments, blogs, text-messages and wiki’s, etc., from patients.

Raison Detra’

Reasons for the frustration include declining reimbursements and higher costs that give doctors only minutes to spend with each patient, news reports about medical errors and drug industry influence fueling patients’ distrust, and the rise of direct-to-consumer drug advertising and medical Web sites that have taught patients to research their own medical issues and made them more skeptical and inquisitive.

Of course, related quality improvement initiatives seem to be loosing ground.

Assessment

One can only wonder if more extensive use of physician-extenders; like PAs, CRNAs, CNMWs, NPs and DNPs are part of the solution; as well as well-trained limited licensed providers like podiatrists, dentists, optometrists and psychologists; along with walk-in, on-site and retail medical clinics, etc?

Conclusion

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Risk Management: It’s Not All About Medical Malpractice Anymore

Book Review

By Murray J. Goodman; MD

In the narrow world of our day-to-day practice, orthopaedic surgeons often think of risk management strictly in terms of avoiding exposure to medical liability lawsuits. But, in the book Insurance and Risk Management Strategies for Physicians and Advisors, author, physician, and healthcare economist David E. Marcinko has assembled a cadre of experts who address the broader issue of risk management.

Link: http://www.amazon.com/Insurance-Management-Strategies-Physicians-Advisors/dp/0763733423/ref=sr_1_3?ie=UTF8&s=books&qid=1217606361&sr=1-3

15 Chapter Overview

This book examines the many important risks that we, as physicians, face daily in the practice of medicine. You may not think of life insurance, sexual harassment, Medicare fraud, marital divorce, and privacy issues as part of a risk management plan, but they are. Dr. Marcinko has written a book that provides an initial reference point for these diverse issues.

Each of the 15 chapters covers a single area, providing a broad overview as well as specific information and recommendations. This book addresses the personal, professional and business risks physicians face on a daily basis.

Personal Insurance Matters

The personal side of insurance is first, beginning with a discussion on insuring the doctor’s life. The chapter explains the various types of policies available, as well as various permutations and combinations of policy provisions. It briefly discusses both health insurance and long-term care insurance. It includes the critical features to look for in selecting a long-term care policy for yourself and the necessary criteria for successfully filing a claim under such a policy.

Practice Insurance Matters

Many orthopaedic practices are also small businesses, so property insurance and the business uses of life insurance, such as in buy-out and succession planning, are covered. The author reviews the use of restrictive covenants and employment contracts, providing examples of what works and what does not. One of the questions this chapter addresses is the difference in applicability between a restrictive covenant with regard to a departing employed physician and a restrictive covenant included in the sale of a medical practice.

Compliance Topics and Medical Workplace Regulations

Recent actions by the Department of Justice [DOJ] and activities of the Office of the Inspector General [OIG] regarding Medicare have focused attention on compliance issues. The text provides a good overview on medical documentation and healthcare compliance, including a summary of record-keeping obligations.

In addition, the author includes pointers on how a medical practice can avoid running afoul of the federal False Claims Act, fraud and abuse statutes, Stark and safe harbor laws, and the “alphabet soup” of HIPAA, OSHA, and ERISA regulations. Risks involved with serving as an expert witness, doing peer review and taking call are also covered. The discussions are as timely as those sponsored by the AAOS. The chapter on medical malpractice even includes a discussion of physician self-regulation and expert witness discipline.

Sexual Harassment Issues

The section on sexual harassment explains what constitutes a hostile work environment and what the physician’s role should be in risk avoidance. Complimenting an employee’s dress or telling a slightly off-color joke may seem innocent enough, but not if they meet the two criteria that determine offensive behavior and can lead to a lawsuit. Violence in the workplace is discussed as it relates to patients and employees, both as perpetrators and as victims. The author recommends that every orthopaedic practice have a policy and a plan in place to deal with these issues should they arise.

Malpractice Liability and Going to Court

One-quarter of the book is devoted to medical liability risks. Although the discussion of the medical liability crisis might be a bit dated and only too familiar to many readers, the section on the anatomy and procedures of a medical liability trial and the physician defendant’s role in that process is excellent. From subpoena to verdict, the process is laid out. Written by a malpractice attorney who is also a physician, the chapter provides solid advice on how to respond to the subpoena, secure the medical record [make an exact copy and seal it], and find personal counsel.

Pre-Nuptial Agreements, Divorce and Asset Protection

The financial risks of divorce are rarely covered in books geared to medical professionals, but this text examines them in detail. It also discusses prenuptial agreements and the special circumstances surrounding older divorcing medical professionals. Final chapters cover asset protection principles and how to select insurance and financial advisers who specialize in serving medical professionals.

Recommended Reading

Each chapter is authored by an expert in that particular field, but the text has a uniform consistency and approach, listing basic principles and citing specific examples to illustrate the issues involved. Ample references are provided, including written texts and articles, case law, and Internet Web sites. The table of contents is functional, and the index is well-organized for quick reference.

Insurance and Risk Management Strategies for Physicians and Advisors[Jones and Bartlett Publishers, Sudbury, Mass] is a comprehensive examination of risk management strategies. It does not provide specific legal or financial advice, but it does provide a background in many areas germane to the practical aspects of maintaining a medical practice in this millennium. Although not a stand-alone text, it gives the reader the vocabulary and information necessary to take many of these issues to the next level.

Assessment

“This book is recommended reading for those about to enter the practice of medicine; those already in practice will find it a helpful reference when seeking resources on a particular issue”.

Personal

My wife tells me that because it also addresses the personal and emotional issues affecting physicians’ lives, it is suitable for spouses as well.

Note: Murray J. Goodman, MD, is a member of the Medical Liability Committee. He can be reached at mj-goodman@comcast.net June 2008 AAOS Now http://www.aaos.org/news/aaosnow/jun08/managing2.asp

From the article of the same title AAOS Now (06/08) Goodman, Murray J.

http://www.asoa.org/resources/practice-mgmt-news/practice-management-news.cfm

Conclusion

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Physician Recruiting Success

Senior Leadership’s Contribution
By Allison McCarthy; MBA

If you’re recruiting physicians to your organization, then you probably feel challenged by internal disconnects that hinder your progress. More than likely you deal with one or more of them daily. And for many of these issues you need your senior leader to be your ally, champion and advocate, helping you navigate around those obstacles.

But, exactly what skill set within your leader is your most important resource? And how can you optimize those attributes when you need them?

Leading-Up

Leading up is one of the physician recruiter’s greatest challenges. Getting the right amount of time and attention (to establish an internal environment attractive to candidates) is critical to successfully bringing new physicians into the organization.

Beyond that, it is about having your senior leader play the right role at the right time in the recruitment process to deliver results. Their most vital contributions are:

1. Establishing Priorities
Medical staff development planning and priority setting are senior leadership obligations. And, in today’s high demand/shrinking supply of physicians, most organizations and their senior leadership need to improve their recruitment planning to get ahead of the competition. With the average time to fulfill a recruitment project for some specialties taking 24 months or longer, many recruitment assignments need to start two to three years ahead of projected need. That means having solid delineation of recruitment priorities – not just for the coming 12 months but for the next three or more years. Medical staff development planning and priority setting is the obligation of senior leadership.

2. Clearing Clutter
Some recruitment priorities are unsettling to members of your existing medical staff. Others are important to only a select group and lack organization-wide urgency.

As a result, we can face internal team members that encumber success – either purposefully or innocently obstructing candidate advancement through the interview process. In those instances, your senior leader needs to clear the way – either by negotiating with saboteurs or motivating the unresponsive. This then leads to the third attribute.

3. Communicating the Vision
Establishing physician recruitment as a strategic core competency is not easy. So much of what it takes to achieve the desired goal – a recruited physician – requires many pieces and parts of organizational input and participation. To create that involvement necessitates that the entire enterprise understands the “why” behind the recruitment agenda. Senior leadership must regularly communicate the vision behind the effort.

Only leadership can motivate the parties needed to be involved. Only leadership can establish its urgency among conflicting agendas and clarify priorities when there is uncertainty. Only leadership can guide the necessary cultural change so the organization is receptive to and welcoming of new physicians.

We often assume that because someone is a leader they know what to do. We also know what happens when we assume (you know the old saying right?). But we are the organizational experts on physician recruitment. We are also senior leadership’s eyes and ears to organizational reactions and reverberations.

So, our senior leaders need us to direct them to what is needed. Some key strategies to do that include:

a]. Collecting/Sharing Market Intelligence
David Cottrell in Monday Morning Choices said, “The process of discovering reality includes examining the facts and separating them from feelings and egos.” Regularly sharing information from articles or external statistical resources can help leadership understand the realities of the market and the challenges of recruiting specific specialties needed.

Further, tracking and trending prospect feedback about our opportunities provides the justification senior leaders need to enhance package elements and make them more market attractive. While we can share this information anecdotally, it doesn’t have the same impact on those we are trying to influence. Senior leaders come from a data-driven world. They spend their days reviewing financial statistics and operational performance findings. So, we need to translate our recruitment findings into their decision-making language if we want to influence and change the outcome.

b]. Tracking the Recruitment Process
Not dissimilar to the above, benchmarking the various touch points in the recruitment process identifies the gaps and obstacles that need to be addressed.

A simple spreadsheet that captures those key dates when the candidate moves from one stage in the recruitment process to the other illustrates those situations when consistently there are delays in response by the organization. Match that with candidate rejection feedback and you tell a compelling story about the internal issues that need to be addressed by your senior leader.

c]. Sharing the Wins
All of us need positive reinforcement and your senior leadership and internal organization are no different. Beyond communicating successes, it also means giving credit to those who participated in reaching the goal. When you see all pistons firing – everyone is on-board and doing their part, and the process flows as it should – celebrate those victories and recognize those that contributed in obtaining the prize.

By doing so, inertia often gets lifted by illustrating that success feels good. Momentum is generated for the next recruitment assignment and the entire process has established credibility by demonstrating how much more can be accomplished when there is team energy and involvement.

“Leaders push boundaries. They desire to find a better way. They want to make improvements. They like to see progress. All these things mean making changes, retiring old rules, inventing new procedures.”
John Maxwell

Assessment

As a former in-house recruiter and a consultant to organizations today, I know many health care enterprise senior leaders are looking to the physician strategy team to direct and guide the ways they can be most effective. That is not only an obligation but an opportunity to be leadership’s partner in fulfilling this vital strategic agenda. There is no greater reward!

Conclusion

And so, what do you think, and do, about physician recruiting success? Your thoughts and comments are appreciated.

Related Information Sources:

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

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Physician Compensation Trends Query?

Tacoma / Seattle Washington Area

As compensation professionals, Certified Medical Planners [CMPs] and financial advisors [FAs], what kinds of trends are you observing in physician compensation for multi-specialty hospitals in the Tacoma/Seattle Washington state locations? 

Additionally, what innovations (in 2008) are observed in the manner doctors and hospital leadership are compensated?

Please e-mail ASAP, if possible to Kkyewu1@aol.com

Thank you ever so much!
Warm Regards.
Beverly Motley

 
 
 
 

 

MD Compensation and Benchmarking Tools

MGMA and ValueSource Release Software

Staff Reporters

Free online compensation and productivity benchmarking tools for physician practices are now available from ValueSource Software and the Medical Group Management Association [MGMA].

Dashboards in the Cloud

The two web-based [internet computing] dashboards enable physicians and group practices to enter a few easy-to-find variables about physician compensation, and production and costs, and then compare themselves to national norms. Practice managers select their specialty from a pull-down menu, enter information about compensation, collections, gross charges, ambulatory encounters, surgery/anesthesia cases, and work RVUs, etc.

Assessment

The internet based cloud dashboards compare that data to national norms and produce a series of six gauges that measure physician performance in specific areas.

Conclusion

Please opine if you have used these new tools in your practice, clinic or hospital setting; and tell us what you think. Your review and evaluation is appreciated and will assist Executive-Post readers.

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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Medical Cultural Disparity

A Real or Perceived Contemporary Concept?

Staff Writers

Question

Joseph R. Betancourt, MD, MPH, director of The Disparities Solutions Center at Massachusetts General Hospital [www.massgeneral.org/disparitiessolutions] was asked during a recent interview with Physician’s News Digest how he defined the emerging concept of “medical cultural competency.”

Answer

He replied that he viewed it as basically an “expansion of patient-centered care,” which he said is characterized by the physician’s awareness of and agreement with “the need to be attentive to the health beliefs, values and perspectives of the patient.”

Conclusion

And so, is this the same or different from participatory or collaborative Healthcare 2.0.

Your opinions and comments are appreciated.

Related Information Sources:

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

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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

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Doctors Unite!

On the “Open Letter from America’s Physicians”

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

As we have seen in this healthcare-charged election season, almost every form of political activism or debate has moved online. So, it is no surprise that a coalition of disgruntled physicians would electronically socialize and network together, as seen with www.sermo.com

About Sermo – Peer 2 Peer Doctor Network

First billed as a physician’s only online community, where 65,000 doctors around the nation exchanged the latest medical insights with each other to improve patient clinical outcomes, some portions of the Sermo community have morphed into a kind of political action committee [PAC] representing a particular flavor of zealot doctor activist.

Political Activism

And, not to miss out on a marketing opportunity, Sermo has allowed itself to be used as a vehicle for an open letter signed by physicians, decrying the state of domestic healthcare, that’s only going to get more public.

According to Mr. Matthew Arnold of Medical Marketing & Media, the letter is a physicians’ manifesto of sorts, composed by selected Sermo doctors demanding an end to intrusive insurers and overzealous regulators. To date it has garnered 5,200 signatures in the several weeks since it was posted on www.mmm-online.com

So, You Want a Revolution?

According to Arnold, “There’s a sense of revolution in this,” said Dr. Daniel Palestrant, founder and CEO of the physician social networking site, which boasts around 70,000 members. “It’s doctors coming together for the first time, voicing discontent with the representation they’ve had to date, and making it clear to the public that the quality of care is going to be suffering based on some of these outside forces.” http://www.mmm-online.com/Fed-up-Sermo-docs-draft-manifesto/article/112006

Doctors Unite

The “Open Letter from America’s Physicians,” hosted at www.doctorsunite.org blames “The insurance industry’s undue authority and oppressive control over healthcare processes,” “Excessive and misguided government regulation” and “The practice of defensive medicine in response to a harmful and costly legal environment” for America’s healthcare crisis, and vows: “We, the physicians of the United States, will no longer remain silent. We will not tolerate a healthcare system where those without medical expertise or genuine interest in our patients’ health have absolute control.”

Assessment

As almost every other form of political activism has moved online, don’t be surprised to see more websites, blogs, wikis or social e-communities like this. Of course, if the details get specific, it’s tricky to know whether the coalition of disgruntled doctors will stay together, and/or whether Sermo will emerge as representing a new breed of doctor “turned-political-pundit.”

Conclusion

And so, is political activism an appropriate initiative for the medical community; why or why not?

Might it be considered more self-serving; or more patient centric? Your thoughts and comments are appreciated.

Related Information Sources:

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

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

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Ending Governmental Barriers to e-Prescribing

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AMA’s – HOD Wants End to Governmental e-Prescribing Barriers
[By Staff Writers]

According to Modern Healthcare [June, 2008] the American Medical Association’s-House of Delegates [HODs] adopted a resolution calling for an end to government-imposed barriers to e-prescribing.

The Resolution

The resolution called for the removal of all federal Medicare and state Medicaid requirements mandating the use of paper prescription forms for certain drugs – that the AMA initiate discussions with the federal Drug Enforcement Administration to allow e-prescribing of schedule 2 drugs – and that Medicare or Medicaid payments not be contingent upon adoption of e-prescribing.

Assessment

The resolution also called on the AMA to work with federal and private entities to ensure universal acceptance by pharmacies of electronically transmitted prescriptions.

Pills

Assessment

Should we really bite the [Medicare] “hand that feeds us?”

Conclusion

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Concierge Medical Practice Fee-Setting

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Pricing Decisions for Medical Providers

Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

dem21

Professional fee-setting and related pricing decisions for a concierge medical practice, like most businesses rather than most medical-entities, is complex and will significantly affect the doctor’s profits.

New Markets

When a concierge medical practice is first introduced into a local market, the physician-executive must make a choice between charging higher fees in order to recoup practice launch and development costs quickly; or charging lower fees and/or annual retainer subscriptions and extending his/her losses into the growth stage of the practice’s life-cycle. 

This is why consultants and franchisor’s suggest that it may be better to convert an existing practice in-situ, to a concierge model; than start the concierge practice from de-novo, scratch. Nevertheless, the choice should be a conscious one; rather than automatically made by default.

And, the decision will depend upon how target patients are expected to view the practice and its carefully selected medical services. 

Premium Pricing Strategy

If there is “premium-status or swagger” attached to concierge medical practice ownership, then a “price-skimming” approach might be used.  Price skimming, by definition, means setting initial professional fees high in order to achieve profits sooner; and then lowering them as the practice matures. Doctors who use this strategy will experience profits during the introductory stage of the concierge practice’s life cycle, and then reap organizational and operational economies of scale, down-line.

Early Adopter Strategy

If status is not an issue, the doctor may decide to charge lower fees in an attempt to achieve more rapid market local penetration and faster movement into the more profitable early-adopter stage.

A word of warning! If you set initial fees much lower than a price you can maintain and still make a profit, or have adequate working-capital set aside, it is imperative that you make the patient-subscriber aware of the fact that this initial low price is a special promotion that will be increased when over. Patients do not react very positively to unexpected large price increases and may believe the doctor is simply engaging in gouging activity.

Competition

If a doctor has competitors in the local marketplace, s/he can price services above, equal to, or below them.

Fees above one’s competitors implies that services are superior and deserve higher fees; while pricing below the competition level can imply the doctor is proving extra-value to patients in terms of cost-savings.

Pricing at the competitive level is the hardest strategy to follow for any concierge medical practice, but is the only appropriate one in an environment of pure competition. This is typically not yet the case for CM in most areas, to-date.

Assessment

Before settling on a specific fee schedule for your practice, make sure that you know the type of competitive environment that surrounds you and whether demand for your concierge medical services is elastic or inelastic.

Conclusion

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The Herd Mentality of Wall Street [Advice or Avarice?]

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Understanding the Channel-of-Distribution Follies

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Former Investment Advisor and Reformed Certified Financial Planner™dem23

As a former surgeon, insurance agent, physician-executive who took an honest run at Wall Street’s PPMC infamy in the late 90s; a board certified financial advisor and stock-broker; and current writer, editor, publisher and speaker-consultant on health economic topics – I am not your typical citizen journalist or blogger. Although, I am the founding editor-in-chief of a successful peer-reviewed 1,200 page, quarterly print journal, our companion on-ground publication

For example, I’m not crusty; honest! I don’t often wear – but do have – a fedora, and only occasionally look like I just slouched out of Ben Hecht’s circa,1928 play, “The Font Page.”  I prefer stubble to a shave, and ooze skepticism. OK; call it cynicism, if you will. I do however, reckon myself a professional and independent journalist; as well as one heck-of-a-health economist, personal financial consultant and certified “doubting Thomas.”

Independent Means Un-Bossed and Un-Bowed

Yet, I don’t belong to the American Medical Association [AMA], the Financial Planning Association [FPA] or the American Management Association [AMA]. Actually, I’m not really a team player at all; although my wife does call me one who is “carefully selective”. She is aware of the few teams I’ve successfully played for in my career.

And, I am not afraid to write about the financial services industry; in print or online [see The Financial Services Industry Explained].

Link: https://healthcarefinancials.wordpress.com/2007/11/28/the-financial-services-industry

The Implosion

And so, it is with much repetitive irony that I watch supposedly independent and credible Wall Street firms stagger from one mistake to another, every few years, goading their retail financial advisors to promote – dare I say it – “push” – one flimsy financial product or strategy [CDOs and sub-prime home mortgages] that doesn’t work anymore for the sake of lucre.

And then, the same firm’s clean-house after imploding like they have recently done, by rounding up folks to blame, and firing them for having a herd-mentality.

Shame on them; their advisors [really non-fiduciary brokers and salesmen], naïve clients; and especially the clients that are medical colleagues. Shit-aki, mushrooms for brains; all!

This time however, it was the well known CEO heads that were lopped off. To use a financial medical-metaphor, these guys were “de-capitated”:

  • Merrill Lynch = Stan O’Neal
  • Citigroup = Charles Prince
  • UBS =   Peter Wuffli and Marcel Ospel
  • Wachovia = Ken Thompson
  • AIG = Maurice “Hank” Greenberg
  • Bear Stearns = James Cayne 

Of course, I wrote, called and tried to contact several of these “star CEOs” several years ago, to no avail. For a while, I was probably even on their secretarial email radar and telephone block lists.   

Mary’s Lamb to Slaughter

Now, one must wonder if/when the CEO slaughter of Kerry Killinger at WaMu will follow-much like Mary’s little lamb? So far, it hasn’t completely; but he has been stripped of his role as Chairman of the Board.

Remember, Executive Post readers, it was Kerry who oversaw the star-crossed folly into the sub-prime credit-lending fiasco that haunts us all. But, rest assured, I won’t try to contact him. He is very busy at the moment.

Reputations Lost?

So, will these Wall Street firms lose their pristine reputations as kings-of-the-universe? Nope, not a chance! Some pundits even say that in 2-3 years, the public will have forgotten the shenanigans of these guys and their investment banks and wire-houses [broker-dealers]. It’s called the science of “reputational-risk-management” and these firms coldly calculate it into their business plans.

Just Say No

I say, don’t let them. I say, never-forget. I say, ask for and demand a fiduciary financial advisor next time. It wont’ indemnify you from all financial mischief, of course, but it’ll be a good start. Use an independent registered financial advisor and dis-intermediate the broker-salesmen.

http://www.CertifiedMedicalPlanner.org

Or, don’t be surprised when, not if, something similar happens again.

Assessment

To see how staggering the recent write-downs and credit-loses some firms have written-off, per wholesale banking employee [non-retail brokerage or private client wealth management staff],

Just visit this website: www.HereIsTheCity.com

The site’s findings are amazing.

Full Disclosure

I was a “financial advisor” for SunAmerica/AIG more than a decade ago. I saw the industry “inside-out” with developing problems; back then.

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Conclusion

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Physician’s Managed-Care Ethical Dilemma

Caring for [Retail] Patients -or- [Wholesale] Populations

By Render S. Davis; MHA, CHE

Crawford Long Hospital at Emory University

Atlanta, Georgia, USAbiz-book

In today’s health care environment, physicians face a myriad of dilemmas in their daily practice. Time constraints, diminished professional autonomy, declining incomes, explosive growth in technology, and deteriorating public trust combined with increasing public demands are only some of the most obvious problems plaguing practitioners. Although some who have been adversely impacted by these changes are quick to lay blame at the foot of “Managed Care Organizations (MCOs),” this anger may be, to some extent, misdirected.

Managed Care

While there are ample faults in managed care as it is currently practiced, its theory and principles are ethically sound. Healthcare should be “managed” – for continuity, quality, value, and optimal outcomes – regardless of the mechanisms by which the caregivers are paid.  Practicing medicine within managed care still entails obligations to care for patients and to respect their autonomy, but now providers have been placed in a disquieting role as resource managers, requiring a new approach to finding better, more cost-effective ways to meet these obligations, while being held accountable to a larger community to which the individual belongs (e.g. a health plan or employee group) for the costs incurred in delivering care. 

For example, an article in the Hastings Center Report, summed up this new approach by noting that managed care is based “…on the foundation of a philosophy of care that, however well or poorly articulated, responds to the needs of individual patients in the context of population-based mechanisms to assess needs and distribute resources…”

Current Examination

In light of the above ethical principles, an examination of the current practice of managed care reveals an uneven and troubled landscape that continues to be impacted by declining sources of revenue for non-profit managed care organizations and falling profits for the proprietary companies.

Across the board, both types of MCOs have been damaged by the precipitous drop in investment income in the wake of the stock market’s decline since 2000 and again more recently in 2007 and 2008.

Consequently, to maintain adequate services or meet shareholder expectations, managed care organizations have further restricted coverage and/or pushed up premiums to either employers or enrollees.

A Public-Good

Although MCO emphasis on health promotion and illness prevention is viewed as a public good, there remain many highly publicized instances where the health of individual patients has been jeopardized by apparently arbitrary policies and decisions made by managed care organizations, ostensibly in the name of cost containment.  Among especially notable issues have been: 

  • Delayed referral of patients to specialty physicians, or denials of access to specialized services, primarily based on resource allocation and cost considerations;
  • Rigidly enforced practice guidelines and programmatic standards that potentially penalize a physician’s exercise of his or her clinical judgment;
  • Crafting of incentives that encourage physicians to withhold clinically pertinent information from patients, and to discourage physicians from serving as advocates for their patients;  
  • Declining consumer choice of health plans and providers where consumers with health insurance are unwilling to demand improvements for fear of losing the coverage they have;
  • Failure of many MCOs, especially those operated as proprietary entities, to acknowledge an obligation to improve community health and broaden access to services to persons such as those with handicapping conditions, the poor, the disenfranchised, undocumented aliens, and others with legitimate, unmet, health care needs;
  • Subordination of quality access and treatments in favor of cost containment, etc.

But, these issues, according to John LaPuma MD, make managed care “morally vulnerable” and fraught with public suspicion regarding its core values. Consequently, physicians practicing medicine today are faced with very real dilemmas in such areas as patient advocacy, access to and scope of care, informed consent, conflict of interest, continuity of care, and patient choice.

“Double-Agency” Dilemma

In a speech given at Georgetown University some years ago, Marcia Angell MD, Executive Editor of The New England Journal of Medicine [NEJM], described the physician’s primary dilemma within the framework of managed care practice as one of “double agency,” where physicians are being asked to be “both advocates for individual patients and allocators of finite healthcare resources to the larger populations of enrollees of health plans.” 

This is a role that seems to impinge on the fundamental tenets of patient advocacy articulated in the Hippocratic Oath.  By the terms of many managed care insurance plans, a physician’s income is directly related to savings generated in the delivery of care, a tactic criticized by former Surgeon General C. Everett Koop, M.D. who wrote, “Something is wrong with a system that spends more and more each year to provide less and less service.”

ROI and Shareholder Value

Many of the proprietary (for-profit) managed care organizations acknowledge their primary business objective is the return of value to shareholders and increased ROI, with obligations to provide expanded access and broader health care coverage to plan enrollees a secondary consideration. Yet, as regular readers of the Executive-Post are aware, some non-profits are not much better!

While he was Speaker of the Oregon State House, former Governor John Kitzhaber (a physician) addressed this concern when he wrote of the “insidious problem permeating our health care system…the perverse set of incentives that leads health care providers to act as isolated economic entities focused on their own well-being, instead of viewing themselves as community resources whose primary role is – or should be – to promote the health of the nation.”

Conclusion

And so, in light of this troubled ethical and moral environment, please comment on some of the specific dilemmas confronting physicians in daily practice; and please include your solutions?

And, when Marcia Angell MD, of the NEJM, called today’s doctors – “allocators” – did she mean that physicians should now become healthcare economists, too?

Related Information Sources:

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

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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How to Study Medicine

Practice Management -or- “Sutures for Life”

Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Although we are apostles of the still living Kenneth J. Arrow PhD – the Noble Prize winning health economist – we also remember David Cheever MD as much more than a surgical innovator.

http://nobelprize.org/nobel_prizes/economics/laureates/1972/arrow-autobio.html

And, like Arrow, his human compassion and true fiduciary character is revealed in the following passage from a lecture delivered before the Harvard Medical School class of 1871, entitled “How to Study Medicine.”

”If you seek for wealth you have mistaken your avocation. There must be something more and something higher. That something is a love of your profession; a passion for science for its own sake; a broad humanity, which covers all the sick with a mantle of charity. Never lose sight of that motive, for if it once takes flight, your profession is reduced to a trade, and there is absolutely nothing left …”

… “As long as you can keep alive the sacred flame of this early passion which first called you to embrace the medical profession, so long shall you be warmed, sustained, upheld amid disappointment, unjust treatment or reverses …”

Note: David W. Cheever MD served as Professor of Surgery Emeritus for HMS. He performed the first esophagectomy in the US at BCH.

Conclusion

Your comments and practice philosophy are appreciated.

Related Information Sources:

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

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

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

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

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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Nobel Prize Medal

 

 

 

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

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.

Related Information Sources:

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

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

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

Healthcare Organizations: www.HealthcareFinancials.com

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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Physicians, Nurses and Healthcare Executives Only

WHERE KINETIC OPPORTUNITIES AND POTENTIAL ENERGY CONVERGE

Meet OnLine More … to Learn and Earn More 

Wellsprings à à à

Has your medical practice, clinic or healthcare career plateaued? Are you looking for the path to economic freedom or corporate advancement in the healthcare industrial complex, your own medical practice or professional medical specialty?

Finding the right combination of career success and monetary rewards can be challenging in the increasingly competitive healthcare sector!

www.HealthcareFinancials.wordpress.com may be the solution! Read, review, rant, rave, learn and opine about the converging medical practice, financial and management industries at home, the hospital, clinic or office. With more than fifty different categories, and hundreds of informative posts and follow-up comments by leading national experts, there is sure to be something of vital interest to all stakeholders. Public and private threads are available. All by just signing up for a free online subscription!

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www.HealthcareFinancials.wordpress.com offers solutions. Connect with health management consultants, accountants and financial advisors. Post your opportunities and needs in public or private. Read comments, post advertisements, make inquires and connect with like minded physicians, executives, nurses, advisors, financial planners and consultants. All by just signing up for a free online subscription!

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Physician Seeking Senior HIT Position

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Dr. Richard J. Mata; MD, MS-MI, MS-CIS, CMP™ [Hon]

Dr. Mata

Richard “Rick” Mata, M.D., worked as a Network Administrator and Programmer at the Texas State Treasury after completing an Internship in Internal Medicine. He is adjunct Associate Professor of Health Services Research at Texas State University and is currently consulting for AT&T Customer Analytics Division.

As Founding Chief Medical Information Officer [CMIO] of www.RickTelMed.com, his full CV may be viewed at: http://www.scguild.com/Resume/6264I.html

Goal: Experienced and multi-degreed physician seeking a senior CXO or leadership position in healthcare information technology on a FT or PT basis; also available for interim, local or remote consulting positions.

MORE: HIT Security

Contact: RickTelMed@satx.rr.com

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[Thank you for advertising on the Medical Executive-Post]

***

The Employed Physician Business Model

Employed Doctors Enjoy Several Compensation Options

By Dr. David Edward Marcinko; MBA, CMP™

biz-book1According to corporate medical recruiter Kris Barlow RN MBA, physicians can select from various employment models that may include fringe benefit packages (life, health, dental, disability insurance; medical society and hospital dues, journals, vacations, auto, and CEUs, etc.) equal to 25-40% of salary [personal communication]. 

And, this medical business model is fast growing as the various types below demonstrate. 

Independent Contractor or Employee 

A payer has the right to control or direct only the result of the work done by an independent contractor, and not the means or methods of accomplishing the result.

By contrast, anyone who performs services for another is an employee if he or she can control what will be done and how it will be done. Employed physicians are usually not compensated as independent contractors. 

New Practitioner Salaries: 

Published annually for new practitioners by The Health Care Group®, the Physician Starting Salary Survey collects and collates nationwide data on new physician employment compensation.

The guide reports first, second and third year of starting physicians’ salary and incentives, but with large high-low spreads. It also includes information about co-ownership provisions, benefits and restrictive covenants.

The survey is categorized by specialty and results are based on information provided by medical practices, health care advisors, physicians, and health care consultants across the country. The figures represent basic elements of the bid/ask process for establishing optimal salary and benefit amounts for new physicians entering private practice.

Available for no charge from the Health Care Group (800.473.0030 or www.HealthCareGroup.com) 

Public Equity Relationships 

The public equity roll-up model of medical partnerships in the late 1990s offered employed physicians experience within a large group whose decisions were made by managers.  Compensation was controlled and replaced with the stress of investor expectations, as Physician Practice Management Corporations (PPMCs) needed to grow revenues by 10-15% annually to maintain price-to-earnings ratios. If stock was held in a growing PPMC, physician employees shared in both practice and corporate compensation

But, by 2007, a survey of the Cain Brothers Physician Practice Management Corporation Index of public PPMCs, revealed a market capitalization loss of more than 95% since inception.

Newer Healthcare Delivery and Physician Compensation Models

Today, whether independent or employed, physicians can pursue several creative compensation models not available a decade ago:

MSO Contracting: 

According to consultant Jeffrey Peters, physicians maintain private practice in this model, but contract with a management services organization to relieve administrative burdens. Physicians maintain control with less stress, but, as MSO contracts are expensive (18-45% revenue), compensation diminishes, and rests on MSO competence.

Locum Tenens Practitioner:

Locum 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 negotiable).  However, a LT firm typically will not cover taxes. 

Cash Based Compensation:  

A Cash Based Compensation (CBC) model attracts patients who pay cash for desirable services, such as surgeons who dispense scar reducers or in areas such as pain relief, weight loss, aesthetic procedures, and natural health.  

Any well-rounded CBC program should include: patient demand; low entry cost; little marketing costs; existing employees to administer the program; and an operational plan. With time and effort, profit for physician compensation may increase 10-20% annually.

Values Based Health Insurance Model:

According to some pundits,instead of the one size fits all approach of traditional health insurance, a “clinically-sensitive” cost-sharing system that supports co-payments related to evidence-based value for targeted patients seems plausible. 

In this model, out-of-pocket costs are based on price and a cost/quality tradeoff in clinical circumstances: low co-payments for interventions of highest value, and higher co-payments for interventions with little proven health benefit. Smarter benefit packages are designed to combine disease management with cost sharing to address spending growth.

Global Healthcare Model: 

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. Both 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. Although this 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.  

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.

dhimc-book1Conclusion

Regardless of the salaried compensation model, its review and understanding is vital for long-term success.

How have the above compensation models affected your medical practice business model, and salary, if any?

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

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