Off-Road Touring with Dr. Marcinko [Part I]

Posted on July 20, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

“Using-Up” Health Insurance

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Dateline: June 18-19th, 2009

I flew into Marquette Michigan last night on a puddle jumper from Chicago, Illinois. Marquette will be the home base on my current book promotion and public/private speaking tour. This second leg of our trip, from Atlanta, was delayed for mechanical reasons. So, rather than follow directions from American Airlines regarding new arrangements, and rushing to wait in a long line of humanity for a new boarding pass on a much later flight, I simply called the travel assistance number on my cell phone. We were re-routed by computer from American, to a Delta Airlines flight, that caused no additional time lag as we later learned the other passengers boarded their American flight three hours late. Many of the elderly and slower moving folks even missed connecting flights which necessitated overnight hotel stays, in some cases.

THINK: outside the box independently, and don’t follow directions mindlessly.

About Marquette, Michigan

The City of Marquette is located in the central region of Michigan’s Upper Peninsula. With a population of 20,714, it is the UP’s largest community. In addition to being a population center, it serves as the regional center for education, health care, recreation, and retail. This regional draw is particularly evident due to Northern Michigan University and Marquette General Hospital, both of which are located in the City of Marquette. Of course, I visited both.

Quality Healthcare for the Upper Peninsula

So, the next morning I called some friends who suggested we head over to the Marquette Upper Peninsula Healthcare Network System, on Washington Street, for an unplanned and unofficial stop on our current “signing and opining” tour. It seemed very busy for a Friday morning; so we gathered some colleagues and ambled over to Viering’s Restaurant where we discussed the local economy, current state of the healthcare industry and the Obama Administration’s ideas for healthcare reform. When I expressed my surprise at the number of patients in the clinic waiting room areas, I was informed that an unexpected corporate layoff resulted in patients “wanting to use their health insurance, before being RIFed [Reduced-in-Force].” Now, as a doctor, and insurance agent, I find this attitude both very strange; yet not uncommon.

“Using-Up” Health Insurance

I can honestly say that after more than three-decades in the business, I have never heard a single soon-to-be unemployed client say,” I need to use up my life insurance”, or “auto insurance”, or “homeowner’s insurance”, etc. So, what gives with health insurance?

Health Insurance IS Different

Insurance of all types is sold to economically protect against catastrophic events like pre-mature death, auto accidents, or home destruction. But life insurance doesn’t pay for non-lethal issues; auto insurance doesn’t pay for new tires, tune-ups or oil changes; and home owner’s insurance doesn’t pay for regular upkeep and maintenance, etc. So, why do some patients believe that health insurance necessarily needs to be used-up? Were they not healthy before the lay-off announcement; or did they suddenly become ill, thereafter? What do you think? Is this just a local phenomenon, or would it be [is it] pandemic in any community given the same or similar circumstances?

Assessment

For me, this scenario clearly demonstrates two things. First, that Health Insurance is thought of as a personal right and/or corporate fringe-benefit; rather than true financial indemnification. Second, it demonstrates the ability of patients to think ahead; unlike the airline customers on my initial trip here. So, if patients can be forward thinking about their health insurance needs, why don’t they think ahead about their personal health care needs? Why don’t more of us exercise regularly, watch our blood pressure and weight, and/or avoid drugs, alcohol and promiscuous sex, etc. If we can monitor and pay for routine auto and home maintenance ourselves; why not our routine health needs? Isn’t good health our most important personal asset? Aren’t we worth it? Do we really want to abrogate our very lives to others? Do we want to concede our responsibilities to a third party, ie, a national [single-payer] governmental controlled healthcare? Those patients wanting to “use their health insurance”, before unemployment, certainly seem to think so.

About Off Road with Dr. Marcinko

These sporadic off-road segments will continue through-out my 2009 summer promotional tour. On the one hand, formal attendance at several engagements was initially a bit sparse because of the death of several recent celebrities and entertainer types. On the other hand, local book stores and sponsors noted a spike in our CD and book sales, as well as interest in our online www.CertifiedMedicalPlanner.com program and premier quarterly guide: Healthcare Organizations [Journal of Financial Management Strategies] www.HealthcareFinancials.com

Conclusion

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Filed under: Health Economics, Health Insurance, iMBA, Inc., Marketing & Advertising, Media Mentions and PR, Op-Editorials, Sponsors, Touring with Marcinko | Tagged: American Airlines, auto insurance, certified medical planner, CMP, david marcinko, Delta Airlines, doctor, Health Insurance, healthcare, healthcare reform, insurance agent, marquette general hospital, marquette MI, Marquette Upper Peninsula Healthcare System, Michigan, Northern Michigan University, obama, RIF, Upper Peninsula, Viering’s Restaurant, www.certifiedmedicalplanner.com | 1 Comment »

Medicare Scam Alert Notice

Posted on July 17, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Fearing Medicare Payment Gaps

By Staff Reporters

June 18, 2009

The Centers for Medicare and Medicaid Services (CMS) issued the following “Scam Alert Notice”

“CMS has become aware of a scam where perpetrators are sending faxes to physician offices posing as the Medicare carrier or Medicare Administrative Contractor (MAC). The fax instructs physician staff to respond to a questionnaire to provide an account information update within 48 hours in order to prevent a gap in Medicare payments. The fax may have the CMS logo and/or the contractor logo to enhance the appearance of authenticity.”

Medicare Contractors

Furthermore, CMS said that “Medicare FFS providers, including physicians, non-physician practitioners, should be wary of this type of request. If you receive a request for information in the manner described above, please check with your contractor before submitting any information. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov website” found at:

Link: http://www.cms.hhs.gov/MLNGenInfo/

Link: http://www.cms.hhs.gov/MedicareProviderSupEnroll.

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Janis Oshensky Lobbies Congress – Not Dentists

Posted on July 16, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Show Me the Math

By Darrell K. Pruitt; DDS

I have noted here far too many times how it disappoints me that Delta Dental Plans Association vice president Janis Oshensky repeatedly chooses to turn to politicians rather than discuss Delta Dental’s arguably egregious and harmful policies with me, a dentist. I intend to put a stop to such disrespect one PR expert at a time if necessary.

Long ago I warned Oshensky that if she didn’t talk to me, she should probably just shut up in order to preserve what’s left of her Internet reputation. Since by posting her Letter to the Editor on POLITICO.com today, she obviously ignored my advice, this highly critical comment will reliably join three others of mine on her first page soon enough. Her employer is sacrificing her like a pawn.

The following comment is the one I posted on POLITICO.com in response to Oshensky’s letter. It might just help the vice president to finally come to a decision on this issue one way or the other. Either way, marketplace conversation like this cannot help but lead to safer air for the community … My pleasure.

http://www.politico.com/news/stories/0709/24873.html

Dear POLITICO.com Editor:

This comment and subsequent invitation to Janis Oshensky is in response to the Delta Dental Plans Association vice president’s July 14, 2009 letter to you. Her letter is the most recent message she successfully sent Congress using a political news Website. Even though Ms. Oshensky holds the position of VP of dental relations as well as public policy, she has avoided answering this dentist’s questions about Delta Dental’s policies for months. If Ms. Oshensky is willing to do so, I would love for her to join me in discussion of Delta Dental’s taxation subsidy right here on POLITICO.com so that our lawmakers can witness a more balanced view of the issues.

Hello – It’s Me

Hello. My name is D. Kellus; Pruitt DDS, and I’m a practicing dentist in Fort Worth, Texas. It is my professional opinion that my patients are harmed by the policies of managed care dental plans like that sold by DDPA because there is no accountability to their clients or dentists. There is barely any accountability to those who select and pay for Delta’s products – dental patients’ naive bosses.

Like virtually every US citizen, your readers probably couldn’t care less about the dental industry. It is precisely because dentistry has been uninteresting for decades that make the microcosm of health care incredibly interesting to me. Let me uncover for your appreciation the event horizon in dental history. You could learn about more than just dentistry.

If left to natural forces of human nature, what happens to value when there is no accountability? For example, what do the 1975 East German Trabant and the 1979 Ford Pinto have in common? By popular vote, those products not only represent the two worst automobiles ever made, but the state shielded both manufacturers from accountability to consumers. Poor quality happens.

Oshensky argues against the taxation of managed care dental benefits like those sold to employers by Delta Dental. Let me offer that if Delta’s product were taxed like income, its value would quickly dive below the market threshold that attracts purchasers’ consideration.

Allow Me to Show-You the Math

Recently, Delta Dental of Michigan lost the accounts of thousands of GM retirees when their group dental benefits were cut in bankruptcy negotiations with UAW. Suddenly, Delta found itself forced to market their product to individuals who for once have the choice to keep their money. Faced with true competition for healthcare dollars, Delta leaders desperately cobbled together individual policies for the retirees who want to continue with their coverage. Even though Delta did everything possible to lower the cost of their coverage, the cheapest of the plans they offered still runs about $30 per person per month, and covers only 50% of everything, including preventive. So for premiums of $360 per year plus half the preferred providers’ 20% to 30% discounted fees, is this a bargain for Michigan retirees?

Free Markets

In my free-market, fee-for-service practice, if a patient comes in for two cleanings and routine x-rays during a year, 100% of my bill is $208. This is the market price in my neighborhood that is continually challenged by lively competition with other dentists for new patients who may not even have dental benefits. Those customers pay in full at the time of visit, just like most people whose bosses purchased Delta Dental Plans.

Value Comparisons

So let’s compare value of Delta Dental’s product with cash. If I were a Delta Dental preferred provider, my fee of $208, less Delta’s 25% discount would be $156. Never mind that my wife has problems with my 70% cut in pay, let’s move on.

The patient’s half of the $156 I earned is $78. $360 + $78 = $438. So for one uneventful year of discounted dental services with a dentist chosen from a list of names, a patient can expect to spend more than twice as much than if they paid the free-market price at the point of service.

Assessment

Not only is that hardly a bargain, but it is my opinion that managed care dentistry is dentistry by the lowest bidder with no quality control. That should be enough meat to get this conversation rolling. Now it’s your turn Ms. Oshensky. I think you have to admit that you’ve got holes to mend in the dental relations part of your job.

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Filed under: "Doctors Only", Career Development, Ethics, Health Insurance, Managed Care, Practice Management, Pruitt's Platform | Tagged: ADA, Darrell Pruitt, DDPA, DDS, delta dental, Delta Dental Michigan, dentists, DMD, GM, HMO, Janis Oshensky, managed dental care, POLITICO, PPO, UAW | 3 Comments »

Health Plan Management Navigator

Posted on July 15, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

July 2009 Edition

By Douglas B. Sherlock; CFA, MBA

Attached below, find the July 2009 Edition of Plan Management Navigator. In this month’s edition, we summarize the results of Independent / Provider-Sponsored Healthcare Plans. The 16 plans collectively serve 5.7 million members and are leaders in their communities.

Link: Navigator_07-09

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Managed Care, Monthly Reports, Research & Development | Tagged: douglas sherlock, Health Insurance, health plan, healthcare plans, managed care plans, Plan Management Navigator, Sherlock Company | 1 Comment »

ADA / IDM Breakup – You Heard it Here First

Posted on July 14, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Will CareCredit be the Next ADA Subsidiary to Fail?

I saw a warning sign last week.

By Darrell K. Pruitt; DDS

My aggressive writing hobby has understandably brought me in hard contact with public relations people whose job is to insulate good ol’ boys from accountability – even if it means taking hits for the team and staining their reputations. Let’s face the fact we all of us involved in public relations know but don’t dare discuss: Depending on the ethics of one’s employer, PR professionals are sometimes used up like expendable pawns. And avoiding bylines for press releases no longer shields anyone from accountability.

I often silently stalk PR employees (Gasp!) on the Internet who work for sleazy companies just to better understand them. I’ve discovered that it is not hard to find and exploit the weaknesses of those whose heart isn’t behind selling their employer’s product. Sometimes all it takes is a fistful of transparency to cause defenseless representatives to completely shut up, and that alone makes our neighborhood safer. Committee-approved methods of evasion are as simple-minded as committees, so it doesn’t take long to figure them out – exposing the shameful ethics of those who sign off on the use of lame, institutional trickery.

For example, here’s a very popular, traditional PR trick: If a huge business entity such as the ADA has bad news they can no longer keep secret from customers, professional PR-types will advise their bosses to post bad news on a Friday to soften the blow. When traditional leaders find that they can no longer sidestep accountability, delaying accountability until a busy news day is the next best thing one can purchase. Even though the tricks seem simple, there are people who study evasion science as part of obtaining a degree in marketing.

So how good is the ADA’s PR team? How much time did ADA members’ employees buy for leaders before they had to quietly acknowledge an expensive failure?

On July 10, a Friday, “ADA/idm to phase out service” was posted on ADA News Online without a byline. (Another PR trick: When the ADA posts an orphan without a name, it means someone is ashamed of the bastard.)

http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3655

“ADA Business Enterprises, Inc. (ADABEI), a wholly owned ADA subsidiary, announced today that ADA Intelligent Dental Marketing (ADAidm) of Salt Lake City, one of its joint venture companies, is no longer able to provide marketing services to its customers due to significant production and operational difficulties.”

Now the ADA must refund money to members in a depressed market. Could this embarrassment for our professional organization have been quietly avoided instead of delayed and magnified? I personally started seeing clues of CEO Trajan King’s reticence long ago, and warned ADA leaders in Chicago about my concerns. Nobody ever responded to my numerous, sincere warnings.

These are highly critical times on Capitol Hill and our patients trust us to represent their welfare. Dentists are their last hope, because there is nobody else who cares. Practicing dentists are solely responsible for assuring the benevolence of our niche market, and we are losing control publicly. Disasters like the ADA/IDM make the ADA look foolish to Congress, and word gets around fast on the Internet.

This morning, I read an article posted on The NY Times titled “Study Measures the Chatter of the News Cycle, “ written by Steve Lohr.

http://www.nytimes.com/2009/07/13/technology/internet/13influence.html?_r=1

Researchers at Cornell used powerful computers and sophisticated algorithms to accomplish an unprecedented analysis of news articles and comments on the Web during the 2008 presidential campaign. They studied the characteristics of the news cycle by scanning 1.6 million mainstream media sites and blogs for repeated phrases and tracking the history of their appearances.

Lohr writes: “The researchers’ data points to an evolving model of news media. While most news flowed from the traditional media to the blogs, the study found that 3.5 percent of story lines originated in the blogs and later made their way to traditional media.”

The study also shows that traditional news outlets are still quicker than blogs by 2.5 hours. I should now point out that the Cornell study was performed using data from very popular, huge news items collected during a presidential election – not hidden, niche news like dentistry’s.

If you are involved in the dental industry, where are you more likely to read time-sensitive news about our profession first? In an ADA publication, or from D. Kellus Pruitt; DDS?

Whereas traditional media is 2.5 hours quicker with popular topics, I scooped traditional ADA News Online by three weeks when I posted “ADA/idm – A bad union after all?” on the PennWell forum.

http://community.pennwelldentalgroup.com/forum/topics/adaidm-a-bad-union-after-all

So what about the warning sign I saw concerning CareCredit – a wholly-owned subsidiary of the ADA?

When Trajan King, former CEO of the defunct ADA/IDM partnership refused to acknowledge my questions, I immediately suspected something was terribly wrong with the union of my non-profit professional organization and his for-profit Utah advertisement company. Six months later, my fears were confirmed. Now then, I hope it grabs someone’s attention that I see the same warning signs coming from the ADA’s CareCredit business. Note this date: July 13, 2009.

On Thursday, July 9, CareCredit purchased a press release on dentalblogs.com: “CareCredit Adds 24-Month, No-Interst [sic] Payment Plan” (no byline).

http://www.dentalblogs.com

Since dental problems only get worse, I consider the idea of extending credit to dental patients is a benevolent thought during these hard financial times. I also say that the offer appears to have been put together out of generosity and not greed like the ADA/IDM disaster. However, at 4:54 pm on the same day that CareCredit’s press release was posted, I submitted a difficult question for the anonymous author of the piece who works PR for CareCredit – and is an ADA employee.

“If the Red Flags Rule is not delayed for the third time in three weeks, how will it affect those who offer Care Credit?”

I was given the hopeful response “Your comment is awaiting moderation,” but days later there is no sign that my question is being considered at all. Please, oh please ask yourself: What could CareCredit leaders be hiding and how much will it end up costing ADA membership?

I will not be ignored by anyone. Today, I submitted two follow-up questions on dentalblogs.com. I considered warning the anonymous moderator that this is being simulposted on other blogs, as well as described on Twitter, but then I thought, why spoil the fun? Let the leaders of the ADA Business Enterprises, Inc. (ADABEI) get word of my e-Attack from their colleagues. Won’t they be surprised!

Oh, and for those who are wondering what happened to ADA/IDM CEO Trajan King – he quit.

Dear Dentalblogs.com moderator:

On July 9 at 4:54 pm, I submitted a sincere question concerning how the Red Flags Rule will affect ADA members who sign up for CareCredit. Instead of posting it with the promise of an answer, you regretfully chose to censor an ADA member. Today, July 13, I have a second and third question: Why did you ignore my first one and who is your boss?

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Filed under: "Doctors Only", Breaking News, Career Development, Ethics, Health Insurance, Information Technology, Marketing & Advertising, Media Mentions and PR, Pruitt's Platform, Research & Development | Tagged: ADA, ADA Business Enterprises, ADA/IDM, ADABEI, American Dental Association, CareCredit, Darrell Pruitt, dentists, IDM, Intellignet Dental Marketing, red flag rules, Steve Lohr, Trajan King | 12 Comments »

Essay of Atul Gawande MD in the New Yorker

Posted on July 9, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

The McAllen Redux

We urge all ME-P subscribers and followers to read Atul Gawande’s piece in the New Yorker that appeared as an essay on McAllen, Texas – the little Texas town with the dubious honor of being one of the most expensive health care markets in the country, today.

Link: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

As Dr. Gawande noted, in 2006, Medicare spent about $15,000 per enrollee there – close to twice the national average, and three thousand dollars more per person than McAllen’s per capita income of $12,000.

Commentary

Then, take at look at the comment by OMB Director Peter R. Orszag, posted on Thursday, June 4th, 2009 at 10:50 am; entitled the McAllen Redux

http://www.whitehouse.gov/omb/blog/09/06/04/McAllenRedux/

Assessment

Who says bloggers, and citizen journalists, get no respect?

Conclusion

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Filed under: Alerts Sign-Up, Breaking News, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Media Mentions and PR, Practice Management, Quality Initiatives | Tagged: Atul Gawabde, CMS, Health Insurance, McAllen Redux, McAllen Texas, medicare, New Yorker, OMB, Peter R. Orszag | 6 Comments »

Concierge Medicine and the “Zombie” Medical Practices

Posted on July 7, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Continued Growth of Boutique Medical Practices Today

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

The boutique, or direct reimbursement, or cash based medicine, or concierge medical practice business model requires an annual fee for personalized treatment that includes amenities far beyond those offered in the typical practice, or suggested by physician medical unions. Patients pay annual out-of-pocket fees for top tier service, but also use traditional health insurance to cover allowable expenses, such as inpatient hospital stays, outpatient diagnostics and care, and basic tests and physician exams. Typical annual fees can range from $1,500 to $ 5,000 per patient, to family fees that top $25,000 a year, or more. The concept, initially developed for busy corporate executives, has now made its way to others desiring such service.

A Higher Level of Care

Medical providers get to provide a much higher level of care and get to know their patients as they enjoy the incentive to spend appropriate time with them, and over time, get to know them within their unique social/cultural context as well (hence the house calls become important). Patients enjoy the access, the attentiveness, and are willing to spend cash to have the type of unhurried, contemplative time with physicians that is required to develop a trusted relationship and deliver high quality care. The financial remuneration potential is compelling as well.

Now, let us compare and contrast various parameters of traditional medical practice [third party reimbursement] with the same parameters of so-called “new-wave” concierge medicine. Then, let the next-generation of doctors decide.

Current Traditional Model

patients seen at 15-20 min increments
2,000 – 3,000 patients
Paperwork, administrative burdens, frustrations, and lack coordinated care
Impersonal experience (long waits, un-intelligible interactions with health care system)
Average Salary = $150,000-250,000

Concierge Practice Model Potential

direct relationship with patients
300-500 patients
$1,500 – $3,000 access/retainer fee
Reduced overhead, positive interactions, care coordination and increased quality
Personalized experience (reduced headaches and paperwork with transparent pricing)
24/7 access, same day appointments with multiple other amenities
Average Salary = $100,000 – $500,000

Enter the Franchisors

Concierge medical practices can be developed organically, or use a franchise business model [personal communication, Suzanne R. Dewey, Forté Partners, LLC, Williamstown, MA]. Examples of franchisors include:

Elite Health: http://elitehealth.com
Health Advocate: http://healthadvocate.com National organization with over 4,300 client relationships.
MD2 International: http://www.md2.com/home.php
MDVIP: http://www.mdvip.com
ModernMed: http://www.modernmed.com

Opponents and Pessimists

There have been plenty of opponents, within medicine and outside, to the idea of concierge practices almost from the first day. For example,

”The state of Washington’s insurance commissioner attacked the concept of practices offering all the primary care patients needed for a prepaid fee or retainer, arguing that such practices amounted to the business of underwriting health insurance. He said that the practices would have to meet all the regulatory requirements for such an insurance business, including establishing capital reserves and maintaining loss reserves for the payment of claims. It didn’t work, and besides, few concierge practices offer free traditional medical care once retainers are paid–most concierge physician’s bill insurance plans for all the services covered under their patients’ coverage. The Medicare folks chimed in and managed to drive one physician out of business, arguing that he had tried to charge Medicare patients an extra $600 a year for services already covered by Medicare, hence he was guilty of illegal “balance billing.” Rather than fight Medicare over the issue, the doctor gave up and closed his practice. [C. Davis, “Big Problems for Medicare and Concierge Medicine,” Sierra Sacramento Valley Medicine, 55:3, May/June, 2004 (www.ssvms.org)]”

Attacking ME?

Objections to concierge medicine focus on both its causes and its effects, and some critics have even attack me, personally. For example, just look what “they” said in the online journal: “Health Care Strategic Management.”

”Many critics argue that concierge medicine merely reflects physician greed and unconcern over the needs of the community. Indeed, a recent book by David Marcinko, Business of Medical Practice [Advanced Profit Maximization Techniques for Savvy Doctors], includes a chapter on “The Case for Concierge Medicine” (Ch. 24) as one of the ways ‘savvy’ physicians can maximize their profit, as if that is what medicine is all about. While the image of physicians may retain some Marcus Welby elements of their rushing to the hospital or a patient’s home in the middle of the night, most physicians would rather stay home and leave the job to someone else, it is argued”.

Nicht Schadenfreude

Just think! My mother always feared I’d be a no-body. Good publicity – bad publicity – just spell the name correctly. Schadenfreude may be defined as a “largely unanticipated delight in the suffering of another which is cognized as trivial “ and I take no delight in the slow collapse of traditional medical practice models; or the economic, professional or personal pain of colleagues. But, I also often tell my critics – and clients – that although it’s awfully nice to be altruistic; I am always mindful of the competitive business adage: “no margin-no mission.” And, in as much as this attack was written in July 2005, I can only wonder if I was prescient, or just lucky? With all due respect, I believe it was the former, rather than the later. Why so? Well, just consider how fast www.ChoiceMed.com is growing. This stuff is not rocket-science.

www.MedicalBusinessAdvisors.com

About Concierge Choice Physicians

Concierge Choice Physicians: http://choice.md is a national organization offering a hybrid business model. Physicians divide their practice between a traditional practice and a retainer practice. The retainer practice is limited to approximately 150 patients. A typical concierge practitioner may have 300-500 patients, while the norm for a traditionalist is about 2,000-3,000 patients.

Assessment – Whither the “Zombies”

I, also ruefully wonder how many “zombie” medical practices [practitioners] are out there? You know the kind – a medical practice with neither a good/bad balance sheet. One with only subsistence level operating performance; a practice that is not growing organically or thru merger activity. It is just barely existing as the doctor-in-charge slowly, agonizingly, milks it to death; or retires, whichever comes first.

Conclusion

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Filed under: Career Development, CMP Program, Ethics, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Practice Management, Professional Liability, Research & Development, Risk Management, Sponsors | Tagged: boutique medical practice, Business Medical Practice, c Davis, cash based medicine, choice.md, ChoiceMed, concierge medicine, david marcinko, direct reimbursement medicine, elite health, health advocate, Health Care Strategic Management, MD2 International, MDVIP, ModernMed, zombie medical practices | 11 Comments »

Blue Cross/Blue Shield of Texas on Facebook

Posted on July 6, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Let’s Have Some Fun!

[By Darrell K. Pruitt; DDS]

Hello, sports fans. Have you missed me? It’s been about five days since I posted a comment that didn’t follow an article authored by someone else.

My last one was “Pruitt’s Platform – Introduction to an Adventure.” It’s unusual for me to go so long between posting stand-alone pieces, but after putting that title to my introduction, and compounding the challenge by promising to never push out bland stuff, I set my standard high. It took me a few days, but I finally found a deserving old target on a brand new venue that I think will hold your interest. BCBSTX and I have an intense history, so I assume they charged someone anonymous and shy to follow everything I write. I welcome you, whoever you are. Yea, you. The one hiding in the dark corner, justifiably afraid to utter a peep. Keep your pointed head down, friend, and try not to wet your nice pants.

BCBSTX, you should be disappointed to learn that I found your Facebook account. Even for a fat dinosaur, you are an especially thick and slow-moving easy target. I recommend you just surrender now to transparency and start the confessions and reparations before the lawsuits become huge and the lawyers profit more from your collapse than the Texan dental patients you’ve harmed. Let me remind you that the repeal of the McCarran-Ferguson Act is just around the corner, and we all know about the rumor (started by me) that there are attorneys across the nation just waiting to file class-action lawsuits against BCBS for unfair business practices, including restraint of trade for using the NPI number to drive satisfied patients from dental homes they preferred. Finally, BCBSTX will be subject to the same anti-trust laws as the doctors they fear, and I am here to make sure BCBSTX feels the pain. Look what happened to Dell Computer when that huge dinosaur was surrounded by Jeff Jarvis and Dell Hell. The game I’m playing with you is a more nimble, improved variation of Dell Hell, using fewer vulgar words.

You should know by now you are too fat and too slow to hide from me and the sports fans I bring. Nevertheless, I am always fair in telling my targets my goals before I go on to accomplish them. Here is what I am going to do to you, BCBSTX: I intend to pull your anonymous, unaccountable butt out into the wide open for everyone to see – especially the lawmakers you lobby and support with generous donations. Did you know that there is a rumor (also started by me) that some of those same lawmakers you consider friends are aware of most of what I write on the same day I post it? The transparency I bring will eventually trap and crush you, BCBSTX. Or, you can immediately come out and meet me for an open discussion about the inevitable reformation of dental insurance in Texas – putting humble, obedient bureaucrats with names under the direct control of dentists and patients. And of course, it is understood that in order to save Texas citizens millions of dollars in healthcare expense, there will be drastic downsizing of BCBSTX Dental, just like Delta Dental and ADA/IDM are experiencing right now. That means no more bonuses and no more frivolous pursuits like publishing, printing and mailing to Texas dentists those expensive self-serving brochures joyfully titled “NPI Times.” I suggest you get your resumes in order, BCBSTX employees. I’m very good at having my way with archaic business models. Others I have attacked, such as ADA/IDM and Delta Dental, are clearly failing. Coincidence? Perhaps you’d like to tell yourself that when I undermine your support every time you come up for air. Why not send out your sharpest PR specialists? Oh please, would you? Also, equip them with committee-approved talking points that I’ll hang around their necks for a long time.

When I discovered that BCBSTX had a Twitter account, I started asking anonymous employees of BCBSTX about their new NPI number requirement for processing dental claims – even for dentists who have no contractual relationship with the company. But rather than answer a dentist’s questions about their dental policy (incredibly stupid, BCBSTX), the leaders of the command and control company who can no longer command or control their own socks, responded by blocking me from following them. That was irresponsible, childish behavior from one of the largest and most powerful dental insurance companies in the state. Shouldn’t it be important for BCBSTX to respect dentists who must deal with their cumbersome rules?

At a time when managed care dental companies like BCBSTX are lobbying Congress hard to preserve their taxation subsidy, I think it is important for lawmakers to recognize that these huge stakeholders neglect the welfare of those they serve: the principles – dentists and their patients. We are your constituents who count, Congress. Not discount dentistry brokers whose products will not sell in the free market without mandates and taxpayer assistance – simply because they are lousy products.

If BCBSTX had not opened a Facebook account, I would not have opened one myself. I discovered my fat, defenseless opponent when I googlesearched “BCBSTX” the other day. On their first page was the link “What is the NPI number of BCBSTX? – Facebook.” It features a client’s naïve, insignificant question about the NPI number, and it opened the door for my informed, significant one which I copied below, as well as posted on Twitter.

http://www.facebook.com/topic.php?uid=93487018652&topic=8926

By the way, I was disappointed to see that my comment “BCBS-TX Dental Insurance is Rude to everyone,” which I posted on the Medical Executive-Post over three months ago, was no longer on BCBSTX’s first page. It was their third hit for weeks. But since I hadn’t given the comment a bump lately, it has dropped down to the bottom of their second page. Can’t have that! If you don’t mind, please click once or more on the following link and stay there a few minutes. That way, it will push the blunt criticism back up onto BCBSTX’s first page and will once again warn potential clients of BCBSTX’s poor business ethics. If you’re going to be there anyway, why not go ahead and read the sucker? You could find it interesting. Lots of people do.

https://healthcarefinancials.wordpress.com/2009/03/27/bcbs-tx-dental-insurance-is-rude-to-everyone/

As I wrap up this comment, I’ll share with you with the question I left BCBSTX on Facebook almost 6 hours ago concerning their NPI policy. I don’t think Facebook was a good idea for BCBSTX leaders. Sit back and watch me get someone fired today.

Dear BCBSTX:

I would like to point out to readers more information about the NPI number which you are not likely to share. If you have BCBSTX dental insurance, and your dentist does not have an NPI number, BCBSTX will not process your dental claim and the premiums you will have paid to BCBSTX will become unearned profit for BCBSTX.

Is that true, BCBS-TX? Yes or no?

Conclusion

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Filed under: Career Development, Health Insurance, Information Technology, Pruitt's Platform | Tagged: ADA, ADA/IDN, BCBS, BCBSTX, Darrell Pruitt, DDS, Dell, delta dental, dentist, Facebook, Jeff Jarvis, McCarran-Fergusan Act, NPI, NPI Number, twitter | 19 Comments »

Government-Enabled Patient “Bounty Hunters”

Posted on June 30, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Spider Webbing Technology May Trip-Up Miscreant Doctors

By Dr. David Edward Marcinko; MBA CMP™

Under the Health Insurance Portability Accountability Act (HIPAA), the U. S. Department of Health and Human Service (HHS) have operated an “Incentive Program for Fraud and Abuse Information.”

In this program, HHS pays $100 – $1,000 to Medicare recipients who report abuse in the program.

To assist patients in spotting fraud, HHS has published examples of potential fraud, which include:

medical services not provided;
duplicated services or procedures;
more expenses, services, or procedures claimed for than provided (upcoding/billing);
misused Medicare cards and numbers;
medical telemarketing scams; and
no-medical necessity.

Real Health Fraud Exists

There is no question that real fraud exists. The Office of Inspector General of HHS saved American taxpayers a record $32 billion in 2006, according to Inspector General Glenn A. Fine.Savings were achieved through an intensive and continuing crackdown on waste, fraud, and abuse in Medicare and over 300 other HHS programs. To discourage flagrant allegations, regulations require that reported information directly contribute to monetary recovery for activities not already under investigation. For the DRA in 2009, this includes the following:

promoting state False Claims Acts (section 6032);
enhancing the Fair and Accurate Credit Transaction Act, with “red flags” (PL 108-159); see http://www.gpo.gov/fdsys/pkg/PLAW-108publ159/content-detail.html
employee education about false claims recovery (section 6033);
augmenting the Medicaid Integrity Program (section 6034);
enhancing third party recovery (section 6035); and
“mining” medical claims for potential fraud with the help of sophisticated computer technology algorithms – called “spider-webbing” – which locate a common insurance claim denominator and then follow the thread throughout claims review. Indicators of possible fraud include doctors charging more than peers; providers who administer more tests or procedures per patient; providers who conduct medically “unlikely” procedures; providers who bill for more expensive procedures and equipment when there are cheaper options; and patients who travel long distances for treatment.

Assessment

CMS and private companies are able to save far more money by detecting fraud before claims are paid than recovering the money after the fact. And so, a further erosion of patient confidence can be expected as CMS, and private insurers, assume the “bounty hunter” view of healthcare providers.

Conclusion

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Filed under: "Doctors Only", Career Development, Ethics, Health Insurance, iMBA, Inc., Information Technology | Tagged: CMS, david marcinko, DRA, Fair and Accurate Credit Transaction Act, false claims act, fragmented billing, Glen A. Fine, healthcare abuse, healthcare fraud, HIPAA, HSS, Incentive Program for Fraud and Abuse Information, Medicaid Integrity Program, medical claims mining, medicare, medicare cliams mining, spider webbing, unbundled medical billing, unbundling, www.healthcarefinancials.com | 5 Comments »

On Growing Tensions in Healthcare Services Markets

Posted on June 21, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Stressors Affecting all Stakeholders

[By Robert James Cimsai; MHA, AVA, ASA, CMP™]

http://www.HealthCapital.com

The changes in reimbursement for Medicare services through the introduction of prospective payment systems and physician reimbursement cuts for professional services, as well as the increased focus on patient quality and transparency initiatives and health 2.0 collaboration have forced healthcare providers to look for more efficient ways to provide services, as well as additional sources of revenue and margin-producing business.

Additionally, with the rise of corporate healthcare provider networks and health systems, together with rising healthcare costs, competition among providers has become prevalent in the healthcare industry.

Assessment

Strict control of reimbursement costs from payers and consistent decreases in physician professional component fee reimbursement yields; reduction in traditional hospital inpatient use; and higher costs of capital have all contributed to the trend of physician investment in outpatient (and inpatient) specialty provider enterprises [ASCs, specialty hospitals and clinics, etc] , which often compete with general acute care community hospital providers.

Conclusion

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GM Bankruptcy Hits Delta Dental Hard

Posted on June 17, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

United Auto Workers Retirees Lose Benefits

[By Darrell K. Pruitt; DDS]

It’s no longer just the recent rash of bad PR on the Internet that has some Delta Dental employees worried about losing their jobs. Okemos, Michigan, home to Delta Dental of Michigan is downstream from GM. If Delta employees are laid off because of decreased sales of benefits packages, Okemos will lose even more of its disappearing tax base. And, this week we learn that United Auto Workers [UAW] retirees will lose their Delta dental benefits in GM’s bankruptcy.

The Michigan Messenger

I discovered a short article today on the Michigan Messenger Website, written by Ed Brayton, titled “GM’s UAW retirees to lose Delta Dental coverage.” Brayton closes with a sad lament: “It was only last November that Tim Daman, a Lansing Regional Chamber of Commerce vice president, declared that with the office expansion, 2008 was ‘really Delta’s year.’ It appears that 2009 will not be.” Less than a year before Daman’s optimistic comment, Delta Dental announced that it was expanding its existing office space by 25,000 square-feet including 20,000 for a new data center. It’s unfortunate that the squandered money wasn’t spent on GM retirees’ teeth before they lost their dental insurance. Is it any wonder that Americans pay so much for so little healthcare?

Eyeing the Situation

And, what was Delta planning to do with that much data space anyway? Are Delta’s computers that huge, or was someone anticipating that future claims processing will require lots of soon to be unemployed Okemos citizens? I think if Colombo, a detective played by Peter Falk in a TV show long ago, were to cast his good eye on this situation with Delta Dental, he would see something odd about risking so much healthcare money on “data” rather than rewarding bonuses to executives who managed to save those huge amounts of money on payments to dentists. He’d scratch his head with the same hand holding a cigar, and say something like, “If Delta was willing to invest that much into say, a data mining project; they must have been planning on saving even more money on dental care for GM retirees somehow. Where was that money going to come from?

Public Relations Perspective

Ari Adler, the same Delta PR employee who a few months ago publicly announced that Delta Dental guarantees its dentistry, offered prepared statements about the bad news for Delta, but would not comment on how this enormous loss in business might ultimately change the company’s plans. He was only allowed to offer that the company is “studying the impact of this situation on the organization.” He assured Brayton that the building is going up as planned. I hope Delta doesn’t back out of its guarantees on fillings. That would be especially cruel to GM retirees.

More: GM’s UAW Retirees to Lose Delta Dental Coverage

Dental provider plans to offer special options for retirees, whose coverage could end as early as next month

By Ed Brayton 6/8/09 12:11 PM

http://michiganmessenger.com/20507/gms-uaw-retirees-to-lose-delta-dental-coverage

Assessment

It’s a real puzzler, Columbo. But, I’d bet you could figure it out by the end of the show. Peter Falk and family, I wish you the best.

Managing Editor’s Note: Dr. Dave Marcinko our publisher will be on a book and speaking tour in Michigan, and the Upper Peninsula later this month. He will be “signing and opining” – “preaching and teaching” to all ME-P advocates and others who attend. So, be sure to stop by any venue, and say hello. And, we will report back on his trip later this summer.

Link: https://healthcarefinancials.wordpress.com/dr-david-marcinko%e2%80%99s-bookings/

Conclusion

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Filed under: Alerts Sign-Up, Breaking News, Career Development, Events-Planner, Health Insurance, Interviews, Managed Care, Marketing & Advertising, Media Mentions and PR, Practice Management, Research & Development, Sponsors | Tagged: Ari Adler, book tour, Darrell Pruitt, david marcinko, Delta Dental Michigan, dental insurance, Ed Brayton, General Motors, GM, GM bankruptcy, healthcare benefits, Lansing, Michigan Messenger, Okemos, Tim Daman, UAW, United Auto Workers | 8 Comments »

Medical Coding and Billing Vocabulary

Posted on June 11, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Basic HIT Nomenclature and HIPAA

[By Richard J. Mata; MD, MIS, CMP™ [Hon]

For the Health Information Technology [HIT] department of a hospital, clinic or medical practice and its coders, the following medical vocabularies are mandated by the Health Insurance Portability and Accountability Act [HIPAA].

Diseases

For diseases: the 9th or 10th International Classification of Diseases (ICD) Clinical Modification should be used. ICD9-CM is maintained by the Centers for Disease Control National Center for Health Statistics, while ICD-10 is maintained by the World Health Organization.

Procedures

For medical procedures: a combination of ICD-9-CM, Current Procedural Terminology maintained by the American Medical Association, the Current Dental Terminology maintained by the American Dental Association, and Healthcare Common Procedure Coding System (HCPCS) maintained by CMS, which is also used for medical devices.

Pharmaceuticals

For drugs: these should be coded according to their National Drug Code classification.

Assessment

“A recent change to Medicare policy made by the Centers for Medicare & Medicaid Services (CMS) helps ensure claims processing isn’t delayed when the only missing information on the CMS-1490S form is the provider or supplier’s National Provider Identifier (NPI).

CMS Transmittal 1747, Change Request 6434, issued May 22, notifies A/B Medicare Administrative Contractors (MAC) and carriers of editorial changes to Medicare policy in Pub. 100-04, Medicare Claims Processing Manual, chapter 1 regarding the monitoring of claims submission violations and the handling of incomplete or invalid claims.

In either case, as stated in the transmittal, “If the beneficiary furnishes all other information but fails to supply the provider or supplier’s NPI, the contractor shall not return the claim but rather look up the provider or supplier’s NPI using the NPI registry.”

http://www.aapc.com/news/index.php/2009/06/missing-npi-no-reason-to-deny-says-cms/

Conclusion

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Filed under: Glossary Terms, Health Insurance, Information Technology, Practice Management, Research & Development | Tagged: ADA, AMA, CDC, CDT, Centers for Disease Control National Center for Health Statistics, CMS, CPT, current dental terminology, current procedural terminology, david marcinko, HCPCS, Healthcare Common Procedure Coding System, HIPAA, hope hetico, ICD-10, ICD-9, international classification of diseases, IT, MAC, medicare, National Drug Code, National Provider Identifier, NPI, Richard Mata, WHO | 2 Comments »

Why Coding Professionals?

Posted on June 7, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

More on the NPI, the AAPC, Censorship and Quality Health Care

By Darrell K. Pruitt; DDS

For those who have been following me recently on Twitter (Proots), you know that unlike me, John Hamm has not yet been kicked off of DrBicuspid, and is awaiting a response from Dr. David J. Pettigrew – a dental coding expert with 14 years of experience as Chief Dental Officer for BCBS of New Jersey. I can only shadow the conversation because, as I said, I was kicked off.

Through John Hamm, I sent word to Dr. Pettigrew that he should just shut up and not enter into a discussion about the NPI number. Pettigrew told Johnhamm that I should come onto the DrBicuspid forum and say that in front of everyone. Of course, I am unable to do that because as shameful as it is to my family, I am still banned from posting anything on DrBicuspid.

For real-time developments concerning Dr. Pettigrew’s public defense of the NPI number, it would be better to follow that chunk of drama on Twitter or DrBicuspid. I’ve got other things cooking here. Can you smell it yet?

As you can see, sports fans, I have had Internet contact with a new class of fat, slow-moving healthcare IT stakeholders, and I haven’t been building long-term relationships fortified by good will – if you know what I mean. 14 years of employment at BCBS of New Jersey fails to impress me much.

American Academy of Professional Coders

Those who have studied alphanumeric science have a national organization called the American Academy of Professional Coders [AAPC] which represents business consultants in a growing healthcare niche. Most are employed by providers who are too busy actually performing healthcare to play games with insurance companies for the money owed them. Like SEO professionals who know gimmicks to increase a client’s page rank in relation to competitors, or perhaps a bolus of bad news from a special bastard, professional coders maximize providers’ profits by keeping on top of the ever-changing hoops involved in paying doctors almost all that is owed them following a shorter than average delay.

ICD-10 is Coming

Learning coding is job security these days because in a few years the mandated ICD-10 codes will force even dental offices to hire IT staff, which also cuts down on the nation’s unemployment. I’ve taken a peek at the ICD-10, and it makes the ICD-9 look like simple algebra. I’d stick with well-trained coding professionals. They’ll cost more but you do want to approach making a profit, don’t you?

Of Censorship

I submitted the following stinker to be posted on the AAPC Website. To their credit, it was posted almost immediately. That could be a good sign … OOPS! Several minutes later it went back under moderation. I think someone is having problems with it. You’ll have to read it to understand why. It’s tricky to let go of, yet if it remains posted, it looks like a concession. Some poor slob in the AAPC is in a bad position. I hope you are enjoying this as much as I am.

-Darrell

CMS Transmittal 1747, Change Request 6434, issued May 22, notifies A/B Medicare Administrative Contractors (MAC) and carriers of editorial changes to Medicare policy in Pub. 100-04, Medicare Claims Processing Manual, chapter 1 regarding the monitoring of claims submission violations and the handling of incomplete or invalid claims.

http://www.aapc.com/news/index.php/2009/06/missing-npi-no-reason-to-deny-says-cms/

“How does an NPI number improve patient care?”

By D. Kellus Pruitt DDS – posted on AAPC Website, 6.4.09

I see that nobody from the American Academy of Professional Coders has yet attempted to answer my question. Some visitors to the AAPC Website who have followed the comments to the article “Missing NPI Won’t Delay Processing – CMS” (no byline) may think the lack of an answer is odd – that is if they happen to notice. The novice professional coder who still does not know much about HIPAA could easily assume that since the article itself is almost a week old, the lack of a response to my question is nothing more than the natural fading of interest. At some point, people logically move on to newer posts and other parts of their lives.

But I know a secret.

Based on nothing more than glaring silence from anonymous officials of AAPC, I know that my question of whether the NPI number improves care did not go unnoticed by a few knowledgeable and sharp individuals. They know enough not to touch a transparently trick question. The answer of course is:

The NPI number does nothing to improve patient care (Gasp!)

There’s more. Five years ago informatics experts (coders), promised that the ten digit identification number for providers will speed payments lightning fast. When is the last time you heard that fib? I cannot fault abundant optimism, AAPC, but by now you are surely aware that physicians have had to wait for a year or more for payment because of foul-ups at NPPES. Some have had to take out loans to pay the salaries of coding professionals and other new IT members of their staffs.

Improving Healthcare?

And as far as “improving” patient care? That would be worse than a fib. That would be called a harmful lie that upsets me in a very personal way. I know where it is documented that dental patients have been forced to leave dentists they preferred simply because one-third of the dentists in Texas do not have NPI numbers. BCBSTX requires that their clients only see dentists who have the numbers. Otherwise, the client has to pay their dental bill in full and BCBSTX isn’t even obligated to refund the employer the insurance premium. Yet BCBSTX sales reps tell these employers that their employees can see any Texas dentist they choose.

I’m sorry. Sometimes I ramble.

To keep it fair, I will ask if there is anyone who would like to point out the benefits of the NPI number. Your AAPC members and many others, including enthusiastic newbie coders, are interested in hearing from leaders of the organization. Many careers are built upon the complexities caused by digitalization and informatics. I don’t blame you for the complications. After all, you don’t make the rules – you just get along with them really well. It’s like our unavoidably complicated tax code and accountants. Accountants call themselves professionals. So why the hell shouldn’t you?

The Medical Executive-Post

Let me say that I am grateful that you believe enough in transparency that this comment remains posted. It wouldn’t surprise me if someone briefly considered deleting it until they discovered that it will be on the PennWell forum and probably on the Medical Executive-Post anyway. And of course, we can all see that you chose the honorable thing to do.

NPI Fallacy

The NPI fallacy reminds me of a scene in the Mike Judge movie “Idiocracy,” when a character 500 years in the future named Frito is asked why fields are fruitlessly irrigated with a politically-correct brand of green colored sports drink instead of water. Frito, who got his law degree from Costco, doesn’t even have to suffer minimal thought before he quickly repeats what he’s heard so many times, “’Cause it’s got ‘lectrolytes.”

Grnerod finds it incredible that I don’t have an NPI number. “How on earth are you billing and getting paid without an NPI?”

I told him (?) that I don’t work if I don’t get paid. Call me an old school radical.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. What are your feelings on the NPI situation? Does it really improve health care, or not? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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The Power of “ME Inc” for Physicians

Posted on June 3, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Embracing a New Competitive Practice Culture

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

There are more than 900,000 physicians in the United States. Yet, the brutal supply/demand/demographic calculus of the matter is that there are just too many aging patients chasing too few doctors. Compensation and reimbursement is plummeting as Uncle Sam becomes the payer-of-choice for more than 52% of us. And, the government as payer will likely increase with the Obama Administration. So, going forward, it is not difficult to imagine the following four rules for a new-wave competitive medical care culture for all physicians.

[A] Rule No. 1

Forget about large office suites, surgery centers, fancy equipment and the bricks and mortar that comprised traditional medical practices. One doctor with a great idea, good bedside manner or competitive advantage, can outfox a slew of CPAs, while still serving the public and making money. It’s a unit-of-one healthcare economy where “ME Inc.”, is the standard and physicians must maneuver for advantages that boost their standing and credibility among patients and payers. Examples include patient satisfaction surveys, the rise of evidence-based medicine; outcomes research analysis, concierge medicine, direct reimbursement payment plans, and economic credentialing; etc.

[B] Rule No. 2

Challenge conventional wisdom, think outside the traditional payer box, recapture your dreams and ambitions, disregard conventional gurus and work harder – and smarter – than you have ever worked before. Remember the old saying, “if everyone is thinking alike, then nobody is thinking”. Do insurance panel members think rationally or react irrationally?

However, you should realize the power of networking, vertical integration and the establishment of virtual medical practices, which come together to treat a patient, and then disband when a successful outcome achieved. Job security in this structure is achieved with successful outcomes, and perhaps not necessarily a degree in the near future. Medical futurists even presume the establishment of virtual medical schools and hospitals, where students and doctors learn and practice their art on cyber-entities that look and feel like real patients, but are generated electronically through the wonders of virtual reality units.

www.HealthcareFinancials.com

[C] Rule No 3

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. The conformity of health insurance plans are an operational standard and a straitjacket on creativity. Doctors should create and innovate, not blindly follow entrenched medical society leaders into oblivion. Seek, and practice, health 2.0 collaboration with all stakeholders.

[D] Rule No 4

Realize that the present situation 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 health plans adhere to any of the above rules?

Assessment

Regardless of the future de facto business model of the learned profession of medicine, current practice models are no longer the structure of choice. Rather, a more laissez-faire and highly competitive business model should be pursued. Physicians have been slow to accept this philosophy. Remember, as a physician, if you merely want a static job with promised security, pledged retirement benefits, limited goals and structured regulations; join a health plan panel and become their laborer.

However, if you desire more, such as the possibility of a dynamic career, the unlimited security of your brainpower, non-defined retirement contributions, infinite potential with rules you can create along the way; incorporate the power of ME, Inc., in everything you do. Remain a competitive professional and be a physician ... Get fly!

Conclusion

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About Timely Medical Alternatives; Inc

Posted on May 30, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding Canadian Health System Alternatives

By Staff Reporters

In 2003, Timely Medical Alternatives Inc. was formed to help Canadians, on long medical waiting lists, to take personal responsibility for their own medical care and “Leave the queue” [the national healthcare system waiting-list].

Urgent Need

According to their website, the need for private medical services is thriving in Canada. The mission of Timely Medical Alternatives [TMA] is to accommodate Canadian’s needs for private medical services by providing them with options, referrals to hospitals, clinics and diagnostic imaging facilities.

Link: http://www.timelymedical.ca

Assessment

Timely Medical Alternatives, a PPO, says it is able to expedite most types of private medical services from diagnostics to virtually all types of surgery, including procedures not available within the Canadian healthcare system. Wait times for clients are measured in days rather than in months or years.

Link: www.HealthDictionarySeries.com

Sicko Alternative

The movie documentary Sicko was directed by Michael Moore in 2007. It compared the highly profitable American health care industry to other nations, and HMO horror stories

Link: www.michaelmoore.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Please compare and contrast TMA to “Sicko”, our current domestic health system, and the Obama administration’s vision of national healthcare for the US; and opine .Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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Beware the Faux Medical Journals

Posted on May 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

When is a “Journal” … not a Journal?

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

Allow me to begin this post by making the unusual disclosure that I was the Editor-in-Chief of a print guide in healthcare finance and economics [aka periodical or journal].

Formally, the title was: Healthcare Organizations [Financial Management Strategies]. At 2 volumes, and more than 1,200 pages, it was quite a job to update it quarterly. And, with more than two dozen contributing authors, it was a labor of love indeed. Alas … no more!

Varying Levels of Credibility

Now, we doctors know that medical journals are not all alike. There are different levels of “credibility.” Some are peer-reviewed, others not. Some are trade magazines. Frankly, some “real” journals are better, and more respected than others. Some entrenched journals are in decline, while other emerging journals are leading-edge in the health 2.0 space. Still others, like the formerly esteemed Journal of the American Medical Association [JAMA], have been accused of outright censorship.

Link: https://healthcarefinancials.wordpress.com/2009/04/02/is-jama-censoring-physician-dissent/

Adventures

Of course, doctors also know that pharmaceutical companies routinely offer us reprints of articles from medical journals that are favorable to their products. But, news of a Merck-sponsored publication for doctors in Australia has come to light in a personal injury lawsuit over Vioxx. It raised more than a few eyebrows in international medical publishing circles. It may have even crossed the line of journalistic, not to mention medical, ethics.

Read: Merck Paid for Medical ‘Journal’ Without Disclosure; by Natasha Singer, May 13, 2009.

Link: http://www.nytimes.com/2009/05/14/business/14vioxxside.html?_r=1&adxnnl=1&adxnnlx=1242313549-xaAEwW4MCd7pJh9OdgWdUQ

Mis-Adverntures

Tracy Staton wrote more about these mis-adventures in a story, dated May 14, 2009, in FiercePharma.

Analysis and Apology

Analysis in the Pipeline: http://seekingalpha.com/article/136942-merck-and-elsevier-cross-the-line-in-joint-medical-journal?source=yahoo

Libology Mea Culpa: http://www.libology.com/blog/tag/excerpta-medica

Assessment

Perhaps; Merck ought to read our Medical-Executive Post on health journalists?

Link: https://healthcarefinancials.wordpress.com/2009/03/17/battered-health-journalists

Or, our Medical-Executive Post on medical experts, reporters and journalists?

Link: https://healthcarefinancials.wordpress.com/2009/03/09/healthcare-experts-versus-health-journalists

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Employers and eDocAmerica

Posted on May 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

An Emerging Health 2.0 Benefits Program

By Staff Reporters

eDocAmerica’s mission is to improve health by providing direct, online access to medical services, making it much more convenient to get the information for employees to take better care of themselves.

Services

Services enable employees to provide better self care, to lead to a healthier life, and to visit a physician only when necessary. Medical problems can often be managed with the tools available on eDocAmerica’s website. Services include medical information from board certified physicians, and educational material about the medical conditions of employees and family members. Physician responses are authoritative and are made within 24 hours from the time of the request, with most responses arriving in three to four hours. Problems that require a more rapid response should be managed by a visit to a personal physician or an emergency facility.

MD Online

MD Online LLC [dba eDocAmerica] is a fully funded, private company. eDocAmerica has a ‘no advertising policy’ and therefore does not host or receive funding from advertising from the display of commercial content. It is an HONcode compliant website. (www.hon.ch)

Benefits

eDocAmerica provides an innovative and effective Health 2.0 employee benefit program that purports to:

Increase employee satisfaction and morale
Decrease absenteeism
Save money on health care costs
Improve employees’ health
Provide online access to board certified physicians.

Assessment

eDocAmerica allows employees or members to have access to board certified, experienced physicians to consult with them about health care. eDocAmerica physicians provide personal advice, suggest treatment alternatives, use links to websites, provide patient information from other sources, or refer employees to their specialists – all from the workplace desktop computer or from home. The cost of eDocAmerica for a year for one employee is less than one primary care visit.

More Info
email: info@edocamerica.com and phone: 1-866-525-eDoc (3362)

Conclusion

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Economic Facts your Dentist Doesn’t Want You to Know

Posted on May 25, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Some Office Visit Schedules Linked to Insurance Payment

By D. Kellus Pruitt; DDS

http://thebulletin.us/articles/2009/05/21/herb_denenberg/doc4a15404e56e5f308210565.txt

Here is the link to an article written by Herb Denenberg titled: “Some Facts Your Dentist Doesn’t Want You to Know”. In it, he shared with his readers some information about dentistry that is hard to find. I submitted the following comment.

Dear Herb Denenberg,

Yours was a great article, and as a dentist with 27 years in a comfortable practice and 32 years in an expensive marriage, I find your cost-saving points oh so painfully accurate. Nevertheless, I must honestly agree that not only can some patients safely go a year or more between check-ups (ouch!), but many don’t need bitewing x-rays every year either (Good thing neither my patients nor my wife read the stuff I write).

Of BiteWing X-Rays

Readers who are hopefully from places other than the east side of Fort Worth can easily understand that the more treatment and x-rays I recommend, the more money I make. I must honestly add that my devoted and trusting dental patients, like most Fort Worth dentists’ patients, are reliably willing to accept my recommendations for these kinds of procedures without questioning the need. Let me put it this way: Annual bitewings are an easy $56 sale, mostly because fee-for-service insurance pays for them at 100% anyway. (If an angry dentist should ask who told you that, it wasn’t me). That is why it should not be taken lightly my approval of the advice about dentistry published in the book “1,001 Things They Won’t Tell You.” And; they won’t, sometimes.

Ethics and EBD

True to ethics I learned at the University of Texas dental school, in San Antonio (UTHSC), in the last six months, my hygienists and I have been determining which patients are safe to go a year and a half without routine bitewing x-rays. They are commonly taken every year simply because it has always been that way, and that interval was adopted as the minimum time most insurers allow. As readers can see, not a hint of Evidence-Based Dentistry [EBD] was involved in that determination. It was just a 1950’s guess.

Extended Prophylactic Schedules

This week we found four candidates in our practice for extended schedules. Our honesty will save these patients (their insurance companies) money by eliminating unnecessary care. And I really, really hate saving insurance companies money, on principle alone.

In My Defense

In my defense of continuing to maintain a large number of my patients on 6 month prophys and 12 month x-rays – and with the hope of restraining local dentists from throwing rocks through my windows – let me say up front that most people still need the old-school schedule in order to prevent disease. And, a few of the more fragile cases need x-rays and cleanings even more often than insurance allows.

Assessment

My patients and I are fortunate that I can freely charge the prices I deem necessary in order to put my patients’ interests above my wife’s. Let’s face it. Ethics are invisible to dental patients and they are not free. Ethics are a precious courtesy that dentists who accept managed care insurance find themselves forced to eliminate because contracts prevent them from raising fees as the market demands. Managed care dentistry is dentistry by the lowest bidder with no quality control. I only wish that someone would have pointed out that chunk of information in the book. Now, I’d better have my wife go ahead and start my car in the morning when she grabs the paper.

Conclusion

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Filed under: "Doctors Only", Career Development, Ethics, Health Economics, Health Insurance, Managed Care, Practice Management | Tagged: ADA, bite wing X-rays, cavities, Darrell Pruitt, DDS, dental visits, DMD, EBD, evidence based dentistry, Herb Denenberg, UTHSC | 7 Comments »

Health Care Costs and the Domestic Budget

Posted on May 19, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

The Real Budget Defecit

[By Staff Reporters]

The Obama Administration has made comprehensive health insurance, and health care, reform a priority.

The goal is to transform the domestic health-care system so that it improves efficiencies, increases value and provides care for all citizens.

Current Situation

Recently, two important facts that all ME-P readers know, were re-confirmed:

Health-care costs are the key to the nation’s economic future.
The medical community agrees that great efficiencies are possible in how it is practiced.

Variations

It is well known that health-care costs vary across significant regions of the country, as well as hospitals and doctors within a region – even for patients with a same/similar diagnosis. This must end, according to the Director of the White House Office of Management and Budget [OMB]. Director Peter R. Orszag explained in a WSJ interview below, that practice variation is unnecessary and wasteful, and that evidence-based-medical practices and comparative-effectiveness-research is a good idea for all healthcare stakeholders.

The Baucus-Grassley Policy Options for Expanding Healthcare Coverage report is also included for your review and commentary.

Two New Reports

Wall Street Journal on May 15, 2009.

1. Link http://online.wsj.com/article/SB124234365947221489.html

2. Link: http://finance.senate.gov/press/Bpress/2009press/prb051109.pdf

Assessment

Once accomplished, it is hope that the nation will be on a sustainable fiscal path that builds a new foundation for our economy for generations to come.

Conclusion

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HSA and MSA Contribution Limits for HDHCPs

Posted on May 16, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Tabular Charts of Dollar Amounts for FAs and MDs

[By Staff Reporters]

IRS Requirements for 2008
	Single Plan	Family Plan
Minimum Deductible	$1,100	$2,200
Maximum Out-of-Pocket	$5,600	$11,200
Contribution Limit	$2,900	$5,800
Catch-Up Contribution (55 or older)*	$900	$900
* If a spouse is 55 or older, a second HSA/MSA may be established and a second catch up up contribution of $900 may be made to that account if desired.

IRS Requirements for 2009
	Single Plan	Family Plan
Minimum Deductible	$1,150	$2,300
Maximum Out-of-Pocket	$5,800	$11,600
Contribution Limit	$3,000	$5,950
Catch-Up Contribution (55 or older)*	$1,000	$1,000
* If a spouse is 55 or older, a second HSA/MSA may be established and a second catch up up contribution of $1000 may be made to that account if desired.

Conclusion

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Physician [Fee] Schedule Augmentation

Posted on May 14, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Organizing and Analyzing Financial Data

[By Christy Clodwick; MHA]

After all medical practice management data has been gathered, organize it onto a spreadsheet or chart. This analysis report will help to determine the codes and/or health plans that should be targeted for process improvement.

Focus … Focus … Focus

The focus should be on the highest volume and dollar value codes. Does this mean patients with unusual conditions or low dollar value codes are not treated? Hopefully it will not; but it will push this process forward and the practice will see the greatest benefit from these categories. When you review the report and find that a fee is being paid at a much lower rate, this would be indicative of a necessary negotiation with the payer for an increase for that procedure. Most health plans are committed to preventing disease. Maybe, but they are still actually aimed at treating diseases; not preventing them. If this is true of many payers then they should be willing to provide the incentives for those services to be carried out. You will find that some payers’ fee schedules are very much out of line with a percentage of Medicare payments, therefore the practice administrator should focus on those payers and bring evidence of the inadequacies to their attention.

The Specialists

Specialists are, for the most part, paid at a higher rate than primary care physicians not usually for the same service! And, with GPs as gatekeepers, the specialty doc incomes may have actually decreased in some instances, while the GPs may have increased. There was a time when Medicare had two conversion factors, and this was the result. This inequity could also be used as a tool for better reimbursement rates.

Finalizing the Fee and Revenue Analysis

When the final preparations of the fee analysis have been completed, it is time to react to the results of the findings. There are several options to choose from when it has been determined that a health plans fee schedule is not in tune with the practice’s financial growth. The practice should act on these results as soon as they are discovered, to avoid the loss of any more revenue.

No longer Accepting Health Plans

During the analysis phase, you may determine that a health plan’s payment levels are extremely low. You will have to determine whether the plan is worth negotiating or the practice administrator should consider dropping out of the plan altogether at the end of the contract period. It will have to be carefully determined by the local market. If the practice is in a highly competitive market, this process should not be considered as first choice. However, if the market is very slim, the health care purchaser will be responsible for complaining to the health insurance plan provider that there is simply not enough physician coverage for their employees for the area. This could be a very effective way to force a negotiation with the health care company. If this were the case, the area would have less managed care and more MC/MD.

Not Accepting New Patients from Low Paying Health Plans

One option would be to not accept any more patients from the health plan that is reimbursing the practice with low rates. Although this may initially lower your patient count, over time the practice will benefit from new patients with health plans that have a better reimbursement policy. Include snapshot of what the final analysis or report should look like and the details of what it should include. This can be used in any specialty to assist in putting together the individual practice analysis to achieve the same results. But is it noble or ethical? What about any willing provider laws?

The Future for Health Care Reimbursement

The health care purchasers who pay most of the bills, such as employers and the government, will soon be challenging the annual increase and the overall cost of health care. The cost increases of the hospital and pharmacy sectors of healthcare are far higher than that of the physician. However, the pressure for cost containment is being felt across the board. This will eventually depress future reimbursement for all healthcare providers. In the future it will be hard for practices to keep up with the demands of labor, malpractice and supply cost increase. All medical providers need to plan for this future paradigm. To offset this trend, physicians will need to get the most out of the work that they are doing today as well as look to new revenue generating procedures for their practice that will be cheaper and more convenient to the patient.

Process Improvement

The biggest benefits will come from continually improving the process of the daily operations of the practice, as well as ensuring accurate diagnostic coding. This will enable a practice to keep up with charge capturing through the explanation of benefits (EOB) when the charge has been processed and paid by the health insurance provider. When this process identifies that there is room for negotiation, the provider should proceed for a better reimbursement rate. If the provider is in a dominant market, the payers will be more likely to issue sweeping fee increases and so can you give me an example of this ever happening? By completing a Practice Fee Analysis, any practice should be able to use this tool to demonstrate the inequities and negotiate a better reimbursement rate for the practice.

Assessment

The first step in the negotiation process would be to contact a representative of the health insurance company that is in question. If you can produce compelling evidence to the representative, the negotiation process should be the next meeting. These folks may be fired if they do what you suggest, too frequently. Continually updating the practice fee schedule will help the practice stay on top of the contracts that it practices under. Practices that present a well-documented argument may (almost never) be rewarded with positive payer response. Again, proper planning will make for great future performance in any health care practice.

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Defining and Understanding “Boutique Medicine”

Posted on April 28, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What it is – How it Works

By Dr. David Edward Marcinko MBA

http://www.CertifiedMedicalPlanner.org

According to colleague Robert James Cimasi of Health Capital Consultants LLC in St. Louis MO, concierge or boutique medical practices began in the mid-1970s, and are now in many major metropolitan areas. Concierge medicine is described as a “return to old-fashioned medicine,” where physicians limit their client base and devote more time to each patient. Patients can usually get in to see their physician within a day, and most have 24-hour access to their physician by beeper or cell phone.

The Doctor’s Perspective

Physicians who turn to concierge medicine are typically tired of not having enough time with their patients and dealing with overbooked caseloads, and are looking for a way of balancing their lives while still providing quality care for their patients. Patients who have physicians in this type of practice appreciate the “perks” they get for paying a yearly fee — similar to “annual membership dues.” These fees can range anywhere from $1,000 per year to $10,000 per year depending on the patient’s age, benefits received, area of the country, and practice.

Patient Amenities

Amenities vary by practice, but some include longer physician office visits, increased access to physicians, e-mailed “newsletters” or condition-specific information, physicians accompanying patients on visits to specialists, and house calls. In order to provide more attentive care and amenities to patients, physicians often decrease their patient load to approximately 10-25% of their managed care load. Thus, most of their patients must find other physicians, leading to potential increases in the patient load of managed care physicians.

Elitist Patients

Although concierge medicine may provide many benefits for patients (including more, and in some cases, nearly unlimited access to their physicians), it has been met with some scrutiny. Some say that this type of medicine is elitist, that it is available only to wealthy patients who can pay the annual fees. Medicare beneficiaries who are members of a concierge practice have received political attention, because many politicians have said that the annual fees patients pay is a lot more than the Medicare rate and thus is illegal billing.

Critics

Critics also emphasize that healthcare needs to be first-rate for everyone, something that the current managed care system prevents. The implication that managed care means second-class medicine has also been a fear cited by critics.

Assessment

However, concierge physicians portray their clients as mostly middle-income people who are willing to pay more for this kind of care. Concierge medicine is not a substitute for health insurance. Patients typically keep their traditional insurance to pay for any tests or scans ordered by the physician.

MORE: https://medicalexecutivepost.com/2009/10/26/customer-relationship-management-and-the-nascent-concierge-medical-practice/

Conclusion

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Filed under: Career Development, Glossary Terms, Health Insurance, Managed Care, Quality Initiatives, Research & Development | Tagged: boutique medicine, concierge medicine, david marcinko, hope hetico, retainer medicine, robert james cimasi, www.healthcarefinancials.com, www.HealthDictionaySeries.com | 7 Comments »

Understanding the Emergency Medical Treatment and Active Labor Act

Posted on April 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

An Important and Contemporary Issue – Once Again

[By Patricia Trites; MPA, CHBC, CMP™ (Hon) with Staff Reporters]

The Emergency Medical Treatment and Active Labor Act (EMTALA) is receiving increasing scrutiny from prosecutors during these times of financials stress and credit tightening. The statute is intended to ensure that all patients who come to the emergency department of a hospital receive care, regardless of their insurance or ability to pay. Both hospitals and physicians need to work together to ensure compliance with the provisions of this law.

Triad of Requirements

EMTALA imposes three fundamental requirements upon hospitals that participate in the Medicare program with regard to patients requesting emergency care.

First, the hospital must conduct an appropriate medical screening examination to determine if an emergency medical condition exists.

Second, if the hospital determines that an emergency medical condition exists, it must either provide the treatment necessary to stabilize the emergency medical condition or comply with the statute’s requirements to affect a proper transfer of a patient whose condition has not been stabilized. A hospital is considered to have met this second requirement if an individual refuses the hospital’s offer of additional examination or treatment, or refuses to consent to a transfer, after having been informed of the risks and benefits of treatment.

Third, EMTALA’s requirement is activated if an individual’s emergency medical condition has not been stabilized.

Hospital Transfers

A hospital may not transfer an individual with an unstable emergency medical condition unless:

(1) the individual or his or her representative makes a written request for transfer to another medical facility after being informed of the risk of transfer and the transferring hospital’s obligation under the statute to provide additional examination or treatment;

(2) a physician has signed a certification summarizing the medical risks and benefits of a transfer and certifying that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the transfer outweigh the increased risks; or

(3) a qualified medical person signs the certification after the physician, in consultation with the qualified medical person, has made the determination that the benefits of transfer outweigh the increased risks, if a physician is not physically present when the transfer decision is made. The physician must later countersign the certification.

On-Call Responsibilities

One area of particular concern is physician on-call responsibilities. Physician practices whose members serve as on-call hospital emergency room physicians are advised to familiarize themselves with the hospital’s policies regarding on-call physicians. This can be done by reviewing the medical staff bylaws or policies and procedures of the hospital that must define the responsibility of on-call physicians to respond to, examine, and treat patients with emergency medical conditions. Physicians should also be aware of the requirement that, when medically indicated, on-call physicians must generally come to the hospital to examine the patient. Patients may be sent to see the on-call physician at a hospital-owned contiguous or on-campus facility to conduct or complete the medical screening examination due to the following reasons:

all persons with the same medical condition are moved to this location;
there is a bona fide medical reason to move the patient;
qualified medical personnel accompany the patient; and
teaching physicians may participate.

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Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: "Doctors Only", Career Development, Ethics, Glossary Terms, Health Insurance, Health Law & Policy, iMBA, Inc., Managed Care, Practice Management, Recommended Books | Tagged: CMP, david marcinko, emergency care, emergency department, Emergency Medical Treatment and Active Labor Act, emergency room, EMTALA, ER, healthcare, hope hetico, hospital, medicare, Pati Trites, www.healthcarefinancials.com, www.healthdictionaryseries.com | 9 Comments »

Healthcare Projections and the US Budget 2007-09

Posted on April 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Issues and Challenges for Obama Administration Reform

By Staff Reporters

Read the complete testimony and statement of Peter R. Orzag, OMB Director, to the US Senate, dated June 21, 2007.

For more information:

Congressional Budget Office

Second and D Streets; SW

Washington, DC 20515

Link: 06-21-healthcarereform

Assessment

Now, almost two years later, and with the new Obama Administration, has your opinion changed on the potential of healthcare reform; why or why not?

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated?

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Filed under: Career Development, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Managed Care | Tagged: COngressional Budget Office, healthcare reform, Obama Administration, OMB, OMB Director, Orzag testimony on health reform, Peter Orzag, US Senate | Leave a comment »

Understanding Modern Health Plan Delivery Models

Posted on April 25, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

By Defining Terms and Concepts

Staff Writers

www.HealthcareFinancials.com

Here are four important health care delivery models that should be understood by all financial advisors, their clients, patients and the public:

1. PHYSICIAN ORGANIZATION (PO)

A PO is a group of physicians banding together, usually for the purpose of contracting with managed care entities, or to represent the physician component in a Physician Hospital Organization. The PO is a managed care contracting entity owned by and composed exclusively of physicians. The PO tends to be more tightly controlled in terms of members and adherence to treatment protocols than an Independent Physician Association. POs typically share information systems, claims-processing procedures, financial data, medical records, and other technical support functions.

2. PHYSICIAN PRACTICE MANAGEMENT CORPORATION (PPMC)

A firm that purchases physicians’ practices in exchange for a percentage of the gross receivables. The PPMC leases the office back to the doctor or employs the doctor on a salaried basis. The PPMC then contracts with the areas MCOs.

3. POINT OF SERVICE PLAN (POSP)

A type of managed care plan that allows members to choose whether to seek medical care within the plan’s network or seek medical care out of network at the point of service (i.e., at the time services are rendered). It allows members to pay little or nothing, if they stay within the established HMO delivery system. But, it also permits members to choose and receive services from an outside doctor, any time, if they are willing to pay higher co-payments, deductibles and possibly monthly premiums. It is also called an “open-ended” plan.

4. PREFERRED PROVIDER ORGANIZATION (PPO)

A PPO is a select, approved panel of physicians, hospitals, and other providers who agree to accept a discounted fee schedule for patients and to follow utilization review and pre-authorization protocols for certain treatments. It is a system in which a payer negotiates lower prices with certain doctors and hospitals. Patients who go to a preferred provider get a higher benefit — for example, 90% or 100% coverage of their costs — than patients who go outside the network.

Assessment

Link: www.HealthDictionarySeries.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated?

Link: https://healthcarefinancials.wordpress.com/2009/03/13/rip-retail-financial-services-industry/

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Filed under: "Advisors Only", Book Reviews, Career Development, Glossary Terms, Health Insurance, iMBA, Inc., Managed Care, Practice Management | Tagged: david marcinko, dictionary of health insurance and managed care, financial advisors, health maintenance organization, HMO, hope hetico, managed care organization, MCO, physician organization, physician practice management corporation, PO, point of service health plan, POS, PPMC, PPO, preferred provider organization, www.healthdictionaryseries.com | 2 Comments »

Understanding the Health Maintenance Organization Delivery Model

Posted on April 24, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Defining Terms and Concepts

By Staff Writers

www.HealthcareFinancials.com

An HMO is a legal corporation that offers health insurance and medical care. It is a health care delivery system that provides comprehensive services for subscribing members in a particular geographic area. Most HMO care is provided through a managed network made up of MD/DOs, hospitals, and other allopathic/osteopathic professionals selected by the HMO. HMO enrollees are required to obtain care from this network of providers in order for their care to be covered, except in cases of emergency. All the care the members may need is paid for by the single monthly fee, plus nominal co-payments. HMOs typically offer a range of health care services at a fixed price (capitation).

Different Types

The types of HMOs are:

1. STAFF MODEL: Organization owns its clinics and employs its doctors.

2. GROUP MODEL: Contract with medical groups for services.

3. INDEPENDENT PHYSICIAN ASSOCIATION (IPA) MODEL: IPA contract that in turn contracts with individual physicians.

4. DIRECT CONTRACT or NETWORK MODEL: Contracts directly with individual physicians.

5. MIXED MODEL: Members get options ranging from staff to IPA models.

6. OPEN-PANEL MODEL: A managed care plan or HMO where members can see any provider for an extra premium cost.

Assessment

Link: www.HealthDictionarySeries.com

Conclusion

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Filed under: "Ask-an-Advisor", Book Reviews, Career Development, Glossary Terms, Health Insurance, iMBA, Inc., Managed Care | Tagged: david marcinko, Dctionary of Health Insurance and Managed Care, DDS, DO, DPM, Group Model HMO, health maintenance organization, HMO, hope hetico, IPA, Managed Care, MD, medical network, mixed model HMO, open panel HMO, staf model HMO, www.healthdictionaryseries.com | 1 Comment »

Alternative Design Options for a Public Health Plan

Posted on April 23, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

New Lewin Group Report Examines Potential Impact

[By Staff Reporters]

April 6, 2009

FALLS CHURCH, VA – The Lewin Group released a report titled “The Cost and Coverage Impacts of a Public Plan: Alternative Design Options.” The report examines potential impacts that a “public health plan” might have in competing for enrollment with the private insurance industry.

Healthcare Reform

As ME-P readers are aware, a public plan is currently being considered in a number of health reform proposals being considered by President Obama and the US Congress. This analysis enhances prior work done by The Lewin Group of the major party presidential candidate’s health reform proposals, during the 2008 campaign, as well as more recent analyses of the Congressional plans now being considered. The report estimates the impact on cost and coverage based on different levels of eligibility and reimbursement rates.

Key Findings Review

According to The Health Care Blog writer Robert Laszewski, key study findings include:

If Medicare payment levels are used in the public plan, premiums would be up to 30 percent less than premiums for comparable private coverage. On average, the monthly premium in the public plan for a typical benefits package would be $761 per family compared with an average of $970 per family in the private market for the same coverage.
If as the President proposed, eligibility is limited to only small employers, individuals and the self-employed, public plan enrollment would reach 42.9 million people. The number of people with private coverage would fall by 32.0 million people. If private payer reimbursement levels are used by the public plan, enrollment would be lower, with only 10.4 million people switching to the public plan from private insurance.
If the public plan is opened to all employers as proposed by former Senators Clinton and Edwards, at Medicare payment levels we estimate that about 131.2 million people would enroll in the public plan. The number of people with private health insurance would decline by 119.1 million people. This would be a two-thirds reduction in the number of people with private coverage (currently 170 million people). Here again, if the higher private payer levels are used, enrollment in private insurance would decline by only 12.5 million people.
Assuming Medicare reimbursement rates and eligibility for all individuals and employers, provider net income would decline under this public plan proposal, even after accounting for reduced uncompensated care and increased utilization for the newly insured. Net hospital revenues would fall by $36 billion (4.6 percent), and physician net income would fall by $33 billion (6.8 percent). If eligibility is restricted to individuals and small firms, net hospital revenues would actually increase by $11.3 billion due to the increase in newly insured individuals. But net physician incomes would decline by $3.0 billion.

Assessment

Full report: lewin-report

Conclusion

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Filed under: Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: lewin group, medicare, national healthcare, obama, public health, self-employed, Senator Clinton, Senator Edwards, socialized medicine, uncompensated care | 4 Comments »

About Medlytix.com

Posted on April 22, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

On Patient Payment Behavior Scoring

[By Staff Reporters]

Medlytix is a healthcare consulting and technology firm specializing in the field of predictive payment analytics. Utilizing sophisticated data mining and scoring strategies, the company reports enhanced hospital revenue cycles and collections for healthcare providers across the country.

The Business of Healthcare

It is a fact that consumers treat medical bills differently than other financial obligations. So, Medlytix customizes revenue-enhancement strategies to target each provider’s individual market.

Suite of Services

All stakeholders benefit from a more efficient operation – from provider to patient. Medlytix offers expertise and technology to enhance the cash conversion and revenue cycle by eliminating inefficiencies while maximizing collections. A customized strategy that’s based on specific needs is crafted. Three offerings include: 1.Medilyzer, 2. Predyx, and 3. Consulting services to improve the bottom line.

Non-Profits Hospitals

Non-profit hospitals exist to serve their communities with quality healthcare accessible to all. By helping hospitals pinpoint charity-care patients who are truly in need, the focus is on the patient.

Assessment

The mission of Medlytix is to build a healthier bottom line for hospitals. As fiscal strength improves, better hospitals provide better service to patients.

Conclusion

How does this relate to emails? 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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ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: Accounting, Health Insurance, Healthcare Finance, Information Technology, Practice Management | Tagged: behavior scoring, data mining, healthcare economics, Healthcare Finance, hospital cash conversion, hospital reenue cycle, medilyzer, Medlytix, non-profit hospitals, predictive begavior, predictive payment analytics, predyx | 1 Comment »

Become a Published Print Author with Us

Posted on April 22, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

The Business of Medical Practice [3^rd Edition]

By Hope Rachel Hetico RN, MHA, CMP™

[Managing Editor]

Dear Colleagues,

As you may know, we are commencing work on the third edition of our best selling book: The Business of Medical Practice

TOC 1st: http://www.amazon.com/Business-Medical-Practice-Maximizing-Doctors/dp/0826113117/ref=sr_1_8?ie=UTF8&s=books&qid=1231111232&sr=1-8

TOC 2nd: http://www.springerpub.com/prod.aspx?prod_id=23759

Invitation to Contribute

Accordingly, we would be honored for you to consider contributing a new or revised chapter, in your area of expertise, for a low-effort but high-yield contribution. Our goal is to help physician colleagues and management executives benefit from nationally known experts, as an essential platform for their success in the healthcare 2.0 business industry. Many topics are still available: [health accounting and costing; law, policy and administration; Medicare fraud and abuse; coding and insurance; HIT, grid and cloud computing; finance and economics, competitive models, collaboration and leadership, etc].

Support Always Available

Editorial support is available, and you would enjoy increasing subject-matter notoriety, exposure and public relations in an erudite and credible fashion. As a reader, or preferably a subscriber to the ME-P, your synergy in this space may be ideal. Time line for submission of a 5,000-7,500 word chapter is ample, and in a prose writing style that is “wide, not deep.”

A Health 2.0 Initiative

And, be sure to address health 2.0 modernity. Update chapters from the second edition are also available.

Definition: https://healthcarefinancials.wordpress.com/2008/09/12/emerging-healthcare-20-initiatives

Assessment

Please contact me for more details, if interested. A best selling-book is rare; while a third-edition volume even more so. Join us in this project. Regardless, we trust you will remain apostles of our core ME-P vision, “uniting medical mission and financial profit margin”, promoting it whenever possible.

Front Matter Link: frontmatter1advancedbusinessmedicine4

Contact Info:

MarcinkoAdvisors@msn.com

770.448.0769

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On Continuity of Medical Care and HIMSS

Posted on April 13, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Considering Pay-for-Retention [P-4-R]

By Darrell K Pruitt; DDS

Here is the question on lots of minds these days; how can we change the way medical providers are paid so they are both incentivized and adequately compensated to provide consistent, high-quality, patient-centered medical homes?

My Novel Idea

Here is a solid, common sense idea; increase providers’ pay gradually according to how long the doctors retain patients – who are free to choose any doctor they wish. Consistency is the mortar of a medical home [i.e., pay-4-retention].

An Ounce of Prevention

If prevention, which predates eHRs by thousands of years, is more than just a modern buzzword, the nation can still shave much more expense from health care by promoting continual, personalized care for consumers than from digital health records alone – void of prevention incentives. Who in the audience still cannot understand that concept? Think of it this way. How do business leaders in the land of the free retain the best employees? They pay bonuses. Even waiters get tips to encourage interest in providing service consumers will return for. What do US physicians get? Guaranteed cuts in their Medicaid payments over the next decade. Physicians no longer encourage their children to become doctors. Surprised? Scared?

Consumers Should Rule

In place of consumers ruling their healthcare in the US, well-positioned, giant stakeholders have persuaded lawmakers to offer physicians bonus money (that will later be taken away), not for curing patients, but for using digital records “in a meaningful manner.” It’s called “Mark and Michael Leavitts’ Clicking for Cash.” Since the rules are made up along the way, they change like the weather. That is why the larger and more progressive medical facilities pay bonuses to retain their best “Coders” and other informatics specialists who keep up with the current Ingenix-styled games in order to maximize profits. It is my opinion that health care IT’s complexity works well with the economic stimulus plan to improve employment in the nation. Entrepreneurial stakeholders will continue to be movie-star popular right up until the complete collapse of Medicare. Then they’ll be impossible to find www.HealthDictionarySeries.com

HIMSS

Have you ever heard of HIMSS?

“The Healthcare Information and Management Systems Society (HIMSS) is the healthcare industry’s membership organization exclusively focused on providing leadership for the optimal use of healthcare information technology (IT) and management systems for the betterment of healthcare.”

– From the HIMSS Web site.

HIMSS Annual Meeting

A week ago, HIMSS convened its annual convention in Chicago. The keynote speakers for the four day event were actor Dennis Quaid; followed by the Chairman and CEO of Kaiser Foundation Health Plan, George C. Halvorson; then the economist and former Chairman, Board of Governors of the Federal Reserve, Alan Greenspan, and finally; Jerry M. Linenger, MD, MSSM, MPH, PhD, Captain, Medical Corps, USN (Ret.), NASA Astronaut, and Space Analyst, NBC News. As one can tell, healthcare IT has lots of momentum. In fact, Dave Roberts, the HIMSS vice president for government relations confidently told Bob Brewin on NextGov.com

“The e-records initiative is an entitlement program like Social Security.”

http://www.nextgov.com/nextgov/ng_20090406_1509.php

Another Entitlement Program – Entitlement for Whom

In Regina Herzlinger’s 2007 book “Who Killed Health Care?” the Harvard School of Business professor argues that entitled stakeholders, including a few ambitious members of HIMSS, are destroying health care in the name of reform. In the first half of her 260 page book, she spells out entrepreneurial malfeasance in simple well-annotated terms. In the last half, she describes why Consumer-Driven Health Care [CDHC] makes sense to her. Professor Herzlinger does not specifically mention the words “medical home” in her book, yet she emphasizes the importance of continuity of care. To promote continuity, she suggests that managed care insurance policies be extended to three years duration and longer. Although she also does not mention dentistry, it is obvious to me that since chronic illnesses like diabetes are exacerbated by poor oral health, continuity of care in dentistry is of special importance. It occasionally takes years to improve some patients’ oral health care. And sometimes we fail.

Assessment

If these assumptions about continuity of care are accurate, it follows that the physical and economic health of the nation depends on long-term medical insurance contracts with employers and freedom-of-choice in providers. So is prevention worth holding ourselves accountable to consumers for once? Maybe it is just me, but I think unprecedented truth in healthcare will soon emerge regardless of stakeholders’ needs for confusion and obscurity. It is called consumerism. And it goes hand-in-hand with the Hippocratic Oath, the free-market and common sense.

Conclusion

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Filed under: Career Development, Ethics, Health Insurance, Information Technology, Managed Care, Op-Editorials, Practice Management, Quality Initiatives, Recommended Books, Research & Development | Tagged: ADA, Alan Greenspan, Bob Brewin, CDHC, consumer driven healthcare, CPT codes, Darrell Pruitt, David Roberts, DDS, Dennis Quaid, EMRs, eRs, George C. Halvorson, HBS, Herzlinger, HIMSS, Hippocratic Oath, HIT, insurance coers, IT, Jerry M. Linenger, Mark Leavitt, medical home, michael leavitt, P4R, Regina Herzlinger, www.healthcarefinancials.com, www.healthdictionaryseries.com, www.NextGov.com | 3 Comments »

More about Healthcare Organizations [Financial Management Strategies]

Posted on April 12, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Our Print-Journal Preface

By Hope Rachel Hetico; RN, MHA, CMP™

As Managing Editor of a two volume – 1,200 pages – premium quarterly print journal, I am often asked about our Preface.

A Two-Volume Guide

As so, our hope is that Healthcare Organizations: [Financial Management Strategies] will shape the hospital management landscape by following three important principles.

What it is – How it works

1. First, we have assembled a world-class editorial advisory board and independent team of contributors and asked them to draw on their experience in economic thought leadership and managerial decision making in the healthcare industrial complex. Like many readers, each struggles mightily with the decreasing revenues, increasing costs, and high consumer expectations in today’s competitive healthcare marketplace. Yet, their practical experience and applied operating vision is a source of objective information, informed opinion, and crucial information for this manual and its quarterly updates.

2. Second, our writing style allows us to condense a great deal of information into each quarterly issue. We integrate prose, applications and regulatory perspectives with real-world case models, as well as charts, tables, diagrams, sample contracts, and checklists. The result is a comprehensive oeuvre of financial management and operation strategies, vital to all healthcare facility administrators, comptrollers, physician-executives, and consulting business advisors.

3. Third, as editors, we prefer engaged readers who demand compelling content. According to conventional wisdom, printed manuals like this one should be a relic of the past, from an era before instant messaging and high-speed connectivity. Our experience shows just the opposite. Applied healthcare economics and management literature has grown exponentially in the past decade and the plethora of Internet information makes updates that sort through the clutter and provide strategic analysis all the more valuable. Oh, it should provide some personality and wit, too! Don’t forget, beneath the spreadsheets, profit and loss statements, and financial models are patients, colleagues and investors who depend on you.

www.HealthcareFinancials.com

Assessment

Rest assured, Healthcare Organizations: [Financial Management Strategies] will become an important peer-reviewed vehicle for the advancement of working knowledge and the dissemination of research information and best practices in our field. In the years ahead, we trust these principles will enhance utility and add value to your subscription. Most importantly, we hope to increase your return on investment [ROI] in some small increment.

Visit and Order Now

Specialty Technical Publishers

8 – 14th Street

Blaine, WA 98230

1-800-251-0381

orders@stpub.com

http://www.stpub.com/pubs/ho.htm

TOC: http://www.stpub.com/pdfs/toc_ho.pdf

Conclusion

And so, your thoughts and comments on this Medical Executive-Post, complimentary e-companion are appreciated. If you would like to contribute material or suggest topics for a future update, please contact me. Subscribers, have we attained our goals and objectives, as a work-in-progress in this preface statement?

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Physician Advisors: www.CertifiedMedicalPlanner.com

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Filed under: "Advisors Only", "Doctors Only", Accounting, Book Reviews, Career Development, Ethics, Experts Invited, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, iMBA, Inc., Information Technology, Managed Care, Media Mentions and PR, Practice Management, Practice Worth, Professional Liability, Quality Initiatives, Recommended Books, Research & Development, Risk Management, Sponsors, Taxation | Tagged: ARs, ASC, asset management, capitation, CEO, CFO, claims management, clinics, competitive healthcare strategies, COO, cost management, CPT codes, CXO, david marcinko, DDS, dentists, DO, doctors, DPM, EHRs, EMRs, EMTALA, endowments, EOQ, ePHRs, health fraud, health information technology, Healthcare Organizations, HIPPA, hope hetico, hospitals, IBNRs, ICD-10, ICD-9, inventory management, MD, Medicaid, medical compliance, medical practices, medicare, MedPAC, nurse executives, nurses, OSHA, osteopath, Patriot Act, physician-executives, physicians, podiatrist, Sarbox, social medicine, workplace violence | Leave a comment »

What HMO’s Seek in Private Managed Care Contracts

Posted on April 12, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Whole Sale – Not Retail – Medicine is Growing

By Dr. David Edward Marcinko; MBA, CPHQ, CMP™

[Publisher-in-Chief]

The conversion to managed healthcare, and capitation financing, is a significant marketing force and not merely a temporary business trend. More than 60% of all physicians (MD/DO) in the country are now employees of a MCO, HMO, PHO, etc. Those that embrace these forces will thrive, while those opposed will not.

Achieve Geographic Desirability

After you have evaluated the HMOs in your geographic area, you must then make your practice more attractive to them, since there are far too many physicians in most regions today. The following issues are considered by most MCO financial managers and business experts, as they decide whether or not to include you in their network.

General Standards:

1. Is there a local or community need for your practice, with a sound patient base that is not too small or large? Remember, practices that already have a significant number of patients have some form of leverage since MCOs know that patients do not like swithcing their primary care doctors or pediatrician, and women do not want to be forced to change their Ob/Gyn specialist. If the group leaves the plan, members may complain to their employers and give a negative impression of the plan.

2. A positive Return on Investment (ROI) from your economically sound practice is important to MCO’s because they wish to continue their relationship with you. Often, this means it is difficult for younger practitioners to enter a plan, since plan actuaries realize that there is a high attrition rate among new practitioners. On the other hand, they also realize that more established practices have high overhead costs and may tend to enter into less lucrative contract offerings just to pay the bills.

3. A merger or acquisition is a strategy for the MCO internal business plan that affords a seamless union should a practice decide to sell out or consolidate at a later date. Therefore, such as strategy should include things as: strong managerial and cost accounting principals, a group identity rather than individual mindset, profitability, transferable systems and processes, corporatized form of business, and a vertically integrated organization if a multi-specialty group.

4. Human resources, capital and IT service to synergism with existing MIS framework? This is often difficult for the solo or small group practice and may portend the need to consolidate with similar groups to achieve needed economies of scale and capital, especially in areas of high MCO penetration.

5. Consolidated financial statements conforming to GAAP (Generally Accepted Accounting Principals), IRC (Internal Revenue Code), OIJ (Office of the Inspector General), and other appraisal standards.

6. Strong and respected MD leadership in the medical and business community? MCO’s prefer to deal with physician executives with advanced degrees. You may not need a MBA or CPA, but you should be familiar with basic business, managerial and financial principals. This includes a conceptual understanding of horizontal and vertical integration, cost principals, cost volume analysis, financial ratio analysis and cost behavior?

7. Be willing to treat all conditions and types of patients. The adage,”more risk equates to more reward” is still applicable and most groups should take all the full risk contracting they can handle, providing they are not pooled contracts.

8. Are you a team player or solo act? The former personality type might do better in a group or MCO driven practice, while a fee for service market is still possible and may be better suited to the latter personality type.

9. Valid license, DEA narcotics license, CME, adequate malpractice insurance, board qualification/certification, hospital privileges, agree with the managed care philosophy, and have partners in a group practice that meet all the same participation criteria. Be available for periodic MCO review by a company representative.

Specific Medical Office Standards MCOs Desire

· Clean, presentable with a professional appearance.

· Readily accessible with barrier free design (OSHA).

· Appropriate medical emergency and resuscitation equipment.

· Waiting room to accommodate 5-7 patients with private changing areas.

· Adequate capacity (i.e., 5,000-10,000 member minimum), BP and office assistants for the plan.

· Office hour minimum (i.e., 20 hours/week)

· 24/7 on-call coverage with electronic tracking.

· MCO approved sub-contractors.

Assessment

Always remember, in the game of negotiations, today’s enemy – may be tomorrow’s ally.

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: "Advisors Only", "Doctors Only", Book Reviews, Career Development, Health Insurance, Managed Care, Practice Management, Recommended Books | 1 Comment »

About: Healthcare Organizations [Financial Management Strategies]

Posted on April 11, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Our Print Mission Statement

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

Publisher-in-Chief

As Editor-in-Chief of a two volume – 1,200 pages – premium quarterly print journal, I am often asked about our mission statement; or the journal’s raison d’etra.

A Two-Volume Guide

As so, Healthcare Organizations: [Financial Management Strategies], with its quarterly updates, will promote and integrate academic and applied research, and serve as a multi-disciplined communications forum for the dissemination of financial, managerial, business and related economic information to decision makers in hospitals, outpatient centers, clinics, medical practices and all mature and emerging healthcare organizations.

Target Market and Ideal Reader

Healthcare Organizations [Financial Management Strategies] and its quarterly updates should be in the hands of all:

* CFOs, CEOs, COOs, CTOs, VPs and CIOs from every type of hospital and healthcare organization including: public, federal, state, Veteran’s Administration and Indian Health Services hospitals; district, rural, long-term care and community hospitals; specialty, children’s and rehabilitation hospitals; diagnostic imaging centers and laboratories; private, religious-sponsored, and psychiatric institutions.

* Physician Hospital Organizations, Management Services Organizations (MSOs), Independent Practice Associations (IPAs), Group Practices Without Walls (GPWWs), Integrated Delivery Systems (IDSs) and their administrators, comptrollers, cost accountants, budget directors, cash managers, auditors, healthcare attorneys and consultants, and actuaries, and all endowment fund directors, executives, consultants and strategic financial managers.

* Ambulatory care centers, hospices, and outpatient clinics; skilled nursing facilities, integrated networks and group practices; academic medical centers, nurses and physician executives; business school and health administration students, and all economic decision-makers and directors of allopathic, dental, podiatric and osteopathic healthcare organizations.

Assessment

After publication, my suggestion is to read, study and act upon the guide in this way:

1. First, browse through the entire text.

2. Next, slowly read those chapters and sections that are of specific interest to your professional efforts.

3. Then, extrapolate portions that can be implemented in specific strategies helpful to your healthcare setting.

4. Finally, use its’ ME-P updates as a reference manual to return to time and time again; and enjoy!

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: Accounting, Book Reviews, Career Development, Drugs and Pharma, Ethics, Experts Invited, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, iMBA, Inc., Information Technology, Managed Care, Practice Management, Practice Worth, Professional Liability, Recommended Books, Research & Development, Risk Management, Sponsors | Tagged: administrators, ASCs, CEO, CFO, children’s hospitals, clinics, community hospitals, COO, CXO, david marcinko, diagnostic imaging centers, DO, doctors, DPM, healthcare administration, Healthcare Organizations, hospital management, hospitals, Indian Health Services, laboratories, long term care, MD, medical journals, medical practice management, medical practices, nurse executives, nurses, oasteopaths, OD, office managers, outpatient centers, physicians, physisician executives, podiatrists, practice managers, psychiatric institutions, rehabilitation hospitals, RNs, rural hospitals, specialty hospitals, Veterans Administration | 1 Comment »

Direct Reimbursement [DR] and RiskManagers.Us

Posted on April 6, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Transparent Dental Benefits versus Confusion

[By Darrell K. Pruitt; DDS]

“If you are not a part of the solution, there is good money to be made prolonging the problem.”

Company slogan- www.riskmanagers.us

Meet Mr. William Rusteberg

Today, I met William Rusteberg on the PennWell forum when he replied to the thread, “Why the long NPI, BCBS-TX?” which I copied below, along with my response which includes a plug for Direct Reimbursement [DR].

http://community.pennwelldentalgroup.com/forum/topics/why-the-long-npi-bcbstx?page=1&commentId=2013420%3AComment%3A26976&x=1#2013420Comment26976

Mr. Rusteberg represents a company called RiskManagers.Us, whose specialty involves the benefits market, yet it is not exactly an insurance company – just like there is no such thing as true dental insurance. RiskManagers.us is a firm that works directly with businesses to identify and develop cost-effective benefits packages – emphasizing transparency and fairness. Now that is refreshing, friends!

Defining RiskManagers.Us

Here is how RiskManagers.us describes itself:

“We do not work for an insurance company, we work for you. As an independent brokerage, and consulting firm we can represent any licensed insurance company in Texas, Colorado, Mississippi, Louisiana, Alabama, Illinois & Florida.”

If one visits the Web site’s “Reference Library,” here are some of the topics offered:

· Self Funding – Need a second opinion?

· Texas leads in transparency issues

· Can’t get claim information? HB 2015 May Solve Your Problem

· Medical Stop Loss Through a Captive

· PPO Discounts – Games People Play

· PPO Networks – Shell Game

· Can Hospitals waive Deductibles in Texas?

“What is a NPI number?”

Mr. Rusteberg’s initial question on the PennWell forum simply asked, “What is a NPI number?” Following my explanation, he wrote:

“It seems that many of those in your profession would do well in accepting cash only, or directly working with employer groups who sponsor dental/medical plans on a direct pay basis. We have had good success in doing this for our clients – we have one employer in San Antonio who pays medical care providers directly and quickly – providers like it and the plan pays a fair and reasonable rate, not relying on a PPO network to “re-price” claims. We have done the same on dental plans, eliminating the insurance company, PPO network and paying dental care providers submitted charges directly and quickly. We see little or no trend increases on dental charges using this method. In my view, insurance companies interfere in patient – provider relationships in a financially detrimental way.”

Thanks for your reply.

My Response:

I like you, William;

What you describe sounds like my all-time, personal favorite dental benefits plan. It is called Direct Reimbursement {DR}, and it not only gives the employer the unlimited capability to design a plan which reflects the level of commitment desired by the company, but most importantly, it naturally preserves quality of care by allowing employees unlimited freedom of choice in dentists. And that’s as good as the market gets.

http://www.directreimbursement.com/

In addition, since there are no NPI requirements for DR, employees are also permitted see dentists who decline NPI numbers for ethical reasons. That increases employees’ choice by 50% over BCBS-TX clients, according to recent information provided by the Healthcare IT Transition Group.

http://www.npidentify.com/stats.htm#states

Little Management Needed

Just like the benefits plans you mention, with DR, very little money is spent on management because such policies are so simple and transparent that there is no room for profit-enhancing (wasteful) confusion used by unethical companies like BCBSTX, Aetna, Cigna, UnitedHealth, Delta Dental, United Concordia, and so many other members of the National Association of Dental Plans (NADP).

Assessment

Without transparency and the invisible hand of freedom-of-choice, free-market competition for healthcare dollars disappears as fast as executive bonuses rise. We’ll see where it goes from here. It would sure be swell if a Direct Reimbursement representative takes interest in the conversation; anyone home?

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

DICTIONARIES: http://www.springerpub.com/Search/marcinko
PHYSICIANS: www.MedicalBusinessAdvisors.com
PRACTICES: www.BusinessofMedicalPractice.com
HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
CLINICS: http://www.crcpress.com/product/isbn/9781439879900
ADVISORS: www.CertifiedMedicalPlanner.org
BLOG: www.MedicalExecutivePost.com
FINANCE:Financial Planning for Physicians and Advisors
INSURANCE:Risk Management and Insurance Strategies for Physicians and Advisors

Filed under: "Doctors Only", Breaking News, Career Development, Ethics, Health Economics, Health Insurance, Managed Care, Op-Editorials, Practice Management | Tagged: ADA, Aetna, BCBS-TX, Cigna, concierge medicine, Darrell Pruitt, david marcinko, delta dental, dental benefits, dental insurance, dentists, direct reimbursement, discount dentistry, doctors, Heal;thcare IT Transition Group, HIPAA, HMO, IPA, managed dental care, MCO, NADP, National Association of Dental Plans, NPI Number, PennWell forum, PPO, private pay healthcare, RiskManagers.Us, self insurance, United Concordia, UnitedHealth, William Rusteberg, www.RiskManagers.Us | 12 Comments »

Hospital Non-Profit Care and Community Benefits

Posted on April 6, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

The IRS Sounds-Off

Staff Reporters

According to the Internal Revenue Service [IRS], a survey of nearly 500 not-for-profit hospitals in 2006 revealed that 9 percent total revenues were dedicated to community benefit. The just finalized 2006 report warned that attempts to set a percentage threshold for determining compliance may have a

“disproportionate impact on hospitals, depending upon their size, where they are located their community benefit mix, and other hospital and community demographics.”

Link: http://greisguide.com/?p=1059

Definition

The current “community benefit” standard was established by the IRS in 1969 in Revenue Ruling 69-545. The standard sets out factors to be considered in measuring community benefit, including: (i) a board made up of a broad base of community members; (ii) an open medical staff; (iii) participation in Medicare and Medicaid; (iv) application of surplus funds toward improving facilities, equipment, patient care, medical training, research, and education; and (v) a full-time emergency room open to all regardless of ability to pay (the emergency room standard applies differently to tax-exempt Long Term and Acute Care Hospitals [LTACH] that do not maintain a full array of emergency department services). Under the current community benefit standard, individual hospitals are given flexibility to determine what services will-best serve their communities.

www.HealthDictionarySeries.com

Assessment

Some pundits suggest that if Congress doesn’t establish new charity care requirements, the IRS should revert to its community benefit standard last in force in 1969.

Interim Report: http://greisguide.com/wp-content/uploads/2009/02/eo_interim_hospital_report_072007.pdf

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Filed under: Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Quality Initiatives | Tagged: community benefit, congress, IRS, LTACH, Medicaid, medicare, non-profit hospitals, not-for-profit hospitals, Revenue Ruling 69-545, www.healthdictionaryseries.com | 8 Comments »

Defining Current Dental Terminology [CDT®] Codes

Posted on April 5, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What they Are – How they Work

By Staff Reporters

OMAP Unique Procedure Codes*

The HHS [Health and Human Services] Office of Medical Assistance Program’s [OMAP] unique procedure codes were originally listed in the appropriate service guides. The maintenance of these codes was the responsibility of OMAP. These procedure codes were reviewed as needed and deleted either when a program no longer exists or when other Healthcare Common Procedure Coding System [HCPCS] codes are created which fully describe the service. Most of the unique codes were created to meet the needs of specialized services or programs. OMAP’s unique procedure codes were all five character configurations with the following alpha/numeric combinations: four numeric/one alpha (e.g., 7300Y); three numeric, two alpha (e.g., 206EP); two alpha/three numeric (e.g., BA311); or three alpha/two numeric (e.g., VIS01).

Current Dental Terminology (CDT procedure codes)

The American Dental Association’s (ADA) Code on Dental Procedures and Nomenclature is contained in the CDT-3 user guide. The maintenance of these codes is the responsibility of the Council on Dental Benefit Programs with consultation from: Blue Cross and Blue Shield Association, the Health Insurance Association of America, the Health Care Financing Association, National Electronic Information Corporation, and the American Dental Association recognized dental specialty organizations. The ADA updates the user guide approximately every five years. CDT codes are five-character, alpha-numeric configurations (e.g., D2110). Contact the American Dental Association to obtain a current copy of the CDT-3 Users Manual.

* Note: Due to HIPAA (Health Insurance Portability and Accountability Act) requirements, Medicare Local codes and OMAP Unique codes were replaced with national standard procedure codes.

www.HealthcareFinancials.com

Assessment

For more terminology information, please refer to the Dictionary of Health Economics and Finance.

www.HealthDictionarySeries.com

Conclusion

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Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

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Filed under: "Doctors Only", Book Reviews, Career Development, Glossary Terms, Health Insurance, iMBA, Inc., Practice Management, Recommended Books | Tagged: ADA, American Dental Association, American Dental Association's Code on Dental Procedures and Nomenclature, Blue Cross and Blue Shield Association, CDT, CMS, current dental terminology codes, HCPCS, Health Care Financing Association, Health Insurance Association of America, Healthcare Common Procedure Coding System, HHS, HIPAA, National Electronic Information Corporation, OMAP | 6 Comments »

Inspect our 2-Volume Hospital Print Guide [for Free]

Posted on April 5, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

ADVETISEMENT

Evaluate “Healthcare Organizations” [Financial Management Strategies] AND Order Now!

By Dr. David Edward Marcinko; MBA

By Professor Hope Rachel Hetico; RN, MHA

[Editor and Managing Editor]

As healthcare continues to evolve, leaders and executives have the formidable and immediate challenge of creating both short-term and long-term financial strategies. Given that today’s knowledge-base is different from that of even six-months ago, and the need is for solutions to tomorrow’s economic problems, success seems always just beyond your grasp!

Why Subscribe?

But fortunately, you can be ready; Healthcare Organizations: [Financial Management Strategies] is your blueprint for success. To ensure your organization’s competitive edge and perhaps even its survival, you must quickly gain the financial management tools and techniques necessary to lead in the 21st century. What you learn and implement using this Guide enables you to respond proactively to the rapidly changing healthcare environment. Your subscription to Healthcare Organizations: [Financial Management Strategies] not only helps you lead, it brings together healthcare executives and visionary thought leaders to help you develop essential models and successful financial management strategies, going forward.

www.HealthcareFinancials.com

Subscription Support

Specialty Technical Publishers is pleased to provide customer information and support services for Healthcare Organizations: [Financial Management Strategies] by phone, fax, or e-mail. Customer information services hours are between 7 am and 5 pm Pacific Standard Time; or http://www.stpub.com/pubs/custinfo.htm
Testimonials

“This well-organized financial management guide is easy to use and perfect for the healthcare organization, hospital or clinic manager; CFO, CEO, administrator or comptroller; CNO, CMO or physician-executive who is tasked with developing, implementing and extending a comprehensive (and integrated) financial, accounting, health economics and enterprise-wide business management program.”

Operating Room Supervisor

Hospital Administrator

Baltimore, Maryland

Assessment

For today … for tomorrow … for all healthcare organizations … for you! Remember, the Guide is available on a 30-day, risk-free trial. You may contact http://www.STPub.com at (604) 983-3434, fax (604) 983-3445, or e-mail at custinfo@stpub.com to place an order, or ask questions regarding pricing and/or availability. All shipments arrive within 5 to 10 days. Prepayment is required for all international shipments and a courier charge will be added to the subscription price. After hours, we suggest you review the STP website FAQs section for answer to your inquiry: www.stpub.com/pubs/custinfo.htm

Specialty Technical Publishers

8 – 14th Street

Blaine, WA 98230

1-800-251-0381

orders@stpub.com

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Filed under: "Advisors Only", "Doctors Only", Book Reviews, Breaking News, Career Development, Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, iMBA, Inc., Information Technology, Managed Care, Marketing & Advertising, MAST-HEAD, Media Mentions and PR, Op-Editorials, Practice Management, Professional Liability, Quality Initiatives, Recommended Books, Research & Development, Risk Management | Tagged: CEO, certified medical planner, CFO, clinics medical clinics, CXO, david marcinko, doctors, health dictionary series, healthcare administrators, healthcare managers, Healthcare Organizations: [Financial Management Strategies], hope hetico, hospical, hospital administration, hospital administrator, hospital journal, iMBA, medical business advisors, medical office, medical practice, medical practice management, nurse executive, nurses, ospital guide, physician executive, Specialty Technical Publishers, www.certifiedmedicalplanner.com, www.healthdictionaryseries.com, www.medicalbusinessadvisors.com | Leave a comment »

Defining Current Procedural Terminology [CPT®] Codes

Posted on April 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

What they are – How they work

By Staff Reporters

The American Medical Association’s Physicians’ Current Procedural Terminology® is contained in the CPT user guide. The maintenance of these codes is the responsibility of the American Medical Association with consultation from the AMA CPT Editorial Panel, Advisory Committee, and the AMA CPT Health Care Professionals Advisory Committee. Procedure codes in the CPT user guide are reviewed and revised annually. The Health Care Financing Administration’s – now CMS – Common Procedure Coding System [HCPCS] lists three levels:

Level I National Codes

CPT codes are five-character, all numeric configurations (e.g., 99215). Contact the American Medical Association to obtain a current copy of the CPT® Users Manual.

Level II National Codes

The HCPCS Level II National codes are contained in the HCPCS user’s guide and are published in the Federal Register. The maintenance of these codes is the responsibility of the Health Care Financing Administration [CMS]. Procedure codes in the HCPCS user guide are reviewed and revised annually. HCPCS codes are five characters with one alpha and four numeric configurations (e.g., A0042). Contact any publishing company that provides medical coding reference books to obtain a current copy of the current HCPCS User Manual.

Level III Medicare Local Codes*

Historically, local Medicare carriers developed local procedure codes which were published in the local Medicare Newsletters. The maintenance of these codes was the responsibility of the local Medicare carrier. Medicare local procedure codes were all five-character configurations with the following alpha/numeric configuration: one alpha, (W, X, Y or Z) with four numeric configurations (e.g., Y5523); and two alphas, (W, X, Y or Z) same character with three numeric identifiers (e.g., XX001). Contact your local Medicare carriers to obtain their Medicare Newsletters.

* Note: Due to HIPAA (Health Insurance Portability and Accountability Act) requirements, Medicare Local codes and the Office of Medicare Assistance Program Unique [OMAPU] codes were replaced with national standard procedure codes.

Assessment

For more terminology information, please refer to the Dictionary of Health Economics and Finance.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated?

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

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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Filed under: Career Development, Glossary Terms, Health Insurance, iMBA, Inc., Managed Care, Practice Management, Sponsors | Tagged: AMA, AMA CPT Health care professionals advisory committee, American Medical Associaion, CMS, CPT, CPT codes, CPT Editorial Panel, DPT, evel I National Codes, HCFA, HCPCS, HIPAA, Level II codes, Level III Medical Local COdes, medical biller, medical billing, medical coder, medical coding, Medical Newsletters, medicare, www.healthdictionaryseries.com | 5 Comments »

Evaluate our 2-Volume Institutional Print Guide

Posted on April 4, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Healthcare Organizations [Financial Management Strategies]

ADVERTISEMENT

www.HealthcareFinancials.com

Our 1,200 pages, 2-volume, quarterly institutional print guide Healthcare Organizations [Financial Management Strategies] is available on a 30-day, risk-free trial.

You may contact http://www.STPub.com at (604) 983-3434, fax (604) 983-3445, or e-mail at custinfo@stpub.com to place an order, or ask questions regarding pricing and/or availability.

All shipments arrive within 5 to 10 days. Prepayment is required for all international shipments and a small courier charge will be added to the subscription price.

After hours, we suggest you review the STP website FAQs section for answer to your inquiry: www.stpub.com/pubs/custinfo.htm

Assessment

Review and Ordering Information:

Specialty Technical Publishers

8 – 14th Street

Blaine, WA 98230

1-800-251-0381

orders@stpub.com

http://www.stpub.com/pubs/ho.htm

TOC: http://www.stpub.com/pdfs/toc_ho.pdf

Note: The guide is sponsored by www.MedicalBusinessAdvisors.com with contributions from www.CertifiedMedicalPlanner.com and is edited by ME-P’s Dr. David E. Marcinko and Professor Hope R. Hetico; RN, MHA. Definitions and terms supplied by www.HealthDictionarySeries.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated? Reviews from current journal-guide subscribers are encouraged and appreciated.

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Filed under: "Advisors Only", "Doctors Only", Book Reviews, Career Development, Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, iMBA, Inc., Information Technology, Managed Care, Practice Management, Practice Worth, Professional Liability, Quality Initiatives, Recommended Books, Research & Development, Risk Management, Sponsors | Tagged: accountants, AMA, APMA, ASCs, certified medical planner, clinics, CMS, cost accounting, CPT codes, david marcinko, doctors, halth insurance, health dictionary series, Health Economics, healthcare, healthcare administration, Healthcare Finance, Healthcare Organizations, hope hetico, hospitals, lawyers, medical business advisors, medical care, medical clinics, medical practice management, nurses, nursing homes, physician's practice, Risk Management, Specialty Technical Publishers | Leave a comment »

Blindsiding Delta Dental

Posted on April 3, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Delta Dental Sends More Easy Prey My Way

By Darrell K. Pruitt; DDS

When it comes to blindsiding witless PR departments, what good is Schadenfreude if it can’t be shared for the entertainment of my large collection of quirky, unshaven sports fans – a special class of readers who would stick around to watch the sequelae of an ignited paper bag on a front porch … even if from a safe distance.

Devoted and Abandoned Employees

The rumor is, watching PR professionals silently vanish from the Internet is becoming a popular spectator sport – especially when it’s the more expensive hacks for sleazy discount dental companies like Delta Dental. I intend to show you that when someone writes really nasty things about their most devoted employees – employees who publicly donate their name and reputation to Internet branding for the interests of Delta Dental – Delta Dental will still not come to their defense (No wagering, please). The devoted and abandoned, whose objectives in life are to take hits for some team, make easy prey.

Thinking of Ari Adler

Remember Ari Adler? He heads Delta’s Corporate and Public Affairs division, and was quoted in DrBicuspid Assistant Editor Rabia Mughal’s article, “Dentists or patients: Who should get the insurance check?”

http://www.drbicuspid.com/index.aspx?d=1&sec=sup&sub=pmt&pag=dis&ItemID=301436&wf=34

It was on DrBicuspid that Adler broke the news to the nation that Delta Dental now guarantees the fillings done by their preferred providers. When confronted by a special bastard to explain Delta’s unprecedented sales pitch, Adler immediately sat his butt down and shut up. (See “I will hurt you Delta Dental”)

http://community.pennwelldentalgroup.com/forum/topics/i-will-hurt-you-delta-dental

Lost in Web Space

That was two months ago, and Adler still hasn’t uttered another peep on behalf of Delta Dental. Now doesn’t that make the air in the land of the free just a little more pleasant? And yesterday, Rabia Mughal posted another article illustrating managed care dentistry’s level of ethics titled “Study: Insurers’ market power lowers dentists’ income.”

http://www.drbicuspid.com/index.aspx?sec=sup&sub=pmt&pag=dis&ItemID=301668&wf=34

Mughal describes the findings of a study titled “The effects of insurance carrier market power on dentists and patients” that appeared in the January edition of the JADA. Here is the abstract of the study:

http://jada.ada.org/cgi/content/abstract/140/1/90

The effects of insurance carrier market power on dentists and patients

By L. Jackson Brown; DDS, PhD

By Albert H. Guay; DMD

By Donald R. House; PhD

Background

Market power among dental insurance carriers is a carrier’s ability to reimburse dentists at rates below what would exist in more competitive areas. Competition among carriers for dentists’ participation in their networks protects dentists from highly discounted fees. The authors examined the extent to which dental insurance carriers facing less competition increase fee discounts.

Methods

The authors selected a sample of dentists from listings of general practitioners. They identified 219 metropolitan areas and contacted 11,542 dentists in those areas by mail, telephone or both. A total of 8,017 dentists completed surveys (a response rate of 69.46 percent). The authors’ key focus was the possible relationship between carrier market power and the size of the fee discount. The authors compared discounts across metropolitan areas with their differing levels of insurance coverage and carrier market shares.

Results

Carrier market power was directly related to the sizes of fee discounts. The larger discounts were found where there was significant dental insurance coverage and few carriers providing this coverage. Dentists’ net incomes were significantly less in areas with larger fee discounts.

Conclusions and Practice Implications

Dental insurance carrier market power leads to increased fee discounts. These higher discounts reduce dentists’ earnings. Although the larger discounts may result in lower overall patient costs, this patient benefit is temporary. Ultimately, the number of practicing dentists in these communities will decrease as dentists seek improved practicing conditions elsewhere. This reduction will lead to overall fee increases until the earning potential of dentists is restored.

Abbreviations: IPAs: Independent practice associations. • PPO: Preferred provider organization. • UCR: Usual, customary and reasonable.

####################

As one can imagine, Delta Dental, the largest dental discount service in America, did not like what both the ADA study and Mughal had to say about discount dentistry brokers. This time though, instead of sending Ari Adler into the wide open spaces once more, Delta sacrificed a new, unsuspecting traditional-type of PR executive whose feelings have never been hurt. Her name is Janis Oshensky, and she is the vice president of professional relations for Delta Dental Plans Association.

Enter Again Ms. Janis Oshensky

Ms. Oshensky confidently said that it is her opinion that the study is flawed. Here is what Ms. Oshensky told Mughal:

“The study speculates that dentists will leave markets dominated by a few large carriers, which would lead to higher fees for uninsured patients and reduced access to care. In fact, the miniscule effect of concentration on the fees paid to dentists — as they are reported in the study — is unlikely to trigger a mass exodus of dentists from concentrated areas.”

Ms. Oshensky further states – on dentists’ behalf – that we actually realize that discounts do not necessarily mean less pay, and that network participation increases dental visits (for the same pay). Now that woman deserves a company wristwatch!

Devoted to Delta

To show you how devoted Oshensky is to Delta Dental, her act almost fooled me into believing that she believes the NPI number makes sense. That’s no joke. Look at what she posted on the Delta Dental Website celebrating Delta’s success, and you will see what I mean:

“Thanks to all of the dentists and health professionals who have applied for NPIs and who have notified us of their new identifiers. While we’re not ready to completely replace the current identifiers with NPIs, we’re making great progress and will work to keep dentists and their office staff informed about our NPI readiness.”

http://www.deltadentalnj.com/npi/PrepareToAccept.shtml

Now that’s talent. I would imagine that she probably charges more than Adler ever will. Her name is all over the Internet on behalf of Delta Dental, and she sounds even more enthusiastic about the NPI number than Patrick Cannady of the ADA Department of Dental Informatics did a couple of years ago when his department was still telling ADA members to quickly volunteer for the ten digit identifier. You know, come to think of it, Delta Dental’s Website closely resembles the ADA’s. How do you think that happened?

Re-Enter Rabia Mughal

My hat goes off to author Rabia Mughal. How he can successfully lure another Delta Dental slow-mover into the open following the ambush of Ari Adler is pure genius in a mis-match of wits.

Assessment

So here we go again, sports fans. Come on out, Janis Oshensky, I can make you famous. Please bring everything you know about the NPI number with you as well because I have a few questions to ask … or not. Schadenfreude macht Freude.

Conclusion

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Filed under: "Advisors Only", "Doctors Only", Alerts Sign-Up, Career Development, Ethics, Health Insurance, Managed Care, Op-Editorials, Practice Management, Quality Initiatives, Research & Development | Tagged: ADA, ADA Department of Dental Informatics, Albert Guay, Ari Adler, Darrell Pruitt, delta dental, dentists, discount dentistry, Donald House, DrBicuspid, IPAs, JADA, Janis Oshensky, L Jackson Brown, Managed Care, NPA, NPI Number, Patrick Cannady, PPOs, PR, Rabia Mughal’s, UCR | 17 Comments »

Usual and Customary UnitedHealthcare?

Posted on March 30, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

More on “Sleazy” Healthcare Stakeholders

[By Darrell K. Pruitt; DDS]

If the leaders of the American Dental Association have the power and stoic determination to casually sweep aside trouble-making members who might tarnish their image, one would think that they could certainly avoid associating with sleazy healthcare stakeholders; such as UnitedHealthcare.

The Insurance Giants

Have you ever suspected that insurance giants like UnitedHealthcare, WellPoint, Aetna and Cigna (and other members of the National Association of Dental Plans) lie to patients when the say a dentist’s fees are above “usual, customary and reasonable” levels? You could be correct. NY Attorney General Andrew Cuomo says UnitedHealthcare, WellPoint, Aetna and Cigna lie to physicians’ patients – understating New York state physician’s fees up to 28 percent. Why would the crooks treat dentists’ patients any differently?

Employing Tapeworms to Control Fat

Cuomo caught UHC and others cheating their customers with smoke, mirrors and Ingenix – its wholly-owned data mining and consulting subsidiary. Who would have guessed that UHC would tweak Ingenix to manipulate claims data to favor UHC and other insurance companies who subscribe to their services? These are the same parasites who want to run the nation’s Pay-For-Performance (P4P) mandate – a cornerstone of President Bush’s healthcare reform ideas. They want to tweak professional reputations for healthcare reform and the common good.

And of Ingenix

Ingenix is a full-service consulting business for insurers, backed with the credibility of 14 years of accumulated health claims it is privy to. The “friend in the business” not only cooks the data to produce profit-enhancing Usual, Customary and Reasonable (UCR) fee schedules, Ingenix is also active in “pay-for-performance program assessment, strategy, planning, design, implementation, evaluation and improvement.”

http://www.ingenixconsulting.com/about_history.html

So if you like the way UnitedHealthcare dental consultants treat you now, just wait until they are given authority to determine your worth to society using Ingenix leveraging tools.

P-4-P

I first read about pay-for-performance [P4P] in dentistry in February 2006 in an email from Patrick Cannady who is an employee in the ADA Department of Dental Informatics. He told me that nation-wide quality control in dentistry is an important benefit of having a HIPAA-compliant, paperless dental practice – and that the Department of Dental Informatics is very excited about the opportunity to help prepare US dentists for the future. A month or so later, I learned that the NPI number the ADA still pushes on membership is the crucial legal link to government-approved P4P data-mills like Ingenix – a wholly-owned UnitedHealthcare profit center. Do you think it is odd that the NPI is “voluntary,” yet irreversible?

AMA’s Award

In January, the AMA was awarded $350 million in a lawsuit against UnitedHealthcare and Ingenix on behalf of physicians, and they plan to sue other major insurance companies as well. So what has the ADA done to discourage UnitedHealthcare’s and other NADP members’ atrocious behavior that undeniably harms dental patients? You won’t believe it when I tell you. Here’s more: In a recent Associated Press interview, Sen. Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee, said UnitedHealthcare is nothing but a company of cheats. He says, “They’re lowballing deliberately. They deliberately cut the numbers so the consumer has to pay more of the cost.”

http://www.google.com/hostednews/ap/article/ALeqM5gL4XFckx9sah3eFEMuHYD3V2WGhQD97763800

So if Cannady’s department is all for P4P and other benefits from interoperable digital records, the question on most ADA members’ minds should be: What does the ADA think of UnitedHealthcare?

ADA News Online

Two weeks ago the ADA News Online posted an advertisement that looks like an article (with no byline) for the spring meeting of the American Association of Dental Consultants (AADC) on May 7-9 in Scottsdale, Arizona.

http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=3493

Since it is so well known that UnitedHealthcare is the major funding sponsor of the AADC, the word in the neighborhood says AADC, like Ingenix, is another UnitedHealthcare profit center awaiting the wrecking-ball.

Link: http://www.google.com/hostednews/ap/article/ALeqM5gL4XFckx9sah3eFEMuHYD3V2WGhQD97763800

Assessment

Last year’s annual meeting of the dental consultants – who deny dental claims to protect the ethics in dentistry – featured ADA Senior Vice-President Dr. John Luther as a guest speaker. Dr. Luther is Cannady’s boss. He oversees the Department of Dental Informatics. Yep. The ADA is tight with UnitedHealthcare. One can tell a person’s character by the company he or she keeps.

Conclusion

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Filed under: Breaking News, Career Development, Ethics, Health Insurance, Health Law & Policy, Managed Care, Op-Editorials | Tagged: AADC, ADA, Aetna and Cigna, AMA, American Association of Dental Consultants, Department of Dental Informatics, Ingenix, Jay Rockefeller, John Luther, National Association of Dental Plans, NPA, NY Attorney General Andrew Cuomo, P4P, Patrick Cannady, Science and Transportation Committee, Senate Commerce, UCR, UHC, UnitedHealthcare, WellPoint | 3 Comments »

Future of Health Publishing and Business Journalism

Posted on March 27, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Good Content and “Fly” Beats the Competition

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

Last month, Steve Brawner [Steve Brawner Communications, a free-lance journalist for the Medical Business News, Inc., and the publisher of Medical News of Arkansas] contacted me to talk about hospitals, healthcare economics and the current financial dilemma in medical care. The interview will appear, as a special report, in April

But, after discussing answers to his top ten questions, we at the Institute of Medical Business Advisors, Inc www.MedicalBusinessAdvisors.com posited another interesting query. It was not on any particular subject area of our expertise, but aimed at us as electronic-publishers, reporters and health journalists.

The Future of Journalism

In other words, the question was:

“What do we think is the future business model for health journalism?”

Now, we’ve been mulling this thought over some time now, and our opinion goes something like this:

“We don’t – the old media is collapsing.”

And, while I don’t pity the likes of Chicago billionaire Sam Zell [the so-called “grave-dancer” for his penchant to buy distressed companies on the cheap and revitalize them for profit] – poor Sam – he was a very successful real-estate entrepreneur and the Chairman of Equity Group Investments. He thought this knowledge or luck was transferrable to the publishing industry, it wasn’t.

But, I do feel for distressed print newspapers like the Seattle Post Intelligencer, Chicago Tribune and especially the Baltimore Sun; as a native Balti-moron. I have both a favorite uncle, and older cousin, whose entire careers were spent in the print and ink business, there.

Link: https://healthcarefinancials.wordpress.com/2009/03/09/healthcare-experts-versus-health-journalists/

New Media “Fly”

How has this happened? Well, Google destroyed the advertising model for most media, and blogs and social networks have democratized the commentary / opinion playing field to some greater / lesser extent. Think: Mark Zuckerberg [Facebook] of Harvard, whose parents are both physicians – incidentally Mark’s got “fly” – Zell does not. We got the electrons at the ME-P, but little cash.

The Problem

The problem is that not many “new” media outlets, like the Medical Executive-Post, can afford to take on the interesting part of publishing; which is paying real investigative journalists. Think: The Huffington Post. Something I would love to be able to do; as there’s lots of muck to be raked in health economics, finance, administration, health IT; as well as medically focused financial planning, Wall Street and related personal investing activities for doctors – an integrated oeuvre of topics to say the least.

www.HealthDictionarySeries.com

Our Own Investigative Reporter

About the closest we have to a true investigative reporter is Darrel K. Pruitt; DDS. And, although he is no Bob Woodward or Carl Bernstein; he does occasionally do a good job. Think: William Mark Felt as FBI agent “deep-throat”.

Of course, as regular readers of the ME-P are aware, Darrell broke the dental profession’s [allegedly dufus] conspiracy with CCHIT [allegedly faux], and regularly reports on the folly of eHRs, eDRs, NPIs and eMRs. Think: citizen doctor journalist.

Link: https://healthcarefinancials.wordpress.com/2009/03/02/cchit-is-prejudiced-and-lacks-diversity-%e2%80%93-an-indictment/

Link: https://healthcarefinancials.wordpress.com/2009/03/02/avi-baumstein-and-hipaa-compliancy/

Link: https://healthcarefinancials.wordpress.com/2009/03/04/don%e2%80%99t-rush-ehrs/

Assessment

But, when the ME-P gets financially solid enough to hire others, and put them into the mix of expertise, commentary and free-labor entrepreneur punditry we now have on the site; then there’ll be no need for the current newspapers [at least insofar as our covered topic channels are concerned]. Until then; we don’t know what the answer is, but it, like the economy, doesn’t look good for the print media space.

Link: http://www.shirky.com/weblog/2009/03/newspapers-and-thinking-the-unthinkable

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As Editor-in-Chief of the premium subscription, two volume, 1,200 pages, institutional print-guide Healthcare Organizations [Financial Management Strategies], we prefer engaged readers who demand compelling content; old or new media.

www.HealthcareFinancials.com

According to the conventional wisdom expressed above, this printed guide should be a relic of the past, from an era before instant messaging and high-speed connectivity. But, our experience shows just the opposite. Applied healthcare economics and financial management literature has grown exponentially in the past decade and the plethora of internet information makes updates that sort through the clutter and provide strategic analysis all the more valuable.

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TOC: http://www.stpub.com/pdfs/toc_ho.pdf

Purchase: Call 1-800-251-0381 or email orders@stpub.com

Conclusion

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Filed under: Book Reviews, Health Economics, Health Insurance, Healthcare Finance, iMBA, Inc., Managed Care, Media Mentions and PR, Practice Management, Recommended Books, Research & Development | Tagged: Baltimore Sun, Bob Woodward, Carl Bernstein, Chicgo Tribune, Darrell Pruitt, eDRs, EHRs, EMRs, Facebook, health journalist, Healthcare Organizations, hospitals, iMBA, Inc., journalism, Mark Zuckerberg, Medical Business News Inc, medical clinics, Medical News of Arkansas, NPI, Sam Zell, Seattle Post Intelligencier, William Mark Felt | 1 Comment »

Obama on the SGR Physician Payment Formula

Posted on March 27, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Solo Doctors and and Small Group Practices May Benefit

By Staff Reporters

According to Diana Manos of Healthcare Finance News, on March 23, 2009, small medical group practices and solo and/or independent physicians may benefit most from the recently proposed Obama healthcare budget. In it, President Obama asked Congress for $76.8 billion for the Department of Health and Human Services [DHHS] for fiscal year 2010. Some funding would come from changes to the way healthcare is provided, with a new emphasis on pay-for-performance [P4P] for Medicare providers.

The AMA’s Response

It was reported that, Joseph M. Heyman, MD, chairman of the American Medical Association’s Board of Trustees, said the AMA is pleased with the administration’s proposed new baseline – or projected spending over a period of time – or Medicare physician payment updates.

“Unlike previous budget forecasts, the administration’s new budget baseline recognizes that Congress needs to and will act to avert the serious access crisis that looms as physicians face drastic payment cuts in the coming decade due to the failed Medicare physician payment formula,” he is reported to have said. Furthermore,

“The AMA strongly supports the use of a realistic baseline as a foundation for Congress to move forward with a permanent solution to the flawed SGR physician payment formula, and urges the committee and Congress to ensure that a new Medicare physician payment baseline is adopted in the 2010 Fiscal Year (FY) Budget Resolution.”

Assessment

Under the president’s budget request, Medicare Advantage would be revamped; physicians and hospitals could expect to be paid for performance [P4P] under Medicare; pharmaceutical companies would face steeper competition from generic drug companies and the government would clamp down on inadvertent and fraudulent overpayments under Medicare. The budget also calls for “comprehensive, but fiscally responsible reforms” to the physician payment formula [Sustainable Growth Rate], moving toward rewarding doctors for efficient quality care.

Link: http://www.healthcarefinancenews.com/news/small-physician-practices-can-expect-real-changes-healthcare-under-obama-budget

Conclusion

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Filed under: Health Economics, Health Insurance, Healthcare Finance | Tagged: AMA, DHHS, HITECH, Joseph M. Heyman, MA, Medicare Advantage, Obama Healthcare, P4P, Pay-for-Performance, SGR, sustainable growth rate | 59 Comments »

BCBS-TX Dental Insurance is Rude to Everyone

Posted on March 27, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Why the Long NPI – BCBSTX?

[By Darrell Pruitt; DDS]

More than a year ago, Dr. Robert Ahlstrom, an ADA [American Dental Association] and NHII (National Healthcare Information Infrastructure) task force member, told attendees to the ADA’s 3rd International Evidence-Based Dentistry Conference that the NPI number is

“Critical to the future of dentistry.”

But, to this day, he refuses to reveal why. Even though I have learned that he is a very shy man on the Internet; on that Sunday in May in ADA Headquarters, he confidently added,

“It is only voluntary unless you want to get paid.”

His case-closed proclamation shut down discussion cold in a Soviet manner. Did I mention that this occurred at an “Evidence-Based Dentistry” conference? Soviet East Germany was also called the German Democratic Republic.

NPI Harmful to Dentists and Patients

There is nothing evidence-based or otherwise about the NPI number – that benefits anyone but healthcare stakeholders. In fact, the number actually harms both dentists and patients. Like Ahlstrom, the irreversible NPI number is simply un-American. However, the NPI means profit for sleazy dental insurance companies like BCBS of Texas – especially when dentists’ reimbursements for work done long ago are delayed by NPI-NPPES screw-ups. Some physicians’ payments have been delayed for a year or more because of NPPES crosswalk difficulties. Who needs that?

Veteran’s Example Scenario

A new patient called my office this week wanting an appointment to start a crown. We don’t normally block off two and one-half hours for a patient on the first visit, but the Veteran told my office manager that before he was recently discharged, they did a root canal, post build-up and temporary on a tooth that still needs a crown. I like to think other dentists would also risk big holes in their schedules for Veterans. We owe them at least that much.

BCBSTX Dental Insurance

When he showed up with his BCBSTX dental insurance information, my office manager had to tell him that even though his boss was promised by the BCBSTX sales representative that the dental benefits package he bought for his employees was good anywhere, it cannot be used in my office because I do not have an NPI number. I am licensed to practice dentistry in the state of Texas, but that is not enough for BCBSTX. Capricious qualifications are certainly their choice if they prefer to do business that way in Texas, but why does BCBSTX leave it to my office manager to inform their clients about their deception? If a client who pays premiums to BCBSTX likes a dentist who does not have an NPI number, those premiums are pure profit for BCBSTX. It is easy to understand that the more obstacles BCBSTX can put between their clients and obligations to cover their dental bills, the bigger are the bonuses for executives. What’s more, BCBSTX’s leaders’ lousy work ethic permeates the entire dental insurance industry. Compared to BCBSTX executives, AIG executives who kept bonus money should be honored as national heroes.

BCBSTX Rude to Everyone

As the Veteran who almost became my patient works to fit him-self back into society, perhaps the next opportunity he has to break away from work for a few hours, he will be lucky enough to come across a dentist who has an NPI number. If things go well, BCBSTX will not have wasted a Veteran’s time twice – and wrecked a dentist’s schedule – for what? BCBSTX has nothing against Veterans in particular, they are rude to everyone. Since nobody from the company can be held personally accountable, tyranny is as natural as Ponzi schemes.

Attention Texas Employers:

I wish deceptive business practices which insurance companies use to cheat their clients were against the law in Texas. Attention Texas employers; as a dentist who has witnessed harm from BCBSTX, I warn you not to waste money on their dental plan. BCBSTX’s sales reps cannot be trusted to tell the truth and will aggravate your employees as well as neighborhood dentists.

Assessment

If BCBSTX gets away with this dishonesty, what other senseless, but profit-enhancing hoops will they demand next year? How many more dentists and patients can an Attorney General allow them to cheat before speaking up? Come out and fight for your honor, BCBSTX … or not. I bring more than your best attorney can handle and I am waiting.

Conclusion

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Filed under: "Doctors Only", Career Development, Health Insurance, Information Technology, Military Medicine, Quality Initiatives, Risk Management | Tagged: ADA, BCBSTX, Blue Cross, Blue Shield, dental benefits, dental insurane, evidence based dentristy, evidence based medicine, Health Insurance, insurance fringe benefits, National Healthcare Information Infrastructure, NPI Number, NPPES, Robert Ahlstrom, Veterans | 22 Comments »

HMO Physician Office Visit Co-Payment Creep

Posted on March 26, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Patients Showing Doctors the Money [1999–2008]

By Staff Reporters

Copayment	2008	1999
$5	6%	23%
$10	16%	60%
$15	29%	12%
$20	30%	1%
Other	19%	3%

Source: Kaiser/HRETHRET Survey of Employer-Sponsored Health Benefits

www.kff.org

Assessment

Considering the “down and dirty” interest rate “rule of 72”, a twice doubling of copayments from $5 to $20, and a Hewlett-Packard 12-C hand-held financial calculator; allow us to suggest an annual copayment rise of 15% percent for the decade.

Conclusion

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Dictionary of Health Economics and Finance
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***

Filed under: Career Development, Health Insurance, Managed Care, Practice Management | Tagged: copay, copayments, Employer Sponsored Health Benefits, fringe benefits, Hewlett-Packard 12-C, high deductible health plan, HSA, insurance deductibles, interest rates, Kaiser, rule of 72 | 1 Comment »

Medicare and Medicaid Health IT Network Proposal

Posted on March 25, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Governmental Initiative for the Elderly and Poor

By Staff Reporters

According to Nancy Ferris of Government Health IT, on Mar 18, 2009, a rapid learning health information data network could close some gaps in medical knowledge and cut costs for Medicare and Medicaid recipients.

A Congressional Letter

In a letter to Congress, a group of health policy experts urged creation of a network to share information on Medicare and Medicaid patients in order to improve treatment received. In particular, Lynn Etheredge, one signatory of the letter, wants information to be shared on “dual eligible’s”. This term is defined as low income, elderly patients who receive money for medical care from both Medicare [Federal] and Medicaid [State] sources.

www.HealthDictionarySeries.com

According to Etheredge, there are 7 million such dually-eligible patients in the US, which represents 40 percent of Medicaid spending, and 25 percent of Medicare spending. Etheredge and the others suggest that a network backed by government policy would hasten treatments for everyone.

Assessment

Others who signed the letter include Kenneth Kizer, who created the health-records system for the Department of Veteran Affairs; Commonwealth Fund President Karen Davis; National Quality Forum [NQF] President and CEO Janet Corrigan and National Committee for Quality Assurance [NCQA] President Margaret O’Kane.

Link: http://govhealthit.com/articles/2009/03/18/network-for-data-on-medicaid-medicare-patients.aspx

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. One conclusion of this letter was that“[Researchers] spend way too much time simply acquiring data.” Do you agree, why or why not? Please opine. Will networked eHRs, eMRs and eDRs really save money and time; or cost money and time? Can they be inter-operable and connected on a nationally networked basis that is cost-effective, secure and available to all providers? What about CCHIT, and other vendors?

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Filed under: Health Insurance, Health Law & Policy, Information Technology, Quality Initiatives | Tagged: CCHIT, Commonwealth Fund, Congressional letter, Department of Veteran Affairs, healt information technology, Health I.T., HIPAA, HIT, Information Technology, Janet Corrigan, Karen Davis, Kenneth Kizer, Lynn Etheredge, Margaret O'Kane, Medicaid, medicare, National Committee for Quality Assurance, National Quality Forum, NCQA, NQF, old patients, poor patients | 2 Comments »

This Time the Hospital Financial Crisis is Different

Posted on March 19, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Oh Really … No so Fast!

Submitted by J. Wayne Firebaugh, Jr; CPA, CFP®, CMP™

Dr. Malcolm T. MacEachern, Director of Hospital Activities for the American College of Surgeons, presciently observed that:

… Our hospitals are now involved in the worst financial crisis they have ever experienced. It is absolutely necessary to all of us to put our heads together and try to find some solution. If we are to have effective results we must have concerted and coordinated immediate action. … Repeated adjustments of expenses to income have been made. Never before has there been such a careful analysis of hospital accounting and study of financial policies. It is entirely possible for us to inaugurate improvements in business methods which will lead to greater ways and means of financing hospitals in the future … It is true that all hospitals have already trimmed their sales to better meet the financial conditions of their respective communities. This has been chiefly through economies of administration. There has been more or less universal reduction in personnel and salaries; many economies have been affected. Everything possible has been done to reduce expenditures but this has not been sufficient to bring about immediate relief in the majority of instances. The continuance of the present economic conditions will force hospitals generally to further action. The time has come when this problem must be given even greater thought, both from its community and from its national aspect…

Source: Steinberg, C. Overview of the US Healthcare System; American Hospital Association 2003.

Many hospital CXOs, healthcare administrators and physician executives would agree that Dr. MacEachern accurately describes today’s healthcare funding environment. However, they might be startled to learn that Dr. MacEachern made these observations in 1932! There is the old truism that there is nothing new under the sun.

American Hospital Association Statistics

Healthcare statistics suggested that the financial crisis is much the same today as it was for hospitals during the Great Depression. The American Hospital Association’s (AHA) reported gloomy statistics for hospitals include:

In 2001, 29% of hospitals had negative total margins.
Approximately $101.3 billion of uncompensated care was provided between 1997 and 2001 with an average annual increase of 16% during that time period.
Emergency departments in 62% of all hospitals report operating at, or over, capacity.
Technology costs are soaring as traditional technologies such as X-Ray machines, for $175,000, are being replaced by contemporary technologies such as CAT Scanners at $1 million that are in turn being replaced by CT Functional Imaging with PET Scans costing $2.3 million. Even such a “simple” instrument as a scalpel that costs $20, is being replaced by equipment for electrocautery costing $12,000, that is then being replaced by harmonic scalpels costing $30,000.
Between 2000 and 2002, 33% of hospitals reported increases in liability premiums of more than 100%.
The average age of hospital plants has increased 21% from 7.9 years to 9.6 years in just one decade.
In the four years ending 2002, hospital bond downgrades have outpaced hospital bond upgrades by almost 5 to 1.

Editor’s Assessment

As editor’s of the premium subscription, two volume, 1,200 pages, institutional print-guide Healthcare Organizations [Financial Management Strategies], we prefer engaged readers and contributors like Mr. Firebaugh, who demand and create compelling content like the above. Please review these links for same.

www.HealthcareFinancials.com

Info: http://www.stpub.com/pubs/ho.htm

TOC: http://www.stpub.com/pdfs/toc_ho.pdf

Purchase: Call 1-800-251-0381 or email orders@stpub.com

Conclusion

Always beware the words: “this time it’s different;” as it rarely is. And so, your thoughts and comments on this Medical Executive-Post are appreciated. Please opine and subscribe to the ME-P here; it’s fast, free and secure.

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Filed under: Career Development, Health Economics, Health Insurance, Healthcare Finance, Managed Care, Marketing & Advertising, Media Mentions and PR, Recommended Books | Tagged: AHA, American College Surgeons, American Hospital Association, CAT, CT, david marcinko, financial crisis, hope hetico, hospitals, medical crisis management, MRI, PET, Wayne Firebaugh | 4 Comments »

About the Convenient Care Association

Posted on March 18, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Developing Best Medical Practices and Retail Operating Standards

By Staff Reporters

The Convenient Care Association [CCA] is comprised of companies, medical providers and healthcare systems that provide patients and consumers with accessible, affordable and quality healthcare in retail-based locations. The CCA works primarily to enhance and sustain the growth of the convenient care industry through sharing of best practices and common standards of operation. It was founded in October 2006.

About CCA

According to their website, the first Convenient Care Clinics [CCCs] opened in 2000, and the industry grew quickly since then. Today there are approximately 1,060 clinics in operation, and CCA member clinics represent more than 95% of the industry. To date, CCCs have served more than 3.5 million patients with its nurse practitioners [NPs] and physician assistants [PAs].

Link: http://www.ccaclinics.org/index.php?option=com_content&view=article&id=4&Itemid=11

Growth and Expansion

With this rapid expansion, and projected continued growth, it quickly became clear that the shared concerns and needs of both providers and patients could best be served through an association that allowed for:

Sharing best practices, common standards of operation, experiences and ideas.
Developing common standards of operation to ensure the highest quality of care.
A united voice to advance the needs of CCCs and their customers
A unified effort to promote the concept of CCCs, and to respond to questions about this evolving industry.
Reaching out to the existing medical community and creating new partnerships.
Building synergies with traditional medical service providers.

Assessment

The Public Health Management Corporation [PHMC], a nonprofit public health institute, provides executive management and administrative support for the Convenient Care Association. For more information, contact Tine Hansen-Turton at (215) 731-7140.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Have you ever used a retail medical clinic and what was your experience? Will this business model save primary care medicine?

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Filed under: Career Development, Health Insurance, Managed Care, Practice Management, Quality Initiatives | Tagged: CCA, convenient care association, convenient care clinics, NPs, nurse practitioner, PAs, physician assistant, primary care, rimary care medicine | 9 Comments »

Medical Office Cash Collection Procedures

Posted on March 17, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Going Green and Getting the Cash

[By Staff Reporters]

According to Shannon Doyle, an independent consultant for the MGMA Health Care Consulting Group on March 9, 2009, the continued growth of high-deductible health insurance plans and health savings accounts has caused medical practices to increasingly rely on front-desk personnel to collect from patients.

Three Modern Collections Rules

The following medical practice procedures will markedly increase upfront office collections:

Train staff to handle exceptions. What is your policy if the patient payment is significant? Will you allow 25% payments—one today and three over the next three months? Communicate your policy to all staff. What will you do if a patient shows up without an insurance card? There will be other exceptions. Train employees to call the appropriate practice-management contact when an exception does not fit in the categories you provide and make sure those managers are responsive.
Understand that not everyone will shine in collections. The value of this new front-desk function should be reflected in job descriptions and wages. Track staff performance and hold employees accountable for collection goals. The most successful practices collect in the 90% range.
Provide professional signage that states your basic policy: “Payments are due at time of service.” Avoid typewritten, lengthy explanations taped to walls or desks that look like clutter.

Assessment

Furthermore, Mr. Doyle suggested that physician-executives and office managers recognize that significant changes in front-desk procedure require staff training. But, even before that, you must develop a template to help employees quickly get the information they need.

For example, according to Rachel Pentin-Maki; RN, MHA of www.MedicalBusinessAdvisors.com make and update a matrix-guide reflecting the health plans that cover 80% of office patients. Include each plan’s variable components like co-insurance, deductibles and services that require pre-authorization. Then, create a list of names and phone numbers for staff to verify coverage and amounts. Be sure to include examples of plans’ insurance cards and highlight the pertinent information. By following these few guidelines, it is hoped that collection percentages can be improved in the challenging future.

Link: http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090309/MODERNPHYSICIAN/303019984/-1/newsletter06&nocache=1

Does this post change the meaning of the term “going green?”

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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ADVISORS: www.CertifiedMedicalPlanner.org
FINANCE: Financial Planning for Physicians and Advisors
INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
Dictionary of Health Economics and Finance
Dictionary of Health Information Technology and Security
Dictionary of Health Insurance and Managed Care

Filed under: Career Development, Health Insurance, iMBA, Practice Management | Tagged: cash medical practice, cash value practice, HDHPs, Health Insurance, health savings account, HSAs, Inc., institute of medical business advisors, medical savings account, MSAs, rachel pentin-maki | 2 Comments »

AHRQ Report on Uninsured Hospitalizations

Posted on March 17, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Differs from Insured Hospitalizations

By Staff Reporters

According to Tracey Walker, Senior Editor of Healthcare Executive News on March 13, 2009, the number of uninsured hospitalizations increased by 34%, over the last 10-year period, and the number of Medicaid hospitalizations increased by 36%. However, a newt report from the Agency for Healthcare Research and Quality (AHRQ) suggests the number of privately insured hospitalizations remained about the same.

AHRQ Report

According to the report, hospital charges increased for the uninsured faster than for overall hospital charges (76% for compared with 69% for all hospital stays). The average hospital charge for an uninsured stay in 2006 was $19,400 compared to $11,000 in 1997 (after adjusting for inflation). The average length of stay for the uninsured remained the same at about 4 days per hospital visit. Other findings included:

Compared to all hospital stays, uninsured hospitalizations begin in the emergency department much more frequently (60% for the uninsured compared to 44% for all hospital stays).
The number of uninsured hospitalizations for skin infections rose sharply over the 10-year period, increasing from about 28,000 stays in 1997 to about 75,000 stays in 2006. Early appropriate outpatient treatment for skin infections can usually prevent the need for hospitalization.
There was a 36% increase in hospitalizations billed to Medicaid during the 10-year period.

Assessment

According to AHRQ, on average the costs (not charges) to provide hospital care to the uninsured are about $1,500 less expensive ($6,800 vs. $8,400 per hospital stay) than costs for all other hospital stays.

Assessment

Lack of health insurance has serious consequences on individuals and societies. For example, the uninsured may be more likely to delay or forgo necessary medical care until eventual hospitalization makes care much more expensive. And philosophically,

“As spending on Medicaid increases; the number of uninsured hospitalizations ought to decrease proportionally—adjusted for population increases”

So says, Hope Hetico; RN, MHA, CMP™ of www.HealthcareFinancials.com.

“But, this was not the case, and determining exactly why will require more studies.”

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Does a similar inverse relationship hold for public versus private education, housing and transportation?

Why or why not? Some pundits wonder if it is due to private entities having more “skin-in-the game?” Please opine?

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Filed under: Health Economics, Health Insurance, Healthcare Finance, Insurance Matters, Surveys and Voting | Tagged: Agency for Healthcare Research and Quality, AHRQ, Health Insurance, hospital admissions, hospital charges, hospital costs, hospital stays, hospitalizations, insured patients, uninsured patients | 2 Comments »

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