Negotiating Physician Fee Schedules

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

Better Data for Improved Fixed Compensation

[By Christy Clodwick; MHA]

[By Dr. David E. Marcinko MBA]

It is known that most health plans operate with fixed fee schedules. While these fee schedules have little or nothing to do with RBRVS, and most are based on a percentage of what Medicare pays, the question is: “are they tied to levels that are more than 3 or 4 years old?” Physicians who have no negotiating tools or a plan in place, and who question the methodology that the payers are using, are (too casual-left) with a ‘take it or leave it’ response from the health insurance provider.

Gathering the Data

A good solid foundation of data is necessary to negotiate better reimbursement rates successfully. The practice administrator or accountant (not 1 in 100 accountants can actually do this) should have this information readily available, especially if the office has an automated billing system.

Steps to Preparing a Fee Analysis

First and foremost, the medical management team in charge of this project will need to determine the most commonly used CPT® codes for the practice. The bulk of primary care or family practice physician fees should be derived from the revenue of the office visit, hospital and preventive medicine codes. This in turn may limit the number of codes for the study. The frequency of each CPT code should be listed over a 12 month period. If applicable, laboratory fees should also be included to see if there are fluctuating reimbursement schemes for these services. The codes on the list should account for at least 75% of the total practice charges.

Determining Top Payers and Reimbursement by Payer

It is known that Medicare and Medicaid use established fee schedules and do not negotiate, therefore the focus should be on the other major payers that make up the bulk of the reimbursement. In this process, make sure that the payers in the report are the practice’s top payers. The practice administrator will also need to determine the reimbursement for each code that is sent to the various payers’ list in the report. The administrator or team leader (the average GP has 3-4 employees, so I don’t think there would be a team leader, here). For this project we can use the Explanation of Benefits EOB that is received from each payer that has been selected for the report. When including this data, make sure the allowed amount, not the paid amount, is referenced. After this information has been gathered, each payer’s reimbursement rate will need to be calculated as a percentage of Medicare’s reimbursement rate. Medicare’s current rates for any geographical area can be found through the “Medicare Physician Fee Schedule Look-up” tool at:

Link: https://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?p_sid=1reSKuxj

This site also provides a reference to Relative Value Unit, (RVU) that Medicare assigns to each code.

RVU Conversion Factors

It is important for the practice administrator or manager to understand the RVU conversion factors and how they work, simply because most payers are in the beginning stages of using this method. To calculate a payment for service you multiply a particular CPT Code by the Medicare conversion factor for that code. For an example we will use the code 99214 – office visit. The Relative Value Unit for that Code is 2.2. The Medicare conversion factor for the same code is $37.34. The calculation would result in a rate of $82.15. Geographical adjustments must be taken into account when performing these calculations. The next step in this process would be to review the fees for each code listed in the report. Calculate each fee as a percentage of Medicare’s rates. You will find different statistics for each payer.

Apply the Rules and Process

Follow these basic rules when applying this new process:

First, if the charges are being reimbursed at 100%, the fee may be too low. At this point, raising the fee for that code would be acceptable (Usually not the case). Next, If several fees are in this category, the practice should just set all its fees to a percentage of Medicare reimbursement across the board, such as 125 percent (many managed care plans pay at less than MC, i.e., 80% MC). Finally, a tiered fee schedule would be applicable if the payers seem to pay more for certain procedures or diagnostic studies. That would set evaluation and management codes at 125 percent of Medicare reimbursement while charging 150 of Medicare reimbursement for other procedures and diagnostic tests.

Assessment

The medical practice administrator should make sure that, no matter which fee schedule is best suited for the practice, it is updated annually to prevent loss of any increases that may occur per payer.

Conclusion

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Improving Financial Viability of Medical Practices

Posted on May 10, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Medical Practice Financial Management

By Christy Clodwick; MHA

To combat the climate of barriers and frustrations in medical practice today, physician executives and administrators need to create innovative ways to change and improve medical providers’ outlook in the health care marketplace.

Many Barriers

The barriers—federal anti-trust laws, lack of state or federal regulatory action, marketplace resistance and tremendous cost pressures—are being confronted throughout the healthcare sector and are being felt by medical practices of all sizes, including hospital organizations, medical organizations as well as independent solo practitioners. Although there are tremendous financial pressures in operating a healthcare practice, the demand for healthcare is on the rise. To remain viable in today’s healthcare market place, strategic planning is needed at all levels of every practice’s processes.

Disenchanted Doctors

It is increasingly acknowledged that physicians in today’s health care market are becoming disenchanted with the reimbursement compensation from managed care. This also affects the outlook that they have on the medical profession as a whole. It is important to point out that there are ways to put processes in place to combat or, at the very least, survive all the changes taking place. Strategies can be put in place to offset the high demand for quality care and the discouragement and outrage that physicians are feeling about reimbursement. Physicians did not learn the business side of medicine in medical school, although many physicians today are choosing to diversify their careers by going back to school to get an MBA, or even just further business knowledge, to stay abreast of the changes. Selecting an outside source to assist a practice with the needs of business growth planning can be difficult, if the physician or practice administrator does not know what the needs really are. The best option would be to ask for a recommendation from a colleague who has hired consultants to assist in his or her practice, or to call on the local hospital administrator for assistance in locating an appropriate consultancy firm or management company.

The Planning Process and Process Improvements

The planning process of any business operation should always include management systems that clarify the business strategy and the metrics that most reflect success with that strategy. They should provide the framework to prioritize resources for projects that will improve the metrics, and leverage leaders who will manage the efforts for rapid, sustainable, and improved business results. This plan should also include improvement of processes that are already in place. In essence, this should be a corporate wide approach to process improvements and management of the processes to control the outcome of the progress of these changes.

Driving Success for Plan Development and Implementation

During the plan development stage, all aspects of operations have to be included in the plan in order to ensure a successful outcome. The plan for a healthcare practice should include time management, cost containment, third party reimbursement (to include annual contract(s) review as many practices have 100-200 contracts), insurance coding and compliance, accounting, business management, capitation economics, marketing and business development, medical advertising, and especially important is the health information management system. Plan development, in short, should focus on:

Understanding and managing patient demands and requirements (this is clinical material).
Aligning key business processes to achieve those requirements.
Using rigorous data analysis to minimize variations in those processes, i.e. fee analysis, revenue analysis, and time management.
Driving rapid and sustainable improvement of business processes.

Future Health Economic Policy

With all the changes that have occurred in healthcare, it is safe to assume it will be a struggle to come up with a perfect plan that will sustain all future changes in such a volatile healthcare market. Practice reimbursement would be a good place to start since this is the lifeblood of any healthcare provider. Income from fees has not nominally increased for more than a decade. The introduction of the Resource Based Relative Value Scale (RBRVS), as well as the adoption of a national fee schedule by Medicare, has virtually eliminated a practice’s ability to generate more income from insurance plans by increasing what the practice charges for its services.

www.HealthDictionarySeries.com

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Red Flag Rules in Dentistry

Posted on May 1, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Mayday for Identity Theft Provisions 2009

By Darrell K. Pruitt; DDS

On October 22, 2008, the FTC announced that it would delay the enforcement of the Red Flags Rule for healthcare providers for six months – until May 1, 2009. A handful of attentive dentists, as well as ADA Chief Legal Counsel, Tamara Kempf, released a sigh of relief. Ms. Kempf immediately went to work to persuade the FTC to delay enforcement “indefinitely.”

The FTC Delay

Four days later, Kempf caught the mood of the few who were paying attention in her quote for an article on DentalCompare.com:

“We are very pleased that the Federal Trade Commission has postponed for six months its implementation of the ‘Red Flags Rules.’”

http://www.dentalcompare.com/news.asp?newsid=250078

The DentalCompare article continues:

“If the FTC persists in its position that dentists are covered by the rule as creditors, the ADA will make available a sample compliance plan or program well in advance of the new enforcement date. Dentists will have sufficient time to consult with their personal attorneys and to put an appropriate identity theft prevention program into place, according to the ADA’s Legal Division.”

The ADA Legal Division

Did the ADA’s Legal Division follow through with its promise? If information about the Red Flags Rule is posted on the ADA News Online Website early tomorrow morning, is a 24 day warning considered by the ADA to be “well in advance”? (Emphasis mine) As reassuring as Kempf’s words sounded five months ago, it can be argued that the ADA’s intentions were misrepresented to DentalCompare. I checked the ADA Online Website and found nothing at all about preparation for the Red Flags Rule – at least not yet.

http://www.ada.org/prof/resources/pubs/adanews/index.asp

ADA Archives

When I searched the ADA archives for “Red Flags Rule,” I was provided seven links to the topic, but none included “a sample compliance plan or a program.” Three of the links are irrelevant, three are to articles about the delay of the FTC enforcement, and one is a link to a hopeful letter dated November 24, 2008 and addressed to William E. Kovacic, Chairman of the Federal Trade Commission. In other words, I found nothing that will help dentists become FTC compliant well ahead of time.

HIPAA

If the ADA’s help in preparing members for the 1996 HIPAA Rule is any indication of the help members can expect with Red Flags Rule, it will take the ADA at least 13 years to start on the Red Flags. The leaders of the otherwise conservative ADA seem to have bet a huge chunk of membership trust that Kempf and the Legal Affairs department would succeed in delaying Red Flags enforcement indefinitely, and that the Department of Dental Informatics would not have to admit that contrary to what they led members to believe, computers in dental offices are rapidly becoming too dangerous and too expensive for the profession. For many dentists, pegboards, carbon paper and ledger cards are looking better and better. You can forget about paperless practices. What happened, ADA?

The groveling November 24 letter to the FTC chairman that was signed by Kempf and cc’d to ADA President Dr. Johns S. Findley and President-elect Dr. Ronald L. Tankersley, officially begs for forgiveness and appeals for bureaucratic mercy to allow dentists to be excluded from becoming Red Flags-covered entities.

http://www.ada.org/prof/advocacy/let_081124_redflags.pdf

Since the fines for non-compliance of both HIPAA and the Red Flags Rule are obscene, and since the leaders of the ADA continue to fail to inform members what they should do to prepare for unannounced inspections from either HHS or the FTC, I will once again do the Department of Dental Informatics job for them, and let readers in on the secret.

An Economic Threat

If you wish to continue to accept assignment from insurance companies, and/or otherwise extend credit to your patients, the FTC recently posted a helpful pdf document titled “Fighting Fraud with the Red Flags Rule – A How to Guide for Business.”

http://www.ftc.gov/bcp/edu/pubs/business/idtheft/bus23.pdf

Dentists have become the nation’s unpaid fraud inspectors. And if a dentist’s practice is computerized, the more will be expected, or rather, demanded of the dentist, by law.

Here is a brief description of dentists’ Red Flags obligations lifted from the FTC document:

An Overview

The Red Flags Rule sets out how certain businesses and organizations must develop, implement, and administer their Identity Theft Prevention Programs. Your Program must include four basic elements, which together create a framework to address the threat of identity theft:

First: Your Program must include reasonable policies and procedures to identify the “red flags” of identity theft you may run across in the day-to-day operation of your business. Red flags are suspicious patterns or practices, or specific activities that indicate the possibility of identity theft. For example, if a customer has to provide some form of identification to open an account with your company, an ID that looks like it might be fake would be a “red flag” for your business.

Second: Your Program must be designed to detect the red flags you’ve identified. For example, if you’ve identified fake IDs as a red flag, you must have procedures in place to detect possible fake, forged, or altered identification.

Third: Your Program must spell out appropriate actions you’ll take when you detect red flags.

Fourth: Because identity theft is an ever-changing threat, you must address how you will re-evaluate your Program periodically to reflect new risks from this crime.

Note: More “red-flag” information may be obtained from the 2 volume, 1,200 pages, premium print guide: Healthcare Organizations [Financial Management Strategies].

www.HealthcareFinancials.com

Assessment

Since my business office still uses the pegboard, and no patients’ identifiers are on any computer, my official Red Flags policy is simple:

“Staff; if you notice anything unusual in relation to our patients’ accounts; or if you are handed an unusual-looking drivers license, notify me immediately”.

-The Management

My official notice will be fastened with thumb tacks to my wall of safety posters by May 1, 2008, and I will be in full compliance with not only HIPAA, but the Red Flags Rule as well. If the government continues its reckless, heavy-handed, one-size-fits-all laws, it won’t be long before I’ll be able to further undercut the fees charged by all computerized dental offices, and still make more profit. I say bring out the Department of Agriculture.

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Filed under: Alerts Sign-Up, Book Reviews, Breaking News, Career Development, Health Law & Policy, Healthcare Finance, iMBA, Inc., Information Technology, Managed Care, Practice Management, Professional Liability, Risk Management | Tagged: accounting ledger cards, ADA, AMA, American Dental Association, carbon paper, DDI, DentalCompare.com, Department of Dental Informatics, Dr. Ronald L. Tankersley, fake IDs, FTC, HIPAA, HSS, ID, identity theft prevention, Johns S. Findley, pegboards, red flag rules, Tamara Kempf, William E. Kovacic | 32 Comments »

MSFT Amalga Video for Hospitals and Health Systems

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

It Was One Year Ago Today … Updated for 2009

By Staff Reporters

Release of a new unified intelligence system allows enterprise health providers to unlock the power of all data from their existing IT systems.

REDMOND, Wash. — April 9, 2008

Microsoft Corp. today announced the availability of Microsoft Amalga, the new unified intelligence system that allows hospital enterprises to unlock the power of all their data sitting in isolated clinical, financial and administrative solutions.

What it is – How it works

Amalga is part of the Microsoft Amalga Family of Health Enterprise Systems, a portfolio of enterprise-class health solutions that provides rich integration, giving clinicians and executive’s quick access to valuable, up-to-the-minute information across their health enterprise. Microsoft also announced the availability of the Amalga family of health enterprise products across Europe at conhIT 2008, a healthcare IT conference being held in Berlin this week (http://www.microsoft.com/emea/presscentre).

Health Vault

The patient compliment to Amalga is MSFT’s Health Vault initiative which helps consumers collect, store, and share critical patient health information, for free.

www.HealthVault.com

Assessment 2009

Video interview, by Matthew Holt, originally appeared on The Health Care Blog [THCB] on April 16th, 2009.

Link: http://www.thehealthcareblog.com/the_health_care_blog/2009/04/interview-microsoft-health-solutions-.html#comments

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On Baseline Medical Practice Compliance Audits

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

Establishing a Reference Point is Key to Success

Submitted by Pati Trites; MPA, CHBC with Staff Reporters

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There are several types of compliance audits that a medical practice, clinic or healthcare organization might need to perform. The starting point is to obtain a baseline audit. The next step, discussed elsewhere on this ME-P, is periodic audits or reviews that are performed after information is obtained from the baseline audit.

Baseline Audits

Baseline audits are preliminary assessments to develop a reference point. Until a medical practice or healthcare organization establishes a track record with items such as coding accuracy or documentation to support medical necessity, it is difficult to determine any performance issues. In the spirit of Total Quality Management [TQM], the information that is shared should be done in a non-punitive manner to demonstrate that the intent of the process is to create a positive environment geared towards fixing the problems. A baseline audit can help any organization understand where the program is and establish a reference for future activities.

Assessment

Additional audits can also be performed whenever new employees are added, or if there are complaints, or issues that arise in the course of business.

Conclusion

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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/

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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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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

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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?

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Sherlock Expense Evaluation Report [SEER]

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

ADVERTISEMENT

Plan Management Navigator

By Marco Georeno

Ph: 215-628-2289

Please find attached the April 2009 edition of Plan Management Navigator. In it we provide an update on the timing of the Blue Cross Blue Shield universe and the Independent / Provider-Sponsored editions of the Sherlock Expense Evaluation Report (SEER). In addition, we expect to circulate the benchmarking surveys for the Medicaid and Medicare universes on or about June 1st, for completion by July 20^th, 2009.

Benchmarking Studies

If you are interested in participating in our benchmarking studies please contact us as soon as possible. Additional information about SEER is available at www.sherlockco.com/seer.shtml or by contacting Doug Sherlock (sherlock@sherlockco.com).

Best Practices for the Healthcare Enterprise

We also endeavor to provide an enterprise view of best practice. Best practice is typically considered to be the most efficient way of achieving a desired outcome. We believe that the best way of determining the best practice in its most practical application is to start with an overall objective and weigh all particular practices in light of how they contribute to that overall objective.

In that vein, over the next several months, Sherlock Company will be offering web conferences focused on best practices. The first conference will address activities within Customer Services, as well as activities or effects in other functional areas. This web conference will be held on Wednesday May 20th at 2:30 PM, Eastern Time. The costs will be $225. Participation is free of charge to health plans participating in our 2009 benchmarking studies. If you are interested in participating, please email Erin Sawchuk (erinsawchuk@sherlockco.com) or call at 215-628-2289.

Assessment

This edition of Navigator also discusses the latest private health plan Dashboard results for the trailing three months ended January 31, 2009.

Link: navigator

Sincerely,
Sherlock Company

Marco Georeno – Analyst
mgeoreno@sherlockco.com

Fax: 215-542-0690

Conclusion

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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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Will the SEC Protect eMRs [Welcome to my Healthcare Nightmare]

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

A Frightening Progressive Policy Institute [PPI] Report – Redeux

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

It is no surprise to ME-P readers, that I am a big fan of Dr. Regina E. Herzlinger, the Nancy R. McPherson professor of business administration and chair at Harvard Business School. I quote her often, in our books, despite her recent MA fiascos chronicled here. I am also a competitive medical analyst, IT devotee and health economist, who was a CFP® designee for more than a decade; before my fiduciary reformation. In her books, Creating New Healthcare Ventures and Market Term in Healthcare, Regi rightly states that many medical professionals are becoming depressed at the current state of affairs in healthcare, and want to give up their careers, entirely. We all know that many doctors, like me, no longer wish their kids to follow our professional footstep [Busia; please don’t roll-over in your grave – I know what I am doing – RIP].

But, is the same emerging trend true for FAs?

Medical Career Changers

For example, Gigi Hirsch, MD, a former ER physician and instructor at Harvard Medical School grew so disenchanted with clinical medicine, that she ditched her career and started her own business, MD IntelliNet, in Brookline, Mass. The company places doctors in non-traditional jobs by pairing them with venture capitalists and other businesses seeking physicians. Of course, this re-engineering and formal re-education has been the experience of my personal career journey, as well.

“Don’t Give up Practice, Yet”

And, Herzlinger implores in her book, Market Driven Healthcare, “don’t give up practice, yet.”

Patients Concerned Too

On the other hand, patients and healthcare consumers are also worrying about the looming so-called governmental free-for-all regarding healthcare delivery, mandated benefits and taxes, federally mandated electronic medical records, and data collection reportage and security; etc. Can you say “Big Brother” or “Command and Controll?”

Assessment

So, now may be the time to review Regi’s op-ed piece and policy report, penned for the PPI back, in 1999. It concerns patient and consumer healthcare protections. And, in this time of an Obama administration push for national healthcare – perhaps a prescient word to the wise might be sufficient.

Link: herzlinger

Conclusion

Your thoughts and comments on this Medical Executive-Post are appreciated? Should there be a healthcare SEC surrogate, much link the financial SEC? Or, would another governmental agency be as incompetent as Wall Street’s SEC and FINRA? Do we want FA wonks directing our healthcare needs? As an SEC controlled broker-dealer, and/or FA drone, should you even pursue same in your financial planning practice? What about the independent’s, CFPs and RIA’s? 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 this ME-P. It is fast, free and secure.

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About Certified Medical Planner™

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

SPONSOR NOTICE

Top 10 Reasons to Become a

Certified Medical Planner™

1. Expertise: Provide health economics, business and financial advice to physicians.

2. Credibility: Gain health industry recognition and fiduciary clout.

3. Opportunity: Focus on the lucrative and expanding physician advisory niche.

4. Recognition: Join a select group of advisory experts.

5. Distinction: Become quality; rather than product driven.

6. Achievement: 500 hours of financial, health economics and management education.

7. Evidence: Validate deep healthcare industry knowledge.

8. Resource: CMP™ text and hand books, dictionaries, and institutional print journal.

9. Distinction: Set yourself apart with our chartered logo and trade-mark identity.

10. Commitment: Become the “go-to” financial advisor for all medical professionals.

www.CertifiedMedicalPlanner.com

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GAO “Stings” FDA and HHS

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

Bogus Medical Products and Human Testing

[By Darrell K. Pruitt; DDS]

On March 27, 2009, I found the following Associated Press article about a Government Accounting Office (GAO) sting operation. For dentists who are awaiting the final rules from the FDA on the toxicity of amalgam, expect emotional-capricious and expensive. Forget about science, or even logic. For physicians awaiting HHS-supported usability in eMRs … well, good luck.

The HHS – Institutional Review Board

Recently, the GAO successfully gained approval from an HHS-registered institutional review board (IRB) for a bogus and dangerous medical product to be used in human testing. An independent IRB member called pouring a liter of the mystery product into the stomach of a woman following surgery the “riskiest thing I’ve ever seen on this board.”

Daniel Dueber Responds

So what did Daniel Dueber, CEO of the careless IRB, have to say in defense of his company? Since there is no defense, what could he say? According to the AP article, he chose to attack the GAO instead:

“The review board that fell for the GAO ruse, Coast IRB LLC, of Colorado Springs, charged that the GAO violated federal and state criminal laws by falsely representing itself to be a medical device company and forging a medical license. ‘We got hoodwinked,’ said Daniel Dueber, Coast IRB’s chief executive.”

Bart Stupak Responds

Representative Bart Stupak, a Michigan Democrat and chairman of the House Energy and Commerce Committee’s oversight and investigations panel, replied,

“You didn’t get hoodwinked. You took the bait – hook, line, and sinker.”

That’s not all. For those who hoped for rational and well-considered decisions from the Department of Health and Human Services in the Obama administration, it might disappoint some to learn that the GAO was also successful in registering a fictitious IRB.

Assessment

The president of the fake board is a dog named Trooper. If we end up with a Cabinet Secretary at HHS who is a dog-lover as well as a tax-payer, will he or she protect and feed Trooper?

Link:

http://www.boston.com/business/healthcare/articles/2009/03/27/gao_team_wins_approval_for_fake_medical_product

Conclusion

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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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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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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 »

Social Media in Health 2.0

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

Emerging Collaborative Trends

[By Staff Reporters]

All readers of the ME-P are aware that social media is going to play a significant role in health 2.0 initiatives going forward.

Social Media Use Growing

According to Dan Bowman of FierceHealthIT, on April 3, 2009, whether we want it to happen or not, social media – much like mobile technology – is going to play a big role in the future of healthcare. From professional networks, to collaborative consumer media and doctor rating websites, healthcare professionals across the nation are jumping on the bandwagon. And, with the federal government pushing physicians’ offices to utilize electronic medical records, it is only a matter of time before healthcare make a concerted push into social media, as well.

Publishers and Editors

“As a medical, practice management and health economics writer for almost four decades, I appreciated how electronic connectivity and social media facilitates communication in a quick and effective manner, and allows broadcast to large groups of people”

Dr. David Edward Marcinko; MBA

[ME-P Publisher-in-Chief]

The Research

A Manhattan Research survey found that 60 million US healthcare consumers use social media to find healthcare information online. A similar survey found that 60 percent of physicians are interested in, or are already using physician social networks. That same study concluded that “physicians who are currently participating in online physician communities and social networks write a mean of 24 more prescriptions a week than” their more old-fashioned counterparts.

Assessment

Of course, more Rxs – or more medical care for that matter – is not a quality indicator at all. Nevertheless, social media is not to be taken lightly.

Link: http://www.fiercehealthit.com/tags/ozmosis?utm_medium=nl&utm_source=internal&cmp-id=EMC-NL-FHI&dest=FHI

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: Career Development, Experts Invited, Glossary Terms, iMBA, Information Technology, Managed Care, Marketing & Advertising, Practice Management, Quality Initiatives, Research & Development | Tagged: blogs, cloud, cloud computing, collaborative healthcare, computers, email, gird, grid computing, hardware, health information technology, HIT, IT, networks, online, online healthcare, PCs, social media, software, websites, wikis | 7 Comments »

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 »

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

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Opinion Poll on eMRs

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

SPONSORED ADVERTISEMENT

www.MedicalBusinessAdvisors.com

Please Vote

Filed under: "Advisors Only", "Doctors Only", Career Development, Health Economics, Health Law & Policy, iMBA, Inc., Information Technology, Managed Care, Practice Management, Research & Development, Sponsors, Surveys and Voting, Voting Polls | Tagged: digital medical records, EHRs, electronic health records, electronic medical recrods, EMRs, health information technolgy, HIPAA, HIT, medical records IT | 3 Comments »

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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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

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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 »

On Drug Reps as Future Dinosaurs

Posted on March 31, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

More Doctors Closing Office Doors to Drug Salesmen

[By Staff Reporters]

According to Kevin B. O’Reilly, of the AMNews on 3/23/09, drug reps may soon become dinosaurs-of-sorts. And, the relationship between doctors and drug reps is cloudy, darkening and may never be the same again.

Changing Relationships

Pharmaceutical companies, battered by sluggish drug pipelines, the looming loss of blockbuster patented drugs, an economy in recession and scrutiny of their relationships with physicians; are re-examining the value of sending drug reps into doctors’ offices. Detailers are struggling to grab a shrinking slice of physicians’ valuable time, and attention, while adjusting to new drug industry rules banning freebies such as pens and notepads.

Declining Reputations

While most physicians still have positive views of detailers and drug-makers, those sentiments are cooling. And, the next-generation of medical students and future physicians may be another driver of this wave. About one in four physician’s works in a practice that refuses to see drug reps. Of doctors who do see reps, about 40% will meet with detailers only with scheduled appointments. The by-appointment-only figure jumped 23% during the last six months of 2008, according to a survey of more than 227,000 medical practices representing 640,000 physicians that was released in February.

***

Assessment

What is your practice policy on this issue? Are drug reps being replaced by webcasts, podcasts, IMs, text-messages, cell phone advertisements, direct-to-doctor [D2D] communications and/or some other new-wave social media or rich e-format?

Channel Surfing the ME-P

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: "Doctors Only", Drugs and Pharma, Ethics, Managed Care, Practice Management | Tagged: Big Pharma and Drugs, big-pharma, D2C, D2D, detailers, drug makers, drug reps, generic, IMs, patent, pharmaceuticals, text messages, webcasts | 13 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

Disclaimer about HealthcareFinancials.com

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.

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

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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 »

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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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, 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 »

Independent Medical Practitioner as Solo Primary Care Surrogate

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

Doctors Facing a Bleak Future Business and Financial Planning Model

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

According to Physicians News, on March 19, 2009, the demand for family physicians is growing. Proposals for health system reform focus on increasing the number of primary care physicians in America. Yet, despite these trends, the number of future physicians who chose family medicine dipped this year, according to the 2009 National Resident Matching Program. What gives?

NRMP

The National Resident Matching Program [NRMP] recently announced that a total of 2,329 graduating medical students matched to family medicine training programs. This is a decrease in total student matches from 2008, when 2,404 family medicine residency positions were filled.

Primary Care Demand Explodes

Meanwhile, demand for primary care physicians continues to skyrocket. For example, in its most recent recruitment survey, Merritt Hawkins, a national physician recruiting company, reported primary care physician search assignments had more than doubled from 341 in 2003 to 848 last year.

The Decline of Solo Medical Practitioners

Regular readers and subscribers to this Medical Executive- Post are aware of the declining number of solo medical practitioners; we have been sounding the alarm here, in our books, journal, speaking engagements and elsewhere for years now.

In fact, the statistic that we often cite is that more than 40% of the nation’s physicians are employed doctors; not employers as in the past. This business model shift has occurred over the past decade or so, and has accelerated of late. The decline in solo and independent doctors has occurred elsewhere as well, but much more slowly [i.e., dentistry, podiatry and osteopathy] as these specialties have been somewhat isolated from the traditional allopathic mainstream.

Going forward, this solitary model seems to be a good thing, and a fortunate result of the un-intended consequence of previously keeping these folks out of the healthcare mainstream.

The Decline of Independent Medical Practitioners

Now, in the March 2009 issue of Healthcare Finance News, we learn that the number of hospital owned physician practices has been climbing over the last four years, according to the Medical Group Management Association [MGMA]. Think: PHOs back-in-the-day.

And, while this trend only marginally affects patients and patient care, it is quite disruptive to physicians, their families, personal wealth accumulation, retirement and estate planning endeavors.

For example, according to Professor Hope Rachel Hetico, RN, MHA, CMP™ of our firm www.MedicalBusinessAdvisors.com

“The professional good-will valuation component of a medical practice is being decimated. Today, some practices are being bought and sold for tangible asset value, only.

Assessment

Therefore, allow me to identify this emerging trend which suggests independent medical practice as reflective of solo primary medical care. In other words, as independence goes the way of the “dodo-bird”, so goes primary care practitioners precisely at a time when the later is needed more than the former.

Why? Employed doctors stay that way by making money for their employer and hospital-bosses. Specialists make more money than primary care doctors. So, if you want to stay an employed doctor; which specialty would you pursue?

Answer: The NRMP class this year spoke out loud and clear. Any specialty but primary care!

Channel Surfing the ME-P

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: "Doctors Only", Career Development, Estate Planning, Financial Planning, iMBA, Inc., Managed Care, Op-Editorials, Practice Management, Practice Worth, Retirement and Benefits | Tagged: ADA, allopath, AMA, APMA, david marcinko, DDS, dentist, DO, doctor, DPM, family practitioner, hope hetico, iMBA, Inc., internist, MD, National Resident Matching Program, OD, optometrist, osteopath, pho, physician, podiatrist, primary care, residency match, www.healthcarefinancials.com, www.healthdictionaryseries.com, www.medicalbusinessadvisors.com | 15 Comments »

Medical Practice Financial Statement Valuation Adjustments

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

Why Benchmarks are Out – and Scrutiny is In

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chief

CEO: www.MedicalBusinessAdvisors.com

As discussed elsewhere on this ME-P, the medical practice appraiser’s primary goal is to determine the value of the business based on its expected earnings or cash flow. To accomplish this, the medical practice appraiser looks to the company’s historical financial statements to see how it has been reporting its earnings. Because of differences in accounting practices across organizations, the appraiser must analyze how the medical practice’s financial statements differ from those of other practices and how those differences might have an effect on the practice’s value. This is particularly true when the appraiser is comparing the performance of the medical practice company being valued with those of so-called industry benchmarks. In all instances, it is important that the appraiser compare numbers that have been accounted for in the same way. Below is a discussion of the most common adjustments.

Nonrecurring or Extraordinary Items

Nonrecurring or extraordinary items of income or expense reported by the practice will be eliminated from the profit and loss statement. These include the following:

• Insurance settlements (income or expense) or life insurance proceeds on the death of the key physician-partner.

• Large payments in settlement of lawsuits (either as income or as expense).

• The gain or loss on the sale of certain assets or portions of the practice which are not likely to be repeated.

• Expenses related to the start-up or discontinuance of a new or old segment of the practice.

• Moving and related expenses.

• Expenses relating to fire or flood damage not covered by insurance.

• Adjustments to prior years’ financial statements when the practice discontinued an employee benefit (such as eliminating the company’s pension or profit-sharing plan).

• Adjustments for income and/or expenses related to non-operating assets, such as a portfolio of marketable securities not used in the practice or medical real estate held for investment purposes.

Valuation Calculations

The appraiser needs to gather the following facts regarding the financial statements of the practice and may need to make adjustments to account for these differences. The information will give the appraiser an understanding of the company’s normalized earnings and will be used to make valuation calculations.

• How does a specialty practice [such as physiatry’s DME] value its inventory—LIFO or FIFO? In certain specialties, inventory is accounted for on the LIFO or “last-in, first-out” basis. When prices are rising, profits are reduced because the DME items being sold are presumably bought most recently at higher prices. The “old” or lower-cost inventory is held in reserve while the higher-cost inventory is sold off. This situation may reverse in times of recession and low or no inflation. At that point, profits will be distorted by the low-cost items. Recognizing these facts, practice owners have more commonly used FIFO or “first-in, first-out,” inventory accounting to value their inventory.

• What kind of reserves has the practice been taking for doubtful accounts receivable? Some doctors will not – or very slowly – write off bad debts or take reserves for them, and thus the income is improperly overstated. The appraiser will look at the actual bad debt expenses relative to the doubtful accounts receivable booked to determine if the practice’s adjustments are reasonable.

• How does the practice depreciate its hard assets? A variety of approved methods are used to depreciate assets over their useful lives. It is important for the appraiser to recognize the impact these methods have on corporate earnings. Some assets can be depreciated over a short time frame, which will mean higher annual write-offs; others, such as real estate, must be depreciated over a much longer period and thus will have a smaller impact on annual expenses.

Asset-Related Issues

The appraiser must address asset-related issues, such as:

• Has the practice’s assets been valued recently? If not, will current appraisals be required?

• Are any non-operating assets carried on the books of the practice? These assets may have to be valued separately and added to the operating value of the business.

Assessment

In our experience valuating medical practices, adjustments made for excess compensation and perquisites paid to the physician-owner and other family members, are the most common items of contention between buyer and seller.

For example, above average physician income usually equates to lower medical practice transferrable enterprise value; and vice versa.

Link: https://healthcarefinancials.wordpress.com/2007/11/30/90

Channel Surfing the ME-P

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

Product Details

Filed under: "Advisors Only", "Doctors Only", Accounting, Career Development, Managed Care, Practice Management, Practice Worth, Professional Liability, Taxation | 1 Comment »

Consultants and Hospital Employment Statistics

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

Economic Conditions Better than Other Major Industries

By Staff Reporters

According to Richard Pizzi, on March 9th, Healthcare Finance Newsweek reported that employment at US hospitals climbed 0.14 percent in February to a seasonally adjusted 4,719,300 people.

Bureau of Labor Statistics

Responding to just issued BLS data, the number employed was 6,800 more than in January and 131,800 more than in February 2008. Without seasonal adjustments, which remove the effects of fluctuations due to seasonal events, hospitals employed 4,703,700 people in February 2009, 2,200 more than in January and 130,100 more than a year ago.

Impact on Healthcare Consultants

This was good news for financial advisors, insurance agents and accountants; medical management consultants and health economists; HIT suppliers and related DME vendors, etc.

Assessment

The news was not so good in other areas of the American economy, however, as the national unemployment rate rose from 7.6 percent to 8.1 percent. The US economy shed an additional 651,000 jobs in February 2009. But, according to Rachel Pentin-Maki; RN, MHA of www.MedicalBusinessAdvisors.com

“Employment continues to be strong in almost all aspects of the healthcare industrial complex. This includes professionals, technicians, nurses and para-professionals, as well. However, in the long-term, we believe that medicine will not attract the best and brightest young minds in the future. The economic, political and competitive demographics are just not favorable.”

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Is healthcare really a recession proof industry? What about those bright young minds; where will they go for professional careers, instead?

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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

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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 »

The No Insurance Club

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

Emerging Pre-Paid Cash-Based Medicine

By Bob Grove

Healthcare in America is in Turmoil. The No Insurance Club [NIC] feels private contracts may be the solution. More and more Americans are going without healthcare especially preventative healthcare. The reasons – costs are too high, patients can’t get accepted due to a pre-existing condition, companies are cutting back on benefits, people have been laid off from work; and the list goes on.

Governmental Solutions

What’s being done to improve healthcare? Barack Obama and the Government want more control and regulation and the system seems to be leaning toward socialized care. Private insurance companies continue to increase premiums, which prices healthcare out of reach for the average American. Employers can no longer float the cost of insurance so they pass it on to their employees. Patients aren’t the only ones being affected by the current state of healthcare. More and more doctors are going out of business and hospitals are cutting back due to escalating costs and payment defaults.

Private Solutions

The current remedy; Americans are taking out private major medical policies for catastrophic events with high-deductibles [MSA/HSAs] to keep monthly premiums down, or are turning to Medicaid, mini retail-clinics at grocery stores/pharmacies, and emergency room visits for common illnesses.

Innovative Solutions

What about prevention and maintenance? More than 90 percent of health related issues can be taken care of with preventative care and maintenance but only a small percentage of Americans currently enjoy the benefit of preventative healthcare.

The No Insurance Club

The NIC has come up with a fresh look at healthcare by offering an affordable alternative to traditional insurance options.

NIC Benefits and Features

The No Insurance Club connects patients with participating board certified physicians that will treat and care for preventative healthcare needs for a one-time prepaid annual membership fee:

NIC patients make a one-time annual payment that is typically less than a one-month premium with traditional insurance.
Patients receive up to 12 office visits per year that also include immunizations, $4 or less in-office prescriptions, and additional services including blood tests.
No deductible, no co-pays, no premiums.
No surprise bills to patients.
Viable alternative to COBRA for employees laid off from work.
Low cost option for the self-employed.

Assessment

What’s in it for the doctors? How about no insurance clerks, no need to snail mail medical insurance claims or use expensive electronic claims submission clearinghouse services, no bad debts or bad expense write-offs, no ARs; and fast cash!

Link: http://www.noinsuranceclub.com/

I would be happy to speak with and connect ME-P readers, participating doctors and even patients for interviews to learn more about the NIC network and its benefits.

Bob Grove

Wild West PR

(801) 651-0290

bob@wildwestpr.com

Conclusion

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Filed under: Career Development, Health Insurance, Information Technology, Managed Care, Media Mentions and PR | Tagged: ARs, bad debt expenses, BDE, cash medical visits, COBRA, david marcinko, HMO, Medicad, medical ARs, medicare, no insurance club, obama, PPO, pre paid health care, private pay health care | 3 Comments »

Healthcare Experts versus Health Journalists

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

Appreciating the Distinction

By Dr. David Edward Marcinko; MBA

Publisher-in-Chief

As the healthcare reform, and eMR controversy unfolds, I am struck by the more-than-linguistic distinction between the terms “healthcare expert” and “health journalist.”

Link: www.HealthDictionarySeries.com

Historical Perspectives

Historically, as a peer-reviewed writer, editor, medical expert witness and now electronic publisher for almost four decades, I always sought the journalist’s title. I think the longing began in my formative years when I read that after the French Revolution, Sir Edmund Burke, looked up at the Press Gallery of the House of Commons, and said, ‘”Yonder sits the Fourth Estate, and they are more important than them all.”

Link: www.MedicalBusinessAdvisors.com

Expert versus Reporter

However, I no longer covet this title. Why? I’ve finally realized that it is far better to be a real subject-matter expert, than a journalist [read reporter]. The former creates news through knowledge, informed deeds and thought-leadership; while the later simply writes about various topics without same.

Link: www.HealthcareFinancials.com

Assessment

And so, in light of the eHR controversy, perhaps a word to the “wise” AMA, ADA, APMA, AOA and CCHIT leadership is sufficient; with apologies to Sir Edmund? Regardless of specialty, our guiding medical principles should always be; Omnia pro Aegroto [all for the patient].

Link: https://healthcarefinancials.wordpress.com/2009/01/31/about-the-ahcj/

Conclusion

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Filed under: Ethics, Experts Invited, Health Insurance, Managed Care, Research & Development | Tagged: david marcinko, healthcare experts, healthcare reporters, hope hetico | 7 Comments »

Sherlock Health Plan Management Navigator

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

Information System Implications on Health Plans

By Douglas B. Sherlock; MBA, CFA

Messrs. and Mesdames

Attached, please find the February 2009 edition of our Health Plan Management Navigator.
Link: sherlock-company

The Sherlock Expense Evaluation Report

In this month’s edition, we endeavor to better understand the functional area of information systems [IS] and its implications on health plans. Information systems, based on the results from out 2008 Sherlock Expense Evaluation Report (SEER) displayed overall anti-scalability in costs. In order to better comprehend IS and its influence on health plans overall, we performed numerous analyses that looked at relationships between IS and other aspects, such as scalability, variety of product offerings, commitment to ASO products and other functional areas.

Assessment

The results suggest that scale does not appear to play a role in IS costs and that more of a concentration in ASO products seemed to lower IS costs. It also appears that management of information systems, in the context of its support to other functional areas, is an inexact science.

Conclusion

Additional information about SEER is available at www.sherlockco.com/seer.shtml or; by contacting me at: sherlock@sherlockco.com

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Filed under: Breaking News, Health Economics, Health Insurance, Healthcare Finance, Information Technology, Managed Care, Monthly Reports | Tagged: ASO, Douglas B. Sherlock, health information systems, HIT, HMO, Loyola College, MCO, PPA, Sherlock Company, Sherlock Expense Evaluation Report | Leave a comment »

Introducing Douglas B. Sherlock MBA CFA

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

About Our Newest Thought-Leader

By Ann Miller; RN, MHA

Douglas B. Sherlock CFA is President of Sherlock Company which assists health plans, their business partners and their investors in the treasury and control functions of finance.

Resume

Prior to the founding of Sherlock Company, Mr. Sherlock was Vice President of Financial Analysis of U.S. Healthcare, Inc. where he directed the company’s merger and joint venture activity, its investor relations program and its HMO product for Medicare beneficiaries. Sherlock was formerly Vice President of Salomon Brothers, Inc where he specialized in the financial research of prepaid health plans and hospital systems, and assisted in the capital formation and merger activities of health care companies. He was the Greenwich Survey First Place HMO Analyst and a runner-up in the Institutional Investor polls.

Professional Associations and Memberships

Mr. Sherlock is a Chartered Financial Analyst. He has been a member of the Financial Accounting Policy Committee of the CFA Institute. He has served on the Editorial Board of Inquiry, a journal of health care organization, provision and financing published by the Blue Cross Blue Shield Association, and is a reviewer for Chartered Financial Analyst. He has been a member of the Financial Accounting Policy Committee. Sherlock is a frequent speaker before health care groups including the American Association of Health Plans, the HealthCare Financial Management Association, and the Blue Cross Blue Shield Association. The research of Sherlock Company has recently been cited in such periodicals as The New York Times, Forbes, Investor’s Business Daily, Modern Healthcare, Hospitals, The Wall Street Journal, HMO Managers Letter, Business Week and The Medical Business Journal.

Educational Background

Mr. Sherlock holds an M.B.A. in finance from Loyola College in Maryland. He received his bachelor’s degree in economics from Franklin and Marshall College, Lancaster, Pennsylvania.

Conclusion

We look forward to his contributions and now professionally welcome him warmly, as our newest ME-P thought-leader.

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Filed under: Breaking News, Health Economics, Health Insurance, Healthcare Finance, Managed Care, Op-Editorials, Practice Worth, Research & Development | Tagged: American Association of Health Plans, Blue Cross Blue Shield Association, Business Week, CFA, Chartered Financial Analyst, Douglas B. Sherlock CFA, Financial Accounting Policy Committee, financial analyst, Forbes, HMO, HMO Managers Letter, hospitals, Investor’s Business Daily, Modern Healthcare, Salomon Brothers, Sherlock Company, The Medical Business Journal, The New York Times, The Wall Street Journal | 1 Comment »

Doctors Censoring Patients

Posted on March 2, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Another Emerging Ethical Dilemma

[By Hope Rachel Hetico; RN, MHA, CMP™]

Much has been said, and much has been written, about the various healthcare 2.0 initiatives and the new-wave patient collaborative schemes among medical stakeholders. Even our federal government, vis-a-vie, the American Recovery and Reinvestment Act [ARRA], of 2009 [“stimulus”] has increased funding related to health information technology [HIT] for physicians, hospitals and healthcare organizations; hopefully to benefit us all.

Information Technology Money

In fact, according to Steve Lieber, President of the Health Information Management Systems Society [HIMSS], about $20 billion will be investment into health information technology [HIT] at one time. Some money will flow into the current calendar year, some dollars will flow in subsequent years, and some funding will be available until spent.

Consumer-Oriented Websites

And so, it comes with surprise and dismay to me that some doctors may be telling their patients to censor themselves – or find another physician. This, of course, is anathema to consumer oriented websites like RateMDs and Vitals.com, etc. These sites give internet users the chance to recommend and review physicians and hospitals nationwide.

Unethical Behavior

But, some ethicists believe that such self-interested behavior is not professional and when a doctor acts primarily out of self-interest, it is ethically suspect. For example, according to Fox News on February 19, 2009, among groups spearheading the move to censor is a company called Medical Justice® which says it’s only helping protect doctors from online libel as an “emerging threat” within the medical profession. Founder Dr. Jeffrey Segal, a former neurosurgeon robustly supports the consumer rating sites in theory, but in practice they aren’t properly monitored and can do irreparable harm to a doctor’s reputation – especially when people pretending to be former patients write phony reviews.

Assessment

Medical Justice® has been mentioned on this forum before, and according to its website

Medical Justice® creates a practice infrastructure to prevent, deter, and respond to frivolous medical malpractice suits. A membership-based organization, Medical Justice® is relentlessly committed to protecting physicians’ reputations and practices.

Link: http://www.medicaljustice.com

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

Link: https://healthcarefinancials.wordpress.com/2008/04/17/physician-peer-review

Industry Indignation Index: 65

Channel Surfing the ME-P

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: Ethics, Industry Indignation Index, Information Technology, Managed Care, Op-Editorials, Quality Initiatives, Research & Development | Tagged: AARA, Center for Peer Review Justice, Dr. Jeffrey Segal, HIMSS, HIT, IT, Medical Justice, RateMDs.com, Steve Lieber, Vitals.com | 20 Comments »

ME-P Sponsor of Intellectual Capital

Posted on March 2, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

www.HealthcareFinancials.com

By Ann Miller; RN, MHA

Executive Director

All hospitals, healthcare systems and organizations use a variety of teaching, educational and didactic techniques to bring value to patients, payers, providers, governments and third-party intermediaries.

Intellectual Capital

This intellectual capital is the sum total of all knowledge and expertise used to serve the healthcare industrial complex and its’ stakeholders. Leaders, CXOs, CEOs, CFO, managers, administrators and employees provide most all of this current cognitive capital.

Print Journal Guide

We believe that Healthcare Organizations: [Financial Management Strategies] adds to this intellectual capital by guiding you, empowering your organization, and creating value for your patients, employees, investors and clients by bridging the intersection of medical mission and profit margin.

Assessment

www.HealthcareFinancials.com seeks to “Bridge the Intersection of Medical Mission and Profit Margin”; using the aggregated free-labor knowledge of those in the industry. There is just no better method available.

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

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Filed under: "Advisors Only", "Doctors Only", Accounting, Alerts Sign-Up, Career Development, Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, iMBA, Inc., Information Technology, Managed Care, Media Mentions and PR, Recommended Books, Research & Development, Sponsors | Tagged: ASCs, brent metfessell, Calvin Wiese, Carol Miller, CEO, CFO, Charles Fenton, clinics, CXO, Darrell Pruitt, david marcinko, David Nash, David Piasecki, Gary Bode, Groegory O. Ginn, healthcare, Hope Hetcio, hospitals, karen white, Managed Care, medical care, Pati Trites, public health, Richard Helppie, Richard Mata, Robert Cimasi, Todd Zigrang, Wayne Firebaugh, www.certifiedmedicalplanner.com, www.healthcarefinancials.com, www.medicalbusinessadvisors.com, www.STPub.com | Leave a comment »

Collaborative Dental Health 2.0 [Part One of a Three Part Series]

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

Consumerism is the Hippocratic Way

By Darrell K. Pruitt; DDS

The Appearance of DR. Oogle

By September of 2005, when I finally worked up enough courage to ask a patient to post a review for me on DR. Oogle (doctoroogle.com) – a web-based patient referral site – my dental practice had been invisible and struggling for a few years and was still disappearing. It was the most discouraging period in my career.

Following the Golden Rule

In spite of my efforts to always treat my patients like I would want to be treated myself, I was headed for either managed care, which I consider to be an unethical model for dentistry, or bankruptcy. The progressive betrayal of my profession and my patients by leaders in dentistry spawned bitterness and high blood pressure that I still suffer today – even though my practice has fully recovered. My hygienist and I are currently booked almost solid for the next two weeks. I know also that in the next three, misfortune could arise. I have no idea what is in store for dentistry in tomorrow’s economy. If I was in the business of selling advice, or DR. Oogle, I would probably be tempted to radiate much more confidence than I truly feel.

Back in the Day

When I graduated from dental school in 1982, I was reassured by dentists I respected that one’s practice location is not important if one works hard to consistently provide patients with one’s best efforts. Dr. Earl Estep, a practice development guru from Athens, Texas, taught me decades ago that word-of-mouth is much more effective for attracting patients who are ready to spend money than advertisements provide, and that one should never forget to ask for referrals, even if it feels “unprofessional.” This is still solid advice. For example, two days ago, in a special marketing feature on Jim Du Molin’s The Wealthy Dentist Blog, Chris Barnard suggested,

“Enlist your existing patients in your practice success. Actively seek those all-important word of mouth referrals from your patients.”

Link: http://www.thewealthydentist.com/blog/727/practice-marketing-in-down-times

Even though Barnard doesn’t mention patient referral sites such as DR. Oogle, his other ideas which may or may not fit one’s practice image include quarterly letters, $10 gas cards and iPod raffles in order to

“… Let them know who you are beyond that white lab coat …!”

Just Do it … and Ask

I personally think it is much less complicated, as well as much cheaper, to simply select a recently satisfied patient, look the person in the eye and ask,

“Would you mind putting in a good word for me on this website?”

Handing a patient a business card with the website handwritten on it becomes easier to do after the first dozen or so, but don’t expect immediate results. My success rate was around 45% when I was actively pursuing favors. When I reached 90 reviews after around nine months, I quit pestering my patients with requests for reviews. Active participation in a patient referral site also provides the incentive to improve one’s practice by motivating both dentists and staff to become wrapped up in treating each patient with extra-special care in the hopes of a nice review. Before anyone knows it, personalized, attentive care becomes a habit, I have found. Other than those who sell ads and party favors, everyone wins.

Enter Dr. Oogle

I came across DR. Oogle in March 2005. The open-source patient satisfaction measurement application was born in San Francisco at the very end of the .com bust, and had been actively gathering word-of-mouth data about dentists for over two years when I began observing its progress. By then, DR. Oogle had already accumulated an impressive amount of information concerning patient satisfaction with many of nation’s dentists. I suspect that today, Dr. Oogle’s volume of data is insurmountable by potential competitors.

Akin to Wikipedia

I found DR Oogle’s revolutionary marketing concept fascinating simply because like Wikipedia, it is not supported by advertising – thus avoiding a tremendous built-in and transparent bias. The company’s profits are derived solely from dentists like me who agree to pay reasonable monthly fees for the opportunity to participate in the application by displaying their customers’ opinions for public scrutiny. It is what I call playing to win rather than playing not to lose. Five months before I purchased the service, I published an article about DR. Oogle in The Twelfth Night, the monthly newsletter of my local dental society. I believe mine was the first mention of such web-based patient referral sites in any dental publication. Here is the article:

Patient Driven Referral Services

[From: “The Twelfth Night” April, 2005]

In a small community people as a general rule know a lot more about their neighbors than do people in a city. They also know a lot more about the doctors and dentists in town since there are only a few. It is fairly common to talk to neighbors and friends to get opinions on who is the best dentist, who to avoid, who is the cheapest, who has the most up to date equipment.

In a small community, as well as in a city, even a neighbor’s recommendation carries more weight than a dentist’s paid advertisement. I would imagine that sales of 1 800 Dentist subscriptions are significantly lower in rural Texas than in the metropolitan areas on a per capita basis. The dentists in small communities know that they are far too easy to find to need to spend money for a referral service or for much advertisement at all.

Well, Fort Worth and cities across the nation are becoming smaller dental communities because of the internet. If any of you have googled your name, you may have picked up a hit by one or more patient driven referral services (PDRS). And, if you have not done this lately, you should. There is a good possibility that the information about your practice location may contain errors. But more importantly, you may read something pleasingly flattering or terribly humbling about your practice written by a patient you saw last week.

Dr. Oogle is presently the most popular PDRS. A patient’s comments about his or her dentist is posted only after the patient accepts the terms of the agreement; which are that the patient is neither a relative nor an employee of the dentist and that the patient is not otherwise being compensated for the review. The website also requires an authentic e-mail address and other personal information for verification purposes.

There is a filtering system in place in which employees of Dr. Oogle reject (at their discretion) comments which are too good or too bad to be credible. And there are other ways in which dentists can handle bad reviews and are described on their website. There is, I suppose, always room for an attorney or two if the other attempts at removing a bad review fail.

But, if the PDRS’s survive the lawsuits, and if the first review which comes up under your name happens to be a real stinker written by an easily disgruntled and fervently vindictive patient (I think his name is Fred. You probably know him as he changes dentists often), and if you cannot get it otherwise removed, perhaps you should bury it under as many good reviews as you can encourage your patients to submit. This reaction, not surprisingly, is the reaction recommended by Dr. Oogle. In fact, they also recommend that we routinely ask our patients to submit reviews to them. I imagine that there are already dentists who have had cards printed for this purpose.

Like it or not, our patients are being given more power in the marketing of our practices and their influence is growing. Dr. Oogle’s first reviews of dentists in the greater Ft. Worth area occurred in September of ’04. By the first of February, 5½ months later, there were only 18 dentists who had been reviewed by at least one patient. As of today, one month later (March 7), there are 16 more. By the time this is published the number could be close to 50. Who knows how many reviews will be posted a year from now if the public perceives value in this kind of information. Many more of us will be listed as either good or bad dentists; legitimately or not.

Regardless of the outcome of Dr. Oogle’s venture into dentistry, the fact that the public has a thirst for “unbiased” sources of information concerning our practices tells us that more than ever before we have to treat each patient as our most important source of new business or a disappointed patient could soon become a significant obstacle for growth.

Another good thing is that a patient who has to choose a dentist from a list at least soon may have some guidance; other than the fact that his insurance company thinks they are all equally swell.

Darrell K. Pruitt; DDS

[April 2005]

Investigative Reporting

Since writing the unprecedented article, I have performed numerous simple investigations comparing DR. Oogle’s ratings to dentists’ names on preferred provider lists for various cities. Invariably, the vast majority of the dentists who sign managed care contracts are found in the bottom 50% of the ratings. Sorry if I hurt some colleagues’ feelings, but that is cold fact. Anyone with a preferred provider list can confirm it. I suspect it has been done thousands of times by many anxious people holding new annual lists of strangers’ names in just the last year. Alert dentists should note that humans are choosy when it comes to trusting someone to use sharp, rotating instruments in their mouths. Dentistry is not like buying a can of beans as discount brokers would have their naïve and trusting clients believe, and most importantly, ethics are not for free.

Apart from the common sense rule that a purchaser of intricate handwork to exacting tolerances generally gets what the dental patient pays for, what else causes fee-for-service dentists to be generally favored over preferred providers? I think it has to do with hunger. If one’s meals arrive daily without effort, one forgets how to fish.

Managed care and preferred provider lists protect contract dentists from the naturally cleansing free-market principles taught by economist Adam Smith centuries ago. The beauty of competition in the marketplace occurs every time a dis-satisfied patient shops for a new dentist. When reliable information about patient satisfaction is available, quality is rewarded and encouraged in the neighborhood. Free-market capitalism works as reliably as classical operant conditioning in the best of possible worlds.

Assessment

It is my opinion that there has always been something dishonest and un-American about discount dentistry with no quality control. I think we need to expose the unfair and unethical managed care business model to free-market forces even if it involves the calculated promotion of a simple, foolproof scheme for dentists interested in graduating from preferred provider lists. Those who feel trapped can begin their escape immediately by preparing some business cards for their managed care dental patients who by now are easily impressed by compassion. I’ll share more in Part 2.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. If US dental patients are lucky, Web 2.0 transparency arrived just in time. Consumerism rules naturally.

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Filed under: Career Development, Ethics, Experts Invited, Information Technology, Managed Care, Marketing & Advertising, Media Mentions and PR, Practice Management | Tagged: Chris Barnard, Darrell Pruitt, DDS, dentist, DR. ooogle, Earl Estep, health 2.0, health 3.0, Jim Du Molin, PDRS, social networks, the wealthy dentist blog | 4 Comments »

WellCare Medicare-Advantage Scandal

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

Company “Misled and Confused Medicare Beneficiaries”?

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

According to Jacob Goldstein, of the WSJ, on February 20, 2009, WellCare the publicly traded company that some folks “love-to-hate”, and manages health coverage for Medicare and Medicaid beneficiaries, is in trouble again. In a recent letter, the Feds ordered the company to stop enrolling new Medicare beneficiaries, effective March 7, 2009. The sanction will be in effect until the Centers for Medicare and Medicaid Services [CMS] is satisfied that the company has corrected the alleged deficiencies.

Letter from the Feds

Adjusted for enrollment, the rate of complaints about WellCare’s marketing of Medicare Advantage plans are three times the national average, the letter says. The letter goes on to allege that the company “misled and confused Medicare beneficiaries” and “engaged in unauthorized door-to-door solicitation.” CMS also accuses WellCare’s agents of “misleading beneficiaries and misrepresenting WellCare plans at sales events in December 2008″ and failing to “discover forged applications through its own monitoring systems.” Of course, the company said it would continue to work with independent third-parties to ensure that it is compliant with CMS.

Click here to read the letter.

Oh Regina – Say it Ain’t So!

Finally, and perhaps the most personally distasteful for me in this whole sordid affair is not the fact that WellCare allegedly tried to rip off old folks. It’s just that Dr. Regina Herzlinger, the Harvard Business School professor – mother of a physician herself and proponent of healthcare competition and Consumer Directed Health Care Plans [CDHCPs] and a WellCare BOD member – apparently sold $2.3 million worth of stock in Wellcare three months before the FBI arrived.

Assessment

I first became aware of Regina Herzlinger’s work while in business school [not HBS] in the early 1990s. I recall calling her office for advice and referencing her several times in both editions of my best-selling book, the Business of Medical Practice [Profit Maximizing Techniques for Savvy Doctors]. She even came to Piedmont Hospital, here in Atlanta, last year on a healthcare speaking tour promoted in the local newspapers. What a shame. All co-incidence; ask Regina? Link: www.MedicalBusinessAdvisors.com

Industry Indignation Index: 35

Full disclosure: I am the founder of www.CertifiedMedicalPlanner.com and a reformed insurance agent, registered investment advisor and Certified Financial Planner™

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Do you think WellCare “Misled and Confused Medicare Beneficiaries?” You may opine and decide.

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About In-Situ Medical Practitioners

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

Searching for Definitional Clarity

Staff Reporters

Apparently, there is a growing trend toward so called “in-situ medical practitioners”. In this model, specialists like internists or diabetologists, add a certain medical expertise to address a large number of patients with specific needs in a general or primary care practice.

Link: www.HealthDictionarySeries.com

Business Savvy

This clearly indicates that physicians are becoming more business savvy, are becoming more sophisticated in driving the growth of their practice, and better understand the structure and needs of their local health care market.

Assessment

Regardless, the basic principles of relationship building and relationship management apply – treating each party with mutual respect and engaging in open and honest dialogue. Of course, we seek input form readers and subscribers to further define this emerging trend; if not merely a group of isolated incidents made known to us.

Conclusion

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

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Understanding Healthcare Competition

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

Funneling Porter’s Five Forces of Business

Staff Reporters

Michael Porter PhD, of Harvard Business School, is considered by many to be one of the world’s leading authorities on competitive strategy and international competitiveness.

In 1980, he published Competitive Strategy: Techniques for Analyzing Industries and Competitors, in which he argued that all businesses must respond to five competitive forces. And now, these thoughts have been condensed for the healthcare industrial complex by Robert James Cimasi; MHA, CMP™ of Health Capital Consultants, LLC, in St. Louis, MO. They are cited below from the print journal-guide www.HealthcareFinancials.com

1. The Threat of New Market Entrants

This force may be defined as the risk of a similar company entering your local marketplace and winning business. There are many barriers to entry of new market entrants in healthcare including: the high cost of equipment, licensure, requirement for physicians and other highly trained technicians, development of physician referral networks and provider contracts, and other significant regulatory requirements.

Certificate of Need (CON) laws, which require governmental approval for new healthcare facilities, equipment, and services that have been in place since they were federally mandated in 1974. State CON laws create a regulatory barrier to entry. New medical provider entrants commonly faced substantial political opposition by established interests, which is manifested in the CON review process.

2. The Bargaining Power of Suppliers

A supplier can be defined as any business relationship or vendor you rely on to deliver your product, service or outcome. Healthcare equipment is a highly technical product produced by a limited number of manufacturers. This reduces the range of choices for providers and can increase costs.

3. Threats from Substitute Products or Services

Substitute products or services are those that are sufficiently equivalent in function or utility to offer consumers an alternate choice of product or service. An illustration of this in healthcare would be diagnostic imaging, or PET scans, as a substitute for surgery, which is often a more costly and risky option for patients. The threat of less invasive or less expensive diagnostic tests other than diagnostic imaging is relatively small for the near term future.

4. The Bargaining Power of Buyers

This force is the degree of negotiating leverage of an industry’s buyers or customers. The buyers of healthcare services are ultimately the patients. However, the competitive force of buyers is manifested through healthcare insurers including the US and state governments through the Medicare, Medicaid, TRICARE, and other programs; managed care payers (e.g., Blue Cross/Blue Shield affiliates); workers’ compensation insurers; and others.

In addition to the government, many of these healthcare insurers are large, national companies, often publicly traded, commanding significant bargaining power over healthcare provider reimbursement.

5. Rivalry among Existing Firms

This is ongoing competition between existing firms without consideration of the other competitive forces which define industries. Healthcare providers face pressure from other existing providers to obtain favorable provider contracts; maintain the latest technology; increase efficiencies; and lower prices.

Link:

http://www.thehealthcareblog.com/the_health_care_blog/2009/02/making-price-competition-work-.html#comments

Assessment

And so, these forces should be considers by all new, mid-career, and mature independent medical practitioners. They should also be combined with an internal organizational SWOT analysis as well.

Conclusion

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

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Dismal World Video-View of American Healthcare

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

BBC Documentary Takes on Obama’s Plan

Staff Reporters

Did you know that a new British Broadcasting Corporation [BBC] documentary takes on newly elected President Barack S. Obama’s plans for American health care system?

Emotional Pleas Tug at Citizenry Heart Strings

According to Nick Cargo – of the BBC on January 25 – a January 19th episode of BBC’s One’s Panorama, the world’s longest running television documentary show, tackles the dismal state of health care in the United States. Of course, it emotionally parses on the lengths to which our estimated [high-side] 45 million uninsured citizens [only 8 million remain uninsured for 2 years, or more] go in pursuit of care, the pharmaceutical industry’s rigged pricing against the American patient, and the insurance industry’s efforts to deny care whenever possible.

About Health Care for America Now

According to documentary comments regarding freedom-of-choice in our medical care; “It’s really a system of legalized bribery,” said Richard Kirsch of Healthcare for America Now. “As one congressman says, we’re the only people in the world who are expected to take money from strangers and provide nothing in return.”

Health Care for America Now is a national grassroots campaign organizing millions of Americans to win a guarantee of quality, affordable health care for all. Their goal is to create organizations that can mobilize people at work, at home, in their neighborhoods, and online www.healthcareforamericanow.org

Assessment

Due to licensing restrictions, the Panorama episode, “What Now, Mr. President?” is not for domestic consumption and is only officially available to view online from connections within the United Kingdom. However, it has also been uploaded to YouTube, where it appears in three parts below.

Video: http://rawstory.com/news/2008/BBC_documentary_takes_on_Obamas_plans_0125.html

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Watch the video and decide for yourself; then opine here. Is the BBC view equal to the world view of US healthcare modernity?

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Collaborative Dental Health 2.0 [Upcoming Three Part Series]

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

Hippocratic Dental Consumerism

By Darrell K. Pruitt; DDS

Even before the downturn in the economy sent dentists scrambling for new sources of patients, these were already times of revolutionary changes in the marketing of dental care. To those who are alert, the Internet-enabled chaos signals a rare opportunity if one sides with consumers rather than tradition. It takes confidence to welcome transparency, and it looks increasingly bad when dentists resist accountability in traditional ways – like suing. Yelp; because of a bad review that was posted on the patient referral site. That is the second stupidest thing one can do. Being perhaps a geeky student of the Internet, and sort of nosey, I have been tracking the popularity of dentists’ comments on a few Internet venues for quite a while, because of my own curiosity. I also get ornery enjoyment from reporting to my friends my opinion of what is really happening in my profession that nobody else talks about. My hobby could be called fuzzy data mining based on a platform of precise subjectivity.

For more intricate and dependable real-time information, I choose the surveys reported on The Wealthy Dentist Blog, hosted by Jim Du Molin. They are the best around.

Link: http://www.thewealthydentist.com/blog/

American Dental Association

The ADA also provides nice, formal presentations of even more accurate information, but it is often dated and not ground-level relevant like Du Molin’s studies. Until the Internet came along, gathering useful information about dentists’ prevailing attitudes outside one’s professional circle was virtually impossible, and dentists are well aware that even within these circles, colleagues’ opinions at dental meetings are sometimes intentionally misleading – perhaps mine are less reliable as well at social gatherings. I never talk this frankly in real life.

Dental Information Silos

Talk about information silos! No less that 85% of dentists in the nation are owners of solo private practices (ADA News), and only 2% have bubbly personalities (my guess). Dentists’ quiet isolation, which is arguably favored by what I would guess would be around 85% of dentists in the nation, is a unique characteristic in modern healthcare that is part of a unique labor-intensive art – performed to exacting tolerances in an unpredictable environment – intricate work that most consumers know little about. Yet the ultra-personal accountability welcomed by almost all solo dentists is the way even neighborhood physicians once practiced their trade for thousands of years before modern stakeholders became involved.

Hippocratic Oath

Is working alone with one’s chosen staff the most efficient way to provide dental care? No way. But for me personally, maintaining complete control of the care I provide from start-to-finish for those who depend on me is safer for them and a better business model for me than any alternative I have seen yet. In my opinion, there is no room in the Hippocratic Oath for less than 100% devotion to the patients’ interests. More than two thousand years later, it is called consumerism, and it is 180 degrees counter to stakeholders’ interests, preferred provider lists and universal healthcare. And, it probably comes as no surprise that last October I observed that the most popular comments that were posted shifted from news about the benefits of high-tech inventions in dentistry to advice for how to survive in a tough economy. The whole nation is concerned about finances, and getting one’s teeth cleaned is commonly sacrificed when things get tough. Don’t even mention implants and crowns.

2009 Recession

At the risk of sounding ostentatious as well as pedantic, I will offer that (for the time being) my practice is not suffering from a downturn that many of my local colleagues are enduring. In fact, I am actually busier than I was this time last year – and I made more profit in 2008 than ever before in 26 years of practice. I am also discovering that patients I lost long ago are returning now that they no longer have provider lists. They are also finding that my prices are not so high after all (in fairness, I should add that it has been longer than usual since I have raised fees – except for full gold restorations, of course). Since I am not in the business of selling advice, I am not afraid to also admit that my practice still experienced a couple of slow periods in the late fall – directly attributable to the initial shock of the downturn. But I cannot say that the slowdown was any worse than other times in the last few years, and it certainly hasn’t been as bad as what dentists in Michigan must endure. My sympathy and best wishes go out to my colleagues up north. Things could all turn for the worse for me tomorrow, but for right now, I’m somewhere between surviving and thriving, for what that is worth; nothing spectacular, but solid.

Three Part Series

This posting, which I hope some readers find useful, will be a multi-part series. I haven’t worked everything out yet, and my outline is subject to change, but here is what I have in mind.

In Part One, I’ll describe how my active participation in DR. Oogle (doctoroogle.com) has not only kept my name off of preferred provider lists, but it has also improved the quality of care my staff and I provide, as well as improved the working atmosphere in the office. Transparency will do that.

Then, in Part Two, I will offer my suggestion how one can use DR. Oogle or similar patient referral site to “graduate” from managed care into fee-for-service dentistry without losing patients or profit. As a naughty teaser, let me hint that over three years ago, I offered the idea as an article for the monthly newsletter of my local dental society, only to be refused publication for the first time in over two decades of submissions. I was told that an official nixed it as a transparent “scheme” to harm managed care dental companies, and was therefore below the standards of ADA publications.

“Image is everything”

-ADA/Intelligent Dental Marketing

Finally, in Part Three, I’ll describe how a good offense is also a handy defense – perhaps even in defense against malpractice litigation. Hopefully, a few sincere readers will consider playing to win rather than playing not to lose. And, for those who still don’t see my point, I will reveal how to play not to lose. Fair is fair. It costs from $625 to $1995 per year, and in my opinion, is the stupidest thing one can do. Hope you enjoy this three part series.

Assessment

Editor’s Note: This post was first published on PennWell. Dr. Pruitt blogs here and at others sites. His insights are applicable to most all medical specialties.

Conclusion

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

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Hospital Cafeteria Plan Elections

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

On Health and Dependent Care

By Dr. David Edward Marcinko; MBA, CMP™

[Publisher-in-Chief]

I wrote a bit about hospital cafeteria plans in an earlier blog post.

Link: https://healthcarefinancials.wordpress.com/2008/04/02/hospital-cafeteria-plans/

Now, any hospital, or other employee given the opportunity to participate in a cafeteria plan should consider the following important two elections; health and dependent care.

Healthcare [Working Spouse]

If the employee is married and has a spouse who also works, and the employer-provided health benefits are better under the spouse’s plan, then the employee should elect to be covered by the spouse’s plan and choose another nontaxable benefit or a cash benefit that would be taxable under his or her own cafeteria plan, such as dependent-care coverage or group term insurance coverage. Switching health insurance requires planning to eliminate potential gaps in coverage created by insurance enrollment criteria. If the employee does not need the salary or cafeteria-plan benefits to meet current expenses, he or she should consider contributing the cash to a 401(k) plan and defer the tax liability.

Healthcare [Non-Working Souse]

If the employee has no working spouse and the employee’s plan is the only source for certain health benefits, the employee should consider what type of benefits he or she really needs for his or her family. In other words, can the employee get the necessary benefits under the company plan cheaper than he or she could individually, after taking into account that individual coverage will be paid with after-tax dollars, whereas under a cafeteria plan such benefits can be paid with before-tax dollars?

For example, if an employee who is in the 30% tax bracket is provided a $6,000 plan by her employer. He or she would have to be able to get a comparable plan independently for only $3,741 to be in the same position on an after-tax basis. ($6,000 minus income taxes of $1,800 = $4,200, $4,200 minus $459 of avoided FICA

Dependent-Care

An employee who has a choice of including dependent-care costs may be entitled to an income-tax credit for such expenses if, the employer does not reimburse them. Thus, if a credit is worth the same or more than the payment under the cafeteria plan, the employee may choose to contribute those dollars toward additional health or life insurance.

Assessment

There is no doubt why healthcare and dependent care are the two most important cafeteria plan election determinants that clients seek in our advisory practice. The issues are that vital to all employees.

Conclusion

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Maintenance of Medical Board Certification

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

Status Growing in Importance – or Sham

Dr. David Edward Marcinko; MBA, CMP™

And Staff Reporters

Increasingly, efforts to boost quality and gain better value from the world’s most costly healthcare system are including attention to Maintenance of Board Certification [BOBC], a little-understood but rigorous process by which physicians maintain board certification status and then keep it.

Hillary-Care Redeux

Back in the day, circa late 1970s – early 1980s, medical board certification was indeed a rigorous process; and still is to a very large extent. For example, Democratic presidential candidate Hillary Rodham Clinton, in laying out the quality portion of her three-part healthcare reform plan last year, specifically touted these programs as a key step in enhancing quality. From the presidential campaign trail to hospital and health plan board rooms, Board Certification and the Maintenance of Board Certification is a growing force in the industry.

But, is maintaining recertification status another matter of true quality import?

Major Health Plans On-Board

Several of the nation’s biggest health plans—including Aetna, Cigna, Humana, UnitedHealth Group and national and regional Blue Cross and Blue Shield organizations—are embracing Maintenance of Certification as part of their recognition and reward programs. Physicians who do not participate are not highlighted in plan directories and miss out on higher plan reimbursements.

Yet, why do we have “red flag” issues, “never-events” policies and/or the rise of “checklist-medicine” for risk reduction if these continuing education programs are so effective?

Allow me to cite the raging over-treatment epidemic, especially in specialties like arthroscopic orthopedics, radiology imaging [CT and MRI scans] and invasive cardiology, etc. Not to mention recent, and not so recent, Institute of Medicine [IOM] quality chasm reports for in-hospital patient deaths, complications and infections, etc.

Assessment

Of course, savvy hospital administrators and physician executives, of all stripes, are examining ways to use elements of board certification maintenance to respond to the Joint Commission’s new requirements for physician credentialing and privileging. Furthermore, the National Quality Forum [NQF] and the AQA quality alliance will be considering Maintenance of Certification for quality measurement endorsement.

Source: Cary Sennett and Christine Cassel, Modern Healthcare

Joint Commission Relevance in Modernity

But, is the Joint Commission itself even as relevant today, as in the past? Or – is its [political, quality and economic] status, might and swagger being reduced in favor of modern new-wave insights from health 2.0 collaboration activities and emerging formal organizations like DNV Healthcare Inc., a division of the Norwegian company.

As subscribers and Medical Executive-Post readers are aware, Det Norske Veritas [DNV] has recently been charged with immediately determining if hospitals are in compliance with the Medicare Conditions of Participation [COP]. The company’s authority to accredit hospitals runs through September 26, 2012. DNV joins the American Osteopathic Association [AOA] as the only other national hospital accrediting agency approved by the Centers for Medicare and Medicaid Servicers [CMS].

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. Is medical board certification and maintenance status of real value – or just fluff – much like the continuing education and licensure requirements of insurance agents, stock-brokers and financial advisors, etc? Is it less for medical education – and more for liability risk reduction – or PR – you decide?

Disclosure: I am a reformed insurance agent, stock-broker, board certified quality review physician and Certified Financial Planner®.

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

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Defining Hospital Competitive Markets

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

Clarifying Often Nebulous and Contentious Terminology

[By Staff Reporters]

According to Robert James Cimasi; MHA, CMP™ of Health Capital Consultants LLC in St. Louis, MO; the definition of a hospital’s “market” is often nebulous.

Ambiguous Terms

Some entities are defined by terms as ambiguous as “acute care inpatient hospitals,” “specialty hospitals,” or “anchor hospitals.” This ambiguity occurs because healthcare is increasingly provided on an outpatient basis, and general acute care inpatient hospitals face competition from a range of allied healthcare providers for the medical services they deliver.

Link: www.HealthcareFinancials.com

US Supreme Court Explains

For example, none other than the US Supreme Court has explained that the determination of relevant hospital product and geographic markets is “a necessary predicate” to deciding whether a hospital merger contravenes the Clayton Act (antitrust).

Assessment

For additional information, please see United States v. Marine Ban Corporation Inc., 418 U.S. 602, 618 (1974) (citing United States v. E.I. Du Pont De Nemours & Co., 353 U.S. 586, 593 (1957); Brown Shoe Co. v. United States, 370 U.S. 294, 324 (1962).

Conclusion

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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

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[HEALTH INSURANCE, MANAGED CARE, ECONOMICS, FINANCE AND HEALTH INFORMATION TECHNOLOGY COMPANION DICTIONARY SET]

[Mike Stahl PhD MBA] *** [Foreword Dr.Mata MD CIS] *** [Dr. Getzen PhD]

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Filed under: Glossary Terms, Health Law & Policy, Managed Care | Tagged: Health Capital Consultants, healthcare competition, healthcare facilities, hospitals, LLC, physician owned hospitals, Robert Cimasi, specialty hospitals | 2 Comments »

Illuminating the Congressional Federal Health Board

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

A Next-Gen -or- Last-Gen National Model

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

[By Staff Reporters]

Beware; all Medicare and other private health insurance recipients.

Why?

On December 4, 2008, and according to Robert E. Moffit PhD, the Director of the Center for Health Policy Studies [CHPS] at The Heritage Foundation, Presidential Obama proposed the creation of an institute that would judge the “comparative effectiveness” of medical treatments, procedures, and therapies, as well as drugs, devices, and technologies.

Congressional FRB Model

This Congressional Federal Health Board [FHB] would be modeled on the Federal Reserve Board [FRB] with a governing body of politically appointed experts, but “insulated from politics” and possess many powers similar to the proposed National Health Board [NHB], a key feature of the ill-fated Health Security Act [HSA] of 1993.

New Health Board

This new health board would also:

Set the rules for health insurers who would participate in a national health insurance exchange and recommend benefits coverage, including drugs and medical procedures backed by “solid evidence”;
“Rank” therapies and medical services based on their cost effectiveness;
Suggest priorities for medical research; and
“Align incentives with the provision of quality care,” as defined by the health board, through Medicare-style “pay for performance” rules for doctors and other medical professionals who comply with government practice guidelines.

Assessment

For ordinary Americans unsatisfied with the new Federal Health Board, there would be little recourse since it would likely be independent of Congress and the White House. For medical providers, according to Hope Hetico; RN, MHA of this Medical Executive-Post, it would be an operational nightmare that makes the managed care logistical problems of condition coverage, pre-certifications and pre-treatment authorizations, etc., seem a non-issue.

In other words, is this new FHB really the next-generation of medical collaboration and communication vis-a-vie health 2.0; or just another bloated last-generation command control model?

Link: http://www.heritage.org/research/healthcare/wm2155.cfm

Conclusion

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

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PRACTICES: www.BusinessofMedicalPractice.com
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FINANCE:Financial Planning for Physicians and Advisors
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Filed under: Ethics, Health Insurance, Health Law & Policy, Managed Care, Military Medicine, Quality Initiatives | 3 Comments »

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