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    Dr. Marcinko is originally from Loyola University MD, Temple University in Philadelphia and the Milton S. Hershey Medical Center in PA; as well as Oglethorpe University and Emory University in Georgia, the Atlanta Hospital & Medical Center; Kellogg-Keller Graduate School of Business and Management in Chicago, and the Aachen City University Hospital, Koln-Germany. He became one of the most innovative global thought leaders in medical business entrepreneurship today by leveraging and adding value with strategies to grow revenues and EBITDA while reducing non-essential expenditures and improving dated operational in-efficiencies.

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    As a state licensed life, P&C and health insurance agent; and dual SEC registered investment advisor and representative, Marcinko was Founding Dean of the fiduciary and niche focused CERTIFIED MEDICAL PLANNER® chartered professional designation education program; as well as Chief Editor of the three print format HEALTH DICTIONARY SERIES® and online Wiki Project.

    Dr. David E. Marcinko’s professional memberships included: ASHE, AHIMA, ACHE, ACME, ACPE, MGMA, FMMA, FPA and HIMSS. He was a MSFT Beta tester, Google Scholar, “H” Index favorite and one of LinkedIn’s “Top Cited Voices”.

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The Emerging Discipline of “Slow Medicine” and Professional Liability

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Examining the Heuristic Relationship between Face-Time and Medical Negligence Lawsuits 

By Dr. David Edward Marcinko MBA CMP™

www.BusinessofMedicalPractice.com

[Editor-in-Chief]

Our colleague and blogger Kent Bottles MD has been thinking and posting about the emerging philosophy of “slow medicine”. Of course, health economists realize how complex and difficult it is to transform American health care so that we will enjoy lower per-capita costs along with increased medical care quality in our lives. Unfortunately, grass root practitioners have done just the opposite these last two decades or so. In other words, practicing “faster medicine” with assembly line efficiency relegating office visits to 15, 10 or even 7 minute increments etc, in order to compensate for diminishing MCO/HMO reimbursement. And, this may have been a financially acute perspective for modernity until now!

Defining the Obvious

Slow medicine is practiced by a small, but growing subculture whose pioneer and spokesperson is Dr. Dennis McCullough, author of the book My Mother, Your Mother [Embracing “Slow Medicine,” The Compassionate Approach to Caring for Your Aging Loved Ones].

In other words, slow medicine is a philosophy and set of practices that believes in a conservative medical approach to both acute and chronic care. However, I believe there may be more to it than first perceived.

Link: http://www.thehealthcareblog.com/the_health_care_blog/2010/12/slow-medicine.html#comments

My Experiences

After serving as a medical expert witness in hundreds of malpractice cases [consulting, chart review, discovery depositions, trial appearances and sworn testimony] – both directly and indirectly and for both plaintiff and defendant doctors [predominately] – thru almost twenty year of private practice, my gut tells me the following:

“Patients do not sue doctors they personally like – they do sue doctors they do not like.”

In my opinion and experience, great clinical doctors are often sued while their lesser adept souls are not. Moreover, I believe this pleasing reduced liability relationships is enhanced by more patient face-time; not less. This is not a function of competency, but one of human relationships and “connectedness” with one’s caregiver. It will not be changed by eMRs, or more diagnostic tests [malpractice phobia] or procedures. It will be improved by intense physical examination, touching, eye contact, sympathy, empathy and time [aka: a TRUSTING relationship and pleasing bedside manner forged by TIME]. Period!

And so, for our business managers, CEOs and medical executive readers, let us compromise on terminology and call it “slower medicine.”

Assessment

Link: http://www.amazon.com/Insurance-Management-Strategies-Physicians-Advisors/dp/0763733423/ref=sr_1_3?ie=UTF8&s=books&qid=1275315795&sr=1-3

Conclusion

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The Medicare Cost-Control Efficiency Paradox

Essay on the Eight-Hundred Pound Gorilla in the Medical Treatment Room

By Dr. David E. Marcinko MBA

[Editor-in-Chief]

According to economist Austin Frakt PhD, and others, there is a school of thought that says Congress is incapable of controlling costs in the Medicare and Medicaid System [CMS].

And, then there is the reality known by all practicing medical professionals regardless of specialty orientation or degree designation. That is to say, CMS really can control healthcare costs and with great ferocity and efficiency, and to non-public sectors as well …. PARADOXICAL?

On Getting What You Wish For

Blogger Ezra Klein opines that one of the dirty little secrets of the health-care system is that Medicare has done a much better job controlling costs than private health insurers.

http://voices.washingtonpost.com/ezra-klein/2010/11/what_happens_when_medicare_con.html

A Forehead-Palm Moment

Of course, we doctors know that the real problem is that Medicare seemingly [think Seinfeld’s character George Costanza] controls costs all too well; but not really. It is just that CMS pays doctors too little and thus it appears costs are controlled. What really is happening is that physician fees are being reduced carte’ blanche.

Nevertheless, and regardless of semantics, CMS will never control costs much more efficiently than private insurance companies or doctors will simply abandon Medicare for related payment models like direct reimbursement or concierge medicine. This is happening right now. Physicians, osteopaths and podiatrists etc, are opting out of Medicare in increasingly large numbers. In a world where there’s only Medicare and Medicare to control costs, doctors can either take the pay cut or stop seeing patients, and stop being doctors. “Taking what they are given – because they’re working for a livin.”

So sorry that this seems like a forehead-palm moment for Ezra, but not for healthcare practitioners or the ME-P!

Too Much Demand Elsewhere

And, as we see from other countries, many young bright folks want to be doctors, even if being a doctor doesn’t make one particularly wealthy [high demand and high eventual supply produces lower provider costs in the long term?]. Think medical tourism.

Not so much the case anymore in this country [lower demand and lower eventual supply produces higher reimbursement costs to the doctor survivors in the very long term?].

Our Domestic World

But, we are not elsewhere. In fact, in our present domestic healthcare ecosystem, when Medicare decides to control costs, many doctors can simply stop accepting Medicare patients, and the politicians will lose their jobs. One political party then declares that Medicare is rationing and will hurt senior citizens. The other party capitulates and pays MDs more [SGR]. Then, the federal budget looks bad as it does now. The circle is complete when one party asserts that Medicare actually can’t contain costs but the private insurance companies will.  It all fails, in an unending circular Boolean-like loop of illogic.

Listen Up!

So, listen up AARP, politicians, CMS and seniors as I admonish you to be careful what you wish for [medical cost controls]. It might just come true. As Ezra rightly says; rinse, repeat – rinse, repeat – ad nausea. You simply can’t have it both ways.  You either choose to spend less and offend certain cohorts, or spend more and offend different factions.  Either way, you’re going to piss someone off. A good healthcare reimbursement system would try to make that decision rationally [a-politically]. But, at least it would make an economics driven decision; wouldn’t it?

Assessment

Is CMS really the eight hundred pound cost-controlled gorilla in the increasingly large Medicare treatment room? Why or why not? Now, relative to the ACA of 2010, please read: The Case for Public Plan Choice in National Health Reform [Key to Cost Control and Quality Coverage], by Jacob S. Hacker, PhD. Link: Jacob Hacker Public Plan Choice

Conclusion

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Useful Managed Care Provider, Staffing, Activity and Financial Trends

Part Two

By Dr. David Edward Marcinko MBA

[Publisher-in-Chief]

Dr. DEMIf you read this ME-P regularly or have read my earlier blogs, you know that I am writing a book on practice management for the private medical practitioner.

The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors]; third edition: www.BusinessofMedicalPractice.com

Link: Front Matter BoMP – 3

A recent story in the Chicago Tribune on the difficult business life of private practitioners today reminds me that I need to keep my nose to the grindstone.

For example, according to the sanofi-aventis Pharmaceutical Company Managed Care Digest Series, for 2008-10, the following patterns and comparative trend information has been empirically determined and may provide a basic starting point for medical practitioners to share business management, facilities, personnel, and records information for enhanced success www.managedcaredigest.com

Mid-Level Provider and Staffing Trends

  • Mid-level provider use increased among multi-specialty groups, especially in those with more than half of their revenue from capitated contracts. Use also rose with the size of the practice and was highest with OB/GYN groups.
  • Medical support staff for all multi-specialty groups fell and was lowest in medical groups with less than 10 full-time equivalent (FTE) physicians. However, groups with a large amount of capitated revenue actually added support staff. Smaller groups limited support staff.
  • Compensation costs of support staff increased and the percentages of total operating costs associated with laboratories, professional liability insurance, IT services, and imaging also increased. Support staff costs increase with capitation levels and more than half of all operating costs are tied to support staff endeavors.

Managed Care Activity and Contracting Trends

  • More medical group practices are likely to own interests in preferred provider organizations (PPOs) than in HMOs and the percentages of groups with managed care revenue continues to rise. Multi-specialty and large groups also derive more revenue from MCOs than single specialty or smaller groups.
  • Managed care has little effect on physician payment methods that are still predominantly based on productivity. Physicians were paid differently for at-risk managed care contracts in only a small percentage of cases.
  • Most medical groups (75%) participating in managed care medicine have PPO contracts. Group practices contract with network HMOs more often than solo practices. Single-specialty groups more often have PPO contracts.
  • Capitated lives often raise capitation revenues in large group practices. Group practices are more highly capitated than smaller groups or solo practices. Almost 30% of highly capitated medical groups have more than 15 contracts and 22% have globally capitated contracts.
  • Higher capitation is linked with increased risk contracting. Larger groups have more risk contracting than smaller groups.

Physician Health

Financial Profile Trends

  • Medicare fee-for-service reimbursement is decreasing. Highly capitated groups incur high consulting fees.
  • The share of total gross charges for OB/GYN groups associated with managed care at-risk contracts is rising while non-managed care, or not-at-risk charges are declining.
  • Capitated contracts have little effect on the amount of on-site office non-surgical work. Off-site surgeries are most common for surgery groups, not medical groups.
  • Half of all charges are for on-site non-surgical procedures.
  • Highly capitated medical groups have higher operating costs and lower net profits.
  • Groups without capitation have higher laboratory expenses than those who do.
  • Physician costs are highest in orthopedic surgery group practices. Generally, median costs at most specialty levels are rising and profits shrinking.

Assessment

Obviously, the above information is only a gauge since regional differences, and certain medical sub-specialty practices and carve-outs, do exist.

Part One: Useful Managed Care Patterns and Procedural Utilization Trends

Conclusion

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Avoiding Managed Care Contract Pitfalls

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By Staff Reporters

There are several key pitfalls to watch out for when evaluating a managed care organization contract, as noted and continually revised by the Advisory Board Company, and others.

  • Profitability — Less than 52% of all senior physician executives know whether their managed care contracts are profitable. “Many simply sign up and hope for the best.”
  • Financial Data — 90% of all executives said the ability to obtain financial information was valuable, yet only 50% could obtain the needed data.
  • Information Technology — IT hardware and sophisticated software is needed to gather, evaluate, and interpret clinical and financial data; yet it is typically “unavailable to the solo or small group practice.”
  • Underpayments — This rate is typically between 3 – 10% and is usually “left on the table.”
  • Cash Flow Forecasting — MCO contracting will soon begin yearly (or longer) compensation disbursements, “causing significant cash flow problems to many physicians.”
  • Stop-Loss Minimums — SLMs are one-time up-front premium charges for stop-loss insurance. However, if the contract is prematurely terminated, you may not receive a pro rata refund unless you ask for it!
  • Automatic Contract Renewals ACRs or “evergreen” contracts automatically renew unless one party objects. This is convenient for both the payor and payee, but may result in overlapping renewal and re-negotiation deadlines. Hence, a contract may be continued on a sub-optimal basis, to the detriment of the providers.
  • Eliminate Retroactive Denials — Eliminate the rejection of claims that were either directly or indirectly approved, initially.  Sample: “MCO reserves the right to perform utilization review [prospective, retrospective and/or concurrent] and to adjust or deny payments for medically inappropriate services.”  
  • Define “Clean” and “Dirty Claims” — Eliminate the rejection of standard medical claim formats like CMS-1450, CMS-1500 or UB-92 for non-material reasons. Make payment of appropriate clean claims within some specific time period, like 30 days, in order to enhance free cash flows.
  • Reject Silent or Faux HMO or PPs, etc — Eliminate leased medical networks or affiliates and reject further payment discounts to larger subscriber cohorts than originally anticipated.
  • Include Terms for Health Information Technology — Eliminate the economic risk of leading edge electronic advancements like EMRs, PHRs, CPOEs, and so on.  
  • Establish ability to recover payments after contract termination — Eliminate financial carry forward for an excessive period of time.
  • Preserve Payment Ability — Provide medical services if requested by patients, who are then billed directly.
  • Minimize Differentials — Establish a standardized rate structure [fee schedule] for all plans and then grant discounts for administrative or other efficiencies; rather than have different schedules for each individual plan.

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Conclusion

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Understanding the Medical Career Choice!

Regrets and Recriminations – or Joy and Bliss?

By Eugene Schmuckler PhD, MBA

http://www.CertifiedMedicalPlanner.org

By Dr. David E. Marcinko MBA

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Jimmy’s mother called out to him at seven in the morning, “Jimmy, get up. It’s time for school.” There was no answer. She called again, this time more loudly, “Jimmy, get up! It’s time for school!” Once more there was no more answer. Exasperated, she went to his room and shook him saying, “Jimmy, it’s time to get ready for school.”

He answered, “Mother, I’m not going to school. There are fifteen hundred kids at that school and every one of them hates me. I’m not going to school.”

“Get to school!” she replied sharply.

“But, Mother, all the teachers hate me, too. I saw three of them talking the other day and one of them was pointing his finger at me. I know they all hate me so I’m not going to school,” Jimmy answered.

“Get to school!” his mother demanded again.

“But mother, I don’t understand it. Why would you want to put me through all of that torture and suffering?” he protested.

“Jimmy, for two good reasons,” she fired back. “First, you’re forty-two years old. Secondly, you’re the principal.”

Similar Physician Sentiments

Many of us have had conversations with medical colleagues at which time sentiments of those expressed by Jimmy have been voiced. The career choice that was made many years ago is now, for some reason, no longer as exciting, interesting and enjoyable, as it was when we first began in the field. The career that was undertaken with great anticipation is now something to dread.

The reason for this is occurrence is not that difficult to understand. Two of the most important decisions individuals are asked to make are ones for which the least amount of training is offered: choice of spouse and choice of career. How many college students receive a degree in the field they identified when they first enrolled at the college or university? In fact, how many entering freshmen list their choice of major as undecided? It is only during the sophomore year when a major must be declared is the choice actually made. So, career choices made at the age of 19 might be due to having taken a course that was interesting or easy, appeared to have many entry level jobs, did not require additional educational or professional training requirements, or was a form of the “family business.” Now as an adult, the individual is functioning in a career field that was selected for him or her by an eighteen-year-old.

Judging Career Success

How do we judge career success? A career represents more than just the job or sequence of jobs we hold in a lifetime. The typical standard for a successful career is by judging how high the individual goes in the organization, how much money is earned, or one’s standing attained in the medical profession.

Yet, career success actually needs to be judged on several dimensions. Career adaptability refers to the willingness and capacity to change occupations and/or the work setting to maintain a standard of career progress.  Many of you did not anticipate the managed care, Health 2.0, or political changes in your chosen medical profession, or specialty, when you began your training.

A second factor is career attitudes. These are your own attitudes about the work itself, our place of work, your level of achievement, and the relationship between work and other parts of your life.

Medical Career Identity

Career identity is that part of your life related to occupational and organizational activities. This is the unique way in which we believe that we fit into the world. Our career is only one part of our being. We play many roles in life each of which combine to make up or totality. At any point in time one role may be more important than another [life saving physicians versus retail sales clerk]. The importance of the roles will generally change over time. Thus at some point you may choose to identify more with your career, and at other times, with your family.

inheritance

Career Performance

A final factor is career performance, a function of both the level of objective career success and the level of psychological success.  How much you earn and your reputation factor into, and reflect, objective career success. To be recognized as a “leader” in a medical field and asked to submit chapters for inclusion in text-books, medical journals or new-wave blogs such as this may be a more important indicator of career success than money.

Psychological success is the second measure of career performance. It is achieved when your self-esteem, the value you place on yourself, increases. As you can see, there is a direct relationship between psychological success and objective success. It may increase as you advance in pay and status at work or decrease with job disappointment and failure. Self-esteem may also increase as one begins to sense personal worth in other ways such as family involvement or developing confidence and competence in a particular field, such as consistently shooting par on the golf course. At that point, objective career success may be secondary in your life. This is why many people choose to become active in their church or in politics. Even though one may have slowed down on the job, or in their professional career they can be extremely content with their life.

Case Model Scenario

Consider the following situation.

You are traveling on business. Although you are on a direct flight, you have a one-hour layover before the second leg of the flight and your final destination. Leaving the plane, after having placed the “occupied” card on your seat you walk down the concourse. On the way, you encounter a friend that you knew in high school. The two of you sit to have a cup of coffee and then you realize that your departure time is rapidly approaching. In fact, you will be cutting it quite close. Running down the concourse you return to the gate only to find that the door has been closed, the jetway is being retracted and the plane is being backed away from the gate. You stare out the window watching the plane go to the end of the runway and then begin its takeoff. Something goes horrible wrong and the plane crashes on takeoff, bursting into flames. It is apparent that there will be no survivors.

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Assessment

To the world you are on that plane (remember the occupied card). Traveling on business your generous insurance policy will be activated. In anticipation of being in a location where they may not have ATM machines you have a good deal of cash, sufficient for at least a month.

Conclusion

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INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors


McNally, D. Even Eagles Need A Push, New York, NY: Delacorte Press, 1991.

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Some Insight on Medicare Advantage Plans

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Enter the Bounty Hunter Insurance Agents

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[By Dr. David Edward Marcinko; MBA]

[Publisher-in-Chief]

As a health insurance agent and industry insider for more than a decade, I know first hand that the agents and brokers who enroll senior citizens in Medicare Advantage (MA) plans often make more on those members than the health plans themselves. 

Example:

For example, up to $400-600 can be spent on an insurance agent/broker fee by the health plan, contributing to a total member acquisition cost that can exceed 10% of the premium dollar. And, this commission fee or bounty on “grandma” – much like a bulls-eye target on her back – was much higher back in the day. Hence, all the “free” seminars, luncheons, trinkets and other senior citizen freebies cloaked as information dissemination.

Acquisition Costs High

Even if Medicare Advantage plans could deliver the actual health care benefits at a considerably lower cost than traditional Medicare Fee for Service (FFS); it is very possible that the entire savings could be consumed by member acquisition costs.

Assessment

Now, as a doctor, insurance agent, financial advisor, health economist and future MC patient, I believe that traditional Medicare is a very tough act to follow; and is still the best deal around, by far. Now, try to convince my dad.

Conclusion

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