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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.

    Professor David Marcinko was a board certified surgical fellow, hospital medical staff President, public and population health advocate, and Chief Executive & Education Officer with more than 425 published papers; 5,150 op-ed pieces and over 135+ domestic / international presentations to his credit; including the top ten [10] biggest drug, DME and pharmaceutical companies and financial services firms in the nation. He is also a best-selling Amazon author with 30 published academic text books in four languages [National Institute of Health, Library of Congress and Library of Medicine].

    Dr. David E. Marcinko is past Editor-in-Chief of the prestigious “Journal of Health Care Finance”, and a former Certified Financial Planner® who was named “Health Economist of the Year” in 2010. He is a Federal and State court approved expert witness featured in hundreds of peer reviewed medical, business, economics trade journals and publications [AMA, ADA, APMA, AAOS, Physicians Practice, Investment Advisor, Physician’s Money Digest and MD News] etc.

    Later, Dr. Marcinko was a vital recruited BOD member of several innovative companies like Physicians Nexus, First Global Financial Advisors and the Physician Services Group Inc; as well as mentor and coach for Deloitte-Touche and other start-up firms in Silicon Valley, CA.

    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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Healthcare Policy on Health and Ethics

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By Ben’s Bitter Blog

Healthcare Policy on Health and Ethics Healthcare policy is defined as “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society” (WHO, 2016).

Do you believe that your life is affected by healthcare policy?

YES. The policy directs which doctor you can see, which hospital you can visit, and […]

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Healthcare Policy on Health and Ethics

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Broadening the Strategic Value of Integrated Medical Provider Management‏

How Health Plans Can Create Scalable and Competitive Products that Enable Affordable and High-Quality Care

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By Sam Muppalla – Vice President, McKesson Health Solutions Network Performance Management

[Part 6 in a 6 part series]

Over the past few weeks, I’ve covered a lot of ground in this ME-P series of six essays. We looked at the pressures on health plans and the ways in which those pressures are forcing a new dynamic in how the plans create new, scalable competitive products that enable affordable, high-quality care. We talked about some of the innovations that leading health plans are bringing to the areas of product, network, care model and reimbursement designs.

The pilot initiatives in these areas continue to show positive results. The next level of scaling requires an integrated and automated approach to enable health plans to deploy, manage and maintain these innovations in a much more rapid fashion. This all has to be done without increasing health plan costs while delivering new value to a health plan’s customers, providers and members.

Affordable Care Can be Achieved

It is our position at NPM that achieving this alignment will deliver affordable care. Additionally, through this alignment, health plans will gain a competitive and cost savings leadership position. Through collaborative and independent research with our health plan partners, we have identified three main areas of competitive and cost savings leadership. The potential cost savings of achieving alignment are impressive. For example, working with a regional Blues plan with three million members, the potential cost savings due to achieving an integrated approach to network design were projected to be:

Administrative Cost Savings [Total Potential Annual Savings = $13 million to $25 million]

  • Provider data administration cost reductions: $5 million to $10 million
  • Provider outreach cost reductions: $0.75 million to $1.25 million
  • Contract management cost reductions: $1 million to $3 million
  • Administrative reimbursement cost reductions: $3 million to $5 million
  • Provider service cost reductions: $1.5 million to $2.5 million
  • Credentialing cost reductions: $1.5 million to $3 million

Medical Cost Savings [Total Potential Annual Savings = $45 million to $100 million]

  • Streamlined member health advocacy: $5 million to $10 million
  • Pay for Performance: $15 million to $40 million
  • Network design and performance improvements: $25 million to $50 million

Provider IT Cost Savings [Total Potential Annual Savings = $.5 million to $2.5 million]

  • Redundant system consolidations: $0.25 million to $2 million
  • IT change management cost reductions: $0.25 million to $0.5 million

The total aggregated annual potential for savings is between $59 million and $127 million.

Some Final Thoughts

In 2009, the National Health Expenditure (NHE) rose to $2.5 trillion or 17.6 percent of the Gross Domestic Product (GDP) with private health insurance accounting for 32 percent of the NHE. Yet all of this spending is not translating into any measure of higher quality care as the World Health Organization (WHO) also ranks the U.S. as 72nd in overall level of health in the world. To affect high-quality, affordable care, health plans must be able to harness innovative product, network, care model and reimbursement designs. Network design is the critical element that will orchestrate the operational scaling of innovation. Therefore, automation of network design and efficient implementation of it through end-to-end integration will be crucial to success of health plans in the post reform world.

Assessment

Thanks for taking the time to follow me, and the ME-P, on this journey. If you’ve joined us late in the discussion, fear not. We’ve collected all the related threads in the Unlocking Affordable Care by Aligning Products white paper, which you can download by visiting our website at http://ow.ly/7MFKb.

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Reflections on Healthcare and Karate in Finland; etc.

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One Visiting Doctor’s Experience on Healthcare … There and Elsewhere!

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

[Publisher-in-Chiefdr-david-marcinko12]

As readers and colleagues know, I’m a great fan of the Finnish culture, lifestyle and people. I’ve visited the country several times, touring and speaking, meeting with government, academia and local industry leaders and politicians in Helsinki, Tempere, Seinajori, Turku, Oulu and Northern Lapland, among other places; and especially Rovaniemi which is home to the world’s most northern branch restaurant of McDonald’s. Of course, the famed Arktikum there is also very comprehensive museum of arts, science and technology. Every time my wife and I visit, we learn more about the language, the arts and tradition.

Recent Visit to Finland

On our most recent month-long visit to Finland, we were able to visit a Japanese Honbu [karate gymnasium], meet several black-belt Taido karate students, and even take an actual class to stay in shape. I’ve been an avid runner for more than 30 years so aerobic cardio-vascular output was not-problematic. The trip was also remarkable for the many insights into the challenges of the Finnish healthcare system, their plans for eHRs and their emerging interest in American medical care. I’ve also made several friends and new colleagues, ingested cold raw dead-fish stew, and mastered the Finnish railway system. And so, my national healthcare service impressions follow; along with a bit more about the art and science of Taido styled karate.

Taido in Finlandkarate-mac

Prior to our departure, we asked my daughter’s karate instructor, Sensei Uchida in Atlanta, GA, about the possibility of attending a Taido work-out in Finland. We were surprised when he informed us that the country has the largest number of Taido students in the world, second only to Japan. This interesting fact was later confirmed by the Finnish Athletic Association. The reason is that this form of exercise is covered under the country’s national health insurance system and is available to all citizens, free of charge. But, of course, income taxes are very high.

In fact, we learned that just the city of Helsinki itself, had nine Honbu’s to choose from and we selected what proved to be the most interesting, indeed! Another American instructor, Sensei Brent, mentioned that he visited the country a few years ago and still has some Taido friends from there, too.

The Taido Karate Honbu

Built during World War II to protect the population living in the City of Tempere from bombs, the Gymnasium in North East Helsinki is built into the side of a huge granite mountain, not unlike our own Stone Mountain here in Atlanta. Since it was originally constructed as an air-raid shelter during WW II, with many snaking corridors and smaller caverns, it is cool all year round with many miles of tunnels maintaining an even 56 degree temperature, just like natural underground caves. No air conditioning is needed for the short summers, and no heating system is needed for the very long winters.

Enter the Health Gymnasium

As we entered the “Health Gymnasium” as it was known, it was as if we were walking into a long tunnel through the woods, about 100 yards long. This entrance to the bomb shelter was really a railroad track line that was still visible after all these years. It was guarded by two huge iron doors several stories high. Inside, was a general reception area where we were directed to the actual Taido Honbu, itself, known as Budo # 6. As we walked through the long winding corridors, we noted that the walls were solid granite, painted white, and that each studio was separated only by a color-coded curtain; much like long rows with individual partitions. There was no graffiti and, although there was no sound-proof protection, the entire Gymnasium was surprisingly quiet.

A Linguistics Error

As we walked along, we noted studios for fencing, gymnastics, boxing and kickboxing, table tennis, ballet, weight lifting, volleyball, rowing and many different types of Karate and other martial arts, like Aikido, Bando Thaing, Capoei, Gatka, Hapkido, JuJitsu, Judo, Kendo, Kung Fu, Sumo and of course Tai Kwon Do. But alas, no Taido Honbu! We were horrified. Did we make a linguistic error! Was the term Taido misinterpreted as a generic terms for all these others types of martial arts or Karate forms? My daughter Mackenzie’s enthusiasm was crushed [after seven years of intensive study, with both national and international competition] as she is a black-belt candidate still in need of some teaching and karate internship credits to reach her ultimate goal. After-all, she brought her Gi [uniform] a long way to not to be able to use it. So, back to the reception area we went, inquiring again in our rudimentary Finnish. Fortunately, the problem was not a language faux-pau at all, but a one of timing. In our excitement, we had merely arrived an hour too early. Soon, the sign on one of the larger partitioned studios was changed to “TAIDO”, and students began filling-in, talking, laughing and giggling before class, just like they do in Atlanta.

Teaching Introductions

The class was comprised of blue, green and brown belt student [there are eight belt ranks], even though we took care to register for the same rank as daughter, Mackenzie. But, it was for about a dozen young adults, ages 18-30, and evenly split between guys and gals! No children. One student had been taking classes for about two years (she averaged 3-4 classes per week), while another was in his ninth year (able to participate only about once or twice per week). Nevertheless, Mac was agreeable to work-out with the adults, under the leadership of Sense Arie, who spoke English and was very cordial to us. When he then asked us what we had learned, we quickly listed Untai, Sentai and Hentai hokis [ritual movements; a Hoki is a pattern of techniques originally put together for mental and physical health and as a practice form of “free fighting.”], as he replied, “that will be sufficient for today”. No doubt, he and the other students were as curious about us, as we were about them. Introductions were made to all students, including moms, dads, grand-moms and grand-dads. We then settled down to watch Mackenzie and the class.

Class Comparisons

Like the Finnish healthcare system, the Taido karate class itself had several similarities and several differences compared to what we are used to, in Atlanta, GA.

1. First, the students and instructors wore the same colored GIs; solid black pants with roughly woven white tops. The GIs also were fancier with many epilates, patches and insignias. The belt color-coded system of the States was not used. Shoes were left outside, all bowed as a sign of respect upon entry, and lined up according to rank. There were no mirrors, horizontal warm-up bares, and virtually no padding in the mats on the floor! The epithet OUS, was replaced by a loudly shouted, EEEE!

2. Second, it was a longer class; an hour and a half, with a ten minute break in-between. Warm-ups were also longer and a bit more strenuous and aerobic orientated; running backwards, sideways and with lunges often performed in-between the hoki’s.  But again, this was an adult class.

3. Third, the class was subdivided into smaller groups like our own, to practice kicks and punches initiated by sound or hand movement, as reaction-time was tested and improved. Mac’s partner had to kneel for her to reach his out-stretched hands, and she in turn had to raise her hands high overhead, as palms were used as targets. Her older partner worked with great diligence to best his younger opponent.  

Finally, the ritualized hoki’s terminated a bit differently than our own, and they were performed much more slowly; almost ritualistically and with great concentration. And, form was a bit more casual than what were are used to, and not as sharp or precise as American Sensei Uchida or Sensei Matsuaki usually demands. 

Health Status of Finlandersfinnish-american-students

Health services are available to all in Finland, regardless of their financial situation. Public health services are mainly financed from tax revenues. The child mortality rate in Finland is one of the lowest in the world; the infant mortality rate is below 4% and the life expectancy for a girl born now is 81 years, for a boy it is 73 years. Much like the US, the life expectancy of Finnish men has deteriorated by cardiovascular disease, excessive consumption of alcohol and accidents. Cardiovascular mortality has declined in response to effective health and nutritional education in recent decades but excessive blood cholesterol levels and obesity remain common in Finland. Smoking and drug abuse are significantly less frequent in Finland than in Europe on average. But, alcoholism and depression are national concerns because of the dark, prolonged and harsh winter climates. The aim of Finnish health policy is to lengthen the active and healthy lifetimes of citizens, to improve quality of life, and to diminish differences in health between population groups. Prevention receives particular emphasis in primary health care.

Finnish Healthcare System

The larger health care system in Finland is attracting international attention. For example, the European Observatory on Health Care Systems just launched a report examining Finland’s health system alongside that of other European countries. The system also has certain special features compared with systems in other countries. The main responsibility for organizing and financing health care is delegated to 448 local municipalities, which have exceptionally small and homogenous population bases, by US comparison. Another special feature is the existence of parallel financing and delivery systems alongside the municipal service system. The Finnish health care system survived the severe economic crisis of the 1990s fairly well, even though marked cuts were made in many public-sector budgets. As a result, it has emerged stronger today. The quantity and quality of health care services were largely maintained by improved management, efficiencies, electronic connectivity and resource allocation. A number of other initiatives are now developing in different directions.

Finnish Medical Association

On a more grass-roots level patient-care basis, the Finnish Medical Association [FMA] collaborates with various authorities and decision-making bodies in relation to the development of personalized medical care in Finland. It pursues patient initiatives and issues a number of statements each year with the aim of improving health care and related legislation, and puts forward plans to ensure a sound financial basis for provision of health services. For example, the national strike by physicians in 2001 drew national attention to the critical lack of resources provided for health care. The FMA plays a significant role in establishing a general patient insurance scheme and developing a family-doctor [US medical-home concept] system for Finnish health centers and practitioners. The Association promotes the rights of patients to have access to the treatment they need promptly. But, the possibilities for choosing a doctor and place of treatment need to be improved.

Contemporary Profile of a Health System in Transition

The Finnish healthcare system, much like the domestic healthcare system, is undergoing a period of reflection, modernization and reform. A special report, known as the Health Care Systems in Transition (HiT) series, profiles and analyzes the health care systems of over 40 European countries, Australia, Canada and the USA. The report for Finland was written by Ms Jutta Järvelin, Researcher at STAKES (the National Research and Development Centre for Welfare and Health), and in collaboration with the Finnish Ministry of Social Affairs and Health and the Observatory. STAKES is a center of expertise overseen by the Ministry of Social Affairs and Health.

On Finnish Longevity

Finnish super-centenarian Aarne Armas “Arska” Arvonen, the oldest Finnish male ever, just passed away at age 111 on January 1, 2009. He was the last living person in Finland who was born in the 1890s, and the third oldest man in Europe. He was also the seventh oldest man in the world. At the time of his death, Aronen was considered among the 20 oldest verified men to have ever lived in Europe.

Assessment

The formal report, Health Care Systems in Transition – Finland [Vol. 4, No 1. 2002]; Copenhagen, European Observatory on Health Care Systems, 2002 is available on the European Observatory on Health Care Systems website:

www.observatory.dk

http://www.euro.who.int/document/e74071.pdf

The report can also be ordered from the European Observatory on Health Care Systems, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen, Denmark, tel. +45 39 17 1363, fax +45 39 17 1818.

e-mail: observatory@who.dk

And, additional more current information can be obtained from:

Researcher Jutta Järvelin

STAKES, tel. +358 9 3967 2254

e-mail: jutta.jarvelin@stakes.fi and,

WHO e-mail: vge@who.dk

Conclusion

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Dr. Atul Gawande’s “Checklist Manifesto” and Book Review

Healthcare Reform’s Rock Star -or- Much Needed Plain Speaker?

By Hope Rachel Hetico; RN, MHA, CMP™

[Managing Editor]

Here is an essay-interview by Rahul K. Parikh MD, with Atul Gawande MD, as they talk about medicine, checklists and quality healthcare.

Book Review

In Gawande’s third book, “The Checklist Manifesto: How to Get Things Right,” he explores how doctors and other professionals become overwhelmed with the complexity of their work. And, are then more likely to fail.

As with most problems that sound overwhelmingly complex, the fix may be quite easy, when reframed with a new mindset and fresh set of young eyes.

Assessment

Gawande’s proposed solution is simple and inexpensive, if not terribly sexy: a checklist. Sound too mundane? Keep in mind that Gawande has previously proved, in conjunction with the World Health Organization [WHO], that doctors and surgical teams who use checklists save lives.

Link: http://www.salon.com/books/int/2010/02/02/atul_gawande_checklist/index.html

Conclusion

And so, your thoughts and comments on this ME-P are appreciated.

Is Atul this generation’s healthcare quality guru, much like Robert Wachter MD. Or, is he a man-child not afraid to say that the Emperor has no clothes? Please opine.

Conclusion

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Understanding Medical Billing Methodologies

The Cash Conversion Cycle

[By Staff Reporters]

Most patients and financial advisors don’t have a clue about how doctor’s get paid in our current system; but it’s not by magic. Yet, a number of different steps occur during the processing of a medical claim that can be seen in a flow chart. Each step in the process can be mapped out and each is subject to claim payment-or-claim rejection. A payment time line for a typical FFS or PPO can also be subjected to a number of variables, depending on different factors including staff competency, time, outside vendors, information management, management decisions in general, or regulatory requirements. The total transit times may take weeks for electronic claims or up to two-years for some paper based claims.

First Make the Diagnosis

• ICD-9 alpha numeric code for disease classes, not billing.

• HHS offers ICD-9 [CM] for MDs and facilities.

• WHO-1900, updated every 3-10 years, e-ICD-10 [2013].

• Diagnostic Statistical Manual Mental Disorders, 4th Edition [DSM-IV].

Then Select the Current Procedure Terminology® Code

Medical, surgical and diagnostic task & service billing code numbers [5-digit] of AMA used by payers:

• Thousands updated annually

• Secretive with registered mark ®

• Office Visits: [brief, inter, extended, etc]

• # 99214 physical exam

• # 90658 H1N1 flu shot

• # 12002 one-inch laceration suture

• CDT® and HCPCS codes, too!

Document the Visit in Patient Progress Notes

Subjective:

“I was gardening and noticed my wrist was swollen and itched like crazy”

Objective:

A 4 inch linear red rash with circular oozing papules and swollen skin is present. Patient is wearing a small tennis bracelet which was tight.

Assessment:

Rule out rues dermatitidis versus nickel allergy.

Plan:

Soap soaks, with OTC calamine lotion with Rx oral diphenhydramine or [benadryl].

Submit the “Super Bill”

Not a “big bill” or expensive medical invoice; just an invoice

• Official standard billing form used by doctors submitting MC/MD claims.

• Also used by some private insurers and managed care plans.

• Contains patient demographics, diagnostic codes, CPT®, HCPC codes, etc.

• Generic billing form, like the generic HCFA 1500 claim form.

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Medical Coding and Billing Vocabulary

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Basic HIT Nomenclature and HIPAA

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

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

Diseases 

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

Procedures

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

Pharmaceuticals

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

Assessment

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

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

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

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

Conclusion

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