The New America - Second Rate and Falling

There seems to be a general sense of dissatisfaction that pervades our lives today.  It touches us not only when we evaluate our own sense of self worth, but also reaches into our professional lives and grabs the satisfaction that work should bring.

Perhaps the current economic state of our country is to blame.  Or maybe our inherent sense of fear about the safety and security of our homeland.  Before the towers fell, we would awake and think about what tomorrow would bring.  Now, some parts of our minds worry that we may not make it through another day.  On September 11th, 2001, I remember driving home from work and being overcome by the pervasive silence that marked my journey.  People seemed to drive in a trance-like state, their hands at ten and two, knuckles white without awareness that they gripped the wheel a bit harder than usual.   I was overcome by the feeling that after this event we would live our futures being kinder and gentler to each other.  We would see the worth in each of our fellow citizens and treat each other with a new sense of respect and consideration.  But that didn't happen.

First the towers fell and then the economy tumbled to the ground as well.  We witnessed yet another war where our young men and women died in the sand fighting against weapons of mass destruction that were a fantasy of another group of men that would profit from bullets, tanks and oil.  We found out that it was not a kinder, gentler nation.  Bernie Madoff, the Wall Street tycoons and the banks that we supported with our hard earned dollars bilked us of billions of dollars.  The Dow took a downward spiral along with the savings of those who had worked a lifetime to put away a few dollars.  Jobs were lost and we now lived in a country where we produce nothing but lives that are designed to be wasted at war.

We fool ourselves into a sense of complacency by concentrating our attention on the cultural media.  Reality shows that highlight fools more lulled than ourselves.  The Kardashian marriage, rich Housewives fist fighting in public arenas, the zero IQ's of the Jersey Shore, posting our meaningless nonsense on Facebook and Twitter, never commenting on just how drastically our lives have changed. Sometimes, I think what emerged from the ashes of the Towers was a new sense of greed and self loathing and an attitude that life has become cheaper, instead of more valuable.  Many of us lucky enough to have jobs clock in strictly for the check and our sense of caring for our fellow man has gone the way of our country's greatness. Instead of engaging in meaningful dialogue, we drug ourselves with media hype, until we believe that there is something worthwhile about everything we do and say.

We used to have the greatest healthcare system in the world.  Now, doctors caution patients to avoid hospital stays as much as possible, for truly your very life is now in the hands of those whose apathy is palpable.  Amazingly, we discuss ways to avoid treatment for our patients, and actually have a plan to reward ourselves for doing so.  It is all too much like "The Emperors New Clothes," to remain comfortable for anyone who is rational and righteous.

Wake Up America and take stock of how you are being manipulated before your ashes join those of the innocents who perished for a nation that is on it's way to becoming second rate.  

Greed- and Your Reputation in the Medical Community

Those of us involved in the healthcare industry love to share the tidbits and gossip of what's going on in the practices in our community.  While there may be hundreds of practices in our particular demographic area, word spreads like wildfire when a physician practice does not work or play well with others.  A practice may find itself literally blackballed when it comes to referrals from colleagues when business models are based on the Gordon Geko philosophy of "greed is good."

There is a world of difference between a healthy attitude of ambition and a toxic desire for money that allows certain physicians to ignore the rules of healthy partnerships and collaborations.

In our current climate of reimbursement reductions, physicians are using their imagination and resources to create marketing programs and lease space arrangements that should benefit all parties involved.  Many practices have enjoyed great success as a result of these collaborations, however, certain parties cannot find satisfaction unless they take much more than their mutual agreement called for, or worse, find a way to constantly renegotiate their business deals to their own advantage.  It may take a while for the manhandled party to realize they are on the short end of the deal, but sooner or later the deal falls apart and the reputation of the physician who did not keep his promises often cannot be repaired.  

We have seen a societal change in our country where fair play and hard work is downplayed in favor of winning at any price.  Pride in a job well done has been replaced by the sole desire for material reward.  Indeed, it becomes increasingly difficult to find employees or even professional staff who operate with kindness and consideration both for patients and colleagues alike.   All of us have born witness to those barracuda physicians who operate as if they were the only game in town.  Partnerships are broken, employees become disgruntled and burn out, and fellow physicians stay as far away from the practice as possible.

Often, these "bad press" practices initially enjoyed moderate success and were well respected in their communities.  Over time, however, they failed to acknowledge some basic truths.  The first and most important rule that is disregarded is that every business eventually reaches the "glass ceiling of cash."
There are only so many patients that can be effectively treated in a business day.  You may have taken your practice into the millions of dollars range, but eventually you will reach a level of reimbursement that is appropriate for your specialty and the number of physicians that you employ.  The expectation of a "no limit" cash flow year after year, is unrealistic and the physicians who deny this basic tenant will go over and above the rules of fair business practices.  

A second and perhaps more grievous error is the hiring of multi-specialty physicians outside of your specialty before due diligence is performed.   Practices who deal in this behavior are constantly in a revolving door situation where physicians come and go, often at great expense and legal consequences.  These physicians do not make an adequate study of whether or not the incoming physician will be a good fit for their patient demographics and they may not realize that they are now paying for a physician in the same specialty as those doctors in their community who provided them with referrals.  They ignore the warning signs for the sake of "empire building" and may lose the possibility of future practice growth.  Many of these business deals end up in disaster, especially when the physicians who join the group do not meet their expected financial goals.  The comings and goings of these doctors have serious implications for the hiring practice and the unhappy physician who ends up leaving the practice will eventually voice his complaints loud and clearly in the community at large.

A medical practice cannot exist in a vacuum.  Those in our community will not experience our level of skill or caring attitude in the exam room.  We will be judged by our fair and equitable business practices and once our reputation is damaged, repair may not be possible.

Finding Your Fit

For those of us who have worked hard and successfully in the health care industry, opportunity often allows us to move forward up the chain of command.   Some navigate these changes and find a home in their new position, while others may end up feeling adrift and realize that their new job is just not the right fit.  Sometimes, we are motivated by the money, sometimes just the flattery that accompanies advancement is enough to induce us to move forward in our careers.  What should motivate us, make us stay in our new jobs, or admit that moving on was a mistake? 

The biggest falsehood in any career move is believing the adage that what one man can do - another can do just as well.  The fact that we have been noticed and appreciated for our work ethic does not necessarily mean that we can make a smooth and happy transition to any job description.  In order to assess our chances for satisfaction, it is necessary to make an honest appraisal of our skills and to understand where our motivation lies when it comes to career choices.

Many individuals report to work each and every day for no other reason than their weekly paycheck.  There is noting wrong with having the sole motivation to satisfy our financial obligations, and indeed how many of us would continue the grind of the work week if we suddenly won Lotto?  If you find that this describes your attitude toward work, then as long as you do your best each day, you should accept that climbing the ladder of success may not be for you. 

First and foremost, all of us should take an honest appraisal of our skills.  If paperwork drives you absolutely mad and sitting behind a desk for eight hours is akin to water torture, you probably should not think about taking an administrative position.  The money may be great and initially your ego may be flattered, but eventually you will find yourself bogged down by your responsibilities and your job satisfaction will continue to decline.  This is especially true if you have spent a large portion of your career at the bedside or engaging in some form of direct patient care.  Although difficult, many health care professionals who have moved into administration find that they pine for the days of one to one contact with patients.

Secondly, you should always consider your training before you accept any position.  What skills have you honed in your career?  Are your skills transferable to a new role in health care?  What is the learning curve?  

Most of us expect that we will have a mentor to aid us in our new roles, but without essential skills in place we may still flounder.  Our mentors may also be struggling, especially since health care is ever changing the way we process information and patients, so daily access to those who can make our transitions smoother may not be readily available.  Successful transitions involve the ability to customize our new positions so that they reflect our strengths.  Trying to make an exact fit into the existing job description will not allow for growth and positive change.   Claim the playing field as your own and use your essential skills to individualize your position, so that you and your new opportunity will be seen and appreciated as one entity. 

 

Help in the USA ? Not Anymore

There was a recent news story about the construction of a house made strictly from materials made in the USA.  Every single product from nails to bathroom fixtures was a product produced here.   The builder compiled a list of each product and their associated costs to forward to construction companies throughout this country.  His best estimate showed that new construction comprised of only American produced products would result in the creation of over 200,000 new jobs.

I couldn't help but wonder when we decided that American labor, which once led the world in innovation, was suddenly no longer a desirable work force.  One need to merely go online and search for something as arbitrary as American made sweaters to find how few goods are available with the Made in the USA label.

We have become a nation where the rewards of our consumption are reaped overseas and many of our citizens are barely making it from paycheck to paycheck.

It's difficult to understand why our nation allows corporations the luxury of selling their goods in this country while denying its citizens the opportunity to produce them for a livable wage.  The American public has been duped into believing that the demands of organized labor are just too extreme to keep our jobs at home, but in order to live at home, in this country, we cannot afford to work for the wages paid in China or Indonesia or wherever else the production of our goods and services have gone. Indeed, for most American families the cost of living is what may no longer be the greatest nation in the world is now a hardship rather than a privilege.

We have paid and continue to pay the incredible high cost of premiums for our homes and cars and to provide health care for our families.  The insurance companies who provide this protection consistently show staggering profits while Americans are struggling to put food on the table week to week.  Our out of pocket co-payment and prescription costs are rising, while our government makes an effort to keep testing and services farther from the reaches of those that support it.  To add insult to injury, the same companies that we continue to make richer are farming their customer support bases away from the United States, further denying us the opportunity to profit from the billions of dollars they make year to year.

Anyone who has worked in a medical office and has had to call customer service for claims or insurance verification knows what it is like to speak to someone who is virtually impossible to understand.  My billing department used to pray each time that they dialed United Health Care, hoping to be connected to an American representative rather than someone in India who could neither be heard or understood.  Does United Health Care insure citizens in Bombay?  Highly doubtful!  Why then should jobs for an American company be done on foreign soil?    What incentives are we giving these giant profit making machines to keep jobs here?   Further, what penalties are we imposing for those who take jobs out of the hands of our citizens while collecting their money?  It's truly pathetic and even worse when the money that they claim to save by using foreign labor never seems to translate into lower costs for their goods and services!

In order for us to solve our current financial dilemma, we had better stop pandering to multi-billion dollar companies who take jobs from American hands.  Who do they think they are fooling?

Treating Our Patients To Addiction

Like many Americans and indeed people throughout the world, I have been following the trial of Dr. Conrad Murray, the physician who treated Michael Jackson and is now charged with involuntary manslaughter in his death.   Jackson died from Propofol intoxication, Propofol being a drug administered in hospitals or ambulatory surgical centers as an anesthetic.  In the case of Dr. Murray, propofol was used in order to assist Michael Jackson get a good nights sleep- administered in his bedroom, through an IV, which is amazing in and of itself.  Why he agreed to use this anesthetic in the first place is even more amazing.

Having first hand experience with Propofol, during a colonoscopy/ endoscopy, I can tell you that waking up from this drug is akin to spending a week in the Bahamas, without the tan.  You feel as if you have taken the best nap of your life and your mood is one of sheer elation.  This feeling is common to almost everyone who has had an experience with Propofol and I must admit that you do have a quickly fleeting desire to purchase a six pack of the drug to take home.   The fact is that drugs are addictive, aside from the physical component, simply because they make you feel good long before they make you feel awful.

Now the case of Dr. Murray certainly seems bizarre, but physicians all over the world can become enchanted with their patients, even though they may not be "The King of Pop."  Doctors want to alleviate not only pain, but also an entire host of other patient complaints that give their patients less than an optimum lifestyle.  Insomnia, headache, menstrual cramps, muscle aches - treated with a swipe of pen on script pad.  Creating in many instances a whole garden of future addicts.

Put quite simply, the drugs exist, so why not use them?

There are, of course, those drug seeking patients who travel from physician to physician to obtain the medications that they now need for their daily survival.  Many patients, however, present to their patients with acute and chronic pain, unaware that abuse of medication to treat this pain will eventually become a way of life.  In many cases, physicians simply do not take the time to adequately explain how the medications that they prescribe can lead to overuse or addiction.  They treat the symptoms with drugs to alleviate pain, without realizing that the majority of patients are not aware of the implications of these drugs.  Pain relief equals pills and pills lead to more pills and so on and so on.  In addition the courting of physicians by the pharmaceutical companies tend to minimize the side effects of their products and gear their efforts to make their medications as appealing as possible.  You merely need to watch the commercials for some of the new drugs brought to market and if you are not shaking your head at the list of side-effects, you are certainly in the minority.

Perhaps patients and doctors alike need to realize that not every physical pain needs immediate treatment.    Physicians need to make sure that they take the time to assess the patient's lifestyle, diet and exercise regime before writing a script to deal with a symptom that could be addressed with simple lifestyle changes.  There needs to be a larger learning curve where physicians are better informed in the use of natural and herbal supplements that may work just as well as prescription medications.  Acupuncture and chiropractic treatments may also provide relief for acute and chronic pain as well as physical therapy.
We need to begin to align ourselves with modalities and lose the fear of having our patients seek alternative therapies.

As our largest population group continues to age, we must be mindful of using drugs that are often rushed to market with catastrophic consequences.   Continuing education in our various specialties should always include embracing less invasive techniques. 

Medicine in the Age of Carelessness

Talk to anyone who has worked in the medical arena for a significant period of time and inevitably you will hear the same complaint: "Nobody Cares Anymore!"   This is not endemic to only medicine, but in our dealings with each other as well as with patients, there is a new attitude that is best described as self-serving and unfeeling.  This applies to the largest hospital systems and the smallest medical office, where physicians are trying to eek out their existence on a day to day basis.

We have become a rude society indulged in a say anything and feel justified attitude that leaves most patients feeling as if they have entered a twilight zone, far removed from the past, where they are no more than a name and number.  I have been serving the needs of medicine for the past twenty years, and I am shocked at the lack of professionalism I find both as an administrator, and as a patient in the offices I work for and make use of as a patient.

Front office staffs are short and unmannerly and the patient is no longer the number one priority.  Physicians and other health care practitioners who are now forced to see larger volumes of patients are prone to more mistakes than they were in the past and I fear that those patients unfortunate enough that they cannot act as they own advocate will fall victim to an increase in sub-standard care.

Nurses are overwhelmed with the number of patients they are expected to care for on their particular units and the paperwork has become an overwhelming catastrophe that does not insure the patient's well being but rather puts it into greater jeopardy.  Nurse no longer appear at the bedside at the first bell ring and patient's without a family member to assist them during their stay often express serious complaints regarding their hospital stays.   The days where nursing is a profession for the most caring and dedicated of individuals has gone the same direction as flight attendants and indeed we are forced to feel as if we are traveling in steerage when we are forced to seek hospital care.

What are we doing as a nation and as a society to deal with these issues?  Perhaps payment for patient satisfaction scores is one answer, but right now all we are doing is giving our physicians and staffs greater obstacles to billing and coding.  So we become more overwhelmed that we were in the past, and the likelihood that this is going to positively affect our patient care is quite slim.

Carelessness in dealing with our patients is now standard fare even as we listen to physicians and staff complain about cuts in reimbursements.   Perhaps we are getting exactly the payments we deserve for the standards of courtesy and professional care that we are rendering today.  Perhaps, we will go the way of the airlines - no meals, no pillows and blankets - smaller seats - and zero advocates.  What can we expect when we have allowed ourselves to practice as a level that is strictly coach rather than first class!

It's time for us to wake up and promote the complete package of professionalism that existed in days gone by.  We need to take the time and promote an arena of excellence before we price ourselves right out of the market and health care becomes little more than a series of walk in clinics that provide only the most basic of care.  It's time to change our attitudes and realize that we are only as good as the patients think we are..... Nothing more !

An Alternative to Hospital Takeover

Many smaller practices have a good patient base, often by serving their immediate communities.  Despite committed patients and active days, some physicians still find that the overhead costs of running their own shop overwhelming.  Often, these physicians turn to hospital employ to solve their cash flow problems, but this situation often has problems of its own.

Hospital employ always means a loss of control.   Staff may be supplied by the hospital and it is often difficult to obtain the goods and services that are a part of your normal routine.  Large hospital corporations are not especially suited to a personal relationship with each physician and you may find yourself somewhat invisible in a large crowd.

One alternative is to seek a partnership with a large established private practice in your area, even if this practice is not aligned with your particular specialty.  These partnerships have proved very successful for a large number of physicians and can be tailored so that you keep more of your independence, while profiting from the protection of a larger revenue source.

The physician may find that in most cases, he or she will be able to maintain their practice address and even the majority of their employees.  Instead of outsourcing for billing, many of the larger private practices have enjoyed great success in revenue collection and this will ultimately save the physician from the monthly costs associated with a billing company.

Parent corporations will often also make an investment in the look of your practice, completing necessary  updates to hardware and software as well as office decor and furniture.  Bills from the physicians practice will be paid by the parent corporation as well and deducted from a bonus structure as overhead.
Suddenly, the physician who joins a large group will find themselves able to dedicated more of their time to patient care and less to the stresses of running and paying for their practice costs.

Prior to any commitment, the physician must take a realistic look at their annual salary expectations.  Contracts for these types of arrangements usually mean that you will be paid a salary for your services and a quarterly or annual bonus minus overhead for your contributions to the parent company.  You can expect both your salary and bonus structure to grow since you will now enjoy the benefits of a new referral source and any marketing efforts the parent company makes on your behalf.

You will be dedicated not only to your own practice but to the success of the parent company as well and will enjoy an easier one on one for meetings and negotiations than you would find in a hospital setting.  Private practice management is at your disposal and less distracted by hospital expectations.   In addition, you will have staff coverage for vacations and personal time.

Make sure that your agreement allows you access to statistics regarding your billing reimbursements.  You may need to reassign your Medicare and private insurance benefits, so you will need to prepare for the changes well in advance to any agreed upon start date in order to assure that your personal revenue remains on track.

Joining a private practice can afford you a new support group for your goals and future ambitions.  Growing your practice is beneficial to the parent corporation so you should gain a new sense of encouragement and a team behind you to assist you in moving ever forward.

Simple Prep Work Can Save You Hours For Credentialing

In an earlier blog, I posted some good tips for credentialing your doctors.  From what I have seen lately on discussions on Linkedin, folks are really having a hard time using CAQH, so I thought it was worth taking the time to outline some of the simple prep work that can save you hours of time during the credentialing process.

Indeed, no physician hired into our group was allowed to start unless I had a copy of each of the documents needed for credentialing.   You would be amazed at how quickly the papers reached my desk!

Although we live in the new "paperless" age, you would be wise to organize a folder for each physician in your practice that contains all the paperwork necessary to make the constant credentialing processes a breeze.  On the outside of each folder, I note the following:
Physician's Name, Address, Home Phone, Cell Phone, Pager #,  Date of Birth, Social Security Number, Spouse's Name.
Name and Address of Undergraduate School and Date of graduation.  I also then list : Medical School Name and Address, Date of graduation, Internship location and name of program supervisor and dates, residency- the same and fellowship- the same
State Licensee Number and Expiration Date / UPIN
DEA Number and Expiration Date
NPI number
CAQH number / User ID and password
Medicare / Medicaid ID numbers.
Hospital Affiliations
Malpractice Insurance

A copy of these documents are stored inside the folder, so that easy access allows you to fly through the application process. As I update Registrations and DEA, I merely change the expiration dates on the outside of the folder.   Contained in the folder can also be:
Name/ Address and Phone of 3 physicians for recommendations.
CME credits
ACLS  Certifications
Infection Control Certificate and on and on.

Pulling and making a copy is the hardest work you will have to do after your individual folders are created.  You may also want to consider scanning these into a word document under each doctors name. I have used both methods and still kept the folders up to date because in the long run, I found them easier to use and peruse!

CAQH ID numbers can easily be obtained from a variety of insurance plans.  If you go to the CAQH web-site, they will advise you how to get your personal CAQH number.  The initial application can be lengthy process, but after you input the physicians data once, keeping the file up to date is simple and fast.   Those insurers that demand their own application will almost invariably accept CAQH downloads as long as they have an original signature.

Prepare in advance and you will find that credentialing is an easy and sometimes enjoyable process.

What Makes a Great Consultant ?

Consulting is much more than merely bringing your expertise to a practice and expecting it to fly.  Despite their best efforts, many consultants hired to turn around a failing practice find that they have not or cannot make a significant difference and their entry and exit is often a short and painful process.  In my years in the medical arena, I have seen a number of consultants who barely had time to sign their contracts before they were hastily dismissed.  Physicians who seem thrilled at the idea of having an individual or firm come in to analyze and make changes to their practice can easily become overwhelmed long before change implementation becomes a reality.  Needless to say, this is a huge disappointment to the consultants who have probably spent countless hours preparing for a new challenge only to see themselves curbside without really knowing why.

Several key factors can alleviate this situation. They are simple and logical and will help assure that your consulting experience is satisfying and financially rewarding.

1.  It is an absolute necessity for the physician who heads your consulting practice to inform their staff of your arrival well in advance.  The physician may hold an office meeting where you are introduced or you may prepare a memo to the staff advising them of your arrival and intended goals.   Your goals should always address the initiative to create a team environment of success and to assure the staff that you are looking for ways to enhance their job descriptions, not to eliminate jobs.  If you are speaking to the staff in a meeting, you may want to address how you have made a difference in other practices and that your recommendations are open to suggestion and feedback.

2.   Read and understand the temperature of the room-  A uniform standard of excellence does not mean that every practice functions the same.  Throughout their tenure, a physician and his staff have developed a comfort level with their style of medicine and their team approach.   Unfortunately, too often consultants arm themselves with what they consider the keys to success, but never unlock the personalities or goals and desires of the staff.  Don't be too quick to judge the day to day operations of the individuals in the practice until you have a complete understanding of their routines.  Often, what you may consider the failure to accomplish set goals is due to a needy and demanding physician who sidetracks his or her staff, rather than an employee who is lacking in necessary success skills.

3.   Avoid the gangbuster mentality -  DO NOT under any circumstances alienate the staff.  Suggested changes to protocol or policy should not merely be promoted, but rather the reasons that these changes will positively affect the practice must be carefully explained, over and over again, if necessary until the staff realizes that you are acting in their best interest.  I try to explain to staff that changes that will increase or insure a steady practice revenue is the key to their moving forward as well.  You must work to instill the idea that the personal goals of the staff will only be realized if the practice enjoys success.

4.  Roll up your sleeves and dig in -  Talking about doing- and actually doing are two very different things.  You should be willing and able to perform any task changes that you propose.  You will be viewed in an entirely different light when you actually answer a phone or make an appointment.  Becoming part of the team, rather than merely running the team is a sure way to enhance your image and to reinforce the positive changes you are brining to the workplace.

5.  Rigidity is never an asset -  Be willing to compromise your goals and proposals so that they adapt to the work flow of each individual practice.  You may want to see confirmation calls made at a certain time of day and may have excellent reasons for your proposals.  However, if this cannot work in a certain setting, you must acknowledge other ways to accomplish the same result.

6.  Never alienate a Patient -  I have seen consultants meet with patients that have an outstanding balance and all but demand ransom of their firstborn.  Needless to say, these consultants were shown the door almost immediately after this little show.  Do not assume that insuring collection from every patient is the goal of the practice and by all means always treat each patient with courtesy and respect.  Check with the physician or office manager before attempting to meet with any patient.

7.   First organize -  An office that looks and feels messy will never be organized.  Your first priority is to create a workplace that is neat and clean.  I always recommend ways to remove clutter and help make individual work space an easier and more enjoyable place to accomplish daily routines.  Simple measures such as bins and trays are inexpensive and the staff truly appreciates any small tokens that help them feel that their workplace is one where important things happen.

8.  Analyze the daily routine of the physician - Sometimes you come to realize that the physician is the main reason that the practice is failing to thrive.  This is a difficult situation to address, but it still remains your responsibility if your are going to succeed in your consulting goals.  You would be wise to create a written outline addressing how the physician might make improvements - I mean suggesting - delicately. In many cases, your feedback will be greatly appreciated.  In others, not so much a lot!  Either way, you will be able to rest assured that you have accomplished your goals, even if change is not possible.

Developing Your Practice EHR

As you set up the parameters and templates for your Electronic Health Records, it is wise to keep in mind that the initial work will be labor intensive.  You will want to take the time and approach this work with a thoughtful attitude and realize that the work you do at this time should mean smooth sailing in the future.

Prior to creating your practice templates or pull down menus, you would be wise to carefully examine at least ten to fifteen initial examination reports and the same number of follow up reports, so that you have can be assured that you follow the same pattern that your physician does when he verbally dictates his reports.  

Some EHR systems, especially those that are free or offered at bargain rates will not have the ability to build in a letterhead feature, so you if you have the option to create new templates, this should be your first order of business.   You can do each line of your address, phone and fax as a separate listing, so that you can select ALL for an initial evaluation and select only the physician name and title for follow up exams that may not be mailed to other physicians.

Most dictated letters follow a pattern of : History or Chief Complaint /  Review of Systems/ Physical Exam / Impression/ Treatment and finally Plan.   If you would like to follow this procedure in a point and click system, you will need to create a template that shows these highlighted areas and then fill in the appropriate text as follows.   An easy way to customize your templates is to initially choose five to ten of your most common phrases under each one of these headings.  You can then click the heading and find exactly what you are looking for under each topic of your exam.

Many EHR systems come pre-loaded with the specialty procedure codes that your office most frequently uses.  If this works for you, it may be less work-intensive than building your templates on your own.  However, there are benefits to starting at square one, since most practices usually have a uniformity to their physician consults and follow ups and you may find that you are somewhat confused if there are overloads of information that you do not generally use on a day to day basis.  

Systems will also offer you the opportunity to transfer your entire patient base into the new EHR system.  In many cases, this may not be the best choice.  When you do automatic transfer, your data may end up skewed, or some patients may appear more than once.  Insurance information may not transfer seamlessly and you will end up doing more work than it takes to manually enter your patients one by one.   Pick a start date for the use of your EHR that will give you time to input patients with appointments 30-60 days in the future.   You can scan in the insurance cards that should be on file in your charts or add the insurance manually for each patient.   This not only assures that data is transferred correctly, but it also gives you the opportunity to cull old charts that are sitting in your file room, and to re-verify the insurance of any patient that has not been seen in your office for 90 days or longer.

As you are culling your charts, you may also want to send reminders to patients that are past due for a visit or procedure and new patients scheduled for 30-60 days in the future can receive their registration forms in the mail, which always makes check in an easier process.

The process of entering your patients into your EHR system will also help you organize old charts for storage or to arrange shredding of PHI for patients not seen for seven years or longer.   You may want to consider this process as part of an overall practice audit and the chance to determine how organized your front office staff has been in obtaining and filing needed PHI information.

Make sure that you seek hardware recommendations from the company supplying your EHR software.  Some tablets are not compatible with every EHR system, so choose wisely.   Make sure that the software vendor is prepared to assist you in synching your tablets or PC's to the printers and faxes in your office.

Managing Your Patient Follow-Up

It would be wonderful if every physician could monitor the patient relationships of their front office and assure themselves that patients are always treated with respect and a helpful attitude.  Unfortunately, this is more dream than reality and even the strongest administrator cannot always be at the front desk to hear every phone conversation or to make sure that follow-up appointments and confirmation calls are made in a timely manner.

Physicians know it is never easy to entrust your patients to anyone outside of the exam room, and the effect that your front office staff can have on your patient's perception of your practice can be the stuff of sleepless nights!   While the investment you have made in your practice represents a large portion of your life and career, for many of your ancillary staff, your day to day operations are merely a job.  It is difficult to motivate any staff day after day and despite your best efforts your staff may not always embrace a team work state of mind.

In the best case scenario, where your employees are dedicated to the daily grind of eight to ten hours of ringing phones, appointments, authorizations and referrals, practice burn out is a common thread that runs through many of even the best practices.

Fortunately, there are several options that can diminish the overwhelming tasks that are part and parcel of any front office staff.  Several excellent companies are available in today's health care market that can make a large difference in your practice and help alleviate some of the front office tasks so that a greater concentration can be made to the revenue stream.  

Options such as auto-confirmation calls have been adopted by many of the more successful practices. Choosing this option will mean that an independent firm will call your patients, usually via an electronic voice message, informing them of their appointment date and time and requesting that the patient press 1 to confirm their visit.  Additional features, such as directions to the office, phone and fax number, and parking information can be added to these calls.  Reminders to patients to have their insurance cards, co-payments and any referrals are also options you may consider.   Your office will usually receive an
 e-mail message confirming your appointments and cancellations, so that you can reschedule any missed or cancelled visits as soon as possible.

Features such as patient reminder cards and/or reminder calls can also be assigned to an outside agency and serve an important function in keeping your patient base current with their care.  Some of these businesses may be able to access your actual scheduling software and confirm directly into your system.  Just make sure that all PHI is protected by a contractual agreement that patient information cannot be shared or sold to any outside company.  You may also want to add a feature to your HIPAA paperwork to make sure that it is acceptable to leave an appointment reminder on the patient's phone message.

You may also want to invest in a feature that will survey your patients on their office experience.  Despite what you consider to be your best efforts in practice analysis, you may be surprised at the smallest of details that patients are noticing during their visit.  Surveys can assess both the professional and ancillary staff and assist in employee and professional staff evaluation.  A detailed spread sheet is often available as part of your contract that will highlight the positives and negatives of your patient experience.

The better companies that offer these features may also provide you with a monthly or quarterly report that will detail the number of cancellations and visits to your practice.  These will prove to be an important part of your practice analysis and can help you identify and alleviate problems before they pose a significant threat to your practice revenue.

While you will want to assure that your front office staff has job descriptions that keep them busy and active each day, you want to guard against overwhelming them with tasks that may fall by the wayside.  Keep in mind that maintaining those aspects of your practice that will guarantee optimum reimbursement are those that should always be in the forefront of your operation.  Utilizing services that can free your ancillary staff to this goal can be the key to your future success.

Must Have Publications

A few years ago, it was easy to develop a relationship with a Provider Representative working for Medicare.  These dedicated individuals were happy to answer all your billing and provider enrollment questions and would help guide you through any changes and implementations that your practice decided to put into play.  I cannot tell you how many times I spoke to these great folks and how invaluable their information was.  Sadly, my personal contacts at Medicare have all moved forward or retired and it is now much more difficult to make a personal connection with any insurance plan representative.  Indeed, many of the larger insurers have networked their Provider Representative units oversees and it sometimes becomes impossible for you to even understand what they are saying, let alone develop any form of professional one on one relationships.

While we are busy running the day to day operations of our practice, changes to procedure coding and reimbursements can slip through the cracks and have a financial impact on our practice that may take some time to correct.  I always advise larger practices to assign a staff member to act as a Medicare and insurance liaison in addition to their regular practice responsibilities.  This individual would be responsible with keeping up to date on Medicare and commercial insurance changes that can impact your practice.  Usually this means downloading and examining the commercial network bulletins along with the Medicare Part B newsletter, which should be a part of each practice routine.

The Medicare Part B newsletter is available online to all providers who electronically bill Medicare for their services.  The newsletter lists changes in coding and reimbursement rates, along with physician incentives.  The publication will also allow you the opportunity to enroll in Medicare seminars that will cover a broad range of topics to assist the beginner to the expert in optimizing their reimbursements.
Downloading the Part B newsletter will allow the practice to quickly implement changes and to avoid costly billing errors.  Those areas that are specific to your practice should be downloaded and reviewed by your billing staff and understood by your professional and clinical teams.  While it can be burdensome at times to wade through all the information that is not relevant to your concentration, the Part B newsletter should be reviewed carefully and its examination should be an important part of your practice routine.

The commercial insurance plans also publish newsletters that will provide you with changes to your billing formats as well as updates and important phone numbers and web-sites that will make your claims  follow up an easier task.  These are also available on line and will help you to understand specific modifiers and any differences in billing that exist between your Medicare and commercial claims.   Discussions relating to information in these commercial newsletters should be a part of your monthly billing meeting.  Changes should be quickly implemented and deadlines for changes should be noted in cases where appeals may be needed.

Another must have relationship should exist between your practice and The Coding Institute.  Since 1947, The Coding Institute has been assisting doctors in developing strategies for a more profitable practice.  They offer a variety of products including Specialty Coding Alerts, SuperCoder.com and Audio Education to their enrollees.  Their quarterly publications can be specifically tailored to meet the needs of your particular specialty and they will quickly become invaluable additions to maintaining the financial health of your practice.  The Coding Institute is currently offering a boot-camp that will assist your practice with solutions to the changes involved in adopting the ICD-10.   This one and a half day training course will allow you to master the skills needed to correctly code using ICD-10 CM.  You can contact the Coding Institute directly @ 1-800 508-2582 for more information.

Hospital Based Practices - Do They Serve Anyone's Need ?

In order for private practices to thrive in the current health care climate, they must maintain a standard of excellence in both patient care and financial matters.   Those who fall short of either mark often bail out of having control over their own business and shelter themselves under the umbrella of a hospital based practice.

Basically there are two types of physicians who opt to align themselves with a hospital model.  The first brand of physicians who choose to abandon the idea of private practice are those who have not and can not understand or involve themselves in the business of medicine.  Since physicians never receive training in running a successful practice, there is a trial and error period involved in creating a structure that succeeds.  Some doctors will try their best and still fail, while others refuse to believe that they have any other responsibility than to practice medicine.  Either way, you will usually find these doctors functioning in a disorganized office that is always on the brink of one catastrophe or another and bail out is sometimes their only means of survival.

The other physicians who need the hospital model are those egomaniacs that have expanded their original model to include either offices or equipment that they can not afford or maintain.  They find themselves in a situation where overhead continues to accumulate, without the patient volume to offset these expenses.

Initially, the idea of a hospital based practice may seem like the greatest invention since sliced bread and indeed physicians who refuse or cannot grasp what it takes to make a successful private practice may find their salvation here.   What could be better, they wonder, than to lose all financial responsibilities, bill and salary paying, and maintenance for the office and equipment?   Ahh!, to just come in each day, collect a salary and go home with a clear head.  Wonderful, right?   Well, before we pay homage to the gods of hospital employ, we should be aware of the many pitfalls that can plague this arrangement and make us realize that it may not be the nirvana that we hoped for.

First and foremost are the staff problems.  While some hospitals will negotiate with physicians and allow them to bring their former staff members with them as part of their deal, many hospitals will require that the new take-over practice use their employees.   Many hospitals are now using their R.N. staff  as part of their practice management team.  This is a great idea if you need blood draws or IV placement, not so much a lot if you need staff that is familiar with verification and authorizations, front desk staffing, and billing protocols.  Many R.N. have never run a private practice before and have no prior understanding of the nuts and bolts of everyday practice life and all that it entails.   Without a team mentality for success, you may find yourself short of your financial goals at the end of each quarter and eventually find that you cannot meet the expectations of your contract.

As hospital employees, your staff is paid by the managing organization and they may have little to zero interest in making the success of your practice their number one goal.   You may have some input into employee evaluations and raises, but in most cases the employee is protected by the hospital job description that was agreed upon at their time of hire and asking them to perform additional tasks or even to change protocols or procedures is akin to expecting them to perform open heart surgery during their lunch hour.   You are just another nameless, faceless physician to these workers and if you could not motivate staff in your own practice, then you can forget about motivating employees who have no direct connection to you at all.  In most hospitals, employees have constant access to human resources and administration if their little world is interrupted in any way, and you may come to find out that unless an employee is in violation of the most serious of crimes, you will be gone before they are!

You will now find yourself in a situation where you have to submit written requests for any and all equipment that is needed to run your daily operations successfully.  Should these requests be granted, you will be placed on the list of all other requests and can expect to wait, sometimes for weeks for a new printer, fax, or telephone.  When these finally do arrive, you can hope and pray that they first work and that they are compatible with your other equipment.  Wait times can be endless.....

Your billing may now be outsourced and reports may go directly and exclusively to the hospital controllers office.  If the billing department is located somewhere off campus, you will never be able to see EOB's and other insurance correspondence and will rely on nameless and faceless personnel to make your financial decisions.  You may never find out if there are a particular set of problems that are preventing the optimization of your financial goals and again you may never meet or exceed your contracted goals.  You could find yourself making the same amount of money year after year, without knowing why your goals are not being met.  And if you did not understand the business of medicine before, you will now find yourself in the deepest and darkest of corners.

Patients may be billed and even harassed for charges that you may have waived or made some time concessions for without your knowledge or input.  What you will get are the patient complaints and exits that can result from a billing staff that does not act in your best interest.  The hospital may not accept all plans that you were formally par with and more patients will exit because of this problem as well.  You may be expected to perform a number of charity procedures and see these patients for private visits as well and this can have an important impact on the number of profitable visits during a financial quarter.
You can also forget about referring to physicians that are not part of the hospital staff.  You will be judged and evaluated upon your constant referral to hospital staff and they can be a tough task master.  Some hospitals may even expect that you obtain their approval prior to vacation and sick time and you may be expected on call whenever other members of the staff are away.  Your life is no longer your own and unfortunately this is exactly what you bargained for.

Finally, there may come a day when someone realizes that the hospital based practice is just another referrals for money scheme.  Eventually, these practices will only be allowed in areas where the affiliated hospital is the only game in town, so if won't matter where the patient is admitted, since no other options exist.  In most urban areas, this is far from the case and your patients, surprisingly enough, may not always want to be admitted to your employer hospital.  Then - What ? 

Patient Waiting Times - How Long Is Too Long?

Patients need to realize that a physician's office is not a restaurant.  You may not get called to your table immediately and your doctor may have times where the schedule falls behind due to emergencies or especially complicated patients with an extended history of illness and medications.

You should expect that the care you will be rendered when you finally see the doctor will be unhurried and that all of your questions and treatment options will be discussed in detail.  When you leave the office, you should be satisfied that you received the best treatment possible and that you are certain of any post visit instruction.

Unfortunately, many physician practices have no idea what a schedule means and chronically run behind schedule day after day.   The problem here is two fold.  First, if a physician is not meeting his daily schedule obligations and patients and extended waiting times are the norm, his or her schedule is almost certainly overcrowded.   Every office should have a time protocol for both new patients and return visits and gauge the physicians overall practice style and adjust his schedule accordingly.   In the rush to meet volume requirements, you may end up losing valuable patients along with new patients who will leave prior to their visit or never return.   After only a few weeks, the front office should be aware of the practice style of each of their physicians and adjust time schedules to meet his or her method of treatment.

Secondly, the front office should note the ebb and flow of daily visits.  If the physician is running two hours behind, the front office staff should call the next set of patients and ask them to arrive two hours later.  Often the staff is anxious to go home for the day and would rather deal with disgruntled patients who approach the front desk to voice complaints rather than having to put in extra hours or call in alternate staff to cover the late hours.  

In the worst case scenario, patients are put into a treatment room and forgotten for extended periods of time, behind a closed door without reading materials or anything else to do.  Many patients will wait for ridiculous amounts of time without opening the door and checking on the doctors progress, while others will simply get dressed and exit without saying a word to the staff.   They will often, however, be quite vocal to friends and family and can exert a substantial negative impact on your practice.  I have left one of my favorite doctors after time and again his eleven o'clock patients were not seen until one p.m.  I just did not have the time to wait two hours for each visit and although he was attentive and well skilled when he finally did see me, the burden of this wait just became too much.

We patients should expect a reasonable wait of fifteen to twenty minutes, and understand that treating patients can be complicated and difficult, but extended wait times mean that the office is not run properly and this problem is often symptomatic of other problems that may include a discourteous staff, lack of return phone calls or in the worst case problems that can result in medical malpractice.

Physicians often try to schedule an entire patient day without allowing for a break for lunch or to take and return important phone calls.  This is an unreasonable way to practice and one that cannot be sustained for any extended period of time without significant breakdown in patient care and waiting times.  Even if a physician has a fifteen minute lunch and uses the rest of his break time to catch up, each doctor should have at the very least a forty five minute mid-day break built into an eight hour schedule.

Front office staff should also have scheduled breaks and lunch time to avoid burn out.  It is often a good idea to place the phone on service during lunch hour so that the office has a quiet time each day to recharge and enjoy a few minutes of peace.  You may want to schedule your last morning session patient thirty minutes prior to lunch hour and try to save this time for a return patient rather than a new visit that may run overtime.  New patient visits may be best scheduled for the first visit in the morning, right after lunch and an hour prior to the end of office hours.  Back to back new patient scheduled visits will certainly contribute to longer waiting times so schedules should be built with specific new patient slots that work best for each particular office and practice style.   You should, however, try to schedule new patients within twenty four hours of appointment request whenever possible.  Unless your physician is the only game in town, new patients will shop around for an earlier appointment.

Should a patient become sullen and critical with the physician due to a long waiting time, the doctor should apologize for the wait and explain that certain visits may become complicated and the schedule cannot be written in stone.  The staff should always be patient and courteous with those waiting to be seen and if the patient should become overly hostile, management should take charge and try to smooth out the problem rather than leaving the often already overworked front office to deal with it alone.

You are not going to satisfy each patient who visits your office, but you should make every attempt to give your patients the opportunity to be seen in a timely manner and adjust your office schedule to meet these particular needs.  

Hats Off to Our Health Care Workers in New York

To all the health care workers who dedicated their time and efforts during Hurricane Irene, you have our deepest gratitude !
 
Making a smooth evacuation from one hospital location to another is no small effort and our area hospitals handled it with the skill and dedication that we have come to expect in our New York area.  So many nurses and doctors put in tremendous amounts of overtime to assure the health and safety of our patients as they were transferred to facilities throughout our state.   Those healthcare professionals evacuated from their own homes made a new weekend home in their hospitals, with little regard for their own possessions.

We still have the greatest city in the world and these efforts by our NY healthcare professionals is just another indication of how New Yorker's always rise to the the occasion.

Great Job Everyone !

Smart Shopping for Your Medical Practice

All of us in the healthcare industry are well aware that it's all about the overhead!   For many practices, the day to day costs of running the ship can have a serious impact on overall financial health.  With some careful planning and smart shopping, your budget can remain intact.

So many practices in serious financial shape spend money foolishly simply because they are not taking the time to become smart shoppers.   It is relatively simple to make some significant changes in your shopping habits that will quickly add more dollars to the practice coffers.  The following tips can alleviate both the stress of running out of supplies and keep your overhead from running you over!

1.   Do Not purchase toilet paper or hand towels from the same vendor that provides you with your injectables and/or medication.  You will pay dearly for the privilege and way above sale prices for these items.  Shop supermarket sales, especially when Scott tissue 20 roll, for example, is on sale.  Buy 2-3 packages which will give you 40-60 rolls anytime the local grocer advertises this bargain.

2.  Install a simple paper towel holder on the wall above your sinks and purchase bulk supplies of paper towels when they are on sale.  Consider using an electric hand dryer in your patient restrooms instead of hand towels, which are often quite costly and are sometimes used two or three at a time.

3.  Buy liquid soap at your local dollar store or purchase the large drum of refill soap and a funnel to re-fill the bottles when empty.

4.   Consider using a local laundry service instead of disposable paper gowns.  Many practices are now installing their own washers and dryers when they build or update their suites.  If you do not have the room in your office, you can get a great price for your laundry at most laundromats in your area.  Many will pick up and deliver your laundry for you and you will get to use the same gowns over and over, instead of purchasing a new supply of paper gowns each month.

5.   Even if you have a cleaning service, you will need to do some maintenance to keep your office clean and neat.  Again, Do Not order your cleaning supplies from Staples or Office Max.  They will charge you well above the wholesale prices you can get when these items are on sale.  I do feel, however, that every medical office should invest in a good vacuum, broom, and sponge mop for those spills and paper messes that are part of the everyday life of a medical office.  You may want to add a decent rug cleaner to the above mentioned items to avoid permanent stains when spills happen.

6.   If you are still using a chart system, purchase less expensive charts and consider using tabs to separate your dictation, lab results, etc.   The cheaper charts hold up just as well and can help you realize substantial savings.

7.   Now that the age of free pens, post it notes, and other little goodies is almost at an end, you will need to stock up on pens and paperclips whenever they are on sale.  The end of August and beginning of September, when back to schools sales are in full swing, is the perfect time to pick up these items for far less than you will during the year.  Make sure your patients are not walking away from the front desk with the office pens and this is least likely to happen with a plain black Bic pen which you can find on sale @ 10 for 99 cents in places such as Target and Wal-Mart.

8.   Do whatever you have to do, to find room to store and organize your supplies.  Clean out an old closet or put shelves in your file room.  Whatever area you choose to store your supplies, they should be easily visible for inventory.  Don't wait till the last minute to shop for your needed items, rather, take the time to shop sales and then stock up.  You will find that you do not have to shop for the same items month after month if you become a savvy shopper and buy in bulk.

9.   Vendors such as Costco and Price Club can also be another good place to look around for bargains.  Just make sure that what you purchase there is worth the membership cost each year.  Frankly, I would rather look for sales at my local Pathmark than troll the aisles of those immense warehouses, but this is a matter of personal preference.

10.   Try shopping online for lab coats.  The prices are cheaper and as long as you know your measurements, you will get the same quality as you would from a private vendor.  Ask yourself if it is really necessary to have the physicians or staff members name embroidered on the pocket.  You can create your own name tags in house by using your computer generated logo and printing the name.  Name tag kits are available at your local crafts store for far less than personal embroidery, so check it out before you spend.

11.  W.B. Mason is an excellent provider for your paper supplies and their prices are often much cheaper than Staples.  In an emergency, W.B. Mason will hand deliver any supplies you request and their sales staff is always courteous and helpful.

12.  Make sure you test your copier before purchasing paper.  Some copiers are fussy about paper and will repeatedly jam if the paper quality is not recommended for the machine.  In most cases, a standard white, inexpensive paper will work in most machines, but give the paper a try before you buy in bulk.

13.   For office hardware, shop the big names such as Dell and Hewlett Packard.  They usually have a business lease/ buy program with great prices.  You can also shop Best Buy and see if their geek squad will work with you to support your hardware.  Check carefully before purchasing new or replacement phones.  The AT&T products are good hardware but may be costly.  You want to make sure that your phones are meant to last since they will be used and abused on a daily basis.  In this case, you may want to spend a little more for a better product with good support and replacement policies.

14.   Keep your supply area clean and well organized.  One staff member should be in charge of the shopping and inventory.  After you have shopped the bargains for a few months, you will have a good idea of your inventory budget.  Money should be assigned strictly to keep your supplies from running low.  Don't be hesitant to shop around and change brands if you find a better price.  Do a 90 day price check to make sure you are always getting the best bang for your buck.

Medical Malpractice and EHR

Each year approximately 7.5 percent of doctors have a malpractice claim filed against them with the largest concentrations in the fields of neuros and cardiac surgeons.  Only 1 in 5 cases are successful, but the financial and emotional tolls they can take on a practice are substantial.

EHR systems usually contain a practice specific template that is geared to the specialty and makes it easier for physicians to pull down their most commonly used diagnosis and procedure codes.  This allows for the production of a clean encounter or billing sheet and gives the physician the advantage of billing at the highest allowable codes for his services.   Upon completion of the electronic dictation, the note is usually sealed and changes are not permitted after electronic signature.

Systems that include features such as Dragon-Speak will allow you more room to include patients with a more complicated history than those that work exclusively with pull down or click menus.  Voice recognition systems are much improved than in past years, but it still may take some time to recognize new words or phrases when you use them for the first time.

There are just so many diagnosis and procedure codes that you can program into your system before you start making it profitable and usable, but it is necessary to guard against letting the system dictate what codes you use for your patient's visits.  This is especially true to protect yourself in case of a malpractice claim against the practice.

Traditional dictation allows you to pre-program your review of systems while it also give you the opportunity to create a more complete record tailored to your patient's specific symptoms and history.  You have room to break away from the boilerplate notes that are often part and parcel of most EHR systems.  The EHR notes may be fine for insurance reimbursements where notes are requested, but if you rely on a standard note using only your typical pull down options, you may find yourself coming up short should your practice be subject to a malpractice claim.

You will want to assure that your EHR system allows you to easily input those specific symptoms and histories that are not part of your usual patient routine.  A combination of a pull down menu and some dictation program will give your practice the opportunity to create unique notes when they are necessary.

It has recently been decided that EHR records may be used in cases of malpractice defense and these notes will be as carefully scrutinized as those that were handwritten several years ago.  The EHR system also may make your practice prey to unfinished notes that may remain incomplete unless you have a good checks and balance system in place.  You may be able to produce a viable encounter with just the basic input, but your note may not be good enough to provide you with a good defense in a malpractice case.

You should view your EHR system as an ongoing creation and it may be wise to make a careful analysis of your patient notes every ninety days to make sure that you are not carbon copying note after note regardless of patient presentation.  Assure yourself that you are in charge of the finished product and that you are satisfied with the result.  In our old system of dictation, the physician was required to think about his description of each particular patient and to use his thoughts to create an effective record.  Let's not rely on the built in technology of EHR to organize and create our thoughts for us.

We will be dealing with a more savvy patient population in the future and we will want to assure that we do not fall prey to damage that originates from our systems, despite our goal of excellence in medical care.

The Hospital Conundrum

Last week, there was an interesting piece on the evening news.  A child was bitten by the family dog and required the services of a plastic surgeon in the emergency room.  The procedure went fine and the child and his parents returned home, unaware that the plastic surgeon that handled their case was not part of their insurance plan.  The parents received a four thousand dollar bill for the physician's services.

A year ago, my brother drove the three miles to his local hospital after suffering chest pains.  After determining that he did indeed have a serious heart attack, the hospital transported him via ambulance to their sister hospital, thirty minutes away for a cardiac catherization.   Later that same month, he received a two thousand dollar bill for ambulance services!

There is a patient's bill of rights for all hospital treatment.  This bill is usually standard for all patients and covers the rights to privacy as well as the right of the patient to allow or refuse treatment and to make decisions regarding this treatment or have them made by their health care proxy in cases where a conscious decision by the patient is not possible.   The bill of rights also allows the patient to be treated by a physician that participates in their health care plan.

Now, we are all aware that emergency services are aptly named and none of us would want to wait for a participating physician in cases where emergency services are needed in a life or death situation.  Someone who is having a heart attack is certainly not going to phone around town to find an ambulance company who participates in their plan, nor is someone who is bleeding going to call their insurance company to find a par physician to assure that no out of pocket expenses are charged.

Who should be responsible for situations such as those outlined above?  Once again, we see case after case where those individuals who are actively insured and paying their premiums on time are still charged fees that may be a serious hardship for a working family.  The hospitals would argue that the large number of uninsured or underinsured patients that come to the ER for treatment have posed a serious financial threat to their future survival.   The insurance companies realize that past coverage that included a zero payment for ER services meant more and more individuals turned to their hospital emergency rooms to avoid any out of pocket expense.  Now, most insurance plans have a deductible and or co-payment for ER services and expect the physicians who practice there to par with their plan.  Patient bills for non par services often go unpaid, even after the most stringent collection efforts and are eventually written off as bad debt.  This is just another example of why our health care system is overtaxed.

Perhaps hospitals and insurance carriers need to come to a better arrangement when it comes to emergency room coverage.   Should a physician decide not to be a par provider with certain plans, then he or she should agree to provide coverage for 50% of the reasonable and customary fee for services.  This would assure that patient's are not straddled with overwhelming hospital bills and still provide the physician with some form of reimbursement for their services.

It is not always the physician's choice not to participate in a particular plan.  The insurance companies will often gauge the number of specialists in a demographic area and decide to close their panel when the area is adequately covered.   Hospitals may not par or even drop a particular carrier if they feel the reasonable and customary fees are not enough to cover the expense of caring for the covered members.
In any case, the patient is the one who generally loses in the battle for coverage and the health care system in general also pays a steep price.

Will the new Obama plan help alleviate these problems?  Once all citizens are covered, will doctors still receive an adequate fee that motivates them to continue to provide care?  We know that by 2025, we will face a shortfall of physicians in the United States and cuts in reimbursement rates and the need to see more and more patients to make the same or less money than in past days is certainly a factor affecting the predicted shortfall.  We may indeed face a future where students are hesitant to choose medicine as a career.  We are regulating ourselves out of business just at the time where the largest population is going to be taxing the system even further.  Once we de-privatize medicine and move toward a more socialized system, we will definitely see a change in the quality of care that our physicians provide and that we as patients have paid for our entire lives.

Terminating An Employee

It is never an easy task to terminate an employee.  After sifting through resumes, interviewing, and finally choosing a candidate, it is so frustrating to find that your employee choice was not what you expected.
In this economy, you will have been inundated with hundreds of resumes for every posted job.  Although you were certain to ask for specific skills in your posting, you will find that you receive resumes from persons in all walks of life and more times than not, these individuals lack the skills that you are seeking.

When you finally find what you think is the right person to fit your job description, you may discover after a period of time that it wasn't the right person at all.   People can misrepresent their skills and experience levels, which is why it is always necessary to perform a thorough background check.  Often times you will find that your candidate has been employed in an office not far from your own and you may know the office manager or human resources manager, where the candidate was employed.  You should have a specific task list ready prior to your background check and you may feel free to ask if your candidate was proficient at the tasks you require.  You may also ask whether the former employer would consider re-hire of this employee, but you may not delve into the personal details of their lives.

Many on-line companies offer inexpensive background checks that will detail any prior undesirable history and you may feel free to use these tools as long as you have the prospective employees understanding and signature on file allowing you to investigate their past.   Should your office require drug testing, you will want to use an independent laboratory and send only those candidates that you are considering seriously.

As previously discussed, you should have a standard training schedule and your new employee should be able to perform certain tasks independently, within an expected time frame.  In addition to becoming proficient at their new job description, your new hire must show that they are able and willing to work well with their colleagues and show courtesy and respect to both the patients and their fellow workers.

Despite your best efforts to integrate your new hire into your work force, they may fall short of your expectations and you may discover that this individual is not suited to your organization.  In this case, your most important task is to document each instance where the employee has fallen short of expectations.  Your report should be in writing and you should meet with the employee and explain how they have not met your expectations and obtain their signature post meeting.   A careful record of problems will avoid any labor issues in the future should you decide to terminate this employee.  

You may want to consider whether or not an employee who does not show promise for their hired job description may be able to make a good fit elsewhere in your organization.  Perhaps they have show a particular talent in working with patients, or they are not great with patients, but are highly skilled at obtaining referrals or pre-certifications.  Since they have already become familiar with your office and your other employees, it will save you additional training.  Alert the employee to the possibility that you are considering them for an alternative position and should this new position hold a lower salary or benefit level, make sure they have a clear understanding of the ramifications of a lateral move and agree to it in writing.  Assure the employe that this change does not represent a demotion, but an attempt to keep them employed at a job where their particular skills may be better represented.

If all else fails and you must terminate the employee, you would be wise to provide them with copies of your evaluations and discuss their positive skills and suggest that they may be better suited to a different type of employment.  Unless there has been a clear cut violation of the policies and procedures in your employee handbook, or instances of behavior that you have stated hold zero tolerance, it is never necessary to treat a terminated employee with anything less than courtesy and respect.

It is never easy for someone to lose a job and the employee often feels humiliated and deeply hurt that they could not meet the practice expectations.  Your purpose is not to demean any individual but to express appreciation for their efforts and to suggest that their particular skill set is not suited to your office needs.  Make sure that you provide your employee with an exit interview and information necessary to obtain Cobra coverage, if your office has provided health insurance or other benefits that the employee may want to continue to receive.  In cases, where immediate dismissal is not an issue, you will want to give the employee some notice prior to their last day of work.  You may want to restrict their computer access during their last days or even simplify their job description.  Assure them that they will be paid, according to the payroll schedule for any last days of work.  Do not hold paychecks hostage, even if your employee did not respond well to their dismissal or chose not to finish out their last days.

Remember the way you treat your former employees reflects as strongly on the practice as your treatment of your present ones.   You will find that even terminated employees will be gracious when it comes to the practice reputation if you treat them with a sense of genuine loss and disappointment that their skills did not match your needs. 

Prescription Drugs - Panacea or Tragedy

Most patients in this country feel that if they schedule a sick visit with their physician and they don't come home with a prescription, then they really weren't sick.  Those white sheets and the pills that come from the local pharmacy are proof positive that going to the doctor was a wise move.  We are a pill freak culture and the drug companies that supply us with our daily doses are laughing all the way to the bank.

Trillions of dollars are made each year by the pharmaceutical companies and there is little reason to wonder why so many drugs are rushed to market each year to keep the cash flowing.  After drugs such as Avandia prove to be fatal to many patients, we are often left to wonder who is overseeing drug trials and how are such good results published with such horrible consequences?   I attended elementary school with a little girl who was missing an arm as a result of Thalidomide, my daughter-in laws cousin died from a prescription heartburn medication, and I saw the effects of Avandia on my own mother.

One answer lies in the fact that the American public has an insatiable demand for immediate gratification.  We feel pain and expect immediate relief, without giving much consideration to the consequences of the medication that we ingest so mindlessly.  Over the years, I have consulted with two physical medicine and rehabilitation practices and during my years there, the staff came to realize just how many drug seeking patients are floating around in the general population.  These individuals may have started out with a real injury or some form of chronic pain.  Instead of seeking some alternative relief after initial doses of medications did not ease their pain, they move instead to a chronic cycle of pills and more pills, using any and all methods to obtain their meds.  Drug seeking patients may move from doctor to doctor and try to fill scripts at different pharmacies to avoid detection.  Luckily, the larger chain pharmacies are now alerting each other when patients try to fill multiple scripts for narcotics.  They will also act to notify the physicians in question, trying to put a stop to what could be a life threatening situation.

More PM&R practices are now using trigger point injections, physical therapy and even acupuncture rather than medication to treat acute and chronic pain.  They are examining the patient's lifestyle, work and home environment and suggesting exercise and ergonomic strategies that will promote a healthier lifestyle where the patient is less prone to injury or exacerbation of pain.  Patient's are often grateful for a more homeopathic approach to their complaints and find that by making small changes in their daily activities, they can become pain free without medication and its associated risks.

Type II diabetic patient should always be encouraged to change their diet and exercise routines before they become one of the millions of Americans whose blood sugar levels are dependent on medication.   The same holds true for those of us who suffer from high cholesterol.  There are some homeopathic remedies, such are red yeast rice, which can lower cholesterol without the side effects of most statins and I have seen cardiologists recommend these over the counter drugs to patients who could not tolerate or refused statin treatment.

It is important for our doctors to adequately explain to patients that viral syndromes do not respond to antibiotic treatment so it is not always necessary to receive medication for a cold or sore throat.  In cases, where serious illness has been ruled out, patients with such problems as chronic headaches or other chronic pain, should be encouraged to seek help from a homeopathic provider before embarking on a future where medication is the only way to alleviate pain.

We are starting to see some progress towards a blend of allopathic and homeopathic treatments in a number of our medical communities.  Physicians and Chiropractors are often working together to treat some chronic pain patients, and many doctors are now embracing the use of acupuncture and herbal therapies with their patients.

All of us are grateful for the extraordinary drugs and vaccines that have kept us healthy and safe from diseases, but we must admit that some of the drugs that come to market may have tragic consequences, and that no drug is without its effect on the human body.  
 

The Insurance Game

Month after month, we, the faithful, pay our insurance premiums or face the probability that we will be denied health care coverage if we should become ill.  All over our country, those who have lost their jobs, or fell on difficult times found that their children could no longer visit their pediatrician, husbands and wives pray nightly that serious illness will not land on their doorstep.

Even those of us lucky enough to have current coverage have to sweat it out every time we need a test or procedure, the recommendation of our physicians not good enough to guarantee us diagnosis and treatment, unless our carriers feel that we should be privileged enough to get a positive nod.

Our physicians wait patiently for reimbursement for services, in a cat and mouse game of how long can we keep our money in the bank before we need to release a check for payment.  How many notes will we request?  Letters of medical necessity?  People are no sicker now than they were forty years ago, when the physician would send a hand written note to the insurance giants and received a check, most times for close to the full amount billed.  How did our physicians and our patients lose the ability to gain assured treatment ?  Who are these guys and what's their problem?

Certainly there is no greater rip-off in the American way of life than car insurance.  We pay month after month for a service we don't use and then get charged an even higher fee if, heaven forbid, we do make a claim.  Think about it for a minute.  Every month, a charge for nothing....  I could understand if our premiums payed for oil changes, or new tires, or a tune-up every six months, but literally we send a check to a strange location for NO service.  Only in America!!!!!  

I propose that for every year we do not make a claim, our total premium, minus a small administrative fee should be refunded in full.  You say you want to boost the economy?  What would be better than getting a check every year on December 31st for driving safely?  Imagine how much of this money would serve as a stimulus to the economy.   Perhaps, instead of billions of dollars in profits each year, the insurance giants would only make millions.  What a damn shame !!!!

It wouldn't be a bad idea to make the same transition with health insurance.  Instead of forming more ACO groups, whose sole purpose is to save money by denying treatment, let's reward our patients for making an effort towards preventative medicine.   No emergency room visits in a year would guarantee you a refund on your yearly premium.  Compliance with testing and physician recommendations would give you another small bonus.  Enrolling in an exercise program - more cash....  Soon, we would have a society where individuals sought treatment to maintain health and prevent illness, rather than using their local emergency room as a refuge for a sore throat because in many cases, emergency care is covered in full.

We expect the American public to pick up the slack for every shortfall in our country and to pretend that they don't have the foggiest notion of the profits made by the insurance companies, year after year.  We expect physicians to render excellence in health care, when their reimbursements are cut again and again.
Right now, we pay a ridiculous amount for gas and home heating oil, but I can assure you that the big shots at Exxon or Mobil are not going hungry to be able to afford their prescription medicine.

In the years to come, we will lose many good physicians and our future students will avoid the study of medicine like the plague.  It's time we stopped dreaming and expecting the American middle class to keep doling out dollars for zero services. 

Women and Health Care

Over the past ten years, we have seen extensive changes in the healthcare industry and those of us involved in dealing with these changes often channel our energy into making sure that our office is in compliance with everything new that comes our way.   We pride ourselves on implementing the details that will make our office state of the art and dedicate ourselves to the difficult challenges that we need to follow carefully.

So many discussions that I have seen recently come from my colleagues who are interested in assuring that medical practices meet today's tough standards.  The discussions that I have seen my brilliant colleagues promote are no doubt helpful and necessary, but sometimes it seems as if we are talking about the best way to organize and run an empty location.  In keeping with this idea, I would like to discuss the disparity that still exists in the diagnosis and treatment of men and women.

Five years ago, I was diagnosed with Graves disease.  For those who are not aware, Graves is basically auto-immune hyperthyroid disease and can pose serious health risks if not treated, or not treated properly.  I was lucky enough to be diagnosed and treated early in the progression of the disease and finally received treatment with radioactive iodine in the hopes of alleviating my symptoms.  This treatment may eventually lead to hypothyroidism and I will need to be treated with other medications to keep me in a normal range.

Hyperthyroidism, like many thyroid disorders can have a neuro-psychological component, which may include anxiety, depression, rapid heart rate and in some cases can manifest itself as bi-polar disorder.
Some Grave's patients may experience these feelings even if their ranges are just slightly abnormal and others may have blood results that are off the charts and remain unaware of the disease until they suffer some serious health risks.

My experiences with Graves were the first time I noticed how difficult it can be for physicians to recognize and treat the components of disease that are not strictly physical.   Indeed, at times over the past five years I felt like one of Freud's garden variety neurotics anytime I would express a symptom that was outside the physician's realm of expertise.   If I expressed the fact that I felt more anxious than usual, the physician would state: "People get anxious for all kinds of reasons!"  It got so bad, that I found myself searching the internet looking for research that would convince me that I was not neurotic or crazy.   I looked at message boards where Grave's patients discussed their symptoms and noted that these patients were meeting with the same denial from their physicians.  I finally decided to seek help from a female doctor who assured me that the symptoms that I was experiencing were all part of the Grave's syndrome.

As a younger woman, I was treated by the same family physician who treated my parents and grandparents.  He knew our entire family history, including the state of our mental as well as physical health and was able to diagnosis and provide treatment that included both our physical symptoms as well as our genetic pre-disposition to certain diseases.  That time is long past and it is unfortunate that medical care has become so specialized and so limited that patient treatment is no longer a consideration of the individual as a whole, but rather Part A and Part B and all the other parts that make us who we are demand that we see an entire arsenal of doctors to keep ourselves healthy and happy.

I have accompanied my husband on many of his doctor visits and have noted the clear difference in the way physicians treat his complaints.  They seem to listen more carefully and prescribe treatment for the slightest of his complaints.  Since I have worked in this industry for so long, I know many of these physicians and even this fact has not made much of a difference.  I am not alone in this feeling and have found that many of the women I know make it a priority to see a female physician for all their health care needs.

In order for us to provide our patients with excellence in health care as we move forward into the future, we need to see our patients not merely as a symptom, but as an entire individual who may need help with both the physical and psychological implications of disease.  A quick family history will not help us in this goal.  We need to spend more time listening to our patients and to assure that we do not merely discharge them to another provider if we are outside our comfort zone.

Missing Billing Sheets

Despite the push forward to electronic medical records, many physicians in my New York area are still using the old chart system.  Some physicians are not even ready to e-prescribe and have told me that when the penalty matches the cost of the system, they will think about spending the money to update and participate.

I have implemented my "Daily Data Sheet" in the routine of many practices.  It is available in an installment of this blog and has succeeded in increasing the amount of daily co-payments that are collected and has tried to assure that the amount of billing sheets matches the amount of patients that are logged in each day after they sign in for services.  The purpose of the data sheet is two-fold.  One is to prompt the front desk or check-in to collect the correct co-payment amount for each purpose.  The second is to assure that each patient that signs in has an appropriate encounter for his or her visit.  Herein may lie the rub!

Some physicians do not think it is a priority to finish their billing sheets each day and in some respects you can hardly blame them.  With the cuts in reimbursements, more patient visits are required to keep the financial aspect of the practice on track.  These means more patients and less hours in a normal work day.   Secondly, the insurance companies are requesting patients notes for almost everything and this means that a short progress note, made in the chart, is no longer viable, even for the quickest of return visits.  Consequently, for each minute that the doctor is dictating his patient notes, patients wait in the exam room or if the physician jots a quick progress note, with the intention of finishing his dictation after business hours, he may find himself without any other life but the one he pursues in the office.

This can present a serious problem, especially if the practice is farming its billing out to a service.  The daily package often goes out incomplete.  The physician reasons that if the majority of his claims go out complete, than he will catch up in a few days and this won't present a serious problem.  Wrong !!!!
Your daily billing package should always go out complete or you will find yourself mired in paperwork with no end in sight.   Your billing company will be contacting you daily or weekly to find out if the patient listed on the data sheet was seen and if so, where is the encounter ?   If these issues are not immediately addressed, you will receive the same request from the billing company over and over again, and find your office pulling the same charts, copying the same letters, and sending the same notes again and again, wasting valuable time.

Saving five charts today means ten charts tomorrow and so on and so on, until the doctor is literally buried in unfinished work.  An incomplete billing package means that encounters from June will be completed in August and this will have a cumulative effect on your daily revenue.

What's the solution?  Short of taking charts home on the weekends, which many physicians do and which is not a good practice, or in keeping with HIPAA policies, the answer is to make time to finish all of your dictation the same day as you see the patients.   Regardless of how you prepare chart notes, the doctor always knows what services he renders to each patient.  Therefore, a completed billing sheet should accompany each patient exit.  If notes are necessary, you can jot a quick progress note in the chart and mark the outside of the chart with a sticky note that will alert the physician that he has not dictated for this particular patient.  For those truly fanatical physicians, you can make a copy of the encounter and mark it with a D- for dictation and place it on the outside of the chart, removing and disposing of it when the dictation is completed.

I have seen doctors keep a record of patient visits on the outside cover of the chart, noting special procedures performed.  You could initial this medical log sheet every time you dictate on a patient and be assured that all work is completed.  Those charts without an initial complete, can be placed to the side and dictated at a more convenient time in the physicians schedule.  This outer chart logging of procedures also reminds the doctor when a patient needs a follow up test or procedure, without them having to explore all the chart pages individually.  This method also serves to make life easier when calling patients to remind them that they need a return visit.

At the end of each day of patient appointments, the number of patients seen should equal the number of billing sheets that are turned over to be processed.  While this may seem so old fashioned to those who are already entrenched in the spirit of the electronic world, it is essential to those physicians who have not yet made the leap.  While so many doctors get comfortable in their old ways of doing business, the business world of medicine is leaving them behind.  Whatever it takes to get the job accomplished and to prevent the duplication of tasks is mandatory if your practice is going to survive the health care changes that are here now and in the future.