Manage My Practice

1. Everyone is waiting for the other shoe to drop on Medicare payments.
2. Private practices may not have the in-house expertise to implement an EMR and may not be able to afford a consultant (although some states are receiving grants to help practices – check your state’s grant here.)
3. There is a lot of confusion on the parts of Meaningful Use that have been clarified and of course, on those that haven’t.
4. Administrators are distracted by RAC, PECOS, HIPAA , PQRI, eRx and RCM.
5. Some practices have spent years avoiding Medicare and Medicaid patients and now don’t have the patient numbers to participate.
6. Everyone and their uncle is selling an EMR – who can tell the long-timers who are about to be bought from the short-timers who might last forever?
7. Physicians are worried about the drop in production that (some say) happens when a practice launches an EMR.
8. There seems to be as many horror stories as there are success stories with EMRs.
9. Practices that are affiliated with a hospital are nervous about tying themselves to the hospital in such a serious way as hopping on their EMR package.
10. Because two practices can have absolutely opposite experiences with the same EMR, no one can find consistent recommendations for any single product. (It’s not the product, it’s the implementation!)
11. Bonus Reason: lots of people are confused about how to qualify for the ARRA money (read my post about this here.)

HEALTHCARE BILL IMPACT ON INDIVIDUALS AND RAGE

A number of people asked me about the impact of health reform on them as individuals. Here is a great story from the Atlanta Journal-Constitution that takes specific examples of individuals and families and speculates on how the new bill(s) will impact them.

For 2010, the changes are minimal:

• Dependent children may be covered by their parents’ health insurance policies until age 26.
• A high-risk insurance pool will open for people with pre-existing conditions who have been uninsured for six months.
• In 2011 Medicare will pay for an annual checkup, and deductibles and co-payments for many preventive services and screenings will be eliminated. The Medicare prescription drug doughnut hole will gradually narrow every year until it is eliminated in 2020. People in the “doughnut hole” could receive a $250 rebate this year.

I have to say that I’ve been dumbfounded by the fury raised over the passage of the new healthcare legislation. I realize that the bills separate people into winners (uninsured, providers with uncompensated charity care, patients with pre-existing conditions, Medicare patients, providers who see Medicaid patients, families with adult children, etc.) and losers (companies who have to pony up more money for their retired employees, insurance companies, illegal immigrants, high wage earners, etc.), but this story placed the fury into a different perspective for me. It’s a good read.

CONCIERGE PRACTICES

What does healthcare reform mean for the physician practice? Many are predicting the rise of concierge practices (also called boutique medicine, retainer practices, VIP medicine and cash practices) as physicians find they cannot survive if their patient population is predominantly Medicare, Medicaid and uninsured patients. Concierge practices fall into two categories:

• The first operates on an insurance+ model, which means that the practice accepts and files the insurance for the patient, but also requires an additional out-of-pocket fee of anywhere from $1500 to $1800 per year to be a patient of the practice. The fee is to cover services that Medicare and commercial insurance do not, such as physicals, phone consultations, wellness counseling and patient education.
• The second operates on a strictly cash basis and the practice does not accept or file any insurance for the patient. The patient pays a flat fee per year for care (usually in the $5,000 to $15,000 range) and all primary care is provided for that amount. The patient still needs to carry insurance for prescriptions, hospital services and sub-specialist services. Imagine being a manager in this type of practice – no pre-authorizations, no insurance department, no eligibility checking, no refunds…

Concierge medicine has not been around that long, but it is growing in popularity by leaps and bounds. The first acknowledged concierge practice was formed in 1996 in the Pacific Northwest. In 2002, CMS (Centers for Medicare and Medicaid) published a memo stating that physicians may enter into retainer agreements with their patients as long as these agreements do not violate any Medicare requirements. In 2003, the Department of Health and Human Services ruled that concierge medical practices are not illegal. Today, there are approximately 5,000 physicians using the concierge model in the United States today.

MEDICARE CUTS, MEDICARE CLAIMS AND DON BERWICK

Shortly after all the shouting and voting on healthcare reform was over, Congress recessed for two weeks leaving the controversy over the 21.5% cuts required by the SGR formula still unsettled. CMS has advised the MACs to again hold claims for services provided from April 1 to April 10 to give Congress a chance to get back to work and back to voting for an additional delay (or not) for the cuts. If the cuts are allowed to stand, many physicians will start making their own cuts by minimizing the number of Medicare and Medicaid patients they will see.

Amidst this craziness, a voice of sanity is heard and it is Donald Berwick, MD, current President of the Institute for Healthcare Improvement (IHI) and probable Obama pick for the head of CMS. If you don’t know Don Berwick or the IHI, click here to read an interview with him about the IHI’s “100,000 Lives Campaign” or watch the video below of him speaking about the dimensions of quality. Good stuff!

Version 16.1 of the CCI edit database is scheduled to be effective on April 1, 2010.There are 2,054 new edit pairs effective for this release.35 of these are effective retroactive to October 1, 2009.This means that if you billed for and were paid on one or more of these retroactive edits, you may be subject to repayment.

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142 edit pairs are reported as terminated (no longer effective) for this release.Four are terminated retroactive to December 31, 2005; four are retroactive to December 31, 2006 and 76 are shown as terminated retroactive to December 31, 2007.I guess this means that if you were denied due to a CCI edit pair during these periods, you should be able to resubmit the claim and get paid.

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You can expect 1,947 changes with respect to the modifier indicator with 1,892 going from an indicator of 0 (no modifier permitted) to an indicator of 1 (modifier permitted).55 edit pairs report a change in the modifier indicator from a 1 to a 0.

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In total, there are 1,337 duplicate edit pairs in the database. These are records that were made effective at one point, then terminated and then made effective again.There are also currently 5,309 swapped pairs.These are edit pairs that were introduced in one order (i.e., 99350 as column 1 and 96416 as column 2), terminated and then re-activated in the opposite order (i.e., 96416 as column 1 and 99350 as column 2).

As I write this Sunday night I am listening to the US House of Representatives’ discussion/posturing prior to a ‘yes” or “no” vote for the Senate’s healthcare reform bill H. R. 3590. I don’t usually listen to CNN Live, but I want to remember this moment as I think it is the beginning of significant change in healthcare.

I’m not sure what this change will be, but many things that have been status quo for healthcare during my career might change almost beyond recognition by the time I retire. This, I think, is a good thing. I don’t think the current system is bad, but I sure think it could be better. As with any change, there will be good things, bad things, and unintended good and bad things. It should be fascinating.

Discussion has now timed out and the representatives are voting; 216 votes are needed to pass. The vote has just been announced (10:45 p.m.) and it is 219 Yeas to 210 Nays and the bill is passed! The next step is for it to be signed into law by President Obama, which might happen tonight or tomorrow.

Now the representatives are voting on H.R. 4872 – “The Health Care and Education Affordability Reconciliation Act of 2010″ which contains fixes to H.R. 3590 that have been negotiated between the two chambers. The bill has just passed (11:37 p.m.) with 220 Yeas and 211 Nays! 4872 will now go to the Senate for a vote which some are predicting will pass as early as Tuesday.

President Obama spoke from the White House after the votes and said “Tonight we answered the call of history.” The passage of these bills has been compared to the passage of Medicare in 1965 and the passage of Social Security in 1935.

Here are details of both bills.

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Details on H.R. 3590 Patient Protection and Affordable Care Act

Cost: $940 billion over ten years.

Deficit: Would reduce the deficit by $143 billion over the first ten years. Would reduce the deficit by $1.2 trillion dollars in the second ten years.

Coverage: Would expand coverage to 32 million Americans who are currently uninsured.

Health Insurance Exchanges:

• The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 percent and 400 percent of poverty level.
• Separate exchanges would be created for small businesses to purchase coverage — effective 2014.
• Funding available to states to establish exchanges within one year of enactment and until January 1, 2015.

Subsidies: Individuals and families who make between 100 percent – 400 percent of the Federal Poverty Level (FPL) and want to purchase their own health insurance on an exchange are eligible for subsidies. They cannot be eligible for Medicare, Medicaid and cannot be covered by an employer. Eligible buyers receive premium credits and there is a cap for how much they have to contribute to their premiums on a sliding scale. Federal Poverty Level for family of four is $22,050.

Paying for the Plan:

• Medicare Payroll tax on investment income — Starting in 2012, the Medicare Payroll Tax will be expanded to include unearned income. That will be a 3.8 percent tax on investment income for families making more than $250,000 per year ($200,000 for individuals).
• Excise Tax — Beginning in 2018, insurance companies will pay a 40 percent excise tax on so-called “Cadillac” high-end insurance plans worth over $27,500 for families ($10,200 for individuals). Dental and vision plans are exempt and will not be counted in the total cost of a family’s plan.
• Tanning Tax — 10 percent excise tax on indoor tanning services.

Medicare:

• Closes the Medicare prescription drug “donut hole” by 2020. Seniors who hit the donut hole by 2010 will receive a $250 rebate.
• Beginning in 2011, seniors in the gap will receive a 50 percent discount on brand name drugs. The bill also includes $500 billion in Medicare cuts over the next decade.

Medicaid: Expands Medicaid to include 133 percent of federal poverty level which is $29,327 for a family of four.

• Requires states to expand Medicaid to include childless adults starting in 2014.
• Federal Government pays 100 percent of costs for covering newly eligible individuals through 2016.
• Illegal immigrants are not eligible for Medicaid.

Insurance Reforms:

• Six months after enactment, insurance companies can no longer deny children coverage based on a preexisting condition.
• Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions.
• Insurance companies must allow children to stay on their parent’s insurance plans through age 26.

Abortion:

• The bill segregates private insurance premium funds from taxpayer funds. Individuals would have to pay for abortion coverage by making two separate payments, private funds would have to be kept in a separate account from federal and taxpayer funds.
• No health care plan would be required to offer abortion coverage. States could pass legislation choosing to opt out of offering abortion coverage through the exchange.

**Separately, anti-abortion Democrats worked out language with the White House on an executive order that would state that no federal funds can be used to pay for abortions except in the case of rape, incest or health of the mother. (Read more here)

Individual Mandate: In 2014, everyone must purchase health insurance or face a $695 annual fine. There are some exceptions for low-income people.

Employer Mandate: Technically, there is no employer mandate. Employers with more than 50 employees must provide health insurance or pay a fine of $2000 per worker each year if any worker receives federal subsidies to purchase health insurance. Fines applied to entire number of employees minus some allowances.

Immigration: Illegal immigrants will not be allowed to buy health insurance in the exchanges — even if they pay completely with their own money.

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Details on H.R. 4872 – “The Health Care and Education Affordability Reconciliation Act of 2010″ (fixes to 3590)

COST: $940 billion over 10 years, according to the Congressional Budget Office.

HOW MANY COVERED: 32 million uninsured. Major coverage expansion begins in 2014. When fully phased in, 95 percent of eligible Americans would have coverage, compared with 83 percent today.

INSURANCE MANDATE: Almost everyone is required to be insured or else pay a fine. There is an exemption for low-income people. Mandate takes effect in 2014.

INSURANCE MARKET REFORMS: Major consumer safeguards take effect in 2014. Insurers prohibited from denying coverage to people with medical problems or charging them more. Higher premiums for women would be banned. Starting this year, insurers would be forbidden from placing lifetime dollar limits on policies, and from denying coverage to children because of pre-existing medical problems. Parents would be able to keep older kids on their policies up to age 26. A new high-risk pool would offer coverage to uninsured people with medical problems until 2014, when the coverage expansion goes into high gear.

MEDICAID: Expands the federal-state Medicaid insurance program for the poor to cover people with incomes up to 133 percent of the federal poverty level, $29,327 a year for a family of four. Childless adults would be covered for the first time, starting in 2014. The federal government would pay 100 percent of the tab for covering newly eligible individuals through 2016. A special deal that would have given Nebraska 100 percent federal financing for newly eligible Medicaid recipients in perpetuity is eliminated. A different, one-time deal negotiated by Democratic Sen. Mary Landrieu for her state, Louisiana, worth as much as $300 million, remains.

TAXES: Dramatically scales back a Senate-passed tax on high-cost insurance plans that was opposed by House Democrats and labor unions. The tax would be delayed until 2018, and the thresholds at which it is imposed would be $10,200 for individuals and $27,500 for families. To make up for the lost revenue, the bill applies an increased Medicare payroll tax to investment income as well as wages for individuals making more than $200,000, or married couples above $250,000. The tax on investment income would be 3.8 percent.

PRESCRIPTION DRUGS: Gradually closes the doughnut hole coverage gap in the Medicare prescription drug benefit that seniors fall into once they have spent $2,830. Seniors who hit the gap this year will receive a $250 rebate. Beginning in 2011, seniors in the gap receive a discount on brand name drugs, initially 50 percent off. When the gap is completely eliminated in 2020, seniors will still be responsible for 25 percent of the cost of their medications until Medicares catastrophic coverage kicks in.

EMPLOYER RESPONSIBILITY: As in the Senate bill, businesses are not required to offer coverage. Instead, employers are hit with a fee if the government subsidizes their workers coverage. The $2,000-per-employee fee would be assessed on the companys entire workforce, minus an allowance. Companies with 50 or fewer workers are exempt from the requirement. Part-time workers are included in the calculations, counting two part-timers as one full-time worker.

SUBSIDIES: The proposal provides more generous tax credits for purchasing insurance than the original Senate bill did. The aid is available on a sliding scale for households making up to four times the federal poverty level, $88,200 for a family of four. Premiums for a family of four making $44,000 would be capped at around 6 percent of income.

HOW YOU CHOOSE YOUR HEALTH INSURANCE: Small businesses, the self-employed and the uninsured could pick a plan offered through new state-based purchasing pools called exchanges, opening for business in 2014. The exchanges would offer the same kind of purchasing power that employees of big companies benefit from. People working for medium-to-large firms would not see major changes. But if they lose their jobs or strike out on their own, they may be eligible for subsidized coverage through the exchange.

GOVERNMENT-RUN PLAN: No government-run insurance plan. People purchasing coverage through the new insurance exchanges would have the option of signing up for national plans overseen by the federal office that manages the health plans available to members of Congress. Those plans would be private, but one would have to be nonprofit.

ABORTION: The proposal keeps the abortion provision in the Senate bill. Abortion opponents disagree on whether restrictions on taxpayer funding go far enough. The bill tries to maintain a strict separation between taxpayer dollars and private premiums that would pay for abortion coverage. No health plan would be required to cover abortion. In plans that do cover abortion, policyholders would have to pay for it separately, and that money would have to be kept in a separate account from taxpayer money. States could ban abortion coverage in plans offered through the exchange. Exceptions would be made for cases of rape, incest and danger to the life of the mother.

STUDENT LOAN OVERHAUL: Requires the government to originate student loans, closing out a role for banks and other private lenders who charge a fee. The savings projected to be more than $60 billion over a decade are plowed into higher Pell Grants for needy college students and increased support for historically black colleges.

MEDICARE: Extends Medicares solvency by at least nine years and reduces the rate of its growth by 1.4 percent, while closing the doughnut hole for seniors, meaning there will no longer be a gap in coverage of medication.

With huge growth in 2009, social media is not just a passing trend used by online marketers; its a real, effective method of communicating ideas, sharing information and connecting with people across all age and socioeconomic groups. Healthcare, while slower to adopt the social media wave than other industries, is coming to realize the potential social media tools provide to develop connections with patients, potential patients, along with other physicians and healthcare leaders around the world.

What are some of the driving forces behind this explosion in popularity? One reason is that as consumers, were no longer trusting of advertising and we dont want to be marketed to, we want to be engaged, build a relationship, make the company earn our trust and hear our friends or familys review of their experiences. In fact, studies show that today, only 14% of people trust advertising, whereas 78% of people trust recommendations and referrals. Companies are using social media outlets to build relationships, trust and encourage recommendations and referrals from their engaged consumer base. As practice, hospital and physician growth are so strongly correlated to patient referral and recommendation volumes, it is only natural healthcare organizations look to social media outlets to continue to foster patient relationships and increase referral volumes.

As of February 2010, where is the healthcare industry in its adoption of this social media explosion? Larger organizations and health systems are utilizing the power to connect, share and engage their patients. While, on average, smaller private physician groups and individual physician offices are still slightly hesitant and dipping their toes in the social media pool cautiously. One can understand why healthcare professionals do need to take a more strategic approach to interacting and engaging patients online with potential HIPAA privacy issues and other challenges looming. However, with a carefully crafted social media strategy, many health organizations are realizing the benefits of becoming more accessible in their marketing and reaching out to inform, educate and build trust with patients. According to Ed Bennett (edbennet.org) hospitals are currently at a 53% adoption rate, with 336 Facebook pages, 430 Twitter Accounts, 254 YouTube Channels and 70 blogs. In total, 557 health systems are reported to be participating in some capacity with social media, with the term social media encapsulating many forms and tools, including Facebook, Twitter, YouTube, blogs, LinkedIn, Flickr, and a number of patient forums.

How are healthcare organizations using these tools effectively? Lets focus on the top three tools currently adopted and being utilized in the healthcare social media sector.

Facebook: Physician practices and health systems alike are using Facebook as a dynamic, community-based website. It has become a place where physicians and leaders can post timely, organic or professional videos to educate patients and also connect on a more personal level. As a valuable resource for health information sharing, many organizations are taking the embarrassment out of sensitive subject matter and addressing specific medical problems, questions and issues for patients. Also, introductions to staff members and tours of the facilities are assisting organizations with connecting with their patients outside the four walls of their office and building rapport before patients even arrive for their appointment. Practices are also encouraging patients to participate and engage on their site through discussions and contests. Private practitioners are more likely to start their social media strategy with just a Facebook Fan Page, while larger health systems and hospitals are embracing other social media tools in combination with Facebook in their initial strategy.

Twitter: Twitter is being adopted quickly by the larger health systems as a way to share information, publicize events like health screenings, fairs and clinics and also connect with other health organizations. I like to think of it as a public relations channel for these hospital and health systems. Whats great is that in short, 140 character or less tweets, these organizations are sharing a wealth of information to their patients and those patients are finding ways to access this health information and the system like never before. Overall the smaller, private practitioners are not as quick to adopt Twitter as they are a practice website or even Facebook, but many are starting to realize the benefits of utilizing this community as a way to share their expertise and knowledge, along with driving traffic to their websites.

YouTube: Healthcare organizations are using YouTube like their own, private television station that can be shared with millions of viewers across the world. Again, more popular amongst the larger health organizations, videos of procedures, interviews with clinicians, tours of new facilities and patient testimonials are being posted in a searchable, user-friendly manner to continue to enhance brand awareness, build trust and gain patient loyalty. This social media tool can be used much like Facebook, easing patient fears and answering tough or embarrassing questions. It can also give patients a visual insight into the facility so they know what to expect before arriving at an appointment or for a procedure. It can act as an online referral source, highlighting patients that have had outstanding experiences and are recommending that organization to over a billion of their closest friends and family online. YouTube is the second largest search engine and healthcare professionals are quickly utilizing its power to share and connect with patients.

The fact of the matter is that for all industries, including healthcare, social media is both a curse and a blessing. Patients, who are now consumers with choices, can post content and interact freely with their physicians and their hospitals, sharing both outstanding experiences and negative experiences. Many health professionals are worried about their vulnerability, but social media is real life, online. As 2010 progresses, youll be seeing more and more attention placed on social media by healthcare professionals and by the end of the year, it will be a necessity for organizations to be participating and engaging online, or be left out.

Here’s a companion piece to my recent list “50 Ways to Attract New Patients to Your Practice.” Once a patient makes an appointment to see your provider, be sure to keep them coming back by wowing them with your customer service.

FRIENDLY

1. Introduce yourself to patients. “Hi, I’m Jane and I am Dr. Smith’s assistant and I’ll be working with you today.”
2. Wear a visible and readable name tag with your first name in large letters.
3. Smile and speak to all patients, family members, and vendors in the practice. If anyone has a question mark on their face or is hesitating, be sure and ask “May I help you?”
4. Always smile while speaking on the phone and always introduce yourself. “Good morning, Dr. Smith’s Practice, this is Jane. How may I help you?”
5. Providers should always shake hands with patients and others in the exam room. That first touch is so important!
6. New patients should receive a special welcome and should receive special attention, remembering that the patient doesn’t know how the practice works.
7. Have a patient information brochure that describes your practice’s services, providers, and policies on medication refills, after-hours services, filing insurance, filling out forms, and making payments.
8. Have multiple ways for patients to complete their registration information – forms mailed to them, online completion, completion in the practice at a computer kiosk, completion at the practice with personal help, or pre-registration by phone.
9. Ask patients how they would like you to communicate with them about lab/test results – telephone (home, work or cell), email, mail, phone retrieval and let them know (in writing if possible) when they should call if they haven’t heard from you.
10. Place tablets and pens in the waiting area so patients can write down questions for their provider while they are waiting.
11. Have computers in the waiting area for patients to use. Have Wifi for patients to use their own computers while waiting. Have instructions available for using the Internet to look up medical information and provide a written list of medical websites that your providers recommend. Place this information on your website.
12. Prior to touching a patient in the exam room, assistants and providers should wash or sanitize their hands and be sure the patient can see them doing it. Additionally, it’s good to say to the patient “Let me wash/sanitize my hands before I examine you.” so the patient knows you are practicing good infection control.
13. Provide staff with patient questions and preferred answers so everyone can answer most questions and no one tells patients “That’s our policy.”
14. Have a water fountain with cups in the reception area.
15. If you have a television in the reception area, make sure patients can change the channel or the volume.
16. Invite patients to become a friend of the practice on Facebook and communicate regularly with your patients keeping them up-to-date on practice news, health news and local events.
17. Pretend that every patient is a mystery shopper (and they are!) and treat them like a VIP.
18. Give patients a way to reach a real person on the phone, and a way to go through the automated attendant. Remember that not every patient wants or needs the same thing.
19. Have an annual open house or patient appreciation day and do blood pressure checks or home safety checklists. Serve healthy snacks and visit with your patients.
20. Call 2 days before the patient’s appointment and remind them of the date and time of the appointment. Ask them to press “1″ if they plan to keep the appointment and “2″ if they would like to cancel the appointment.
21. When the patient is checking out, ask “Were all your questions answered today?”
22. If you give out wrapped candies, make sure to supply sugar-free candies as well as regular.

EASY

1. Have multiple ways for patients to complete their registration information – forms mailed to them, online completion, completion in the practice at a computer kiosk, completion at the practice with personal help, or pre-registration by phone.
2. If your parking lot is shared with other businesses, make sure there are parking spaces marked specifically for your patients.
3. Use wayfinding systems to help patients navigate around your practice. Many patients will not read signs, but will identify symbols or pictures if you explain the system. Use themes for providers or services to help patients find their way when coming out of the bathroom or lab. Carpet or tile designs and art pieces can also be used creatively to direct patients in and out.
4. If you have a choice, front-load your practice space with patient rooms and leave the furthest rooms for non-patient activities such as offices and staff rooms.
5. Give patients their medication list and problem list on a wallet-sized card.
6. Bring services to the patient exam room instead of having your patients move around the practice.
7. Offer numerous payment options including financial assistance, Medicaid enrollment, medical loans, checking account drafts through debit cards and credit card drafts.
8. Offer a “chat with the insurance lady” feature on your secure portal.
9. Have new patient pre-appointments for patients to meet with staff to take baseline vitals, log medications and prep chart prior to their first visit.
10. Have maps available for patients for any place you might be referring them to, whether in town or out of town.
11. Give patients a sheet to take with them that lists medication changes, future appointments, referrals and has a place for them to write down questions between appointments.
12. Give patients a customized sheet that shows the name of their medication, what the medication looks like and how to take the medication.
13. Send patients emails or letters and post on your website any information relating to hot topics in the news – vaccines, radiation exposure, etc.
14. Make your website a one-stop destination for practice information, health information, practice forms and secure messaging with the practice.

UNEXPECTED

1. If a patient has a particularly unhappy experience in your practice: a long wait, a mixed-up appointment, give them a gift card with a sincere apology.
2. Hand-write an apology to a patient who has had an bad experience with a staff member.
3. Validate parking for patients if they have to pay to park to come to your practice.
4. Ask patients to rate your service – have forms in the exam rooms and in the waiting room and in new patient packets and on your website.
5. If your practice is near a shopping or eating area, give patients a pager to buzz or ring when it is time to see the provider.
6. Use your EMR or voice recognition to complete the patient’s medical record and print them a copy of it to take with them when they leave the exam room.
7. Have a blanket warmer to give patients who are sick, or have come in on a gurney a warm blanket.
8. Go through the daily obituaries to know when patients have passed and send condolences to the family.
9. Have an option on your phone system to speak to the manager and take complaints personally. Answer all complaints and call any patients back who leave messages, and any patients that employees tell you had a problem at the practice.
10. Call new patients the day after their appointment to see if they had any questions after their first visit.
11. Call particularly sick patients the day after an appointment to see if they are improving. (Thanks to Kristen Baird.)
12. Give patients who call a benchmark for when they will hear back from you (2 hours for same-day visits, 6 hours for questions, etc.) and exceed your own benchmarks.
13. Have a mystery shopper come to your practice and tell you what you don’t know about your practice.
14. Send your patients a birthday card.

What do you do in your practice that is Friendly, Easy for patients or Unexpected?

Congratulations on your promotion to Office Manager!

It can be very hard to successfully move from being a co-worker to being the office manager, but it can definitely be done. It took me a long time to be able to separate my relationships with the staff from my responsibilities as a manager. I tell people who work for me that if we have a personal friendship, it will in no way change any decision I make as a manager and I stick to that.

This is my recommendation:
Meet with each of the staff one on one and talk to them about your concerns. Tell them you value their friendship and the relationship you’ve had, but in your new role you might be called upon to fulfill some duties that they would classify as “unfriendlike.” Let them know that you are taking your new responsibilities seriously and that you will need to protect the organization first and foremost. Tell them that the best outcome for everyone is a win-win situation where the employee and the organization are both winners, but if it comes down to a hard decision, you will need to act in the best interest of the practice.

As far as how you act:
Read my article on eating lunch with the staff. Do not get drawn into discussions about work with the staff when at social events. Try never to drink with co-workers so you don’t say something you’ll regret in the morning! No matter what, keep things confidential. Be careful what you share, even with the physicians, as they sometimes are unable to keep confidences. Make sure to tell the same thing to all staff, for instance, put policy changes or protocol changes in writing so everyone hears the same thing. Be very careful to not be seen as having favorites.

I hope this helps and please write back with more questions!

NOTE: Read my latest post on how to register and attest for the EHR Incentive Programs here.

Where Did the Idea of Meaningful Use of Electronic Medical Records Come From?

The American Recovery and Reinvestment Act of 2009 was signed by President Obama on February 17, 2009. The Law includes the Health Information Technology for Economic and Clinical Health Act or the HITECH Act. The HITECH Act establishes programs under Medicare and Medicaid to provide incentive payments for the Meaningful Use of Certified Electronic Health Records technology.

The goal of the HITECH legislation is to improve healthcare outcomes, to facilitate access to care and to simplify care. It is believed that the installation of electronic health records in medical practices is only the beginning. The goals of HITECH will be met when the EHR is used in a meaningful way.

What is Meaningful Use (MU)?

There are three identified components of Stage I Meaningful Use. They are:

1. Use of a certified EHR in a meaningful manner such as e-prescribing.
2. Use of Certified EHR Technology for the exchange of health information (exchange data with other providers of care or business partners such labs or pharmacies)
3. Use of Certified EHR Technology to submit clinical quality and other measures.

The first stage of Meaningful Use is capturing and sharing the data. Meaningful Use Stage II is advanced clinical processes and Stage III is starting to look Meaningful Use of an EHR in the context of improved healthcare outcomes.

There are 25 specific criteria for MU Stage I listed in this article in Healthcare IT News:

[1] Objective: Use CPOE (Computerized Physician Order Entry)
Measure: CPOE is used for at least 80 percent of all orders

[2] Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The EP (Eligible Provider) has enabled this functionality

[3] Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data.

[4] Objective: Generate and transmit permissible prescriptions electronically (eRx).
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

[5] Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of none if the patient is not currently prescribed any medication) recorded as structured data.

[6] Objective: Maintain active medication allergy list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of none if the patient has no medication allergies) recorded as structured data.

[7] Objective: Record demographics.
Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data

[8] Objective: Record and chart changes in vital signs.
Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.

[9] Objective: Record smoking status for patients 13 years old or older
Measure: At least 80 percent of all unique patients 13 years old or older seen by the EP smoking status recorded

[10] Objective: Incorporate clinical lab-test results into EHR as structured data.
Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

[11] Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
Measure: Generate at least one report listing patients of the EP with a specific condition.

Have the Details of MU been finalized?

The comment period for the NPRM (Notice of Proposed Rule Making) for Meaningful Use is currently open but will close on March 15, 2010. You can read the NPRM here. Many individuals and organizations have expressed concern that the timeline for implementing EHR and meeting MU criteria is too short for the majority of providers. The American Academy of Family Physicians (AAFP) recently sent a 7-page letter to acting CMS Administrator Charlene Frizzera (see story here) that included the following concerns:

1. The administrative burden of reporting computerized physician order entry measures is excessive to the point of being unachievable for most eligible providers.
2. The rule could require manually entering results from laboratories that don’t have an interoperable interface with the physician’s electronic health record.
3. The term health information is used throughout the proposed rule, but is never defined.
4. A requirement that a patient’s health information be shared with that patient within 48 hours doesn’t take in account that physicians or their staff may not be able to process the information if that 48-hour period includes weekend days.
5. There is no incentive for physicians who meet less than 100% of the proposed requirements, so it is an all-or-nothing approach.

The Medical Group Management Association recently surveyed (see Modern Healthcare story here) 445 physician practice administrators in February 2010 with the following feedback:

1. Nearly all are aware of the upcoming incentive programs for meaningful use of electronic health records, but fear the programs will reduce physician productivity.
2. 68% of respondents expect physician productivity will decrease if all 25 proposed meaningful use criteria are implemented.
3. Nearly one-third believe the decrease in productivity will be greater than 10 percent.
4. Almost 25% of practices without an EHR doubt some of their providers will ever attempt to qualify for incentives.
5. Among practices with an EHR, nearly 84 percent believe some of their physicians will attempt to qualify for Medicare or Medicaid incentives by the end of 2011.

How Do I Comment on the MU Standard?

You can submit your comments on the NPRM on MU here.

You can read comments already submitted here.

How Do I Know if My EHR is Certified?

No EHRs have been certified for the CMS Incentive Program and the certifying bodies have not yet been announced. It seems reasonable that CCHIT will be one certifying body, but there are expected to be others. If your vendor tells you that his EHR is certified before the rule has been finalized and the certifying bodies have been announced, ask him “For what?”

What Does it Mean to Be Eligible? (description courtesy of Everything HITECH)

This term encompasses three general types of payers to establish eligibility: 1) Medicare Fee For Services (FFS), 2) Medicare Advantage (MA) and 3) Medicaid.

For hospitals tobe eligible, they can be acute care (excluding long term care facilities), critical access hospitals, children’s hospitals.

For providers, these include non-hospital-basedphysicians who receive reimbursement through Medicare FFS program or a contractual relationship with a qualifying MA organization. The Act defines the term “hospital based” eligible professional to mean an EP such as a pathologist, anesthesiologist,or emergency physician, who furnishes substantially all of his or her Medicare covered professional services during the relevant EHR reporting period in a hospital setting (whether inpatient or outpatient) through the use of the facilities and equipment of the hospital, including the hospitals qualified EHR’s (Fed Reg p. 1905). The determining factor is the site of service as to whether the service is hospital based or not. If the EP provides at least 90 % of their services in a hospital inpatient, hospital outpatient or hospital emergency room setting (Point of Service codes 21, 22, 23), then they are considered a hospital based EP and not eligible for EHR incentive payments (i.e. providing substantially all of his or her Medicare covered professional services).

There is a difference between Medicare and Medicaid when it comes to defining an eligible professional for EHR incentive payment purposes. Medicare defines an eligible professional as (Fed Reg p. 1996):

1. doctor of medicine or doctor of osteopathy
2. doctor of dental surgery or dental medicine
3. doctor of podiatric medicine
4. doctor of optometry
5. chiropractor

Medicaid, on on the other hand, defines an eligible professional as (Fed Reg p. 2001):

1. physician
2. dentist
3. certified nurse-midwife
4. nurse practitioner
5. physician assistant practicing in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic, led by a physician assistant.

What are the Guidelines for Providing Patients With Their Medical Records Electronically?

Under HIPAA, patients currently have the ability to access their medical records. Meaningful Use does not change HIPAA in that regard. You may charge patients for the expense related to providing paper or electronic medical records. Each state has its own schedule for charging for medical records (state-by-state schedule here.)

Do Eligible Providers Have to be Participating With Medicare to Receive the Incentive Money?

No, the eligibility requirements only relate to the benchmarks for the percentage of Medicaid patients you have, or amount of allowed Medicare charges you have.

Can Eligible Providers Work at Locations Other Than Hospitals and Private Practices and Receive the Incentive Money?

The location where the provider works is not the issue. The issue is whether or not the provider meets the requirements, either for Medicare or Medicaid, to be considered eligible for the program.

It doesnt matter where the provider accesses the certified EHR. If they meet the eligibility criteria, and they are using a certified EHR, they can collect on the stimulus money.

What Are Health Provider Shortage Areas?

Physicians practicing in determined health provider shortage (detailed info here) areas will be eligible for a 10% bonus payment.

How Does This Incentive Relate to ePrescribing or PQRI?

If the PQRI Program is extended in its current form, practices can participate in both PQRI and an EHR Incentive Plan.

If the EP chooses to participate in the Medicare EHR Incentive Program, they cannot participate in the Medicare eRx Incentive Program simultaneously. If the EP chooses to participate in the Medicaid EHR Incentive Program, they can participate in the Medicare eRx Incentive Program simultaneously.

Also, e-prescribing penalties sunset after 2014, so that no physician will be subject to penalties for failing to both e-prescribe and use an EHR!

How Do EPs Get Paid For Meaningful Use of a Certified EHR?

For the first payment year only, all an EP or hospital has to do is to be a “meaningful user” for a continuous 90-day period during the payment year. Hospitals’ payment year is October 1 to September 30 and EPs’ payment year is the calendar year. You must start and complete the 90-day period within the payment year with no overlapping.

Also, if you can qualify as a Medicaid Eligible Provider (or Hospital), are in the process of adopting, implementing or upgrading your EHR and your Medicaid patient volume is at least 30% (Pediatricians only need 20% minimum and Hospitals need 10% minimum), you can collect your incentive money without meeting Meaningful Use criteria.

Attestation forms and forms of other types are most likely the way that EPs will provide information to apply for the incentive funds, although the details have not yet been released.

What Does it Mean to Transition From One Program (Medicaid or Medicare) to Another?

EPs who meet the eligibility requirements for both the Medicare and Medicaid incentive programs will be able to participate in only one program, and will have to designate which one they would like to participate in. After their initial designation, EPs are allowed to change their program selection only once during payment years 2012 through 2014.

To Recap:

How Do I Get My EHR Stimulus Money?

1. Decide whether you are an eligible provider for any of the programs.
2. If you are, buy a certified EMR (once certification has been defined.)
3. Use your EMR in a way that demonstrates your meaningful use of the product.
4. Pass “GO” and collect your money.

ARRA (Stimulus Bill) Acronyms

A/I/U Adopt, implement or upgrade
CAH Critical Access Hospital
CCN CMS Certification Number
CDS Clinical Decision Support
CMS Centers for Medicare & Medicaid Services
CY Calendar Year
EHR Electronic Health Record
EP Eligible Professional
eRx E-Prescribing
FFS Fee-for-service
FY Federal Fiscal Year
HHS U.S. Department of Health and Human Services
HIT Health Information Technology
HITECH Act Health Information Technology for Electronic and Clinical Health Act
HITPC Health Information Technology Policy Committee
HIPAA Health Insurance Portability and Accountability Act of 1996
HPSA Health Professional Shortage Area
IFR Interim Final Rule
MA Medicare Advantage
MCMP Medicare Care Management Performance Demonstration
MITA-Medicaid Information Technology Architecture
MU Meaningful Use
NPI National Provider Identifier
NPRM Notice of Proposed Rulemaking
OMB Office of Management and Budget
ONC Office of the National Coordinator of Health Information Technology
PQRI Medicare Physician Quality Reporting Initiative
Recovery Act American Reinvestment & Recovery Act of 2009
TIN Taxpayer Identification Number

For more information who is eligible and for how much, read my post “ARRA Eligible Providers: Who Is Eligible to Receive Stimulus Money and How Much is Available Per Provider?”

UPDATE: On June 24, 2010 the House and Senate passed legislation to further delay the Medicare cuts until November 30, 2010. More here.

*****

Late Tuesday night (March 2), the Senate passed a 30-day extension to the delay in the 21.5% Medicare payment cut. The House passed a similar measure last week. If the extension is signed by President Obama tomorrow, March 3, Congress will have another 28 or so days to figure this payment thing out and managers can continue to sweat it out.

Stay tuned for possible additional delays: earlier today Senator Max Baucus (D-Mont.) and Senate Majority Leader Harry Reid (D-Nev.) unveiled a $150 billion jobs bill that would delay the 21% cut in Medicare reimbursements until August.

CMS is not processing claims until March 12 so they can pay the correct amount and not have to make additional payments to providers. Payments will still reach providers within the 14-day time frame required.