Manage My Practice

I am very pleased to be the speaker for a free webinar sponsored by Integrated Healthcare Systems. The webinar will be on one of my favorite topics – front-end patient collections – and will air live on Tuesday, May 11th, at 2:30 Eastern time.

Topics I will address include:

•    WHY would a practice move from a back-end collections strategy to a front-end strategy?

•    WHERE does patient education fit into the patient collections program?

•    WHAT can be collected at the time of service: co-pays, co-insurance, deductibles, estimates and deposits?

•    WHEN should a practice use technology to improve time-of-service collections?

•    HOW can managers train staff to overcome their fear of talking to patients about money?

Attendees will have the opportunity to purchase my book, “30 Days to a Front-End Patient Collection Program” for a special promotional price.

Register here for the webinar.

In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm: A New Health System for the 21st Century, which outlined fundamental changes that must be made in order to improve healthcare in the United States.  Here is a quote from the book:

“The U.S. health care delivery system does not provide consistent, high-quality medical care to all people.  Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge–yet there is strong evidence that this frequently is not the case.  Health care harms patients too frequently and routinely fails to deliver its potential benefits.  Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.”

Although the concepts in the books have been widely implemented in the inpatient setting (100,000 Lives Campaign and now 5 Million Lives Campaign), not as much has been done in the outpatient setting, predominantly because inpatient safety has been (rightfully) highlighted by needless deaths and injury (The Josie King Story, The Dennis Quaid Story.)  These same concepts must be applied in the outpatient setting to achieve improved patient care and patient satisfaction.  Ultimately, patients will demand to know what medical practices are doing to provide safe, effective, patient-centered, timely, efficient and equitable care.  This is a great book to read (you can read it online) and think about in preparation for the changes coming with healthcare reform, “Payment for Performance” (P4P) and electronic medical records promulgation.

Aim #1: Care should be SAFE: Patients should not be harmed by the care that is intended to help them. Current estimates from the Agency for Healthcare Research and Quality place medical errors as the eighth leading cause of death in this country. About 7,000 — people per year are estimated to die from medication errors alone — about 16 percent more deaths than the number attributable to work-related injuries.

Aim #2: Care should be EFFECTIVE: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit. Estimates are that about half of all physicians rely on clinical experience rather than evidence to make decisions. But should they? Experts say that physicians in most practices do not see enough patients with the same conditions over long enough time to draw scientifically valid conclusions about their treatment.

Aim #3: Care should be PATIENT-CENTERED, respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. One study of physician-patient interactions showed that physicians listen to patients’ concerns for an average of 18 seconds before interrupting. Medical schools are beginning to place greater emphasis on the development of good patient-interaction skills.

Aim #4: Care should be TIMELY: reducing waits and sometimes harmful delays for both those who receive care and those who give care. Many hospital Emergency Departments (EDs) are symptomatic of a system that cannot reliably give timely care. One recent survey revealed the average wait at “crowded” EDs was one hour. One third of U.S. EDs report they must periodically divert ambulances to other facilities.

Aim #5: Care should be EFFICIENT: avoiding waste, including waste of equipment, supplies, ideas and energy. Some experts estimate that most physicians are productive only 50% of their time, in part because the system works against them. Working smarter, not harder, can reduce non-clinical work and increase “face time” with patients.

Aim #6: Care should be EQUITABLE: care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. There is a growing number of studies showing disparities in care and treatment for some population groups. The implications can be dramatic: for example, the life expectancy of a black child is seven years shorter than that of a white child in Baltimore, Maryland, USA.

You can download a PowerPoint program from the Institute for Healthcare Improvement (IHI) that cover the concepts in the book for free here.  Registration is required, but it is free and gives you access to lots of tools and resources.

You can also read the book for free online by clicking on the “READ” icon below.  No registration is required.

What books, websites, blogs, organizations or people would you add to the list of resources to prepare us for the changes of the future?

A good “good-bye” or closure to the office visit can save the practice follow-up phone calls and can help the patient get the most from their time at the practice.

1. The provider should end the visit by having the patient or caregiver repeat back what the plan of care is so the provider can assess their understanding.  Some practices give patients a takeaway form that has any medication changes and suggestions for diet, exercise, or repeat lab work, and others dictate the office visit and give the patient a paper copy of their visit documentation before leaving the office.
2. If the patient is having any lab work or tests, information about when the results are expected to be reported to the practice and how the practice will be informing the patient is important.  Giving the patient very specific instructions in writing on calling the practice if they haven’t heard back can eliminate a lot of unnecessary phone calls for the practice and a lot of unnecessary worry on the patient’s part.
3. The medical assistant or nurse can walk the patient to the check-out desk and ask “Were all your questions answered today?” As an alternative, the check-out person can ask that question, and if need be, either bring the patient back to the clinic area, or page the assistant to come to the check-out area to speak with the patient if there are questions.
4. There should be very clear communication on when the patient is to return if a return appointment is needed.  If the patient is not able to make the appointment at check-out for any reason, the practice should have a manual or electronic tickler to follow-up with the patient and schedule the appointment at a later date.
5. When on the phone with patients staff should always finish a conversation with a recap, repeating the information the patient asked for and making sure the patient had time to write it down.  Trying not to rush a patient off the phone, but doing things in a friendly yet businesslike way is an art!

Note: Letting the patient know how your practice will handle their calls is an important thing to discuss with new patients.  Will the patient get to speak with the doctor or the nurse? How soon will someone call back?  How does a patient communicate an urgent need?  Discussing these practice protocols before the patient needs to know can help a patient have confidence in your practice and reduce repeat calls and confusion.

When a payer or health plan calls your practice and requests records or requests an on-site visit to review charts, follow this guideline:

1. Be professional at all times.  Audits can be nerve-wracking and can be a drain on internal resources, but there is always something to be learned from the process.
2. Ask for the request in writing, to include the names of the patients whose charts will be accessed, the dates of service covered under the audit, the name of the auditor, the specific reason for the audit, what the result from the audit will entail (warnings, sanctions, grading, etc.) and if the result will be published in any form anywhere.  Request that the specific information culled from the audit be shared with your practice in an usable form.
3. Review your contract with the payer for any language related to the payer’s rights to access information, the description of the information, and any payment due to the practice for the labor and resources used in producing the records.  Check with your state insurance laws for any information regarding such requests.  Note that Medicare Advantage plans do not have contracts with practices, so you do have the right to charge for the labor and resources necessary to produce records.
4. When the information arrives from the payer, confirm that the patients named in the audit have records in your practice.
5. If the explanation for the audit is unclear, request more in-depth information in writing.
6. Review records or charts requested by the payer and be sure to remove any documentation that does not specifically refer to the dates being included in the audit.  Do not give the entire chart to the auditor.
7. For practices with EMRs, print the appropriate documentation for the auditor if they request an on-site visit.  Do not give the entire chart to the auditor.
8. If you are satisfied that all requirements are being met by the payer, schedule the audit, or arrange for records to be sent.  If coming on-site, arrange for a quiet place for the auditor to review records, preferably close to you so you can observe, answer questions and ask questions.
9. Analyze the feedback received to improve any areas needed and document your effort as a part of your compliance plan.  Have all practice employees sign off on any compliance plan updates.

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

*****

Close on the heels of an affirmative Senate vote, the House of Representatives approved HR 4851 (Continuing Extension Act of 2010) which once more delays, albeit temporarily, the mandated 21.2% physician fee cuts tied to the SGR.  The bill now goes to the President to be signed.

What is the SGR? The Sustainable Growth Rate is a general marker of inflation. In 1998, due to concerns of rapidly escalating healthcare costs, Medicare payments for physicians were permanently tied to the SGR.  As healthcare inflation has outstripped general inflation since 2002, the cost of physician services has exceeded the predicted SGR. Every year since then, a predicted cut in Medicare physician fees has been bitterly fought, a temporary fix has been passed and the cumulative effect grows.

Many physician organizations are lobbying for the permanent repeal of tying Medicare rates to the SGR, but there are varying opinions on what would take its place and what it would cost to make the change.

Here is the recent history of the Medicare physician fees by year, the proposed cuts and the actual change in physician fees:

2002 -5.4% cut proposed  – None made
2003 -4.4% cut proposed – 1.6% increase given
2004 -4.5% cut  proposed – 1.5% increase given
2005 -3.3% cut  proposed – 1.5% increase given
2006 -4.4% cut proposed – Freeze at 2005 level
2007 -5% cut  proposed- Freeze at 2005 level
2008 -10.1% cut proposed -  0.5% increase given
2009 -15% cut  proposed – 1.1% increase given
2010 -21% cut  – ??????

Hopefully, no Medicare claims have actually been paid at the 2010 level, although it was reported that the system with new rates in place was being thoroughly “tested” today.  If no checks went out with 2010 reimbursement and no “makeup” checks are generated, I suspect more than just a few of the taxpayers’ dollars will have been saved.

Not on facebook yet?

CMS is.

There’s nothing I can say but close your door for 16 minutes and 59 seconds and watch this.

mhealth is short for “Mobile Health” and is medical and public health practice supported by mobile devices, like MP3 players and smartphones. Here’s a link for more info on smartphones, medical applications and other fun stuff from Epocrates.

The last conference I went to might be the last conference I ever go to.  I do like some parts of conferences, but not all, or even most. Medical manager conferences do not seem to have changed since I first started going to them in the late 80′s.  Big sessions with big names. Little sessions with little names. The Exhibit Hall. Parties. Get-togethers. Late nights and early mornings.

I usually expect to accomplish two things during the conference.

One is to pick up some little pearl of wisdom from a random conversation that goes like this:

THEM: Blah blah blah blah.
ME: Hey, what did you just say?
THEM: Blah blah blah blah.
ME: You do that? At your practice? And it works?
THEM: Blah.
ME: How do you do that?
THEM: Blah blah blah blah yadda yadda yadda.
ME: I’ve gotta try it – thanks so much! Hey can I get your card and call you if I get stuck?
THEM: Blah yadda yadda.
ME: Yeah, great to meet you too!

The second is the brain time I get during a totally boring session when I can think without interruption about a problem I’m trying to solve.  I can reflect, scribble notes and no one cares. The phone is not ringing, there’s not a line at my door, there’s not a to-do list to do in my to-do book.  One thing I can never get enough of is time to think.  Work is full, almost every minute, with noise and interruptions and lots of people needing something.  What I need, what we all need, is more time to think.  If you never have time to think, or plan, or process, there is no managing going on.

Here is what my dream conference would look like:

1. Speakers on big screens – What is the value of having a big name speaker come personally to a conference?  Have them speak virtually.  Save a lot of money for us and save a lot of time for them.  Come to think of it, what do the big names actually contribute to the conference?  I’m not sure.
2. Infomercials – Why not have the exhibitors do infomercials at breaks in the programs? Anyone can make a video explaining their product. The videos could be available on the conference YouTube Channel for anyone who misses the infomercials and wants to flip through them.
3. No exhibit hall – I’ve heard so many vendors say they won’t have the budget soon to attend conferences.  How do vendors raise the money to attend conferences, give out goodies and door prizes and sponsor parties? By raising their product price, of course.  When I hear people say “We couldn’t have a conference without the exhibit hall,” I think “I bet we could have a better conference without the exhibit hall.”  No exhibit hall means a lot more time to meet with people I really want to see. No exhibit hall means I don’t have to carry home a bunch of literature I don’t want. No exhibit hall means I don’t have to feel guilty about finding the fastest way from the front of the hall to the coffee stand/food/bar.
4. Breakouts on demand – I’d like to go to smaller breakout sessions when I want to fit them into my schedule.  If I get into a great discussion with someone, I don’t want to drop it to run to a session, I want to go with the flow.  Breakouts could be constantly running on screens in dedicated rooms, or I could get them on my laptop whenever I was ready for them.
5. The Unconference - there are several versions of the Unconference, but the version I’ve been exposed to is one where a huge block of time at a conference was completely unprogrammed.  It was the second day of a two-day conference and all throughout the first day, attendees wrote things they wanted to talk about on Post-it notes and stuck them on a big blank wall.  The conference organizers were responsible for combining like ideas, assigning a time and a room and finding a facilitator for the topic.  I came to a conference with a need and my need was met!  Conferences, especially large ones, by necessity must choose topics and book speakers far in advance.  With as fluid as healthcare now is, conferences need to match the fluidity of healthcare to be pertinent.
6. Networking, networking, networking – What can’t I get ANY other place? A conversation with my peers.  People with different experiences, different perspectives and different ideas.  That’s the best thing I can bring home from a conference.

What does your dream conference look like?