January is a tough time for independent medical practices for several reasons:
- In private practices, the physicians typically don’t carry over any cash from year to year, so the practice starts in January from a cash position of zero.
- Most deductibles begin in January – if practices don’t collect deductibles at time of service, they find themselves hurting because their revenue goes way down.
- The Medicare debacle every year creates improper (lower) reimbursement as Congress struggles to the last possible minute over physician payments. (Here’s a simple yet helpful exercise for Congress. Congress, close your eyes and think of your favorite Medicare-age person. Is it you, your wife, your mother, your father, your neighbor or best friend? Now think of that person not being able to see a doctor when they need to because all doctors have opted out of Medicare and the only place they can get care is the local Emergency Room. It is a very ugly picture. What other profession is MADE to accept payment that is less than it costs to provide? Who do you love, Congress, who won’t be able to get care?)
- Many annual maintenance contracts come due in January
- Deals on large purchases are good (think EMRs) as vendors try to book revenue in the current year. Practices tend to make commitments to purchases now that will have to be paid for in the new year
What’s a practice to do?
Everyone knows what a mess we’ve had in the past when CMS has had to pay according to the SGR, then it was reversed at the last minute and CMS had to pay additional amounts on services they had considered paid in full – a headache no matter how good your software is.
To avoid that, CMS will hold any claims for 10 business days before re-evaluating based on any change in the Medicare fee schedule for 2012. This will not actually hold anyone’s payments, as Medicare pays their claims in 14 days.
CMS made the following announcement today:
Like other medical conditions, behavioral health issues span the spectrum from mild to significant mental illness (SMI). There are many national studies, such as the Impact Model, showing the benefits of identification and treatment of depression in the primary care setting. Many practices have added a mental health clinician or social worker to their staff to expand on-site care for those needing lower level behavioral health services and to reduce the stigma for patients accessing mental health services. It is care for those with more significant mental illness that becomes challenging to the primary care practice.
What is the relationship of SMI to physical health?
The National Council for Community Behavioral Healthcare reports that 3 out of 5 individuals with a SMI die from a preventable health condition. In general, the life expectancy of a person with SMI is 25 years less than the average population. They have a higher incidence of chronic medical conditions for individuals exacerbated by smoking, obesity, homelessness, and sometimes by the very drugs used to treat their psychiatric condition. There are many reasons for the lack of medical care for these individuals including social isolation, cost, transportation, and inability to fit in to a primary care practice culture of focused discussions. Many use the emergency department for routine care rather than establishing and maintaining a relationship with a primary care practice.
Barriers to behavioral health services and to primary care for behavioral health patients
Mary Pat: Where does the name of your company, Lutrum, come from?
Ed Garay: When I was developing a name for this company, I didn’t want to be like every other healthcare IT services company with health, md, medical, etc. as part of their name. I wanted it to represent something deeper about what we do and who we are as an IT organization. Although we are IT specialists, I realized that one of the things that I am always working with my team on is to listen and understand our clients needs. Which lead me to creating the name, Lutrum. Lutrum is a slight variant of the Latin word Lutra. Lutra means otter in English. And the otter symbolizes empathy.
Mary Pat: What led up to you starting your own business?
Ed Garay: In late 2000, I worked as an IT Director for an organization that continued to downsize. I came to a career crossroad. With starting to support under 100 systems, and the network running in tip-top shape, there was really no need for me to be there full-time in the long run. So, do I look for another job that cant possibly be as fulfilling as where I was, or do I take a leap of faith and start up my own business and share my knowledge with the masses? Through the feedback of mentors and other resources that knew me personally and professionally, I was highly motivated to take the leap of faith and have never looked back. My business career has evolved over the years and has naturally lead me to Lutrum.
Mary Pat: What are Managed IT Services?
Many physicians have some type of lab testing capability in their practices, with most practice labs classified as Waived Labs, which means having a Certificate of Waiver. This Certificate enables a practice to perform simple tests including tests such as urine dipsticks, rapid Strep A for sore throats, Mono Tests, pregnancy slide tests on urine, and Rapid Flu tests.
There is little effort required to become or maintain a Waived Lab
There are no personnel qualification requirements, and the only regulation is to follow the manufacturer’s instructions on the test packages. In order to obtain a Certificate of Waiver, an application form (the CMS116 form) must be completed and submitted to CLIA at the state CLIA office. The CLIA office will issue a CLIA identification number and the practice will receive a bill for the Certificate of Waiver for $150. Life is wonderfully simple at a Certificate of Waiver level.
One of the most exciting trends in modern healthcare can be found at the intersection of two larger societal changes: the shifting demographics of an aging Baby-Boomer population, and the fast adoption of smart mobile devices and mobile application platforms. As robust, secure and intuitive mHealth applications are adopted, patients are more empowered to monitor and share their health data outside of a traditional medical office or hospital setting. As healthcare delivery system already short on providers becomes even more taxed, mHealth applications will allow the system as a whole (patients, caregivers, loved ones, and payers) to navigate health decisions in a more efficient and informed way.
This quote from the Deloitte Center for Health Solutions 2010 Survey of Health Care Consumers says it all:
Boomers view tech-enabled health products as a way to foster control and ongoing independence for themselves, especially in light of the rise in incidence in chronic disease with aging, and their desire to reduce costs. Nearly 56% of boomers show a high willingness to use in-home health monitoring devices in tandem with care of their primary physician.
What are the advantages of pushing home health medical data from the source to the care provider?
- Minimum lag time between data collection and the clinicians ability to review it.
- Reduction in errors associated with human intervention in data entry.
- Intuitive and simple interfaces promote active patient involvement and caregiver communication in healthcare management.
- Secure sharing of PHI (Protected Health Information) with patient, family members, and approved internal and external stakeholders in health.
Here are just a few of the companies and products available now (or in the near future) that might change your mind about where and how health data is captured and shared. Each of these products automates the capture of health data and the transfer of the data in a usable format to an Electronic Health Record.
Near Field Communications
NFC (Near Field Communications) is a wireless technology that allows for quick transfer of data between two sensors that are fairly close (an inch or two) together. The secure transfer allows for seamless data tracking inside caregivers workflow. For example: medical supplies, drugs, injectables and fluids can be fitted with low cost sensors that are swiped past a patients sensor to indicate they will be administered to the patient, and then again past the providers sensor to indicate a finished procedure, capturing time of administration, dosage, and patient information without slowing down the care to enter this critical data by writing them down, typing them in, or just resolving to remember them for later entry.
Gentag makes the data sensors and applications that manufacturers can use to send data via cell phone to the hospital or physician for seamless inclusion in the electronic medical record (EMR). Monitoring of blood pressure, fever, weight management and urinalysis are just a few of the ways Gentag has improved data capture in healthcare.
iMPak Health makes a cholesterol monitor the size of a credit card that accepts a small blood sample to process for triglyceride levels. The data is uploaded wirelessly to a cell phone that transmits it to a health provider.
Smart Fabrics and Wearable Monitors
Researchers at the Universidad Carlos III de Madrid in Spain developed a fascinating concept for an Intelligent T-Shirt that uses sensors woven into a washable fabric to create a hospital garment that does more than preserve the patients modesty. The sensors in the fabric can detect and record temperature, bioelectric impulses (for ECG monitoring), as well as the patients location, current resting position, and level of physical activity.
Copenhagen Institute of Interaction Design graduate Pedro Nakazato Andrade has designed a dynamic cast called Bones that collects muscle activity data around a fracture area by using electromyographic (EMG) sensors to report the patients progress to physicians automatically. This could reduce the need for follow-up visits and imaging, or change the specifics of rehabilitation.
The Basis Band is a wristwatch-type accessory that monitors heart rate by directing light into the skin to image blood flow. It also uses a heat sensor for skin temperature changes, an accelerometer for recording movement and activity, and sensors for galvanic skin response. The band also gives customers access to a free, web-based health dashboard to oversee the data the device collects and transmits.
There are still some considerable hurdles to full adoption of mobile home health monitoring. Very few patients use only one medical device, so not only do monitoring devices need to work with networked EHR technologies, they have to be integrated with each other to present a comprehensive picture of health to providers and Health Information Exchanges (HIEs). Also, as patients navigate the system of generalists, specialists, and emergency care providers, the possibility of encountering multiple software and hardware platforms will require flexible, integrated solutions that can run on any device. As with any networked application of sensitive data, security and availability are major factors in a success deployment. Unless patients can count on the privacy of their data, and providers can count on the uptime of their software, healthcare systems wont be able to realize the full benefit of mHealth installations. On top of that, more monitoring of patient health means that there will be even more data to be collected on each patient, and on the population as a whole. While more data means more opportunity for large scale research and analysis for the public benefit, it also means more data has to be secured and protected as a part of the health record, requiring even more security and storage resources. And finally, the Food and Drug Administration will have a large say in the future of mHealth application development through industry regulation. Device makers and application developers will certainly have to work within a governmental framework which will have a large say in the time-to-market of many possible products.
With all that being said, the opportunity to meet the demographic challenges of an already stressed healthcare system with mobile home health monitoring and Electronic Health Records will be one of the major themes of the future of both the heath and technology industries.
I haven’t written much about the impending 29% Medicare physician payment cut. This threatened cut has happened every year for the past 10 years. Every year at the last second, Washington is convinced that if cuts take place, physicians really will stop seeing Medicare patients and they halt the cut.
It’s not a bluff. Physicians can’t afford to see Medicare patients, TriCare (ex-military) patients and disabled patients with Medicare benefits now, and they will drop out by the tens of thousands if they get paid any less. Any businessperson worth their salt will tell you that when revenue does not exceed expenses, you do not have a sustainable business model. Physician have cut expenses to the bone, taken deep cuts in their salaries and ultimately have sold their practices when they just can’t make it anymore.
But never mind the doctor, what about the patients? What happens to them when physicians stop seeing Medicare patients? Texas Medical Association has made an outstanding video that explains it in language we can all understand.
Other organizations that are working to eliminate physician reimbursement being tied to the SGR are MGMA and the AMA.
In between polishing off leftover turkey and stuffing, we’re looking back over some of our most popular posts from the month in case you might’ve missed them the first go round. Thankfully Presenting, The Best of Manage My Practice, November 2011!
- Compliance: a critical issue for all practices, but a subject so expansive, where do you even begin? Learn the “Big Three” with Stark, False Claims and Anti-Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare
- Are your record retention policies up to date? Can you say with confidence that you have hard copies of everything you should? Find out with Record Retention Simplified – The Ultimate Guideline
- Are you or someone you know thinking about Medical Coding as a a possible career? Follow along with Coder Bob in Tales of a Coder Part III: School Begins
- Are you the kind of leader that can see your group through the toughest of times? Bob Cooper asks practice managers in Are You a Resilient Leader?
We’ve started this monthly wrap-up to make sure you don’t miss any of the great stuff we post throughout the month on Manage My Practice, but we also want to hear from you! What were your favorite posts and discussions this month? Did we skip over your favorite from November? Let us know in the comments!
This is a guest post from Joe Hage, CEO of medical device marketing consultancy Medical Marcom.
My friend Michael Paquin is a fellow of HIMSS, the Health Information Management Systems Society, and an expert in EMR connectivity, Meaningful Use, and the pitfalls of both. Michael shares his thoughts on both in this short video, which is also in transcript form below.
Michael Paquin: I think if we are looking at physicians today and trying to address some of the problems they’re having in their offices and what they’re afraid of in purchasing an Electronic Medical Record, I think we have to start from the beginning and that is service and implementation.
I want to empower all physicians to make vendors give them the service they need. Getting an EMR is just one part of the puzzle in being successful in achieving your Meaningful Use dollar.
The Meaning Use dollars over a five-year period can add up to about $48,000 to $64,000 depending if you’re applying for Medicare or Medicaid. What you really need to think about is that purchase price and negotiate it well, don’t overspend but do overspend if you will, I know that’s contradictory, but do overspend when it comes to implementation and training.
A lot of doctors purchase an Electronic Medical Record and think they can have the training done in 3 days. I’d like you to think about that for just a moment.
If each and every one of you just bought Microsoft Office and brought it into your practice for the first year or first training, could you get trained on PowerPoint, Outlook, Word, Excel all the different features of Microsoft Office in three days while you’re not seeing patients or you are seeing patients? Can you train all 3-4 nurses in your office? What does that mean?
So what I’m suggesting to you is take the time to get trained so that you can use the product correctly. What I’m seeing out in the marketplace is doctors starting to go with their second or third vendor for their Electronic Medical Record software because they have an unsuccessful first brush with Vendor A or Vendor B – they weren’t trained.
All these systems have workflow issues, all of them are trying to address them, and all of them are trying to get better. None of them are going to be perfect but what’s going to make a perfect EMR installation for you is the training.
- Make sure you negotiate all the prices.
- Make sure you buy from a vendor that is certified by the ONC.
- Make sure you’ve got that certification.
Certification means when you get your Meaningful Use dollars you can show your product was certified. So there is a lot to getting ready for purchasing an EMR, there is a lot to choosing the right vendor.
Make sure that you get in touch with an EMR consultant, there are a lot of lessons learned that will pay for a consultant’s time. Anyway in this first video I think we’ve covered enough but feel free to contact me with any questions.
Joe Hage: So I’ll paraphrase. When you’re choosing an EMR partner make sure that it is going to be around and one that can provide you with the level of training you need.
Michael Paquin: And certified.
Joe Hage: And certified, Michael thank you very much.
Mary Pat: If you remember, my friend Bob decided he wanted to become a medical coder and asked for help. He chose Allied Schools because he felt he made a connection with the people at Allied and they also offered an attractive payment plan. Bob has started the program and wrote this for me about his experience so far.
Bob: I recently received my first package of school supplies from the Allied Schools. When I opened the box I found a welcome packet with instructions for getting help online, two textbooks (Medical Terminology and Anatomy and Physiology) and a couple of CD-ROM discs. I was ready to begin.
Medical Terminology
I began with Medical Terminology. The instructions that I found when I logged online for the first time were to read and complete the exercises in the first chapter of the textbook.
The course began with basic word structure. I learned about suffixes, prefixes and root forms. The various incarnations of all of these parts were a matter of pure memorization. It was reassuring that I did know some of them from family medical issues and from studying Greek and Latin words in school many years ago. The instructions were to look at the ending first for part of the term’s meaning, and then to move to the left for the root form and any prefix. By combining these, the meaning of the term emerges.
For instance: HEMATOLOGY.
- logy means the study of.
- hemat/o the root form for blood.
Therefore, hematology is the study of blood.
There are hundreds of root forms, suffixes and prefixes but thankfully, Chapter 1 did not try to teach me all of them at once! Examples were given for the words presented, the text was full of colorful illustrations and short cuts, and memory devices were introduced along the way. Next came over twenty pages of exercises with answers so that I could check my progress. The exercises were offered in a variety of formats in an effort to keep you from getting too focused on one method of memorizing, as well as keeping it as fresh as possible. There were fill-in-the blank and multiple-choice quizzes, medical word scrambles and even some short word problems that described simple medical cases where you had to determine what term best described the cases. It was a very thorough attack at memorizing a fair amount of material.
After I made myself work through the book exercises twice, I logged online and started the computer work. What I discovered was a rehash of the book but it was presented in an easy-to-follow manner that moved very quickly. What I also discovered was that if I had absorbed the material well from the text, the computer rehash went quickly.
Then I was presented with an online practice test that they said could be taken as many times as I wanted, but they recommended that I not move on to the real test until I had achieved at least a 90% score.
Im proud to report I got 90% on my first try and them moved on to do the formal test that required a 70% to pass. And ta – dah.. I passed with 100%! (OK, I just could not help but brag a little bit.) The real point though is that by studying hard on the book you should achieve great success with the computer portion of the program and success is what we all want.
In addition to the books I received two computer discs and I found them to be wonderful additions to the study program. One disc has a collection of additional exercises, glossaries, flash cards and animated lessons that examine different parts of the body. There were even some arcade games based on Wheel of Fortune and Concentration – cute, fun and one more way to get the information lodged in your brain forever.
The second disc went over all of the terms introduced in each chapter and gave an audio definition that was very helpful in making sure I understood the correct pronunciation. There was a spelling bee section on this disc as well that presented yet another approach for people more inclined toward audio learning as opposed to visual. All in all, the discs were a very comprehensive and a powerful reinforcement of work to memorize the material thoroughly. I am now on to the next section covering body cavities, body planes, body systems and sections of the spine.
What I’ve Learned
My normal procedure for working on this class is to sit down at the kitchen table and review the exercises in the book for the section I am studying. I can easily spend an hour or two with the book and seldom do I realize how much time has passed before I stand up for a break. Two hours a day writing out answers in a notebook (I am not writing in the book) helps me to get the material down. In an effort to mix it up a little bit, I sometimes pull out the discs and play one of the arcade games for fun. When I feel confident about a section I move on and do the online portion. I try to get two hours in every day but I am lucky to actually do it 3 or 4 days a week.
Over the last few weeks I have made progress but I have also learned a lot about what is required to be successful in this ambitious endeavor.
- You must make the time to work at the program. If you do not set aside time every day or at least every other day, you will move slowly. If you cant make yourself sit down and do the work, you will not be able to get through the program.
- You must get your mind in study mode. It has been a few years since I was in school and even though I spent quite a bit of time with homemade flash cards and a couple of the Dummies books, I still had to make the old brain work. It is a challenge, but it is refreshing.
- You must memorize. A lot. Study the different sections and don’t let yourself take any short cuts because it is not good enough to be able to answer just the multiple-choice questions. You must know the terms and meanings and they must be in your head and ready to spring forth when needed.
So far, I am really pleased with the program I chose. A number of different approaches are offered in order to reinforce the memorization required, and practice quizzes and exams allow you to feel comfortable before moving on to new material. There is no short cut to what must be done – it’s all about putting in the time and the discipline. I am not moving as fast as I hoped I would, but I think I will pick up some steam when I get through the terminology and anatomy and start on the actual coding portion.
Next time – Bob reconsiders his choice.
