Managing and Marketing Your Medical Practice

The Tragedy of Travon

2013-07-14T17:15:00.000-04:00

Travon Martin is your child and mine. His death is not about race or religion or suspicion of criminal activity. It is America, depicted to the world as a nation trapped in its Wild West mentality, where every man is the sheriff, gun at the ready, to protect the freedom of our land - from each other.

I took a trip to Target yesterday to buy a new toaster oven. My morning bread was suddenly a warm brown on one side and Wonder white on the other, so I figured it was time. I didn't pack a weapon or hollow point bullets to protect myself from the other families buying food or a new toaster of their own. I was not accosted in the parking lot and made it to the store and home without having to kill a child or any other citizen who looked the least bit shady. My belief in the Constitution of the United States remained intact, despite the fact that it was not necessary to exercise my Second Amendment rights.

The world has gone completely insane when the watchman becomes the hunter.

I have two sons who have luckily grown to manhood without having to see the barrel of a gun pointed in their direction. This is not to say that seventeen was a time where they exercised great prudence; where their decision making was flawless or even intelligent. Seventeen is the time for stupidity. The time when you think you can put up your dukes and fight out a problem or a stalker. Where you walk in the rain to get a bag of Skittles. It's the time when curse words color your thoughts, where you think you are immortal, where you fight the boogeyman and get him before he gets you.

It is not the time to die in the dark; in the rain. At the hands of a stranger.

Watching the George Zimmerman trial, as the mother of sons, I gave thanks to God every day that it wasn't my children in the dark Florida night. Not because I live in a better neighborhood, or because my children are white. I gave thanks for the coincidence that my children never fought with someone armed. I have no doubts that, like all boys of a certain age, there were times when my children had a little too much testosterone and not enough good sense. But through the grace of God, they never met a man who vowed to protect and care for his neighbors as long as they weren't walking slowly through the raindrops.

I gave thanks for those who spoke to them, without the use of violence, when they were someplace where they shouldn't have been. Have we become so disconnected, so fearful of each other, that George Zimmerman could not have identified himself? Couldn't he have said: "Son, do you live in this neighborhood?" Might he have informed Travon that he was indeed the neighborhood watch ? In its most simple form, the touch of a button to lower a car window, to speak as one human being to another, and Travon Martin is home with his mom, or visiting his father or talking to Rachel Jentel on his cell phone.

We think we have achieved justice because we conducted a trial. We applaud ourselves for the process of having our peers decide whether taking a life with a semi-automatic weapon was justified. The pundits discuss the rules of law and as always those seeking to further divide us make it an issue of race.

Something at my own core wants to shout: "It's the guns stupid!" "It's all about the guns."

Paula Deen and the American PC Pendulum

2013-06-25T11:05:00.000-04:00

We Americans have a tendency towards extremism and while we share a strong national pride, we have not always had the most stellar history.

Slavery, the Civil War, the deaths of Lincoln, Martin Luther King, John and Robert Kennedy, and our propensity towards violence are not a shining example of "the land of the free and home of the brave."

Even when we self correct, we go too far.

Now, I am not familiar with the life of Paula Deen. I have seen her a few times on the morning talk shows where she seemed like a cute southern grandmother who liked to cook with lots of butter and cream. From what I understand, she is quite successful at plying her trade, so there will be no need to run out for additional Kleenex to mourn for her supposed financial setbacks.

For the past few days, there have been countless of news hours dedicated to the fact that a 66 year old woman raised in the South admitted to having used the dreaded "N" word. Was it last week? When she was twelve or fifteen? The Food Network saw fit to cancel her cooking show and the media pundits have shaken their collective heads in obvious destain for her hideous sin of admission. Suddenly, some woman who can make a good biscuit is the "Hitler of 2013."

As usual, we have gone way too far.

The American obsession with Political Correctness has undoubtedly given us some important guidelines that have benefitted us in our workplaces, and hopefully have had an impact on sexual harassment. But, there is no doubt that they have also contributed to our social isolation and our inability to communicate or educate each other. We don't really know what to say to each other anymore. They certainly have not put an end to bullying in school or protected our children from gun violence. In the hysteria of the Paula Deen incident, they will surely contribute to honing our deceptive skills and you can bet that no one will admit that they have ever used a racial slur.

Ms. Deen is a product of the cultural and social history of the South. In years past, this history included the Klan, separate bathrooms and drinking fountains, riding on the back of the bus, and educational segregation, all things too unbelievable for most young Americans to even contemplate. But, many of us of a certain age do remember. It doesn't matter if you grew up in Mississippi or Long Island, prejudicial behavior was pervasive everywhere.

Sociologists remind us that all prejudice originates from fear. Fear of our differences and fear of change. Indeed, Ms. Deen has stated that one of her relatives committed suicide after the Civil War. He could not fathom a world without slavery, which was his fear.

As a young woman in the nineteen sixties, I was part of the peace and love generation. We embraced the ideas of equality for people of every color and for women's rights, which were still in the "back of the bus"stage. But don't think for a moment that I could have dated an African American boy. My parents were from a different generation and their fears ruled their lives as well.

It is 2013 now. While we have all been influenced by the social and political mores of our past, certainly Ms. Deen is old enough to have made her own choices in life. As a young woman, influenced by her parents and social climate, she may indeed have used the "N" word. I'm sure its part of a very distant past, and I would bet that her children were raised in a climate where the word was not part of the daily vocabulary.

Should we choose to fire every Southern, or for that matter Northern, individual over the age of 50 who has used "the word," at some point in their lives, America would be a third world country.

There is a point where our sensitivities become reminiscent of a lynching. Isn't this the very thing our ancestors fought and died to avoid?

Variations in Generic Prescription Drug Pricing - One More Factor in Our HealthCare Crisis

2013-06-22T15:26:00.002-04:00

As if aging was not hideous enough, a trip past my glass kitchen cabinet where I now store a multitude of prescription drugs, is a constant reminder that I am no longer in the springtime of my existence.

Synthroid for my radiated thyroid, prescription Protonix for heartburn, high blood pressure pills, cholesterol meds, and most recently a bottle of Plavix from having an aortic aneurysm repair. Oh, Joy and Happiness!

It could be much worse, I guess, and my recovery from the stent placement has proceeded to the point where I can almost, but not quite, cross my legs again - without wincing in pain. What did make me wince, however, was the monthly out of pocket cost to swallow down the daily doses required to keep me upright.

All this pill popping was a relatively new phenomenon for me so despite my vast experience in managing a number of medical practices, I had no idea how much these colorful and varied shaped disease fighters cost.

My husband's medical plan requires that we pay up- front for our prescriptions. We then mail the receipts and wait to be reimbursed at 80% of the cost. The check always arrives in a timely manner, but until very recently, I was shelling out about three hundred a month to the lovely person behind the counter at my local CVS. I pay less for my 2012 Honda lease - and it's much, much bigger. One realizes why so many seniors have to make the choice between eating and taking their prescribed medications and I consider myself lucky that I could squeeze our budget to cover these costs without having to eat Ritz crackers for our evening meal.

I decided to investigate and was shocked to find that there was an overwhelming difference in the costs of prescription medication from place to place. Not just a one or two dollar difference, mind you, but differences so staggering that there is really no reasonable explanation.

Plavix is now available as the generic Clopidogrel. For thirty pills at CVS, the up-front cost was $157.49. At Pathmark, the same prescription cost me $11.30.

The generic prescription Protonix was $89.00 at CVS. Pathmark - $11.00 even.

How can this possibly make sense? I sent an e-mail to CVS on Friday asking for an explanation and I can't imagine what they could tell me to account for the difference in pricing. If the drugs cost them that much to purchase and so many patients pay only a co-pay of $15.00 or $20.00, how can CVS afford to stay in business ? Do the uninsured or self pay patients make up the difference?

I can't claim to know what the insurance companies are reimbursing pharmacies for drugs covered under a co-pay plan, but if it is $157.49 for Clopidogrel, then how does Pathmark afford to stay in business. Do they supply the drug manufacturers with free food?

There has been much discussion regarding the institution of federally controlled health care, but shouldn't there be some consistency in what patients are charged for services? In medicine, we cannot charge our patients over and above the contracted reasonable and customary fees. Shouldn't there be a reasonable fee for medications as well?

The Ryan Voucher System and Sleepless Nights

2012-09-12T14:10:00.002-04:00

Simply put; Paul Ryan's "Voucher System," for Seniors keeps me up at night. After spending twenty years in healthcare I consider myself an expert in the insurance game and can state without reservation that the insurance carriers make Bonnie and Clyde look like The Salvation Army. Insurance companies represent an extremely powerful lobby whose influence on Capital Hill makes me wonder how much they contributed to the Romney/ Ryan campaign chest, now and prior to his nomination for Vice President ?

One of the biggest frustrations faced by any practice administrator is the constant battle to receive reimbursement for even the most carefully prepared, cleanest transmitted, and authorized up the gazoo claim ! Working on an accounts receivable can drive the most dedicated and experienced billing employee to distraction. But I digress. Let's look at the dynamics behind a voucher system for Seniors and discuss the obstacles that make this system such a poor idea.

Alternative health insurers have spent decades wooing seniors in communities throughout the United States and offering them Medicare alternative plans that would free them from the yearly Medicare deductible and provide prescription coverage with either a small or zero co-payment. Seniors who found the Medicare deductible a financial hardship and whose prescription costs were skyrocketing signed up in droves.

The first problem was that at least 50% of those seniors who adopted the Medicare alternative plans had no idea that they would be giving up their Medicare Part B coverage. They presented for care in physicians offices with their Medicare card, without realizing that they retained only Medicare Part A.

Secondly, some plans did require a referral from the patients primary care physician and these referrals were also absent at time of visit, especially for those that presented for an emergent visit, where the staff did not have the time to verify their coverage and in many cases were under the impression that the patient was covered by Medicare, where a referral was unnecessary.

In addition, patients had no real understanding of which tests and procedures were covered under the new plan and many hospitals that these patients had used for years; hospitals in their own community, as well as some of the hospitals who provide specialized care for cancer treatment, etc, did not accept their new primary coverage.

In short, a large portion of the seniors that were treated in facilities that I personally managed had less than a clue about any of the above problems.

The practices that I spent the majority of my time managing were all located on Long Island, twenty short minutes from Manhattan, one of the most cosmopolitan and sophisticated cities in the world. If my patients were confused, can you imagine expecting seniors who live in rural areas of the USA to suddenly start shopping around for competitive insurance rates and to outline their health histories and needs for specialized care, before deciding where to use their voucher coverage? People, this is just ridiculous! As an Administrator for Cardiology, it was a herculean effort to staff my front office with enough employees to answer the countless questions regarding testing procedures and physician instructions. Whose practice, or what organization is going to be responsible for assisting seniors in making their insurance choices?

I guess the insurance companies can sponsor more breakfast and luncheons, but based on my past experience this will not be an adequate salve for the problem. As far as the Ryan plan forcing the insurance carriers to become rate competitive, I can hardly keep a straight face! These companies are big, profit driven, monsters, whose bottom line is profit, profit, profit. Once rates for companies participating in Ryan's plan are established, trust me, there is no where they will go but up. Is Ryan going to assure us that there will be a cap on voucher costs? I think not!

Campaign rhetoric is full of the promise that Medicare is no longer a viable system and will collapse in the years ahead. Those who oppose the Obama Health Care Plan tell us that small businesses will go bankrupt providing health care coverage for their employees. Perhaps I live in the age of the dodo, but we baby boomers most often chose our jobs based on the benefit package available, including health care coverage, which, by the way, was most often free of employee contributions. Companies who did not offer coverage were often stuck with the lot of substandard employees who had a hard time finding work anywhere. During the ten years that I worked for Varig Airlines, I was 100% covered by Cigna Insurance after my probationary period was successfully completed. In addition, Varig matched my pension contributions dollar for dollar up to 6% of my total earnings. Those were the days, when the CEO of companies based in America collected a fair wage for performance and profits from a hard days work were shared equally, up and down the line.

Today, most companies expect their employees to pay a portion of their coverage and the Obama plan is not asking employers to fully fund health care. There are inexpensive plans on the market that provide basic coverage, with slightly higher deductibles, that most small businesses should be able to afford, providing that the small business owner does not expect to walk away each week with the lion's share of the profits representing far more than a fair and equitable wage. The Republican Party is vehement in their opposition of the Obama Plan and threaten to repeal it the moment they take office. Or keep some of it. That seems to be the latest in the Romney/Ryan plan. Politicians have been working to come up with an idea for health care for its citizens for the past fifty years, but when a plan is proposed, it is met with a resounding NO. Eventually NO leads to NOTHING, and this seems to be the hallmark of American politics for the past decade.

When Medicare was born, we had no assurances that it would be a success or fail miserably. This is true for Social Security, the Head Start Program, and programs that put Americans to work during the depression. If the Obama plan turns out to be a loser, we can kiss it goodbye. But to simply deny its existence, or scrap it, in favor of NOTHING? Is this counter-productive or am I living in the land of the hopelessly optimistic? Instead, as the Republicans desire, we should scrap Medicare, and replace it with tickets for coverage. Tickets? Just because most seniors remember the early days of Disneyland, where E-tickets gave you the best ride, doesn't mean that we want to take that ride, or save it for ten years for our fellow cronies to use !

Of course, if we made or produced anything in this country anymore, we could offer more opportunities for business to grow and thrive and the question of a business covering their employees would not suddenly seem as if it was a new and nightmarish idea. All at once, we are proclaiming that the idea of an employer providing his workers with coverage is as horrific as Hiroshima. When did we develop this sense of memory loss regarding the connection between employment and insurance coverage? I would have to speculate that we disregarded the fact that it ever existed in the light of our new desire to covet more profits.

Some would proclaim that our jobs are too slim and our population too large to provide benefits that existed for decades in the past. Well people, if we stopped sending American jobs overseas. If China paid a fair import tax. If we did a better job of patrolling our borders, then perhaps American business could put Americans to work, and protect them in times of sickness and health.

Having owned a start up medical practice, it was my job to provide the employees with coverage. I did the research, I paid the premiums, I investigated new plans each year, and was still able to draw a fair salary for the efforts of my labors. This is not an anti-success idea, nor does it represent a desire to keep small businesses small. Over the past few decades, Wall Street and the banking institutions have flaunted the fact that their bigwigs brought home billions, while those who made those profits possible; well - who cares!

We have become a society that applauds greed and bulldozes over anyone who dares stand in the way while we plunder our corporations, lay off workers, export our jobs, and do it all with a shrug of apathy. If we see it often enough, we become immune to the disgrace of it and literally become the fairy tale of '"The Emperors New Clothes." We keep saying that the king is clothed, while our failures are nakedly apparent. We might start to solve some of our problems, if just one of our politicians decided to finally tell the truth!

Let us also realize that citizens without adequate health care coverage often present in our hospital emergency rooms, where patients cannot be pre-screened and treatment cannot be denied. Overwhelming costs for treating the uninsured have allowed thousands of smaller hospitals to be gobbled up by larger health care systems where treatment becomes standardized, and may be inferior. Forget about bankrupting small businesses; should we ever face the day where our healthcare system is bankrupt, our problems will be far greater than a lack of profitability.

Those who wish to ignore the poor and disenfranchised fail to realize that they may not ignore us. As poverty and unemployment increase; when those without jobs or those who are homeless are ignored, it is not speculative to remind ourselves that crime increases. Desperate people perform desperate acts. Eventually, there is no ivory tower, or apathy to protect us.

Finally, as a representative of the generation who have or will approach the age where we can avail ourselves of the benefits of senior status, I am far from fooled by the constant blather of those who point out that the reserves for our time will not be available. Certainly, Obama, Romney, and Ryan can pay the costs for their health care with the spare change that lines their pockets. Unfortunately, most of my generation cannot do the same. There is enough blame for both sides of the aisle. If the politicians are so concerned with the issue of health care coverage for the uninsured, why don't they just give all of us the same Federal Plan, which covers their every ache and pain so effortlessly.

Perhaps the government should rename the baby boomer generation, AIG, or Morgan Stanley. They might suddenly find a trillion dollars or so to keep the Medicare system intact.

Stimulating The Economy

2012-09-06T11:59:00.002-04:00

The 2012 Presidential race is reaching fever pitch. Both the Republican and Democratic candidates agree that our economy is in the toilet, but neither Romney or Obama seem to be able to communicate exactly what plans they have for economic recovery. More government, less government, and the grey area in between don't leave any of us in the middle class tremendously optimistic about the future.

The fact is, that despite all of their experience in business or politics, most citizens are fearful that any great idea for economic growth will die on the vine or become the victim of bi-partisan immovability.

Perhaps it might be a good idea to first take a look at the state of the economy, admit some hard to swallow truths and then take action to move forward. Many of us struggling to maintain our status in the middle class discuss these issues with our family, friends, and neighbors in our community. It's difficult to understand why the ideas that spring from our conversations have never been previously considered or implemented.

In this blog post, I will attempt to lay out some of the ideas that spring from the work place and the dining room tables across America. Agree or disagree with them, but admit that at least our thinking caps are in place.

1. In order to spend money to stimulate the economy, middle class pockets need to contain more than laundry lint. It's impossible to buy goods or purchase services if you are barely able to pay the bills or put food on the table. American banks received billions of dollars in bail out cash, but not one dollar was spent to bail out the millions of Americans who lost their homes, their jobs, and many of their hopes for the future. One good idea may be the initiation of a state lottery program, administrated by the Federal Government and named,"Free Mortgage Money."

Instead of picking a series of numbers, Lottery players would purchase a $2.00 ticket that would be fed into a computer. The paid ticket would entitle its holder to enter their names, address and amount of mortgage debt into the "Free Mortgage" computer. At the end of each week, for every two million dollars played, one million would be paid to the state coffers and one million dollars would be used to pay off up to two hundred and fifty thousand dollars of the winners mortgage debt. The computers would be set to randomly pick the names of the winners and calculate how many winners would benefit each week, depending on the money owed by the winner and the amount of money collected in lottery play.

The technology would be simple to implement and winners names and addresses could be posted on a web-site each week. The winners would report to their local lottery office where administrators could assist them in transferring funds directly to the institution holding their mortgage debt. Perhaps we could use some of the thousands of brilliant law graduates who have passed the bar and remain unable to find a job in their field to administrate this process.

All parties benefit from such a program: states get a weekly infusion of funds, the mortgage winner now has the funds to purchase more goods and services, and even the banks who seem to require your first born child before they give you anything, could use the cash infusions to create new mortgage money or to offer low interest loans. Law school graduates could finally move out of their parents basement, gain work force experience, and have a salary to pay back some of their enormous school loans.

2. In most of the Northeastern states, property and school taxes are beyond belief. My own taxes are close to ten thousand dollars a year and most of my neighbors question just what we are getting for our money. Certainly in other parts of our country there is garbage collection and snow removal for less than ten grand a year. Our roads in New York are filled with potholes and many of our public and parochial schools are using desks from the 1950's. For the most part, our homes are modest and many of us have a lot that measures 40 by 100, so its not like we are paying for an estate that holds our collection of Arabian ponies. If you have ever traveled to other parts of our country and looked at the sizes of homes and lots, you have no doubt shaken your head in disbelief when you become aware that you are paying double or triple the taxes of your fellow citizens.

Yes, wages may be higher in the Northeast and job opportunities more plentiful, but the disparity between salaries and the prices of homes in our neighborhoods are not what they used to be when our parents moved from the cities to suburbia. For those of us whose kids are grown and gone from the nest, enormous school taxes are especially hard to swallow.

Perhaps it might be more equitable to offer a tax rebate or reduction to homeowners whose children are no longer enrolled in the school system. A 50% reduction in school taxes for these families seems fair and solves an even larger problem. Currently those who rent in a community are exempt from payment of school taxes. This includes those who are not yet citizens, or are in the country illegally, as well as those who are not home owners. If your children are registered to attend schools in the community, you should be responsible to shoulder some of the costs of their education, despite the fact that you do not own property.

3. Those currently unemployed for more than six months should be required to perform some form of community service in order to receive a weekly check. This should also be true for those who collect welfare and are not caring for young children or a sick family member. Teachers can offer tutoring or mentoring services for schools in their community. Those in the legal field, who have lost their jobs, or who cannot find a job, can provide free assistance for a certain number of hours each week for those citizens who require and may not be able to afford such services privately.

We have seen the large number of individuals who turn out each winter to clear snow from stadiums or streets. Thousands have shown up for these jobs to earn $12.00 an hour. With our employment rate holding steady at 8%, why can't we create jobs for individuals to shovel snow for seniors who register in advance for these services at their local town halls. In spring and summer, these same individuals can be trained to make street repairs or to clean and refurbish our parks, many of which are unfit for use by the community. This is certainly a solution to work for welfare and does not cost the Federal or local governments additional funds.

Construction companies who have suffered from a lack of projects due to the economy could receive a government grant to rebuild and refurbish the large number of abandoned buildings that are found in and around the New York area and other parts of the country. Thousands of new jobs would be created and these buildings could be turned into low cost housing so that none of our citizens are forced to live in the cars or on the streets of our nation.

All such buildings should be manned by adequate security forces such as those that are utilized by the tonier apartments in our cities. This would avoid the influx of drugs or destruction of property that caused the abandonment of these buildings in the first place.

Adequate security forces for such projects would provide jobs for returning veterans or for those who have received security training and continue to seek elusive employment.

Small businesses would spring up to serve the needs of these communities and the community would continue to develop and grow.

4. Years ago, I purchased clothes made in the United States that I was able to wear for years. Today, our country makes absolutely nothing. Even Calvin or Anne Klein can't seem to make their apparel lines outside of Malaysia or China! The goods we now purchase are often substandard and you are lucky to make it through one season with the clothes produced overseas. Perhaps, we are not purchasing consumer items because our stores are stocked with inferior goods.

Many of the communities in our country have hundreds of empty storefronts representing the efforts of small business to compete with the foreign countries that now produce everything from our underwear to our toaster ovens, electronics and automobiles.

Our Federal government needs to sponsor a new program called: "Made in the USA." The abandoned storefronts in our neighborhoods could be turned into shops where we start producing at least our own clothing again. As a child, I watched my grandmother proudly work for the ILGWU and produce some of the most well made and affordable clothing offered for consumers in the United States. Even if we started with a small storefront and some knitting machines, subsidized by state or Federal dollars, certainly we could produce sweaters that American consumers would be proud to purchase and wear. Let's utilize the same expertise that made the ILGWU such a great organization. With so many unemployed, I can predict that thousands would show up for the opportunity to either practice their skills or be trained to produce quality goods. Wages could start off on the lower end with the chance for those employed in these businesses to eventually own the business or at least share in the profits. Stores that agree to display American made sweaters would receive an tax break for showing these items in their stores and keeping their prices competitive.

In order for us to succeed as a country, we need to stop the massive import of foreign made goods.

5. Instead of tolerating the insane costs of heating oil or electricity, lets provide our citizens with the tools to convert part or all of their homes to solar efficient dwellings. Today, it costs about thirty thousand dollars to install the equipment needed to harness solar energy, a cost too prohibitive for most citizens in these trying economic times. If we want our citizens to spend money to stimulate the economy, why don't we provide them with the tools to save on the high cost of monthly energy use. It cannot be that difficult to train employees to install such systems, creating not only new jobs in the industry but significant savings to American consumers. Perhaps our leaders need to start with a program that is possible, instead of the loftier plans proposed each year and yet here we are, still dependent on foreign energy sources.

Solar energy would also allow us to utilize cars that are not dependent on gasoline. Right now the cost of plugging in your car every evening would force most of us to work three jobs just to pay our electric bills. Buying an electric car is just not an option that we could afford to adopt without solar energy to defray the cost. Let's keep it simple people and create jobs that would allow citizens of the United States to profit from their creation.

If we calling our citizens to action and making promises that we will give them access to the American dream, we need to have the kind of leadership that spends money on programs that will allow us to grow and prosper. If we can afford to bail out the banks, the automobile industry, and finance wars that cost us billions of dollars and thousands of American lives, perhaps we can provide our citizens with some simple solutions.

Tom Cruise, Scientology, and the Crazy Women in his life

2012-09-05T15:16:00.000-04:00

Once again, the media is chock full of stories about the trials and tribulations of the women who have come and gone in the life of Tom Cruise. Countless photos of Katie Holmes clutching little Suri protectively in her arms on the streets of Manhattan, as if the child could suddenly be in harms way from the wacky reach of Scientology, in the midst of hundreds of paparazzi!

Now we find out that Vanity Fair's October issue will feature a story about Scientology's auditions for a suitable spouse for Tom. Supposedly, prior to the "Katie days," Tom's church conducted a massive search for the perfect woman who would not only worship Tom but also show the proper reverence to the hierarchy of L. Ron's disciples. The woman in question was supposedly required to dye her hair, and shave her incisors in order to become the perfect woman for Tom and members of the Celebrity Center of the church.
When the romance went south, the poor dear was forced to scrub toilets with a toothbrush and censured for her failure to make Tom dance across a couch in the Oprah Winfrey studios.

Obviously, the trod upon women who dated or married Cruise had only the purest of intentions and had spent much of the time before meeting him probing the surface of an obscure planet, making them totally unaware that Tom was even remotely affiliated with Scientology, let alone that they might be expected to become affiliated as well.

I don't know much about the principles of Scientology, nor would I assume to judge any form of worship, other than those who advocated doing harm to others. I do like to think, however, that before I agreed to date or marry someone, I would have a complete understanding of my partners commitments and obligations. Tom Cruise doesn't do much for me; I mean he is no "Baldwin," as far as I am concerned, but there is no doubt he is a man with money, power and charisma. Perhaps, these were the charms that convinced his former partners to overlook his dedication to a religion that appears to be a major part of his philosophy of life.

When she married Cruise, Holmes had a Scientology ceremony. His best man was a major honcho in the Scientology community, and his children, from his marriage to Nicole Kidman, practiced his faith. Perhaps that should have given Holmes the slightest of clues to Cruise's intentions regarding their own lives and future offspring. It not as if Cruise suddenly jumped on this particular bandwagon and experienced an instantaneous conversion and demanded her conversion as well. Had Holmes considered his religion some crazy cultish dogma, it should have been her obligation to assign those characteristics to her future husband as well.

Maybe Vanity Fair should consider writing an article titled,"Women Who Deny." They could interview a wide variety of women who swear to having no prior inkling that their husbands were gay, abusive, gamblers, drunks, or drug users, until well after they dressed in white and marched down the aisle. It might be hard to swallow, since the magazine seems to cater to women who aspire to independence, ambition, and shopping for just the right shoes and handbags, but still, with the right slant, some readers might just buy it.

If Its Good Enough for The Congress, It's Good Enough For Me

2012-08-30T15:52:00.002-04:00

Candidates for President on both sides of the aisle are accusing each other of trashing the Medicare system and robbing seniors of the benefits they have funded. "Medicare is bloated," they claim. "We cannot support the system without positive change."

Ryan is suggesting a voucher system, where seniors can purchase insurance and look for the most competitive rates, even suggesting that our quest for coverage take us from state to state. The Democrats are pushing for stronger control of any Federal program they can lay their hands on and all of us know how successful this can be!

Frankly, Are They Kidding?

Does anyone imagine that suddenly our benevolent insurance companies are going to offer first fair and then competitive rates for insurance coverage that will be covered in total by a voucher? People, please! We bailed out the banking industry and now it is almost necessary to hand over your first born to get even a car loan. Can we believe that the insurance companies will suddenly sacrifice profits and provide coverage that pays 80% of medical costs and procedures? Seriously?

I say, forget this nonsense and let all Seniors be covered by the same plan that covers members of Congress. They have possibly the most comprehensive health care plan on the planet. No paperwork, no vouchers, no phone calls or soliciting of quotes. They are elected, they are covered. End of story.

The New America - Second Rate and Falling

2011-11-09T13:20:00.001-05:00

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

2011-10-20T14:56:00.000-04:00

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

2011-10-19T10:45:00.000-04:00

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

2011-10-12T15:17:00.000-04:00

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

2011-10-11T14:39:00.000-04:00

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

2011-09-29T12:41:00.000-04:00

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

2011-09-26T09:57:00.000-04:00

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

2011-09-20T14:24:00.000-04:00

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 ?

2011-09-16T14:47:00.000-04:00

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

2011-09-13T13:39:00.000-04:00

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

2011-09-12T11:08:00.000-04:00

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

2011-09-07T11:50:00.000-04:00

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 ?

2011-09-05T12:19:00.000-04:00

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?

2011-08-31T12:11:00.000-04:00

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

2011-08-29T12:13:00.000-04:00

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

2011-08-24T12:59:00.000-04:00

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

2011-08-23T15:06:00.000-04:00

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

2011-08-22T10:42:00.000-04:00

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.